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Ii b ""T of Con V"'" Catqns_in_Pu b~<oti on Do ..

Ad.om~

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Phumorol~ fo r

a po\hoplrysioloJk OWlOoch / Mi<hoel

Patrick Ad.m~ ulrnd Nonn"" HoU""d [r~3rd M.
p.:<m.
Include. bibliographical r.r.~. 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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tion pr... ntrd in this book. Th. autbors, rdito ... and tho publimer, boweYfT, gnnOl a"ept any r(~lIIjbilily for erron or
omi .. ions or for consequ.n= from application of tho information in this book and make no warranty, tlJ'",ssor implird, with
r~spect to its contenu.
Th. authorsand publish" ha", ,,,,,rtrd eYfiy dfon to ,nsn",
that druSs..!tions and do,,&,o .. t forth in this text a", in accord
with currrnt =mmendations and procti.. at tim. of publication. How"".r, in vi.w of ongoing ",..aRCh, changes in go",rnm.nt "sulations, and the constant flow of information ",lating to
drug thtrapyand rtactions. th. re-ddHis ut&M 10 ,hKk Ih~ pad:.a&, inserts of all drugs for any change in indications or do ..&, and
for addrd warning and precautions. This is partkularlyimportant
wh.n tho =mm,nd,d ag.nt is a now and/or infn<J.u.ndy ,mployed drug.

PubUd ... r: )uIit Lovin AIaandor

AsoiBt ... t to PubU.h." Rtgin. Bruno
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About the Authors

Michael Patrick Adams, PhD, is an acoompJished educator, author, and national speaker. The
Na tional Institu te 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 faculty of Lansing Community College and 51. Pe tf."rsburg College, and w;u IXan of Health Programs at Pasco- H ernando 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 ~tter

anti more caringplact.

-MPA

leland Norman Holland,Jr., PhD (Norm) over 20 years ago started ou t 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.! educatio n, 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 ionw ide. 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 work~Jife readiness. He mntin~
ues to motiv:ate students in the lifelong pursui t oflearning.
I wOllld Ii~ 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 SO Il, arid Joshua
Na,haaie~ my nllmber three "O.~
-LNH

NURSE CONTRIBUTOR

Carol Quam Urban, PhD, RN

is the Assistant Dean for Undergraduate Nursing and an Assis tant 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 academic difficulties, outcomes-based education, effective educational mCKlels using computer-based learning, and servicebased learning. She has also publ ished articles on the ethial needs of at-risk students,
She is a member of Sigma Thet~ Tau - Epsilon Zeta chapte r, Alpha Chi, the National A.ssoci~tion for Developmental
Educa tion, Na tion al College Learning Center Associa tion. 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

n urse contr ibutors and reviewers who provided their
unique knowledge and expertise 10 this project. Their in-

SUPPLEMENT CONTRIBUTORS
Rosem ary Ba kasa, RN, MSN, PhD
Bry"nt and Stratton CollegeEasdab: Campul
Easdak<:, Ohio
Imtruaar. Rnouru M.,nual

PuwtrAlin"
Ma r ge G ing r ich , RN, MSN
Harrisburg Area Community College
Harrisburg, ~nnsylvania
MyNursinglAb

Sandnl L. G u sta fson, RN, MA

Hibbing Community College
Hibbing, Minnesota
MyNllrsinglAb
Fra nk Lyerla, PhD, RN
Southern Illinois UnMnity Edwardsville
Edwardsvill<:,lIIinoi.
Te.t Bank
Ba rba ra Ma xwell , 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 n ine Ra y, SA, BSN, MSN, RN ,CRRN
CiKO College
CiKo, Tent
MyNursinglAb

REVIEWERS
Joy Ach e- Reed , RN , MSN
Indiana Waley,,," Univo:rsity
Marion, Indiana
Ene li a O. Alfred, RN, BSN, MA, MEd
Kmt State UniV<:rsi ty, TUKaTaW'iU
N<:w Philadelphia, Ohio
Rosem a r y Ba bsa, RN, MSN, PhD
Bryant and Stratton CollegeEastlili Campus
Eastlake, Ohio

"

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~ights, suggestions,

eye for detail, and dedic ation to q u ality

nursing ed uca tion were evident and enabled us to prepa re
an accu rate, relevant, aoo useful pha r maCOlogy textbook.

Kat hy Black , MSN

Iowa W... t<:rn CommunityCoIl<u
Council Bluff.. Iowa

t o ra McGuire, RN, MS
Joliet Junior Colleg<:
IoIi<:l , llIinois

Il e n e Bone, RN, MS
Gat<:WaY Community CoIleg<:
Phoenix, Arizona

Cydney Kin g M ull en , RN, PhD

~dhiHs Community Colleu
Pinehurst, North Carolina

Donn a 1.. Bumpus, RN,MSN

Lamar Univenity
BcaunlOnt, Tens

Ch ri ~tin a

D,ul en e C la rk, RN, MSN

P"nnsylvania Stat" University
University P~rk, ~nnsylvania
Lucille Di r k , RN, MSN
AT'S lnstitut" ofThnology
Highland H<'ighu, Ohio
Ma.r yAnn Ede lman, RN, MS, CNS
Kingsborough CommunityConege
Brooklyn, N<:w York
Ja cqu e line Frock, RN, MSN
Oklahoma City Community CoLkg"
Oklahoma City,Oklahoma
M e ki Jnco bsG rah aJII , RN,MSN
Univel'lily of North Carolina
at Pembro"
Pembroke, North Carolina
Sa nd n L G u s ta rso n , RN, MA
Hibbing Community College
Hibbing, Minnesota
Lorr ie S. Jo nes,ARNPC
Polk State Coll<u
Winter Ha ......., floridd
Ka thl een Krov, RN, MSN, CNM, CNE
Raritan V~[]ey Community College
Somervill<:, New Jersey
Lora J. Leon a 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

Ca ro l O lso n , RN. MSN

Antonio College
~ Antonio, TeDS
~

Janice Ra mirez, RN, MSN, BC, CRRN,

eNE
North Idaho CoUeg ..
Coeur d'A1el~, Idaho
La uri e Simm o n s, 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 n e E Swi h ar t, RN, BSN, MEd ,
MSN , CRNJ, WCON, PCCN
Pu:;o-Hernando Community CoIkg<:
New Port Richey, Florida
An ni e Thotllll5, RN, PhD
MaKdla Niehoff School of Nursing
Chicago, lllinois
Ka thy Trumme r, RN, MS,CNS
Front Range Community College-Westminster Campus
Westminster, Colol1ldo
Ke ith 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 W h it e h ea d , MS,
FNPC,CSN,CLNC
Milwauktt A~a Thnical College
Milwauktt, Wi5C(lnsin

Preface
WhenSludl.'nts an.asked which subject in their nllning program 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. physiology, chemistry, and pathology as WI.'Il as the social sciences
of psychology and sociology. Not properly applying pharmacology 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 majority 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 difficulty connecting phamlacotherapy to therapeutic goals and
patient wellness. The pathophysiology approach of this textbook 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 pharmacology is truly a fascinating, lifelong journey.

ORGANIZATION AND STRUCTUREA 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 information 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 student 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 connec tion between pharmacology,
pathophysiology, and the nursing care learned in other clinical courses.

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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 classification are introduced in detail in the chapter. Smdents are less
intimidated when they can focus th eir learning on one representative drug in each class.
New to This Edition
The third edition of Pharmllcology for Nurses: A PtlthophysiologicAppflXlch 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.
EX PANDED! 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 gro ups.
NEW! Treating the Diverse Patient features discuss the
nursing considerations of a diverse population.
Updated! Nursing Pt()l;ess Focus Charts
Enha nced 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 Ab o ut Terminology
The term "health care provider" is used to denote the physician, nurse practitioner, and any other health professional
who is legally authorized to prescribe drugs.

vii

ACKNOWLEDGMENTS
When authoring a textbook such as this, a huge number of
dedicaled and lalented professionals are needed 10 bring the
in ilial vision to reality. Kelly Trakalo. Senior Acquisitions
Editor, and Maura Connor, Editor- in-Chief, are responsible
for helping us sculpt the vision for the teJI:1. Our Developmental 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 neussur expertise for our comprem-nsive supplement package
was UUfft"l Sweeney, Editorial Assistant.

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1'he design staff OI l Pearson, especi;ally Cluis Weigand.

crea led 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 provided expert and professional gu idance in all aspects of the
a rt and production process.
Although difficult and challenging. the study of pharmaco logy 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 sluden15
will be able to provide safe, effective nursing care 10 patien15
undergoing drug therapy. We hope students and facu lty w,ill
share with US theirexperitnces using this textbook and aU L15
resources.

Learning Pharmacology in Context

... The organization by body systems (units) and diseases
25.2 Patho g e 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

(c~pters) clearly places the drugs in context wi th how they are used
therapeu tically. You can e35ily loca te al l relevant anatomy, physiology,
pathophysiology, and pharmacology in the same chapter in which we
present co mplete information for the drug classifications used to
trea t 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.

m ..11;", or "'lIJtrictin,omAlion. Tho diKomfon IN'/' n

JIoouidrr """ pru<ftd d.-.. tb< J.tt or ... aoo

dja.,tD 1M WIt

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

DRUGS AT A GLANCE

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.

OIl6ANlCIllWU . .1<1

O~ ",_ "",_ ", ,,,

---

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lEr"'AI*IIlI&K 1.00:ElS{AII1A6OII1ST1l

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tiott_

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' . .0"""
.10IJ11Cl,.""..
_ _ , .111

AD.lll1ICI DllJCi5 101 Ml'OCMDlAt IIIAICIIOII

PIIARMFACTS
Anginil~oris

......

1M! 9 ntIIon AlHllunlIIM lI9III pKln; 5(11,000 lIN a!fI tall

... PharmFacts present pertinent faman<! statistics reb-ted 10 the disease,

providing you with a social and economk perspective ofthedisease.

1OII."Iho_u t.~<IIIN!o .... O!lltUm ..

M youordi.llnf.rcuo"

..... _1.1 _ _

IIpfIIIn::~

. ...... _IIIM11,...

_Clllf_oIIllfP*ltl sporIIIodngMb .... hmlll!m.

_ 6O!ri If 1ho p6nU wile cIfd!Udc11!f7 0111 Iud lit pr!IM

~dlho""....

peak effect, when know n

Adverse Effects and
Contrai ndications
Interactions with drugs, he rbs. and
food
Treatment of overdose and
an tidotes, where applicable

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iou"' ..
. . . . ._ _

............,.-..-.....-

1J.1I> _ _ _ .... _

-__.
--

01 _ _ _ _ . . .

MUlS
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.....

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....

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411'1lM1 UFIlCTS

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R ~_

......... _ , .".IWJ .....,.

NTIJIACTOIS

..

.......

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-"
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......
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.........
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_ n . . ... _ .. "' ...... , -...

..

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_

....., .. II..w:II . .
~

Pharm acokinetics, induding onset

of action, dura tion, half-life, and

....

OI!. _ _ ~ _ . . ._

Actions and Uses

Administration Alerts

N:lIOII$ AND 1,111[5

lIdI...... _
.. _

They Indude:

_
..
-..-- _--,.,---_

....,,,_...... _,..._m.
........... ...
<

,.

Prototype Drug boxes clearly

summarize important medications.

Prototype Approach and

...__

~_""_III"""",_(IIS

-"'---"'-"-"...... .....

11. _ _ _

.~--{

""*_ _.IIN!
.
..,..
~.-.--.......,.....".,,.
...... _r- _ _
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_~loIoIICaUIIrnc$

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-"
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lor

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I.

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 Th~ ~lwlar Actlwotlng S~.m and Rebt. d RRgIon.1n the Brain ant Imporbnt
ANal of Focus for Drugs Uslto r rut A.... '-ty ~ Anx'-tyRl latad Symptoms

.... Pharmacotherapy Illustrated

bo.les viSU3!1y illustrate the drug ther
al')' process and its impact on the dis1'3.'ie, showing you specifically how the
drug 3cts to counteract the effects of
dlseaseon the body.

---_
. _ ...
---------.......... . . .
...............
......
~

-~--

..-

.....

Mechanism of Action anim3wd tutorials featured in MyNursking Kit clearly ~ow drug
action at the molecular, tissue, OI"8an, and system II'YeIs.. ....
M ECHANI SM OF A CTION A NIMATI ONS

Acetiminophell
Acyck:Nil

(11.33

Donzosil

'"l6

AmirXI.UOlle
AIolYastatIt

'"'

Epinl'Phrine
Epoietin alta
EsdUq,ram
EstrJdiol
Fluconamie
FllJClleline
FurosemiJe
Glipizidt
Hepalin
lntefiell)fl alfa
lmdo..

(ajotriol
(iprotioum
(ydobenuptillf
(ydoph:Jsphamide

Diazepam
Digoxin
Oiphen/ty!;kamine
Dopamine

C<12
(11.47

,.,.
(hll
(h17
(II. 15
(11.24

"
19

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Ch.23
(h.29
(U8
(h. 14
(1L45
(ILJS
(h.16
(h.24
Ch.44
(1L27
(h.ll
(U1l

lQ)QQ>
lisi11Op"iI
Metllotrexate
Meth>1phenidale
MoIJII*"Ie
Napro.m
Nifedipine

0,,,,,,,,,,
Oxycodollt
Pmidlin
PixalJlillf
PropmtOiol

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(IL 18

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Venlafaxine

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ZickJfudine
lolpidem

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~.,

Providing aNursing Focus

Once you understand how a drug works on the body-i.e., its actions, therapeutic effects.
potential side effects and interactio ns, and more-you begin to understand the "why~ of the
interventions you will take as the nurse. Each chapter guides you to the content that is essential 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 med ications--from assessment, nursing diagnoses, planning,
implementation with interventions and rationales, through evaluationand induding patient teaching and discharge planning.

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.

Additional Nursing Process Focus charts are available on MyNu r5in gKit .

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have been added throughout
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Errors are brief patientbased scenarios that illustrate potential pitfalls that
nurses encou nt er and can
lead to medication errors.
Each scenario ends with a
question asking you to identifywhat 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 conventional drugs.
As a nurse, you need to assess dienls to see if they are using any natural remedies 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.

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io

Home & Community ....

Considerations alert you
to concern.s and teaching
implications for care settings
outside the hospital.

The tools at the end of each chapter and on the ao mpanyi ng media resources help yo u test
your understanding of the drugs and nursing care presen ted in th at chapter. Using these
tools will help )U U su eoo in your pharmacology course, in the di ni cal set ting, on the
NCLEXRN", and ultinlauly in professional nursing practice.

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co rrela te to sections wi thi n the chapter. You , an use th is sucd nct summary to erusure tha t you und erstand
the concepts before moving on to the
next chapter. The numbering of these
co ncepts helps yo u easil y locate that
se"ion within the chapter if yo u need
furth er review.

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,.

NClEX-RN- Review Que$tion$ prepa re you for ...

course exams on the cha ptt'l' content using all
NCLEXIt fo rmats. Appendix D provides answers
and rational es.

CRITICAL THINKING QUESTIONS

L A l~ ')af'oId potitt>t (,ovid> " 1"'0 1) i.ailmill<'d 10 th.
lobo .nd doIm.y unit and .... "" thot m. II '-inf! <OIl
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MyNursingKIt Each chapter ~

provides a reminder to visi t
MyNursi ngKit nt
(www.myn ursingkit.co m) fo r
additio na l chap ter review and
reso un::es.
xli

LibraryPirate

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patien' __

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.... CritlUlI Thinking

Questions help yo u
apply the essenti al
components of nu rsi ng
care thro ugh case-based
scenarios. Appendix D
provides answers.

Core Concepts
in Pharmacology

CHAPTER 1

Introduction to Pharmacology: Drug Regulation and Approval

CHAPTER 1

Drug Classes and Schedules

CHAPTER J

Principles of Drug Administration

CHAPTER4

Pharmacokinetics

CHAPTER 5

Pharmacodynamics

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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 ~reils 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 overthe-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 consume rs.
, O. Identify the nurse's role in the drug approval process.

KEY TERMS
biologjn (X1gt4
dinical investigation fUJI6
diniGlI phal~ trials JX!gt6
complementary and alternative therapies

"",

drug

{!all 4

Food and Drug Admini stration (FDA) rcgt 5

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FDA's Criti ca l Path Initiatiw ptTJt6

formulary ~4
Inftstigational New Drug Application UNO)
fRi"

mfdication
NDArnifw

PQl}f4

plqtl

pharmacology ptTJt J
pharmacopoeia ftlf/l' 4
pharmacotherapy ptTJt4
postmarbting surveillu ce ~7
predinkal inwst igation pq;16
therapeutics (!11;!4

Choplfl 1 Introduction to Pham...:oIogy: DNg RegulUIon

ore drugs are being IIdmlnlstered to patients than

ever before. More than 3 bllnon preS(:flptlons are

di~pensed each year In the united States. About one half of

all Americans take one prescription drug regularly, and one

out of

si~

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 u se.

1.1 History of Pharmacology

Thestoryofphannacology is rich and exdting. f.lled with accidental 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
"pr~riptions~ on cl3)'tablets in 3000 S.c. At aboullhe same
time, the Chine~ recorded the fbI Tsao (Great Herb;Il), a 40~
volume oompendium of pl3nt remedies d3ting to 2700 Soc.
The Egyptians followed in 1500 B.C. by archivi ng their reme~
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 en titled - Pharmacologia sen Manuduc~
tio aoo. Materiam M edicum: by Samuel Dale, in 1693. Before this date, the study of herbal remedies was called
- Materia Medica,~ a term that penisted into the early 2OI:h
century.
Although the ex:Iict starting da te is obscure, modern pharmaoology is thought to have begun in the early 1800s. At
that time, chemists were rnakingremarbble progress in is0lating spKific substances from complex mixtures. This en
abled scientists to isola te 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 researchers used themselves u test subjects. Frooerich Ser~
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 recog~
nized when the first department of pharmacology was es~
tablished in Estonia in 1847. John Jacob Abel, who is
considered the father of American pharmacology owing to
his many contribu t ions to the field, founded the first pharmacology department in the United States at the University
of Michigan in 1890.

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~od "PPIO'o'~t

In the 20th century, the pace of Change in all areas of medicine continued exponentially. Pharmacologists no longer
needed to rely on the slow, laborious process of isolating active agents from Karce natural products; they could synthesize 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 substance is extracted from the Pacific yew tree, 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 "stud y." Thus, pharmJcology is most simply defined
as the study of medicine. Pharmacology is an expansivesubjed: ranging from understanding how drugs are administered, 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 o n 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 pharm~oology 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 nctiv~ in educating, managing, and monitoring the proper use of drugs.
This applies not only 10 nurses in clinics, hosp itals, and
home health care settings b ut also to nurses woo teach and

!z

i
o

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, pharmacology 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 graduation . One never completely masters every facet of drug action 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 treatment 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 desirable (therapeutic) or undesirable (a dverse). After a drug is
administered, it is called a mrdication. From a larger perspective, 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

"t

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 maximize 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 margin 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 require a physicians order. In most cases, patients may treat
themselves safely if they carefully follow instructions included 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 appointment with a physician is required, thus saving time
and money. Without the assistance of a health ca re 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 n ot be aware that some aTe drugs
can impair their ability to function safely. Self-treatment is
sometimes ineffectual, and the potential for harm may increase if the disease is allowed to progress.

1.6 Drug Regulations and Standards

other suh,tances sllch '" fooil" hOIl",hold prodllct<, and

Uotilthe 19th cemnry, there were few standards or guide_

cosmetics. Many agents such as antiperspirants, sunscret'ns,

toothpaste, and shampoos might alter the body's normal activities, but they are not necessarily considered medically
therapeutic, as are drugs .
Although most modern drugs are synthesized in a laboratory, liolOlj ics are agents naturally produced in animal cells,
by microorganisms, or by the body itself. Examples of biologies include hormones, monoclonal antibodies, natural
blood products and components, interferons, and vaccines.
Biologics are used to treat a wide variety of illnesses and
conditions.
Other therapeutic approaches include (omplemrntaryand il lternativetherapirs. These involve natural plant extracts, herbs,
vitamins, minerals, dietary supplements, and many techniquesconsidered by some to be unconventional. Such therapies include aCUplUlcture, hypnosis, biofeedback, and
massage. Because of their great popularity, herhal and alter-

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 rheumatism; epilepsy treatment for spasms, hysteria, and alcoholism; and fat reducers for a slender, healthy figure. Many
of these early concoctions proved ineffective, though harmless. At their worst, some contained hazardous levels of dangerous or addictive subs tances. 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 standards, 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 synthesis. In 1852, a national professional society of pharmacists called the American Pharmaceutical Association

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Ooop!tf 1 Inuoductlon to PhiollTlKoIogy: Ofll9 ~ul",1on . od Appr~1

(MhA) was founded. From 1852 to 1975, two major compendia maintained drug standards in the Un ited Stat es, the
U.s. Phurmacopoeiu and the Nutionul Formulary (NF) established by the APhA. All drug products wne covered in
the USP; pharmaceutical in gredients were covered in the
NF. In 1975. the two entities merged into a singl e publi catiOll , th e U.S. Pharmilco/'Mill- Niltionill Formlda,y ( USPNF) . Th e current document of about 2,400 pages contains
3,777 drug monog raphs in ]64 chapters. Official monographs and interim revision announcements for the USPNF 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 amo unts
of ingredients found within the container. Sample labels a re
illU5trated in ~ Figure 1.\.
In the early 1900s, the United States began todevdop and
enforce tougher d r 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 Sherley
Amendment prohibited the sale of drugs labeled with false
therapeutic claims that were intended to defr:lUd the con sumer. In 1938, Co ngress passed the Food, Drug, and Cosmetic Act. This was the first law preventing the sale of drugs
that had not been thoroughly tested before marketing. Later
amendmen ts to th is law required drug companies to prove
the safet y and effiOKY 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 Supplement Health and Education Act of 1994 in an attempt to
COlIIroI misleading indu.m y daims. A brief timdine of ma jor events in U.S. drug regulation is shown in ~ Figure 1.2.

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MaIItrcbodf PtIoImocrotlcois.

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"

PHARMFACTS

Consumer Spending on Prescription Drugs

Spmdingon~dNgs _ublbaut 10'110olMioNl he.ttto

......

.t.t 1M tInI 01 tht 21st <tl'illll")' (1999-2000), ~ dNg

opflufnwn inuMfd by mort m.n 200'lIo comjlilfd to !be NIIy 1~.
T1If aYl'ligf lIUmberof pmaiption drugs takrn per ",timt CM'rt!J~
UIlIM of" 1m ~.boot 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 ~mge cost ~ pmcription was ibout $29.00.
101.11 p/Iamo.KeUtiu1 nprllditurtS in tilt Unitrd SUtts 1wY!' ioc:~!ed
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 officially established as an ~seno:y of the U.S. Department of
Health and Human Services. The Center for Drug Evaluation 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 a s facilitating the availability of safe, effective drugs; keeping unsafe or ineffective drugs off the market; improving the
health of Americans; and providing clear, easily undersundable drug information for sa fe and effective use. Any
pharmaceutiaJ laboratory, whethel'" private, public, or academic, must solicit FDA approval before marketing a drug .
Another branch oflhe FDA, the Centerfor Biologia; Eval uation and Research (C BER), regulates the use of biologics
including serums, vaccines, and blood products. One historical achievement involving biologics was the 1986 Childhood Vaccine Act. This aet authorized the FDA to acquire
information about patien ts taking vaccines, to recall biologics, and to recomme nd civil penalties if guidelines rellrdi~
biologia; were not followed .
The FDA also oversees administration of herbal products
and dietary supplements through the Center for Food Safety
and Applied Nut ritio n (C FSAN ). Herbal products and di etarysupplements are regulated by the Dieury Supplelllent
Health and Educa lionACI of 1994. This act does nol provid e
the same degree of prot K lion for consumers as the Food,
Drug, and Cosmeti c Act of 1938. For example, herbal and
dietary supplements can be marketed without prior approval 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.

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 Formu ltory (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 ... 1Bureau 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 Ac t tocontrcl!he qUlllity of Hnms and otharbfoodmlalld producta.

tlOl

The PUIS Food a nd Drug Ac t ga1l8 the gllYllmmen\ powe' tooontrol the Itobeing 01 medicines.

181 2

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
"",51 s ubm~ a New Drug AppIk:lltion (NDA) to the
FDA prior to marf<eting a new drug.

1144

Congraas passed the Publ ic Hedh Se rvice Act. CCM!Iring many health issues inclo.rding bioIogiCIII ptOdllCla and the oonlrot
oIlXlITWTIIInicabie diseases.

11 75

The U.s. PhllfmllCOfNl's and National Fo<mulsry a mco.rr><:e<l their union. The USP-NF became a single standardized
publiClltion.

lilli

Congreas pas.sed the Childhood Vaccine Ac t. 11 owthorized lhe FDA to acquire information ebout pllliento la king vaccines, to
recall biologics. a nd to """"""",nd civit penalti_ if guidelines regarding biologic""" wore not foIlowod.

11188

The FDA we officirtly Hlablished as a n agoncy 01 the U.S. Deputment of Hedh a nd Hume n Servicea.

10112

Congraas p assed the Presc ription 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 Diete ry Suppfement H_ lth a nd Educ ation Act thai ,e qui,,"s clear ta beii"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

""""anI_

The Biote rro riam 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, ~ ..... ,,<loo~, u,,.j (uoslfi""..<lI"lioi u1i"" tu all"", lur ..<l~iliu"..1"""'I"<tI, .. ,....... ,"" .. _ uI
oow drugs a nd medical products. Thia eldended the reforms i~ from 1997. The FDA. Cr~ ice l PIIth In~iati Yl 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 different doses, and to look for adverse effects. Extensive testing 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-

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ways reflect the way a human responds, preclinical investigation results are always inconclusive. Animal testing may
overestimate or underestimate the actual risk to humans.
In January2007, the FDA restated its concern that a number of innovative and critical medical products had decreased sinc"" the 19905. The FDA's Critia l Path InitiatiYl! was an
effort to modernize the sciences to enhance the use of bioinformation to improve the "safety, effectiveness, and manu facrurability of candidate medical products." Listed areas of
improvement haw been the fields of genomics and proteonomics, imaging, and bioinformatics.
CliniGlI inYl!stigation, the second stage of drug testing, takes
place in three different stages termed dink. l phaSl' trials. Clinical phase trials are the longest part of the drug approval
process. Clinical pharmacologists first perform tests on
healthy volunteers to determine proper dosage and to as-

CNplfll

Pr"",linical
Inves tigation
(Stage 1)

NOli. Review
(Stage 3)

Range: 2-10 y......

Aw"'9": 5 ye""

Rar>gfI: 1-3

~,

-,

Clinicel
Investigation
(Stage 2)

,N'
Avemge: 18

Inuoductlon to Ph,uTnacology: DN9 Re<}ulotlon 00<1 .<.pproval

FIMge:2

'
~ ...
i""

.....

Postmarketing
Studies
(Stage 4)

Adwf'&8
Reaction
Reporting

"

I.,;tial
Synthesis

'ilO~

Survey",
Sampli"9'
Tasting

Animal
Testing

Inspections

II
3DDay

FDA T"""

c::::J

NDA

IndustryT""" c:::::::::J
Submitted
Figure 1.3 A new drug development IImellne, with the four pha5l's of dlug approval
Safety Review

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, worsens 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 patient<. If ~ nrng

~pr""rs

tn he effective

~nn

withnnt ... rinn<

side effects, approval for marketing may be accelerated, or

the drug may be used immediately in special cases with careful 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 allowed 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 significant therapeutic benefits, and the product is reasonably 501fe
for initial use in humans (e.g., HlV-positive patients). Companies 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 finalized. Clinical phase III trials and animal testing may continue depending on the results obtained from preclinical

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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.

urjt 1

Co .... Cor.cepts In Pha,mac:oIogy

L IFESPAN CONSIDERATIONS
Th~ Question: AIt the,t

areolS of patient drug therapy wiler! <lcfvtorw drug

fWnli hal'!' (Onsisttfltly(onlributfd to ~rious injury,di~bility,or dUlh~
The Study: Rr5emhrB I'Krmly oomp!etfd <I re'litwof all <ldvrrw drug
eY!'nli reporlrd to till' FDA ~lI(e 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 10 pol~nty It; fm I dnJ9!: dioin, b.lndronate, {Iorwepam, heparin.
(apt<itabi~, rntth<ldooe, riton.J'lir, iIotretinoin, ftnta nyI, <I nd inter~ron
beta. In 101M innanfrS,drug fmlitits ~re 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 ~re (iroioK dysrhythmia!,
depression with stlf-injury, and Inere MilltOU! reactions.
Nursing Imp~ (ations: Nurws should oollltantly reviewtill' littrarure to look
for drugs lhaolMYl' ~n ,eportfd, recalled, or umidem:i dangerous dU!'
to manufa(\urio9 ~ftty isluts.ln are.J1 of drug tlll'I<IPY wlll're mmmon
or reptlitift advtrw re.Ktionl hal'!' bttn ooted,lpWil uutions Ihould
b!o otn:ised
XlII!l': Mor:wr, r 1. (~M. R., & flJrtltrg. C D. ~mrl\lrl<h lOO8~rm 1.
lmlllurt rrx 5I!'" I./tdkJllion I'rI/(es.Ja/iJilyI5,1iJ09. ht1p://WWW.lImp.~
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 issues 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 experimental and clinical dat~ that must be examined in the
drug review process. Some NDAs contain more than
l00,O<Xl pages. Even after all experiments have been concluded 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 recent 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 criticisms of manufacturers and the public are certainly understandable-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 ineffective in treating disease.

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Prescription Drug Costs and the "Doughnut

Hole"" for Senior Citizens
In January 2006, prescription drug (OYtIage through Mfdiure Pan DWtflt
imo effffi, in part to help prottd seniorcitiztns (mOlt _r age 65) from tatolStrophK 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 and
mot allOT( mMKitions.Molt than 8091. of all seniors t.IU at Imtont prts<ribed medKalion mh day. rhe avtr<lgt older penon is 1.1 ki ng roore ma nfou,
prel(ription mfdiutions at on~, 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 O((U~ whtfl drug IpI'nding totals art betWl'tn $2,250 and $5,100. This gap MS been tt noo:! till'
'doughnut OOIe' and (U~nt stuclif"s MI'!' suggrntd that ll'llio~ re,uhing tMt
doughnut holewill redKe spending on their medic:atiolll by 14% t04O'll.,dt
pl'nding on whether tilt haYl' add~iollil insu,a II(t (_ragt. With most se
niors taking daily mediutions for (hronic: (onditions, this dtUUIl' in IpeOding may l1lI'an thit ll'llioo are foregoing their most nffiied medic:atiolll.

In the early 1990s, owing to pressures from organized consumer groups and various drug manufacturers,gowmmental officials began to plan how to speed up the drug review
process. Reasons identified for the delay in the FDA drugapproval procer.s included outdated guidelines, poor communication,and in'lufficient staff to handle the workload.
In 1992, FDA officials, members of Congress, and representatives 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 emplo~es 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 IdinKil trials ukl' <lbout 1 yea, and inOtve 20 t080 OOIlllilI.
hrakhy OkJnt~n.
Phase II dinKal trials Ian about 2 ~mand involl'!' 100 to 300 volunteer
patitnn with tlll'disull'.
Phasr III dinic:,11 triall take about 1 ~arsand i~ 1,000 to 1.000
patitnli in hospiulland dinic: <lgtrKits.
For tvery 5,000 (hemiuls moll emer predinic:al ~ting. only 5 mau it to
human ~ting.Of these 5 pottfltial dfU9!,only 1is finally ipprowd.

CNpltl t

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' ptrfOlIlll'd,follow~ ~ mrnsift d nical uiak or
tffiilg door il humans.

Step 2

Adrug oompany (ompltlrsa drug IUbmis~on to lfIoakh una~.

This !!pOIt dtt,iis imporlilrt lift!)' ,nd dffflimlffi information
ilduding ttstilg data,how thr drug prtdxtwil lit productd ~nd
padtagtd.and r~ttd t~ic: mfilland ~ rNCtioos.

Step 3

A(ommitttl' of drug 9pfflSilduding mrdical ~nd drug sdfotists

II'Yiews thr drug lUbmil~oo to idffitify potrotial bffiri"ttsand drug
risl::~

Step4

H~fth uoada Ift'iews infoonatiooabout thr drug prodlKl and

passe 00 impormt dttai sto hrakh prattitionm and torI\Um~

Step S

H~fth CoJoada illlltS i HotiCl' ofCompiiantt (HOC} and Dru]

Idffitifitatioo N!I1lbrr lOIN). Both prrrrit thr manufacum to
market tilt drug produn.

Step 6

H~fth Canada rnoritors thr rtkaivffirs5 ofthr drug ind~

((IOO1nsaftrr it has bffiJ rnarRtm Tlisis donr by rtguar
illpKlioo, notites, nN5itum, and ~~badc 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 byallowing more U.S. resources to be used for oomprehensiye reviews 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 thefedernl department working in partnership with provincial and
territorial governments. The Health Products and Food
Brnnch ( HPFB) of Heallh Canada is responsible for ensuring 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

Inuoductlon to Ph,um<KoIogy: 0"'9 Regulation . 0<1 ... pproval

Therapeutic Products Directornte (TPD) authorizes marketing 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 Biologics ~nd Cenetic Ther~pie.

Director~te

(BCTD) ",suhtes bi _

ologic drugs (drugs derived from living sources ) and

rndiopharmaceuticals. Products regulated by the BGlD include 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 ~n important regulatory document specifying that drugs cannot be marketed
without a Notice of Compliance (NOC) and Drug Identification 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 period of Phase IV (Step 6 in Canada) that nurses have the
most frequent opportunities to participate in the drug approval process. \VhiIe nurses working at larger, urban medial centers may participate in administering medications
during Phase II and III trials, all nurses administering medications monitor for thernpeutic effects and adverse reactions from the drugs they gi~ to their patients. \'/henever a
possible drug reaction is noted, nurses are responsible for reporting 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 administrntion 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.

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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.

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 continuous 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).

1.9 Once critidzed (o r 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 approval process but will have the most frequent opportunities during Phase IV, posll1lllrketing surveillance.

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 dJ anged in recent years~
1. In many respects, the role of the FDA continues long after
the initial drug approval. Explain the conlinued involve
ment ofthe FDA

4. Identify opportunities that nurses have in eduClIting, ad

ministering, an d monitoring th e proper use of drugs.

See Appendix D for answerJ and mtionuks for all activities.

EXPLOflE
M'jtiu~iI!;l(iI:

Is JOlI' one $lOp lor ~r*oe dlapler t'f'Oiew mal!rills artd

mwlcaS- Prltl/ilf~ lor IM,ItC8SS <MIt! ilddiliooal tlClue~ practictr
Que5IIons. Intt;raCllve _grmen15 and aCll\;~s. web Iin<.s, ~
and videos. and more!
RI'lgI.!lt~ yoo- I!CUS.'r

mtIIllmm the lrant d)OJ! bDOIC at

......"'I.a.gk it.cam .

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Drug Classes and Schedules

LEARNING OUTCOMES
After rmding this chapt~ the student should be abk to:
1 . Explain the basis for placing drugs into therapeutic and pharmacologic

dasses.
2. Discuss the prototype IIpprollch 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. E~plllin 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.

KEY TERMS
biOilvailability plgt14
chtmicillnamr M ill
combination drug {XiIj111
controll~dllJbstan~ ~14
d~pfndfn'f pu;t 14

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g~neri(nam~ fll9t'1J

sd1~duled

mechanism of action {!alt 12

pharma(ologi( dassifiution Jllf/l'l;
prototype drug fJ<1jt 1]

thrrap~utH: classification po:jt

drugs

{!alt 14

trail! name pi1IIf 13

withdrawal fUJ l 14

1]

Unft 1 Core Concepl$1n Phorm.rology

he student beginning the study of pharmKoIogy 11

quickly confron ted 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 usefuln~ in treating particular diseases. This is
referred to :lS a theflptutK daSlification. Druss may also be Ofganized 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. Som e d rugs influence
blood dolling. whereas others lower blood choles terol or
prevent the onset of stroke. Drugs may be uwd to treat ell'
vated blood pr~ure, heart failure, abnonnal rhythm. chl'St
pain, heart att:Jck, or circulatory shock. Thu s, drugs that
treat cardiac disorders may be placed in several types of
therapeutic classes, for example, anticoagulants, antihyperlipidemia. 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 addr~1'S 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 Usefuln~s

_........

Therapeuttc CllIssJtlcaaon

inIkJem blood donilg

M11ial191NOO

~lbIddloltlltfOl

Mlli/!)'perIipidmIiG
anI~

reilft IICIIIIWI urM rhythni

M1~

n_iI9N

Riln.jnah

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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

Phafmacologk da5s1f1callon

IowfI'I ~ 'IIJUn~

~k

block! hr.n (,1100111 chInntls

CikiII1I chInnri bIod.rr

block! hmrmaI.ctiviIy

angicrlmsill-{OlWff\jng !'IIl)'m~
inhibitor

block! ph)'liologit rmtiom to SlItSI

.1iRntr9ic:maqonilt

dilatrsptrip/lfr.lllbldv~

vl\odilalDr

body. Table Z.Z shows a variety of pharmaoo1ogic cl~ifiCll

Dam using hypertension as an example. A diuretic treats hypertension 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 classifiClltion 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 wellunderstood drug model with whichothl'l'drugs in its representative 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 actio n. 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 popular 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 Inten~tional Union of Pure and Applied
Chemistry ( IUPAC). A dru8 has only one chemical name,

O\.apur I

which is sometimes helpful in predicting asubstance's physical 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 ch emical

name for diazepam: 7-chloro-J,3-dihydro-I-methyl-5ph,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 ch emical
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 com plicated
when first encountered, knowing them will become invaluable 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 Administration ( FDA ), the U,S, Pharmacopoeia, and the World
Health Orga nization (WHO ), routinely describe a medica tion by its generic name, Because there is only one generic
name for each drug, health care providers often u se 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 proprietary 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 ~ars 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 market a generic equivalent drug for another 10 years, The rationale 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 because of the dozens of product names containing similar ingredients, 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

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TABLE 2 3
...

Drug Cb.", 00 SdM'dule.

13

Examples of Brand-Name Products

Containing Popular Generic
Substances

Generic SubstancE'

8rand Names

ispiin

~,Anadn.A!pfr9um, &aye', Butmil,

Ecotrin. Empiril, [x(edin. Maprin, NOOjfIic.
Salatin, SaJocoi. Sallprin, Su~ Ialwin.
Tnapt,eo.l 0, 'mqLim, Venn, ZORpin

AIIeIdryI. Beoaay~ Benahist. ~te,

Ulidryl, Compol. DiaJi st. Dip/Ieoadi~
8dm}~ ffnyIJist. F~ Hydramine. H)UiJ.
InsoJIIIaI, NoOOryI, NordryI, Nytol, Tuma~

ibuprofeon

""""

AdYil, Ammoi, Aplifen, Brufen. Hakran.

Mtdipml. MidoIlOO, Mouin, Ntuv~,
No\ooprofen, ltJprin. Pamprin~ 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 d rug 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 medication, Because there is no competition, the price is generally 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 popular medicine, Once the exdusive rights end, competing
oompanies market the generic drug for less money, and consumer savings may be considerable, In some states, pharmacists may routinely substitute a generic drug when the
prescription calls for a brand name, In other states, the pharmacist 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 significant 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 equivalen t? 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

14

linK I

Cort Conc.pU III Pho,moa>1ogy

PHARMfAcrS

MarkQting and Promotional Spending

Whrn ~'Itniom of ~1rI (lam/) bIoumt"oub!e. Y~riovs
IrgilIiCtics by Brislol-Mym Squibb dNytd M rnuy!(lIll.1I~t. Tht
Mrli1l!d ~ion~1 cost IIHDII5UJIIm b 211101l! ,"!lof potr..
mrfllionlQllIIOIl!lI'un SI biIon.
PromOliorul ~dill\l on pmaiption dlJl9S r= II _ S28 billion ill
2008,up from S16.6 bimon in 2000 000 $9.2 bi11"KIII in 1996 Sptndill\l on (DIISUmt' drug adftrlMmfnts on ttlrmion ~nd in print
mtdio incrustd to O'/ef H.l billion in 2008, up from S2.$ billion in 2000
ondS791 million in 1m
Consurnt! ~tI (Ioiim thlt ~naI ~l'rItiwmrnu dri\le up
drllliOO foI tilt n~ ~ 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 aff~IS absorption of
a drug, or its distribution to the targe! cells, can certainly affect drug :!Clion . Meuuring howlonga drug lakes lo exert its
effect gives phann;lCOlogisll; a crude measureofbioaV1lilabi lily. For example, if a patient is in circulatory shock and it
taUs the generic-equivalent drug 5 minutts longer to produce 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 minutes, 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 infonn or norify p;1tienlS of substitutions. PhannaceuticaJ companies and some health care practitioners have supported th is
action, claiming th3t gene ric drugs---even {~ that have
small differences in bioavailability and bioequivalencecould adversely affect patient outcomes in {hose with critical 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 formulary 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.

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~{r 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 expresses 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 compelling desire to continue drug use. These concepts are discussed 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 potential 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
aUaUowed. They h3ve little or no therapeutic value or are intended 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 m~y be dispenred without a
prescription because Ihe quantities of the controlled drug
are so low thatlhe possibility of Colusing dependence is extremely remote. Table 2.4 gives the five drug Mfledules wilh
examples. Not all drugs with an abuse potential are regu_
lated or placed into schedu lts. 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 Ac t of 1970
and later revisions. The Controlled Substances Act is also
called the Comprehensive DrugAbuse Preventionand Control 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_ peop~ ~ drimg IIldH thr
inlkltlKf of~ 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 17.,I.~hoogh it is ille~1 in thf Unittd
Slalei 10 srll tohmo to undrrq )'DUth~ in molt Ule Ihe)' Iff able to
pu~ thtrn prnonally.
From 191M to 1008, tmr"}rflq dep~rtmtlltl!"tOnhof ilbIMd s.ubnlnc:ts
sud! II glmmiI h)Id~ kid {GIIB;stlftl nl~Fallasy}, RllImw,
(rntfI nlmesj,Juptfari4Spid.l; l moll\l OIhtn),lnd MDMA
{dItmiYllIoIlIIf ),4~td~mphNmint;SUff{1\atIIt

~'-IIlCRth.Jn2.~

n 2008, 1l'IOII' man 18 rrilion Amtrich.tMtd or_dfprndrm 0/1

ei1lIfr IkohoJ or.n~.

ABlE2.4 1 U.S. Drug Schedules and Examples

Orug
Schedule

'"

,
y

Potential for

"'"~
Potential

PotenUal for
Physical
Dependency

Dependency

Examples

Therapeutic Use

hight\l

high

Umittd or 00 therJpMK UII'

high

high

...

rr.odtr,,~

h"
h"
h"

hftOil,iyltrgic Jod ditlhylamide {LSOl,

rnan"juani,and IMthaqual~

moderat~

-.

....,
....,

~hoIoglc

_",_d.",[P.'.~;",.
IMthador'ot, Jnd IMlhamphnamilll'
anabolic 11ffiids,(lHI~ineand h)'ltocodone
w~h aspiril or Tylmol, and !OIIII' barbiturate

1-

dextropropolyphtnt,pmtizocine,
mtprObarnat~ diiztpam, ilpruolam

1-

OTC(oogh medicile with (orIrine,

dip/lffioxylat~ 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 special 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 permitted. 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 oontrolled 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 covered in Part IV,Schedule H, ofthe Canadian Food and Drugs
Act. Theseweredrugs used in the course of a chemical oranalytical procedure for medical, laboratory, industrial, educational, or research purposes. They included hallucinogens
such as lysergic acid diethylamide (LSD), MDMA, and 2,5dimethoxy-4-methylamphetamine (DOM; street name
STp). Schedule F drugs were those drugs requiring a prescription for their sale. Examples were methylphenidate (Ritalin), 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 Controlled Drugs and Substances Act. It repeals the Narcotic

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}
Ultd thtrJpNtiul1 with ~ion;
!OIIII' rtugs oolongft" UII'd

IIstd therapMil:aly without

~ioo

Control Act and Parts III and IV of the Food and DrugAct.
It further establishes eight schedules of controlled substances; two classes of pre<:ursors are covered in one schedule. 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 Convention on Narcotic Drugs, the Convt'ntion on Psychotropic Substances, and the United Nations Convention
Against Illicit Traffic in Narcotic Drugs and Psychotropic
Substances.
Throughout Canada, both prescription and nonprescription 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 symptoms. Other nonprescription drugs may be sold without
monitoring.

~ ~l.E 2 .~ 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 nor-.x~ioo drugs mon~ORd fur~'" by
phalllliOsts

'"

All ~ion drugs 001 rnooitorrd fur sa'" by

phalllliOsts

16

UnK I

( .... Concepts III Plarma<ology

" ' Chapter REVIEW

ljt)
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.

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.

CRITICAL THINKING QUESTIONS

1. What is the difference between therapeuti' and pharma -

S. A nurse is preparing to giYI! a patient mediutions and

cologic classifications! Identify the following classifications as therapeutic or pharmacologic: beta-adrenergic

blocker, oral contraceptive, laxative, folic acid antagonist,
and antianginal agent.

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.

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?

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EXPLORE

~'-----,

M)"f'llrsir1g1(it is )WI one stop kr online ctlapter I!-.lew materialS and

="'"

",so"ce.. I'f~,. lor

w;lh a<lditiono! IlClf)(- S1)lo p!1!Cli ""
Ques1Io!1S, Imenlctll'~ assi(rfllents a"ld BClMtfes. web links. snlmatlollil
arid ,ideos. and mael
Fl!gISIe! )'GIl" al:Ce~ OllIe !rom tn~ front oI)'D!I" bxik 11\
WWW.nlI.ll.. siRgkilclIfII .

Principles of Drug
Administration

LEARNING OUTCOMES
Aher rtoding this chQpr~ the studtnt should be! able to:

1.

DiKUSS drug administration as II component of afe,effective nursing

(Me,utllizlng the nursing process.

2.

D~rbe the role s and r6pOn sibilities of the nurse regarding drug
administration.
Explain how the five rights of drug administration affect patient safety.
Giw- 5peciflC examples ofhow the nurse can increase patient
complian ce In taking mediclliions.
Inte rpret drug orders that contain a bbreviations.
Compare and contrast the three systems of meawrelTlE'fll used in

3.
4.
5.
6.

phanTIacology.
7. Explain the proper methods of adminh lering enteral, topical, and

parenteral drugs.
8. Compare lind contra st the advantages and disadvllnU!ges of each route
of drug administration.

KEY TERMS
aI~lUctio.

/l4}tla

~is ptl/}t18

apolhwryS)'Slfill {Id'JIll

ASAPortier JXII}tlO
~U~t dff(( pogt 15
buuaI route {II19t 2J
aKIIpIiilD(t p:1qt19
tnlenlroute

ptlJtll

tnlmuoatrd {II1IJtll

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fj", rights of drug .dminiltr.Jlion

houwhold systftJI pogt 11

inllldtrm3l(lD) 1XJ9t}8
inlrilllUKUIarIlM) pogt}9
inlrll'ltfl(lus(1Y)
meb'K l~ttm"heUurtrnHl
parflllHalroutt ptl9t 18
PRNorder pillJtlO

P'9t 19

roolm ordfl'S 1XJ9t lO

mgif order fJIIV lO

slandi ngorder ptl9tlO
ST'" ",der fXI}t 10

,.J'

subnrlalleOUl fJIIV 18
ptl9tll

sublingualro~le ptl9tl]

IlIIIiiMdrelease pogt ll
thrft dlKks of chg lIdministratiol

f'JI}t 19

18

UnK I Co<e COO(ept< III Ph.,macology

he primary role of the nurse in d rug 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 nurs ing 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 n urse 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
iln1g~ ~nil thi! prlli!nti~l COMi!qlli!nC~_~ 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 pharmacotherapeutics to clinical practice. Some adverse effects, however,
are not preventable. It is vital that the nurse be prepared

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PHARMFACTS

Potentially Fatal Drug Reactions

Toxic Epidermal Necrolysis (TENI

H~ ,nd ~adly drug~mb:~d ,Ut"l ic: ~action

Charamrizrd II)' widesp~ad epid!11l1i11 sloughing, WIled by mm~
dilinl~gration ofkemiOOC)'les
Sevm tpmrmal dtU{hment irrroiYing thetop ~r oftht skin and
mIKGm m~mbranes
Muhil~rm o"lan invo/wmt nt and ~'Ih iltht ~adion il 001
~(lIgnired 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,
urba~nr (lrg~to~), tht ,mibiotic: trimelhoprirnlsuNamtthowolf
(Bactrim, Seplral, and other dru~ but a nOffill with tht lilt of any
prtsaiption or OK ~pa"tion. in{krding ibuprofen (AdYil Motrin)
Risk of dNth ~(ft'a\f"S ifth~ offending drug ilquidly withdrawn and
SUpportN~ u~ 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 w~hin 1to 14 days of ph,rmacotherap)'
Start ofSJS usually signaled II)' nonspKiIK upp!1 ~pi"lory inre.:tion
(URI) with dlills, frftr"nd m,laise
Gen~ralired blinmiM, Itsions follow within a fN days
Skin !laughing of 10% ofth~ 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 allergic 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 product, it is the nurse's responsibility to alert all pecsotulel by
docwnenting theallergy in the medical record and byappropriately labeling patient records and the medication administration 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 pharmacist so the medication regimen can be evaluated for
cross -sensitivity among various pharmacologic products.
Anaphyluis is a severe type of allergic reaction that involves the massive, systemic release of histamine and other
chemical mediators of inflammation that can lead to lifethreatening shock. Symptoms such as acute dyspnea and
the sudden appearance of hypotension or tachycardia following drug administration are indicative of anaphylaxis,
which must receive immediate treatment. The pharmacotherapy of allergic reactions and anaphylaxis is covered
in chapters 38 and 2900, respectively.

01",1<,1

3.2 The Rights of Drug

Administration
The traditional f~ rights of drug administration form the operational 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, depending on particular academic curricula or agency policies. 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 conjunction with the five rights help to ensure patien t safety
and drug effectiveness. Traditionally these checks incorporate 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 multidisciplinary endeavors. Responsibility for accurate drug administration 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. Factors 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 pharmacology, comp~an{! is taking a medication in the manner
prescribed by the health care provider, or in the case ofOTC

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Pr1ndpl ... ofONgAdmlnlmatlon

19

A VO IDIN G M EDICATIO N E RRORS

Tht FDA "Id !hi- Amt riun Hospital k soc:iation Ir.Kk drug emlB thu occu, in
hNkh {.I~Sf1tings. 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 diag~ 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' nu~
.slll' or sill' ~'fl'slO .dministtr!hl- mtdiutions)
ikuUIf the nufW is often the final he.lth ClIlf pmr~ 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 noncompliance 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 remember 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 information that the p.1tient must know regarding the prescribed 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 ~i.l
knowltdgt .nd tfChn;que. The flJBe must h....!' knowltdgt 01 growth ,nd
~Iopmtnl patteffll. Whf n possibit, till' child lhould bt giffl <I (hoic:f fl'garding W UIt of. spoon, droppt~ or syrill9f. A m.llfl-of-fllct Mlitude
should bf pfl'lfnltd in giving. child rntdit.tions: Using th~au ordisOOntll)'
is unacctp"ble. 0,<11 rntditations that must lit aW.td for t~ dlildto IW~~
low can bf mill'd with ILIYofl'd syrup,jflly,or fruit pu~ 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<lYdmlop
.n unpleas.Jnl asIQ(ialion with tIII'!t iterm.nd 'thMlO(onlUme IIII'm in t~
lulUfl'. To pll'\'l'llt naUlt<l, rntdications c<ln bf p~eded .nd followed with sij)l
of <I wbonattd bt>imgt th" is poured 0Yff aushtd itt.

20

linK I Core Con~1S III Pho,moc:ology

associaled side effects, ~nd pott'lltial interacliollS with other

medica tioos, foods, herba l supplements, or alcohol. Pat ients
need to be rem inded that they share an active role in ensu ring their own Illedic~tion effe<:tiveness and safery.
Many factors can inllut'llu whether patients romply with
pharma'Olhl'ra py. The drus may be 100 e:rpfflsive or may
no t be approved by the patient's health insur:r.nce plan. P.dtients sometimes forget doses of medications, espteiall y
when they must be taken three or four times per day. Patients often discontinue the use of drugs that have annoying
side effects or those that impair major lifestyle chokes. Adverse effects that often prompt nonrompliance ue
headache, diuiness, naus.ea, diarrhea, or impotence.
Patients oflen Illke medi ca tions in an un expected manner, somerimes self-adjusting their doses. Some pat ients believe 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 noncompliance to the nu rse for fear of being Il'prim;J.nded or
feeling embarr<tssed. Because the reasons for noncompliance are many and varied, the nurse must be vigilant in
questioning p3tients about their medications. \\fhen pharmacotherapy fails to produce the expected outcomes, noncompliance should be considered a possible t'}lpJanalion.

3.4 Drug Orders and Time Schedules

Health care providers use accepted abbreviations to rommunKate the directions and times for drug administr.ation.
Table 3.1 lists common abbrevia tions that relate to universally sched uled times.
A HAT onItr refers to any medication that is needed immediately, and is to be given only once. [t is ofun associated with emergency medications that are needed for
Iife.threatening si tuations. The term STAT comes from
statim, the latin word meaning ~ immediately.~ The phys ician normally notifies the nurse of any STAT order so it

_....TA8lf 3.1

Drug Admlillstration Abbn!viations

Meaning

..~-

...

.......

up

u p!U1e

'"

...

~~

horhr

"
"
"'
00

PM

PRH

i6 dtsimllilSlllfard

twiceperlWy

'mp

.
.......

mtrilmUKUlar
~

lilt\' mNIi; lilt\' HliIg

~_h

~-

"1Im~~

"

(W, rime per IWy

q2h

emy 1 hoo.n (r'ltn ",whtn firll gWen)

,Ih

MI)' 4 hoo.n

q6h

MIl6hoo.n(t'ltn)

..

,,~

....

SW

[r'ltn)

MIl' hoo.n (fYtII)

...

Ml)'llholn

1nrneIia1tlr, .. ona

.-

thmti'nts prr IIiJ

nw, InIlitUlr r", Safr Mtdul ~es 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 lIIt'n~Uy";qod:lnIlNd u~"emy other day:For
o1htr rommrndllions, 1ft the otIidil Joint Corrmissioo"Do Not Ust li5f:

P HARMFACTS

GrapefruitJuice and Drug Interactions

Grlprfnit;..ice II\iJ no! be SIR b peopIrwho IiR (fruin lIIfdiutiom.
(~(most liktlylllronoids) in!jIJprfnit juiu kIwPr me.-iYity of
SjIfdr: ~ in Ittt inmIiwI t~ WI ramttiIy Imkdown
IMIiutions. This iIows I J.~ imount of mrdic.Jtion to ~ tht
bIoocIs~Im.1t1U1ting 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 intihilumints 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 mibth~1 (JIo!icor).
Glilprfnit;..ice IMuldbe~ .. 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 ~of medrN. (he(k me
~W>eI.

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ca n be obtai ned from th e pharmacy and administered immediately. 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 wrill~n o rdn.
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
d~r (Latin: pro re IIOrD ) is ad ministered 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 ~s STAT, ASAP, NOW, or
PRN are called routint 0Idtn.. These are usually carried OUI
within 2 hours of the time the o rder is written by the physi_
cian. A ~0I'dft 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 o f postoperative PRN pre_
scriptions that art written for all patienl5 who have

"'... l<r3 Prlndple<oION9Admlnlnr. tIon

undergone a specific surgical procedure. A common standing order for patients who have had a tonsillectomy is
~Tylenol 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, usually at least every 7 days. Prescriptions for narcotics and
other scheduled drugs are often automatically discontinued after 72 hours, unless specifically reordered by the
phpician. Automatic ~top 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 system drugs and antihypertell'iives are best administered at
bedtime, because they may cause drowsiness. Sildenafil (Viagra) 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 correctlydocwnem 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 refused or omitted, this fact must be recorded on the appropriate 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.

use the metric system, these older systems are still encountered. In 2005, the Joint Commission (JCAHO), the accrediting organization for health care agencies, added
"apothecary units" to its official "Do Not Use" list. But because not all health care agencies are accredited by JCAHO
and until the metric system totally replaces the other systems, 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 approximately 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, cylindrical spoons, and medication cups. These are preferred over
the traditional household measuring spoon because they
are more accurate. Eating utensils that are commonly referred 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, tablespoons, and "salt spoons,n it is recommended that a
measuring spoon used for cooking be used rather than

Metric, Apothecary, and Household

Approximate Measurement
Equivalents

. .I

Hou~hold

Metrlc

Apothl!Glry

1.1

lS- 16milims

lH6drops

4-SmL

1 Hliddram

1 INSpoon Of 60 ttops

3.S Systems of Measurement

lH6mL

4nliddrams

Dosages are labeled and dispensed according to their weight

or volume. Three systems of measurement are used in pharmacology: 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 centimeter (cc) is a measurement of volume that is equivalent to I
mL of fluid, but the c( abbreviation is no longer used because it can be mistaken for the abbreviation for unit (u)
aud <.~...., l1l~die~liuJJ "Trurs. Th" mdrie w"ijjht uf ~ drug i,
stated in kilogralIl.'i (kg), grams (g), milligrams (mg),or microgralIl.'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

lO-11mL

8 Hlid dramsor 1ftuid O:JII(~

2tablrlpoons

240-250mL

8 Hlid (Ilms 1112 pin)

19lalSOfCl4l

SOI.I

1 pint

2gLtsItSOf 1 rups

Il

31 Hlid Olme Of 1 quirt

4 gLtsItS Of 4(UP! Of

I.,

1/6Ograin

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21

1tabirlpOOll Of

l-4twpoOlls

60-64.,

1 grain

300-1151119

Sgrains

I,
I.

"-

15- 16grails

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.

22

UnK 1

CDf~ 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 before 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 per~on 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 ~ntera l 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-

LibraryPirate

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" b"~aus,, uf tl, .. iT .... St" uf us ... i" SUIll" ~""""" tabId, lllay

be scored for more individualized dosing.

Some patients, particularly children, have difficulty swallowing 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 capsules unless the manufacturer specifically states this is permissible. Some drugs are inactivated by crushing or
opening, whereas others severely irritate the stomach mucosa 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 entrri(-<oat~d tablets are designed to dissolve in the al kaline enviromnent of the ~maJl 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 dedines 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.
S u sta in ~dreleilSe 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 (S R) medications, these forms allow 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 disadvantages. The patient must be conscious and able to swallow 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.

01",1<,1 Pr1ndpl ... ofON9Admlnl",atlon

TABlElJ I Enteral Drug Administration

Drug Form

A.

titblt~capsul~orliquid

...

Administration Guidelines
I. MIffi that paliffit is alffi aod Iu sibility to swalloloi.

1.

23

Plac:~ titbltlS or tlpsU~s into mfdication G4l

1 IUquid, shakr I~ bOIl~ to mil ~ i9ffi~iod mmul! tht dw illo ~ rup 011 ~ ~\'!"I.

s.

- 8.

,
lUblinqual

llaod tht patimt I~ rtII'diulion rup .

otm i ~asl 01 wattr to la(~ilat~ lwalowing tfNo mfdK.Jtion. Mi. or juic:~ nwy ~ oifmodil oot (ontraiodicatm
Rmlaiow~h patienl !Ilt~a l

mftkatioo isswalowtd.

I. MIffi thit patiffit iSaiffi aod luI ibilityto hold ~~oo !lldft"tonqut.

1.

Plac:~

sublinguallabltlllldtftooglll'.

1 10ItrIKI patim: oot 10 dItw or swillow tilt tlbltl, or ~ ~ tabltl around with tooglIt.

0-

IlIItrIIu p.lti~JJI to aHow titl!let to 1il\OM {Omplcte~ bcfort lWillowing wlil'a .

s.

Rmlaio w~h palienl to dumriot that oil ~ mfdK.Jlion Iu I dil5Olvfd.

Offer i ~Iolwattr;ilpalienl d6i1!1.

I.

M~U that patiffit isal~rI aod lui abilityto hold ~~oo btI'IIftO Iiii' I1Jms aod tfNo dltrl.

1. Plac:t bucullibltt btI'IIftO Iiii' I1Jm lint ald ~ dIt6.

1 10lIruc\ pati~nt oot 10 dItw or swallow I~ titblt~ or ~ ~ tabltl around with tooglIt.

.. 1011100
s.

,
D.

na~stric:iodga5l1ollOmy

pati~nt 10 alow titbltt 10 dslOMo aHIlpluely

Rmlaiow~h paliffil toduemiot thatal

bcfort lwalowing wwa .

oltfNo mfdication lui dis5Olvfd.

otm i ~uolwattl;ilpali~nl !itsill'l.

I. Adrrioist liquid forms wIIfII (mliblt to il'(ljd dogging till' I~.

1. If 1Oid.<rIIIh find, inlo powdtr and mix thoroughly with allml30 mLofWilnn wal~ !Il~1 dislOl"lfd.
1 M~llald vffify lUbe pIi(emtOt.

s.

,
,.

TlI1I offlft'ding. ff appicabl~ 10 palient .

Mpilat~ SiomKil (ootmll iod meillR I~ r~dual volurtll'. Hgruttr than 100 mLlor in adJlt,dIKk igl'M' policy.
Rttum rtsiduallii gram, aodflUlh with water.
fOIl" m~tIon loto syrtIrJe tlant! aod illowto ftowloto III! lID' bygral'lly.GIw 00 IIlI'dkalloo ~ralety,lmhIng
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 ~t aspira~oo .

SUBLINGUAL AND BUCCAL DRUG

ADMINISTRATION
For sublingual and buccal administration, the tablet is not
swallowed but kept in the mouth. The mucosa of the oral
cavity contains a rich blood supply that provides an excellent absorptive sumce for certain drugs. Medications given
by this route are not subjected to destructive digestive enzymes, 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 the rich
blood supply in this region, the sublingual route results in a
rapid onset of action. Sublingual dosage forms are most often formulated as rapidly disintegrating tablets or as soft
gelatin capsules filled with liquid drug.
When multiple drugs have been ordered, the sublingual
preparations sh ould be administered after oral medications
have been swallowed. The patient should be instructed not

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to move the drug with the tongue, nor to eat or drink anything until the medication has completely dissolved. The
sublingual mucosa is not suitable for extended-release formulations because it is a relatively small area and is constantly 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.
To administer by the buccal rout~, 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 sublingual area, where it would be more rapidly absorbed, or to
the back of the throat, where it could be swallowed. The buccal 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 sustainedrelease delivery because o f the greater mucosal surface area
of the former. Drugs formulated for buccal administration

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 metabolism 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

m~ha

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 longterm care. Drugs administered through these tubes are usually 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 administered 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 guidelines 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, respirato r y tract,
urinary tract, vagina, and rectum. These applications include 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.

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TREATING THE DIVERSE PATIENT

Religious Fasting and Compliance

with MlKlication Administration
Pftgiws fallilg periods; a~ 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 authoritits may aIow the taking of I!qJRd medirniJns daing the fiS~ but drptndilg on tilt ~timt's 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 obserRMf of futing pffl:>ds with tht ~tifnt. tilt rU"II' un Bpkne opportun~ to
deYrIop suatf9its with tilt ~timt 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 fu~ mhtr than an
M'I)' 6 hw- dole). Kthe patifnt is unable to romp!)' with medUiiJn administration rbi19 futing pfflxIs dut to l!iilioui beim, the pmuibing lItalth {a~
prOOirr shluldal50 beootifitd.

_ Inhalations: Drugs applied to the rcspi .... toryt .... ct by

inhalers, nebulizers, o r 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. Antineo p lastic agt'nts may be irtstilled into
the urinary bladder via catheter to treat tumors of the bladdt'r mucosa. Corticosteroids are spr~d 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-

01",1<,3

Prlndple<oION9Admlnlnr. tIon

25

..;;,9,

~1w.

,
(.)

(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 fiiKarfooJPHco/~.

sorbed very slowly, and amounts reaching the general circulation 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-

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 a~idental injury to the eye during administration.
For the young child, demonstrating the procedure using a
doU facilitates cooperation and decreases anxiety.

ple, a nitroglycerin patch is applied to th e skin not to treat a

local skin condition but to treat a systemic condition, coronary artery disease. Likewise, prochlorperazine (Compazine) 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 effects and those given for systemic effects is an importantone
for the nurse. In the case of local drugs, absorption is undesirable and may cause side effects. For systemic drugs, absorption is essential for the therapeutic action of the drug.
With either type of topical agent, drugs should not be applied to abraded or denuded skin, unless directed to do so.

The otic route is used to treat local conditions of the ear, indud.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 administering otic medications.

TRANSDERMAL DELIVERY SYSTEM

NASAL ADMINISTRATION

The use of traIl'idennal patches provides an effective means of

delivering certain medications. Examples include nitroglycerin for angina pectoris and scopolamin e (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 regular basis, using a site romtion routine, which should be documented 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 bypassdigestiw enzymes. Table 3.4 (section A} and ~ Figure 32 illustrate the major points oftraIl'idennal drug delivery.

The nasal route is used for both local and systemic drug administration. The nasal mucosa provides an exceUent absorptive surface for certain medications. Advantages of this
route include ease of use and avoidance of the first -pass effect and digestive enzymes. Nasal spray formulations of corticosteroids have revolutionized the treatment of allergic
rhinitis owing to their high safety margin when administered 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 common. 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 sinusesare being treated. The same holds true for treatment of

OPHTHALMIC ADMINISTRATION
The ophthalmic route is used to treat local conditions of the
~ and surrounding structures. Common indications include 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-

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OTIC ADMINISTRATION

26

Unft 1

Core ConeoplS In Phorm..colagy

TABLE 3.4 111 Topical Drug Admrnlstratlon

Drug Form
A. trlnlodtfraal

AdmlnlstraUon Guldeilnl!'l

I. Obtain tlitll6tn"lWl patd\, MId rt~ rtIm/I.([,-,tr'sguldtliM1.. AppIicJtion ~It! ,,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 ~dI.,mdunlt iru.
4. u~ng .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 ~pef to dr.... dry,.r.;IlwiIIfM skin.

,. ROWt ~1rS II prMIII.!tin iIrir.tion.

7.
B. ophlhi1n:

1.a~~dtwithd.ttt,lirH,illdlniti~!..

1. Instruct pHimI to lit l4Ift1ll iii with hud 1i91l~ tiftd bad..

Z. With nondoIIinant hind.lMllowtf lld down ~nt~ 10 expose me COft;,Mjy.1 ~autingJ 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 th~ 1lIIY M1Wle thf blQtftflex.
5. InRil preaibrd numbft"eI drDpS Inlo the emt!"! oflllt pocRt. A"IOiII tllUdlilg ~III eonjlJlctiYal SlCwith tip ol~.
,. Wapplying lintmmt apPJ. thillile ohimm!"!l1 f'leNy"'9 infl!1 ~ of Iowtr lid rnM9i1. film ~ to l1',li(1' QflthIJl,.

1. Instruct lilt ~ti!11t todolf ~ g!1ltty. ~ gtnIlt prtSSlft with firIge!" to the ~111Kt 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 t~. f!JlIovt enss fM1Ikation IIOI.Ild eyt.

,.

C.

~k

RtpOOlRpper.DoIKII~~dropper..

1. Instruct patitnl to lit on sick 0110 ~I with he.d ti~rd so tIIIl.fftctrd NO" is l.ti:Ig up.
Z. ntc~ dun 1he 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
(,I~I dwilg Ihe

Instl!;jtionllthe ~

l. Hold drawer 114indt KIo"totNr til\il,iII'Id Instill pmuIlfd n!l"nbtfof dropIlnto theWif oflhe t.. Q~ 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 OIdereI1~k...mh ~ion ind inIrn _irtolttt ....tmIOst pin rJ ~iI ~~I .
1.
D.

naSiI~

WPt lIrf Wlkrtiort that rfIIJMt liipped from theNr eN with. tInue.

1. All: thl piliem toblow the IIOIt to (y ~SaI pisligfl..

Z. Draw

1(1'.

mntc1 ~Ok.fIII' of

mug imo drowtr.

l Instruct Iht pitirnt IOqlfII iIId br!atht tIwoogh 1ht IHlIlIL

4. HoIdlhe tip of!he drqlp just i~ IIw IIOIri.ind Mhout ,mini tile IIOIt willi the ~ dirf<1 ,lie soknion literaly tllWild Iht
midilll'lIlIIt supm.:.- mndII ofltt~ 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 5moutt!..

'- DiIcMd.., mnaining DUn that nin 1ht chlppet

E.

R9~1

1. Instruct Iht patirnt 10 _

i supilll' poIition with trim brnt~d stpamtd

L Plm _-dJbIt hDianI: into m~ alp.

l

AppIy~OjIffi~ay.ndl!iri:alt1htllllJlldtdrnd.

4. ElpOIt 1ht ,a.j~1 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..
'- KUlingi 1MI".,ltj.or 1o.I"g!1l~Y il5fI1 ijlpIic.Jt0l5 CIII.1onij the postfrior~a.j~ Win.nd sicM1ypus/llhe pI\IIqff urtil ffIIplJ.
Rtm~ tIw applicator and pIar;r on i pipft" tClll'd.
1. o\sk the pilimt tol_ ~ and f(l'Nin IJDJ iI the ~ III ~po!iTion lor 5-10 minutn foIowing instnian.

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01",1<,1

TABLE3.4

Pr1ndpl ... ofON9Admlnl",.tlon

27

Topical Drug Administration (Contlnutdj

Drug Form

F. rMilsuppWrOOts

Idmlnlstratlon Guidelines
1. InSIrUCI tilt palimt 10 lie on 1m ~de (Sims'po~Iioo).
2. Apply glove;opm 5Uppos~ory and lubriutt I~ bhlll mI.Suppositorifs afl' de~ for tilt rouoded ffid to be f~ng out, toum Itss
pr~SUfl' on t~ inlM\al All ljtlindrr,l~r~ dl'U~~9 tilt palitn~s ~ to push iI OUI.
3.

LWrKaI~ I~ ~omI fOfl'fingrr of Ihr dominaniliand with walrrsoIubil' l!briunt

.. Inform tIM! pa~enl..men lhe stppOIilory iSlo be illll'fll'd;irrstnKt tIM! pa~eIt to take ~ow,deep bmJths ~nd deep~ email! wring
inlffiion, to rriix Ih~ anal5phinctrr.
s. Gtnlly inll'rt tilt IWiYttd mI II supp&Silory into tilt fl'{\lIr\ be)'Ond th~ anal- rMaI ridljl' 10l'rllllfl' rl'r~ntion.
6.

InSlrUClt~

patient 10 fl'main in lilt Sim(p&Sition or lie supilM' to prMnt 9poJsion of~ II.ppOsilory.

7. InSIrUCI tilt patimt 10 fl'tlin tilt supposiroryfor . ,Iull 30 minut~ toalow absorption tOO((\I",1II1ts111it llppJIiIory iladmirillefl'd
to lIimlbtt dtfKilion.

-I'I ,-_~_J
.. Flgure.3J (3) Inl\llilng an ~e ointment
Source: 0 JennyTllomas Phorography.

Ib(
Into the lowerconjun(\lval sac;(b) pressing on the nasolacrimal duct

the eustachian tube. Table 3.4 (section D) and .. Figure 3.5 illustrateimportant facts related to nasal drug administration.

VAGINAL ADMINISTRATION

,.. Flgure J.4 Instlilingeardrops

Source: 0 EJena D:xlioon.

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The vaginal route is used to deliver medications for treating 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 instruct the patient to em pty her bladder, to lessen both the
discomfort during treatment and the possibility of irritating or injuring the vaginal lining. The patient should be offered a perineal pad following administration. Table 3.4
(section E) and ,.. Figure 3.6 (a) and (b) provide guidelines
regarding vaginal drug administration.

28

Unft 1 (o<e Concepl5

In PtmmKology

(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 expected to identify and use appropriate materiai.s for p.a r.
enteral drug delivery, includ ing specialized equip ment and
techniques innllved in the prep.aration and adm inistrat ion
of injectable product!;. The nurse must know the correct
anatomical locations for parenteral administration, and
safe~ procedures regarding hal<lrdous equipment disposal.

INTRADERMAL AND SUBCUTANEOUS

ADMINISTRATION
~ F/gIK~ 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 delin'ring drugs to patients who ate comatose or who are experiencing nausea and vomiting. Rectal drugs are normally
in suppository form. although a few laxatives and diagnos.
tic agents are giv~>fI 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 bywGyofth~ liv",";
thus, the first-pass effect is avoided, as are the digestive enzymes of the upper Cl tract. Table ).4 (Stion F) gives selected details regarding rect;ll drug administration.

3.8 Parenteral Drug Administration

Parenteral administration refers to the dispensing of medications by routes other than oral or topical. The pamllffal
routt delivers drugs via;l needle into the skin byers, subcutaneous tissue, muscles,or veins. More advanced parenteral
delivery includes administration in to arteries, body cavities

'"

Injection into the skin deliven druS' to the blood vessels

thai supply the various layen of the skin. DruS' m~y be injected 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. Di~dv3ntages 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 b lood
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 int~er.
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 ~re

,. Flgur~ 1.6 VaglMI drug admlnlsll~tlon:(~} Instilling a V3gtnal supposltory;(b) using an applkiltorto Insnna viglrlal (ream

Sourer. ProfV.X!fducotJorVPH College.

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OI ...lfrJ PrtndpiesoiONgAdmtnlnratlon

29

10"_15

Epjderm..

....

Subcutaneous

,.,

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 following:
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 absorption, 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 injections, it is usually not necessary to aspirate prior to the injection. It depends upon what is being injected, and the
patient's anatomy. Aspiration might prevent inadvt'rtent ad-

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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 insulins should not be given IV; therefore, aspiration is justified. Heparin, on the other hand, can be safely administered
IV, and so aspiration is not required. Note that tuberculinsyringes and insulin syringes are not intt'rchangeable, so the
nurse should not substitute one for the other. Table 3.5 (section B) and ~ Figure 3.8 include important information regarding subcutaneous drug administration.

INTRAMUSCULAR ADMINISTRATION
An intramuscular (1M) injection delivers medication into specific 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 subcutaneous 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 deltoid 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

10

UnK I

(Of" (""(epl:<

10 Pho,ma<:ology

ABLE 3J I Parenteral Drug Administration

Drug Form

A.

Administration Guidelines

inIOOmnaIrOUl~

I. Prtpal! mtdi<lllion in J luberwin or l mL IYrinljt with J prultadItd 16- to 17~UIjt,3/8 to Sl$.indJ 1IffiI1I'.
1. Appy gllI'I~ ard dUII\e injKIion sit~ wilh antiltplic swab il , arrulilr malion. Allow 10 ai dJ.
1. With tho ,n:! indufingtrofllOlllbninanl hand, sprNd lkin taut
4. illffi n~.l'ith bel'ri fuilg upwa!d.al all9l1'of 10- 15".
urtil rntir~ beI'ri isunder mn; donol ,spi"alt.

S.

Advil:U~ n~

6.

Slowly injKI rmi<a1ion 10 form !mil wlltal or bltb.

7. Withdraw ~ quidl):and pat 5it~ grntlywirh 51ffill' 1 x 1 ~UlI' pad. Do noI mmagl'all'i.
8. il5lnrcl I~ pati~nt noI to lID or !ratd! t~aru

9. Drawcirdt a'OIInd perimeterofinjKtion !it~.R~ad in 48 to 72 hoIn.

1. Prtp.lll' IlriGliion in J I-to lillL Iyringt ~RIJ J 23- to ZS--gauqc, In-to Sf8.i1Kh nmIlr.For ~rjn.1hr
lI'(ommrndl'd nffilt is 1/8 jndJ and 2S-26~UIjt.
1.

Choo~ W, Jl':idog ill'as of bony prorrioerKl', major ntr'II'~ Jnd ~ood I'I'slfk. For IItparin, dIW: with agmcy
policy fortht ptfrrrtd injKtion !itrs.

1. Chk prt'Iiousroution !it~Jnd sdffi a nfW all'a for injKtion.

4. Appy gllI'I~ ifd ~all\e jnjKIion sir~ with antiltplic swab il , drrulilr malion.
S..... owto JirdJ.
6. BIIlth t~ 5kin ilttWferl th!ll1b~d jndex finger of nondorrifUnt hand or spr~ad tM fftllt,~jl !ltIstJntial
5lbrutantOUl tis~.

7. illffi n~ at 4,'or 90' i oglultprndiog 00 bocIy ~lr:9O' ff obeIr;45" ff i"ltr~ wright Ktht pa~trt ~ '/try thin.
gather 5kin at ilU of nffill' jfllfflion and idminilttr at 90' ~gI~.
8. For nonheparilin"rtion~aspirate 111 Jlliiog bad: on plungtr. Wblood i~n, withd,aw t~ 1IffiIt,liKaro tht
~~d PffPi'~ J new jnjtaion.for htparin, 00 not aspirat~il th~ un dilmaqe SlI"KIIIUlinq tillUtland (jIM
tnri~og.

9.

iljtam~imion!lowly.

10. Remol'l' nttd~ quidd~and grntly malQljt !it~ w~h amis~plkswab. For htpiril,oo noIlIIiISIigt th~ sit~,asltis
may G1U\1' bnisilg or ~ffiliog.

-----4-( intramUICWr rout~"/erllrt9U1NI

{difftortrlt admiri mition guidelillfl
-':I apply lotht dooogk/lul,
vaSlU! IiIleralil,and delloid
musdt sir~)

1. Prtpal! mtdi<lllion uling i 10-to 11-9ilUljt,1-IO 15indJ f"ftIIt.

1. App, gllI'I~ ard ~all\e I'I'nIrt9ulul injKIioo ~I~ with antiltplic !Wib in a mular mon. Allow to af dJ.

1.

loc.Jl~ site 111 JUdng tilt handwirh I"ftI on I~ grutertnKhanler Jnd thlll1b ItrIIIJrd urrbikus.Poinl totlltanlerior"
iii(!pilll' withtllt indufinger, sprridilg th~ m~ fingerto pointtoward I~ ilii( Ues! {formingJ V).lnjKI
mtrka~onwhn tlltY-!hiptd al!a oftlw induand Itirdfinger.(NoI~:TM ~ how to Iwte I~ventrogk/l~il sit~.)

4. illffi nffilt with smooth,dilrtlike!1lOl'l'llltrltata 90' JogI~ wirhin Vshaptdarra.

5. ,l.spirate. Jndttlerw br bIood.HIHIod iPpUn,witlltawllR nffiIIo.dm tIw I)'riflljt.and pr~ i ntWinjKtion.
6. iljta m~Kition !lowly ,ndwith smooth, ~1'I'n prtSllR on tilt plungtr.
7. P.trno\'I' lIffiI~ quidd,.
8. Appy pr~lIRto lilt with i dry, ster'it 2 x 2 gauzt Jnd IlliISiIjt viqJrously toUl'iI~ warmth and promoI~
abIorpIion of te m~Kition into tilt musdt.
1. Toarkldrugto.nlVftlidumtailN'l:

a. Verify ordtrand (ompatibil~yofdrug with IV Hlid.

b.

~fl' rrriwion ina,- to 2O-mL syrilljt uling J

I-to I.Hndl. 19-10 21~UIjt III'~II'. {Typiully in an ildull.a

may ViryWith t~ patitnl's body silr ilnd tIw l!a5Oll

11~UIjt ~~ i! UII'd for Hlid iltniniltration,but tIw ~If

for IV admiristration.j
(. Apply glon, Jnd 'SItlS injtaion !it~ for ligfll and symptoms ofinllammation or 9tranlOtion.

pori on IV tkJid (ontailN'l ~d ~all\e with antiltptic: swilb.

d.

loc.Jl~ m~j{jtion

~.

(.urfUly in!ffi III'~~ or i(ms dtW~ inlo port and injKl mtdiution.
Wtthdraw 1N'fd~ and mix!Olution by routing (OIluintr!"lld 10 rnd.

g. H'ng(QIluiItr and dIM inflllion rit~.

----'----"---

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0I ...l<r1

Pr1ndpl ... ofON9Admlnl",.tlon

31

2. Toadd aug 10 an IVbolus 11'.1 pYIh) uling aistilg IV iotor IV Iod: Irt'~il):
i . 'krify unltr and tompatibilily ofdlllC) with IV ftuid.
b. DnrrmiottM: torrt'd rat~ ofioflllion.
Co

Dnermint ff IVfl!ithil! infilling it proptr rail' 11'.1 lint) and IhilllI! YI~ ~adtqJal~.

d.

Prepar~ 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 YI~ IIV b~).

9-

a~n~ tubing or Iod: pori withartilrptit IWaband ilM1 ~dI~ inlo pori.

h. Hadmiri >lffiog mtdititioo IhltlUljh 010 9isIing IV lint, otdlJll!, titling by pinching just i~ lilt iljKlioo port.
SIoII'Iy iojKt mtllic.Jtion!l'm dt5i9:laltll tim~ U\Ui11y 001 fi>ltr tllan 1 mUmin, unlm Iptdfm

j. WiIhdr.w !)'!iogt. R tlu~ tubing.nd mill!! proprr IV infuyoo if lIIDj.o 9istilg IV ~1It.
l

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 regarding 1M injections is given in Table 3.5 and ~ Figu re 3.9.
The four conunon sites for intramuscular injections are as
follows:

Epidermis

0."..

.-

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.

\'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/PH CoI/eg{'.

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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, "'~~"l'( [ur SIll~ll-vuJUIll"
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 directly 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 d igestive
system and the first-pass effect of the liver. The three basic
types of IV administration are as follows:
l nt rm~nous

1. Large-volume infusion: This type of IV administration

is for fluid maintenance, replacement, or

Epidef ",, ~

0"'''''5

.,.

J
jj

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 d angerous. Once injected, the medication cannot be retrieved. If the drug solution or the
needle is contaminated, pathogens have a direct route to the
hlood.tream and hodytis",,,'_<_P~tient. who ~re reciving IV
injections must be closely monitored for adverse reactions.
Some adverse reactions occur immediately after injection;

yt

''''''''""~
~ssue
Muscle

(b(

(.(

(
,. Figure l.1l Intramuscular 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.

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01 ...1<, j

'\

Prlnd pleo; 01 ON9 Admlnlnr.tIon

33

f(}

-,

\~
4

C",,"-

,,

-/

--f

-"
/

Piggyback

Primary

'"'

~,

Piggybar; k"
pri mary
w ith bac kcheck
valva

"'"

C"""'

"\,

...._---'

""""" >",'

(!

(b)
("
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.

(,' ' - - -

(b)
Figure J.12 IV bolus admlnlstratlon. (a) The part Is cleaned;
(b) the drug Is administered through the port using a needleless
syringe
~

FlgureJ.l I A Baxter Infusion pump

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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 de~r, refer to the numbered section within the ch~pter for review.
3.1

The nun;(' mll5t boaVI' a oomprehensive knowledge oflile actions and sJ de efftcts of dru~ before they are admin istered
to limit the number and st'~ityof 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..

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
measuremen t.
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, u rinary
tract, v.lgina. and rectum.

3.1

Parenteral admini$tratio n is the dispensJng of medica tions via a needle, U5ually Into the ski n I~yers ([D ), suoottaneoU5 tissue, muscles (IM), or veins (IV).

3J For pharmacologic campHance, the patient must understand and person~lly aa:ept the value aSSOCiated with the
pteS(;ribed drug regimen. Understandin g the reasons for
noncompliance nn help the nurse Increase th e SUe5S of
pharmacotht'tapy.
lA

There are established o rders and time schedules by which

medlntlons are routinely administered. Documentation
of drug administntion and reporting of side effects are
impon~nI responsibilit ies oflhe nurse.

NCLEX-RN REVIEW QUESTIONS

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.
Before adm inistering drugs by the enteral route, the nurse
should evaluate wh ich of tilt followin g!
1. Ability of the patient to lie supine
2. CompatibilityoftM drug with IV fluid
J. Abilityofthepatien.ttoswaDow
4. PAtency of the injection pon
Which o f the following is the highest nursing priority
when a patient has an allergic reaction to a newly prescribed medication?
I . illSlruct the p~tient 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
The order reads, ~Lasix 40 mg IV STAT.~ Which of the fol lowing actions should the nurse take!
I . Administer the medication ",ithin 30 minutes of the
0"",_

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2. Administer the IDl'dication within 5 minutes of the

0"",_

3, Administer the medication as required by the p~tlent's

oondition.
4. Assess thepatient'surinaryOOlput prior to
administration and hold medication If output is less
than 3OmUh.
Whlchoft he following med ications would not be administered through a nasogastrk tube! (Select aU that apply. )
I . liquids
2, Enteric-coa ted tablets
J. Sustained-release tablets
4. Finely crushed tablets
5. IV medications
A diabelk patient has been NPO since midnight for surgery in the morning. He usually takes an oral hypo glycem ic drug to control his diabetes. Whal would be the
action fo r the nurse to take concernin g the administration 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..

mx

OIIpltll

PrII\dplI'S of DNg Admlnlltr~tlon

lS

CRITICAL THINKING QUESTIONS

1. Why do errors continue to occur despite the fuet thalllw.>
nurse follows the five rights and three checks of drug administration!

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.

2. What strategies can the nUrliel'mpJoytoensul'l'drug com-

pllaoce for a patient who Is refusing to lake hisor her medication!

3. Compare the on], topical, 1M, subcutaneous, and tv

routes. Which has lhe fastest onset of drug action? Which

rou tes 3\'oid the he p,alic first-pass effect? Which require
strict aseptic techn ique-?

EXPLORE

fiii!iilllilln3!fir'- -----,

M'jIiu"" gKllIll ytu'

t'I!\e

SID(Ilor Q1'IIIIlI! duJ(lIer "',.... 1IIIl1lri!!:I arid

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!

mo\JfctS,

Reglibr '/WI ~ss wdIIl<\Im Ihti hilt of IW' book at

_....,., .. l>IoogkJt"""' .

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Pharmacokinetics

LEARNING OUTCOMES
After reading this chapter,

mestudent should be able to:

1.
2.
3.
4.
5.

Explain the applications of pharmacokinetics to clinical practice.

Identif)' the four components of pharmacokinetics.
Explain how substances travel across plasma membranes.
Discuss factors affecting drug absorption.
Explain the metabolism of drugs and its applications to
pharmacotherapy.
6 . Discuss how drugs are distributed throughout the body.
7 . D"~criu,, how pl,,~rn" 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.

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 paqt4 1

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enzym~ 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
loading dose Ill'll' 41
maintman(f dost patIf 41

patIf 0/0

metabolism ~o/O
minimum df~ctiW' (oncentration
pharma(okinflics ~ 11
plasmahalflife (t",) ~42
prodrug meo/O
therapeuticrange fOJI4 2
toxinon(entration patIf 41

~41

("'pI"~

PNrm;orokl .... l\n

edications are given to achieve a desirable effect. To

4.2 The Passage of Drugs

produce this effect, the drug must reach its target

Through Plasma Membranes

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 "medicine~ and kinetics, which
means "mo"ement or motion.~ 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 gastrointestinal 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 barriers 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 physiologic 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 response 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: absorption, distribution, metabolism, and excretion, as illustrated
in .. Figure 4.1.

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37

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 proteins and other molecules interspersed in the membrane.
This lipophilic membrane is relatively impermeable to large
molecules, ions, and polar molecules. These physical characteristics 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, howe~r, 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 receptors, 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, intestinal anti-infectives, and some radiologic contrast agents,
must be absorbed to produce an effect.
Absorption is the primary pharmacokinetic factor determining the length of time it takes a drug to produce its effect.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 absorbed 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

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 absorbed more quickly and have a more rapid onset of action
Ihan those given in low concenlrations. The speed of digestive 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 infmion 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 example 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 becomes 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 nonionized form in an alkaline environment; therefore, basic

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drugs are absorbed and distributed better in alkaline environments such as in the small intestine. The pH of the local 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 significantlydelayabsorption of the antibiotic. High-fat meals can
slow stomach motility significantly and delay the absorption
of oral medications taken with the meal. Dietary supplements 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 decrease intestinal transit time and reduce drug absorption
(Scott & Elmer, 2002). The nurse must be aware of drug interactions and advise patients to avoid known combinations
offoods and medications that significantlyaffect drug action.

(lIopl" !

Plllsma '" (pH" 7.4)

ASA- .. HCI

""

(nooionized)

(a) Stomach (pH " 2)

ASA .. HCO.

j
ASA(io";zed)

intestine !pH" 8)

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
(b) Small
Flgure4.2

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 th~ir target cells, because many drugs bind reversibly to plasma proteins, particularly albumin, to form drug-protein com pl~lE5.
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
on e drug displaces another from plasma proteins. The displaced medication can immediately reach high levels in the
h l ooo.tre~m ann pmnllCl' ~nve"", effect . Omz "ch~. a.._
pirin or valproates for example, displace Coumadin from
the drug- protein complex, thus raising blood levels of free
Coum~din and dramatically enhancing the risk of hemorrhage. 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 entering. These barriers are referred to as the blood-br. in barrifr and
fe1al -pla(~ntal barritr. Some medications such as sedatives,
antianxiety agents, and antioonvuisants readily cross the

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 determines 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 barriers 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 affinity, or attraction, for
certain medications. Examples of agents that are attracted to
adipose tissue are thiopental (Pentothal), diazepam (Valiwn), and lipid-soluble vitamins. Tetracycline binds to cal

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Freo

dfUII
mclecules

(.)

TI_

""~

(')
Figure

::;1'

Capillllriu

, ~ ,
,

TI_

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,,

40

.
,

UtIlI!

COffCooCeptslllPNrmoc"logy

blood-brain barrier to produce actions in the central nerw)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 .. nri~ lI y h"rmful .<uhlr:mC"-'
from ~sing from the mother's bloodstream to the felWi.
Substances s uch as alcohol, cocaine, caffeine, and certain
prescription rued ications, however, easily cross the placen tal
barrier and can potentially harm the fetus. Consequently, no
prescription medication, OTe drug, or herbal therapy
should be taken by a patient who is pregn~nt 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.

Firs11"'_
melaooism

4.5 Metabolism of Medications

M~aboIism, ~Iso called biommsformllrion, is the process of
chemicaUy converting a drug to a fonn that is usually more
easily removed from the body. Metabolism involves complex 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 reactions 3 5 they p"" through the liver, including hydrolysis, ox
idation, and reduction. During metabolism, the addition of
side chains, k oown as (lHI~te, makes drugs more water soluble and more easily excreted by the IOOneys.
Most metabolism in the liver i~ accomplished by the
hfpatkmktojomalmzylllfj~t~m. This enzyme complex is so metimes callt<! the P-450 system, named after cytochrome
P-450, which is a key component of the system. As they relate 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 molecule more a..:tive than the original For example, the na rcotic 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 pharmacologk ~ctivity unless they are first metabolized 10 their
active form by the body. Examples of prodrugs include bena:upril ( lotensin) and losartan (Cozaar).
Changes in the function of the hepatic mkrosomal enzymes can significantly affl'l:t drug metabolism. A fewdruss
have the ability to increase metabolic activity in th e liver, a
process called tRzymt induction. For example, phenobarbital
causes the liver to synthesi:u more microsom~J enzyrnl':'l. By
doing so, phenobarbital increases the ratt'of its own nlelabo ]ism, as well as that of other drug'> metabolized in tht' liver.
]n these patit'nts, higher doses of medica tion may be requirt<! to achieve the optimum tht'rapt'utic effect.
urtain patients have decreased ht>patic metabolic activity. which may alter drug action. HepatK enzyme activ ity is

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PoI,,1 vein
~

Flgure4.4 First-pass etfect:(a) drugs are absorbed;(b) drugs

enter hepatic

port~1

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 middle-~ge patients. Patients with ~vere liver
damage, such as that a used by cirrhosis, will require reductiom in drug dosage because of the decreased metabolic activity. urtain genetic disorders have been recognized in
which patienl$ lack specific meta b olic enzymes; drug
dosages in these patients must be adjusted accordingly. The
nurse should pay alreful attention to laboratory values th~t
may indicate Jiver di~ase so that doses may be adjll5ted.
Metabo]ism has a numbeTof additional therapeutic <onsequences.. AI; illustrated in ~ Figure 4.4, drugs ab50rbt<! afteroral adminiuration cross directly into the hepatic POrlal
circulation, which arries blood 10 the liVl.'r before it is distributed toother body tissues.. Thus,as blood passes through
the liver circulation, some drugs can be completely meubolized to an inactive form before they ever reach the general
circulation. This flfl\pass effect is an impo rtant 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 portan t because the concen tration of druW; in the blood-

(lIopltl4

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 th e body by numerous
organs and tissues, the primary site of e.u:retion is the kid~
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 re~
nal tubule. Mechanisms of reabsorption are the same as absorption 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
did~1 t1ln1lle of Ihe nephMn. For enm]'!le, only 10% of ~
dose of penicillin G is filtered at the glomerulus; 90% is secreted into the renal tubule. As with metabolic enzyme activity, 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 envirorunent. 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 diminished 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 kidneyfunction in patients receiving drugs that may be nephrotoxic
{low margin of safety}. The pharmacotherapy of renal failure 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 affect gas exchange, including diffusion, gas solubility, and
pulmonary blood flow. The elimination ofvolatileanesthet-

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Plaml;KOkllM'!Ic:.

41

ics following surgery is primarily dependent on respiratory

activity. The faster the breathing rate, the greater the excretion. 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 WImetabolized 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 experience when given IV drugs is an example of the secretion of
agents into the saliva. Another example of glandular excretion is the garlic smell that can be detected when standing
next to a perspiring person who has recently eaten garlic. Excretion into breast milk is of considerable importance for basic drugs such as morphine or codeine, as these can achieve
high concentrations and potentially affect the nursing infant. Nursing mothers should always check with their health
care provider before taking any prescription medication,
OTC drug, or herbal supplement. Pharmacology of the pregnant or breast-feeding patient is discussed in chapter 700.
Some dnJ~ ~r'" u.:r<':ted in Ihe hill.', ~ prorp_~~ known ~~
biliary excretion. In many cases, drugs secreted into bile will
enter the duodenum and eHmtually leave the body in the feees. However, most bile is circulated back to the liver by
~nterohepatiUl'rin:ulati:m, as illustrated in ,. Figure 4.5.A percentage of the drug may be recirculated numerous times with the
bile. Biliary reabsorption is extremely influential in prolonging the activity of cardiac glyoosides, some antibiotics, and
phenothiazines. Recirculated drugs are ultimately metabolized by the liver and excreted by the kidneys. Recirculation
and elimilliltion of drugs through biliary excretion may continue 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, btuus~ the older adull poJllllation Ll~
""'Il' drugs .imukllltOUSly (an a"'rage of 1I'1'ffi) than otht r ige grou~ and
b~uUll' of norma Idedi~ in hepatio: and Il'IlII function. (hronic di SNII'S thit
affrct ph"macokinetia 1ft' 1110 p~nt ""'ft' oft~n in older adults. In addition, older adults may not ~illbly Il'pon IMI"II' drug tifls or may [onsmotht m ~ns 01 a9in9 or of their di~ [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 <IMI"II' rifrrts ooted b)' a hukh call' provide~ 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 th~ paritnt~ Thf study aUlhor. ft'(ommend
thit h~akh [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 problem~

42

UnK 1 Co<e Concepts III Plarma<ology

BOle t.anspo.ted from !he

IMIt to the small ,ntesl,ne
by wey of the gallbladde.

BOle Mils eb50rbed aod circulated

back to lh6 li_ by wa.y 01 the
capilla.... 01 !he d;gesti .... lr8Cl

StOJTllld!

and h9patic porIal win

Smllil intestine

". 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 (Eskalith) 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 demonstrates two plasma drug levels. First is the minimum df~ctift (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 amcenlration and the toxic conct'ntration is called the therapfulic
range of the drug. These values have great clinical significance. 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 ~IT""liv~~ull<.ulr~liuu, 3llJ IiI", p~li""1
will not experience pain relief. Two or three tablets will increase the plasm a level of aspirin into the therapeutic range,
and the pain will subside. Taking sixor more tablets may result 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

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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 action is its plasma halfli~{tVl)' defined as the length of time required 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 halflife of several hours or days. The greatt'T tht' half-life, the
longer it takes a medica tion 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 pharmacokinetic variable with important clinical applications. Drugs
with relativt'ly short half-lives, such as aspirin (t,,, = 15 to
20 ",illUl.,,;) musl [..., ~v"u <: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 renal 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.

(lIopltl4

"

43

T""

___ .c ~~~_Ii:"!'_

I::,

Thenlp8Ulic
,n,'II"

!,
~
" ,
~
< ,
,

Plaml;KOkllM'!Ic:.

- - Ci.tJ~,;.--

Dum!"", 01 action

.-,
TMIT'Ii

.,

Nltion

,...,

----Th!;.;.-----'."-~-

elled;""
concentmlion

D,

"

Time (hours)
,.. flgure4.6 Single-dose drug administration:
pharma{oklnetlc values for this drug are as fall om: onset of
action = 2 hours;duratlon o f 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

"

, ~~~~~~~~~~~~
12

24

gs 411 GO 72 114 9S 108 120 132

Time (hours)
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

Figure 4.7

d~

The plateau may be reached faster by administration of

loading doses followed by regular maintenance doses. A

4.9 Loading Doses

and Maintenance Doses

lOildingdos! is a higher amown of drug, often given only once

or twice to "prime~ the bloodstream with a sufficient level of
drug. Before plasma levels can drop back toward zero, inter~re

pbsm~

Few drugs a .... administered as" single dose. Repeated doses

mittent mlintenanc. do ...

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 continuouslywithin 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 oontinuous therapeutic level of drug to body tissues . Theoretically, it takes approximately four half-lives to reach this
equilibrium. If the medication is given as a continuous infusion, the plateau can be reached quickly and be maintained
with little or no fluctuation in drug plasma lewIs.

ooncentration in the therapeutic range. Although blood levels 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.

wven to keep the

drug

C\ , ' -

Ll ' " Chapter REVIEW

KEY CONCEPTS
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 determine movement of drugs throughout the body. The four
components of pharmaookinetics are absorption, metabolism, distribution, and excretion.

LibraryPirate

4.3 Absorption is the process by which a drug moves from the

site of administration to the bloodstream. Absorption depends on the size of the drug molecule, its lipid solubility,
its degree of ionization, and interactions with food or
other medications.

44

Un~ t

Con Concepts 111 PN,mxoiogy

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 bra in barriers.

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.

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 significa ntly affect drug action.

4.1

Plasma half-life represents till.' duration of action for

most drugs.

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.

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.

NCLEX-RN' REVIEW QUESTIONS

A patient has an order for a tetracyclJneantiblotlc and has

been instructed to avoid taking the medicatio n with

foods. beverages, or drugs that contain calcium. iron, o r
magnesIum. What stage of the pharmaooklnetk processes
is behind the rationale for thi!; instruction?
I. Absorption
2. Distribution
J. Metabolism
4. Excretion
The patient has a malignant bu in 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
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 medicatio n administr.ltion
J. An increased dost'of prescribed drug'i
4_ AU preKribed drugs m~ begiven by lntr.lmusro1ar
Injtion.

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

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
The nurse understands that with gl~nduJar activIty, '"tersoluble drugs may be secreted into (select all that apply):
I . saliva.
2. sweat.
J. breast milk.

4_ bUe.
5. feces..

CRITICAL THINKING QUESTIONS

1. Describe the types of obstacles drugs face from the time
they are administered until they reach their target ~ls.
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. EIplain why drUg<; metabolized through the first-pass effect might need to be admin istered by the parenteral route.

SuAppendix D for answers and rationales for a/1 activiria.

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from 1M Iron! fl yrur IlOOlc

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at

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 me dications.
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

7.
8.
9.
10.

dinical practice.
Compare and contrast the terms potency and efficacy.
Distinguish between an agonist,a partial agonist,and an antagonist.
Explain the relationship between receptors and drug action.
Explain possible future developments in the field of pharmacogenetics.

KEY TERMS
agonist fll}tSO
antagonist pq50
dficacy piJl}f49
~qurn(Jdiltributim

gradrd dost-responl~

idiosyncratic response

rur'fl' patjl'46
{XIgt 47

Jf!~ 50

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median effl'Ctivedosr (ED,J [JIlIIt0/6

median I~thal dos~ ( lD,J {II19t0/6
median toxkitydoSf(TD,.l filXJf47
nons(lfcifK crllular ~sponsu {OJ / SO
partial agonist ~50
pharmacodynamics fXXlI' 0/6

pharmacogen!tics {l!9t 51
pot~ncy ~0/8
~ceptor

pu;e49

sKond mrsstng!r fllI}t49

thrraprutic index P:!9t 47

46

Unft 1 (o<e Concepl5

In PtmmKology

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. This 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

Do... of rMd>cation (mg)

,.. FigureS.' Frequencydfstrfbutfon curw: fnterpatlent

The term pharmmxlynamks co mes from the root words

varfabllfty fn drug response

pharmuco, which means "medicine," and dYllamics, which

means "change. In simplest temlS, pharmacodynamics
refers to how a medicine changes the body. A more complete
definition explains pharmacodynamics as the branch of
pharmacology concerned with the mochanisms of drug ac
tion and the relationships betwee n drug concentration and
responses in the body.
Philrmaaxiynamics has important dinical applications.
Health care providers must be ~b le to predict whether a drug
will produce ~ significant ch.ange in ~ti ents. Although diniwn. un.~u ~iu Ih.,,-;,, ... 1 wilh ,",Vt'l'''''t\'' d~ 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 effec tive treaunenl.
Interpatient va riabi 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 wa s increased, more and mo re patients responded.
Some patients required very high doses to elicit the desired
response. The pe;lk of th e curve indicates the largest number 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 thedes ired 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.
H

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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 patients. Drug guides so me_
times report the EDl<) as the aver~ge or st~nd~rd dose.
The interpatient variability shown in Figure 5.1 has im.
portant clinical implications. Fi rst, the nu rse sho uld realize
that the standard o r average dose pred icls a satisfactory
therapeutic response for only hal/the popUlation. In o ther
words, m~ny ~tients will require more or less than the avo
erage dose for optimum phannacotherapy. Using the sys
tolic blood pressure example, assume Ih~t a b~ 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 o nly 10 mg to achieve blood pressu re reduction.
Other ~tienl5 in this grou pwill proJ,bly haVl" no reduction
in blood pressure. By observing the pa tient, taking vi tal
signs, and monitoring associ ated laboratory data, the nurse
uses skills that are critical in det ennining whether the average dose is effective for th e patient. It is not enough to sim _
ply memorize an average dose for ~ drug: the nurse must
know when and how to adjust th is 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 i",li.idu~1 pOlli"lIl ~ uuly uu" .. urnp'-'
nent of effective pharmacother3p y. The nurse must also be
able to predict whether the dose is safe fo r the p3tient.
Frequency distribution curves c~n 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 ch~pter 1010 . The

Choptfl;

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 nontoxic 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,
~",140 Illl! j, lh .. ~v"r~I!" j.,thu/ <.I~". n .., ED", ~",J LD", ~r"
used to calculate an important value in pharmacology, a
drug's theraprutic indel, the ratio of a drug's LO", to its ED","
Therapeutic index

median lethal dose L0 50

c'~="iC'==C':"i:;c
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 therapeutic index is a measure of a drug's safety margin: The higher
the value, the safer the medication.

,.,

'".

co.

, ""
]

i "'"
z

'"
, ,

'" " '" 01"drug '"X " '" " '"

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 effective 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 ""flll'~r" Ufl" Ufl'K will, ~l1ullJ"r.
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 DoseResponse 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 concept 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 response obtained at different doses of the drug, one can explain 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 flatness 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

mg

(a.) Drug X T1" LD~ ",~,,4

E~
to

,.,

,''-

CD.

~ '"

"""'" ,

'00

,"
"-

~, ''''

l "'"
'"
, ,

"
,
,"

Phase 2

.~

'" " '" "drug '"Z " '" " '"

,
(b) Drug Z :TI", LD~ "gQ,,2
ED.. to
mg 01

"",H '

,.. Flgure5.2 Therapeutic Index: (a) drug X has a therapeutic

Index of 4;(b) drug Z has a therapeutic Index of 2

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". Flgur! 5.3

'00
'"
Oose (log)
Dos ...... response relationship

'"'"

10,000

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 example,if the dose is doubled, twice as much response is obtained.
This is the most desirable range of doses for pharmaootherapeutics, 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 effective at treating a disorder. For example, some antineo plastic drugs kill more cancer cells than others; some

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. Furthermore, 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, potency is a way to compare the doses of two independently
administered drugs in terms of how much is needed to prodm:ea particular response. A useful way to visualize the concept of potency is by examining dose-response curves.
Compare the two drugs shown in ~ Figure 5.4a. In this ex-

'00

'I
~. "

!
",/

..

11
b

E:c

"

,.j

Dotted ~"" indicates the

sa"", dOGe lor both drugs

"

'00

"'00

10.000

COO'"

0"""

'00

1"19>'"

ili

"
H
~E

.,
>-

f ~
p

_c

0"",.

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

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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 produces a higher maximal response.
Which is more important to the success of pharmacotherapy, potency or efficacy? Perhaps the best way to understand these conC!'pts is to use the specific example of
headache pain. Two common OTC analgesics are ibuprofen (100 mg) and aspirin (650 mg). The fact that ibuprofen 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 ibuprofen and can effectively treat this type of pain. From a pharmacotherapeutic 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 patient 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 d rugs 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 fundamental 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 hormones, neurotransmitters, and growth factors.
Although a drug receptor can be any type of macromolecule, the vast majority are proteins. As shown in ~ Figure 5.5,
a receptor is depicted as a three-dimensional protein associated with the cellular plasma membrane. The extracellular structural component of the receptor usually consists
of several protein subunits arranged around a central canal
0 1" channel. Other receptors consist of many membranesparming 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 between 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

Fiw st......-.!o , joined in

penta""" , _ell willi
lou, t,ansmembrane

8.

segmant.

(a) Voltage"9"tod chanool

(b) Chemical-gatod channel

Binding site

..

One .trand with

....., transmmrbrane

'"".

c
(c) G-ptotein~inked channel
~

Flgure5.5 Cellular receptors

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Ion PO'" (Gprol . inlinked channel)

50

'1

i"
i
,
i
o

UnIII

CO<O (OO(epl'; III Phormoc:ology

adenosine monophosphate (cyclic AMP), the release of intracellular 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 enzymes in the cytoplasm. By interacting with these types
of receptors, medications are able to inhibit protein synthesis 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 subtypes permit the fme-tlUling~ of pharmacology. For example, 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 subtypes 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 development of new medicatioilli that activate very specific receptors 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, depressing 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 consequences can result. In simplest terms, a specific activity of
the cell is either enhanced or inhibited. Theactual biochemical 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 response that mimics the effect of the endogenous regulatory
molecule. For example, when the drug bethanechol (Urecholine) is administered, it binds to acetylcholine reptors
in the autonomic nervous system and produces thesameactions 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

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than the endogenous chemical. The term partial agonist describes a medication that produces a weaker, or less efficacious, 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 agonisls for the receptor binding sites. For example, the drug atropine 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 acetylcholine, 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 pharmacokinetic factors. For example, antagonists may slow the absorption of a drug. Ry sp"~ding lip met"~holi.m or eXCTet"ion, ~n
antagonist can enhance the removal of a drug from the
body. The relationships that occur between agonists and antagonists explain manyofthedrug-drug and drug-food interactions that occur in the body.

5.7 Pharmacology of the Future:

Customizing Drug Therapy
Until recently, it was thought that single drugs should provide safe and effective treatment to every pllient in the
same way. Unfortunately, a significant portion of the population either develops unacceptable side effts to certain
drugs or is unresponsive to them. Many scientists and clinicians 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 specific 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 administering a drug may someday address idiosyncratic
differences.
TREATING THE DIVER5E PATIENT

Enzyme Deficiency in Certain Ethnic

Populations
Pha~ has identiIifd a numberofptoprwho a~deficitnt in thel'fll)TIII'glurosr-6-phosphatedth)drogtn~(G6PD).lhisffiZ)'me~rsstfuialinGlr

boh)drall' melabolism. Mairs 01 MtditmalH'an ard African d!scent a~ mo~

IRlyto ~press thisdf,filinKy. h ~ rstimall'd to oI~ 400 mili:n ~ worklwid!'. Thf disorder ~ GIUIed by IIIIIlItions nthe DNA ItrIKtlR that fIICOde for
G6PQ reulting in ontor moll' oImioo oKij mangrs in tilt pro1I'in moItoR .FalIONing administmoo of (min drugs. such as prifNQUifll',suifonaridrs, or nitrdurintoin, an oIClI1I' hnnoIysis; of ml bbod cells 01111 due 10 the brNking of
(hemi:al bonck in the hl'lII09bbin moleru~ 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'dicalions. Fortunat~, " - oI~ good akM\atiYr choiu5 b thrst ml'dications.

CNpttr5 I'hormac:odyn.min

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

51

pharmacogenetic information may someday allow for customized drug therapy. Although therapies based on a patien!"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.

.;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 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 concerned with how drugs produce change in patients, and
the differences in patient r"'pon""s to medications.

5.4

Potency. the dose of medication required to produce a particubr response, and efficacy, the magnitude of maximal
response to a drug, orc means of compo ring medications.

The therapeutic index, expressed mathematically as

TD'iO 7 ED'iO> is a value representing the margin o f safety
of a drug. The higher the therapeutic index, the safer the
drug.

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.

5.2

5.)

The graded dose-response relationship describes how the

therapeutic response to a drug changes as the medication
dose is increased.

5.1 In the future, pharmacotherapy will likely be customized

to match the genetic makeup of each patient.

NCLEX-RN " REVIEW QUESTIONS

What is the term for unpredictable and unexplained drug

reactions?
1. Adverse reactions
2. Idiosyncratic reactions
3. Enzyme--specific reactions
4. Urutltered reactions

A drug that occupies a receptor site and prewnl5endoge-

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 require 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 patien t who rouIinelyusesacetaminophen at home
for pain relief
3. A patient who quickly develops allergies to multiple
medications
4. A patien t 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 ~na rrow 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.

nous chemicals from acting is ca.J.led alan:

I. antagonist
2. partial agonist.
3. agonist.
4. promgonist.
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
The term used to describe the magnitude of maximal response that can be produced from a particula r drug is:
1. efficacious.
2. toxic.
3. polent.
4. comparable.

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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, wh~1 happens in the

~olberw SO% oflhe patients after a dose has been adminis1....001

2. T","O drugs au C(Hl'Ipetlng lOr a reapt~on a masl ceO that

will cause the release of histamIne when actiY1lted. Compare 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.

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EXPLORE

~---- - - - - ,

*'"

tlyttursngKit is ftII,I' lIr1e

k:f 0t*It dl.er It'<iew mlle1&is and
rnout ..... Pt __ Ito" OU<CAI will> ;od~ NClEX"'1ofYIo Pt~
Ip'Stim. tnttnlClll.\Ol ~ ard
wtillli'M, ~
iIItd rideos. iIId morel
~:/flU

acII_

-=- mc!e frt)m !!Ie ~I d ytlUt" IiIK* II

_....,.,. . . .kito:Glll.

armacology
nd the
Nurse-Patient
Relationsh ip

CHAPTER 6

The Nursing Process in Pharmacology

CHAPTER 7

Drug Administration Throughout the life Span

CHAPTER 8

Psychosocial, Gender, and Cultural Influences on Pharmacotherapy

CHAPTER 9

Medication Errors and Risk Reduction

CHAPTER 10

Herbal and Alternative Therapies

CHAPTER 11

SubstanceAbuse

CHAPTER 12

Emergency Preparedness and Poisonings

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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 as~ssmentdata 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.

KEY TERMS
.~mm~m

phil! plJlJr55

baseline dna fII1!' 55

e'liluation phiW

{I/Jqd9

goal fIIlI1'57

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implementation phaw

jllJlTjIJ

nur1ing diigOOIM fIIl1'57

nu~ng

proem {11IJ<'55

objectivto data 1'1111' "

outrom.

f'JI1'jIJ

planning phis. fIIJI1' 57

l ubjKtive dilla fill!' 55

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 interdisciplinary 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 unfamiliar with the nursing process are encouraged to consult
one of the many excellent fundamentals of nursing textbooks for a more detailed explanation.

6.1 Assessment of the Patient

The aSltsSmenl pha~ 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 continues 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.

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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'rceives, and objec:tive dati gathered through physical assessment,laboratory tests, and other diagnostic sources.
The initial health history is tailored to the patient's dinical condition. A complete history is the most detailed., but
the nurse must consider tht' appropriatt'ness of Ihis history 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 questions to ask in the initial history relate to history of drug allergy; 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 questioru such as the pregnancy slatus of women of childbearing 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 condition. 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 assessments 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 cardiovascular syslem. Baseline electrolyte values are important parameters to obtain, because many medications affect
electrolyte balance. Renal and hepatic function tests are essential 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 medications.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 improved over time? If a patient is not experiencing the therapeutic 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.

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 lOO~rI!([\!'saibt)

A~)'OII haYiog artf plin?lDtsaibl')

A~)'OII uptrimciog Ollltr s)TIlproms?l Espffialy pffiiOffit to mtdicitiolllolrt' naw.a, vomiting. ~~, iidJing.
diu inm, !horlMn 01 brt'ath, ntI'/OU!rItSS or inxiouwsl, pllpita~om or ~arl "IIunning. "and Wl'a~s or filtigUl'.)

Alt )'Oll illffijil toartf mrdicitions?

Alt)'Oll allffijil to artf lood~ ffil'ilonmffitil IltIruncrs (t.g., pollffi or"lNlOIIar alltl9its), tapt. !lips. or dNOIm?
Whal spe<ifKollIy happtnSw~n)'Oll UPMmc:~ analtrg)'?
hit mtlkal histOil

Do)'OU hal'! a hiltOil of thoot5, hNIl or valCWr (ondiIion~ ~Ialory (ondiIion~ or nl'urologic: (onditions?
Do)'OU hal'! artf dmniIloIogic: (onditions?

folmiylillory

IbvWt'l1't~lIeitedinthep.iIl?Cu~tly?

Hi! artfOlH' in )'OU,fimily ~ diffKUt~ with in, mftkations? (DeaitJIo)

OoHafl)'Olll' in yOII' filmily hol'l t an,Yljnifi(,lnt mtdi<al probItms?

Drug liltory

Whal prtIIJiption mtdicition Sile you amnlly tilting? (Lilt drug naml', dosq, and lil'qumq of idminilt!a~on.)
What non~pIion/lJlC mtIka~omart')'OII tilting? (Lilt IIolme,tIoIaqt. i nd Ir~.)
What ~ pr&riprion or OK. hal'!')'011 takrn willin!hl' plit month or two?

1IoI'I~ 100 Mr UpnitlKN iny sidttllemor !JllllWls)TIlproms with in, mtIka~om? (DeaitJIo)

Whal do 100 U-, or what Wl'1I')W tiugh~ iboul t~ mftkations?

Do)'OU Ulfan, hfflIal or homropathic: lI'IIltde? Artf IlUtritiolloJl IUbstance or Yilamins?
idtnlify all t~ hNkh GIrt' pnr.'idtrs you hal'!sttn lor ~atth 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.)

Pl'rsonal- sodal histOil

A~)'OIIbrt'asHffiiogl

Do)'OU~okt?
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 in\U!aIK~ or !hi' abi~ly to ifford mNicilions?

~alth

ri51:. hiltOil

Do)'OU hal'!artf lisl:oryofdtpresion or o!hl'r mentil IllII'Ss?

Do)lOO U\uny!lrM drugs or iltidt !UHt~n{el

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 effects, as weU as follow-up vital signs and laboratory reports.
Here again, baseline data are compared with the current assessment to determine what changes have occurred since
the initiation of pharmacotherapy. The Nursing Process Focus flowcharts provided in chapters 13 through 4900 illustrate key assessment data that the nurse should gather that
are associated with specific medications or classes of drugs.
Finally, it is important to assess the ability of the patient
to assume responsibility for self-administration of medica -

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tion. Will the patient require assistance obtaining or purchasing 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 understand 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 parenteral medications at home, when necessary?
After analyzing the assessment data, the nursedetermines
patient-specific nursing diagnoses appropriate for the drugs

prescribed. These diagnoses will form the

maining steps of the Nursing Process.

b~sis

for the re-

MEDICATION ERRORS
AND DIETARV SUPPLEMENTS
Herbal and vitamin su pplements ca n have powerful effects
on the body that can inl1uen<:e the success of presc ription
drug therapy. In $Ome cases.o\"tr-the-coun ter supplements
cr.n enhance the effects of prescription drugs, whereas in
other insran<:es supplements may cancel the th~rapeutic effectsofa medication. Fore.umple.many patients with heart
d isease 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 abno rmal blK'ding. AI. another example.
high doses of calcium supplements can cancel the beneficial
antihyperteru;ive effects of drugs such as nifedipine (Procardial, a cr.lciwn channel blocker.
Few controUed studies have ex:lmined how concu rrent
use of natural supp lements 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 diilgno~ 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 ca re given. Un like medical
diagnoses that focus on a di5e;lseor cond ition, nursingdiagnoses focus on a patienl's response to actual or potential
health and life processes. The North American Nursing Diagnosis Association (NANDA ) defines nuningdiagnoses as;
A clinical judgment about individual. family. or community responses to actual or potential healthllife processes.
Per NANDA, nUf$ing diagnoses provide the basis for selection of nursing inlerventions 10 achie~ 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 th~t nursing diagnoses focus on the patieut's
needs, not the nurse's needs. A primHY nu rsing role is to enable patients to become active participants in their own
care. Byincluding the patient in identifying needs, the nurse
encourages the patient to take a more ~ctiVl?: role in working
toward meeting the identified gools.
Whenapplioo to pharm~cotherapy, the diagnosis phase of
the nursing process addresses three main areas of concern.
Promoting therapeutic drug effects
Minimizing adverse drug tffects and to."(jcity

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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 tre~lment of pain;
focus on potential problems such as a risk for deficient Ouid
volume; or concentrateon maint:lining the pa tient's current
level of well ness. Thediagnosis 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 factor, 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 administration. Some are nursing specific that lIle nurse can
manage independently, whereas other problems are multidisciplinary and require collaboration with other members
of the health care team.
Two of the most co mmon nursing diagnoses for medication administration are D~ruic"t Klrowlcdge and NOIIcompliallce. Knowledge deficit may occur when the patient
was given a new prescription and has no previous uper ience
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 p~tient's knowledge regarding the drugs currently being taken and evaluate
whether the drug edu(;ltion was adequate. Noncompliance,
aJso called nonadherence, assumes that the patient was properly e.:IU(;lte.:l about the medication b ut has made Ihe decision not to t:lke it. It is vit:ll that the nurse assess possible
factors leading to the noncompliance before establish ing this
diagnosis. Does the patient understand why the medicatio n
was prescribed? Was dosing and scheduling informa tion explained? 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 noncompliance related to inadequate fi nancial resources?
Table6.2 providesan abbrrnatoo list of $Orne of the common 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 exhaustive list of all NANDA_approved diagnoses, and the establishment 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 diagnoses, formulates desired outcomes, and selects nursing
interventions that can assist the patient to return to establish 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 wha t the nurse wi)) do. The objective

58

UnK2 J>harmKoIogy.nd tl>eNufW-Pati<'nt R.... tlonmlp

NANDA-Approved Nursing Diagnoses

ActiYity IntoWmn

Rill::forlnjul}

Intffffiift /-jrwlf1 C1t.inu

Offidtnt I(nowld9!'

Anl:i~

Rill:: for Impaiml Lim" FlIKIim

Hilt 101 A~lation

Impaird Ph)'lical Mobility

IntfI'ffiivt Blulhill9 Panm

HiUIN

Dffiustd CardioKDuIpU

Honromplii()(~

R~i diotSS for

ImbiliuKtd Huu~ion

Erha'xtd (omfort

Impai~ 'krtIi1 {ommurimion

ImpaR d Oril MocOUl MembrilN'

umtipation
Risk for {onlaminalion

""

Intff~CopiIl9

StIHn DtfKil

RiIUorPoilOlling

[hrrllei

Oimrlltd StoIOI)' i'mrplion

MorilDillr~

Stxuai OyIfunction

RiskforFilk

ImpaR dSkin Int~

Fitigue

Oimrlltd Sltep Pinffll

Ddioml Fluid Vol~

Strns<lvfllNd

En~1 FluidVolume

Rill::forSlidde

Impai~ Gas

ImpaR d SwilioowilHJ

Enhill4}e

Intffffiivt HNIth MiinlenaOO'

Risk for CompromMd HUllliln Digrity
H)'pffihmnii
Hypothffinii
IlI(ontiOOK~

Risk for Infection

IlN'fIenjy~ ThtrapMK ~mtn

Manogellltllt
ImpaRd~ition

Oimrlltd 'fhou9:lt Proc:~SfS

IlN'fIectjy ~ TMUI' Pmulion

Uriniry Relention

measures of th ose 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 establish clear, realistic goals and outcomes so that planned interventions 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 involves 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 situation. For a patient with a thrombus in the lower extremity

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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 anticoagulant 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 [XItient on pain medication, relief of pain is a priority established before treatment of the nausea, vomiting, or dizziness
caused by the medication. The nurse should remember, howev\T, that planning for the prevention or treatment of expected adverse effects is an integral step of the plalllling phase.
Outcomes are the specific criteria used to measure attainment of the selected g0.11s. They are written to include the
subject (usually the [XItient), the actions required by that subject, under what circWl15tances. the expected performance,
and the specific time frame in which the subject will accomplish 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 syringe provided, given subcutaneously into the anterior abdominal areas, in 2 days (l day prior to discharge)." This
outcome includes the subject ([XItient), actions {demonstrate
injection},circumstances (using a preloadedsyringe), performance (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. in 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 determines 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 impl~mrnt.tion Jilasr is when the nurse applies the knowledge, skills, and principles of nursing care to help move the
patient toward the desired goal and optimal wellness. implementation 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 m edication, continuing to assess the
patient and monitoring d rug effects, and carrying out the interventionsdeveloped in the planning phase to maximize the
therapeutic response and prevent adverse events.

TREATING THE DIVERSE PATIENT

Non- English-Speaking
and Culturally Div@ulitPatilitnu

MIne shaul:! kIIov< in mOO', wh.n tranWfun sel'lim aoo iotrrpmm a~

Milablt in th~r hNhh cart faciity to alUit with COOlllUlication. The nuBl'
shlUd use interpreter's Sft'/i;:e w~ Milablt, 'Ridating with ~ int~
that lItor w iI ablt to undl'~taoo the patitntMany dialects a~ similar but no!
thf. same,aoo blowilg anothtr IiIlHJIagt is lid: th~ 5:a0ll' ~ lIlderllindilg th~
rulw~. Can tht intrrprfter undmtand the patient's Ianglllge ard rulwral expmlions or nUilrns W!"I mJUljh for ~ COOlllUlimion to 011"1 Ha famil)o
OII'IIIber is intrlpmD!rspOOal~ if a chid is int~ for a PftIll or matiYe.
be SU~ th.n tilt ~firnundmtardund ~ats tht information 100; to
tht ruse bekftexpiaining it in thl' patitot's own Ia~.lhis is rspHialy importantifthttrartliation isa SlIIlmaryofwh.n wn said rather than a iroe-b)o~ine
translation.Bmrean i~ is availablf,orif one is ullmilabie,UII' pi:1Urrs,
simpiedrav.inqs.lIOIlftIbalrurs,andbodyla~toCOOll1llllitaltwith ~pa

tient. ~ oIWa~ of rulwral)- btifd I"ICHI'Ierbal romllUlication brhaioo (r.g.,UIe

of pMOOal ~ eye {OO\a(~ or lack of f)'f (OOt.J(\). Gender sensitivitirs rrLltfd
to arku~ (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 ofttll ~ norm. WhfII \\Olrting with patitnh of other rufnfts,arIop:ing a IIIOIl' bmal styrmay be lIIOIl'appropriatl'.

Monitoring drug effects is a prima r 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 suggests the need 10 reassess pharmacotherapy. Monitoring
may require a reassessment of the patient's physical condition, vital signs, body weight, lab values, and/o r 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 documentation 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 follow-up assessment data that the nurse has gathered.
Patient teaching is a vital oomponent of the nurse's interventions for a patient receiving medications. Knowledge
deficit, and even noncompliance, is directly related to the
type and quality of medication education that a patient receives. State nurse practice ac~ and regulating bodies such as
the Joint Commission on Accreditation of Healthcare Organizations (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 pharmacotherapy are the safe administration of medications, with the best
therapeutic outcomes possible, teaching is aimed at provid-

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ing the patient with the information necessary to ensure this

occurs. Every nurse-patiem interaction can present an opportWlity for teaching. Small portions of education given
uv~r tiIJl~ an, Un~JJ HJur ... dr","liv~ lhaH I~rg" alJJuWll, uf ill formation given on only one occasion. Discussing medications 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 questions 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 includes 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 providing the teaching to verify that the patient has Wlderstood
the information.
Pediatric patients often present special challenges to patient teaching. Specialized pediatric teaching materials may
assist the nurse in teaching these patients. Paren~ of children must be included in the medication administrntion
process. The nurse must base medication administrntion in
pediatric patients on safe pediatric dosages and limiting potential 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 medication errors, since drug administrntion in children often requires 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 serious adverse effec~ in infants and children.
The elderly population also presents the nurse with additional nursing considerations. Age-appropriate teaching
materials that are repeated slowly and provided in small increments 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. Because of chronic diseases, elderly patients often take multiple drugs that maycause many drug-drug interactions.

6 .S Evaluating the Effects

of Medications
The tvaluiltion phair compares the patient's current health status with the desired outcome. This step is important to determine 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 appropriate, and the problem or risk was resolved. The nurse and
patients can then address the next highest priority health

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

Important Questions and Observations

lberapwlil: UII' and OUUOIlII'S

(an)'Oll I~IIIIM' tiN' 1IiI0II! of 1011" IMdiulionand whal ~ is ustdfor?

Whal will)'Oll look fOlio knOll' llialtht lIM'Ika~on is di'Mift? {Howwill)'Oll kIKIII' WI th~ 1IM'Ii<inl' is 'IIOJIking?!

Moniloring sid~ and~ ~flffi:s

Whidl ~ dIMS (in ytI'J hand~ by)'OUN'lf? (~.g., ~rrpIt lIiIultl,diarrhN)

Whidl ~ dIMS s.houId you rtpOIt to 1001 health 0:;11"1' provider? (~.g.,UIlflll~ (ilt! OfllilUll'i 01 YOIllitinq.nirrllM'
<inilts~~Hdingl

Medication ministration

(an)'Oll t~1I1IM' hOI\' mum oftht IIM'IiGflion)'OU should ta~? (milligram~ numbl'r oftab~t~mililitmoflirpd, ~\(.)
(an)'Oll t~1I1IM' how oft~)'OU shoWd taU~?
Whal ~llI'qLifl'lllenuall' ntmSlIl wIIffi)'Oll take this lIM'Iiution? (~.g.!au- w~h 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? (~.g.,using i brondIodilator brfor~ using a
cortkost~roid imller)
(an)'Oll shOll' ml' how you willljft YIMI"ltIf!he mtdKation? (r .g., r)'l' rtops, SltxUlanaus injraions)
What spffial monitoring is r~rtd btfOll')'OII takethis OII!diution? (~.g.ptR rat~) Can you dtmonSUil~ this fOlIlM'?
Bastd on tllal mon~orinq. wIIffi should )'OIl nor tak~ th~ 1IM'Ii<a~on?
Do you know how,orwllefr. to ROR' this mtdkadonl

What should)'OU rb ff yoo misl! doSI'?

OIiN'r monitoring and spffial r~RmffiU

AII'!he1l' i OY sptdal ttlts )'OU should ~ rriaRd to this lIM'Iiution? (~.g. fi~-Slid. gllKose ltoIrk.lhffilpeutic drug

'''''

lIowoft!"n shoUd !hesH~s til' done?

Whal OIiN'r lIM'Iiutiom should)'OU oortakr with this mtdkation?
AII' !he1l' aoy foods 01 beomagtl)'OU mUR not 11m whi~ uking this 1IM'Ii<a~on?

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.
As it relates to phanlL1cotherapy,evaluation is used to de~
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

require revision. The drug dose may need to be increased,

more time may be needed to achit'Ye therapeutic drug levels, 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 considers 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.

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.Assessment of the patient receiving medications includes
health history information, physical assessment data, lab

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values and other measurable data, and an assessment of

medication effe<:ts, including both therapeutic and side
effe<:ts..

6.2

Nursing diagnoses are writtl'n to address thl' patil'nt's responses related to drug administration. They are developed 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 "'" d~""loped from the nu~

ing diagnoses, direct the interventions required by the plan
of care. Goals focus on what the patient should be able to
achieve, an d outcomes provide the specific, measurable
criteria that will be used to measure goal attainment.

peutic response and m inimize adverse effects of the drug.

Key interventions required of the nurse include monitoring 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.

6.4 The implementation phase involves administering the

drug, and carrying out interventions to promote a thera-

NCLEX-RN " REVIEW QUESTIONS

Which of the following is an incorrect statement regarding 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.
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.

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' h as successfully self-managed her diet and insulin therapy for the past 2 years. She confides in the nurse
that she deliberntely skipped some of her insulin doses because she did not want to gain l'il'ight,and shl' is afraid of

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
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

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 supported 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

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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.

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 pat~nt Information about thedrug being JdmlnIsteraL kIoentify the information that the nurse should
teach thl! patient during medication administr.lllon.

SAppfndix D foran$WtTS and rAtionaks for aD activities.

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EXPLOflE

~ .- - - - - - - ,

/t.)'I'lItSirIg1CI is )WI' _ _ lor onL'Ie aaptef moiI!w II'IIItl!rilis _

mwrces. I'HIpi<t lor 11.10:. . wiIh ~ ~-stwIt IIQCIiI;t
~ IIIIInc:IIiIIe ~ an:! ~ wdI Hs, RIlIIIXnI
and >'deos.'" lII0I11
1'.fV.*I')WI' ICCe!I COIle frtJn k ~")IIB billie 11\
_.ntrnur~.

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 fa ctors 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 c~ngl!'$ that occur in thl' older
adult.and how these affl'Ct pharmilcotherapy.

9.

Develop nursing Interwntlons that maximize pharmacotherapeutic

outcoml's in thl' older adu lt.

KEY TERMS
older adulthood fX19' li

f'OIT 71
embryoniqM!riod f'Il1"65

polyphmnacy fXJI" 7l

ft1il~riod fllJlY65

p~implantat~n

adolf'l{~n(f

infilnCY fllJlJ'68

middle ild ukhood fX1IT 7l

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period fXJI"65
prfl(oool child fXJIJ' 70

Khoolage child PJt 70

Imlogen JI09'65
loddlerhocxl JII1F69
young adulthood fX1IJ' 7]

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 ....... u l'1II that drug. "I'
de~vered 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 predictable sequence, whereas psychomotor and cognitive development 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 healthpattern impairmenLS c:r.n be approp riately 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 holistic care. The very nature of phannacology requires that the
nur~ consider the individuality of each patient and the
specifics of age, growth, and development in relation to
pharmaCOkinetics and pharmacooyna m ics.

DRUG ADMINISTRATION DURING

PREGNANCY AND LACTATION
Health care providers elU'rcise great caution when ini tiating pharmacotherapy during pregnancy or lactation
(>- Figure 1.2). ''-/hen possible, drug thCf"Dpy is postponed
until after pregmnq and lactation, or nonpharmacologic alternatives are implemented. There are wme serious ronditions, however, tlut may require pharmacotherapy in such
patienlS. For example, if the patient has epilepsy, hypertension, 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 n~es
sary to treat inf~tions during pregnancy; acute urinary tnet
infections and ~U3Dy tnl15mined infections aTe relatively
common and can hann the fetus. In a U cao;es, health ca re

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,.. 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 membrane: Some substances readily pass from m()ther to fetus,
whereas the transport of other substances is blocked. The feW merrbl"lllles rontain enzymes tlut detoxify certain substances 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), cardiovascular, circulatory, and renal systems of women. Some
of these changes alter drug pharmacokinetics and pharmacodynamics and may affect the success of therapy.
ABSORPTION Ho rmCInaJ 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 Hemodynam ic 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

CNp1fll

drugs and decreases pl asma protein ooncentl':ltions,

affecting drug distribution. Blood n ow to the uterus,
kidneys, and skin is increased, whereas now to the skeletal
mlL'lCles is diminished. Alter~tions in lipid levels m.ayalter
drug transport and d istribution, especially during the third
trimester. Drug metabolism iocreases for (er tain drugs,
most notably an ticonvulnts such as (arbamazepine ,
phenytoin, and valproic acid. which may require higher
doses during pregn~ncy. Fat-soluble drugs are distributed
into the Lipidrich breast milk and are ultinutdy passed to
the lactating infant.
EXC RETION By the third tri mester of pregnancy, blood flow

through the mother's kidneys incr~s 40% to 50%. This

in( reae has a direct effect on renal plas ma flow, glomerular
ftllnltion nile, and renal tubu lar absorption. Thus, drug
e.xcretion nltes may be in creased, affecting dosage timing
and onset of action.

Drug Admllllm.tlOll Throughoot the L~e Sp;on

55

to teratogens. Teratogenic ~gents taken during th is phase

ca.n lead to structural malformation and spon taneous abor_
tion. Thespecific abnormality depends upo n which orga n is
fonning at the time of exposure.

FmI period: The fetal phase is from 9 to 40 weeks postconception or until birth. During this tim e, there is continued
growth and matunltion of the baby's organ sys tems. Blood
flow to the placenta increases and placental vascular mem branes bewme thinner. Such alterations maximize the transfer of substances from the maternal cirrulation 10 the fetal
blood. As a result, the fetus may recei\'c brgerdoses of medicatioru; and other substances taken by the mother. Because
the felus lacks mature metabolic mzymes and efficien t excretion 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 orga n function, r.ilher than gross
structural malfonnatiom.

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 permanent abnormality in structure or function, causes growth
retardation, or alliSeS death. The ba seline incidence of teratogenic evenl5 is approximately 3% of all pregnancies. Pott'ntial ft'lal consequences include intrauterine fetal death,
physical malformations, growth impairment, behavioral
abnormalities, and neo natal toxicity.
lbere a~ no "abso lute~ tera togens. 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 inc reasing with higher doses. The
timing of d rug 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 development, 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. Thes ped fK 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 d ays, 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 ~all _o r_none~
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 neg3 tive environmnrt for
the embryo and potentially cause intrauterine growth
retardation.
EmbrYUlitperiod : During th e embryonic period, from 3 to
8 w~ks postcOllception, there is rapid d~velopment of internal strudures. This is the period of tnaltimum sensitivity

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PREGNANCY DRUG CATEGORIES AND REGISTRIES

Fortunately, the number of prescriptio n 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 sa fety. New or infrequently
used drugs for which there is inadequate ~fety 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 p~gnancy ategorits th.at
da:i-:lity medica.tioru; according to their risks during preglWlCy. Table 7.1 lisl5 the fiw pregnancy categorits, which
guide the health alee tealll ~nd the pat ient in selecting drugs
that are least hazardous for the fetus. Examples of prescr iption drugs that are as.soda ted 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 terouagenicity 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 bOOluselaboratory animals have different physiological, metabolic, and
gmetic charaderistia. Most infoml~tion about fctal malformations and abnonnalities is atnlpolated from these animal
data and may only be crud e approxi m~ tions 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 pregnancy 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 d~rlyoutweigh 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 tr u~ safety.
lbe system does not india te how the dose should be adj usted
during pregnancy or lactation. Mos t drugs are category C

66

UnK2

J>ha,mKology.nd tiseNufW-p.Uent R.... tlonmlp

TABLE7.1. Current FDA Pregnancy Category Ratings with Exampli!s

Risk Category

Interpretation
~t~ Wfi,ontrolN

5Iudits iI ~m VIOOItil hol'l~ nOi !hownan

ilKrelll'd risk 01 fl'taI abnormalititl to tile fttUi in any trirtlt\ttt of prtgllilrK1.

""",

Pmlat.ll mukMtilrins, iflllAin. th)fOlint, folic: . OO

Animal5llKil's hol'l~ JMiltd ootvidmc~ 01 hilm to thl' f~tus; ~ thm

Pmdllils,rtphalosporin~azithromydn.oJ(~t.lminop/lffi.

.1"1' 00 odtquall' aOO wtll-<ontrolltd m.odits in pl"l'9nant WIIIIIffi.

ibI.profm in th~ firlt aOO Ittond tri"nfstm

OR
Anilllil15lod~s h.w~ !hown.n adYers!' rfl'ta. but adtqwt~aOO
MI~rontrolltd

5Iode in pr~ntwomm haft f.J~N to dtmon5llat~ risk to

thl' f~lUIin .ny tri"nfSil'r.
(

/l.nimalltlKil's hol'l~ !hown.n . dYersr rfl'K1aOO!herr 'I~ no .dIoquat~ and

5ILde in ~ntwomm.

MI~rontroll~d

OR

M&St prl'saiprion meditinrs;aminitrotials SIKh is darittromydn, nuoroquinolone, aOO 8.Ktrim; srlKti..,.

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

in pr~ntWOllll'n.

w~~rontrolled stLde

~t~ ~I-<OIltrolltd or obstrvational5ludits iI pr~nt VIOOItil hol'l~

demOllltlall'd . rill:: to thl' fl'tus.
H~,thI' btMfitsofthl'laP'l'may~lhI'pottiltiai risk.Fwm""',
thl' tro;t lIIiIy b.- oJ(rtpt.lilll' if ndfd in a lifHl"Rail'llitllj ~lWtion or Sl'rious
disease for whidt life- tro;tlUmot b.- used IX <R inrffeaiv~.

~te ~I-<OIltrolltd or obltrvilional5ludits iI anilllilk or prtgnant

ACE inlibiton, an9ioll'lllin rmptor blod:fts (ARBs) in thI'

Ittond and thild trimetft~ gtllamitil,ibuprofl'n in thl'
tlinl trirtlt\ttt; tetrar1dilltl, l'rrmilrin, alrohol. aOO nic:otilH'

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

pl~t.Thert is 00 iKiwion for uS!' in prtgnanq.

because very high doses in laboratory animals often produce teratogenic effects. All category D and X drugs should
be avoided during pregnancy due to their potential for causing 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 information from women who took medications during pregnancy.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 evaluated. Registries may be maintained by drug companies,governmental 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

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7.3 Pharmacotherapy

of the Lactating Patient

A large nwnber of drugs are secreted into breast milk. FortWlately, there are relatively few instances where drugs secreted into breast milk have been found to cause injury to
infants. For the few drugs that are absolutely contraindicated 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 soluble, 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 often remain at subclinical levels. Regarding the role of protein 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 .

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ABLE 7.2

Drug Admllllm.Uon Throughootthe L~e Spin

67

Selected Drugs Associated

with Adverso Effects During

" Breast-Feeding
Drug

~rted Effect 01 Rtason5

for Concem

ibutolol~

If19OItmion:tw~rdii;~

iIIiodMant((onInnt)

~sm

~MI'Ii'Ie

~.poorsltepilgpHtem

aljlijn alii OIhlr wIiqIa(~

~~

atenokJl {lmlmIinj

(j1l'lOlls: ~

Imr10aiptinf (hrIodtI)
(BI~

.....

~ ~1oII.: IIWII' lit hmrdousUlIIIf

CoaInt il'll0IDuc1on:klbl;litJ. ~
~ntntlttl'l~\ti!lJrtI

rf9OIl11inr (EJgDltat)

~dilf'rI~i.(OIMA!ions(dost'I UIfd in

migrW.e ~tMioru)
nuoe~~

(Prout")

haloptridol (HaIdd)

lithiLm (Elbith)

fffclingard ~ng disorders.rMuudlWiQh!

9Iin.coic
DIi~ in developrntnt.ll ~
OnHhhd to OIIf-half(~apffilk bIoOO
COf(ctntJition In Infuts

p/lffiindioM

AnticoagulaM:iI{I!astd proIhrombin and

phfnobarbilal(wminil)

Sffition;lnfantilt ~safl:tfwtlnilg from

jrim~

melhtmoglobilemia
~Ion, ~ probItms

pirtialth~stinti~
m~k contili'lng Fi'enoNlbitil.

(Mpdine)

IlMNiziIe (AnMdne)

1I'*" .... nm

SrxNtr.fIOOI"TM Jra" CIf()ugsand OIlIer (~sInloHurun Brt~

Mit"b!' ArHIi<MI ""'_CIf ~ria. ComIIittft on 0r\r9S. 290t.~
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 h.",a~ ' milk. Thi~ allnw~ the
nurse to aid the patient in making respon5ible choices regarding lactation and in reducing exposure of her newborn
to potentially harmful substances (.- Figure 7.2). The same
guidelines for drug use apply during th e breast_feeding period as during pregnancy-drugs sho uld 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 so metim es useful to administer it immediately after breast-feeding, or whe n the infant will be
sleeping for an x tended 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 breastfeeds her infant. The nurse c;rn assist the mother in protecting the child's S<lfety by teaching her to avoid iUidl drugs,
a1oohol , and tobacco products during lacta tion.

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.- Figure 7J Treating the bl"eat-feedlng mother

So/xCl: Clmnt 1homas FfKxO!1~

When considering the effects of drugs on the breastfeeding infant, the 1UIWlint of drug that actually reaches the
infant's tissues must be considered. Some mediauions produce no adverse effects beawe they are dest royed in the in fant's G I s~tem, or are unable to be absorbed across theG I
tract. ThlH, although many drugs a~ .!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 th e effect of drugs during bClation
relates to the infant's ability to metabolize sm all amo unts of
drugs. Premature, neonatal, and seriously ill infants ma y br
at greater risk for adverse effects bec;ruse th ey la ck drug metabolizing enzymes.
So me 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 a mo unt of drug
exposure to the infant. The mother sho uld not breastfeed while the drug is at its peak level.
Drugs that ha'e long half- lives (o r active metabolites)
should be a'oided beause the y c;r n accumulate in the

6B

Unftl

Ph.l fmKology lind The Nutse-PILUen!

ReI~!Ion"'lp

infant's plasma. Examples include barbiturates,

benzodiazcpines. mepnidine, and f1uoxetine.
Whene"er possib le, drugs with high protein~bindin8
ability should be Sf lected bau.se they a re not secreted
as readily to the milk.

arc herbal products and dietary suppLements should

be avoided duri ng l;actation, unless s~ifKally pre$Cl"ibed
by the health are provider bea.use the safE'lyoflTlO!\! of
these products 10 t!"le infant has not been determined.

All

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 ~onn an in_depth history and prenatal asstSSment to eilmlnate potentially hazardous substances, substitute alternative drugs, or adjust
medication dOSOlges. The patient needs to be thoroughly informed about the risks to both herself and her unborn child
related to the use of drugs, alcohol, tobao, alternative thera pies, and
mediations. Indude the foUowing points
when teaching p<ltient5 about drug therapy during pregnancy:

ore

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.

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 beca use 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 in~
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, in fan ts, toddlers, prt'$Chool ,
sdiool age, and adolescent.

7.5 Pharmacotherapy of Infants

I.IIIKJ is me period from birth to 12 months of age (,.

Fig~
urI,' 7.2 ). The first 28 days of life are referred to as the

PHARMhCTS

Fetal Effects Caused by Specific Drug Usa

During Pregnancy
IoVrijuan.: 1ow--H1h~ht bibie!. risk 04" prtlllilm d/,liftry,
withdrlW.1 ~rmptoms (oying.nd uembrll"l\l)
Cwinr:inat.Jstd risk d ITiKimq, P~II! dtlNrry,1lIi1formalioM of
Rttl rmm.nd kiItyI, bthiYioo-.1 disll.lrb.~ ijitltl)', irriLlbir, {r,Wig}
H~roin: inc:rti!ed mk of misa.r~, Iow-billh~ight habits,
withdfilW.llrmptOrtu,diarrh~ .. fffl\ ItIming, )'aWning, trtmol"l,
I~izurt!, ill!gul.r brtithing,.nd initability, ill(fNstd mk of ~ddtn

inf,nt death Iyndlllmt ($IDS)

Tob,a:o: inc:fNstd rilk of nillbirthl. premaNrt ~liYtry,low-birth~ht
ba~, iocrnr.td risk of lU~n infjnt death Iyrdn:rnt (SlDS)
Akoho~,lr:ohoI-~l.Jted birth dtfuts flIngng fu:lm !I\is(J~,nd !lilbirth
10 ~,I iIcohoIlYnd_{ltIIIn IUNrt;joint ~;and PftIbIrms.,,;m
attmtion, mmIOf); inteIigmcf, (oonIirWln, and Pfl)bli!m dving)
SWIlr. McfttIIlfDfrrll1Il"fS51'O"f~IIrt!.WII"MIwmIJrr 1,1009.

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neonatal period During this time, nursing care and phannatow: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 immedi~tely after taking the drug, the dose
may be reordered. The following nursi ng interventions and
parental teaching points are important for this age group:
cotru>rapy~ ... direct...!

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 asp iration.
If rectal suppositories are administered, the buttocks

CNplfl1 Dfug Admllll'tnllon Th'oughoot t"" ute Sp;In

69

.. Figure 7.] Treating the Infant

Source: Persson fdKar/ooJPHCoilege.

should be held together for 5 to 10 minutes to pre~nt

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 welldeveloped 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 de~loped
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 inje ction sites, the
nurse must rolllte injection sites from one leg to the next
to avoid overuse and to prevent inflammation and
excessi~ 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 materials, plants, and food products that are improperly stored.
Parents should be instructed to request child-resistant con-

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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 challenging. At this stage, the child is rapidly developing increased 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 explanations to the toodler will prolong the procedure and create additional anxiety. Short, concrete explanations followed
by immediate drug administration are best for this age

70

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P'harm oc: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 vehicle such as jam, syrup, or fruit puree, if por.sible. Encourage
parents to mix the medication in the smallest amount possible 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! JJl~uj<.in"
in milk, orange juice, or cereals, because the child may associate these healthful foods with bad- tasting medications. Pbarmaceutical companies often formulate pediatric medicines in
sweet syrups to increase the ease of drug administration.
1M injections for toddlers should be given into the vastus 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 h elpful 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 administration 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 toddler if nece' .... ry.

7.7 Pharmacotherapy
of Preschoolers
and SchoolMAge Children
The p~Khool ch il d ranges in age from 3 to 5 years. During
this period, the child begins to refine g ross and fine motor
Lt FESPAN C ONStDERAT tO NS

Iron Poisoning
One of tht It.lding WIllS of poilonings in thildrm undu t~ "9t of 6 is iron
poisoning.lron il oltm found in vitaminl of .11 kincb: plfllal.l~ ptdialrit..lnd
aduk vitaminl.Ptdiatric vitaminl may bI' ~rtiwlarly tmpting and may hal'!'
tht mtt and .lpptmn, of a ndy that tht ,hild il familiar with. Plt'lWtal vitamins molY hold .l ~rtic:ulardangerduetot~ ilK~a!td amounts ofiron and
011itr romponenll. And vit.minl all' not ,lw.l~ 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 I.IbIt~
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< Dn~ <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.

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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 administered to help them feel better. Nonetheless , medications
and other potentially dangerous products must still be safely
,luww uul uf Lht" dr.ilcl', rt",,~h.
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 lateraiis 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 medication 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 restrained, 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 opportunities to play-act troubling experiences with dolls. When the
child plays the role of doctor or nurse by giving a "sick~ 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 Khool ag~ 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 progressively 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 ingesting 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 alternatives to provide a sense of control and to encourage cooperation. 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 enjoyable. Making children feel that they are willing participants in medication administration, rather than victims, is
an important fOWldation for compliance. Praise for cooperation is appropriate for any pediatric patient and sets the

o..p1tl1 Drug Admllll'tnllon Throughoonhl' life Spoon

71

Figure 7.4 Treating thl! younger school-age child

5o/JrCI': PeaWfl

fliJcQr/ooJPHCoilege.

PHARMFACTS
Po isoning
"'cording 10 tht National Erntf9t1K)' Ikdiul MlOXialion (NEIM):
Yc:h ~~~ 2 million Ameriunull' poison~d
Poisoning "n bf plt'Vrnltd tfJrough ~dK,lIion ~ nd aWilll'ntU.
Min~ poisonings 0((111 in (hildren under6 )'ears of illt.
hlukl (in bf poisontd b)' taking t~ wrong dose of mtdiution, ronliJling
d~ll'nt mtdkations,or i(cidtntill~ splashing a poison on 11M- skin or in
Ih~t)'l'S.

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 old~ 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
Adoll'S(~ncf

occurs between ages 13 and 16 years. Rapid physical growth and psychologic maturation have a great impact
on personality development. The adolescent strongly relates

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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 knowledge. 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, inhalents, and methamphetamine.
The most common needs for the pharmacotherapy of
teens are for skin problems, headaches, menstrual symptoms, 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

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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.d ulthood (40 to 65 years of age), and older adulthood (over 65 years of age). Within each of these divisionsare
similar biophysical, psychosocial, and spiritual characteristics 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 conditions exist. The use of vitamins, minerals, and herbal reme~
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" Ir,,~tJJl"nt ofh"rp"',l'!ulJurrl,,,a, syphilis, ~",l HIV iIl["~
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

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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 positi~ 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, hypertension, obesity, arthritis, cancer, and anxiety begin to
surface in late middle age. The U'ieof drugs to treat hypertension, hyperlipidemia, digestive disorders, erectile dysfunction, 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 during this time of life. The use of antidepressants and antianxiety agents is prominent in the population older than 50.

7.10 Pharmacotherapy

of Older Adults
DurinI'! ll,,, 20lh L,,"tury, anllllpruvoo <ju~lity ufli[" ~",J 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,

Choplfl7 Drug Admtnlm. Uon It\'ooghounhe L~e Span

Figure 7.6 T\'I'atlngtl\v oIdl'f adult

5oixcI': T'Pa500 EMaflol!lPH CoJIegt.

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 npla ce 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 ordered by other practitioners. Polypharmacy dramatically increases the ri~ 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 thou gh predictable phystologkaJ and ps~hosoCl31
changes occur with aging, significan t va riabil ity exists
among pati t'lm. Fol e:umple, al though cognitive dedine
and memory 10$5 certainly occur along the agi ng continuwn , there is a grea l variation in geriatrk pat ien ts. 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 assessment is alw3}'5 ntCes.sary ( . Figure 7.6 ).
\\lhen administering med icatio ns to older adults. the
nurse should offer the patien t the sa me degree of independence 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

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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
ph armacist for regular sc rew_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 sys tems, multipl e and .severe illness.
polypharmacy, and unreliable compliance. By understanding th"""change., the n"~Cln avni(! m~ny::KI~f. drngef_
feets in older patients.
[ngeriatric patients, the functioning ability of all major organ systems progressively declines. For this reason, all phases
of pharmacokinetics are affected, a nd appropriate adjustments 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 varietyof changes. For example, immun e system function diminishes with aging , so autoimmune diseases and infoctions
occur more frequently in elderl y patien ts. Thus, there is an
increased need for influenza and pn eum oni 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
b lood How to digestive organs. Beca un of increased gastric
pH,orailablets and capsules that require high levels of acid
fnr aMorpri,m may lake lnn~ In diAAOlVl'. and. t'-"'(.....e
take longer to become available to the tissues.
Distr ibut io n: Increased body fat in the geriatric patient proa 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 increasing the ri~ for drug toxicily. For example, elderly patient> who have reduced body Huid experience more
orthostatic hypotension. The decline in lean body mus and
totalbody water leads to an increased concentration of watersoluble drugs, because the drugis distributed in a smaJlervo lumeof w.ater. The aging liver produces less albumin, resulting in decreased plasma protein -b inding ability and
increased levels of free drug in the bloodstream , th ereby increasing the potential fordrug--drug intera ctions. Th eaging
cardiovascular system has decreased ca rdb c 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, effective level.
vid~

Metabolism: Enzyme production in the liver decreases and

the visceral blood flow is diminished , resulting in reduced

74

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P'harm Kology . 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 intensifies drug response. The decline in hepatic function reduces
first-pass metabolism. (Recall that first-pass metabolism relates 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 standard dosage, the interval between doses, and the duration of
side effects.
Excretion: Older adults have reduced renal blood flow,
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 reduced, 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 ~d""rse drug re<l.ction< in older
adults is caused by the accumulation of toxic amounts of
drugs secondary to impaired renal excrt'1:ion.

....

TREATING THE DIVERSE PATIENT

Patients with Speaking. Visual,

or Hearing Impairments
Ve~l (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 resp:.nse. Cbrify U, paraphramg 1M tepOlIiI' badt to tht patitnt UII' gestures.
bod)' bnglligt. "Ill 'fl"SIno ~tions if writi1g or dtawing is tif'Iiam. AlkJw .drquale tine br ~. 8e l'IjIKialy avml' of ~I W>s,!lJ(h ~s grill\a(inq.....t.m pet"bnning inteMnti:rn that IN)'UUII' diKombt or pail.
I'rviitJe ~att ligIrting b patitnU with ilual impairmtlluantl be <lWire
of row tre phtaling oil'l'tbal tOtnllUlication aflem tilt message tOlM)'fli Rrme_ 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 a~ of tIOfM'tbal rues.Uptain ilt~lYtI1tions in ~ilil 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 ,",~r tre patient inti ol'IOil spNlting

ku:llyor!houtinq.epeWllyifhNring~i~areusrd.lfilitlMalOOUmofbadt

grouoo noist.n possib!!'. W~ or thw to (brify...erbal rommulli"iJn,am

UlfIlOllYMJ'lgtSturesaoo bod)'lII~toai:J(OtnmtJliatDn.AlkJw ~t
UII., lor lOInllululiun dId re>p<II ..... Alallllh.r 1I..,rUn of~ .. 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.

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 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.

7.6 Drug administration to toddlers can be challenging;

short, concrete explanations followed by immediate drug
administration are usually best for the toddler.

The effects of drugs on a growing embryo or fetus depends

on gestational stag<' and the 3moUllt of drug received. Pharmacotherapy during p~gnancy 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.

7.7 Preschool and younger school-age children can begin to

a.,ist with medication administration.

Breast-feeding women must be aware that many d rugs

and other substances can appear in milk and cause ad verse effects to the infant.

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.

7l

73

7A Patient education is especially critical during pr<'gllancy

and lactation for the safety of the mother and baby and to
en~ure ~u,u:MfuJ pharmawlogk outcome<;.

7.5

During infancy, pharmacotherapy is directed toward the

safety of the child and teaching the parents how to properly administer medications and care for the infant.

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7.8 P}wrntacologic compliance in the adolescent is depen dent on an understanding of and respect for the uniqueness of the person in this stage of growth and
dewlopment.

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 biochemical functions.

Ooop!tf 1 Inuoductlon to PhiollTlKoIogy: Ofll9 ~ul",1on . od Appr~1

(MhA) was founded. From 1852 to 1975, two major compendia maintained drug standards in the Un ited Stat es, the
U.s. Phurmacopoeiu and the Nutionul Formulary (NF) established by the APhA. All drug products wne covered in
the USP; pharmaceutical in gredients were covered in the
NF. In 1975. the two entities merged into a singl e publi catiOll , th e U.S. Pharmilco/'Mill- Niltionill Formlda,y ( USPNF) . Th e current document of about 2,400 pages contains
3,777 drug monog raphs in ]64 chapters. Official monographs and interim revision announcements for the USPNF 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 amo unts
of ingredients found within the container. Sample labels a re
illU5trated in ~ Figure 1.\.
In the early 1900s, the United States began todevdop and
enforce tougher d r 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 Sherley
Amendment prohibited the sale of drugs labeled with false
therapeutic claims that were intended to defr:lUd the con sumer. In 1938, Co ngress passed the Food, Drug, and Cosmetic Act. This was the first law preventing the sale of drugs
that had not been thoroughly tested before marketing. Later
amendmen ts to th is law required drug companies to prove
the safet y and effiOKY 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 Supplement Health and Education Act of 1994 in an attempt to
COlIIroI misleading indu.m y daims. A brief timdine of ma jor events in U.S. drug regulation is shown in ~ Figure 1.2.

_0___

....r..oc"""',_
-,

Idb
Ih1fu
' II

Un

R
lblln-Sli'
~tI
_
_ ~ _ 2D.
_

'00_

-_--.---,
--....

.. ~-

_
.. _
--,
-_
........ Restoril"
...... _
.---....."".i!.
---,
b_
----"'n.....,.
_ _
--~
-~

....

- - -~

. -.110. ...

- ,-

II

Ii

o.ce ~,,.."

l00~".

temazepam
. es.USP

_--

_tM' _.'.~_

Ar.tIinotIr1odf

.. Flgure l . 1 EJc .. m~ofusPtalH>ts

"".
-i!i- ,~ I,
-,
~~

5ot.m>: COUI"f''iIf~Hoiolrls~I5 Corpota1lOnand

MaIItrcbodf PtIoImocrotlcois.

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"

PHARMFACTS

Consumer Spending on Prescription Drugs

Spmdingon~dNgs _ublbaut 10'110olMioNl he.ttto

......

.t.t 1M tInI 01 tht 21st <tl'illll")' (1999-2000), ~ dNg

opflufnwn inuMfd by mort m.n 200'lIo comjlilfd to !be NIIy 1~.
T1If aYl'ligf lIUmberof pmaiption drugs takrn per ",timt CM'rt!J~
UIlIM of" 1m ~.boot 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 ~mge cost ~ pmcription was ibout $29.00.
101.11 p/Iamo.KeUtiu1 nprllditurtS in tilt Unitrd SUtts 1wY!' ioc:~!ed
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 officially established as an ~seno:y of the U.S. Department of
Health and Human Services. The Center for Drug Evaluation 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 a s facilitating the availability of safe, effective drugs; keeping unsafe or ineffective drugs off the market; improving the
health of Americans; and providing clear, easily undersundable drug information for sa fe and effective use. Any
pharmaceutiaJ laboratory, whethel'" private, public, or academic, must solicit FDA approval before marketing a drug .
Another branch oflhe FDA, the Centerfor Biologia; Eval uation and Research (C BER), regulates the use of biologics
including serums, vaccines, and blood products. One historical achievement involving biologics was the 1986 Childhood Vaccine Act. This aet authorized the FDA to acquire
information about patien ts taking vaccines, to recall biologics, and to recomme nd civil penalties if guidelines rellrdi~
biologia; were not followed .
The FDA also oversees administration of herbal products
and dietary supplements through the Center for Food Safety
and Applied Nut ritio n (C FSAN ). Herbal products and di etarysupplements are regulated by the Dieury Supplelllent
Health and Educa lionACI of 1994. This act does nol provid e
the same degree of prot K lion for consumers as the Food,
Drug, and Cosmeti c Act of 1938. For example, herbal and
dietary supplements can be marketed without prior approval 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.

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 eth nkllycan 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

ca re outcorroes.
7. (onW)' tlow genetic polylTlOfpnisms can Influence pharmacotherapy.
8. Relate the Implkalionsof gendefto the actions of certain drugs..

-,....

KEY TERMS

rull1nl compnolKf

pi1Jt J8

mMcitypqlB

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geHticpolymorp/IMI pi1Jt~
holillK ,.,17
hlllllM illegratiol 'JfK1id poqrll

phamiCttHetia JIIlIJ'1JO
psydlosMiil tnT II
spirilu ily fIIJ9t II

C1up1frl

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 suc h as absorption, metabolism,

plasma protein binding.and excretion mechanisms were examined 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 interaction s. Chapter 7010 examined how pharmacokinetic

P5y<:ho",,"l """" ..... 00 Culrur.llnfluenc:e< on I'h.1rmocothe<ap)"

77

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 enzyme. Sophisticated technology is used to identify, image,
and classify the specific structural or fimctional abnormality. Somehow, the total patient is lost in this focus of categorizing 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 dimension! are lost. Yet, these dimensions can have a profound impact on the success of pharmacotherapy. The nun;~ must
consciously direct care toward a holistic treatment of each
indiyidual patient, in his or her psychosocial, spiritual, and
communal context.

and pharmacodynamic factors change patient respo nses

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 view~ as an integrated biologic, psychosocial, cultural, communicating whole, existing and functioning within the commWlal environment. Simply stated, the
recipient of care must be regarded in a holisti(context to better understand how established risk factors such as age, genetics, 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 interoollllected and interdI"]Jendent. Thus, when considering a patient'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 experience 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 symptoms, 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 specific di.!casc., their cau.e.,and treatment . Di,ease i, viewed

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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 con~ compassion and empathy, to give and forgive, to enjoy life, and to find peace of mind and fulfillment
in li~ing. 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 psychosocial situation often require a blending of individualized nursing care and therapeutic drugs, in conjunction
with psychotherapeutic cOWlseling. The term psycho-socialspirimal is appearing more frequently in nursing literature.
It is now acknowledged that when patients have strongspiritual or religious beliefs, these may greatly influence their
perceptions of illness and even affect the outcomes of pharmacotherapy. 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 mod~1

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 impact on wellness and preferred methods of medical treatment, nursing care, and pharmacotherapy.
The psychosocial history of the patient is an essential component of the initial interview and assessment. This history
delves into the personal life of the patient, with inquiries directed toward lifestyle preferences, religious beliefs, sexual
practices, alcohol intake, and tobacco and nonpresc ription
drug "-"'. The nw,e lllu,1 demon,lrate .sen,itivitywhen gathering these types of data. If a trusting nurse-patient relationship 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 treatment, 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 acceptable 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 believe 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 personal 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 effeets. Trivializing the limitations of pharmacotherapy or minimizing potential adverse effects can cause the patient to have
unrealistic expectations regarding treatment. The nursepatient 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 infonnation regarding the benefits and effects of drug therapy.

8.3 Cultural and Ethnic Influences

on Pharmacotherapy
Although often used interchangeably, thedefinitions of culture 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 biuluKi~ ~",.l K,,"di~ siII1il~rili"". (ul tu,~ is ~ sd uf belief" v~l
ues, and norms that provide meaning for an individual or
group. People within a culture have common rituals, religious beliefs, language, and certain expectations of behavior. 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-

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TREATING THE DIVERSE PATIENT

Medication Adherli!nce
Poor adhertOO' to.J pre5aibtd mtdirnion is brcomi~ known >IS Ammca's"other
drug probltm" but roe that has hNlth ind fillinciil ~ MIl 'lNler
thin sU!st.J~ ilKu.lt is estin.Jttd that appro:lirwel)o ~ oftht 2 bilion PII'scriptions filfd ~ach )'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
Dn'eIfilltht~tilllApproxinatdy 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 Ndrqu.J1~ oJ((fIS to heikh GIli', all' Oil!' 01
!ht 91tl.p1111011 il risk.
Ibz Il'I'/e a vitil
in ilKft'iSi~ mtdK.imn mll'ra, both btcaust 01
!ht trustIU II'Lnionship nurse rstablish with their P.J00rts, and betause they all'
oftrn the main IOU~ 01 medication tdJGItion for tht P.Jtimt and thei, fami~
PMYiditg simpif drug inbnnation to help thr P.Jtitnt urderst.wl why J mtdiation 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 ~OKh SIK(filM hNlth UII' Yisit. the nu~ Gin go OY!'I the rneO!ation h~tory,askiJg tptItions 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 obuiri~ mtdK.J1ions and other
lI'qUill'd flt(ffiitifl,lIJ~all'a~ the hNlthull' proYidmil tlltbrrirontol
proYiIitg mtdiGItion mation ind foIllw-t4J that willlI'IUk iI poMtr..r rutrollrl to htalth and prMnlilg nrgatiYe hNlth ~fIeCtS. andMlllarger~i
tull'l,asa II'IUkoi poor III!'ditation adhererl(f.

"*

currence of specific drug effects as pCTcci""d and interpreted 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 Caucasians. Some research now suggests that variations in metabolic processes among various ethnic groups can significantly
impact drug therapy. Through technologic advancement, researchers have identified specific regions on various chromo somes that influence ht>patic metabolism. Certain
antidysrhythmics, antidt>pressanl5, and opioids may be metabolized differently in individuals of African, Native Anlerican, 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 traditions and their potential impact on the patient's care. People
hold cultural beliefs (religious or ideologic) that may chalI,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~ll'pl., [hat illustr"t-.; u,i.>; puirrt is tit .. JiIT.,r.,rr~~ irr Udi .. r sys terns between age groups--each with il5 own unique culture.
(ultu,al (ompetfn(~ in health care is the ability of practitioners 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 requires knowledge of this diversity, as well as an attitude of

CNplfrl Psyc:ho<oclalGende< oo (ulru..llnnu..nc:", on PNrm ocothe<apy

openness and sensitivity. Understanding and respecting the
beliefs of the patient are keys to establishing and maintaining 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 thes e "f_
fed behavior. Nurses can instill trust by attentiveness to individual 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.

79

PHARMFACTS

Minority Statistics and Health Care

In 2000, the m,jority ~thnic: group in th~ United SUites was non-H isp'nic:
Whites, .. 71%.
8y 2025,Ih. poput.tion of non-Hispanic: Whit... is "Pfi~ 10 dKlN~ 10
61%"nd mu f,lItoS5'16 b)' lO4~.
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 r't~ . mong Aroon Am~riuns i! m<n than doublr that
ofwhil:6. HNIt dill'.!I(' douh rates ,ft' mor~ lh,n-4O% higher for AhK.!n
Americans th,n forwhites.~ d.am r't~ for ,II (all(ffl is 30% highu for
AfrKin Americans Ih,n for whiles; for prostlle WK.~ it i! m<n than
double that for whil:6.
Hispanics Ijying in tlte United Stall'S are almost twil:eas like~ 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 ra~almO:ll 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,
ltoll ~11p.1/'WWW.fdc.'JIf/lrnIK1lMl1llNrtH.JWn

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
(r~~(JIl~ll'" h~v~ ~x.is(~ct

fur

(huu,~",.b

uf r~~"

~"ct

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 Environmental

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-

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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 environmental factors have the polential to affect health and access 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 people are reluctant to seek health care for fear of bankrupting
the family unit. Older adults fear losing their retirement savings 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 treatment 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 agencies 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, understand, and act on health information (Andrus & Roth,
2002 ). The functional illiteracy rate is even higher in certain populations, particularly non- Englishspeaking individuals and older patients. The nurse must be aware that
these patients may not be able to read drug labels, lUlderstand written treatment instructions, or read brochures describing their disease or therapy. FlUlctional illiteracy can
result in a lack of understandinR about the importance of

 FI9ur,8.1 Anurse communicates with her non-Engllsh-spea klng patient through an Inlerpreler
SOUrce; A1000n EoPJCorloolPH College.

;;

,i
f
i
,
o

pharmacothenpy and can lead 10 poor compliance. The

nurse must atlempt to iden tify these patients and provide
them wi th broch ures, instr uctions, and educa lional materia ls that un be understood. For non-English-speaki ng
patients or those for whom English is their second language. the nurse should have proper materials in the patien t's primary language, o r provide an interpreler who un
help with accurate translations (. Figure 6.1 ). The nurse
should ask the patient to repea t importan t 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 resu lt in significant diffe rences in
patienlJ' ability to handle cer tain medications. Some of
these differences are created when a m utation occu rs in
the portion o i DNA responsible for encoding a certain
metabolic enzyme. A single base mu tation in DNA may
result in an amino acid change in the eru:yme, which alters
il5 function. This creates a geMti c polymo rphisrl-two or
more versions of the same enzyme. The best characterized
genetic polymorphism! ha ve been discovered in enzymes
that metabolize drugs, and in proteins that serve as Te(eptUl) fur oJ, U!!). Ph".'dwgnl!"liu j~ (h" ~(uoJy uf !!~II,,(j~ Y~rj
ations that give rise to differences in the way patients
handle medicatio ns.
Genetic polymo rphisms are most o ften iden tified in specific ethnic groups, because people in an ethnic group have
been located in the same geographic area and have married

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PHARMFACTS

Community !-Iealth Statistics

in the United States
Arntriurnhcr ~ ir tilt sutuM rill~signific.Jndy 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 ofy~ lIftI"09Oliun
m~

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,., ~igIr
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

"".
o thers wi thin the s~me group for hundreds of genera tions .
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.

Choplfrl

P,ydK)"OC:"~ Gellde< rod

Culrur.llnlluenc:", on PNrm.mthe<apy

81

ABLE8.1. Enzyme Polymorphisms of Importance to Pharmacotherapy

Enzyme

Result of Polymorphism

Drugs U!oIng This Metabolic Enzyme/Pathway

A(tlyltralilferall'

Slow ac:tl1iation in Scaodilaviarn,Jew5, North MOOn

CauusiaOl; fast iKl'tylation in l.pallN

tlffrint. IrJdraialillt, isoniazid,jl"mioamide

Dtbrisoquin IrJdrox~

Poorly mmboliml i1 Asiam and Afritlll.lJnffitlm

am~riptylillf, illipramin r. ptfJlhftwiot, halopffidoI. propranolol.

metoprolol. codtiIt, rnorphin~

Poorly mmboliml i1 Asiam and Afritlll Arnffitlm

The relationship between genetic make-up and drug response has been documented for decades. The firsl polymorphism was discovered in acetyltransferase, an enzyme
that metabolizes isoniazid (INH), a drug prescribed for tuberculosis. The metabolic process, known as acetylation, occurs abnormally slowly in certain Caucasians. The reduced
hepatic metabolism and subsequent clearance by the kidney can cause the drug to build to toxic levels in these patients, who are known as slow acetylators. The opposite
effect, fast acetylation, is found in many patients of Japanese descenl.
In recent years, several other enzynte polymorphisms
have been identified. Asian Americans are less able to metabolize 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 betaadrenergic 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 diazepam (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 disease 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 populations have shown that between 1.5 and 3 times as many
women suffer from the disease. Alzheimer's disease is be~Ulllillg r~glliL.t:oJ iI:i

a majur "wu[[Jt:n'li. ht:allh

is:;ut:,~

aluug

with osteoporosis, breast cancer, and fertility disorders.

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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 antihypertensive 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 embarrassing for males. Similarly, certain drugs can cause masculine side effects such as increased hair growth, which can
be a cause of nonadherence in women taking these medications.Also in females, the estrogen contained in oral contraceptives 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 leaching 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-tomuscle ratio. In addition, cerebral blood flow variances between males and females may alter the response to certain
analgesics. An example is the benzodiazepines given for anxiety; 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 conducted 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 geuder, assessment of polential pharmacokinetic and pharmacodynamic 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 exclusion of prescription of female contraceptives by an employer's health care provider was deemed sex discrimination.

82

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"".,miKolog)r and Ih~Nu ....... 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 ch~pter. 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

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 m edication response.

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. Import~nt 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.

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 ~ffect nursing care and pharmacotherapy. Differ
ences In diet, use of alternatIve thel1lples, I't'rceptlons of
....-ellness, ~nd genetic makeup can influence patient drug
response.

NCLEX-RNOREVIEW 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 comp~tible 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.

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 mater~lI about the drug.
2. provide [.,bels and instructions in large print.
J. ;lS8e5S the reading levels~nd have patIents repM
iUMrudiulIs tu oJ~lt<nJliJl" wl<.l~[""aJloJiJlg.

4. provide instructions only when family members are

present

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.

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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.
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

CRITICAL THINKING QUESTIONS

1. A 72-year-old Afrlnn American heart p.uitnt who has
been treated for ~trlal 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

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

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?

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Medication Errors
and Risk Reduction

LEARNING OUTCOMES
After reading this chapter, t~ 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

7.

errors and incidents.

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.

KEY TERMS
rrwdication administration I'KlJ'd (MAR) fIIlI1'8iJ
m,dicatim 'ITOr fIIlI1'lJj

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med ication elm" index fIIlI1'lJj

med ication Il'(ondliation fIIlI1'!fJ

polypharmacy pogtl/(J
rill! management fIIlI1'91

Chop''' 9

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
may

cau~c

~a ny

preventable event that

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 m ~dicati on f rrar indH. This index categorizes medication
errors by evaluating the extent of the harm an error can
cause( ~ 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 misinterpretations, miscalculations, misadministrations, handwriting 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 patient. This relationship is dependent on the competence of
the health care provider, as well as the patient's full adherence with the drug therapy regimen. This dual responsibility provides a simple, though useful, way to conceptualize
medication errors as resulting from health care provider error 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

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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 morbidityand preventable death within hospitals. When a medication 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 frequent 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 errors. 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

86

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P'harmoc:ology . nd theNurse--p. lil'nt Relationship

---.--C~lIInoe s

NCC MERP Index for

Categorizing Medication
Errors Algorithm

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

Impairment 01 the physical, emotional, or psychological

"'nction or structure 01 the bodyand/or pain r9sohing
therefrom,
Mon~oring

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, do~brillatiOf1, 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 Figu re 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

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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,

CNpta' 9 Me<i""1100 Errors and Risk Reduction

87

ABlE9.1. Abbreviations to Avoid in Medication Administration

Abbreviation

Intended Meaning

Common Error

"

Un~s

Miltam. i l i moor i fOIl' (4) lI'5Uhing in lW~rdOII'.AIIo mistakm for'"' (cubM: (rJliml'l~nl whm poorly
'NIiIttfl.

.,
....

Mimqallll

Mislam. for"mcf Imiligramt) lI'5Uhing inan O'mdo~.

latn ibbrtoiiatiOO for "try day

The pffiod afl:~t~Viul _imtlbffiJ mimktn for ~ "I, ' ind iIH' aug has bffiJ gi'ml "OID'(kIII"
~~ daly) rathtrthan daily.

!.itn ibbrtoiiatiOO for "try

OIhtrd.y

Milinterpreted as "Oil" (daily) or"OID' (fOIl" tiMl dal ~ ).If t~ "0' is pooIt1 'NIiItl'fl, it loot! ~ke i pfflod or "I:

so

SubruuntOOl

Miltam. i lOSr (~inguall whtn pooIfy wrinm.

tiw

~timeaWffl;

Misintrrpreted as "thlff timtl a day" or"twite a wm."

"

Disdlirgt; 01110 ditoorlillUf

htimft meditationliul'!' bffiJ prtINnm, dittontimll'd wIIffi O/C, (intfflied to mI'~ "discharge") Won
misill~edil"dKoo~nue, ' btuu~ ~was foIowrd by i list of drug!.

W.Hnrtngth

Misinl<'rpretod as tho ~n .blnWtion"W,"(hOII" of lI..p}.

UD::(mtiml'l<'n

Mislam. il "U"(unin) whm poorly wrintfl.

AU,AS,AO

latn abbrtoiia~oo for both ~B,

Mitinl<'rpretod as th~ L1~n abblniation ' 01./"' (both ey~ );"OS" (idt ey~);"OD" (rillt ~,r).

Itft~a~rj,jllur

'"

MS, MS04, MgS04

Inwnational unit

Miltam. ulV Ontri"l~nous) or 10 (tm).

Confuted for 0lIl' inothtr

un m~an morpIint !UtiI<' or migntSiJm 5Ullat~.

Nort: From the Nationil Cocninating (0000 for MedK.ittion Error Rrponing and P~1ion, Cl I998- 100/i.AlI Rights Rl'sm'ed.

HOME

&

COMMUNITY CONSIDERATIONS

Preventing Medication Errors in the Home

Ih~ U.S. Phannac:opty'S Saif: Meditation I.M Expert Comminte (Santell &
Coutim, lOMjlt'pOnt that meditation !'lron O((Um n9 in tilt hom~ aft' tilt ~.
!Uk of (ommuniution probltllll (21%), know\edgt deIirit (19%), ind inade
quat~ or loKking roonitoring (4%). T~n pen:tfIt of ~rron aft' {auted by lack of
(ffi to information. Warfarin is thf drug most frequently (9%) associated
with m~diution trron in tilt homl'; OOIt in ffl'quency jft' intu~n (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 nthis study, th~ p.ttitn~ famil~,
or Cil"rgivrr is It'pOHed to 1It.ll fault in 399j, of ~rron. the nurSl' in 36%, and
the p~irian or phifTlloKist in 11%. This ltudy poinn out thr nfed for betlef
~ient educ.Jtion,a tolt in which the nu~ 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 responsibility to report all occurrences. In severe cases, adverse 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 supervision and medical treatments.
The Food and Drug Administration (FDA) has coordinated 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-

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counttr (OTC) drugs, biologics, medical and radiationemitting 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 provide assistance with medication errors is the National Coordinating 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 prevention education.

DOCUMENTING INTHE PATIENT'S

MEDICAL RECORD
All facilities should have clear policies and procedures that
provide guidance on reporting medication errors. Documentation 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 error occurred. Documentation in the medical record must
include specific nursing interventions that were implemented following the error to protect patient safety, such as
monitoring vital signs and assessing the patient for possible

88

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PNr mocology ~Jld

theNurw-P~tlE<lt

R.... tlon$hlp

complica tions. Failure to report nursing actions implies ei ther negligence ( i.e., no int erventions were taken) o r 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 ca lled " Incident Reports,~ MOccurrence
ReporIll,M o r similar ti tles. The specific details of th e l'I"ror
should be recorded in a factual and objective mannl'!". The
report allo~ th", n urse 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 managemen t penonnd for quality
improvement and assurance and may be ustd by nursing
administration and education to identify co mmon 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 actio n , or if the nurse forgets to document
interventions in the patient's char t.
Hospitals and health care agendes mon itor medicat ion
errors through quality and perform:an<:e improvement programs. The results of quality improvement programs alert
staff and administrati\'e personnel abom trmds within
particular units and may serve as indicators of qUJIlity patient 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""lth a m: organiZlltioru as a method to prcv" nt fum...,
Il1i5takes. By an swering three bask questions: What hap~
pened, why did it happen , and what can be done to prevmt
it from happening again?, RCA seeks to prevent anotheroccurrence. Many agencies also co ntinue RCA with the question, has the risk of recurrence actually been reduced?, by
analyzing data postoccurrence. The overall goal of reporting medication errors and co nducting 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 p~rtkular form of event
termed ~sentinel events." Se ntinel 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 e vent, sentinel events are alW<lJ" invt5tigated

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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 n urse 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, cu rrent health concerns, and use ofOTC

medications and herbal supplements. For all medications
taken prior to assessm ent, ensu re 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 d etermine 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 du ring m edication administration that
could result in an error. Wh en 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 medica tion ~ccording 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 mea sure
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 administratio n.
Open medications immediatel y prior to
administering the medicat ion and in the presence of
the patient.

Chop''' 9

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 patien t 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 reports of fatal medication errors that it received from 1993
to 1998. The most common types of errors reported involved administering an improper dose (41 %), giving the
wrong drug ( 16%), and using the wrong route of administration ( 16%). Almost half of the fatal medication errors

C.-gory t.
M error oocurred thE
may h_ contributed to
or ruoJted in the
paenfa d.... th

c.r;....., A:
~"OI

DefInitIons
Harm
Impairment 01 the
physical, emotional, or
p,!I)o'd>oIogicallunction 01

Cat~ H:

~ 8:

M . "'" ocaMTed but

the error <id not ...,.,
... prien! 1M "..,..,.. 01

.....,

orrissian' doai reach !he

Cetegory G:
An ........ occu .... d thal
""'Y hit.... contribut.. d to or
... sulted in permanent
patient harm

C ..egoryC:
An . rror <>CaIfT1Id that
the p.-ient but did nee
".... pAtient harm

...

hospitalization

" - ''''

the palilKllltnd
raquired inter .... ntion

Error, Death

,.. Flgure9.2 NCC MERP Ind ex for Categorlzll"l9 Medication Errors

Source: Cl lOO1 Nar/vool Coordinating Coonell f()( Med/aJll()(l Error Reporflng and Prl!vMrkxl.A11 rfghrJ r~served.

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Int.rvention
May include change
in therapy 01 ltCtive
medicallsu'llical

N.c.... ryto
Su.tain Life
Includes cardiova!IaJlar
and resp;ratory 5,-"""rt
(e .g., CPA, doIibrilation,
intubation)

...... tedin

Error, Harm

Mon~oring

Int.rv.ntion

tomporvy harm to

thero/rom

tmalment

An error ocaMTed thai

reAChed the patient and
~ moritoring to
conIi rm thai it .--uIIed in no
harm 10 the pAlient and'or
required int--.tion
to precIucIe herm

Error. No Harm

clNctu .. of the body

and/or pain reGuHing

To observe or ... cord

r.. l.......m physioIogiCilI
or psychological sign.

Cetegory F:
An e ""r occu .... d that ""'Y
ha.... contributed to or
I"85OJtod in t.. mporary
harm to the pat .. nt and
reqli ... d in~ial or

89

occurred in patients older than 60 years . There is an increase in the risk for er rors in the elderly population because they often take nwnerous medications, have
multiple health care providers, and are experiencing normal age-related changes in physiology. Children are another vulnerable population because they receive
medication dosages based on weight (which increases the
possibility of dosage m iscalculations), and the thempeutic dosages are much smaller.
Nurses must be vigilant in keeping up to date on pharmacotherapeutics 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 current drug references available. Nurses can also call the pharmacy 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 updated daily or weekly by downloading information so that
the information is current. Nurses need to familiarize themselves with research on preventing medical errors to maintain evidence-based practice skills.

An e""r occurred lIlal

mquired int.. lVIIOtion
_ u r y 10 suclain ile

I 0 No Error

MedlGotloo Erro" .00 Risk Reduc:tlon

9.6 Medication Reconciliation

L ifESPAN CONSIDERATIONS

Ag". R" lat"d InUlls in Drug Administration

The Pedi. tric: Po p ul. t io n
A1w~ doubIt-dIKk YkubtioM will iI\Olht! IIIIISf b ptdi~1rit drug
~trllioII.

.lk<liutions!lll)' fIftd to ~ auWd or idminiltfl(C/ in a liquid Iotm.

Alkp.iffntsorc.~howthechild 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 9amp~ 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 bJI.~or CDIIdintnl, btUll!

th.lt tilt mtdiclrtian does nOl ~iwitIr thu ~ (e.f.,Kidio: food

_ H Mf1 ~I DflIIIgr Pc:~
in!rrKI with p""').UstIll9'rie.s
bids .nd ~!of p.iUmu who ~~bttir: oron ir.totogtnir: dim..
WmiJirlg~ into.lI)'~food! 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

rna,

to OIh~, (.~i.e".

Rememberth.t mediclrtiom mly Me idiol)'flCruir: effeas on pediatric:

p.ititnu.Atry UIlIIU.1 ~artion should be inwstiglttd.nd. poIsibiedrug

effect comidmd.
The Elde rl y Population
~berttru the frtqutlK)'of ad'I!'rst ftfr.cts of rntdiclrrions is
~ in tIderly pWftu baiM oflflK~.bitt 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 ff'lOns:(OSt.~ of the pill or
ublet.and Ital or pmeim:! ad'I!'IW efftm.Explort ff.lOns fo, Itfu1
,nd ti~e 'PPlOpriate !ion to ensult tht islUl' is rtSOI'I!'d (t.g., switth
from ll,uge,diffir:u~ 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 ~ iI~tion.
YIIUiI dlitlgesllll)' IlliR ~tion bbrisliffir:u/t to IUd. Fo.-I\orM
adnWitrltio!'l. pIUI'idr largr-prinl itstnrr:tions,
\tile ~.~
\Md if 1WOed,.1'Id rt<omrnrnd ~ al ~tions with ltIe
PN rm.wist Nth time prescription is fiItd Mr W 1If. <o1or, and 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.

l1li.

"

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Many geriatrk patif nts ha\'e5eve!'al drronic medical disorders,eac:h of which may be trtated by individual spfdaliSlS.
It is rommon for these patil'llts to receive multipl e presc:riptions, sometimes for thf same oondition, that have
conflicting pharmacologic actions, a condition t~rm~d
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 frequ~ncy of administration is a major challenge for both patients an d health care providers. Failurt to
properly record mediation information, and oommuniOitethat 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:a tions a patient is taking in an attempt to reduce
duplicat ion, omissions. dosing erro rs, or drug interactions. For example, when a patient is admitted to c:are. the
nurse record s all medications the patient has been taking
at home, induding their dose, route, and frequenc:y. This
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 cart~ are the most likely
placfS that medicat ion rfconciliation errors have bun
found to ~ur.
In 2004, lCAHO identified hundreds of SfriOU!l medication ",rors attributed to mediation reconc:iliation and dfveloped recomml'lldations for their prevention. Hospitals
are now encouraged to implement a process for doc:umenting a complete list of the patil'llt's current medic:ations upon
the patient's admission. Medications should indude prescription mooiClIio ns, ore medications, vitamins, and
herbal products. This medication list should be oommunicated to the next provider of service when a patient is referred or transferred to another setting, service, physician.
or level of art within or outside the organization. On discharge from the faci lity, provide the patient with thf rompletf 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 immediately.

CNpt.. 9 MedlGotloo Erro.uOO RiskRedualon

H OME

& C OMMUNITY
C ONSIDERATIONS
- -

OTe Drugs and Medication Errors

Patitnt US~ ofOTC drugs and natural thtrapies is.! (ommon INson for ad~
~.Jaions ind IIH'diution erron. For ~m~,taking amibiotiu un toWl'r tilt
fifrcti'l~1It\5 of oral rontrxeptim.OTC amihistamine un imer,l(t ldversely
with ,koho~ seriatiYel, amidepres wrm, and amih)'put~n ~Yl'S. [MOO rag~ p'OOl1lto:
Carry a list of J II m~jgtions. ilKluding Ole drugs, di~ary supplements.
,nd medic:inal hfrbs.
Br SU~ famil), and '/arious h~akh care provicltrs holl'r a rop)' of this list
In{~ vitlmins,lmriYl'S,steeping pilis,and binh (ontrol pills.
If possib~,lMolII' pharmacy for all p~riptions, beulM tilt pharm.Kist
is an 6(rl~nt 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.

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.

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 accessing the cabinet and removing a medication dose. These
automated systems also maintain an inventory of drug
supplies.
Larger health care agencies often have risk-manag~m~nt departments to examine risks and minimize the nwnber of
medication errors. Risk-management personnel investigate
incidents, track data, identify problems, and provide recommendations 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.

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Th r QUfstion: What a~ tilt moll common types of mediution mors

occurring in Pfdiitric Poltients?
Th r Study: Arnitw oftht lit~r~tull'going b"k to 1969 found on~ 32
,"YoInt paptrs in tllr !cimtifK literuull' tholt aoIminrdthe irKidence
and nalUll' of IMdic:nion rrrors in dtild~n.The m~t (ommon typ~ of
rrrorwM deliYering an inrormt ON.ln SOml' coIltS,this in'lOiYed
administering 10 times tilt Mnnal ON. The moll freqU!'nt drug
moc:iat~ with thef'rors ~ antibiotic:sand srdatiYes. Tlltadual mo.
rile WJI not po!sibietocakulatedU!' to tllr snull numherof studies.
Nursin g Impliutions: The oIuthors o~r a number of (ommon--srru
suggestions to oIwid medication errors in this population, ioduding
doubll'-<hfiking thf dostS, verifying J If)' m~iutions or do~ 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, ~,KhQJi; l f. & ~ I.
(2006~ Sr;1i'mIIIt rni'w I1f IItdki1IioII 111m In ptdllffk pllIIf'IIB: 5uqgf5I/orI! III
pIl'lImfllldklllil1nmors.tldllH"tll 11M' MMliofPharmao:01IIf!ap): ~10~
1766-1776.

92

Unft2 PNrmocology ~Jld the N urw-P~tlE<lt 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 misinterpretation, and misU!ldersundlng of verbal Of phone
onkrs. Wbether the patient ls In;ured or not, it is still a
medication e rror.

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 m edicatIon administratIon.

9.2

NumerolL'l facton cont ribute to medIcation t'rro!'$, in cluding mistakes in the five rights of drug admlnisu3tion,
failing to foU ow 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 ca re provlden of aU medications tht'y
art' taking, or not following Instructions.

9.6

Medication reconcil iation is an important means of reducing medication errors. Med ication 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-appropria te ntedication 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.

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.

9.8

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 incident report . The FDA and NCC MERP are IWO agencies
that tradr: medication erron and provide data to help in.... ilul.. p..........Jw"," lu pl~Y~nl IJlt'm.

Facilities use riskmanage ment departntents and agency

policies and procedures to decrease the Incidence of medication errors. Automated, computerized, ltxked cabinets
for medication storage are a means of SOIfekeeplngofmedications and keepirtg tra(k of Inventory at the unit k-vel.

9.9 The FDA (MedWatm ), the Institute of Safe Medicatio n

Practices (ISMP ), and th e U.s. Pllarmacopeia (MEDMARX) arethree agencies that tndr: medication errors and
provide databases of error incidence, error types. and lev_
els ofbarm lOr bealth ca~ professionals and/Of consumers.

NCLEX-RN- REVIEW QUESTIONS

Each nUIlie is responsible for becoming f:amlliar with tht'

nurse practi.:eacts o(thestate In which be o r 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 sta t...

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.

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4.

notifythe~cian

and document the error In a report

only.
The patient wilh liver dysfunctio n experiences toxicity to
a drug following administ ra tion ofsevenJ doses. This ad verse reaction may bave been prevented If the nurse had
followed which ph ase of the nursing process!
]. Assessment
2. Planning
3. Implementation
4. Evaluation
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 med ication ord ..rs.
3. identifying potential uDSolfe medication facilities.
4. examining interdisciplirlary caUSo!S of errors and
assisting profeWonais In Wll)'S to avoid mistakes.

o.,pt.'

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.

MedkooUon Errors iK1d Risk Redxuon

9)

When the nurse enters the patient's room with a medication, thepatien! stateli ~ l'mon 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 "una ble to give" and skip the
d"",.

CRITICAL THINKING QUEST'-'.IO

"'N
" 'S
= -_ _ _ _ _ _ _ _ _ _ _ _ _ __
1. A registered nurse Is assigned to a team of ('Igb l patients.
Six of these palients have mediations scheduled foroneea.day dosing at ]();OO a.m. Explain how the nurse will be
able to administer these drugs to the patl('nts at the ~right
time.~

2. A health care provider writes an order for 1)'lmol 3 PO

qJ-.4 for mild pain. The nurse evalua tes this order and is
concerned that it is incomplete. Identify the probable concern and describe what the nurse should do prior to administering 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-

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rlenced nurse notlces the error during the evening shift

change. Ident ify each person who is responsible for the error 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 a~(jtjmat t~-1lti'le practice
Quesmn~. In!/'J'&C!iI,'t ASSIgment'l tnl lClNiIIes. 'M:b 1Wls. Mlmatfons
i nc! ~. nI meI
1II!gL'Ur you' a~ CMe trom !lie fnw11 d )'GUf book at

www.mynursnglUt.c.n.

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. Ana lyze reasons wbyherbill and dietary supplements Mve intrea5e'd In

popularity.
3. Identify the parUofan herb thill may (ontain active ingredienU and
the typeS of formulations 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
~pplements.

6. Discuss the role of the nurw in teac hin g 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.

KEY TERMS
MIlIIliuI J'III"'1S
(_plementir)'iIIId ilblNtM! lIlfIIi:ine{o.M)

.....

ditlllryMlppkolll'M

[JIlIJt9/J

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DiftarJSupplelllfl'll nlll Nonpmrn,tien Drug

herb JIIlIJ''1S

CD115IIIIIl'fPre1titnAct Pl'9!I
Diftilf)' Supplelllfflf IINII~ ilnd EiMaliin Act

5p1'cial!y~ment JIIIII''If!

(DSIO} of 19'J04 JII 9/J

erba l supplements and alternative therap ies represent

TABLE 10.11 Complementary and Alternative

II mu ltibill ion-dollar industry. Sales of dieta ry supplementsaloneexceed $17 bill ion annua lly,with moreth an 158

. . . . . . Therapies
Healing Method

Examples

million consumers using them. Despite the fact that these

AitrrnatiYr IINlth UI! ~rms

Naturopathy

therapies have not been subjected to the same scientific

scrutiny as prescription medications, consumers turn to

Hom~thy

ChiropraaK

these treatments for II variety of reasons. Many people have

Hali";~ Ame!k.in rMdicit~(~.g" !Wt.ll

Iod9rs, mrlkilll' whrtI)
(hilll'H tradtional mmnr (r.g.,
I(Upunct\R, Chiller hrrmJ

the impression that natu ral substances have more hea ling
power than synthetic medications. The ready availabi lity of
herbal supplements at a reasonable cost, combined with effective marketing strateg ies, has convinced many con-

Hrrb.J1 thrrapir5

Ilnritional !Upplrmrou

sume rs to try them. This chapter examines the role of

complementary and alternative therapies in the p revention
and treatment of disease.

10.1 Alternative Therapies

Complementary an d aitrmat i"ft' medicine (CAM) comprises an extremely diven;e set of therapies and healing systems that
are considered to be outside mainstream health care. Although diverse, the major CAM systems have common
characteristics.

SprdIl lirts

Manual healing

Prrnu~thrr'"

Hand-lIIrchtrd bioftrklthrr~

Mild- body int~nlions

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 subjected to rigorous clinical and scientific study. It is likely that
some of these therapies will be found ineffective, whereas others will become mairu;tream treaOTIt'fIts. The line between
what is defined as an altern.1tive therapy and what is considered 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, massage, 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 anxiety 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 adverse effects and improved adherence with the therapeutic
regimen.
The nurse should be sensitive to the patient's need for alternative treatment and not be judgmental. Both advamages

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""

HypROlherapy

Guided imagrry
Biofffillldl

Focus on treating each person as an individual.

Considen; the health of the whole person.
Emphasizes the integration of mind and body.

...,""

".,

Momnmtorirntrd thrrapits (r 4, music,

Spmual

Shamans

Faithandf'1Yff
~lII'Iia

Qr,toxifying thrrapirs

Anilllillmistrd therapy

and limitations must be presented to patients so they may

make rational and informed decisions about their treatment. Pharmacotherapy and alternative therapies can serve
complemenl:lry and essential roles in the healing of the total 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 thousands of years. One of t he earliest re.:orded uses of plant
products was a prescription 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.

96

UntI2 I"ha"mKology . nd th.Nur.e--P~!Im! R..... Uonmlp

TABLE 10.2

",'

Best-Selling Herbal Supplements, in Rank Order

Herb

Medicinal Part

Herb Feature
(Chapter)

Pr1maI}'Uw(s)

(Iarb!lry

BmitsJjuic~

PrfoItnl uinary 100 in'Klion

So

.."

SOUIU of prolrin. vitllTin~ ind mintrall; leI~f of IIItnOP<lHaI !)'IIIptom~ prMrt

Garlic

Sawl"imeno

,
,

Ginl::gt

EdJill!lU

Milt.l.iSl~

St.Joirl'IW(II\

.,.
.""

11

(')lliO'iillWar dill'u~.ln~(ill(tr
Rm~ bbxI dIoIeslmi, ItclOO' blood pr!SlU~. inliloaq.,jalion

TrUlmmtof btnign prOllilK Ir!pMrophy

21

Lu~and~

Impnw~ 1IIffiIOIY. rNw dizzn!'lS

Erti~planl

EnllaOO' inmullf symlll, inti-inllammator}

31

A.. ~lIIin, protffiillll again Illi'll'r Ii least

Il

...,

17

FIowr~I~Slmll

Rm~ .I!ion. ~dlKl'allliel~anl~inflaovnalCf)'

"-

Roo'

RelifoI~ Sl~I\~nIlaOO' immullf \yllI'm.lIKrNII' fa~

lS

45

"

...

ROlli!

Relidof mmopaUR symptoml

81

GrffiltN

".~

ProYidt antioxidant the'aP1; IIIWtr LDI.. dIoIetftOi; prt'Itnt (,)1I(tr; ~iM Ilomam

Il

Evtrir9 !limlOll'

~oil

SOUIt~ of ell'fltial

fall)' addI,~iI'f of ~SlnJiII Of menopaUlaI symplom~ ~id

of rhttmatoid a1hrilillnd Oilier inflamm.nCf)' i)'IIlIIlOfDl

"

13

VaieM

RoolS

RelifoI~ Sl~I\promot~ IIttp

14

14

HomYlJGit 'IIftd

Lu~andnHIlS

n1la00' \9W1 finaiol

"

Graptlffil9100

~oil

!toult~ ot ell'fllial lall)' add\, inlilllid.!n~ 1't\I0r~ mitnxirruliltion to tislue

10

prob!tllll,naUll'l, vomlng

Souill': Ci\\l~~ 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 regulatory agencies required that products be safe and labeled accurately, 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 experienced a remarkable resurgence, such that the majority of
adult Americans are currently taking botanicals on a regular 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 industry, increased attention to natural alternatives, and a renewed 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 alternatives. Nurses have been instrumental in promoting selfcare and recommending CAM therapies for patients, when
applicable.

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PHARMFACTS

Alternative Therapies in America

0111' of th~ lirgest nonstitntifK studie of Initudts IOWlro arnnilNe thtrapie",rveyM 46,000 ~and Wil rtpOI'lI'd in (omumtr R~rn, May 2000.
Findings ofthillludy Mit' u foIloW5;
Siny-fi'/l!' pe((~nl of those IUrveyfd did not UR alttrnatr.! th~ rap~~
primarily btuus~ the)- ~~ milfied with ltandard mtdiolt~atmmlS.
Thirty-fi'/l!' pt((~m uI~d alll'miti~ Ihtrapie, primarily to :tlie!'
symptoms that ~~ 001 SlK{esfully ~<lIed with IOlMntonal thtrap~s.
Th~ ptOpIe mostliktly to try IlttrnatiYt- thmpits wm thll\~ in Sf'/~~
pain Ofwith llresl.
For llmost III mtdiol londitions. ft'Ipondtnts lIall'd that prestription
drugs WM' molt' elFecti'/l!' than h~rllal Ihtrapie.
For balk pain and fibrom)'illgia, ~p musd!- Illi\W wu r<lled molt'
rffKtift than prHUiption drugs.
T~nty-fiVl' p~ltent oftholt who tried ah~mati~ did 10 on the
ft'UImm~ndation of a ph~ian Of nul'\t.Only 5% ofdcxto'J dilapplO'fed
of allmatNe thtrapie.

10.3 Herbal Product Formulations

The pharmacologically active chemicals in an herbal product 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 underground rhizomes and roots are used for their healing

o..plfllO Herb,1 ,00 "'~ern . 1fvto The,ap5e<

LIFE SPAN CONSIDERATIONS

Dietary Supplements and the Older Adult

Can dimlY IUpplellll'MI improw the health of older arultsl Agrowing body
of rl'idrncr is lhowing thit the 1M of rupplellll'flt; un poIitNely inlUtnce
senior< beahh. DirtaIY rupplellll'flU ha~ heen SlJ(Cf'llfu11y used to enhince
their immuor S)'IIMI~ rMucr !horHffiIl rnrmolJ lillS,~!fIl the risks of
Alzheimer'! dilulI', and improYr a<erall health. Nutrition.ll clefidencirs in(lNsegrwtlywith age. and supplements help prwem or eliminate these derKirlKirl in ~nio~ In .Jdciition, !Ome reealth has lhown that older adults
who hi!' low ie'lel! offalate and vitamin Bu haft an ilKrused risk of developing Alzheimer! disrall'. The nurse Ihoold a\!rsltbe ~ far sum rupplemenu in all rldert~ patirnu. The nulll' \hoold be awall' that hrrbal and dirtary
IUpplemenu (an he Hpemift; tiM, tht~ Ihould not be automatically induded in tlNUllt mplim.ln .Jdciition, older adults !hould be f<luutf<l 01110
the risks of megavitamin ther.!p~.

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 capsules made from the dried herbs. Other solid products are
salves and ointments that are administered topically. Liquid formulations are made by extracting the active chemicals 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.

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 delivered 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 active 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

"""

BIad:: (ohOlh mimme

Calura !a>grada barlr
Edinaru pulJl'.l"ea herb

Gingrrrhizome
Ginkgo lea/

Standardlzatlon

Percent

Tr~rrprne ~yIIOO

_0
""'""'"

"

PIIlgent aH!Ipooods

Gruter than 10
24-25

l/ydrol~anth~enK

RaYOgIyaJ~drs

""~.

Ginll'll9root

Ginseosidrs

lU

Kava kan rhiKmt

.-~

4<-41

Milk tliule root

Silymnin

Saw palmetta /nit

St.John's'llOlt

Fatty aOdsand sterols

Hyperidns

1>-00

Hyper/orin

>-S

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0J-0.5

97

.,
~

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

98

UnK2 J>harm Kology.nd theNufW-p. Uent R.... tlonmlp

TABLE 10.4
Product

liquid Formulations of Herbal

Products
()eoscrlptlon
Frt 5h or dri~ htrbs ,lit boiltd in Wittl' for -60 miMe IIllil
IIlKh of l~ liqJid has boil~ off; '/trY (OII(rIItril~

Acliv! ilgrtdiffiu ,lit mloKl~ using Of9anic: IOivtnlS 10 form a

highly (I'lI(ffiUiltd ~q!id or sold form;wi'mIt may ~

rtrnlWfI:i or llt ~rl ofw fiNI prodoct

Infusion

".
1ill(l!l'1'

Frtsh or dri~ htrbs il~ !OoJUd in hoi wa!tI' forloog ptriorI~at

INstl5 milU!e;S!lllrIIjtrth.in tras
Frtsh or dri~ htrbs .. rt SOoJUd in hoi waltl'for 5--10 minUltl
btfurr ingtStion; aHlmliffil

Acliv! ilgrtdiffiu .. rt t1:lr.K1~ usingakohol by !OoJking lilt

htrb;akohol rt'm,illlas ~n ofl~ i~id

...,

..

,. 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 prescription 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 manufacturer. 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, vitamiru, 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 WIreasonable~ risk to the public. It also requires these products
to be clearly labeled by the manufacturer as "dietary supplements." An example of an herbal label for black cohosh is
shown in ;o. Figure 10.3.

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Ib)
Figure 10.3

La~lIng of black (ohosh:la) front label with

general health claim and (b) back la~1 with more health claims
and FDA disclaimer

;0.

Unfortunately, the DSHEA has several significant flaws

that have led to a lack of standardization in the dietary supplement 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 la bels 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.....

CNplfltO Herbal .J>d Ak ...n.U.... """,rap",",

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 attempt to protect comwners, Congress passed the Di~arySup"
plt mfnt .nd Nonp~miption Drug (onsulTII'r Protedion Act, which took
effect in 2007. Companies marketing herbal and dietary
supplements are now required to include contact information (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
~serious adverse event~ is defmed as any adverse reaction resulting in death, a life-threatening experience, inpatient
hospitalization, a persistent or significant disability or incapacity, 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 medical judgment. Companies must keep records of such
events for at least 6 years, and the records are subject to inspection 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, toxins, 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 ~naturar does not always mean ~better" or
Asafe."There is no question that some botaniClIs contain active chemicals as powerful as, and perhaps more effective
than, some currently approved medications. Thousands of
years of experience, combined with current scientific research, have shown that some herbal remedies have therapeutic actions. Because a subslllnce comes from a natural
product, however, does not make it safe or effective. For example, poison ivy is natural, but it certainly is not safe or
therapeutic. Natural products may not offer an improvement 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 healing, suffer harmful effects, and endanger health.
Because some herbal prooucts contain ingredients that interact with prescription drugs, nurses should include questions on dietary supplements when obtaining medical
histories. Patients taking medications with potentially serious 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

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99

women should never take these products without approval

of their health care provider. The nurse should also remember that the potential for any drug interaction increases in
olde, adults, especially those with hepatic or renal impairment. Drug interactions with selected herbs are listed in
Tablt 10.5. Herbal-drug interactions are noted, where applic'lble, in the prototype drug features throughout this text.
Another warning that mu~t be heeded with natural products 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 starting 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 information on herbal prOOucts because there is a good possibility that their patients are using them to supplement
traditional medicines. Patientsshould beadvised to beskeptical 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 medicine!, but instead should be supportive and seek to llIlderstand 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 disorders and discuss which treatment or combination of treatments will best meet their health goals.

, 0.6 Specialty Supplements

Sprc:ilky supplemfnts are nonherbal dietary products used to
enhance a wide variety of body functions. These supplements form a diverse group of substances obtained from
plant and anirnalsources. Theyare more specific in their actio n than herbal products and are generally targeted for one
or a smaller number of conditions. The most popular specialty supplements are listed in Table 10.6.
In general, speci.1lty supplements have a legitimate ra tionale for their use. For example, chondroitin and glucosamine 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 substance 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 products, the nurse should advise patients to beskeptical about the
health claims regarding the use of these supplements.

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

Comments

EdlinoKea (fcllirmtll (III{IIItQ)

Amiodaronr,anabolic: !Itroids,ktllK~ melhoIrwtt

f\mible ilKl1'aIf!I IItpaloloxic:ity

~ ( rOllllo:mrn,oo"Mjum)

Alpirin and othtr NSAIIlI, IItparin, warfarin (Coumadin)

~au~ ~ffiing rill!

Garlic: (ABium >cniKlm)

Alpirin and othtr NSAIIlI, warfarin

~au~ ~ffiing rilk

III\U~n,OIiII Itypo9y<rmkaqenll

Additivt hypogly.:mMt tffffii

Gingtr (ljngibfr offldoolt)

Alpinn and othtr NSAlIlI, IItparin, warfarin

~~ ~ffiing nlk

Ginkgo (Ginkycbiloba)

Antitonvul!oanu

flruibledrt.~ intitOlTlu!oant tffKli~1

Alpinnand NSAIOI
IltplriHndwarfaril

GiIlltll9 (1'ImI' ljIJinquefo6llllBltJlhfNxomlf

stOOfOlllJ)

GoIdrost~1

(I/jdrollilamildmlil)

St. John., wort (I/)ptrirum ptl'fMllUmj

~ata~ blffiing potmtial

Triqdit .nlidfpl!l!oant>

fIJIliblt drt.~ riZLn' thrNdd

eNS~nu

~au~ Itdition

OilJOlin (Lanmrin)

~(JN~ toxicity

Oiurttiu

flruible aUffiwled diLn'lic: ~ffil

III\U~n .nd DIal hypogl)'lmMt agffill

~ma~ h)'pJglytmlic: tffffil

W;Jrf.ril

OMta~ antit~lant t ffffil

Oiurt tks

May drota~ diuretk dltas

eNS dtpm!oanu and opioid .nalqt5ia

~au~ Itdation

e~ (~ndimm_)

May dKrealt cydolporiM itl'tk

Etwirmz. indinaYir

Otmi ltd inlirtlnMral aaivity

ProtUlt inhibitoo

OMtaltd anlir~nwiral aaiYity ofindinavir

SMnivt SffiIlonin reuptal:.t inhibit~ triqdic:

flJlsibie ltlOlonin I1ndKlllH"

ntidepr~nts

\/al""n (VlIk.mauflfd",,/i>j

Warfaril

Otmiltd antitoagulant dlffi,

&,,,bi\!I"ot... btnlOd~"..and 0100 CNS .q..-"ont>

F\IImtiot. ltdotion

"Strotonin I1ndromt:h~diui"..~ IWUting.agitation

1iiJ1t: Il.JIi modifltd from www.pmlhalt.a:rnltrogguidtl

1ABLE 10.6 I Selected Specialty Supplements

Primary Uses

Supplement Feature (Chapterl

Amino . rid,

Blrild proten, mUldt !Irmglh,and m:hnlKt

Cimitilll'

ErNlKt mtr9)' and !pOfIl pffionnantr. htart htakh,IIItII"aY, immulll' flllaion,

. nd malt ftrtilily

"

Cotr\zyrM 01 0

PrMIII hurt diltu,prol'idtantiolidinltOOolp1

II

"'"

Boost immLnt functioMand IIlI'IIIOIY

Fish oil

Rrdutt dIoItstmll Ieoim. mhalKt' lI'ain flnaion, irm.J1t viIWI . a..ity ltlot to pl!ltntt
of OIIII'ga--l fatty adds)

II

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

lDcrobodllJil oodoplilus

Maintain inlt!iin.1 hukh

~tnium

Rrdutt the rilk of trluin typtl o/Untrl

VitaminC

PrMIIlion of rokk

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"
"

IlIoplfltO H<>mal .od Allem"tlW' Theuple,

101

"". Chapter REVIEW

KEY CONCEPTS
The numkred kry concepM provide a ~uccinct ~ummary 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 diverse therapies and healing systems used by many people
for disease prevention and self-healing.

1994, which does not require safety or efficacy testing

prior to marketing. Recent laws have been passed to safeguard consumer safety regarding dietary supplements.

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.

10.5 Natural products may haw pharmacologic actions and

result in adverse effects, including significanl interactions
with prescription medications.

10.3 Herbal productsareavailable in a varietyofformulations;

some contain standardized extracts, and others contain
whole herbs.

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 controlled, scien tific testing.

10.4 Herbal products and dietary supplements are regulated by

the Dietary Supplemenl Heallh and Education Act of

NCLEX-RN" REVIEW QUESTIONS

The nurse oblains information during the admission inlerview 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 .
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.
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.

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II

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.
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.
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 ~nsive 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.

~peciahy

t 02

U"U Pllannacology ano:htllt Nurse-P~tlHlt Rebllonthlp

CRITICAL THINKING QUESTIONS

t. A 44-year_old breast !;aneer $urvivor is placed on (amOlifen (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 myocardial infaraion. He is on the anticoagulant warfurin
(Coumadin) and an tidysrhythmic 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.

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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 fo r (lmw,," and mtiana/es fa r all activities.

EXPLORE

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cnl(ll~r re.io!w materials arK!

willi aclcIiIIoRal tQ.EX'-5l71e lQC\ice

Questirns. Inleracthie 9!JmU11S and

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l\egISlI!l' JOUIICt:I'!SS mOl! from 1M from ~ -,.rur booic at

wwwJllYT\Lnit!lkitcam.

Substance Abuse

DRUGS AT A GLANCE

LEARNING OUTCOMES

CNS DEPRESSANTS pq;Jt 101

Sedatives and Sedative-Hypnotics , . /01
Opioids p!XJt 101
Ethyl Alcohol PJ1 101

After reading this chapt~ the student should be able to:

CANNABINOIDS [QJo!t
Marijuana P190(})
HALLUCINOGENS p /OJ
LSD
'I
Other Halludnogtns pq;Jt' 10
CNSSTIMUlANTS pogtl/()

fill"

Amphetamillts and Methy\pllenidate ~I/()

Cocaine piY/t1ll
Caffeint pi/f 11/
HlmTlNE P'gtlll
TONco) 1M and Hicol~f pi1I}tlll
THENURSl'SROI.E IN SU8STANCUBUSE ,..I1}

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 recognl~e drug tolerance In patients.

S. In the following drug dalses,explaln the mlljor characteristi cs of libuse,
dependence, and toll.'fancl.': alcohol. nicotine, marijuana, hallUCinogens,
eNS stimulant .. sedati"., .. and o plold , .

6.

Describe the roll.' ofthi.' nurSl.' In delivering

substance abuse isSUE's.

ellre to IndIYlduIIIs who have

KEY TERMS
addiction {!IJgt /()j
anPlltion df:fic ivllyptr a(tivky disGrd~r (ADH DI
PJttll
brnlodia~1M fWt 101
IJOSItolMucr PIt ns
dtliritnUff'HflS (OT) /'}tIll

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dflta9-tetrllhydnxannabinol (THO pill}t 1m

Msignfr drugs pajt 1IU

rtticular fonnltion
l<'IIat~e pajt 1C1

opioid pajt lUI

phJ\iCllldl.'pmdl.'rKe jllJtlOS
pS)'I:RdfIics pajt /09
pS)'l:ltoIogi[dl.'pmdl.'rKe pll}tIOS

Iubilarn:ubule

pajt 110

jllJt1()j

toi.rall(e pill}t ~

withdrawallJndromt

fXJ}t /OS

104

Untl2

Pharmac:ology and thfo

Nu.....-P~iI<'nt Rel.otlomhlp

hroughout history, individuals have consumed both

11 .2 Neurobiologic

natu ral substances and prescription drugs to inc rease

and Psychosocial Components

of Substance Abuse

performance, assist with relaxation,alter psychologic: state,

and to enhance social interaction. Substance abuse has a
tremendous societal, economic:, and health impact. Although the terms drug abuse and substance abuse have
been used interchangeably,

substance abuse Is often con-

side red more inclusive because of t he involved legal and illegal agents, misused household Items,and drugs available
tor medication pu rposes. 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 pa tient's own culture and society.

Addict ion is an overwhelming compulsion that drives someone to take drugs repetitively, despite serious health and social consequences. It is impossible to accurately predict
whether a person will become a substance abuser. Attempts
to predict a person's addictive tende ncy 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

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, cocaine, nicotine, caffeine, and alcohol- are obtained from
natural sources. Others are synthetic or d~signtr d rugl, 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 prescription involve agents such as volatile inhalants. Ketamine
and gamma hydroxybutyrate (G H B) are examples of misused legal anesthetics. Athletes often abuse legal anabolic
steroids. Frequently abused illegal substances include marijuana, heroin (opioids), and hallucinogens such as lysergic
acid diethylamide ( LSD) and methamphetamines. Phencyclidine hydrochloride ( PCP) is a hallucinogen with a history
of abuse bu t not so much presently. Huffing of organic,
household, or industrial chemical products is not Wlcommono 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 cocaine acquired by users is obtained illegally. LSD is now illegal, 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, ],,,~au,,, pati""ts r"purt"J hallu~jllatiu"s,Jdu,iuJl',
and anxiety a fter recovering from anesthesia. Many amphetamines once used for bronchodilation were discontinued in
the 19805 after unpleasant psychotic episodes were reported. The swn of this information relates to the diversity
of substances within our culture, which patients can either
misuse or abuse.

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PHARMFACTS

SubstanCl! Abuso in tho Unitod Statc!s

Twenl)'~ht million Americans 11M us~

iIIKit drugsat INst onct.

rille for substanct
abust problerm ~ptcially with btnrodiuepine, opioids, i nd akohol.lt is
estimattd that 6% to 8'l(j of health proft-lSionak M~a substanct abust

NUfVS ,lOd other ht akh (a~ providtrS all' <II inc~i!fd

probltm.
25% of high hool <tudtnlS Ust an ~J.g.1 drug monthly.
Ivl tstimmd l 4million Amtoom have ul>ell ht roin during thtir li~.
About one in fil'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 (hild~n of nonakDholic: P'll'Ots.
Akohol is an important f<Ktor io 68% of mansLlughttr"S,54% of murdtrs,
48% of robberits, ,nd 44%ofbul9la~.
Among)'OlJthbt~otheagl'Soflland 17, 7.2 million h~druok
akohol at Imt onct.Giris wt'~ as liuly as ~ 10 drink akohol.
Baroitura~ovtrdost is a fa(lOr in almost one third of all dru!l""ll'lated
deaths.
36% of 10th-glide student! and 46%of 12th-g~t studt nts hm
Il'ported using I!Iirijuao, , nd hashish.
Almost8% ofhigh school stoiors hal't ~ported using (ouilll'.
1 million Amtriuns Mt Ustd (!luiIII' on a monthly basis;about 567,000
Me ustd (f,(k(ouint.

Approximat~ 70% of the (!luiIII' tnttring the United Stat~ rotneS from
Colombia and paslf"S thlOlHjh south Florid.!.
16% ofSth graders and 11% of 11th graders hal't ~port~ usingvolatilt
iohaLints.
30% of all Amt riuOl all'(igall'l~ltrours, in{Uding 25% who all'
bttwttn tht igtS of 11 and 25.
41% of 10th-glide studtnts and S4%of 12th-g~t studtrtts hm
'rport..! .".,kin\! <iy.,. un. 8'l(j uf 12~,-\!,.dr ,\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.

CNp1IIl1

Sobnan<l',o..bu...

t 05

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 be~
gin with a legitimate need for pharmacotherapy. For exam~
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 prescription 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. Prescription drugs in fuct rarely cause addiction when used as
pr"-'Crihecl

~ncl ~CCClrding

to

~cc.eptecl

mroic.al pmtocok A.

mentioned in chapters I and :ZOOO, nwnerous laws have

been passed in an attempt to limit substance abuse and addiction. The risk of addiction caused by prescription medications 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.

Th r QUfstion: Arr thf ll'(onneuions be_n a sedenlilry lifestylt,s~

Il'bted disorder\, Ind drug addiction?
Thf Stilly: Sc:iffitists ill' be9nning 10 bf,1ifwo that mrtisr may help ~Yrllt
addi:ti:1II1O akohollnd drup, and this may apply 10 various dlMJiul
!Ubltall'S~ welLEmtra!lJl}gfsts thit fll't<ising tefmall' SO% less
~krly to I/IlOke than their inanjy~ rooo\frp.lI15. Forty peltrrlt art IHs likrly
to apl'rimmt...mh IIIdrij:JaIld.AliJIts woomgq in somet)1leof regular
ph~1 activity all' less lilrely lOabul!' akohol than thai!' who ~adiully
frrtM.AerobH: flI'rtil!'lf11m to ~1hf likrlihood thit IIIfIIIbmolthe
general popYlition willeH out ttw, l!Wan:ling r~ts 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 ~monary hNkh,forustd physical actiYity
srems to drcrease tilt pre\'i1rn<r 01 (fllilir Stm5-rriated disordfflllKh is
anrift)<,dr~,ind 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 Ph~1 AaIl1\)' iIId ll>K1If PrfWIII Drug Abwl PromoIIng i fu~
R~g(Sdfna> lotnloml F'lrIl'Iltloo. MMngltrfltNMtmilmdrrJ1I'ofOl!J9.'JItM
(NNW, Nrl!brollruttum It HNlrh (N11q, Bl>rt1rsd4 .Ill! BIt 54, 2tlIt

, '.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 depefulence. Substance dependence is classified into two categories, physical dependence and psychologic dependence.
Physkal depmd~n(r 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 accustomed 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, psyd1dogicdependrn(~ refers to a condition where
no obvious physical signs of disoomfort are observed after the
agent is disoontinued. The user, however, will have an overwhelming 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 responsible for relapses during therapy. For psychologic dependence to occur, relatively high doses of drugs are usually
taken fora prolonged period of time. Examples include marijuana and antianxiety drugs. On the other hand, psychologic

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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 substance is discontinued, withdrawal s)'lldrome may occur. Pre~
scription drugs are often used to reduce the severity of
withdrawal symptoms. For example, alcohol withdrawal
might be treated with the short-acting benzodiazepine, oxazepam (Serax); opioid withdrawal might be treated with
methadone. Symptoms of nicotine withdrawal might be relievt'd with replacement therapy in the form of nicotine
patches or chewing gum. For withdrawal from CNS stimulants, hallucinogens, marijuana, or inhalants, specific pharmacologic 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 substance abuse treatment facility. Examples of drugs and associated 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 taking 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

106

Pl\armacology and tt..> Nu.....-P.1k'n1 Ret.tklmhlp

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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 ~~on,diminiWd l!ft~

rrlpirator} dtpmWn

~1Lrn,delirillll

~rbitll'a~
Btnzodiaz~1\K

IlI\OIIInia,inutl1, wuknm,abdomilal aamp~ tJftllOl;a_ua,lMJlI'~

skin h)'pel'loffiliti\'ity rOOions, halllKilations, delWiIlll

~tll' CNS.s!ion, tl1'lllOl', diaphm~~ vorriting, cy.Inosis,

InlMlnia,rtltlt!sn~abdGmiul pail,rulM~, 5rIiIivity 10 MghtJM

Sfl/MfIIMct, confulion, diminilhtd r~xt~ coma

lItididl~ fil~ mUldt

!4Ur.:I,

lid1yC.lfdii,~~SIOUs lI'spi"ilionl

lwitdlt!

CouilWJM
JmpMimillt!

MrotiIl dqmsion,anxiuy,mll'lIW fit~ h!llgl'r

Oysrhyr:hmia~ inlla-w,lkin paI~ psydlo~!

1l.!l100n09ffil

IYrrIy obstrffiI; rkopffidtnl on sprdfK drug

PinK lI'actiom, (onfusion, ~ullftll'i Wn, iOO1'~ in blood

pmslR,psydIotK~iR stat~

Imubility,lI'stltslrH'I\illlOllllia, umor,dlil~ W!'ighllou

"'-ri):Jaru

r;-OtilW

wphw, paranoia, pank lI'.wion~ halllKiutiorK, p!)'(hotkKkro

Irritability,inxitty,lI'lIIts\llesl,hurl.!dlts.iool'istdapp6~~,inlOllllia.
inabil~y

10 (OIKffitral~,dffiU 5o! in lItarl raltand blood preSIlft

IWNti'l1j. rt\tItsl/lrlS, diiaRd pupiI~ agitation, goosttunps, 1Iflnor,

violml yawring.Oistd heart raR and blood prts!lJ'l', nausul'lom~iIg.
ibdominil uamps inrl pain.mUld~ !pi!illli w~h kilking IIIIl'mIIml~
wftght Iosl
Ex(ts~

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 pharmacotherapy,a patient may find that 2 mg of a sedative is effective for inducing sleep. After taking the medication for
several month<;, the patient notices that it takes 4 mg or perhaps 6 mg to fall asleep. De~lopment of drug tolerance is
common for substances that affect the nervous system. Toleram:e should be thought of as a natural consequence of
continued drug use and not be considered evidence of addiction 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 narcoticanalgesicsafter 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 constrict the pupils. Patients will often endure annoying side
effects of drugs, such as the sedation caused byantihistamines, if they know that tolerance to these effects will
quickly develop.

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w"

HUrl palpit.Jtions, t.Jdr,IIlT)'Ihrri.J~ (onflllion.~rtslion, 5o!i11Rl

RtspiralOl)' dtpm~on, tyan&lil, UIR'Irlt IOOIndelKt,(OIIU

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 anesthetics. 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 CONS IDER ATIONS

Abuse of Volatile Inhalants

by Children and Adolescents
Man~ pilt'llU a~ IDrumed that thtir (hildlt'll willimoh tobai(o or mInjwna 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 ch~mkil~ known as hrJfing, is roost pR'{ilent in the 10- to ll~ar-old 191' group and de<lines with a9l';olM'in fi~chil
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 ~n whipped crt'ilm propellants. These ~I!
irf aYiilablt in thr hom~, in ltorr-s, iM in the wortpLl(t.ihry 111' intxprmi'',
Itgalinrl GIn bt us~d 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. Nu~ who worlc with
ptdiatrit patients should bt /Mile of th~ widespread nalUlI' of this typr of
iOOIl',IOO advisf pa~nl! to kerp a ,loll' watth on voIatilt substilKH.

CNpttrll

The terms immullity and resiltallce are often confused

with tolerance. These terms more correctly refer to the immune system and infections and should not be used interchangeably 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 barbiturates, non barbiturate sedative-hypnotics, benzodiazepines, 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 tolerance develop when these agents are taken for extended periods at high doses (chapter 200) . Patients sometimes abuse
these drugs by faking prescriptions or by maring their medication with friends. Sedatives are commonly combined
with other drugs of abuse, such as CNS stimulants or alcohol. 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 (Seoo nal),
and a combination of secob.1rbital and amobarbital (Tuinal). The medical use of barbiturates and nonbarbiturate
,ooMive-hyl'notio; hu. declined markeclly over the l'''-~t 20
years. The use of barbiturates in treating sleep disorders is
discussed in chaptt'r 1400, and their w;e for epilepsy treatment 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-

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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 abusing 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
~i ~dl, 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 effeels, including the brief, intense rush of euphoria sought by
heroin addicls. Individuals experience a range of CNS effe,Is from extreme pleasure to slowed body activities and
profound sedation. Signs include constricted pupils, an increase 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 narcotic sometimes used to treat opioid addiction. Although
melh~done

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 exposed 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 morphine, 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 consequences associated with long-term use, small quantities of

10 8

Unlll

Pha~1ogy ~nd the

Nurse-Pitlent AeL.lUomhlp

alcohol consumed on a d~ily basis have been found to reduce the risk of stroke ~nd hent att~ck.
Alcohol is classified as a eNS depre5S;lnt because it slows
the region of the brain responsible for alertness and wakethe blood-brnin barrier,so its
fulness. Alcohol easily
effects are ~rved within 5 to 30 minut es afte!' consumption. Effects of alcohol ~/'(' dirlly proportional to the
amount consumed, and include relaxation, sedation, memory impairment, 10$$ of mOl:or coordination, reduced judgment, 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 an tidepressants can cause drowsines.o;,
memor y diffiruities, and loss of motor coordination. Cer
tain mouthwashes contain ~lcohol and ca use the breath to
smell like alcohol. Duringasses.o;ment, the sk illed nurse must
consider these factors before confirming alcohol use.
The presen,e offood in the sto mach slows the absorption
of alcohol, thus delaying the onset of drug a,tion.
Metabolism, or detoxification of ~lcohol 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 hypotension, respiratory failure, and coma. Death due to alcohol 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 res uh .
With acute a1oohol withdrawal. benzodiazepines are the
preferred drugdass for lTeatment (Valium or LLbrium therapy). \'/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 w~b of cessation 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 ~dverse 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 abnormalities ill blood cloning and nutritional deficiencies. It also
sensitizes the patient to the effects of all medications metabolized by the liver. I=or alcoholic patients, the nurse should
begin therapy with reduced medkation doses until the adverse effects of pharmacotherapy an be assessed.
~liriumtl'@ffiHl (DT) may occ ur in individuals who have constantlyconsumed alcohol for a longer period of time. Symptoms are hallucinations, confl.lSion, disorientation , and

,rosses

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COMPLEMENTAR Y AND ALTERNATtVE T HERAPIES

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 (~lI\urift.The tctM ingrtditftt
in mr, milk tMtIr plant{Si,am,.-..um), ~rin,1Ii1 been aH'IlinMdto
math~IJIiIitie(Rimbalii.J.cobs,~o,'GIwd,2OO1~

Stuclin 11m shown that .ilrin iI iI* to new.1izt the ~ of ilkohol,

and iIOlIIty stitdlff' Mr If9I'ntmm It tcU II l ~tiolidu. 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 Mltic.J~ propMies hil\le ilM been docu
IIIftItfil {Song H i1..lOOti~ Milk tNult lin bftn diinwd 10 ttOJo:~ lilt gIOWth
of (iJ1\(ff uk Most (liims ~Jding mil tMtIr h.w not M mUd
through CO!ItroIHi mJcfe.

agitation. Many patients experience anxiety, panic, par.lnoia, and sensations of something craw ling 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 tSOC ). Long term treatment for alcohol abuse includes behavioral counseling and self-help groups such as Alcoholics Anonymous.
Disulfiram (Antabuse) may be given to disc:ourage rel~l'ses.
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 effe.::tiveonlyin highly motivated patients,sin,e the success of
pharmacothe!'apy is entirely dependent on patient oompliance. Alcohol sensitivilf continues for up to 2 weeks after
disulfiram has been discontinued. As a pregnancy ategory X
drug, disulfiram shou ld neve!' be Imn during pregnancy.
In addition to disulfiram, ao;amprosate akium (Campral, I=orest) is an FDA.approved d.rug for maintaining alcohol abstinence in patients with alcohol dependence. Studies
comparing the therapeutic benefit of disulfiram with aat mprosat~ have not b.oen fully d~ mo~tratN. nl~ drug mOlY
benefit patients who are not candidates for naltre.'tOnt therapy. (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 contraindicated 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-

Choptflll

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 d~lt;t.
9-tetrahydrocannabinol (THO.

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.

MARIJUANA

11.8 Hallucinogens

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 marijuana slows motor activity, decreases coordination, and
causes disconnected thoughts, feelings of paranoia, and euphoria. 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 ve~ls. 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 introduces four times more particulates (tar) into the llUlgs than
tobacco smoke. Smoking marijuana on a daily basis may incrt'ase the risk of lung cancer and other respiratory disorders. Ouonic use is associated with a lack of motivation in
achieving or pursuing life goals.
Unlike many abused substances, marijuana produces little 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

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 report completely difft'rent symptoffi'i, and tht' same person
may reporl different symptoms with each use. Users who
take LSD and psilocybin (magic mushrooms,or~shrooffi'i")
( 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 lUlusually 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 experit'nces can be terrifying and may include anxiety, panic
attacks, confusion, severe depression, and paranoia.

/H,, - CH.

C- N

CH. - CH.

OP(OH),

CH,

I
W-CH.-

CH, - N(CH.l.

,
I

Ps ilocybin
(4-phosphoryl-OMn

LSD

Flgu~ 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.

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11 0

Untl2 Phannac:ology ~nd tho> Nu......-P.tk>nt Relatklmhlp

Mescali ne

. 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

.. 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 ~II"'; uf uuluuJl ~h~r~~l"r' ur IIr~l'h.i~s rd~l...u lu <.Ieull ~ul
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 after 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 pr~ure, 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 .5)'Jlthc~iz.cd 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

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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 exhilaration, improve mental and physical perfonnance, reduce
appetite, prolong wakefulness, or simply ~get high." Stimulants include the amphetamines, rocaine, methylphenidate,
and caffeine.

AMPHETAMINES AND METHYLPHENIDATE

CNS stimulants have effects similar to those of the neurotransmitter 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 gi~ the user a feeling of self~onfid~n"", 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 cardiovascula r and respiratory activity, resulting in increased blood pressure and increased 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 illega l methamphetamine
(meth) laboratories. A structural analogue of methamphet-

CNplfr II

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 defic it!
hyperilCtivity disorder (ADHD). Ritalin has a calming effect in
children who are inattentive or hyperactive. By stimulating 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 discussed in chapter 1600.
Ritalin is a Schedule II drug that has many of the same effects 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 injected IV. Ritalin is sometimes mixed with heroin, a combination 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 Andean 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 similar to those of the amphetamines, although its effects are
usually more rapid and intense. It is the second most commonly abused illicit drug in the United States. Routes of administration 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 ternperature.After the fe~lings of euphoria diminish, the user is
left with a sense of irritability, insomnia, dep ression, and extreme distrust. Some users report the sensation that insects
are crawling WIder the skin. Users who snort cocaine develop 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 amphetamines 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

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SUbstalKf ... b.."e

111

added to OTC pain relievers because it has been shown to increase the effectiveness of these medications. Caffeine travels to almost all parts of the body after ingestion, and several
hou", ar~ 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, irritability,and insonmia. The physical effects of caffeine include
broru:hodilation, increased blood pressure, increased production of stomach acid, and changes in blood glucose levels. Repeated 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 although 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, stronglyaddictive, 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 consider 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 several hours.
Nicotine affects many body systems including the nervous, cardiovascular, and endocrine systems. Nicotine
stimulates the CNS directly, causing increased alertness and
ability to focus, feelings of relaxation, and light-head~dness.
The cardiovascular effects of nicotine include an accelerated he.1rt rate and increased blood pressure, caused by activation of nicotinic receptors located throughout the
autonomic nervous system (chapter l3OO). These cardiovascular effects can be particularly serious in patients taking 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 affects the endocrine system by increasing the basal metabolic rate, leading to weight loss. Nicotine also reduces
appetite. Otronicsmokingleads to bronchitis, emphysema,
and lung cancer.
Both psychologic and physical dependence occur relatively quickly with nicotine. Once started on tobacco, patit'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

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 hig~t
ra~ ~among Ameri<an Inciam i nd AIasb Natim.Afri:an Americans al!o~ i
hMjl Pf".m olvnoking.~ kIwrIt PIM~lKf ~ imong Alian American and
Hiijlanic: womm. Of paMmar ((I!)(f!n is tilt 1M 01 oHhomising by the tobao indUllry to targtt !pKifK agt Of ethnic: glOJps thrrugh mrming in magalintS
publilhedfor~ifK fthnicgroups DrOll Idta tebilion WrM.
SmokiIg and other tobHoo !Ill aft' major contributors of tilt thrfl' itading
QUItS of d9th iI African Americans- lltan dilt3ll', UIK~ and , . A!ritan
American men art at lealt SO% IIIOft' ~u~ to rIMIop king call(ff than Wh~
mtn.(~broyuaMr diltall' ~!Wier as hMjl amongAfric:anAmfflcan men {ompoalfd with White men.Afri:.n Amfflcan women do oot lart any bettff: The incidenuolltrokes illW~asligharnong Afric:an.o\rnfflc:anwomenasamongWh~
women. Nul>eS moukl mate thti" ethni!aly d~ 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

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 diagnoses. 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 communication skills and by demonstrating a nonjudgmental,empathetic attitude, the nurse can build a trusting relationship
with patients.
It is often difficult for a health care provider not to condemn 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 consequences 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 social 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.

KEY CONCEPTS
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 individuals. All of these substances share th .. common characteristic of alterin g brain physiology and/or perreption.
III Addiction is an overwhelming compulsion to continue re-

peated drug use that has both nt'Urobiologic and psychosocial components.
113 Certain substanCf'S can calise both physical and psychologic 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.

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11.5 Tolerance is a biologic condition that ocrurs with repeated use of certain substances, and results in the necessity 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 coordination.
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.

CNpUI" II

SUb"."", Abu,,,

113

11 .3 Hallucinogoms, including LSD, cause an altered state of

thought and perception similar to dreams. Their effects
are extremely variable and unpredictable.

11 .10 Nicotine is a powerful and highly addicti"e cardiovascular and CNS stimulant that has serious adverse effects
with chronic use.

11 .9 CNS stimulants-induding amphetamines, methylpheni date, caffeine, and cocaine--increase the activity of the CNS
and produce tncreased w.tkefulness.

11 .11 The nurse serves an important role in educating patients

about the consequences of drug abl1St' and in recommendlng approprtme treatment

NCLEX-RN " REVIEW QUESTIONS

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
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
A l3-year-old boy has been showing signs of paranoia and
anxiety and, according to his parents, has been ~acting
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
youn g 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
Th<' p"ticnt with a history of alcohol abuse is admitted to
the hospital. The nursing cu e plan includes assessment of

the patient for which of the following symptoms indicative 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

1:1

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 nicotine! (Select all that apply. )
I . Headaches and insomnia
2. Increased appetite
3. Tremors
4. IllSOmnia
S. Increased heart rote and blood pressure
What is the difference between physical and psychologic
depe!ldence~

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.

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 ~just one dose."' The nurse is con cerned that the mother lacks sufficient knowledge to be
helpful. What teachin]!. does the nurse conduct?

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2. Thewifeof a 24-year-old professional football player isadmilled 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 interventions should the nurse perform!

11 4

UnII2

PNo'~ology

and tho> Nufw--P.ik'n1 Relallomhlp

1, A 44-year-old bushll'SSman travels weekly for 1115 romp<l lIy and has h.ad difficulty skeping in MOlle hotel aft~r another: 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
someth ing Sl ronger: What does the nurse consider as plrt
of the assessment!

See Appendix D forall$wers and rationales for all activitlrs,

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EXPLORE

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one stDCIlor cnlLre

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indl'i:lecs, m mont
fIeg_ )l1li' IICC\!. 0'J0e fftWn die fmnI M \IDlJJ Mr* 81
www.mynll'lingtutcam ,

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 e~amples 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 e~posures.
11. Explain fundamental elements of toxicity treatment provided by the
nurse.
12. Describe specific antidotes used to treat common overdosed
substances and toxins.

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

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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

11 6

Untl2 Phannac:oiogy .00 ttl<> NufW-p. Uem Rel.1tlon,hlp

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 identify,isolate, or treat the causes of global diseases,a major incident could easily overwhelm health care resources and
produce a catastrophic loss of life. Drugs are a major component of emergency preparedness plans. Drugs are also a

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 federal agencies as the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Defense have
stepped up efforts to inform, educate. and prepare the public 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

component of poison removal protocols, and some drugs

serve as antidotes to counteract the effects of specific poisons. 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 nuclear 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 regarding disease outbreaks was focused mainly on the spread of
traditional infectious diseases. These included possible epidemics caused by influenza, tuberculosis, cholera, and HI V.
Table 12.1 lists the 10 most dangerous infectiou~ 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 awareness 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-

TABLE 12.1
DIsease

PHARMFACTS

Potgntial Chgmical and Biologic Aggnts

for Terrorist Attacks
Robtrt SttYMI, th~ 63-)'Nr-01d rmplu,ft of Am~riun M~dg whoditd in
Florida on October 5, 2001, wu the firl! jlfrwn to die from anthrax in th~
United Sme in 25 ~m.
In 1979,ac:ddental reIN!I' of amhraxfrom a IflNrm lab in the Soviet
Union killed 68 ptOpIe. The problem was mred to a f, uk, air fik~r.
Tht Ebola virus uusn dwh by hemormagK fewor in up to 9O%0lthe
patienn who !how dinic.!1 s~mptorm ofinmtion.
Eboia viruses <I~ found in {ffltral AfrKa.Akhough thelOUn:~ of th~
viruses in na1U~ ~mains unknown. monkeys (Jig. homans) appm 10 br
llJI(~ptibie to infection and ~Ift as soon:ftof the ViM ~ infected.
WtdtsplNd publK Im<lllpox I'aCdnations (Ns~d in the Unitt<! Stat~s
in 1972.
It is fttimatt<! that7 million to 8 million dalft ohmalipoJ I'aCdneart in
!IOTag!' at the CDC. This ma cannot br mrl)- ~ished. sinc:f all
ymine production facilities Yo'! ~ dismantltd aft~r 1980, and n~w Ruine
production ~oirft 24 to 36 months.
MOlt n~ agtnts ~~original~ produred in <I l1'arch for insKtilides,
bot bK.iUII' of their toJ:Kit)o, theyWffl' evaluat~d for military l/\('.
(hen!ic.!!s us~d in bioterTorist olds need not tit Sl3phistKat~d or difficuk to
obtain: ToUt inckJstrial chtm Kals IlKh as chlorine, phosgtne, and
h)'drvgm cyanide a~ used in (Qmmtrti.J1 m.nufolduring . nd a~ rudiiy
,w<lilablt.

The 10 Most Dangerous Infectious Diseases in the World. 2000

Causattve Agent

Target

Deaths per Year (mliltons)

hn~nza

IiMmDphiIuf ill1lwfllM

Rt5piratoryl)'lll'll1

17

T!btn:ulosis

Mywooatrium rubmlosis

""ffi

'fibricrhoJtfUl'

"""

Oigfsti',or, UK!

I.'
I.S

Immolll' ~5p(m~

l.l

AI.
Miltaria

"',,'"

IItpititis B
Whooping (oujl
Tmnus
OengUl'ffflf

Human imm!llOdtficitrq virus

PIolmodirJ,"f~

6tooddisortltr

'.S

Rubtola l'irus

L!IIgsand mtningts

0.%

IItpititis hM (H8V)

"'"

0.""

~r.ltOl")'IYIi~m

0.41

Enti~ body Onf~(\ions)

o.m

Enti~ body

0.1 4

Son/ertlloperllJl5is

I OusDidum m.ID
Ral'iviM

(fe'ml

Soultt: .kJ1y 2001 rtpor1 by th~ 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 greatest concern include acutely infectious diseases such as anthrax, 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 disasters 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.

In 2001 1CAHO issued new standards that shifted the focus from disaster preparedness to emergency management.
The newer standards included more than just responding to
the immediate casualties caused bya disaster, they also considered 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 coordinate its efforts with community resources, such as other
hospitals and public health agencies. State and federal agencies revised their emergency preparedness guidelines in an
attempt to plan more rationally for a range of disasters including 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 occur 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

TABLE 121 I Categories of Infectious Agents

Category

Descrtptton

EXllmples

Agtnl> thilt:tan t~ ~Iy lit diSlminalrd or tr.Inlm~lrd pmon 10 person; (,JIM hi91
mortall1, with poIt nlial for m,p" poJIIic htakh impaa; rrighl (,JIM]I\tIIi( panic ,nd
social Ihruption; or rt!pire !pfdaI action for public htallh prt~dlltSl

BtxiIIu! onrhrud! [afthrax)

Oosuidium IIorulioom lolin [boIU~5III)

Hmd5lllQ ruIoffn<is [ 1~rri.J)
~ map" [smalpox)

Viral hffiIorrhagicil'W'n lUlhas MarllJrg and EboIa

!miIb'Q pmif~)

Agtnl> thilt:are modffilltly til)' 10 dilsffilinatt; catrlt lI"IOdtratt morbidly and low
mortally; Of requll' spffiti( mnc:mlffill of (1)('\ diagl105IK (,Jpadty ,nd mlwlK td
mlNlt IlrlrillalKt

Broal/Q sptOO [brIn11oli1)

IilJrklrolderiQ mo/Id (~oden)

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
C!~dium ponum
(

mt'rgilHj pathogl'nlthat (OWd lit tnginmtd for mall dilltminalion iIeGIultoithti"

milolbilit): tilit 01 prooiKtion and ml'itlllmtion, and potential for tigh morbiditJ and
mortall1 rate ,nd major htakh impam

Hantavirul6
MutKtug-rristanl1Ubfflulosi I
Nipah Vlus [NiYJ
fld.-bomr ffiI~I~1 vi'ul6
Ydowfl>oltr

SouA?hllp:l/Www.bl.k.9O'I'~iCjtntlist-<ittgOlY.alp

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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 firstresponder teams as a resource to their commWlity.
Dia~'wsis 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 casualties. Although planning for such an event is an important
part of disaster preparedness, individual health care agencies and local commWlities could easily be overwhelmed by
such a crisis. Shortages of needed drugs, medical equipment, and supplies would be expected.
The Strategic National Stockpile (SNS), formerly called the National Pharmaceutical Stockpile, is a program designed to
ensure the immediate deployment of essential medical materials to a community in the event of a large-scale chemical
or biologic attack. Managed by the CDC, the stockpile consists 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 locations 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 situation by federal goverrunent officials.
11",""""".1 SNS ""JJlPU"~Jlt "",,,j,c,,, uf a ..,ncl..-rnd ndYro 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 pharmaceuticals more specific to the chemical or biologic agent
used in the attack. VMI packages are designed to arrive
within 24 to 36 hours.

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The stockpiling of antibiotics and vaccines by local hospitals, clinics, or individuals for the purpose of preparing
for a bioterrorist act is not recommended. Pharmaceuticals 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 incidf.'nt hdps nurses plan and implement emerg,m,y preparedness 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 empl~s were threatened,
and the U.S. Postal Service was interrupted for several weeks.
There was initial concern that anthrax outbreaks might disrupt 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, induding cattle, sheep, goats, horses, donkeys, pigs, American bison, 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. Clinical 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 symptoms associated with almost every form of anthrax. Another
component, the aruhrax binding receptor, allows the bacterium 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.
ll,,,,,~ 'pur .... an, lh~ ",aill ~au,~ fur puuliL ],,,altl, ~U"L~rll,
because they are responsible for producing inhalation anthrax, 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

TABLE 123 I Clinical Manifestations of Anthrax

Gistroinl61inalanllnl

Dl&r1ptlon

Symptoms

MOil (0III00Il but lust (omplmd form of anthm; ~lmosI

~lways 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 1Wffk; uonol lit spmld by ptrsoMU.ptIIOI

Ra!! form of anthlax;w~hOUl t!!atmftl~(,)n lit ltlhal in !4l 10

SOlI) of UI6; muks from t.!1ing oIIutr il-rontaminatrd food,

~ throa~ diffirull1 swallowing. cramping diarrllN, and

ibOJrninallWl'lIiIg

<0000

usualymt~l

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

site for tissue injury and fluid accumulation. Meningitis is

also a common pathology. If treatment is delayed, inhalation 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 effective 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 concerned 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 confinned.lndiscrimina te, U1mecessaryuse of antibiotics can be
expensive, can cause !ignificant side effects, and can promote
the appearance of r~istant 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 subcutaneous 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 recommended.At this time, the CDC recommends vaccination
for only select populations: laboratory personnel who work

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Initially, folligut.oInd feoItl far Itmoll days, foIowtd by pmiIltlll

(ougholnd shortnm ofbrr..Jth;w~houl natmftl~rluth <an rmit
withil4-6 days

with anthrax, military personnel deployed to high-lisk areas, 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 preventing 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 officials thought had essentially been eI"3dicated in 1994. Although 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 underdeveloped 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 (a round 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 (2 00,000 base pairs) has been sequenced 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.

,
9

1 20

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Phannacology and ttl<> Nu,.....-Patient R.... tlon'hlp

There are no effective therapies for treating patients infected by most types of viruses that could be used in a bioterrorist 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 quantity to administer to every person in the United States. The
variola vaccine provides a high level of protection if given
prior to exposure, or u p to 3 days later. Protection may last
from 3 to 5 years. The following are contraindications to receiving the smallpox vaccine, Wlless the individual has confirmed 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)

signs of exposure to nerve gas agents relate to overstimulation by the neurotransmitter acetylcholine (Ach) at both
central and peripheral sites located throughout the body.
Acetylcholine is normally degl1lded by the enzyme acetylcholinesterase (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, invollUltary urination and defecation, confusion, convulsions,
and death are the direct result of Ach overstimulation. To
remedy this condition, nerve agent antidote and Mark I injector kit.. that contain the anticholinergic drug atropine ora related 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 receptors are discussed in detail in chapter lJOO.

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 vaccination 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 serious.ln the case of smallpo.'t vaccination, for example, it is estimated 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 million), 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 discomfort 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' ... '~v<:r... [,ml ... ri"g. Ta['l~ 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 significance is nern ag~nu. Exposure to these acutely toxic chemicals can cause convulsions and loss of consciousness within
seconds, and respiratory failure within minutes. Almost all

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12.7 Ionizing Radiation

In addition to releasing biologic and chemical weapons, it is
possiblethat bioterrorists could develop nuclear bombs capable of mass destruction. In such a scenario, the greatest number 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 initial explosion. Smaller scale I1Idiation exposure could occur
lhruugh

l~r"'ri'lallad.,u"!!u<.l~arpuw,,,," I'la!!l,uruy lh~ r~

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. Ac:ut~ radiation syndrom~, sometimes
called radiation sickness, can occur within hours or days af
ter extreme doses. Immediate symptoms are nausea, vomiting, and diarrhea. Later symptolll'> include weight loss,
anorexia, fatigue, and bone marrow suppression. Patients
who survive the acute exposure are at high risk for developing 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, taking 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, americium, curium, and cesiwn-\37, but these are more likely to
r""ull [rUlll i!!krll"l ralh ... r lhall ~.:d ... r"al raui~liu" =pu,ur~

(Table 20.600). One of the main radioisotopes produced

by a nuclear explosion is iodine-131. Because iodine is naturally concentrated in the thyroid gland, 1-131 will immediately enter the thyroid and dama ge thyroid ceUs. For
example, following the Chernobyl nudear disaster, the incidence of thyroid cancer in Ukrainejwnped from 4 to 6 cases

TABLE 11.4 1 Chti!mical Warfarti! Agti!nts and Trti!atmti!nts

Category

Signs of Discomfort/Fatality

AntldoteS/Flrst Aid

1lrpnIdir19 on the rotM qn~ S)'Rl!Ioms rna)' tit ~0Wft

to ~ar ind rumulatil'l' lkpmdr19 on 9posurt tiM:
miosis, runny nost, diflkWty bruthilg. tru:ssMo
... Imtion. II>tu.I, """'~i ng, aamping, invdmury
trinalion and defw~on ,lwildlir19 and jerking c(
musdts,hNdadlts,wnfI6ion,(Offl~ (oma,death.

Htrn ~t intidott ind Mirl:: IinjKtor k~s with atropint oil!

aViilatkRush ~ immtdiatdyw~h witer.AppIy sodi!lll
bimlHHlate or 5% iqJid blum soiUlion totht skin. Do oot
;r<Iooovomiling.

IIydrogtn qarilk (liquid)

Red ~Hulllilg 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.

t)~ogen tHoridt (gas)

loss c( aWttite. irritation 01 the rnpiritOl)' tract.

poJrnonary edf,ma,duth

Oxygen and amyl nitratt may be !j'/fll. Give patient mik Of

water. Do not indoce mtirHj.

Oiuinm, turir19 rye~ tlirs!, thrGaI irritation, mills,

I! spilator) ind m ....1Orl fili!R, C)'illOlis, Irostbit~type

PrtMlk fmh iiI. Aanirister 0X)'900. Rush ryes with IIOIIIIiI

sailll' or water.lUo~ patiml wann and cam.

NERVE AGENTS

GA- Tibun(liquid)
GB- Sarin (ga~ liquid)
GO-Somin (liqJidl

VX(ga\f(llJ\ lquid)
BLDOD AGENTS

CHOKING/VOMITING AGENTS
Pho~(gas)

"om
Adimsitt--DM (ay5lamlll' dsptnstd
inOoffilsol)

Irritation of the e)'esind rnpiratOll lri(\,IHjhmm of

thedlest, nausta,ind l'OrTIitirHj

BLiSTER/VESICANT AGENTS
Pho~ oxillll' (aystillilt or ~q!id)

MU5laId- ltwisitt

MilI!R- fU

tlitroqm mUllard-----flM-l, HN-2, HM-l

Sulfur mustard ~11I

DrSlllKtion of mocousmerrbi"anrs, rye tissue.~d skin

(sWrutalll'OlJl edema), folowed by scab formation:
rritation oIthe ryrs, II> salllll'lllbranrs, and lungs;
n.llKN and vom~ing; fmn.nion rI bI;""" 011 thr ,kin:
(ytolOlk rei(\ion! in hematopoietic: tissoo indUling
IIoot mallOllt",11"Iph nodes, spIffiI, ind endocme

".

-.

Rin~ no~ i ndthllloit with !iIiIII', water, 10% solution of

sodium bKirbonate. TI!at the skin w~h oo-ated IaIuJn

FkIsh affffitd i rei with (opious quanlities of water. H

ingtslN. do flO( indlKt vomiting. Rulli iflKted il"ta w~h
water.Treat the skinw~h 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 PtMII~~ Mediolll' wtbs~t: 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 thyroid gland. It is effective even if taken 3 to 4 hours after radiation 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 radioisotopesgenerated 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 exposures in the United States. Of these exposures, both pharmaceutic 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-

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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 approach 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 method~ither
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 treatment. Fwtdamental to the patient's survival is maintaining the
patient's airway, breathing, and circulation. In addition, it is
important to make sure that proper blood slumse levels are

1 22

UrdU

TABLE 11.S

Pharmacolog)r and ttwo NufSl'--P,tlent R.... tlon'hlp

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

Fomgn boIR!/IO'f"miK~lant(IIJI

120,m

Cdd and tough prfpafaOOns

m,m

"
"I.'
I.'
...

Topkal ~ljlloos

105,308

'.1.

Ptstidd!1

%.811

Antideprl's~nlS

95,317

Bit!1and l"II'IffiOI1\itiom

82,lll

14

CardiO'.'a\(wr~

,,-

80,416

13
11

Antilillamint\

76,531
75,07(1

Food prodxlS/lood poisoriog

66,115

1.'

Antiniuobiais

11

6,017

1.7

M.'
"
63,331

1.'

HonnOlltl ind hormont inta.goniru

51,875

1.1

Gastrointrstinal p~ratioo!

50,914

1.1

49,516

1.1

Chtmic.Jis

47,557

Slimw,m ind Ilrtl'l ~

46.139

I.'
I..

PianlS
'fmmim

"--

1.7

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' ba~ on 1,403.539 ruman npo!UlI's.

maintained and that arterial blood gases are stable. Treatment

of any developing seizures is important (chapter lSOO ),
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 bicarbonate produces a more alkaline urine and enhances the acretion of acidic ~ (i.e.,aspirin and barbiturates); ammonium
chloride produces a more acidic urine and enhances the acretion 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 perform this decontamination alone, the nurse or person pro-

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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 promotesemesis 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 tre~tment . 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 withdraw 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 protective 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 prevent poisons from absorption. Examples of substances that
do not adhere very well to charcoal are alcohols, hydrocarbons, cyanides, iron, boron, lithium, heavy metals, corrosives, 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.
Wholf.!Jo~1 irrigation may be considered for potentially toxic
ingestions of sustained-release or enteric-coated drugs. Patients seem to derive benefit from whole-bowel irrigation after being exposed to potentially toxic ingestions of iron, lead,
zinc, or illicit drugs. Whole-bowel irrigation is contraindicated in patients with bowel obstruction, perforation, compromised airway, or hemodynamic instability. The
procedure should be used cautiously with debilitated patients or with patients whose medical condition might be
further compromised with this treatment. Whole-bowel irrigation 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 remaining 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; how~r. throughout the text, the Prototype:: Treatment
ofOverdose boxes will remind the reader of specific antidotes.
Table 12.6 swrunarizes specific antidotes and their use for
particular overdosed substances and toxins.

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; dloli~ rt(~et ~nlS;itllykhoinest~iII' imibitOl'llpilal)'mpathomimtliej

Lnd loOOty (hNyY IlII'taI poisonilg)

uk:i!lll !OrA

Caloom OisOOium Vmtoall

defrroxirrine

Df:sltral

Iron tOlidty (bravy melal poisoning)

digoJ:inimmllM fab

Digibind

OigoQn;dqtoxin (uldi.KglytOlidli

diMruproi

BALinOiI

ftumurnil
fornepizoll

......

....

ltIKa.'om

r.oo!tigmn.

....

Anlizoll

ArsmK,goIdand roeKIf)' tOlioty (hliVY metal poisoning)

8mzodimpine\ (!edatiR--h)1lllOlic)
1hyIrnt' gl)lr:oIlO1idty lantiflffir poiIoniog}

ImUin (h)'p:>g~tflllgl
WdklWorin

Metliotrwtl; foIitadd bIoding~lS (antilt(lplilSlK/in~mMaboliltl

~~"

Opioid a9ffilS; morphilt (opioid aoalge5il:)

Pro.in

Ntu-omu"",llr blocking Igrnl> (nondo poIarizilg bIoclli)

ptneIratl uk:i!lll tri!Odium

RadiooKtil'l' plUlooirm.americ:i!lll and turium (radiooKt~6pOIU1l')

ptneIratl lin(\rilOdium

RadiooKtil'l' plutooirm. americ:i!lll and turium lradiooKt~ 6pOIU1l' I

Pffiidliamint
~igmint

Cuprimn.. Dtpffi

CopptI.ion,lNd,alltlli~ gad and mtlOlry 100idty [hNyY IlII'tlI

Ant~iriJm

CholinllgK bIodilgagenl~atropiOl 5UHltt lintidloli~)

RadiooKtil'l' iodne tOlioty (nuOOr bomb;radiNOO 6pOIIR)

potmi!llliodrlt
pralidoxime
protarrine 5lA/atl
prusManbhr
IlKOIlll'l

vitamin K

poiIonilg)

Pm.....

--

RadiogardiSl'

Cholinffi~aSl' inhbitm; OOJanop/lOlptlal~ neOlli9:nine; ph)'lOlti9:nine (patal1fl'pathomimllit)

Hlp.lrin (pall'llt~al antitoagjart)

RadiooKtil'l' t ~um-l]7; nooridioaoaive thali!lll (ridioaoaM tfSirm tlpollR; thallium p:i lOIliog}
ltad, meo:~ and ilRllKtoxidty (htavy metal p:i lOlling)

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 Bioterro rism 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 important public issues.
12.2 Nurses play key roles in emergt'ncy preparedness, includ ing providing education, resources, diagnosis and treatment, and planning.
12.] Th", Strategic National Stockpile {SNS} is used to rapidly
deploy medical nec:essities to communities experiencing a

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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 inhalation , or by the uttaneous route . Antibiotic therapy
can be successful if given prophylactically or shortly after 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.

1 24

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Phannac:ology ~nd 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.

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_

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

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 bioterrorist attack including: (Select all that apply. )
1. helping to plan and de'\o-elop emergrncy management

4. He\tdache
5. Cough and dyspnea

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

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

Which of these medications is primarily used for the

treatment of anthrax?
1. Diphtheria vaa:ine
2. Amoxicillin (Amoxil)

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.

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 tissut:>; uth~r Ihan Ih., Ihyruiu )\land!
3. What is the purpose of the SNS {Strategic National Stockpile}?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 preparedness and treatment of poisonings?

See Appendix D for answers and rationales forall aCTivities.

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EXPLORE

fiij"ll!lifing!tlJ------,

MyNursil1 gM is )'011"
~rQjs.

0Il~

SlOp fur

o nl,,)~

chapter

r1!vi~

materialS and

Prepare to! sua:ess wi1!J additiofJal NCLox"'-sl'/1e Il1Ictic9

~"""InM. In!""",,,," ~OM1 '""' ...,

and ~ideos. and mOle!

..-:tiItm""". wm

link . I""'Tlm.

Regi ster )OOt oc ce~ moe !rom 1he IfMl ~ \'OIlr IlOOJ< 81
...-.myn..-.-.gkit clII1I .

UN I T

The Nervous
System

CHAPTER 13

Drugs Affecting the Autonomic Nervous System

CHAPTER 14

Drugs for Anxiety and Insomnia

CHAPTER 15

Drugs for Seizures

CHAPTER 16

Drugs for Emotional and Mood Disorders

CHAPTER 17

Drugs for Psychoses

CHAPTER 18

Drugs for the Control of Pain

CHAPTER 19

Drugs for Local and General Anesthesia

CHAPTER 10

Drugs for Degenerative Diseases of the Nervous System

CHAPTER 21

Drugs for Nturomuscular Disorders

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Drugs Affecting the

Autonomic Nervous System

DRUGS AT A GLANCE

LEARNING OUTCOMES

ADRENERGICAGENTS(SYMPATHOMIMHICS)

Aher Ta3ding this 'hQPI~ the student should !leobll! to:

""ou

Go) phenylephrine (Nro-5ynepl!rfne) (XJIJf m

AORENERGI(-BlOCXINGAGENTS /X'iIt1J6
Go) promsln (Mllllprf!!ss) (XJIJf IJl

CHOLI NERGICAGENTS

(PARASYMPATHOMIMETlCS)

(XJIJf

116

Direct-Acting Pal1lsympathomimetia
Q

berhanedlol (DwoId, Urechol/ne)

""]9

"",~

Cholin!sterase Inhibitors (XJIJf /39

CHOLI NERGICBLOCKING AGENTS

(ANTICHOlINERGICS)

pilI/tl40

Go) atroplnr (Jolro-Ptn, AffOpalr,Alroplso/)

"" ,.

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 Iphal~' alphal" OOta 1-, or beta1-ad renergic receptors, and
nlcotlnk or muscarinic receptors.
6. Discuss the classification and naming of autonomic d rugs 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 cholinerglcblocking agents.

KEY TERMS
H~tyk:hol int(Ach)

(holintrgic

paJ019

oKetykbol in~teralt (Ac:.[) fJ1JI}t

ad~rgk 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

bet.rf!!(tptOf(~rf(tp IOf) {IJI}t/JO

CiJlHhobminu PIl'll! 110

(en l~l M'rYoos system (CNS)

pi1//t III

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fIIX}t IJI

fight-o!'ftight rMpOme po:Jt l18

ganglionic sJ1'l.ljHt ~ 119
Ilonoliline oxidase (MAO) fIIX}t t~
lluKarinic: fIIX}t III
IlJlStneniagrnis fD}t 139
.icorinic: fllX}tll1
'Oflpi.~phri1le(N() 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 nt~on JOlt 119

rfiHld.digeltrfiponse pogt l18

somatic nemus system ptXJt III
sympilllteri( nmollS sys'~m piXJt 118
SJlTlllillllolytic: fIIX}t III
SJlTlllillhonIimflic pogt m
s)'I'Iapse ptXJt 1]1}
synaptic tr.msrninion

ptXJt I}I}

OIoplfl 11 Orug<Affealngthe ..... tooom Ic Nervo'" Sylll'm

127

he study of nervous system pharmacology, or neuro-

13.1 The Peripheral Nervous System

pharmacology, extends overthe next eight chapters.Tradi-

The nervous system has two major divisions: the central nero
YOussystem{CNS) and the peripheral nerYOussystem. The CNS consists of the brain and spinal cord. The peripheral nervous
system consists of all nervous tissue outside the CNS, including sensory and motor neurons. The basic functions of
the nervous system are as follows:

tionally, neuropharmacology begins with a study of the

autonomic nervous system.A firm grasp of autonomic physiology is necessary to understand cardiovascular, renal, respiratory; gastrointestinal, reproductive, and ophthalmic function.

Autonomic drugs are important because they mimic Involundrugs is essential to the treatment of disorders affecting many
body systems, induding abnormalities in heart rate and

Recognizing changes in the internal and external

environments
Processing and intt'!!rating the environmental changes
that are perceived

rhythm, hypertension, asthma, glaucoma, and even II runny

nose. This chapter serves dual purposes.First,it is a condse reo

Reacting to the environmental changes by producing an

action or resporu;e

viewof autonomic nervous system physiology,a subject that is

~ 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

tary bodily functions. A thorough knowledge of autonomic

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.

I The Ne rvous System I

Periplwr.t Nervous Syste m (P NS)

(Inlnsmils signals between the CNS
and the real 01 the body)

Centrel Nervous Syste m (CNS)

(reootivM and processu information:
inmalaa aclion)

Bra in
(rece;_ and processes
sensory infonnlllion;
in~ialBs ... sponsos;
.\0",. memorie.;
gene ",'e. thoo.9>ts
and e motiOM)

Sp ine l Cord
(conduct. si gnals \0 and
from the brain; controls
...tIM ItCiMties)

Motor tieu'one
(carry signals from the
CNS that control the
aclMt",s 01 """"""s
a nd glancb)

Senaory Neurons
(carry oignaLs 10
Ihe CNS from
"""SO'Yorgans)

j
Somatic Nervou s System
'''''kul~ M "" hfly
""""""",Is by ac:tiwIing
skeletal rnJSCIes)

Autonom ic Nervo us S ystem

(""nl''''''j' .......... ,l ~ '~'''''''''''_
by inlluencr.g organs, glands,
and s mooth rTUICIe)

Sympathetic Division
(prepare. the body for
stressful or _rgalic
aclMty; 'light or flighr)

Pa",sympathetic Division
(dominates dumg ~ "",s 01
"rest and digestion";
dirocta maintonance I>CIMtiH )

I
Ad .... ".,rgic ReceplDtS

....
j

I
~

Figure 1.3.1 Functional divisions of the peripheral nervous system

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...

Cholinergic Receptors

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 sympathetic and the parasympathetic nervous systems. \Vith a
few exceptions, organs and glands receive nerves from both

branches of the autonomic nervous system. The major actions of the two divisions are shown in ~ Figure 13.2.lt isessential that the student learn these general regulatory
actions early in the study of pharmacology, because knowledge 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
~sponse. 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 toskeletal 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 under nonstressful conditions and produces symptoms called
the Ifttanddigest Iftponse. Digestive processes are promoted,

PARASYMPATliETIC
DIVISION
rest lind digllst

SYMPATHETIC
DIVISION
"fight DO" 119>1'"

constricts

dilatas pupil

",,'
stimJlat....
salivation

inhibOls
saivation

constricts

btonchi""'"

dilates
bronchioles

stimulates
digeslion

inhibOls
digestion

stimJlales
gallbladd."

.ti..uates
rela a .... at

...., {

~-

'~H
sea.. t....
"";.-...phri"" and
norepi.-...phri""

conl ...ct.

.. ...

stimulates
sox of9lln5

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 K1~, 2001. Upper Saddle RIver, NJ, Prenfke H111. Reprinted IIy pennlllkJn.

LibraryPirate

OIoplfl 11

actions of the parasympathetic division are the opposite of

those of the sympathetic division.
A proper balance of the two autonomic branches is required for body homeostasis. Under most circumstances,
the two branches cooperate to achieve a balance of readiness 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 increased 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 constriction of arterioles is controlled entirely by the sympathetic
branch. Sympathetic stimulation causes constriction of arterioles, whereas lack of stimulation ClUSes vasodilation.
Sweat glands are also controlled only bysympathetic nerws.
In the male reproductive system, the roles are complementary. For example, erection of the penis is a function of the
p~ra.~ympMh~tic divi~ion, and ~jacul~tion i~ ci\nTTOll~d hy
the sympathE1:ic branch.

The dassic smdy of drugs affecting autonomic function centers 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 system. 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 naturally stimulated by the autonomic neurotransmitter.

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 neurons, 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< n ~uron. 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 neurotransmitters, o r have a simila r 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.

Ventral spinal cord

~

Figure 1.33 Basic structure of the autonomic pathway

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129

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. nruB.~ thM Mtach to thi! [lo.~t.~a]'>tic T~rg~T.~
and prevent the natural neurotransmitter from reaching
its receptors will inhibit autonomic function.

13.3 Structure and Function

of Autonomic Synapses

angliook: neuron

..... tooomk: Nervous Sylll'm

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.

and heart rate and blood pressure decline. Not as much air
is needed, so the bronchi constrict. Generally, most of the

Drug< Affeatng the

13.4 Norepinephrine
and Acetylcholine
The two primary neurotrafl'lmitters of the autonomic nervous system are nOl!pinrphrinr (NE) and acetylcholin r (Ac:hl. A detailed knowledge of the underlying physiology of these
neurotransmitters is required for proper understanding of
drug action. When reading the following sections, the student should refer to the sites of acetylcholine and norepinephrine action shown in ~ Figure 13.4.

': J?"I

.,.,.,..

Ganglionc

PostgangIionk: neuIOn

--

Target

130

Unlll TheNelv"",.Sy.tem

Sympathetic pathway

Aen
\

h-

Cholinergic
,eceplo, (nicotinic)

;I~

Veol,al Cho/i""'9 ic Autonomic

sp;nal _ anglionia

Adrenergic
po.tganglionje

"""

-~
Ach
\

l~...}

ChoI;""rgic
preganglionic

Autonomic

synapse

~~

ChoIi""rgic
Ach
"'ceptor (nicotinic) \

I
ChoI;nergic
post9anglionje

/ChoIiMrgiC

"~~f

(::c)

Targel
tiSSUII

~'oo

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 acetylcholine 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 dobutamine. There are rroncatecholamirre dr ugs, which have a
slightly different chemical structure than the catecholamines, 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 sympathetic neurons are called adrenrrgic, which comes from the
word adrerralirr.
Adrenergic receptors are of two basic types, alpha reCfptors
(a. receptors) and brta receptors (~ rfcrptors). These receptors are
further divided into the subtypes alpha" alpha,. beta" and
beta,. Activation of each receptor subtype results in a characteristic set of physiologic responses, which are generally
swnmarizedinTable 13.1.
The significance of these receptor subtypes to pharmacologycannot be overslllted. Some drugs are selective and activate only one type of adrenergic receptor, whereas others
affect all receptor subtypes. Furthermore, a drug may activate one type of receptor at low doses and begin to affect
ull,,,, ''''-''pluT ~uulyp'" ''" ll,,, Ju, .. i, im.,,,..... J. Cummilting 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 phenylalanine and tyrosine. The final step of the synthesis involves
the conversion of dopamine to norepinephrine. NE is stored

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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 functional 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 elicits the dassic fight-or-flight symptoms. The action of epinephrine is terminated through hepatic metabolism, rather
than reuptake.
Other types of adrenergic receptors exist. Although
Jup~",j"" w .... u"~,, IllUught tu fUlldiull unly~" ~ ~h"nLiur.1
precursor to norepinephrine, research has determined that
dopamine serves a larger role as a neurotransmitter. Five
dopaminergic receptors (0, through 0 ,) have been discovered 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

IlIop1fl 11

Drug< Affealng the

..... tooomk: Nerv"", Sylll'm

13 1

TABLE 13 1 I Types of Autonomic Receptors

Neurotranvnltter
~ntphri!lt (~drmtf9K)

oK~tykhoIiIt (moli~1

........,,
'rn,

Primary Locations

ResponSE's

AI sympalhtlio: I~rgel organ! u(tpllh~ hun

(oOllooion of blood \'!'sld ~ !ilation of plJpik

Prtl)'lliplio: mnenj{!ItI'/~ Imllinill

Hein and tiO'Itys

Intibilion of rdta5l' of nortpinephrin~

lnuu~ lII'an ru~ and fmt of {ontriKlion; mea~ of rmn

'rn,

AI sympalhtlio: largtl organ! m:tpllh~ hun

Intibilion of lnIOOIh ~

Nicotinio:

fbIIlJin9ioriulturOlll

S~mula~on of IIIIOOIh musdr and ~nd

Musurinic:

H",

Drm.J1td heart ratr ind fOKl' of {ontr~aion

fllrasympalhtlio: largel:organ! olhtfthan iI'It lItan

S~rnula~on of IIIIOOIh rnusd~ and ~nd stmIiOlll

Receptor

(chapter 2(00 ). Dopamine receptors in the peripheral nervous system are located in the arterioles of the kidney and
other viscera. Although these receptors likely ha~ 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 actions of Ach at theganglia resemble those of nicotine, theactive 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. Activation ofthesc cholinergic receptors ca u ses tachycardia, hypt'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 therapeutic 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 nervous system results in the classic symptoms of parasympatht'tic stimulation shown in Figure 13.2. Early research

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1fmIi0lll

discovered that these actions closely resemble those produced when a patient ingests the poisonous mushroom
Amanita muscaria. Because of this similarity, these Ach receptors were named rnulrarink receptors. Unlike the nicotinic
receptors, which havt' few pharmacologic applications,
muscarinic receptors art' affected by a number of medications,and these are discussed in subsequent sections of this
chapter.
The physiology of acetykholint' affords several mechanisms by which drugs may act. Acetylcholine is synthesized in the presynaptic nerve tt'rminal from choline and
acetyl coenzyme A. Once synthesized,Ach is stored in vesicles in the presynaptic neuron. \'/b.en an action potential
=c.b.es the nerYe ending, Ach is released into the syn~ptic
cleft, where it diffuses across to find nicotinic or muscarinic receptors. Ach in the synaptic cleft is rapidly destroyed by the enzyme atftyirnolinestrrne(khE), and choline
is reused. The choline is taken up by the presynaptic neuron 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 parasympathetic 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-orflight 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.

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 increase 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 constricting 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 autonomic drugs early in the study of pharmacology will reap
rewards later in the course when these drugs are applied to
various ~tems.

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
Sympathomimetic~ produce many of the ~ame =ponse. a.
the anticholinergics. However, because the sympathetic nervous 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 norepinephrine and a short duration of action, and must be administered 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 endogenow; 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-

TABLE 13.2 1 Adrenergic Agents tSympathomimeticsJ

DN,
Prtmary Receptor Subtypi!

.....

Prtmary USE'

Jlbuttrol (~mt i, Vmtolin)

Bm,

doridilt (C,uapre)

Alp/IJ, in CHS

Hyptntn~on

dexmtdetornidM HO (PrradeJ:)

Alp/IJ, in CHS

Sfdation

dobutamiM (Dobutrrx)

Bm,

urdiK !limUafl

doparniot(lntr~n)

Alp/IJ, aod btli,

'M

tpiotPlrilll' (AdrtrW~n, othffil

AIp/IJ ald bua

urdiK arret.a!ltlni

fonnottrol (Foradin

Bm,

Asthrru, COPD

iIoprot~(~)

B6.l,aod~li,

IIII'taproltfl'OOl (Alupmt)

Bm,

IIII'taraminoi (AramilH')

Alp/IJ, aod btlJ,

IIII'th)'l~

....
........

(Aldorntl)

rnidodriot (ProAmatiot)
lIOfl'PiotPlrilr (~a1ermol, u,YOphrd)
OI)'rtJetlloline (A/rin aod olhrrs)
Q

phenyltphrilH' (Hro-S)'IItItlrilH')

Alp/IJ, in CHS
AIp/IJ ald ~ta,

........

Asthrru, dysrhythrnii~ hein failufl'

Hyptntn~on
Hyptlttn~on

'M
tQ5aI (ongtItion
1Q5aI (ongtItion

pltlldotptlrdiot (SlWftd aod othe~)

Alp/IJ ald ~Ii

1Q5aI ror.getion

rittdiot(Yutopu)

Bm,
Bm,
Bm,

Slowilg ofuttOlH' (oru~

lilrntlmll (5trMllt)
tffloutalilH' (BlI'thiot aod otllm)

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.....

OttongeSlifl

IlIoplfl 13

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.
few agents, such as ephedrine, act by both direct and indirect mechanisms.
Most effects of sympathomimetics are predictabLe based
on their autonomic actions, dependent on which adrenergic

Ne,,,,,,,, SY'lem

1n

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

lh" ",,""p IUf f"-

Sum" 'Ylllpali,ulllimd.iu. af~ lluJl.,d<.li,,,,slilllul~li..llgmuf~

sponses are so different, the student will need to memorize

the specific subcLass(es} of receptors activated by each sympathomimetic. Specific subclasses of receptors and therapeutic applicat ions are as follows:

th.1n one type of adrenergic receptor. For example, epinephrine

stimulates four types of adrenergic receptors and used for
cardiac arrest and astluna. Pseudoephedrine (Sudafed and others) stimulates both alpha, and beta, receptors and
as a
nasal decongestant. Isoproterenol (lsuprel) stimulates both
beta, and beta, receptors and
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 mostlyextensions of their autonomic actions. Cardiovascular effects
such as tachycardia, hypertension, and dysrhythmias are
particularly troublesome and may Limit therapy. Largedoses

ft:U:pl uf suulyp'" af" sli JJl urul"u .

B~~au,,,

0nJqs Affealng tt... ""lOooml<

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
in the sympathetic nervous

Drug

Therapeutic (I ass: Nasal decongestant; mydriatic agent;antihypotensive

ACTIONS AND USES
Phenyltphrifl!' is a ~alphNdrentrgic: igonistthit ismilablt in !M'Iil
dili"t J!Ot formulations, including intr.l naul, ophthalmic, Mlbc:utl neous, and
IV. All oKtionsand indic:ations ire ~l1~nsions ofin sympathetic: stimulation.

InWnaSil Administrilion:

~ i11ri1n.!1ily

p/IfnyItphrilt rW~ n.!Iilrongntion

oollop!,

ronllridilgsmall ~ 'IM'Is i1 1M

"",m~

Topi:~1

Administr ilion:

mminalionl, p/II'n)Wphrine

Pa_

tope-ally to 1M f~
1M pupl without (~U!ilg !MJVfiunt

ra l Administ rat~n: ~pamltHal oIdrniristriltion phal)Wpw"iIf

f~oKU~h)llOlflllionUONd byspilal~III'IIIIfIi.IOI Y6Wf 'iIIodt.Bfau~

p/IfnyIfphrilt

~~i!JOIIiIt iKtivil~ ~prorb::~ rei.Jwayfew

~at

OOIeI.II!!oogfr dur.ltioo

iji'/el phfnylfplniw IOfI1I' advolOligfi

~Mphrifl!' i1 trNting oKUt~ h)'polfrllirn

silJjfiunt

~
PJin~ine

ADMINISTRATION ALERTS
Parentt ral ~dministr.ltion (an (~use tisMl~ injury with rxtrav.llition.
Phenyltphrifl!' ophthalmic: drops fIIiIy dafllilgt soft (OIIUct It~.
PrrgnilK)'utegory(

PHARMACOKINETICS
Onll"t: ImmNiat~ 10- 15 min IM/suiKuuneous
~k : 5-10 min IV; 15- 10 min IV/MliKUlantoUl
Halflife: Irss than 15 min 10-60 min IMisubcuufl!'OUs
Duration:
min 1V;30-120 min IMf!Ubcutan~us;3~ h topical

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Pharmacologic (lass: Adrenergic agent (sympathomimetic)

ADVERSE EFFECTS
Wht n tht drug is usN topically or inmnaally, sm Nler:n Jre uncommon. Intranaal un (an
burning of tht mlK()\oJ and rebound (OIlgtltion usN
for prolongfd ptriods {(hapter 11 00). Ophthalmi4: preparations (in (JIM
narro~n91t glaIKofllil IKondary to tlltir mydriatic:
High
GIn
ft'1I9 bradl'mdY d~to tilt Mmion of blood pft'!!Urt (ausN stimulation of alpha, lKfIIIOfS.
Wh~ usN parentml~,tht drug should
usN with GlUlion in patitnn
with adv.!ncN mranary artery disuse Of hyptnfllsion. Anlit!)" ft'!tlessnes~
and tft'mOf
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
pft'Ssure and Vl'ntric:ular ti(h)'uroi.J.
Contr aindi wionl:This drug should oot usN in patitnn with arutt panmoatitis, hean dise.N, ht patitis, or n,IfTOW-inglt glaIKofllil.
INTERACTIONS
Drug iorar:ti005
h)'pff1er6M> uilis.lnut.Nd etIKts
0((111 with triq<ir: an~ts,
alkaloids, OI)1och lrilibitory
O(UI
j]pIw
ttKtH'l.~ineis inuwnpatibltwith
prl'poIIationIlfflrir:saits).
PhtnyIfphrilll' rna, (auII' dysrll)1trrUl
tM in (ombi\alion with dgoxil.

LlbTl51s:
HflbaVFood: Unknown
Trrat mt nt of Overdose: OV!'rdos~ may
udlyr:ardia oInd h)'pffimsion.
Treatment with an alpha blo.:ker SIKh il plltntoi;!mifl!' (Regitifl!') fIIiIy ind~
(attd to dt<rus~ blood pres5Ure.
Ie

frIr

Ie rNs

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1 54

Unlll

lheNetv"",.Synem

TABLE 14 1 Stag"5 of SI""p

DescrIption
At tilt on~ of ~etp, tilt pa~~u ~in a stJ~ of
IttIwsintSs for abouJ: 110 7minutfi. ~rilg th~ timr, tilt
patimt can ~ Nsify aWilkt,",d.Th~ ~ lasll for abouJ:
4%loS%ofI01a1~lint.

NREM llagt2

TIlt paliffil un llill ~ mily awaktntd. JJis stJ~

CMSiiMes lilt 9r~aleSUmOl.l"lI 01'101.11 .Iup [ilM, m-:,
1055%.

NI'iEM~l

TIlt patiffitlNy IIIIM imo orOUI of a ~ sIe~ Hun

ratt and blood pIHlUfI' fal ;giSlrointrllinal activity lilts.
JJis ~ige Iaru for abOUl4% 10 6% oftotJl sIefp timt .

"REM stJgt4

TIlt dtrpo!lI stJgt of sIe~ thilllagt laIIS i litdt 10/H}tI"

lhan ~ 1 or SU~ 1 ~l\abOUll2% 10 15%. Th~is
[~

lIagc wring wtidJ nightmares omr in dikttn.

~lting ~illo i

common ~harior for this~.

Hun rite and blood pR"ISlR Jl'lllain iow;ljisutintestinal

aniY~y 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 ~"Itf"I 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 ~gents that slow
neuronal activity in the brain. Patients experiencing aru.iety
or sleep disorders benefit from four general classes of medications: 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 ha~ an ability to reduce anxiety symptoms by altering levels of two important neurotransmitters
in the brain, norepinephrine and serotonin. Restoration of
neurotransmitter imbalances may reduce symptoms associated with depression, panic, obsessive-compulsive behavior, and phobia. Typical antidepressants include tricyclic
antidepressants (TCAs ), selective serotonin reuptake inhibitors (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 barbiturates but have similar therapeutic uses. Other eNS depressants that have a calming effect in the body include the
opioids (chapter 1aoo ) and ethyl alcohol {chapter 1200}.

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eNS depression should be viewed as a continuum ranging 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 ~ee les. efficacious. Medic~tion. th~t depress
the eNS are sometimes called sfdati-m because of their abilityto 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 serlati~-hypnoti c is often used to describe 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 psychologic dependence, as discussed in chapter 1200. The withdrawal syndrome for some eNS depressants can cause
life-threatening neurologic reactions, including fever, psychosis, and seizures. Other withdrawal symptoms include
increased heart rate and lowered blood pressure; loss of appetite; muscle cramps; impairment of memory, wncentration, 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 including general anxiety disorder, obsessive--compulsive disorder,
panic, social phobia, and post-traumatic stress disorder.
Given the effectiveness of antidepressants for these conditions, many believe that in the future, anxiolytics and antidepressants 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 experience 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 activ~tion of the autonomic
nervous system. For panic attacks, the most useful therapy is
to help the patient becom e 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.

IlIapttr I(

Drug. 10< Anxk>ty.nd In'iOmna.

155

TABLE 1,( 2 Antidepressants for Treatment of Anxiety Symptoms

Route and Adult Dose (max dose where Indicated)

On"

Adverse Effects

TRICYCUC ANTIDEPRESSANT'S (TCAs)

am~rip1)'~nt IElavil)

PO; 75- 100 mglda~ may gOOlia11'1 iOO!a~ 10 150- 300 mgfday
(Ult Iowtr ~ in norhoIpitalilfd patimts)

dom",amine !Anilr.in~)

PO; 75-300 mglday in dividfd ~

dcsipliminr (tIoIpf.1mil,
Prnoffine.OIhe-s)

PO; 7~-100 mglday.l btdIim~ or in lividcl:l ~ maygr.dually

inuult 10 150-300 mglda, (lISt 100000doie in oIdft ad'*:
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

for tilt ProlOly~ Drug box 00 )

PO; 7S- 100 mglday (max:lOO mgfday) in lingitor divided dole

nortript~ine IAvrrll~, "'lInrlor)

PO; 2S mg ~d or ~d,<J".trually ioor.1rd to l00- 1SO mg/day

uimipramine {StI"montilj

PO; 7S- 100 mglday (max 300 mgfday) in divided 00Its

~5id!llion,dnirJfl~orrhimQ~(hyportmion,

rtymoorh,mn5lipaD"on, urm rmnrioo, weigh! #11,

f1m1Of, ~Jrfly/IlIrrim, bWfd rifion, JIgIr! m)'JriofiJ

AIl.nuOCV!Ws.!!2!! maTOW ~sioo,~nm.

hNrt blod, "'I a!'!lJiotdema offalt toogue or

"""""

MONOAMINE OXIDASE INHIBITORS (MAOls)

p/lftlflzint(tjartll)

PO; IS mg ~d, rapidy inuu~ng toat INII60 mgldar, may net<:!!4l

to90m9Idi)'

trin)kypromine IPolmate)

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)')

Orlllmir h)'JIoleruion, cm:sriplllion, rty 1IIOIIfh, MlMtI

!b:~en~taM.b!m!hmri!l

/taro ilKkitt ammon admsIo tfIe(\~ .IIiIIIfIIiniu. 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 SS RIs treat not only panic symptoms but also

symptoms of obsessive-compulsive disorder and phobias
(Table 14.3). Popular SSRIs available for treatment of anxiety symptoms and depression include citalopram (Celexa),

TABLE 1,( 3 1 Antidepressants for Anxiety Symptoms, Restlessness, and Depression

Route and Adult Dose (max dose where Indicated)
On"
SELECTIVE SEROTONIN REUPTAKE INHIBITDRS(SSRls)
dtalopram ICdw)

PO;Yotl1 at 20 mglday; may ilouse 10 40 rng/day Hnrtdrd

!:Idtalopram oolale (lnipro)

ftuoxetint (Prom)

PO; 10 mgldar, may inurlll' 1010 mglday WlIffiIedaft~r 1wk

PO; 10 mglday in a.m.;1IIi)' iOO1'alt IJj' 20 rJl9/di)' it ~
inl......... l.....:80 "'II/doy);whm "",bio: may ,wil<h 10 _ 9CJ..mg
lUIlail~rdrnt tapll.it per~ek (mD:90 mgIwk)

ftU'/Olil1lil~ (1Jriox1

PO; !liIt wilh SO mg/day;may inuull' !lowly up to300 mglday

giftn al bedtine ordividtd bid

puoxe~M

PO; 2O~ rng/day

l!'.til)

!tf1ralinr (ldoft)

Adverse Effects

Mw>t41OO1iring. dry moom, imcmnkl,5OmfX)/trrt,

I1todocM, Ilfm:wJl'l~ D~ GI mJl!UOOocO'1. ~1IMXiD,
JmJd dylfuocrioo, Dgirkll. dizzir.ru, fafigw

StM!!! Joh!l\!l!! ,ynd"",,~ ntr.m ~

INoyibypomooja oDd 5ljdd oljty (np!'dally iD
,bildlml oIl1norrnol bll:fIi!ll1l:1llml~ PI:tdKlm~[
cli!turbam:e. ~lU~\:,aUlonomis: jnmbirtr with
po$siblt rapid /luawlions of vital !ian\:, snm
IwDooh~lmji mOl'"jn svnOOuDP

PO; begin with 50 mg/day;graoilall'1 iOO!all' fflf'! fewwms

iCtordilg to rtspOnll' (range: 50-100 rng)

ATYPICAL ANTIDEPRESSANTS
miniLlpinr (Remeron)

PO; 1Smglday in a singe doIr il bedtime; may inatall' MIJ'

1- 1wk (max: 4S mg/di)')

tr.zodonr IDrlyrtll

PO; 1~ mglday in dividN ~ may iooelll' by ~ mg/d.ty am

3- 4 days (max: 4OO-liOO mg/di)')

YeIllafaxile (fffemr) (di>~1ied is

an SHR~ Sf!' mapter 1600 )

po; !tarl with 37.S mg/di)' sustained rrlelll' and iOO1'.lIl' 10

75- US mglday 5U11ained mUll'

I[aro ilKkite a:mmon admsIo tfIe(\~~ilKkitts loffiousadYelSl' efltru.

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fmIIic htarl rot! arid I!IC1C1d prtS5I!ff, orrfli1l[Q~(

hyporemion,drymMll. dilZillflJ,f<lI!n<WfKt, ~
MlfIlitilg..wto6111]

5Mre min!!)' iml1!!lIi'Ii\)',men!<!! mlgl d!i!!ml thjJ

include mrrme atilation p!!l!RIsina t9 dtliiLnl and
(oma ~i!lI~~lyinmiklrffil

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 conveniently into tht other categories. Mirtazapine ntay be useful
in managing sl~p 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 attacks, agitation, insomnia, and hostility. See chapter ]600
for i mrorl~ot rrim~ry ~clion.< ~ocl ~cIv~"", ~ffect< of ~n licl~_
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

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; MAO Is potentia te 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.

Escltalopram Oxalate (Lexapro)

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 W'~lanin 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 d~
prHsion.Unlabeltd U!H include thr uutment of panic disorden.

ADVERSE EFFECTS
Srrious ~ions includr dizzinrs~ naum, ifllOmn;" IOmnoitrmr,ronlulion,
,nd seizure if laken in OY!'rdoI!'.
Contraindications: This drug should not br used in p,tienu who aft bruslfeeding or within 14 da~ of MAOI thr"py.

ADMINISTRATION ALERTS
This medicaticn 5hou1d not br started until 14 days ha~Npsrd ,fler dis(ontinuing ' "I MAOI d~.
Inmn of IftIOI or hepatic im poi""""l or in oIdtr adults, rtductd d...... ift

autoncrnic. h~iij h)'pi'lIhtmia, rigilil~daphorM,i!IId ~tic:

"""'"

DoW' incftmelU should br stpar,ted by 'Iitan] Wl'rk.

Pl!gnallQ ~ry t

INTERACTIONS
1Wg- 1)ug: MAOfs IhoIMI bIo iI'IOidfd U to ll'IOIonins~,rY~ Irf
mal9lants~ ~with "'-Wfs aUrI mr:in IwfmMMoisis,
tpthHmi',MId ....ooorricinsubilily.
bdlil/oplam wil 0.:.- pI.Mw 1eftI. or meloproIoI.od <inetidi ... "","'. ,...!
U\f or aIaIhoI MId oml'f(HS~B rnayfllh.wtO/Sdepr~nl!lfforu;
palifru shcUd.woid akohol whfn tJkiIg this drug.

Lab Tests: Unknolrm

IkorbaVFoorl: lisf<1Ulion with htrbaI ~B IIKh ill St lohn\"IlO!l, wtich

rna, YU5I' serotonin s)"lldronwo DI inul'dll' 1M ~fffi of!5dtJlopool

PHARMACOKINETICS
Onset: Wnh OIKHlail)' doIinllsttad)o-Stltr plasrru (oncmmtiom
can br INCIiN within] wk
Peak: 5h
Halflifr: 25- 35 h
Duration: V, ri.Jblt

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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 .

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Benzodiazepines
The benzodiazepines are one of the most widely prescribed drug classes. The root word benZ() refers to an aromatic 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 nitrogen 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 introduction 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, although they produce considerably less physical dependence
and result in less tolerance than the barbiturates.

"n"
ANXIETYTHERAPY

cHordiaztpOlIid!, (librill!l)

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 inhibitory 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 CNSdepressants, or if the patient suffers from sleep apnea.
Most benzodiazepines are given orally. Those that can be
given parenterally, such as diazepam (Valium) and 10razepam (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. Benwdiazepines 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 benwdiazepines used to treat short-term insomnia aredifferem from
those used to treat generalized anxiety disorder.
Benzodiazepines have a number of other important indications. 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

Route and Adult Dose (max dose where Indicated)
alprazolam (Xanax)

Drug.1o< ,.""lety.OO In<omn"

Adverse Effects

f anxiay: PO;Ol5-0.5 mg tid (mn:. mglda,)

~Itdolion,ltrhl7g)',oumQ

f panic attad:~ PO; 1- 2mg tid (max: 8 mg/day)

Aru!~ hywmi!~ !!il~t haloonat"ont i!l{[ultd

Mild in~I)':PO; ~-10 JOg tidar !jd;1M.IIV; SO- 1oo JOg 1 hbt(~a
mfdKal proadlI"~
SfoI~r~ anxiety: PO; 2O-1S JOg lid or qid; IMIIV; 50- 100 mg foIOW!'d

mUld~ 1!!!!li!:~! ~I inl!!!irmmt, roroomiQl !t1t1

ampng W()IIlrn wboare preg[),JDI rewUWy
imp.JillMnl due to hrpmilwjllioo. rtSpirjllO!l
pslion,lmnaO\wm,cardoyasruar tollapse

by2HOmgtidorqid
doniztpam (l<1000pinJ
dorazrpate (Tranxe~)

PO; 1-2 mg./day in dMdtddoSfS (mal:. mgld.,)

dimpam(Valum) (Itt j)igt 174

for t(w, PrototYIH' Drug boJ: 00 )

PO;HOmgbid
IMIIV; 2- 10 mg:rrprat ffnffiled in 3-. h

PO;H mg./day in dMdtddows (mal: 10 mlJ/da)')

ioraupam (Ativin)

oxaupam (Strax)

PO; 15 mgld., at btdtime (mal:60 III9Id., in dvidtd MS)

PO; 10-30 mgtid or qid

INSOMNIA THERAPY

ffiazolam(Prosom)

PO; 1 mgat btdtime; may iIKIM!' to 2JOg ff nMSsar}

~II1frlIr()/m(t, hfadocllt,mtmayimpomnr

ftlNazrpam (D.Jlmalll'j

PO;15- 30mgllt btdtimt

AIJiDUIOM{tIj!

qlWl'pam (Doral)

PO; 7.5- 15 mgu btdtim~

~maz~pIIn

PO; 7.5- 30 mgat bMim~

(Rl"lloriIJ

triarolim (Hikion}

PO;O. 125-11.25 mgu btdtim ~ (nw::05 mglda,)

IrQ/ia inoot~ ammon id'Imt tffem; underlining inoote sffiousad>imt ~fltas.

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<pIN

158

Until Thl'Ne<voo,Sy'tem
Il'r Prototype Drug

Lorazepam (AtlVan)

Ther api! ut ic (lass: SedatiYt'-hypn otic; anxi olytic anesthet ic adju net

Pharmacologic (lass: BenzOOiazepine;GABA.-receptor a!jonist

ACTIONS AND USES

ADVERSE EFFECTS

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 pot~m brnzodia~pillH.lt ha, an Htended haNlif~ of 10 to 20 houl5, whim allow! for onu- or I"';u-,t.rby oral do,ing.ln addition to bring UIed '" an amio~tic, Iorall'j)im is u,~d '" .J tnanestheoc
m~dic.ilion to providt ,~tion,and forth~ managMlffit of ,taM ~piltpticus.

The moll common .J<M1Sf eflect. of Imzepam af! drowsiness .J nd sedation,

which may demall' with ti~. Whtn g~n in higher d=s or t:, the IV IOOI~,
roof! ,fftf! ~u may br obs~rnd, IlKh J I amnt~a, W1'iknffi, disoriffitalion, atnia, de~p disturbanc:~, blood pre'Uf! changr~ blurml vision, double ision,I"OIUIN,.nd I'Omiting.
Conlraindications: This drug should not br UII'd in j)ititnu with acute 1"01 nowi nglt glauc:omJ, primary d!"preliYe disordtn, or p,ychOlis, and .hould br
.Jl'Oidtd for th ~ mal"Olgrment of 1I'\'eC"! uCKomrol1fd j)iin.

ADMINISTRATION ALERTS
Wh~n administt ring IV, monitor rtspiratiom el'l'lY 5 to IS
airway and ~tative fquipm~nt acu-IIiblt.
Pl!goanq category D

PHARMACOKINETICS
1At5l!t: 1- 5min 1V;15-30min 1M

Peak: 2 h PO;90minlM
Half~ife: 111-20 h
Duration: Van;.blt

minut~'. H<l"I~

INTERACTIONS

1Wg-1Wg: loraz~minteram willl ~drug~for tKolmple,(OIKlJrrent 1M

of(l6diopr~nl5, iJ:Wng ikohol, potentiale5Sfdo~"ltefk>m m iKmsesthe
rill; of rfljliritory ~ arKI d&J\h.lorazepam CIIiI1 contribute !odigolil
toIici!)' '" inc:lNIing the II'fCIII rigmin level.5)"11l1!oml~rilual thoJlIg@\,
nausN, "IOOIf!i!g.diuill5l,arKI confusion.
loraupam roayrItmR ihl'ilIlujOO:iIIorism Mlec:tsof~ m i~

l --

labTfltl: Untnown

IIorbaVhcxl: u..~ ... i!h herlwt ~.f aample,wd.I!ion

pro<lK:~ IIfIbs SCKh ill 00, valerian, dlacmmilf,or hops ma, haole in ~itM>
efffCt with ml'dif.Jtion.Stimulant hairs sum oil CJOIU kola and rna huang may ffdlKe
ihl'drug~ elfectil'enesI.

TrNtm~nt

of !mrdo,e: IfoMrdoll' ocrur~ llurna~nil (Romuiconl..J spe<ific:

brnzodiazepint IffeIItor anta9Ollis~ un br admin~tmd to IlWI5I! CNS d~
p~sant~cl5.

Rtftr IrI My/mIrrgKl for Q Mnbrg /'rOCef.l foon spt(1fc IrIIM /tug.

Other uses include treatment of alcohol withdrawal

symptoms (chapter 1200). central muscle relaxation
(chapter 2100). and as induction agents in general anesthesia (chapter 19CO).

Barbiturates
Barbiturates are drugs derived from barbituric ~cid. 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 avail~bility of more effective medications.
The risk of psychologic and phr-;ical dependence is highseveral are Schedule II drugs. The withdr~wal syndrome
from barbiturates is extremely severe and can befatal. Overdose results in profoWld respiratory depression, hypoten-

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L tFESPAN CONS tDERATtO NS

Fall Risk in Older Adults and Benzodiazepines

For ptrsons oMf thr 'g~ of 6S, f,lk &rr onr of thr Ie&ding YU~ of injuryf!lated mit! toem~I\1ffiQd!"panmenu.Whill' mukipll'risk fJetol5llKh .J. visual impairrn~n~urioary inc:ominmu, and physic.illimitations JII rontribut~
to an iCKf!J 51! in fall ri,1e, druglllKh '" the btnmdialt'pilll' group 11m the poIf1Itial for inCIN~ng this ri,k.
All patitnu preuibrd a brnzodiazepin~ drug should br yutioned about
tilt pos~br'it, of~mtduion,ronfusion,or imj)iirm mobiliry, which mayoccur eYffi at oorroal doms. This is espffi.Jlly t~ for the oldu patitnt who is
PIOn.! to f~lk. Tht nurlt sllould also tvawte the safm-of thr homt rnvironmm~ otlltr risk fJetOl5 rontributing to in,omnia (t.g., diurffic lU), and HpIof! oondlllCj options that ma, br useful in treating the patient'. underlying
insomnia oc amiety suc:h <IS ,hort cb)'li~ naps to dKlNI~ th~ sito~p ddrt"or
going to brei u th~ same timH .Kh night.WlItnever possiblt, tilt ~t ~
of a btnzodiazepin~ for th~ shonest amount of tim~ ,hould bt ull'd.

sion, and shock. Barbiturates have been used to commit suicide, and death due to overdose is not uncommon.
Barbitur~tes 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

IlIapttr It

Drug' lot AnxKoty.nd In'iOmnla

I S9

TABLE 14 SI Barbiturates for Sedation and Insomnia

On"

Route and Adult Dose (mn dose where Indicated)

Adverse Effects

SHORT ACTING

ptntobarbital sodiu m(Nerrbutal)

Stdati~:PO;10 -10 mg

bid orqid

Hypnotic PO;I20-lOOmg;IM.I50-200mg
Stdati~:PO: 100-100 mgld.lyiI thrn

diYidN ~

I/ypnolkPOIIM; 100- 200 mIj

INTERMEDIATE ACTING

amobarbital (Amytal)

Stdati~: PO; lO -,O mg

bid orlid

IIddwI stdIlion

HypnolicPO/IM;6,- 200 mIj (madOO mg)

aprobirbital (Ah.ntt )

Stdati~:PO:4Omlj1id

AqriInul !K'IIo~\:,angioed~ ma Sleyenr Johnm

lYndrome rnPiratorrdeprn!ion (ituialOfY

roUapsr ,JQD!'.! Luyn!IP\I)j'1ll

Hypnotil:PO; 40- 160 mg

buuba!bilil sodium (Butilol )

Stdati~: PO; 15- 10 mg t id or qid

HypnoticPO; SO- I00 mg oil btdlime

LONG ACTING

mtphobarbital (MebaralJ

Stdati~:PO;11 - 100 mg

phenobarbital (Luminal) (~e ~ge 171

for 1~ Prototype Drug box 00 )

Stdati~:PO;10- 110 mg fd.ly;IV!1M ,100-100 Ill9fday

tid or qid

~~samoItno:r

100 nul!K)'\o~ ~ ftlDiratro dwrnioo,

St(Wj1 JohlllOll !yndromtufoliati~ rlemlal~!

(fiR) CHSderuuion roma dwb

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 system. At higher doses, some barbiturates can induce anestheSi.1 (chapter 1900).
When taken for prolonged periods, barbiturates stimulate 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 includes cross-to lerance to other eNS depressants such as the
opioids. Tolerance does not develop, however, to the respiratory 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 barbiturates (see Table 14.6). In addition to nonbenzodiazepine,

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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 paraldehyde (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. Buspirone (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 Wldear 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 reptors. 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 withdrawal problems are less of a concern with buspirone. Therapy may take several weeks to achieve optimal results.
Zolpidem (Ambien ) is a &hedule IV controUed substance limited to the sho rt-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

Unlll TteNetvoo,Synem

160

..,. Prototype Drug

Zolpldem (Ambren)

Therape utic (lass: Sedative- hypnotic

Phanna co logic ( lass: fl onbenzod iazepine GA BA" receptor agonist; nonbenzodiazepint,

nonbarbiturate CNSdepressant

AalONS AND USES

ADVERSE EFFECTS

Although it is a 1Il0b~nzodimpint.zolpidtm <1m in a limilar fashion to facilititf GABA-mediat~d eNS dtprrslion io tht limbic. thalamic,and hypothalamic:
~ions.1t prem.H stagnln and IV of sftpand halooly mioor~Is on REM
Sftp."Theonlyindicationforzolpidemisforshort-urminsomniaman<lgl'OII'ot
(7to l 0diys).
ADMINISTRATION ALERTS

BeulMof rapid onSfl, 7- 27 mioutH,9iy~ immediate/)' btfore btdtiOll'.

P~oanqrnrgory8

~~efFts in(kKltdi)1im~ sNation.(Onlulion. <l mOHia.dizriOH~rIeprrs

wn, Oiulfa.<lnd wmiting.

Contraindications: lactating womm should nottae this drug.

INTERACTIONS
1Wg- 1Wg: Drug inteOOionswith zdpidem ~iII irKrNIfin!edatioo whfn
UIfd (ooo.mntlywilh othl'lCl6~inWIingakohol. Phfncr.hiaziMS
iII9MOtCHS~

Lab TfIIs: Unknown

HfrbaVFood: W~ tJUn with food, absorptioo ~ !iIowfd s9lilKarttJ and the
(1\\1'{

PHARMACOKINETICS
On",t: 7 27 nin

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<lzepine It(~tor aotaogonist maybe htlpful.

~ak:

O.5--Bh
Half~ifto: 1.7- 2.5h
Duration: H h

TABLE 14.6

ofiKlion lOIybe delayed

T.... tm ~nt of Ove rdo, ~: GfMI. liHd ."mptomatic: ~nd support;" OII'.1Wln

Rtr'tr IrIMyMnbrgnfrxa MlslrlqPrwI!l"l FoMsp/It IrIrMltrJ9.

Miscellaneous Drugs for Anxiety and Insomnia

Orug

Route and Adult Dose (max dosewhere Indicated)

Adverse Effects

NONBENZODIAZEPI NE. NONBARBITURATE e NS DEPRESSANTS

buspiront (Bl6pir)

Sedativr:PO;7.S- 15 mg i1 d'lidtd dose~ m~ i )(rml' t.,

Smglda'"tr"f 2- 3 d~s if OI'rdtd (1OI1:6OIJI9Iday)
SedatiY~:IV; ioadilg dosr

I m{9l\g owr10 min; maintl'llarut

dw 0.2- 0.7 m(gIkgJtr

H)1IOOtic:: PO; 2mg at btdtime; dependi" 9on t/if a~. dinic:.J1

rnpon~. and toltrilKe of ttw, patil'll~ doll' maybe IOWMd to
lmgPO

l>illinru, IrfOOodIe, dlllWlirrt"l~ 1WlltI, (orip,

Qr<ll'iq. fOIOirn;, bilftf mffallk 10Ile, dry mruth,
diorrIrtD, hypoltmion
Am:i~dema g!!lioormt,txfoiat~c derman~

IookSl"l'IIS- Jotmon syn!tpm!: lOiphYiaxil,

Il'pratpry faj!! roma W!klro dNlb

SedatiYr:PO;200 mg bidortid
H)1IOOtic::PO; SOO mg- I gil brdti~
reOII'ItronjRomm)

H)1IOOtk:PO;3 mg al btddOll'

liI/fplon (Sonata)

H)1IOOtic::PO; 10 mg at bedtiOll' (mad l) rngIday)

Q lOIpidem (Ambito)

H)1IOOtic::PO;5- 10 mg it bedtimt

ANTISEIZURE MEDICATION

vaiproic:idd(DrpatrM) (Ite~ 176

Sodal alUlitty symptoms: PO; 250 m9 tid (1011:60 mglkgfday)

for ttw, PrOlOiypr [hog box OO )

WotiOfl, dlOWliot~ 1IQIj1tll, Imlirir4 proioogtd

bImInga11If'

OcnJ torna wilh ovcr<Jo\t liver f.J~Ufl:. DaOON~til,

prolonged blmiOQ t~, bo!l !!I!T?W s!!W!lsion
BETA BLDC KERS
a l~ noIoI

(Tenonnil) (Ite pq m for

Sodal alUlitty symptoms: PO; 25- 100 mglday

tilt ProtOlype Ilrugbox OO)

propranolol (Inderll) (Ite ~ 164 for

tilt ProiOlype Ilrugbox 00 )

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Sodal anUtl, s,mptoms:PO; 40 mg bid :max:l20 mg'd~)

Brod)fQrdio, hyporrmiOfl, ronlilli<w1, IQrigw,

drowinru
ADiplribq k mmiOD!

Stmm

JqbD\9D!mdmml'

tui( ffidermt l fINO/YIis. erloiiatM dermat~iI,

Cllaplflt(

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 ca tegory B. Zolpidem is used with caution in individuals with a high risk of suicide, because there is a potential 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 structurally unrelated to other drugs used to
treat insomnia,eswpiclone (Lunesta ) has properties similar
to those ofwlpidem (Ambien). The effectiveness of eswpiclone has been shown in outpatient and sleep Inb studies,
but the drug has not directly been compared withzolpidem
or other hypnotics. However, eswpido ne's longer elimination half-life, about twice as long as that of wlpidem, may
give it an advantage in maintaining sleep and decreasing

NURSING PROCESS FOCUS

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 advertised 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 duration 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 (Benadryl) and hydroxyzine (Vistaril). These: are antihistamines
that produce drowsiness and may be beneficial in calming patients. They offer the advantage of not causing dependence, although. 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). Doxylamine (Unisom) is another antihistamine medication commonlyused as a night-time OTC sleep aid.

PATIENTS RECEIVING DRUGS FOR ANXIETY DISORDERS

Assessment

Baselin! assrssmtnt priorto administration:

Undtfltmd th~ ~ason tht drug has ~n prtKribtd in order to me s for
thtrapwtic: fffects.
Obmin a (omplttt htakh histOf)' ilKluding htPitic, ~na~ ~irato!)',
cardiornarlaror ntUroIogic: diltas~, rntntal status, narrow-ang lt glaucoma,
and prrgnaocy or brmm~ding.Obtain a drug hil10ry including alll'''lie,
(urrent plt'\{ription and OK drug~ h~rNl prtparition~ and (ifltinr and
akohol ulI'.Bt altn to ~iblt drug int~roKtions.
~III'SS IIrI'SI and roping patt~1TII (t.g.,l"lIisting or pel(rN~d I1rrt~duration,
(oping mtdlanilrmor ~rntdie)
Obmin a !Ieep histo!)' (~.g.,~li\)' and ~ntity oilleep. ~tlelsnelor
lrequmt wakelulne~sooring or apnea, remtditl ustd lor slt~p,(onrems).
['/<Ilua~ appropri.ltt laboralo!)' findings (t.g., h~ ~tic: or ~na Ilunction

Potential Nursing Diagnoses

Anlitty
Disturbtd Sletp Pattern
Fatigue
lnrfff,uN~ Coping
ktjyity IntoltrdlK~ (~Iattd to loss of sltrp Of ddytimt *tpines)
D~l(ient KnowIedgt (drug thtrapy)
Risk for lnju!)', Risk for Falls (~lattd to adYmt ~ffKh of drug thtrapy)

studia).
Obmin N5tlin~ vital signs and Wl'ighlA~ the patitnt's risk for lills.
AslI'Ss tht patient's ability to It(~iYr and undtflund instllluion.llKlude thr
la mily and carf<jiYrfl as I"ftdtd.
Asst lSmtnt throughout il dministration:
AslI'Ss for dt~1fd thrrapeutK rfletn (! .g.,I1i1rmntl of implO'/tm~nt in
anl~ty,appetit~,ability to (.i ll)' out AOCs. and iftp patterns normal~).
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 ildvtrw tlfem: ~)[(esiYr dinine~
drowsi III'ss,light-htadtdnrss, (onfusion, agitatio n, palpitation ~ !aC:hlUidia,
diuines or light-htadtdne~ and mUlQlIos~1 Wl'aknes~
(conrlrwed)

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162

Unltl

TheNetvOll'Sy""'"

NURSING PROCESS FOCUS

PATIENTS RECEIVING DRUGS FOR ANXIETY DISORDERS (Continued)

Planning: Patient Go.ls and Ex pected Outcomes

Thr patimt wit:

U~M!lCt rlIef....tic tfffm ~~.t 01\ tilt _
the drug is kin9 gjYen {t.g..dem.Sfd ,nxitty, impJOfd sIetp ~tttrns},
k lite from"Of ~ millimal,.1Mrw tlfKb.
YtrbaI~,tII LJIIdemardng of the drug, 1M. advent tfftm,.nd r!q.md ~ns.
Demonltr.lt proper seIf...inistr.don ohhe mtdic.tion (t.g.dOlt, timing, whtto to notify plOi6tf).

Implemtntation
Inte-rvtntloM and (Ra tio nales)
h 'lring tMr.ptutic tff~l:
CoMinut .ssmmtnts as d&ribed tarlit!" Iof thmptVtic tfft.:1!. (If tilt
drug is gjYen for .nxiety, tilt pabtnt repom dtm-nd .~, imprlM'd
sletpand rating h.biu,~ {Oping,.nd abilitylo (;IllY out ADls
IOithout anxitty.1f lilt drug is giwn for slttp, tht palitllt re,orts lilt .bility
10 fan and ~in .11~.nd impro~ diytimt wikeulnmJ
Minirnldn91dftlSt fffKb:
Continur to I!IOII ~or vital sigm. mmt.1 shM, and lOOIIfIIItian .nd bIIancr
ptriodic.J~ k paniculally CMious with oIcItr .duM wbo.m 011 inaN!I:d
risk for fillh.{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 forlighthN~dnt!SOf diuintS~ Monitor Imbularion until tht tfft<ts of drug lit
known. {Dizzintss.nd dlOWlintss for a plDblged pmod oflilll!' rnayoour;
~Pf.1 011 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
~ion. {Ntutologic changes may indiuae O'itrrntdiutioft orfl'lt<u fA
IIttpdeprinrionJ

Palit nt and family Education

~ilt tht INbtnl in dtvtloping htalthy(oping .tr.t~its and sIttp habits

wittJ ~1MaI kI approprioll~ hukh cart proI'i~~ as ~

r-r~ thf pUnt to 1r.fqI. sIttp diMyofbedtimt, tilt timt inYoIYtd

trying to fill ~ tht~lity.nd quantity oIs1etAdaytimtsltotpintSs,tk.

1Ndr tilt patitntto mt m IJing or sitting kllt.nding IIowl~ to .void

diuintssorfds.

Ostruct the patient to uiliof ...!islinct prior to getting out fA btd 01

itttmpring IOwal ilont,Mtd to i'IOid dfiving OIothtr iKtMtits rtq.jring
mtntal a~ or physical (oordin, tioo unti tIlt~~ of tilt drug.~

......

Dwuct the patiml or m~ to im!1lldiattl, ~port rousing Ittlww,

disofitntation. confusian, dIinges in bth.wior Of moor!, sIurr!d spm:h, Of

oltma.

lslffi i)rdiMlgn in visull~, blrrrtdYision, 1os:s of ptl"ip/ltral vision,

Itting rainbow halo.lround Ii9ht~~1Ilt f)Ie pain.or.ny oftht~
symptorm K<ompanitd by RoMI' nd lOIlIiling and ~ immtdi.n~.
(I~awd intr~tK pfPI~" patitnu with ~rrow-angif gl. lJ(OlIW m.!,
ouur in patiml! taking btnmdiilfpints..!

Ostruct the patiml to irnrntliatdy report ,tIIJYisu.1 dwngts or t"Yt pa ....

Monitor al'lt<t.nd emotion.!1SI.IDS. (~ lIWy incrfill:' risl of mmul

~pfPIsion.tspe<~lIy in ~u with suicicIaIltndt!lCies.Conwrrtlll 1M of
akohol and othfl" eNSdrprtSwnts in_ thtel'lt<ts and tht riskJ

Instruct the patient to report signifium moodchangts,tspt<ially

~pfPIsio" nd to .void ikoboI.nd othfl" CNS dtprtssalltS wt.ilt t~king

Enmur'l]f appr!)pri.l(! IhstyIt <h.lngts:1owmd ~~ inlike including

ore mtdic.JtiotI~ that (OIluinufftirlt, inataSfd tRI{M during th.! da, but
not immtdiat~ befm bedtimt.limittd or no akohol in"k.nd srnokillO
~satioll (Nut!J~ lifetyW challgtS will IUppln and minmin th.1ftd for
drug thtr'JIIluffeint.rId nimtint rrvy demiSe tht ~ffi ohM
drug. AkdJol and otlltr CHS~presj,Jnts IIIi)' incr.iSe tht ~ml' tffem of
thtdnICJS.)

[n(our'ge 1M pititm to ~ I ht.hhy &t)4~ of ~ 01

abslirlf!ICt from uiftirlt,nKotW, ind a1cI>hol;.lrId irK/US! 1'X~r<ist.
Advise the poo...t to disc .... ..n OlC m.dirniom with the h.. W. ar.
pIDI'idtr to etSUn' affrine c. .kohol is no! indudtd in me formulation..

Altoid. brupl dilCominualion of thtrapy. (Wibdrawil symptoms, induding

~nd .nmry and !ltfpltssntss, a~ possillit with abrupt discontinuation
.ftt.r Iong-ltrm 1M.)

Ostruct tilt patient to I.iR tht drug txaetIr ~ prI'ICribed .nd to not Slop ;;
.bruptly.

lslffi ho~storagt of IMIiutions.1Id idmtify risks for ~ K1icm.

(1hmIosagt mar oc(Ur if the patitm likl's addition.ldosts when ~ or
disoritnMd m mtdiutionrifl'ctsJ

OstnKt tilt- patient th.lt thtst drugs should no! be krpl" tht btdsiOt to
..m:I liking adcIlio~1 dosts wlltn drowsy.

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.......

Cllaplfll( Drug'lo< ,.""lety.oo In<omn"

NURSING PROCESS FOCUS

163

PATIENTS RECEIVING DRUGS FOR ANXIETY DISORDERS (COllffllUtd)

Impleme ntatio n

IntelVe nti o ns and (Rati o nale s)

Pati e nt a nd Fa mily Edu cati o n

Trach thr !)'titnt nonphil~ologic: mtlhods for str~s II'lief ,nd for
implO'/td sleep h)OJimr.Rfier to appropriat~ heakh GIli' providers or
IUppon groups as IIffdtd

A'les prior melhods of IIIflS II'dlKtion or slttp h)'gitnl'. Rtinfor(t

prl'\'ious~ ustd ~ffKtiYe m~thods ,nd teac:h ntw (oping .kills. (Drug
tiltr' py is ustd for tht mort~st , rooum of tim!' possible. ~Ioping other
(oping skilk or improl'ed sleep hygitnr ~y ieslfn the rwd for drug
tiltr,py.)

Patirnt underst anding of drug thrrapy:

U", opponunit;.. during odminimillion of m.dK"tion,~nd during
~ <lIwtnts to dis(U15 the rational~ for drug theraPl', desill'd therlpMK
OU1{om~~ most {ommoniy o~ Im~eflern, !),r,mtlel> forwhr n
to (illl the health GIli' provide~'nd Ill)' nKtl!.lIY monitoring or
prtuUliolll.(Using timr ruring rursing Urt helps to optimizt ,nd rtinfortr
ke)' teaching areasJ
Patirnt R lfadministrilt io n of drug thrril PY:
When administrring thr mrdKation, inmu(\ th~ patiom. flmily,orGllI'9i~r
in proper stK--administration of drug. r.g., taking only amount pll'l(ribed.
(Utilizing tim. during 1MJ~,dministration of thesr drucp helps to ~nfon:.
1I'ac:hing.)

Th. potiom ,hould bubl. 1<1 ""I< tilt 11'1>01\ for th. drug;oppropn.l<
dose and IChfduling;what ,mrlt rffects to oIM~ for and when to
II'port; and the amici!)'t~d length of mtdKation therapy.

Th~

patitm is ablt to di~ appropriate dosing and administration needs.

Evaluatio n of Outco me Criterii!l

['/aluat~ thr ~ffectiYeMSS ofdrug

ihtr,py by confinning that !)'tirnt ~Isand np1l'd out{om~s hl'lf been m!'t (~Planning1 .

. 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

14.)
14.4

14.7

The limbic system and the reticular activating system are

specific regions of the brain responsible for anxiety and
wakefulness.

When taken properly, antidepressants can reduce symptoms of panic and anxiety. First-line medications include the selective serotonin reuptake inhibitors (SSRls )
and other antidepressants; tricyclic antidepressants
(TCAs) and monoamine oxidase inhibitors (MAOIs)
are older drug groups.

14.1

Anxiety can be managed through pharmacologic and

nonpharmacologic strategies.

Benzodiazepines are drugs of choice for the management of anxiety disorders and insonmia.

14.9

Because of their adverse effects and high potential for dependency, barbiturates are rarely used to treat insomnia..

Insomnia is a sleep disorder that may be caused by anxiety. 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..

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14.10 Some commonly prescribed agents and CNS depressants not related to the benzodiazepines or barbiturates
are used for the treatment of anxiety and sleeplessness.

16 4

Until

Thl'Ne<voo,Synem

NCLEX-RN " REVIEW QUESTIONS

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

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.

A 32-Ye'ar-old female patient has lJe.en taking lorazepam

(Ativan ) for her anxiety and is brought into the emergency 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.

A patient hasheengiwn instructionsaboUi the newly prescribed medication alprazolam (Xanax). Which of these
statements, if made by the' patient, would indicatt'that the
patient nreds furtht'r instruction!

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 upset.~

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' 1am 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.

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, explain to the student nurse why both medications should be
administered.

2. A 42-year-old female patient with ovarian canU'r sufft'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.

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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 information can tht' nurse offt'r this patit'nt regarding the normal changes in sleep pattt'rns associated with aging! What
would you recommend for this patient?
Sec Appendix D fo rans",,,rs and rationale, for all activitie.

EXPLORE

~.-----,

M)'NuI"$i1g1Q1 is ywr COle SIOjl1or ol1ine CIlIlPW r1!vIo!w materi&ls and

reliW rQls. I'lllll<ire for IiUGCIlSS with alfdilional NCL EX""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 ..*.t kil c .....

Drugs for Seizures

DRUGS AT A GLANCE

LEARNING OUTCOMES

DRUGSTHAT POTENTIATE GABA ACTION pa;t 1i\1

After readin fJ this chapter, the student should be able to:

Barbiturates fJt1j 1 III

O phenolJoroJfol/Lurnt'la/J pogt III

Benzodiaztpines

(K1IJt III
I4I diozepam (\otll/um) (K1IJt 174

Newer GADA-Related 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

1. Compare and contrast the terms selzures,convu/s/onJ. and tp/kpsy.

2. Recognize possible ca uses of seizures.
3. Relate signs and symptoms to specific types of seizures.
4. Describe th e nur$E"s role In the pharmacologic management of sel:nJres

of an acute nature and epilepsy.

S. E~plaln the Importance o f patient drug com pliance In the
pharmacotherapy of epilepsy and seizures.
6. Fo r each of the drug classes listed in Drugs at a Glance, know
representative drug examples and explain their mechanism of drug
action, primary actlons,a nd Important adverse effects.
7. Cate-gorlze drug s used in the treatme nt of seizu res based on their
dassification and mechani sm of action.
8 . Use the nursing process to care for patients receiving drug ther<!lpyfor
epilepsy and seizu res.

KEY TERMS

abstn(!seizurl' (XJfJt m
atonies/jzure paqt 168
convullions pogt 1M
rdampsia (IQIJt 167
epilepsy patll'166

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febr~t S!'izull' fO'!t 166

gamma-aminobutyri,a,id IGABA)
gt nt ralizfdS!'izu ll' ~167
myoclonic: stillm: JUjI m

I.,

~1J(J

partiallfocal) sfizull' pu;t

stirurr pu;t 166
status tpiltptirus f'!'!t 171
tonic-donicseizull' pl9t168

166

U"IIJ 1heNe<vooISyltem

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 o f memory.
This chapter examines the phan1l1K()(OOapy ustd to treat
epilepsy and different kinds of selzure~.

SEIZURES
A wizIR or dinially dt'le(Ubie sign of tpilfpsy is a disturbance
of electrical activity in the brain that may affKt ConscioUliness,motor activity, andsens:ltion. Seizures are aused byabnormal or uncontrolled n~uronaJ 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 normal 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.Although 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 referred to as anristizure drugs rather than a"ricoru'loonN. Recognizing also that antiseiwre drug'> are commonly called
antWpil..pric drugs (AEDs), dle term anristizure in thi!; chapter applies to the treatment of all seizu re- rel~ted symptoms
indudingsigns of epilepsy.

15.1 Causes of Seizures

Aseizure is really considered symptomatic of an und~rlying
disorder, rather than th~ d isease ilSelf. Triggers includ~ exposure to stroDe o r flkkering lighlS or tht occurrenc~ of
small fluid and electrolyte imbalances. Patients ap~~r to

~raIia<:I
~

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 iocidence approaching 2% for febrile seizures and 1% for idiop3thic epilepsy. Cena in 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 prese nt as an acute situation, o r 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 exi!;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 subs tances 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: Chan ges in oxygenation such as those

caused by respiratory hypoxia and arbon monox ide
poisoning, and changes in pl'l'fusion such as those
caused by hypotension, Cl'I'ebrai vascu lar 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 press ure,
and damage brain tissue by disrupting blood flow.

tonic-dorOc MillIN

Figure 15. I EEG rl!<Ofdlngs showing tne dffferencfs IM!tween normal,absence setzurf',aod geooralt~ tonlc-dook: sqjaJf1! trKlngs

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''''''If.t5 Drug<forSelzult'1
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 considering the serious nature of seizures, patients should consult with their health care provider to determine the most
appropriate plan of action for seizure control. \Vhen patients become pregnant, extreme caution is necessary. Most
antiseizure drugs are pregnancy category D. Some antiseizure drugs may cause folate deficiency, a condition correlated 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:perience 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 person is driving a vehicle or performing a dangerous activity.
Almost all states will not grant,orwill take away, a driver's licen... ami r"'l"ire a ,~il.llre_free period hefoTe gmnting th~
license. Without successful pharmacotherapy, epilepsy can
severely limit participation in school, employment, and social activities and can affect self-esteem. Chronic depression
may accompany poorly controlled seizures. Important considerations 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 pharmacotherapy, patient- family support, and education, effective
seizure control can b~ 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 CO NStDERATtON S

Seizure Etiologies Based on Genetics

and Age-Related Factors
Tht tliologie thi! triggtrtht dmlopmtnt of childhood l'pi~, fary
oKcocding to agt.
Coogtnital abnormalit~ ofthr CNS, ptrinml brain injury, aocl metabolic
im balance a~ UlWIIy ~lated to ~izu~ ictiYity in lH'ooate, info! nts, i ocI

..,"'.

Inherited tpiitpsie,(NS inftaiool,aocl ntlJroIogic dtgtneratil'l'

dilordm a~ linkrd to smUItS that h.wt thtir oostl in latrrchildhood.
Ctrm-al triuO\l,rereblO'<il(ular disorde~,aocl ntoplastic dilti~
II'pretm the most frec;Utnt (,JU~ of ~izultS in theaduk population.

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167

and difficulty speaking are other behaviors a person may exhibit during a seizure. Determining the cause of recurrent
seizures is important for planning appropriate drug selection 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 identified 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 sti lU~s may be recognized based onsymptoms observed during a seizure episode. Some symptoms
are subtle and reflect the specific nature of neuronal misfiring; others are more comple."I:.

15.3 General Concepts

of Antiseizure Pharmacotherapy
The choice of drug for antiseizure pharmacotherapy depeoel. on sign. presenloo hythe patient, Ihe pMi enT" p revi_
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 control 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 effective drug concentration. If seizure activity continues, a
different 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 addition, the newer antiseizure drugs are generally better tolerated 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 neuropathic 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 issued 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 encouraged to pay dose attention to changes in mood and not to
make chanRes in antiseiz ure r/'Rimen without coruultin~

"

TABLE 15. 11 Classification of Seizures and Symptoms

Classification
Partiil

"""

Simp~panial

Symptoms

Complu panial (ps)'diomo!or)

-'

Ilfactory.iuditory.i'Khiswl halkKinations
Inl\'n~

mlO!ions

lwiKhingofi'm~ltg~andoo

Awol (preading)

Britf ptriod of (onfusion or ~ss afit!Wiro with no mrnlOll of s.rizLno Iposri!/QI roofug'm)
flJnblingw~h Of aUtmplilg to ~ dolhing
No IfIIIOn~ to 'lffilil (ommandl

0;;;.,

~(pr!~min

Atonic (drop iruOO)

Tonic-don i( (lJind mill)

lanilg a few Ittonds

mn most oftm in mildlm (mild rum inlo!paC!. 11M not mpond tovrlllillstimwtion.milY hav~
fuuffing ~ids Of jrrkingl
MisdiaogllOlt(j often (6pt(iiliy in m~d) as ADO Ofdayd'~ming
Falling Of stumbling for no fl'ason

lanilg a few Ittonds

Atl'a (preading)
Inttn~ ItIIIdr (onuaction (tonic: pha~) foIlowIod II)' akemating (onuactim and rriaLition of musdrs
(dooic:pha~)

Cl)ing at IJr9n"ngmi, Iral'fllungs; loss ofbowtl~ (ont,oI; shallow oo-atling with ptriods 01
ipMa;U5Uiliy lining 1- 1miMe
Disorientation ind dtfp ~~ ifitl sftllll' 1posrk1~lut)
SptWlsyndrome

Ftbrilt lfilll'r

lonic:- donic: inil'itylming 1- 1 minute

Rapid '~!rn 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

Consideredamrdic:il~nq
Comiooouslfil!ll' actil'il:~ whidJ un ~id to(OIIIi and~atli

with Iheir health care provider. The sum of this review indicated that although the older antiseizure drugs have serious clinical drawbacks, so do the newer antiseizure
drugs.
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.

How Antiseizure Pharmacotherapy Works

The goal of antiseizure pharmacotherapy is to suppress neuronal activity just enough to prevent abnormal or repetitive

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PHARMFACTS

Epilepsy
Thf word tpilrpsy is ~rived f,om the Gfl'rk word tpiIqnKJ, muning"to
IiIkr hold of Of to~.
About2millionAmerKanlhaw~pilepsy.
One of f'YI'ry 100 trrnag~rs h.il rpilrpsy.
Of the U.S. populnion, 10% will hoiVI' seizurH within thrir Iiletillll'.
Most PfOplewith seizurH an')OOngtI' than 4S ~rars of alit.
Contrary 10 populu btlitt il is impossiblt to 1W!llow the tongue during a
ltU:uR.and ont mould n~' lorn' an objf(1 into the mouth of someone
who is having a ~il:Ufl'.
Epiltpsy is nOlI menlill iIInt55; mildfl'n with rpilepl~ h.ivr 10 I<Om
equivalent to tho~ oI(hild~n wilhout the disordtr.
~amolll prople who had rpilepsy inc:ludt .kJlius (1~1i~ Almnder the
GrN~ Napolron, Vinc:~t van Gogh,Cha~ OKktn~JNn of An, matn,
Aqatha Christit, Truman Capote,and Richa,d Bunon.
Among iduk akoholics l1'(~ving IrNtment fo, withdrawa~over haN will
l'iIIperierK:~ still"e within 6 hours upon aniving for ut'.Hmtni.

("'Plfr 15

DRUGS THAT POTENTIATE GABA

dial~m(Vaium)

gabapmtin (Nell'onIin)
~m(Ati\\ln)

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' (lri ~pllll)
pht~oin

(Ililantil)

nlproi(~ ( Dtpak_)

lOOisamide (ZOntgran)

,
,
,
,
,
,
,
,
,
,
,
,
,

SUCCINIMIDES
t\h&IUximide (ZaroJltinj

Abwnce

Tonlc-Clonlc

Myoclonic

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 affecting 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 betler conlrolled drugs. Recenlly, a fourth mechanism has been
proposed and studied, anlagonism of the primary excitalOry neurotrall5mil1er glutamate. Glutamate works in concert with the cell's Na ... K ... ATPase pump, which helps 10
restore ion balances across neuronal membranes after fir-

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169

,
,
,
,
,
,
,
,
,
,

,
,
,

'Ant~lUfI' df1191 ~d forUll inadjll'Ktiw 1htrapyor monothrra~.Chtd mark! ind~

firing. To this end, there are three general mechanisms by

which antiseizure drugs act:

Drug<; for Selzure.

,
,

potmtial UIlSas wellasappwml indiutions.

COMPLEMENTARY AND A LTERNATIVE T HERAPIES

The Ketogenic Diet for Epilepsy

Tht ketogtnic: diet is used when ~irufl'l (.)nnot bf (ontrolled through p~r
~othefjpy or when tllm are ul\a((eptabk' id"irl1l' diem to ~ mtdic:.ltions. Bdofl' antitpiltoptic: drugs well' deYrIoptd, this ditt Wi! i primal)'
tfl'Ument forfpi~,.
The ktlogenic: dift is a strin~mi)' (ikulated ditt that is high in fat and low
in urboh)llrates ,lIld protein. It limits watfr intaklo to avoid kIoto!H'diknion
and (ifl'fUli)' (ontrots (iloric: inta kr. Eim mfal has tht samf ketogtnic: ratio of
g offat to 1g of protein and wboh)llratdxlri fat is usuali)' giwn in tilt
fonn of (ft'am.
Rest.Jn:h wggests th~t the diet prodlKes ~ high 51KU'SS rate fur (enain p.ltitnu (Crw, 2009). About 0111' third of thf (hildrfllllling it bfooml' sub"intially sfizurt frrf whilto one third ~~ their seizures fl'dlKtd by SO% (It"I'Y &.
Cooptr,200lj. Tht diet apptm to be equally ~tctift for nff)' sfizufl' I)'pr.
Tilt most frr~mly II'pOntd adYef"Sf eifll in(kidt vomiting, fatigUl', (onst~
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 influx of positive ions into the ceU, so this is consistent with
the last two mechanisms.

170

Unltl TheNe<vomSy'tem

PHARMACOTHERAPY ILLUSTRATED
15.1 Model of the GABA Receptor- Chloride Channel Molecules in Relationship
to Antiseizure Pharmacotherapy
Seizure Ktivity: E pHp'-'

2 Unc:ontroled ............ chcn.rv-

Unc>c>nIroIled neuronal discharge

Drugs that pot..,liale GABA &etions:

8enzodi8Z~"""

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 action of gamma-aminobutyri( acid (GABA), the primary inhibitory
neurotransmitter in the brain. These drugs mimic the effects of GABA by stimulating an influx of chloride ions that
interact with the GABA receptor---chloride channel molecule. 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.

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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 GABAAand GABAB 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 degrading 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.

''''''lfr 15 Drug< for Selzu""

171

TABLE 15.3 1 Antis"izure Drugs That Potentiate GABA Action

On"

Route and Adult Dose (max dose where Indicated)

Adverse Effects

BARBITURATES

amobarbitallAmytin

1V;6HOOmg(mil:1 g)

mtphob.Jrbitall Mtbiral)

PO:400-600 mglday

Ag@DuloMO\jiSuwrn_Ig/DlQIlwD!tpme ,JOOioo!erN

For partialand gmaliztd srizll'ts:PO.lOO-1OO IJI9/tIay:IVm,l,

Y!)'!IQOSWIlll, ~mlory dwrnion,CtlSd!:prrnion.

coma dNlh

p/IffiobarbiIaHwmina')

200~ rng !4l10

20 rng~

For status I'piIrpliru\.: IV; 15- 181119ibJ il ~ng~ ordMdtd dolts

(mn:20rngIkg)
prirridont 1Mysoillt)

PO:lSO rnglda~ iooMed by 2SO rngIwk!4l1O max rl2 9 in I'M)

10 foor dividtd dolts

BENZODIAZEPINES

doniztpam (KIooopinJ

po; 15 rngIday in lhrt!' dvidtd dolts, ilaustd by 0.;- 1.0 mg

MIY] day, unl~ IftMtsill' controled

dorUl'paltlTraro:~lIt)

PO; 75 rng lid

1M1IV;5- IO rng (rtptala1 nffiltd il10--15 mil inl~rlals !4l10

30 mg; rl'ptiligainal IH'fIItdMIY 2- 4 hI

diazl'pam (Valium)

IV pum; iltnilist mul!ion 011 5 ffi9lmin

Iormpam (A~van) (Ite pa.;t 158 for
"'" Pmlotypo'Dn"l hnJOO)

IV; 4 rng il ;e,ntd ~owI)' ill mg/mil; if inadtquau ff!pornt ifl

10 min.moy fl'JH'ir ""'.

NEWER GABA-RELATED DRUGS

gabilpmtin (Nl'\IIOnlinJ

For additionall~: PO, llart with 300 mg 00 day 1:300 rng

bid 00 day 2:300 mg tid on day];con~fU 10 iKrNS! a.'I'Il wi;
tool ~ 011,200 mglday (400 rngtid);moy ioot'iltto
1,&X1- 1,400 rngIda,

pll'gabillil (l)Tica)

PO;!lart with 150 mglda,:may tit ioor.astd up to]OO mgiday

wilhil 0IIt W!'rto: (max:600 rngIday)

liagabilH' [GabitriJ

PO;!lart with 4rngIda,;may ilKll'ilt by 4-8 m9ldayMIY wffi:.

!4l to 56 mglday in two 10 fOll' li'Iidtd 00sts

lOpiramatt (Topamax)

PO:!lart with 50 rngIday,inuustd by 50 mg/Wk totftctiv~IH'I'

(mil: 1,600 rngIda,)

Barbiturates
Barbiturates are organic compounds derived from barbituric acid. All derivatives intensify the effect of GABA in the
brain and generally depress the firing of CNS neurons.

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

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l1roIrillE'l~ dizzillE'l~ foli~e, Jed!riw1, UlllJooIt~ I'IrTigol;

~r<ll'i4 coofuliOll, asrlrfnio, IrtododIe, III'nII7, fll'nOO>'It1\.
mffOOf)' cfflfcrlry, cfflfcrlly IOOO'nrnnillQ, pi)'dIomom

!IowiIg.ll)'S!agmIJ1. ~ naMG, K"mi~1Ii rmrrxiIl

5rrio1J5 dj5fogurjng,Joe! debjlj!atDg @W Wddro

IIleJ:Dlaintd dmh il tpim (5(JDEP1;withdrimllrizll'n
00 discoo~nua~oo of drug

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
neonM~I ."';7Ilr~_. _

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 phenobarbital. Primidone (Mysoline) has a phannaoologic profile
similar to phenobarbital and is among the drugs used effectivelr to potentiate GABA action.
Amobarbital (Amy tal) is an intermediate-acting barbiturate given 1M or IV to terminate statusl'pil~pticus. Unlike phenobarbital. 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.

,a
2

"~

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

ADVERSE EFFECTS

is a long-acting barbirurate usrd for tilt management of a variel)' of seizurrs. k is also und to promote lI~ep. Phen obarbitalshould not ~ wd
for pain ....1;.(", it ma, i!l<rNIU pot~t'< ~n<itivity to poin.
Phtnobarbitt Iam biochtmicaliy by tnhallCing the xtion of tht GABA neurotransmitter, which is rrsponsible for suppressing abOO/mal neuronal discharges that can caUll' ~Iepsy.

Plltnobarbital is. Schedule IV drug thit m" talU drptndencd ommon side
rifls indudt drowsinffi, vitamin drr"iffiOts (vitamin D; folat~ Of II,; and
Bu). nd laryngo<pa<m<.With ownIo.... phmoborbiul m. , cause .. ~'" ""Pi_
I1tory depreSlion, (NS deprtlSion, coma, ~nd death.
Contraindications: Mminimation of phtnobarbit,1 is inadvil:able in m e of
hypernn~tivil)' to b,rbiturates, ~ uncontrolled pain, prHxisiting (NS deprrslion, porphyri.t~!t"\'!'''' ~piratol)' disease with dyspnta or obstruction,
and glaucoma or prostatic hypertrophy.

Ph~nob.Jrbital

ADMINISTRATION ALERTS

Parenteral phenobarbital is .! !oit-tillueirritanllM injffiions ma,prodJcr

a local infbmmatol)' ",action. IV administration is ra ....1y Ull'd,btcause utra'/illation rna, producr tissut nrcrosis.
(onlrolled substa!l<f:Schtdult IV
P"'9nancy categol)' D

INTERACTIONS
I)ug- l)ug: PIKonobarIitaI inreraru with mony otIPr ~ for !LJmplf. ~!ohoo.jd
no! II! 1M with akohol If other (1fS dioprflSann. The!t substance! pottrtiate
barbiunte action,ino&l\iIg til! rill: of ift-thr&llHlilg ~OI)' dep"fISion or
ooIiac arr& PhPnobarbitai iOONlfS til! rnetilbotilm of manyother d~ r!'diKing
their~1.

PHARMACOKINETICS
(),sel: 20-60 min PO; Smin IV

......,.

Lab Tests: BarbilUra!l'! mayaffm lrom!ul)toalein test! and ~\oI'I"um

Peak: 8- 12 h PO; 30 min IV

IlerbaVForxl: K.No! arK! villerian I!Ia1 potmtiale rdalion.

Half~ife:2....sd.~

Trtatment of INtrdole: Thert is no spuific trutmtnl for owrdost. Drug rtmo\\ll may ~ momplished b, g'lIric IaIll9t or U\e of .!aivated diartoaL He-

Duration:6- 10 h PD;4- 10 h IV

modialysis may ~ effective in facilitating ",moval of ph~oobarbital from the

body. T",urntnt is !Up~ ,nd oonsists mainl, of endotrach~.1 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.

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 clonazepam (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 alltis~uur~ uru!\'> fur shurl-t"r", ,,,iotu,,,
control.
The benzodiazepines are one of the most widely prescribed dasses of drugs, used not only to control seizures
but also for anxiety, skeletal muscle spasms, and alcohol
withdrawal symptoms.

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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 tll~ 11"",I,ulu uf ""urunal liri,,!\, ur th"y may
interfere with transduction of the excitatory neurotransmitter 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.

("",10,15

Drug<fo,Selzu,e.

173

TABLE 15.4 1 Hydantoins and Related Drugs

""9

ROUle and Adull Dose (max dose wh>re Indlca1ed)

Adve~

IV; inijia! dosr 15- 10 IIIIj P[lkg all00- 150 mg PElmin f~ by

H mg PfJtgIday

Scmoolfoct,.towJ~ dirzjfltlj, n)'5logmu~

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!

Effects

HYDANTOINS

fosphtnytoin (u"dIyx)
Q trJ)'Ioin (Dilanlin)

9i/l9ival

~fMrpklfill

purpuric dermal~is;Ste~n! ktlnlOll !'!IIdr9mt;IO*

tpidrnnal nrqply!is;~a!(ular(OUapst(,J1OOc arm!

PHENYTOINL1KE DRUGS

PO;lOO mg bid,lJadUiIIy iOOl'aitd 10800-1,200 mglday il l~ 10

fOIl' rhidfd dosr!

LrnOOX--YSliIUl \)'Ildromr: PO;stJn ailS ffi9/kglday in m!RlofOll'

~mt, oou~ mritD;,Qoorai~

rhidtd dosrs; may wasr 15 nJ9/kg al ~rlIy inlmais 10 malof

Agranul[!()WiI; iplank iot!!!W; buRoul. rooIiali~

45 mWt9lday

dermaJj[jrS!mm lohDloo 5vodromcgiccojder!M

Partial srUlftS;PO;SLlnwilh 1)00 m~day in 1~ 10 four rhidtd

dosri; may ilUl'aII' by 600 "'9iday mry 2 wk (max; 1,600 mglday)
lamolriljilr (LJrniaal)

PO;SO ~day for 2 wk, 1IIffi SO IIIIj bid for 2wk; may ilKrusr 9radlil1y
!4l10 lOO-SOO m~day in 2 dividtd dosr! (mal;700 mglday)

lMIi,aulam (Krppfa)

PO;SOO mglWKr daily (mal;l,OOO mg lOlal ptr day)

orurIIazrpiM (Triirplal)

PO;initialion of monol00ip)',300 IIIIj lwicr daly,iOOl'asr 100 mglday

~1'B1 thld day UplO 1,200 nl9lday

Q '/a~add

POIIV; 15 mglkglday il rividtd dost! whffi Itw 101.11 da~y dosr i\

IJNlr1 1han 2SO mg; irKJUsr 5- 10ffi9/kg/day ~~'1 wk until srUlftS
irr oontrdltd (madO m9Iday)

(Drpak_,Drpakol~)"

lWirltlS, MIDiIl,lOmoomr:t, Mtidht, dip/o/i~, blurred ~

/lQ"JimI indiqeUiro. rlliJim, Ifukopmio, proIongfd blMling

~~~boM

marrow depm~on;,CU(( II"ffl"IallUI(:

paOOl'ilijirhml blod:rnpira!p!'f depmsioo

PO; 100400 mglday

-

OPE = phtnytoil ~q!i'lalmu

" I):hrr fonnWlion I of valproir: add inckJdt ill wI1~ valprMr,and rhalprotx sodium.
Irdia ildialr oommon idvrrsr rflrm;.IIlId!:diniog. indialrs srriws admsr rfI~m.

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 provides effective seizure suppression, withoul the abuse potential or eNS depression associated with barbiturates.
Patients vary significantly in their ability to metabolize
phenytoin; therefore, dosages are highly individualized. Because 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 treatment of status epilepticus.
Phenytoin-related d rugs are used less frequently. Several
widely used drugs sha re a mechanism of action similar 10
lhat of the hydantoins, including carbamazepine (Tegretol), oxcarbazepine (Trileptal), and valproic acid (Depakene, Depakote), which is also available as valproate and
divalproex sodium. Because carbamazepine produces

LibraryPirate

fewer adverse effects than phenytoin or phenobarbital, it is

a drug of choice for tonic- clonic and partial seizures. Oxcarbazepine 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 metabolizing enzymes. Levetiracetam (Keppra) and zonisamide

~
i
i

". Prototype Drug

I Diazepam (Valium)

Therapeutic (lass: Antiseizure drug

Pharmam\og i< ( la ll: BflllOdiuepile; GABA. rtctp(or agonist

ACTIONS AND USES

ADVERSE EFFECTS

D~zt~m

Beause 01 toielllnce.nc! ~cy, ust of diaz:~m is JtSMled for s/Iort.

ttrm seizuJt mntro~ Of fof status rpptio:us.When gimJ IY, h)'llOtensioo, 1I"l/!'
ruLu
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 t~n6 months 0101

binds 10 the GABA rKe plGl'-<hloridtchinneh throughout the (NS.1t

prodtKfS itI tflfm by wp~ill!llWllrtlflil Iivity in tIw, mbic: ~tem inc!

SU~lIftIt impulsts tim might be tlimmitttd 10 the rtticuLn . ctiwitill!l s)'!Iml. EffKb of thi5 drug i~ supprelion of ibnonnal neuroroal fori t!wt INJ
CMe seizures. c.lmirIg withN: SIIong std<Ition. ilIId sktlrt.! mUlde Jtlu~tion.
When iMdorally.m.WlIIJm iheripMX riKb nwy tJkt from I to 2-.-b.Tot.
"~e 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-SO h
Dmtion: 2-1hl'l); lHiO min IV

(Zonegra m ) are approved for adjunaive therapy of partial

seizures in ad ul ts. Among the newer an tiseizure drugs, lev
etinceta m is generally less reactive and has Itss adverse ef
fec ts than the othe r antiseizure med ica ti ons. Conversely,
1.Onisamide is a sulfonamide and can trigger hypersensitiv+
ity reactions in some patients. Felbamate (Felbatol) can
also ca use potentially fatal rt'ac tioru in patients indudi ng
aplastic anemia and liver failure.

DRUGS THAT SUPPRESS CALCIUM INFLUX

Neurotransmitters, hormones, and some med ications bind
to nt'uronal me mbranes, stimulating the entry of calcium.

TABLE 15.S

Succinimides

we.

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< ~plI'od.1t !wI th!' Iolmt iction
as that of phenytoin, although tffrill on GABA and ykium (h anntls allo make
this drug ~milar to btruodiazepine "Id ",ainimidf5. k i< !M1U1 for. MIle
rangt of Itizull' /)'~ ilKlOOing ableoc:t stilU~ and mixrd types of stizurrs.
Otlltr UIfS indurr pR'Vemion of migraiO!' hNdac:hts and ~atm~m ofbipola,
disordtr.
ADMINISTRATION ALERTS
Valproic acid ~ a GI initam.AdviIt patitnll oot to mfW nteodtd-rtleast
ublru IItlaUI~ mouth \l3l1'Offi will (Kwr.
Do not mil v.lproic i(id I)'IIJP with yrbonat~d be~ageI bt<aUst they
will triggtr irnrnedi.n~ II'ltast of th~ 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 ~ry 0

ADVERSE EFFECTS
Side ellras iKkm !fdation,drowsms,GI upstI.and prolonged bletding bill!'.
Other NItm iKkm v~1 dilrulbalKn,lIIUidt WNkne~ tll'mtr; Pl){homotor
igitltion, boot nYmlW IUpprmion, 'Might gain, abOJmilal oa mp!, rash, alopr0" pruritu~ photo5t05itivity, t~ mukifOllO!', and fatal ~OIo:Go:ity.
Contraindication!: Hypmeositivity may oc:rur. Th~ medication Ihould not be
admin~ttrtd to patitml with I~r di!ult, bletding dysfunctiol, palKlI'ilit~,
ind (ongtnital mmbolic di<ordtn..
INTERACTIONS
l)ug-l)ug: YaiproiI: arid inlerarts wiIIl many dlll9l. f 1'IiIm~,aIJi 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, beozOliaz~ and othtr OIS IIfpm.sam pciPlltialf CHS dnr@l~t
iKIicn lIIf of dooazfpam (OIKUIl!fltly with uproil:add may ilduaiNoo
If'illl@l.lIaIproiI: add ino~loKum ~I and p/lfoyroil ~~
larnoiri9irw. ~toin,and ri~n IowflVaiproil: add ~
Lab 11'115: Unknown

Ili!rbaVFoo:1: Unknown

PHARMACOKINETICS
()Jstt: RNdi~' ab!orbed from th~ GI tract
Peak: 1--4h
Half~ife: S- lJ h

TlNtment of Owordose: Theil' i< no Ipe(ifK tll'anneot for OftdOle. Drug 11'mo\\ll may lit ac(omplishtd by gastric: li~, usr of activated dwrroal, or la~
ilin. TlI'almtm ~ IUppon~ and (onsim mainly of maiOtlinlig tht airway
ind bll'ilhiog. monitoring plltrr;toin Ievek,ind appropriately tl1'ating adl'l'llt
l)'IlIptolnS.

Duration: Variablt

RM lIIMyMnlngKlfo( ~ MnIlIgl'rof.t5.IFooII'ijI/It IIIMItrJg.

.... Prototype Drug

I EthOSUXimide (Zarontm)

Therapeutic CIaS!: Antiseizure drug

Phannacolog ic Cia!!: Succinimide

AalONS AND USES

Ethowu midt i< adrug of (hoic~ for ableoc:~ (petit maO Itizull'!. k depll'SIt! the
activity of IltUI'OIlS in tilt motor mnn by elmting tilt IltUlOIIil thrr4lold.1t is
uwal~ intffNtil!' igainn ps)'(homotor or tonic-donic Itizurrs; ~r, 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 (

ADVERSE EFFECTS
Etho!urimidt nYyimpairmentaland physicalabilitits.~ho!isormrerTll' mood
swirqs, inWding depl!'!Sion with a'rt ",icidal intent, un 0ffiI". Behavioral
dw~ ill' more promilent in Ilalitnts with I history of psyrhi.mc: ilM!. (mtral OI'I'IOIIS S)'SItm efferu indJde diuine~ he.Klac:ht, lethargy, fat~.nalia,
Iftppattemdisturbaras,atttnliondiflkuity,andhimJpI.Bontmarrowsupprts<ion.nd blood dyKruia, ... p05Siblo, ... ;' <y<1rmic: "'I'I"~
Otlltr lI'actions ilKlude gingiva Ih)'pertroph)' and tongut sWflling. Common
Iide ~fferu all' abdominal di<I~!and Wfight los!.
Contraindications: HY~lIensitivity may (KW'. Do oot ulr this medication in
mrs of !rftre lin, or kidney diINlt. Safety in (hildll'n YOUOgtl!hi n3 ~an of
agt !ws not ~n tstablishtd.

...

INTERACTIONS
PHARMACOKINETICS
()Jstt: Rtadi~' ab!orbed from thr GI tract
Peak: 4 h
Half~ife: 30 hin (hildll'O;60 h in adull!

I)ug-l)ug: thosu~ inoNsts p/l@nyroinIoKOOI,",,!.'hJproiI:a:idraws

f1IIo!UDnidf IflIIm lewis to lkKtual~ ~1KlI!fi and IIKIMfJ.

Duration: Variablt

TlNlment of OwordOS!: Th~re i< no Ipe(ifK trurmmt for OftdOlr. Drug 11'mo\\ll nYy indoor rmesi< unltss the patitnt i< (omato~ or mll'Jl~ng. TlI'arIO!'nt may be mompii!hed by gillric: Imgt, usr of activattd (haKoal or
m!wniu,ind geo~ral supponiW' mu",rrs. Htmodialysi< may be eIflMo in
fariliutingll'lIIO\\Il of t rhosuximide from tht bod)'.

Lab 115Is: lktoown

Ili!rbaVFoo:1: GinlGjo may rf<i1Kf tIIf thflapeutic: fffK1iwom 0( MhoiIIIimidf.

RM 1II MyMnlngKlfo( ~ MnIlIgPrl!Ct5.IFooII!pK1/I: 1II1M1trJg.

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("'Plfr 15

NURSING PROCESS FOCUS

Drug<; for Selzure.

177

PATIENTS RECEIVINGANTlSEIZUR' DRUG TH'RAPY

Assessment

Pote ntial Nursing Diagnose s

Baselinr assessment priort o admini stration:

UndtrsLlnd th~ INson 1~ drug has bn presc:ribtd in onlmo uses for
t ...... p.uti< .ffu.

Obtain 1compltt. lItahh history induding IItpatic, rma~(,)rdiornrular,or

nrurologic dil!'~;mffitil \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 ~rbal ~pmtions.B. altrno pos~bIt
drug interactions.
Obtain IsNuft' histor, (r.g. frrqurlK~,duration, physical symptoms,
prodromal warn ing~ Irngth of po5tim Iptriod).
Obtain ~5elin~ viLli sig~, weighl"nd in ptdiatril: patirnU.heighl
Obtain 1~Iopmrmal histor, in ptdiatril: patitnts (~.g., OOSTll lmlof
growth and dfeiopmtftl,Khool ptrforman~).
Evaluate approp riat. laboratory findi~ (.g., eBe, ~ltnrolytes, hfpatic or
r. nallUnnion \tudits).
Ailes t~ ~timt's abilit)- to rec~m ,nd undtrmnd i~tnKtion.11Kk.odt
tilt family and ca~iYl'fs 011 ne!'dtd.

low S~-Est.~m (situational orchroni<; ft'IaIN to dil~~ effrcts)

Impair~ 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)

Assess ment thro ughout Idministrati on:

Allel for dtsired t~"pMic e~ts (r.g., diminilhfd or ablffiCt of ..izurr
activit)o).

Conti..", pniodic monitoring of(O(,.nd lim- and ",..Ifunction Iwdits.

Asses ViLli signs and Wl'ight pmodicall~ or ij symptoms warrant.ksel
h~ght and Wl'ight in all ptdiatril: PltitntS.
ASIeI for Ind promptly rrport adft ~ e~ts: rxmsiv~ dill.iness,
dlllWlinm,lighthudtdlll'Sl, confulion, agitation, palpiLltionl,
tich)l:ardia, burrt'd or doublt vision, continuotJl ..izurr activit)-, skin
rilht~ broiling or biffiling. i bdominal pain, jaundk~, changt in {olor of
Itool,flank ~in,ind h~maturia.
Planning: Patie nt Goals a nd Outcomes
Ih. patitnt wiu:
U:ptntlKt tlitraptUlic effrcts dtptndtnt on t~ r. ilOn th. drug is being given (.g.,~iItd or abl!'nt I!'izull.'adjyit)-j.
~ ~ from,or tlptntlKt minima~adv~rl!' ~fferu.
V.rNl~ an undtrstanding Ofthtdrug'I!IIt, ,dv~~ .ffts,and rrquiml precautio~.
Demonltra!. proper s~lfadmioistration oftht medication (r.g"~, timing. wh. nto notif)o provider).
Implementation
Interve nti on s and (Rati o na le s)
Ensuring therilpeutk efffits:
Continue messments on described .Irlicr for theraptUlic efffS.
IAntill'izurr drugs may not rompirtrly R"IOt;~ symptoms but Irrquenq
and seY!'~ of ~ure shoold bt diminishtd.)
Minimizing adft ne effects:
Continue to monitor l'itallig~,fIII'MallLlnrs,cooniination,and ~1i1K~
periodicalI}'. Enlu ft' patirnt s.J~tr. 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!' dlllWlin~s ,rod
diuilll'Sl, hypoteo\ion, or im pairro flll'ntal and physic.i Iabilitits, inc:"'iI ~ng
lilt risk offalk.nd injJr,J

Patie nt and Fa mily Educati o n

Tmlt tht patitn~ family,or {llt9ier to ktrp a Mit diaryof frt<;(uenq,
I)'~,ltngth. protiromalsymptoml,and partictal period.

Tnch th. j)ititnt to riIt from lying or lilting to nanding slowly to mid
dill.inen or falk.
l~tllJ(t th~ patirM to call for u~tan~ prior to gening oot ofbtd or
attempting to walkaloll!', and to aYoid driYing or atlltr oJ(tivit~ 1tqUiring
mtftLlI altnness or physical coordination until th~ tffNIs of th. drug a",

k_.

(conrlrruefi)

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NURSING PROCESS FOCUS

PATIENTS RECEIVINGANTISEIZURE DRUG THERAPY (Conrlnued)

Implementation

Inte rve nti o ns a nd (Rati o na les)

Cominue to monitor ~igh~ Wl'igh~and ~lopmtntalltYel in pMiatril:

poatitms.ln tht s<hooI-11jt (hild,I!I;m s<hooI ptrformalKt.{Ad''r~
tffn of antileirurt drugs or unll'SOlved ~izull's may hinder normal
growth and devflopmfm.)
Cominue to monitor drug It:Yrb, C8(,rroa) and liepalit fuoction,~nd
poalKlI'aiic t~. (AntMzure drugs requill' periodic drug Intis to
romlitr t~ It:\'eI with symptoms.AntMzure drugs may UIM
hrpato\O);icity a nd '/iIlproic I(id may ta!M poalKlI'atitis isan ad"/mt
rfffft.)

Aslffi klr (hinges in the tt~1 of (on sciousness, disoritntation or (onfusion,

or agitation. (Nr Utologit du nqes may indiutf o~rrnediution or ad''rIt
drugrffn.)
Aslffi klr manges in visual acuity, blumd vision, 1m of peripheral vision,
~ing rainbow halosaround light~.Kure rye poain,or any of the~
symptoms I(rompanied by naum and wmiting and II'pOIt immediatt~.
(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
talJ~ blood dj'SUHYS ind ilKrused (halKrs of blerding or inkrtion.)
Monitor allfit and motional stilus. (Antistizull' drugs IIU)' in(lI'asr t~
risk of mental deprrssion and suicide.Conc:umm u~ of akohol or other
eNS deprrss.Jnts ilKlI'a~ t~ ~mand t~ risk.)
Aslffi the rondition ofgums and oral hl'lienr m!'~sure;.(Hydantoins i nd
phenytoin-like druqs may calllt gingival hyperplasia, inuming the risk of
oral infe(\ion~)
En{QIJriljt appropriatf lifrstytt ~ nd dittiry (hanges: inaNsed intakeof
vitimin K. D, folil: ~{id,~nd vitamin B-ric:h ioods:loWI'red "ffeillC' intake
inc:luding OK medications that {ontain Uffein!';i nd limited or no akohol
inta~. (Caffein!' and nic:otin!' miyde{ft'~ thf riftivenrss of tIMbtnzodinepinrs. Barbituratrs, drugs with GABA oKtion, and hyda ntoins and
phenytoin-)il? druqs afftct thr absorption of vitirnins K. D, fo)it a{ id, and B
vitimins. Akohol and other eNS dfprrsunts may inc:rea~ Ihf itIYrof
rffn of the amistizull' drugs.)
Monitor (hildren for pariooxiull\'SjlOmt to ~ rbiturat~. (HyptrKlivit)o
mayocwr.)
Aslffi women 0f (hild-btaring IIjt for thf possibility of prt9nanC)', pian s
for pregnanq, brmt -fetding, and rontr.Kfp live u~. (Antiseizure
medications are tilrgory Din pre9nanc:,.l!irbirurat~ deell'ilsr t~
riftivenm of oral (ontliKrptives and additional forms of (ontrueption
should be used.)
Avoid abrupt dis.:ontinuuion ofthffilpy.(Status epiltplirus rrwy Q(ur with
ibrupt discontinuation.)
Aslffi hom!' slar"9l' of meditations and identify risks for rorrlive "tion.
(DYerdos.JgI' ~~ O{cur if the p.ttitnt tikrs<ldditioni) dam when drowsy
or disoritmed from mrdic:.ilion rfftm.DYerdo!.agt with barbituratrs m~y
pKM'latal.)
PlO'Iide MIOtioBillsupport and appropriatt II'fmals u nreded. (T~ilment
with antileirurt drugs may require using (ombinations of drugs and seizure
I(uvity may diminish but may not bt II'soiffiLSoc:i.JI isolition i nd low selfrst~m may occur with (ontinued ~izull' disorder.)

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Pati e nt a nd Fa mily Edu catio n

Tt.Kh tht patitnt's familyorcart gmr to ~p ~larl)o s<ileduled
appointments with tht htalth ('11' pltlider and rt porl any de''lopmentll
IigSOl{on(eflls.

)nmuu thr p.llient on thr IIC'rdto return periodkaUy for lab wort.
IlIIIruct t~ poatitnt to UIIY a walltt identification utd or Wl'ar medical
idmifution it'M'11' ildiming a smtJredilorder and antisMR medKation.
T_ h thf patitnt to promptly rt port any abdomini llHlin,poanKuiarly in t~
upptr quadrants;(ha~ in slool (oIor;)'fllowing of sdera or skin;or
dlluoed urinr.
InstnKt t~ patien~ family, or cart9m r to immediatrly II'port inc:lI'iIsing
!fthargy, disorientation, {OfIfiKio n, (hangl's in brhavior or mood, durre:l
Ipffih,or mxil.
InstnKt t~ patienl to immediately report any visual (hange or ~e pain.

Ttadl thf patitnl to promptly report any signs ofinc:reasro bruising,

blreding..or inftions (e.g.,1OII' throat and fIow,skin ruh).
InstllKt t~ patien~ family, or cart9mr to II'port significant mood (h angrs,
rspe<ially deprrssion, and to 110 id akohol and other eNS deprma nts whitt
taking thf drug.
InslnKt t~ patienl to rrwimain m:ellent oral hl'lient and ~p rtgUlarl)o
I{heduled dent!) appointm~ nts.
ErKouraljt tht patitnt to deerea ~ or ~ bslain from caffeinr, nicotinr, and
akoho~and ilKlI'l~ intl~ of folic: .Kid,and vitamins B, O,~nd K- ric:h foods.
./dvisf t~ poatient to discuss all Ole medications with t~ health care
provider to ensull' that caflein!' or akohol is not inc:luded in tht
formulation.

InstnKt the patien~ family,orcar!gmr to notify t~ health ure provider if

tht patitnt rxhibits hyptrKti,, b!'hnior.
DisCU\5 PlI'9nanq and family planning with wornrn of (hild-buring q.
Explain thr tfft of medicltions on pregnane-; ~nd brea st-fmling Ind thf
nred to disc:uss any PlI'9fUnq plans with the hrlkh (all' pltlider.OisMs
tht nml for ~dditional forms of (ontroKeption, ilKluding barril'r m!'thods,
with patients tlking ~rbitUl<ltl'l for!Nure romrol.

InstnKt t~ patient to ta~ the drug eX.Ktly u presc:ribed and to not stop it
abruptly.
InstnKt t~ patient that ~ drugs should not bt ktpt at the bedside and
toavoid taking additiona)!lasn whrn drowsy.

Tt.Kh tht patitn~ family,or w egiver about support groups and ma~
appropriate II'ffrrals II nmled.

(lIIplfr 15 Drug<; for s...lUr~ '

NURSING PROCESS FOCUS

179

PATIENTS RECEIVINGANTISEIZURE DRUG THERAPY (COOllnued)

Implementation

Interventions and (Rationales )

Patient and Famil y Education

(1os~1y monilOr lilt IV infusion ~I~ wh~n using IV anliseilU~ drugs.AIIIV

drips should ~gil'ffi via infusion pump. (Bffizod~nrs, hydanlOins,<lnd
b.Jrbiturnesa~ irritltinglO lht vrin.BlafKhing and pain U lilt IV sitt '~

Te<lm tht patient to imOll'diately report pain or buming at the IV ~~ or in

atremity with IV.

indiutors of mr,mution <lnd the IV infusion should be immediatl'ly

nopped and the provider ronloKtt<l for funhtr treum!'nt ordt~ 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 rariooal~ for drug theraPl', drsi~d tlitraptUlic
Ol/I(omrs,most commonly obsrrvtd <I~~ eflect>, parameters forwhen
to call the health we plO'/~ and afT1 nf5sary monitoring or
ple(autiom.(lkingtimr ruring riming carr helps to optim~ and
r~infofu by INChing "~,,.)
Patint stlfadministriltio n of drug therilPY:
Wlltn administering thr mrdication,imtOKt tht palil'm. family,or
cart9~r 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.)

The patitm should R a~ to Stitt the ~a!On for tht drug; appropriate doW'
and lCheduling; willi! <I~rW' eflect:> 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 d~ring
phirmoKokinetiu 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,1tirmgoakand npKtM outcomes hn'l' ~ 11\I't (W'tPlanning1.
~ rrItIIH,

IH,QOO IUfor 1M ridflllllfl1fr"hj(h mtst rmirIgljcm~pIy. i"Stt~lJotllt IWingf'rol.mFOMUli* milr<flm 14ilfrmDlDlreIomilfl ~tnd

No~~ltr!gsCIO

. 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. Pregnancy 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 syndromes. 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 indicatoo for seizures. Both drug classes have serious draw-

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backs. Anti.seizure drug therapy works by suppressing

repetitive and abnormal neuronal firing. Distinct mechanisms 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

180

Until TheNelv"",.Sy.tem

for absence seizures, myoclonic seizures, and to terminate

status epilepticus.

otrigine treat all major types of seizures. Several d rugs

in this class act by more than one mechanism .

15.6 Hydantoin and related drugs act by delaying sodium in flux into neurons. Phenytoin, carbamazepine, and oxcarbazepine are broad -spectrum drugs used for aU types of
epilepsy except absence seizures. Valproic acid and lam -

15.7 Succinimides act by delaying calcium influx into neurons.

Ethosuximide {Zarontin} is a drug of choice for absence
seizures.

NCLEX-RN " REVIEW QUESTIONS

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. ~My relatiVl' had seizures l>ecauseof a large tumor
growing in his musdes."
4. "Seizures may ou;ur after a head injury."

The nursing student asks the nurse to explain the action

of the anti.seizure medication, phenytoin. The nurse explains 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.

The nurse re;:ognizes that several chemicals inhibit neurotransmiller function in the brain. The primary inhibitory
transmiller in the brain is:
1. sodium.
2. GABA.
3. chloride.
4. calcium.

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.

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}

CRITICAL TH INKING 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

LibraryPirate

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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and videos. and mClIOl

Flegi!JIer)'DIX accegs CO!II! rmm me front a/ \'OUI bor:t lit

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Drugs for Emotional

and Mood Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES
After reading mis chapler, the student should be able to:

ANTIDEPRESSANTS JIalII8J
TricydicAntidepressants (TCAs)

(JY/t

184

Q Im/pram!n!' (Torronl/) {IQIJt 187

~lectiYe Serotonin Reuptake Inhibitors
(SSRls) {IQIJt 164
Q 5f'rtro Une {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 melhylphenlda re (Ritalin)

Nonstimulant Drugs forADHD

{IQIJt

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 Drug s at a Glance, recognize
representative drug examples, explain their me chani sm of action,
primary action s, and important adve rse effects.
6. Categorize drug s 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 so rders.

Ill!

{lQlJt200

KEY TERMS
attention deficit-hyper.ctivity di~rder (ADHD)
Ill"" 191

bipolar disorder (ilIIjt 189

depression ftlf/l'lll.'
dysthymicdisordrr {lJ9t181
rlectroronvulsi'ft' thuapy (ECT ) (IQIJt 183
major depressivr di~rder ftlf/l' Ill.'

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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) {UJllS4
tyramine {!all 189

182

UnllJ TheNe"""ISSystem

nappropriate or unusually Intense emotions are among the

veIl' depressive symptoms that may prevenl a person from

leading causes of menta l health disorders. Although mood

feeling well or functioning normally. Because depressed patients may be found in multiple settings, every nurSE' should
be proficient in the assl$S ment of patients affiicted wilh this
condition.
Some women experiellCe intense mood shifts associa ted
with hormoNI changes d uri ng the m ens trual cycle, pregnancy, childbirth, and m enopause. Up to 80% o(women experience pMtparl\n dtpmsion during the first seve ral weeks
after birth of their baby. About 10% of new mothers experience a major deprl$Sive episode within 6 months related to
the dnmatic hormona l shith th:lt occur during pouddivery.
Along wi th the hormonal ch:l nges, additiona l situationa l
stresses su ch as responsibi litieli at home or work. single par_
enthood, and caring for children o r for aging p;).fents, may
contribute to tbeonset of sym pto ms. If mood is severely depressed and persists long enough, many women wiUlikely
benefit from medical treatment, including those with premenstrua] 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 informatio n aboul mood shifts
prior to th eir discharge. Health care providers in obstetri cian's offices, pediatric outpatient settings,and family med_
icine centers are encou raged 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 depress ion is associated 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.

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 Individual 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 defidthyperactivity disorder, is . Iso Included In this chapter.

DEPRESSION
DrpmWn is ~ d isorder dUr.lcterized by 11 ~d o r desponden t
mood. Many symptoms art associ3tW with deprl$Sion, including 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 elderlyadults , 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,~llift disorder is estimated to affect 5% to 10% of adults in
the United Sta tes. The Amerinn Psychiatric Association's
Diagnostic and SIIl/;slieai Manual of Mental DislJrders. 4th
edition (DS M- IV), describes the following criteria for diagnosis of a major depre:s.<;ive disorder: a deprE'SSli'd affrct plus
at least five of the following symptoms lauing for a minimwn o f 2 weeks:
_ Difficulty sleeping o r sleeping too much
- Extremely tired; without energy
_ Abnormal eating patterns (e;) ting too much o r not
enough)
- Vague physica l sympto ms (G I p~ in,jointlmuscle pain,
or headacha)
- Inability to coneentnte or make ded sions
- Feelings of despair, guilt, and misery; lack of self_worth
Obsessed with deilth (ex pressing ~ wish to di e or to
commit suicide)
_ Avoiding psychosocial and interperson al inter:actions
_ Lack of interest in personal appearance or $(')(
- Delusions or hallucinations
The majority of depressed patients are not found in psychiatric hospitals but i n m~instre~m society. For proper di agnosis and treatment to occur, recognition of depll'ssion is
often a ooUabo rative effort a mong health nIl' providers. For
example, it might be the ph.armacisl who recognius that a
customer is dep ressed when he or she buys N tuT31 or overthe-counter (arc) remedies to cont rol anxiety symptoms
or to induce sleep. o,sth,lfli< cfjOfdH is cruHa(leriud by less Se -

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T REATING THE D IVERSE PATIENT

Cultural Influences and the Trutment

of Depression
To W,1IlderllaOd ;mypatimtYl41a ~sutItring&om.-.IOCixI.tI.r.fi(
lIlII_be""'~
Ilf,p~OII lind othn" mm~ ihul is ohen ignofed in "'..",., ~
{ommtlnitin ~ of!he tmnmdou! .mount of stigm.1ttKhed toil
Emomm aft' IIrgrir 1lIpprmed.~wn pititftll ttf1d to (QII"It to tilt
mmtion of mmuI hulth wortm II~ in IfIe (OUMof theirJlntII,.nd
often IIlw ftfiing of hopelelintli.1t should be ..ottd thn kiul ~nd
African Ammnl gener.l~ metibolizt .nt~prtllolnts mOlt slowl1li11n
othn" !Ubgroups;th~. ioitWi dom lhould be r!dtxtd to 'Oid drug
toxicity.
Alterrlltift thmpifs M h 011 t~II'~ often UItd to tru t emotiofl/ll
iIIntlses within lOme Hilp.lnic Am~riun groups;thus, mtdiul ~Ip ma~
001 lit IOlIght for t~lIment of dePr!ISion. Tlltrt is often. stig~
attachrd to mental hu~h probleml.long with tilt btlief that religious
plilctiUS wililOlvr ment.1 he.Jlth probiffi"ls.Hispanics meubolilt
antidep~lolnll about tilt lolme.1 othtr IUbgroups,.khough t~.rt
r!po!lS of 9rtat~r SlIIUptibi~tr to anticholiM!gic ffft<U.
SaM ~Ie 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.

o..plfll6

Psychotic: deprrssion is char,Jcterized by the expression of intense mood shifts and unusual beh~viors. Depressive signs
and loss of oont~ct with re.tiity, haJludn~tions, delusiom,
and disorganized spee<:h patterns are the behaviors observed. For psychotic patien ts and for patients with extreme
mood swings, severe behaviors are often treatable wi th antips~hOl ic ther,Jpy. ~ se<:tion ]6.8 of this chapter and
dlap ter 1700.

16.2 Assessment and Treatment

of Depression
The fint step in im plementing appropriate treatment for
depression is ~ complete health e.umination. Cert~in drugs.
such ~s glucocorticoids, levodopa, and oral co ntr,Jceptives,
can cause the same symptoms as depression, and the health
care provider should rule out this possibi lity. Depress ion
may be mimicked by a variety of medICal and ne urologic
diso rders, 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 evaluation is often performed to confirm the diagnosi s.
During initial health exDmin~tions, inquiries should be
made about alcohol ~nd drug use, and any thoughts about
death or suicide. Thi. exam should indude questions about
any family histol)' of depressive illness. If other family members have been treated, the nuTS(' shou ld document what
therapies they may ha ve reived ~nd which were efftive
or helpful.
To detennine a OOIlTS(' of treatment, health care providers
and nurses assess for ""'eIl-a"epted sym ptoms of depression. In general, seYtI"e depressive illness. pa rticularly that
which is recurren t, will TJu ire both med ication and psydlotherapy to adliew the best response. Cou nsel in g thera
pies hel p patients gain insight into and resolve their
problems through "a-bal interac tion with the therapis t. Be
havioral therapies hllp patients learn how to obtain m ore
satisfaction and rewards through their own ~ct iom and how
to unlearn the behavioral patterns that cont r ibute to or result from mood shifts.
Helpful short_term psychotherapies for some forms of
dep ression are illlerpt'1'SCllal and rogn;r;l'6-behavioraJ rherapies. Interpt'rsonal ttll'rapies focus on the patien t's disturbed
personal relalionships Ihat both ClUse and e.ucerbate the
dep ression. Cognilil'e-behavior3\ therapies help patients
change the negati ve Sl yles of thought and behavior often associated 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, e~(trCKOllYulsin
t~rapy (ECT) oon tinues to be ~ useful treatment. Although
ECT is found to besaie, there~restill deaths (I in 10,000 patients). Other seriom complic~tions related to seizure ~ctiv
ity and aneslhesi~ may be c~used by ECT (Jan iak, 2002).
Rent studies sugg~t that repetitive tranSCfan ial magnetic
stimulation (rTMS) is an tffe<:tive somatic treat men t for

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Drug' for

EmoUon~t ~nd

Mood Disooden

183

maj or depressive disorder (O'Reardon, 2007). Thil trutment 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 m e best pmfession.ti care, the patient wi th depr=ion may take a long time to recover. Many individ uals
with major depression have mu ltiple 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 o ut , frustrated, or even depressed themselves. They
m ay experience episodes of anger towa rd 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 ~ble to assist the
family members of a person suffering from depression. Family members may need counseling themselves.

ANTIDEPRESSANTS
Drugs used to treat depression are ca tegorized as antid epressants. Antidepress.ants trea t depression by enh.anci ng mood.
Over the years, mood has rome to represent a broader term ,
encompassing feelings of phobia, obsessive-compu lsive behavior, panic, and anxiety. Thus, an tidepr~nu are often
prescribed for these disorders as well. Rent studies link depression and anxiety to similar neurotransmitter dysfunction , and both .\.eem 10 respond to treatment with
antidepr~nt 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 importan t warning ~bout antidepresSints; In
2004, the U.S. Food and DrugAdm inistration issued an advisory~black box warning" to be included at the beginni ng
of drug package inserts and d rug in format ion sheE1s. The
advisory was iss ued to patien ts, fam ilies, and heahh professionals to closely monilor adults and children taking l nt idepres..<ants for warning signs of suicide, espe<:ially at the
beginning of treatment and when doses are ch~nged. The

PHARMFACTS

Patients with Depressive Symptoms

""jor~ion, 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 ~dol

UUlmrnt.

Nosl pitirnl'l (OIIsidft"dtpltSsion I weakntss lather~ an inne-ss.

not", is 00 rommon . . ~Of mnic: II(IOf reIit~to deprrssion-it

unl\awrlr IOill)'Ollr.

"

184

Until The

/IIe<v",,, Sy'tem

FDA further advised IIlat certain signs might be expected

among certain patients including anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania. 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 neurotransmitters in regioru; of the brain connected with focused cognition 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, antidepressants 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 norepinephrine and blocking the enzymatic breakdown of norepinephrine. 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 neurotransmitter uptake, enhances activation of adrenergic receptors. 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, tricy<~(antidf
(TCAs) were the mainstay of depression pharma cotherapy from the early 1960s lUltil the 19805, and are still
used today.
p~ssants

16.4 Treating Depression

with Tricyclic Antidepressants
Tricyclic antidepressants act by inhibiting the presynaptic reuptake 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 som etimes 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.

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However, TCAscontinued to have some unpleasant and serious 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 initiation 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, especially for patients with del~d excretion. Anticholinergic effects, 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. Significant 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~IliVl! srroton in ~uptak~ inhibitors (SSRls).
ThE"}' have become drugs of choice in the treatment of depression 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 hypothalamus, limbic system, medulla, and spinal cord. It is important 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 depression_ 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 receptors in the brain, but thE"}' did not know how this change was
connected with depression. Ongoing efforts to find antidepressants with fewer side effects led to the de~lopment of

A VO IDIN G M ED ICATI O N ERR ORS

A2J..yw-old man WI! ~dmitttd Ihis moming following a suicidt Jttt mpt
when his girlfriend broke up with him. Wht n tilt nurse enl~S his room with
his medications, h~ is ulking on tilt ttltphont with his girlfriend. Ht ma~
t yecoMaa with Jnd motions for iIII' IlUrst 10 lu l'l' his IIIfIIk.uions on tilt
tablt 10 lit (an take th~m bttr.Tht nurst,oot wantinglO inltrrupt his(onl'l'rs.ltion, pun tht mtdiutionsontMublt,ltavrs iIII' room,anddlam tlltmedkations. Wh.u ~rror did th~ nUBf (ommit and what is tilt appropri.J1e nu r~ng
intmentionl

PHARMACOTHERAPY ILLUSTRATED
16.1 Antidepressant Therapy Is Directed Toward the Amelioration
of Depressive Symptoms

o
e

No...'p'n..ph ...... (NE) ____

Of

____

HfOton,n (S-HT)

Tncydic anlid&pnossantll
",1'WbiI r.. uptake of
NE and !rH T intc the
P!5Y""I'tOc: terminal; .....

:.

PcetsynapIIC

_ . ""
NE or 5-HT

No.maIy.

5 HT if; .....sed.
5HTbinds to its
po6b~lic rec.pt0l'

o 5HT
o
o "..

binds to its
p'"Y"l'P4ic reoeptor.

'.' .V
' .
I.

Step ~ ",suits in Jen

5 HT being ~oased.

rotonin uptake
ill bIocksd, ITION &-HT
wi' be available in
!he synapIic apace.

elfe.cIs . . ""'"' drrtm8lic.

TeA. productl the.n.a. by

Inhibiling !he ~ of

SSRI, bIodIlhe
reuptaka of ..otcrin
into preaynaptic .......
t.-min8le. Incfeaeed
Ie....,. 01 aerotonin

neuro!mrwnitl. . inlo
Pf'M)"I4ptic nerve tmI!\Qt..

The affected
neurot ...nemitt. . I n
norepinephrine lind MfOlonin..
SNR!. ha .... a llirrilar
mechanilm. Their dMmicel
IIructI.Iu ... d iffen!l'1l from

indut;:e ~OmPID.

cNro!tM in prw)'Mplic
and ~ynaplic:

........on. of !he bf1lin.

Pno.ynIlf)tX: receptorI

t..come ' - ,..,.;tive

"'04

and pomynaplic
"""'P1ors become ""'"'

....a;.....

Tyroeine

'-do<>'

MAOM inhlb~ MAO .-.zyme

IICIMty iMide preaynaptic

~nephri ....

('~

), .

"","\0
0"-...'"

/fi'

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_I"'"'.......

em,-

enzyme IICIMty.
, 101 opio' epho io..

lhett ......... ta
Ihoo action of
rooreplnephrine

and oIIwr

neurotranamitt......
degraded . MAOI. have an
ell.,;! of ..,t.nc:.d
catecholamine reIe&ae.

o
e
e

NE ;. ... leased.
NE binds wiIh

ilS.-"tOf.
The..:lion of NE
ia tenninal&d by
MAO and COMT.

MAO MonoM'Iine ollid...

COMT" Catechol anme

O-melhyllrwwleraae

II MAO I'lnhibited, NE
ia net btokon down as

quiddy ,00 prodUON

" """"' d,,,,,,,,!ic elllICt.

TABLE 16 1 Antidepressants

0""

Routt ilnd Adult Dose (ma~ doS& where Indicated)

~mill1XYlil~ (Elm)

Adik: PO; 75-100 1ll9lda)' (fIIol'j'!Jidllilly inoNlI'to lSO-lOO 1ll9lda)'~

GtMric PO: lG-25 mgJl btdIine (may glfiWIJ ilKJtfll' 10 25-150

.\dYerSt Effects

TRICYCLIC ANTIDEPRESSANTS (TeAs)

~m(I(,Jpinr !All'ndil)

OJI""

AIkIIl: PO;br9n wittJ 100 mg/dIf (IIYY ncrull'lII day 110 lOO 1ll9lda)');
GtMric PO: 2S mg It btd:imt:1U)' ino:tNlI' ~ )-7 dqs IG SG-150

I'IIgfday (max:. mglday)

"

domipr~ (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 bMimr;ruygr~dlilly 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 depr!s~Oft:PO;$I!" 100-150
I'IIgfdar. 9~'" 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 th~ 10 11M diw~d doIn(molX:60 mgIday)

trinipminr.' (Surmonli)

PO; 15-100 mgfu, (max: 300 rncYdi'/)

cilaiopmll (C!lw)

PO;$I! at 2Omgfu, (max:40 mg/dayj

Q nduIopilm ~e

PO; 10 mglday:mI1 ilatall'tG 1(1 mg ~fttf 1'II1II;

lkroRtint(Pro!ac)

PO; 2G mgfday II tilt a.m.lIY)'lImall' by 2GlIM}'day nwtHlJintft'/als

(IIIU: 80 mglda)'k wilen stable !NY lW~dt 10 I 9(l.mg mlirwd-alUll'
~ otI(f -u, (m.:911 mg/'IIt)

~(l1Ma)

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

p.lttMeIine (PiXi)

Dtprusion:PO; 10-50 fr9IdaJ' (flloIX:BO m~);~pdsM!

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

Q !MfiI~(l*ft)

Art.IIt: PO; sun wilh 50 mg/dar.lJld~11y incrtlll' evtf)' ftw IIIftb to I

~ of SO-1OO mg; CieNtrlcltalt with 2S mgldaJ

"i

..

~(WeUbutrln;lybM)

M!

lOO""'tm> "(We rmlt til T""i"i''''

~dry~in~KIIIIIOkn((fINdachr,
_l~ ~ GI rlistrJfNllln,tlniMSl, I/IIOrrxi~,

ffrlgw, JlIIIIdys~ Jiddd IdtQ~III,ItdIl'fO(OIi~

-~ <rre1!Jl!1lt
5fm:!J!-!qhmm

PO; 15-100 mg ticI(grtiltf tllln 450 mg/ilayiMlull'l rIsIt 101 flti_

11ISOIIIIII~, 1/IIIIISftt.d!y ~ comtipotfo1lnota!td

IillllldprtlSlftlfltShforr~dni/JPI~~

<IrA.-tine {(ym~lllo) (SHIll)

PO;40-60 rrgldaJln lIIe 01' I.... ~ doIn

m~ (RmIftOI'I)

PO; 15 mg/day iI. !ingko doll'iI! brdI.iM;fIIol'j' inoNlI' MIJ \- l wk

(11111: 45 mgldao)')

IWNIiIl9- ..".lMJrrtdriliM,/rfodh( ,__

rrmid/li ~/fK1ffJtdQppefir(Mhttslatk
b)Jll1lfMiorr._ldysUlcDorlIlJidddidtiIIIr rnJ
1I'fO(0Iin syndrrmI

PO; 50- 100 mg bld;may II'IataII' upto 1~ rig/day

5trlTO)-lghpm 5'!!l!!mmr

trarocli:lnt (Deyrfl)

1'0; ISO mg/dq: ruy matall' bJ SO mgldar Mf)' 3-4 daps~ to

nnlafaxint (Efftmf) (9IRI)

PO;25-125mgtid

bind;

lI'actions)

...>

_Olin f1'I4l!mt
:!Qt!!I.2!l!!!l:!I.~ IllIlr!2! m!i!!!! aL:!!~~ hUll

ATYPICAl ANTIDEPR ESSANTS

>

dIy~ RlflSlipt!rbt,. wiMfYA'lemior1, /lMtrdtiliM,

IIf1dMJif, II'IIUd ItSIImc~ 1I/icidQ11dNtit:rn m

SELECTlVE SEROTON IN REUPTAKE INH IBfT()qS (SSRls)

J ,"-,

O~~ l#dtIOOII,~ Mlrmotic /Ifpoftmn,

-mol'"

MAO INHIBITORS (MAO Is)

iIoOOcIwid (Ma-pIin)
Q

Jilmdzine (Mardil)

tranplcrprooline (Pamatr)

PO; 10-30 mgfdaJ(lNx:1O 1IlI)'day)

PO; 15 mg ti:! (nwx:90 mgldiJ)

PO; 10 mg/diJ ~ 20 mg in a.'ul'd 10 1119 iI p.m.); mar irKrHII' by 10

mglda, at3-wlo: intmrak up 10 60 mglday

Irdiailldiut~ commonadYtf!l'ffffru;~Dlime II'rioIr;HYtfIl' ~

LibraryPirate

Omtni~ il!Grril,orrllU!larkhypor~bbrtd

1i!.i:IIr, ___ mmtipation, _txil,dry_rh,urillllry

Iftfntion, II'IIHI dysI\!oc~ suicidol idMi1II tnd
_<n'~ syndrrmI

BtUtiWllad

""""

1ri~II:milr: U~il

Wll1iI1Qll

1lI>p1tl16

;Or Prototype Drug

Drug'1o< Emollon.11 arod Mood D11ord ...,

187

I Imipramine (Toframl)

Therapeutic (I ass: Anlidepressant;treatrnent of nocturnal enuresis (bed-wetting) in children

ACTIONS AND USES
Imipramiot bloc:b thIo I\'IIptakt of ~roton in and norepin~ phriot imo 1II'f'/~ ter
mina k.1t is USfd mainly ~r major depres,ion, although il is 0((.1 Iiona II)' uled for
thIo treatment of I1O(tumal enuresis in children. The IIJrs~ may find irnipramiot
prescribtd lor a oomber of unb~ltd 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 2or 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 hypoglycemia.
Imipramine cau<es .lnticholinerqie tffKts.md may potentiate eIftcts of
antidJoIinergic: drugs administered during surgery.
Do not discontinUl' abruptly, because mound dysphorY, irritability, or
S~pltssnffi may O(tur.

Plf9nanqcategoryC

PHARMACOKINETICS
Onsrt: ~,than 1h
Peak: 1- 2 hPO;30min 1M
Halflife:8-16h
~on: Variilble

Pharmacologic (lass: Tricydic antidepressant

ADVERSE EFFECTS
Side efftm incUdl' sedation, dlOW! illl'Ss, bkJITl'd filion, dry mouth, J nd cardiamrular symptoms sum '" dysrhythmia~ lINn blod, and 9tlfllle hyprrtellsion. ~nts that mimie the action of norepinephrilll' or serotonin should be
aYOidtel ~CilU 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 (.I~ of iKU1l' recovery af
1l'r Ml dtf1S in bundle-branch conduction, narrow~ngle glaucoma, and ~
Wit ft'nJI or hepatic impairment Pnitnn should not !lSI' this drug within 14
days of dilrominuing MAC4~

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 ilamfd5flUmiNl'k alld possilH< toxidt~lmipr.llniN mayrM'Bf!lM>
.:lm,~weflKnof dooidillfalld potmtiat~O!S~sion.U\i> of oral
COOllOKfPtil'fl may mu or ~illipramillflmls.~ram ma,OI to
dttiliumand (j(ilyQrdia.~ "gam IIIiI1 p-oduu> ~nuloqlosis.
Pheno!hialine; c~ ilamfd iIIlkhotifm9ic: and SfdaIiw HlKl>.
SympillllomiMOO; may rrur: n a diac lOlidty. Ml1h~phMidm or dmetidilll' may
~!hI> HlKnofillipramMld CiUII' toxidty.f'hfnytoi1 is IN fflKIMwhi>n
!.1loPn wim imipramiw JMOk may Il!'iuk in OOIro1fptic maI~t \)'IlItorIII'.
Li bIfSlS: ImipramillfprocUcfl~ IMIodgu:O'if tr%. ENion ofserum
~irmiland atlritliol' pho:I~1lII' ~ li ~.
Helba VFood: H5ba1suppk>mmn SIKh iI ~ pri nrOlf oil or gi1k1jO. may101m
!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' J irwa~ CIl)'gt~
tion,and Vl'milation.Monitor cardiac rhythm and vitalsigns.Gutric Ia~ may
be indiuted.Acti"latf<1 {haKoolshould be administ~red.
It!ftr Ie M}M!rl/ngK1l for Q Nurlifllj Prru1s foals spKlk Ie rlrls ~

an additional category of medications, the selective serotonin reuptake inhibitors (SSRIs).

Whereas the tricyclic: class inhibits the reuptake of both
norepinephrine and serotonin into presynaptic nerve terminals, the SSRIs selectively target serotonin. Increased levels 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 mechanism is illustrated in Pharmacology IIIwilrated 16.1 .
Today, SSRIs have approximately the same efficacy at reli""'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 hypertension) and anticholinergic tffects (dry mouth, blurred
vision, urinary retention, and constipation) are less common 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.

LibraryPirate

In general, SSRIs t'licit a therapeutic response more

quickly than TCAs.
One of tht' most conunon side effects ofSSRIs relates to 5e)luai 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 patients who are sexually actM>, these side effects may result in
noncompliance with pharmacotherapy. Other conunon side
effects of SSRIs include tl.1 llSea, 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 taking 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 tricyclic antidepressant, lithirun,or a numbt'rof other medications. Symptoms of SES include mt'ntal status changes
(confusion, aru::iety, restlessness), hypertension, trt'mors,

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 antidep ressant drug
classes. Thus, ~atypical" 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, duloxetine (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

C OMPLEMENTARY AND A LTERNATIVE T HERAPIES

St.John's Wort for Dllprllssion

0"" of Ih~ ,"""I pupuLII h. rb> in Ih~ 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 nam~ from a legend that mI

spots DlKt afIPNrrd Dn its Ita15 on tht annil't~ry 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\ tffectift 1\ tricydic: amilep~nll and SSIIs (filltpa~ Sillgl'~ &Itlltr,
2006). Rtctnl analyles also IlJ9geSIlhat !he herb may be l"ffuctiYe for major cit
~ and that it (,JUleS ~ aMllt tl'lKts than uaditilnal drugs (Lindt.
~ &Kriston, 2008).StJohn'l wort may imtrKl with many rnteimions, in
cUding onl (Ontraap~, warfam,di1ci1,and C){bspori"ot. k mould not bt
!aUn mlKUm>nllywith >lntidt~m 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
photo\ellS~ 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

I Sertraltne (Zoloft)

Therapeutic (lass: Antidepressant

Phannacologic (lass: Selective serotonin reuptake inhibitor (SSRI)

AalONS AND USES

ADVERSE EFFECTS

Semalint is used fDr tht UUlment of deprt 5SiDn, >luiely, Dbstssi~~

(Dm pu Isive disorder, >I nd pan ic:.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 p~mtnstrwl dysphoric:disorder,posHrllJmatK stress
disordt~ and social anxitty disordet Thm~ iKtilns include ffihalKtllll'm
of mood and implO'/tllll'm of alft with maximum fffects obstrnd aher sn
ml Wffks.

MvtrSf eiff(ts ilKludt >lgi!ation, insomnia, headhe, dimntlS, SomnoitlKt,

and fa~. Tau atrtrn~ prruutionl in p.ititnts with wdiac: disuSf, hepatic:
impaillTl!'nl, stizurr disordtrs, su icid.il mation, mania, or hypom i nia.
Contr.l indications: ColKomitanl=of~rtralillfand MAOis orprimoride is not
advistd.Amabuse should lit >lwided lIt(a= of!he akohol content of lhe drug
OOlKt nllille.
INTERACTIONS

ADMINISTRATION ALERTS

k is recommtoded thaI ~nraliOl' be giYeo in !he morning or t~niog.

When >ldministeriog 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.
P~oanC)' wf90ry C
PHARMACOKINETICS
I},~t
~ak:

2..... wk
Unknown

Half~ift: 24h

Duration: Variablt (atensiYe bindiog with ItrIIm proleinl)

LibraryPirate

Drug-Drug: Hijily jnIH1 bcMIId lIIldicOllionsllKh migoxil 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

~pI'Ill'IIIion,anI SfroIn nsyndromt,dlalamriled bylHladw,~
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. JOOn~ WDn or Itryp! .......
lOavoid 1fI00onin sy~.
Trratment of Overdost: TheR' is no IptCm{ treatment forOY!'rdosr. [mergency
IIII'diul ntention and gtntral IUpportil't mtuurts may be 1If(~IUI)'. Symp
10m I of OIItrdost ilKludt [\jUSfil, vomiting, Irrmo~ ~izurr~ agiution, diuilll'S~
hyptractjyity, rnydria ~s, tac:hlUrdi.J, and coma.
RRftrIOMyN1!~l fIII ~ MmhjftocmForu!!pf'dt IOlhll rtII!/'

IlIopltl16 Drug. lor Emot"""'t ar.d Mood Olsome"

ceptors, thereby enhancing release of these neurotransmitters. Nefazodone (available in generic form only) is similar
to Remeron. It was originally designed to treat depression,
and causes minimal cardiovascular effects, fewer anticholinergic effects, less sed.1lion, and less sexual dysfunction than
the other antidepressants. Trazodone ( Desyrel) is most frequentlyused 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] inhibits monoamine oxidase, the enzyme that terminates the
actions of neurotransmitters such as dopamine, norepinephrine, 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 enzyme monoamine oxidase (MAO). By decreasing the effecti\eness 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 Illustrated 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 effective as TCAs and SSRIs in treating depression. However,
because of drug-drug and food-drug interactions, hepatotoxicity, and the development of safer antidepressants,
MAOIsare now reserved for patients who are not responsive
to other antidepressant classes.

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 concurrently with other antidepressants or sympathomimetic
drugs. Combining an MAOI with an SSRI can produce serotonin syndrome. If MAOIs are given with antihypertensives,
the patient can experience severe hypotension. MAOis also
potentiate the hypoglycemic effects of insulin and oral antidiabetic drugs. Hyperpyrexia (elevation of body temperature) 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 result is a sudden release of norepinephrine, causing acute hypertension. 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 patient~ with ~ymptoms 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 characterized by extreme and opposite moods, episodes of depression
that alternate with episodes of mania. Although patients usually experience extreme episodes, periods may shift between

TABLE 16.2 1 Foods Containing Tyramine

_Frutts
....,

..

Rai~ns

Datry Products

Akohol

Cl"ftst(O!tagf cMef ~obyl

"",

.,.,

Sourar~m

WiMl (fSJIfdilly rfd wine)

M~"

SMOfdimn i'lff
Pat~
Me~t9tOOI

Pidled or kiwmd liming

P~Mi product~ induding mut tendmms

(anned/igl

Prppfrooi
Salami

""""

BobJI.ilhot dogs;

Vegetables

Sauces

Podsoflrold beanl(/ava bNns)

So)' WlKf

LibraryPirate

189

Yeast

Other Foods to Avotd

,I,llymtOf)'ust9!1Kll

Chocolate

.... Prototype Drug

I Phenelzine (Nardll)

Therapeutic (lass: Antidepressant

Pharmacologic (lass: Monoamine oxidase inhibitor (MAOI)

ACTIONS AND USES

Ph~ntlzine prodH:~s its ~fiKtsby int"lmi~inhibition of moooimintooolll';
thtrffo~, it inte05 iIies th~ Ni"Kls of oo~n~phrint in adreo!'J9ic synipll"S. k is
us~d to m,nigt symptoms of dtlftlSion not rt'Ipomr;~ to othtr typtS of phirml(olhffilp)', ,00 is oc(a\iooil~ med lor p,nK disordtr. Drug ~fI~ds may persist for 2to 1 WffIu .lIter theripy is disrominUl'd

ADMINISTRATION ALERTS
WI>lIOUI ~~. of 2 to) wt~ks I .. J<quired bolo .. imrodueing orhor
drugs.
Abrupt disrontillJition of this drug rna)' caus~ .. brond hypffit'nsion.
Pr<goanq category (

ADVERSE EFFECTS
Common side t1Fts I~ rollltipation,dry mouth,orthostatic hypot~nlion, insomnia, naUIN, and Iosl of appetit~.1t may illUNlI' hei n ril1~ and neural activity,ltadiog to dtlirium, mania, InriHjo, and roovuisions. ~ hypenemion
may occur when ingtStiog foods containing \ylimine. Srizurt'l, rtSpiratory d~
p~~n,cil{ulatory (oIlapll'"nd com, may occur in calrl of ~etI' ~ert\Iu.
(ontraind ications: Patitnts with cardiovalrular or (ert bmra !(uiar distall', h~
pili< 0/ JPIl,1 imp"inn~nt,~nd phParhmmorytnnu ",..,Id not '''''Ihi< dnHJ.
INTERACTIONS
1Wg-1Wg: MiIIrf othHdrugsiflKt thriKlicrl 01 ~~.(on(u1fnillll' 01
tritydI: ilntidfpmsants ind SSRk IhoUd be iI'IOidiod bKNIe the (ootilation un
<aII1f tl'mpffatln ~aIion mwtm.()piates.ind:.ting IlK'pfridiDf,!ihcUd be

PHARMACOKINETICS
()Jsrt: 2Wftks

Pei k: V,riablt
Half~i~:Variablt

Duration:48-96h

iMlidfd due to iMINIfd riIIr oIl!IpiIiII(fY fa~1I"f (f hyptmlWf uiIiI.

SympatbonimHklmay pr~a IIypfnHIIMailk. (alleilll' may II!ItIk in
Glrtbc: ~ialiIId~.

tab 11511: I'IIIoHziIt un ptOIiKe i \Iio1ldY false inuN'iIo iI \eI\IIO biinDn. Si n

plaleitt ~ tan "" iIIfc:tI'd, tar~ 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 eplwdJ~,
(f StJolln\ wonmayte\Ut in, IIypKll'OIi'lfuM.

TlNtmml ofOftrdose: 10te05iYl' symptomatic indlUpporlr;r t!Ntmem may

be ~Rd.lnduc:tion 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 diall'pam,g~n "'"Y sklw~. Hypertemion Ihould ~
t..attd appropriatt~ with ukium (hanotl bloc:km. Hypotension and mruiar
rolapSl' should ~ truttd with IV fItids i nd. if nKelilry, blood pressu~ titration
with an IV infulion of I d~ute prtS5OI' i9fOt Body temperilUrt shouk] be monitored dosely, ,nd ~lJIir,tion should ~ supported Mih appropriate measures.
_

extremes, or there may be prolonged times when mood is normal. 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 Section 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 functioning of neurotransmitters or receptors in the brain. Hypomania may involve an excess of excitatory neurotransmitters
(such as norepinephrine or glutamate) or a deficiency of inhibitory 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-

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III MyMIsIngClfDf. MnlngPtrxI!5!i fUIspKJ/I{ to 1M druiJ.

lier in this chapter (section 16.1). Patients with bipolar disorder also display signs of mania, an emotional state ,haracterized 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 l"y~huJHulur
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)

NURSING PROCESS fOCUS

l' Drugs lor [molloN I MOd Mood DboJdm

191

PATIENTS RECEIVING ANTIDEPRESSANTTHERAPY

Assessme nt

Potential Nursing Diagnoses

~int .suslllltnl prio,lO ad minisuMion:

Undtntll'ld 1M Imoo ~ drug hi ~n preaibed in orOO 10 .IIftS for
thmptUlicelru.
Oblain. com plett ht.kh hislClr)' in<kIding hep.tic, ItNlurologic,
taordiol'<HaJl.i~or ~roIogic dM.~,o.m-nt mtnl.lsUlm,Nrrovr.ngIIo
glaI,l(O~' ~'n<);or brtt-f(tdiIl9-Obuin . drug hhtDry in<iudilg
.&etgies._1 prtl(riplion IIId dru;s,.nd he!bII p~ralions..8e
aIffi: 10 po!~ drug inlffi<tion\..
Oblain. history of deprtUion 01 mood diIonIer,incUdilg. f~mily histOf)'
of Wmt.rId SoMrity.lbe obit~t ~g lools wbtI1 possible (t.g.,
8td ~pJesioo Innnlorr or r.fflatric: ~sion 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, gll,l(~,
hep.IK.nd It~ furl(tion studiH).
Assrss the pibmt"s abrlity to m:tift .nd undtnu nd instruction. IndudI'
W bmily and U~iffl Cl$1IffiIed.

ore

lneflmift CGping
.....,.,~

ArtJiety
Ois~ Jhought i'nxHIfS
Sleep p.Utm Oisnrmrl(e
~runtSflf.u~
o Imb.rlan<td Ibrition, Morf or lHs Than Body Rfqui~~B

Dysfunc:liorwl Grining
Sociillsolation,lmpairfd SoOaIlmer.lI(tion
Aktrtd Flmil, '~1fS
UrNI)' Rtttntion (reIatf<l to .ntkholintrgic tift(B oIdnrg therapy)
Noncompl"lolnce (INted to ~ drug t l'lKu oIdt(fl'ol\fd Sell1i1lli1do
illldlorwtightr;.i11
~runtKnowItdgt(drug~)
Risk for ~H-1irKtrd Violence, Risk for ~If-Mutiation, Risk b Suicide, Risk

me

lor kt,iJ1)'

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 tIwf~peuri<: ~).
Conlinut periodic monitoril'lg ofeBc.~es. glucosc.and 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 OIlighlhudt<! 1ItU, drowsiness,. confusion, ac;utiln, suicicLJl idrnion~
pilpilations,. U(ltyardj,,1H.md or double "fis ion, skin ll'lbes, bruising or
bleeding. .bdomiN Ipain, jllII1dice, d\allgt in color 0111001, flank pain. mel
hrm.turia.

Pla nning; Patie nt Goa ls a nd Expected Outco mes

TIlt p.ititm wit
bperitn<t wf'pMic eKtS dtptndtnt on lilt ltiSOll tht drug is being 9~tn (e.g., inaeast<! mood,lnsened dtp!eSsion).
lie !Itt frorn,orUptMnct minilllil~ ~ t trll.
o YtrNl~ iln .... dtrmnding oIlIItdrug's lise, IdYtnt eKecu. and ~ prtCautions_
Oemonsl~t plTlper se/f-ildmiMlli1tion 01 tIw medication (e.g.,dolt, liming, wht n10 notify proMf).

Implementat io n
Inte rven tions and (Ratio nales)
Ensuring thel'ilpHtk effects:
Continut .mfSSmtnts as dewibtd t . rlitr lor tIwr. ptUtir t trls. (Drugs
us.td fordtpmsion IIIiI)" take 2to 8Wftks befo~ fuR rfffma~ ~.ilrd.
Use objKtit mtalUrH,t.g., IIKk Dfprtlsion I~ntol)'; whm possiblt to
htl pqua rIify tlwrlptUtic: reults. For outpitient thmpr; JRl(riplions m.~
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 Educatio n

.....

o 1NdJ tht patiennhat lull rifms 1IIiI~ not IKrurfor a prolongtd ptriod of
bne but thilt ~ imprvmntnt v-.oukl be noticra~ .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 Iideatiom
immtdiatt ly_

(Cootlnued)

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192

U,*l The Ne!\lou sSyuem

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIDEPRESSANT THERAPY (Conllnutd)

Implem tn1l11ion

InterV1! ntions and (Rati o nales)

Minilllizill9 .dftnt tffedS:

Cominut 10 lIIOIIilor vital ~ IIIfIltal suM, and cOOldfiltion and
t..~nct periodiully, Enwrt pimm loI'"r.mooitor . mbulation umil the
fffu of ItIe drug aft known.!It partiaAlrt, cautiM witt! older adults
who a~ ill: inmo.-l risk fOr falk. (Anlidep~loInl d~ l1li)' cal/S~
dIowsiness Qdizzintu, bypo\fnsion,or ~irtd troeIIQI . nd plrJsial
abililits,irKftuing tilt, risk off4llt and irfJIJ'J
Cominut to lIIOII ~or <BC,eItwoIytn, and ~.I.nd hep.ificfunction.
(Antidtpmwnt drugs m.y ta\M .ot~ U in ~ efft<t.)

Pati t nt and Fami ly Eduuotio n

INCh tilt, pailiffl: II rin from lying or lining 10 nanding dowIr 10 avoid
oizzinessorf&
Instruct the patimt to cd for iSsistanc~ prior k! gt'lting out of bed or
alt~pting to wal alo~, .J nd .. avoid drimg or other actiritin ftqJDIg
mtnQI.ltrtness or ph)'!iul coordination lind rifNb of the drug II!

....".

Instruct the pitient on the ~ k! retum period ically for bob WOIk.
TNCh tilt, pailifnl k! promptly rtpMt any .Jbdominal pain, partiarbrly in tilt
upprI' quaclrinu,dJinge1 in stool (010~~ 01 Idm orstin,or
~urir.e.

~Iffi

klr dlingrs in mI ofconl(iouInm,disoritntalion orconiusion, Of

~ion. {Nrua?Iogic chall9tS may indiu., oodtr or avmordication,

tucerbatiolt of other PI)'C hinric iIInts!, 01' ~dnIg tftMuJ

m truct the P'timt. fi mily,OI' G~il'rr toimmrdiat~1y rtpOrt ioc~.J!ing

lrtIIifgy, d"liOritnotion, {ooMion, th. 1Igt'S in bmavior or mood, agiulion or
OIggrtuion, stmd speh, 01' iUri! ,

Ic!!e\ b~ in viIlwI iKlIity,bkJrml 'Iision,1OIS d pffiphmIvi!ion.5fti1g

r;Wrbow lYbsarotnd iIlh6,1OM eye ~ordltw IYfI1*IIII$ac~ br
_ a ind\lCll'l'iil:ing i nd ~ im~.(lnoe.l!fdillmptic prtS!UIt in
~widJ _
.... gllOOlIIIa rrwy OWIrin ~ tatilJl Tllil

Instnxt the pititnt 10 imrnfdia~ ~port'fIJ ~I dw.'1grs or~ pain.

Mooitor~llr SQIIA. (Llrly signs of SESand "rptrtt nSM crisis

with MA(J thmpy incl.* IlIpid inc~ in blood JRSSlft and puM.

Instruct the patitftllO immtdii~ I!port _

hNdicflt. dizzi~lS,

pMnlh~sias, ,..lpUtions,lh"Gldia,{he!: poIin. MIM' or 'fOI'Il~ing.

diaphoresis, 01' t-[

~Iffi k>r bruising, blmflnq.OI' Vgm of inttion.(JU.s may (.Iu~ blood

6y$cri$ils ;lIId inuu~ ch.ncrs of ~g or infwioft.)

TNCh tht pailiffl: II promptly ~rt any signs of incl!-.I bruising.

blmf"mg,or in~ (t4, ~ throat ~nd ~ $kin 1lI!II).

~Iffi klr dry mouth,bllIIRd I'ision,OOnary ~tion, and ~lIIil

drsfunction. (AnticholiMfgic -ik~ tffrm .nd ~lWl dysfunction, induIing
loss of libido i nd imPO~il! common i nticltprtss.alll adYtnt tffffu.
Toleranct to .JrnhaliM!gictffKl! UIUi.,6MIops in 2to 4 Wftks,)

Tth tht paitirnt ~ 1M itt dJips, frtqumt sipsofw.ttr, 01" cMwing glm or
bard candy to alfNt~ dry mouth and to noid lIkohol-bistd mouthWilWs,
which miYinot.l:!e dryness.
U~ of"dry ~" cI!cps.nd mUng f)'e5 ptOO:fruly l1li)' h~1p to dKl9K dry
rJ! ~in(j. TNCh tht ,..tienllO report ,IllY fmirJgs 01 I(IlIIchines!or~

pail immedi.ntly.

.,....

Instruct the pititnt to promptly ~rt diflirulty with urination, hrsitarqOf

I ncoulllgt tilt pilient to diswss COllctrns ilbout !eX\IiI1 function ing and
k! th~ hNlth {.I~ pI"O'fiOO if COrKtms.tffft mrditOllion compliolrn.
Encoulllgt appropn.t~ I~ and dietllry changtS to rtd:n tht li~ihood
of Might QliIt:iMrmtd irltakt offruilslnd \lt9tUblts, M 'se<! ~
and 9I!rtM !rw,b is dejRUion rrfu,~tinnKr from akohol,.nd n oiding
Ii~ meals brfoI! btdtime.

mel

For patimu uking MAOI~~~ USUlI dirt..,. intaR and proYide

instruction on Ioock. ~ a nd lIIf!di<a~ns 10~. (foods and
brotmgrs{ocuining tyIlImiM. akohcA,OO stimulants and ad~~R
drugs,IIiKDtin,.nd othtr CNSdepr6Sints may{aIM significant adw-rw
tffKu including hypert~lnM crisis or profound hy~oJ
.\!laid . brupt diIlontinu.nion of IhffiIpy. (Profound dtprmf:.rJ, !~izurtS, or
withdrawal symptoms ma,. ocrur with .brupt dilcontinuation.)

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mInK! the pititm, family,or {.I~iYl'l indittlry.nd mrdiGtion

~oirtiom. PID'ride wrinm .nd Yl'tb.II imtruaion.
Instruct the pitimc 10 imm~ ~port _
lIt,ad.J~dizzint\.!,
pMnlh~sias. p.llpitatiom, t.Jchrca rdil, {he!: polin. MIM. or 'fOI'Iliting.
diaphoresis, or ft'O'r[
Instruct the pititm 10 taR thtdnrg mct!y ill pltSCribtd and to not stotJ it
abruptly.

0I0p1fll'

NURSING PROCESS FOCUS

Drugs lot Emotlo....1ar.d Mood Oloord....

193

PATIENTS RECEIVING ANTIDEPRESSANT THERAPY ((OfIIInUlldJ

Implementation
Patie nt a nd Family EduUltion

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

Ihr patitnt sholAd be i~ to Ililt the rrilSoOll b tilt druIj;awropn.tr dIM

and Khrd:d"mg;alld wllill ~effe(tI to obwrw to. alld when to rr~t

....

commonlyobstMd~e&m,p.lIll~bwhento(il thehe.khu~
~andu'1 ~'1 moritori~or prmutirn..(lkingtimt<k.ring

nmilg ca~ ht~ to optinizt alld ~nbn:~ Ir)' I~i(hilg IIN~)

Palirnt ~Ifadmlnlnr.ttla n of dNg t herapr:

When idministtling the mecIiution,imtlU(t thr patient, famii);or
ur~r in ~ seW-idminismlioo of drug,~.9. take 1M dNg itS
pmuibtd alld do 1101 wbltitutr bwm.. jlltilizing timedllring /\Witadministration 01 tt- drugs htlps kI rrillortt l00.ing.)

T~i(h the palitnt to ~ke 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" tbtr~ 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.

Eva luation of Outcome Cri te ria

'I<Iluatr rfft<Uytl'ltlS of drug theraPl' by (onfifTning Ihat patient goals.nd elpKtfd outtomn hm IIfrn met brr1'lIInnin().
SNWIt " 1kI' 1st(i/tu!1l towlidl rbet oo~,,1iDnI ~

DRUGS FOR BIPOLAR DISORDER

Drugs for bipobr disordel'" are CllIed mood JtoJbiliHl"s. b3uu
th ey have the abililY 10 moderate e.xt r eme shifts in emotions between m3nia and depre:s.sion. Antiseizure drugs
and atypical antipsychotic drugs are also used for mood
stabiliution in bipolar patients.

16.8 Pha rmacotherapy

of Bipolar Disorder
For years, the traditklOaitreatment of bipolar disorder has

been. Lithium ( Eskalilh ), as m onotherapy 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, lamotrigine (Lamictal), may be even more effective than lithium.
Lamotrigine is parlicularly helpful for patients who haveeJI.perienced ch ronic depression and have not reived efftive treatment with Ihe other mood stabilizers. Table 16.3
lists selected drugs used to treat bipolar disorder. In addition
to the listed a nti sei~ure agents,gaoopen tin (Neurontin ), Ol{
Clrbazepine ("Irileptal ), lopiramate ("Lopam ax), and ron

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isamide (Zonegran) all have beneficial effects for mood sta

bilization (chapler 1500).
Atypical anti psychotics have been. effeCIive mood stabilizers 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 Clorazil 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 beginning therapy, and every 2 10 3 months thereafter. To ensure
therapeutic aclion , concenlrations of lithium in the blood
mu~t remain within the range of 0.6 to I.S mEq/ L C lose
monitoring encourages compliance and helps prevent toxicity. Lithium acts like sodium in the body, so conditions in
which sodium is lost (e.g., excess ive sweating or dehydration) can cause lithium toxicity and serwn sodium levels
will be monitored along with lithium levels. Lithium overdose may be treated with hemodialysis and supportive care.
Baseline studies of renal, cardiac, and thyroid status are indiCiled, as well as baseline eltclrolyt e studies.
It is not unusual for olher drugs 10 be used in combination with lithium for the control of bipolar disord t'l". During a patient's depressed Slag<', tricyclic antidepressa nts or
bupropion (Wellbutrin ) may be necessary. Duri ng the

19 4

Unlll Thl'Ne<voo,Sy'tem

TABLE 16 31 Drugs for Bipolar Disord"r

Dru,

Routeand Adult Dose (max dose where IndIcated)

ithum (Esulith)

PO;

ANTISEIZURE DRUGS

i1~ial:600 mg tid;maintenanu:3oo mgtid (max:H glda,)

Adverse Effects

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

Ylbimazrpil~ (T~oI)

PO; 200 mg bid, gradual, ilam~d 10 800-1,200 mglday in

th~ to fOIl' dividtddo\e

~am~oranQ,~ hfrldIdie naMII,dipiopio. bIlJrmI

lamouiginr (LAmmi)

PO; 50 mglday for 2'IIftk>, tIIffi 50 mg bid for lWffk~mol)'

ilKJUle lJadualy '" to lOO- SOO mglday in two diIoidtd dolts

HNft b!o<l aplastic aOOllia rr!piratOlY detmli9l1, exloHtin

dmnaliti~ Stmm Johoson !yndrom~.to!!i< Mrrmal on:roIy5is,
elm> (oma.~ath (with O'wdosrlliver liiluft' panqratitil

~IkJ", mlilriI1II, dlll'llflirltlI, fWIi'G, I'Omi~ng, pr%fIgfd bIMIirlg tiff!('

(max:7oomglday)
valproit i(id (Ilrpaktnr)

PO;l5O mg tid (max:60 mglkglday)

(~~176Ior~

Prototy,", Drug bcJxOO)

ATYPICAL ANTIPSYCHOTIC DRUGS
a~pr.uol~ (Abitily)

PO; 10-15 mg/day (max: 30 mglday)

oIanzapinr (1)'III'W)

Adult: PO; stan with 5- 10mglday; may il'ltfmt by 25- 5mg

M!Y wffic (ralH}P 11)-15 mgidol)';max:20 mglday).Gffiauic
PO; lIart with 5mglday

quetiapiDl'fl.mara!~
(~I)

PO; lIart with 15 mg bid; mol)' Masr to a tal9tt ~ 01

300400 mglday in divided dolts

zipra~donr (Gtodon)

PO; 1~ mg bid;ilaeasr by 1 mg daily 10 in initial tal9fl ~ of

6mglday
PO; 20 mg bid (mad) mg bid)

Tildrjcorriia, /folUitnl (eM!!; iWlrion, tlzil1fI~ IINdlKht, lighrfrtadedflru, lOfIlOOItlKt, OflOOy, ntrl'OIIIIltIS, Msriiry, inIOmfiQ,
11011~ I'Omirilg, rorurip<Ili9l1, ~killJOfiIlll, okorMio

Alnnuocy!Olit nwro!fPlK rnaiooam syndrom~ (wei

~indm~(9I11roon~~ffiI;~indk:itesrriOlliidmsrtflrctS. ---~--~ Prototype Drug

I Lithium (Eskallth)

Therapeutic (lass: Mood stabilizing drug;bipo(ar affective disorder drug

ACTtONS AND USES

Ahhough t~ ~oo mechanism of lion is oct (IN~ ithilm has been thought to
alter ionK activity and tilt activitifS of nrulOOS rontairing dopImiDl', norrpinrphriOI', 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'rotonin it the r~tor may ~ bloded and thaI ~ syntIIaSI' kina~l beta
may be inhibittd within liMo nruron.TheSI' ani:msl!nd 10 stabiiIr a widtr ra~
of (elkJlar tlllnsc1ucti>n pathways. ihtraptUlK KIions aft' ~abilimiJn of mood
durilg periods of mania, and amideplt'SQ nt ~tre.:n 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 __ b,~tifnts shooJd be
abl!o to bener (Onc~mrab.' arod function in ~-<.ift'.

Pha rmaco(ogic ((ass: G(utamate inhibitor;serotonin receptor

antagonist
ADVERSE EFFECTS
Lithium mily aul(' dizziro~ filtig!Je,sIlon-trrm m!'mory los~inclt'aIed urination, naUS!'a, wmiting,loss of appetit~, abdominal ~in. diarthN, dl)' mouth,
lIlJS(uiarweakDl'ls, ind ~ight tft'mm.Patifrru should not haY!' i s.alt-flffdiet
when tlking this drug. beuUS!' it rtdlKfS lithum O{ft'09l1.
Contraind ications: This drug is {omraindkatN in dtbilitatN ~tim!S and Poltifnl5 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 iIId~mtitth! rateoflihiun~lliIrMiGm.wf

fIIJl'!O:lof~aOO inaN\.!thf t6rofithl.m tIJ6ciy.(omlH'nI~of

ADMINISTRATION ALERTS
lithium has.J narrowtherapeutidlou.: ratio; the risle of toxicity is high.
Acute o'mdosaqe m.JYbe UNiN by h~modialysis.

ilNn,ma,GlUSI'afllldQlemergerqNrold<anpdl'llliiltfdrugarnn

Prrgnancy categPl)' 0

IIfrbaVFood: Unknown

PHARMACOKINETICS
IAlset:S -7da)'l
Peak: 10-21 days
~M:lI)-17h

Duration: Varia~

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~dfll9lt.Iltilllfllinal)'lfImoo!hat,nqElwi:b!ll>jUl)vi.Jf&aof

Lab Tflts: Unlnolrm

Treatment of Oerdose: Th~rr is no spr<ific: [ft'almenl for OY!'rdos~. Tr~atment

is supportil'l', illduding gastric lalllqt, ulrll'ttion of Auid and eltttrolyt~ imbalanc~, and rrgulation of rtnalfunction iog. Hernodial)'sis is an Nl'KliI'l' and rapid
means of fI'IIIoving th~ ion from th~ 2\'efI'~ lOu.: patient howeYer, rt<0YerY
time may be prolonged.

IlI>pltlt6 Drug' lor Emol1onol arod Mood D""rd...,

NURSING PROCESS FOCUS

195

PATIENTS RECEIVING THERAPY FOR BIPOLAR DISORDER " SKAlITH)

Assessm e nt

Potentilll Nursing Dillgnoses

Bllselinr a,srssmrnt priorto administration:

o Undtr>tind th~ Il'ason the drug has ~n prec:ribfd in ol'lltr10 mes for
lhtraptUtic: ~ffts.
o Obtain I (omplue lIt~ hh history induding IItpalK, rma~(,)rdiowrular,or
nturologic dil!'~. Obtain I drug history induding alier9ie, {urr~nt
prec:ription and ore drugs,and herbal preparalions.Br alm 10 pos~bIe
drug imeraaions.
o Obtain a history oIdeplfi-Sion or mood dilordtr, ilKUding <I family history
of sa~ and \fW'm,. UI!' objectiv~ SUHning tools when possiblt (r.g.,
~k Otpll'lYon lIT/emory).
o Obtain bi5elin~ vitil signs and W!'ight
o ['/<Iluateappropnate laboratory findi~ (e.g., MctrolytH (esptCially
wciiumj,CB(, hepalic and Il'nalfulKtion studies).
o AllI'Ss the ~tienl's ability to Il'{~m and undtrmnd instllKtion.llKkidt
lht family and {all'9iYl'lS al llffdtd.

o Anmt)'
o DislurbtdThought Proc:e stS
o SftpPatlemOisturban(f
DerKient Self.{all'
o ImbilalKrd flutrilion,More or ~s Than Body Rtquilt'flll'flll (rspeciall-;
!Odium)
o SocialilOlation, Im~ill'd Socia llnleraction
o Akell'd Family Proc:HStl
o OtrKient KnowIedgt (drug therapy)
o Risle for Stlf-Di!ro~d YiolelK~, Ri!le for Stlf-MUlilalion, Risk for Suicidt, Risk
Iorlnjury

Assessment throughout iI dministration:

o Asses for dHill'd therapMic t A'em (r.g., slabiliztd mood,les5ol'lling
~ion. nannalill'd a{tivit)' ltYeIs,apptlitl', and SftP~ltemsj.
o Continue periodic monitoring of rlt(trolytes,(BC,and hep.atk and ll'I1al
fUnction srudies. Orug 1t~1s will ~ monitOll'd IrtqUl'lltly or as sympl01111
warram.
o Continue to monitor vital signs and W!'"ighl
~sses for Ind promptly Il'pon a~~ eflto:n: diuintU,drowsifl6\ lighlhNdfd III'SS, fatigUl', muse: It W!'iIkritss, slight tremor>, thirst. nalllN,
I'Omiting.dianh~a,dry moulh, ilKll'n<i urinary outpul, shon-temJ
m~mory Ioss,and loKh~ardia.
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 minima~advtrl!' tffem.
o Vtrbalize an undtr>landing ofthedrug's USf, ad-ifill' effects, and Il'qui~ Pll'Cautions.
DtmOmlrate plllptr Irlf-il dministration 01 tht mtdication (e.g.,doIe, timing. wht nto notify provider).
Implementation
Interventions and (Ratiol\llle s)

Plltient and Fll mily Education

Ensuring thrrilpeutic effects:

o Continue aslflwmB as describfd ea rlier for lhmptUlic tffeas.{Lithium
maytake 210 3 W!'tkl btioll' full t flto:uart Il'lliztd UI!' objectivr
mwull'l, t.g., BNk Dtpll'lsion I~nlory, when possible 10 htl pqwmily
lhelipMic Il'sult~ H~'II' t~ ~lienl sign a"No IIarmfNo Suicidt"(onma
auppropriale.)

o TNCh the ~tirnl thu full tffNII flIiIy not O{(Ur for Sf'll'fal Wffkl bul thu
10m!' imp("{I'Hm!'nt should ~ notictable aittr beginning thtr~py.
o [1l(ourage tht patient 10 keep ill "ppoinlmenu wilh the therap~t and 10
disrusl ongoing symploms oIdtpll'Ssion and mania,and immtdiattly
Il'pOI1 any suiciclal idtations.

Minimizing adftlSe efflfCts:

o Continue to monitor druglfl'fls, MctrolytH (ept(ially sodium), CBC,and
I!IIiII and hepatic function .Maintiin a norm~1 Auid balalKt. (Lithilm is an
~tnt~1 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 ~Iso ll'Suh in Iossorgain of lithium.)

o InslnKt lht piliem on lht nrtd to rdum ptriodically b r lab work.

o InllMt lilt paliemto flIiIinlain a nannll salt Ind fkJid intakt, withoul
unusual or dramatic in(ll'astS ordeCll'iIfI in oonnal ditto
o TNCh the ~titnt that (onditions SIKh as dehydration may fl'SUk in
~boonnal drug IfI'fIs and to immfdiately Il'pOn any symptollll SIKh as
th ir>~ diuiness, {(InMion, or musde weakness and 10 ~ (IUlious with
mortising or on hot days, il9crs~'II' lW!'aling may Iud 10 Auid ~nd
!Odium Ios~ Rtpon U(HSm lhir>t or urination promptly.
(Conr/ooed)

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19 6

Until Thl'Ne<voo,Sy'tem

NURSING PROCESS FOCUS

PATIENTS RECEIVING THERAPY FOR BIPOLAR DISORDER (ESKAUTH) (Confillui)

Implem e ntation

Inte rve nti o ns a nd (Rati o na les)

Pati e nt a nd Fa mily Edu catio n

Weigh the patitnt diily and ~pon <I Might g<lin or IoSI of 1 kg
(appro:.:imately 21b) or more in a 24-hour ptriod. Mmu~ imakt and
output in tho hospitoliN<! potion!. (o.il~ _ight is on >u"t. "''''U~ of

Huid staM aM takel into aount intaite,OUIput,and ins~nsiblt mltS.

Diuresis is indicat.d by output lignirlUndygrt'atrr than intallt.)

Hoi!, the

Ia"'.

patient _igh self diily, ideally at the

ti",. of diy, and If(ord
'Might HiM' tho patitm It'pOn a Wl'ight 101\ or g<lin of mort than 1kg
(.pp..,.iorw.1y lib) in. l .... hour pMod.
Advise the p.uient to rominur to (o1IIU~enough liqJids to ~main
adequately, but not o'mly, hydrated. Drinking when thil'lty, avoiding
akoholic bt~ .. 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

agitation. (Neurologic: (hanges may indic:.Jte unlltr -or ol'ffrnrdication,
wctrbation of other ply<:hiatric iIInfll,or ~drug tfftrnJ

Insuu(\ tho parien~ family,or<art9~r to immtdiately 1t'p00 ilKlN.ing

lethargy, disorientation, <onMion, change< in bthavior or mood, agitation
or aggression, surred Ipffih,or mxia.

Monitor ~nal status, (BC. BUN,crt'atini~,uric acid, and urinaiysis.(Lithium

may Wilt dtgtntrativr <hangfl in the kidney, whic:h in<lN.fI drug
tOllic:ity.)

uri~outpul. hematuria,
or urine Itdimtm; IoWt'r abdomin.ll tendemm or funk pain; naUlti;or
diarrhea to the heakh <are provicll'r.

Cominur to roonitor <.Irdj,JalQJlar ItatUl ilKluding vitll sign. and apic:.J1

pullt. !lithium toric:it)- may rflUk in <ardiacdysrltythmia< or angina. 1M
with <aulion in patienll with i history of (OronaI)' iOtl)' diSl'alt or heart

IlIItnKt tht patient to imrnrdiatrly It'pOn palpitationl,<lIest prrSlUrt',or

pain,esprcially if i(rompanied by dNiO.a;ordiaphorosis.

--+---=- IlIIlnKt tho patient to promptly rt'port dt<1N d

disNs~.)

Patimt IInd'lStanding of drug thrra py:

lMoppor1IIliOOduring idmimtratm d rnrdiationlandduing
assf\!OlI'nI\lO discusl rationale for dlUl thtr.!PJ dtsirrd thtr.!peutJ: 0I/00JII"0e!,
moll 0lIII~ ob!eMd ad!'Il!' eifI'ds, pararnetrl5 for whrn to (all tilt
hNhh 10ft pro'<idt~and any IIffi'Slal)' monitorilg or plt'COllJli:m. (Usilg tin!'
ruring rul5ing Ull'heipl to opti~ard 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 nu~
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 ta~ thr rnrdication 011 follows:

Taktl'J:iKt!y 011 orderod and UII' tho lame roanufactult'l's brand eoch
ti~ 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, fne~or(hangtl
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 ha~ been rntt (Sf!' Planning1.

manic phases, a benzodiazepine will moderate manic

symptoms. In cases of extreme agitation, delusions, or hallucinations, 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 relapse, psychologic therapies and sleep mana gement are
co nsidered e.'l:tremely critical components of bipolar disorder thera py.

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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 third,~ allo diagOOSfd with dtpnollion.
~bout one fifth ,110 ha~ a leaming dis.ibilit)o.

1lI>p1tl16 Drug. for Emotlonilt and Mood OfsoJde.s

ATTENTION DEFICITHYPERACTIVITY DISORDER

A condition characterized by poor attention span, behavior
COCIlrol issues, and/or hyperactivity is called ,Ilmtion
dtool-ll)'pffactilitJ disonlef (AllHD). Although the cond ition is

nonnaUydiagnosed in chiJdhood,symptomsof ADHD may

enend into adulthood.

16.9 Characteristics of ADHD

In reality, ADHO is neither an emO(ional d isorder 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

~al3,

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. Symptoms 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 conventiona l routine; 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

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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 single gene has oot been isolated and a sj'OOfic mechanism of genetic transmission is nOi known. The interplayof genetics;md
envirOllment may be a con tributi ng dynamic. Recent evidence suggests thai hyperactivi ty may be rela ted to a defICi t o r
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-carbohydrate 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 AD HD. Whena
chikl i.. refe""" fnr """ing, i, i.< impnr'an' In l"f'T1"lfn1hf.r ,h~1
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 diagnoses, and to create an individuahed plan of care. A relevant nursing care pbn ~n 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 educating 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 inapprop riatebduvior.Sdf-esteem must be
fostered in the child so that strengths In self-"'"Orth can deveIop.1t is important for the child to develop a trusting relationship with health care providers and learn the importance
ofmedication management and compliance.
One third to OlIe half of children diagnOSl with AD H D
also experience symptoms of attention dysfunction in their
adult years. Symptoms of attention deficit disorder (ADD)
in adults appear similar to mood disorders. Symptoms include anxiety, mania, restlessness, and depression, which
can cause difficulties in interpersonal relationships. Some
patients have difficulty h olding jobs and may have an increased risk for aloohol and drug abuse. Untreated ADD or
ADHD has been linked to low self-esteem, diminished social 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 ~reas
of the central nerwus system that heightm alertness and increase focus. Recently, a IlOI1CNS stimulant was 3ppt"O\lcd to
treat ADHo. Agents for treatingADHD are listed in Table 16.4.

198

Unlll

TABLE 16 4

Tt~

/IIe<v"",.

System

Drugs for Attention Deficit- Hyperactivity Disorder

Roull' and Adult Oose (max dose where Indlcatedl

Adv~rse

Imrabiiry, III'flOOW'1I, IfSlItsm'~ inlOllllW,

t!JPhorio, PQ/pirkru

Arldefal~XR)

6),!al'l oId:PO;5mg one orlWOtinel/day;1N)' iOONIo! by 5mg 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

bmzphe~int (DiRx)

PO:b-SO mgl-l ~mrl ptrday {max: 150 rrg/day)

dexmmyiphtrida:t (Foolin)

Child oIderthan 6yeal'l:PO:15 mg bid may iroNlo! by 25- 5rng/wfH

(mal: 20 mglda,~ 5mglday 9tM d lI'~a!o! may illUl'aII' by. mg/wffk

DN'

Effects

eNS STIMULANTS

I>-- and I amphetJnint rownic:

minurt (,I.ddtIa1l) ial!O avaiablt a.

Ad~PO: B mg bid; may ilma lo! ~ 2.5 - 5ng/day at WffUy ilttr'"k

(mal:20 mglday)
dextroilmp/l6amir~

(Duedrintj

Sudden duth lreDO!lfd in mldrtn w~h

5\IUCIln i u rdia( abnormal~i rll

dn:wtory

coIlapsr. 9 foiati"lt trmat"tis. anrnia.livt r

l - 51!iJl'lold:PO; 2.5 mg 0fH' or two ~mei/~; ma, ilmalo! ~ 25 mg at

Wffkly intt Mk

(a l!Oa"liila~t al ~roStatand

Dmdrint Spm'*,)

6),!il'lold:PO:5 mg OIl!' orlWO tineslday:irmalo! by 5mg at wtftIy

intmal. (max:40 mglday)

i ldwmftlilmintl'o'ylall!o!)

PO:30 mg 0IICl' daily in ~ am.{max: 70 mglday)

methamphetJmilf {Dffix)"Il)

6),!al'l oId:PO;2.S- 5mg 0fH' or two ~mei/~; ma, inuealo! ~ 5mg at

WffkIy intt Mk (max: 20- 25 mglday)
PO; 5- 10 mg ~<m brukfall and lund!, with lJadwl iOOl'alo! of . - 10
mg/'IIftIral IIffiItd (max:60 mg/day)

NONSTIMULANT FOR ADD/ADHD

,... Prototype Drug

I Methylphentdate (Rltalm)

Therapeutic (las.: Anention defidt-hypelllcti..;ty disorder drug

Pharmacologic Class: Central nervollS system (CNS) stimula"

AatONS AND USES

ADVERSE EFFECTS

Mtthylphenidateacti"lates t~ reticular adi'l<lling systt m,(.lusing ht ightt ntd

alertntl! in yaricu! regiom of th~ brain, panirularly t~ (enters a\5ociated
with focus and <lItention.Acti"lation is panglly adlie'l~d by t~ '*~ of 1ItUrotrammimol'l su:h al noll'pintphrine and dopamilll'.lmpulsiftntll, hyptractwitpnd dilrup:i"I~ bthayior are usually rM.oc:td within <I few vmoln. Thts.e
(hanges promot~ impro~ pl)'(~ial intt r.J{\iom and acadenlic: performallCt. Ammritrmal,mencitd mu ll' form ofmethyphenidatt wasapproYed
in 2006 (!laytrarw).
ADMINISTRATION ALERTS

In a nonADHD patitn~ methylph~nirlat~ (austl nt l'lOUlntl. Ind insomnia.

All patit nll art at rilk for ilT!'guLu ~an bta~ high blood p~re, and liver
toxicity. B~uust methylphenidate isa xhtdult II drug, it has the potentia Ifor
(.l using dtpenrimt w~n 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.

Susuinedffltall' ub!ru must btswallowtd wholt. Breaking orclUshing

SR u blets (.lu;es immtdiate II'INII' of tilt entiR' dost.

INTERACTIONS
I)ug- l)ug: ~idolf illHittl with manydnJ9l.FIX" mmplt, ~ may

Controlltd suhtallCt": Schedule II drug

PlI'9l1inq UIf90ry C
PHARMACOKINETICS
1A1~t: lm trun 60min
Pl!ak: 2 h;3-li IUltaintd II'INSt
Half~ifto: 2..... h
Duration: 3-6 h;8 h su.uintd reluse;8-12 h mtndtd relea~

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~ ~efIKti_lof anticorr.Ulanll,anticoagwnll,andg~1II'.

(roc"-""t thfr...., wih doniclirof IIIiII' illUUlf oiIW_ ffftru.Anlil)"pfrtfllli'm 01

odIfI OIS stimWnll could poIfIItialf 1M _onstrictift action of
lIM'~midalf. MA(hmayproducf hWHIMli'll' crM.

Lab TI5ts: Uninown

IkorballFoo:I: Adminiltration \into! r8.itiw to mNk and mNI compo:Ition IN)'
rwd ildWiliJal~tration.

Treatment of OverdOlf: There is 00 ,perific trmment for Ot'rdost.Sigm and

l)'IIlptOIlll of arutt ~rdoll' R'lUk principally from Ot'I'ltimulation oft~ eNS
<I nd from 6Ci'\Ii!' Iympathornimetic elferu. Emergency mtdicahn~ mian and
gt ntralsupportivt lIII'alUlI'I may he lIKessary.

OIiptflt6 Drugs for EmotloNl ar.d Mood DliOrd..-s

NURSING PROCESS FOCUS

1"

PATIENTS RECEIVING TREATMENT FOR ADHD, ADD

Assessment

Potentllli Nursing 01llgnos.5

Baselinr ISHssment priorlo IIdminislralioo:

Und!'nund lhr INson the drug has ~n pmcribtd in orDtr to mes for
thmptUlic: t1FfCts.
Obtain. compitte i1Nhh history including hepilic:, rtnilCirdio'l~lOJlitor
naualogi< dilNlr, including ~leply. Obtain. drug history including
allergies,eurmlt plfl(ription ~nd Ol( drugs, and hflbal pl\'par~tioltl.1k
alert to pos~bIr drug intemtionl
Obtain I IO(gl and bthivioral histo~.UltobjeaiYt S(lttning tools when
polSible.
Obtain. nutritional history.nd HIfIS norm. 1~p paltrrns.
Obtain ~selinr vital sigm,.nd heighund weight.
E~luate appropri.nr l.iboratory findinqs (e.g., electrolytr~ (BC hepatic:
and mlil function studies).
AslrSs the patitnt"s ability to re<tiYt.nd undtrsUnd inltnKtion.lncludt
the family .nd {.~i",,"s as nerdrd.

Imbal.incrd Nutrition, lrss Than Body RrqJiR'mrms

Disturbed Sletp Pattrm
Altered Family Proo:tSItS
~mt 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:iillntrriction

ASSfls mtnllhroughoul iI dminisltation:

AslrSs for dt~red theriptUlic: e fie<u (e.g., incrt' sed ability to focu~
normiliud i{~vity Ieels with lesltned impulsivity, maintfllantt of
norm.1 i ppetitr .nd ~p paltrms).
Continur periodic: monitoring of rittlroiytes;, (BC"md hepatic: and I\'nal
~nction truditl
(ondnur to monitor vital sigm, .nd height and wright wttkly.
Assess for.nd promptly I\'porI idftntffie<b:dizzinrlS, lighthNdrdntl!,ln~,lgiuotion,fJ(rlliYt phySic:.tIICtivity, t.drfurog,
inclI'asrd blood p!ffiUr~ h)'ptrtrlllion,.nd palpitations.

Planning: Patient Goals and Expected Outcomes

Tht p.titm will:
uptrienct ther~ptutic: effts dtptndfm on the rmon th r drug is bting givrn (t.g. improl'rd ability to focu~ ~stntd pyKhomotor symptoms).
1It'!Ift from, or tlptntnce minimll idvr~ rfffCts.
Vrrb,aliu.n underst.nding ohhedrug's use,ld-;e~ eff!s"nd R'qJil!d preuutions.
Demonstratt proptr seIf-ildministration of the medication (e.g.,dolt, timing. when to notify providrr).
Implementation
Intervention s and (Rati o nale s)

Plltient lind Fllmily Educlltion

--+--

Ensuring ther. peutlc effects:

Continur asltllments.s decribrd u rlitr for theril ptutic: effts.
(Thmpeuo{ ~ffts includr the ability to iotlft and stay~n-IIsk.ltsstntd
impulsiYity,ind improved IO(g IimtriltliomJ

T~h the p.titnl, family,or cil~ivrr to keep;r \O(gVbehal'iorill di.J~.

InwM- !Chaol f.eult)' and othrru~il'fn (r.g.,.ftrr""lchooi YII').

(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.)

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
find PUM Ioc:ation mOlt Mil)' frk and hm the ~titnt. family, or wegil'tr
R'tum..:frlOOllllr~te pullt taking beioll'going homr.

Wrigh thr ~titnt 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)

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
p~ !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'orothrrstimul.iou.
(Conrmued)

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200

Unlll Thi'Ne<vDI"Sy'tem

NURSING PROCESS FOCUS

PATIENTS RECEIVING TREATMENT FOR ADHD, ADD (COt!lInuw)

Implementation

Interventions and (Rati o nales)

Patient and Family Edu cation

Cominut to monitOl\leep patt!'lllS. (Stimulatort efied,of dfIIQ IIIIIV ,flKt

oormal ,ftpirogpattern,and may indiutHx(!1~1'I' dOIagt.l

Instruct tilt patient family.or Cill1'oim to inform thl- providerof dimrption

to ,leep, incrmed ~itllion rurirog the day (po,~bJe effea from lackof
,leep).OIH<ffiil'l' ~11!1' rurirog tilt rIa)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
ll'izures and Il'port immediat~.(bmsil'l' (NS stimulation II1II)' (aUII'
ll'izures uan ,dvelll' efl'ed)

Instruct tilt patient family.or {all'gil'l'r to immediately II'pon tlflllOl' or

,eizure-! to the health "II' providet

kl('S, the Iftd for rominuous medK.-ttion or I'ftd ilr dIU] holidays with th e
pat~nt f, mil)o. ca~iI'I'~ and health we PlU'fid!'l baled on the
lO{iaVbeh.J'Iior,1 diart findirtg!.(Dtpendent on tlltdtg""' d~ drug
holidays 0I'!'f oon---smool days or VoKiltion periods may he IffimmendedJ

o Te,ch the patien~ f,mii)<,orurt9i1'1'r about the us~ of drug holidays.Jnd

expIolI' option,.lf tilt drug dole is" the upper r,~of dOSl',considef
taperirog tilt doll' prior to beginnirog the drug holid,y to ,void rebound
hyperactivit)' or agitation.

kll'U the oome !'II'Iironllll'ntfor medication \ilfMy and the I'ftd for
,ppropria~ intl'M'lltion ~ Mvile the fam i~ 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 Saf~rd 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
(OIIImon~ obsmoed advl'lll'etre.:15, parallll'ltfS b when to cal the heahh
IlII1' (IIO'I~ and all)' IIK!1s.J1)' monitoring orprtuutiom..(lkirog time
!bing nulling w~ helps tooptimilr and rffifolU' kr)' teaching alNsJ
Patimt self-administration of drug therapy:
When administe rirog the mediution. instllKt the patil'll~ fami~. or
(,~il'!'l in the propersrH-idministration of drug. f.g . take the drug as
pr~S(rihed and do oot sullstiMe brand,. (Utilizing time durirog nur5eadmini,tration of these drugs helps to r~nfon:e tmhing.)

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.
Teach the fami~ oruregil'l'r about pr~ription renewal r!1trictions ij.f.,
new prncription each tilll!',oo refills, pltKription may oot becalled in) and
expIolI' Khool polkits lf9,rding in~chool use (e.g_. 'irogle.dose \I'Ilt eam
do)o. oun:d bii"or piKk =d ij multidoscs "'01).

The patient family. or ulI'giver ,hoold bt ,ble to stile the ~a50n for the
drug;approprilltt doll' and Kheduling;.Jnd WMt ildYl'lll' efferu to obII'lI'I'
for ,nd when to ~pon.Jnd when to II'pon them.

Teach the pilil'llt to take the mediution al follows:

o Take exactly as ordrrrd and in the momirog to p~t insomnia.
o Do oot takedouble or Utr, doles to ill{~a~ m~ntal focus or to plI"I'!'nt
lleepines,. The drug will not achiel'l' th!5f effects but will ill{rta~ the
adoi!lII'erre.:u ofthedrug.
o Do oot ablllptlydiKominut the mediution without cOlllUkirog the
he,khweprovider.

Ev aluation of Outcome Criteria

16.10 Pharmacotherapy of ADHD

"t

The main treatment for ADH D are CNS stimulants. Stimulants reverse many of the symptoms, helping patients focus
on tasks. Drugs prescribed for ADHD include D- and l-amphetamine racemic mixture (Adderall), benzphetamine
(Didrex), de.:'l:methylphenidate (Focalin), dextroamphetamine (Dexedrine), lisdexamfetamine (Vyvanse), methamphetamine (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.

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Patients taking CNS stimulants must be carefully monitored. CNS stimulants used to tr""t AD HD may crute pu_
adoxical hyperactivity. Adverse reactions include insonmia,
nervousness, anorexia, and weight loss. Occasionally, a patient may suffer from dizziness, depression, irritability, nausea, 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 appetite suppressant to lose weight.
Non-CNS stimulants have been tried for AD HD; however, they exhibit less efficacy. Clonidine (Catapres) issometimes prescribed when patients are extremely aggressive,
acth"e, o r have difficulty faUing asleep. Atypical antidepres-

Li fESPA N C O NSIDERATIONS

Methylphenidate Use In Older Aduhs

\Ir'IIR nd~1t (RjQIin1 his If~ bn CDRIidt~ IIWg lIN
dlilcftn.m 1M iI ~ ~n tbr use of odwf ~ DIS Itindilm. is
iIIamWIg.~_tt hu IIttft s'-" l!I.IintMnw.Rfuinm,MId ..
dramt.u.lnd~i~oIdtfalts.~lIUIieslwft.holUlt

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
Frtq,ItnI ..... signs, HjIKiIIy Wood PftS- ' .1hcUI~lIseltd.~e ~ MId lilt ~ ~
.. nualionshauld Iho ~ ....itcftd.And 1MI00IIgtili dIt ~WIIIWIIUI
UUI.~ CIIIIiJsion 01' IgiuIion.stIauId ~ pmmpdr 1tpOfIfd.

_1Oftd.

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 o r 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}'arpears 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 ato~ne should be monitored dosdy for
increased risk ofsuidde ideation.

KEY CONCEPTS
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 th~ numbered sectio n witllin the chapter for revM'w.
16,1 Everynurwshoukl bf, proflcltntln Iheassessment of patitnu with signs of depreaion. Dep.-eWon has many
forms and chal1iiCleristlcs.. and 115 identification and etiology areessenllallOr propel'" Ill'atment.
1'-2

163

Approaches to treatment of major depression inwlw a

proper htaltll I.'DITllnatlon. medIcations. p5ycoothentpeutic thnlquet.lnd e\tfO)nvulsiw or rTMS ther
apy. Thtre is an important warning from 1M FDA about
anlidfPll'5Unts.
Anlldtpressanu act by corrtlng neuro!l1iiosmltter imbalance 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 a~ 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 depressive symptoms.

16.4 Tricydic anlidepressmts all' older mediatlons used

mainly lOr the treatUlellt of major depll'SSion. obIes.Yve-compulsi~ disorders. and panic attacks. They llave un
pleasant and serious side effects.
16.5

SS Rls act by selectiVely blocking the reuptake of 51'roton in in nerve tennlnals. Ilec:aUSf of fewer side effects,
SSRI5 are drugs of choice In the pharmaCOl.herapyof de-

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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 serious 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 expressive psychomotor activity and Irritability.

lU

lithium (Esblith ). antlSl'Qure drugs. and atypical an

tipsychotic drugs are ustd to treat bipolar dUorder.
Lithium i!; effect~for purely manic or purely depressiVe
stages. Anl lsel.zure drugs are more effective In tile trea t
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 o f pyschotic depll'SSlon.

16.9 Attention defidt-hypernClivity disorder (ADHO ) Is a

common behavioral condition occurring prlmarlly in

cllildren and is diuacleriztd by difficulty p~ylng 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.

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.

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

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.

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.

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.

3. dl'Cf"f' ....... dn,gdep..ndenceand ...",,,,<st.h ...

4. prevent hypenensivecrisis.

Which of the foUowing symptoms would indicate to the

nurst' that a patient is experiencing lithium toxicity? (Select 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

4 . Mnnitnrhlnnd p'l'S"<nl"f' for hypnten.<inn .

2. 1 wt't'k.
3. a month or longer.
4. within 24 hours after staning thedrug.

CRITICAL THINKING QUESTIONS

1. A l2 -year-old girl has been diagnosed with AD HD. Her
parents have been reluctant to agree with the pediatrician's
recommendation for pharmacologic management; however, 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 support 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' regarding when she should begin feeling "more like myself."
How should the nurse respond!

3. A 26-year-old mother of three children comes to the prenatal 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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Drugs for Psychoses

DRUGS AT A GLANCE

LEARNING OUTCOMES

CONVENTIONALANTIPSYCHOTICS
Phenothiazines 1lUJtlO5

After reading this chapter, rhe student should be able to:

pagt.ni

Q chlofpromal1nehydrochkNlde
(Thofazlrw) fXXJl ](JJ

Nonphenothiazines plJlJOllJ
Q haJopmdoi (Holda/) plI}t }(M

ATYPICALANTIPSYCHOTICS

pl9t}(18

r/spefIdone (RJsperdaJ)

{II1Jt m

Dopamine System Stabilizers (DSSs)

plI}t 1I6

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
schizoph renia.
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.

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

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illusion s fllKlt lfJ4

nfgative symptoms JXT;' lfJ4
neuroleptic {II1Jt ~
nruroleptit malignant syndrome (NMS)
paranoia pot}f 104

pot}f ~

parkinsonism fllKlt l1J6

positive symptoms {II1JtlfJ4
schizoaffrctivr disorder fIIKIt 105
sthilOphrr nia paqt 104
tardiYr dyskinrsia {II1Jt )()5

204

Unlll

The

/IIeIv"",, System

evere mental illness can be incapacitating forthe patient

PHARMFACTS

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
chlo rpromazine (Thorazine) in the 1950s,and the development 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 stimuli ), disorganized behavior, and a difficulty relating to others. 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 trying to harm them. Because these patients are Wlable to distinguish 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 psychotic 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 dama ge,
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 normally 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 commWlication, withdrawal from other people and the outside environment, 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, affecting 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.

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Psychoses
Sjrmptoms of psychosis .reoftm moc:iatfd with othtr ment.1 hNlth
problems indJding subll.nc:t .bust,depmsion, .nd dtln!'ntia.
~)'(hoti( disorotrsare .mong tilt moll misundtmood mtntal htalth
disordeB in North Amerita.
Approximattly 3 million AflII'riufIS havt !(himphrenia.
Patients with ~)'(hOi~oft~ 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 include 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 activities. Negative symptoms are characteristic of the indifferent
personality exhibited by many people with schizophrenia.
Proper diagnosis of positive and negatiw symptoms is important for selection of the ~ppropriate antipsychotic drug.
The cause of schizophreni.1 has not been detemlined, although 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 responsible 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

CNplfr17

ON9'/orPsycho ... ,

205

.ad.. ta

"

Dopamine

.....

Figure 17. 1 Basalganglia:overstlmulallon of dopamine

receptors may be responsible for schizophrenia

synapses and competing with dopamine. By blocking a majority of the D, receptors, antipsychotic drugs reduce the
symptoms of schizophrenia. ,.. Figure 17.2 illustrates antipsyt:hotic drug action a\ the dopaminergic receptor.
Sc:hizoaffl!Ctivedisordtl is a condition in which the patient exhibitssymptoms of1:oth schizophrenia and mood disorder.
For example, an acute schizoaffective reaction may include
distorted perceptiotl'l, hallucinatiotl'i, and delusions, followed 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 psychoses. 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

~rultures hil'fVl'rydiflorem ~ on IhfQlM of and trratmtnt for
mental ~m~ ~b.mdation d manyoftlwstmenul hfahhtrrnntnts ir.olYrs
htrbsand~l heali-og rwthods.Arntrilan Indansmay~lJeIIttdb)'therom
lIlInit)o1raditionarmtdmman,whomaytlratmtnUll)'lllptomswithas'M'l!
~ and he!bs.Afric.anAmeOOm maygotoa traditional \OOdoo priestorOOief
!tram fort~atmen1,and t.ty frtquentIy hrm to tmll memall)'lllptorm.
Hispanics sm ,",atl1lfflt fmn a Iol hea~calltd a rurmdm:I;and they may
htrbs su:h as (himomit, ~nnill.and 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 a~ beIiMd to (,lUll' mental ill11m. BKalIW' brlieB can vary wiie~ within rultures tlrmltlYrs,a tIIoroo.qJ ruttunl autI!menI d ftli1qs and beIitfs about health and 'M'lntSl will assist the
!tralth QIl' ~ in proYi:Iilg the IIIOIt appropriatt !air possilk-.

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\ :.
~

Dopamine (0,)
. ,",,~

i
>

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 reduce 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 negati~e 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 patient 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 effects, and needs of the patient. For example, patients with

206

Until TheNelv"",,Sy.rem

psychoses as well as Parkinson's disease nero an antipsychotic with minimal extrapyramidal sid e effects. Those who
operate machinery need a drug that does not cause sedation. Men and women who are sexually active may want a
drug without negative effects on sexual interaction. The experience 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
atypi~ antipsychotics. The conventional drugs for ps),(hoses
indude the phenothiazines and phenothiazine-like drugs.

Phenothiazines
The phenothiazines are most effective at treating the positive signs of schizophrenia, such as hallucinations and delusions, and have been the treatment of choice for psychoses
for 50 years.

17.4 Treating Psychoses

with Phenothiazines
The conventional antipsychotics, sometimes called flrstgeneration 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 phenothiazine:s are now available to treat mental illness. All
block the excitement associated with the positive symptoms
of .chizophr.. nia, although th~ diff.. r in potency and .ideeffect proftles. Hallucinations and delusions often begin to
diminish within days. Other symptoms, however, may require 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 conventional 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 hypotension, and urinary retention are common. Ejaculation
disorders occur in a high percentage of patients taking phenothiazines; 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 anticholinergic effects, whereas chlorpromazine (1borazine) has
a high incidence of anticholinergic effects.lhioridazine (MelbriO 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
betw~n a therapeutic and a lethal dose; deaths due to overdoses of antipsychotic drugs are uncommon.
Extrapyramidal effects are a particulMly serious set of adverse rea(tioru; to antipsychotic drugs. Extrapyramidal ~dr dfl.'ds
(EPS) include acute dystonia, akathisia, parkinsonism, and tardive dyskinesia. Acute dystonias occur early in the course of
phannacotherapy, and involve severe muscle spasms, particularly 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 shuffiinggait. 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)

o ddpromazine Ha (lhorazile)

5tdQ~ drotll'5inru,~ UIIOpyranidoi J)'mplGm\.

lM/lY;15- 50 rng (nw::600 rng r'lrty ~ h)

romtipalion, pIror05t1lJiriYiry, orl/KmQrk h"",rtmio'l.

urtJaryrmntion

ftuphrnuilr IKI (I'frm~i, Prohin)

PO;O.5- 10 mglda1 (max:1O mgiday)

ptIjI/Irnazinr (Phrnazilr,Triafon)

PO; 4-16 mg bid toqid (nw::64 rngIda,)

proddprrilzinr (CompalinrJ

PO:O.5- 10 mglda1 (max:1O mgid.y)

thioridazile IKI (Mrliarin

PO;50- 100 mg lid (mal:800 mgid.yJ

trift~azine Ha

as Strlizilr)

l0ri9naliy markrlrd

Adverse effects

PO;15- 100 mg tid orqid (nw:: 1,000 mg/d.y)

PO; 1-1 mg bid; (mill: 10 rngIda,J

1M; 1-1 mg "rr"l4-6 h (mill0 rngIda,J

IIOIi<> indG>10 <OIIImon .mrs< dh:m;~indi<.l<5 S<riou> odvt .... olh:<1~

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Apu09Wis, pa!!C)'!pprniil.ilnaphy\agoid r~ioo.

Indin II"!:lIIimiolllf~!llItIlIillllollilllolDi !XIIiblllf
hyootbrrmy mmk ilew Wq!m unr!!!!lolinrddNth

CNplfr17 Oru9,lorJ>,ydl<'''''

207

TABLE 17 2 Adverse Effects of Conventional Antipsychotic Drugs

Effect

Dt>sc~pllon

A(U\! dyltonia

SIo\'m1pl1llll, pir~(wrty!he b.Kk rrusdt~longut,and ladil mum; lW~ding mol'l'mtlts

AkaltilU

Consunt pi(i1g wilh r~li'I!, (ompoJ siv! rnov!IMnll

AntidlolintrgK dftcts

ilrllllOllh,l.myGlrdia, bhm d vision

Hypoll'fl~on

P~rticwrty \oMIl' whl'fl!he pi~tIt

IIN'oItplk maligr.antsynd~

High ft'Itr; (onfusion, rrusdt rigQl~and hig/lltlurtl uwil! kir.aI!;G1n ~ faul

mows q.i<kly Irom ~ rtlurtlbeot 10 ill upright po~tion

Parkinsonism

Tl!I1IOI;musdt ~ty,ll00ptd poIlUI!,~nd

SIodi~on

Usually dininishts wilh (ootinued thn'ap)'

shuffling ga~

SIoml dysfunaion

mpoWKt and dimirishedlibido

1Irtift dyskintSia

BizaITl' lOII9J!' and loa mlWl'fIIenllsum " lip smading ind 'IIOIIIIlike moIioos 01 tilt l~; puffing 01 dims. unrontrolltd

dltwing mO'ffllln'l1l

.... Prototype Drug

Chlorpromazine Hydrochloride (Thorazme)

Th~rap~uti( ( La ~s: Con~ntional antip~yrhoti(;schi10phrf'l1ia drllCJ

Pharmamlll9ic ( Ia l~: D, dopamilll' Il'cpptor antagonist;p/1pnothia1inp

ACTIONS AND USES

ADVERSE EFFECTS

Chlorpromuillt plVt'ides symptomatic: R'lief of positive Iymptoms of s(hizophlfnia and controls manic symptoms in piUenIl with schizoollftcti'fl' disordtr.
Man, pilients mUlt ukt chiorpromazilll' for 7 or 8 weeks bfflllt' Ih~ up~i
t nct improl'l'mt nl Extmnt 'gitation may ~ IrNttd with 1M or IV injKtions,
whkh ~gin to mwithin mirutts.(hlorpromazine can also (ontrol ~ nauSN and Of11iting.

Strong blockade of alphNdR'ncrgic: Jt<eptm and weak bloxbdt of dlOliocrgk ~fpton upliin somt of dllorpromazinf'l ad'fI'M efrecu. Common ,d'fI'~ tfftm 'If diuinm. drowsintll, and orthostatk hypotension.
ulUapyrlmidallide 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 ~POSfd 10
warmtr ltmperatulfsshould ~ monitortd more (J,uly ~r 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, induding ,ubc:onic.J1 brain damagt, bolll' marrow dtPlfllion, and IIt)ot'S 1)11drornt.(hiorprornazilll' is conlr<lindk,ted in 1.Kution.

ADMINISTRATION ALERTS

Do not crush or open lUIuined-relNl! forms.

When administert<l 1M, g~ dtfp IM,only in l~ upperoul~ 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
naul!'alvomiting..dizzilll'l~ IIfmOn,or dyskilll'lia may ocrur.
IV forms should ~ lntd only during surgtf)' or lorStfflf hkrup!.
Pregni ncyUltgory(

PHARMACOKINETICS

On..t; 1O~ min

~k; 2-.4 hPO; 15-lOmin IMIIV
Halflife; 6 h
Duration: 30 h

INTERACTIONS
DIIII}-DIIJ!I; (hIorpromazi~interam wi!lllfWlai dll~.F ~,conCU"lfnt
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 bTesll; (hktpromazi~ mil')' ilKlNl! <lphaIin ftoccul.nion and ~ibIy O!h@r
lim function Ifill. Fall!-jHIIiliw Il'IUhs may om. for anyIast, 5-~lOIyioo
iCf!ic: add, poiphctIi~OOJI'fII, urobiRlgfn,and ..... bilirWin. FoJM..posilil'l' ...
faI ....!If9OtM Pf"9'IOIK)" !tm may ,..ut.
Hm VFood; (.wa ind StJohn\ won may OO&I!I' lMrist and lfWIilyoldystonia.

TrNt ment of OftrdOS!; Tlltlf is 00 speciJi< trtatllll'ni for OIItn:l=; patients

aR' tR"!N symptomatitally. [PS may bt: tR',tN with antipartinlonism dllJljI,
barbitural~ or diplltnhydramilll' (8enadryl). AYOid producing Ifspiralory citplffiion with thtl!' trNlmt nts.
9tftr /() M)NUIlIngm for Q MmlrJ} I'n:lasI fooJl Jjlt(1t /() rIrIs df!!9.

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 periods, the extrapyramidal symptoms m ay become permanent. 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-

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nia without producing some degree of extrapyramidal effects. In these paTients, drll8 therapy may be warranted to
treat EPS symptoms. Concurrent pharmacotherapy with
an anticholinergic drll8 may prevent some of the extrapyramidal signs (chapter lJOO ). For acute dystonia,
benztropine (Cogentin) may be given parenterally. Levodopa (Dopar, Larodopa) is usually avoided, since its abilityto increase dopamine function antagonizes the action of

the phenothiazines. Beta-adrenergic blockers and benzodiazepines are sometimes given 10 reduce signs of alca th isia.

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' an tipsychotic cla!;!; oonsists of drugs whose chemical structures are dissimilar to the
phenothiazines (Table 17.3).lntroduced shortly after the phenothiazines, the nonphenothiarines were initially expected to
produce fewer side effects. Unfortunately, this appears to not
bt the c:ase.1be spectru m of adverse effects for the nonphe-

~ Prototype Drug

nothiazines is identical with that for the phenothiazines, although 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 monitored, because of the potential additive effects.
Drugs in the nonphenothiazine class ha,e the same therapeutic e ffects and efficacy as the phenothiazines. They are
also believed to act by the same mechanism a5 the phenothiazine!. 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.

Halopertdol (Ha/dol)

TherapMic Class: CollWfllionaiantipsydlotK;sdmlphrenia<tug

ACTIONS AND USES

PIYIIMCo logi( ClaSI: Dzdopamint rmpIOI' antagonist; nonp/lenothiAline

ADVERSE EFFECTS

H~loptIidol is dlSlilitd chtrnically u ~ but)'lOflhtMM.1u primary lISt is fOi lilt

Haloptridol p!OChICH Itss ~dation and h)'pOtension than (hiolJllOmuint, but

mlf1i9t1llfll1 of iruI~ Inc! chronic: psydJotic: dilonltli. II may bt ustd to IJN(

patienu wilh TClUltttt's syndtomt ~nd thildmt with st'ftlt beha'tiof problems
well uunplll'lORd IggrHSMntlS MIIItJPlosiw hypm:xcit.lbility.h iuppnlllimilte/y SO times _ potttllthan thlolpromazine but l\utqual ~fIiU<Y in ~
lieving symptorm of schizoptmia. HaidolLA is .Io~ pRp.lrltion that
lam lor Ipproximalely 1 Wftb following 1M 01 subo.Ju~ ~trilliI:ML
This is pal1kulolrly btnefKilllO! Pftitnts who ~It UJl(ooptr~lift 01 unablt to
uu n mrdicatioos.

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 ~r rifu of
thenpy (In bt dtttnnintd.Although thi! inc:idenlr of NMS is r.lrI', it can occur.

ADMINISTRATION ALERTS
Do lICK ilbrupdJ lWonmue,OI_ aMB!' ~actiom maYO(rtII".

TIlt INtitntllMt

tau 1M rTIfIiution IS CHdtml fOf IIItrapMX IHIIIS

IODtOIr.

If 1M patient dots not (limply with or.1 thrrapy, injectab~ attndedRluSf haloperidol shlDcl bt (OfI~
Prf9IIiIKY Ulf90ry (

PHARMACOKINETICS

!met 3O-lSmin
Puk: 2~h PO;lO-20 min 1M
HalHiM: 12- 37 h PO;lO-19h 1Y;17- 1S hIM
Duration: VoIrwbit

ContraindKations: Ph.~otllmpy..mh IIOIIphtftothiazinrs is not.dristd if

ttw, patient is ~eiwing mtdication for illl)' of the loIowing <onditiom.: PartinlOll'S disult, seizurt disofdm,.oholism,and _
menu! dt9itssion.
INTERACTIONS
CN;I-ttug: IWIope!idoIMract5 ..;ra1Oi"otugs. fOI~tlMfoIowiIg
~IIeaNlf1hfrlfl'mlabsctpllal1ll~lem..n ;nI~

(l)fQnilg ifUCids, \rIo6opi (., ilaN~ dlill<fS 111 ItlOdopa 1OIicty), itmn
tilaNledlloo! 111 a_r lllUcMMj<tQ[m,),~p/ItaJIoin (.,
iIIaNsts m.e of p/ItQJtoin tolid!Jl, rf.... .-.d bt\.J iIIIICbrs~ iIuNSf
tIIood lewis 111 I\aIopf!idoI.lhus INtifI9 to podIII! lOIm,lllalo9tridol inhibits 1hf
.riInof(~ri"IJ~pMtn!iws.

... 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 ..we~ 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!. Hypo1msion sIIouId bt UIUIItmatd wilh IV tIuid~ plasma,or Ulll<tmrattd aIbumin,or v.!Op~!Or drucJs.
II!lI>r a MyItlJlnijKl ffII. MnJnq frf'f5 Fo:I!I!pf(/II( a 1M d"u9-

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RoIpI.,11 OtugsforPsychows

209

TABU 17.3 Conventional Antipsychotic Drugs: Nonphenothiazines

"'''''
cHo!pothixmr (brawn)

Routeancl Adult Dose (max dose where Indicated)

Adverse Effects

PO; 7S~150 mg/day (maX:600 rntj/day)

5fdatiOrl.f1~mit'" dfOldlltl1 tltff1J{1frllmidd symptom~ flt'mlll

" ~Ioptridol (Kaldol)

PO;Ol~S mg

Ofthostlltt IIyptmiaI

bid or tid

1M : 2~SmgMIY4h

PO;uart with 10 mgfd.ly and rapidly inmast to

IIG~ 100 mg/d.iy In diYiMd dolls (mal:150 mgJday)
mdi~

HCI (Mabin)

PO;50~75I19'da, in lIu~to four dMdfd dost!; ma, irKRast

to 100 m!JId.iy in 3-4 d.iJ1 (mar:lli 119'day)

pinozide (Orap)

PO; l ~ll19'day in dMdfd dnst!; ,adualy ilKn!ast ntry

othtr day to 7~ 16 mg/day (mar: 10 mglday)

thiothilene HO {Haoantj

PO; 2 mg tid:may irmast up to 15 mg/diy (mar:60 mg/1Iay)

~ncicate common adtrsc dfts; lIlIIk!iDiDilnllcatts 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 com~ hrakh history id..ding hepitic. renal. urologic.
{aroionsrula~ ~ritory,or neumlogic.disNst (tspMilly Parlilson's
distast Of Stizu~), QJnenl 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 memaldisorden, including a family
hiSioryofsamtand ~ty.
Asstls for disturbalKts in thought Pfocn~, pen:tplion, wtrbal
communiUlion,afftct, bthaYio~ interptl"sonal n!Litionsilips, and self-Un!.
1M obje<tiYe screening tools per tht health c.a~ otgPllcy.
Obtain ~stliof yital signs and M"ighl
EvaluaU! appropri.llf Liboralory findings (~.!J,,{BC. eiKtrolytes,glucOSf,
hepatic and n!1Ia1 function swdits, drug IUttning).
Asstls the patient's ability to!"tUm: and understand instnKtion.lnducle
the family and u~iYm as needed..

Potential NursIng Diagnoses

Disturbed Thought Procts~

Disrurbed Sensory Perreprion (auditory, visuaO
DisturbN PersOf1al kientity
AnxittJ(stYt~panic)
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

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,. g~ htp.ltic and
n!nal 'metion studies, and thtraptUtic: drug Inti!.
Asses litiI s9JS,~IJ orthosmr.: bbod prtSS\I~and IWigh ptriocicaty.
Assess ilr and promptly ffPOn iKMr5t effKlS:dizziYss Of li)ht-btDdness,
confu~i!limion,sui<iclal ideations, hypotension, t.rn,urola, il"l(l!lW' in
Itmptutult, bk.rntd or cIoubit vision. skinrashes,. br\isiIrg Of blttdi~
abdominal pail\)aurdct, (!lange in color ofstool, flank pain, II nd hematuria.
AsStls for and prompdt n!port6IIapyramid.i1(EPSI ~ploms inckKfing
pstudoparkinsonism, ac:u~ dystonia!, akathisia,and ~!diW' dy1tilltSias
(Stt "Minimizing advtr5t effts"in tilt following se<tionl.
Immediately report signs and ~ploms of neuroleptic: II1ilignanl
Iyndromt (HMS):unstabie blood Pn!ssure, titvattd ttmpera\un!,
diap/rorM-,dyspnta, musdt rigidity, and incontintMt.
(ConrfooPd)

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210

Unlll

Th~

/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 ,ymptom"delusion~ paraooia,
hallucinations).
8. mt from, or experienct minimal. "IYefSt tlfKh.
Velbaliz~ an undemanding of the drug's UI!', adorot tlftru, j nd rrquifl'd prK.!uUons.
Dtroonm~~ properself.a.dministr~tion of tht medication (t.g.,deM, timing. when to notify plO'/idtrJ when pouible.

Implementation
Interve nti ons and (Rilti o nll les)
En suring 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 ntgati~t 'ymptom, of the disorder. Gradual
improlm\ent o~ Sf"Ieral wtt'H to month, may lit oot.d)

Pllt ient lind Family Educati o n

Tt,uh thr patim~ 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 r~uirtd during ilGlIt, farly period of
therapy.

Monitor patient complianct with thr drug ~imen.(Tht P'tsenCt of Sf"Itlt'

mental dison:lers may It'IUk in oonc:omplianct with mtdiutKrn.Rrgula~
ClInsistent dosing is fS~tial to ClImcting tht undtrlying disorOO. ~UIM
the dlll9' do not QJIt' tilt undtrlying disordt~ if It'gular adminisuation i,
dilruptN,symptom, m~y return abrupti)o.lmramunular depot in~etion,
may nttd to lIt(onsidtlt'd if thronic oonc:omplianct continUfS.j

IIIYOIvt the famii)o and (al!giver to the flIent pos~bIt in l'IIwring tilt
patitm I!mains on rt'9Ular mtdirnion rootiOfS.
EIl\UI! that the patitnttakl'S tht mtdication as prescribtdlkm It~
mtdication, at the btd,idt.
Quetion tht pos~bilityof oonc:omplianct ~ original ,ymptoms or advt~
tflKn !Udclen~ inclNM' in ifl'quenq or ,tytriry.

Minimizing ildYflSf effts:

CominUl'to monitor vital sign, periodicali)o, tspe.:ially orthoslittK blood
prtSSUfl'. Kttp 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 inc:rt'iI ~ mil 10, falls.lAntipsythoticdlll9' may calM hypotl'llsion,
inc:rt'~~ng the risk offalk and injuryJ

Ha'lf the patitnt riM' from lying or sining to ,tanding !Jowl~ to ilwid
diuineuor falk.
Instruct the ~ient 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 acti~itits requiring mental "ltnOfS,or ph)"lical
coordination umil tlfKh of the drug "It' known.

ContinUl'to monitor motor activil'l,(oordination and balanc:~ ,nd for EPS

symptoms, inc:kJding:
I'W'udoparkiMOllism: tl!mo~ 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 dyskillfSia~'chortoalhetoid' moYt"",nn wch is lip !IIIicking.
wormlikt mowmenuofthl' tongut,unrontrolltd chewing. and
grimacing (EPS mil)' be an unawidablt ~dvtrst .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
pretm.(~elt' 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
,ignifrcant~ 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,.)

LibraryPirate

In,truct the patim~family,or cal!givtr to immtdiattly rtpOrt EPS

symptom, for additional tlt'atmem.

a..".. 17
NURSING PROCESS FOCUS

OruglforPsychoses

211

PATIENTS RECEIVING CONVENTIONAL ANTIPSYCHOTIC THERAPY (ConrJnuM)

Implem e ntation

Intervention s and (Rationale s)

Patie nt and Fami ly Edualltion

Mon~orfor...d immfdia~ ~rt ligns ,nd l)'II1ptoml ofNMS:Im

- .- .C,- +.-:-,C-...
_ the p.ltRnI, f,mily,oru~i...er toilllllll!diat~1y ~ 'ny minge

blood p~~~ltoiat~ tt!nptf.lrutl',diaphomis,rIy5jxw, mUl(ir riljdily,

iltd in<OIIbnern.(NMS is, r'f!! but potentia~ fatallrndlome thac IIlUIt
be le<ogniM ,rd tleatnl inmtdiollel):)

.. '"'" of (onsciouslltl~rlmtnltl'm~atlM,9(ffiiw SWNting,!l'mI'

mIIIdt rigidi~ _leiled m,ifniOlllor lhortntsl ofbreilh,or
ioomtinmlf.

Continue to monitor (BC,tIfwolytes. ~J ,nd hepitil; Nncrion nd

tMr'pMK drug ltoiel1. (Antips)J(hotKdru!P m'1 C'lM bone m,mIW
~ion and Mp.lloloxiri!y n ad'lmt rffrm.)

IIIIWCI the ~itnt on the ~ to II'tum periodicilly for lib WQlk.

lNdr the palitit 10 promptly ~rt any ibdominal pain, particubrly in the

Mon~orfor iltooolinfrgil: elFu. irdJding dry moU1h.dfOWlinm.

nr:OIIrage lip! of wate~iI;l' (hips, hard und);or thewingl}Ulll to U~

IIOUth dl'YMl~AI'Did 11co~ mout"-HIlH. 'tAlKh III' drying to lilt
IfIU(OI,) Ind wIIidI!h~ PIOOrt m,ydrink.
IIItlffit ditty fibef int'~ and adequalt IUd int'~.
Rtport Urilliry relefttion to tM health ClI! pm& promptt,.

bllllred l'iIion,romtipation,ind Urillil)' letention. Pmide Iymptomllic

trMmem 10 e,~ effb.. (AntidJoli IIfrgK sym ptorm ,re l1li mon ..t.ome
~uof ,ntiplydiotk ~.TOlerin<' to 'ntidlolinergic rifcts
dMIoPI Oft! time.)

\/lUI'"

IIPP" quadr.Jnu, <h, ~ in stool {010~ )'fIIowing of I(m or mn, darkrflfd

urine,lkin fl~, Iow-grildt 1M!'\, gtIItrillllfliM or ch~9H in bfhlvior
or K\;"ily lMI,or rednffi or -cling ,nMId ICH of in;ury.

phOllenWlCy.)

~ith tilt p,titflc, ',mil~.oru~ to ilPpiJsunsal'fll (SPf 15 or abow)

priorto IIIn txposllft or enwrt ptOIKti...e clothing is worn. Plomptiy ItpOrt
illlJllbum to ~ heakh UfI' prwiIer.

Mon~o!for Moho! and iIIegiI drug lM. Clked con<lIIft'IIti); these ause in
irroeilsed OIS~l.int etft or In o:acerbation in ~tic

IIIIWCI the ~itnt to aYoid ,Icohol ,nd illtg,ldrug 1M." tilt patient 10
community IUpport groups sud! ill M or HAiIIlppropri.tr..

Mon~orforsunbuming Of 1I~.(Antipsydlotil; df19S c.M

I)'II1ptom~

Monitorafftine u~. (list ofClffeine-<OIIt.1irring subsunce may M90IIt

tM rfftruof antip)'Chotia..)

Mon~orfor IoIIIOking. (lIf..,-smoking nYYcltutirlt the met.lboiilmof

IOmI'

,ntiP!YdIOtiO IlKh ;tI IIiIoperidol, leading to dtaN!td rifiucJl)

kid! tilt pllitrc, f,mily,ol'Cl~ toa'lOid Clifeine-<OIIuining

~ges, Iooch,and OT( mediutionl.,nd .. 1Nd food Iibm when in
cIoob of whetlwrlllt produtt corQilll (,I~.
Jllltnxt the p.ltRn\ to IlopOf dKrti~ ImolQng. Refer tile ~tient to
IIIlOking {eloJlion progriflll" l ndiuted.

---"---+---'

htint umlent.,.dln9 of dnr9 thefiIPY:

tM opportlllliie! during adminiltration of mfdiutio'll and during
iIIltS~U to cflSMl fltionlle fordrug ther~py.desirtd theripeulil;
O!.IIcom6,ftmt (om~ obsmtd idwtrse e!fecu, ~fIr'I1eterl fOfwhtn
10 ull t~ hNlth u~ p~ Ind 111)" I\MSlary monitoring or
prtuutions. U~ brid tJplinatiolll during tWntI of deIuIionl or
hilKilloltiom.{Uling time during nunir\g (ile helps tooptimizt ,nd
reinlon:l' ~ ~aching ~II';tI.griel,{orMteftl 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 nurwadminillfltion of!h~ drug! htJj)! to ~infolU' tNching.)

The ~tRn~ fimit:or u~ should ~ ibIe tonate thr fI'iIIOII for the
d!urJ;ilPPIOpriiltl' ~ and sdwdrling;and whit ildYerseefftl tOOWM
for iltd when10 ~ thtm.

leith the ~tirftI,or family.or tiI~iYer co t.I~ 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" m~iution is tiI~n euatywhen and ;tI ordefrd.tMof iI
ulend.Jr co mdr dOSH fIIiI"1 be helpful
lithe m~iution tiI!MIdruwmell.!aRiit brdtime. Taltnn<e to
ilnticholinergK effrru IlKh is drowlillflS UIU.i~ ~ _r time.
Do not IbruprlJdilcOlltillUl! the rnediution.

Evaluation of Outcome Criteria

kiluate the tftitiJene!1 of drug ther,py byamfinning that ~tRM goil! iltd txpted goal! have ~n mtl (leI'i'lanning1.
5tt WlIeIII.' RIllJ kf isD tI.tug5rott1idtrbtMlIII~II1fi111Q~

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Until

Th~ /lle<vOI"

Sy'tem

17.6 Treating Psychoses

with Atypical Antipsychotics
Th~ approval of dozapin~ (Clozaril), th~ first atypical antipsychotic, marked the first major advance in the pharmacotherapy of psychoses since the discovery of
chlorpromazine decades earli~r. Oozapine, and th~ other
drugs in this class, ar~ called second gen~ration, or atypical,
because they have a broader spectrum of action than the conwntional antipsychotics, controlling both the positive and
n~gative SYJllptoms of schizophrenia (Table 17.4). Furthermore, at therapeutic doses they exhibit their antipsychotic actions 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 different 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-ad renergic
receptors, which is thought to acooWlt for soJlle oftheir prop-

~ Prototype Drug

Rtspendone (Rtsperda/)

Therapeutic (lass: Atypkal antipsymotic; schizophrenia drug

Pha rmacol 0gic(lass: Dl dopamine receptor antagooist (weaker affinity fcf

Dj replors); serotonin (5-HTj reptor antagonist

ACTIONS AND USES

T~rlpMil ~Ifts of rispfridOOl' inckJde ~atmentlnd prevl'Iltion of Ilhizo.
phmlia rela~ and HpltSsion of bipolu milnia symptom~ RisperidOOl' also
tR'an ~mptoms of irritability in autistK (hildml. upIed R'sulu aR' a R'dlKtion of Hritmtnl, paranoia, or nrgatiW' IIthavioB as5O(iated with pysdiosis. Ef
f~ o((ur primilrily from blockade of dopamilll' type 2, ItfOwnin 1)'111' 2,and
alphl, admlelljil R'(~tOB located within t~ CHS. For a full range of eflti~
ness, the drug is sometillll'S (ombilH'd with lithium (Esblith,lithobid) or valpro.1!e (Depakene, DepHon). Risperidone is a long-acting ~paralion, whilh
following 1M adm inistration, R'lea~ only a small amount After a ]-wk 1iIg.
the ItSt of the drug rele.JSI"S and IiIsts for approximately.~ \I'I'ks. PO pR'paratiom R'1t~ sooner ~nd hlW' Il ~2 w~k Ons!'t of oKtion.
ADMINISTRAT10N ALERTS

SeW'ral weeks aR' rtqUired for thmpMK eifl<IINelll'S5.

When switching from other antiplymotics, dillontinut
avoid umlap.

medil~tions

to

Plf9nancy category (
PHARMACOKINETICS
IAtSl'I:

Peak:

erties. Because the atypical drugs are only loosely bound to Dl

receptors, theyproduce few~r extrapyramidal side effects than
the oonventional anti psychotics.
Although there are fewer side effects with atypical antipsychotics, adverse effects are still significant, and patients must be carefully monitored. The ust' of atypical
anti psychotics have recently been differentially associated
with an increased risk of weight gain, diabetes, and hypertriglyceridemia. 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 associated with obesity and its risk factors. Risperidone
(risperdal) and some of the other antipsychotic drugs increase prolactin levels, which can lead to mt'nstrual disorders, decreased libido, and osteoporosis in women. In
men, high prolactin levels can cause lack of libido and impotence. There is also concern that somt' atypical drugs
alter glucose metabolism, attributing to the onset of typt'
2 diabetes.

1 ~2wkPO;lwkIM

4~wk

Half~ifdOh

Duration: 6wk

LibraryPirate

ADVERSE EFFECTS
Common adRr~ efftlts aR' Htrapyrimidtl R'aions (involunury shaking of
the ~Id, lH'Ck,andanm),hypmcril'ity, fatigut,naulu,diuinm, viswldirturbanc6, ~I'f,and orthosUlil hypotension. Risperidolll' mil)' (1= Wl'ight gain
and hyptrgl)l:fmia, thus wolltlling gllKoSl' comm in diabetic patients.
Contraind ications: If older adults with dementia'R'liIted ps~ are giW'll
risperidone, they aR' at an increa sed risk for ~art failure, pneumonia, or sudden
death. Patients with undtrlying Iol rdiov;J sru1ar diSl'~ 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"/lIivrrdistaSl'.
INTERACTIONS
1Wg~1Wg: PoJli@nutaking rispmIorII' IlKUdMid(HS~u 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 eIf~ 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 l~izoraIl.
~ en.., ittrhn withflimiwlion by the kid~ofdolipilH' KlwriO,
whidl a1O ifl(r&lIeI the risk of advtrw rN11ion~
LableIS: RiIpfridoIH' en.., (oJIIII' iOO"UIfd II'IIIIl prolactin It"Il'Ii and ifl(JMfd AU
l~nilll' 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 ~,1lKh IS bYi, ' ilffian,or

dlamomilf, whidl mayifl(JI'U ~~CNS 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 (onsidered in tR'ating oven:los.Jge. Est,blish and mainu in ana irway; tnsuR' ldeqwte
oxygenation and W'Iltiliition. Maintain carGtovaI<U1ar function.

TABLE 17.4

Atypical Antipsychotic Drugs

0""

Route and Adult Dose (max dose where Indicated)

Adverse Effects

aripiplalOlt (ADlify)

PO; 11>-15 ""llday (mal;lO mgld~)

IOChyradio,. rnnitnrfMf,~ dininru,

donpnt lClouri)

PO; run at 15- 50 mgldoIy and titrit~ to a tal9tl do~ oil Sl>-4,O mglday
in 1dol)'\; m~ i1ma~ furthe- (max;900 mglday)
Ad!lt; PO;run with , -10 mgldar. may ilKll'aII' by 1.5- 5""l ~~ wtd!
(range 11>-15 mglday;madO mglday).GffiatricPO;lt.lnwith Smg/day
PO;6mg1day (max; 11mglday)

oIanzapilll' [Zyprm)
paliptridolll' (lfMgi)
quetiapilll' fumarate (S6oqueI)

25 mg bid;may inu~i~ to ol targtl dolt 0( lOO-400mglday in

dvidtd doItI(mil; &XI mglday)

(.) riIpftidoIII' (Rilptldal)

PO; 14""l bid; illR'aII' by 1""l daily toan in~ial target dolt 016 mgld~
PO;10""l bid (max;OO mg bid)

lipfilidont (Gtodon)

hfodhe,fg/lr~,lOmooitoce,QnMy,

III'rII:1IIWl~ IrJJriiry, immr~ rn!U>t4

Kllllirirrg,

cmsriplllioll.lK'limonilm, okmlrilio"
~rnidI1I.l)'mploml"

Ag!i\DulocyKtlj;.rreyrPIeptic maljooant

!'t"!Id!9rM l!i!~l

PO;runw~h

1M; 10 mg ~vrry 1h (mal;40 Ill9iday)

NURSING PROCESS FOCUS

PATIENTS RECEIVING ATYPICAL ANTIPSYCHOTIC THERAPY

Assessment
Baselinr assmmf nt prio rto administration;
Undtrmnd thr ~alon the drug hal ~n presc:ribN in ordtr to mel for
~ripwtic:dts.

Obtain a complt~ htahh hiro:q indu:lilg hepatic, 1flIi1, uroIo.jc,

(,Jmiuia\CIU~ repiratOl)\OI III'IIUbgic:d~(r!pt<iaI~ ParDnlOO'l riIN~
or IMtre),rul1!lll mental stalUS,~lIC)',or blNst-fN,;Iing.ObIainadrug
hiliO!y indu:lilg ahlirs,rul1!lll ~oo 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, behavio~ interpftlOnal ~latioDlhips, and \elf-(i~.
UI!' .ti~Krtening took ptr ~ health (aft' agtnq.
Obtain ~lfIint vitll signsand Wl'ight
['/iIlua~ appropriate labor<llory findilJ9l (t.g., C&, M(\roiytrs, 91uc:CM,
htpatic and II'nallulKtion lIudit~ lipid 1t~ls,drug Klffning).
AllI'Ss the patient's ability to m:tivt and undtrltlnd inm\l(\ion.llKl~
the family and "ft'9iI'l'lS as needtd.

Potential Nursing Diagnoses

DisturbedThought Promse
Disturbed ~mory PtKtption (auditory,vilu.Jl)
Disturbed Personalldffitity
Anxitty (snrft', panic:)
ImpairtdVerbal Communic:ation
ImpairN Sociallnteranoo
Intffmivt H~akhMaintffiilKt
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 plO(~lI'S, Caft'9iver Rolt Smin

ASSfssmrnt throughout Idministration:

AllI'Ss for dtsirtd thtraptlllic: t flem (r.g., oonnalizing thought procr!lI'S,
Irs \riling driusions, halluc:iDilion ~ imprumn~m in )IOIiti~ or ntgati"l~
symptom~ability to return to normal ADIJ, imprwemrm in appetitr and
slttp patterns).
ContinUl' periodic: monitoring of CBC, rirdrolytes, glurol!', htpatic and
~nal furxtion studits, lipid Itvtls, and thtraprutic drug Itl'eis.
AII!'!.s vital signs, rljlKially onholtltK bkiod prrlSlR, and WI'i91 ptOOOOl~.
Alsm brand promptly rtport idvtrl!'tff~lI;diuilm or light-htMnrss,
(onfusion, agitation, sum. 1ideations, 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 prompt~ ~port tJtrapyramidal ([PS) symptoml in(kiding
pswdoparkin IOnism, ac:utr d)'ltonias, i!lath ilia, an:! timi~ dyskinrsia I
(set' Minimizing advt~rflem' in ~ following Ir(tion).
Immtdi<llt}y ft'port signs and symptoms of NMS; Lllltibit blood pII'IllR,
t lmttd IffilperallR,riaphcum,dy\pIll'a, IIIUIdt rigi:lity,and illCOnt~.
(COnrlrwed)

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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 symptoms,delusion~ paraooia,
hallucinations).
Bt fret from, or exptrien(r minimal. idYerst tfftcts.
Velbaliz~ an undemanding of the drug's UI!', adoror dfrru, j nd rrquilt'd p!.!uUons.
Dtroonm~~ properselhdministrition of tht mediution (r.Q.,d(M, timing. when to notify plO'/idtrJ when pouible.
tmplementation
tnte rve nti o ns a nd (Rilti o nll les)

Pllti e nt lind Fll mily Educlltio n

En. uring therilpeutk tfffCh:

Cominue i ssmmrm. i lde(riiltd tarlier for th~aptUtic tfit(u. (Drug.
UIed for p,yc:horn and ~hizophlt'nia do oot (urt tht uoclerlying disordtr
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 mtdicaticrn.Rtgula~
(onsislmt doling is e>l'llti.tl to (ometing tht underlying di,ordtr. BtuIM
tilt drug. do nol <II.., lilt undtrlying di>ordt~ if "'9uiar .dministration i.
di>rupttd. symptom, miy return abrupdy.)

Minimizing ildftlSf effKts:

Cominue to roonitor vital ~n, pfflodiu lly, t,peciallyortho,tatK blood
pre~1t' 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

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 thtl<lpy.
Su pportivr, inpatient Ult' may be rtquired during thl' irutt,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.
En~re 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 Jdvt~
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 -homrfootpatimt mtdiution,
oI\'Did driving orother oIctiYitit1lt'quiring mtmal alertnrss or p~1
roordimion umil the tiff(/S of the drug ilt' known.

--+~~

Monitor for Jnd immtdiiltly It'port ~ns and symptolll! of NMS: unstable
blood pteSure,mattd ten1peraru.."diaphor~s,dysplII'i,mul(le rigidit):
loel inrontintnc:t. (NMS is a rare but potenti.tlly fml syndromt that must
~ rt(ognized and uuted immediately.)

Instrua thr patim~ lam ily, or urtgil'l to immtdiolltly It'port all)' changt1
in IevtI of cOnsOouSlltu,eltvattd ttmperalUlt',tJ(tS~Swtiling...mlt'
mu!<le rigidit)o, inc:reiStd rrspirations or !honnrss of brtilh. or
inc:ontinenc:t .

Cominue 10 monitor rootor Jdivit)o,coordination and balanc:e,iloel for EPS

symptolll!,inc:kJding:
~parkillSOllism: tlt'mo~ 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 d~toni is: Itl'It mUl(Ie spasms of bc:t, roOlJlt, neck, or back
lardil'!' dyWMia~'(hol!Oathttoid' lMYtmen~ !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.)

Instrua thr poatienl, lam ily, or urtgiYl'r to immtdiattly It'port EPS

symptOIll! for idditional ueatmtnl

En~re adtquatt nutrition aoel

AuK! intake iltardive dyWlII'1ias art

pretm.(Stvtlt' chorroathl'toid tongut movtmtm milY ~nilic:antly
hinder or plt'l'Mt adt~tt nutrition.)
Ensurt patient saftly if p>tUdoparl:in>on~m 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.)

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Choplfr 17 0"'9' lor J>sy<:ho",.

NURSING PROCESS FOCUS

21 5

PATIENTS RECEIVING ATYPICAL ANTIPSYCHOTIC THERAPY (Continued)

Implementation

Interventions and (Rati o nale s)

Pati e nt a nd Fa mily Edu cati o n

Continue to monitor CBC, elmrolytes,gluc:~ rmal and hepatic: fuMtion,

lipid levtls, and thtrapMio: drug IeYels.(Arypiul antipsythoti( drugs w.:h
as risptridone lila)' uuse <10 iM~'1I' in gluc:OII' ~Isand 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 po!~ble with all of the antipsythotic: drugs.)

InstllKt the patient on the need to return periodiuli)' for lab woll
Teath the patitnt to promp~y report any abdominal pain, panirularl)' in the
upper qJidra nts; (hi ngt1 in 1100 I(oIor; ytllowing of Kie ra or ,kin; da rI:ened
urine; skin rashes; Iow..gradt ~;general mala~ or (hanges in beh~vior
or ~iYity leYrI;or If<illtll orswelling aroond sill5 ofinjury.
TNdJ wdiabetic: patitn~ f~mii)',"ta~iYerto monitorthe bbxllUCJoIr ~
frequentl)' and II'pOII (onsillent elMtion, to w hNkh tall' prafider.

Monitorfor antidlolinergic: t ffffiS iMkJding dry mouth,drowsilll's.,bulTI'd

vision,oonstipation, and urinlry ~te mion. Pmridt S)Tl1ptOlliitic: tll'itment
to e_effem.(Antitholintrgic: symptoms all'(ommon adY!'rll' ~KU of
antipl)'lhotit drugs. Toltrantt 10 anlitholintr<jit tfftcts usualI)' dewlops

[Moorage ,ips of water, ic:t (hips. hard (andy, or (hewing gum to filS!'
mouth drynffi. AYoid akoholb.Jsed mouthwashes, whic:h a~ drying to the
mlXOla and whic:h the !)Mitnt m~y drink.
Ioc:reu e dietary fiber imakeand adeqJate fluid intake.
Report urinary II'tention to t~ health (ire provider prompti)'.

~rtime.)

Monitorfor weight gain, g)'nKomastia (bINS! enlarqtllll'fl~ ttndemtss in

~ther gender),and (hanges in ~ondary 5eX\IiI1 (h~riKteristia (e.g.,
amenonhei,im poterut). (Arypiul antipsytootit drugs may tallll' 'Might
gain <lnd haY!' pituitary tfj"Kts.lmpotente and weight gain may be
signifK.l m~ilOns for oooc:ompliaMe.)

Tmh the patitm, f~mily,or mt<)i'lmo 'Migh tht patitnl daii)' ~nd ~n I
signiliunt 'Might gain (afer 2 kg. 4 to S pounds perw~k) to the htalth
(,1re p~ider.

[Moorage, heakhy ditt ofin{l~illrd fruin and I'e9!'tables, <ldeqJate

prott in intlkt, and ioc:~~~ ~tnise.
AddrelS IHIIiII oooc:ellll in a mutt roffaa lllinntl <l nd ~fl'l as <lppropriate
to the he<lkh (I~ proYider.

--+- InstllKt the patitm to avoid Ikohol and illtgil drug

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:

u~. Reftrthe patitm to

(OOlmunity support groups w.:h <l sAAor NA 1\ appropriatt.

')'IIIptom~)

Monitoruffeioe LIII'. (U,t of caffeilll'"<ontaining ~bstaMtI nv; neqate

the Mfff1I of antipl)'lhotia.)

Teath the p.nitm, famii)', or mf<)i'ltrto awid (affeilll'"<ontaining

btwrages, ioods,and medkations,and to ~Jd food labels when in
doubt of whethtr tht product rontain, (aff~nt.

Monitorfor smoking.(HtiIYy smoking mol)' dKreJS!' metabolism of IO~

antipsythotiu leading tOdet~l~ t fliu(,.)

InstllKt the patilom to ,top or dft:~J S!'srooking.Rtfl'l the patitnt to

.rooking (tIation progr~ l1li, if indic:ated.

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 t~ htalth UII' p~ and any ntttlary monitoring or
prtulllions.UII' brief explalliltion,lklring timts of dtiusionsor
halkKinations. (Using ti~during nursing UII' helps to optim~ and
reinfon:t key reathing a~~s. 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 ~infon:e teiKhing.).

ore

The patitm, lamii)',ormf9mr ,hould be <lblt to .tate the ~'lOn forthe

drug; awoprWte dosr and s(heduling; ~nd what ad'lmr effl'cts to observe
for and when to ~port them.

Tt.J(h the p.ltitn~ fJmily,or (art<:Ji'lerto take the medic:ation as follows:

TJkeemtl)' as ordered and !III' the >a~ manufa(turef. brand tilth time
the pIflIription is fillt<I.(SwitdJing brands may result in differing
phanniKokinttiu and akeration, in therapeutic: tfft<t}.
Ensu~ that all the medic:ation is taken 6iKt~ when ,nd as ordered.U S!'
of a "lendar to trac:k doSl'l maybe helpful.
If t~ 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 txp!'(ted Olll{OOle, haY!' bttn met (see Planning1.
5tf TIIbIt IHforQ htlfihlJl rowlidr rIIet rurlirrl) 0II00m ~

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Until

The /lle<v01" System

17.7 Treating Psychoses

with Dopamine System Stabilizers
Due to side effects caused by conventional and atypical antipsychotic medications, a more recent drug class was devel oped to better meet the needs of patients with psycltoses
(Bailey, 2(03). T he newer class is called dopamine sysrem Sfabili:rers (DSSs) or dopamine partial agonists. Aripiprawle
(Ability) received FDA approval in 2002 for the treatment of
schiwphrenia and schiwaffective disorder. Because ari -

piprazole controls both the positive and negative symptoms

of schizophrenia, it is grouped in Table 17.4 with tlte atypical antipsycltotic drugs.
Aripiprawle-Ireated patients appear to exh.ibit fewer EPS
than patients treated witlt haloperidol (Haldol). Anticholinergic adverse effects are virtually nonexistent. In fact, the incidence of adverse effects generally wmpared to the other
atypical antipsycltotic drugs is very low. Notableside effects,
however, include headache, nausea/vomiting, fever, wnstipation, and anxiety.

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 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 commWlication. withdrawal from other people and the
environment, and a high risk for suicide.

17J Pharmaoologic Jrulnagemenl of psy,hoses is diffkult becauS<' the ad verse 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 -

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 efficacy as other antipsychotic classes, with fewer serious
side effects.

NCLEX-RN" REVIEW QUESTIONS

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.

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.

A 20 -yea r-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.
Nursing implications of th e 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.

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Con,'" th""'."'~in..o_ ,.,.I""", fOrm for ""-<ier ",,~lIowine.

~11

Which of the following data collected by the nurse during

the history and physkal isa oontraindication for a patient
to receive fluphenaZIne (Perm ltil, ProlixlnJ!
I. Di~betes mellitus
2. Age older than 70
3. Bone marrow depressIon
4. Hypertension

OI\l!lsf(W~holol'S

217

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.

CRITICAL THINKING QUESTIONS

1. A 22-year-()ld male patient has been on haloperidol (HaldollA) for 2 weeks for the treatment of schizophrenia.
During a follow -up ~ssessment, the nurse notices that the
patient kee~ rubbing his neck and is wmplaining of neck
spasms. What Is the nurse's Initial actIon? What is the potential cause of the sore neck and what would be the potential 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. Wh~t is a priority of care for thLs patient? What teaching is important
for this patient?
3. A 20-rear-oId, newly diagnosed patient with sdIizophrenia has been on chlorpromazine (Thorazine) and is doing

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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

~------,

MyttlrsiI1g~ Is ywr one $IOj) 'Of CWIIine d1aptff review mater1als aI'ld
tt'SWrCfi. Prepare ,~ 5iJC(;6S5 with additional trux"'-5IyIe ~

QlIeSIlDr\s, ItllenICIM IMI~ and a&II\Jldes., web linIc!!, MlmallOn~

and ~. and tl\{)l"e!

R8QilICef your access code tmm the Iroot 01 I'OJr Imk at

wnM.mynU"lingkit com.

Drugs for the Control of Pain

DRUGS AT A GLANCE

LEARNING OUTCOMES

OPIOIDANALGESICS {IIIltllD
OpioidAgonists f'Jt}fll/

After reading this chapler,

Q morphine (AsrramOlp/l Pf, DUfOmorph,

Ol~rs) 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

Centrally Acting Drugs p!XJt il9
ANTIMIGRAINE DRUGS fi'Xllll3
~m
pogelJ3
Q IUmIlrrlplanOmltrex)
Additional Drugs f'J'II'lJJ

ErgotAlkaloids

Triptans

n 234

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

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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.

methadon~ mainttnan(e pqjl1l7

migrain~ pi1tjI' i 1O

mu ~(!ptor 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)
substance P pYJe no
tension htadarne {!QIJt i 10

{!QIJt ili

OIop1flli Drugs fa< the ConT,oI of Plrn

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!! mechanism that helps us t o .woid potentially o;Wn.a.glng $Ituations

and mcourages us t o seek medical help. Although the neu-

oids have the potential for dependence and can ,ause . ignificant 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 effects.Some techniques used for reducing pain :l.re as follows:

ral and chemiul me<hanlsms'Of PlIln ate f!llrly stralghtfor-

Acupuncture

ward,many psyt:hoIoglc a nd emotional processes ate II pan

Biofeedback therapy

of this

e~enc:e. Anxiety, fatigue, aocl de~$S1oo can increa se the perception of paln;posltlve ,,"ltudes lind support

r.hssage

from yregivers may reduce the perception of pain. For ex-

M~tation or prayer

ample, OI1lt patients tolerate their PlIIn better If they know

the

o f trauma and the medic.I cour5e$ ;,val1able to

Heat or cold packs

Rdaxation therapy

treat their discomfort. There 11ft many options for pain as-

Art or music therapy

Imagery

sessment and the treatment of plIln-lIssoc\aled dlloOl'ders.

Chiropractic manipulation

OUI'Ct

2t 9

Hypnosis

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 numeric 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 therapies. Successful pain management depends not only on an
accurate a.ssessment of how the patient feds but an understanding 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 usuaUy results in feelings of helplessness and hopelessness for
Ihe patient.
Pain may alO be dassified according to illi Ource.lnjury
to rissrl~ 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 sensations). In contrast, I~urop'thitpain results from injury 10 ,Ill:
lIerves and is typically described by patients as bumillg,
mooring, or 1111mb pain. Whereas nociceptive pain responds
qui(~ wdl (u ~UIlV~JI(iulI~1 paiu-II:lid IIr~lIi~a(iUII~, ".,urupathic pain is more difficult to manage.

Therapeutic or physical touch

Transcutaneous electrical nerve stimulation (TENS)
Energy therapies such as Reiki and Qi gong
Patients with intractable cancer pain sometimes require
invasive techniques as rapidly growing tumors press
011 vital tissues and nerves. C hemotherapy :l.nd surgical
treatments for cancer can cause severe pain. Radiation therapy 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 tre~tment of canc,r pain
usuaUy inwlves opioids ~nd o ther adjuvant d rugs. Opioid
drugs used to relieve cancer pain m ay 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 directlv into neuronal tissue is occasionally performed to produce" nerve blocks. In many iJlSunces, nerve blocks
irreversibly stop impulse transmission and have the poten_
tial to provide total pain relief.
mOl?

PHARMFACT5

Pain
Pain il a (ammon l)'fIlptom, rule<ttd by the following statistics:
E",ry)ON' in Amm<.,.ppltllliJllilld'l' 16 million ~pk: ocp<:rio:JI(~ (hroni<
~rthritic:~in.

ilia!! than 11 million ,l(lult! 11m 1!pOrttd low b.Kk pain, while 19 million

, 8.2 Nonpharmacologic Techniques

for Pain Management
Although for most patients,d rugsare qui teeifective at relieving pain, many ha,e significant side effects. For example, at
high doses, aspirin causes gastrointestinal (GI) binding. Opi-

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~ have ~(fI] th~ ~in on' lIIOft(hronit bisis.

It leollt SO million people,~ luflyor parNlty djs,bltd due til paio.
t.Ior! than 509Ii of aclulb nperifO(~ IIU!de pain Hth )'rilt.
UJ 10 4O%0f people with una.- ~rt modtr"t to 5e'ItI'f paio wih

~.-

I;;

22 0

Unlll

Tte """"D." Synem

T REATING THE D IVERSE P ATIENT

Cultural Influences on Pain Expression

and Perception

"t

Howa per;on repcmklO p.lin ,ndchoc= thtl)'ped p.lil manqrrrntmayilt

an.,11y dell'llllirrd. Establishing ,n optII therapMil: ~LlIiOl\ship with tht p.ltitm it of UImOII illport,~ The IIJ~ shoUd repra th!o p.ltimt's uitm and
nerds ClNKemilg tisor htr p.li'l,olI wtli as dioKfof ~ tll'atrnenlAssessing tht patitnt'Sbd~1 ,nd rustoms by istfllilg. ~i1g II'Spf<I, and ,lbNing
tht p.ltirnt to ht~ ,,_ 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 ~it( 'o'Ihtrras othmrTl')' bdieYr tha tht~ ofp.lil symptoms, wch olIopenI)o worrying or
(rylrllj, is, sicJl d IftakllN. Pail mani9fOlfnt ,Iso...,~ (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 ~r to !U,~mativeth!or,~
!lKh as herbs, therroal thtr.lprs, acuPUlI:tu~ rna!SI9t, ,nd mflitatlJn. Prol)'l'l"
pYys ,n importam rolf within AfrKiln Amffiun ,nd Hisp.loK ruitull'S.

Sub5tanoe P

Receplor fo,

Opioids (enkep'>a ~ns) ot

.... rolonin (5-HT) or
nomp;nepIorine
The .... inhibit the
'e"'a .... oI .... bs1anoe P

Receplor fo,

.... bslance P opioids, serolonin,

Descending inhibitory
endogenous opioidI

ot norepioophrine

lse''''orOn.norBpinephme
","u""," (corning
down from the b,ain)

18.3 The Neural Mechanisms of Pain

The process of pain transmission be-gins when pain receptors are stimulated. These receptors, called noc:i(tptors, are free
nerve endings located throughout the body. The nerve impulse 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,neurotransmitters 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 message, although other neurotransmitter candidates have been
proposed. Spinal neurotransmitters are critical because they
control whether pain signals continue to the brain. The activity of substance P may be affected by other neurotransmitters released from neurons located within the CNS. One
group of neurotransmitters called endog~nou 50pi cids 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 employed to manage pain, and they act at different locations:
The opioids act within the CNS, whereas the nonsteroidal

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,"0

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% morphine 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 similar to that of the opiates. For example, morphine is a natural narcotic; meperidine is a synthetic narcotic. ~ioi d is a
general term referring to any of these substances, natural or
synthetic, and is often used interchangeably with the term

opiate.

IlYplflll

Narcotic is a general term often used to describe opioid

drugs that produce analgesia and CNS depression. In common 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 hallucinogens, 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 management, the mu and kapp. ~{!ptors 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 hydrochloride (Talwin), exert mixed opioid agonist-antagonist
effects by activating the kappa receptors but blocking the mu
receptors. Opioid blockers such as na loxone (Narcan) inhibit 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.

agonis1

anla.gonsl

Morphine

Pent azocine

COOO~

8utotphelnol

NalOllone

clln f<1C11J11ors

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

most clinically useful classification method is by effectiveness, which places opiates into categories of strong or moder~ 1e ~c1ivity.

Opiates produce many important effects other than analgesia . They are t'ffectivt' at suppressing the cough reflex and
at slowing the motility of the GI tract for cases of severe diarrhea. M powerful CNS depressants, opioids can cause sedation, 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, sedation, 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 respiratory depression. Because of this tendency, some patients
have not received complete pain relief.

Narcotic opioid agonists bind to opioid receptors and produce 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
~milderM classes of analgesics). More th.an 20 different opioids are available as medications, which may be classified by
similarities in their chemical structures, by their mechanisms of action, or by their effectiveness (Table 18.2). The

22 1

PurQ opioid

Pureopioid

Opioid Agonists

TABLE 18.1
Response

Drug; 10< tho> Comrol of Poln

Responses Produced by Activation of Specific Oplold Receptors

Mu Receptor

Kappa Receptor

Analge5i.J

.'

.'

Dtumfll Gl motiity

.'

.'

Euphori'

.'

~wl~

.'

iIt!pimory dtpmsion

.'

S!da~on

.'

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.'

222

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TABLE 18.2 Opioids for Pain Manag"m"nt

Route and Adult Do5e (max do5ewhere Indicated)

Drug

Adverse Effects

OPIOIO AGONIST'S WITH HIGH EFFECTIVENESS

Ir,'dromorphone ~orjdr, (~laudid)

PO;I--4I111j~~4--i.hpm

~001 tanr~tr l\J'w.ilromoran)

PO; 2~11lllj tid- qid pm

drrlWlinm, dilziflm

mrptridillf hydrochloride l[lrmrrol)

PO; 5O-1SO IIIIj ~~ 3--4 h pm

methadon!, hydrochlorid!, (Dolophillf)

PO;25~ 10 IIIIj r'll'I)']--4 h pm

Anaphy!a<!oid lI'~on.@1Iia( .flts!,

!tI'm reWtOlY depmsjon or allffi
(onl'Jlsions

o morphinr IUlfatr (Miramorph PF,

PO; 10--30 IIIIj r'll'l)' 4 h pm

Prurim,.cmsripio/l._,~olioQ.

~ramorph,OIhet!)

OPIOIO AGONIST'S WITH MODERATE EFFECTIVENESS

I:. -.

PO;IS--i.Olllljrjd

Wo~on, MU5lO, (omliPQIion, dizziflm

Ir,'dllKodonr bitaru~t~ (I/ydIn)

PO; 5 ~ 10 IIIIj r~ 4-6 h pm (max: 15 mg/doIr)

OI)'(odon~ hydrodlloridr (Ox)'Contin); IIXJ(OIbIr

PO; 5 ~ 10 IIIIj rjd pm

HtNtOioxisitY. !tSt!iIa!p!'f dtpmsion.

drru,l1O!Y ooIlaDg (om~

j,

t~thila!~ (Pt-rUKtI-S, Roxictl, OI~tI)

propox)'lWnt hydrochloride (0.I'l00)

PO; 6S IIIIj (HCI form) or 100 IIIIj (na/ll)'lat~ form) "try 4 h

propox)'lWnt nap:l)'1at~ (IMrwn-tl)

PRN (mal:l90 mglday HCI; mal:600 mglday na/ll)'latt )

>

OPIOIO ANTAGONIST'S

"
t

name/m~ hydrodlloridr (RMI)

SuIKwIM'OlJl./lMllY;lHf 1mg/ml (OIKmtralion

Nmopoid dependent:05 mgl70 kg

OpioiddepMdent:O.l

m~kg

Mwltorrdjom"am, diffirulty Jlttting,

OIl.lie~~f!eOOO1~1tIfIliti!g.
~lIdomioolpoin

HtNtOioxidty

IY;H~l rng;may "" ~trd MIY 2~1 min upto 10 mg ij

IIt(tslil)'

PO; 25 mg IoIIowtd by amiller 2S mg in 1h ij mwithdrawal

repon~ (max:&Xi mg/da,)

nal!reJ:OIII' IrfdrodJloride [Trwn. R~Yia)

OPIOIOS WITH MIXED AGONIST~ ANTAGONIST EFFECTS

buprrnorphilM' hydrochloride (~)

1M/1Y;0.31111j f'll'l)' 6 h (mal:O.61111j"fIY 4 h)

butorphinol tartrit~ (Stidd)

1M; 1--4 mg fVff1l--4 h pm (mal: 4 mgldo~)

dtzocillf (Oalgan)

1Y;15~ 10 IIIIj (UlUiIIy 5 mg)"try 2--4 h

nabuplilM' hyrtodllorjdr, (Hubain)

SubrulaIM'OlJl./lMllY; 1 0~20 mg MIY l--i.h pm jmn: 160 mglday)

pmUlOOIIf hyd rodJloride (Talwin)

PO;50-100 IIIIj r~ 3--4 h jmal:600 mg/day)

1M;5 ~10mg(UIUiIIy

-c-cc--c-'--'-""'
--c--

lmMlinm,~ 1ig/rfOO!dtftlru,
euphori~, MU5lO, (IIImmy Iii", lweQ~1Ii
~Dbdomill<1l PQ~ wrnIipotion

RopjrAJOa drw1'iion shod

lOmg)f'II'I)' Hh

MIlY;]O mg MI)' 3--. h(1IIiI:360 mglda,)

lldicr indKite romroon advmt tffMs; lIII1flIiliDg. indKitts strious adm~ tlhru.

\'/hen used according to accepted medical practice, patients 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 instance, patients are allowed to self-medicate with opiate
medication by the pressing of a button. Safe levels of scheduled pain medication are delivered with an infusion pwnp.
In the pha rmaoologic 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-

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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, oombination analgesics are as follows:
Vicodin (hydrocooone, 5 mg; acetaminophen, 500 mg)
Peroocet (oxyoodone hydrodJloride, 7.5 mg;
acetaminophen, 325 mg)

IlIaplfl tl

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 often prescribed as a cough suppressant and is covered in
chapter 3SOO . Opioids used in treating diarrhea are presented in chapter 4100 .

Opioid Antagonists
Opioid antagonists are substances that prevent the effects of
opioid agonists. Many druJ!;S are considered competitive antagonists because they compete with opioids for access to
the opioid receptor.

for Prototype Drug

Drug< fo< the Control 01 p.ln

223

LtFE SPAN 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 th~orie, tht iging pro:fi~ behavioral (ue, subtif ~igns of
discomfort,and Vl'rb<ll and oorrmbal responses to pain <lie <I must..-hen it
<orn~ to tffrttiVl' pain manag~m~m. OIdtf patients may haVl' a tif.:rNsN
pereption of pain or may !imply ignOll' pain is i "natural"colllfqlltllCl' of aging. Staus~ thelt patients ~utntly go uodenntdiuttd, i thorough assessmtlR is I"ftded.As with idults, bel~ in 5elf-1!pOI1 when oIIltlSing forpain in
<hilCren is imporu nt Ot-;~Iopm~ntally appropriat~ pain-rating tools all' mil.lbleaocl should be usN on <I consistent b.ilis. Comfort measull's shOlId also
beul~d

...... t nidministering 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 dizri~~ 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 injury 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.

I Morphine (Astramorph PF, Duramorph, others)

Therapeutic (lass: O~ioid 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 Citdiac mUKif. k is !Md for symptomatic ll'Iief of s~rious acute and (hronic piin
iittf oonnarcolk .na igesn haYf fa iltd, is prN~thetic: medication, to Il'lil'-Ye
shorlnts5 ofbrNth i>SOtatedwith hein failureand pulmoniry~,aocl for
,mile {liest pain mnnemd with MI.
ADMINISTRATION ALERTS
TbeorallOlution miY~ gWen sublinlJlilly.
The oral sokllion (orne! in multiplt stll'llgths; carefulI)' ~ drug ordmand libels ~forudministering.
Morphine (iuses ~r'pheral 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

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ADVERSE EFFECTS
Morphill' may (iUS~ ~phoria (ll'IlifSVl~~ dtpression, and anxiety), halb:ioatio n~ OlUIti, 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 aIl'
taken fur prolongtd pffloih.
Contraindi utions: Morphine may inten ~fy or misk the pain of gallblacldtr disN~, 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 interac~ with WIl'I"iII m.gs. for txamplt, <llOOIIfI1t Uf of
(~dft:~n.llKhaiakOOol,othl'l opoids.lJI'IIfI"aI~lfdali'lfs.in:l

antidtp'fSldllts luch ai tMO itoibilm aIKI triqdic:5 potrruiat@!thtactiooof

opiates.i~ tht rill: of!f'll'lf rrspiralory dft:lMooaodOOih.
LlbTl5l1:

Unknown

Herba ~Food: \'OOimIH!, kiwa kiwa,vaIHiao, and St. .Iolm i wort may potentiatt tw
~ Ii lIHI~nt.

Treatment of O"ferdme: IV .ldministruion of nalolOOI' is the spe<iIic trratment Other IINtments indud~ iawated charroa~ a lixauY!', aocl a (ounteractiog 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
;

224

Unltl

Thl'NetvO'"S)/lt'''''

NURSING PROCESS FOCUS

PATIENTS RECEIVING OPIOIDTHERAPY

Assessment

Potential Nursing Diagnoses

Billellne assessment prior to administration:

Understand the rtuon the drug ~s bttn prescribed in Older to assess 101
the!apeutic ./feds.
Obt,in a complete heakh histor)' including wdiO'<i!cular.lltllroIogic,
~pi titOr)'. htpatic, rt'nal. unce~ 9illibladdtr or urologic di 1M.; IR9nancy;
01 b~st-Iwliog.Nolt JfCent surqeriesor injuries. Obtain ~ drug histor)'
including ililelgies. cuJlent prts<ription and drug~and herNl
prt'pilratiom.B. ller! to po\l;iblt drug intmdions.
AsSffi the leftl 01 pain. Use ob~diYf lCrt'rning tools when possi~ (. g..
HAC( [llCe,limbs,anm. cr)'. conso!abiliryl for infants or Yfryyoung chiklrt n.
WOll9"S,ktr FACES sulr for (hildren, numeriul riling S(11e for fClultsl.
Assns history 01 pain ilnd whit has worktd RK(fSlful~ or not for the
patient in the Plst
Obt,in ~Iine 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.

orc

Acute or Chron ic Pilin (Iflated to inju!),. disult,orlUlgical pnxedurt)

Intllect~e Brtathiog P,tt.rn (rtIat.dto pain ordrug thtrapy,~ially
whrn g~en in the prtSl'nce olothe! CNS deprt'\l;, nts SIKh as anesthetics
postoptlatiYfIy)
Connip~tion (rtlilttd to iltlvtrsedrug efflS)
Dtfi<ient Knowlrdgt (rtlilted to drug therJpy)
Risk forlnj,Jr)',Risk for Falls (rtlated to Idv.~ drug effects)

Assessment throughout administration:

AsSffi i:lr ~irtd lhe!apeulic dfu (e.g., abltnt org~tly diminished
pain, Ibil~y to fJlO'<e mort easily without pain. carr)' out postoperll~e
trfilt~t 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 signs.espe(iil~ blood pressure, PUM, and respirillOlY rllt.
o Assns i:lr ilnd Jtport fCl.erse effts:w:elSivt dizzintlS,drowsintS~
confusion, il9~alion. hypol.mion. IlCh)'Card~. brfClypnu, Ind pinpoint
pupils.
Planning : Patient Go als lind Expected Outcomes
The patient will:
Experience therapeutic tffts dependent 00 the rtilSOl1 the drug is being gi~ (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 Ust,ad~f tffws,Jnd Jtquirtd pttuUlions.
o Dtmonllrillt proper IfII-administr"ion 01 the medic"ion (e.g.,dose, timing, whtn to notify pJOYidtr),
Implementlltion
Inte rventi o ns a nd (Rati o nales)
Ensuring thtrJpeutlc ,ffed s:
Continue I \l;fSSmeOU I sdfICribed earlitr for thtrapeutic effects. Gift drug
IItftnthe Stili 01 lcutt pain and .ncouragt rt'gularfy ICh~m.rled do~ for
the lim 24 to 48 hou~ postopemiYfIy for adequate postoptrltivt pain
rtlief. Provide ~ition,1 comfort IntiIsures to supplem.m drug therapy.
(Com~tent us. of I pain filling scale by ,II providers will help quantify the
1e~1 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 ~n 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

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Patie nt a nd Fa mil y Edu catio n

Teach the paitnt that p,in relitt rather than mtrI'ly (ootrol,is the (!NI of
therapy.
Encoutaljf the patient to tab thedrug (OIIS~trntly during the ac:u!e
postoperatiVl' or proctdUrt period tith.rthan reqUf'Sting on~ when p, in is
~m.

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 LIIt~itionl~
nonphannKoiogi( p,in rtlitf ttdlniquf'!, e.g.,dismaion with ttltvision or
music. bi<krubs,guided imaljfr)'.

NURSING PROCESS FOCUS

PATIENTS RECEIVING OPIOIDTHERAPY (ConrlnuQ<;/)

Impleme ntatio n
Interve nti o ns and (Rati o nales)
Minimizing ad'ftrlf rifKts:
o ContinU!' to monitor vital ~igm,r~ially respirnionland pu~OJ[irnetl)' is
ordrred, poltoperativ~1y and in patienn with arut~ pain.For terminal WKtr
pain, obtain imtrunion I from thr onc:oiogist or hospi~ providtr on any dOl~
I!"Itrictionl. (Respiratol)' tieprrllion is thr mOlt (OOlmon with thr first do!l'
of an opioid and whengr..eo in tilt pre~~ of othrr (NS deprrwnb, e.g.,
postoperatiY!'1y when thr pa~m may still ~ ~lprMnc:ing tfftru of
geo~1<I1 aOI'lthtIia. Cou nt rrspiratiom More giving the opioid drug and
(ontlo(\ the plOl'ider bef~ giving if the I!"Ipirationl are bdow 12 bft'athl
per minute inth~ , duk pa~n~ or 011 ordtft'd in th~ (hild. ContinU!' to alll'li
thr respiratory "t~ tvrl)' 15 to 30 minutes for the first 4 hours. For terminal
tall(('I pain, the drug may not ~ withheld regard~11 oftht I!"Ipiratory 1<I\e,
dtprndtm on thr proYider.)

Patie nt a nd Fa mil y Edu cati o n

[lI(ouraqe thr patil'nt totakr ~ brNrhI in thr poltoperauY!' period.

[lI(ouraqecomilleot pain mrdication usage to ill(ru!l' activity toler-m(t .
[lI(ouraqe thr patient with terminal (anc:('I to lak~ thr doll' IOmisteotly
around th~ dock with pm dole 011 r~irrd.AdviIl' tht family or mt9iv~r
on the PlOllidefl in!!rudionl for adequate pain relief and to (onlan thr
providtr if any pain remain~

Monitorthr blood prffiUft' ind pu~ periodically or if 5)'mptoms warrant

En.ul\' pnil'n! .. /My, monitor ambulnion untiltht .ffttl:< ofdrug oil\'
known.8t panicularly uutious with oIdtr iduks whoare at an inc:re,utd
risk for foil Is. (Opioids may UUII' hypottn!ion as an adl'l'lSr tffr" and
in{lUs~ thr risk offalls or injuril'sJ

o Tea{h the jHltil'nt to 1M from lying or litting to standing llowly to avoid

diuiOl''' or loll .
o InstllKl the ~tient to (all for assislaro:r prior to gttting out of brd or atttmptilg
to wa. abn ~, and to aOi:l diving or other anjyitits rtqtimg mental alrrtOl'sl
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.

(DKlUsro perisuu is,n ~ effect ofopioiddrugs. Si/nifkantly
diminishedor abll'llt ~ 1OU000are ft'portedto the hNlth careproYidef
immediately. Mditional fkJ ids and fibtr may ta!l' (onstipation but ~titiooal
medicatiom suc:h as MiralaxorCoiaa- may ~ retPred.)

o Ttath tht jHltil'nt to inau!l' fluids to II prrday and to iro:lUs~ tht iotakr
of dil'til)' fibl'lSuc:h is fruit, l'l'9'Ia~,and whoII' g~ins.
InstllJ{tth~ patil'm to report!l'l'l'II' {onstipation to thr hNith tart
providtrfor additional idvkt on 1a1iltiY!'l or stool SOftfners.

Monitor for itthing or {00l pia inu of it(hing. (Opioids m~y UUII' histamilll'
relm~ and it{hing or a II'fIS.Jtion of itthing.ln s~vell'taIl'I,antihistamilll'S
may ~ rrquift'd.kml br it{hing as an 9pKtrd sideeffett Y!'I>US signs
and lymptOnu of tllll' alltrqy/.naph~aJis:(hafl(jrs in vi,,1 sig~ tsptdilly
hypoten!ion and tI{hyra rdia, d)'lplII'a, or unica ria J

Tm htht jHltil'nt to rt port it{hing to thr h~akh (are plOllidtr, ~~ially ij

itthing is II'Ym or ioc:reuing.
InstllJ{t thr paritm to immediately report all)' itthing asSO{iatrd with
diuiness or light-hr~ednesl, difIKulty blt'ath iog.. pa Ipiutions, or
significanthiY!'l.

o ASIl'lI for (llanges in IeY!'I of ooll\{iouslll'S~disorimtation or {onfusion,

agitllion, h~~ach~ slugcj ish or pinpoint pupils, or ~izures. (Nturoiogk
{lIangti may indiut~ ovennrdiution, ill(lU5<rd imrmi nial pressure, or
~Y!'rst drug tlfeill.OIdft" .dJlu may ~at risk for (onfusion and falls.)

o ImtllJ{t th~ patient, family,oruregiver to immediately rt'pOrt in{reasing

leth a19)', disoMntation, oonfusion, (lla nges in ~hal'ior or mood, i4jitation
or ' ggrffiioo, IUrrrd Ipffih,itlJia, or ~izures.
o Ensure patient safety if disoritntltion is pr~t

o Asll'ls for urinary ft'teotion,tspfd.11y in thr postoperatiY!' prriod.{Opioids

may ('UII' urinal)' rttt mion as an adY!'rs~ t/fr(l)

o [lI(ourage thr patient to IIIOYI' about in btrI and to start ~arly ambulation
as soon ilallo~d postoperatively.klist to i nolTllill voiding position if
unable to usr bathroom or IOmm~.
InstllJ{t th~ patitm to immediat~1y 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.

If a basal do~ is not givrn (ontinuousty, asll'ls that pain ft'liI'fis adt~te
and oonwt thr providtr if pain remains prt-ll'Ot Ttac:h and t ll(ourage thr
patitot to U!l' s~lf-rnrdKatioo {ontrol button whtntm pain is prestn~
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' ~ms inadequatr for !\'lief.)
Patirnt understanding of drug thfrapy:
o U!I' opponunitits during administration of m~dicationland during
as Il'Imltntlto dis{\/!l the rationale for drug thrrap)', dt~red thmprutic
out{OOle~ moll (ommonlyo~ adve rsttffetn, paramettrs forwht n
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

InstllJ{t th~ patitnt, family,orurrgiver on tht Ull'of thr PCA pump.

[lI(ouraqe uII' on an iI~ften-il-OffiIed b.sis .nd t mphasize the
limitations pft'ltnt to pro\e(t the patient (i.e.,oveniolt is not plslib~).

o Thr parii'm should ~ able to lIatt thr It'alon for thr drug,appropriate
doII'and sdlrduliog,and what ~Y!'I!I' efftru to obItIV!' for and whrn to
rt portthem.

(Conr/nu~d)

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22 6

Until "TheNelvoo. Sy.tem

NURSING PROCESS FOCUS

PATIENTS R'CEIVING OPIOIDTH'RAPY (COO'",."

Implem entilltion

Inter ve nti o ns iII nd (Rillti o nill les)

Pati ent iII nd Fill mily Edu cilltio n

Patimt stlladministration of drug thtrapy:

When administering t~ medic.Jlioo,iostllKl I~ p.atieo~ family, orcart<jM-r
in proptr ~admin islration of drug, e-9., take tht drug aI plI'!criWcl wlltn
I"ftdtd (Utilizing time during nunt-administration olthfse drugs helps 10
reinfoKt teac:hing.)

Teach the patimt to tau the medic.Jlion as follows:

Beforl.' tilt ~ in btcomtS sel'l'fl' , nd for cancer ~in, as coosislenti)' as
possible.
If u~ng a patient-rontrolltd i nalgesii (PO.) plJmp:use thr seIf-dosallt
button wllmtl'l'f ~in begins to ilKruse or btfott activitie SIKh as
~ning at tilt btdsidt.
Takt with food to dt<rmeGI upset.
Btf.luse opioids art sct-.edtRd drugs (rrost oftto (11 thlOlJ!t! IV),~11aw
~ nsale , nd used thednJ1 to the pmon ~timg tht pro!l(~
ooly.AddibJnalpmci~i:lltSmlJ' bt lle(~ ltlrd-u;! ~contintrd

bt)OOCI the Mil pr!I(Iiptioo (t.g.,~i1 rmikart notabYed b (~1

drugs).Do not sm wihany 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' proYiIerb~rd~posaL
EVillluilltion 01 Outcome Criteriill

[valuall' effeuivtotSl of drug therapy II)' confirming that ~tient goa Is and 6 pt(\ed outcome haVl' been roo (SI'!' "Planniog1.
SH TQbIf' tlJ.lflU lill ~dfl!lp rcwhidHIrI'lt rNniIIq~clilm 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
Therapeutic (lass:

may be abused for its psychoactive effects; however, morphine, 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.

Naloxone (Narcan)

A~m for treatmenl of arute opioid OYerdose and m~use

Pharmacologic (lass:

~ioid

receptor antagonist

ACTIONS AND USES

ADVERSE EFFECTS

Mamone is a pIJ~ opioid amagonis~ blocking bolh mu i nd kap~ ttceptoo. k

is UIed for complett or partial ~~I of opioid rifKls in ernerg!'1K)' situations
wlltn ac:UIl' opioid ~f is susptued. Givrn intra~ly, it brgins 10 11"Vl'f\e opioidinitiiied (NS and respiratory dtpreslion within minute .k will im
mediill'ly cause opioid withdrawal symptoms in ~titnts physicallydtptndtm
on opioick. k is , ko used to Ittu postopfl"ative opioid dtpres lion. k is O{usion
ally given as idjunctM-ll1mpy to ~~ hypott nlion causfd II)' septic shock.

Nalox~ itself has minilllil toUcil)'.l\owtovf~ rtW~1 of t~ rifKls of opioick

llliy ttsult in rapid loss of analgeia, i(){rrased blood pttlSU~ Ift'mors, hypl'l.
vemiiation, nauleil and I'Omiting, and drowsiOfls.
(ontr~indiratian.: N. Inxa"" "'nuld Mt br u...d for ""pirat".., rIPprP"inn
caused II)' nonopioid medications.

ADMINISTRAT ION 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- Smin IM;1- 5minsubrutaflE'OUll)'

f'eik:S- 1Smin
Hall~ift: ro-l00min
Duration: 4S min

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INTERACTIONS
I)ug- l)ug: 1lru9 inteOOionl ildlHlf a It'VN of thf aoaIgrsic: .lfem of opioid
agonists iIOd mind..,m.: O:ugs.

Lab T~1S: 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 othersupportiVl' mNSUII'I i l indicat:ed.~l~atm.nts
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.

IlIoplflll

Once injected or inhaled, heroin rapidly crosses the

blood-brain barrier to enter the brain, where it is membolized 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 intense 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 addiction, 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 depression and other acu te 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 activity stimulate the opioid receptor; thus, they cause analgesia. 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 euphoric 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 discontinue 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 continued, they feel ~nomt;ll," and many can continue work or social 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 dependence may occur for manymonths,and even years, following 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

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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 patients to return to productive work and social relationships
without the physical, emotional, and criminal risks of illegal drug use.
A newer treatment option is to administer buprenorphine (Subutex), a mixed opioid agonist-antagonist, by the
.ublinSual route. Buprenorphine i. used ""rty in opioid
abuse therapy to prevent opioid withdrawal symptoms. Another combination agent, Suboxone, contains both
buprenorphine and naloxone, and is used later in the maintenance of opioid addiction.
Health care providers should always be aware that when
administering opioids with mbred agonist-antagonist activity, their pain-blocking properties are reduced when administered 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 opioid 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 nociceptor lew!. When tissue is damaged, chemical mediators
are released locally, including histamine, potassium ion, hydrogen 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, inflammation 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 antiinflammatory activity, as well as analgesic properties.

22 8

Unlll Tte Netvoo, System

TABLE 18. 3
Dru,

Nonopioid Analgesics
RoulI' and Adult Dose (max dose where Indicated)

Adver~

Effects

NSAIDs: ASPIRI"I AND OTHER SALICYLATES

Q iSpirin (_)'IQlkyliI: acid,.\SA)

PO;350-6,O mg f'ltr)' (h (max:. gfllay)

dIoint wlicylatt (Arthropan)

PO:(3)'-870 mg

wll.JLltt (llisakid)

PO;32>-3,OOO mglliay il divided ~("D:4 glda,)

{2.'-' mL)Mry 4 h

Broocbqg!i)m apaph'llanic:!hod hemglytk iDmJia

NSAIDs: IBUPROFEN AND RELATED DRUGS

didof~( (Ciulialn, Vdta~ )

po; 50 mg bid-.:tid (mal:lOO mgldqJ

di'hllilal (Doload)

PO; 1,000 mg followtd by 500 mg bid-tid

t\oOOIi( (lodint)

PO; 100-400 mg tid- qid

frnoprofffi ukilll1 (HaKon)

PO;lOO mg tid-ljd

WIIjfSTioo,IIfW4 ocrulrblood Icl\ QIII1R:li4

IrtixJodIe,dn:Iwfinru,dlzirHIJ5
Aplagi<arrem@ dOlQ:jnd!K!'!! peptiq la'r GI
b!ttdimuQranu!oMosi~ Imnoospa~ lameal
NrnMprriDhrral f!Iema ~naphY!alis MUlt !l'nal
faik!Jpomi~!IQ (onsti'l<nio!l. djarrOO

Ikubiprofffi (........ idj

PO; 50-100 mg tid- qid (miX:lOO mglda/)

bupro/ffi (Advil, Motrin)

PO;400 mg tid-ljd (max: 1,100 mgfday)

i"IdoIntthHio (lndodo)

PO; 2),-50 mg bid-tid (miX:200 mg/da,~ 01 75 mg lustaiOl'd

rdNIot 001' to twotinnlday

ketoprofffi (Aaron.Orudi,)

PO: 11.5-50 mg lid- qid

ketoroLK tJOOltthiinint (Toridol)

PO; 10 mg ~d pm (mal:40 mgfday)

IOI'f~mic:add(PtoIItI)

PO; lIliding dolot: >00 tog; MiioltnalKt obit: 150 mg Mf'/ 6 h pm

IOI'loxic:.Jm(Mobic:)

PO; 75 mglda, (miX: I, mgfda,) 7.S- I'mg daly

nalPurrlttont (Rdaltn)

PO; 1,000 mglda, (mal :2.000 mglda,)

naproen (Naproln Naprrlan)

PO; 500 mg followtd by 100-2,0 I09Iid-qid (mn: 1,250 mglda,)

naproRll !OdiU1l
(AIel'!', Anaprox,OI~)

PO; 250->00 mg bid (miX: 1,000 mg/daynapronn)

OliIpro.zin (Ilaypro)

PO;600-I,lOO mglilay (mn: 1.&X1 mglrII,)

piroxkam (ffldtntI

PO; 10-20 mg _totwo timtsldq (mil: 20 mglday)

ruindH (Cjnorin

PO; 150-lOO mg bid (max:400 mgfday)

tolmttil (ToIKtinJ

PO;400 mg tid (max:2IJ/dolY)

NSAIDs: CDX-2 INHIBITORS

po; l00-lOO mg f'ltry6-8 h or 100 mg o;id

crIroIxib (~I

Abdomiool poin, dlzirHIJ5, lrHdIxilt, Iiml5i~~

h~ry

CaUI"OUI Ulot

ACETAMINOPHEN
Q

ol(mmi~ (TyitnOI) (It\'

... 472b"liIt PKtypf IlrIJl 001 010 )

dut to fDA

rrnew

oraDdryinQIaJhoiCJ

PO;32)'-6>0 mg f'ltry (-6 h

CENTRALLY ACTING DRUGS

l!epalotoxid\y l!epati( (oma I(U!e renal failure

doridilt (Citapr~

PO;O.1 mg bid-lid (max:O.8 mgfday )

I/ypoumktr, dry mcurIr,(omriptllion, ~

trarnadoi (UlUim)

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

AnaphyOOkrtlion

~Qrktr,dizzi~

II'rTiN fQIi~ htiJ/o(hf

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 tfftm;~indic:itts strious idl'!'rst tfltm.

Aspirin, Ibuprofen, and COX-2lnhibitors

Aspirin and ibuprofen are available OTC and are inexpensive.
Ibuprofen and related medications are available in many dif-

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ferent formulations, including those designed for children.

They are safe and produce adverse effects only at high doses.
After tissue damage. prostaglandins are formed with the
help of two enzymes called cyclooxygenase type 1 (COX-')

o..pter 11 ClnJ9' lor tho> Cont.oI of Poln

229

cox '" Cydooxygena....

PGs '" P",staglandina

",

block ph. l.....1

..gg."II "~on

",

pain and
'nlt B mma~on

Selectiw
COX-2 inhibito

o Celecoxib

Non_ lectiw
COX inhibitor.

o Aspirin
olbuprolon

Free"""""
endings
(nociceptor)

'.0

transmission

L_" .,

Tissued"""'98

"'.0

to increase
body te<rpe.llture

,. Figure J8J Mechanisms of pain at the nociceptor level

and cydooX}'genasetype 2 (COX-2).Aspirin and ibuprofenrelated 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 inflammatory prostaglandins, the selective COX-2 inhibitors provide 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 transmission 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

LibraryPirate

sweating and dissipation of heat. It is the primary alternative 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, tramadol is the most widely prescribed. Tramadol has weak opioid activity, although it is not thought to relieve pain by this
mechanism. Its main action is to inhibit reuptake of norepinephrine and serotonin in spinal neurons. Tramadol is well
tolerated, but conunon adverse effects are vertigo, dizzine!>S,
headache, nausea, vomiting,oonstipation, and lethargy.

230

Un'll Thi'Ne<vol"Sy'tem

"', Prototype Drug

Asp,nn (Acetylsal'cyl,cAc,d,ASAJ

Therapeutic (lass: Nonopioid analgesic; nonsteroidal anti-inflammatory

drug (NSAID); antipyretic
ACTIONS AND USES

ADVERSE EFFECTS

Aspirin inhibits pronaglaooin synthtsis inOlv~d in the pro<~ Ie of ~ in and inflammation and protium mild to rnocIfrite reliefof fewor. k has limit~d elfects
on p~iph~al blood 1'ffi~Is.utusing nsooiLllioo aoo lWt'ating.Aspirin ha, signmnt intXoagulant ictiYity,lOO this proptrty is rtSporIsibll' for its ability to
rroUCf tilt risk of monalil)' following Ml.iloo to It'du th~ incidelUe olnrol~.
Aspirin has also ~n foundto rroUCt th~ rilkof (olorfaal utlK~,ahhough the
m~thanism bt' which it alforos this prot~ ~ffKl is unknown.

At high dolts. such as ~ used totrut IfW," inflammatol)' disorden,upirin

rruy utUIf gastric dil(omfon aoo bletding btutUll' of its antiplat~lI't efit(B.
ntm-<Oatt!! tablwand bulftrrd preparaborn aft' available for patient; who
6pfI"itIKt GI side effects.
Contraindications: ~US~ aspirin ilKlt'lle bftding tillll',it should oot bt
9Mn to patitrm rr<eiving anticoagulant thtrapy wm as warlirin, htparin, and
plic.ully<in.

ADMINISTRATION ALERTS

INTERACTIONS
I)ug-l)ug: OOrurreflt l1li' of phfnobartitaI, anOOdl, and 9WKottioim rruy
demai.! illpiin"s etIKt; . .l6pirin may potMWIf thf iKIion of oral h)1lOl#fmic
O:ugs. Ule(/; of tl>AlOi,lI"iroslU d~ such as prrbfnKid, btta bIockm,
SJirordaamt,and IUIa Ikugs may bf Iif<mIfd whfn rombitIN wi hillpiril.

PlateII'! aggregation inhibition (iIlMd by aspirin is inn~si~. Aspirin

should be disCDntinued IlWek prior totlectivt IUrgery.
Aspirin is tJ(rttt!! in the uriIII' aoo alfects uriIII' tfiting for gllKOIe and
oth~ mmbolit~~ wch as vanili)olmandtl"K acid (VMA).
PregOilIKY utegory 0

PHARMACOKINETICS

()jset: 1 h
Peak: 2--4h
Half~ift: 15- 20 min (aspirin);2- ] h Iwlicylateat low dolf); molt' than
20 h (salicyl.att ill high dose)
Duration: 2( h

i TENSION HEADACHES AND MIGRAINES

o

I
1!,
"

Pharmacologic ( lass: Salicylate;cydooxygenase (COX! inhibitor

Headaches are some of the most oommon complaints of patients. Living with headaches can interfere with ADLs, thus
causing grea l di.tr.,. . The pain and inability to focuo and
concentrate result in work-related absences and difficulties
caring for home and family. \'/hen the headaches are persistent, or occur as migTllines, drug therapy is warranted.

lollAin,lIIPIhotrmIf, phion)1oin. sUfonamid.>i. and PfOidlll may iooUlf ~

WhM;r;piin istal;M wfth ikohol,~dtrMliI'6,51trOid1,or orne! HS.IJOs,
thin ~an iKlNII'd nlk for g;r;tric:!KH";.
labIi5Is: ASJino may taIIII' proIongfd jnIhrorIIbil ~IIM' by dfousilg

prothfWlbit production. A\piin may also IIl!riln with PJlVOOCY ttIU,.1Id

dl>t:1UIf fIOOIlfvellof chI:WmroI,potasWn. PBI,T"a"dT~H91 ~ Itwl!
may taIIII' abnormalffit.! II I'll'!" IurKtion !fIB.

IWrbaVFoo:l: Fnerf~, g.B. gill9fl,and ginkgo may i1aml' thf risk of blttding.
T~tment 01Overdose: TrNllllfllt may inWd!- an~of tlltlollowing:artivatfd
Challi~ gastric lavaqr, wau'',or drug theraPl' for Dl'!'rdolt symptorm wch as
diuines~ drowsines,abdominal ~in.or 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 nitrates, 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.

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, causing a steady and lingering pain. Although quite painful, tension headaches are self-limiting and generally considered an
annoyance rather than a medical emergency. Tension
headaches can usually be effectively treated with OTC analgesics 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-

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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' bo~ hm milraillti than girk.

Aft~r puberty. WOOlM have four to tight times more migraines thi n I11I'II.
Ht~iOO migraiOfiipptitr monly among propIt in thtir 21>saoo 3I>s.
PeMOI with i family history oflltadarllt or migraine hal'l'a higher
(halK~ of d~vtloping ~ disordtB.

NURSING PROCESS FOCUS

PATIENTS RECEIVING N5AIDTHERAPY

Assess ment

Poltntlal Nursing Diag noses

Bastline IISHlnWnl prior to ad minillultion:

Undtnund tilt reasonthtdrughasbttnp!e(ribedinordHtom&kK

F'HI IAcuteorOwonid

Wr<lpMK df~.

Rill! for Injury (n:llled to adwne drug effts)

Ob~in, (omplete ~Irh

history inWdillg htp,til:, n:rlll.fespirato/y,

CMdiol<asarll~ 0r neurologic dU. It; pn:gna My. or b!Mt *Ning. OM
drug h~tory mooing .1Hgie, aJm:m pn:Kription ind OTC druqs, hfrbiI
~rltiofts.Qffeine,nicoblt and ak:ollollM.Bealert \(I pos~bII! drug

intefa<tions.
Obtain wstiM vitll signsind Might
hiluatt appop riltf bboroJlOl)' findiJIgI (f.g., CBC,(OigUIation ~nd!,
bleeding tirM, hf~tic III rm.lfunction slm).
AMls tht pilimt's abllitylo r~(fift imd UOOU'lt.lnd etrunion.lndudI'
W bmil)' .ndc.tJf9i~ as needed.
lssHs mrnt thID ' ghout .ckninisIJltion:

AlWSs for dtsir!d thtrapMi( rifeo:ts (f.g.. pa;n is dr<rta~ 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" stools. htm.JtflJlt~ Of mffM-.ground _is, blood in tilt
slooO, abdominal ",in, stftre tinniM,d~~ dro~, lighthudrdnHS,canMion,~, fUphorii ordrprHSion,pilpitatioM,
uch)o:arlii, hypm~ion, inoNled respfltHy ratt and drpth, pulmorllry
congestion, and rdrma.

Planning: P,tle nt GOlls and Ex pected Outcomes

TIlt pitifm wiI:
Exptrirn<e wr.pMic effects (f.g.,~ or abstnt piin, drt~ signs Ind srmplOms ofinillmmltion).
~ ~ fmon,orv:prrimcr rninima~ acImw rlfts.
VrrNl~ 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).

Implementation
Interve ntions and (Rationa les)

Pati ent and Family Educatio n

Ensuring tMupeutic 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 im~. Tht
proI'idrr should be notified ifw polin inm:ase.)
Minimizi t g ad'ftrsr effects.:
Continur to monitorptriodit lab wort:h~tio:: and Ifllll imaion ttru"
(I(,<lnd ~tion stlJdirs Of biffiling time. (Aspirin and wli<ylatfS
affKt plateleuggn:gatiott.lnd should ~ monitored ifUlotd Ioog term or if
tlI(fI~YI: bftding or bruMlg is ooted. ,l,maminopilrrl YII be htp,notoxi<
in Ia"lf doses or if taken w4len htpatio:: d,simdion is pretnlJ

ltadl the ~tirnt 10 SUpp~1MfIt drug thtl1pyw~h nonpNfmiCologic

JIINSU~ {e.g. rNxation trdJ niquf!. diYMiorwy d~1r.Jdions SlJ(h is
telmsionor fIMi<J and to n:port inclf.lsing pain unn:1iMd by drug.

Il\SllII(t the p,nitnl on tht Iftd to Iftum prriodiully for lab work if on the
drugs long tmII.
ltad! thf ",tirnlto abstiin from alcohol whit taking acflilminophtn.Men
who consu~lIKRthan twoakoholic bnmges prf &y Of womrn who
(onsumr JllCRwn Ont akoholic ~ prr &y should mm.uh tbN
.....Ith "' r~ pMidrr btf..~ tHing .<rt.minophm.

---'---

{Conrlnued}

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232

Unlll TheNe<vol"Sy'lem

NURSING PROCESS FOCUS

PATIENTS RECEIVING NSAIDTHERAPY (Contln(Jed)

Implementation

Inte rve nti o ns and (Rationales)

Patient an d Fa mily Education

Monitor for .Jbdominal painJIbc:k or t,flY nook. blood in till' nool.

III'maleme1isor (O~round emnis, diuinffi.light.he,dtdntlli .J nd
h)'potemion, e~ially ~ as!oc:ial~ with tam)'{ardia.(NSIdOs ma~ (.JIU
Glblffilir.g.)

Innllltthepatiemto inrMdiatl'ly rrport any,q.sor ')'IIlptornsofGl blerding.

Teac:h till' patient to t<l~ the drug with food or milk to dKrt'.J~GI irritation
and to ,wallow enteric~OiIt~ tabiru whoit without au~ing or breaking.
Akohol ule should bt 'l'Oidtd or e~minaled.

Monitor for tinnittn,diffiruity lII'aring.light.he~nffi.or diffKUit)' with

~LtlKe.Jnd rt'pOn promptly.(NSIdOs ,nd QIKyLttes may btototOJic and
(.JlU lII'aring loss.)

ImtnKl tllf patitot to immediateiy repon any signs or symptoms of ringing.

humming. buui ng in tm, diffKull)' with balalKf, diuinffi or venigo, or
nalUa.

Monitor uri III' output .J nd rt'na IfulKtion 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.)

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.

Avoid the lUof aspirin or !.llicyLttn in (hildrt'n under 18 unl~! uplicitly

ordI'r~ by tllf hNlth w e provider.(Mpirin has bet-n .JSloc:iat~ with an
ilKrt'altd risk ofReyts ,yndroml' in (hildren un~r 18. p,nirularf)'
moc:iat~ with tllf fkJ virus and wnlla iofto:tiom.)

ImtnKt partnu to lU NSIdOs or ac:mmioopllfn in (hildren un~r 18 for

ft-mor ~in (Ontro~unl~s otht rvme ordmd by IIII' pro'li~[
Ttac:h ~renu to rtad Ltbtlson all OTe medications.Jnd to avoid
formulatiom with alpirin or salicylate on lhe labtl.

Patimt understanding of drug thrrapy:

Use opportunities during administration of medKaiiom ,nd during
I,,, ..mtntl to diKu.. rationalt for drug llIfrll')'. <It~rrd th.rapwlK
ou/(omes. man (ommonly oblm'td ad~ efftm, tHIraml'tl'n forwlll'n
10 call tllf health "r. proYider.and any ~ffiil)' monitoring or
prfuutions.(Using timl' during nming (<In:' h~1lS to optimilr and
n:'infortt keytu(hing area~)
Patimt self-administ ration of drug thtrap1:
WIII'n administering tllf mtdiution, imtnKt tllf patieo~ family. or
(<lA:'giY!'r in PflIP" seif-adminisuation of drug.e.g., with food or mill
(Utilizing tiIMduring nur~-adminismtion of thf'St drugs helps to
n:<inforttleac:hing. Hou~hold me.J!uring deYK~ SIKh as teaspoom d~r
signifKantly in s~ and ,moont and should not bt wd for ptdiatrio: or
l~iddoll'S.)

Tilf ~tien~ family,orcalt9~r should ill' abit to ltate llll' 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 tHItito~ family,or"A:'g~r is abit to discuss appropriale doling ,nd

administration needs,ilKluding the following:
NSAI05 ~ould bt ta~n with food or milk to dfin:'~ 61 upset.
liquid OMsof oJ(~tamioophe n or NSAIDs should bt mtwrrd with the
elKiosfd dosage (UP, dropper, or spoon .If that measuring devKe is 00
Ion~r 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' effKl~III's! of drug lheral')' by (onfirming that j)atitnl goals <lnd ~ed ouuomes hom bet-n m(l (_"Planning").
5tf TM!It III mdn"ll5AJ(f,'fllf~ IilllidflllJl rcwhich rhm fllningaaim\

~pIy.

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 occurring. 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 throughout the CNS, and in the cardiovascular and GI systems. At
least five receptor subtypes have bffn identified. In addition

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to the triptaru;, other drugs acting at serotonergic receptors

include the popular antianxiety drugs fluoxetine (Prozac)
and buspironc (BuSpar)_
Pharmacotherapy of migraine termination generally begins 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 convenient, patients who experience nausea and vomiting during
the migraine rna)' require an alternative dosage form. In tranasal formulations and prefJlled syrin~es of triptans He

~Pl

TABLE 18 4 Ant.migraine Drugs

Rout" and Adult 00sI! (mu do!il' wher" Indlcaled)
On"

II Drugs 100M Conlrol of P~ln

Hl

Adverw Effects

ERGOT ALKALOIOS
dilydlOffgOlalrine m~tt (O.HHS,
MigI,nal)

1M; 1mg;lNy be ~ealed" Hllnttrv,lstoa lotal on tog

(lNl:'ffi9.I'wk)

tlgotnine urtm~ I[rgoSUt) tI~mill

with Glfltine (Caftlgol, ErQtOlhm)

PO; 1-2mg followed by 1-2 mg"try 30 min ullil ~~

Slops (nw::6 mg/d.lyor 10 O\9I'WkJ

Wtat~ fkWltq.l'Omi~f1g.iJIJnormd pth,pnfflM

...-

DtilillD wmd:ii:t:fId~ Irl:1 iOlwniDml

TRIPTANS
aknouiptan (AIM}

PO;615- 1l5 mg; may irptat in 1 hiffll!<e\.Sary (max:

2 tabs/d.ly)

A.!IIieiIiD,tingli"9-wmlll}lffllI1lioo.~

elMripun (Rtlpaxl

PO; ~ mg; may ~,tln 2 hifnmary (max:80 mgld.ly)

~lrUr"!nil!!a!i!!!l !!II ~rd~m!!

froutriptan(flM)

PO; 25 mg; lNy Itpt'.t In 2 h WnKtssar:y 1m,.: 75 mg/day)

nar"riptln (""'~I

PO; 1- 25mg; may ~at il4 hifnmafJ (max: 5mg'd.ly)

rilatriptan lM.iult)

PO; S-10 mg;may ~'t ill hiffIt{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 ~at il2 hifnmafJ (max: 10 mg/d.ly)

verli90

ANTISEIZURE DRUGS
topiram.tt llopimax)

PO; ltart ""'th SO mg/My,lname I1i 50 mgt.ek 10

tff~llmM: 1.600 mg/day)

Yilprok acid (OepiW, Dtpakott)

PO; 250 mg bid (max: 100 mg/day)

/(QIISttI, M)II1irl"9-std1rion,~ wtOtnm

Um~ilG

Ilm!: !!lil!lM~~l2D

BETAADRENERGIC BlOCKERS
.tenolol (Tenormln) lsee pi9I! 347 fOfl~
PtoIotypeDrugbo:w: OC

PO; 2HO mg/d.ly (mal: 100 m9l<11y)

8It!dycQrdQ, hyporrrrs/(JIt (/If, arnl\m drowsIr.m,

'_IIIQ

metoprolol(~~)

PO; 50-100 mg one 10 twolimHld.ly (mil: (SO mgllby)

proprjoolol hyoi"ochloridt( hdtralJ (1ft

~!Je 364 fort~ Protot)'Pl! Drug boJ( 00 )

PO; 00-240 mglday in diYiikd dales; lNy need

1'0-240 mg/dly

BmndmNl!!I.o!iatM: Itrmati!il.mou!omnn
II Kllba!!!: iritation rash ~iIll!!2!:!; QI!!W;!m!

~mololIBlotmn)

PO; 10 mg bid;mllinawf 10 60 mg/dllin IWO divided doses

aNP!W!aJ~ SIM!I!-Jo!rnm

Syndrprm

CALCtUM CHANNEL BLOCKERS

nifedipine (Proc.Jrth) (5 ~!Je lOS for the
PtoIOI)lK Drug boJc 00 )

PO; 10-10 mg tid (max: 180 IIMJ/day)

nlmodplfH! (Nimolop)

PO;6O mg ffflY 4 hfor 21 days;SUrttilerapy within 96 hours

of !Ub,.,(hnoid htrnorrhagt

Wtlipamil hydrodllorid/, IIIop~n) 1Sf!' pagI'

366 for t~ Pl"o\OlYpt Drug box OO )

l)jzzj~ ~rlIlodtmm. fOOd &islriJ9,lwr

sen!irirlry.C#QrrWperip/ltrlll tdem411todoche
ItyportllSl(Jltarnsr/pll~()f)

MI ,w b!oct

~Da!p!0Jki!y

PO; 40-00 IIMJ lid IINI:l'O IIMJ/dayl

TRICYC LIC ANTiOEPRESSANTS

PO; 75- 100 mglday

"'dIl!ion.d'tIwmts~orrhoMQti(ltyportmion.blurred

imipramill (Tofranil) (1ft ~ 187fort~

PtoIol)lK Drug bo:w: 00 )

PO; 75- 100 IIIC)fday Imax:lOO IIMJlday)

mioo.Jghl mydriaJiJ,ttymoufll,urifIQrytrrf~
(omtiporioo

prot~ylill (V"l"Iactil)

PO 15-40 mg/cliry illlul'e to fOIl" dvided dwllfllil:

6Omg/day)

anqiofdtrnol bon rrnrrow !!rrmsion

am~ripty~ne hydioo:tjoridf

[Eiavi)

MI

a!!l!!l~~,)!\ ~

mnoomosn

MISCELLANEOUS ORUGS
meth)"WflJiIIt ($inStIl)

PO; (-8 mg/dily in diYicied dole!

riboliavillYitamin B,)

M' !l.ppImtenl: PO;5- 1Omg/day

FordriidtlKy:PO; 5- 30 mg/da1 in diwided doses

IIQIia illCkatt Ullllmon id'Ime tftoo~~irKicate sffiousadwl'l"\e eflKu.

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/(1IlMQ, 1tIfIiri"9-std1!ion.~ WfDknts.!.

diW>lo,.rion cf iii", (M- ,;,.mi" 8j. poinfu/ u,;",/i""

S!:!~!l!!m2l1!!M!J

234

Until

Th~

/lle<vOI" Sy'tem

availabl~ for patients who are able to self-administer the

medication.
For patients who ar~ unresponsi~ 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 th~ 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, Migranal). Dihydroergotamine is giv~n parenterally and as a
nasal spruy. Because th~ ergot alkaloids interact with adrenergic and dopaminergic receptors as well as serotonergic receptors, they produce multiple actions and side effects.
Many ergot alkaloids ar~ 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 ha~ 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 th~ various drugs, the beta blocker proprn -

..,. Prototype Drug

COMPLEMENTARY AND ALTERNATIVE THERAPIES

Evening Primrose Oil for Pain

~ing primr= (Primui<l himJ) is a plant natM to North Ameriu. The oil
extracted from tilt I~ of tilt pLtm (Olluins high amounts of g.Jmlllil
linoltnic acid, <In ~eMial fatty acid thai is ~il"!d II)' the body for normal
growth ,nd ~pllll'lli.
EYeIling primrosr oil hi. twn used for a Ltf9r numbtr ofdivern mnditions.
Ihr mongen KientifK ~vidrll(~ is for tl"!ating Zt1llil,1l rondition (hariCIerized 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 prrmenlIrual')'Ildrolll!', I"!learch hi. not shown lhe IItrb to ~ efffi:tivf for this indication Ulog, 2(01). Other daimt<l uItS indude diabttir: lII'uropathy,(holtllerol
Ifduction, mukiplt Illtrosis, oI nd plfVfntion of strokt; ~f~ I(itntm.: !"Iiden(e is not ol~uate towppon thflfindiuUons.Evening primroleoil is YerY
I.l~. Thetr is some mll(~m that it IIIiIY Iowtr the~izuft' th~hold 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 insomnia in addition to their migraines .

Sumatnptan (Imltrex)

Therapeutit Class: Antimigraineagent

PharmacologicClass: TriptaniS-HT (motonin) reptor agentivasoroffilrictor of intracranial

arteries

ACTIONS AND USES

ADVERSE EFFECTS

Sumuriptan beIon~ to a rtLttively III'Wer group of antimigraine drugs koown

.H tilt triptan~ 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 m20
minutel;the dole may ~ rtpeated60minutf"loliterthe filii injKtion,to oi maximum of tWO dose ptr day.lf taken o!lllly, IUllliluiptan .hould ~ administe,ro
.H lOOn 01\ poI~bIe aitfr the migraine is 'UIpf(1ed or hal ~n.

Solii!' diuin~, drow.ines!, or 01 warming IfIlsation may ~ tlptl"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 ptori~ hyprnenlion,or dia~tf"l.

ADMINtSTRATlON ALERTS

Sullliluiptan m,y prooiKt cardiac isclltmil in IUlaptiblt ptrwnl with no

prI"YioUI (ardia( ~nts. Heakh cal"! pIIJidrl5 mol, opt moIdminint'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
tquipmeMoK(f"lliblt.
Sullliluiptan \electively ,ro!Kf"I wotid oIIterioil blood flow. Monitor
dian9l" in It-Ifl of (OOI(~l and o~ 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

Half~ife: 2 h
Duration: l ..... 48h

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INTERACTIONS
I)ug-l)ug: Sum.!tripUn ReroKll wth ~ d~FII" fIi~,jn ilKlNlfd
ffl'fU may (]I" WMo t.en with moooamiM' OIida1t inhibitoo IMAOfs) and
~.".serctooin rftlpli~inhibitol5ISSR1.1.Furthfr ~ 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.. tri~
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.

c..,1II'1'

NURSING PROCESS FOCUS

Oru!Jslorthec.ontfolofP~ln

1]5

PATIENTS RECEIVING TRIPTAN THERAPY

Pote nti~1

A.uenmerrt
lIawoIin~ ISS6I111~nt prior to administr. ion:
UndeI5t1nd 1bt ~ason tilt cWg ~ ~n pm<ribtd in ordeIlO auns fof
therapMK ~fIects.
Obtain i {ompkot~ health histOf} inWcling unliovHaA.r~nrurologK,
htpllic..or ~ d~~;plf1ll'oall(';or b~~t-fwling.OIK.tin it drug
history iIIdud ing illtrgit1. ontnt presaiption and ore drugs, h~rbal
IRP'Iratioo!, {i~n~,nicotJn.t.,and ilmbollM.BeaRrt 10 poI~bIe drug

NI,I15in9 Diagno5u

Anat Pain
intfftil't fiNllh Mlinltl'oaOO! (rtlattd 10 mbilit, 10 mI"'9t ~tMtiH of
eliiii' liYingwi1hdvonK~inl
~tiI'tCopMlg{rtLiltdllldwolrK~in)
DefKitntK~(drugthtr.py)

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 aWblAlSeSs tilt hislOfy of the polin and wlwt 1115 worbd wcctSiful1y 01 not for
the patifnt in the ~st
MlualtappropNte Liboralory findings {t-g., (BC,hepitic or renal bJniotr
stooitsl.
Mesthep;ltiffit'sabllilyto~~iftindundtrmndinstruction.lndude
the family ancIulf1liYffS as netded.
lsHll m~ntlhl"O,ghou1l"'nistlition:

~wssfor~theIiPftllit:d'k<n(f.g.,headachep;lin is~~

or

absent).
ConlinUl' monitoringltftl of{OOKiou\nm.nd nrurobj:: symptoms (r..g.,
num~lor~ing).

AlSeSs vi~ sigM, especiilJ, blood p _ and pulsf periodically.

ContinUl' pmocIit: monitritg ofhe~1ir: MId rual furKtion studits.
Aswslstms i nd oopill9 p.itltms for po!5ib1e symptom <OOeIation (t.g.,
ecistill9 or pnttiYtd st~ ibilion,copi"!l mKhanismsOf rttnfdie).
Mel for and promptly rtport adYtlV~:{hest pain ortightnKl,
p.llpitiltiom, u<lryard~, lIypenertsion, diuintsl, lightheadednesl,

{onMion,ind flUmbnKI or tinglill9 in ntmnitits.

Plillnning: Pilltlent GoiIII5 iIInd Expected Ou t(o mu

TIlt ~titnt wit:

Experitn<t iOOipMK tlfts dfprndtnl on the rtilson tlrt drug is ~ 9i'<~n (e.g~abstnt or ~ heada< piin,prtwfllirm of ~Ulf hueli{he p.lin
flam migf,. "uti:).
Be frtt from,OI"tlpt'Mnr:t miniml~ ilMrwtfl"ts.
Ytrbalizt,n urrdtrsla~ 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.
Implementilltion
Inte rvention. Ind (Aa t ionl l.. )

Ensuring lhe... ~ulic ffl'eds:

ContinUl' ~ts il6&ribN ta rl~r 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 t!r~ IMdiution
brim ~ bKo~ W'fm' for bHttrrontrol.PMr ftf btgiM within
first ItftfiI minutes afte- administratioll.)

Pa ti. nt and Family Education

....,.

lNdr the p.ltimnhat Plin rtWf; latht r than mmly {O~ is thegoal of
EnlDUrlgt tht patitm to tlktthe drug bdIre a hfarbc:he bfc~ ~
and ronsisturtly ~ ordroml.
Explain th~ 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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23 6

Unltl

TheNe!\rouSSyslflTl

NURSING PROCESS FOCUS

PATIENTS RECEIVING TRIPTANTHERAPY (COIlltlUfi1)

Implementation

Interve ntio n $ and (Rati onale5)

_ _ _+C
" C'C"C"::.
t and family Eduuotion

Mini..izill9ldftnt fft'ts:
Moni!l:lr the blood pl!SSIIIt IIld fIU~ ~IJy ~u,. in palifftUIt
ris.\: for UtWgrmtd c.tdiomOJwltlisu~.urdio'lua.Ursta1us should be
monito~ ~nll,folowing 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 ~ltSI risl)

OIu~!Of ch.1IgtI in ~,Chalacttt; Ofduration ofhudichf. (SudcIHJ

~ of"th\llldefd.lp qwlity

c.n si9~1 wbioollOid

hrmo~Hudache th.1 difftl in ~Iity and.1t ac(flll\plnied by such

IiIjnl u fnft, ruh,or Iliff ntd: II\a)' hmId mfflingilil.)

Continue to mo!l~O/ ~rOIOgiC st.tus ptriodkally. (~s ollight

hNdtdnm m., be !!111ft! to htadachf,MllcMBedlll!l tffffi,O/ m..,

lnstnxt tht pI~m 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, lighlhNMdntl5,1II bUrmI vision..

IiIjn.l~iKhI-miaJ

Monitor Wt.I)" inllkf offoods thaI (OOliin Iyramillf, u~t, akohol, or

othtrfood~{XwMloochol ~ ml'~ I narutt
migl~int. (rmbting symptoms with Iood Of beYtli~~lil11 in Ifirving
tht(aUlfoflhtht~J

Patiftll ulcltrttanding of eng thmpr.

list opportUrtitie doril\9.dminillrauOll of medkltiofts.nd during
UlffimtOU 10 diIlun t!r rItionait for drug mt/apy, dts~ thtraptlltic
1II,1\(0mes, lII0I1commonlyobservtd ~ rlin,.,.rilmtteB forwhen
to call the IItailfl (alf plO'l'iclef..nd an, nemsary monitoring or
PfNautions. {Iking limt dumg nurling CilR' htlps to optirrm and rftnfot
key teaching ~iII.l
Patiftlt lelf~dministr.ion of drug therlflJ:
When ,l!lmontring t~ mtdK.ition,instnICt the pltinJl.bmi~. 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

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 fooch, bet~ 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 obst~ 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 t~ ItChniJlf.(Pain or
I!dness lllhe in;t<tion S~t is CDmmOll but II!.UIlly disaPIIUII within in
how alttr 1M clost iI takm)
lnstnxt the pltitm that an ' ppIOfIna!r inuan.asal dost ii_splay iota
ONE nostril unltsloth_ist ordt~ by the hNlth c.1t p!Oidtr.

Evaluation of Outcome Criteria

&aIIr.tt t ffKtitnelof drug thmpy iI1 <onfirm ill9 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 clea r, refer to the numbered section within the chapter for review.
18.1

Pain is assessed and classified as acute or chronic, nociceptor or neuropathic .

18.2

Nonpharmacologic techniques such as massage,

biofeedback therapy, and meditation are often important 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 interaction 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 motilityofthe Gl tract.

18.6

Opioidantagonists maybe used to reverse the symptoms

of opioid toxicity or owrdose. such as sedation and res
piratory depression .

18.7 Opioid withdrawal can result in severe symptoms, and

dependence is often treated with methadone maintenance and newer drug combination therapies.
18.3

Nonopioid analgesics, such as aspirin, acetantinophen,

and the selective COX-2 inhibitors, are effective in treating mild to moderate pain and fever.

18.9

Headaches are classified as tension headaches or migraines. Migraines maybe preceded by auras, and symptoms include nausea and 'omiting.

18.1 0 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.

NCLEX-RN" REVIEW QUESTIONS

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.

The nurse recognizes that opioid analgesics exert their action 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.

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.

The nurse administers morphine sulfate 4 mg IV to a patient for trrutment of severe pain. Which of the following

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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 analgesics 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 relief 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.

CRITICAL THINKING QUESTIONS

1. A patient is on a palielll~'Qnlrolled analgesia (PCA)
pump to manage postoperative pain related to recen t 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 resp imtory rate of 8 breaths per
minute and oxygen sa turalion of 84%. What is the
nurse's initial response? What are the nurse's subse<Juent

3. A 58-rear-old palient with a history of a recent MI is on

beta-blocker and antkoagubnt therapy. The patie nt also
has a history of arthritis. and during a renl f1~re-\lp began laking aspirin because it helped control pain in tlk>
past. What teaching or recommendation would the nurse
have for th is patient!
Su Appendix D jor llnswtn" lind rationales for all activirieJ.

actions?
1. A 64-year-old patient has had a long_sta nding 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?

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Drugs for Local

and General Anesthesia

LEARNING OUTCOMES

DRUGS AT A GLANCE
lOCAL ANESTHETICS
Amides (IIt141

Aftef reading this ChClpltr, the studtn! should ~ obk to:

~UO

lidocaine (Kylocolne) pog04J

Esters (llJ}tW
Q

GENERAL ANESTHETICS ".146

Inhalation Agents p!IIJtl#

&lses

Itlkltlll!Uqulds (JfJIJt147
ho/orhan. (F/uoIIIDMJ , . ut

Intra'ltnousAgtnts pogtUJ
lIarbltumtt and BorbHurot1ct ~u
plllltlSI
Q rh~nrol{PmfothaQ pogtlSl
0p/0ltJ$ ,..151
9fnzodlcwptlfS ptIIJtXI

Opioids

ptIIJt1S1

ptJ9t lS1

Hewomu!(UlarBlodling Agents

administering local anesthetics.

2. Describe differe nces betwee n the two maJ or chemi cal classes of loclli
anesthetics.
3, Explain why epinephrin e and sodium hydroxide are $Ometlmes
Included in local anesthetic cartridges.

!ifl41

nllrousO/(~ {JIig/141

ADJUHClSTOANESTHESIA

1. Com part and contrast th e five major cllnlclIl techniqu es for

ptJIJ/15]

wcdnyk/lOJlM (MIInf) /111ft 15J

4. Identify the action s of generaillnesthetics on the eNS.

S. Com pare lind contru t the two prlrTUlry ways that general anesthe sia
may be Induced
6. Identify-the four stages of generalanesthesiCl.
7. Foreach of the drug cla5~ listed In Drugs at a Glance, know
represenultlve drug examplnand explain their mechanisms of action.
primM)' actions, and Important lId~rse 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.

KEY TERMS
amide (II19t241
balanced anethelia

(JI19t 246

nil!!' fJIJIIt)j]

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gfnerll anrsthfsia {X1gt 2W

local anuthfsil paqtl!
lIt'uro!f,ptanalgftil poqt 148

lIt'uromuS(ulu bloxkfr poqt 25J

lurgici lantSthtsia poqt 246

24 0

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Th~

/lle<vOI" System

nesthesia Is a medical procedure performed by admin-

Istering d rugs that cause a loss of sensation. l o cil l

II nesth es ili occurs when sensation is lost to a limited partof
the body without loss of consciousness. Generlll anes thesia
requires different dasses of drugs that cause loss of sensation to the entire body, usually resulting in a loss of consciousness.This chapter examines drugs used for both local

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 example, 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 anesthesia are summarized in Table \9.1.

and general ane sthesia.

Local Anesthetics

LOCAL ANESTHESIA

Local anesthetics are drugs that produce a rapid loss of sensation to a limited part of the body. They produce their therapeutic effect by blocking the entry of sodiwn ions into
neurons.

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
dent~l 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.

(h)

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 illustrated 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

Infi~ra/"",

(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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Chop! 19

Drug, /0, lOGlI .nd ""...... 1Ar>e<sthes.la

241

TABLE 19 1 Methods of local Anesthetic Administration

Rout{'

Formulatlon/M{'1:hod

C){'5C~ptlon

[pid .... ll nnlhffio

Injtaion ;"toth. opiduRil lpKo oflll< spinll conI

Mon <ommonly.>O<I in ob!lrtrio dui"lliobor Ind doliv<1"/

hfikration (fitid bIodo:) 'III'WIts~

Dna injl'Clion inlo t iuUI' immtdiato to lilt IUlgiYl m

.

[hJg dffulti inlO tisWl' toblodo:. 5pf(ific: groupollll'l'~ i1 a

IlllaU alN ~ 10 tilt IUrgiYl !it.

Dna in;ction into t ilsUl' Ih.t may btdil1.nllrom tilt

Gpft"aliDn !it.

[hJg iflKtS n~n bund~ Irmllg lilt SI.I1JitaI na;usrd 10 bIodo:

ItMation i1 i limb Of lalgl' 011., of iht fa<o

Injtaion illo tho (mbral5pinal ftuid (C5f)

[hJg .fIKt'i large, lt9orulall'l lIKhas iht tow.r .bOJmm and

'"

~Iird 10 mlKom mmlbralll'l induli"ll iht ~ ~p~ g!lll~

llalil mtmbralll'S, and Itroal; 'm'! saito Unlt!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 epinephrine to lidocaine (Xylocaine), for example, increases the duration 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.
~------~--~------,

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.

condJction ia
tllmporllnly 8U9pended
preventing pain ,.;gnat
Irom "",c:hing the e NS.

N_

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Unlll TheNe<vol"Sy'tem

24 2

PHARMFACTS

C OMPLEMEtHARY AND A LTERNATIVE T HERAPIES

Anesthesia and Anesthetics

Mo~tlun

20 million peoplt rMY!' grnt rJIJlIHthetia ta{h YNr in tilt

UnittdSw6.
About lulf of all gtneral anenhetiaa~ administmd by a nu~
anrsthetist.
Tlltfim mtdkal JPplUiions of Jnrsthetia were in 1842, using ew~
amI. in lS46, using nitrouHIlid!.
Herbal prodKu may intetact with anesthetia;St.lohn's WOIllllily
inlen~fy 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 solutions to increase the effectiveness of the anesthetic in regions that have extensive local infection or abscesses.
Bacteria tend to acidify an infected site, and local anesthetics are less effective in this type of environment. Adding alkaline substances such as sodium hydroxide or sodium
bicarbonate neutralizes the region and createsa more favorable 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.

CloVlls for Dental Pain

0111' naturalll'medy for tooth pain is oil of doYl'l, a n.nurallUbstan~ w~
use date! bac:k thousands of )'l'ars in Chi~ mtdkilil'. umatd from tht
{iOYe plant ~mia, tllgtnol is tht actM {heniiGJl tlut prodlKrs a numbing
elfKl. k worb rspecia I~ well 10 rdental wits (Ia'Iitiet).T1It htro is.t pplitd by
soaking a pit{f of{onon and pading it aroond tlltgums dost lOW alfttd
tooth. D~mim lOIIl~imes raommrnd it for temporary rtlit!" of a toothM:he
(AlqaIffl,Alyah)\l,& Arodt,rslOn, 20(6). CloY!' orl Ius oI n anl~K tift" tlut
hiS bttn rtpOntd to kill miuoorganilml.
OtherUlet of {iOYe oiltlut lac:k reliablt !{itmific rvidffic:f indudt treatment
of pft'malU~ejol{ulation,1ow libido,and it-YI'r redlKtion.Ckrn oil is ~ry safe,
with r.Jsh Jnd GI upset being the most {ommon adve~ ~ts. Clove oil may
inaNst tilt rilk for blttding and lhoold be lMd {autioUliy in ~ienll taking
antiroagulantl.

Cocaine was the ftrst local anesthetic widely used for medical 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 potential 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 significant decline in the use of the drug. Ont' ester, benzocaine
(Solarcaine, others) is used as a topical OTC agent for treating a large number of painful conditions, includingsunbum,
insect bites, hemorrhoids, sore throat, and minor wounds.

TABLE 19.21 Selected l ocal Anesthetics

. '"

Chemical Classification

Orug

. ooil. (!.optodont)
bupiv.uilll' (Ma"YiIll')
dilHKiilll' (NuptrGJiIlf, NlpfItIi nal)
Q

lidoCiIiIt (Xylocaile)

priocaile (CitantSlj
ropWac.Jilll' (Naropio)

f-[slfrs

lItnzooilll' (AmtriGlilt,Soiauailll', othtn)

d"joroprocailll' (Ht5IYilll' I

Gent'ral Adverst' Effects

Difficulll bn>~lhi!!!l Of ~.llowilg,!!:!Il!"l!!!l !!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

proGIilll' (tfu.oocaill
ttu~ain~ (Ponioailll')

MiKtilintOUs ilgftlil

11~1ia inli<att

dydonilll' (Dydoritl
pramoxilll' (Tronotllalll'l

rommon .dl'fllfttlll;~ iId<at.. striousadYl'I\I' ttItm.

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Bl!ming. stinging. 5l'f\l~rim <II oppiratioo liIl'

Rt!i!:at!l!lomrd!Harrm

CNptor l'

"eo

Drug. /0. lOGlI 000 """",.1 Ar>e-;thel.la

243

Example

o
,,~

R- C - O -A

"

Procaine

o
Amidoo

"

R- NH- C - R

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

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 drsrhythmias, are possible. Patients with a history of
cardiovascular disease are often given forms of local anesthetics that contain no epinephrine to reduce the potential

I Lidocaine (Xylocame)

Therapeutic (lass: Anesthetic (locaVtopical); antidysrhythmic (dass IB)

Pha rmacologic (lass: Sodium channel blocker; amide

ACTlONS AND USES

ADVERSE EFFECTS

Lidouifll',the monfrftjutmly UIfd injmJblt local ilfII'SthetK, KIs by blocking

~ronil 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 5Ubcuwwou~y to treilt dysrftythmias, as
disc:uslfd in (haptef B OO . Atopitill Ionn isallo milll~.

Whrn 'idouinr is usrd for ineitlirsi.l, me effecu ilre uncommon. M ti r\Y

symptom of lOJitity is (NS ",iomen~ leading to irritability and (onfusion.
rious ildvmt rffKls ilKkidt convulsions, respiratory dtp~sion, and urdi.lc i rrest. Iknil the effect of the antlthtlit diminishes, patitnts mily injure
themstlvrs by biting or dltWillC) illNS of the mooth that ha~ no ~nsalion fo~
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 ~
dy5rhythmi.l~ silltll brildyutdia,ind It'~redtg~ of hean block.

ADMINISTRATION ALERTS

Solutions of lidouilM! (onlilinillC) presmatiYft or tpintphrifll' are intrnded for 1001 afll'Stlrsi.l only, ind mun neY!'r ~giYrn pamltefaUy for
dysrftythmias.
Do nOi apply topitalliiouinr to IIIrgr ~in areas or to brokrn or abraded
ilreas, bKaIM !oignifiunt absorption IIIiI)' cur. Do nOi allow it to (ome in
ClIn!Xl with the r)'H.
For spinal or epidural bIoc:k, u~ only preparations !pr(ifK.l II)' 1II~1rd for IV

=.

PregninquttgoryB

PHARMACOKINETICS

Q,scot: 4Hl0 ~ 1V;5--1 Smin lM;l- Smin topical

fINk: Lmtllan 30 n in
Halflife: l.S-1 h
DJration: 10-20 millV;60-90 min 1M; lO~ min topical; more than
100 min injent<l for Inesthrsi.l

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INTERACTIONS

--

BarIil..-atPI may dKlNIt' the oKlility oIIOooR.11KINIfd iIIKI!i 01

Iidouilll' (II" ff ~ (onruuntly with dmMidiw, quiidi~, ani btta bIodH".11
Iidoui",,~ IMd on a rfgvlar basis,its ff1K1iwornma,dmin~h wIwn IMdwilh
Drug-~rug:

I..ibTi5ls: IncJN\fd(PK

Herba~Food: 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 lip~ tlirst pain, irrrlJ.llar heart ~iI~ niIMi, yomitiog, tllmon,
and sHureac:liYity.

Rl'1'e" Ie M)Nu1lJnqKJ/ All" Q NiJrlirll} Pn:ms fooJ5 Jjlt(1f{ Ie rills d~

I,if

244

Unlll "TheNelvoo.Sy.tem

NURSING PROCESS FOCUS

PATIENTS .ECEIVING LOCAL ANESTHESIA

Assessment

Potenti al Nursing Dia gnoses

BiStline assess mfnt pri or to administrat ion:

Understand the ~J50n the drug his been prfnriilfd in order to as~ for
therapMic: fiff,m.
Obtain a (Ompletf health hillory indudi ng (ardmascular, hepatic, rfnal,
~pir.tof)\ or neurologi< disnIC; prtgn.ocy; or 1!rt<I-fre:iinlj. Obtain
drug hillory induding allergits,(urrent p~ription and OK drug~ ht~1
preparations,,,fffinr, nKotinr,Jnd akohollM.1f tilt patiem rtplru an
,lIfrg~ to ' caint' drugs, no tt the spfCifK ~oKtions the patient tlPfriflKf<!.
St ."" to p<mib" drug int...aion.
llJ"in ~Iinr ritllsigns and weight.
AsSffi for a~" of broken skin,abmions, burm,oroth.. wounds in a~, to
bf In'iltfd with 1oc,1 inrsthetic:.
Enklatt laboratory findill9l .ppropri.tf to the pro(fru~ 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.

Pain (Il'lated to undtrtying disem pnxm or condition,mllndary to IUrgtry

ordtntalpl\J(tdu~)

DrrKient Knowledge (drug tlM<r' py)

Risk for Aspiration

RisldorlnlKtion
Risldorlnjury

Assfss~nt

through out administration:

AsSffi for dtsir! th ..apeutK rffB (r.g.,1oo1 or ~gional .~a numbllfls).
Allffi YiI.1 ~ns, cspc<it liy blood prtSsurt and pullC if rtgion.1 blod: is
UIed.Report a BP less thin 90160, puiSI' abo~ l00,or per ()aramrtf rsas
orderf<! by the hNlth,,~ plO'/ider.
AsSffi thr local or rf<jional u ra blocked.Exp:t blan(hing in a Iooliz! .~a
if the 1oc,1 inrsihetK (omaiotd rpinrphrint.lf, lI'9ional alN was blocktd,
periodically asSfiS thr ability to IIIO~ limbs dis,,1 to tIM< block.
AsSffi thf Itftl of (00 sciouSlH'ls if a largt Il'giona IbkKi Win giYl'O. Report
'0)' ilKlNsing drowsinfll, diuinrss,lighi -headednffi, confusion, or
,gitation immrdiattly.
AsSffi for and promptly ~port ad~ fffrds:brad){<lrdit or tac:h){<lKiia,
hypottnsion or hypellrnsion"nd dyspnt,.
Planning: Pat ient Goa ls a nd Expecte d Outco mes

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.
~rnonmall' pIOPfr stlf-administration oftht mrdK.tion Ir.g. dosr, timiog, when to notify plO'/ider).
Imple me ntat io n
Interve nti o ns a nd (Rati o na les)

Pat ie nt and Fa mil y Educati o n

En. uring thtrl~utic 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 induded in the solution .If a largt Il'gionJ I
.~a is bIoc:kfd, r.g., rpidur~l the ~tient may rtgain samr motor ability
btfo~ <l'Os,tion Il'tums ,nd tIM< Il'tum of IIIOtOf "ti~it~ signals ritr:lNliog
imlsof ints~.An ability 10 pel(ri";~ prnlU~-1)'pe srotaliorll m.y
~m,in 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 '""'.)

Trach the ()a tient that tIlr UN m.y br numb for se~r.tl 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 ~nrsthesia (r.g.,.tnsation of"luggio( during suturing) but that no
()ain should ~ ~h.HaI'l' tIM< patient ,ifn tIlr he.kh ca~ proI'idu if IIIO~
than a .Iight pIl'SSUIl' <l'Osation or.ny ()ain is notic:td ruriog ,nmhesia.
Trach the ()atiem that it is normal to ~in 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.

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Chop'.. t'

NURSING PROCESS FOCUS

Drug, /0, lout.odGe ..... t Ane<the<.I.o

245

PATIENTS RECEIVING lOCAL ANESTHESIA (Continued)

Impl e me ntatio n

Inte rventi o ns and (Rati o nale s)

Minimizing ad'ftrse effed:s:
(o,ninue 10 monilO' vit.lsign<,npeci.J11-, blood IR,sull'.nd pul<e 10,
paDenU gmn ,~ion.lanesthe!i.J.lmmtdiitel-, 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 ordlo(ll'~ in
,tspi,atol)' 'ilt. (Advelle tifls ofOOlantltlll'w all' ,a't. Rtgional
bIoc:ks may caUSt hypotension with till' possibility of
uchyurdii.
B,adyurdii, hypotension, ~Il'.std 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:.)

Patie nt a nd Fa mily Edu ca ti o n

Instruct the patient to Il'port any in(fl'lIing nalllN, drowsiness. dizzintll,
light-headtdlltlS,confusion, or .ro:ie1)o immediitf~.

,.fieJ

uution the patient 001 10 tat,dww gum, or drink until the IIIOU1h
~nsation 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' effKti~ 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 um~ swallowing !m.Jtion and gag ,tilt. Il'lums.)

Instruct the patient 10 Il'frain from eating or drinking for 1 houror moll'
postanesthesii or umilstlllition has oom~ Il'lUmed 10 tilt oral cayity
orthroat

[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
m~mtfltand inaease the risk allall< or inju,iesJ

Instruct the patient to call 10, misun<r prio, 10 getting out of bed or
anempting 10 walk .Ione post- epwr. Iblock,. 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.

ASlesalNS of ab,asion,bums, or open wounds ij a 001 anesthetic was

applied to the all'a.(Luge open 0' dtnudtd ill'lSIlll)' inaN!~ t~amounl
of drug absorption into the gen~,al ci,ulation.lkr !terile tKhnique to
appl-, drug to open all'a!.)
!!rId ~lIlabek (artfUlly be,~ using pall'ntml IOlutions. (Solution<
(ornaining ~pinephrilll' mUll fIWfr be ustd IV orlo, oot.nesthesii in
all'lI of de<ll'astd ciltulat ion !~g., fingertips, tOl'S, rulobrs Jdu~ to
\\IIOCOnlllKtNr t!fern.)
Monitor pain Il'litf in Pilienl! polt- Il'gionil block (e.g., r piciJral). (Pain
~nsation will in(ll'~ a! tilt ll'9ional block ~all afF.Additional pain ll'Iief
may br Il'quill'<l.)

tnllruct the patient to ~n inaN!td Il'dnm, 1Wt'1Iing, 0' d,ain~e 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 t~ patient to Il'port any discomfort or pain i! the anesthesii wt'III

ofI.

Patint understanding of drug therapy:

1M oppoMunitit. during ~minim;nion of m. dimion. Ind during

IIItS!mtflts to dim/U the rationalt 10, drug theraPl', desill'd therapeutic

outcomt~ moll (ommoni>' obsmtd ~~,~ellects, pa,amttell forwhf n
10 call tilt health CilIl' plOY~ and any nKeSsal)' monitoring or
prro:aUlionl.(Using timf during 'Iming ca,t helps to optim~ and
Itinlorc~ key teaching a,ras.)

Patirnt self.administntio n of drug thf ripy;

When ~ministtring tht mtdication,in<truct tht patient, lamily,or
<.1ll'9m, in p"'p<'I .. lf~mini!llilion of tilt drug.. .g., uk. Ih.drug is
prescribed whrn1II'KItd. (Utilizing tifnl' dun ng nurse-adm inimation of
t~dllJ9l ht lp! to ll'infOKf tea(hing.)

The pat;'nt .hould bt Iblt 10 ,!.Ito the " .. on for tilt drug, .nticipltod

sensation I, a nd a~1Se effects to obsmoe lor and 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.

Eva luati on of Outcome Crite ria

haluatr thr eirectiYene!s of drug the,aPl' by oonfirmingthat patientgNisand opKItd outcomrs ha~ been fnl't (~Planning").
5u r.bIt 19.1forQ htDfItrJ'I' ",w/Wdr rIr6t ""';"'1""'"

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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 expected unless the local anesthetic is absorbed rapidl),orisaccidentally injected directl), into a blood vessel.

TABLE 19.3

'UO'
1

Stages of General Anesthesia

CharacterIstics
tmot pain:Thr ~iffit IoII>s grnrralltll~tion but may ~
awau.This stagr pI(ffilslll~1 thl' patiffit lose (oosdousnm.
Exdtemrru and Ir,' pn-anil'~,: Thr patiffit may ~ dtiirious ~d
try to ~ T~tmrflt Hurt ratt and bruThing mayIIrcorM
irrt<jUlar and blood prrISUfl' (,]0 iKru~.IV oJ9rII!I art
admiri!l8M Ilffl, to aim th~ patiffit.

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.

Sunj<alaM:llhl'sia:SktlmI musdts btiomt fl'Imdand

driri!lll stabii=CardiovallWr and bfuThing auivitirs
stabil~.~ ~mrflll skM and IhI' patimT btiomes still.
Sull}tl)' bt90s hffl' and rrrnaiosllltillhl' proadul! mils.

19.4 Characteristics
of General Anesthesia

Par.lIy~lotlhl' mrrlula fl'9ion io!be brain (rtspon~bIe fof

(ootroling If'ipiratory ~d wdio'mruiar Klivily):lfbfuThing or
thl' hun stop!,duth {wkl mUI. Thk IIilgC k ulWlIy ~
d."iIlOj ynll'ldld""'ll.rn..

The goal of general anesthesia is to provide a rapid and complete 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 areas. 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 balan~d anesthrsia, allows 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 occurs; thus it is called surgical anrsthesia. \'lhen seeking surgical
anesthesia, it is desirable to progress through stage 2 as rapidl), as possible, as this stllge proouces distressing symptoms.
These stages are listed in Tablt' 19.3.

TABLE 19.4

Q n~rous oxide

Go.

General anesthetics are drugs that rapidly product' lUlconsciousness and total analgesia. These drugs are usually administered by tht' IV or inhalation roUles. To supplement
the effects of a gt'neral anesthetic, adjunct drugs are gi~n
before, during, and after surgery.

19.5 Pharmacotherapy with Inhaled

General Anesthetics
There are TWO primary methods of inducing general anesthesia. Intravenous agents are usually administered first because They act within a few seconds. After the patient loses
consciousness, inhaled agentl are used TO maintain the anesthesia. During short surgical procedures or those requiring
lower stages of anesthesia, the IV agents may bt' used alone.
Inhaled genera l anesthetics, listed in Tablt' 19.4, may be
gases or volatile liquids. T hese agents produce tht'ir effects
by preventing the flow of sodium into neurons in The
CNS, thus delaying nerve impulses and producing a dra-

Inhaled General Anesthetics

"""

"'"

General Anesthetics

G>neral Adverse Effects

Oillif)tj~ ~1IDU1fO, tup/riJ~~, lmIi~ng
Ma~goaO!

\bIati~

liqtid

hypffillwnia apnea, MIlOS;'

dtsfhrrant (Sup_)

OrOW5inm, 00lI~ I'Omirilg

rfIfturaot (E!brant)

M~dial dep!ession

Q halothane (Roothane)

isofhrrant (Fu~~J
meThoxyllurant (Pmthraot)
~rant (Ultantl

Irdi<> ir.dkoto <om1llOR odv<:"" <fforu;cndaiioiM ir.dkot<5 sc:rious .d~sc: olltm.

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rnarkrrl hl1!!l:lenS!2!! Il!I!mooao: va~oostriQ!!!!!.!lmi!loloxid!l

~ Prototype Drug
Therap~ti c Class:

I Nitrous OXide

General anesthetic

Pharmacolog ic Class: Inhalation gaseous agent

ACTIONS AND USES

ADVERSE EFFECTS

Tilt main oKtion 01 nitrous oxidlo is analqcia uultd by ~pprewn of pain

mtChanilll'l! in tilt CNS. This a~m h.n <I low potency and doe not procItn <I
complttr 1015 of conKiou!lIeS! 01 profound maxation of skelttal mUldr. Bruuse nilrous co:id .. doe! not iMoc~ IUrgi{al ar.etthesiJ (stage 1), it is commonly
combintd with other ~"liul<l nesthetic a~nts. Nitrous olidlo is idea I for denul
pnxrdJlI'! btuuse tilt p-atitnt remain! colI\{iou! and un follow inruucticrn
wh ilt tlptnencinglull analgtYa.

Whr n usrd in low to moderollt dolts, nitrou! OJide produc:es lew <I~ tfInn.At higlltr doles, p-atitnn tlh ibit Klint adYMr sign! 01 stq 2 antllhtsia
wc:h <I! anlitty, aUtrml'nt. and comb.niYrnrs~ lO'ftring tht inhaled dolt win
quickly rtVtlse thes~ 'Mise ~tftcts. As nilrous omr is ~xhaltd, tilt patitnt may
temporarily ha~ 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 ~lII'ral alll'!thetic:s inlreqllerltly prodln li!'r d.Jma~. Nitrous oxidlo
has thr potential to lit abustd by Ulm (lOIIlttimrs medical personntl) who tnjoy thr rtlaRd,ltdat~ statt that tilt drug producrs.
Contraindi cations: Thi! dlll9 is cootraindiuttd in patitnn with an impolift'd
le!'IolcOO\Ciou!lII'!~htad injury, inability tocomp/)' with inllrucrion~decom
pr!"!!ion ~dlleS! (nitrogtn naltosis, <l ir r mboiism, air mnsport), undi.lgooltd
abdominoll p-ain or marktd disttmion, bowel obstruction, hypotension, Ylock,
chronk obstructi!' pulmonary diseol~, C)'anolis, or chell trauma with plll'llmothOiail.

ADMINISTRATION ALERT

Establi!h~n

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 anesl~i.I rapidly alter nitrous oxide is
~utd.
----"'

INTERAalONS
Drug-Drug: Sympathomilllflirs 0100 ~inhilitln rna)'~1ol(erbalf

d)'llh)1hm.

_..

li bTl5Is: Unknown

HerlIaVFood: Miktmtlt Ii..... bfiOll' oIoo 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 d~

matic reduction in neural activity. The e.uct mechanism

is not exactly known, although it is likely that ganunaaminobutyric acid (GABA) receptors in the brain are activated. It is not the same mechanism as is known for local
anesthetics. There is some inconclusive evidence suggesting that the mechanism may be rt'lated to that of some antiseizure drugs. There is no specific receptor that binds to
general anesthetics, and they do not seem to affect neurotransmitter 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 procedures. It may also be used in conjunction with other gene!";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, especially those with increased intracranial pressure, should be

LibraryPirate

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 isoflurane (Forane). The most polent of these is halothane
(Fluothane). Some general anesthetics enhance the sensitivity of the heart to drugs such as epinephrine, norepinephrine, 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 anesthetic. 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.

248

Unlll

The

/IIeIv"",, Sy'tem

.... Prototype Drug

Halothane (Fluorhane)

Therape utic (lass: Generalanesthetic

Pharmacologic (lass: Inhalation volatile liquid

ACTIONS AND USES

H~loth~ne proolKes a pot~m Inel of wrgi!ill anesth~w that is rapid in Ollld.
Akhough pot~m. halothant does not prodOO' as mlKh rnusde ~laxation or
analgesia as othtr wlatilt anesthoo. Thtreforr, haloth.Jne is prim.Jri~ UIfd
with other antsthetK agents inckJding mUI& ~lmlllS and analgesk~ Nitrous
oxm is somdimes (ombined with halothane.

PHARMA COKINETICS
()tset: 2- 5 min
Peak: Les than 10 min; the minimum alvtolar (onmltration (MAC) is
0.1591i.MI( is rut<! in older adulK
Half~iM: Variablt
Duration: Halothane's du rilion of action is '/aria bit dot to iulipid solubility. Patifnu !Ol'tl" from .J nesthesii r~thtr rapid~ aft~r halothane is dis(ominuN lvariablt among diflerrm q groups; oldtr adults tJkt longer
to rfWItr).

ADVERSE EFFECTS
Halothane rnodtrately srnsitim tht hean IIIJKIt to epinephrine: thtft'fort'.
dysrhythmia! a~ a mncfm. This qnt Iowtrs blood pft'SSUrl' and the respil1ltion 11111'. k also _nol1lI'S rI'fI9 m~dianisms that normal~ kttp the (ont~ms
of tht stomilm from tnttrill9 tht kJ~. !!aUS! of potenrial iltpalOtoxicity, tht
UII' of halothane has dedined.
Malignant hypertht nnia is a rift' but pot{'fltiil~ fatal aciY!'BI' tffea triggertd t:,r all inhaloltion anesthetics. k caUll'\ mUlde rigidity and ~tft' trntpl'l"oItuft' Mation (up to 4l'C). This rilk is gft'atest whtn halothane is lISt<! with
IIKdnykholine.
H~ Iotha ne dilates the (f~bral '/a\QJlaturt and may, in (Main (onditions, in(INS~ intrauanial pR'"ISu~.

Contraindications: Haloth.Jn~ is contraindicated in ~tients with a h~tory of

signiliunt or m.Jlignam hyPfnhennii aft~r pR'Yious halothane 9posu~.1t
should beusM with (olution in poltienn with hepatic: function im~irllll'fl~ dysrhythmia!, 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
antih~ ~ HaIotIIn pomniatrstlw a<tionofnoodfpoloViling
fIfII~ blocking igHlB.
l~ t.IDn UWK\mIlIy ilIrNIHtIw It'IPIof ~~in tIw(HS, and
sbould bf diKOOtirud 6 to 8 hom b@fore h.JIot~ itdmilliltraticn
SboIrut muIdt WMknHs,rHpiroitory ~ioo,or apaN may IKUl' if
lIiIIothoIIle is iOOIi"istfl!'d (OOOIrirotly with ~inI, iMomy!in,OI
amioogly;olida

Lab leu: Unmown

il@rbaVFoa:I: Untncwn
TrRtment of OmdoS!': No spKiIK
symptomatically.

ther~py

is oI'/ailable; patienu art trl'atfd

RtI\'r 1lI MyMIsIniJR {Ix Q MIsIniJ 1'roce\S FoM lpK/II( IIII1r1! <tug.

HOME

&

---~

COMMUNtTY CONStDERATtONS

--

--~-~----.-

Postanesthesia Follow-Up Care

Patiems ue upt in the in~titnt or outpatient hospital or dink IflIing until
the tffects of an anesthesia a~ ~.Patitnu mol, rtlUm 10 the hoIIII' rovironmt nt following 'min out~tient wrgerits,dtnta~ and diagnostic pro(MUrH using con sdOllS sMoitiGn bl'fort the effects of th~ ~tbtion haoi~ worn
of[ Patiems a~ requirt<! to Mt somron~ with themfor 2( hoUB to monitor
and aSl;ist their lIffiIs.lkually, a toUOW-iJP aslffimem by phone is (om pltttd
b)' tht nuBl' or othtr h~ilith {.)re providtr within 24 iIouB. Providing writt{'fl
imtllKtionsof all hoIIII' caft' rl'qJirtd is ~ssential beilrl' discharge bKiull' vital 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

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used alone, they are often administered with inhaled general anesthetics. Concurrent administration of IV and inhaled anesthetics allows the dose of the inhaled agent to be
reduced, thus lowering the potential for serious side effects. Furthermore, when IV and inhaled anesthetics are
combined, they provide greater analgesia and muscle relaxation than could be provided by the inhaled anesthetic
~lone. \\fhen IV ~ne.thetico are ~dmini.tered ~lone, 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 (Sublimaze) 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) .

CNptor l' Drug. /0, lOGlI .00 "".....1Ar>e-;thel.la

NURSING PROCESS FOCUS

249

PATIENTS RECEIVING GENERAL ANESTHESIA

Assessment

Potential Nursing Diagnoses

&selinr assrssment priorto admini stration:

Undtrstlnd mr IN.on 1~ drug has ~n IRS',ibtd in ol'lltr to IIIfSS lor
tllt,apwlic: effls.
Obtain a (omp~te lIt.hh history ilKklding urdio-asarla~ lfIPir.tor"
htp.tic, ren.I, or neurologic: d~a~; 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 polsiblt drug
intrrauiom.
A!!fI' for. PrrYKM hillory of antslht!oia and Mtt iny 'ignioonl
rmtionl.Obtain. fami')' histor, of allt1thflii probltm~ panic:ularfy
~lattd to t~ USt of ntlromusw Ia r blodm (t .g., .u({in~molint), or any
unUIWI temptratu~ t~t> 1Nttd to suf9tlY.
Obtain ~stlint vitll ~,htigh~.nd weight.Hott tht diy/hour tht
patitrlt Lm . tt or drink.
Evaluall' iabo,.tory findings appropriatt to plO{t<kJ~ (t .g., CBC,
elturolytt~lItpatK or r~nallUnction .rudifl, MRI or CT !Un rtlUltsl.
Obtain rtqui~ preoptlilt~ p.aptrwork (e.g., informtd {oO\en~
(ompleltd history and ~hysil:al).
Adminil1tr any p1fOptritivt .djulKti"ledrug. (r.g.,stdati!',aruigesic:) as

AIllie1)' (rNttd to IUI9ic:al proredu~)

Impaitd Gil Enhangt
lnef'm:ti"lt BJNthing Pattern
Df(~lstd Cardii{ Output
DisruJbt<i Sensor, ~r(rption
N.USN (1Nttd to aa.tlS!' drug tlfem)
Dtfi<iPnt Knowltdgt (drug tMr. p)')
Risk for Injur" Risk for Infection

c.
o

,"
>

,,"'' '

A'!fI' t~ Ie!'! of anxier:y,ind any rolKrm. or qutstionltllt p.atitn~

family, 0' mf9 i"ltr may ha!'. ReinloKe prtoptrativt tt.m iog. induding
detp b~athing fUl(i~.ProYidt t~ f.mily or(aJf9~r with infomlition
on tilt anticip.ttd lenglh of proc:t<kJ1(, w.iting room .~a,ind tl'Itphont
and tiling availabilil)'.
Wlltn working with preiitrK pdtients, allow parrnts orthr (,1't9i!'r to
Ita)' with t~(hild il Iotg is agelKy policy ptrmits to dt(ft'alt p.atitnt
anxitl)'. Providt .imp~ Ilplanations of t~ plO{t<kJ~ appropriate for tilt
qofl~{hild.

Wlltn working with oIdtr .~kl.Mtt i\l;istivt dtvim (t.g .. gia.Sft,

htilring aids) and 1\'IIl00f only when nt(tswr,.Gi"lt to t~ f.mily,
(art9~~ or provide lor lifeketping. En lU,e molt devic:fS .~ ava ila bit in
the pol1optrilivt ptriod.
Inili.te an intl"<lffllOU! mm !itt ~ rtqUi~ lor tilt plO(tdu~.
A'!fI' t~ p.atitrlt's ability to ft'(t~ and undtrstlnd instllKlion.lndudt
the family and (ilf9i!'1! 011 nttdtd.
AsselSm!nt throughout ildmini.tration:
AsSfS.lor dt~ft'd tlitraptUlic: eflem (t.g.,diminilh~ or loss of
(olllciousntsl).
A.SfSS vital ligns, t.ptdilUy blood prtSlU~.nd pullt, frt~mly.Report.
BP itsl than 90/60, pulleabovt 100,or per paramtltrs as ordem:l irI the
htilhh {a~ provider.
M.iint.lin operati!' Ill'riil)'lhroughout proc:tdu,r.
A'!fI! t~ ItYeI of ron.Oousntll in t~ ponoptl.ti!' ptriod.Continue
frtqutllt monitoring ofYitil sign. and pulst oximetry.
~I!fI.lor .nd promptly report .dvtlS!' elfem: bradyu rdii or tI(ityu rdia,
h)'pOtension or hypertel.ion.d~pnt.,and rapidly in(JNsing temptraru~.
Plllnning: Patient Goals lind Expected Outcomes

Tht palitm will:

ExptritrKt therapwlic: tfi"Is (e.9"idf,~!t .ntSl~i.I ruring plO{t<kJ~).
~ ~ frorn,or tlptritlKt minim.~ idvtlS!' effls.
Vtrbal~.n undtm.neing oft~drug'. inttndtd !U,adYffit effls,and ~ui~ plf(iUliolll.
(Continued)

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250

Unlll

Th~

/lle<vOI" Sy'tem

NURSING PROCESS FOCUS

PATIENTS RECEIVING GENERAL ANESTHESIA (Conllnutd)

Impl e me ntati o n

Interve ntio ns a nd (Rati o na les)

Patie nt a nd Fam ily Edu cat io n

En suring theril peutk t fl"trts:

Cominut i lSffiments i sdecribtd tarlier for th~apeutic eifr(l5. Pmride
for patient wfet)o during tilt pll'Optratm and optritive period and iS1E"S1
tilt ItI'I'I of COOl(ious~u, vit.J1 signl,ind mum of molor ilnd ~nsory
sensation poIlOperatm Iy. (The duration of alletllttic action will deptnd
00 tlltdllJ9l UIed and ad~nctil'l' or I"mI1<lI agents usN.)

AsselS for shil'l'ring in tilt poslOptratm period and p~ additionil

bla nRts or wamtth a\ rftded. (General anesthetics dtpr~SI tht CNS ,md
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 ~1Ii f~iIdlIli1gtt'lllperilllJn>.Repon II BP
bmw 9Q/60 or pI'I" palilrnetM ill ordertd by the health we p!O'Iider.
t~1'it or signifiunt bridycardia,or~iI.Repon any iKrNlI' i1
tl'll"9fl"illUfI' inrrxdiattly. (CNS drpll'!!ion wil UUll' dtcfl'aSI'S in ill ritilli9:ls
butli9:lifiynt br.ad)'Cardia,hypotmion,draNsN repililtor; r~or ~a
shook! lit rrported promptly.Malignant "pfflhtrmia iISlOOated with

Provide a quiet environment postoperatmly and Imjuently orient tilt

patient to tilt pollopet"atil'l' ret:OYtry unit.

Continut 10 orient tilt patient in the poIIoptratm ptriod and alia)'

ilnxiety ilbout Ihmring.

Providt an 9planation for all pnxerufl's and monitoring 10 the patiem.

Continut 10 fl'orient tilt patient to tht surroundings frequently in
poslOp~atm period.

!1J((~III'~ il rafl'llnpolfllti.tllyfatal~f~tilndanyimilll'in

tfrrptrillUfI'aboYethtpreoptliltil'l' ~!hcUd IIt reponed inmmatelyJ

PlVlide adequatf pain reliefin tilt immediate postopet"aul'l' ptriod.

(Gen~al iln~tia do not IIt(ffiarily provide ilnalgrlia, drpending on
tilt illjen1.!.deqUiltt pain reliefbt<jins ideilliy in tilt pll'Operiitive pl'riod.
AsII'IS for nooverlJal signs of pain SIKh u restit-1S1IrIS orgrilllilCing as tilt
patient regains (OOICiousntsS.)
En(OlJragt the patifmto take dtep bfl'illhs il nd IIIO'/ e tilt Iu.I'I'r
ertrt'lllitifs ffl'qufmly in the postoptratm pt riod. (Gftlerill illtSthetia
given by inhalation art ~rec:ed viii tilt lungs. Detp breathing mists in
rem~ing tht A'maining antsthetic.Early rangr-of-motion oel(~1 may
IItlp prtWnt ~IIOUI thrombosis and complic:ationsJ

Providt i rationille for pain fl'iief pll'OpI'I"illivtly and elKou ril9t tilt
patient to requet pain medication a\ ablt. Assufl' the patien~ family,or
cartgmr that pain n~ds will befrequently monitOffd.

Teilch the patient dtep bfl'athing run:ises in the prroptratm period and
that t-arly mol'l'ment oflegs will lit flKouraged in the wiy postopet"aul'l'
period,unless othtrwill'ordtfl'd by the PlVlider.

Ensufl' patient saftl)' in tilt poIlOptratm period. FfI'~mly 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 ma~ lit III'CfSlilry until the
patient regains (OOICiousntsS.)

For patifnts fl'(tiving kwamint and othtr drugs uusing

IIfIJroIeptallillgtosia, pmride, quiet, (aim ",~ironmem postproc:MUfl'.
kioid ol'l'nlimulating tht patient ruring rital ligns,using a lOft tooc:h And
txplalliltions of ill proc:t<iuresdollf".(During fl'(0I'I'f)' from
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 th f ra p)':

Use opportunities during tht pll'Optratm period 10 discuss tilt rillionalt
fordrug therapy,desired thmpwtic outcomr-s, moSI commonly obmvtd
ad-;f~ elftru,and alTj nKrlsal)' monitoring or prwutions. (Using till\t
ruring riming cart helps to optimizt and rtinforte key leaching artils.)

uplain tilt full procedufl' ind r~uifl'd pollplIXedural UfI' to tilt patien~
family, or (afl'9i~~.Alert tht family or ufI'gil'l'f that visiting may lit
rt-nOOed during the immediate fl'(01'1'1~ period in order" to minimii'l'
Sl'MOI)' stimulation.

The pillifm shook! lit able to lIatt tht f1'asoo for drug(s),inticipated
II'nsations, ,nd ad,,~ efftru 10 obll'fl'l' for and wlltn to f1'port them.

Evalu i!lti o n of Outco me Crite ri a

haluale tht effK1~ntSl of drug therapy by (oofinning thill patient goals and t xpected OUICOIllrl ha~ ~n mfl (_ "Planninc().
5tf TGbIts rU<1!Id 19.Hxli5ls .trhljl rcwhttr rht!t OOrlirrqlKliIIrIl~.

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TABLE 19 5 I Intravenous Anesthetics

Chemical Classlftcatlon

G@neraIAdverSf' Effects

Drug

Barbit..alts arod b.J !bitu!al~ik~ aqmll

~ lOmidal~

(Amidaltj

mdlohexiial sodum (BlnilaIJ

lJnjrJfl~ (ooMio'l.lIr/5IPQdi)m

IJallblllll ll[(tllliWlllllifRlI:lliIOIId!b~R~ 1iD:[IgI;IIl!iIlm>II1iRb:d.ub

prop<IoI (Dipril'~n)

Btnzodiul'pintl

dmpam(ValiLmJ
Ioraztpim (AlMn)

lJnjrJfl~ dtcNostd ~ltrmru, dirli!ished !ma1IfTQoon

Car~!!(ular roUapg:.laryngosoasm

midarolim hydrodlkfjdf, (~)

aHmlan~ h)'drodlloride (AHmta)
fmunyl tiUall' (Sublimm,oIhn-sj

NaIJSffJ, GI dimJrooocn
M.J1k~ CNS depmsion

l'I'rIIifmtaril hydflKNoride (Ukin)

sufmtanil ciuatr lSufmta)

I reallifW (~talarj

MisctililltOUS

[jlJOliorion, int!tll mllIIood PIPl54!ff' mil plJM n1f~ Wllfusion, n dwnml

Ilolkl ilKicat~ common idvI'fSI' tfIloru;.lllllkl:liniuinoot6 sffious~ I'fiKU

.... Prototype Drug

I Thiopental (Pentothaf)

Therapeutic (Iass: General anesthetic

Pharmacolog ic (lass: Intravenous induction agent;short -.acting barbiturate

ACTIONS AND USES

Thio~tal is tlltoldest IV i IH'Sthtiic:.1t is ultd for b~f medical proc:tdur~und
to rapid~ 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 ~nds! nd a dumion of only 10 to 30 minut6. Un likt IOml' antsthttic:
!gtnts, it his ~ low analgesic propel'Ms.
ADMINISTRATION ALERT
PlI'9nancymegoryC

PHARMACOKINETICS
30--60 ~
~k: 10- 30 min
Half-life: 12 min
Duration: 20-10 min

On~ :

ADVERSE EFFECTS
Lik~ otht r barbirurates. thio~t.J1 can product 5t'Yl'I~ 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 m~ardium arod cause dysrhythmin. Patients may 6pe~1K1' tm~lgffi(f dtlirium postoptrativf~. This (!!M1
hallucin,lIion~ confusion, and tJ<iubility.
Contraindi Clitions:Thio~tal should not lit administefl'd to poatimts with hy~nsitiYity to baroiturat!'! or wi th eins unsuil! bllo for IV idministrarion. Variegatt porphyria or !rutl' intefmitt~t porphyria a~ mmraindications.ln t~
ca~, thiopl'mal or oihl'r barbitural!'S can ClIUse IH'I'II' c1tmyl'lination and CHS
lesions, whic:h may !tad to pain, 'ft!knts~and Iife..th~!tening paralysis.
INTERAalONS
DrurDrug: Thiopental inm!(!S with mooy 0!lIft' 00Jgs. For uilmplt, 1M with OIS
dtpressaIlll pot~tiate\ rllPr_tory arod OIS dtp"Mon. PhMotlia!iIt1 OOf!1f lilt
rM ofhypotemion.
li blets: Unknown
HtIba VFood:

(ava and \\I1Prian may potential! SI'dalion.

Treat mf nt of ImrdOI~: Btuust tilt half~ifr of thiopental is vtl)' brid; Ut'trdose is ~asi~ managrd in tilt surgical suit~ by dilcontinuing tilt drug ind usisting Y!'nlilalion untilrepiritionl [ftum to normal.

19.7 Non a nesthetic Drugs

as Adjuncts to Surgery
A number of drugs are used either to complement the effects of general anesthetics orto treat anticipated side effects
of the anesthesia. These agents, listed in Table 19.6, are

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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 benzodiazepines. Opioids such as morphine may be given to counteract pain that the patient will experience after surgery.

2S2

U.,U n,., HefYo,,,, <;ynem

TABLI19' 1 SelQcted Adjuncts to AnQsthesla

Cheml<ill ClasslfkatlOl'1

AltithoilWfgk

General A.d~

"""

EIfe<I~

~l1IOlIfl!.urWJ"rtftfNI

atropine

Ildrllillulii dllutwrll!lii~ 1W>Mr kID RIY!!lllilii

BtruocIi.utpint

~ JjJrrrd spt/I, tmnor

midwMn{\estd)

Rtlllilllilla Ikmr:iiilo 1~!!llSI1I<n><n'I

<hoIilWf9:<

btchiOKhoi dlIoridt (Duvoid, IIItd101m)

~,~/c"mfitttJ,~

lYiliml golM!~ Iluo IIIRdi

Dop.!minr Ihke'

lbIloprlD~1II' dllllni/llll, r.IIIIPJfDmNfd J.)IIIpImn,.

d~II!WpIiIr)

hyportm.b.\ IIKhyrilrth
I.Jfmaoso.lsm
NNomUKWr~

Opioim

mivurium IMhoooo)

bn:Incho~1ITI

McOOtfosdai~M~hypo/fllliJfl

o JUinyIctIoIint (Mtint)

Rc!pi!3!oa !lwftnign m"ign.M !rtprrtbmnia !!!IN

IltlOCurarine

dm lt.llt[HIII~1r;II:

alfmlinil hydrochDidt (Alfmt.l)

lftIQI1II1. norU!& 61tfstJJtbtlnc~

Irrunyl dtntr (Acliq,~ StbIi~,otMI'l)

WlIY!!![! !kml:a2!! WIlH!; irrm mRiw!!!lIk.....Wn !!I

ftrI.~ ~mCIII"1

im!!l

!!I!W<NSdnrnWn

rtmiftnlilni h)O'odlIoride (lItN.)

suff!uanil dtlate (5ufeou)
Ph~iazir'M'

prorr.tIh.Ilint (PMrwhl', ~n,1llhm)

Utmd1l5ilM,ttymouth
~!l!l~m!!OOM<KiI

hales iocIcate CIIIllOlOll adftr5t ~ffKtS;lDkdioiIg,incbtet Itrioos ~effens.

Anticholinergic.s such as atropine may De admin istered 10

dry secretions and to suppress the bradycardia caused by
some anesthetics.
During surgery, the primary adjuncts are the naJromulO.llar
blo(b~ (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 recep tors at neuromuscular junctions to ca use total skeletal muscle relaxation.
Succinylcholine is used in surgery for ease of tracheal intubation. Mivacurium (Mivacron) is the shortest acting of the

LibraryPirate

nondepobrizing blockers, where.1s tubocurarine is a

longer-acting neuromuscular blocking agent. The nondepolarizing blockers c;lUse muscle paralysis by competing
with acetykholine for ,hoJinergic receptors at nellromus,ular junctions. Once attached to the re<:eptor, the nonpolarizins blockers prevent muscle cont raction.
Pos toperative drugs include analgesics for pain and
antiemetics such as promethazine (Phenergan, others) for
the nausea and vomi ti ng that sometimes occllr during recovery from the anesthetic. Occ.asionaUy a parasymjXIthomimetic 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.

Chopt.. 19

II~ Prototype Drug

Drug, /0, lOGOI . od Gi> ...... ol Ar>e<thesla

253

Succrnylchoirne (Anectme)

Therapeutic (lass: Skeletal muscle paralytic agent; neuromusrular blocker

ACTIONS AND USES
Like the naturollll'llrom nsmiller I{~tykholine. suuinykhol illt acts on cholinergK recrptor lite <II nfliromusruLII junuions. AI. fir;1, ~poIariz.Jtion OC{Ur;.
I nd sulltal mUKIts ronlracl.Aftt r ,epu tro (ontr.Klion~ htl'oWft~ tilt IIII'mbrIll!' is unabit to II'poIarilr.n long II the drug lIays onach~d to th~ rt<eptor.
[ffms all' fim ooted as mus{lt Wl'aml and mu~1t spasml. ['/Iffitual~.
paralysis o(UI"I. Succinykholine is r.lpidly broken down by tht ~l)'1III'
(holinesler~;when the IV infusion is \lopped. tht duration of mion is only <I
flow minull5.lM of IIKcinykholill!' ~(J(e the amount of gelltral anethtlK
needed for procrdult'S.Danlroitll!' sodium (D<l ntrium) is a drug used pll'OperatiYfly or poItoptraliY!'ly to redU(~ 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

Pha rmacolo gic (lass: Depolarizing blocker; acetyldtoline

re<:eplor blodc:ing agent

ADVERSE EFFECTS
Succinykholillt can caus~ complete paralysis of the diaphragm <l nd inten:OItal
mu~lH; thus, IIII'{hanK11 Vl'milation is n~(e\ary during wrgery. Bradycardia
and II'spiralory dtpll'SSion all' txpled <loMlSe eflfch.1f dole all' high. tilt
gangli.l all' affecttd, Llusing U(hycardia. hypotension. <I nd urinary II'ttmion.
P<IIitnn with {tnain gtntlKdtff(l\ may tilpMmc:t <I rapid onle! of tiltll'll\ely high ieY!'r with mu5dt rigidil)'--.l strious (ondition known as malignant hype"h~nnia.
Succinykholill!' should bt t mployed with caution in patitnn with fracture
or musdt Ipum~btcaU\eth~ initial musdt f<lIlKulationsm.ty caus~ additional
trauma. Nturomusrular bloc:kade may bt prolonged in palitml with trypokaltmia. hypocalct mia.or low plasma p~holintSteras~ ltvtls.
Contraindi {alions: Su{(inykholi lit should bt used with atll'lIII' (,JUlion inpatitnu with 1t'IM' bulTll or traum<l. nelJtomUI(IJlar disNsfS, or glaucoma. Succinylcholint is (onmindicated in palitnts with a fami~ 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;""
{ooum n!lywith dindarnycin.ami~ 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
'il.(~ . . ~ 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 maignant~ ~m
If !U(OOjkholi.. is 9ivPn {(.OOJffllily with Uo1Iiac 91y<Dsidt>1,!Mrf ~ incrr.M:! risk
of ~iac dysrhythmias.1f nartotics a~ giwn (OIl()JffI"jjy with '>lKtin)tholirlf, ihfII'
~inc~riskofIJild)U~and!iMatf&

LlbTfSls: Unknown
HOIbaVFood: Unkoown
lINIment ofOverd_: lINiment may involY!'drug thtr~ py forthefoliowing
symptotnl:WI'akness.l.t(k of rooldination. watery ~ and mouth, tmnors. and
s~irull'S. ProbIeml with bruthing requill' tmergtlK)' medital mtalUlI's.
I+tftt [0 M)Nu1l1frglJ/ for Q NullifJ9 I'Ioct1! focus lpt(1k [01Ir/s ~

KEY CONCEPTS
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.

19J Ux:al anesthetics are do1ssified o1S o1mides or esters. The

amides. such as lidocaine (Xylocainel. have generally replaced the esters due to their greater safety.

19.2 Local anesthetics act by blocking sodium channels in neu rons. Epinephrine is sometimes added to prolong the duration of anesthetic action.

19A General anesthesia produces a complete loss of Sl.'rtsation

accompanied by loss of consdousness. This state is usually

LibraryPirate

achieved thr ough the use of multiple medications.

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 Induce deep anesthesia.

19.6 [V anesthetics ue used either alone, (or short procedures,

or in combination with inhalation anesth etics.
19.1 NumI.'JOus IlOnan~hetic medications, including opioids,

antianxiety agents. barbiturates, and neuromuscular bkxkers, are administered as adjuncts to 5Urgery.

NClEX-RN REVIEW QUESTIONS

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.
The nurse observes a co.-orker prepa ring 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.
The nurse recognizes that the main action of nitrous oxide is to:
L. provide total relaxation of sIreIetaI musdes.
2. induce loss of oonsci~
3. cause analgesia by suppressing the pain mechanism In
theCNS.
4. induce stage3 anesthesia.

The nurse should ass-ess the patient for which of the following side elfecl5lf succInylcholine (Antellne) Is used as
an adjWld to anesthesia? (Select aU that apply.)
I . Bradycardia
2. ~headache
J. Hypertension
4. Respiratory depression
5. Urin.1ry frequency
A [XItient is admitted to the postanesthesia recovery un it
(PACU) after receiving keumlne (Ketala r ) 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 ~tients or equlplllt'f1t.

CRITICAL THINKING QUESTIONS

1. An eklerly patient requIres local anesthesia for a 3-cm lxeration to the distal fourth metacarpal of the Ief't hand.
The health care provider requests lidocaIne (Xyloca ine)
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 succinylcholiIlt' (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 recently 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-

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cate that th is patient may require close r monitoring (and

why)? Which is a priority!

Sa Appendix D foransWfrs and rationales for all aCflvifies.

EXPLORE
~r!ingJll ~ ycMII'

rwJlues,

f'I ~.

one stop tor online CI'oa/ller re"f,fW mat!r.als .n:I

h. success Mth additiOll3l

~CLEX"'-tityl~ pradDI

questms, 111IeIl!I:Iive 8S.'IijJlment5 IDI 8CliWil':!. wen 1i'Jks, 8/EIatiom

and 1iOeos. and m!le!

ReglMer you- ~t:e!SS ecdo! from 1M trmI: II! you- boak a1

_
... gkitcam.

Drugs for
Degenerative Diseases
of the Nervous System
DRUGS AT A GLANCE

LEARNING OUTCOMES

DRUGS FOR PARKINSON'S DISEASE JII1ltI51

Afrer readinfJ this chapter, the student should be able to:

OopaminergicAgtnts (ill/t157
" Ievodopa (Larodopo) pilrJt lJ

Anticholintrgics

p:1IJt1S9
Q benmoplne (Cogenrln) ~ 16J

DRUGS FOR ALlHEIMER'S DISEASE

Acttylcholintsterase Inhibitors

fflgt}64

fJII}t164

Q donflpt>l1/ (JIorlcept) fXJI}t 166

DRUGS FOR MULTIPLE SCLEROSIS MI}!!

Immunomodulators pagt167
Immunosupprtssants (Jt1jt 267

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 th e 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 sc lerOSis 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.

KEY TERMS
acrtylcholineteraSf (AchE) IllIJt 164
Alzheimer's disNS! (AD) ,..163
amyloid plaqun p<!'11'163
bradykinrsia (II1JtiS6

d~m~ntia ~ 163
hippoGlmpus pu;t 164
multiplrsderosis (MS) paqt166

corpusstriatum {X1;I151

paricinlOnism pu;t lS6

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neurofibrillarytangl~ Jl!qt263

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

256

Th~

Until

/lle<vOI" Sy'tem

egenerative diseases of the eNS are often difficult to

deal with pharmacologically. Medications are unable to

stop or reverse the progressive natu re ofthese diseases;they

can offer only symptomatic relief. Three common debilitat
ing

and

progressive conditions-Parkinson's disease,

Alzheimer's disease, and m ultiple 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 disorders of the CNS.
The etiology of most neurologic degenerative diseases is
lillknown. Most progress from very subtle signs and symptoms early in the course of the disease, to profolUld neurologic, 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, pharmacotherapy provides only minimal benefit. Currently, medication is
unable to cure any of the degenerotive diseases of the CNS.

PARKINSON'SDISEASE
Parkinson's disease is a degenerative disorder of the CNS
caused by death of neurons that produce the brain neurotransmitter do pamine. It is the seoond most common degenerotive disease of the nervous system, affecting more
than 1.5 millio n Americans. Pharmacotherapy is often successful 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
parkin sonisrt\ 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,

bradyk ine 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 Am~riuln ha-;~ Partinloo's dis~ast.
Most patifnts with Parkinson's disNs~ U~ oIdtr than i9l' so.
Morr than SO% of Parkinson's patienll who hm diffirulty with voluntary
lIIO'Iement all' ~ngef than 60.
Morr men than women de-YeIop Parkinson's dMi~.
Morr than 4 million Ameriu ns haft Alzheimer's dM.m.
Alzheimer's di~.m mainly afftru patients older thin age 6S.
Of all parif,nIl w~h dmtentia,Wl'. to 11m ha~ Alzheimer's dise_.
Morr than 49,000 Ameritans die anrually of Alzh~imer's di~_.
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

D<><e.tptton

Aizhrilrler's dilNlt

ProJtsVvt lossol brain function dlaoomml by memlK1los~(onfusion,and dmmItia

Am)'O!mrdlk Iltml sdtJOSk

Pmgrtsliw WNW!I and WI!tiJ14 01 mUldts GU~ by demucti6/1 01 motfl/ I\t!fOIK

Autosomal--domiiantgeOl'tic: dison:ler ll'Iiliilg in progr~~'Il' dementia i nd inl'OkmYiy, sp.lsmo<i( rtIO''menu of limb and fidal

Huntington's dIor~a

m."'"

Oemyrinatioo of IIN'OOS in the Wlual nervous systml (eNS), ll'Iiliilg in progrn~'Il' WNknm, Yisual disturbaoc:ts, mood akmtioos,
and '091itift driKits
Progr~sift 1011 ofdopalTi~

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in the CNS (,lUling lIflIIor,mm rigidly,and ibnorrnal momnenll i nd pollUIl'

'hlplfl20 Drug< for ~'rM D~ oft'" NeIYOOI System

- Affective flanuring: Patients often have a masked face"

WOOl.'

there is littlt f:acial expression o r blinkin g of th e

,,~.

Although Parkinson's disease is a progressive neurologic

d isorder primarily affecting musd e movement, other h ealth
problems often devebp in these patients, including anxiety,
depression , sleep d istu rbances. d ementia, and disturbances
o f the autonomic nervous sysltm such as dilflCulty urinat ing and performing sexually. Several theories have been proposed to expla in the devd opment of parkinson ism . 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 en tially turmful agents include a rbon mono.lide, cyanide, m anganese,
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 degeneration and destruction of d opamine-producing neurons
found within an a~ of the brain known as th e s~bstanli. nigra. Under normal ci rcumstances, neuron s 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 neurotransmitters dopamine (inhibitory) and acetylch oline (stimulatory) 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 nc tion but al so on blocking the effect of aCelykhol ine within th e corpus str iatum.
Thus, ....1Ien the brain experiences a loss of dopamine w ithin
the substa ntia nigra o r an overactive cholineTglc influence
in the corpus striatum , parkinsonism results.
Exlrapyramidal side effects (EPS) develop for the ~me
neurochemical reasons as Par kinson's d isease. Recall from

L IFE SPAN CO NStD ERAT IONS

living with Alzheimet's

and Parkinson's Disaas8s
80th AIzh!imrf's ilnd PMIinson'slis!ilWI lit ptOgrmiw dtgellffllile lINrologiClMortim. WMfUS l.IzIItimtr'sleids to im~ irmtnts in mmlDfJ, th inking,and ItlSoning, PaRirwI's gn 0:110 the inability 10 hold ImaR ~tms
bo.."", of tftmon ~nd n.idity.1t iJ brcil\lSt of th~ progns ..... s1mptoms
thit patitnts IItfd all the Wip ilnd wpport tllat urtgiven (iln give.Although
nonpllillmac:oloqic m.l~!flleflt wr;h ill proYiding iI Iilft trMronmenl un
ht lp, mrdic.Jtionl iIIt il'lilublt to dow tilt prog,euion ilnd minim~ symptoms. (ilmji ....n will nttd to providt assistanct w~h 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 I~p. Additionill~, many ptopIt with dtmtnriil oftm
sulkr sftpilj)nu.Nt:wltiUrchwggtSu that in ilddition 10 providing iI rootint ,md SlfUC(urtd mvinnmtnt ill Iit~t ilS iI itw hours 01 Mght liqllt.~
wily in 1M tIfrrling, II\a)' Itlp peoplt IMfI9 witll Abhtirntr's maintain I IIOrINI slt!ping paM1\. Pitimrs who It(fflrd Iio/It therilPJ in tIr! eI'IIlng 1M
~iln~tinthersltfp()'(1t.

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257

mapler 17010 that antipsychotic dru gs act th rough ~ bl ockade of dopamine receptors. Treatment with certain antipsymotic drugs may induce parkinson ism -like sy mptom s, or
EJ>S, by interfering with the same neura.l p~lhw~y and funetiorn affected by Ihe lack of dop:!mine.
EPS may occur suddenly and become a media d emergency. Wi th aCUle EP5, pa tients' mu scles may spasm o r bewmt ~ locked up.~ 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 se tt ing, the pa tient should immediately be taken to the emergency room ,
because untreated aCUle episodes o f EPS ca n 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 anticholinergics (cholinergic blockers). Dopaminerg ic 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 th e 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 patien lto perform normal daily activ ities of living (ADu) such as ealing, walking, dressing. and
oothIng. Although pharmacolherapydoes not cure this disorder,symptoms maybe dramatically reduced in some patien ts.
Drug therapy aUempts 10 rl'$to re the funct io nal balance
of doparnineand acef)'lcholine in lhe corpuss lrialum of the
brain. Dopaminergic drugs are used to increase dopam ine
leveh in this region. The drug of choke for parkinson ism is
levodopa (Larodop.a ), a dopaminergk drug that has been
used mo re extensively than any other m edication for this
diso rde r. 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 biosyn thesis 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 co mbining it with earbidopa. lbis combination, marketed as Sin ernet, makts
mOR levodopa available to enter the e NS.
Several additional approaches to enhanci ng dopamin e
are used in treating parkinsonism. Tolcapone (Tas mu), entacapone (Comtan ), and selegiline (Carbex, EJdepr)i ) in h ibit enzymes that normall y destroy levodopl and
dopamine. Selegiline is a monamine oxid ase (MAO) in h ibitor. Apomorphine (Apokyn ), b romocr iptine ( Pa.lod e]),

25 8

Until

Th~

/lle<vOI" Sy'tem

TABLE 20.2 1 Oopamin"rgic Drugs Us"d for Parkinsonism

Drug

Route and Adult Dose (max dost> where Indicated)

Adwrse Effects

amantadine (Syrrmeutl)

PO; 100 mg 1- 1TiRll'!/da)'

Dilmts~ /iqhl-OO!ded1fs~ dilliwlry n:lnfrIIlini

apomorpline

SC;l mg forTIlt frSi do~~'Il'1)' ftw days,dolfl m.y lit inaultd

by I RIg (mil1:6 mg); nmm than 1 wm plSIfI 1It1Wtffi dosr!,
titration should lit II'stamd at 2mg

brornouine (Parkdtl)
tarbidop;t~e l'Odopa

(Sinernet)

ffitaYpOne (Corntan)

In odopa (l.{)opa.lirodopa)

PO; 115-25 mglday up TO 100 mg/day in dMdtddolfl

fIgw. rDMG, I'OI11i!irJi tmlripalio~ orlhos!oril:

hyporellJion, rhorfiform ooo~nrD""
fflOl'I'mmt\, dyJiOliD, djJRIIfliD
m

MI short neuroleptic ma1jgMD[lyMKIIIle

PO; 1 ti bltt rontlinilg 10 mg taJbidopaf100mg It'IOdopa or

15 mg G1rbidop;tflOO mg if,'IOdop.J Tid (mill;6 ubi/day)

imdmdn. EP$ IUminin! liwlaikJrt,smrt

PO; 200 mg givtn with le'/odopHlrbidop;t upTO ~ht ~m~day

IItINTOCI'luarinpm

jprillr.ilpcywjj drPlfI'ipowitb SlDeW!

PO; SOO mg- I gld.y;may lit ilKll'Nd by 100-750 mg ~try

1- 7da)'5

pr.Imi~ dih)'ltodlloridt (Miraptl)

PO;StJrt with o.m mg tid for 1wk;doublt thisdosr for tllt nelt
W'k; (ontinue to iOOl'.l SI' b1 O.1S fll9/dose ~d !'Vl'IY Wl'ek 10 a
target dosr of 15 mg tid

ropini'ole Irfdrodlloridt (~i:J)

PO;Soo with O.1S mg tid; may illll'aII' by 0.25 mgfdosr Tid ~'Il'1)'
WffI: to i tir~T dose of 1 mg Tid

!tIt9line hydrodllorid/, (LDtprrny~

PO; 5 mgldosr bid;dwigreaTtr th.tn 10 mgfday are potenTially

"""'"

PO; 100 mg ~d (milx:600 mgfday)

tokapone (filmar)

(OO~ ~n.Utty, hfOOht,WtpdyWndioo,

~,

pramipexoJe (Mirapex), and ropiniroJe (Requip) dire,tly

activate the dopamin~ receptor and are called dopamine agonists. 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 treatmenTfor Parkinson's disease. For exampl~. 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 progressive dyskinesia symptoms. However, in terms of
activities of daily living (ADLi), some have repor ted tha T
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.
Oth~r dIUgs r~du~iJlK th~ f""luif~[[]~Jlls rUf L-dupa ill clude the catechol-O-m~thyl transferase (COMT) in
hibitors. Like L-dopa, these agents increase concentrations
of existing dopamine in the brain and improve motor fluctuations relating to The wearing-off effect. Examples of this
drug class are entacapone (Comtan) and tolcapone {Tas-

LibraryPirate

mar ). Side effe,ts of COMT inhibitors include mental confusion and hallucinatio ns, 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 (hi~
m~ic:ine for Thousands of ~rdll!' Tiff is plinTed throughout th~ world, induding 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 dis~. The IIII'(lianism of action setms 10 br II'litfd 10 inaming Tilt blood IUpp~ to tht brain b)' dilating bIoodYffi~1s, dK!I'i ~ng t!I!' viscosity 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 ulKomplicit~
Alzhtillll'l"s dMoN. Othtr srudits II<l'It shown no improYeIlll'nT in t!I!' 5)'01Ptoms or progll'lS of Alzh~imtr's diseas~ (DtKosky. Williamson, fiupauick,
Kronmal. ~ Sanon t t al.,2008l.Ginkgo is COMidtred salt; hOWe'/e!; i! may
inause the risk 01 bleeding in patitntstaking antico.agulints. Or:1Ier potl'nul
um for ginkgo thati ll' bting inmtigilled i~asthma,mukiplt sc:ltrosis,
interminfnt claudication, smJ.1 dysfulKtion du~ 10 antm plffiints, i nd insulin II'sistalK~.

''''PIf, 20

Drug<; fo, ~~ tIw 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.

BIIo.aI ganglia:
Drooping

" yelids, open

mouth, drooling

Progressive
deg-eneration 01
neurone in the
rign>!llriatal
palhw"'lcan

Aniipeydlotic
dopamine blocking

"",.

ptOduc,,:

-" l:J (1

Symptoms 01 Pa rkin.", '. Disea.,,:

Trem<>nl (IMting tremors)
Rigid body alructu",

Corpu triatum
striped body'"

SIown_ 01 movemenl
(bradyki.--is)
LOSII 01 balanc"

8 ......llJIIngl..
Inlemal capeule
~olslNctures

10ITT"0S" slripe.

Dopaminergic ag" nt. :

PlOICUraors 10 dopamine:
eg: Levodopa (L-Dopa)
Dopamine receplo, "9""18:
eg: Ropinimle, Pmrnipllllole
Chol inerg ic-bloc king drug. :
8enztropine
Copa mi ne

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 cholinergic blockers, or anticholinergics. By blocking the effect of
acetylcholine, anticholinergics inhibit the overactivity of

LibraryPirate

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 anticholinergics 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 constipation are still troublesome. The centrally acting anticholinergics 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

260

Until lheNetv"",,Synem

fIT Prototype Drug

Levodopa (Larodopa)

Therapeutic (lass: Antiparkinsonagent

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, ltvoOOJlol is often (ombined with otht r medications,!lKh as Llrbidopa,whic:h preI'MI its tlll)'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 1Ituro\eplic: malign,m syndrome (NMS).

ADVERSE EFFECTS
Sidt t1feds of Irodopa in(kIdt unc:ontrolled arod purpost1tss m~mtntl sum
astIItffiding the fingm arod shrugging the shoulders. involuntary IIIO'/ tmtnts,
loss of appetitt.nausea. arod vomiting.Il'uS(1I' twitming arod !palmodic: win king
aft'tarly sigru of toxicity. Orthostatic hypottnsion is (ommon in SOmt palitntl.
TIlt drug shoold lit dilwntinued graduall): bKaust abrupt withdrawal Ll nprodiu oKUtt Jlolrkinsonism.
Contraindicilti ons: L.evoOOJlol is (ontraindicated in tilt tft'atmtnt of narrowang1l' glalKOOIa. panic:ularly in patiffits with suspic:ious pigmtmed lI'sions or iI
history of mt lanomi .This mtdicalion should lit a"loided in m~ 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 drugI.For~.tric)dc:

Plfgnanc:yLlltgOry C

an~IIIkoaNIf ~ of1mldopa. OON If polin h)"poImsion.and m.l1

inuNlf !)fl1pathetit anivit~ 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)\ ~UIf OOIIIMt Ulf
IMf p"~ "pKlMli"ll! aM. HaIopfridoI taken {OOOIfreotly IMf aoligCllill'
tfuo thtriIp@UtKtlff(\! ol~. MethylOOp.! m.ly inc:rNIf lOJ!idty.
Antih)"pfllmlim may (iIlIIf oomfd "poIHIIWf ~IOO!. AnTitoo'o'lNrn may
~ th. thtropMil: offo.mofIHodopo.AntaOd.'onOO"'l.....,...,; ....
00110.01 !odilrn bic;!o:booalf may irKlUif ~ abIorptiln. whi:h (OWd ~
to to~P)OOoIinf ~ ilnliparkiolOOilmfflKts ofk>vorlopa.

PHARMACOKINETICS
IAlset: L.m than 30 min
Peak: 1- 3h
Half~ife: 1 h
Duration: Variablt

lab Tl5Is: AbnomwIilifi in lab l15li filii')' i~ fIf"/iltioos 01 li'ffllunc:tion lf511

sum 011 .ka1ir1f pho:!pholilf, i!p<lrtate aminorrifllferR lAS n.alilnirlf

aminouml'l"olII' (.u n.1oKti<: deh)'drogeoR.and li~rUJin. AboormaIffits in blood
nilro9l'O iIOd pc!Iitivf Coombslf!( 11M i!Iso lK>fn fI'POIIOO.

lfN

Ik>rbaI!JFoo:I: K.lurruyWQMltlll' I;'IIIpIOm! ofl'olrttrlon!.

TrNtment of Overdose: General.upport~ mtasul!'S should hi' uktn , long
with immediatt gamic J,vagt.lml"ilftnollS fluids .hould lit administered judiciOUliy arod an adequatt airway maintJined.

TABL.E 20.3 1 Anticholinergic Drugs and Drugs with Anticholinergic Activity Used for Parkinsonism
Routeand Adult Dole Imax dose where Indl(ated)
Drug
Adverse Effects

bffiztropiotmt~lt (Cogentinl
biptriden hydrodlloridt (,i,kiotlonl
diphtnhydramirH' hydrod"jorid.: (Btnadryl) (~
~ mlorl,"", ProIotyptDrug IHD: OO)

PO;05-1 mgld.y;grmlly inuull' as rH'~ (m.l1:6 mglday)

PO; 2mg Oot IO loor limffid.y

proqdidot hydrochloride (Kmlidrin)

po; 25 mg lid,/ln' mull; may III' iKrull'd 10' mg tid ifldtratfil.

wiTh inadditional, mg al btrItimt (m.ll: 4, - 60 mg/day)

lri,"",xyphffiidyl hydrochloridf (Amot)

PO; 1mg on day 1;1 mg on day 1; thtr1 iOCR'al!' by 1mgffl!Y

3- , d.yl up 10 6-10 mgl~y (m.lI: I, mgld.y)

PO; 2HO mg tid- qid (max: 300 mlJ/~y)

5tdJio~ _.Il!frjripo~on,lty

-=-

moolfl. b/lJrrrd li.<.i1n,dl!1Wlmt5l,

dizzirltS~ rhyrQrdkl. hyporemioll,

.. ~ .dwrl!' .n.m.

IrditJ indici"<OIIImon~.rrM';~iodicil

FIX lirf(.ltooflirlgplO(tsJ ~roQMidI<MllfrgK Iht~ wNriflirlg Procm FooIs:Pariennlktimg Amidloliotrgk rhfrop%pogt 145n d!op/tI 1]0/0.

LibraryPirate

NURSING PROCESS FOCUS

PATIENTS RECEIVING lEVODOPA (lARODOPA) OR UVODOPA

WITH CARBIDOPA (SINEMET )

Assessme nt

Potential Nursing Diag no ses

Baseline Ilmwnent prior to adminiltral ion:

UndenLlnd tIIf rffiOtlth.:drugllM~np!tKribtdinOfOO'lo,ssaskK
thtr,pMit: flfKa.
Obldin, (omplett hrikhhistory incUling Uldio'lill<W~l!IlIS(ulosktlet.Jl
dM,~or gLJumma. Obtiin, drug history inck.odi!19 *'gies,runml
p!tKriptioo...d OlC drug~...d hrm,1 prrpi,,!ionL~ aIM!O poslille
drug imtrKtionl.
Obtain' hi!tory ohht ument aMu...d symptom\fititming
(ond"ttions, ,nd ~bI'il)' to CMT)' out ADU, pirtKularly mobil)' and NtinrJ.
haluatt ~pp!OPNtt laboralo,., findirlgS well II htpnic or /ttI.1 furKtion
studies.
Obtain llisdilt vital Ygn!. bowel wunck.urir.ary oupu1, mUKit II~
Md mtnul SIaM M ipp!Clp!iilt.
AtS1 tile 1Y1imt'1 i1b1litylO ~tift.rId UllCifnund iRmurtion.lndudI' tht

Impaoirtd Ph,n Mobilil)'

knpaiml Swalowi!19
Impaoiml Communiation (It,wl)
Comtip.tioo
StI.utl' DtfKit (lmtin~ ~thing, hygltnt, ~ing)
DtfKitnt KnowltOgt (drug tfItfapy)
RiIlfor In;..y, Rill for Falb (maltd 10 dM_ or adYtrw tffmsof drug
thtr3PY)

f.milyor~'lntt!led.

lsHllmtnllhroighoulldminillration:
Aistil for dnirtd thr"pMic riIeo:ndfpmdtm on tht rUlOn for thtdrug
(t.~, dKrtMtd trtmon, briClytint~, 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, lliotatiDn,.noft'lia,~gia,or dJ.ngtI in menul
lIillI!, including .gitatioo orcoofll!ion..
Planning: Pltle nt Go als and Expected Outcomes

TIlt pilitm wiI::

bptritrKt rlImptUlic tfferts dtptndtllt on tilt rt.1On the drug is bting ~tn (t.g. imp-oytd pi!,n mobility ,nc! coord"tnation,dKrtMtd t_tS,ri~
bradykinHia,.nd inclt.5ld .bilil)' in Iflf--un: oKtivitiesj.
~ ~ ftom.or f~ptrienct 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
Intervention s and (Rat io nale s)

Patie nt li nd Fomily Education

--+--

Ensuring IMr.peutl( efftm:

Continue ~I i111f%1t1m1l ill dtsaibtd utlitr for mmptUlic: tfferts.
Orug thfUpy ma~ like IMriII wtffi Ot months to 1Iat , full fffKt.
Support th.: ~t 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 oKIivities..~ 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 ~n.Particularurt with .mbuLrtion is ~ .1
bradykinHia Ind rigidity mil)" inc:1t.1f tilt tilt 01 f,lb. )

lNdo lilt p.nim~ family,Ot~iverlh,n 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 iflndytinf~, riIjcIity,or tltlllO/\.1t
""nirularlylfftlt.
Assffi tilt pititm'~ lamily'~or uttgim'uolity to tiItfJ out ADlUl
homt.nd ~ tilt n~ for additional ht.1th Galt rtfmIls. [v,kiilf
homt lftl)' rwdi.
(Conrtnued)

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NURSING PROCESS FOCUS

PATIENTS RECEIVING lEVODOPA IlARODOPA) OR lEVOOOPA

WITH CARBIDOPA (SINEMET ) (CollIlnuld)
Implementatio n

Interve nti o n, and (Rali o nales)

Patient and Family Eduu,ti on

Continur to monlOi vital WJns. TXt blood prmull' IyWog,sitting. ilnd

SIi1nding todtlea orthosUtK hypotension. Be pilrtKuIaIIy (ilUlU wkh
okItr iI~lu, wfooall' al an inc:JNSfd risk for byJxJtfmion. Notify 1M hulth
{ill! ptO't'idff if blood PIl'SS\.IIt dKl!~ beyond estibis~ par;Jflletffi or
ifhypotmsion is. KCOmPilnitd by ~ u{hrurdia. {OrtbcnIatir:
hypoifnsion isil common ~ dfta ilnd mily iD(fNSf Ihf ~ of fills or
injllr1.}

Tfh tIM- piltitm 111 ~ from IyWog 10 Iitmg 01 SQnding slowly to;woid
dizzinm orlalls.

Moroitorfor bellavior (hilf"geS.(Drug IMfilPY nil)' illClt.st tilt risk of

Tftch tilt piltitm, Umily,Of Ulegiver IOwiluh found Il'!IGfI in1JIlt<iiItly

ill!)' signs of manges in behilriofOi moocIllJ(h II inm,I5N ~ressioo 01
((IIfusiDn..Provide additiooallotilhh (f Il'ierr* ilS requirtd for wppon
gfOUp,munstling, Ofrespitf 1m.

igitation, confusion, dtpression, 01 wicidal thoughts ind may UIM othfl"

mood dinurbillQS IlJ(h lIS tggressivt bthmorJ

CiI!Niy evaillatt and tepOft do!Hel4ttd symptoms such ilS iMl!ilStd

tll'mon and rigidity !of~ 1M next dose is due orgll'illlJ intn'iISfd
sympl1mS unttl.ted 10 die timing of the dow.(T1lt Il'Il,IIn ofgflduil
incll"~ of ymplOlOI as tIM- nHt ~ COOlrS dUl' m" signil l iI"Maring
off"timt .nd IMdo~ m" need III !of illCll'IsfII, tht inltr'lill of dosq
ild;..sttd,or an Idjunctiw drug addtd.A signifiant and suddtrl inmil~ in
symp1DlM nil)' sign.1 an OI'frdow OI"on-oll"" phtnommoo ~
sympl1mS dri
Ily inclt.lst.1I spmptoms ilit signifiCilnt, hospiu liution
nil)' ~ lfIIuirtd to iSIm for tht miooillt behind t~ec.J(frbillion)

m.ata

Instruct the Piltitnl. filmily,OI u~iYrf to be ilWiII! of ntwly occurring

mUl(It twitdoing,indJding ~pb.JrtISjIiIsm (in rru!des of ~!ds),gruJ,
Duusing trtmors, rigidity, \WNIing,orothtr S)mptOOlS iIOd to Il'!IGfI
thtm il!UllfdiiltfiJ.
EncOllrq ~ patienl filmjy.orur~ to mMouin iI S)'IIIp1OOl diiry if
tffKts SHm to cfmWnisIJ ilS tIIf next dose is dllt. Revitw ~ dial) witt1 tht
~ntan tid! htalthCilIl'I'isH.

Enbltf rutrition.1 intake.(AblOrptiOll 01 If"fodo[)il deuuses with high

PJIlttm muls or high {OIIlUIIlption of food! 01 "titamins that (onu in vilMnin
B., lPrridOJCiM].Symptoms mily drollflalKait,o incrtil~ if .bsorption is
impaim:l as dcM does no( adtqUillfly bSOlb during die timt fJIIfCIfd.)

Tftch ~piltitot\Q takttherMdiCiItionOlliln~l~or \Q...aid

taking tqthtr with a higl!-prol:ein muLAYoid ~tllivt consumption of
wiumin B.-rich foods weh i s such asINMIIiII, whtat gtrm.lortififd
(fll'ais,gfHII vrgttabIes, mNT.. and Itgumt~ and noid muIlMtamins that
((IItilin vitilmin

MotUtor htp.!ic .nd Il'NI MIction Ifl!s ptriodiully. {A dem~ D thest

Tetch I~ [)iItitm, f.mily,Of uregiver ilbout tht import.lICt of Jl!tuming

forfollcw-up Ifb stucliH.

lunctions II\IJ slaw the IMabolism ilrId ellrttian of tht drug,possibly

Itiding ID 0'tIfrd0ll' Of IDIXityJ
MonitDrfOi other drug..mat~ (haoges.(Thr drug II\IJ UUIf urine and
ptlSflifation todalttn in colorJ
Palilmt Uldtrltanding of ~g thuapy:
USt opportUnities durillg .dminiltsatioo 01mtdications.nd during
iSStII/IIfOU to dilcun die miollillt for drug mtr.l[l1, drsill'd thnaprutic
OIIK_, most (ommotllyobsmtd adtlSt rife<:ts,parimttm forwhtn
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 pa1itn~ fami~ 01
CilrtgiYrf in tht proprr \tlladministration ofckugs."d die Ilffii for ~
(omistrnt doling. {Utilizing timt during nurw-adm inistmion of these
drugs hrIps to reinfof{f tOOingJ

s..

Ac!vist 1M piltitnt tfIat UriM 01 swt'at m.y darRo and uodtnhirl5 01 dress
shitkk mily help 1O...aid IUining of clothing.
The piltitfll, filmily,or CilrtgMr shoule! be ilblt to state thf Il'jSOfI for ~
cWg;appropriiltf dow .nd Khed.rling;.nd wfoill iI!Mrw~ 10
oto_ for iI1d whrn \Q Il'port.

Instruct die Piltitnt in pJllpl'f administsation guidelines.EncOllfil9l' die

paOOolfamiy, or ~f 10 "",inuin a m~iCiItion log, noting
symplDms or .dmwderu .Ioog witto tbt dOlI' and timing of
mfIIications.

Evaluation of Outcome Criteria

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cannot tolt'ratt' levodopa, and in combination tht'rapy with

otht'r antiparkinsonism drugs.

HOME

&

COMMUNtTY CONSIDERATIONS

Caring for Loved Ones with Alzheimer's Disease

ALZHEIMER'SDISEASE
Alzht'imt'r's dist'ast' is a dt'Vastating, progressivt', degt'nerativt' disease that generally begins aftt'r age 60. By age 85, as
many as 50% of the population may be affected. Phannacotherapy has limited success in improving the cognitive
function of patients with A1zht'imer's disease.

20.5 Characteristics
of Alzheimer's Disease
Alzht imtr's disrilsr (ADI i. responsible for 70% of all dt'mentia.
Demrntia is a degener:ltive disorder characterized by progressive memory loss, confusion, and an inability to think or
commlUlicate effectively. Consciousness and perception are
usually unaffected. Known causes of dementia include multiple cerebral infarcts, sevt're infections, and toxins. Although 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 following 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

Tht diagoom of Alzhtim~'s diINM' is dt-asming 10 lilt patienl and family

Inl'fIbers .Jli~. Family mtmbm mun dral with many unexptutd clanges.
Tht ~rsonalit, of Iht patient with Alzheimds diINSf slowly (hangrs and
llla)'indudt pa r.J naia. angt~ and frustrillion. Many bmilits i11lf"f11p1 to [art for
their Ioffil one ill ho~ for as long as possibif. A frighl~ing al~1 of
Alzh ~ imds d~a M' is tilt ttllllenq for IItt palifnllO WI ndtr lNIlfi. Thr palifnl
t.J ~Iy bomrs lost aitfr ifaYing thf familiarity of tltt homt ~Yironmtn1. 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 patifnnt a high mHor StYere trauma or dtalh, and it is imporlamfor family
Uft'gWen to ft'<Ognizto Ihis symptom and askfor 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
n u tritional factors, as well as viruses, are considered possible sources of brain damage.
Although the cause may be unknown, structural damage
in the brain of Alzheimt'r's patit'nts has been well documented. Amyloid plaq ufs 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

Benztroptne (Cogentm)

Therapeutic ( lass: Anliparkinson agent

Pha rmacologi( ( lass: Ctntrallyacting dtolinergic receptor antagonist

ACTIONS AND USES

lklllllUpi"" ... 1> by bluc.lil"J ~.....,. d",lillft~ic. ,limul.oliun uf ""."un, in

lh~

(orpul miatum.k

isulf<! for ft'litfof parkilllOllivn s,mptoms and ~r tilt IIutmrnt of EPS brought on by amipsycoolir: pha!T11Koliltrapy. This IMdiution
WPPft'lSf! I~mors but rIot>s not afftcl tJrdi~ dyskinrsia.
ADMINISTRATION ALERTS

nY,

Tilt patitnl rna)' bf ullbif 10 ~K-administfr mtdiution and

netd
assisun(f.
Btnrtropine may bft,ken in dividtd dolts, two 10 four limf1a dlfI. or tht
fmi~ 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
~on:&-10h

ADVERSE EFFECTS
"" rlp!"llc"ll [,"111 it> .ul"IIOm;" liun, bnlllrupin" ,.n uu .. typiul .nl~

(holinergK side rfrecu IIKh as d!)' mouth, conniparion, and tam)n!lh. AdYmf ~al ffltch indudr Sfdition, drowsillfS~ diuinflS, ft'It~YIf"I~
iniubiily. nelVOlMfS~and insomnia.
Contr.indi u tions: Contraindiutions i!l(lude narrow-.Jnglt glaIKoma, myas-.
theni<! ~rnis,.J nd obltruct~ diINlrs of tht gen nOUfina!), and Gl mID.
INTERACTtONS

Drug-Orug: SI>nztropft n_1I with ~ drugs.For OI~,JMonztropine

IhcUd HI bf takton with akohol, triqtic. antid~1I, 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 ~dopamilf rMROI"
oKINltiIn of thf dopamine fKepto! !IW)' produa additi'll' elfKiI. HaIoptridoI
dt<ruIo!I elfKti"lf!ll%
.l.ntii:lIMlliws,phfnothialints, ~diloP'framidf ~t~,andqLini:linf
ilKlM!' antidlolinHgil: tflKlI,and antidiafll"lNb may oiKrtH oIb\o!ption.

nY,

La b Ii5IS: l.Intnown
Herbi~Food: Unhown
Treat mt m ofDlfrone: Physostigmine salKylatt.110 2mg 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}

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>

l
"

."~

26 4

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 neurotransntitter. Because acetylcholine is a major neurotransmitter 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 areas 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'sDisease

Drugs are used to slow memory loss and other progressive
symptoms of dementia. Some drugs are given to treat associated 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.

TABLE 20
Drug

20.6 Treating Alzheimer's Disease

with Acetylcholinesterase Inhibitors

Acetylcholine is naturally degraded in the synapse by the enzyme iI(etylrnolineteIllSl'(Ac:hE). When AchE is inhibited, acetylcholine 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, probably because so many neurons have died; increasing the level
of acetylcholine is effective only if there are functioning neurons 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 enhance the parasympathetic nervous systl'lll (cbapter 1300).
The GI system is most affected, with nausea, vomiting, and diarrhea being reported. Of the agents available for AD, tacrine
(Cognex) isassociated with hepatotoxicity. Rivastigmine (Exelon) 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 interaction with the N"methyl-D-aspartate ( NMDA) re.::eptor. \'/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 reducing nt'uronal calcium overload.

41 Acetylcholinesterase Inhibitors Used for Alzheimer's Disease

Route and Adult Dose (max do' where IndIcated)

Q ~zi hydrodlloridf lAri:tpt)

PO; 5- 10 mg ,t btdtim~

gaiant,milt (Rmdynt, Remin)'l)

PO; Initiall' with mg bid for i11lmt 4wi!; ntolermd, may

illU!iII' b)' 4 mg bid Mry 4wk 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,)

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Adverse Effects
Iwdod'f,dillifJt!~ immmi4 fJQlIItIJ,dQ~ romiring,

mIIlCk mJIJj!~ aroraio, Qlldomiool poi"

HepatolCJ:idty

''''Plfr 20

Drug<; for ~~ tIw Dlsea ..... oft"" Ner""". 5)'-aem

265

PHARMACOTHERAPY ILLUSTRATED
20.2 Alzheimer's Drugs Work by Intensifying the Effect of Acetylcho line
at the Receptor

Characturizad by RbnDlTTloOl 5truc1ulas in tho bnOn:

~di .
ThII brain ohrinu .
Mumory is lorst

Cholinergic: nuuron-

Drug thenpy foc u... on _ t oring or e """""ina

-Wlc:ho .......... in the bnoin .

Cholinest"'.... inhibitor:!
'"9: donapuzi

Fac10re reaponeible for brIIi n coi l d..n

includ e e~o...iV8ln1 n..,,_on of gk.aa mate .
Drug th .... py:

Normally:

o Ach is .",..."ad.

Normal rde 01

E) Thu action 01

N-methyl-D-espartate (NMDA) receptor agents

~:

--no

Ach binds with

its .cup/or.

memrrntino

in a v... t array

Ach is terminatad
by AchE.

ofbrain
functioN ,
incUding the

o inhibited. Ach is
H AchE is

Combination drug the. apy:

donapuzi and "",""",tiM

ability to
speak, """"'.

.......

notbroken down
as quickly and
producea a. mON
dramatic: ellec1.

.... think,end

ChoIine.gic .eceptor

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

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elimination. There is evidence that memantine may be effective in the treamlent of vascular dementia.
Although acetylcholinesterase inhibitors have been the
mainstay in the trea tment of AD dementia, several other
agents are being investigated fortheir possible benefit in delaying the progression of AD. Because at least some of the

266

Until

The

/IIeIv"",, System

.... Prototype Drug

Donepeztl (AT/apt)

Therape utic (lass: Alzheimer's disease agent

Pharmacologic ( lass:

ACTIONS AND USES

Do~il is ~n AchE inhibitor that improyes IIII'mory in (.1m of mild to moderate Alzheimers demtntia by tnhandng tilt effect; of etykholilll' in nt\Irons in th!o cmbl'ill corti'll th" haYe not)'e1 btm damaged. P~tients should
rKtivt ph~rrnacothtr.lpy 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' ofttn Ihort lil'd,and tlltdeg~ofimpro''mem 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

Acetylcho~nesterase inhibitor

ADVERSE EFFECTS
Common side tffNII of dolll'ptzil all' vomitioo. diarrhea. and da~ed urine.
CNSside eflecli include insomnia,syncope, deplI'Ssion, headKhe, and initability. MlJI(uloili leta Iside efleo:t; inckKie mUl(Ie cramp!, arthritis, and bolll' hcNit!. Gene~lizM sid~ effects includt Ile~t, 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 disease Ihould lit monitoll'd carefulI)'.
Contraindications: DolII'p!'zil is contl'ilindic:a!ed in p-atienll with 61 bftding
<l ndjaunditr.

Gift mtdiution prior 10 btdtilll!'.

INTERACTIONS

Mediution is molt effeai!' wherl g~n on a I\'9ULtr sdltdule.

[)ug-[)ug: Oonfpelil wi GltI\f intidlolinfrl,tG to IN< It2; eIIectM. ~ril

in!eram with \f\'erilllllhfr dllllJS. F(f !Llmple, bmanedlol (itMI aIYner~

PII'9I1aIK)' <alf901)' C

PHARMACOKINETICS
Q-/set: Less than 20 min

Pt,ak:Hh
Half~ife: 70h
Duration: Variable

fffm~,phfn)1oin,~,andrfMllpilmay!pffd!he

HnWr:KIn of OOnrp!zi.Quinidi~ (f bllKOnarol! may in~bit!he mlt.Jbolilm of

OOnfpezil 8Kil111' ~ril am by incrtaling dIOIinII9ic:mily,1WII
p.aroll)m~ 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 effen 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.

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 o lanzapine (Zyprexa)
may be used to comrol these episodes. Conventional antipsychotics such as haloperidol ( Hald ol) 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 agitation, may occur in AD patients. Anxiolytics such as buspirone (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 depression interferes with daily activities (chapter 1600).

For the complete nursing process applied tv anticholinesterase

therapy, see Nursing Process Focus: Patients Receiving Pamsympathomimetic Therapy, paxe /41 in chapter / JOO.

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MULTIPLE SClEROSIS
Multiple sclerosis is a chronic, inflammatory, autoimmune
disorder found most prevalent among young adults. Sensory and motor deficits become progressively worse as the
patient grows older. If treatments are started early, the frequency 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 axons 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
neurolo~icdysfunction, which pro~ress at a fairlyrnpid rate .

(""'If I 20

Drug< fOI ~.tfv1o D""a ..... of ,"" Nervoo. SY;lem

267

TABLE 10 S I Disease-Modifying Drugs Used for Multiple Sclerosis

On"

Rouu>and Adult Dow (max dose where Indicated)

Adwrse Effects

IMMUNOMODULATORS
Oizzi~ hwIocht\. Wfaknru,ronillli<l1. Qntry,
mtmd dfprruion,(miJn(/jy;m.irrhi~ rDMII,
KlmitirJ;,ronJripOOon,diorrlIto,I6l!Q/dyifrJnrOOIi,
IWNri~ mmsrrua/ dilordm,.lIMIOfHrio,. ~kf

glaliram~ ac:~t~ (Copaxont,

mpoIymtrIJ
intffifron bttI1~ (A~x. 1Imf)

IM;30f1l(g OIK~ (IfIWffk

SC;44 f1l(g thrtt ~m~ptfwerk

intffifron bttI 1b (BetaltrOllj

SC;2S0f1l(gMIYOIlltfda,

nat~lizum.lb (T)'Iabn1

IV; 300 mg infwd ()ftf 1 hMIY month

sympfOm\.!pIISIkily,~ ll'O(~m

ar IIw injKoon w

SMm,inap/rllam,hmalotoximy!p!U!'tOusilgJim

IMMUNOSUPPRESSANTS
mitoxantront (Ncwantront)

IV; 12 mgim' MIY 1 months (iletiM max: 140 mg/m'J

1iiwlfQ, K>miri~ 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 clinicians and scientists suspect genetic or microbial factors
due to reports that in most cases, MS occurs in regions of
colder climate. One thooryproposes acquired immwlOlogical 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 indude fatigue, heat sensitivity, neuropathic pain, spasticity,
impaired cognitive ability, disruption of balance and coordination, bowel and bladder symptoms, sexual dysfWlction,
dizziness, vertigo, visual impairment, and slurred speech.
The course of MS is unpredictable, and each patient experiences 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 patients with recurring symptoms. This is the case for patients
diagnosed with relapl~-rrmitting 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 J ZOO )
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

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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 severity of MS symptoms and decrease the number of lesions detected 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 concerns 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 basic 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 prefilled syrinses th~t can be stored al room temper~ture 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, weakness, infection, pain, nausea,joint pain, anxiety, and muscle
stiffness are common effects experienced with the immunomoduiatofS.
For progressive-relapsing MS, mitoxantrone (Novantrone)
is the FDA drug approved for MS patients who have not
responded to interferon or giatiramer acetate therapy. Primarilya chemotherapeutic drug, mitoxantrone is substantially 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.

26 8

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.

20.5 Alzheimer's disease is a progressive, degenerative disease

of older adults. Primary symptoms include disorienta tion, confusion, and memory loss.

20.1 Parkinson's diseaSl' is characterized by symptoms of

tremors, muscle rigidity, and postural instability and ambulation caused by the destruction of dopamine-producing
neurons found within thecorpusstriarum. The underlying
biochemical problem is lack of dop.1mine activity and a related overactivity of acetylcholine.

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.

20J The most commonly used medications for parkinson ism

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.

20.7 MS patients often have recurrent episodes of neurologic

dysfunction, which progress at a Iilirly rapid rate. Symptoms 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.

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

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.

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.

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
w~k>.

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.

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The nurse discussed the disease process of multiple sclerosis with the patient and caregiver. What does the nurse
explain is the cause of AD~
1. The cause is unknown. Amyloid plaques and
neurofibrillary tangles have been found in the brain ~ t
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 ~ ging 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 overdose, 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.
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

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

the nurse if this new medicine is appropriate for her husband

to

take. How should the nurse respond?Whal teach -

ing should be donl'?

mUd lndlgeslloll, and also takes multivitamins dally (vItamins A, B" D, and El. She also has a history of diabetes
mellitus type 2. What ~ouJd the nurse include in teaching

Su Ap[nndjJC D for II nSWaJ lind rariou<lltl for ali llcriY;litJ.

for this p;!tient!

-----==-i~-----,

2. A p;ltil'nl Is on Ie-ooopa and benztropine (Cogentin).

During a regubr office fOllow-up, the p;1tienl teUs the

nurse that she is going to Arizona in July 10 visit hergrand_
children. What teaching is importan t for this patient?

3. A 67-yeu-old Alzheimer's patient is on donepezil (Arlcepl ) and has a history of oongeslive heart failure, diabetes
mellitus type 2, and hypertension. The patient's wife asks

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~LORE ~

M)NImllngKllIli \'OUr one SIIJII !er anllfII! c!laptlf lB'fiew mmeriols and
ruourcet. Prepare lor ~ess wim aaditional NClEX"~e practice
Q~ irrhr.lctilltlllSlOgm>IIIis lnI ao;ti'lities. WIIb I~ anDil\i0n5
and vicIoos, and mae!

lIeQ.tSter '1W' a~~ss rode from lhf ffor<t 01 your boot. at

W'I'IW.IIIfIlurAl~kit.com,

Drugs for Neuromuscular

Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES

CENTRALLYACTINGMUSCLE RELAXANTS rx.1n

Aher reading this chapt~, the jtudmt should ~ oble to:

o cyclobenzQfK~ {cycoflu. Fiexerfl}

pqJtll1

DIRECT-ACTI NGAHTISPASMODICS fX1IJtm

o danuol4'n. sodium (DrmrtlumJ IU}t 115

Nondtpolarizing81ocktrs
~ arizi ngBlocb rs

,.]78

PfIfItm

1 . Identify the different body systems cont ributing t o mU SoCIe movemen t .

2 . Discuss nonphllrmacologic 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 skeletal musc le

reillunts, direct-acting antispasmodics, Md skeleul muscle rellixan ts

for short medi(a! procedures.

6 . For each of the drug classes listed in Drugs at II Glance, know

representlltlve drugs,and expl~l n their mechanisms of action, primary
actlons, and Import~nt adverse effects.
7 . Use the nursing process to care for patients who are receivi"lg drug
therapy for muscle spasms.

KEY TERMS

doniupmn paqt m
dystonia {lDgt 171

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lIIU5dupUmi p:IIJt 1lI

nturOlllU5CUlar bIcKlim

paiJt lIS

o..plfll1 DrugsfOfNI'U.omusrularOlsor<ier,

isorders associated with movement are some of the

most difficult conditions to treat beca use their underlying 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 prope r 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 muscu lar disorde rs associated

with muscle spasms. spasticity, and treatments involving the
neuromuscular junction. Many of the drugs used to treat
muscle spasms are distinct from those used for spasticity.

271

PHARMFACTS

Muscle Spasms
Moll' than 12 million PfopIIo worldwide hal'!' musc:1e 'p,nm,.
MUl(le!palms Il"'Il' t llOU9h for drug ther~py ~Il' oftt n found in
piltitnts who h~I'!' othtr dtbilitating disonle~ SIKh II mokt, inju!)',
ntUrodegener<lliYedise.J~, or U'lt'br~1 pillS)'.
Cmb~l p~lS)' is usu~lly i!5O(iattd with n'ffill that O(cur btfort or
dJring birth, but miy lit acquired during tht fi~t ftw months or )'Nnof
life II the ~k ofhtid trauma or inftion.
Dystonia iffKts iboot 250,000 JlNple in the Unittd StattS; it is the thild
most mmmon moY!'ment disordt~ following esltmial tll'mor ,nd
Parkinson'ldisem.
Rrl!'ardll'~ ha~ ft'(ogniZl'd mukiple fonmofinheritable dystonia ,nd
idtntified at lem 10 getlHor(hromosom,llo!atioll! Il'sponsible for tht
mioul maniftst~tionl.

MUSClE SPASMS
MUlde spasms are involWltary contractions of a muscle or
groups of muscles. The muscles become tightened and develop 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 antipsych otic 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 con t raction
is a tonic spilsm, whereas multiple, rapidly repeated contractions 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 o r cold, hydrotherapy,
ultrasound,supervised exercises, massage, and manipulation.
Pharmacotherapy for mU5Cle spasm may include combinations of analgesics, anti-inflammatory agents, an d centrally acting skeletal mU5Cle relaxants. Most skeletal muscle
relaxants relieve symptoms of muscular stiffness and rigidity resulting from muscular injury. They help improve mobility in cases in which patients have restricted movements.
The therapeutic goals are to minimize pain and discomfort,

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increa,~ range of motion, and improve

to function independently.

th~

patient', ability

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 inhibiting upper motor neuron activity, causing CNS depressant
effects, or altering simple spinal reflexes.
Antispasmodic drugs are used to treat local spasms resulting from muscular injury and may be prescribed alone or in
combination with other medications to reduce pain and increase range 01 motion. Commonly used centrally acting
medications include badofen (Lioresal), cyclobenzaprine
(Cyroflex, Rexeril), tizanidine (Zanaflex), and benwdiazepines 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), produces its effect bya mechanism that is not fully known. It inhibits 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. Badofen 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.

272

Unlll Thi'Ne<vDI"Sy'tem

TABLE 11. 11 Centrally Acting Skeletal Muscle Relaxants

Dru,

Route and

Adult Dose (max dose where Indicated)

IOOoI'ffi (Lioman

PO; Smg lid (max:80 IJI9/day)

cariIoprodoi (SofN)
dllorphen~n (~I~ )

PO;lSOmgtid
PO; 800 mg tid 1Il~1 dfMiw'; rt'duu to 400 mg qid orlm

dllorlOWOO~ (P.uaftu. Parafon RKI~)

donmpam(Klooopin)

PO; 150- 500 RIg tid-"d (mn:] glday)

PO; 1.5 mg tid, may ill' iI~ in irmnltnts of 0.5- 1.0 mg

Q dobtnzaprilll' hydnxllloridt (Cycollu.

PO; 10- 20 RIg bid~id (max:60 mglday)

Adverse Effects
l"Jr<:wtJint55,dizmts~dry

_.\ mIotiOfl,illIDiQ, i g/lr-

htodeiIMI~ urioory IrrirQncy Qf rmnrion, hypowllilfI,

bradta!rdQ
[dtrna of 10m. anaphylagi< rt'a(!ipn, rrspiratO!Y

deomsjoo.(oma /aryngo>Mm.wdmw/ar(o!!apse

~myldays

FIo.rol)
diazrpam (Valium) (1ft' palJl' m for

PO; 4-10 RIg bid~id

tilt ProiOlypt' Ilruij box 00)

Ior.izrpam (A/ivan) (~pagt ISS for

lMIlV; 1- 10 mg. Jtpt'it if III'~ ill-4 h

tilt ProiOlypt' Ilruij box OC

IV pump:mililttl m u lion 011 5mglmin

PO; 1-1 RIg bid-~d (mal: 10mg/~)

1III'IaXi/ont (5k~Qn)
IIII'thw~moI

PO; 800 mg tid~id (max: 10 mg/dayl

(Robaxin)

PO; 1.'i 9 qidfor 1-1 days;thtn rmn 10 1 9qid

PO; 100 mg bid

0Iphtnadri1ll' cttm~ (8in~I,Atxon,

M)'oIin,Norllu)

lizanidilll' (bnaflex)

Prototype Drug

Cyclobenzaprlne ((ycof/&, Flexenl)

Therapeutic ( lass: Centrallyacting skeletal musde relaxant

Pharmatologit ( lass: Catecholamine reuptal:e inhibitor

ACTIONS AND USES

C){lobtrJzaprifH' rt'1~ m16d~ spilmsolloul origin withoutinlerfloring with
gtrl~ral mUlde funnion. Th is drug am by .Rprt'lling motor activity primarily in
IIw brainst~m; limit~d ttfem abo ouur in th~ spioal toro.C){lobfnzaprine in(rt'i~ cirrulating ito~1s 01 norepilll'phrin~, 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 (,J~ of acute mustito Spi\tic:ity,
but it is not ~flettiYf in (amol(~rm-al pall)'or disNs~s oltlw brain ind spioal
(oro. This rntdiution is fllNnl to providt th~rapyloronly 2 !o 1 Wffks.

ADMINISTRATION ALERTS
Th~ drug ~ not rt'(Ofllmtnded lor ptdimic: 1M.
Mn imum effKh may tau 1 to 2 weeks.
PrrgoallQ talf90lY B

ADVERSE EFFECTS
~rst rrauions to (){Iob~nzaprin~ indude drowsinffi, blurred vision, dizziIII'SI, df)' mouth, rash, and tathycardi.l. 0111' rt'~aion, ikhough rarf, is swelling of
thetongUl'.
Contraindiutions: CydobtnLlprilll' should bf used with mnion in palitnu
with MI, d)'srh)'thmias,orlf\'t'r~ uroio-lwlardis~~SI'.
INTERACTIONS
~-Ilfll!l:

Akohol, ..... oothiaziws,and oIhPr 0iS dPp"~nts 1IW11aU\f iIiIii"ll'

\fdaI:ion.C~1hoUd 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
T~tment

01 OYl'rdose: TIw

im~nous

administration of 1 10 1 mg 01

p~ostigminf \;I1ic:)ia~ is r~por!fd to ~rsts)'rtlp!oms of poisoning by drugs

with antitholilll'rgic: .Jdivity. Physostigmilll' may bf h~lplul in the !rt'aun~m 01

PHARMACOKINETICS
1h

()}stt

Pt,a k:l~h

HalHiflo: l- ldays
Duration: 12- 14h

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qdobtnzaprin~ ~.

Ro>Ii'r Ie MyMIsJni}D (Qf~ MNlgI'rOCt5.1FlxlllspK/II( ~ /M1t!!g.

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 hallucinations. 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). Benzodiazepines 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 remain 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 refiexes, muscle spasms, scissoring (involuntary crossing of
the legs), and f~d 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. Etiologies most commonly associated with this condition include
neurologic disorders such as cerebral palsy, severe head injury, spinal cord injury or lesions, and stroke. D)'5tonia, a
chronic neurologic disorder, is characterized by involuntary muscle contraction that forces body parts into abnormal, 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 affect 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 adequate in reducing the complications of spasticity. Regular
and consistent physical therapy exercises have been shown
to decrease the severity of symptoms. Types of treatment include muscle stretching to help prevent oontractures, musclegroup 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 antispasmodics that act at the level of the CNS, neuromuscular junction,or muscle tissue.

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COMPLEME NTARY AND A LTERNATIVE T HERAPIES

(ayenn; for Muscular Pain and Tension

u)'!'lInr ((apric~mal!llllll), al50 known as chili prppr~ paprika,or red flrPpl'~
has bffil us~d as a II'medjo for minor musdt pain or trnsion. Caps.! ici II,thr II( ti~ ingll'ditm in (a)'~n~ diminisilts thl- chtmical m~~ngt~ thit Ir;r;ei
thlOU9h th~ ~n501)' ntMS, thtrrb)o dt[ll'asing thl- Sl'II sation of pa in (~eison,
Rag;:n, Ilfl~ khiyaml,& Iwamoto. 2(04). Capsaicin (lI'am (0.025%100.075%)
may bIo applitd dill'niy to tht oIffffi~d ar~oI up to bur times a dajo.1ts elem((\JmJIatH ~r tilllt, 50 (lI'ams containing (aps.!icin netd to bIo oIpplitd II'gUla rtyto bt tffe(1iv~. Although no known mediul (ondition Hists that would
prmot th~ u20f (oI)'etlnt, it should nrm lit oI pplied Ol'rl" brokrn ski~. [I([~r
nal U~ of full-stll'ngth (a)'l'nnt should bIo limited to no Il1011' than 2 days beuu~ it mol, (oIlM skin inflammation, blistm, and ukm.1t also I"ftds to bt
boplaway from ~ and 1lIK0IJI membran~sto oI'1Oid bums. Hands nUit bt
wasllrd thoroughly aft~r usr.
(l)'etln~ lIIoIy 01110 btyken fordiges~probltms,but Mdtnaofd~
nessfor this indication is Iacking.1t isal'ailablt in upsults, 30 10 120 mg,tair.tn
th~ lime.dlily,or I. lIN by Idding 11410 1Ill>pof powder tOI <upofboi~
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 neuromuscular 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 sarcoplasmic reticulum is necessary for skeletal muscle contraction. If the release of calcium is blocked, muscle tension
will be reduced. Other direct-acting drugs indude botuli n wn toxin type A (Botox, Dysport ) and botulinwn toxin
type B ( Myobloc ), used to offer significant relief of symptoms to people with dystonia. Direct-acting drugs are swnmarized 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 muscle relaxant for patients with dystonia. It produces its effect
by blocking the release of acetylcholine from cholinergic
nerve terminals (chapter 1300). Acetylcholine is the natural neurotransmitter necessary for the voluntary contraction of skeletal muscles.
Because of the extreme weakness associated with botulin um, therapies may be needed to improve muscle
strength. To circumvent major problems with mobility or

274

Unltl TheNe<vomSy,lem

PHARMACOTHERAPY ILLUSTRATED
21.1 Mechanism of Action of Direct-Acting Antispasmodics
Spaeticity.

s...,......... oontncting

Admirielnltion of . ntiapurnodic.

Dependent on calcium release

Botulinum toxin AlB (Botox:

MyobIoc) blocks reI_ of Ach.

Dantrol _

Symptoms:

(Dantrum) bIocke

calcium rei ........ within muscle.

Pain
InvnobOlity
lnabiity to perform ADl..e
Myofibrilo

\
(myosin)

=~_ n"o f>lamenla

(actin)

R89Ult of druI:Ilhempy;
Reducad pain
Mobility
Greater ... nge of muscle activity

Initiation of new
Relaxed muac:l...

impul ....

TABLE 21 .2 1 Direct Acting Antispasmodic Drugs

Roull' and Adult Dose (max dose where Indicated)
Drug

Adwr,e Effects

NEUROMUSCULAR JUNCTlON

botulinum tOIin t)"\I!' A(Botox, 0yIp0rt)

botulinum tOIin t)"\I!' B(M)'ObI)

25 !Il~1 injectfd dirKtly into targ~t muldf (max: 3O-day 00Ie

Ihould oot 9fd lOOunitl)

IIeodQcN, dylphoqio,.prOli~ fouirmlllle ~

poi", rnuJdf rm1emru

2,500-5,000 uri61doll' injtaftl dirffil)' into tir~t mUldt;

Anapbylaxh dnp/ygja dNfb

do~ stOOd lit dimlfd~mon9 musdt 1JOUp!

SKELETAL MUSCLE
Q

~ntroIene \Odium

(Oantrium)

PO; 25 mgldar. inul'aII' to 25 mg bid-~d;may iooull' fflf"I

4- 7 dayl up to 100019 bid- tid

Irdies indkit~ wmmoo ad'IffII' ~ffil;.!!!l!i!mi!li!l indkite II'rioui illmll' ~rm.

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MUIdt _~dilli~ diorrhtG

HrMk ncrut;

&

LI FESPAN CONSIDER ATIO NS

H OME

The New Fountain of Youth?

Muscle Relaxant Therapy in the Home Setting

M .n t~ new foonuin of)OOlh, botulinum ttI. in I)'pt A(801011 Cosmetic)

injKtioM Mft' approYfd II)' t~ FDA for t~ Irmporary improl'flllt nt in tht
apptaran~ of moder.ltf 10 stftft' frown lilli's (vMicallilll's btiWffll tht
brows) in iduh patimts aoged 6S ~ars or ~oongf[ It works 10 r5 u frown mus
des b~ blocking 00'/11' im~\lw that triqger wrinklt-<.iusing mlJl(ie [ootra(
tions. (lNting a ID!ooth 'ppearaIKt bttWffIl t~ brows. Administmd in .I
fM tiny injruions of purified protein, this minimall)' inv.nm ~Ullll'llt is
simple and quid:, and dtl~rs dramatic ft'IUlts with minimal discomfort Rt
IUIts un be In as NrI}' u 24 to 48 hours ah~ injKtion,and tht efftn I.Js~
up 10 4 mooths.lnjtctions shoold not be It'pNttd 1IIOft' thn oo(e I'I'II'f)' 3
mooths. Side efftns i~ hfada(~, nausu, flulikt symptoms, tt mporary
eyelid drooping. mild pain, erythema at the injKtion sitt, and mus[1e WNk
n6S.Ar:[ording to t~ Amtrican Socitty for ksthetic: Plastic: SuIlJfI)' (ASAPS),
BotOJ: injtrtions .1 ft' the f3l6t growing cosmetic: proc:tdlJrt in the inrustry.
Plastic: 1Utgl'f)' ~1S known as BoIOXparties- as wt'li as stminars, t'ltnings,
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 limited 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 associated with injections 1<; usually blocked by a local anesthetic.
~ Prototype Drug

C OMMUNITY CONSIDERATIONS

MUI(Ie sp.nms and !pa!tic:ity aft' ronditions that rna)' .Jlftct patients ttroughout 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 ~ated in the horn!'{(ommu nity sfning. Thus, all
igf groups aff able to be with thtir famil)' mtmbel'S and li~ as nollllli a life
as possiblt. T~ main factor to ffmember is that fdKation and ~pport for
u regil'll'rs is trtlt'me/y important to en~ring that patitnts aft' (ompii.-!t with
thtir therapy and that u regiven aff (om pttfm10 admin isler the t~rapy.

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 acetylcholine, thereby prewnting voluntary muscle contraction.
Nicotinic blocking agents are cholillergic (chapter 1300 ).
Neuromuscular blocking agents are classified into two
major categories: nondepolarizing blockers and depolarizing blocken;. Nondepolarizing blockers compete with acetylcholine for the receptor. As long as agents interfere with the
binding of acetylcholine, muscles remain relaxed. Bya related mechanism, depolarizing blockers bind to the acetylcholine receptor and produce a state of continuous
depolarization. This action first results in small fascic~lations

I Dantrolene Sodium (Dantnum)

Therapeutic (lass: Steletal musde relaxant

Pharmacologic (lass: Dire<:t-a(ting antispasmodic; calcium release blocker

ACTIONS AND USES

ADVERSE EFFECTS

D<antrolene is often used for spasticity, flpt(i.lI~ for spasms of the hrad and
III'dt It diff(t~ reinf1 musde spasms by int~rferin9 with thf ffl~.N 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< ;. ~'p<ciolly u..tirllor mu,d~ 'POID!' wI>< nIl><y 0<wr after spinal (ord injury or strokl and in ta\f"I of (frm-al palsy or mukiple
~is,and oc:taSion~l~forthe trtaDntm ofmusc:1e pain ~fter hNl')'l'XI'f(~.
k is ilso used fort~ tffalmtm of malignant hypMhennia.

Advern tlftm ifl(k.odt mUl(It WNknts~ dra.vsilll'l~ dry mouth, dizrilll'1~

nausta, dianhta, tac:hlUrdi.J, enatic: blood prfllUrt, photosensitivity, aid urinar)' ft'Iention.
Contraindi u tions: Patitnts with impairtcl wdia{ Of pulmonary /ufl(lion or
hepatic disNst 5hou1d not ukl thisdrug.

ADMINISTRATION ALERTS

U~

oral

!U~sion

within ~r.J1 days

btU!M

it dot-s not ronuin a

pr~lYilm.

IV solution has i high pHand theftfoft' iS l'lltft'lllf~ initating to tislUl'.

Pregn.JlK)' utt90ry C

PHARMACOKINETICS

Onsrt: 1~2 h
~k: 5h

Halflife: 4- 8h1V;8--9 hPO

Duration: Variable

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INTERACTIONS
Drug-Orug: ImIr<Wfle n\m[\S with many O!hef drugs. For e1am~, ~ moukilKll
bf tal:et withOT( lWgh ~ andantiJistJninei,akohol,Of OIher OiS
dtpres5.ln1l. Verapamil and other ukiOOl dIanneI bbders liter. with dan~!
inuNII the riIk ofYflltriruiaffibrilalioo iIIld urdc'Iilsuur~.

libTi5Is: I..Inkncwn
Herbi~Food: 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}

"

276

Unlll "TheNelvoo.Sy.tem

NURSING PROCESS FOCUS

PATIENTS R,eElVING DRUGS FOR MUSCl' SPASMS OR SPASTICITY

Assess ment

Potenti a l Nursing Di agn oses

BiSfline azess mfnt pri or to administrat ion:

Understand the ~J\On the drug his been prenriilfd in order to as~ for
therapMil fiff,ds.
Obtain a complete health hillory indudi ng cardmascular, !\'Spiratory,
IIepati<, rtni~ or muscuioskeltt.ll dile.Jm.Obtain <I drug hiltory inckiding
allelllies,QJlTI'm p=ription and OlC drugs,and herbal ~piration~ 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 ~lat~ to mobility.
II p~lI'nt illI'IS the iei'd al pain.lJII'objtd~ scrning tools whtn
possible kg., Fl.l(C (1i(t,limbs,arms,(ry,con\Olabilit~l lor inlams or ftry
young child~n, 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 st~ngth,and tht plI'Stnc:e of mUicle
Sp.lsms Jnd typI' honic,dooic, milltd).
AsII'\! the pititnt's i bility to rtl~Y!' and understand instructioo.lndudt
the family or uregilm U ~d

Pain (arultk hrooic,! (~lattd to rruscle sj)wl1s)

Impai~ Phy1K:al Mobility irel.ntd to arutt/rnronil piin)
SrI!.(a~ Dti"Kit (~ing. bathing. hygitne, toileting) (relattd to muscle
Sp.lsrtU,piin)
IMturbtd Body Image (~lated todisability)
Fat9Je
Dl'lKitm Koowledgt (drug thtrapy )
Rilkfor In~ry (ft'lattd to distill' condition,oJ~rwdrug tfftrn)

Assfssment through out administration:

AsSffi for dtsi~ therapeutil tfitllS dtpl'lldtnt on tht ~ason 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 ft'JICIn~clIea~latigue.drowsiness.diuintU,
dry mouth, orthosutil: hypotension, tKh)ocartia, palpitation~ s\Yl'ling of
tongue or fact,diplopia, ui nary ~tnlion, lianbea, or (onmpation.
Planning: Pat ie nt Goa ls a nd Expected Outco mes
The pitient will:
Exptril-nc:e therapeutK tfmts ~pendent on the ~ason the drug iI being given (f.g.,dti:rmtd mUl(lespasm Jnd pain,improvtd p~ilal rrobility and
coordination, and inc:rtJstd ability in !elI-(j ~ activities).
Bt flrt from, or txperierue minimal. ,dmst tfftru.
Verbal~ an uoderstandin 9 01 tilt drug's UII', adYent tfftds, and requi~d p!ff.lutions.
Dtmon strate proptr !ell-administration of tht milation (e.g., dOlI', timing. when to notify provider).
Imple mentat io n
Interve nti o ns a nd (Rati o na les)
En suring 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 \t'n~rntSS, 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
gradwl~ implO'fts with consiltent USi9f.)
Minimizing adftrse el"ffCts:
En !Ure patitnt saltty; 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'I trll'Yl'ral weeks but pain or Sp.lSI1ll filii)' aflrct motor
skills. P'nilular(;l~ with ambulation iI requi~ as piin,Sp.lsms,or
rigidity may inc:~alt the riskof lalls.}

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Patien t a nd Fa mily Ed ucat io n

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, spism~or rigidity ,ft' panicularly II"Ifrt.
As= the pitient~ familis,or (;I~sabilitytoGlny outADLs at horntand
tJ:pIoft' nttdfor additional htalth GI~ Ifierrolls ifdisabi~ywil rrqUR long.
tmn physical thtrapy (e.g., cmbral palsy). Evauate horne safe/)' nttds.
InstllKt the patient to iwid driving or other actiyities requiring men!al
,Ion_, or ph)'lial <oordin"ion unt~ tilt ri"Kts of tho drug Ire known.

NURSING PROCESS FOCUS

PATIENTS RECEIVING DRUGS FOR MUSCLE SPASMS OR SPASTICITY I C _

Implementation

Interve ntions and (Rationales)

Patient and Family Educatio n

(onlilut III monifDr vOl sic}ns, pirticularly blood PfmUIt. TiR ~ blood
pttUUIt IyiIg, ~iting,lnd stMllling fD deiKt orthost.tic hypot~miotL Be

partiwl.lrIy c.wtious with 0& adults wfto if! i11.n m:~~ risl for
~sion. HoI:ify tile hNIth Un! pmider if thf blood pl!SWIt

dtmlStS btyond tsUbIiWd poIrimtl~n 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! ~w.
(Imp_m ~ be o~ Otf dlt first wttt or!WO of thmpy.
Incrtuing ilbility of ROM.~ dKrustd muscle ttndtmm .nII rigid"rry
htlps 10 lIttftmine rffedM:JltSS of drug thffipy.)

le~ 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 im~eIy rtpOrt dizziness, lighl~
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.:hII pmitiollil support,qe:mit

TeiCh me pititm compltmtnury Piin inttfYtntions such is positioning.
muugf. ind moist ~t or ice plCb.(Supponi'le ooning melSUre may
gcfItIt mI:S~ .ppliu6oc1 arht" or cold 10 11M! p,linfuI illtil.distrattion
in(ltil~ 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-tffm1M of dIug.(IMdt rtl.lxants and i1n~smodic dllJ,ll mjf

"'USt

hepatotoxicit, is in ildYtlW tftt<t)

As~1 bowel ~nds 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 ~.w" d:nI.p 1M)' dltile peri!1iI1sis II
an .MM elJt. SigNlicandy dininished Of ibstnt bowm!GU1Id! a~
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
1M! ~u~ if !he constip.tion
isWlm.l

Tt,ch tht p.ltient to iIaNst lluick to 2 Lptf 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.

m.I,

pa" 10 Itport.ny swding of Ior9JIr. fa<t.

Anas fortof9JtOlt.cill swtling.(Ynliit Ii~CJdobtlwpMe ma,

CiIIM swing of tht tongut or t.t.nd should 1M! ItpOfttd immedi.ltdy.,l

InstrucllM
immrdNttly.

Al'Oid the 1M of othtr(16 c\tprHwllll.idJding alcol!ol ind lilt willi

CiIIrtion CDI'ICUntIllIy with antihrptrttnsiY! ~ions . (CHS dtpreswnts
ind akohol ma, inomt the ~ propmiH olthedrug.
Antihypmmw mtditalions 1liiY inumt risk ofhypotmsion.)

le~ 1M jlihenl to Mid or tliniNte *01101 whileon the d~ If othrr

~tivts 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.

Mstssforurinaryltl!ntion ptriodOIIy.(MusdtItLiunts and

antispasmodics may (Mf: urinary rtttl'ltion as In adVMt t~l)

InlUuct 1M patitnt 10 immediattly Ifport .n inability to Oid. and incrtasillg

bIiddtr presSUrt or pain.

Patlnt undtrstlllding of dl1lgtlltripY:

Ikt opJIOrtunitits I1lring administration of mtdic.ltlons 1Mduring
aSleSsJTltllU todiscuss the rltion.lt for drug thtrapy,dtsirtd tiltraptUlic
O\II(omn, moSI common~ oh~ advtrle elfKt!, pmmtltB forwhen
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 n~SHdministrarion of
tlwstdrugs htlps 10 ftinfon:t Itiding.)

Tht Piltitnt slloukl be ilble to stitt the ltiiSM fonflt d~lppropriilte dose
and schedulin!l.nd whit id'l'trst tflt<lS 10 obstM for ind whtn 10 report
thom,

TI .

Instruct tht prititnt in plOPtf idmiMtrarion guiddinn. Tht dow should 1M!
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 COI~

mit
EVAluation of Outcome Criteria
kahYIt tht ~I 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.

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Of Itwo.!

278

UnltJ

TheHe!vous~!tem

or brief repeated muscle movements, followed by relallation

of muscle fibers . Relaxation is short lived wl1il charges across
the muscle membrane are restored (repolarization). Importantly, patients treated with neuromuscular blockers area ble
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 ins tance,
acetylcho line does indeed bind to nicotinic receptors, but
the resulting actions are involuntary and do not invol ve
skeletal muscle contraction (chapter 1300) . Ganglionic
blockers dampen parasympatheti c tone and produce effects
like increased h ea rt rate, dry mouth, uri nary retenti on, and
reduced gastrointestinal activit y. They also dampen sympatheti c tone, res ulting in reduced sweating and less norepinephrine being released from postsynaptic nerve terminals.
A5 an example. meca mylamine (Inversine) is a ganglionic
blocker primarily used to trea t patients with essential hypertension (chapter 2JOC .
The classic exa mple of a nondepoJarizing blocker is
tubocurarine. Tubocura rine and related blocking agents are
used to rela.'\: the muscles of patients being prepared for

longer surgical p~ures (Table 2J.3). Although not preferred for mechanical ventilation or endotracheal intubat ion,
small doses of these agents may be used for intermediate surgical procedures (chapter 1900 ). Concerns of tubocurarinelike tre;atment are over-rdaxation of muscles. As examples,
normal breathing activity (involving the diaphragm, and
glottic and intercostal muscles) and swaUowing act ivity (involving the neck and certain esophageal muscles) require
contraction of skeletal muscle.
Depolarizing agents aJe used primarily to rela.'\: the muscles of patients receiving electroconvulsive therapy (ECf)
(cha pter 1500) and for shorter surgical prQCedures, for eJ\ample, mechanical ventilation and endotro cheal intubation
(chap ter 190"0). Succinylcholine (Anectine. Quelicin) is
the prototype example of a depolarizing blocker. Adverse
effe-cts include persistent paraJ~is in some patients, elevated blood levels of potassium. ma lignant hyperthermia,
and postopt'tative muscle pain. A5 a specifK antido te for
persistent paralysis, patients are often given cholinesterase
inhibito rs. Cholinesterase inhibitors also represent a form
of th eropy fo r diagnosis o r treatment of myasthenia gravis
(chapter 1300) and for the treatment of Alzheimer's disease (chapter 2()OO) and glaucoma (chapter 490'= .

TABU 21 .3. Neuromuscular Blocking Agents

Drug
NON DEPOLARtZtNG BLOCKERS

Duration and Admtnlstratlon ROIlte

itOOIilll1 (TrolUiwn)

Long dll"ion; IV

dwtracurilll1 (JrimbeJ)

Long dll"ion; IV

rIIN.KIIi1ll1 (Mifauon)

Shorttr IiJfation;lV

panatfOllilm (P,vulon)

Long dll"ion; IV

pipMRllilll1 (Arduan)

L~ dll'tion; IV

rorurooium IZmllIOO)

Long dll"ion; IV

t\boaQri~

l~ dll,ti(:n;oIde1t of the nontkpolilrirlng il9"ltl;milktmdlV iIIId 1M

vocwonilll'l (Momnn)

Long dllilion; IV

DEPOLARlZtNG BlOCKERS
Wi"khoIi~ dllarklt tAntj~()Ididn) II pq

~lm oooJ

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m for thf Pm1(lYP'

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 because 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 continuoU'ilycontracted, results from damage to the CNS. Ef-

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 nondepolarizing blockers and depolarizing blockers. Both
agenl5 bind to the acetylcholine nicotinic receptor, relaxing mU'ides by slightly different mechanisms and dura tion of action.

NCLEX-RN" REVIEW QUESTIONS

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.

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.

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.

A patient who was prescribed cydobenzaprine {Cycofle:!:, Flexerilj reports taking propranolol {Inderal} for

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blood pressure control. Appropr~1te 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 dri\~ myself home from the hospitaL~
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."
A patient who has been prescribed badofen (Lioresal) returns to the health care provider after a weekof drug therapy, ,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.

280

Unlll Thl'Ne<v"""Syn "",

CRITICAL THINKING QUESTIONS

1. A 46-year-old male quadriplegic patient has been experiencing severe spastkity in the lower extremities, making it
difficult for him to main tain position in his eleclri, wheel'hair. Prior to the episodes of spastldty. the p~tlent w~s
~ble to maintain a sl UIng 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 determine wh et her the treatm en t 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 can cer. 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?

LibraryPirate

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 physlcaltherapy. After 4 days, the patient reports b~ck 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

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M)'Mlrsi1~1ti! 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 .

U NIT

The
Cardiovascular
and Urinary
Systems

CHAPTER 12

Drugs for lipid Disorders

CHAPTER 23

Drugs for Hypertension

CHAPTER 24

Drugs for Heart Failure

CHAPTER 25

Drugs for Angina Pectoris and Myocardial Infarction

CHAPTER 26

Drugs for Oysrhythrnias

CHAPTER 27

Drugs for Coagulation Disorders

CHAPTER 28

Drugs for Hematopoietic Disorders

CHAPTER 19

Drugs for Shock

CHAPTER 30

Diuretic Therapy and Drugs for Renal Failure

CHAPTER 31

Drugs for Fluid Balance, Electrolyte, and Acid-Base Disorders

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Chapter 22
Drugs for Lipid Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES

HMGCoA REDUCTASE INHIBITORSISTATINS

After reading this chapter,

..

"

Q QIOfVQ5/orJn (Upllor) ptJIJt NJ

~~
Q cholesryramklp (OUes/ran) p:xJt 291

BILE ACID RESINS

NICOTINIC ACID (NIACIN) pxjtNJ

FIBRICACIDAGENTS pI1JI'l91

gemflbrozl/ (Lopldj {XIgt 192

CHOLESTEROL ABSORPTION INHIBITORS pI1JI'l9I

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.

KEY TERMS
ipoprouin (lQ9tl8J
.therosdtrosis tG'II'183
bilracidmin (!QtIt189
dyslipidemia pI1jl185
high-density lipoprotein (HDl)
HMG.CoA ~ductaS!' paqt 187

{OJ1183

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hyperc holrstrrolemia paqt 185

hYPfrlipidemia paqt 185
lecithin f<1jt183
lipoprotein paqt18J
low density lipoprotein (LOU paqt l8J
phospholipid p:lge183

cholesterol transport paqt'18J

rhabdom-,olysis paqt'183
strroid f<1jtl8J
sterol nudeul paqt]8]
triglyteridt paqt'l8J
mylowdensitylipoprotrin (VlDU (llTjlm
re"ftfSr

Choptor 12

esearch during the 19605 and 1970s brought about II

nutritional revolution as new knowledge about lipids

and thei r relationshi p to obesity and cardiovascula r disease

allowed people to make more intelligent lifestyle choices.
Sino, th.>n,advanc... in the diagnosis of lipid disord e rs have

helped identify those patients at greatest risk for cardiovascular 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 ca rdiovascu lar disease remains
the leading cause of death in the 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 important energy source. They account for 90% of total lipids in
the body.
A second class, the pho~holipids, is tbrmed when a phosphate group replaces one of the fatty acids in a triglyceride.
TIlls class of lipids is essential to building plasma membranes. 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 proposed as a remedy for nervous system diseases such as
Alzheimer'sdiseaseand bipolar disorder, but there is no definite 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 triglycerides 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 adequate amolUlts of cholesterol from other chemicals; it is not
necessary 10 provide additional cholesterol in the diet. Dietary 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.

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Drug, fo< Lipid Olsorde"

283

PHARMFACTS

High Blood Cholesterol

Tile incid!"fl~ 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 mal~dblood
dioItstrrollrYels (200 mgldL or abovr). This is4O% to SO% oflh~ .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 hal'('~led
dIOIeslerol.
To lower blood choltstero~both dim!)' cholesterol and satural~d fll!
II1II1 be Il'duud
F.m~ial 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 accomplish this transport, the body fornlS complexes called
lipo~teins, which consist of various amoWlts of cholesterol,
trigl)"cerides,and phospholipids, along with a protein carrier.
The protein component is caUed an ap~rotein (apo- means
~separnted from or derived fromW).
The three most common lipoproteins are classilied according to thei r composition,size,and weight orden6ity, which is
d ue 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 example, high-density lip~rotein (HDL) contains the most apoprotein, up to 50% byweighl. The highest amolUlt of cholesterol
is carried bylowd~nsity lip~rotein ( LDI.). ~ 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 U6~ 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
bu ildup and atherosclerosis. LDL is often caUed abad w cholesterol, because this lipoprotein contributes signilicmtly to
plaque deposits and coronary artery disease. Very low-density
lipopr~ein (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.
H DL is manufactured in the liver and small intestine and
assists in the transport of cholesterol away from th~ body
tissues and back to the liver in a process Cllled re"R~ moles
ttroltransport. The cholesterol component of the HDL is then

284

UnII4 Tho C.rd kIY. ",u lor .00 Url",,'Y Syl1efm

H- O -CH
I

H-O-CH

HO - C - CH,-CH2-CH,a-CH,-CH"-CH,-CH,-CHrrCH,, -CH,-CH,,- ele.

H- O - CH

Fatly , eid.

'----:'"
:c.,~
cc:,----~
~.c'------------------------:~
c,CyC~v
c.:~c,c.-----------------------"
( Hyd(ophl~e)

(Hydrophobic)

beckbooe

,H,

(b) Phospho lipid.

HC - CHl
I

CH,

,H,
I

CH,
I

HC - CH,
CH,

CholestefOl
(e) Steroid.
,.. Flgure22. 1 Chemlcalmucture of lipids

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Testostomne

type of hyperlipidemia that is most familiar to the general

public. Dyslipidemia is the term that refers to abnormal (excess or deficient) levels of lipoproteins. Most patients with
these disorders are asymptomatic and do not seek medical
intervention until cardiovascular disease produces symptoms 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 acquired. Certainly, diets high in saturated fats and lack of exercise contribute greatly to hyperlipidemia and resulting
cardiovascular diseases. However, genetics determines one's
ability to metabolize lipids and contributes to high lipid levels 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

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 considered "good" cholesterol.
Several terms are used to describe lipid disorders.
Hyperlipidemia, the general term meaning "high levels of lipids
in the blood,~ is a major risk factor for cardiovascular disease. Elevated blood cholesterol, or hypl.'rmolu tl.'rolrmiil, is the

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Although high serum cholesterol is associ.1ted with cudiovascular 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 obtained by measuring LOL and HOL. The goal in maintaining 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 Education 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 "borderline~ 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, compared 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 alternathe to cholesterol-lowering medications.

286

UnII4

Th<>(~ rd""'.",ul ..

and Url""ry Syne<",

many patients taking lipid-lowering drugs also have underlying cardiovascular disease, these lifestyle changes are particularly 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 pharmacotherapyshould be a therapeutic goal. FoUowingarethe
JIlusl iJJlPucl~lll lipid-c"d u~Liun li["",l rlt< inl"cv,,"tiuJls,

TABLE 21 .1 1 Standard laboratory Lipid Profilti!s

lYpeofUpld

LaboratoryValue
(mgldL)

Standard

ToIII~troI

<'00

~rabllo

LDl~troI

l1-m

Borderi~

>219

HiIj1ri51::

I <100
100-129

HOLdloitsttrol

TrigIy(ffidel

~imil

Bordtri~

160--189
>100

HiIj1ri51::

high risk

- Maintain weight at an optimum level.

- Implement a medically supervised e:rercise plan.
_ Reduce dietary saturated fats and cholesterol.

\lHyhighrisk

Increase soluble fiber in the diet, sum as that found in

oat bran, apples, beans, and broccoli.
Reduce or eliminate tobacco use.

low

<>"

Bordtri~

>W

~!irabllo

<IW

- Monitor blood lipid levels regularly, as recommended by

the health care provider.

Ne.uorabow optimal

1l1>-159

I <~

high risk

high risk

....,

1>0-199

Bordtri~ high risk

'<100
COH"

High ri51::
\lHyhighrisk

L IFESPAN 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.tientS i nd
mu~iplt 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 haY~ hyptrtension, diabetn, or 'Il' o~.lipid ItYels AlKtuar~ in
childll'n and t~nd 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' aggll'Sljy~ dietary thrliP\' and phlrmarommP\' 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 It'{omm~nded below
10 ~B of agt.The !latin d.ssofdrugs for Iowmng lipid 1n~1s in .~tl
haY~ 9'lined FDA approval, but the COll(Ml OI'I"r rhabdomyo/ysis has led to.
~lKtalKe to PIl'S(ribe thrm in .11 but pethiPS Htreme {I1f!. Chole5t)'f.mi~
(1).H,ItIin) .nd coltstipol (Cole5tid) also hal'!' FDA i PPIOIIII for hyJll'Kholtst~rolMlia in childrm, bur side ~flKU IOmetimtll"!lUlt in poor (omplianc~.
Until molt' lmiICh into standud~ It'{ommenditionl for pediatric d)'llipidemia 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 borderline laboratory values can controltl"leir dyslipidemia entirely through nonpharmacologic means. It is important to
note that all the lifestyle factors for reducing blood lipid levels also apply to cardiovascular disease in general. Because

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Nutritionists recommend that the intake of dietary fat be

less than 30% of the total caloric intake. Cholesterol intake should be reduced as much as possible and not exceed
300 mglday. It is interesting to note that restriction of dietary cholesterol alone will not result in a significant reduction 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 present. 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. Commercially, stanols and sterols are available in products fortified
with Reducol, fOWld in margarines, salad dressings, certain

TREATIN G THE DIVERSE PATIENT

Cultural Dietary Habits

Whfn dflrrtnt rultu ..1groups prrpill' kIOd iI tilt W81 thty haYe been taught by
their okler bmiy lIIfIIIbm.ir can be diffiruk to mlll9t dietlry dIoIettroi imalr.
For ~mple. uiHitional Hilp.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 w~ 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, r~ng habits whilt
mjoying their rultullll~ it is inportamto dler illtemativ~ ideas for plt'p.lring uiHitional foods .. thrr than Il'IIrictilg such foods .Itognhrr. Many new fthnic adcbooks a~ 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!fal btimalr.

Chopltl12

Drug' for Lipid O"",<le"

28 7

In the late 1970s, compowtds isolated from various species of

fungi were round to inhibit cholesterol production in hwnan

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 pathway, HMG(oA red uctase (3- hydroxy-3-methylglularyl coenzyme A reductase ) serves as the primary regulatory .ite for
cholesterol biosynthesis. Under normal conditions, this enzyme is controlled through negative feedback: High levels of
LDL cholesterol in the blood will shut down production of
HMG-CoA reductase, thus turning offthecholeslerol pathway. ~ 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

~el1.<

o n the

cere.ls, and some fruit juices. According to the AHA, the recommended daily intake of plant sterols or stanols is 2 to 3 g.

HMG-CoAREDUCTASE INHIBITORS/STATINS
The statin class of antihyperlipidemics interferes with a critical 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

l~horMory.

Thi.< d ...<..~ of

dnJg~.

koown

~.<

the

sit/tins, has since revolutionized the treatment of lipid disorders. Statins can produce a dramatic 20% to 40% reduction
in LDL-cholesterollevels. In addition to dropping the LDLcholesterol level in the blood, statins can also lower triglyceride and VWL levels, and raise the level of ~good" HDL
cholesterol. These effocts have been shown to reduce the incidence of serious cardiovascular related events by 25% to 30%.

""rf~ce

of liver

~elk

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

TABLE 22.2 I Drugs for Dyslipidemias

Drug

Routeand Adull Dose(max dose where IndIcated)

Adverw Effects

HMG-CoA REDUCTASE INHIBITORS

Q itOl'/alliti1 ILipilor)

PO; 10- 80 mglda, (mal:80 "'9Iday)

ftuViSLuin ILflll)

PO;lO "'9Iday [max:80 mgld~)

IUiiSLllin IM~ilJll)

PO; 10- 20 mg OII(t daily (mal: 80 m9f day immtdilHeiNIt;

60 mg!d~ UI~rdtilt)

piLlViSLllin ILNalo)

PO; H mg OII(t daily lmal:. "'9Iday)

pramlllln IPriVadIot)

PO; 10.... 0 mglda, (ma1:80mglday)

J05lNalliti1 (Cmtor)

PO;S-40 mglda, [mal:80l119iday)

~m\\llLllin

]Zoo:or)

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)

mI~ipd lColtltid)

PO;S-lO glda, in divided dosrs

1Itodocht,~~Dbdomin!1l(JQmpirrg. mydrjo. rml or

pruriJJJl
Rhabdomyoly~ ~

smn: my9Iiti!

-.

(omtiPQrioIi, 1lDUlf4 K>mirirrg.Dbdomin!1lPQ~ 1>Ioo~~

til Iran obsl!lK!ion, viLlmin rlffilitndts rur, to DW at~(!P!ioo

FIBRIC ACID AGENTS

dofibralt

l~tromid-S)

PO;2 glday i12 to 4divided rIosts

imofibrilt Oricor, others)

PO;S4l119iday lmax: 160 mgld~)

n,nofibrK add ITriplixl

PO; 4S- m mg OII(~ daily

Q gemfibroli ILopid)

PO;600 mg bid lmil: 1.soo mglda,)

Abdi:rni!oI pan. rash. m)l!~ foIiqut,ftJlik! l)'OOromf,

dylpf~, nou~ romimg,QJrMni~

Cholelithiasis. pa!\{I!~~tis

OTHER AGENTS

Hypmpidmlia:PO; 10 mglday

mlimibelZtti.l)

~rrtrrulrjo. fllligfJ, obd<:tnt!oI

pm diarrirfo

t!o II'riou) Vdc dfrcll

Hypmpidmlia:PO; 1.S- 3.0 glday i1 di'lidtd doltS lmad y'day)

fMMg.lICIU!f4pruriflJl,heododtt,bIoorirrg.diarrirfo

lIatindelidtnq:PO;l0 lOmglda,

DrnIriIlvniu

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"

"

I
;;

288

UnII4 TheCJrdkwasc:ubr.od Url",,'Y Syuem,

.......

". Figure22J Cholesterol biosynthesis and excretion

and to reduce mortality from cardiovascular disease. The

mechanisms of action of the statins and other d~ for dyslipdidemia 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 ra re 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 because 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.

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Much research is ongoing to discover additional Iherapeutic uses of statins. For example, statim block the vasoconstrictive 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 attempts 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 combination with the statim. Doses for these agents are listed in
Table 22.2.

ChoIU,12

Dwg' (or Lipid Disorder,

2B9

PHARMACOTHERAPY ILLUSTRATED
22.1 Mechanism of Action of lipid-lowering Drugs
Statin.
Interfere with HMG..coA
reductase, the aitical
enzyma in the bioe}<IthMis
01 choIeatOi
Niac in
Dec""""", both VLDl
and LDlfe""fe

.....

Bile acid ~. i ...

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 oflowering 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 Because of their large size. resiru; are not absorbed from the small
intestine, and the bound bile acids and cholesterol are eliminated in the feces. The liver responds to the loss of cholesterol
by making more LDL receptors, which removes ~n 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

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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 binding 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 (WeIchol), has more bile acid~binding capacity than the older
resins. It is formulated in smaller tablets that are easier to
swall ow, and fewer IlIblets are required per day.

2110

UnII4

TheC.,dklv.u:ub,.oo Urinary Synefm

'" Prototype Drug

Atorvastatln (Llpltor)

Therapeutic (lass: Antihyperlipidemic

Pha rmacologic (lass: 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 recepto~ on tht surfatt of lim (~Is. Tilt grtilter numhtr
ofUl rtCtptors in ~vtr cells ~ultt 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, ~tirnu 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 mo~e.

ADVERSE EFFECTS
~~ rfffCts of aTol'/aStatin IiIrt1y Iusr distominwtion of therapy.
HradldJr and GlllImpl.inu 9Jlh .s inttstinal mmping. diarrhea,.nd (onstip.tion art (ommon dUling therapy.A sm.1I ptl{et"l\lgt of ~tirnts rlperirnuo
Irmdam.gt;rhus, lIt~tic fur.ction is monitoltd during tilt fim few monrhsof
therapy. Tht most srrious adYent tfir(t is rh.bdomyol)'iis.
Contrain dications: (ontraindiutions intkKlt serious lim dise.1!', unoplaintd pmi!lt melevations of strum trans;)millilst~ and prior hypt~nsitiY
ity to tht drug.

ADMINISTRATION ALERTS
Administer with food to de<rtasr GI discomfort
M.y Ill' takrn at .n, tillll' of tht day.

I)ug-l)ug: AtOf'/illlalin interact! with ~ othrr drugs. f(If ~,~ filii)'

PrtgnallQ calfgOl)' X

PHARMACOKINETICS
Onset: 2wk
~k: Pblllu wllcl'nmtion, 1-2 h;(holl'stl'lOl reduaion,2-4 v.it
Hillflife: 14 h(20-10 h for aail'l' metJboiit61
DUlmon: Unknown

INTERACTIONS

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, !Jdospori~,aroI f antiflJlgals, m niaci\. Ethanol WUd bf
iMIidN ruirlg thfrapy bffiJUIf 01 mVIm on hl'patic hMion.
Lab115Is: lola, inoNIf IffIIm uansam iIaIf and (rr.Jti~ tinN 1tvPII.
IIfrbaVFood: Gripffruit juitf in~ibits 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 (Ml01,~tims IN,beOOit mwn (oQl0~.
M.nffllililnl 01 (oQl0 dffiOfocy iKlodP h9l blood prffllA', tongI5Iiw hMt
laim,.1Id Iowrnl'l1J~
Treatment of Overdose: Tht~ is 00 Spt(ifK tlNtment for OVl'rdose.
RI'I'fr III MytmJrtqKlr {Ix ~ MnJng I'rtxell Fool! sptd/I( 10 1M Ikug.

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 rtqJi~ 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
htan. salmon, broc:(oIi, spinach, i nd nuts. EIdtrfy peopit .pptar to havt an in(1!'.1ed III'td for(oOl0.
R~porn 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 ~"l CoQl0 "1<1)' bt bt".lic:ia Iin angina ptCtoris, dysrhythmias, ptriodontal diseast,im IllJne disordtB,
neurologic disul!', obtsity, diahttts mrllitus, .nd (tnain UnttB. Considerabit !!"Swd! his httn (ondittl'd on this 'nlioxidlnl.
Inhibition of tilt rnzymt HM G-CoA rtdJru ~ by rht statins dtclNStl CoO 10
Irnk. Many of tilt admS!' riffCtS of statins may lit due to tilt de(rtase in
CoQl0 Irnk, intluding mllKit wtamland rhabdomyolysis.Supplemrntation with CoQl0 may implO'/e m)':l~thy symptoms (O'RionIan, 2OOSI. Likf,
most dirtal)' supplemrnt~ mntrolltd rtS!'~f(h lIudirs art oftl'lliading and
gin (onAicting r=1ts. AI this tillll',nidentt to wpport tht lIS!' of (0010 in
trt.ting ~tiertts 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.

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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 antilipidemic 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
V I .01. level., ~nd h"""n.e T.m. i. <ynthe<ized fTOm VI.oI. The
patient experiences a reduction in LOL levels. It ~Jso has the
desintble effects of reducing triglycerides and increasing H OL
levels. As with other lipid-lowering drugs, maximum therapeutic effects may take a month or longer to achieve.
Although effective at reducing LOL levels by as much as
20%, nicotinic ~cid produces a higher incidence of adverse
effects than the statim. Rushing and hot flashes occur in almost 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 hepatotoxicityand gout are possible. Niacin is not usually prescribed for patients with diabetes mellitus, because the drug
can ntise fasting blood glucose levels. Because of these adverse effects, nicotinic acid is most often used in lower doses
in combination with a stalin or bile acid-binding agent. Taking one aspirin tablet 30 minutes priorto niacin administnttion can reduce lUlcomfortable flushing in many patients.

CIlo",0112

~ Prototype Drug

Drug' fcrUpld 0"",<1<'"

211 1

Cholestyramlne (Ouestran)

Therapeutic Class: Antihyperlipidemic

PharmacologicClass: Bileacidresin

ACTIONS AND USES

Cholenyramine is a ~r 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 int~tinf;thus, it
doe not proO:Ke any 'ystemic: tffKl>.1t may "kt 30days or Iongtr to prod!Kf
~s muimum Nfect. !luHlran bi ods with bilt, ac:ids (rontain ing choltslmll) inan
insoluble rompln that is ellert-ted in the re.:es.Choltslmll ~Isdfdine du!' 10

INTERACTIONS

re.:allo~.

ADMINISTRATION ALERTS
Mix thorooghly with liquid and hom the pam,m drink it immedia~ 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
~:Hwk

ADVERSE EFFECTS
Although dlOlIosryramillt rall'ly produces worious sKIt effeds, poatitnts may ellptritn~constipation. bloating. ljaI"nd nauwoa thit wm!'ti~ limit its UW'.
Contraindi m ions:Th is drug is cOllm indic:.Jted in patitnn with toLlI bilial)' obstruction and in th<M with prior hYpl'lII'nsitivity to the drug.

Becawe niacin is available without a prescription, patients should be instrucled nOI to attempt self-medication
with this drug. One form of niacin available OTC as a vitamin 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.

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 l!Ifdic:.Jtioo~
ChoIfnyraminf may iOONlf thf efIKts of illicOigUan151rf dKrMiIg thf lewis of
"liUmin Kil thf bod)'.

l.i b11511: \.a00l a\partat~ 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 ~!iaI nutrifnll:b.!tHarotfl"lf,takium,folK add, i1In,~OOI,
'litamin 8", -Mamin D,riLlmil E, ftamil K. and rine. ManifNations of nutritn!
dtpIftioo may i1cklde WNkeIII'd rnmllllt \)'11m, ooiovOOlIar probImts. ioo

OIIeopolfWi.
lINI ment of Oerdosr: Theil' is no sptcilic tft'aimem for ~rdose.
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 inhibits the absorption ofchol...terol. There is only one drug in
this ciass,ezetim.ibe (Zelia), which is listed in Table 22.2.

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")' remain 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 prescribed, other fibric acid agents, fenofibrate (Tricor),
fenofibric acid (Triplix), and gemfibrozil (Lopid), are sometimes indicated for patients with excessive triglyceride and
VLDL levels. They are preferred drugs for treating severe hypertriglyceridemia. Combining a fibri<: acid agent with a
slalin resulls in greater decreases in triglyceride levels than

LibraryPirate

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 absorption by as much as 50%, causing less cholesterol 10 enler the blood. Unfortunately, the body responds by
synthesizing more cholesterol; thus, a statin may be administered concurrently.

AVOIDING MEDICATION ERR ORS

Tht nUlle ,dministm tilt following 0,,1 medic:.Jtions orderrd for , 64-~a r
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_

292

..

UnII 4 TheCJrdkwasc:ubr ,nd Urinary Syuem,

Prototype Drug

Gemfibrozil (Loptd)

Therape utic ( lass: Antihyperlipidemic

Pharmacologic (lass: Rbricacidagent

ACTIONS AND USES

[ffKts of gtmfibrozil include up 10 a 50% ~lKtion in VLDl with an in~ in
HDL The me<hanism of achieving this action isunknown. It is Its. t fleo:tive than
the statins <II Io'ftring LDl; tIM, it i. not.J drug of first choict 101 ~lKing lit
Iel'els.Gtmfibrolil is u ken orally at 600 10 1,200 mg/!by.
ADMINISTRATION ALERTS
Administef with ml'ak to dKlI'iI!e GI dist~~

ADVERSE EFFECTS
Gtmfibrozil produc6 fM Iffious ad~ etrfcts, but it may inul'iIse tht li~lihood 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 impairmen~ II'~ 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

PrI'gnalK1 categolY B

anli<Ngulant ~Kn.Cooomntwwihstalits!hcdl bfawidl'd ~ thiI

irmDs thtrilko( rrtJOPaIhyanl ~GemIbOlilmay iIcrN'JIothtffflocG

PHARMACOKINETICS
DnSft: 1- 2 h
PNk: 1-2h
Halflife: I.S h
DUlation: l-4 months

dcfllii1anliiabeticigl'OO.!IaIin!,~andVtamin Kmgoom.

Lab Tl5ts: Ma inoNIf li'IH 1'IlI~\\Ik1e1,and QIIi m

IfIIIn ~ Iewls.May

dtocrI'aI.! hmIo9obin lllgll), hfmaIocrit IHct), ani WI( (011)11.

lk>ibaVFood: fait)' food! may droNIe thf !Ificaq of 9fIll1ibr0liL

Trl'atment of Dn rdose: There is 00 SjlfCifK trl'atment 101 OY!'rdo~
R#rt III MyIUIIngKl ror ~ MIsIniJ 1'roce\S Footl 'ipt(/It: IrIIM d"!Jg.

When given as mono therapy, ezetimibe produces a modest reduction in LD L of about 20%. Adding a statin to the
therapeutic regimen reduces LDL by an additional 15% to
20%. Vytorin is a oom bination tablet containing fored-dose

NURSING PROCESS FOCUS

combinations of ezetim.ibe and simvastatin. Because bile

acid sequestrants inhibit the absorption of ezetimibe, these
drugs should not be taken together.

PATIENTS RECEIVING LIPID-LOWERING THERAPY

Assessment
Bilst line aSHssment prior to administration:
Understand the Itilsan the dlug has betn Prl'lcribe<i in order 10 a!1f"SI for
therapeutic tifects.
Obtain a{omplete heakh histolY including cardmaKular,mU\{\JIos~1m1
(prt-existing (onditions that might rl'lUk in musclt or joinl pain).
ga>lrointeslinal (peptic uk~ dill'.J ~, hMIonboids, inllammalOlY bowel
disNse, chronic constipation, dysphilgi. or tIOphageilmiclUltS), and the
pos~bilityof prtgnalK1.0btain a drug histo!), including alltrgits,culR'm
pl~cription .nd OTC drugs. heib.1 prrpal~tion~and il kohol!M. ~ alen to
pos~blt drug intefactiom..
[nwte .ppropriate laboratolY finding~esptCiill~ li~ fUnction studits
and lipid profilts.
~I( th~ patiem's ability tQ lciYe and ullwmand inltruclion.lndude
family and cartgiYeIS as nredtd.
Asstllment throughout administration:
fol desiltd therapeutic effu (r.g., M~ total cho~eroI,lDl
It~k. in{lI'iIsed HDlIt~~).
CominUf periodic monitoring of lipid plOfiirs, liYef function lIudits, CPK
(UI'atine phosphol:illiSt), and uric acid ItYeis.
~Iffi for advet1t tlftm: mUl(ulosktieul dist:omfort naUSl'~, vomiling,
abdominal Clamping. diil rrhN. Se\'ffe muswloske\etal pa in. unexplained
muscle tendmiessaccompanied by fto~,inabilil)' 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 sl:in, ~
constipation, or straining with passing of lIook 01 tarry stools shoold be
It'pOrted immediattly.
~Iffi

LibraryPirate

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)

(1101'1" 12

NURSING PROCESS FOCUS

Drug. fo< lipid Disorder.

293

PATIENTS RECEIVING LIPID-LOWERING THERAPY (ConllnuMj

Planning: Patient Goals and Expected Outcomes

Ih~ pat~m will:

o

ExptritlKf t~raptUlic: flfects kg.,lowt-rtd total choottroU(l, illUNltd HDI., oormall~r ~nzym~).
or ~lptritlKe mioim'~ idv~B!' ~if1S.
V~rbal~ '0 uodtrst,nding olt~drug'. 1M, ,dv~B!' fifb, aod rrqJi~ prruutiom.

o ~ ~ from,
o

Demonmat~

proper~-Jdminimation of the mediation kg.,doIt, timirog. wh~n to notif,o pmvidtr).

Implementation

Inte rventi on s and (Rati o nale s)

Ensuring therilptutic effects:

Follow i ppropriate adm inistr,tion guideliotl. (Mill)' 01 t~ 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 a nd Fa mily Educati o n

Tfach the IHIt~nt to take t~ drug following appropriate guidelin~as

101101'15:
o 5lQl;u: Tau with e\\'IIiog mNl;awid graPffruit ,nd graptfruit juic:e,
whic:h could inhibit t~drug's metabolilm,luding to toxic ~~Is.
o Bile txidmim: T
i u beforr lIII'als with plenty 01 Huick,mixing powdtrs
orgraou~ thoroughly with liquid. bke01h~ medication. 1hoor
befm,or. houl! aft~~ t~ biif acid rr.in is uun.
o Nitxin: rake with cold Wirer todKfNII' fMhing. Takeollf adultlIrength (325 mg) aspirin 30 mioUl~ befm ~ oia.c:in doW'.
o Rift 0Ii1 agtM: rake with, lIII'al.

ElKoorige ,ppropriatr lin,.~ chin9f.:IO'Mrtd lat intau, ilKrr,Itd

--:- - - t -o, -.-oo ,,,,
- th!o pat~t ,nd fimily to idopt, healthy lifn~ oIlow-fat
I'nrtiW',limittd akohol iotake,and smoking c~satioo. PnMdt fordiMiIian
food cooic~,ilKrealtd I'Rrrise,dtaeastd akoool cOOlumption,and
cORlUkation <IS nttdrd (Hulthy li~s~ chaogrs will .uppon and
,rooking Cl'5mion.
minim~ t~ need for dlll9 therap)'.)
ElKoorq increased iotake oIom~Ij<I-3 ,nd COl'IIl)'IIII' Ql0-rich food,
(e.g.,r"h ruch" salmon and s.udi~, nuts,l!ltra-l'irgin oIi!' and ,,001,
oil~ bffi aM chic:un). Supplem~matioo miy be net'dtd; inllnKt jHII~t
_ _ _t-c"c""
= aclYice of a heakh c.Jfl' proYicIer befoll' wpplrotents 'II' taken.

Minimizing adftn f effKts:

CootinUl' 10 monilOr ptriodic: li!'r iulKtion tests and CPI( ~Is. (Abnormal
lil'tl" function t~ts or ilKlNs~d CPK if~1s may indicate drug-iodlKtd
ad!'11f ~tic eflem or myopathy ,nd should be rrported.)

ImtnKt th~ p,titm on t~ r.ttd to return periodic,11y for lib wall

o CootinUl' 10 as1f\S filr drug-rtlated S1mptom~ which rna, indicate acfo.mr

diem ~rl' ocwrnog. (Lipid-lowering drvg> ollen admnly a!fro the liver
but may also UUII' drug-spte:ifk aMB!' effects.)
o AsII'S' for po"ibil~ oIiocrt'aW"d aM~eflecll whtn I combination of
lipid-Iowfling i9fOB , rr ustd.(Lipid-lowering '9fOB may becombined for
~n~r ~fI.m but thi, ioc:re.W'S thf risk 01 ><I .... r.. ofj"K1S.)

5lQl;u: R~n unusual or uoupliintd muscif tfndemeu, ilKft'asing

mU\(if lHIio, numb~. or tingling 01 ~lu!"mit~s,or eff1S that hinder

nornul ADl actil'itiH.

l!ikood min<: R~n .rwft' n.""", hunbum. {oOltipnion. or
maining with IHllSing stools.Any urry !1oolsor yellowing 01 sclera or

If Iong-tenn th~rap)' is used, rRlUft' adequat~ inukt 01 f,t-50luble vita min,

(A, D,E, K) ,nd folic: acid in thf di or consider wppiementation.(lipidIoworing dllJ9l m, yUlII~ depletion or dimioished .bso'Ptioo 01 IMIf
nutrients.}

Tfach thf pat~nt t~ importan(folreponingYgn,or l)'IItptomS ft'lated

10 t1~ drug eifew al followl:

skin shoold ,150 lit rf porttd.

o Nitxin: Report llank,joio~or slOmach j)ain, or yellowing of .ooa or
skin.
o Filwic Qdd ogerm: R~n uou!W1 bletdiog or bruising. right upPfr
quadraot lHIio, muscif mmpiog.orchaoljl'l in t~ color of thr stool.
10stnKtth~ pit~m ukiog' combination oIlipid-loweriog drug! to ~
alert to l)'IItptom'lflattd to m~eflt{Bol.l!2!h drug~as ,baff.
10stOJ(tth~ pit~m aod family about foods

high io folic id and fattocoRlUk with t~ health "rf plO'fider

.bout poibio oord forviumin ,nd folic: I<id ,upplerntnmion while on
Ioog-term thffilpy.
lOIu~ vitamins <lod ,bout r.ttd

(Conrlnued)

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294

U,*4 The Cardlc;r,c:ubr and UrlNry Syst .....

NURSING PROCESS FOCUS

PATIENTS RECEIVING LIPID-LOWERING THERAPY (Coollnuedl

Im plementation

Intervention s and (Ratio nales)

Patie nt and Family Educatio n

Patitllt ulclentandlng of ~ thu,w.

1M op~ duri", ..tmin~l!<Ition of medic:atiom.nd during

~lIlMnts 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 .dnWliitfri", the rntdOtion.Wlltruct the ~tlndlor fanWy"
p!Opff Itlf-,.jmin~uation of ~t.g, 6Jring thtnrilg mNl.{UtibirIg

1M patient .ncVOf famil,!hooId be able 10 state thf _Io! drug;

apjlropriau rmr and 5dlfllul~whllarfvt.rw rifem loolMrn for and
when to rtpOft;.nd the lll00p.lted length of mediation thmpy.

1M p.ltient Ind bmily a~ able todilM! appropriatt dosn, and

Mmin~tracion ~.

time Ming ~-idministration of ~ drugs help! 10 ~nfoKe

ttichilMjlJ
Evalu ation o f Outcome Crite ri a

Evaluate the tffM~ntll 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" l~ II'IIt1I rlltst IIniI9 tdionI"

.;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.lliOcia led 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

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effedi~

for most patients and are drugs of choice in reducing blood lipid levels.

22.6 The bile add resins bind bile and cholesterol and aa:elerate Iheir eu:retion. These agents can reduce cholesterol
and IDL levels but are not drugs of choictdue to their frequenladve~eff~

22..1 Nicotinic add can be effective 3t]owe ring 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 an tilipidemic 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 cho lesterol

'lIop"< 12

Dfug' f... Lipid OMId.."

295

NCLEX-RN " REVIEW QUESTIONS

Th .. nurse assesses the patient on a stalin drug (HMGCoA 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 cholestero~ HDL,and LDL [{'WI&.

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

The nurse is instructing a patient on home use of oioolink add and will indude important

jnMru~ljon'

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.

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.

CRITICAL THINKING QUESTIONS

1. Identify the plan of care for a patient with hyperlipidemia
who has been pr~ribed 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
flashes.~ 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.

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EXPLORE

~.-----,

is yoor ooe SlOp for online CIl apler Il!'llew materialS 3f1d
reooorCOls. PlUl/are b IiUCCUSS IMtIl ad~ilional t~st)le practice
Quesliln3, Interacti\'e 8S3ilJlVllenl'l Bnd al:lNitie3, web tirK'l . IIllrmtlons
and ~jjeos. and mete!
M~rsing llJl

Aegi!;ler ~ ac ee~ roM from me tront of)'OO! IXlOIc at

_.myn ..smgkilc .....

Drugs for Hypertension

DRUGS AT A GLANCE
DIURETICS

pqJal

(0) hydrochlorothlOZidf (MIctozIde)

....

CALCIUM CHANNEL BLOCKERS

LEARNING OUTCOMES

,.4

p.1JtJ()7

CO) n!fed/plnf (A(/akll,ProcordIO,ot/lfrs)

DRUGS ,UFECrING THE

RENIN- ANGIOTENSIN- ALDOSTERONE SYSTEM

"",.,
Aiigiat~ii:;iii-(o ii..ertiii 9 EnlYm~ (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

Alrer reading this chapIn', the student should be ablt to:

1. Explain how hypertension is d an lfl ed.

2. Summarize the lo ng-term conseque nces of untru ted hypertension.
3. Explain th e effects of cardiac output, pe rl phe ra l resistan ce, a nd blood
volume on bl ood pre ure.
4. Discuss how the vasomotor center, ba roreeepto rs, che moreceptors,
emotio ns, a nd ho rmo nes Influe nce blood press ure.
S. Di~u ss th ~ role of thera~utk: l;fest",1e changes In th e manag<ment of
hype rte nsion.
6. Differen tiate between drug das ~s used forthe primary treatment of
hype rtension a nd those secondary IIgents reserved fo r persistent
hype rtension.
7. Describe the nurse's role in the pharmacologic m.iII'"IlIg-emen t of patients
receiving d rugs for hypertension.
8. Foreach of the drug classes listed in Drugs lit II Glance, know
representative d rug examples, and eKPIliin their mechllnisnu of d rug
action, prima ry actions, and important MJverse effects.
9. Use the nu rsing process to care fo r patients re<elvlng
antihypertensive drugs.

KEY TERMS

pu;tJI~

mdiK output rogt NJ

, hrmorKrptors pu;t N8
diumic: pu;t]1;8

ffftu tamycudia

ugiotenlin II rx;gtJIO
u giotfmiNOII'Itfting t nlynlf (ACl) (II1IJt J10

Intidiumichonnoe{ADH)

~ 1I.. r~nYon( HTN) pq197

strokt wkJ:nt

pl'riplwr. 1ffVstancr pq l<;B

yu0ll10l0f(tnltr pogt]!;8

.Idosterone !XJ!/f 110

(i09t199

llIrtnplon (II1IJtXA

GJkill'JdlanMlbIoxur{(CB) pogtXJl

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ffnin-lI1gio~njHdojwont Iyst~m pq M
Sf(Oft darJ~yptrltnlion rgI199

ptJ//I198

OUplfr21 Oru9,/orHyP.. teo,kIn

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 cardiovascular diseases. According to the American Heart Association, 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 pharmacotherapy.

Because nurses encounter numerous patients with this
condition,having an understanding of the underlying principles of antihypertensive therapy is essential. By improving
public awareness of hypertension and teaching the importance of early intervention, the nurse can contribute signifi-

297

ommendations from Committee Report }NC-7 are summa

rized in Table 23.1.
In addition to classifying HTN into three categoriesprehypertension, 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.

cantly to reducing cardiovascular mortality.

23.1 Definition and Classification

of Hypertension
Hypert~nsion (HTN) is defined as the consistent elevation of systemic arterial blood pressure. The diagnosis of chronic
HTN is rarely made on a single blood pressure measurement. A patient is said to have HTN if they present with a
sustained systolic blood pressure of greater than 140 mmH~
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 cardiovascular 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

TABLE 23 1

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 ~plf.
High blood prt'IUJ~ alfts mo~ 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 ~ple with HTN, mOrt' than 28% do not INlize IhI')o h~Y!' the

mndilion.
Hypertension is t~ most common compliution of prt'9ni1ncy.
Approximately S4,000 Americ~nsdie of HTN per year, it isa contributing
facto.- in 300,000 additional duths e~dJ yw.

Classification and Management of Hypertension in Adults

tntllal Anllhypt'rten!ol~ Therapy
SystoltC/Dlastollc
Blood Pressure (mmHg)
Blood Pressure Clas!olncatton
WlIhoorCompelllng tndtcatton"
With Compelling tndtcallon"

-,

119!79orlfll

No inlihypentnsil'e indiuttd

Hoantihypertrnsiw inlicattd

Other ~nti1typentnsive, as nffiled

~ypertension

1ll}-B9ft11)-!I'}

l.fO-1591W-99

Thiazide diumic {for most patienB}

1600.- hi9:ler/100 or hig~r

Two.aug [ombilation antihyper1tnsil'~

(formost patients)

I Hypertension

5tagf 2 Hypenension

Souin': Halionitl H91 Blood ~1!u1I' EdlKation Progr~m Hationaillein, l.ung& Blood Inst~ute.11O(3)JIK-7 &preIl:Thf Smnrh/Wpilrl rile mil NariiJooIfilmmirlet m
I'rPM1nD'on, Dtlfflion, fllWaion, ~I1fJrrel!l!ntJJI liqh Blood I'rmIJrt. Ioo-ine1hnp://Www.nltlbiJlil.1jO'>'
"Compelilg indK.Jtions i1dude:hein fallft, post....... youlllial infirnion, h9I rill:: for roronary .Jn~ dise~~, diabflfl, dlrorK kid!le)' dst.t\e, ind Murrtnt stroiIl' P'"tnlion

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o
o

i"

iI!

23.2 Factors Responsible

for Blood Pressure
Although many bclors can influence blood pressure, t he
three factors rtSponsible for crea ting the pressure are ca rd iacou tput, blood volume, and peripheral resistan(t. These
are shown in Figure 23.1. An understanding of thl'$(' factors is essen tial for relating the pa thophysiology of HTN 10
its pharmacotherapy.
The volu m e of blood pumped per minute is the ardiilco ulput. The highe r the card iac output, the higher the blood pressure. Drd iac: o utput 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'llliallo 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 ptriph~aoI resislanCf.
Arteries have smooth muscle in their waU s that, when con~
drittNl. will (.~II.(~ Ihe iMid~ di~meter nr Il1m!'n In hu.nm~
smaller, thus Heating more resistance and higher pressur e.
A large numbt>r of drugs affect vascular smooth muscle,
ca usi ng vessels 10 constrict, thus raising blood pressure.
Other drugs cause the smooth muscle to rela.:t, thereby
open ing the l umenand lowering blood pressure. The role of
the autonomic nervous system in controlling puipheral resistance is explai ned in chapler IJOO.
The third h elOr resporuible fOl' blood pressure is the total amount of blood in the vascular system, 01' blood volume. 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 fad ors, cert ai n disea se
states, and pharmacotherapy. More blood in the vascular
system will e:xert additional pressure on the walls o f 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 facto r is used to advantage when t reating hypotension
d ue to shock (chapter 2900 ). In contrast, substances
known as dilftlks can cause Tluid loss through u rination,
thU'l decreasing blood volume and lowering blood pressu re.

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 adequate urine fortrultion, whereas extreme Itypertension an
cause blood "esse!s 10 rupture ,or restrict blood flow tocritical 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 vasomotor center st imulates alpha ,.adrener gic receptors on arterioIes,ausing vasoconstrktion (chapter 1)00).
Receptors in the aorta and the inte rnal carotid artery act
as sensors to provide the vasomoto r ce nter with vital in formation o n 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 p H in the blood. The vasomotor center reads to informa tion from b:lmreceptors and dJemoreceptors by rai sing o r lowering blood prasure accordingly. With
aging or certain disease states such as diabetes, the baroreceptor response may be diminished.
Emotions can also have a profound effect on blood pressure. Anger and st ress can ca use bLood pressure to rise,
whereas me ntal depression and lethargy may cause it to fall.

Peripheral resistanoIw'
diameI"r of .rterioles
AJid Ioao

Det.;<lration
AJid mlen1ion
Aldoote.one
' .<OH

Symplllhetic fl81'VOU11
'YI',. m activity
Rerin/angio1ansin II
t...,..IM in blood
""""";Iy

Cwliac

ouIpUI

P""OIIo;!
eomractiity
. ~rlOlld

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

.,..-

.---.ya. . .

_ ~1helic

FlgurelJ.' Pflmary factofsaffecttng blood pressure

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01",1<,23 DN9,forHYI"'nemlon

299

Blood pl9DUno

C<lmp"IISatory action by
r:ar<tkMIscuta'system

i
Vaoodlaaon

Flgure23.2

. ...... '1 rata

' Strc1<8 VDIUITII

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 pressure on a daily basis. \'lhen given as medications, some of these
agents may have a profOWld effect on blood pressure. For

Because chronic HTN may produce no identifiable symptoms, many people are not aware of their condition. Failure
to control this condition, however, can result in serious consequences. Four target organs are most often affected by
prolonged or improperly controlled HTN: the heart, brain,

ample, injection of epinephrine or norepinephrine will imme-

kidneys, and retina.

diately raise blood pres/iure. Antidiu~,hll"mmr(ADH) is a polent

vasoconstrictor thaI ca n also increase blood pressure by raising blood volume. ADH is available by parenlal administration as the drug vasopressin. The renin-angi:Jtensin-aloosteronr
system is particularly important in thepharmacotherapyofhypertension and is discussed in section 23.9. A sununaryofthe
various nervous and honnonal factors influencing blood pressure is shown in ~ Figure 23.3.

One of the most serious consequences of chronic HTN is

that the heart must work harder to pump blood to the organs 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 supplying 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 prehypertensiw stage cannot be overstated. If the disease is allowed
to progress unchecked, the long-term damage to target organs caused by HTN may be irrewrsible. This is especially
critical in patients with diabetes and those with chronic kidney disease, as these patients are particularly susceptible to
the long-term consequences of HTN.

=-

23.4 Etiology and Pathogenesis

of Hypertension
Hypertension is a complex disease thaI is caused by a combination of genetic and environmental factors. Forthe large
majority of hypertens ive 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 identified. This is called secondary hyprrtrnsion. Certain diseases-such as Cushing's syndrome, hyperthyroidism, and chronic
romal Jj,,~a..,.........;au.~ d~val~J l>]uuJ J.'r"""ur~. 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.

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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

1 00

UnII4

Tte c .,dkIY.",ul., .nd Urinary Synem,

Va somotor cent",
in medul a

Angiot&nsin II

Qung"J

Angiotensin I

Qi""'J

""
8aromceptors

j
'" Vasoconstriction

Chang .... in

e '" Vasodilllion

I~id

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 patients, a 1(}" to 20-lb weight loss often produces a measurable
decrease in blood pressure. Combining a safe weight loss program 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 patients how to control HfN. Because all blood pressure medications have potential adverse effects, it is important that
patients attempt to control their disease through nonpharmacologic means to the greatest extent possible. Important
nonpharmacologic methods for controlling hypertension
are as follows:

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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 morbidity and mortality associated with chronic HTN. Research has
confirmed that maintaining blood pressure within normal
ranges reduces the risk of hypertension-related diseases such

01 ..11.,23 Oru9,lorHyperten,k>n
as stroke and heart failure. Severnl stratt'gies that are used to
achieve this goal are summarized in Pharmaoothernpy Illustrated 23.1.
The pharmacologic management of hypertension is individualized 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 antihypertensive drugs are availablt', and choice of therapy is
often based on the experience of the clinician. Although

antihypertensivt' treatmt'nt varies, there are several principles that guide pharmacotherapy.
In mosl cases, low doses of the initial drug are prescribed
and the patient is re-evaluated, after an appropriate time interval.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

Atpha 2 agoni

Oecreaae .ymp8 the~c

impul ..... from the eNS 10
the heart and arteriole!!,

cllUaing vBsodilillion

Alphe, bloc ker.

Inhibit "Y"'p"thelic
activation in
Brteriot .... c ausing

vem lEllion

D iroot

YQ_ ~ato ...

.---.;....-1. Acl on the omooth

.Ieri""'.,

......,.., of
causng vaoodil9lion

DecreaH the heart

rate end myocardial
oontracti~.

Calcium channel

nodJc:ing cattliac

blocker.
Block calcu m ion
c han",,11 in arterial
smooth mU!ICle.
ca"';ng
vaoodilalion

~""'

Angiotenain
receptor bloc k...
~~

'1

_ _

P,.....MI angiol ...... n

II from reaching ~.
receplors. causing
vaoodilation

ACE inhibilor.

Oiurem.
Incnoase ume output..::l
doocnIau Huid voklme

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301

Block fOlTTllltion of angiote nsin II , causing

vasodilation and block aIdo5t"""",
lIIIC",tion. decreasing fll.icl voIu ....

302

UnII4 Th<> (~ ,d""'.",ul., .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 ~s com_
pelling conditions: heart failure, post- myocardial infarction, 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 often necessary when the patient has not responded to the initial 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.

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 hydrochlorothiazide (Microzide). Selected combination antihypertensives are listed in Table 23.2.
Certain antihypertensive classes cause more frequent or
serious adverse effects and are generally prescribed only
... h~Jl firs(-li""

~11~"('

<.Iu llU( pru<.lu,""

~ '~(~[~dury r~

sponse. The alternative antihypertensive drug classes include 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 basis when therf....1well is often a difficult task for the nurse. Pa-

TABLED.2 I Combination Drugs for Hypertension

TradeName

Thiazide Diuretic

Ao:rurtiK

hyd rodKIrothiazidt

Aldactillidt

hyd rodKIrothiazidt

AVoilidt

hyd rodKIrothiazidt

""
BtniurHCT

hydrodKlrothiazidt

"-

Adrelll'rgic
Agent

........

hydrodKlrothiazidt
bmdroll_liaridt

"-

~ov.lOlfCT

hyd rodKIrothiazidt
hyd rodKIrothiazidt

H. .,

hyd riXtlorothiazidt

Indtridt

hydrod"lorothiazidt

qunapril
irbNrloln

.-""

hydrod"lorothiazidt

(,Jptopril

IIIls.Jrlolo
uiolmltrtne
voIls.Jrloln

hyd rodKIrothiazidt

"".
T....

...,

.-

m!iolpril

btOilepriI

oImlodipO!
VrloI()oInil

....

TemffilfCT

hydrodKlrothiazidt

Iimolidt

hyd rod"Iorothiazidt

Uoi'tiK

hyd rod"Iorothiazidt

rnouipril

VilItlffK

hydrod"lorothiazidt

m!iolpril

l!-!torttK

hydrod"lorothiazidt

'"

hydrod"lorothiazidt

'A'loliabllo if gen~ridonn only

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fmjpiO!

trolodobpril

hyd rod"Iorothiazidt

hyd rodKIrothiazidt

oImlodipO!

bmaztpril

TeWIN IfCT

dllonllal~

oImlodipO!

IoIartoin

_~HC1

lotftllin HCT

m..,

oIm~l1iIo

Dyazid/,

"D.

ACE Inhibitor or
Angiotensin II Blocker

oIm~l1iIo

"""'

PotassJum-spa ring
Diuretic

oImilorid/,

_ru"

timolol

.......

Iililopril
~m_

"'... lfr 21

C OMPLEMENTARY AND A LTERNAT IVE 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 9!'ne ral~ improff dKulation. So~
(Llim thai grape ~ omct improm wound lItaling, ~~ wl(e~ ,nd
towfrs tiMo risk for tiMo Iong-Ierm (onlequemt5 ofdiabeles.
The grape seem, ulually obtained from wintmaking, j re (ru~ed ,nd piKed
into tlbt.~capsut.,or rtquid forms. Typic,1 doses alt' SO to 100 mgllky.Grape
!fed omct has , ntioxidim properties. In 9!'lIfra~ amioUdanu improl'f
wound lit, ling ,nd lI'II'Iir (riluLl rinPI}. Prrliminal} fYmme suqgtSlS it may
W .o~ ben.fit in repairing bloorl ...>d do~ thot could told to Ithuol<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 (aution should be UIfd ij laking anticoagulant drugs bt'I'iIUSI' inaNstd bleeding
may rl'IUIt. Ow rall, tilt btn~fits 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 reduce cost and increase adherence to the therapeutic regimen.
Further reducing compliance is the occurrence of undesirablt' adverse Effects. Some of the antihypertensive drugs cause

DN9' lor Hyperten,"'"

303

embarrassing side effects such as impotence, which may go

unreported. Others cause fatigue and generally make the patient 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. Furthermore, 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 effects 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 antihypertensive classes to enhance their effectiveness. Diuretics are
also used to treat heart failure {ch.1pter 2400}and kidney disorders (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

TABLE 21.3 1 Diuretics for Hypertension

",,'

Route and Adult Dose

(max dose wtH>re Indicated)

Adverse Effects

POTASSIUM-SPARING DIURETICS

PO:5- 10 mq/day (max: 20 mQlday)

Minor hyPf'rtoIfmi4 hwlhe forigw.

1'0; 25- 50 mg OIKf dailr (max: 100 mglday)

0Ilffi'1MfiII (spirmollKloot)

spNnoIactont (AIdaaOlll'j (Iff [II9f m for the

ProIol)'pt Drug box 00 )

PO;15- 100 mg 1-2 times/day (mn: KI mgI~, )

Qxldi:abmial 1m m:Rl:~lmIiil d~b:tlbljgo

hVDO!!jlrellia " am.iornosiund n blood

triamll'rfllf (o,rmium)

1'0;51>-100 mg ~d (max: 300 mgI~y)

amiloridt 1Midamofl
tpitlt'llOllf(lnspr.l)

THIAZIDE AND THIAZIDE-LI KE DIURETICS

dKIrothiazidt (Dini ) (lI'f page m

for lilt Protol,Pf Drug box 00 )

PO:151>-5oo mglday (max: lg1~y)

Minorhyplll"dtrnio,. fotiglll'

dKinhalidont (H)'I)1Itonl

PO; 51>-1 00 I119iday (max: 5(1 mg/da,)

Sianifi@nlhypoblellia,*<trolmdepk!ion
dehl:l!al!!m, !ral!l!l'n~on, maUmlia
hyperdrumia roma blood dyxmia1

IrfdrodKlrothialidt (Mirrozidt)

PO:15- 100 I119iday (max: 50 mglday)

indapamidt (loroI)

PO: I.lH I119iday (max: 5 mglday)

methydotliuide(Endnm)

PO:2.S- Smg 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- 1 0mglday (max: 10 mg/day)

furostmidt (LasW (Iff page 110fortlit ProIotype

Drugbox OO )

PO: 10-80 moIday (max: 600 mQ/day)

toBtmidt (Dtmadtx)

I'OI1V; 11>-20 mgI~y (max:lOO mgl~y)

Ira/kJ indratf ammon id'ItrII' tfttm; undt!lining in riratflll'riOUS ad>imt ffitaS.

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Minor hypckdtrnio,. pIlSlrJrtI IYtpllltf!lim, rinriW~

rnlUl& d~rrlIeG,dizmtsJ, farigue
SigniO@Djhypobleuja bkpod dyllliWl
deh)'lblion.o~oxirID' tkn!>'!m i:n~IaIK~
dmllatOf1lJ!llapse

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 (Na ~ ),
calcium (Ca H ), chloride (CI - ), and potassium (K ~ ). The
mechanisms by which diuretics reduce blood volume differ 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 possible; the specific electrolytt' lost is dependent on the
mechanism of action of the particular drug. Potassium
loss (hypokalemia) is of particular concern for lo op and
thiazide diurE1ics.
Thiazide and thiazide-like diuretics have been the mainstay for the pha rmacotherapy ofHrN for decades. The thiazide 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 prototype 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.
~ Prototype Drug

The primary concern when using potassium-sparing diuretics is the possibility of retaining too much potassium.
Taking potassium supplements with potassiwn-sparing diuretics 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. Spironolactont' (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 effects such as hypokalemia and dehydration is greatt'r because of their ability to remove large amounts of fluid from
the body in a short time period. Loop diuretics are also ototoxic 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 diuretic in widespread use, and it is presented as a prototype
for heart failure in chapter 2400.

I Hydrochlorothiazide (Mlcrozlde)

Therapeutic ( lass: Drugforhypertension and edema

Pharmacologic (lass: Thiazide diuretic

ACTtONS AND USES

ADVERSE EFFECTS

It,dmchlomthiaridt ~ tilt most wid~1y pttsaibtd doo{ [0, HTN.likt null)' d~

urWa, it prtdK~ ~ striom.a;~1II' eflMsand ~ ~~tift.t probing, 10to
20 mmHg rtduailn in bbod pl!"SlU~ P.tiffits with ~YI'r~ HTN Of. (ompelling
(ondition may rtqIlR the addition of. second dlll9 from , difll'rent (lass to controltllt dilNlf. H)droc:hknuthiazidr ~ tht most (ommon agffit bund in fixtddOIf (ombilatiJn drugs klr HTN.lI)droddorothiazidto ~ appruml to trW mite,
fdenu, heart faiu~ HTN,.nd nephn:tK Syn:!rornt.IlJMS IOIne1iIllfS Ust HCU.s
an JiKmiMion for this drug; 1iowt-YIo~ th~ shoold lit awidrd btause it (,JUleS

I/ydnxhlorothiazide ~ well tGierattd ~nd ~mibiu ftw seriotK MYerse effem.

TIlt most (ommon ~ tifeds 'fl' potMtial ~It(trolyte imhal.Jn(~ dU!' to
Iossof H(ffi~ K+ .nd Na ~ .8t(aUSf hypokaltmia m.y (,JIM mdia( rondU(tion abnormalities, patienll ar~ 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.

(onf_ ~ Iljdrochiortthiaridtwith Iljdrocortisone.

H)'drochlorothiazidr.m on tht kidnty IUbult to dtm'~ th~ rtabsorption
of Na+. Normally, man' thin m of tht sodium Mtffing tht kidnl')' ~ R'absorbtd by the body. When hydrochlorothi.uidt blocks th~ rf.bsorption, IMft'
NJ + ~!I'm into tilt urin~. 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

Admin~ter ~ drug ~.rIy in th~ day to pR'Yl'flt IIIXlUrW.

PR'9oancy rnegory 8

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
~Itic: 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
~mfffer:ti~~iIoNIeIthPrisI;ofJl'lliltoDdtym

IMDl.Corti:OIIeroids .n:I~1III'rirn BirKmIf pcOIWn

tms_ giIomrih

~~QIMd"~IIW)'int:ffD~in
todtJHydrodiIorothia dKruststhPmretionoflhilrn iIId(;ll\ Nlto~

Lab Tem: ~thiazidr IIW)' ioofN o;mwn ~,dIoItmnJI,bi~rubin,

~fride,.n:I Ykium IHm. Thedrugrna, dfcrrnrwnm 1MlneWn,

PHARMACOKINETICS

il'lset: l h
Pe.k: ~ h
Half~ife:4 S-120

min

Dur.tion: 6- 12h

potmilm,.n:I Odium 1FIr1l~

1Ierb.:JVFood: GitgobiloboJ may prodOCf a par;l!kIIKiI1 iooNlf in blood prmtI"f.

I.ke with hawthorn (IUd ~ ilJCiditiw h)'pota1~wetfK~
Tftatm~nt of (Mordosr: Dvrrooseis manif6tedas ~lKtrolytedtpletion,whic:h

~ tR'.tfd with infusionl of fluids containing ~I)w.lnfusion of fluids will

Jiso prt'lmt dth)'dration and hypot~nsion.

Rtftf III MyMnJnqKl ror ~ MnJnq /'ro(e\S fiKIIllpf(/II( III 1M iJ"rJg.

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0I ... l<r23 DN9,forHYI"'nemlon

NURSING PROCESS FOCUS

305

PATIENTS RECEIVING DlURETICTHERAPV

Assessme nt

Potenti a l Nursing Di agn oses

Baselinr assrssmrnt priort o admini stration:

Undtr>und th~ Il'asoo the drug has ~n prec:ribfd in ol'lltr 10 mel for
theraptUtic: ~Ifb.
Obtain I (omplUt lIt~hh history induding (jIdio'alruwrdis~ul',
diabete , PIfO]IIaIK)', or breastffflling. Obu in a drug history ilKUding
allel9ies. wrlt'llt pr~riplioo ~nd OlC drugs, IItrbal prrflar~tion~and
akohol USI'.81' alen 10 ~sible drug inl~rol(lionl.
h<llua~ approp.utf laboratol) findings such u tlectrolyt~s, gllK~
(ompiell' blood (OUnl (CBO, hepatic: or Il'IIaI fulKtion studies.uric a{id
!ems,and lipid profiles.
Obtain ~selinr ~igln. yitalsigm (~pKyl~ blood pll'Slure [BPI arid
pu~), bll'ath sounds,lnd card"1<)( monitoring (f.g., ECG,wdy{ output) ij
approp.utf. ~11ffi lor location and (haroKter/amoum of rdtllY, if
prestn!. AsseI ~ll'lilll' hearing and bawn(f.

Dmcient FluidVoume
Fatigue
Dffit'ased CardioK Output (R'lattd to a.m~tflecB 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 Idve~ effb of drug thtrap)')

Assell mrnt throughout iI dminiltration:

~t\.S brdesil!d therapMic: effffil{f.g., ~ S)'lloIic: and dYltoli

BPJ.

Continue ptriadic: monitoring of Mmo~tes,gluc:OSf, CSC,Iipid profiles,

liYel function stud~,((t'atininl',and uric: oKid Ie-;~Is.
AIII'SI for and prompt~ report i.m~tffel:tl:hyp:Jtl'mion, palpimionl,
diuinesl, mUKulolktletal ~aknes or{lamping. llalnU, yomiting,
abdominal era mping, diarrhu, headamt. TinniN! or lItaring loll, Iosl of
halan{1' or inroordinuion, s~ hypolmsion i((omflanitd II)' R'An
luhycardioK dysrhythmias, de<reased urine output. and 'ftight gain or
lois O!'r 1kg (approlimateiy 21b) in a 2+ hour period lhould be rt porttd
immediatf~.

Plll nning: Patient Goa ls li nd Expected Outc omes

Th~

patiem will:
U:ptrielK~ llitrapMic: effb dl'Pffidtnt on the rtawn the th~ drug is being giml (i.f.,de<R'aseci blood PIl'SIUIl').
~ fret from,or ~lpl'rielKe minimal, idw"Sl' ~ffts.
V~rbal~ an undtr>,andiog ohhedrug'1 USI',ldYl'~ flfb, and R'qJired pll'lautions.
DMIOnltrat~ pflllll'l" :self-administration oftht medication k9.,~ timing, wht n to notil)' providtr).
Impl e me ntati o n
Interve ntion s and (Rati o nale s)
Ensuring thrrilpeut k effects:
Continue frequent iIIlffimerllS ill aboY!' 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{ft'~ in
Wfight ~ 1kg pl'rday may indic:.Jtt fll(flSiYf fluid ljiIin.A dt{re~ of
Offr 1kg perday may indicatf !j[(esi'll'diuresis and dthydration.)

Pllti e nt li nd Fll mi ly Edu cllt io n

TeoKh lilt patient and/orfamily how to monitor puisi' and blood prffiUIl'.
Enrure pflllll'l" USl'and funaioning of an-; hom~ rquipment obtaintd.
Hm patitm weigh 11'11 daily and Ifford Wfight along with blood PR'ISUR'
and pu~ mearull'llltnll.

ElKourol9f appropriate lift,style {hangtl.Proyidt for dittitian {onsulmion

as nfflIed. (Heahhy lifest)'1e (hanges will support and minimize the nfflI
for drug ther~py.)

En(OUrage the patitm to adopt,. lItahhy lijest)'1e oflow-fat food dlOic:n,

redU{td Iodum intlu,in{rea\I'd nerd~,decR'astd akohol {Onlumption,
and smoking (esation.

Minimiling ~ d"ftne dt"b:

Continue to monitor yitalligns.Takt blood pft'lSUR' lying, sitting,and
standing 10 dtt~{\ 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
hypoI~sion may ilKll'iII~ the risk of falls and injury.)

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 m~dic:.Jtion ijblood pR'lsure is
90/60 mmHg or btlow, or param~tm 11'1 II)' the hulth cart proYider,ind
ootil)' th~ prwider prompt~.
(ConrlnuefiJ

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NURSING PROCESS FOCUS

PATIENTS RECEIVING DIURETIC THERAPY (Conr/nuoo)

Implernentlltio n

Interve nti ons and (Riltlonilles)

Patient lind family Education

Cootinur 10 monitOl' tlrarolJles, ~,QI(,1ipi:I profile, lim function

Ituditl,(Itatinillt,and urKlcid ~(Mosl diuretics UUIt loss of
sodiJm a/ld potassium Ind may irKlHIt lipid,gb:ose,alld uric. iCid
lel'tls.)

mlnrtthe poatirnt on Ihtlftd III mum ~llIyforLibwortJOd 10 inform

Continur 10 monitor !wring Inc! balano::f,lfIIOrIIng pmislfl1l tinnllA 01'

wrtiqo promptly. (0101_ 01 cranill_ VIU IN)' OIIr, HPKiaDy
with loop diuretia..)

LItxntorypm.onneloliUtKtberapywhM~l'WIbIoodOlm~.

the poatitftl to carry I Williet idtntifiution wd Of WNr mtdiul

iclentilication jNtIr)' indiciting diwetK the.ij)y.
IlI'ltruct 1M pllRnllII ~porI pmii~t tinnitus,OI' baLl nc:f 01' roordilllllion
prnblfms immtdiattly.

EnWft

Wfiq/1 the patRot daily Inc! ~porI. Wl'ighl!pin or loss of 1 kg

(approximattly 21h) or more in a 2~-hour period. Muwre intakund
cuQll/l in tht hospitalized pllitnt. (o.i/r weight is an iC(U/1lt mtasIJl! of
fluicillatus JOd takn info ~wnt intlkt,CIIIlpul.and instmible bslfS.
IMJreis is indicaled by oulput signifk<lndy gl!oJIer than w.11R.)

ilal't the pltitnl.,mgh Iflfdaily, idfally II the Sime timeof da,;and it(ord
wtighl.long with hlood p!t1SOlt Ind fIIlIst meiHU~ts.H.1't the patitnt
I!port wtight 1011 or9iin of molt than 1kg in iI 24-hour period.
Advise lilt poatitftt to (ontillur 10consume mougb ijquids to rtmain
~e/y, but nol 0e!Iy hydrJled.. DrNil'Wl wlw:n 1~1)",<l"fOicling akoholK
~,and fIIwring .dt~l~ 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.

palitftl IiIlrty,epf<i.lly "1hf~.Obsfl"ft' for lighthudtdnes Of dizzines. Monitor Imbulation until effemofdrug a~
known. (Dizziness from orthomtK hypottll'lion m.ly 0((\11.)

lmtlllCl the ~l loallor .ssiltWt pror 10 9fIIilg out libtd 01'

atttmptiIg IOwllk _Ind m woiddrivilg 01 adwr iCtMtiM ~irilg
menlllaleJtness or physiuI coordiMion oom eM 01 the ug are irnowll.

Monitor nUiritioMi SLlM and t!KOur;Jgf ipplllpri.tte intake 10 prmnl

tlectrolyw: imbl Llnc:~(MOlI diurtlics alust sodium Ind potusium loss.
Pot.uiurn-sparing diurelics m., ~ in sodilllllioss but pot.ssium
incrUIf.)

Inslruct ~itnu liking potusiumwmrilgdiurttics (e.g., thilzidts,tbiaziclelikt,and loop diurtlial \1:1 (omumf foods high in potusium:frtsh!ruits such
as stfJWbtrrie.nd bananas;dried !ruiU such <II apricon and pn.rot\;
lfI!'gtI.bln and ~ suchas tomoJIOf'l, bettS,ind dritd bUns;jUKtI such
as or;m9f,C]I"apl'iruit 01' pru~ and fifth mNIs.
lmllllCl p.llifms tlking pJtisslirn-splrirg di.RtiG 10 mil iXKk ~h 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 mineral~s Of specialized sports btI'tr<l9fl.CTypOI arc
sports ~t.I}-,Gamrldf 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 d~te mtIIilus {t.l}-,

pJlydipsia. pol)'phagia) or tleuled blood wg.Ir 10 lItaltfJ (I~ plO't"idK
INbttic palitnts may Iftd 10 mollie)! their blood 9UcOlt Itoitls mOIl!
fl!qur.lIly unl~ eflttof 1M diuretic: ill! kllOWn.

diabtl~ CThiaziM, IhluidHike, I nd loop di.rlttia (oJn (,)UIf

ITjptIg~emia, e5{ItCiltt in diabttiaj

'If

Cbsem sunburning if pflllofl!ltd sun tJp01lr1! hu oco.rnfd.(Somt

diJrtticscaust skin Pilo!OIfnsiIMty.)

Instruct the paIR"1 \I:I_IUfIM~ Inci proItiedothing if pllllonged

sun e:posurt is Inticipaltd.

Instrud the pltirnl \1:1 Jfporl .ny It.J!ikt symOfM:Shor!neS 01 hl!iIIh, !Mr,
sort throa~ rMLIise,joint pain,or prolound latigur.

~ for signs of ink<lion. (Some diumic:s m., dKrUSf wIIitt blood

(til CIlUIIU and lilt bodYl ability to fight inttion.Agranulocyto~ is a

possible ildl'tf5efftect of<iuretK tMfiPY.)

'-timt u.dtlsliinding of drug durapy:
UlfoppOllltlre ~riIg admilistroJlion ofmedotiom aid dtring
.\StI.SrntfIII \1:1 !I5an.s Iht rilticNlt lor drug thmpy, desired Ihmpl'Ulic:
0UIl:00"Ift, most common adI<eI5t tlfa, p.lI3rnettf1 for wht!lm al l tilt
htaIth (;ill! ~and any necmary monitoring or p~(U!Mlg
liAr rurilg lM"Iil'Wl ~ ~ tooptirnilt.wl rmfota' ktytrading a~~

Tht pltirnt anNorw~im- shouk! bt i1ble to stall! lilt rtasort lor lilt drug,
and i1PJ1ropiate dose and IClleduling;what iJ6.otlSt tfftc:ts 10 obstrvt lor and
wbe!l1O rtport ilnd tht ilnticipattdlength of mtdiutillfl tMrapy.

,.Iimt sdhdrninistlillion of dn.g tht'ilPJ:

When administering tilt mfdiution,iIItru{\ the patienl tndfor ftmily in
tilt propl'IIfJ-administr.lli1lfl of tht drug.f.g.,r-arfy ill 1M da, 10 prmnl
disruption of ~tP from nocturia..{ProPfr admw.istration imprum the
tfftclilotntu oftht drug.)

The pltitnt alld a~ tl! iblt to discuss ipproflriate dosing ilIld

.dmnSlflltion ~.

306

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OUplfr21 Dru9,/orHypellemkln

NURSING PROCESS FOCUS

307

PATIENTS RECEIVING DIURETIC THERAPY (Con/muM)

Evalulltion of Outcome Crite rill

[vaIUilt~ tht Nre.:ti~, of drug

ihtrap, by oonfinning that pititm gNkand txpKted oukom~, hnl' bffil ml't (Sle PlanninifJ.

Str TIIbIt 111 for Q 1stIi/hili to wIidr rIleit IIIrlill) 1ilnI gppIy.

CALCIUM CHANNEl BLOCKERS

Cah:ium mann!!'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 m ent of
angina in the early 1980s,it was quickly noted that a "sideeffeet" was the lowering of blood pressure in hypertensive patient . 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 antihypertensive classes. Doses for these agents are listed in Table 23.4.
Contraction of muscle is regulated by the amount of calcium 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 antidysrhythmic in chapter 2600, and diltiazem (Cardizem, Dilacor, 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 hypertension . A newer drug approved in 2008, clevidipine is infused 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 emergencies, nicardipine is also available by the oral route for essential 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

PO:S- l0 mgOlKtdai, (nw:: 10 mglday)

ftlodpilt (Plmdl)

PO:S- l0 Ill9lday (max:1O mgldol1)

i>radipineIDynoCirc)

PO: 1.25- 10 ""I bid (max:20 mglday)

riurdpjne(C.udtn~j

PO:20-40 ""Itid or 3O~ mg;(ar~ SR bid (mu: 120 mgfday)

Q nifedPil~ (MaW, PrOGIrdia,othm)

PO: 10-10 mgtid (max: 180 mgldol1)

rilOldipine (ti5O(0I'")

PO: 10-10 mg bid (mu:60 mglday)

NONSELECTtVE:FOR BOTH BlOODVESSEL5 AND HEART

dikimm (urdinm, DioKor; llamatt) (~

PO: 60-110 mg !U5lailtd edt.!\!' bid (rnax:540 Ill9lday)

p.I9!' 348 for the Pru!ot)"pt Oruij box 00 )

PO;80-160 mgtid (nw::480 mgldol1)

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FMhed >kin. Mlid1rf, dinirltn, pfflp/rfrol

fIirolD, jg/lr-~,OOUJro,

rOlJJfirlorionJarigue, wtt1knru,myrr1~,
~1/rQlI}Io.lrrrpolerta.md5tllJlJ! dyWrlflion

10 8

UnII4 Tte c.,dkIY.",ul., .00 Urinary Synem,

I Nlfed lplne (Ada/at, Procardlo, others)

..,. Prototype Drug

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:
angi~. k is ocas:oOiIIy UIed 10 tINt Raynaud's pheool1ll'OOn .nd hyprrtrophic:
cardiomyopathy.Nifedipinr,Im b)' ~~Iy blocki09 rakium dunnrll in myom:lyl and moJiar mlooth musdr, including thlM in thr COlOOiry ,IlIt'rirs.
This Il'sulu in Ies!oxygrn utilization b)' t~ hNrt.an in(l~.m in cardiac outpu~
and ,I filII in blood PIl'lIUI'I'. k is milabllo "capsules and as HI~nded-relea\('
t,Ibleu(XU.
ADMINISTRATION ALERTS

Do not admin:nl'l imm~dYte-I'I'Ie.m formulations of nifedipinr il an impendi09 MI iSlUspeued,.or within 2 Wftks followi09 ,I confirmed MI.
Administer ni~dipiOl' "psules or ublets w~.1f upsuies or utmded1l'Ie.IIt ublw all' c~divided, or rMhed, t~ rmirr dolt will bedrli"l'!'ll'datonu.
Pll'9 o. nqrattgoryC

with rifedipilll' III blood /lll'=r. Coooi"rmt!llt of n~piIe with ,I lieu bIcIcRr
inm.N'i 1M rill; of COO(j@Sti"lthtartfaln.NlediplII'lIIa1l1mNserumlt"ltl.of
!igolin.leadilg to bradycardia and digoxin toxicit~.I.lcohoI polflfioll!l ~
mDlilati"9 action of n~piIe. and cook! lead to 'Y1K1Ipf taM by a_drop
inbloodpll'l.lUJI'.

IlerbaVFoo:J: GriPfrnit pcr nYY rnhaoo Jhp ab!orption of rifrdipi~ MPIatonin

IIIa1 lImN blood IHSI-lR ind lltan r.1!~.
T~lmfnt 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

~1k:30min
Hall~ile:2 -5h

Duration:4--l! h (24 hrxtrnded 1l'1e,I1t)

I1tI'8" 111 MyMIsIniJU fix a MnJnq 1'rIxt55 fooIl 'ipK/It 1II1M It!!g.

PATIENTS RECEIVING CALCIUM CHANNEl BLOCKER THERAPY

Assessment
Bistline aSSf!!mrnt pri or to admini,tration:
Undtrstand t~rt'50n 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 MI. hean
failull'), mUl{Uloskfleta1 (pft'~uning condition, that mightll'lUk in fatigue,
....,.,Iknffi.IIIJ!C1e or joint ".in), and the possibili!)'of pft'gn'nq.Obuin. drug
h~lor1 illwdinj .Ilrfljin.w".nll"..... ,ipliun .lId OK d,IIIJ',I"''''''
pr~"atiolll,,,d akohol UH'.8e ,lien 10 possible drug intmction,.
E'lilwtf appropriate laboralOry findin95.Mctrolytts,~ially potmum 1M,
I~, fulKtion ru:lie~ and lipid profile.
Obtain baH'li~'Migh~ 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 thlllugh out administration:
AsH'15 klr desirtd therapeutic NitcU (r.g.,1owt1l'd blood f'Il"lUll' within
~,t.blished limit!;; .150 less~ord 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. huda(~. (orutipation. mUlculoskflrtal
fatigue or wukrll5~ fWI iog.. diuinffi. or smwl dysfunction. Myalgia,
,Inhralgia. perip/ll'lal or lacy I~dtma, 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

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INTERACTIONS
I)ug- l)ug: ~ giml cOIICurrently.1IIhH ,Inlil)"pfnflllie\ haonadlitftrifm

lab Tl5ts: M.l\r lImN vakIeI for tilt foIowill9lab tfllS: ,IlaIn p/IoIphalMt,lDH.
ALT.cPK,and ,1ST.

PHARMACOKINETICS
il1..t: 10010min PO

NURSING PROCESS FOCUS

ADVERSE EFFECTS
~JW rffrru of nifedipiOl' all' grnerally minor and all' Il'I.trd 10 nsodilalion
IlKh a, hudar~diuiOl'Ss, 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: T~ only contraindication is prior hype!>l'OsitWity to
nifedipiOl'.

Potential Nursing Diagnoses

DfclNlfd C.rdYC IlItput (dilem proem)
Fatigue (II'Iated to ad~ ~ffKls oldrug th~~py)
Altmd r"sue Pfrfusion (Il'lated toadWIt effKls 01 dlUlJ thmpy)
Activi!), InlOlrrancf (Il'lated toad"l'!'r~ riff(\! 01 drug th!rapy)
v.,..1Dym([lrtion (...Inod 10 adw-'II'~fft.<l<of 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)

OUplfr21 Oru9,/orHypellemkln

NURSING PROCESS FOCUS

309

PATIENTS RECEIVING CALCIUM CHANNEL BLOCKER THERAPY (Conl/nuw)

PliInning: Patient Goal s a nd Expected Outcomes

Thr pat~m wiH:

UprrirlKf thrl<lpeutic: elFeru kg.,decrrm blood presSUIl' to 6 ublished pirallll't~B).
~ ~ from, or nperirlKt minima~ idml!' rfferu.
V~rWl~ an undtBtanding olthrdrug's UI!', adv~B!' effects. and Il'qJi~ pll'GlUliom.
Demonstrate pflllll'l" seIf~dministration of lhe medication {e.g.,doIe, timing. when to notify proYider}.
Implem e ntatio n
Interventi on s and (Rati o nales)
Ensuring therapeut ic effects:
Contin.or frrqurnt meslllll'ntl as drKribed Nrlirr for ther.!peUtK effects. (Bbod
~Ull' and Jllisr should br within normallimitlor within par~met:rB set by
health a ll' prv;idtr.1f drug is givrn for an9naandfordysmythmi.s, significant
improYfflll'nt i1 ~sof pain, palpitation~orECGdtmonltrates improvrmtntJ

ElKourigt appropriate lif~stylr (hange . PJOY~ for d~titian (onsulmion as

nffiltd. (Healthy liirstylt (hanges will suppon and minim~ thr nffil for drug
thrrapy.)

Minimizing adft rst effms:

Continue to monitor vit~1 ~ignd~kI' blood preslOre lying. sining..~nd sunding to
detect onhostatic hypott nsion. ~ (autious with thr~ who i Il' at ilKft'asrd
riskfor hypotension.(CCBs a ul!' wodilation,ll'sulting in Iowt'rtd blood
pIl'IlUll'.Orthostatic hypotension II\a)' in(lNst thr risk offillsand injury.)
ContinUl' to monitor periodic: rle<:trolytt Int!s.espewlly potmilrn,ECG as
appropriatt,and hepatic: and 1l'II~ 1 function labl (Hypokalemia II\a)' ilKlNl!' thr
risk ofd)'Srhythm~J
Enwll' pat~m liIirty, tspttially in tht rldtrty.ObSl'lVl' fordiuiness.Monitor
ambulation until thr elfe<u of thr drug all' known. (Dillinm from onhosutic:
hypotemion may occur.)

Wtigh tht ~tit nt daily and ~n weight gain or lOIS of 1 kg or more in i 24

hour ptriod.{Daily weight is i ni(CUratr mtiWIl' of fkJid statUI and takes into
.K(oum inuu,ou1pUl, and insrnsibit losses.)

ObsrrYe for ~ paradoxic:al in{ft'aI!' in {Iiest pain or angina I)Imptoms.(Stv~ft'

hypotenlion may causr thisand II\a)' indicate blood PIl'SSUft' has dt<rtised 100
quic:kly ortoo sub!canti.lllyJ

Mon~or for signs of Ile~n t.I ii.Jft', wch as ilK~~ ling dysPIIN or posrural

nocturnal dyspnta, rales or"".Kkles"in lungs.or frothy pink-tinged sputum.

((CBlnn declNst myourdi.ll (ontrmility, in(ft'asing tilt riskof htan failull'.)

ObsrrYe for hyperstnsitivity ft'.Ktion, and angiotdtma, t lpt(i.l11y of foKial arta.

OblfNl.' for constipation.(C(Bs may aUl!' tonstipation due ro decll'ased

peristalsis.)

Pati e nt a nd Fa mi ly Edu clitio n

Te.Kh thr pat~nt or family how to monitor pulsr and blood pressurt.
Ensull' p~ Ul!' and fulKtioning of all)' homr ftIuiPllll'llt obuined

En(OlJl<lge tht pat~m to adopt a hti hhy lifestylr oflow--fat food

choic:es, ilKlNStd exm:isr, dt<1l',n ed akohol roll\Umption, and
mKlking (essation.

Teach the patil-nno rise slowlyfrom lying or ~itting to sunding to

al'Oid dizziness or falls.

InltlU thr patimt to stop taking thr mtdiution ifblood PIl'SSUft' is
90/60 mmHg or brlow (or according to pal<lrnetm srt bt' thr hulth
aft' pro~r) and notify pro'Iidtr promptly.

"G<

InltlU thr patimt on tht llI'~d to mum ptliodicallyfor lab work or

Advisr the paurnt to any a walitt identifKalion card or Wtir rneGKal

idtntifintion jtwtlry indicating CCB therapy.

InltlU thr patirnt to a II for assistalKr prior to getting out of brd or

att~mpting to walk aiont, and to avoid driving or othtr iwities
ft'quiring ~ul altnness or ph)'iiul (oordination until th~ tfir(t1 of
tht drug ill' known.

Hm thr patirnt weigh selfdaily, ~ally at thr sallll' timt of day, ind
ft'(oro wtight along with blood pIl'IlUll' ind pulst mtilUft'mtml .
Hm thr patirnt report ~ight 1011 or gain of moll' than 1 kg in a 24hour ptriod.
Inluu thr patimt to immrdiately repln (htlt pain or other angirulil<t I)Imptoml, tspttially if symptoml inaeal!'.

Insuu Ih~ poatientlo immediately repon ~ny ~ IhIll"lntIS of

blNth, frothy sputum, profound fatigUl', or s~lIing of utll'mities as

pos~bIt signs ofhtartfailull'.

InltlU thr patimt to immrdiately 5eek mical attention for

diffirulty brtuhing. throat tightnrss, hiYft or rash, IllUlCIt "amp~
IIl'mor;.or angiotdema around thr f.Kial alN.
InltlU thr patient to ilKft'aI!' Auid i nd fibrr intal<t to f.Kilitatr <tool
p,llSage.
If (onstipation prrsist~ romidtrtht usrof a stoolsofteneror IaxatiVt
illl'{ommt odtd by thr hu hh nrt providtr.
(Continued)

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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)

Patient a nd Fa mil y Edu cati on

Patimt understanding of drug thuap-,:

Usr opportunities during the administration of mrdiutions and Iliring
m~lIIlII'm, to discus, lationale for drug tllrr,p)', dtsill'd th~apeutic outromes,
IIIOiI rommOil advrB!' rlfrru. p,rameters for whrn to (,II health Ill' plO'/ide~
,nd any III'U1s.J f'/ monitoring 01 prrautions. (Using timr ckJring nursing m r
helps to optimize and lrinfon:r uy te.Khing alea~)

The ~tirnt ,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.

Patimt srlfadministration of drug thr rapy:

When administering the mrdiution, instruct the patirnt and/Ol family in proper
(,Ifadmin isnUon of drug. (Propu adminismtion improYes the rfffi:tiYents, of
thedrugJ

The patirnt ,hould br able 10 dis(\m appropriate dosing and

adminismtion 1Iffik.

Evaluation of Outcome Criteria

Evaluate the effed~nr" oIdrug theilPI' by (onfinning that patirnt goak and rxprdrd 0IJ1IOIIII'I hom ~n mrt (_ Plannin().
5H ~ lUfou IisllidnJlplllwIM:hrhrll rllningaaims GppIy.

illustrated in ~ Figure 23.4. Drugs that affect the RAAS decrease 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 final step in this system is angiotensin {onn rting rnzymr (ACE). The
intense vasoconstriction of arterioles caused by angiotensin
II raises blooo p ressure by increasing peripheral resistance.
Angiotensin II also stimulates the secretion of al oosterone,
a hormone from the adrenal cortex. T he 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.....~"re. Th,,~, ~nginten.<in " inc,"""",_< hlnncl pre<.~"r"
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 HT N. ACE inhibitors block the effects of angiotensin 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 HT N. 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, particularly following the first few doses of the drug. A persistent,

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Increas.&d oodium

reabsorplion
I"",,,,,sed blood

p",""re

I""'e ...... d blood

pressu,,"

Flgure13.4 The renln- anglotensln- aldosterone pathway

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
Route and Adult Dose (max dose where Indicated)

On"

Adverse Effects

ACE INHIBITORS
~gle 0:IIt or dvidtd Oul (nw:40 mg/day)

I/flllilldlt, dizziIm, orlfriUlQ~(

bffiaztplil (loteosin)

PO; 111-40 mg in i

uptopril(upo!m)

PO; 6.15- 15 mg lid (mal: 450 mglday)

/rtpolt1llkl\.raJli

PO; 540 mg in i

AIIQionImi ~C!!IHtni!fiilun:.fi!}l0:IIt phroomenon

ffiilapil (If.HotK)

~gle!be

or IWO cividtd dwt (mil: 40 mglday)

tosinopri (Mooopril)

PO; ~-..a mg/day (mal:80 mglday)

li~opril (Prinivil,le!torttk, lffirilJ

PO; 10 mg/da, (max:8() ffi9/day)

(~~

129forth/, Pllllotypl'Drug box OO)

mmipril(Uri'loJI()

PO; 7.5-30 mgfday (mal:lO mglday)

ptrinOOpn (Aaon)

PO; 4 mg onc~ daily (mal: 16 mljiday)

quinapril (Aaupril)

PO; 10-20 mglday (mal:80 mgfday)

l'irripril (AIt"tj

PO; 2.5-5 mg/diy (mal:2O mg/day)

U"indolipril (Malik)

PO; 14 mglday (mad mgfday)

ANGIOTENSIN II RECEPTOR BLDCKERS

Undl'Sirtan (Auc.Joo)

PO; start il16 mgfday (mal:l2 mglday)

~Sirtin

PO; 600 mglday Of 400 mg cjd-bid (mal: 800 mgI day)

(kI!trn)

irWSirtin (Al'ipro)

PO; 150-300 mgfday (max:lOO mgfday)

Ios.Jrtin ((Olia')

PO; 25- 50 mg in i

oIm~rlin(Btnicar)

PO; 211-40 mglday 'mal: 40 mgfday)

telmiSirtin (Mkartil)

PO; 40 mgfday (max:8() ffi9/day)

nlSirtin (Oiovin)

~gl~ 0:IIt or IWO dvidtd dwt (max: 100 mglday)

PO; 80 mglday imal:l20 ffi9/day)

--c-~---c-

IIQII6 indci!tt ammon idYmI' tfIe(\~~indci!te lMousidwffilo ~flffi:s.

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 potassiwnsparing diuretics. Though rare, the most serious adverse effect 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 dilation and increased sodium excretion by the kidneys are
similar to thoseoftht' ACE inhibitors. Angiotensin II receptor 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 d rugs available that block these re-

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ceptors in the kidney are spironolactone (Aldactone) and

eplerenone (Inspra). By preventing aldosterone from reaching 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 ventricular dysfunction.

T REATING THE DIVERSE P ATIENT

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- ~ntih)1ltrtensM- thmp)o rna)' be IIf(e5Sir)' iDOrKOIIII' r!Si!tant H1N i1 AfrKan Amtriuns.
Studits h.M SuggestN thilt [Main intill)'pffl~nsjy~ drug dillts are 1m
tffIoctiYe in Afric.i nAm~riuns. For 6IImpit monotheriPY with ACE inh ibiton,
ingiot~nsin II f"r(tptor bIocktrs Of bm-adrtnergit inligoni!ll dots Mtl!duct blood prt'Iwrt islllKh in African American~ [Omp.lrN to otlier ethnic
groups. Som~ physiciim f"r(ommeod initiatingthffilpy with two drugs to ~n
wre i!lequatt ~ponll'.Bised on dinicaltrials in African American~ th~ FDAipp~~d BiOi!. i fillfd--doSl' [Ombinition of isosorbide dinitrm ind
hydrilazine thit ippHri 10 be p.lrtKularf)o ~ffffiMo at lowering blood pressure
in this population.

31 2

UnII 4 Th"C.rdloY.<;(ubr.oo Urinary Syuem,

I Enalapril (Vasotec)

.... Prototype Dru g

Therapeutic (lass: Drug for hypertension and heart failuR'

Pharmacologic (lass: ACE inhibitor

ACTIONS AND USES

Enalapril isoll!' of tilt mon frr~mly pR'SuibN ACE inhibitors for HTN.Unli~
yptopril (C.POIM), tilt first ACE inhibitor to be malketed, malapril ~ . prolonged h. Iflife, which jltnnits oJdminisuation orut 01 !wict dii~.1t is 'Yolilable
as Dr.II tabltu ~nd ~s ~n IV injection. ~nalapril acts by ~ucing ~ngiolen~n II
and aldosteroll!' ~k 10 prodK. a ,ignili<ant R'dlKtion in blood prfUUrewith
frw miol/! ,dv' rsI' ~tcts. [nalapril may betMd ar monothmp)'01 in {ombination with otht r ntih)"ptl\ensil'tS. Va5effiK is a r~-Ou (ombin. tion of
tulapril and h~rodllorothiazidt.
ADMINISTRATION ALERTS
M. yproduct. first-doll' phenolllfllOn r=king in profound hypott nsion,
which mjY rtluk in !)'OCGpe.
Do noudminill~ if tht patient is prtgnantlht drug is pRgnalK)' m tgoryD.

ADVERSE EFFECTS
Uni~ diJretKs, ACE inhibitors wch <II fnalapril havt little tlFta on . IKIrolytt
b.lalK. but may (')u1I' hyptibltmia. Unli~ btu--adrentrgic blockers, tht ACE
ilhibitors (.I1JIt few o:ardiic advmt clItcts. En.lapril ma, ratJll' orthostatic h,pension when tho! p~tiem mows quickly fmm a supine to an upright position.
Ar. pid fall in blood pit!MIre may o(Qn bllowing the first dos . Otlltl oJdY!'rsuffem 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~tivity and 5houid not bt <ldminislm<1 during pregnancy olla.:tuion.
INTERACTIONS
I)ug- l)ug: M-.n gWfn {Ofl(uJfill!ly,oIIwr antil)"pfrl~ hiwtadditN~flFfds
with fllilaprilon blood prI"I...... Thiazidf diulMiG ilKlMf po~~um 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:Einhibiun.

Lab Tem: May iKJ&N vakIe5 of Ihf f~lowing : 8U Ii, ,lkaIinf phosphalillf, !enim

PHARMACOKINETICS
il"lset: I h PO; 15 min IV
J1ejk: 4-8hPO;4hlV

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.

Half~ife: 2h

DUlation: 12- 24 h PO; 4 h IV

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 M~ 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
~t li .. r fun<lion l1udies,. nd lipid p~r.1M.
Obt. in ~lineWfight, viulligns (flpt(ia l~ BP and pulse),brfillh sounds,ilnd
{Irdia.: monitoring (t.g. ECG,Yrdia( OUIput) if appropriate.AsII'II for the
location and (har-1C1erl.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!, flpt(ially potassium.
Aslt!! fol ~ tfftm: htldllllt, rough,orthosutk hypottnsion, fatigut or
wt.kntl5, diuintl~ 1)'111 ptom, of hyperkalemia, or II'IW Idysfunnion.
Angioedema,1lI rtir:ularly involving tilt filial <l IN, should be rep:lned
immediillt'ly to tilt h.3kh {Ire prwider.

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Potential Nursing Diagnoses

Dtcre. sed Cardiad\Jtput (d istill. 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)
Risklor 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
(poulliuminti~)

0I ..1I0I2l

NURSING PROCESS FOCUS

ON9'/orliype"""1on

3 13

PATIENTS RECEIVING ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITOR

AND ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY (CoIIrJnued)
PliInning: Patient Goal s and Expected Outcomes

Ih~

p,titnt will:
Exptritnl:t tlltrlpMic: efferu k g.demalfd blood presSUII' to t sublished p'r,met~B).
Be ~ from, or uPfritrn minilN~ idww ~lffds.
V~rN)izt ,n undeBlanding olthtdrug's U1t"lt/efll' fIj.ts, and II'lJIill'd prruutions.
Demonsu,tr proptr ~-~dmioimation of!ht medication (t.g.,dose, timing. wh~n to notify providtr).
Implementation
Inte rve nti on s and (Rati o nales)
Ensuring th~r~peutic effects:
ContinUl' nqUl'nt aSSffitnents as d!<l(ribed Nrlitr for !htra pwtic: efflS.
(Blood plt'lSUII' and pu~ should bewithin oolTllilllimil5 orwithin j)ar;lmtltB
ill by lItakh (II!' providtt)
EO(oorlogt ,ppropriate lifrstylt [han91's. Prol'idt for dittitian (onsulmion "
nffil~. (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 th~ eldtrly who,ll' it inc:rm~d 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 lab~ and KG" appropriatt.IHyptrblemii lNy inc:II'~1t
tilt risk of dysrh)<thmias.)
Ensull' j)ititnt s.afM)<,rs~ially in the tldtrly.ObSffit for light-htadedness or
diuiness.Monitor ambulalion until effl'[\lof drug arr known.(Oiui~ from
onhosmic: ilypDtension may oc:rur.)
Monitorfor ptBistent dry COll9h or inc:rti~ng [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 a nd Fa mil y Edu cati on

TNC:h tilt p,tient, f,mily,orc.JII'9Wer how to monitor pu~,nd blood
pr6lU1l'. EnsUII' ptOPfr US~ a nd 1u00tion ing of any home ~uipm~nt
obt,inN.
Enc:ourage the patient to adopt i lItakhy lifestyle oflow-f,t food
[hom, inc:lI'iitd ~rtis~, dwt'iItd ikohol [onsumplion,and
smoking ~sation.
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 paramtl~B It! by heakh Ull' providt~and
oolily the plVt'idrr promptly.
Instruct the j)ititmon the nted to II'tum ptriodica l~ for lab work.
Advis~ 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 umilthe~fle[\lof
tht drug all' known.

~ lilt patitm to anticij)itea dry COll9h that may ptBist Ind to lISt
oonpharmmliogic: measult'llo IlI'all~.g., OTC COll9h lozenge; or hird
c.od~, in"".>td Auid iot.~).
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 reliev~ a 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 II'pon~ immediately.
Instruct the j)ititm on the sigMof hyperulemia (nau..a, illl'9ular
lIt~rtbta~ profound fatig~/mUl(lewt~kness,and mw orfaint pu~)
and to II'pon themimm~iat~ly.
T~ac:h !ht patitm to avoid sak subsiilU!!1 [onuining potassium
[hloride (1((0, (onsuming snadn advtnMct is "I'learolytt-fonifltd,
sptcializtd spons drinln thit (onuin highftls of potauium,or
tl[rss~ inue offoods high in potmllmdifll'll'm from their normal

d"(LOnrlnued)

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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)

Patient a nd Family Eduution

Patimt U.claltancling of dn!g th~l'1PY;

1M000ponuniOeduring ldminiltl1tion of nwdiuIions Ind during
~ to dftM! 1M ~It fordfUg ~~de!~ t/wfapMic
cMtOJllft, IIIO!it {OI!\IlDJ1 ~It tfftm, IWMnttefS forw/wft to uII 1M
hNlth (,I~ ,,",,~1Od Il'IJ ne!Wj' m<IIIitomg or ~(lIsixj 1ft
cbing Ilning ~ help! to optimizt. ind!einbtt ~ IIOOmg arm.)
Patimt iflf-ldmi niltllltion of dill, tlltr.,:
WlIm IdminiRerinq 1M mtdiutiofl, imtnICC the P'I~t Inclfor IoImiy"
proptI ItI-.dministmiorJ of drug.e.9." the &-it cIIM oftlw_
pmuiption It Hdtime. {P.r IClministrmon ~ tMfffn-sof

Thr p.nimt shedd ~.bIrtomtf!he _

for drug, .~t
dost,lOd Kheduling;whar.drrme ~ toobsfflt for ~"fIIhtn to
~ Ind 1M 'nOOpaled IrngttI 01 mtdiutiof1lt1t!~

Thr pUntshouid ~ Iblt 10 diKv!uppnlpriltt domg iJld

idminiw.uiln nMI.

""ruoJ
Evaluation of Outcome Criteril
b.lu.netile ~Kliftne!1 oIdlll!l the!ilPY by COI'Ifirming mil P'litflt goak .nd ~lpt(Ird outOOme! h.m: ~n m~ (1ft'I'limning1.
StIr TalW liS /IHWr*AlJInNbi/ln'. dst ofdrogs 10 v.Ijdt /IIf$t fIri"i Dim IfP):

23.10 Treating Hypertension

with Adrenergic Antagonists
The adrenergic receptor has been a site of pharmacologicaction in the treatment ofHTN since the first such drugs were
developed for this disorder in the 19505. Blockade of adrenergic 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!'5tern 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 ofth~ symp.atheticdivision causes figh t-Of-flight respoOSoe$such as faster
heart rate, an increase in blood pressure. and brOl1(hodib tion.
Antihypertensive drugs have been developed that bind.
the sympathetic fight-or-llight response through a number
of distinct mechan isms, although aU have in rommon the
effect of lowering blood pressure. These me<:hanisms include the following:
Blockade ofbeta,-adrenergic receptors in the heart
Blockade of alpha,-adrenergic receptors in the anerioles
Nonselective blockade of both alpha ,- and beta_
adrenergic receptors
Stimulation of alphal-receptors in the brainstem
(centrally acting)
Blockade of p eripheral adrenergic neurons

BETA-ADRENERGIC BLOCKERS
Of the subclasses of adrenergic antagonists, only the betaadrenergic blockers are considered first-line drugs for the

LibraryPirate

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 juxtaglomerular apparatw, which inhibits the secretion of renin and the
fo rmation of angiotensin II.
Beta blockers have se~eraJ other important therapeutic
applicatioru. By decreasing the cardiac woridoad, beta
blockerscanease the symptoms ofa ngioo pectoris. Syslowing conduction through the myocardium. belli blockers are
able to treat ce rtain types of d)"Srhythmias. Other therapeutic uses include the treatmen t 0{ heart failure, myocardial
infarction, and migraines. Prototypes ofbet;l-adrenergic anugonists can be found for metoprolol ( Lopressor. Toprol) in
chapter 2400, atenolol (fenormi n) in chapler 2500, propranolol ( 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"""'" effecl~ ~Te IIn~ommrm . A~ Ihl': dO~8e i~ ;nrrl':~~I!<l,
beta blockers will slow the heart rate and cause bronchoco nstriction; therefore, they should be used with ca u _
tion in patients with asthma or heart failure. Many patients
report fatigue ~nd activity intolerance at higher doses, be.
cause the reduction in heart rate c3uses the heart to become
less responsive to exertion. Less commo n, though so me times a major cause of tlon~dherence, is the effect of beta
blockers on male sexual function. These agents can cause
decreased libido and erectile dysfunction ( impotence). Because abrupt cessation of belli-blocker therapy can result in
rebound HT N, angioo, and MI , drug doses should be ta_
pered over several weeks.

01",1<,21

ON9' lor Hyperten,"'"

315

TABLE 23.6 Adrenergic Antagonists for Hypertension

Route and Adult Dose (mall dose where Indicated)

AdveIW Effects

oKrilnoioi (SffirJI)

PO;400-800 mglday (mn: 1200 mglday)

ater.o(,j (l~normin):( ~ ~ 347

for tilt Prototypl' Drug box 00 )

PO; 25-5& mglday (mil: 100 mglday)

Folique, imcrn/1i4 dlWl'inru. impoufJCt Of dtcmJJtd

ibido. brl!ll)wdio. 000 rrduJioo

~alolO( (KrrIonr)

PO; 1~40 mgiday (max: 40 ~dayl

biIoproIoI(abm)

po; 25-5 mglday (mn:20 mglday)

lMIoproIoI (lqlrffior, ToproI)

po; ~ 100 m9lday-bid (max: 450 mglday)

oadolol (CDI'}Ird)

PO;40 mgJday (max:l2O mg/day)

piIdoIoI(Virun)

PO; 5 mg tid (mal:60 "'9Iday)

Drug

BETA-ADRENERGIC ANTAGONISTS

AIJanlAoc)Wil la(ynomasm,S!fflM Jo!mon

syndrom~.anaphylaxil:iftlll: drug ~ ab!wt1Y
withdrawn papitations rW:iund hywn:nsioo.
d'Orbythmjal MI

propranolol p~ral) (~ ~9!' 3M

PO; 1~* mg tid or daily (max:320 mglday) IV;05-l0 mg

lor thr Prototy~ Drug box 00 )

t'/tIl4 hoII'5 PRH

~molol (Timoplk) (~ ~ 771

po; 10 mg tid (mal:60 "'9Iday)

lout... Prototypr Drug box 00 )

ALPHA,-ADRENERGtC ANTAGONISTS

Ii.

Q rIoxal!Jlin (Cilldura)

po; 1 mg at btdtim~;may in<rN~ to 16mg/day ina

two divided 11016 (max: 16 "'9Iday)

pral!Jlin (MiniprtSs) (~ ~ 137

for tt... Prototypl' Drug box 00 )

PO; 1 mg It btdtimr;may inaN~ to lmg bid- tid (max:lO

mglday)

teruolin (llytrin)

PO; 1 mg it btdtimr;may in(JN~ 1- 5 mglday (max:lO mglday)

M or

OrlhoJ!QIK hYPoumion,dlzjnru.1wd1rf, tQ/iglJt

Firg-9ose Dhroomenort@drKiJrdia,!IystioN

ALPHA,-ADRENERGIC AGONISTS (CENTRA LLY ACTING)

donidor (Uiaprl'sJ

PO;O.1 mg bid- tid (mal:O.8I119iday)

m~h)'klopa

PO; 250 mg tid [f tid (max:lglday)

(AIdorntI:)

~p/1ffol edema, JedoriM, depmlkt\. htodtxht, tty

mroill. dtclfQJed lbii/o

Hepa, otoxidly, hrn!oIy!k iIOmlia

(jIanulomoprnia

ALPHA, - ANO BETA BLOCKERS

(iM'd~oI
la~t.llol

(COII'g)

(tIormodynt, Trandat~)

PO;3.m mg bid (rna1:50 "'9Iday)

HtfldodIt,dnlWlirltlJ,Dt/y,dfprruioo,kf""gy,

PO; 100 mg tid (max: 1200-1400 mg/day)

impoltOO!
Bm!Ymdia may WOlin! hNn faHu~ jJ)d mall!;

I)IlW!pIDI of hypoglyumy
ADRENERGIC NEURON BLOCKERS (PERIPHERALLY ACTING)

~ne{Sr~~n

PO;15mgdaityi.. tialty:mayrtdxuoO.l -(llSmglda,

ALPHA,-ADRENERGIC BLOCKERS
The alpha,-adrenergic antagonists lower blood pressure directly by blocking sympathetic receptors in arterioles, causing 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 included in this chapter. Other prototypes for alpha blockers
in this textbook include prawsin (Minipress) in chapter
lJOlO , and tamsulosin (RontaX) in 'hapter 4600.

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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 fatigue 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 arterioles. The alpha, agonists cause sedation, dizziness, and
other CNS effects. Abnormalities in sexual function may

316

UnII 4 'It" C.,dkIY.",ub, .nd U,'nary Syne<m

I DoxazOSIn (Cardura)

.... Prototype Drug

Therapeutic (lass: Drug for hypertension and BPH

Pharmacologit (lass: Alpha,-adrenergic blocker

ACTIONS AND USES

Doxazo~n is a !dtcti~ alpha,-adreotl'lK blocker aY.ilabl!- only as t. blell.Be-causr it is ~ti~ for bIoc:king alph. , recepton in mcul.r \fllooth mUldr, it
has trw .~~ ~ on other .utonomic 0lll.ns and is prefrmd over non~1rCtM beta blockeB. ilouzosin dilate .r\l1firs and tins ,lIld is c.l"bl!- of
c. using 01 rapid, profound 10111 in blood pr6!Ure. DOXilzosin and It"Vl'r.l othn
alpha~rI'fI!'IIlK bIoc:keB also relax smooth mu scI!- 01 round the prostatr gland.
Patitnts who hoi\!' benign prostatic hyprrplaliol (BPH) wmetirnrs ft(ei~ this
drug to relieYr S)'"ll ptom sof dysuriol (chapter 4600 ).
ADMINISTRATION ALERTS
Monitor I"tirn~ do~ 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.

ADVERSE EFFECTS
On staning douzosin therapy.some I"titnts tlprrierKe It"fious orthostatic hypotension, .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 rarl'~ stYere enoogh to (,Ju~ 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 likt/v sign of 0I'!'rd0sagr ~ h)opotrnsion,
which is treated with 01 v.soprl'swr andfor IV infusion offluid~
Rtftr 111 MyMnmgn ~ a MnInIJ /'reII fooIl sp1/t 1II1M <trJg

Prf9nancycategory 8

PHARMACOKINETICS
ll1.... t Jh
Pf,ak:l~h
Half~ifto: 9-llh

Duration:14 h

NURSING PROCESS FOCUS

PATIENTS RECEIVING ADRENERGIC-ANTAGONIST THERAPY

Assessment
Bastlin e ISHss ment prior to administ ration:
Undmtand thereolson the drug has bren Prl'!cribed in ordtr to as~ 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
pR'pir~tioM, ard akohol UII'.8t oIlrn to pcmiblr drug imrractions.
E"liluatr appropriate laboritory findings, electrolytt-!, ~ioIll)' potmilm 1M,
gUcosr,hrl"tic and It'IIiII function lIudie, .nd lipid profile.
Obtiin ba~linewrigh~ vitll signs (eprcioll~ 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 th Rl ugh out administrat ion:
As\o!"l5 for desirrd therapeutic effrclS (e.g., Iowrred blood prrS~fI' within
~stiblished limts).
CominU!' frr~m and <afl'ful monitoring ofvital signl,liaily wrighl,.nd urinary
and cardiolc output .1 appropnatr, eJlf<ioIll)' if IV admin~tration is used.
CominU!' prriocfKmonitoring of electro/ytt-!,tlJIf<ioIll)' potassium.
As\o!"l5 for and promptl)' repon adl'!'M rffrcts:bradjUrdiol, hypotension,
dysrhythmioll, rtflu tachycardia, dizzinrss, hudac:he, or drcfl'.sed uriniry
output. Sr'/ffI' hypotension, ~izurrs. dysrhythm ioI s1l"lpitationl may indicate
drug IOJKity oIn:1should be imflll'diatr~ rr poned.

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Pote ntial Nursing Diagn oses

Drcfl'ase<i Cardiol< Output (di",a~ pfO(ffi)

FatigU!' (rI'lated to adYern rffrmof drug thrrapy)
Akered TISWI' Prrfusion (fI'lated to .~~ effeclSofdrug therapy)
Activity Intolrrolner (related to m~effeCllof drug ther.py)
Sexual Ovslunetion (reIatrd to .dYe~ eifeds of drug thnpy)
Dfficitnt Knowledgt (drug therapy)
Rilir. for Follis, Rilkfor Injury (related to h)opotrn~on,dini[m
.Hsociolted with itdveI5~ rffecll)

0I ..1I0I2l

NURSING PROCESS FOCUS

ON9,/orliype"en,1on

3 17

PATIENTS RECEIVING ADRENERGIC-ANTAGONIST THERAPY (Contlnuw)

Pla nning: Pati e nt Goa ls a nd Expected Outcomes

Ihr pat~m wiH:

UprrirlKf thrrapeutic: efferu drprndrnt on thr rralOn thf drug is being giYfn (f.g.,drut'alf<i blood presSUIl').
~ ~ from, or rxperirlKr minima~ idVfB!' flferu.
Vtrbal~ an undf~tanding olthrdrug's ust, art;fB!' flfb, and r?qJill'd pll'CilutioM.
Oemonmatf proper ~-adminimMion of the mediation kg.,dost, timing, whtn to notif,o providrr).
Impl e mentati o n
Interve nti on s and (Rati o nales)
Ensuring therilpeutic effects:
ContinUl' ImjUl'm aSlffiments as drsc:ribed NrI~r fur theraptUtic: efferu. Oil i~
wt-ights should remain at or {lost to ~lfIilll' wt-ight.(Pulst, blood prtssure,and
respiratory r<llr should be within oormallimits or within parameters IfI u,. thr
hNlth carf providrr.An ilKlNse in w~ht 0'IeI" 1 kg (approximately 21b) perday
may indiulf flKN~ fluid giin.)

[lKourol9f appropriate liflostylt changes. Providt for d~titiin (onsulmion "

ntfdtd. (Healthy liflostylt (hanges willsuppon and minimill' lhr ntfd for drug
therapy.Adrentn;lic: bIocken deell'ilSf hun ratr and m.ly Itild to rlt'KM
i"tok-r"Kt.A<.uvity ~ "'",uld t.. i'K"'~ very 9,dIlUdU,.)

Minimizing adft lSe effKts:

ContinUl' to monitor vital signs.Takt blood pressure lying, sining, and standing to
de\e(t orthostatic: hypotf nsion. ~ cautious with thr ~~ who i reat ilKreastd
risk fur hypotension. Notify thf hralth care providtr if blood prt"!!lI1I' or pullf
deell'all' beyond tstablished parallll'tl'ls or if hypotf nsion iIl({omj)il nitd by
rffirx udJ)'Urdia. (Adrenergic: antagon illS decll'all' hrart rate and (lust
modilation, rfSulting in IoWl'II'd blood prNUII'. Onhostatic: hypotension may
in{rust thr risk offalls or injury. RrIIex um)'Cardill milYlignal that thr blood
presSUII' has dropper! too quic:kij orloo sulnlilntiilly.)
ContinUl' {Irdg{ monitoring kg., [(G) "o~1I'd for dysrlrythmias in tillhospitalized patitnt. (Extecllill monitoring dtvic:H will deteo: early lign sof
adY!'B!' ffferu as Wl'1I" roonitoring for theraptUtK rfflomJ
Wfigh thr j)iltitnt dai~ and II'pJn weicjht gain or loss 011 kg or mort' in i 24hour prriod.(Daily weiCjht is ~n il{QJrate lIII'ilSUII' of lkJid SlaM and takes into
I((ount inukt,output.and illlfllsibil' 1015f1.)

Pati ent and Fa mily Educa ti o n

TroKh thr patifO~ fami~, or calt'9il'l how to monitor pulsf ilnd blood
pres sure as appropriate. Ensure proper ust and functioning of any
hoIIII' equipmrm obtaintd.
Hlftlhr pat~m wt-igh ~ cbi~ along with blood presSUIl' and pu~
lIII'asuremfnt~ Rrpon i WE'ight gain or loss of 10011' than 1 kg in a 24hour period.

[mourage thf j)ilt~ntloadopt a huhhy lifestylt of low-fat food

{hoic:ts, lI'du{t{[ wdium inrakt, ilKreasfd mrtM, deerei ltd akohol
{onsumption, and smoking (Nation.
Caution tilt j)iltitnt about sudden ilKrulfI in oKtiYit)' 1twI. i!epon
diuinl'lI, j)illpitations,or shonnfSs ofbrfath that o{{u~ whilt
fllmising.
TN<h tilt patient to 1M sIowlyfrom ~ing to ~ning or standing to
awid dizzilil'Siorfal1s.
In llnKt thr patitnt to stop taking mtdic:ation if blood JmIUII' is
90160 mmHg or below,or per j)ilramflr r; SfI by thr huhh call'
PlWidtr, and immedilltr~ notify pJOl'ider.

InllnKt the patient to report j)illpitationS,mfSt pain,or d)'lprlfil

immtdgteiy.
To allay poniblt anxitty, teach thr pat~nt thr rationalt for all
rquipment ulf<i and tflf IIffiI for irtqurm monitoring.

Hift thr pat~m weicjh ~ cbily, idtal~ at thr >IIIII' tillll' ofday, i nd
1I'(0rd Wl'ight along with blood pressurr and pullf mNSUlI'lIII'nts.
Hift thr pat~m II'port a w~ht giin or Ion of moll' than 1kg in a 24hour period.

Give thr first dose oftill' drug at bedtimE'. Obserie for excffiive drowsiness.(A
fir;t-doll' II'sponSf IIIiI)' rf"IUk in ~ greater initial drop in BP than subsequent
dosts. Some adrenf rgic: blor:ken may (lust lignifiunt drowsilll'Ss and are ulf<i
uutiously in the eldfl'~, who arr at risk furfalls.)

InslnKt the patil>nt to take the fir;t dose of medic:ation at bedtime ~nd

ContinUl' to monitor blood g1ucOlf and approprine lab 'Mlrl (AdR'nI'''l ic:blocking drugs may intfriere with sOlllr 0IiI1 dgbftK drugs or{harqe thr way iI
h)'p09l){tmic: lI'oKtion is peltfiYfd)

TN<h diabttic: pat~nts to monitor blood WCj<Ir IOOre freqUl'mly and to

be i Wall' of subtlt ligns of pos~biI' hypoejl)'<emg (f.g.,nfl'/OUInI'lI,
initabilityl.Pilt~ms 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'
~ionordysphori . )

Too the j)iltifOt to report ulI/SUil fffiings of >ldlll'l5,despondfllC):

ipatiry, or drpression.

to awid driYing or other haurdous oKti'litiH for 12 to 24 hour; after

thr fir;t doll', or wlll-n till- dosage is ilKlI'altd,umil efferu of the drug
ilre known.

(Conr/ooefi)

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UnII4 'It" C.,dkIY.",u b, . nd U,'nary Syne<m

NURSING PROCESS FOCUS

PATIENTS RECEIVING ADRENERGIC-ANTAGONIST THERAPY (Connnued)

Implementation

Interve nti o ns and (Rati o nales)

Patient and Family Educati o n

Provide IoH'yl'{omiort wch on an adequat~ righted room.(AdrentI1jKblocking drugs yn (,JUS!' mm~ and dilfKull)' Iffing in low light 1t-i~1s.)

Caution thl- pati~nt about driving 01 otht r.[tivities in 1o..... light

{onditions 01 at night until thl- t flem ofthl- drug are mOONo.

00 not .bruptly dil<onlinut tht mtdiution. (Rtboond irypmrnlion and

tao:iryurdia may O(wr.)

Tt"h tht patien~ family,or {alt'giv~r not to Slop mtdKation abruptly

and 10 call thl- h~.lth {alt' PlOllidef if paOr-n1 ~ unable to t1u thlmrdiYtion for molt' than 1 d.y dJr to illness.

Patilflt undtlltim ding of drug thrra p-,:

Ulr opportunities during .dmin~tration of mediYtions and during asmlments
to discuss ratior alt for drug thmp)', dtsired thtrapMK outtomes, most
rommoo .dv~1l!' ~IS, pa"mmrs lor wh~n to ull tht hl-akh (alt' providl-~
and any 1H'(!"I\,Iry monitoring or preuutions.(Using timr oiJring nursing Ull'
hl-ipi to optim~t and rrinfon:r uy te.Khing arr.~)
Patilflt stlfadminist rati on of drug therapy:
When admin~trring mtdKations,inl1l1K1 patirnt and/or family in proper selfadministration ir<hn~.(Propl'l admin~mtion improl'!"l tht ~t{tiven!"ls of
thl-drugJ

Th~

patient should ~ able to stalt thr INion 10, thr drug;appropriatr

\(hrdJling;what.dm-st ~t{lI to obse~ for.nd whr-nlo
It'porr; equipment ntfdtd as appropriatr and how to usethat
equipmt nl;and thl-lt'qJilt'd Itngth of mtdication t~api nffiltd
with. ny spl'<ial instllKtion s regarding lI'IIfWing or (ootiluing
prescription al appropri.n~.
~and

InstnKt th~ p.titnt in proper admin~tration ~hniqu!"l, IoIIoW!'d u,.

It'Ium-dtmonstr.tion.
Thr patient should ~ able tod~CU\5 appropriate dosing .nd
administration 1H'eds.

Evaluation of Outcome Criteria

Evaluate thl- fff~1H'1I ofdrug thl-rap)' by {onfirming that patient goals.nd ~~d OIJ\(OIll!"l ha~ ~n m~t (Iff "Planning; .
Sn T!It 116mdtr'Blf~Baklrr"f()f~ Ii5lddrII!P /IIwNchrhN rrIIIinglion!~.

occur. Less common, though potentially severe, adverse

effects include hemolytic anemia . leukopenia, thrombocytopenia,and lupus. With the exception of methyldopa (A1domet), which is sometimes a preferred agent for treating
HTN occurring during pregnancy, these drugs are rarely
prescribed.

ADRENERGIC NEURON BLOCKERS

"t

The earliest drugs for HTN were nonselective agents that

blocked nerve transmission at the ganglia or at both alphaand 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. Indeed, 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 Hypertension

Routeand Adult Dose (max dost'where Injlcated)
Dru,
Q hyoi"aluilH' (~ilH')

PO; 10-50 mg qid (max:300 mglday)

minoxidi ( Lon~m)

PO;S--40 mg/day [max: 100 I1191'd.y)

nitroprussidr (Nitropresj

IY;OJ-{I.S m(glkglmin

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Adverst' Effects
Orllm!~rk hypoleruion, nlJid fIIlmlion, htododIf, polp!~~rka;

IUDII" "

If1joo !jMJ9!azilrJ

dYsrhythmia~Wod

IfWl' bypotrolj:m MI

~1tf21

Prototype Drug

319

I Hydralazme (Apreso/me)

Thna peuti( (lass: Drug forhyperttnsion and htart faill.Kl!

Phannlcoiogi( (lau: Direct-acting vasocilator

ACTIONS AND USES

II~ WI1 ont of!ht filSt ml intihyptrtfMivt drugi tNrktttd in tilt
United S~~s. 1t KIS th,ougk a dilKl modiiatiOft of wriilsmooth musde;it
his lIOefft 011 ~~ins .Thelapy is begun with low dose!, wlJch ill! griClJaJI)o incrwtd until tM des~ !htfjpwtJ:: respon~ is obta~.Aftrl ~I momm
of thmpy. to~"fKf to 1M drug ~p5 and. dougr inuulr may ~ _~wry. A/tllougk hydralazine prodlnS an t'fft<tivt Iftition in blood prmul!,
drugs in other ~n~ptflensiYt dlsse hnt largely ItpIKtd it lilt to 501ftI)'
conmns.The drug is miab~ as tablets and in ~Jl(tral formubtions for thr
~mnl'ntof~~~.

.
.

DN!lSfOf liyplftenslon

ADMINISTRATION ALfRTS
Abfupt withelfjWill of the dfU9 may ~e rebound hypenrnlion .nd
mil'\)'.
Pm}n.nryut~(

ADVERSE EFFECTS
reIitlt.a.yardia, palpiutiont, IkIshing, MUlti and di.Jnhu Ire
common, bIIt IM1 reo!VtilWripy progresse. Pjti~1Il5 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 smous.~ rfrKtBf,UIM of thtse ad_ tffKlS, the 1M of tr,dr1lizint is limited fl'lMtty to p,itients whose 11TH unnot ~(ont,oItd with othtr,wftr mtcI'KaOons.
Contraindimions: ~ of ilS tffts 011 tilt heart, hyd,aliziM is COI"IIIaindicutd in p,itifnuwih iIlgiJ'll,rhtumltic llt.n<b~Ml,ofTj(h)Qrdi
Patiel1u with lupus shoukillOl meiYf hydraluine, is the elrug rail \\'\lOtfI
symptOll\'l.
~ht,

INTERACTIONS
Oruc.t-DfllJ:AdrriMllmg b~1II' MtlllIItw an~m.irall\f
_

h)'flCltHlsion. This indudfs .. ibjdHsf5115fd ill antih)'llfl'lrmMs.

t..I bltits:.IMy produao I bM-po!itiw (OOI'I'IIK 1fIIS.

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 m pensatory response to the sudden decrease in blood pressure ca used
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.. Fortuna lely.
refle.'\" l:lch)Ordia can bf prevented by the concurrent administration of a beta-adrenergic bJocker,wch as propranolol.
A semnd potentially serious side efft"(t of direct vasodilator therapy is sodium and water retention. As blood pressure
drops, blood flow to the kidneys decreases and renin is released as the body activates the RAAS mechanism. Dueto the
vasodi lation caused by the drug therapy, the angiotensin released 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 pressure and canceling the antihypertensive action of the vasodilator. A diuretic may be administered wncurrentl y with a
direct vasodilator to prevent fluid rett'ntion bu t warrants ex-

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HerbaVFoM: Unblown

TrNtll'ltnt of OWdOSf: Tilt most liktly sign of M~ is bypottnsion.

whicb mi)' bt t~ttd with ~ 'HloptSSOf ~ndlOf an IV infusion offluids.
IIlftJ 1I M)NrJM9I'Jr Ix Q/iuflillf I'nxm Ffars sptI(1I rills drIIJ

trem<' cautio n. EJu.:essive diuresis and lowered blood volume

may lead to excessive hypotension and cin:ulatorywllapse.
One direct.acting vasodilator, nitroprusside (Nitrop ress),
is a traditional drug of choice for hypertensive emergency, 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 potentially 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 hypotension and severe reslriction of blood flow to the cerebral, 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' (ca lcium channel blockers), and enalapril
(an ACE inhibitor).

320

UnII4

lheC~,dklYascu~,

and Urinary Systems

NURSING PROCESS FOCUS

PATIENTS RECEIVING DIREa VASODilATOR THERAPY

Potential Nursing Diagnoses

Aue ument
Bileli.e 1_ll lIIe ~t prior toitdmin btr. ion:
Undersund "" rrl50n "" drug III! IieeIpreaibed in otdtr to ilstSllor
""'~pNtic tfmts.

ClJt.l Ji" (~he.ttt. hill", ilcludill\l (.udiou(uIM IIIWcIiIgM~ IImt

biuR),~!OiI ,I'd neurologic r_kIdiftg 1M! 01' (CIIISCiouws~ hil1Dry
oI'CYA,lIud ~ irKruwd Jilrllnnill pm.suIt~ ~i\OfY,lnd die
possibit1 01' iUtoimmu~ ~HflKiI'" l-,sItmic ~ rrytMlNlows.
ClJt.l Ji .. dIug hiuOfY iIIduding I~tmm pmai,tioft wi OKdfug1.MId
~ prtpaf.riom. It tier! 10 POlSi:IIe ~ JitmctiaM.
MUtt! IPPlOpMe Iibor.tory fincIing!,~roIrt",~Kldium.nd
polisrum IMI!,htpatir.nd ~.I fIMioft midir!, ,nd lipid p~
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.

0em1Std (Ifdiic G.itp.1! (dissf PflICHI)

Akt ltd Tiuur ~ioft (rdaltd 10 ~ de<l$ of drug tlln.fIY)
Risk b IrnINloInced FloidVobnr (1N1td 1O.1Sf t h 01' drug

""'nl
Risk b kIjwJ (of91n sysums;rdaltd 10 adftnttlltsol' dIug
1ht.-~fIY)

Risk br impailtd Skin Incet1 (1N1td to idYerst t h 01' drug

""'nl
Drficimt~(dniqthmpy)

Aslellment throll5l~oul HlIlinillralion:

ksn! i>r dnil(d thffiIptlltK tfftl":l1 (r.g., Iowtlld blood prtlllIrt wilhin
tltiblishtd limkl).
Continue frt~nt and (.rtI\JI monitoring oIl'itllloign~ pul~ollimtlry,urinary
.nd cardiac outpu~ ,lnd ditily wtigh~ ts pt<i.11y iflY idmin ~truion is lMd. Blood
prr:lSurrarKI pul~ 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 Ih~
purpoSfJ
Continut ptriodic mon~orill\l of ele<trolytt~tspt<illly potauium.
u.ntinue ~nt p~llSstSlI!Itnu. plrtirull~y MUrologic.u!!l~~nd
ItIpif.tOfYI)'lttfllS.
Alltss lor iIId pNllptly ~rt ~ tffr<tnlKtilM! ~tnlion,
~_, ItfIn Ixhywdia,hf6dlcht,dKrt.\fd urrury ~ptriphml
tdtma, I!Id priapism. SMrt hypoItnsion. ~~itId
~pI"'itJlions N)' indialt dlU\llOllicity ,nd sbwld Itt immtdiattly
ffIIOllm

"lhelYlinltd
Exptlitnu thmpevtit rffts drptndel"lt on the _
tIIedlug is IttWlg cjtnJ (r..g.. dtml1td blood plftllft).
kfHtfro!n.Off~min_MIotswrffrcts.
~iII ~~901thedN9IU1t,~rffKts,.ndltCpJirtd~ltJIiofts.
tltmonllT.1e proptr stIf-.dmil isll.tion 01' tilt mtdiQtion (e.g. dolt, tini1g, whm to natly ptOI'idrf).

Impltmentilltion
Inttl'"ventio nl a nd (Ratio nales)
IRllring thffilpeutit elfetl l:
u.minue IrrlJlent l:ilnsnltml.s.bow lor thmparlk rifutl..lV infusion 01
IIodi~lm may be litrlled Ir!qutntly to i(hit'l!! desirtd dlfm.Vitillsiglll,
(.!!Iii( ilnd urinaryoutput,.nd daily wtights should ~in within limits Itt ""
mr ht.kh cilrr providtr.!Pulsr, blood prtSSUrt,ind rt1pif~ tOf)' fatf lhould be
within nonnil ilimitsorwithin ampublt paramettrs.An i/ICrt.~ in wtight o~r
1kg {approllimitely lib) per day may indiotf ectSsWe Huid ipin ilnd m.y
rrquirt judkious diJrtlic ttrfflPY.)

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Patie nt 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'IWft 1\ appropriate ~ patiem is on oral ther.py at homr. Ensort
the proptr U~ and functioning 01 <1Jry homr rqJipmrnt obllintd.
Ha~ tile patient wtigh stHdaily liong with blood prtSSUrt ind pulsr
mtlSUrtmrnts.lnmur::t patiem to rtporl iI wright gain Of IoSI 01 mort
tbin 1 kg in. Z4--hour period.

CIIopttr ll Drug./ortfypMen.1on

NURSING PROCESS fOCUS

]2 1

PATIENTS RECEIVING DIREOVASODILATORTHERAPY (Conft'luld)

Implementation

Intervention s and (Ratio na les)

Minimizi lg adftt'lf effKts:
Continue 10 monitor vit .. signs frtqutndy.8t caU!iM willi tilt ~ wIIo.re
ill inc~a>fd ri>l for hypolemion; patimls will p~~g 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
h~alth tm pnMder imllrlilRly ff blood ~UJ~or ~ dK~.m ~d
ellablilhfd pmmetM 01' l hypot~mion i> xcomp.nird '" refl~1 t.rn,urd'iol.
(llirect-i(1ing WlIsodilaoo calM signnt ~il.1tion. rtSIIlting in the
POltn~ for dwnatiully ~nCI rapidly Iowmd blood ~rtSUJrt oKCOIIIp.lnird '"
reflex \i(~.)

Patient and Family Ed ucatio n

Inllrucl tilt p.ltient to It'pOrt .ngilli-likt srmptoms (e.g., chts!"1m,
biCk iI nd'or neck polin), palpit.tion!" fiintnel, diuine!" dnM'linns,.
orlitilcli<M.

Conlinue YJdiac monitoring (e.g., Wi) and inYMive monioring (e.g.,card'1oIC

OI.tpul..rtfflilline prtSw~ uardeml in tbe hospitalizrd p.tient. (Monitoring
~ mill indmcting tilly signs of ~ ~ ill wtll ill monitoring far
tber.pwtic tffecu.)

To allay possible an~ 19th tilt patient, family,or Cilffgivtr tilt

IJtion.lefof an ~uipment Vlrd andllle rwd far~t
monitorilg.

Continue flrqueftt physiul IUHSmtnB, particularly lINDIogir,urciK.,ilrId

ltIpiriitOfY,\mmtdiilti)' ~I .,." c~ in levtl of (OII!(iIlwIm, htlache,
orch.Jnges in hurt or MIg KUICh.(VuodilatOl lhtravY filii)' WOrlftl ~-uilling
nrurologic, unliac. or mpaory OOncitionl 011 bloorl plflsure drops.nd
perfusion 10 viul organs dimiMllts.)

Whtn on col thtrlpy ill homr, teach IIIe patien~ famitr,or caregiwr
10 immediattly ~pon (MIIgH in mmul mUll orletlof
cor&iGusnesl" palpitations, dizzintll" dyspnu, inmuinq prodllCtift
couqh (ejIiaIly if frothJ'pulum iI p~nt).

Wtiqh tlrr jIoIDrIll daily and It'pOrt a weigh! gain or Iosl of 1 kq or more in 24hour ptriod or signific.lnt ~helill tdrm.l.(D~ily wright: iI an i(ur;ne mtalU~
of fluid !taM,nd likes into oKCOUnt inlilkt, OUIpU!"nd inlenliblt 1osst1.)

Whrn on wi thtrapy at homr, h.w tilt patient wrirjh seN dail-,;

ideilly al the SilJne time of day,.rId It(GId weight iliong wir:h blood
prtlWIt ICI pulst mnsurements.H.M patif,nllt'pOft, weight
g.linorkmofmare III..! 1 kqin~ 24-Ia.-~iod,or~iplltlill
rde~, es~11y ifincrNsing.

Conlinue kllIIOfIitor IV inMion .ite. l!equentty.(Dirm"ilCting nsodilatoo lii0i,

calM til_dam.gt if m~ilsation 00lIn..)

In.truct IIIe patitntlD report illI)' burning or.linginq pain, swtIl"lII9.

warmth, Ift!nes!"or!mdt~ at IV instrtion si~.

D~ for siqm and symptOms oflupu! in p.ltif,nts taking vasodilatOl\,

paniculilly hydIJIouiIll'. {HycllJlouinr llil bHftlinkrd todruq-irldllCed IupuiJ

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.

f1H oral drug mrlilpy,gM tht finl doseof IIIe drug at bedt.inIr. (A Iint-4ose
rtIpOlIIf IIIiIJ JtIIIIt in i glUl~ initial drop in BP tllin Usequent rIo!e..)

Inltruct IIIe patient to

tbe fim. dcM of mediution.1brdtime
.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.

00 IIOt abrvpct, diKontinue tilt mediutiorl.(Rebound hrpentnsiorl ft

ta<lrycarlia filii)' occur.!

T9Ch dlt patient not 10 st.. mediutioa abruptt, iIld toa.1I tilt
hta~h cart p!OYider if patiffit iI ulliblr to like mediQtioft for ~
than 1 day Ib to iUne...

ElKou~ .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 toqtthr~ tim mil, It.d
to 9t'Kise intoIrfanre. Artirit,-IeYeIs!holM lit inmi!ed 'fell grlUiIly. Alcohol
rolllUmptioo mil, inrruse tM risk ofblood prtlUJ~ ~ted .dvrrse rfrKn.)

EnClllJfigt the paUrnl toarlopt. lItilthy lifestyle of Iow-I.t food

choire,~ sodi.lrn inukr,inClNSed Dmise.~ akohol
cOllllJllllllion smaking JrlSiition.
u.Ulion tht jIoItient about sudden Mille in artMty 1rwI. Repon
diuineu, palpitatiolll,or shortnesl ofblNm that OCCllB while
mrtiling.

:c-:-'---:----::-

me

---:-::---c:-:-:--

iii"

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

Tilt patimt should be.bIe ID lIall' IIIe reilson for IIIe drug;
.ppropria~dosr and IdmLling;what ~r rflKts to oo.rMJot.nd when torepart;.nd thr .micipalrd lenqth 01mediution thmpy.

proI'ide~and.,." necrwry monitorinqor plt(,)ution ... {1.Img timedurinq

nulling (iI~ Mips to op6mizr.nd reirlorte key INChing .Itil.)

{COOIJncJed}

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322

UMl4

n.. Ordlc-=ubr and UrlNry Syn....'

NURSING PROCESS FOCUS

PATIENTS RECEIVING OIRECTVASOOILATORTHERAPY (Continued)

Im ple me ntatio n

Interve ntio ns li nd (Ratio na les)

Patien t a nd Family Edu cation

' .lient selfatM!i nlll rat ion of dru g tMrip1:

Whm .JdmDskriJH,1 medimion~ instruct \he, patient fMIil)o. or IlIr~ in
proptr self..admilisu.Jtion ~niqJH. (PropeI.Jdministr.uian impllWtS tilt
tffKtil'tlltsS of the drug.)

Instruct the patitnt in p~ id mirmmion 1e<hn~ Ioi~""

Ittu..demonmuion.
The patitnt is able to disaM ipprcpiittdosing and idministl1lion

"m.
Evalu at ion o f Ou tcome Cri te ri a
Ev.JIuolll' \he, rffKtiftllffi of drug tlitral'1 b,<onfinninq thilt paoot goal!.Jnd I'JpKtedouko~ hift ~n !lid (~"l.Joning1.

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.

tive, a eCOnd agent from a different class may be added

to the regimen.
23.1

Diuretics are often the first-line medications for HTN

because they have few side effectsandcan w ntral minor
to moderate hypertensio n.

23l

The three primary f.ictors controlling blood pres.sureare

cardiac ou t put. peripheral resistance. and blood vol u me.

23.'

D.3

Many factors help regula te blood prt'$Sure, including the

vasomotor center, b;!roreceptors and chemoreceptors In
the aorta and internal carotid arteries, and the reninangiotensin system.

Cakium channel blockers block calcium Ions from entering 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

23A

Hypertension has recently bten redefmed as a sustained

blood pressure of 140/90 mmHg after mulliple measurements made over several clink: visits. A person with sustaIned blood pressure of 120-139/80--89 mm Hg is saki
to be prehypertensive, and Is at increased risk of doevel oping hypertension.

Blocking the renin--.angiOiensin system prt'VenlS the intense vasoconstriction caused by angiotensin II. These
drugs also decrea.sl' blood \"Olume. whidr. enhances their
antihypertensive effect.

DS

D.6

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.
Pharmawtherapy of HTN often begins with low doses
of a single m edication. If this medication proves ineffec-

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D.l0 Antihypertensiw autonomic agents are available that

block alph3, -adrenergk recl'JllOrs, block beta,- and/or
betaradrenergic receptors, or stimulate alph3r OOrelW.'rgic
re<:eptor.; in the brainstem (centrally acting) .
D.ll A f....... medications lower blood pressure by acting di rectly to relax arteriola r smooth muscle, but these are
nOi widely used due to their numer0U5 skle effects..

~ttrl)

OrugtfOfHypertemlon

123

NCLEX-RNOREVIEW QUESTIONS

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

The nurse prepares to administer hydrochlorothiazide (MIcrozide) 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

The pal lent Is on IWO antihypertensive drugs. The nurse

reoognires that the advantage of combination therapy is:
I. the blood pressure w~1 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.

The dass of antihypertensives that Increases urine production by affecting the renin-angiotensin- aldosterone
pathway Is the:
I. calcium channel blockers.
2. adrenergic blockers.
3. ACE inlubitors.
4. dIrect-acting vasodllators.
The nurse is preparing [0 administer the first dose of
ena laprll (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
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.

CRITICAL THINKING QUESTIONS

1. A 74-yea r-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 hypertension.identify a teaching plan for this patient.

r::::=:-i~-'---,

EXPLORE ~

M)1'AJrYlgKil is your ooe SUIp IIJ' onIdle chaptef

Sa Appendix D !oramwers (md rationales for all activities.

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m!ler\a15 alld

ancIl'icIeo&. and mIlel

RegISter yDIJ ICct:!!! COCII! Imm me froo1 d your _
www.JllYll ...... gkllcom.

1. A patiem is having a hypertensive crisis (2301 ]30), and the

BP needs to be lowered. The patient has an iV drip of nitroprusside (Nitropress) init~1ted. How much would the
nurse want to lower this pa tient's BP? identify three nursing interventions that are crucial when administering this
mediation.

n!\'I!W

tur SIII:C8SIi 'Mth aldibonal 1~-styIe pradic:!

questlDns, Imeracllwi assI~cnIS S.:I K1IdIe:s. web 1m. anlmations
n!WUJC8S. PnllaJB

at

Drugs for Heart Failure

DRUGS AT A GLANCE

LEARNING OUTCOMES

ANGIOTENSIN-CONVERTING ENZYME (ACE)

Alrer reading this chaptn-, the student should be obit to:

INHIBITORS AND ANGIOTENSIN RECEPTOR

BLOCKERS

~J}6

Q "Jlnopr1l (PrtnlVlI,Zestlil)

DIURETICS

PJilI 119

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)

1 . Identify the major disea~5 that accelerate the progression of hea rt

failure.
2 . Rel.,t .. how th e symptom. iI oc lat~ wit h he.ll rt fllll ... r.. "'"y be cau sed
by weakened heart musde and dimini she d (/lrdille output.

3 . Explain how pre load and afterload affect ca rdi ac function.

4 . Describe the nurse'. role in the pharmacologi c mllnllge ment of heart
failure.
S. Fo r each of the drug classes listed In Drugs at II Glance, know
re presentative drug exa mples,lInd e Kplal n thei r mechanisms of action,
primary actions,and important adverse effects.
6 . Use the nursing process to Ulre for patients v.hoa re receiving drug
therapy for heart failu re.

pot}t JJ6

KEY TERMS
dtfrload pr19tJlS
(imliac output (!JfJt Jl5
tardi ~modf~ng po!Jt j}6
contradility fXl9t J2S

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Frnk- St.rlinglaw paJtJ15

~~artf.ilun(HFl rvgtJi$

inotrolliuffffi

~ l15

ptriphtraltdtma fJlJ9fJ}6
pholphoditlttrast r;II9tJJ$
Jnloid {IIl9tJ15

CNplfl24 OI\Jg'fu' ...... nF.,Iu'e

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 decline in mortality for most cardiovascula r disease (CVD) that

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 improvements in survival and the quality of life for patients with HF.

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-

24.2 Cardiovascular Changes

in Heart Failure

tension (HTN) has led to declines in mortality due to heart

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 myocardiwn, it is essential to understand the underlying cardiac 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 ventricle per minute is the cardiac output. The relationship between 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 before 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 contraction is called preload. The more these fibers are strttched,
the more forcefully they will contract, a principle called the
Fr~nk-Starling 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

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 associated with congestion, the more appropriate name is heart
failure.

24.1 The Etiology of Heart Failure

Heart failure (HF) is th~ inability of th~ 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 cardiac muscl~ is a natural consequence of aging, the process
can be caused or accelerated by th~ 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 incidences of CAD and MI. Maintaining blood glucose within
normal values reduces the cardiovascular consequences of
uncontrolled diabete>. Thus, for many patients, HF is a prev~ntabl~ condition; controlling a .... ociated di.ca.c. will
PHARMFACTS

Heart Failure
Heart fJiufl' (Hf) ilKfI'j~ 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 ti~ 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 frr~m in hypertensM patirnnand fiW' ti~
JS frr~m in persons who haW' nperienced J heJrt atuck.

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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, norepinephrin~, 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 overrome for blood to be ejected from the left ventricle. Ala simplifiEd example, if the mean art~rial 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

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 preload, blood "backs up~ into the lungs, resulting in the classic

,,,,ft he~rt f~il_

"Jffi1ptom< of cough ~ncl shortnes..< of h""'th.

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

I
D"",,,,,,,,,d blood pre5l!Ure

Incr" ...... d pmI""d

I
Pulmoollry edema

Dea" ...... d blood

flow to kidnor-

11'~! ~-;

.....,

peripheral

Edema oIlimbol
Increm!Mld

,~"""'"

moo

water

Increased
,,,sistanca

blood volume

Incre ...... d

altarloed

myccardiat

""'"~,
~

Flgure24.1 Pathophysiology of heart failure

LibraryPirate

Drugs can relieve the symptoms of heart failure by a

nwnber of different mechanisms, including slowing the
heart rate, increasing contractility, and reducing the myocardial 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 reason 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

ACE inhibitors were approved for the treatment of hypertension in the 1980s. Since then, research studies have

Reoin-angioteosin
system activatad

Sodium

clition often wo",,"n< M nighT.

24.3 Treatment of Heart Failure

with ACE Inhibitors and
Angiotensin Receptor Blockers

I
ADH

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 failure, the blood backs up into veifl'l, resulting in periphf ral
rdema and engorgement of organs such as the liver.
Through proper pharmacotherapy and lifestyle modifications, 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 decompensation occurs and classic symptoms of HF appear
such as dyspnea on exertion, fatigue, pulmonary congestion, 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-

clearly demonstrated their ability to slow the progression

of heart failure and reduce mortality from this disease. Because 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, afterload, and blood volume substantially decrease the work-

CNp1tI24

Drug. /0,

Hf'artF~lluf"

327

PHARMACOTHERAPY ILLUSTRATED
24.1 Mechanisms of Action of Drugs Used for Hea rt Failure

= Sti....lalion
= 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.

<a~!~tInc ........
cardiac
~
by
r.creasing
theoutput
f"",. of
myocardial oonlraction
(Example: milri""",,)

AC E inhibit or.
Inore&H cardiac
output by Iaft'ering
blood preo.s<n and
dec..,BIIing ftuid

"~

(Ellample: lieinopti)

Cardiac glyco. ide.

Inc:rea ... cardiac output by
inueaeing the force of
myocardial oonIraclion
(Ellample: digoxon)

Increased un"" output

load on the heart and allow it to work more efficiently. Pa~

lients taking ACE inhibitors experience fewer H F~related
symptoms, hospitalizations, and treatment failures. Several
ACE inhibitors have bet'n shown to reduce mortality following acute MI when therapy is started soon after the onset of
symptoms (chaptt'r 25(0).
Another mechanism for blocking the effects of angiotensin is the use of angiotensin receptor blocke rs
(ARBs). The actions of the ARBs are similar to those of
the ACE inhibito rs, as would be expected, since both
classes inhibit angiotensin. In patients with H F, ARBs

LibraryPirate

show equivalent efficacy to the ACE inhibitors. Valsartan (Diovan) and candesartan (Atacand) were approved
to treat H F in 2005. Because research has not yet
demonstrated a dear advantage of ARBs over other
medications, their use in the treatment of H F is usually
reserved for patients unable to tolerate the side effects of
ACE inhibitors.
Please refer to Nursing Process Focus: Patients Receiving ACEI (Angiotensin-Covering Enzyme Inhibitor) and
ARB (Angiotensin Receptor Blocker) Therapy, page 312 in
chapter 2300, for additional information.

TAB1124 11 Drugs for Heart Failure

Route .lnd Adult Dose
(mu dose where Indlc:atedJ

Adverse Effects

gploprIl~~)

PO;&'lS-12S mg lid , _: 150 nl9Idoy)

Iftdht.~oltholtllfk /IfportmM.COIJ9/l

tlliil.priI [\ItsoI) (SH ~ 112 fortlle

PO;LS 11'19 qid-bid [nw:~ nlgf4;y)

"'""

ACE INHIBITORS
Sm!~m:I!!l!t!l1!!!! If.s::!lmDl\( "OI'M!Q(II'll!!!2~

aoo ipcslrm.

ProtoCJpe ~ boxCIO)

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)

blood d!ry"w,

ANGIOTENSIN II RECEPTOR BLOCKERS

~dts.JrIin (AQ(.)nd)

PO; 4 mglday (max:l2 mg/diy)

"fOIISlio (liIwan)

PO;40"'9 bid (m~1: 320 mglclIy)

DIURETICS

100fJllt High (tiling

IMIntlillido! (BuIael)

PO:O.S- l "",day (m..: 10 "9'oI;y)

l.oop,ndtlllizi~

fIro5oM'lklt (Lm)

PO:1G-ICI mg In OlIO! ormort dMdtd dosts

EItc/llJlyfr imIHIkIlcr1, Mhos/DOC hypiltlnJioll

lontmide (1)eN6ex)

PO:10-1(1 mg/clI, (mn: 200 mg/d;yl

(max: 600m~1

rJIItuiM IlIHI T1IkIzIdHlkr

Y.

Idrodllorolhiuide (Miawidtl (Sft ~ 304

PO:lS-ZOO mg In i

btlle ProIolyprDrug boJOO )

li"ridtd ~ (m.u:lOCI mgIda,)

dow or !Ilrff

~r~ !!I!Q!~~ !!rl!cl!jJjon h~~ia

Irtpclnamm!i. O!O!OJjicity (JoopdiMig)

1'I:iI:111i\Jn.,pui"ll:

/lrrHrt./fJriI,9)Ol'Il1I!!OSli illllO.Ilj, ffrigut

Doow l",lomiil ~1I1lI bml:obIHnlt

PassIum-Spdting (AIdosI!tOUAllfagoolliJti
tpltrfllOllt(lO\ID)

PO;lS- SCI mg on<~ doliIJ (mu: 100 mgldoy l

SfllrorooLKtont IAldtontl (Sft ~ m

PO: S-200 mg in ~ doStl(INIt 200 mgfday)

btlle PrOlotyptDrug bolOO l

BETAADRENERGIC BLOCKER

"""""
'' ' '
o

mttoprolol91.et*d rtlw~{1opro1-XI.}

PO:112S mg bid b 1wt (....:25- 5011'19 bid)

PO;lS mg/doy for 1 "!It; Jl5111g1cl1, fOf sr"lm
~StI (....:200 mg/doy)

iltSllllllht
1Ndyc,.
aJllMion
~

dnIor5intU.~r orllcltitSldibldrl,.

Ag@nu!ocytosij.Wyrm!lW"Sfmm- )obrnr.rt
i!!!!i!!m iI!!ilR!!!!i!irif!!! ~r!o!il il i!!!1!1b: 'll'il!Wwn
ptlpit.nioM, ttixI!!Id hmffi!l!iDll W~ thl9ltr1ioo
rtryhytbmjA, or mrordal jyhrmia iN. OI'QII

OIRECTVASOOILATOR

Idr&Dit 'll'ith ~ dnmtr (BiOil

~ (N.no=r)

PO; 1-2 Qbku liel (f u ll UIiIf\(OIILlins 20 Ia9

~ dmuatr .-!d37 511'19 Irjtdrilizillf)
(rMI:2 ublKsldiIJl

Hftldhf,/lII/IqIl'IICt,.mw'rk~

tlzzinm" fPlt% rld!Yflrtlo

Fainti!!!lt3!m: Iifadadof !m!f trtl!!!rtrl5ion wiIto
qrrn1w hpjditr rurtjgo rbvrVlarirt)

1V:11IKiJIkg bam fdlll'lmlt., cmtinuom inllllion

.n 0.01 nltg/kgfmin.

Hnxormlkon,imtfMli mum rlf"flfirliM,MnltKItr

PO;O.llHSmg/daJ

Ntvltf, ImIitiI"/i /ItQdht, ond~ tlWltm:rs wd! OJ

stfirtg bolo$, Q'IfIow-vrttt linge, /I( /lUrif19

DnrhythmLu

CARDIAC GLYCOSIDE

o dio;p:in (D9tH,liJlOllin, unoxiciJIIl

Qyy!rttbmja< J.II hlott

PHOSPHODIESTERASE INHIBITORS
iwmrinont (1_)

IV:I.7) on9 boM gMli !IoMtt GftI" 2-l min;!Iom

S- 10ITl(tt\gfmln (m'lt 10 mgJ'cgIclIy)

o rriIrI"Ior1e (PTirrvtor)

1V;5CI ITI(g Mr 10 min; tMn OJ7H1.75I1KgIkg!min

Irdio indiar:~ IIlI1IID!l oJdJm,r rlfu;~ indic.Jrrl s.trioIaaolwntrlf!m..

LibraryPirate

HmdIIt,ftJP:lF1'fIIion
Dnrtrythmwi

CNplfl 24

.... Prototype Drug

Drugs /0,

1-1<>"" F~IIu,,,

329

I Llslnopnl (PnmVlI, Zestn/)

Therapeutic (lass: Drug for heart failure and HTN

Pharmacologic (lass: ACE inhibitor

ACTIONS AND USES

ADVERSE EFFECTS

BffiuW' of it! valUl' in the tlNtment of both HFand hypmenlion,lisioopril has

br(ome one of th~ mosl ~UI'Ilt~ ~ribM drugs.lisioopril ads by inhibiting angioll'lllin-(ollftrtilg l'IIl.ym~ and dt(l~asing aldolterone IKlMion.
Blood prl'lsure is dKremd and cardiac oulpUI is iIKINIf<i. A5 with olher ACE
inhibitors, 2to 1wtt'ks of Ihtfapy may br required 10 IN(h maximum effectivfnes~ and W'Yefal monthsoftherapy may br r"ftded for cardiac fuIKtion to return 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. rreabn~nt of migrainn is
an off-labrl indication forlisinopril.

lis inojlil is toleraled well by most patirnt~ Th~ most rommon adv~W' ~m
aft' coLgh, headac:he, dillinl'll,orthostatic: hypotenlion, and rash. HypMcal~mi.J
may ocrur during theC"apy; Ihus, Mc:trolytt Itftls art usually monitored pm
iea lIy. Dlher ~ffec" indudt taste dil1urbi IKn,{hfit pain, nau IN, VOID itirg. and
diarma .Though rare, oI ngioedmloi is 01 W'rious adW"II' dl.
Contraind icationl: lisinopril is (ontraindical~d in j)iltienll with ~yper
kalemi! and in thos~ who have prn iously 9per~IKed 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 s~ond and third trimfltm .

ADMINISTRATION ALERTS

Mtasuft' blood pft'lsu~ ;m prior 10 administering lisinoprillo br {~ nain

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 mayha~ high~r blood IrYeIs rt l"ed to renal failu~.
Pft'Cjnancy category ((fim trimn ter) or D(W'{ond and third trimesten).
Us~ during the If(Ond and Ihird trimesters of prl'gnancy molYrnuh in injury
or dtath 10 the MUI.liKontinUl' UW' II soon al pr!9C\i1 nq is luspt(Ied.

PHARMACOKINETICS

Onsd: I h

INTERAalONS

DrurOrug: InOOrnfthidn III 0!IlfI HSAIl); may i lleoo with wnoprit ( AIIilj
~anlihypHltnSiwani";Iy. SKaustoftMaMtivfh)"poltnSiwanion 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 IOIicil~

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: Exc~w iob of foods rich i1 poIillium and polaIlilm-bud salt

Slb5Iinles should lit iWOidfd bKilM of thco pomilyof hypHblfmia.
Treatment of OvrrdoW': ~rdoW' {lUW'S hypolension, which may br ~aled
with the administration of normal saliCll' or a vlSopIffior.
lit frr ro M;rNUrlbrgKJI for Q NuflirrI} I'rtms fOOJHPKI/{ ro rlrls ~

~k :6-8h

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, peripheral edema, and pulmonary congestion. When diuretics reduce 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 research 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 diuretics 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

LibraryPirate

di uretics are also able to function in patients with renal impairment, a n advantage for many patients with decompensated 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, thiazides are generally reserved for patients with mild to moderate 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. Spironolactone. however, is an exception. In addition to being a
potaosium-sparing diuretic, spironolactone is classified as
an aldosterone ,rntagonist. Clinical research has demonstrated 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 ch~pter 23010 , for additional
information.

]]0

UnII4

The (~ ,d"""~"ul. , ,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 minute~ giving p.atients quick ~Iieffrom their
di5trrs,ing symptom!. FuJOll'lllide a(ts by prrftnting the ~.b!orption of
sodium <lnd chloride in the loopofHenIe ~ion of the O!'phron.Comp.~ with
othe, diJft'tiu, furoll'01ide is jXlnKularly beneficial when ca,di output .nd ren.1 flow are severel)o diminished.
ADMINISTRATION ALERTS
Checkthe p.ltien(I II'rum potmiJm !Mis belo~administerin9 thedrug.
Ifpotassium 1ev!-1s.~beIowoorm.l,notify the health urr plO'/ider befoll'
admininering.
!lui' to the prolon9l'd I'OIlfli~ in pft'lll.ru~ inf.rmand neon.tes, the drug
mUll be UJed with uution.
Geriatric p.atientl may requi~ lower dam.
P~nalK)' category C

ADVERSE EFFECTS
~1Il' efIeo:u of furoStillidl', lie thole of mon diuretic:s, iOYOl~ 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 possible dehyd'<ltion ~ nd hypott nsion. HypoYOlemi.J may call1l' orthostatic: hypotension.nd synropt.
Contraind ica\ions: Contr~indicatioos indude hyper lI'ositil'ity to furostmide or
sulfon 1m idI'~ .nurY, hep.atic (oma, . nd 1I'"lelt' Huid or tleurolyte depletion.
INTERACTIONS
1Wg- 1Wg: BKIUII' ~pokaIeaja may<aU\f d)'ilh)l/lm~ il pati@nts!DIg
GlI1bc: o#osidM, (ombination thenpy w;m dgoIin mll5l ~ <afefUly mcmor~
{oo(Wfl'nt Ull'with rortkostflOid!,~lfriti1 B,orodlfl po~~u~ng

augs un rrsUI i1 hypol:almU. Wh@oIjiI'Mwithlithium,eliminationof ithium ~

dKRNd, UUIiIg. hq.a rill; of t~idty. fll"0II'I0idf may dimirish the
~fIIK~ofllMcrr,1WUi 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

PHARMACOKINETICS
il1l1't 30-6) min I'O;S min IV
~.k: 60- 70 min 1'0;20-60 min

IV

Half~ifto:

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 beautiful 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
H F 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 o f the heart.
Although digoxin dearly produces symptomatic improvement in patients, it does not reduce mortality from
H E 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-

LibraryPirate

T~tm.nt of o.,.rdo,@: o..rdoll'will"""kin hypolenlion ~ nd 'rwIl'fluid

<lnd eledrolytt Ios~ Tft'atmrnt is supportive, with r~la(ment 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. Digitalization refers to a procedure in which the dose of digoxin is
gradually increased until tissues become saturated with
the drug, and the symptoms of HF diminish. 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 experience digitalization with digoxin over a period of 7
days, using or~1 dosing. In either cas.. , the go~J 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 contraction 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

CNplfl 24 Drugs /0, ...... n Fallu,e

.... Prototype Drug

I Digoxin (Dlglte/vLanoxm, Lanox/caps)

Therapeutic (lass: Drugfor 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 poIitiv~ inotropic ac:lion. Digoxin ac(omplilhes Ihis by inhibi:ing Ha +K+ ATPall', lhe (ritic.J1 tlll)'lIII' I'I'spolllibir
10, pumping \Odium ionsout of lhe myocardial (ell in achange lor potassium
ionl. Assodium acrumulaltS, ca kium iolll a~ 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 ilK~altS cardiac output. thus alleviating sympoms ofHf and improving fX~lI:ist lOirr.JlKe. The imprwrd cardiac output r~1ts in ilK~' srd uriIII' prOO:Ktion and ,dtsirab~
reduction in blood wlulll', ~lieYing distressing 5)'mptoms 01 pulmonar; (009I'stion and peripher.J1 rdtma.
In addition to its positi .... inotropic efffcl, digoxin affects im pu~ conduction
in the hea It Digoxin has ~e . bility 10 sUPIHffi the sinomia I(SA.! node and \low
~IKlriul (omtion Ihrcugh the ilriumltrirular (AV) node. Btca!M of thell'
<Iction1, digoxin is IOmetimrs used to I~at d~rhythmi,1, is dilru\1f<l in
(hapter 26CX>.
ADMINISTRATION ALERTS
Take the apic.J1 pulll' ~r 1 full minute, noting ra~, rhythm,.nd qualil)' IJt..
fo~ administering. If the pulll' is below the paramtltrt"ltablishrd by the
he.kh ,,~ provider (LlWIIy 60 bealS per minutt), withhold lhe cIos~.nd
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 ca~ provide,
(usually 1.8 nQlmU. withhold thedole and notify lhe prOYidrr.
Use with caution in gmalri( and pediatric: patirnll bK.iUII' thrll' populations may hoM' inadequa~ I'I'nal and hepatic: metabolic tnl)'mrs.
PlI'9nancyCillrgoryA

PHARMACOKINETICS
Onset: 111-90 min PO;S- lO min IV
Peak:~ hPO;1.S

33 1

h PI

Halllife:1--4 days
~n: 6-8da~

have the potential to wo rsen HF, they have become standard therapy for many patients with this chronic disorder. Only two bela blockers are approved for the
treatment of H F-.....Q.rvedilol (Coreg) and metoprolol extended release (Toprol-XL). The doses of these agents are
listed in Table 24.1.
Patients with HF have excessive activation of the sympathetic 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 patients. Extensive clinical research has demonstrated that the

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ADVERSE EFFECTS
The most daogtfOUS adYme tffra of digoxin is its abilil)' 10 (lNte dysrhythmi is, pmirularfy in patirnts who hal'!' h)'pokairmia 0' impaired I'I'ni IfUKtion.
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' rfncts 01 digoxin thrr.Jpy ind~ naUSN, vomiting,latigut, . norexia, ,nd mual
disturlBntfS suc:h is ming halos" ~Iow-gll'en 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 d~rhythmiu unrelated to HF !hoold nOI re<tiYe digoxin bK.JUIl' Ihe drug II\a)' WOBrn theW' (onditions. Digoxin YIouId be administered with caution 10 oldtr adults btcausr
thell' patients aptrience a higher ilKidenc:e of adYl'llt tffrcts. Patients "l'iith renal 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 ~)"!hmial.lJ\.! wim ill
mllilcn,spiOlloiaClOfll',OI potmium \~HllPntlcan INd 10 ~ and
reduce .... the!apMiI: iOion of digoxin. AOOIililtr. tion o f .il with other
poW"/I! iIouopic agenlS yn aulo! ol6di~ effioaI on hoo <llIlIiKlility. Cooo.wIHIt
!lie wi~ beta bIockHI may ,t\Ifi il addiIi~ brody<;lldia. Antacids DI dIoIfIIeriIowfrill OOM)I can dKrNIe the absorption of !igoIin.1fuki:.m ~ olOOiiniliered IV
~with digollin,it un ilafilo! therilkol ~)thmiA ()inidiM, vmponi,
am iod.Joof. and a~ will demu the diltribulion and exuetion of digolin.
thu! inaNsing the rill; of digcl:il tollidty.
La bTl5IS: Unknown
Herbi Hood: GiRSfng may ilafilo! the riIk 01 digollin 10D:it~ ilia huang .and
ephfcIr; may ilriKt d)Yh)11v1iu.

Treat ment of Overdos!: Digoxin CIVffiIoII' un be fatal. Sptc:ific therapy illwlm IVinfusion 01 digoxin immulII' lab (Digibind), which contains <IntiJodiH
specific for digoxin.
IIrftr III M)NUIlIIJqm Alr Q Mmlnlj Pnxrll fIlM Jp1k III/lis drug.

pro per use of beta blockers can dramatically reduce the nwnber 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 increa.\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, especially ACE inhibitors.
The hasic pharmacology of the beta blockers is p r~sented
in chapter 1300. Other uses of the beta-adrenergic blockers are discussed elsewhere in this text: for hypertemion in

"

ll2

Un'U lh"C.,dIoYHCU'" and U"""ry Syll""'''

NURSING PROCESS FOCUS

PATIENTS RECElV'NG D'GDX'NTHERAPY

Assessment

Potential Nursing Diagnoses

Bilsflinf il55fss mfnt prior to administration:

Undermnd the rtuon the dlll9 hils betn prtscribtd in order to asSHS for
the,apeutic tffws.
Obtain a (Om~tf heakh histol1 including mdio'mcuiar (including prrvious MI,
hem faiull', VilI\'UI,rdim~), renaldyslulKtion,dysrhyth mias (rsptCially lINn
bloc:kJ,ilnd prt'glliln()' 01' l,ctation.Obtiin ,dlllll h~lDry including allergies,
current PIl'scription .nd OlC dlU\Js. herbal pll'p.uations,ilnd akohol usr. Bt .len
to pctS~bIe dlllll interiJ(tion~
Obt,in ~Iintwtigh~ vit.!1 UQns (tsptCi.ll~ pul~ and BP). brfilTh lOUnm,and
ECG.Aslt1s for location and characttr of rdema if prmnt.
[v,iwtt 'ppropriate laboratory finding~ *,trol)'lts,tljlfCially potJSli.lmImI,
Il'nil l function studies,.nd lipid profiles.

Orused Cardi.lc Output (disus~ proctsS or rtialf<l tooJdme

efftcts of drug tlitr,py)
Fdtigue (distilse process or Il'lattd to~mlt elftm of dlllll thmpy)
Aht rtd TMIII' PtrliJsion (reIatrd to disNsr proem)
Ac:tivitylntoieranct (reIattd to disNs~ proe~n 01' .dver\t dftcts of
dlllllthmp)')
Otf"itnt Knowltdgt (drug tlitrapy)

I".,."'r.II,.;,.""o ,."......o..,,,,

ASSfSSrMnt thro ughout administration:

As~'15 klr delirtil tlitraptlnic rffKu (t.g., htan ratt ind blood p~IUJt Il'lUm
to,or lI'I1\ain within,oonnal fimits; urintOUlput rtlUlIII to, or is within, norll'lll
limits;~ piriltor)' congestion (if prt!eflt) ~ improl'ed; peripht ral tdell'll (if
prtst nt) ~ impJOI'td; intiof (onsciousnts~ skin colo~ c.lpi lIal1 ttfil~ and otlitr
~n5 of jC)eqlllte perfusion all' within oonnallimiU; fitjglll' lesltnl).
Cominlll' periodic: roonitoring of elec:trolytt~l'Ipeciall)' pltmium, Il'nallulKtion,
.nd drug kYtk.
Asse'15 klr oJdYel"It ffffct~ broJd~rdia, nat.lltil, ~mitinlJ . norecia, visual
(hin~,fatiglll', dizzintu,ordrowsintss. Apulst riTt btlow 60 0' .bol'e 100,
j)i Ipitations, ~n munt dimntss 01' syncope, pe Bi slent i JIIlIl'Xia or \"Omiting.. ,nd
visualchanges !hould bt ttporud ID thr hNkh art provider immtdiatrl)'.
ExercM caution when giving di\1Oxin to the~, 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 tff~u.
Planning: Patient Goalsand Expected Outcomes
The patient will:
Experitnct tlitrapeutic tfftc:ts kg., ht'rt "te.nd blood p~SUrt rtmain within tstabl~htd par~rntttrl, urint cotP'JI inatilsts to oonnal. fMiglll' Its~n~ lung
SO\Jnd! clu~ peripht,.!1 tdema dec:rtilt1).
Be ~t from, or experience minima!. ,tlYersr tfftcts.
Verbal~ an undtrstanding of tlit drug's u~, oJdYefSt effem, iI nd I"fquill'd prtUlJlions.
Otmonn"tt proper self-j(jminist"tion of th~ rooIic'tion (e.g, dOlt, timing. wlltn to notify provider).
tmplementation
tnterventions and (Rationales)

Patie nt lind Family Education

Ensuring therlpeutlc tfftm:

ConTinIII' frrtp'rn ilSlt1YIIt 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.)

TeiICh The patien~ family,or ull'9~r how to mooilOl' pullt and blood
pttllUrt. Enill,e tilt proper \/If and fUnctioning of any hoJlll'
equipJlll'm obtaintd.

Enrou"9t appropriate lifestyllo changes. Provide for diftiti~n consultation ill

fIffiIed (Htikhy lifestyle chaJlC}l'l will IUppon the btntrns ofdrug therap)'.)

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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 Iowfa~)ow..
sodium food choice.
Instruct tilt patient to increast imakl' of pltmi.lmric:h foods mh as
bananas, apricots, kidfit)' btan~ S~tt potatOl'!, and punlJl buner.

IlIopltrU

NURSING PROCESS FOCUS

Drug<forH,,;mF~llure

]3]

PATIENTS RECEIVING DIGOXIN THERAPY (Coof illufti)

Impl e me ntation

Interve ntio ns and (Ratio nale s)

Patient and Filmil )' Educiltion

Minlmlrl., achotrst fffem:

Continue 10 monitor vitahigm.Takun .plol pul!e (AI') !of 1full minu~ 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 ral~ II iI strtnglhtM
comractilitJ.)

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 t~iI)o Id. ~ord 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 Pilitn~ 01 f~ily/cartgivtr buys i IIt1hoi<opt to like
pulst,ttr5Q1t proper ....rstlnding oIl1Nrt rounds (i.t~ 'ul>-6JtI of
hNnbrat is (liE hNrttM:.t), appropMr stet1losropt IM,.nd h_
lIMitn~~ or cartgNtr ltIum demonstrlt~.

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

InslllKtthr patient on 1M IIt'ed to Jttvm ptriodita~ for I.b worl

~ thr patil!nt to tarry Willet idttrtfution cMd 01 wrar mtdicJl
identification jtwtIry iIIdiating dipin therapy.

Weigh tMp.atRmdailyand ~rtaweighigainOilossofl kg OItIIOIII:in .24hour ptriod. (~ily weight is .ft acrur.1t measure of IUd SUM .nd ukts into
I(OUnl int'R,output,and M~bIt Io!m. 'Neght gain 01 edtmil Ny signal
imptnding hra" f.ilurt with ffIIucfd organ ptrMion,mmuiating ltIIin

HaYI'IM patient weigh ItIfdiily, idtaIy 111M ~IIII' ~of diy,and

IKOrd wtight ilong oMth puke mtoIIUrenttrts. H.'/! the lIMitJlt
repOluwtightlossOfgiinofmortthan 1 kg(a~a~y2Iblin
.24-1!cu ptnxl.

!tItale.)
Monitorforsigns of woneing hNrt faiIIR (t.g., inCINSing dyspnu 01 poItur.J1
ftotturnal ct,spnu, ralft OI "aad\ts" in kirI9I> frothy pri.lin~ lfIUIum) .nd
reporl immt<imly. (If signs iIId symplOfM worsen,otlle trtalmtnt options may
neoedtoMmmideredJ

InsllIKt thr IHtient 10 imrnKIi.I~ report.ny StwR shortnessof

bftllh, frothy lputum, profoo nd f.t9. 011 Wl'ning of txtrtmitits ill
possiblr, rigltl of hea" f.lbt.

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 O)nsciousnes~ fatigut. dillioe~Of I}'IKOpt
shoold III, ItjIOftrdJ

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.

1M mra autiotl when ~ng the dow of mtdic.Jtion ordertd.nd 1M

I'Xtrtmt UUlion when mta~g liquid dost!,nptO.ly for pediol!ric patients.
(Diqoxin 1Iai. bng half~.nd toxic IMh m.y =r~ wi!h only slNlamounu
of idditional cWg.)

('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 I~ doz,~ialJfor pediatric patients.

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 thmptUtic OUl(omt~ most
common ~ Nftm,.~m forwheo loall thr pr1)I'i~ and illY
ftKe~ry 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, palien~ bmily,ora.r in
proptr llII-.administr.tion tKhniques. (Proptr .dminislmion imp lOftS thr
rf'IKti'ftntss of thedrug.)

InnllKtIM patient in prop~ adminismtion tKhniqun, IoIIoWfd by

rerum-dtmonmation.
1hr p.ltierl should 111,. 10 disruss .ppropriatt dosing and
.dministr.uion IIffik.

EVllu iltion of Outcome Criteria

kJluatt thr ~I of drug therapy bJmnfinning that patient goals otrId txpttd OI/I(ome h.'/! bffil rntt (_"PLinning1.
Sfr WIlt l4.11111l1ff"rardiK ~f(lf_ittrnMionoborKlf9IDr.

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ll 4

UnII4 Th" O rd kIY.S(ul. r.oo Url....ry Syne<",

.... Prototype Drug

I Metoprolol (Lopressor, ToproJ XL)

Therapeutic ( lass: Drugforheartfailureand HTN

Pharmacologic ( lass: Beta-adrenergic blolier

ACTIONS AND USES

ADVERSE EFFECTS

Metoprolol is stlKti~ beta ,-,drfll~lIJic bIoc:krr , '/<Iilllble in t.bltt, sus"inedreIt.se table~.nd IV fonns.At high~rdos6, it m.~ .Iso.~d bm,l"f(tptors in
brondlial smooth IllU\(te. The drug ..cIS b~ rroucing sympnhetK Slimul ilion of
tilt lItart, thus de<~'lIiog cardiac workload Metoprolol h~ ~n 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[ rompiiutions following an MI.

BaIM it is selectMo for blocking 11m, rKtploo in the he,,!, IIII'toproiol has
flow adverst e~cts on othtr autonomic targets and thus is prefer~ ~r nonselectiv~ beta bIoc:krrs suth as propraoolol for p;ltitnlS with repiratory disorders. ~rw ~ffKtl a~ genmlly minor and ~lat~ to its .utooomic .ctMty,
IUChassiowiog oftht hean rail'.nd hypotension.~us~ ofits multiple ~lIeCB
on the he,rt. patients with hean failu~ should br urefully monitorro. Dthtr
frr~m adYerll'effrcn inckidt abnormal sexual function,drowsi~~ fuigue,
<l ndifllOll1nia.
Contraind ications:This drug is contrai ndicufd in patients with <ll1hma, cardiogrnic shock, ~nus brad)'Cirdiol, ht<ln bIoc:k 9~ut r than first deg~t, and ~I
u rdiac failu~.

ADMINISTRATION ALERTS

During IV administration, monitor thf ECG, blood p~ssure, nd puls~

frrqll!'ntly.
AllI'Ss tht plJlst .nd blood prtsIU~ ~oral administration.Hold if the
pulse is briow 60 bNlS ptr miM~ 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 M e not btt-n rstilbli shtd.
Dosn should be ~cb:fd for t klerly patients btu IM they .~ at risk for
dizli~sand f.lIl.

P~nanq category C

PHARMACOKINETICS

IAlstt: II)...IS min;lUItainfd releas~, unknown

Pe.k: 1.S-4 h; 6--12 h sumintd ~leall'
Half~iflo: 3-4h
Duration: 6 h (24 h sul1ainfd ~lealt)

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 prima ry drugs in this class, hydralazine (Apresoline) 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 dinitrate 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

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INTERACTIONS
I)ug-l)ug: ~t US!' willi dMpDr may rM! il bradyan!ia.lhl
IIlriKfjIIi"115 may CilMincrmed mM~ etft<ts.lMwithakOOolor

antih)'pr!lMli"ll5may r~ iladditiw hypolffllion. MM~ mayenl>.ar"a the

l~ffJ"'l>u( ;"'~i,.nd ur "'I~ .. io. . .,,"

Lab Tl5Is: M!loproloi may incrNlf ~ for the IoIowiog:uric add, ~pidI,
pot.&ium, bi~rUJil, alllillint ~UII',(J&1Iinilll',and antiu:lHr antJ:oocly.

III'rbaVFoo:t: I..InI;nown
Treatment of Overdose: Atropint or isoprot~rrnol can be us~d to ~
br.ulycaroia calISI'd by """,,oprolol OYerdoIl'.Hypotfllsion may be ~r>ed by <I
nsopresor sum as p.~nteral dopamin~ or dobu"mine.

adverse effects, including reflex tachycardia and orthostatic

hypotension, however, limits their use to patients who cannot 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 hydralazine 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 enhances 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 function . 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 acu tely decompensated heart failure.

(lgp", l>I

24.S Treatment of Heart Failure

with Phosphodiesterase Inhibitors
and Other Inotropic Drugs
Advancoo HF can be a medical emerg~ncy, and prompt, effective treatment is neces5llry to avoid organ failure or
death. In addition 10 high doses of diur~tia, use of positive
inotropic drugs is often neces5lll')'. The tWO primary classes
of inotropic agents used for deoompensated HF are phosphodiesterase inhibitors and beta-adrm~rgk agonists.
In the 1980s, twodrugsbwlmeavailable that block theenzyme ~ft"_ in cardiac and smooth muscle. Blocking phosphodiesterase has the effect of increasing !he
amountofcalcium availabl~ for myocardial con traction. The
inhibition results in two main actions that benefit patients
with HF: a positive inotropic action and vasodilation. Cardiac output is improved becaus. of the in crease 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 short-t~rm control of acute
heart failure. ThedosesoftheseagenlSn~ listed in Table 24.1.
Because of their toxicity phosphodiesterase inhibitors are
reserved for patients who have not responded to ACE inhibitors or cardiac glycosides, and they ar~ generally used
for only 2 to 3 days. Prior to 2000, inamrinone was called

H OME
-

&

C OMMUNITY C ONSIDERATIONS
----

-----

Orugsfot Hearl F~llure

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 hours.
The two most common adverse effecls of beta agonist!; are
tach~ardia 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 prototype drug for shock on page 412 tn ch apter l 'JOC .

COMPLEMENTARY AND A LTERNATIVE T HERkPIES

Carnitine for Heart Disease

Cimitilll' iia MlUril ~bltan(t llructurally limilir to ,mino acm. ks primiry
function in mrllboIiim is to mctYe f~n, Kid! from th' bloodstrum into "lis,
whtrt Clmitine aslilu in tilt brtakdown of lipid! ~ nd th' prodlJClion of
' f9)'.Tht bt!t food lOuf{~of (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.

,n-

Psychosocialluues and Adherence In Patients

he.Jn btl/tit, mrlllOf)', immUO! function, illd rrWe lenity. k is sometinfs

with Heart Failure

~IIJ"fJtluntr"lOr~l~

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 im~mrnl politioN' iftstyIt mooific;lIi,," w4Ien dtpms.d. 1hr
mnr lhedd 1I\e5 ~ iIsurs in jNlimu with HF~nd int_ ippfOpri.
.. ~Iy whr!J wlmnl~'''irnts JNf bt .mrII'd 10 utdiic rthibiution progr-,whidl 11m bren sMwa to inoHIt ~hrN'rlu.lt hi! bteII ~
!hit IRstyi!, dwlJ!le f t i-equently rtliled kI tlltd lUg ther~('.9-, ~
snuil desft MId ~t p!ObIft"nll.Many p.lltimu ~h tht ~ty\t
dYll\I~ igliml !hoe drug's benefiu w 6ettrmine th~l tht
riJKu

Camitint hll bttn olmliftly IludiecI. ThM is IIIIid evM:Itna 10 S<lJlport

suppimlmtatioo in pilRnb who ift dtOOtnt inum~int. Although i _ I
dirt wpplits )00 mg ptr d.y, man jNIit!lu, SIKh is ~III or thow
willi Min Ztl~ mar Iftd additionll WOOOIS.Umitirlt ~~
hi! bttn Ihown., irnprr.w_!tM~1!(t in jNlienuwilll ~~Thtlllf
clamilint IIIJY prtWnI 1M DUt.mll(t cI dJlrhy1hmill in!hoearty Itq$ cI
hNrt 1iINw. Ci~ 1111 aka bttn lhown III de<rtllt tI~ IMk
whit ilcruling II)l wrum Inm, thus helping tI minimize 0IIt rJI!hoe major
rill! fKtDn I~'" will br.rt ~. RtltMh hllflllllhown Clmi~

siltr I nomIillifnl}4e. thIy II\f)" bt<ome~sed.

01 'Mig1"l1M\.

.I

--":Ih tho btMin.~ pltifnb CiA l1li10"9"" ~.. whot they (1)11-

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~nOOon","'cI,ignifiu"'bentfitintfltwro:ino!pOl1S~

))6

1tIIIM .

The CirdloYascubr M1d Urinary Sy!lenll

~ Protot ype Drug

I Mllf1none (Pnmacor)

Therllptutlc (111.51: Drug for heirt failure

PhannlCologlc Clm:

ACTIONS AND USES

01 tile two phosphodintrmr inhibKon a.... iYb~ milri1lOll~ is grnmlly ~
ftr~ beause it ~, 1Ir0l1tf ~Iflifund ftwerside effe.m.k isgiwlr only~
tr,ttrously and is primarily !MIl IOf IfIt lIrorHtrm tlltlil", of adnrKtd HUbt
drug 111$ a rapid OrtW of action.lmmediite tfrNtt of marino~ ~ .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 ~fusiofr
poolp should IN- UItd.
Saftt,o ,nd fflicacy IIiIIl' not been HlirblMtd in geriatric and pediatric

patients.
PrtgMncy utt90tY (

Phosphodi~@fase inhibitor

ADVERSE EFFECTS
~ most seriIM ~ ~1fKI of milrinortf is Y!rtOOrlar d)oI;r!Jythmil, lWiich
IIIiY O(cur ~ 1of ~ 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 ~r.mo..lilllillJu:ecirt hypotl'lllialL
Cntion sboItI be IIsed wilen admiMlllmj miri_"lritbligoxill. dotrdlinllrw, (If
GIller mtropitliMJl,WIO' thIoir pMi.,.. ilKKfOlic .tfem. tMlINrt ~ be

-..
PHARMACOKINETICS

DlittHOmin
PI!":IOmin
Half~ift:3-6h

Dur.Iion:Yariablt

L Tesu: lIIIbIown
IifmVFtod: LnI;_

TlNunent of Derdow: Ovmlose UUle h)'polfltSUr, lWiid! is uutfd with

the idministrilion 01 normal saline or i ~sot
111* lit /rIf1U'filqXl ffII. /UJJII9 PreI'! FocJ/l fllKlt/r II 1M d'uJ

. :i Chapter REVIEW
KEY CONCEPTS
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 th in the ch.apter for review.
24.1 Ht'art failur.. is clo!;.-Iy associated with chronk hyperten.

sion, coronary artery disease, and diabetes.

their low safety margin, and the development of more ef-

fec1ive drugs, their use hasdeclinoo.

24.2 Th.. body attempts to compensate for HF by increasing

24 ,6 Beta_adrenergic blockers.s\Qw the heart rate and decrease

cardiac out put. Preload and afterload are two primary

factors determining cardiac outpUl.

blood pressu re. They can dramatically reduct' hospitaliza

tions and increase the survival of pnients with HF.

24.3 ACE inhibitors reduce symptoms of HF by lowering

24 .7 Vasodilators an relieve sympt omsof HF by redudng pre-

blood pressure, reducing peripheral edema, and increasing cardiacoutput. They are drugs of choice for the treatment of HE

load and decreasing the ca.rdiac workload. Nesi ritide (Natrecor) is a newer YlIsodiiator approved for the treatment
of acute HE

24A Diuretics relieve symptoms of HF by reducing fluid overlood and de<:reasing blood pressure.

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 shortterm th ... rapy
ofacute HE

24.5 Cardiac glycosides increase the force of myocardial contraction and were once drugs of choice for HE Because of

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NCLEX - RN ~

REVIEW QUESTIONS

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."

Nursing inlerventioru during initial therapy with ACE inhibitors must include:
I. monitoring ECG.
2. monitoring intake and output.
l. monitoring blood pre5SUre.
4. monitoring !IefUITll~

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.

The nurse reviews lab studies of a patient r~ivlng

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

3. decreasing potassiwn-rkh food In the diet.

4. checking blood pressure three times a day.

The patient Is prescribed dlgOlln (Lanoxin) for treatment

of HF. Which of the following statements by the patient

3. 0XIg.h.
4. diuiness.
5. headache.

Therapeutic effects of positi~ 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.

The teaching pbn for a patient receiving thiazide diuretIcs 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 effecti~
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.

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,------- ~.------,

EXPLORE ~

M'/f*IrsIngM Is JW" Mt SlOp 101 ~nIine dlilpler I't">4e-tor mattrialS lild

fV901Jrce5. Pr~1t for ~ IMlh alktitiooal ua .. Ex-5t,1e prar;tica
QlleSIiJrls, IntertlCllve 8SIi[lmlflllS ancl aClil'lIIes, wm links, aninalions
ancl~. lIIIC!more!

fiegl5er yro- acc::t9S IIIIIr! Imm Iht trmt of)llll.lr boOIc at

www.mrnuru.akll can .

Chapter 25
Drugs for Angina Pectoris
and Myocardial Infarction

DRUGS AT A GLANCE

LEARNING OUTCOMES

ORGANIC NITRATES

Aft,r 'tad/ng this chopler, the Jfudent should be obit to:

(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 (RfIQWl~ ptJgt liI

ADJUNCT DRUGS FOR MYOCARDIAL INFARCTION

",,",

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 to treat the symptoms and
compli cations of myocardial infarctio n.
7 . For eac h of the drug cillsses listed In Dru gs at a Glance, know
representative drug elUlmp les,and exp lain their mechanism of lIctlon,
primary actlons,and Important adverse effects.
8 . Use the nur sing process to care for patients who are rece iving drug
therapy for angina and myoca rdi al Infa rction.

KEY TERMS
anginil p~dc.'is fUjt)19

ilthelOsderosis fX!(}t 339

(orona ry artery bypass graft (CABG) sufgrfy

'"'''''

{oronary artery diseaS!' ((AD) pIl9l' jJ9

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glyroprotein IIbll llii ~ 149

myomdial infarction (MI) ~141
myocardial isch~m ia pI!9f 119
pel(utan~ous transluminal (oronary
angioplasty {PlCA} pagt J1

plaque ~1J9
si lent anginil {XJgt 11
mblranginil pt:!~11
unltabl~ ilngina ~11

vilSospastlc(Prinzmftal's)ilnginii

~ 140

(lIoplHn Drug. (0< Angina """1Orl<.nd Myoc.rdl.llnbrctlon

ll tissues and organs of the body are dependent on

339

II

continuous arterial supply of oxygen and other vital nu-

trients to support life and health. With its high metabolic requi rements,the heart in particular demands II steady source
of oxygen. Should the arterial b lood supply become com-

p romised,cardiovascula r function may become impaired, resulting 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 the systemic circulation in a balanced state of equilibriwn. Any
distW"ban'e in blood flow to the vital organs or the myocardium itself---even for brief episodes---can result in lifethreatening consequences.
The myocardiwn receives its blood supply via the right
and left corona ry arteries, wlticlt arise within tlte aortic sinuses at tlte base of the aorta. These arteries furtlH.'r di~rge
into smaller brancltes that encircle tlte Iteart, bringing cardiac muscle a continuous supply of oxygen and nutrients.
Coronary art~ry dis~asr (CAD) is one of tlte leading causes of
mortality in tlte United States. The primary defining characteristic 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 ischemia 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 demands of the Iteart, and symptoms of angina begin to appear. 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 intravascular narrowing, and a situation that results in partial
or total blockage of tlte vessel. In addition, the plaque impairs nonnal vessel elasticity, and the coronary vessel is unable to dilate properly when the myoamlium needs
additional blood or oxygen, such as during periods of exer~il;~. PIa<ju~ au;uJlluI"tiuIl uu.un; Krauu;illy, uv~r f.'<'riu<.!, uf
40 to 50 years in some individuals, but actually begins to accrue early in life. The de~lopment of atherosclerosis is illustrated in ~ Figure 25.1.

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Moderate

Th......

narrowing
of lumen

occluding I..........,

partially

,OJ
~

Figurf 25.1 AtherosclerosIs In the coronary arteries

Source: MJMMI er 01., Human DlsNse >: A Sy<;tematk: Approach,

6th ed, ~ lOO6, p. 115. fI~nred ~ p.?rmllslori ofrwrSCfl f lixat/oll,

tic, Uppef Saddle Rlvr!r, N1

ANGINA PECTORIS
Angina pfttc."is is acute chest pain caused by insufficient oxygen to a portion of the myoaudium. More than 6 million
Americans have angina pectoris, with over 350,(X)() nt'W
cases occW"ring each ~ar. 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 radiate 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 indic~te
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 emotional distreliS-1l feeling of panic with fear of impending
deatlt. There is usually pallor, dyspnea witlt cyanosis, diaphoresis, 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 pre~nt the proper flow
of oxygen and nutrients to the stressed cardiac muscle.

140

UnII4 The (~ ,d """~"ul. , ,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 occurrences are f~irly predictable as to frequency, intensity,~nd d u _
ration, the condition is described as classic or stabl~an9ina . 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 Wldergoing 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 absence of angina pain. One or more coronary arteries are occluded, 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.ition 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 requiring 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 pharmacologic 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 imm ediately relieved by nitroglycerin. Myocardial infarction, however, carries a high mortality rate if appropriate treatment is
delayed. Pha r macologic intervention must be initiated immediately and systematically maintained in the event of M!.
The nurse should Wlderstand that a number of oonditions-many unrelated to cardiac pathology- may cause
chest pain. These include gallstones, peptic ulcer disease,
esophageal refllL~, biliary disease, pneumonia, musculoskeletal injuries, and certain cancCTS. \I/hen a person pr=nlll with
chest pain, the foremost objective for the health care provid er
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-

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PHARMFACT5

Angina Pectoris
0Yer9 million ~merKans haY!' angina pectoris; 500,000 new mes oc:rur
~.uh)'l'ar.

lO% of the dl'athsdUl' to rardiovmu]a, diseu~ are auributed to

smoking.

Myocardial Infarction
Morethan 1.1 mirIOllAmtrKans6ptrit",~aneworrerurrt'ntMIN(h)'l'ar.
About one third of the patitnn experiMC:ing lolls will die from th~m.
About 60% of the patienu who died wddenly ofMI had no p~
symptorm of the disem.
More than 20% of men and 4O'lb of wom~n will die from MI within 1 )'I'ar
after bring diagnostd.

renee of angina episodes. Such support includes the formulation of a comprehensive plan of care that incorporates
psychosocial support and an individualized teaching plan.
The patient needs to understand the causes of angina, identify the conditions and situations tltat trigger it, and develop motivation to modify behaviors associated with the
disease .
Listing therapeutic lifestyle behaviors that modify the development 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. H owever, 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 following 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 transluminal (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 original narrowed state after the procedure,a stent is sometimes
used in conjunction with a balloon angioplasty.Angioplasty
with stenting typically relieves 90% o f 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

',,"pltll>

Drug.fo< Aogt~ """ron..nd M)'OC. ,d!.1llnr.rctlon

& COMMUNITY CONSIDERATIONS

TREATING THE DIVERSE PATIENT

HOME

The Influence of Gender and Ethnicity on Angina

Cardiopulmonary Resuscitation (CPRJ

and Other Education for Heart Disease

AlHjfU OCQJ~ more ~~ in ftlllille than mal~ 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 (aucawns,andlow.-!t inkian pojUamM.AfritanAmerianfrmaes hM-lWir tilt
riskof angina COOlpiredwith African Amtrian ma~
IlecauleWOllltll mol)' oot~~ angilapainthe 1oJ~ wol)' M~n oo.any
epigastrior,ht!i alN pail,rsprciallyocQJI1;ngwith emtiJn,shluld ~~
gNdMpo!~bringina.Somtwomenmayako milimtheirdismmM,deIaying trNtment.Wralrmmnudie hM-suggrstedthatwomrnand propirfrom
South kia with angina ma)' ~I'r ~ dilial out~ Until more dtfinilil'r
sll.dirs a~ [ooductro, ~nn d any gtnder or ~hnirity!hcUd ~ ffiOlIJraged 10
!l'!'k mmedatr attrntion for {lirst diKombrt ocrumng with emtiJn or rmomnal 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, "bypassing" the blockage in the coronary artery. The result is increased 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. Additionally, successful pharmacotherapy should improve exercise 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 consequences of ischemic heart disease such as dysrhythmias,
heart failure, and MI. To be most effective, pharmacotherapy must be accompanied by therapeutic lifestyle changes
that promote a healthy heart.
Although various drug classes are used to treat the disease, 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)

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341

lINn d~ is tilt numb~Hlne killrr in thr United Sta~. For this

INson it is im[ll'l"ui\<rthit indMduals leam CPR and rnc:ouraqr othrIS to ~
(01lI!' mtifi~d In additiJn, nUM! a~ in a I'iIlw~ position to tducall' those
in thti"ommunit~ on mtlhods 10 lower thtir risks for (0I01Ii1)' lINn dist.!lI'. EckJutiJn [Il'I"taining to positiYt lifestyle ,h.!nges,cootrolling hypertrnsion,.nd smoking [esalion a~ all important is~ to tiKlNSt an indiidwl's
risk.lif6~ (hangl's!lKh Mdt{ft'Ming dieul)' fat inti~ incru~ng intake
of fruit and ~ables..nd ~rtKipiting in rtgUlar ~rrisr.~ rIIt ntiallO
limiting OIl!"S risk 10, (OIOnal)' hfilrt dill'all'.
CoIOllilI)'

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. Betaadrenergic blockers are drugs of choice for preventing
angina pain, although calcium channel blockers are used
when beta blockers are not tolerated well bya patient. Longacting 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 combined with a long-acting nitrate or calcium channel blocker.
Pharmacotherapy Illustrated 25.1 illustrates the mechanisms 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 metabolism 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 myocardial cells. Thus, this is the only antianginal that acts
through its metabolic effects, rather than hemodYllamic effects: Ranolazine does not change heart rate or blood pressure. The drug is well tolerated, with dizziness, nausea,
constipation, and headache being the most frequently reported adverse effects. It is used to prevent anginal episodes:
It will not tenninate an acute attack. The drug is only approved 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 formation of nitric acid, a potent vasodilator, in vascular
smooth muscle.

34 2

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

Ca lciu m channel bloc k. .

[);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

syslom

CDR>nII'Y art""",,

Organic nitrat".

Dilate vein. , reducing the amount 01

!l!oo<:! ~lminlllo:> 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 muscle. 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 decreased, 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 partially occluded coronary artery would allow more oxygen
to reach the ischemic tissue. Although this effect does in deed occur, it is no longer co nsidered the primary mechanism 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

LibraryPirate

more oxygen to reach the myocardium, therebyterminating the pain.

Organic nitrates are of two types, short acting and long acting. 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 instructed 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.

(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

Route and Adult !:lose (max dose where Indicated)

Adve~e

amylnitrit~

Inhalation; llmpul ~ (O.IS--{lJ mQ PRN

~ diriual~ (Dilallt~,lIordiQ

PO:l.S- 10 mg qid (max:48O mglda,)

I/eQdocht, posrurol hypcrP1l5ion, fluJlilll}

offlKt, dizmts\ rash (rrmJdtrmol poKh),

~ monon~ratt (lmdll'.1Imo, Moooktl)

PO:20 mgqid (miX: 240 mgldaywith IUSlitiotd rtlN~)

Q nitrogly(m. (Nnro\la~ NiUo.DtI',

Sl; I tablt! (0.1- 0.6 019) orllplay (0..- 0.8 mg}MIll-) min
(max:llR ~ dosts in 15 min)

On"

Effects

ORGANIC NITRATES

HiIfo.Bid.OIlltrs)
BETAADRENERGIC BLOCKERS

-ro/eroOCt

An"phyla!!is. (iKUialOf1 {OIIaW OX 10

h)'pllrolioo !Y"'o!! d!.!: 19onhomtic

oKtIlnolol (Sfflrll)

PO; 400-S00 mg daily (max: 1,lOO mglday)

o atenolol (TtIIOfIIIin)

PO;lHO mgfda, (max: lOOlll9lday)

fMloproIoI (~tI~. Toprol XL)

PO; 100 019 bid (max: 400 mglda,)

fUdoioi (Colgan!)

PO;4O mgdaily (max:l40 mglday)

AannuloCYlon Ia!yomloum,
StMm )ohmoo !yndrome"natilrlam'

proprlnolol p~ral. ndtral LA) (stI' (Iq 364

for lile ProlOlrpe Drug boxOO I

PO; 10-20 mg bid-tid (max:l20 mglday)

if Ih~ OW is abrup!IY w~hd@W!l.

~molol maltate (Bf'linoI) (stI' pa~

PO; 15-45 mg tid (0111:60 mglday)

771

hI!i~t, iflJOffll1i~, dlllWlinm, irnporffi(t

or iJrorrMd Iibid4 brod)'rGrdio,.lIIIiI
(oofulion

palDjmigm rebound hmrrtmljon litibfN1rojngdWl)1bmja\ or MI may

"'"

for lile ProlOlrpe Drug boxOO)

CALCIUM CHANNEL BLOCKERS

amlodipiOl' (Noms!}

PO;5- 10 mgfda, (mn: 101ll9lday)

Rushed~ heodocht,dniJfs~

btpridl ('I.!sI:or)

PO;200 mglday (max:l6O mg/day)

periphtr edemo, /igIrllIlodlftlru,.

nDul&diorrheo

ditimm (CaniIl'm, (,uti.J X~ Ililic:000XR, bnia

XL niloK)

PO;~lar ~ast; 10 mg tid-1jid (max:480 mglday)

UttrJdr,d rtIrnt; 20- 240 mg bid (max:540 mglday)

HrQiWPXkkv MI 'HE ronfuWo mood

ni(lldipiOl'((,udm~)

PO;lO-4O mg tid or30-60 mg SIt bid (max: 110 mglday)

niffdipiOl' (Adala~ Pnxani.J,OIh~) (~

poll}.' 308 for thd'nllol)'pl' Drug bolOO )

PO; 10-20 mg tid (mil: 180 mglday)

'/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 contractility. These drugs are as effective as the organic nitrates in decreasing 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~fS. 11,~y ~f~ iu~,,1 fUf r~li~111s wllU hav~ Imtl, hYr<'ft~l1"iul1
arrd coronary artery disease because of their antihypertensiveaction. They are considered drugs of choice for the prophylaxis 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

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""'"

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
h~~rl,J11u'l uf whi ...h ~f""lll1il~f tu lhu,,,,ufu~l~ uluu.~fl>. Lik~
beta blockers, calcium channel blockers (CCSS) are used for
a number of cardiovascular conditions. including hypertension (chapter 2JOO ) and dysrhythmias (chapter 2(00).
The calcium channel blockers used for angina are shown in
Table 25.1.

344

UnII4 TheCJrdkwasc:ubr.oo Urinary Syuem,

.... Prototype Dru g

I Nltroglycenn (Nltrostat,Nltro-BId,Nlrro-Dur, others)

Therapeutic (lass: Antianginaldrug

Pha rmacologic (lass: Organic nitrate, vasodilator

ACTIONS AND USES

Nitroglyc:erin, 1h~ aide! .nd most widt~ us~d olg'nic nitrate, c.n be dtliYtred
by. numbel of difftlmt route: wblinlJli~ oral, mrulingual, IV, transmucO!..l~
tr.nsdelnwl, topical,.nd tXltndtdffINlI' forms. It nwy be LIken while an
acute angina ~ is in progfffi or just pOOllo physical acliYity.lMl~n 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 1S minute
aflt l two or th~ d=s 01 !\Jblingual nitroglyt:erin may indicatt MI,and ~mer
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, beuus~
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 p.st~ or ointment to pr~tnt
s~lf-adm in istration.
Plfgnancy rnegollY (

INTERACTIONS
i)ug-i)ug:Cooai"II'Il U\f with ~iIII'-S inhibitoo lsiIdfnafil {V~L
YiI~ [Ltvitla],or tad.!lali IGaI~1J rna, cause IfHlni!ening ir!poten'iion.1Id
GlIliovillClllar coIiplof.!Ist with <l1coIU ...r anlil)"pHlensi'll' drugs may (;llI1f

adcitivehypotl'lllioo.
lab Tl5ts: ~ogIyrnin liioi)' iooNlf voilutl 01 uillaly GlIechoIamines and YMA

PHARMACOKINETICS
1Al1ft: 1- 3 min sublingua ~ 2- Smin buccal; 4O-fIO min trarudtnnal pa\(h

Peak: (-8 min sublingual:(- 10 min bucal; 1- 2 h mnsdtrmal patth

Half~i~: 1..... min
Duration: 30-60 min sublingual;l h buca~ 18- 24 h t.. nsderm.1 pillch

NURSING PROCESS FOCUS

ADVERSE EFFECTS
The ad'Ierst tffrru of nitrogl)'l~rin are usua I~ ",Kliov.J scularin naMe and rarely
life thlutming. kGJ!/If nitrogl)'l~rin an dibte c~lI'brall'ffitls, he.d.ld1~ is <I
tommon side effect and may be 1I"Iert'.lXasion.lly, tilt Yl'IIOUS dilation caus~d
by nilrogl)'Ctrin prodJm Itfln tKh)'C<lldi.J. Somt hukh call' pKll'idm PII'Ilribe beta-adrmergic bIoc:ker to diminish this undtsirable inclus~ in h~an
I<lte. M.O)' 01 tilt side tffrcts of nitroglyarin diminish afltl a few doSI's.
(ontlain diciltions: Nitroglymin should not be given to patitnll with prenisting hypottnsion or with high intrm.nial pll'SSUII' or he.d traumil. Drugs in
this cia" <I II' contr.indiut~d in pericaKiial tampon.dt <lnd COilStn.:tWf periurditis 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 becaus~ the)o may incrt'.tIt intr.O(uial pll'swre. DIohydlation 01 hl'POl'Olemia should be tollf(\ed before nitroqlyuorin is aclministtred:othtrw~, ltlious hypottruion may IHUIt

IIKlfluations.
lk>ibaVFood:Unknown

Trutmrnt of OverdOS!: Hypotension may be rel'l'l"l~d with adminismtion 01

IV oornwl "IiIII'. If mtthemoglobilll'mia is suspKIed, mtthylent blUl' may be
administt red.

PATIENTS RECEIVING NITROGLYCERIN

Asse ss ment

8i1selin e a55f" m~nt prior to administrati on:

Under!Llnd tilt re,lIon the drug his been plecribed in ordtr to asll'lS for
thtrapMic: ~ru.
Obtain a completf lItalth hillolY indudi ng "rdiov.llular (including
prMM Ml,he~n flikrrt, v.lMrllrdismf),CerrbrovllCuiar 1M II('UlOlogic
(including level 01 conlliousnm, history of "rdiov.srular accidtnt (CVA),
lIt~d 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 drug~ herbal pll'pllrations,.nd
.Icohol us~.Bt aware that !/If of ~redile d)'dunction drugs within tht past
2( 1048 houlS may ca!lll' profound.nd prolongrd hypotension wh~n
nitratf"l.re administtred.B~ lien to possible drug intelactions.
Obt.in bastlillt weigh~ viti Isigns (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 <lndfol cruont kin<lll' lab t~SIl may be ordtred
to ru~ out MI.

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Potential Nursing Di agn oses

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 adl'l'l"l~ tfWcts of drug therapy)
F.~ (dis~.1I' procr!sor rebted to <ldvtl"ll' efleo:llofdrug thel<lPY)
Activit)' Imoleranc:e belated to dill'aII' proc:t lS or ~dvtl"ll' ~fIeo:lI of drug
thtraPl')
Ol'ficitm Kmw~dgt (drug th~lapy)
Risk for Falls, Risk for InjJl) (related to acll'l'lII' ~fferu)

c"",,,tll> Drug. (0< Angina PKW<I< .nd M)'OC.rdlallnbrctlon

NURSING PROCESS FOCUS

345

PATIENTS RECEIVING NITROGLYCERIN (Conrlnued)

Assessment

Potentilll Nursing Dillgnoses

Assess m!nt throughout iI dministrati on:

Ailes lor dt~red 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 r.pid-~ng (t.<j. dIIioguaO nitrattl. With
subiingu.1 nitratl'l, talet BP ~and5 milutrsaftergiving thtdosf and
hok! drug ifBP it leI than 90/60, pUl(' isOYtr 100 (or p.ramftr~ilordered).
Ailes Ior.nd prompt~ report ,dvtl1eflffi:n:!l(elivr hypotension,
d~rb)'1hmia~ 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
immediatr~.(hett pIIin R'm.ining p~m aft. r thlff lublingual
nitroglyc:erin tablellgil'trl 5minutt'l .~n ,hoold he fl'ported immiatfly,
el'trl if ~in hatltl5rotd,al thit may he a ~gn of imptnding ilchemia or
infarction.

Planning: Patient Goals lind Expected Outcomes

Ihf p.tirm will:
EJ:ptritrK! therapMK ~Is (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 minima~ idyffll' ~IS.
Vfrbal~.n undt~tanding olthedrug's = .a.ffll' rlFb,and fl'qJired precaution!.
DtrnOnltratt Propl'l :se/f-adminituation of the medj(oltion k9.~ timing. when to notily providtr).
Implementlltion
Interve nti ons and (Ratio nale s)

Plltient an d Fllm ily Educlltion

Ensuring thtraptutic rffeds:

ContinUl' ifl'qUl'ntatSfl5mtrlls at abol't lor therapeutic tlFIS.{At
modillltion OCQJllfrom nitrattl, prtload and alttrlo.id diminish,dKrra~ng
tile workl~ of the he.Jn and dKrta~ng ntyO(ardial ownation nct(lI;
chest ~in diminishe.)

Alk the pIItitnt to b.wfly desaibt the location and rhilractl'l of ~in (USt
~in riling snit lor rapid ilsessmtnt) prior to and .Jltergil'ing nitrattl to
iI!eSS lor tilt mtnt of relid.

ContinUl' to monitor ECG, blood pressufl', and pulsr.(Nitratrs caUl('

...odiLotion and I"'"iblt hyl"'t~nlion. BP "In!m~nt aid. in dourminin9
drug frrqUl'OC)' and dosr. KG monitoring helps dttf(! .a.ffll' eIFIS such
iI fl'fltl QCh){ardia, ilchtmia, or infarctionJ

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.

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 option~)

[n<ourage the patitntto dilculSany chaogt'l in char.J(tt~ s~rity,or

ifl'quency of angina cpisodts with provider.lnstnJCt tilt poatitnt not to ukt
daily alpirin without dilClMing with tht health caR' proyidtr filiI.

For patitnts on traOlderma Initrog~(trin patches, remOVf thr ~t<h lor

6-12 hoollat nigh~or at dirtmd by health taR' proyidtr. (lhit helps
~nt ordtlay thedtvtlopllll'llt oftoltraocf to nitrattl. Rrmoving the
~\(h at nigh~ when nrdi wortlo, d it lelt'lltd, htipsKioid possiblt
angina lattaW during the da)'!iOlf when workload is gfl'.ttr.)

IflltnKt thr p.titm on tht proper l/Ieof nitroglyrerin.Jnd rationale for

removing Ira nsdenn.J Ipat{hes. Alto iflltruct the patimt on trallldermal
~uhet to alwaY''''1l"IOft the ok! ~tth,{lta nl(' tilt ,kin uodtrntath
gently,.!nd to I1lt.ltr littl brioR' applying a new p, tch.

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.)

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-f.~ Iow-sodium food choKt!.
(Conllrwefi)

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34 6

UnII4

Th<>(~ ,d ""' .",ul . ,.nd

U'I .... ry Syne<",

NURSING PROCESS FOCUS

PATIENTS RECEIVING NITROGLYCERIN (Confinued)

Imple mentatio n

Interve nti o ns a nd (Rati o na les)

Pati e nt a nd Fa mily Edu catio n

Minimizing ildftBe rflfits:

CominUl'to monitor vitill ~ns fm:tUl'llt~.8e (lutious with th~ t lderfy who
aft' at iIKrt.lSM risk 10, hyp:Jt~nsion;and j)iltienl! with a prMlisting h~tory
of (l rdiac or cM'bromculard"rsull', or If(~t head injury, whichmay be
~ b)' YoIIodilation. Notify thf IINhh (1 ft' provider immtdi.Jt~1y if
.ngina lMIains unR'iiewd or ifblood PR'lSUR' or puls~ dt(R'aSI' bt)oond
~stablilhed j)ilramtlt Bor 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 o~ dtlllilnd, wol1tning il nginil.)

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 orlalls,~ially if tilkingsublingwl nitr"~~ or
until dlll9 ~fftct; arr known.

CominUl' card~ 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 ~cts.)

To ~Ilay polSiblt .Me!)" ttil(h tilt patient the rationalt for all fqUipment

CominUl' frr~m physica lasll'llmt nU, panicularly OI'urologic. cardiac, and

R'lpiratory.1 mmtdiateiy rt'pln any cha II9t1 in ~I of colI\{iouslltlS,
headiche, or changes in hr,n or lung sounds.(Nitrate therapy may ~n
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'.)

When on oral therapy ilt hornr,instnKt tilt patitnt to immtdiateiy repln

rna II9t1 in mrntaislilllll 0' lew! of colI\{iousntlS, palpitations, dizzintl ~
ri)'spOl'.,or inclNSing producti~cough,~ially if frothy ~tum is
pJtltnt.and Ittk medicalattenrioo.

ReviM tilt mtdications taken by th~ patirm befort discharge.and rfl'irw

InstnKt tilt patient to not tak!- sikll'nafil (Ylilljra), \\Irdenafil (~vitra),or

tarblafil (Ci.alis) while tilking nitratn and to diICuss trtatmrnt OptiOlll for
rrffiile dysfunction with thr IINkh caR' provicII'r.

. 11 prrICription ilS Wl'il as orc medic.Jtions with tht patientCulTI'm UII' of

~rffiiled)'Sfunction drugs ~comraindicatM with nin-alts.(ER'(tile

ri)'slunction drugs toWl'r BP and when combintd with nitr.lI6, can resuk in
II'veII' il nd prolon~ hypotension.)

Pati mt understanding of drug thera py:

Usr opportunities during .dminimation 01 medications and during
,sll'!.\mrms to discus It he rationale for drug thffilP\', drsiR'd theraprutic
oukomrs, moll common adl'ffll'eflect~ paramtttrs lor when to call the
heahh tift' pIO'Iidr~and iI ny nKn l,U), monitoring 0' prKolutions.(Using
timt dJring nun.ing (l R' helps to optim~.nd reinfon:r kry INChing
ft'asJ
Patimt selfadministrat ion of drug therapy:
When idmin~tering mtdititions,instruct tilt pati~~ lamily, or ca~iYer in
proprr II'H-adm inistration 01 drugs and whrn to contact provider. (Proptr
.dminimation in{rt.lsrs thl' ~Cti'ffllffi 01 thr drug.)

U5ed and tIM- OI'td for lrequent monitoring.

Tilt patitnt should be .ble to state tilt 'tillOn lor drug;,ppropMt doll'
.nd sch~dJling;what ad~ ~IKtI 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 th~raP\' nerrll'd with i OY spKial instructions
ft'9arding renewing or continuing prrscription ilappropriat~ .

Tilt patitnt should be able to statr howto lIII'sublingual nitrog~,rin "

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 rmrlll~C)' room.
If blood pressurr monitoring fquipmrnt is aVililable ilt IIomr, h~ thr
j)iltien~ la mily, or "ft'9iv~ lib.- blood prnsull.' prior to s~cond and th ire!
nitrog~cerin dolI'S. Hold the drug ilnd COntllt EMS il BP ~ IeSI than
90/60mmHg.

Eva lu ati o n 01 Outco me Crite ri a

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Cho,lt. n

.... Prototype Drug

Pharmacologic (lass: Beta-adrenergic blocker

ACTIONS AND USES

Attnolol is one of lilt most frequmtly p=ribed drugs intilt United Sta16 dUl'
to iu ~LI1r.t s,fely "Id de(\r.~1ItU in tr~uing, numbtt'of chronicdisorden,
ill(luding lINn failull', Iwtn~nsion, angina, and MI.Ih~ drug ~1KtM1y blocks
bt" .-,dll'll!'rgir Il'(~pto~ in tilt h~art.1ts t l'ffo:tr.ffit Sl in truting ,ngina is utribut~d to its ,bility to sbw h~'n rill~ ,nd reduc:~ contr,,;tilily, bolh 01 which
Iowtr m)'CK.irdial Ol)'9tndemand As with othtr be" blockers, therapy gen~r
,11y btgins with low d~ which , ~ g"dwlly inueall'd until the theraptutic
tfirct is ,,;hieYed. k<aIM of its 7- to ~hour bail-life, it may be t,ken Oll(~ cb ily.
ADMINISTRATION ALERTS
DJring IV adminismtOn, monitor ECG rontinoou~r. blood pm\U~ ,nd
plJl~ ,hould bt "'filed befort, during. , nd aftt rtilt do~ is administered.
As~!S pIJ~ and bIoo:d ~\U~ btIo~ oral administruion. Hold if the
pIJ~ is btIow 60 btu, ptr minult or il tht p"tient is hypotens~.
At~nolol

347

I Atenolol (Tenormm)

Th@rap@utic(lass: Antianginal drug

Drug' (0< Angina PKto<" . nd Myoc:.r<:ll.1lrn/orr:llon

m,y prKipitue broll(hospl!m in su\(~ptiblt p"tients with ini-

tial dosn.
Pregnancy c.JItgory D

r PHARMACOKINET1CS
Onstt: I h

ADVERSE EFFECTS
Being , urdio~~ bela,...Jdll'llt rgic blocker, atenolol has few ,.M~ dIms ontht lung. Tilt mOil frequently Il'pOned adYers~ tfftcts of umdol ind~ flligut. ~,knffi, br"lywdia"nd hypoll'llYon.
Contraindi u tions: ~u~ 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 derornptnm!d hean I, ilurt. Out to it! modilation dI~lI, it is rontraindiuted in j)atiMts 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 ~riouSS)'lllplOm, of atenolol O"t'l'rdo~ al\'
hypotm,ion , nd bradyurdia. Atropine or ilOprolell'llol mil)' be UI~d 10 re.... rs~ ~.adya,di . Al"l'nolol Gin be ~mo....d from lilt <~sltmic ,irr:ulo~on by
h~moo:ialysi~

111'1'8" 10 M)Nurlmg.Q! for Q Nlmirrl} I'rIlml foolHpt(1k 10 rlrls drt!g.

~k: 2--4 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 reduction 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 Calcium Otannel BlockeJ Therapy, page 308 in chapter 2300 , for
the oomplete Nursing Process applied to patients receiving calcium dmnnel blockers.

MYOCARDIAllNFARCTION
H earl 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,

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M I 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 M I is advanced coronary artery disease. 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
casc~de, 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.
N ecrosis of myocardial tissue, which may be irreversible, release, 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 ofM I,and
the one that drMs most patients to seek medical attention.
An electrocardiogram can give important clues as to the extent and location of the Ml. The infarcted region of the myocardiwn is nonconducting and may produce abnormalities
of Qwaves, Twaveo>,and SoT segments (chapter2600) . laboratory test results are used to aid in diagnosis and monitor

34 8

..

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

ADVERSE EFFECTS

likt olh~1 calcium chann~1 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 UI~ul in tilt heatment of atrill drm.ythmi~ and hyptrtemion,
.H well as .uble and v,soij).!stic all9ina. When gil'll as IUStained-relus~ cap1U1e!, it is . dministt rtd onre daily.

Adft~fflect! ofdiltiu~m a!'f genelally OOIIl'OOus.nd ,lIt

ADMINISTRATION ALERTS

()jrill9IV <Idminimation, lilt palient must be conliruou!oiy moo ilortd.and

uidioYeBion equipment mUll be available.
Ext~ndfd..!'fleaSl' 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')

Half~iM:15-9h

OUluion:6-! h 02 h sust.ined ~iei ll')

!'fialt<! 10 v. lOdilation: lIt.ldaclIt, diuinffi, and ~dtma of the anlde and f~l Abrupl withdraw.1 may pmipilate an acUlf . ngillill episod~.
Contraindications: Ililtimm iscOIluaindicattd in patienuwilh AV hun bloc:k,
lick si!lll S)"ndrom~, II"I!'fl' hypotem ion, or ble~dill9 a_rysm, or thOl~ Undelgoing 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 dflJ1l,~!ly

dgoxin If bMHdrfnHI,ic bkdm, Illil)'UlMpartill If (~M! hoo:bIock, ' - '
bikn,or ~ias.OitW:fm IIIiI)' irKrNli'!igoDl or quiridinetem whfn
tak!on (ooumntly.Adci!i'll' ~TmsQn mar om. if Mwilhf!haool, 11m
bIockl.>r5, or antil?!p5Ien!i'll'S.
Lab TelS: tktnown

ilflbaVFoo:t:StJcmi MIIIand r,jnsenIj 1IIiI)'~ tfNo HlKlivfnes of

dlliazHII. G.ric. haw!hom,and goIden ...1may ioofalf tfNo amll)'~nPllSiw ~

ofdiliazflll.
Trtatnlent of Ovtrdole: All\lpine ot isopmttltnol may be used to reve~
br.dyuidia caUSt by dihiazem OYerdoSl'. HypoTension may be R'"I'med by. vaSOpft'llOl wch as dopamine or dobutamine. Cakium chloride can be adminisTt 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.

progress after an MI. Tablf 25.2 describes some of these important laboraTOry values.
Early diagnosis of MI, and prompt initiation of pharmaCOTherapy, can significantly reduce mortality and The longTerm 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 circulation to thf myocardium. Dosages and descriptions of the various thrombolytics are g ivt'n in chapTer27 on page 38JOC> .

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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 symptoms. 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 important TO identify circumstances that contribute to successful thfrapy. Thf development of clinical practice guidelines
to identify those paTifnts who benefit most from thrombolytic 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. AlThough 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 blreding due to interffrence with the normal clotting process. Vital signs must be monitored continuously; signs of bleeding

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: (ura~~ kina~)

Hh

lH4h

HtIa)'S

21- 198 uritllL (vilUel ViI}

'Nidt!y bf,1Wffn iabsand
imong telling prOioWS)

ESIt (~rythrocyl~
Itdimmlation rat~)

fim""

~alWft'ks

,,,,,,,

_.,
LDH(lirut~

male\: 1- 11 mmihr
frlllil!'l:l - ZOmm/lv

dU"ation of Itrt'lSll'SpoIIIf

fu~ng:80-1l0 m91dl

8- 72h

Hcb)'S

8- HtIa)'S

SO- ISOuriuA

m)'C9obin

Hh

Hh

HtIa)'S

HSll9lmL

troporinl

Hh

2H6h

7-10tla)"i

llm(gll.

troporin T

Hh

2H6h

10- HtIa)"i

0.01-<1.1 n9fI.

WB( (wlit~ blood

aI oount)

f~""

l -7t1a)"i

ts- l0.8 x 10' m'9il

call for discontinuation of therapy. Because these drugs are

rapidly destroyed in the blood, stopping the infusion normally 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 Nur~ing 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 ensure that the heart continues functioning and that pennanenl damage from the infarction is minimized. In addition
to thrombolytic therapy to restore perfusion to the myocardiwn, 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 m aintenance 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 considerably more expensive than aspirin, they are usually considered for patients allergic to aspirin or who are at risk for GI
bleeding from aspirin.
Glycoprotein llbll lla inhibitors are antiplatelet agents with a
mechanism of action distinct from that of aspirin. These

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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 p...,v~nt
additional thrombi from fonning. Heparin therapy is generally 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 heparin, such asenoxaparin (Lovenox). The student should refer to chapter 2700 for a comparison of the different
coagulation modifiers and the dosages for these medications.

COMPLEME NTARY AND A LTERNATIVE T HERAPIES

Ginseng and Cardiovascular Disease

Ginseng is o~ of th~ oldtst koown he!bal rt'medies.flonaf 9i1Mfl9 is diltri~

!II~d throughout China, Kortoa, ind Siberia, wh~rt'asflonaf quinqutfoiw is natWe to Ullid.l ~nd tht United Stilt~s. 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.
Gin~ng has been ustd ior(enturifs to promotf gener.ll ~llnfS~ boost immu~ fun,tion, and li'dU(f fMig!ll'. Thtfe ill' lom~ (ia ims thn tht herb !owen
blood glU(o~ ind "n help in the rnanagemem of hyptn~mion.
Gin"'1J9 is thotH}ht to 1\a'I~ (akium (h~ nne! anugonist ~rtions. Tho htrb apptiB toimp~ blood iIowlotheheart in timesoflowOX)9fll supp~,llKh IS
with m)'OUrdiil ischemia. Some rtSur(h has Ihown t1wt gin~ng lowers
blood llI9ir lewis in patients with Iypt 1 diabete.ln addition, IortIt studies
h.M found girung to OOosttlit immu~ S)'SIMI. Tho nu~ should ,,!Ilion
dients who take ginsmg, HUIM herb--1lrug in\l1l'a<tions a~ possible with
ukiJm (hin~1 b~B,oral hypoglyctm~ warfirin,and loop diurt'OO.

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

(b) Infusion of thrombolytics

Superior
~
~

Lei! coronary

"oy
Right _

__

I \, ,- - Leltvenlride
"""'ride

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. Hu man 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 lhr~~ du",," may b., lak"" 5 mi"nl<:>c apart Pain lhall'~r
sists 5 to 10 minutes after the initial dose may indicate an MI,
and the patient should seek immediate medical assistance.
Patients with persis tent pain, heart failure, or severe hypertt'nsion may receive IV nitroglycerin for 24 hours following the onset of pain. The arterial and venous dilation

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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

.... Prototype Drug

I Reteplase (RetavaseJ
Pharmacologic ( la ll: ThcomOOlytic

Therap@Oti((lus: Drug for dissolving blood clots

ACTIONS AND USES

ADVERSE EFFECTS

P~red \hlOUgh n!(OIIIbinatlt DNA thIlOIogy,~p&.st.ru b,-deaving pial-

TIlt moll striouIilMMeffM ofltltpliseil abnoonll blttding.Blttdin, may

bt prolo~ ilt injection liln ilnd ut~tf iflltftion lites. Dywhythmia\ may
O(QA" during myocardial ",~rfusim.
ContraindiuUons: Rettplill' ii CDIItraindiuled in p.1tienb willi actM tleotding or hiltol"Y ofCVA, 0' who hi'o'r hid I't<tnt surgical pm<tdu,e.

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 ~u within 20
minuttl.AlKood 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 p~1 iddition.Jl dol! from Iooning.
~~ may bt IIStd of-l.1btllO ~at I<utt irld dHonic dttp \lein \h,ombo-

~itibirmwlprocku~iIkiIiw.nicDaglHnl~~ndinm.Jlf1llt

si!; ~nd O(dJdtd ~hctm.

ADMINISTRATION ALfRTS
ItmJnstiMt !he drug imlnl'dial.tly prio, to lISt with dilutnl prtMded by
rNnuf~bet; Iwirll1lmil-do not shih.
Do not 9M iny othtrdrug limultaneously thlOugh tilt samt rllint.
Rtttp&.se ind 1IePirin i~ incompatible Md mUll nMr bt <Ombintd in
!be lilnl' soIInion.

PHARMACOKINETICS

Duration: UMnOWO

Y,Nlnmt of CM,rdole: ThM iI no !jl(cifK ~iltment fo, IM!rdost.

sup pressing dysrhythmias. which are se rious and so m etim es fatal compliotio ns 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 os ing for home
therapy. Unless contraindicated, beta-bJO(ker therapy continues for the remainder of the patient's life. For patients
unable to tolera te beta blockers, calcium channel blockers
are an alternative.

ANGIOTENSIN-CONVERTING ENZYME (ACE)

INHIBITORS
Clinical research has demonstrated increased survival for patients administered the ACE inhibitors captopril (Capoten) or

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"'.....,

li bltIu: RtttpYse dfgIidfs plMiIIo9MIiII blood ~tIu ~ IH.m

pbsmiMgtft inI fitfinogflllMls.
HffbiV1oM: GillIgo lilotroJ should bt~ bfQU5til "IIJ iIaMt tbelist; 01

RPM III .\f)MI~ IIIDMIIl/IIj I'rIxffi F/nJptkllltMsdl1Jf

P~nincy~tgory (

Onwt: Immtdiate
Pu k:Unkoown
I!.tIflife: B-16 min

INTERACTIONS
Dn..IrI)uo;ConarIffftt tllffapywilll iSPiM.~15,Jnd pWtMt

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 norma Uy
begun after thrombolytic therapy is completed and the patient '. condition h~ stabilized. IV therapy may be use.:! during the early stages of MI pharmacotherapy.

PAIN MANAGEMENT
The pain associated with an M l ca n be debilitating. Pain
contlol is essen tial to ensure palient comfort and to leduce
sIres.;. Opioids such as morphi ne s ulfate or fen tanyl are
given to ease extreme pain and to sedale the anxious patient Pharmacology of the opioids was presented in
chapter 1SOO.

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 oxygen from the coronary arteries to function properly.
Coronary artery disease, which indudes both angina and
myocardial infarction, is caused by narrowing of the arteriallumen due to atherosderotic plaque.
25.2

r:he<' ("lin on emotional or ph)"'i""l <'Terrion is the mos'

25.4

25.5

Betaadrenergic blockers relieve anginal pain bydecreasing 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.

Angina pectoris is the narrowing of a coronary artery, resuiting in a lack of sufficient oxygen to the heart muscle.
characteristic symptom, although some forms of angina
do not cause pain.

25J

25.6

Angina management may indude nonpharmacologic

therapies such as diet and lifestyle modifications, angio plasty,or s~ery.
Goals for the pharmacotherapy of angirw are to termi nate acute attacks and prevent future episodes. Thory are
usually achiewd by reducing cardiac workload.
The organic nitrates relieve angina by dilating wins and
coronary arteries. Theyare drugs of choice for terminat ing acute episodes of stable angina.

25.8

TI,.,

.,~rly

<!iagll..,,;is uf

lJ 'yuu",Ji~1

illfuLtiUll

ill~r.,,,,,,,

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 blockers. glycoprotein liB/IlIA inhibitors, analgesics, and
ACE inhibitors.

NCLEX-RN REVIEW QUESTIONS

The patient is being discharged with nitroglycerin (Nltro stat). Patient education would include the instruction s:
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 physici~n when ~u h~ve chest pain. He will
teU you how many IlIblets to take."
4. "Pbce three tablets under your tongue and call 91 I."
A prililllry mechanism of action that makes nitrntes useful 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.
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.

LibraryPirate

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.

(,,"pt .. lS

Drug. fo< .....-.gIna Pecto<" and M)'Durdl.lllnfilfCtlon

l5J

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 rtquestlog Ills PRN nltroglyculn spray. The pat len l's blood pressure Is 96/60 mmH! at prnenl. Identify what Ih~ nurse
should do.

2. A patient is reco,"ering from an acu te MI and h.asbeen put

3. Apatient with chest pain has been giwn ttle calcium chanOO
blocUrdiltinml (Canli~m) tVror a Ile3rt l'lIlo!of 118 bf:Iu
per minute. Blood pn:ssurt at thl$ u~ Is 100160 mmHg.
Wllal pl'Kllulions should the nunc' taker
Su Apptndix D for allj"'UJ and rlltio,mlts for all actjvjl~$.

on alenolol (Tenormln ). \\lhalleachln g !.houJd Ihe patient

receive prior lodischalW' (rom the h.ospltalr

r-==:-~'----,

EXPlORE ~
tI.jttI~ 1<;)QIr

-lIIlJII b

,new ~ arcI
ttClO:--$\JIt Pl'\ldlte

orOIe c/llplBI

r9:IIllCH.

Prepare for suo:ess WIth .1liUcN1

QUI:ISIions.

~ _I~ !rI(I

aethiIi .....t:J 1m. IIlimatiols

and WIoos. nI rrae'

RegISter l'IIO.I' al;:l; ~$S eode from 111, Iron! oj !IOU' book.,
'In'fW.IIIt'IM"~k1t.cam.

LibraryPirate

Chapter 26
Drugs for Dysrhythmias

DRUGS AT A GLANCE

LEARNING OUTCOMES

SODIUM CHANNEL BLOCKERS

After reading this chapter, m e student should be able to:

JlljfJS9

Q pfocalmlmld~ (Procanbld) fII1Ijt 361

BETA-ADRENERGIC ANTAGONISTS/BLOCKERS

""J6!

Q propronoJol (lnderat InnoPronXL)

""'~
POTASSIUM CHANNEL BLOCKERS

JUjtJ6J

Q omlooorooe (Cordorone, P/lcI1fOrK!j

~J65

CALCIUM CHANNEl BLOCKERS

{J!lIJt365

Q veropamll (Colan, Ccwera-Hs, Isoprln SR,

Verekm) fXI9I' Jt6

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
abnorm a lity.

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 therapie~ in the
lr" .. lrn""l uf uy.rhylhrnid .

6.

Identify the general mechanism~ of action of anti dysrhythmic drugs.

7. Describe the nurse's role in the pharmacolog ic 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 mechanism s of action, primary
actions,and Important adverse effects.
9. Use the nursing process to care for patients receiving drug therapy for
dysrhythmias.

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

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depolariution jX1Jt 1~
dysrhythmin f'JIIt 155
edopidoci/pa{rmakers

pogt 156

fl~drorardiogram (ECG)

f'JIIt 156

fibrillation pt.TJelSS
impla ntablf cardi overter defi bri nators (K DJ
pu;em

polarized fl!9eJ~
potomium ion mannfl f'JIIt 158
Purkinjefibers pi1I}t 156
refradory period fl!gt 158
~noatrial(SA)nodf ;we156

~nulrhythm fl!gtl56

50dium ion mann rl pi1I}tJ58

OI ... lOr 26 0"'9' for Ophythm",

JYhythmias are abnormalities of electrical conduction

that may resu lt in alterations in heart rate or cardiac

rhythm. Sometimes ca lled 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 o rder to determine the

exact type of rhythm disorder. Proper diagnosis and optimum pharmacotherapy can significantly affect the frequency of dysrhythmias and their consequences.

Dysrhythmias can occur in both healthy and diseased

hearts. Although the actual cause of most dysrhythmia! is elusive, they are closely associated with certain conditions, primarily 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

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 report 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 result in sudden death. Because asymptomatic patients may
not seek medical att~ntion, it is difficult to estimate the frequency of the disease,although it is likely that dysrhythmias
are quite common in the population.
Dysrhythmias are classified by a number of differ~nt
methods. The simplest method is to name dysrhythmias according to th~ 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 interfere with the normal function of the heart. A swnmary of
common dysrhytlunias and a brief description of each abnormality are given in Table 26.1. Although a correct diagnosis of the type of dysrhythmi~ is sometimes difficult, it is
essential for effective treatment.

TABLE 26.1

355

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.
T~ ilKidtn~ of uri.rl ~rhythmias ilKll'a~ 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.
AIaI9t majori\)' of !Udden (ardiac dNths all' btlil'wd to ~caus~ b)'
Y~mrKular dyyhythmiol~

hill fibrillnion .fft<tl 1.5102.2 million ~It in tilt United SUIf<.

Typesof Oysrhythmias

Name of Dysrhythml.

Desc~pt1on

Atrioll or I'tntrirularoo)'Qldia

Rapid lItan beat gruttrtlun 100 beau ptrminut~ innllu;m!!riIwmdlyurdioi ~ mort' W'l'ous
thin atrial udlyurdiol

Aui.ol or I'!'ntrirularflutttr

Ripid,rr<]Ular heartbe~ts; nay ra~ betWffil 200-300 beau/ min; atrial may rtqUir~ tll'atmtnl but is
not uswly lau~ I'tntrirularftu1itr ~RS jmm~tt trNtlllffit

Aui.ol or I'tntrirularfibrillati:HI
Hurt bIodr:

'kr} rapid, !JI(oordillilltd tNl~ compltt~ disorIFonization 01 rh)"ltm Il'IUhing in lad; of .!ltqualt
wdia>c: (ontrinion; II'qu rtl irnrntdialt trutmm

Area 01 lIOTIUIT"Idunion in tit m)'CQ'lli!m; may be partial or aHIlpletr; dassifitd as first, W'(ond, or
thirtl~

I'mniIIUf! aui.ol or pmnatUl' I'!'Ttrilwr (ontr.rctions (PVCs)

An utra ben ofttn ori9illil"ing fKrn J !OIItt other than the SA nodt; not normally W'l"iouI un~ ~
O(Qn in high fi"equtnt:,
SIowlltanbei~ 1m than 6) bNil ptr miMt; may r~R ' 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 simultaneously. 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 conduction 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 action potential approximately 75 times per minute under

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 coordina ted manner, other regions of the heart may begin to initiate beats.
These areas, known as fCtopic foci or "topi( ]IiI(~makm, may
send impulses across the myocardium that compete with
those from the normal oonduction pathway. Although
healthy hearts often experience an extra beat without incident, 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

Te<ling mndilion., wilh ~ norm~l ",ns" of fiO 10 100 '-t.o

no <ymplom<, ~nd do nOl aff""l cardiac o"lpHl. Th"", type..

per minute. This is referred to as the normal sinuslhythm. The

SA node is greatly influenced by the activity of the sympathetic and parasympathetic divisions of the autonomic nervous 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 potentials 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

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 potential 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 ~ledrO(,1rdiogrlm (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 pathologies. For example, a long PR interval suggests a heart block,
and a flat T wave indicates ischemia to the myocardium. Elevated ST segments are used to guide the pharmacotherapy
of MI. A normal ECG and its relationship to impulse conduction in the h""rt is shown in .. Figure 26.2.

"'"'" ---------1i,;;~~~~~---"f,;~;.,- tntornodat

alrial plllhways

"'"'" -------rTt~
tnl"rvootricUar
..,,~

c::,~----cr-T-- AV junction

,""oc'lr- 't-- - Bondle 01 His

,-1--- LeI! bundle branch

RighI bu1dle branch

r;:'7'---- Purkinje liben!

Pu!1<inje system

,.. Flgure26.' Normal conduction pathWay In the heart

Source: Pf'aoon fdOO1 rton/f'H Calege.

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Internodal atrial

conduction pathways

r------------ Bund~ oIH~

\'6<--------';--------

Bunda brar.chw;
Puoonje network

Atrial
depoiariZlOtion

V""tricuia,
,epoIa riZlOtion

V""tria.ola,
depolarization

,
I

I
02

'-----v---'

'---.--'
Q"

,..
I

"

". 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 re~
sulting from the disease. Because these drugs can cause serious 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 medications provides Little or no benefit to the patient. Health care
providers use several nonpharmacologic strategies to eliminate 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-

LibraryPirate

cal activity often allows the SA node to automatically return

mndllction to

~ norm~1

SiOllS rhythm.

Other types of nonpharmacologic treatment include

identification and destruction of the myocardial cells responsible 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. I mplantabl ~ cardiOerter
d~fibrillators (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 capable 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

358

UnII4 TheC.rdloY.<;(ubr ,nd Urinary Syuem,

is necessary for Wlderstanding drug mechanisms. Action potentials 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 negative charge (80 to 90 mY) imide a myocanlial cell membrane
relative 10 the outside of the membrane. A cell having this negative membrane potential is called pdarim:!.
An action potential begins when .odium im mannel. located in
the plasma membrane open and Na+ rushes into the cell producing 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 membrane 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. Blocking potassium, sodium, or cakiwn ion channels is the primary phannacologic strategy used to prevent or terminate
dysrhythmias. ~ Figure 26.3 illustrates the flow of ions during the action potential.
The pwnping action of the heart requires alternating periods of contraction and relaxation. There is a brief period
of time following depohlrization, and most of repolarization, during which the cell cannot initiate another action
potential. This time, known as the rrfillctory period, ensures

Cl aas II
Beta-adrenergic blocker
Propranolol

CII M IV
Calcium channel blockers
' Verapamil
+20mV

OmV

CI I
Sodium channel

........

Procainamide

(a) Resting state before

action potential
An channel gates closed
~

(b) Depolarization
Sodium and calcium
channel gates open

Flgure26.3 ton channels tn myocardtal cetts

LibraryPirate

(e) Repotarization
Potassium channel
gates open

(d) Return to resting state

An channel gates closed

OIoptt,16 Orugl 101 OysrtrythmJu

that the myocardial cell finishes contracting before a second

action potential hegins. Some antidysrhythmic agents produce their eff~ts by prolonging the refractory period.

26.6 Mechanisms and Classification

of Antidysrhythmic Drugs
Antid~rhythmic

drugs a(t by al tering specifi c elec trophysiologic properties ofthe heart. Theydo this through two basic 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,a nd [V,and
a fifth group that indudes In iso::ellaneousdrugs not ading by
oneo(the first (our m('l;hanisms. The five categories of antidysrhythmics and their medu.nisrm are listed in Table 26.2.
The use of antidysrhythmic drugs has significantly declined in recent years. Resear(h studies holve found that the
use of antidysrh yt hmic medications for prophylaxis can actuall y ;ncreast: patient mortality. This is because there is a
narrow margin between a thel'1lpeutk effec t and a toxic eff<>eT with ([nIp? ThM ~ffU.T (.Mtlbc rhythm. Thl'}' hnvi! th i!
ability nO! only tocorrtCl dysrhythmias but also to worsen or
even create new dysrhythmia s. Th ese prod ysrhythmic 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 d ecline in antid ysrhythmic 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
o f dysrhythmia s tha n is the prophylactic useof med ications.

SODIUM CHANNEl8LOCKERS (CLASS I)

The first medical USt of quinidine , a sodium channel
blocker, was recorded in the 18th cen tury. Doses for the

TABLE 26.2

sodium channel blockers, the largest class of ~ntidysrhyth

mies, are li~ted in Table 26.3.

26.7 Treating Dysrhythmias

with Sodium Channel Blockers
Sodiwnchannel blockers, thedass I drugs., are d ivided in to
three subgroups, lA, IB,a nd IC, based o n subtJedifferences
in their mecha nism of aclion.lk-cause the action potential
is dependent on the o p ming of sodium ion channels, a
blockade of these (ha n nels will prevent depolar izat io n.
The spread of the action potential a(ross the myocardiu m
will slow, and areas of ec topk 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 tha t is a prototy~ Ioc~l ~nes thetic in
chapter 1900. This anesthetic_like action slows impuLse
conduction across the heart. Some class [antid ysrhythmics,
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 availability of safer antidysrhythmics.
All the sodium channel blockers h3Y(' the potential to crcate new dysrhythmias or worsen existing o nes. The reduced
heart ra te caused by the drug can cause hypotensi on, dizziness, and syncope. During pharm~COlherapy, the ECG
should be monitored for sigll$ of cardiotoxidty, such as increases in the PR and QT intervals and widening o f QRS
complex.. Somedass I drugs haw significant anticholinergic
effects such as dry mouth, oonst ipa tion. and urinary retention. Special precautions should be t~ken wi th older adu lts,
because anticholinergic side efferu; may worsen urinary
hesitancy in patients with prostate enlargement. Lidocaine
can cause eNS toxicity such as drowsiness, confusion, and
(onvu1sions.

Classlficatton of Ant.dysrhythmics

am

"'0'"

hdtcatlons

IA ~"lIfOOIirwride

Dt\a)os ,~rization; IIIMs {oocMtion 'eIitJ; iOON\eI

d..,tion ~the ~ion pom.t~1

Atrial ftKiIla!ion.~li't~trial {Qn\l'i(tions,.P'iC!,.

V'tIIIIicINr ~

IBmmplt;lidoulnt

'/'(CeitJolttl rtpoLlrimion;~ (oocMtion ftloIity;

dt<rulot! Ii;.ntion of rtion poIto\i,1
ltIl-ignitkolnt t~ on rtpOlirization; lioM{onduction

Sftl'll' wntrio:ular dysrIrythm~

SlOW! tonduction 'IfIodIr. dt<rmn aLlomatidtr. prdongs

AtrialfklutJandftJrillatlorl.~hmla.

SlOW! rtpOIolriu1 ion; looN It! d..i1ion ~ action poItlltia~

p!OIongI rthctory period

St-il'll' ~trial,nd vtntrkIAir dysrIrythmlai

~ Sodl.r"ham@l

111.1

_...

IC ~mplt:flt{iinide

U; BuaaIi'rntr9{ antaqari liS eumplt;

m;PowsiJm chanMl bIoUtfI tumplt:
illiod.illllll'

fHMwn dIirJJ@llIIocbrseuJ!1llt:
,,",pmII

-.,-.,-"

SlOW! COI'Id\r(tQ) 'ItIodr. dt<rmn {OII\ooiIity; praIongI

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359

tIlIJioUr dyIr\Iythmlal

TABLE 26.1 Antidysrhythmic Drugs

Drug

RoutE> and Adutt Do5e (mall dose where Indicated)

Adverse Effects

Ct..ASSIA:SODIUM CHANNEL BLOCKERS

PiI; 100-100 m9!;d (max: 1.100- 1,600 mg/day);thef~

SffiII1 drug 1M! is 1-5 /1I(g/ml

PfWNmide (Proanbid)

PiI; 1 glo.lding dose ~Iowed 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

quinicint glUUI!I.Jte

PiI; 200-600 m9 tid~id (max:3-4 gldq)

quinicine Mlflte

PiI;200-400 m9 lid~id (max;3-4 gldi1l;thelilptt.tk

SffiII1 drug 1M! is 2-5 /1I(gfml

"'-

NlllIUO,lI1IIIirillJ dillrrlw,ftymoutll. umory

May i!RXMe MW drYhythm~ e. WOIJfI\ tlisfoo

ooei" twooll'mjoo blood dymsjaS (miridM jljd

kiM fprouinamjdpl

Ct..ASSIB:SODIUM CHANNEL BLOCKfRS

IlIooint (Xykx.aine) (st!! pigl! 20

for !he Prototypr Dn.I;I box OO )

IV;H mqhnin inlWon rlte(mn:lmglkgptr S-10min)

NIIusta, IIlmiriIlJ drowsinm, dilziJrn, /ootgY

mmetine (Mexitil)

PiI;200-100 mg tid (mu: 1.200 mglday)

May D!!!d!Kt IltW dysItIythmias e. WOIJfI\ Nming

ones' hypotm!ion.ln!tyrri. CNS to"ddty

phm)1Oir1 (DUnlin. Phenytet) (set!

page 175 for the PIototype: Drug

PiI; 100-200 mg tid (mu:625 mglday)

",,,,,, )

(Mdgg'oo

ma6gn,JQ!

bmmbmnu 1)00;"1 WlDJ'l

t)likpl:iru!; if Ibruptly "';!hIRWII

[phrnttoinl

1V;5G-IOO m9"tIJ 10-15 min unll dyytJythmw b

temdllillrd (mu; 1glday)

ClASS Ie: SODIUM CHANNEL BlOCKERS

lIfGIinide (bmbowf)

PiI; lOOrng tid (mu400mglday)

NIIusta, IIlIIIiriIlJ dilzinm,hfodadlt

prtipifmone (Rythmol)

PiI; 150-300 mg tid (mn;9OO mglday)

May D!!!!kKe IltW ctnrhythm~!! W!!Ot!! tlmioo

9MSlnpot(f)!ion. bra!Iyt;ma

ClASS II: BETA-ADRENERGIC BLOCKERS

iCebulolol (Stliln

PiI;lOO-600 mg bid (max: 1.200 mgldaJ)

HIlIoIoI (BrlYibkx)

IV;SIl rocgIkgImin mlinlmlocedw (max: 200 mcgllgfmin)

PiI; lG-3G m9 lid"'1id (max:4!IJ mgf~)

IV;O.5-1.1 mg "tIJ 41lou1J

propr.molol (100011, "noPr.m Xl)

nrigut. insomIio, dJmnirltSI,impoltnaordturosal

,~ btodycDllfD, Qnd(lltIfusio/l

Aqr!IuW!o!k.!armcmpasm SiMll5-.ioImoo
M!d~ .wp!'N!.msf 1M drug klbrmllyvmhdr.wm

paRium n:bouod I!mJrmigo lfr:itruImi19

!ttvhythmin-qlTMlG!!!ii! jid!m!b m.nocrur

CLASS III:POTASSIUM CHANNEL BLOCKERS

MnIodirttlt(Cofdmne,hctrOllt)

doiecilidt (lil:osyn)

PiI;400-600 mg/day (mix: 1,600 mgld.,. as loadill9 dose)

PiI; 125-500 mcg bid tt.1Cd0fl oorininedt.riUkt

Itontdaront (Mu~q)

PiI;400mgljd

bltilide (Cl:lMrt)

IV; 1mglnlwclo-m 10m"

SOIIIoI" (ktapm. 8fl:apiCt M, Sorint)

PiI;80mgbid (miX: 320 mgfdayl

&lrred rlsiaI (QmiodtwnfJ,~Stmitirily,fIIlISea,

KIfIIiri"lQ./MO,mQ
May pn:dKt IlfW !MrtrytbmiH q W9rV!l aisljng
SM' hyootmslon. bradyooia QrlM!O!!i.J ..Ue
syndrome [ampQ!'tt)
[dofelilidsl (!(S
!I'jrjty m"rtiIdr1

.!!!Poedtm'

ClASS IV:CALC IUM CHANNEL SLOCKERS

diltiaztrn (wdiltm, ~rtlir Xl, Dlac:0f XR,

Tiztia Xl, TIUa<) (Itt Pi9t 348
for !he Prototype Dn.I;I box OO )

1V;5-10 mghl (O/l!inuous infuslOl1 for. fl"llximlll1l of 24 II

(max: 15 mghl)

Q I'ffipamit (ulan, (OYtfl-HS, isoptin

PiI;240--480 mg/day

511. Vtrdan) (sttpigt li fof!he

Proto(ypt Drug b.: ( 0)

IV;S-10 mg dil't(t:may Itptatin 15-]11 !Tin if ntt<lt<l

R~JIItd ;tin, lItDdodit. dillintSS, ptriphtrQl NtmII,

Ight.. htod~ MIIW4 dDlrlw

IIm!IQI9Jjcjty M) (HE (pn/lQion AQOd cbi!lCl!"

MISCELlANEOUS ANTIOVSRHYTHMICS

1V;'-12mgglvmua boIusin.ie<tionMfY Hmin ISi"lttdtd

(max: 12 mgflkMJ
IIgoxin (Di!1tel.lanOJin, lanoxiGlpsJ
(spilgt311fe. thtPrototyptDrug

PO;O.11S-G.5mg !jd;therape:utk SffiII1 drug itl'rl is

O.8-1l11)'ml

"'''''')

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

"'"

Irdio ir"ocIiatt common advmtdferu;~ irocIbtes serioui IIMne effects.

"Sotalol i! I beta bIomr, but btQUSoI! ill ardiac. tHem Ill' siniltr to those of amiodarollt,it is ronsidmd I elm III mug.

'"

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,", Prototype Drug

Therap~tic

I Procalnamlde (Procanbld)

Class: Antidysrhythmic

Pharmacologic Class: Sodium dianne! blader/class IA

ACTIONS AND USES

Prouinamidtis anoldtrdrug.a~ in 19SO,th" is(litmically relal~dtotht
local aneslhetic: prouifl!'.Procainamidt bIoc:kllOdum ion channtls in m)'lmdial (elk, thus rmlKing automaticity and slowing rondlKlion of t~ aclion pott ntial KrOSS the myomdum. This slight Mlay in ronduction vtIocity proIon~
the rdractory ptriod ,nd .:an IUppl\'SS dysrhythmias. Poxainamidt is rdemd
to as , broad-spwrum drug beuUIf it has t~ <Ibilil)' to roITKI many d~ft'nt
type of atrial and Yenlrirular dysrlrylhmias. T~ most {ommon dosaqe form is
the Ulmded ft'Itasttablet; howne~ prooinamidt isalso milable in "1lIU1e,
IV, and 1M formulation~ TIlt t~raptUtic Itrum drug 1e'I~1 is4 10 811KglmL TIlt
Ult of prooinamidt has dKlined signifiumlydu~ to th~ ~Iopment of moft'
Ipt(ifund ~ferdruqs.
ADMINISTRATION ALERTS
Un t~ lUpine position during IV adminismtion btuUIt ~ hypotension m.ly OCCUt
Do not break orcrush ~ltendtd-rrieast tablets.
Pregnancymtgory(

PHARMACOKINETICS (PO)
Onset: lOmin

ADVERSE EFFECTS
/lausu, vomiting, <Ibdominal pain, hypotension, and htadache aft' common
during procainamidt therapy. High doses m.J)' prod~CNS effKIIsuch ,sconfusion or psythasis.like aII amidysrllythmic: drugs. procain.l midt has t~ ability
to product ntW dysrhythmiu or worstn existing ones. Alupus~ike syndrome
mayocwr in ]0% to SO% of p-atitnll taking t~drug 1M'! a )'Nr.
Conuaindi{itions: Procainamidt is comraindicaled in patifnlS with {omplete
AV block, 1M' ft' CH F, blood dysera sias, and m)'ilthenia gravis.
INTERACTIONS
DIII!rDIII!I:AIkI.ft(;l(ljiac~fffK6mayoccurff~~

acmnislered with O!ha an~nAdtitm antidlolinfrgic sidf fifloaswil

oaur l prOGliiarnide is IMd III(WIently with anticlulilfrgic !kugs.

liI bTesu: ProGainamidt may ilKll'U vaiu@!1or ihf f~lowing: AS~ AlJ, li'liiii1
ili:ailll' plmplmase, lilli, arKIlflllm Ii~rulin. FaM-plMivI' Coombs Itsl arKI ANA
tilMmayOCCUI.

HerbaVFood: lInknown
lINIment of OYl'rdOSf: Supporti\'l' ireaUllmt is targ~ted to Ie"I'l'lSing hypol~nsion with mopl\'SlOlS and pft"lmting or tft'uing prouinamidt-induced
dylrhythmiotl..
It!ftrrc M)Nrmlfl9l1!lbrQNulllfll} Pnxm fOOlllpf(lkrcllrti~

~k:l - 1.Sh

Halflife:lh
Duration: 1 h (8 h IUSiaintd ft'1e, 1t)

NURSING PROCESS FOCUS

PATIENTS RECEIVINGANTIDYSRHYTHMIC DRUGS

Assessme nt
Baseline assf51ment priort o admini strat ion:
Undtrstand th~ ft'ason t~ drug has 1ln prt'I{ribed in ordtr 10 mfls for
thtra ptUlic: ~1I"Is (t. g., atrial, Vl'mricular dysrlrylhmiasl.
Obtain a complete htakh history including urdiovaswlar (including
preYious dysrhythmias, HTN, Ml,hean fa~ull'),ancl the possibility of
pregnancy. Obtain a drug history induding allerg~~ {um'nt pltSuipbon and
OK drugs, herbal pR'p<lration~ <Ind akohol UI~. ~ aim to possible drug
int..... tions.
Obtain ba!!'ifl!'wt9l~ vital signs (epKially BP and pul!!'), KG (ral~and
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 findi~, ~Ie{trolyte,tsp((iotl~ pomsium
1e1'l'l,ll'n<l1 and liYrr function studies,and lipid profilel.

Pote nt ill l Nursing Dill gnoses

D~(ll'astd Cardia{ Outpul (related to dysrllythmias,dis~~ proct"lSe~or to

ac1l'!'rlt tffech ofdl\Jgtherapy)
Ak~red TIlItI!' Perfusion (related to dysrhylhmia~dilNlt Pl'XflstI,or to
ac1l'!'rlt rifech ofdl\Jg therapy)
~nJitty (reined to dysrhythmias)
FatigU!' (r!lated to dysrhythmiasor to adYl'rst ~fft(ts of drug therapy)
Activity Intoler' nc~ (ft'lated to ~ tffe(l\of drug therapy)
Smlal Oysfunction (ft'lat~d to adverst ell"KII of drug t~rapy)
Deficitnt KnowIedg~ (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)

Assfss mf nt thro ugh out iI dministrati on:

AslfSs for cle-sirm t~raptUlic rifects (t.g.,{onlrol or t liminalion of
dysrll)'lhmia, blood prffiU Il' and pu1lt within etablis~d 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 e1tnro~tes, 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 t~
hNlth Ull' p~idtr immediately.
(Continued!

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362

UnII 4 TheCJrdkwasc:ubr.oo Urinary Syuem,

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTI DYSRHYTHM IC 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 dym.)'Ihmw~ and blood pl"ffiUlt .nd plJM within normal
limin).
Be free from. 01 experierue minimal. . dmse tifed,.
Velbaliz~ an undemandin 9 of lhe drug's UI!', adoror tifrru, j nd rtquirt'd prtaUlions.
Dtmonlll'~ proper ~h:lministr.tion oflhe medication (e.g.,dOlf, timing. when to notify health tale providtr).
Implementation
Inte rve nti o ns a nd (Rati o na les)

Patient a nd Fa mily Edu catio n

En suring therapeutic effect,:

Co,uiflll' f~t lIsessment,oII aboYtfor tlitrapMic efftcu.(OysrftythmiH
haYf diminished or art' rlimilated. Blood prmlR and pullf Ihouk! bt within
oormalliniu orwithin pa!llmetefllfl by IINkh tart' p!O'<idtr.)

To <lliay possible anlliet)o, te.{h the patim~ lamii)o,ortalt'giYe, thr ,atioule

for .11 equipment Ustd and the need for f'equent monitoring.

EnOlUr.ge appropriate lifestylt {hanges. Providt for d~titi.n mnsultation .II

.--ltd (He. khy lifestyle (hanges will IUppon and minimin the need for
drug therapy.)

Enc:ourage the patient to adopt a htakhy lifestyle oflow--fat food {hoKe!,

inc:lNsed exm:isf, decrt'. sed (Jlfeine and <lkohol (OIllUmption,.nd
smoking {ffiation.

Minimizing ildw rse eflKts:

ContinUl'to monitor ECG and pulsefur quality and volume. Take pulse furl
full minute to .HItS, for It'gularity. ContillUl' to 0II1ffi fu, {ompl.inll of
palpitations, {or,eiating palpitations or plJllf ilT\'9ularitits with ECG. (Not aII
dysrh)'thmiH rt' sym ptormtic.Corrtl.ting symptom, with the ECG may
help ~ine tht need forlunhersymptom managl'ment.)

Texh the pat~t.family,or megil'el" how to uke a pffiphe!lll pulse for 1

full minute beflR taking thedrug.Assist the pat~ntto find the plJM aru
that ~ most (onYfn itnt and e.~i)o fell Rord daii)o plJlst r.tl'S and
It'gularity . nd bring It<OIlI to u {h IINlth urt' isit.ln,1nKt the patimt to
ootify the heakh cart' provide, if pulst ~ btlow 60 or abovt 100, therr ~a
ooticNble challC)l' in It'gularity from prrviousl)o feI~ or if palpitltions
develop 0' wa'lfn.

Take blood prrnurt i)oing.sittinq.and mnding to deted onhost.!lic

hypltension. Be cautious with the fim few doll'! of the drug and with the
eldtrty who a,e at ilKfl'ased risk for hypotension.(Antid)'lrhythmic df1191
may ta!M hypotension. AfinHlost elft may OI{ur with a signifitant d,op
in BP with the first few doIt5.0nh0static: hypoten,ion may ilKfl'alf the risk
oflaUsand inju,~.)

T~xh the patient to 1M slow~ from ~ing or litting to IIdnding to jwid

diuiness or lalls.
InstMt the patimt to take the fi,st dose of the new plt:l{ription btfort'
bedtime .nd to be uutious ckJring the ntxt few dOles until drug effects <l rt'
koow".
Texh the patitn~lami~,or (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< ~lKtrolyte ~k, .. pt<i.11y potmium,rrnol

funnion labs,and drug itYelS <l ' nteded.(Hypob lemia in{rt'aIl'! the risk 01
dysrh)'thmiH.ln<ldt~te, 0' high levrls of .ntid~)'Ihmic drug may Ie.d
to inc:lI'astci 0' mort' lethal dym.)'Ihmi.l~)

ImtrU<llhe patimt on th~ n..11 10 rt'tum periodi<. llyfor I. b ...,rI<.

Mvise the patient to uny a wallet idtntifK.ition md or we .. medical
idtntifiution jewelry ind itating antidys,hythmic therapy.

W~igh the patient d!ii)o JOO report a weight gain or loll of 1 kg or more in ~
2HlOu, period. Continue to oIIll'!S for ~IN, noting Ioc.tion <l nd {harXler.
(Daily weight ~.n mu,ate measurr of lkJid !tI1UI.nd tl~es into x{ount
intake,OUIpu~and illlfnsible IosItS.Wrilht gain 0' edema may inditate
advtl"ll' drug tifrmor...,rsening mdio\\Jl{ular distase promlfl.)

HiYe the patient weigh !elf d.Jii)o, iduli)o ~t the ~m~ tim~ of d8;,.nd
It'(ord weig ht along with pulst mealUrrmenll.H.we tht patitm It'pon a
weight loll 0' ljiIin 01 mort' than I kg (appl"Olimately 21b) in a 2+hou,
period.

Monitor for blt'ath I01IIds <I nd lINn sounds (e.g. iKrming dyspnea or posltJ"al
fIO(tumal dyspnea, ralts or"(fol{kIt( il lurqs, frothy pink ~nged sputum.
1IlIIl1IUr; or alra hean IOUM) alii II'por! immed.J~ UrKreaIDg lung
rongestion or _ or \\OJBI' ning hean munnur; may ildicate inpending lINn
lam. Potassiun-<hannel bIodctrs an' .lIOriited with pJntonaI)' toxi:~)

InstMt the patimt to immediately rt'pJn any I!'YI'fl' shortnffi ofb,eath,

frothy sputum, profound la~,or swtiling of v:tremitits.H pollible sign,
ofhein f.ilurt or po.rlmon.1)' toxicity.

Repon anyviswl {hallgl'"l. skin '.Hhe~!Unburning to the health tart'

pra<idt,.(Potmium-{hannei blotkers may (JUst photOltnsitivity, ,kin
rashes, . nd blurred vision.)

Teol{h the patient to It'pon any vision {hanges promptly and to maintlin
It'gula, eyt euminations.
Teol{h the patient 01 importln{~ to 'NUr protffiiYe {lathing and <l PPty
u",-rm-, "'IIuLlrt, during "",iud> of ,uo ~'po>Ure.

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01",1<,26 ON9' for Oy;<hytt\ml..

NURSING PROCESS FOCUS

363

PATIENTS RECEIVINGANTIDYSRHYTHMIC DRUGS (CoortlUro)

Implementation

Inte rventi o ns and (Rati o nal es)

Pati e nt and Fa mily Edu cati o n

Patirnt understandinQ of drug tht rapy:

UII' opplnunitif, during administration of m~dic:.nionland during
alltSllIII'nB todisnru ,uiorult fordrug thtrapy,dei~ thtrapMic:
OUI{om~s.mon common advers~ t1f~{I!, parameter'S for when to (all h~alth
cart pra<ider,and any lIt(~sul)' monitoring or p~autiolll.(Using time
during nursing u~ h~lpllO optimi:eand ~infOr<f ~ylearning .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 th~
efiKtr.enellof tlM<drug.)

The patifmandlor family should be ilb~ to IIUt tIM< ~alOn for drug;
approp.wlt Om and s<lM<ru~ng;wh.n adYl'rll' efiKl! 10 oblffi'l' for and
wlM<n to rtport;equipment nffiItd ill apprnpriat~ ud how to lI!e that
tquipmem;and tIM< rtqJi~ Itngth of lTIfdication thtrapy nmled with
any spKial illltnKtiolll ~ardin9 renewing or mminuing presc:ription as
approp.wtt.
Ttl(h tht patitm to ta~ drugs" M'fIty 'pa{td apan iI> poI~bIt 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 mo~
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 ~Isand 6pKttd out{omes ha\\' bttn IIII't ( ~Piannin().
';t\' rabIt 16.J fur Q ilrikugs (/Illiel-N/ /0 I'IIIth tlltse 1IIM9 DOfll 4'J11'r. W ~ lUling I'rIIml flKl/S IIIbIn. rMp/ff 2100,f~ iltormolioo rrlDred Iillptdk ((lfegoritl

<IlIi"lfImi.tugs (e4.(fId!m(hDnMlIlkKtm~

BETA-ADRENERGIC
ANTAGONISTS/BLOCKERS (CLASS II)
Beta-adrenergic antagonists are widely used for cardiovascular disorders, including hypertension, MI, heart failure,
and dysrhythmias. Their ability to slow the heart rate and
conduction velocity can suppress several types of dysrhythmias. 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 decrease conduction velocity through the AV node. Myocardial 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 channels 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-M I patients, beta blockers decrease the likelihood 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

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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
(CO PD). 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
dysrhythm ias. These drugs prolong the duration of the action 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
~ clel'0l~ri'NI ,IMe, '""Pohri7J1lion depend, on repbce_
ment of potassium inside the cell. By blocking potassium

is in

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 ~1I').BKaU5l' d th~gellf{i.differmte,thedrug lin a sir
nifitamlygll'attreifKton heanlil1t i1 many patientsof AsiIr1 ~l Thenu~
s/WdillltSsthispopUati:>nforpossibll'~andmonitorforpol~bltad
YI'~ INdionsdutto hilhdrug irYI'Is.

364

UnII 4 'It"

C.,dkIY.",u b, . 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 . oon~~ IIttNdll'ntrgic bIoc:u~ .ffKling 00., Il'(rpl0B
in ~ hun, . nd beta, IffePlors in plJlmonary .nd \\!\(\Jlar smooth mUI(Ie. Propranololll'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)' o(ffi~ sympa~tic: stimulation.1t is applO'/rd tOUNt. wide fanfly of d~m~ iKiuding hypfflrmion, angina, .nd migrailll' headKhe,.nd
for prt'"!'ntion 01 MI. ihI' drug is .vailabir in ublet, rnend~d-~_ caJIIUIes,
and IV iorlllJlatims.
ADMINISTRATION ALERTS
Abrupt disrorMinunion II\a)' calM MI, !m'r~ hyptrtenlion, and ~rmriculard)'llhyrhmias.
Sw.llow ~endtd-Il'leu 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<! ft'lea~)

Half~ift':l -5h

Duration:6- 12 h (24 h enendtd Il'Ie_J

ADVERSE EFFECTS
Common
rfferu 01 propranolol indud~ fatigur, hy~t~nsion, and
bradycallfia. Because of th~ . biliQ of prop'. noloIlO llow ~ hun rar~ patirnu
with ~rious ca rdi.Jc: dilordtrs SIKh as heart fa iuft' must lit cartfally moniiOll'd
Adftrse rlFeru sum as diminished libido and impotencr may ~!Uk in nonadheft'llcr in male p.titms. Propranolol ~ould br ust<! caUlioully in diabttiu dur
to irs hypJglyo:rmic ell"Kts and beuusr it m.y ' 1IY!k' the sym~lOms of hypoglyo:emia as the .drenrrgic "fight-or-flight' to hypogl)l:emia i; blocked. This
drug ~ould br used with c. ution in patitnts with Il'dicrd Il'oal rulpIJ~ btciuse
thedrug II\a)' cumuliII' 10 IOl ic ~Is 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.

.amse

INTERACTIONS
1Wg- 1Wg:(0IKII"1m adrnirislBion with oIhfr beta ~m may p-OOUCf
~fff,m IIllMhear~ i!nd toi)'lalooorhypot!Mion Ioa)'fffit.SfatM
both pr~ i!nd 00l1li dIDleI blockm SUpplll! ~f!hl 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 ~'/!ft 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 aIbuteroIlPrOl'Hli~ wil.nugonizf llot aaionI of JroIIOfIOIoI.
Lab TfSU: PrDp"aoolol may gi~a fw O:IMI' for uriy;y ~
IkorbaVFoo:J: Untnown
T~tment of Olerdou: Tll'atment is urgeted
~asopressors. .nd b~)'Urdia with atropilll'

to Il'~rsing hypotension with

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.

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 receptors or sodium channels. For example, in addition to blocking 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, Betapace AF, Sorine) is approved for specific types of atrial and
ventricular d~rhythmias, 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-

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siwn channel blockers slow the heart rate, resulting in serious bradycardia and possible hypotension. The>e adverse effects occur in a significant nwnber of patients. These agenlS
can wo~n 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 signif~
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 in~

.,

OI ... lOr 26 0"'9' for Ol"'hythm" ,

Prototype Drug

36S

I Amlooarone (Cordarone, Pacerone)

The rapeutic ( lass: Class III antidyslhythmic

Pharmaco logic Class: Potassium channel blodo:.er

ACTIONS AND USES

Amiodarone ~ IIlIKlUr.lly ,imilar 10 thyroid hormolil'. k ~ appllll'fd for lilt
trMment of Il'~tant 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 th~ drug'sactiom on thr lItan 1l'1.1I1' to its bIockadtohodium ion channr ls.
Amiodaront ~ ava ila blr 01\ orallablm and.J san IV infusion. IV infusions all' limitro 10 short-trrm thtrap/. normally only 2 to 4 days. Whtn givrn orally, its onlI'IoloKtion may takr II'Tfral Wffk~ Its e1fll, ~t~ un lall. to 8 Wl'rln
alter tht drug ~ disconlinJfd, sincr it M an ntmdtd haK-~fe 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 (PO I
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 serious 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 drsrhythmias. 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 number have been appro\'ed for dysrhythmias. A few CC& such
as diltiazem (Cardium) and verapam.i.l (Calan ) block calciwn ion channels in both the heart and arterioles; the remainder 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 pharmacology 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 betaadrenergic blockers. Effects include reduced automaticity in

LibraryPirate

ADVERSE EFFECTS
The most .moos ~r ~t from amiodarolll' occurs in tilt lung.. wiIh tilt
drug (,lu,ing , pneulMnia~ikr ,yndrome.AmiotbrOlll' l1IiIy ako UUII' ~Iurrro
vision, rashr-s, pholosrnsitivity, naulI'a. wmiting. anorma. laligUl'. dilzilil'ss
and hypotr nsion. Becau,r Ih~ medication ~ concr ntrated b)' Cfltai nt~,ues and
has a p-oIonged haK-life,advrrll' rffts may ~ slow to ll'SoMo.
Contr.indic.tions: Amiodarolll' ~ contraindicaltd in patients with ~Il'
brad)'Uroia. caroiogfn ic shock, sick sinus syndromt .1I'ft1l' sinus node dysrunctio 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 gr~ H"IlarKts 1M acrionI of iIIlicOigWnI5: Thill,1M dolt of
warfotilllllll bf cut by ~ much iIIhiIIlLM wiIIl bm~""'I9i: ttIdM 0/
<.okiumdlanntll>lockm Il10)" ...... orw ..... ~"US 1ndy<a"b....... arrnI, .... 1fI
~A~ IIIi'f ilKfl'<ftpher:rytoin "'wI!!\ItO- to thrfffoid.

La b Tests:May iooUW' YilIII"I r.... 1M following tflt!: nudNr arlibod~ AU,.IST, MId
'ifI1IIl Aalinf p/IoIphalilf. T~
Herba liFood: LM wiIIl edilloKN may QIM an inoMIed rill; of hfpItoIOIidIy..\Iot
cao.~ an iIcrNIfd fffPCI of MTiod;IIOOf.

1IIi,

TIl'atmenl 01DYerdose: Tll'atmrnt d amiodarOlll' O'>'fflb~ 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 refractory period. Calciwn channel blockers are only etTective
against supraventricular dysrhythmias.
ulciwn channel blocke rs are safe medications that are
well tolerated by most patients. As with other antidysrhythmics. bradycardia and hypotension are frequent adVeTS<' 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 disorders, such as hypertension. heart failure, and dysrhythmias, it is not unusual to find elderly patients taking drugs
from multiple classes.

A VO IDIN G M ED I CATIO N E RRORS

Durill9 a moming 'ISrs,men~ thr nurll' o~ thai a WllIic,1 patP.nt has

dtffioped an irregular hran r.llt 01 110 bean per minulf.Thf nurll' lIOIiflfl
tilt rtsidrnl physician, who orrIm .J stal tlectrocardiogram. Al'ntricUar dysrhyt~mia ~ dtttro and tilt physician ttlls tht nUBf to admini51fr lidooi~
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 doll'~. What should tilt nurll' dol
SttAppmd/l () foIlht ~rJI!WI'l

"

,,,~

~
~

i"

-"-

",. Prototype Drug

I Ve rapamll (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 ~'M mnduction 'fHKity and Slabifim ~hythm~
In tile 'lHStb"cakium (~nntl bIoWdt Iowtrs blood pmsu~ ~udng urdIK
workloid.Vtupamil Iiso dilatt'l tile (OJOIIi~ ~t'I, In .mon thit is impor\.lilt when 1M drug is uwd 10 trtal .ogin. (chapter 2S00j. Tlledrug is iYii.
a~ in oral, oral ~ndtd-ft'lu~,.nd

IV fonnuLrtioM. The t!J~tK StIIJm

IfwI i10.o8taO.lmc~ml .

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 ~kJ.
tion is dw and (O(oriess.
PJ!9MJq cat~ (

ADVERSE EFFECTS
AdYtnteftects.~ gtntr.lly miOOf.OO indudt M.d.ldlf,mnllipation,.nd~
potellsion. &aIM tIipolmil un UIM bmlyumil, pititoo with hein f.ikJre
should ~umu'" monitored.
(ontraindimiom: V~pamil is mnlr.Jindiuttd ~ palitrJb with AV twrt
blod, sick sinus syndJOmt, snere h)'pottmion, 01 bletdiog 'Jlfllf)'Un, or !host
unciel9oiJ19 ~troKrinill SUJgtf)'.1Jse widl uUlion in patitntt with ~il 01 hepitic impairment.
INTERACTIONS
IN}-I:nqVmpnW IllS tIlf.t.ility to~ blood Inft! d Iiqollln (Di;t8:.
I.anoIIIn.lanoJlkapsl ,SiJKt digoin and ffiapimil botb !low mndrIctiDn throu9l tht

....,J

AV JICdf. thIi(OII!ImflIIllf "lIIlbe~ moMOIfd III mil brid)unii.lkI'

with Mtih~ 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.

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
Two other drugs, adenosine (Adenocard, Adenoscan) and
digoxin (Digitek, lanoxin, lallOXicaps), are occasionally
w.ed to trea t specific d~rhythmias, but do not act by the
mechanisms previously described. These miscellaneous
agents are listed in Table 26.3.
Adenosine (Adenocard, Adenoscan) is a naturallyocrurring nucleoside_ When given as a 1- to 2-second bolus IV in
jection, adenos ine terminates serious atrial tachycardia by
slowingcondudion through the AV node and decreasing automaticifyoftheSA node. Its primary indication isa ~pedfic
dysrhythmia known as paroxysmal supraventricular tachycardia (PSVf), for which it is a drug of choice. It is also used

LibraryPirate

lrutrnfnt of Omdose: I~t Ot/"'apimil_doItll targetfd IO~

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 dysrhythmias 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 atria l 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 interactions with other medica tions are common, patients
must be carefully monitored during therapy. Additional informat ion on the mechanism of action and the adverse effects of digoxin may be found in chapter 2400 , where this
drug is featured as a prototype cardiac gJycoside for heart
failure.

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

26.2

The frequency of dysrhythmias in the population is difficult 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.

26.6

Antidysrhythmic drugs are classified by their me;;hanism 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 antidysrhythmics., act by slowing the rate of impulse conduction
across the heart.

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.

26.1

Beta-adrenergic blockers act by reducing automaticity as

well as by slowing conduction velocity across the myocardium.

26.9

Potassium channel blockers act byprolongingthe refractory period of the heart.

263

The electrocardiograph may be used to rewrd electrophysiologic 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.

26.10 Calcium chann~l bloch>rs act by reducing outomaticity

and byslowing myocardial conduction velocity. Their actions and effects are similar to those of the beta blockers.
26.11 Digoxin and ad~nosine are used for specific dysrhythmias but do not act by blocking ion channels.

26.5 Changes in sodium and potassiwnlevelsgenerate theaction 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

A type i diabetic on insulin reports that he takes propranolol (Inderal) for his hypertension. This raises a concern
and the nurse will teach the patient to check glucose levels 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.

When monitoring for therapeutic effe;;t of any antidysrhythmic agent, the nurse would be sure to assess:
1. pulse.
2. blood pressure.
3. drug level.
4. hourly urine output.
Because of itseffect on the heart, verapamil {Calan, CoveraHS, isoptin SR, Verelan} should be used with extra caution or is contraindicated in p<ltients with:
1. hypertension.
2. tachycardia

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3. heart failure.
4. angina.

Common ad~["l;t' effe;;ts of antidysrhythmic medications

include: (Select all that apply.)
1. hypotension.
2. hypertension.
3. dizziness.
4. """""=
5. panicattack.5.
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.

368

II

UnII 4

Th<>(~ ,d ""' .",ul ..

. nd U,I""ry Syne<",

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 afternoon, 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

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.

CRITICAL THINKING QUESTIONS

1. A patient with a history of COPD md tachycardia has recently 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?

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.

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Chapter 27
Drugs for Coagulation
Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES

ANTICOAGULANTS

After ft<lding mls chapter, the "udent should ~ able to:

{XI/tJlJ

Parenteral Anticoagulants

pt1IJt313

1 . Illustrate the major steps of hemostasis and fibrinolysis.

2. Describe thromboemboKc disorders that are Indications for toagulatlon

0, hepartJ (HtplocJc} P'J'It 115

Oral Anticoagulants

p1//t3l5
pt1IJt Jl6

modifiers.

o warflll1l1 (Coumodtl)

ANTIPlATELTDRUGS

3. Identify th e primary mechanisms by which coagu lation modifier

drugs act.

fXJ1t3l';

ADPRectptotBlod:tu

pogtJ81

o clopldogrel (PIavIx) (Xl9t.w

,...,

Glymprot~n lib/lila Receptor Antagonists

Drugs for InlermittHit Claudication

THROMBOLYTICS

O olrepw{Ar:rtwu>)

HEMOSTATICS

ptJ9IJU

poI}tJl1
f1II}tJlJ

p;lI)tJU

0, omlrtO1pro/C ocld (Amkot) PIIft J86

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 representatl~
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.

KEY TERMS

antkoagulant ptI9t m
antithrombin III (Xl9t m

doningfa<ton ptJ9t170
coagulation IUltllO
(oagulation~
~mbolus pajt

{XXJl170

glycoplOtein IIbllla (!O}t J)

hemoplliia pajl J7l
helTlOStM pajll'l:l
heJTKJStllic:s , .m
inttnni"rntdndKation {1C} pqJaJ
1owlIKIIetu~'M'ight h~s ( lJd'NHs) p!IIJt

fibrin {Xl9tllO

plasmin

fibrinogH
fibrinolysis

pla~n ptIIJt171

{XI/tJJO

pII(Jt 171

LibraryPirate

pi1IJt 111

prothrombin

pIIIJt Hl

prothrombin actiwator

(J<JJt 1lIl

dvombin pogeJlO
lhrombocytopt~iI ptJIJtJl1

dvomboftwbolicdisorders pajl1l1
Ihrombolytio pqJlJ
IIvomlNs pi1Jt1l1
rissutplasmin09"l Mti,UOf (lPA) pqJ7!
_ Willebrand's ftase (lWDl pq Jl1

370

UnII4

Th<>(~ ,d""'.",ul.,.nd

U'I .... ry Syne<",

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 perhaps death.Too much clotting, however,can also be dangerous.The physiologic processes of hemostasis must maintain a
delicate balance between blood fluidity and coagulation.
A number of diseases and conditions can affect hemostasis, including myocardial infarction (MI), cerebrovascular accident (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,. Adhesion 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

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 damaged cells initiate a series of complex reactions called the
coagulation cascadr. Coagulation occurs when fibrin threads
~r""l"'~

",,,,,hwurk

lh~llrap'

bluuu

Vessel injury

Vessel spasm

Plalelets adhere
to injUry site and
aggregate 10
larm plug
Insoluble librin
slr&nds form and

coagulate
,. Flgure27.J Baslcstepslnhi'mostasls

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~Ul1'lill1"'nls~u lh~llh",y

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 biochemical processes, lead to coagulation. The intrinsic pathway 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 outcome 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 activator 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 constantly circulate through the blood in an inactive form.
Vitamin K is required for tht' liver to make four of the dotting factors. Because of the crucial importance of the Jivt'r in

CNpltl 27 Drug; /0, C""'Iulation DIso,der,

Injured vassel

371

PHARMFACTS

r1'IiI!Jf
""'' ,""
~

Clotting Disorders
von WiI~brJnd's disuSf (vWD) is th~ moll wmmon h~rI'ditary blffiling

damaged cells

diloJd~~(iluSl'd b)' J rlerlCifficy of thr protein yon Wil~br"id f.l(tor

(yWF), which pbys a r* in pl.neltt oJggrl'gation and ads ua writr for

f~orVlII.

Marl' than 2 million paliffil5 raoc:h )'Nrdrvrlop a deep Vl'in thrombo~

Facto. X

(DVT).

J
PfoIhron-bin activalor (ProIhrornbOnase)

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 b rlKl% of all hemophilia (ilSI'!..
Hrmophilia B, or"ChristmudisriSf,"is i heJfdilary abmKr of (Ioning
f~orIX.

Moll' than 1S,000 peoplt in tilt United S!a!~ have hemophilia Aor B.

1----------- -------,

(t)

'''''''~.o _ Th......

Uve.

J :$
:

i
----1-+ Fibrinogen

PIIIsma

L ___________________

Injured vossel

....

Insoluble fib,..,

"

Figure 27.1 Major steps In the coagulation cascade:

common pathway

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 digests the fibrin strands to remove the clot . The body normally 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
creating thesl! clotting factors, patients 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; circu~

lation must eventually be re5tored so that the tissue can resume normal activities. The process of clot removal is called
fibrinolysis. It is initiated within 24 to 48 hours of clot formation and continues lUltii the dot is dissolved.

To diagnose a bleeding disorder, a thorough health history

and physical examination is necessary. Laboratory tests
measuring coagulation must be obtained. These may include prothrombin time (PT), thrombin time, activated
partial thromboplastin time (aPTT), and in some instances,
a bleeding time. Platelet count is also important when assessing 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 undesirable dots . Once a stationary dot, called a thrombus. forms

Plasminogen

TIssuo plasminogon

Thrombolylico
~

Flgure27.3 Primary steps In fibrinolysis

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Clot breaking up
into "okIbie fragments

372

UnII4 TheCJrdkwasc:ubr.nd Url",,'Y Syuem,

TABLE 27.1 laboratory Testing for Coagulation Disorders

''''
Activittd dotting limt
Activittdpartial
thrombopiaSlil timt
(aPm
Blffiing~m~

Hrparin~Hi

()@sc:rlpllon

NormalValues

Significance

Used to mon~or hi4jl\.do~ ~rin

phinnao:OIheraP1;'1so lIII'd b~,dlling,
and afltr IUf9I'l)' or mtdiul pnKtOJll'S

70- 100 IKOIHk; 400-500 It(onds ruing

(oronary byp.ID s~

Used to mon~or heparin phi!Tllalllltrapy

lS- 351K01Hk; 15- 2 tim6

the prl'uutmmt vlll~

Hi91I'i1Iu~s indiute' risl::forblttding

,nd thit ~Iin OJII' may IItI'd to iN'
"".~
Hi91I'i1Iu~s indiute' risl::forblttding
,nd thit htpilin OJII' may IItI'd to iN'

.-

h~than

"'.~

Used forgentral di~oI ro.llJUlation

1--9 minLl6 (fommn)

lISfd to monitor heparin or LMWH

phannao:OIlltraP1 in pa~mts with hrparin

O.l--{l.7 intema~onal
0.4-1.1 intema~onal

un~"ml for
un~shnl for

long blMingtimt may ioditatea low

platdet (ount or antic:o.gu,nt thn"iP1
htpirin;
LMWH

l6istalKt
Platdetaull
Prothrombin timl' (PT)

Thron"bin ~m~

Part of a (ompltl~ blood IOIIlt

~ to monitorwarfilrin tlltropy
Used to ~!tS! for fibrilKl9ftl dtfitiffiq;
may iN' lISI'd to monitor ~ffta~\.I 01
heparin phi!Tllalllltropy

Hi91l'i1luts indiute , risk for blttding

ind that htpirin or LMWH do~ 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;

2.5- 3.5 toplMnt mtrial thrombosis

Hictll'illue, indiute' risl::for blttding

ind that anti(~t do~ mi)' I"ftd
to iN' rttlotrd

Il-1S SKOnd!

ProIongtd vlllU6 may (1((\1" with

htparin phirmiloihn"iP1

"Coaoglbtion valU6 all' alwi)' s ilKi'liduaiitd for ~ach patimt.

COMPLE MENTARY AND A LTERNATIVE T HER APIES

Garlic for Cardiovascular Health
G.irlic W/ium lOfivum) is on~ oftllt besHtuditd hrrbs. StI'er.l1 d~lI'ntsub
ltanG'S, known ~alJiacrouf oil!, 11m iH'en isobted from garlic: and ~own to
haY!' pharmacologic ,,,Mly. Dosa.gt forms in{kIdt ~ting PlI'paft'd garlic: oil or
the ~h bulbs from tilt plant
Modtm (bims for garlic: 1M! haY!' forused on tilt IiIdiomtubr ~t~m:
tll'abntm of high blood lipid Ir~1s, athefOsd~rom. and hypert~nsion. Othtr
moderndaims ill' t~t garlic: 1I'duc:~ tbxI gluc:OIt IeYeIs and has antibacterial i nd antirotOpl.lIIic: activit)'.
Likt m,ny othtr IUppltm~nu. garlic: liktly hiS OI"IIt hNlth iInItfits, but
(omroll~. stitmific studies all' ohtlliatking ,nd the l6uh! all' mnm.Garlic:
hiS bun !hown to de<~i~ tilt aggll'9'lDon or"nic:kilH'''" of platelet;, thus
pnxkKing an intKoagubnt rifed (R,hman & ~,lOO6). Thm is !OIIl~ 11'stan:h to Ihow that tilt hMl hils a !mall ~lfed on ~ring 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:oagubm mrdiutions lhould limit their int,kt of garli( to a\'{lid bltrding (ompliutions. Oia brtic: patitnu lhould monitor their blood glut<M IMIs dostl)' if
taking high dos6 ofg.Jrlic.

in a vessel, it often grows larger as more fibrin is added. Artrrial thrombi are particularly problematic because they deprive 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.
Pieces of a thrombus may break off and travel through the
bloodstream to affect other vessels. A traveling dot is called

LibraryPirate

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. Patients with indwelling catheters and mechanical heart valves
are susceptible to thrombi fonnation and frequently receiw
prophylactic antiooagulant therapy. Thromboembolic disordt'rs are the most oommon indications for pharmacotherapy with coagulation modifit'rs.
Bleedingdisorders are characterized by abnormal dot formation. The most oommon nonhereditary bleeding disorder
is a deficiency of platelets known as thrombocytopenia, which results from any oondition that suppresses bont' marrowfunction.lmm unosuppressant drugs and most of the medications
used for cancer chemotherapy may cause this oondition.
Hemophilias are bleeding disorders caused by genetic deficiencies in specific dotting factors. Theyare typified by prolonged coagulation times, whim result in persistent
bleroing that 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 hemophilia have this type. Hemophilia is treated byadministering the absent dotting factor and, in acUit' situations, by
transfusing fresh frozen plasma. yon Wiliebran d's di s~ast (vW D) is

Choplfl 21

Drug; lor CNgutation Olsord<'"

373

TABLE 271 1 Mechanisms of Action of Coagulation Modifiers

Type of Modtflcatlon

Mechanism

i'rrm.tion ofdol formation

klhbilion of spKific: doIting factors

klhbilion of plitelet actioos

RtrnoIril of an aistilg dol

(lot dissoll'fd by ttw, drug

PromoIion of dot formation

klhiJition offilril dtstruction

H OME

&

COMMUNITY CONSIDERATIONS

Patients Taking AnticoagulantTherapy

The drugs gMn for(OiOjulitioo disordtrs require inteosiY~ patient education.
The Pitient is it a high risk for ~re blffiliog romplimions. The nurs~ must
(onsider the eduutionallMl and ability oftht patient to understand t~ im
ponall' of following ho~ mtdication instructions. To ensure that alltwk of
b ming <iI pobiitios i", awrn:d, wrino II, "friba t .udiO/Yiwi t.nd domoostr~

lion mflhods of patieott~i(hiog 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 btcaus~ of agt,rog'
nitiYt impainntnt, or Stll\Ol)" impa illlll'n~ 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.

:::::ft~'O"

An~plitelet

ThrOOlbolytic:
1Itm01iitic:

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. Patients 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 Pha rmacotherapy

with Anticoagula nts
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 concentrate as weU as desmopressin (DDAVP), which promotes the
release of stored vWF. For the most severely affected patients, plasma products containing vWF may be required.

27.4 Mecha nisms of Coagulation

Modification
Drugs can modify hemostasis by four basic mechanisms, as
swnmarized in Table 27 .2. The most commonly prescribed
coagulation modifiers aretheanti(oig uiants, which are used to
prevent the formation of clots. These drugs can either inhibit 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
th rombolyti(!, 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. H emostatics are used to speed clot formation, thereby limiting bleeding from a surgical site.
To prevent serious adverM' effects, pharmacotherapy with
coagulation modifiers is individualized to each patient.

LibraryPirate

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 anticoagulation is heparin. H eparin acts by enhancing actions of antithrombin III . Antith rombin III is a protein in plasma that
inactivates thrombin (and several other procoagulant enzymes) and inhibits coagulation. Within minutes after intravenous (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 similar to that of heparin, except their inhibition is more
specific to active factor X (see Figure 27.2). LMWH s are parenteral anticoagulants that possess the same degree of anticoagulant activity as heparin but have several advantages.
Their duration of action is two to four times longer than

374

UnII4

TABLE 27.3

TheC.,dklv.sc:ub,.oo Urinary Synem,

fondapamUl(Arillra)
Go)

Anticoagulants

Drug

litpam (HepIock)

Route and Adult Dose (max dose where IndlcatOO)

s.""".~,l.; W'. ~,"~" ".. h"'~ ,.

~'''''

Adverse Effects

~.".""''''~';~''''-''''

QMmi<I (fmdopaioox)
HemooIl.~

1'1' iofulion; 5,<KKI--40, 000 uriulda,

anaRh)'!aQj (b~rinl

' '.

SubartaOl'OUS; 15,llOO-lO,<KKI un~s bid

Q warfaril (Ccunadinl

PO;2- 1511l9fday

LOW-MOLECULAR-WEIGHT HEPARINS (LMWHs)

daltrpam (FrollJOill

Subcu:iOl'OUS; 1,sOO-5,<KKI unilslday for 5- 10days (max: 18,000

iOll'rnatiooal unijsld.,)

fflJXiparin (Lamm)

Subcu:iOl'OUl; 30 mg bid for 7- 10 d.,s

tiIz.Jpamlinl'lOlltp)

SubartaOl'OUS; 175 un~sIkg dlily for itlwI6days

Mioor blm!ing. nolllM, K>miring. hmrorOfflll,1ooJ (Xirr. fmr

HernooIli~ Ihrom!!!!m~nia,1!i!!lmol!mia

anaRh)'!illis

OIRECTTHROMBIN INHIBITORS
ilgitrob.!O (Aw.II,tlo'muo)

l'I';lllKg~n

biYairudil(An9omax)

1'1';0.75 mgIkg initial bolus loIloftd by 1.75 1IHJ11!g,t! lor 4h

dtsirudin (lprivask)

SubrutantoUl; 15 mg bid lor9- U d.,s Imax:80 IIl9fday)

1'1';0.4 m9 initial boIuI (mal:44 mg), follllYlfll by
0.15 1IHJ11!gl1l (max: 165 mg,t!)for HO days

Itpiodo ~OOan)

Imu: 10 IIKgl1!glmil)

Fwtr,1I<RIIf4 ~11t,,(sm Il'liorn,Mpoli(.irmt1l~miIor

bIfflfing. bkflQj~ (bivoltudn)

XriOUI inlemal

~morrha~

Iloiio irolirn. <OI!IrroJIl advmot d'IU;lIIIIIaIiniIIi/irolirn.. ..nw. .dm.. dfHt .

WQri~rio

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 response 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 thrombocytopenia. LMWHs have become the drugs of choice for

LibraryPirate

a number of clotting disorders, including the prevention of

DVT following surgery.
A third class of parent~ral anticoagulants includes direo;;t
thrombin inhibitors such as lepirudin (Refludan). These
drugs bind to the active site of thrombin , preventing the formation 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 obtained, usually one and .a half to three times the control
value. The thrombin inhibitors have limited therapeutic
uses. Bivalirudin (Angiomax) is administered in combination with aspirin to prevent thrombi in patients lUldergoing
angioplasty. Argatroban {Acova, Novastan ) and lepirudin
~re imlicaTed for preven t 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 approved in 2009 to treat patients who have a congenital deficiency of antithrombin Ill. These patients have a high
incidence of blood clots, especially DVT. Antithrombin
(Atryn) is unusual because it is obtained from geneticallyengineered goats. The goats are engineered through recombinant 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 thromboembolic events in hereditary antithrombin deficient
patients.

Choplflll o.ug, /0, Coagulation Ol1Order,

p,. Prototype Drug

I Heparin (Hep/ock)

The rapeutic (lass: Anticoagulant (Parroterol)

Pharmacologic ( lass: Indirect thrombin inhibitor

ACTIONS AND USES

Heparin i< a natural 1Uj)ltlnCt fouoo in tht liYl'l' aOO in th~ lining ofblood YeS1eIs.1t; oormal funuion ~ 10 prolong coagulation timt, tlltfflly prev!'nting HCffiiYt doning within blood YeSlI'k. As a rtlUlt, heparin prev!'nt; lilt
tnlafgemtnt of ~xi<ting Got;.J 00 Ih~ 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 activity.lh~ 00Id of action for IV h~parin i< immedialt,
wht rw \Ubculiln~OIJS 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 t~rin indudt DVT, pulmonuy tmboli<m, unstablt
<lngin.J, ewlYing MI, and ,rt"ltntion of Ihrombosi< in high-risk palimn.
ADMINISTRATION ALERTS
H~parin i< poorly .hI".brd b)' Ibr(~ mil""'" """"I'#of "pid 1IIP,.boIi<m
b)' the IItpatic tIIlylllf ht parin.tll'. Thtrefore, it must tie gim! ffllltr subMantOUsly or th'0U911V bolus injtaion or coolinuous infusion.
Whtn gjying IV IItpam,a wtighl-bmd oomogram may tie ustd.lh~ hepa rin nomogram synmr calculales lilt appropnatt heparin doI~ using palienl wtigh~ ,PTI IIIIUI', ,00 dinical iooication for tilt drug (t.g.,
~p-Yl'in thrombo!i~ 'Mt coronary syndromt).Ih~ UII' of the nomogram dtcrmes the ""net of medication calculation tlrors aOO for omor uncltr -tlltraptUlic doses.
Whtn admini<ttring IItparin subcutl otOWly, Ot"Il'r draw biCk the syringe
pkmgt! 00' the ~It has tntmd the skin, aOO nt"l~r massage the sile
,fter in~(\ion. Doinglithercan ronlribur~ to blt~ding or tissllt diJllilge.

1M administration i<cornraiOOicaltd dllt to blttding risk.

PlI'9na"'1 caltgory (

PHARMACOKINETICS (SUBCUTANEOUS )

ADVERSE EFFECTS
Ab nomal M~tding may occur during IItpa rin tlltrapy. Should aPTI becollll' prolonged ortoxicity ~ obsmtd, stopping tilt infusion wilill'sult in dimini<htd
anticol9Jlanl oajyity within hours.
Contraindications: Heparin lhould not tie admini<w~d 10 pol~rns withac~
inlf mM blt~ding, blt~ding di<ordtll, s~re hyptrtmsion, II'Ctnt lrauna, inumarial htlllorrfrage,or bacterial moourtiiti<. Htparin~OOucrd throllbocytoptnia (HIT) i< a s~rious complication Ihat ocrurs in up to ~ of patitnt;
IiIking the drug.More s~re symptoms usua I~ apIINr aft~r S10 10 days d therapy, thIS, freqUtnl blood Iabor.llOry I~ting should tie coOOucttd during this ptriod.Athough thrombocytoptnia UlUally Itad! 10 HCffiiYt bl~~ding, HIT causes
the opposite efFect: an ;,eTNSt in aawll' thrombotrnbolic t"I~rnl. Tilt ~at~nl
may exptritoc~ lI'fious and t"I~n liflo-thlN1~ning thrombolis. Although the
half-life oflltparin i< britt it may IiIk~ <I ....,.~k afr~, 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
Drug-~rug:

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
SfrIrn~andtrigl~maybfdffiMtod.

"-

Herbalifood: Hemal qrpItmfnts that may aflKI c~ such ~ gingfl;9ric.

!P"!M te.J,fnmlW,..- ginkgoWUd bf.mided bfGlw Ihfy mayiocflW' them

Treatmfnl of O"ft'rtiOSf: If s~rious hemorrhagt oca)~, a sptCiIic anla9Oni<~

protafrilll' sul/alr,may tIe<ldministmd IV (1 mg fortvl'ry 100units ofheparin)
10 lII'ulr.1l~ IItparin's .JOtica-agulam acrivity. Protimilll' sulfal~ hal.JO Otll'\ of
iCtion of SminUl~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/}

Ons~t: lO-Wmin

Pto.k: 1 h
Half li~: 90min

Duration:8- 12 h

ORAL ANTICOAGULANTS
The most commonly prescribed oral anticoagulant is warfarin (Coumadin). Warfarin acts by inhibiting the hepatic
synthesis of coagulation factors II, VII, IX, and X. Often, patients 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. PentoxifyIline reduces the vlioosity of red blood cells and increases
their flexibility. It is given to increase the microcirculation in
patients with intermittent claudication.

LibraryPirate

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 especiaU)"at rislc. Specific antagonists may be administered to reverse 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'rfering with platt'let aggregation. Unlike the anticoagulants,
which are used primarily to prevent thrombosis in veins,

"

376

UnII 4 'It" C.,dklv'l(ub, .nd U,'nary Syne<m

,.. Prototype Drug

I Warfa ri n (Coumadm)

Therapeutic (lass: Anticoagulant (oral)

"

Pharmacologic (Ias~: Vitamin Kantagonist

ACTIONS AND USES

Indications for wuf.rin Ih!'l"py indudt thf pre!'l'ltion of (riA. MI. DVT nd pulmonal)' !'I'Ilbolim in patirnt; undtfl10ing hip or kn~ sUIgrI)',or in thosr with
Iong'le,m indwelling (rn!!.,1 '/eI'oIM cathrten 0' prosthetic heart al~. The
drug may he gil'!'llio prnem thromboembolic ~nts in highrisk palienlS following an MI or oWl .trial fibrillation ~sode.
Unlib- with hfparin, thf anticoagulanl actMI)' of warf,rin (.In tab- It'Iml
days to ~aoch its mnimum rife(\.Th~ 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 S)'nhrs~of {Ioning fmon II,VII,IX.andX ~dimini~rd.Bause
I~ (loning faaoo a~ normally cirrulating in the bIood,it tab-ss~r<ll days
for thfir plasma Jto/els 10 fall nd for the 'nticoagulant rflKt of warf.rin 10 'Jr
pear.Another ~a;oo 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 ~ar~s from 110 10 mcg/mL,IO .{hie'le.n INR
HIlii' of 2.0 10 3.0.
ADMINISTRATION ALERTS
If liil'th~.teling bleeding O((UII during th!'l'apy, the anticoagulant ef
il'cts ofwarf.;n (.In he rmlKrd by 1M or subcut.neous .dmin~1r.llion of
iu'ntagon~~ vitamin K,.
Plf9nanq categol)' X

ADVERSE EFFECTS
The most Sfrious adYl'fII' rffKt of w.rfarin ~ ,bnann.!1 biffilifl!j. On d~(ontin
uation of lher,py. thr ,ntico'lJll.m oKtiity of warfarin may pell~t for up 10
10 days.
Contraindications: PnienlS with ~(~t trauma ctiYe internal bleeding.
b~rding dilOrdrn, intraocranial hemorffia,gt. 1t'I!'I'I' hypen~1io1l, bactt rial en
domdit~,or Il"I!'I'I' hepatic or renal impiinnenl4100ld 001 take warfarin.
INTERACTIONS
I)ug- l)ug: EnM~'II' prolHn bincing is Jl"lpon~bIt for nlrni'lOUl dr",--1Irug
inll'liK1ions, ilWdiIg an ifl(ffUd efIKr: of warfarin wfth aIutIoI, H'iA Ill, d~
5SRII and other ... idi>prf!Unt~, SifloidI,nibicOO and oonel. [00, 9 warli!rin
merapy, iIIf pititnt !hooId not taI;~ iIII'/ other prmiption or OK d!:ugI oolels

awowd byillf hmh (,J~pro'Iid.

lab TI511: Untrlown

HerbaVFoo:J: lMof wirfarin with hIom.l w~!>wm oISgf@l'l1m,gngo,

fHerfew.garlK. UiIlbfrI)'. chamornie, and gingH may iKmsIo 1M rill: of blHding.
Trmtment of Omdow: The s.petitK trtat~t for 0'I!'I'd0M' is oral or par
entml admin~mtion of vitamin K, When .dminill!'l'l'd IV, vitamin K, (.In~
~efll' thf 'nticoagulant efftcll of warf.rin with in 6 houn.
_

JIIMyM1t<.logKlrft1t. MI<Ing PrlXP!Mtf '{iH~ "'1M droiJ-

PHARMACOKINETICS (POI
Q,wU-7 dqs
PNk:0.5- 1diys

Halfliil': 0.5-3 days

D.!r.tion: 3- 5days

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTICOAGULANT THERAPY

Assessment
Butline assessment prior to .dministration:
Undmtand the ~.!On lhe drug has heen p=ribed in order to ust'Ss for
lhe,apeutic efHcts (e.g, p~tion olthrombosis from developing wIltn
phlebitis is p~~d.
Obtain a (ompitte ht.lth his!ol)' induding urdmasrular (induding HTN.
MI. he.n f.iu,,).nd penphf,,1 ~al(ulardiINM' (induding
Ihrombophlebiris). ~r"ory (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< ~hility af
. ko .... lism or pfl'gn'IIC)'.Mkwornm of ~nrual.ge.bout length and
heavinessof uSlaI mrrntrual flow. Obtain. drug h~101)' inW:ling allergifl.
rurrflll pre!(ri~ion . nd OK drugs. he!bal pr~r"ion~ and .kohoi lM. ~
.~n 10 possible drug interoKtiorn.
Obtain bmlilll' wtight, vital signs, KG (~ ippropriilt'), .nd bre~h 1OUnds.
MIeSI for p~II'Ke, ~il)'.loution 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), ~nal .nd liYer function studifl, .nelial blood
galeS (ABGs) u.!pproprinl'"nd lipid profilei.

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Pote ntial Nursing Diagnoses

P,in (malrd 10 Ihrombos~'nd lessrned p!1fusion)
Intiftcu...e Tissue Perfusion (~I.ttd 10 dtc:JNlrd cill::ulation in afftcled
.~I

Impiirm Skin Integril)o (in IoWl'reltrrmitifi ~latrd 10 intffrcti...e tilwe

perfusion)
Anxiety (~lalt'd to possible hospitalization, ufl(ertainty Ut'tr mioUllII'Is of
illlII'Is)
Delicitnt Knowledge (drug lherapy)
Ri!k fo, Injul)' (blerding. ~1'lrd 10 .a.efll' eifKtS of .mico.gJI. m
therapy)

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTICOAGULANT THERAPY (ContkluPd)

Asseument

Pot. ntia l Nu rsi ng Oiagno$U

Assessment tllto _ghout IClministrl tion:

ASSfts for dtsirtd thm ptUtil: etf!<ts (e,g.,uu of phlebitis exhibits signs of
impJOVtmenl witfl oo IJIllplOms of lluorN:losis formonion;signs ~ nd
symptmlsofmtingthro~showgfJ~linprolll'lllfntt.g., ~

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, htm~rurii, bli<lItifJY stools, Iul bIttdi~ "colfeeground'" emesi!, 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 piin, .~uollbdomitlal wall
SWf:Hing or fimmtls,. klmbil pain. ordrtutd ~ 01 (onsciousJlfSS.
Planning: Patient Goals and Expected Outcom.-s

Thf JNl~nt wiD:

Experimte t!lef.pMiI: tfi"tS dependent on tilt rtason the drug is being glvtn (e.g., PJM!ltion of thrombo$is or limit~ mellSion of elisting thrombosis).
~ frt(! fulm,or tl~~JlCf minim.l~ idvfrw effects.
VfriNlizr In undmtanding oftht dfU\l's USI!, .!ivtrwritS,iIld rtepJi~ p~uticm.
D~JlIlr.Itf p~ ~.6minis\J~ion of tilt lIII!'di~tiorI (t.9.dow.timir9. whfn \(I JICIlify pto"rider).
Impl. m. nt ation
Int. rv. ntl o ns and (Ratlonal u)

EJICOUf~e wty imbuillion posto~fltively in the IIo5piu~zed

patient Ind
if tilt patient is on be1:iftSt or has ~rnile1l
mobility.l't'rform pusie ROM in JNtirms wIIo i~ unatw to ~rm oIctit
ROM.(Eirly ambulatioo "nd ROM plt'Otil~ ~ susis and tIvombosis
form.tion, itlsming the Mtd for "nticoagulant tbmpy.)
~ finge of motion fROM}

ASSfts tilt poIOent's lift1~ and occasions oftrol"feilMr mrodtd ItngtM of

ti~.(ProIo~ 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.)

Patkent and Family Education

---\--

Ensuring thtrlp. utic effects:

ConlinII' frlqumt asZSflH'IIb as d&riII'd earlifr for lfIerJ~utX efFts,. t'.g.
mting Irta Ii pllrbitis exhibits lignsolirnpro'lftfltnl;ggns.rd symp\(lJllS
of existng tiwombosis IIIow IJI~I impJMmellt;lrd ptriphml pUsHiIt
improWlg in qlDlity Ird YObnt'. (Am~nG help prtYtflllht bmlatioll
of t!wornbi or PfeY"lt tlisting tbrombi from inawing in silt.)

EJICOUf~t .ppropriate 6~style 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, aclw!r~ tfft'rts:

Mr:Initor fl>r s9J$ ind symplm1S of eJ{tssi'o'e visible blffiling: bleeding ~ IV
sitts,. wounds,.txttssi'o'e t(drymosis.~hi~, hmllruria, bladlt, JI)' stools,.
rt<U1 bftding. (otr~ HI'Itsis, episuxis, blffiling from gums.
hemoptySis, prolonged indIOf ht.vy menstrualllow, lnd for ocwlt
blding. (FrtqUt'fl1 .SSftsmtnt for both vistit' iIld (uh blmfing is
n~tsl<lry to pn'YCIIl htmorrhagt' and to Slillt tolrty (O(!tc\ive tn:'atmrm as
appropriatt. )

To ,lila, poslibl~ Iraitt)', t~IDl th~ poItirnt, folrnily, orumfrmtlM.' rational!'

for . 11 fq.JipmentiMd (t.g.,.nrifmbolil: I"'~ itllffmitttnt pJIt'UmatK
5~ntial compttSsion dmm) Ind tM M'ed for frrquent monitoring.

Assist the patient with ambuWtion postopeflllvtJ, liM ttach lICliYt ROM.
Tuch the p.itien~ firnil)', or Urt'i.jlvtf Ilow 10 ptrform p.ssivt IllM
e..1tists for p.it~rru wIIo _ ~nabIt' to ~ a(IM ROM.

Ewlt' patimts iIId coolUmrf$aboiJ: thrombosis prmIItion Iklting

t~: PfrKdK sIRlthinll!bort pt'Iiods of .mbulation,noid lining for
prolonged ~~ and iJICrtlSing Huid inuR.

EJICOUri9uht patimt 10 oIdopt a htillth)' ift'styleof Iowfll food choil:t!,

in~~ ~iw.dJnstd Ufftiflt' i nd oIkohol (onsumption, and
smoting {Kl<Ition. pfllidt in approprim {ornu~aIion (t.g.,diMitiin) as
nHd~.

Tuch tht pitient f.rniI)',OI cart'i.jlvtr ~gns .nd symptoms of t'lttSsie

blding. iJICkiding occult blffiJIng.tf mt'mll ~Ing OCcuJl"PftsSU~
OftrtM sitt should bt held up to 15 minutH. tfbletding (ontinuH,is
5MIt, Of is K(Qmpani~ by dIz:zintls Of 5)'nCQ111'. immrdiatt medial
attelltm (e.g., 91 1) should bt obt.ined.
Women of me!lsuuallgf should rtpor! mtS~ 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.

n.~ (.,d""'~uio,

and UrlNry Sy""'"

NURSING PROCESS fOCUS

PATIENTS RECEIVING ANTlCOAGULANTTHERAPY (COIIllnued)

Impl e mentati on

Interve ntio ns lind (Ra tio nales)

Pat ient li nd Fa mily Ed ucatio n

CaminlJl' to 1Il(III~0I ~ Ilbs (apn.,Pland/OIINR),CBC,and pj,Itlm.

(Thtr.peOOc aPTI "nd II !MIs "I! usu.a, 15-2.S timts the norm,,1
mnlrol Vlu,.INR is usuaIy 1- 35 014. VlOO below ttw, noon indiut~
~-tllerapeuti< ievtlsof the drug;..-aIun ~ tile noon indicatt I hisI/I
poltnti.ll for bleoeding "nd Ilemonbage.QIC, tspe(i.lt,. RBC, Hgb "rd Ikt.
Ind pIa\M!neIs ,houId lml.Iin w~hin nonnallimits.lltaNsing niue on
tIw eB( maJ ild nit tl(tS~ bkfd ing and tIw nted IlII!WSS for 1ocMion.)

inslrUCt ~titnt on nrfd to ~m periociQIJIor Lib work i nd 10 Ikn lab

ptrsonntl that .lnti<oaguLint therapy is bMg \Md.
inslrUCt tht patimtto (.IffY a .111tt identfution (.Ird orwu, medical
idrmirl(.ltion jrwrlry indic.ltmg antiCoiglMIU thera~

CantinlJl' to nm~OI ~~hmI pulws lor quality and 1'OIu!rre,.nd

mmpllinu of Ingina or(1IHr ~in.~ptci.I., if lIN or of wlldtn OIllt1 or
..:companied by dysprIu {Mon~oring b fII'W or w6dtn onset of pain is
nt<HSlf)"to ~m.urt prompt tJUtmeni of possible embolI

kh the patiml b:Il!pOrt .... J 511ddu pain in dJe~ It9s or (.II-/ts,

dJstfll'l, orllf"W-(lll\d anginll plin immediitrly.

Minim~ opportunities for i""ry or bIefdi!tg whert possiblr:.Il1Oid 1M

injection!, pmide 10ft toothbM h, iM br Cllllious wlltn providi"9 (.I~

tspe(i.lDywithedtrfy. hi"ll!' mort frag~~ sUn. (AntJ:OiIjuLims 11M tht

rill of bIding Ind Ci\MS of e'lrn minor iIIffiIiog should be MIicIfd when
possibkJ

inllru(f the patiml on ways to minimizt cwor\l,lnities b injury or

blffiling wllm pouibk:
Swikh to a softtoothbrusIJ .nd insp!!J!ms after bruslJing.
lM.n tltruic fuor if pouitlk or be (.wtious with i safttJ rnor,hoIding
prolonged pltSwrt O~
nKks.
Ik mllru witIJ food prt~rnioo,~pKiaIJ 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 ~xptrirl"lCt sUn ItilfSOI Kdrymosis
IIlDrt fmr,IentIy.

SIN.

Ooseiy Mluile .In n~w p!l!'S(riptions or 1M of Ole nwdiOOons for dIug

int~,jctions. (h\a1T1 drugs i~1.IC1 with i~Lints, inousing ~
dwnu for bleeding.AlI OT{ mediutions ron1.lining sa&yIat~~ f.g.~,
i rtcontr_icned)

inslrUCltlle patiml to consul! the heillh C.Irt p""..idtr briM liking IIIJ
fII'W prtSCripbonOl Ole meditation, inWding herbal p!tIIoltions.

Mainl.iin IIOfTJIiI dit~mding inaNSts OIdKlNIfI in YiTimin K-ridl

foods (e.g. 1jli~us,bn)(coIi,(.Ib~, CiUIifIoWl'~ uk)and limit 01
tlimillollt ikoIIoI imakt.IY",min Kis I\t(tSsaf)" foftllt sl'lthtsisol cloning
.nU. Suddtn in(rtiJleS 01" ~ in diftary intaktaf WOlin I - rid!
foodsmayi~or~the t~sof .... tir:Oi9ULinlS,
paJlKularlycnl.lntico.gulanl tMJ~~ Exe~ inlikt of iIcohol, _ TWO
drinks Pfl"diJ in mtn 01 one in womrn,mq .~t' tht ~~S afOlilI
iMicoagwnts.)

kh lilt paUmI to main1.lin a normal dift,.-roi:Iing inouws 01

dKrtases in 'liumin K-rich foods I nd lim it 01 dimi nat~ Ilmbol intake.
V"umin Kwppltmtnt~and plOTein suppiemeftl drinks (t.g..(nSU~OI
bst) thai ohm Mft itamin I .dded Ihould Iiso lit, noided.
Adrise ~titnlS to llIOid emssive inl.iktaf _1IhoI v.+.ilr on 0IiI1
iniKoagU"nts.

AsSt!.S ilf .IJIJS)'IJ\ptoms ofiwpariti1 (t.g..dirktning urine, light ordiymlored nook. ~d!y lkin,jaundicf of!der.io orskin,ilxlomioil pain rsprriIlly
in right upper ~dfim 1RUQ)) in ~tients rmiviog 0111 inticO.l!J!Linl
Wlipy. (Drug-induc:ed htpatiti1 is I possibk .dftBt' riFt of or.1
.micoagul.illl ttw,rapy.)

inslrUCl the patiml to ~

sign! of possilk! M~tm immrdi.lt~
Hpf'ciaU, lbcb!Jinal discomfort that Ioxaim to tilt Roo.

Patienl uRclmtanding of drug thmpr.

1M oppoflllnilies during idministration af medications Ind durinll
aslf1SmenI! to dis.:uss rollionalt for drug Wflp)', dtsiRdthtrapNtir::
Ol/l(omes. mosl (ommon idftrseelltm, parametffl forwben to Gil M.1Ih
art pmidtf,and.ny nKtssaf)" monitoringo, p~(lking time
cl!riog rusing C.Irt helps to optim~ Ind mnfon:r Ry Irhiog arm .)

LibraryPirate

in,

The patient should lit, Ible to state the rtuon lor drug;.pplOjlri.nedoSt
Ind S(he<kJiing; what advt!w tHfm to obsmoe for and wlltn III rtport;
tqUipment ~ as appropriate and how to 1M that fqIIipmtnt;and tIw
~ired ItrJgth of mediuOOn thfflp)' ~ with lOY sptci.ll instructions
rtgardiog II!'MWing 01 coJllinunJ presaiption as approprialt.

Chopltl 27 0nJq< /0, C~ulatloo Disorders

NURSING PROCESS FOCUS

379

PATIENTS RECEIVING ANTICOAGULANT THERAPY (COlltlnued)

Implementation
Pat ie nt a nd Family Edu c~ti on

Interve nti o ns and (Rati o nale s)

Patint selfadm inistnt io n of drug therilPY:
When administering ~ications, iflltnKt t~ patien~ lamily,or (')'t9~' in
proptrstiladministration tKhniq!le'l lollowed by retum dtmoflltration.
(PJOptr drug administration inaeoMl tIlr rifectiY!'nrss of thr drug.)

'!radJ thr ~irn~ 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 ~ilin~rtKlilla90~ilnglt.
InjKtion is giY!'n withoot alpirating lor blood rrtum.
Relu~ skin and hold slight prellUft' 10 Iilr but do not m;lIUge afU.
HaY!' pitien~ fam it;, Of cart9iY!'r return-dtmonmillr trlhniqur umil
proptr tKhniqur is UIKI and they ilft'lomfortable giving injKtion.
Tralh t~ 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 H~ 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 arteries. 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 profou ndly in-

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

TABLE 27.4 1 Antiplatelet Agents

"n"

Route and Adult Dose (max do'>!' where tndtcated)

alpirin (ASA,am,t!Ntil1lk add)

(w pilqt 230 for the PJOIOIypt Drug

PO; 80 mgldly to 650 mg bid

lJl(rt~~doItim t'!!!.!l!

" ~I
d~rnoIt (Pmantinl'j

1. ."'-_....., .;.
Adver'>!' Effects

blsmm !~m:inl

PO; 7S ~ 100 mg qid

(US cffeas ltipyridameJlrl anaphylaxjs

~

D~ abdomin~lpoin.'fflI. ~OO d~rrIIN

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)

D~dzzinru,ponQInjtio~fite,

rplilbilidr (htt9'i ~n)

IV; 100 mlgi1l:g in~ial!QUI om 1 ~2 min;thrn 2mlg/kglmin for 24~ 72 h

Hrnlorm~, 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

hyporen5ioo.b~ mioor/llttdllg

AGENTS FOR INTERMITTENT CLAUDICATION

dlollolzol (PlmtJ

PO; 100 mg bid

pentoxifylilll' (Trentalj

PO;400mgtid

D)5p('pli4IXX1SfG, 1'mli00i dzzinru,

ffl)'Qf9io, htodacht

Tam't(,Jrtli ind polpit.J1iom lsilostazoll eNS

Mt

~ff~! Il!t!!toxib:!i~ 1 ~a'lfilit!ll'

Ir~1kl inootr ammon ~ rIf~(\~.IIIIIIt!Iiniu inticatrs IMOIIS adw-rw eflKr:~

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380

UnII4 TheCJrd kIY.",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 anticoagulant activity is well documented. Aspirin acts by binding irreversibly to the enzyme cydooxygenase in platelets. This
binding inhibits the formation of thromboxane A" 3 powerful inducer of platelet aggregation. The anticoagulant effect of a single dose of aspirin may persist for as long as a
week. Concurrent use of aspirin with other coa gulation
modifiers should be avoided, unless approved by the prescriber. Aspirin is featured as a drug prototype for pain relief in ch~pter I SCOO, ~nd i. also indica ted for prevention of
strokes and MI in chapter 2500, and reduction of inflammation in chapter 3300.
The ADP receptor blockers are a small group of drugs that
irreversiblyaher the plasma membrane of platelets. This alteration 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 patients 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 recep tor 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

Glycoprotein li b/lila is an enzyme neces.saryfor platelet ass rega tion. These drugs are used to prevent thrombi in patients experiencing a recent MI, stroke, or percutaneous translwninal
coronary angioplasty ( PTCA). Although these drugs are the
most effecti~ 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~pies for myoc~rdi~1 ischemi~ are benefici~l 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 muscle. Pentoxifylline also has antiplatelet action. Cilostawl
(Pletal ) inhibits platelet aggregation and promotes vasodilation, which brings additional blood to ischemic muscles.
Both drugs are given orally and show only modest improvement in IC symptoms. Exercise and therapeutic lifestyle
changes are necessary for maximum benefit.

AVOtDtNG MEDtCATtON ERRORS

A b~ut-ffflling mothtr dMlops thrombophlebit~ W,rf,rin (Coum,din)
2 mg onc:~ , day isordmd. What shouklt~ IIJrs~ qutStion ,boutthis order!
Sir .I{IfItndIrO ibr /ht54!gqtlUd_.

I Clopldogrel (Plav/x)

Therapeutic Class: Antiplatelet drug

Pharmacologic Class: ADP re<:eptorblocker

ACTIONS AND USES

CIopidog~1 is indic,lIfd for th~ plI"'ntion of throm boem boIK eYl'n1l in palients

with a f"e(t m hillory of MI, CVA, or pfflph~r~l ant rydimll'.lt is ,Iso approYed
for thrombi prophyluis in patitnts with unll,bIe angirw, induding thOll' who
a~ f"e(eiYing mrul,r bypass pnx~rures or 'ngioplasry.lt m<ly he gi!'n offl,btl to p~t thrombi formation in pillienll with (oronary <I n~ry IIt nts, <I nd
10 pre't't'nt postoptrativ~ dt~p !'in Ihromboll'S.8euUll' I~ drug is rlptnsiY~,
it is usu,lI~ pl"rl(ribf<i for pillients unable 10 toler.lte Hpirin, which h" similar
anticoagulant "tivity.lt is gWtn orally.
C\opidog~1 prolongs bleeding timt by inhibiting plolelet ,gg~9ition direaly inhibiting ADP binding to its f"e(eptor. This binding is illl"'rlible ,nd I~
platelet will he ,lfenfd for the ~l!Iiindtr ofits life sp,n.

ADMINISTRATION ALERTS
T,blen should not he {Mh~d or split.
Discomin~ drug" Ie"t Sdays prior 10 surgtry.
PrtgnallQ GIItgOry 8

PHARMACOKINETICS (PO)
Onset: 1- 2 h

!flU h
Halflife:8 h
Durat ion: Unknown

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ADVERSE EFFECTS
C\opidogr~ is gmmlly welllole"ted. F~u~nt ao:i!'lll' elfem indudt flulikt
syndroltK', headach~, diuines, and rHh or pruritus. lib> other {oaguLllion
modifiers, bleeding is a pol~mial adYffiee!'l1l
Contraindications: C\opidog~1 is (onmindicatfd in p,tieot; with <Ictm
ble~ding.

INTERACTIONS
[)ug- [)ug: LMwith arIir:~B,othfr 'n~"'lqnB, thrombol)1ic: ~
(f NSAIlS, 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 inhilitOl\~n, W!apiIIIIi ,(f Zift!ltast may diminish

tIN> i ntiplilfk>t aaioos of dJpidoIpl.
Lab Ti5ts:~rtI prolongs bIKoIing tiM.
IkorballFooo: Herbil ~ thilil!l'(I {\ligWtiCIl sum H lfflIfl!W,~
IN,ginigo,tish oiI, ~(f 9iricl!li)' ilmN tIN> rill: ofblHdilg.
T~tment

of OYerdOll': In mrs of poisoning, plotelet transfusions may he

lIe{rss.Jry to plI"'nt htmonhagt.

RtI'tr 10 MyMIsJrtgKI tllf Q MnJrJq Pr~ fooIl spK1It 10 IIrI! Ituq.

0\0p1IIf 'U

NURSING PROCESS FOCUS

Dnq; for eo..gul;otlon DI5order,

]81

PATIENTS RECEIVING ANTIPLATElH THERAPY

Potential Nursing Diag n05U

lIawoIin ~ ISS6wmnt prior 10 ad ministration:

Undel5undlbt JNsontlWcWg~~nlftl(ribtdinordeltoassmlcH
therlpMK ~fItS (~.g., dtatm risk of dtwloptntnl of(vAund Mil
Obtain a {omprl~ htalth hislOfl inWcling unliomaAir r..dJding HTN,
MJ, PICA witIJ Slfllt plac:tlllflll} and lWfiphrfal "al(uLv~, r~1Dry
(indlding prt'fious pull!IONf1 tmbolisml. lltUlOJogK (indudinglfttltl
head injury and (VA}, hrp.Iit 0111'1111 d&u~diabttn, ptpIK ukef1istI~,
hyptf(h~ttllllrmia,and 1M pos~biky oIakoholism or pll'9nalKJAst
WOfllfll of mrnstnJll.gt lboul tht length.nd htivinffi 01 USUII menltnlll
flaw. Obt.in. drug h~tory irdodiog i~rurm1t pRSaiplion ind m(
d~ hffb.JI p~ratioM, ilnd akohol-.BIo alen III pouilll~ drug

IrwfFtaivt TISWt hflusion (lriitted 10 llratiSed dmJlilian in afltcled

~.I

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 anlipLr~t t/wrapJ)

intefauioM.
Obtain bilfliM Might, lUI signs, ECG (if approprior~j, DI bll'olth sooods.
"'iel for plI'Wn{e, lJloIity, Ioution of.ngina, and fOf pmfII{t of ~a
or{1Ies1 ~Alsell exlttemities for IYmpIOmI of Ihrombophltb~is (t.g.,
wirmth, swrliing.l~nclrmel in (al( positM /loman's ~n) and for Iocmon
arJd dlirmnh mounl 01"'1, if pll'WnL
halua~ .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 iI~nllttltion:
ASies for dnftd IhtflpMK &b (~.g., no symp!!lm! of thrombM
fonnalian).
CoI\tinut periodic ntonitoring of ilPPfOPri,l~ lib v.kIts (t4-, (Be, plill'leH,
bleeding tirMj.
A1sessbr~~OOlingfrornIlptltWDUndlirn.~mosii,~,
e,ilulis,bitfdng from gums, ind for oo:wit ~i~ sudlill pallo~dWiness,
frrpc:ttnsion, !iJCh)'!'lrdia,abcbminal pain,_111 d abdomirwl wal swrIingOf
firmlltlS,Unbir pain,Of clrmlltd ~d lDnI(ioo\ntss..

Planning: Pltlent Go a ls 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 minima~ iClftrse ~Ifu.
VtrNlizt 1ft Ultdtl5l.nding of the drug's lISt, .ltftrse tfttI, lod ~ preuutiolls.
Oemonslralt proprr !elf-admiration of tht mediGltlon (~.g"~ timing. whtn to notify pnMdrr).
Imple me ntatio n
Interventions and (Rationa les)
lMurlng thttlpeutlc tfl"tm:
Contin ... ;mc>>mrnt> '" ckscribod ~.rl;"r Icrthoropoubc clkru,c.g. no
symptomscf thrombotK moio:t;signsand symptoms u to 9isting
pmphtlli. run. IinsufliUrncy show gradual im PfQftmen~ wd1 as
pll'ious ptriphefal ~ pain bas ~hed or & ~linin.ted;OI"
pmpht,,1 puMs all' imprll\'ing in IJloIIiIy DI mumf. (Antiplitelel: drugs
hrlp pll'Wllt the formatXJn of !hromb~ panirularly in 1M ilntriorlsJUml.)
EIKOUfilCjt .ppropriatt IifrstyIr {ilangH.J'rooridt for rlirtitian {onsdtition II
n~ed. (Smoking illUNseI platrlrt ilg9ll'9ilion and promotts the
fonnation of thrombi. Hulthy rrftstylr dwngts will suppon and mininm
tilt nted fordrug tIltllp)'J

Pa tient and fami ly Education

k.o<h pil!ionts of d""",,,,,, .,..,ptom. toot..cn.: for,ckpmclrnl on Ih~
II'lIOn thtdrug bas bftn ordtmI (~.g. 5UdcItII onltt of klltss
tlftiog onr sicIr or limb [CYA[; mid, p.r Ie txmmit-; witbouI: pmphtll!
p.rIlotI [mm.locdusion)).

Encourtg~ Irw p.rtiflltto ~ a htalthy ifrnyIrof Jow--bl food dJoim,.

~ t~lnd ~II'I~ {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)

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NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTI PLATELET THERAPY (Coo"'"""

Implementation
Potient lind Fomily Ed uc;.ation

Intervt oti o n5 l1nd (Roti onoles)

M.,imizing.dWl'lt tffem:

Monitor 101 signs and symptoms ofbftdirg: oozing allY ~lf5 orwounck,
tcd1ymosis, peted1~, herMurw, lMc:~rry stools, rffiil blmling."wffttground ftIlf~, tpinuis, ~n9 from gums,. prolongtd lind/or ht.wy
menstNoli flow, ~nd fOf occult blctd~SU(h is pillo~ diuinesl,
hypot~ion, tach)'Cilrdi.l, abdominal pii", a~H of abdomilllli wlIll sWI!lIing
Of firmllffi, "'mbar plIin, Of deutllsed kvtI of (OIIKiousne5s, (The risk of
bWding nom IIntipialflet thtrllpy is not as ~\Iett u it is for i1111it:CWguI.UItS.
but it lllouid be monitored while tilt paticflt is on .ntip!attlet thmpy.)

jnduding IX(UIt bletding,and 10 I!port any (onctnlS to the health (ill!

plOYidtr prompt"'.
Womffi of m~nstrual iI9t should I!port 9(t!sr.~1y h~avy or prolongrd
mtnStruaI blttding olACI kttp oJ ~ <ount".nd I!port to tilt hNIth <al!
plWider.

(onlillucto monitor I.Ibs,.imWing(B<, pIatt~l,and lipi;llrvtb.I(8( al!d

pl.Jleltt ~ shoold I!main within normal ~mits.MatTf patients wid!
lIneNI dirusf ha~ COOOIrTrot lipid disoldm lind may need .ddition.1
trtllttMnl ~1I5ing nUts on tilt (Be may indicate mesiw blefding
lind the need 10 HIeSS for IoutioJl.)

Inslruct the patieftl on th~ 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!: th~r.lpy.

CDntiftut to manitOf ptriphffill polit! for quality and 'tOIum~, <Dmplaints of

angina orchnt pain,t!ptdally if new Of of suddenonset or aompanied by
dyspnN. (Monitoring for ntw or sudden OI'Istt of pain is ntmury to tfllUn!'
promptl1!atrntflt of possible emboli.)

Ttarn tilt patiffit, family, or uregie- to I!por1 oliff sudden pain in dlfU,
Itqs, or (.~;~ta;or new-olllet anginal pain immtdiattly.

Miflimize oPPOftunitin iof injJ!), or bietding when!' possible: avoid 1M

inje<tion!" pro'IicR ~ft 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.)

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,erptd.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.

(iostly ffiluate iIIl new pmaiptions or list of Of( mtdicatiom 10, drug
interactions. (Many drugs intelitt witlr antipla teltts. ill(ltuing the <hall( t
for ~ing. AII ore mtdkatiolll containirlg uJicy\ate!"e.g..l5pirin,and
NSAlDs.e.g.. ibuprokn, should not bt taktn unlts!othtrwist ordertd b,. a

InltnKt the patieftt to (l)fllUlt the health <alt plll'o'idef belon!' taking any
ntW pn!'S(ription or OlC Illfdiution, inWding Mrbal ~atioM.

Team tIM! patitnt OfCilrtgrm signs lind symplDrm of tllCtSSivt bftding,

Makhu~p!OYidK)

Main\lin a nomul ~ and limit akohol in\lkt.(blrniYt intakt I;If al<Dllol.

~~r two drinks ~ diy in mu or Ont in wornttI, may aktrth~ ~ffl!Cti_1
of antiplatelet drugs and ill(rta It the risk of bletding.)
Patifllt understandi ng of drug thera py.
1M opportUnities during ildmin istlation of mtdicatiom and durin !I
ilSSfSSmcnts 10 discuss the rationale for drug thtr<lpy, dni~ 1hcrapeutic
outcomes. most (ommon adYme ~ffem, paramttm for when to caU tilt
ht.Jkb U~ pro~.nd any ne<:~ury monitoring or plt<autions. (Using
tim~ ruring nursing c.u~ Mips to OJ)timin and r~fu tty ffithing

T~arn 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 appropria te and how to lrst that tQuipmtnt;olACI tilt
~ui~ length 01 medication thflilPY ncded with any sptcial imlrvctions
n!'garding ItIltwing Of <Dntinuing presaiption as applOpriate.

a~l5.)

Patifllt \elfadmin istrat ion of drug thuap,:

Whm administering roo:Iiutions. instruct tM patim~ family,or cln!'giver in
proper stlf-adm inistration kclrn~. (PlOptradministr.ltion will ill(ltast
tilt tffecti_sof tilt drug.)

Tead! the patiffit, f.Jmily, or uregiver in proper sdf-administration

tKhniqutl.

Evaluatio n of Outco me Crite ria

Evaluaff thteffmMntII oIdM) tlltnpy by coofirming that ~t goal! and exptcttd outcomes 11m bttn mH (Sft!"Planning1.
Stf TIII!It ]7.4fDta I;.r tIdlugJ fD w/rIdr thtst IIInhIg IIl/iIm

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Chopltl 21

Drug< /0, C~u!atloo Disorder,

383

TABLE 17.5 I Thrombolytics

On"
Q

iktpli ~(AClil'ilr, TPA)

Route and Adult Dose (max dose where IndlcaU>ci)

Adverse Effects

IV; 60 mg init~11y thtn 20 mgl1l infu~ o'm next 2h

SuptrfidDlbludflgl1lirtecrionsire\ Q//ergkrHcWIIl

mtpli~ ( Rrt.lQ~) (~pq lSI

for t~ ProlOlrpe Drug box OC

IV; IOunit!am2min;ll'pmdo~ i1 30min

\U~tokiMll' (KabikiMll')

IV; 2SO,00G-15 milion !Il ~, rrm60 Rin

tenenepla~ (lNK.a~)

IV; lo-SO mg infwd um Smoods

hyptntfl~on

THROMBOLYTICS
It is often mistakenly believed that the purpose of anticoa gulants such as heparin or warfarin (Coumadin) is to digest
and remove pre-existing dots, but this is not the case. A totally 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 a nd breaks down fibrinogen, prothrombin,

"'" Prototype Drug

'jrriolll jmema( b!etding jm@mnjalbw gabage

and other plasma proteins and clotting factors. Unlike the

anticoagulants, which can only prevent dots, thrombolytics
actually diswlve the inso lub le fibrin within the dot. These
agents are administered for disorders in which an intravascular 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 permanent tissue damage. The therapeutic effect of thrombolytics 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 prevent excessive bleeding, thrombolytics have a narrow margin of safety between dissolving "normal" and "abnormal"

I Alteplase (Actrvase)

Therapeutic CI ass: Drug for dissolving dots

Pharmacologic Class: Thrombolytic

ACTIONS AND USES

ProdlKrd through rKombinimDNA \e(hnology,ak~pbseis id~ntiu Ito t~en
l)'m!' human iiiSUI' pb,mioogrn acti"ffior (TPAj.k with OIh~r thromoolytin,
the primary mion ofal~is to(OOYerl plolSminogen to pblmio, whic:hth~n
dilroirn fibrin (blS. To a(hitft muiOlJm tffKt, theripY ,hould bt<j in immrdiue~ after tilt OriW of I~mptom'. Al~ elm not rn.ibit th~ allffijic: rmlion! ~tf1 with strrptolr:inas~.Akeplas~ is a drug of (OOKf 10, t~ tl"fitmem of
evA dlH.'to thrombus and isulofd ofl-iabtito 1"1',101"1' th~ pat~ ncy oflV (athtten.
ADMINISTRATION ALERTS
Drug must btgil'nwithin 12 hounofonm ofsymptomsofMland within
1 hounof thrombotic (VA for maxiOlJm effectiYeroMt
Avoid paremml injr(1ions during alteplas~ infusion to deuuS!' risk of
blffiling.
Pll'gnancymegoryC

ADVERSE EFFECTS
The mOil (ommon adver~ effrCl of ik~pb se is bleeding, whic:h rTIiIY ouu, supertKiilly 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(hyOIOIe, ~mitomolS, or t pistu is !hoold immediately bt I"I'ponrd to tilt htalth
m r prwidtr.
Conlraindi (ations: Al~ is (ootraindKit~d in actil' internal bleeding,history of CVA within the past 2 month n!(~m traurTlil or surgery, !f"I'1"I' unc:ootrollrd hypertension, imramnial neoplasm,or arterio'l~OOUI rTIiIlforrTliltion.
INTERACTIONS
Drug-Drug: (roru~t UII' with iIl~OIIlJwnts, iIltiplatPlft . .ts,OI HSAlIlI,

inWctiIg ilpi"in, INY iOOtalf thf IN of 1iHding.

lib Tl5Is: Aktpla!e will i10Me PT and aPn.

HerlIaVFood: lN withsupplfmtnlS thitaflKr: roagw!ion sIKh olS f~, 1)IHO
IN. giok\lO. filii oil 9ioQPt 01 gric:!ohould bf a'lllidfd. ~fI(f thty """ ifl(JNI(' thf
rr.tofliHding.

Trratmenl of Oerdose: Therr is 110 lpI'{ifKtrutment for OY!'rdos~.

PHARMACOKINETlCS
Onset: lmmediat~
Peak: 5- 10 min after infUsion is di,ronoflll'd
Halflif~ : 10 min
Duration: 1h

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IftfPf III M}MJrllng/l1f fer Q Mmi"9 I'rIKm F/KJJ5 J{lt(1k III rills drug.

38 4

UnII4 Th"C.rdloY.<;(ubr.oo Urinary Syuem,

NURSING PROCESS FOCUS

PATIENTS R,eElVING THROMBOlYTICTH'RAPY

Asse ssm e nt

Potential Nursing Diagnoses

Bilsrlin e assess mrnt prior to administrati on:

Understand the INson the drug h" bft.n Ple(ribtd in ordel to as~ lor
thelapeutic tffrds (e.Cj., tft'atmem 01 MI, (VA, pulmonary fflIboI~ m).
Obtain a (ompiete heakh history induding wdiolla!(ular,ptripheral
va!(uial d~'l!e, 1~latOry, nturologic (ilKludingll'(l'nt he~ in~ry),
ft'(l'nt SUl9fnts or inj.rRe, hepatic olll'llal d~aS!',diabtt6, 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 drug~
herbal prepaluiolll,and ikohol USI'. 8l' alffi to possible dlllO interactions.
Obuin baS!'lilK'"M'ighl, vital sign~ ECG, and bft'ath sounds.AsSffi the
p,eflKe, ~Iit)o,and location 01 angina, i nd lor p,erlKe 01 d~pI)!'a 01
(hen pain. A,~ nturologic nullS.
[vawtt iaboratoryfindi~ (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 (il!hrte~anerialline).

Pain (maiN to thrombor~and ItIIml'd perfusion)

Indti"f!' flSsue Prrflrsion (lI'ia!l'd todl'CINSI'd ciltuiation in .fitl'd
'~I

Impaired Gn lu:ha nqe (pulmonary fnt bali)

Impaired Skin Integrity(in IoWl'HlltlMlit~ matl'd to ilK'fitift tilMle
perflrsion)
Anxirty (ft'lated to (ondition, hospitalization)
DerldtntK~(drugth"'ilp)')
Risk follnjury (bleeding and hemonh.9", rNtl'd to adftrw rffec~ 01
thrombo~tK therap)')

Assessment thro ugh out administration:

CominUl' iII'"",m alll5l111ents fo, thel1lptu!ic: dfr(ts (e.Cj., angina h"
diminished signifKolntly or ~eliminatl'd and ECG findings within normal
limit~ lespilatol)' l'Ifon and ABGs ,ignirKolntiy impltlYN).
CominUl' fII'"",m monitoring 01 appropriue lab vaoo (f.g., 11gb, Hct,
platelm, RBC, urina~is,ABGs).
Monitor vital signs ind ECG l"Iery lS minutes during the filii houl 01
infulion,and then ~ry 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. "roifffglound" emew., ep~t.Jlis, bftding lrom gum~hemoptYlil, ~hythmi.~
.nd lor <Karlt biffiling. IU(h ill pallo~ diuine~ hypotmlion, tac:h~ rdia,
.bdomin.l poin, ..~., of .bdominol w.lI ,_lIing or firmn ...,lumbar polin.
or drclNll'd Itvel01 (on!(iouwss.
Monitor nturologic ,taM fll'qUl'nt~, e,pecially ~ thrombolytin all' USI'd

forCVA.
Pl anning: Patie nt Goal s a nd Expec ted Outco me s
The~iemwill:

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 minimal,.rIYers.~.
Verbalize an understanding 01 the drug's uS!', ad'/erse tffrru, and requill'd preautions.
~mon,mte prop~r stll-administration olllKffi'ry po'Hhrombolytic ml'diutions (e.g.,doIf, timing. whm to notif)o plOllidfl").
Impl e mentati o n
Interve nti o ns a nd (Rati o na les)

En suring theril peut k rffrets:

CominUl' fII'"",m mesments m leaibrd 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 a~(ted 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 I~etylr (hanges will suppan
nd minimize the need lor furuft' drug thelap)'.)

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Pat ient a nd Fa mily Educa ti o n

T~oKh the patient about all p!O(NUI!"!.nd

theilllKffift)o priol to
beginning thrombolytic therap)'.
To allay anxiety, teoKh the ~im~ lami~, or (ale9i!'1 the lationale for all
equipmmt uSl'd.
Enroulolgt' the patient tompt , he.khy I~etylr ollow-Iatlood (hoice,
ilKlI'aSl'd eIItK~,decll"SI'd ufleinr and akohol (olllUmption,oInd
1I110king (e~tion. PIOYide fo, iI ppropriat. (onsultation (~.g., dietitian) aI
~

...

Chopltl 27

NURSING PROCESS FOCUS

0nJq< /0, C~ulatloo O""rde"

385

PATIENTS RECEIVING THROMBOLYTIC THERAPY (Conrfnuro)

Implementation

Inte rventi o ns and (Rati o nale s)

Patie nt a nd Family Edu cliti on

Minimizing adft rle eft"ms:

Monitorfrr~tIy for ligrn and symplomlof 9(es~ blffiling. 5lKh u
pallo~ Itypottnsion, t!oC:lryu rdil, diuines, sudlle n ~~ft' h~ad.Khe,lumb.J r
pain, or dem.!ed bel of (onsciouslll'ss. (Fft'qUent asleSSIIltnl lor both
visible and oc(ull bietodiog illII'Celal)' to Ift'/~m Ulernivr hemorrbq
and to lIan wt, (Onffiil' liNIment as poI~ble.Bietodiog risk iI elevated
up to 2 to4 dI)'lo poIHlf<llment ,nd if the pal~nt iI milintained on
antiroaguLint or amiplat~lel therapy poIHhromboIytiG.)

Allay anxitl)' by ft'aslUring the p;iltitnl and 6plainiog ralionale fo,

ift'qUtnt monitoriog.PKIYidt adeqWIt' pain ft'litf as appropriale.

Monitorviul signl and ECG rl'l'ry 1Sminutes duriog the fim hour of
infulion,and !hen ffl!Y 10 milllMl dJriog ft'IIIiinderofinfusion and lor
lilt firsl 8 hours. Report ~II)' dy! rhythmias immrdilt~ly. (Obu iniog vi,,)
sigrn frequently will ilSffi for adl'~ ~ffrm of the drug indudiog
hypoltn<ion ~nd 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.)

To allay poI~ble anxiety, team the patitn~ family,or uft'9imthe rationale

lor ,II rquipmtnl!Md .nd the rwd for frr~m monitoring.
Teach the patient to repon all)' p;iI)pit.rtion~ dyspnea,or aogini
poltinfUlion.

Maintain the patitm on bedrel and with limited ictiVity during Ihr
infulion.(Limited ph)'liul mivil)' and bedrest ~aS!' thechan(e for
bruiling, iojury, a nd bleediog.)

Provide in 6pLlnation and rilionale lhat aaivity will be limited duriog

infusion and lor up to 8 hours plsHroatllll'lli.

Mooitor neu,oIo gic: SUM fft'qUemly, especially if th rombolytiG are !Md for
CVA. (A 9Jddeo diange in neurologic: staM 0' sudden I!"',r headache ila
poIIible lign of an intracraoial bietod with inm,srd imrmanill pRssure.)

To alLly poI~ble anxiety, team the patitnl the rationile for the frequent
asl!'l!O\tnu aod pKlYidt ft'assuraoc:r.
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 iO\\ll~ proe:eduresduriog the iofUsioo aod up to 8 hours

poItinMion. (An punmr ft' site or lilt of irr;a~I' procedure will (Ieate an
additional ~te for bleeding.Whelll'Yl'l" 010 irr;a~I' PlIKedUft' mUlt be u;rd,
the ~tr mUlt be maintained uoder presore fo, 10 minutes or longer 10
prtmIt hemorrhage.)

Tu(h the patient that ~fttr aoy required procedure~ pft'lSU~ will be
maintained to the sit~ for a prolonged period oltime.

Continue to monitor lab work (Hgb, Hct, pla!~lel (ounu,and bftdiog rime)
freqUtnlly POSH~~tllll'lli.PModK CBe aod ABGI may also be monitored.
Activity may be limited duriog thil poltiofusioo time period. (The risk of
bleeding remainl high for 1 to 4 day; postinfusioo.)

Provide an opLination for the nHd for activity ft'Itriction and ~m

monitoring during this til1M'.

Patint unMrstanding of drug thtrapy:

US!' opponuoities during admioiltratioo of Ihrombolytic: thmpy to explain
II-.. wionilr In, drug therapy. dMired theraprutK oul<ome~ re",ired
monitoriog for adl'l~ efft<1\, and pft'Cautions thaI wm be taken during the
infulion ind in the immrdilt~ postinfusion time period.(Uliog time dJriog
nur>ing Uft' helps to re'ISUft' the patient ind allay iOXiety.)
Provide supparr and ~UlUraO(f to the family and uft'9iYenduring the
til1M' of tlNtment (Providing suPPOrt. reallUraoc:~ and i pproprialt'
rtferrals, e.g., pastoral (ilre or lO(ial \elVU suppart,asliru family members
in astressful ~ruation.)

Patint HIfadm inistution of drug thtupy;

Provide edJutioo during the poItinMion period about required m~diul
(ilre foilow-ull postiofusioo drug therapy! f.g., aotic:oagulaou or
antiplatrift drugs),and lifesl)'lechinges. (Utiliziog til1M' during nursing (i~
hdpi to reiolo~ teaching and aSIffi lor all)'que tiorn or roOC:fIIIS the
patitn~ family, or ur~il'r may hoM.)

The patitnt should hal'ean u~tanding of th~ rationale behind

thrombolytic: th. ,apy. "'luipmrnt. and monitnring thaI will be u'od.~nd
the w e required in the postiofusioo period.
Allow family member> limelO dis{\J\S iNrs,cOIKrms,and provide merral
to appropriilt~ suppan aod aoc:ilLiry provider> uappropriate.

Teil(h the patien~ family,or(ilreg~r io proper 1~If-admioilmtion

\e(hoiques of amic:oagulanu or antiplateiet drugl as appropriate.

Evaluation of Outcome Criteria

Evailliltr the ~til'l'Ol'ls of drug therapy by roofinning that patient goakand 6pffifd ou\(om~s hoiVI' been met (lee Plaoniog").
5tI' TIIbIt 17.5 for Q i5r!h1/> Ie wIidr rheit IIIflifJl} Iilns ~

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386

UnII4 TheCJrdkwasc:ubr.od Url",,'Y Syuem,

TABlE27.6

H@mostatics

Drug
Q

Route and Adult ~ (max dose where Indicated)

Adverse Effects

IV;(-, 9 for I h,llIffi I- U5 gIh ,Iuil bIding iHontrolltd

Mergk lkinrtGrliom, htodQcM

1V;2 milWon KIU ~(liding ~)follo.Yfd by >00,000 KIUI1l duing proI:ft1Jr~

IV; 10 mg/kg,llne to kiIIlintI daly for 2108 da)'!

nep/nIOlicilV

'llinocaproic:~ (Amic.u)

'prolinin (Tlu)'IoI)
trinwmK add ((ykIobpron,L)'\l~)

AnaphyliBk ibrooilOlh broomOllN1Dl

PO; Two6SO I119litm~ mrt!' troo daWyfor a maximum of 5days

clots. Vital signs must be monitored continuously, ~nd signs

of bleeding call for disoontinu~tion of therapy. Because
these drugs are rapidly destroyed in the bloodstre~m, discontinuation of the infusion normally results in the immedi~te termin~tion of thrombolytic ~ctivity. After the dot is
succer.sfullydir.solved with the thrombolyti c, therapy with a
coagulation modifier is generally initiated to prevent the reformation of clots.
Since the discovery of streptokinase, the first thrombolytic, there have been a number of subsequent generations 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 th~n
older drugs in this class. TPA, m~rketed as alteplase (Activase). has replaced urokinase as the drug of choice in clearing 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

HEMOSTATICS
Hemostatics, also called antijibrinoiytics, have an action opposite 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 gro u p of drugs used to prevent and treat excessive bleeding 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 indications 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.

I Amlnocaprolc Acid (Arnlcar)

Therapeutic (lass: Clot stabilizer

Pharmacologic( lass: Hemostaticlantifibrinolytic

ACTIONS AND USES

Aminouproic add is precribed in ytuarions in which the~ is IlUrssWe bleeding ~ulUclots a~ ~ing dilloiYfd plt'matureiy. Thedrug.!ds by inactjy~ting
plasminogtn, th~ Plt'(ursor of thf elll)'mt plasmin that diqtslS the fibrin dot.
During aan~ hemorrhagf, tIK-drug (,n ~ giYellIV to It'dK~ blt~ding in 1to 1
hours. k is ,Iso mibblt in ubltt form. It is most (ommonly prtscribed Iollowing 1UJ9tf)' to I!dtn postoptra~ blt~ding.Thetheraptutic.lffim ~ is 100
to400mtglmL
ADMINISTRATION ALERTS
Aminooproic acid mayc.Jus~ hypotension and bracljUrdia when gNfn IV.
Aslf"Is vital signs frtqllfntly and pb(~ thf patitnt on a (ardiac: monitor to
assess for dysrhythmin.
Pregnancy cattgOl)' (

ADVERSE EFFECTS
Btcalllf aminouproic ,rid trods to stabilize (1011, it should ~ us~d uutiowJy
in p,titnn with a history of thrombofmbolic dilf.J ~. Rapid IV ,dminisuuion
may uu~ hypotension and/or br~dyurdia. Side tifls uegenmlly mild.
Contraindications: Aminouproic acid is (onmindicattd in pititnll with dislfIIlin,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 of()yerdo~: Th~ is no t~~tmentforoverdo~.

Rtfff IIMyMl5/ngK1 ror~ Mnlngl'rei! fooIl~ IIIMItug.

PHARMACOKINETICS (POI
()(lft: Unknown
PNk:lh
Half~i~:Unknown

D.!ration: Unknown

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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 injured area.
27J Diseases of hemostasis include thromboembolic disorders caused by thrombi and emboli, thrombocytopenia,
and bleeding di,orden ,uch a, hemophilia and von
Willebrand's disease.

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-molecularweight heparins and thrombin inhibitors are also available.
27.6 Sewral drugs prolong bleeding time by interfering with
the aggregation of plalelets. Antiplatelet drugs include aspirin,ADP blockers,glycoprolein lIb/IlIa receptor antagonists, and miscellaneous agents for treating intermittent
claudication.
27.7 Thrombolytks are used to diMolve ai,ting

illlrnva,~ular

clots in patients with Ml or CYA.

27,4 The normal coagulation pr0ct'5S can be modified by a

n.! Hemostatics or antifibrinol)1ics are used to promote the

numlx>r of different mechanisms, including inhibiting

specific clotting factors, dissolving fibrin, and inhibiting
plalelet function.

formation of dots in patients with excessiw bleeding

from surgical sites.

NCLEX-RN" REVIEW QUESTIONS

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
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 thick.~
2. "heparin does nol thin the bkxxl but prewnts clots
from forming as l'aSily in the blood vesse1s.~
3. "heparin decreases the nWllberof ptateletsso that blood
clots more slowly."
4. "heparin dissolves the dol."
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 ta~ 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.

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4. teaching the patient to monitor for the development

ofDy[.
S. teaching the importance of drinking grapefruit juice
daily.
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.
A patient is receiving a thrombolytic agent. alteplase (Activase), following an acule myocardial in1rclion. Which
condition is most likely attributed to thrombolytic therapy with th is agent!
I. Skin rash with urtiOlria
2. Wheezing with labored respiratioJl.'i
3. Bruising and epistaxis
4. Temperatureelevation of 100.8 ~F
A patient has started clopidogrel (Plavix) afterexperienc
ing a TIA (transienl is.:hemic attack). The desired therapetllic 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.

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 ga rbled 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 p rior to administering the medication to
the patieni1

1. A patient is receiving enouparin subcutaneously after beIng diagnosed with thrombophlebitis.. What precautions
should be taken when giving this medication?
See Appendix D for anSWf71 and rationales for all activities.

r--i~"------,

EXPLORE ~

yoo.rr one $!CO tor Mhoe thaD!er revtew lI"'atenas lnd

l1l3,lurws. Prepaoe b :;o.n:1SS with a!kltional NClex- .5IyI~ prnodioo
quesIioI1s, illleraCWe assrj1ltl\!llls and lIdrIiIIes, iMMl lilks, animations
an::! widoos. and mere!

MyttJrsirlgt<i! is

RegISUr your at:eeS!l ~!rom the Iron! 01 ~ 000k as

www.-yn ..5ingklUom .

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Drugs for Hematopoietic

Disorders

DRUGS AT A GLANCE

LEARN ING OUTCOMES

HEMATOPOIETIC GROWTH FAaORS

Erythropoietin pagt191

After reading this chapter, the student should be able 10:

(XTJt J\tl

Q epoerln alfo (Epogen, Proem) fXl}t J9.'

(olony-Stimulating Factors tJ'm

Q fllgrosrlm (Neupogm) {1J(}I'195

PlateletEnhancers pu;elW
ANTIANEMIAAGENTS f1JI}tJ98

Q cy<lnocoboJamln (Co#omlsl, NQ5CoboIJ

""

Vitamin BIl and Folic Acid

Iron fOJt J99

{IJge 398

o fetTOU5 wlfale (FrosoJ, others) POIJf 401

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 tran splant.
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 tran sfer 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 hem atopo ietic disorders.

KEY TERMS
anemiil fX1I}tJ9l
(olony-stimulating factor(CSF)
erythropoietin {JQIIt 191
ferritin (X1IJt399

PU;f 394

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folicacidffolate (X1IJt399
heITliltopoiesis fIO'It m
hemosidrrin Jl1Jt 399
intrinsicflctor paJtJ98

pemicious(mr galoblastic)lnrmia
stem (fn {IOtItNJ
thrombopoietin (JO"/t 397
transferrin fIO'It 399

(X1IJtm

UnII4 TheC.rdloY.<;(ubr ,nd Urinary

390

Sy""'"'

he blood serves all other cells in the body and Is the only

ma,,,,w

fluid tissue. Because of its diverse functions, diseases af-

fecting blood constituents have widespread effects on the

body. Correspondingly, drugs for treating blood d isorders

will affect cells in many different tissues. This chapter will examine medications used to enhance the functions of erythrocytes, 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 hormones 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
Apmjnant woman', body procb:~s 45% mo~ blood b.iUIl' it {ontains
nlllritnuand oxygtn for t~growing fetus.TIIt g~at6t ill{~u~ in blood
procb:tion O{{u~ around Wffk 20 of prl'gnanq.
Adtficitnc:y ofvitamin H",folat~or vitamin S. may in{lt'~ tht blood
~ ofoomocyst~illl',an amino acid normall~ found in th~ blood.An
elevattd blood IrwI of OOlllOC"fSteilH.' ~ a risk factor for hun dMill' and

,"".

VtgI'tanans who do not rat IIII'm,mh, ~ggs,m il~ or milk products arl' . t
high risk fordewloping vitamin H" defKifru~. Vtgmrians may find
adtqwtt amounts in fortifuod (moals, rutritional suppltllll'nts,or ~mt.
Admin~tr.nion of folic acid during Jlrl'9nancy Iw ~n found to It'(]UCf
n!'Ural tube birth dmas in t~ newborn.
HeolV)' mtnstrual ptriock mayIt'IUk in ronsiderablt iron loss.

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Megakaryoblast

I
Th"'mbopoielin
tlllorieo.A<intt

Leukocyte
atom ""U

Colonystimutating

~cto ..

~,6f

0".......
Platelets

Erythrocyte
stem ""U

Macrophagos
.. Flgure28.J Hematopolests

"a ..
c

G,atl~ocytes

.-'.--.

Erythrocytes

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.

01 ..11.,21 DN9' for Hem.topol"Uc: D""rders

__" ,",",. , 1.

TABLE 28 1 Hematopoietic Growth Factors

On"

Routeand Adult Do,e(maxd~where Indicated)

Go) ~oe'lll.H.lEpoIJftl, Proott)

SulKullrItOIA/IV;l~SOO ulllu/kg/dolo! mrte Iimts/wt, Uiualy

'"'......"V...5.""'~'P.W.

st.vung WIth 50-100 IIInsAgldw 1II1~ 1'rg!T 1In"~ of

lO ~ll%lmu 16%) ~rmhfd.IIn!hot*lOOlllaN Io! by mort
th.n ku POlnll In'ny 1.-wk pmod

I" .

391

Adverse Effects

"'f..........""'_.. ~"'_

lPlpirory irrtKIiOll, tdemo

H'llltftm5ion.1rizu!t~ he.!! [)ilu[t MI

COLONY-STIMULATING FACTORS
Go) rdgraslin !HtuplHJftl):
gr.IIJIocytKSF

IV; 5mc:g.t:91dolY II!' ~min ilflllion,may irKrulo! by5mc:gikgldoJY

(max:10 mc:glkglday~ Smc:glkgldayslb.:lItlnfOlJU' ~ngIf dolo!,
may inuulo! by 5m(9lbjlday (max:l0 mOj/bJlda,1

fMikll)'!Idnlmt, fmor,rlilpl1fQ, 1lfUlf4 M1miTifl9,OOIN'

pon (J/lrgromallimJ

ptqfilgmtim (He~\lal

SulKu~6 mg on(~ PfI' difmothft.p)' tydf .llfall14 h.flft

m!Util~ IIfIit.ullil ef!wi!lo 19l1li!ll~ltimi

uOOKl@(yusramoiml

!anJ~rnollim (llutilN'j:

1V;15O mc:g/IIWdll inlultd Il'Ift 2 hfor 21 dll~ btgin H hafttr

boot m,rrowtrinsfulion.nd oot Its:! thin 14 h.ftfr ~51 dolo! of
dlfmotheiaP'l' or 11 haftfr LtIt racli.tion IheiaP'l'

dlfmOlheiaP'l'
gr'lIJkqt~moKrophoogK5F

Boot pain . rJhralgia.ltwml:!oqtpw!'.Ml!ltO!lS

PLATELET ENHANCERS
oprrl'lrlin (NfIIIIIf9i)

SulKutarItOUI; SO m(gikg OIKI' daily 51,ning 6~ 14 h.ftfl

(ompleting difmother.p)' for 14-11 da~or 11111 pIiIlfie'l (OIInt ~
at ltallSO,OOOJmd

fdtmq, fwlr, lrIadodIf, dilIilN'S'l, dylplN'Q, foriqIJI. ralh,

OO!MI, tIMIi~

T,(h)'{,Jrdi. ffbrilt nMroooi . plein! fffusion.

aruldia,is

.nal!!!rl";~!In!!!l1hm;~

fllrombopag (f'romau.)

PO; SO mg OII(f daily (max: 75 mglday)

h llrQIgio. mydrjo, pIIrtllhtlio, irmmnio

rompJoltim (HpI.le)

!Ubwt.~ 1mc:g/bJ (mal; 10

Boo!: ma!JOW"fibrO$iutromwmboliwn hrmalologi(

m(9lbj/Wk)

m.~glliw.~lolOJ:id!! {fltrornboo')(]i

IIQIio ilKkaTt ammon idmse ~a~~iIKkaTe Sfriousadwl'lo! fflfaS.

28.2 Pharmacotherapy

LIFESPAN CONS IDERATIONS

with Erythropoietin

Epoilltin Alta as the Nlllw UBlood Doping"

"Blood doping. withdr,.,.ing blood from.n aThlell'.nd then rH"osiusing it
befort' a (ompelitift sponing rwn~ has befn used bysoll\t nhlell'l in <I nat
tempt to g.in a (OIIIpelitift tdgt. With in((~olIfd RBCs .nd hightr hemoglobin, thf oxygeIl-urrying ('J)a(iry of tilt blood is thought to in(~ilf, boosting
endu"IKe. Bmll'lo! the blood ustd is the athldf'S <Mn, prr~enl drug
!(rt'I'ning do6 oot dtTtr:t folfign drugs or sulnu nm. Chal'9f1 of blood dop
ing <I ~ diffiruh to pro~ btuuse uhlell'l an naTUf.lI~ 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 in~ blood wiume ,nd
moosity holft led to hyptrll'OSion, thrombosis,.nd dtnh.
Blood doping hiS dianged with The milability of ~in <l1f. Bfrall'lo!
epoetin nimulate RBC prOOxtion, the aThletl' ma~ ~ to withdraw less
blood initi<lll, .nd then rt'ly on fpoftin to boost RBCs r'len mort' POIIrt'tr.nslusion,of fportin may be u!o!d .Ione. BtraUSf it mol)' be used Wffkl bIo
fo~ a sporting ~nt. 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 pla~. kty role in providill9 oKW.
r.1l' info!Jllolnon <lbout fpoetin and (ounseling <ldoies'nts .bM the riskl
.nd adYl'l'lf t~u~of fPOflin or .ny OIhersporu.enhanr:ing drugs.

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 hemoglobin, which is required for a functional erythrocyTe.
The primary signal for the increased secretion of erythropoietin 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, Procrit). Darbepoetin alfa (Aranesp) is a newer agent thaT is
closely related to epoetin alfa. It has the same action, effectiveness, and safeI)' profile; however, it has a two to Three
times longer duration of action that allows it to be administered 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. Research has shown that the administration of these drugs

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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.

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

ADVERSE EFFECTS

Epoetin alia is mille through rtlombinant DH~ thooloqy . nd is functionally

idmtiul to humin erythropo~in. BecalM of in ability 10 stimulate etythropoirlis, e~tin iili. is tffrctive in tINting disorders cat/ltd by rItticierq in
red blood ~I formation. Patients with chronic II'nal failull' often canoot secn!'te
l'IIough endogell:llls etythropo~in, 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
HIV-inftaed patifflu. Epoetin alf. is usually .Jdministered by tilt subcutaneous
route th ~ times per Wffkuntil. theraptUlic II'Sponst is oKhieed (usually 2to
6Wffks).
ADMINISTRATION ALERTS

The suocutall!OUS nxlte is gtoerally pn!'ferred o~r IV, since IooMr d~ all'
I"ftded .nd a~tion 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
~ak: Unkno\\ll
Hall~ir.: 41l h
Duration: Unknown

Epoetin alia haslnl'ral FDA bond warnings that indudt tilt fol'a.ving:
The dlll9 may inclNse the risk of II'rious wdiomrulu nffits, thromboembolic ~nu, and 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 patMoots 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 ~nt adve~ efFects include htacbcht, fem, nausN,dianllt., and edtllY.
Patifnts taking epoetin .J Ifa who all' on dialym nwy n!'q uire 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 alf~ will be 9,e<ll1y rtducrd in pa1itnts with iron
dtrKMoncy or other vitamin-dtplettd statH. Most p.tMontSll'Cti"l' iron supplements 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 ~tin Ha 10 paritnts with myeloid nwlignancMoslIJ(h as lIl)'eiogtnousleuktmia beca!M the dlll9 nwy incll"~ tumor growth.
INTERACTIONS
I)ug- l)ug: 1'-aft' oodnic;;)ly~tO:lHj irI~Jacticn!; with ~ ilia.

labTests: lktnown
IIorbovr 00:1: Unknown
T~tment of Dmdosr: Ol'ffiloll' may lead 10 po~tmia (too nwll)' f rythrocytes), 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

Assessme nt

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 folikrn!',cance,
1I1'atment.!.
Obtain a complete lItalth histol)' including mdion scular (including HTN, Mil
.nd periphe'oIl'.Jl[ular dill"~.lI'spiriliory (induding prfYious pulmonary
embolism), nf\I\Jiogic (including (VA), or hepatic or II'n.J Idisrast. (lbta in a drug
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).

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Potentia l Nursin g Di ag noses

loefitclivr TissUl' Perfusion (rtlated 10 underlying disordef)

Activit~ InlOler.nce (related to underlying disorder)
FaDgUl' (1I'1attd to undtrlying dilOrdtrl
Deficitnt Kna.vledgt (dlll9 tlltrapy)
Riskfor Injury (1I'lattd to oId'lelll'drug efftru)

00..,1<' lS DN9' for Hematopolelk Disorder,

NURSING PROCESS FOCUS

393

PATIENTS RECEIVING 'POETIN ALFA (Coo',,"',

Assessm e nt

Potentii!ll Nursing Dii!lgnoses

Assess ment thro ughout ildministrati on:

Continue aS~lI'1lI'Ilt 10, tlltraptUlic effects (e.g., Hct, RBC (ount signif"iI ndy
implOVfd patient's oKtiYity 1e~land general seru of'M'lI-bting hill impl"l)Yed).
Continue ~uent monitoring of appropriate lab 'laluts (e.g., CBC,aPTT.INR).
Monitor~it.ll ~nl ~uent~, tspedall)' blood prtIlUfI',during tilt first 2wrt'ks
oftherap)'.
Asltss 10, adverse effects: HTN, lItada(ht,neuroiogic (hilngts in lenl of
(omOousnffi or p~onitory signs and symptoms of seizu,e oKtivit)',angina,
signs of thrombosis deYcloprnent in peripheral ntremities.
Planning: Patient GOi!ll s i!lnd Expected Outc omes
The patient will:
uperie-rKe tlltrapeutic effects dtpendem on the 'filIOn the drug is ~ng gr.tn (f.g.,nperience incrust in oKtivity fevd less fatigue and shortnffi ofbreillh
onljlenion).
~ ~ from, 0' experienct minima~ adverse efftas.
Verbalize an un&manding oftlltdrug's UIf,adverse efferu.and f1'qJirro prl'(lutions.
Demonstrate proper stIf-idministmion of the mediGition (t.g.,~, timing, when to notif)o provider).
Implem e ntati o n
Interve ntion s and (Rati o nale s)
Ensuring tht rilpeutic effects:
Continue ~uent 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
Encoorol<jt adeqwl\' ~t perioIk and adequatt fluid intlke. (The patient may be
signiflU ntly fatigued due to low Hbg and H{lAdeqJate fluid intlR helps
maintlin adtqUilI\' lkJid balan~ ill Hct levels ~.)
Minimizing adft rse effKts:
Continue to monitor for adverse effects, I"IpKial~ 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 {fIfblil~ may
akooc:rur.j

Pi!ltient i!l nd Fi!l mily Edu ca ti o n

Inmumhe patient on the IlffiI to retum freqJemly for follow-up
labwork.

Encourage tilt ",tient to rfit wlltn fatMJied and to space ictivitil"l

throughout the day to allow for idtquate rt'St periods.
En(ourage inuke of water and non-hyperosmolar beveril9!"l.
TNCh tilt patien~ fami~, or (iI~ier how to monitor pulsr ilnd blood
prt'SIUft' ill iI pproprial\'. Ensurt' the proper 1M and functioning of all)'
horne tquipmrm obtained.
InllnKt the patitn~ f~mily,or (iI~iver to report he.Hbc1lt (espKially
ij 5Udden onset or It"Vtft'j,changr-s in 1e~1 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).

Asltss mnspormion needs of the patient and wer to appropriate rt'sour(tS is

nffiled.(Driving may be ~trictrd up to 90days after initiation of drug ther~py.)

Advise the patiem to (onsult with the health (1ft' provider about
driving orother hillan:lousactivitil"l duringthe first It"VfIiIl momhs of
drug therap)'.

Continue to monitor am priorto dialysis in patienllwith chronic renal failure.

(The he",rin ~during dial~ may need to be ifl{re~1ed as tilt Hct incrt'lI6)

uplain any chalHj!"l in medication routine to the patient and provide a

Wlltn idmin~tering to prern.lturt' infams,IM prt'IfMlive-frre fonnulations.

(Epottin ~II~ may (omain pft'lflYuim slKh ill benzylakohol, which may (11M
MiHal galping syndrome.,

To allay anxiet): offer part'nt> rationales for all tre~trnenu provided lor
the infant

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 in~dtqJate.{111t rtSpllllf to epoetin ilia miy be dtmaled ijblood
IeYeb of iron, fol ic oKid, and itamin Bu are deficient)

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 brtads.le~fy green vegeubles, citrus fruits.dried
beans and peas).

ruion~le.

rContlrnJedj

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394

UnII4 TheCJrdkIY.",ubr . nd Url",,'Y 5y11","'

NURSING PROCESS FOCUS

PATIENTS RECEIVING EPOETINAlFA (Conflnuwl

Implementation

Inte rve nti o ns a nd (Rati o na les)

Pati e nt a nd Fa mi ly Edu cati o n

Patient undentanding of drug therapy:

Use opportunitifs during adminisuation of IIH'dic.itions and during . ISmllH'ou
to discuss ratiollllit fordrug thmpy,desirtd thera~ OU\(OIlH"S, IlIOIt
oommon .dv~1'S!' ~ffts. param~l~rs for wh~n to oolily th~ health (il1l' pJO'/idt~
. nd ~ny lII'{rswry monitoring or preuutions. (Using time during nursing ('Il'
help, to optim~ and r~nfon:r kry te.Khing .re.J ~)

Ih~

patient should lItabk to state th~ INIon for the drug. . ppropri.J1l'
to 00rr1ft for and whrn to
report;.nd the anticipaled length of medicalion thffilpy.

~ and I(h~ruling;what ad~ Nfem

Pati""t .elf-a dmini. trati on of drug the rapy:

When . dminiltering lIH'<Iiutions,instllKt the patirn~ lami~, Of ('Il'gi!'r in

proper rrH-administr.nion thn~ IoIIoWfd by return deroonstmion.IProper
.dmini5lr.llion inuNm tilt ~oivrnm oIth~ 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 9!'ntlywarm~d in the hand
All i.Jh are for OIII'-tillH'!M on~ and any remaining amount should lit

Teach the patien~ famiiy.or {all'giv~r in proper IfII-administration

thn~,.lfindwelling 10ft mheter (e.g.,lnsul\on 10ft wheter) is
IrIt in plm for injtions, teach the patient the proper W~ ofthe sit~,
uthrler, and any I(heduir for rotating ,ites.
Ha!' tilt pollirn~ lamily,orcarrijmr Il'tum-deroonstrall' tw.niq~
until me proper tKhniq~ iI UIed .J nd th~y all' {omfomblt giving the
injection.

dilurded.
II indWl'lIing subanantOlll 10ft mlltt~r (e .g.,llIIUfIon soft !athrler), the
p.lIien~ family, or Llll'giver should lit taught a pproprull' site m~. inrrrtion
te<hniqut as appropriat~, or !{hl'dult for rotolling sites.

Evaluation of Outcome Criteria

28.3 Pharmacotherapy with ColonyStimulating Factors

Regulation of white blood cell (WEC) production, or

leukopoiesis, is more complicated than t'ryIhropoiesis becaust' there are difft'rent types of leukocytes in tht' blood.
Pharmacologically, the most important substances control~
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'dications are listed in Tablt' 2B.I.
When the body receives a bacterial challt'nge, the production 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 mature leukocytes. The CSFs not only increase tht' production
of new leukocytes, they also activate existing white blood
cells. Examples of enhanced functions include increased migration 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 neutrophil and macrophage production. The process of identifying 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.

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Tht'goal ofCSF pharmaotherapy is to produce a !"lipid increase 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, CS Fs
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 sustained 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 bloodstream and be.:ome platt'lets. A single megakaryocyte can
produce thousands of platelets.

0Up1tl2S Drugs for Hemilopolefk: D~()f('ers

po, Prototype Drug

39S

I Fllg rasnm (Neupogen)

Theraptutic (lass: Drug forincrnsing neutrophil produdion

Pha rmac:oIogic (lass: Colony stimulating fador

AalONS AND USES

ADVERSE EFFEaS

Filgmtim is burn~ G.(Sf p/OdlJ(ed thlllugb ItM1Ibinotllt ONA te<hnoiogy.1tI

two primiry .ctions i~ 10 ilKreiS~ neutrophil prOOlICtion in 1M bone marrow
inc! to enh'lK~ the phi9OCY1K .00 {)1otoxic fulKbons of txisling roeutrophils.
This is particuLlltt important for ~tI with neutl"Opmia.which often is as
sodiled with ~~ ~I .00 fufl9il inftctions. Administliltion of tilgrastim will shon~n the length of time of JleUtJopeJlii in CiIK~r pnienn w~
bont marrow hn ~ wpp~std by anlinroplastic Igffttl Of in p.atienlS following bon~ malTOYl or stem (dllliI~.nn. h may.!so be used in pititnn
with AIDS-related imllJJ~pp~sion. 1t is idministertd wban.JltOUIIy Of '"

Although filgr;mim is wtli toltrattd, tbt dl1J9 is associlttd with potCllti.J11y Ifrious idwr..e fffKtS ind clost monitoring is ~uirm80nt piin miY o(aJr in up
to 1J9Io of pat1ttllS If(tjying tilgliIstim.Asmall ptltl!fltagt of pititMS may !It~p an allelqic ~action. 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! riftru wch is I1'Spimory failul1', intracranial hemonflagt,l1"Iinal hemorrhage,
<lnd MI. F~aI 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.

~lYinfusion.

ADMINISTRATION ALERTS

Do not admin&erwithin 24 hours btfmOf aft~ dlMIOthellPJ with cytotoO:.ntsbeolM"'iswilg~tIy~asttllft~offjlgrastim.

Prtgnancyutl!gory(
PHARMACOKINETICS ISUBCUTANEOUSI

Onstt.:. h
P9:2- 8h
Half-lilt:lS h

lNTERAalONS
Drug-Drug; 8fCiUse ilIl!illtOP6ti: dllI9S and ~-Rilll.Hing b<t0l5 prodIKf
oppoIitf rJrKl5,rqaitim is IIOIDninistfflld unl~ iIIltJast 241Hu51fifr a
ct.erIIOIhtf~ !tIlion.

1.1. TfStI:~UfS f the IoIIcwilg maybtincrNsed:lMocyttalilnt pMpIWst,

wn.m alt.JlN phMp/ImIf,~ricacJl, nI LDH.
Hl'lbillIFoot Untnown
TrNI~ft1I of ~rdo~: fheR is not~~lmi!fIlto..o~.

*'

1Ir.., tI /rtyNrNlJIIgIOt frx, Nun/III) I'IIxm ffKJJj ipfdk this d1IJ9.

DlI'ation: 1wk

NURSING PROCESS FOCUS

PATIENTS RECEIVING COLONY STIMULATING FACTORS

AsseS5ment
Baseline tlSH5Imtnt priorto 6dminhtriltion:
Undtnlind IIIf ~ the d~ has betn prNribtd in order to iS~S 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 rt'(~nt or Clllltllt infections, '~WII
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
concf~iofls.Obliiin <I drug hislory including .llellJits. cu~nt 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
~ndtdMt.llJOphiis) = SOOO X 05 = AH(oflSOO.]

Potential Nursing Diagnoses

Anxitty {rtbttd tocolKems ibout stRoUSIItSI of undtlJying d"rsonl~;

insufl IKtlfini lKill (OIKe!llS)

Ftar {l1'wted 10 concuns aboot seriousntlS of undtrlying disoldtt;
insur.IK~Ifin~lKial (OIKems)
N.tMly Intoltra~ (rmltd 10 lInd~lying disonltl Of drug treatmtnt
of disorder)
Filigut (mated 10 underlying disorder Ofdrug tre.lmenl of disorder)
~IKno~ {drug ther.py)
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 ...dCiI('9~)

Assess mtnt Ihra.ghout adminlstratlon:

(Olltinut oJIleSsmcnt for tMlilptUtK dfe<ts (t.g., (BC <lnd WBC 01 AN( has
in(~iI5fd, no signs 01 symptoms ofini.tion).
(Olltinut ~uml 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 (~ts,
and sttmum), fever, IIiIlIIfl,anortxia, hyptruricemia. _mil, Sf Mprtlsion on
E(G,angina. rtspiratory diststS!, and allergic: rmtion.Continut 10 alleS! for
infection . 00 f~tigut rtlol\ed to d~ tmtment (t.g.,chnnolMlilpt).
(Comrnued)

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] 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

TM~iffitwill:

ExpentlKt ther~pMK tfftru dtprndent on the It'aIOII the drug is being giYeO (t.g.,oprntncr inumt WBUAN( Irvr~ 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, and Il'qJil1'd Pll'Uutions.
DtlMllstralt prop~r selhdministr~tion of the rnMiution (f .g.,do!t, timing. when to nooft pfOl'idtr).
Implementlltion
Inte rve nti o ns li nd (Rllti o na le s)

Plltie nt li nd Famil y Edu cllti on

Ensuring theril peutic effeds:

ContinUl' flrqJem olS:iI'S!IIItrru illCienribN til rlitr for tilmptUO( tfi'KlS. (A
1M in WBC and!or AN( (OIln!; will dtpend on condition uMm, e.g., dtpth iI nd
I!ongth of nadir from cytotOXKcherrothelapy.)

Instruct tht piltitmon the nffil to ll'Iurn frequent~ for IoIIow-tJp

lab work.

En(Oll"gt adequate I1'st ptriods,nd adeqwtt lkJid in"kt. (Patient tna)' be

!oigniflUnt~ filtigued dtJIo to the dfllCj therapy ror the distil:;tcondition.
Adtquatt ftuid int,kt helps mainlilin adequatt urina!)' output and prtVrm
UTk)

r-:--&;OUragt the pilDentto It'5t when fatigued and to spiKt oKtMtits

throughout the da~ to allow for ,dtquatt I!1t ptliock.
ElKouragt the inlilkt of w.ttl" and non-hypemmolar bel'e<ages.,nd
drinking WMntI'e< thi~ty.

Minimizing ildft ~e effects:

(ontinUl' to monitor for ,mr:;t tffKu: bo~ pain (esptCwliy lowtr buk,
posttrior ilwc mm, and IIt mum), il'1'!'~ nalM', ,nomiil, hyperuricemia,
,nemia, ST dtpmsion on ECG, angina,ll'Ipimory distrrs~ .nd . lltrgK
I1'mion.Continut to as~s for inlKtion il nd fatigue It'lattd to dfllCj
tl1'Umffi~ t.g., chemotherapy. (Bone pilin tt nds to IXcur 1 to 3 days prior to

';
;ft ';ff,.I"ft~WOr
.. "'"""fWW,;"
~"" ,. ...
~3
' _"
..
_ .......
... .. y, ~. ~ .~
,y ""'."~~
..
.. y . . . u-. .......
u ...
... .u.
~~ ,

y~

".y~~".y

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 iSUili ion of
s,rgramostim a nd should bto rtponrd immNiatt ly. H~ptrurictmw mil~ caUIl'
goutlike conditions.)

Instruct tht piltitmto It'port il lI)' Stfflt' _ pilin not rd~ by

nonnaKotK anaiqeia.
Teach the patitm to imrnMiattly I1'pon any pillpitations,diuill6\
angillil,or dyspne,.
Gout-prOlll' piltitnu should repon signs and s~mptoms of gout . nd
inclt',u tiuid intake 10 enhanuo the rt nai f iimimion oi uric acid .

Mainlilin m. tirulous inil'ction control measul!"!. Rtpon any !oigns and symptoms
01 inil'ctions ormer imrnMiattly. (TM piltient will cominue to be,t risk for
infKtions umil WBClANC 1!o~1s rist. OpportunistK inil'ctions sum as ~tast and
virum SIKh as herprs ~mpl!ox maY lXcut Pilramrtt~ will be!d by heil hh ('It'
proYicler for Il'pOning ftl'e<. e.g.. all)' ttmjlfraNIt' Ultl l005'F,dtptnd..,t on tht
underlying dill'<I:;tcond"rtion and dfllCj ther<lPY.)

Instruct tht piltitmin hygitntand inil'ction control mtiisurrsllKh as:

Freqlll'llth;rndwashing.
AI'oiding uowdtd indoor plac:rs.
AI'oiding peopl!o with known inIKtions or )'Dung childl1'n who h;rl'l' iI
higher risk 01 h.riing iln inil'ction.
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'lerand symptoms ofinfKtion SIKh as:
wounds w"rlh redness or drainilgf. inclt'asing cough,ilKJNsing filligue,
whitt pilttoo on oral rrAKOUS memb"lI6orwhi~ and "rIchy aginill
dis<h;rrge. or itch~ blisttr-like l'!'Sidrs on skin.

Mon"rlor ECG jlfriodKallyfor ST stgmem dtprt'ssion or dysrhythmias ilnd I1'pon

immtdialely. (S~rgr<lrrostim tna)' uuse !oigniliunt ST dtprtssion with potorlrial
ror lfI"ious dysmythmias,npecially in piltients with prt'lious cardiac condition~)

Team thr p,titm to I1'pon all)' pillpitation~ diuill6\or angina

imrnMiately.

Monitor for !oigns of dyspntil or rrspirato!)' distl1'lI. rspeciallywht n

mompilnitd by OO)'Cardia and hypotension. and rt port imm.diattly.
(Sargrarrostim may UlIII' It'Spiratorydislll'ss iIIgranuloc:yttcounts 1M,
r!pf(ially in piltimtl with prNxilting rnpiroltory dilordtrs.)

Ttach the patitm to I1'pon lll)' dyspne',lt'Spirato!)' distl1's~

pillpiwions.ordiuiness immediately.

Mon"rlor for !oigns and symptoms of ,ll!orgK-type It'ac:tions.(Tht piltitm m,y be

hyptlll'nMt~ to proteins from E. cdi usN todtl'!'lop tM dfllCj.)

Teilch the patitm to I1'pon symptoms of ailergK INCtion SIKh as rash,

unitil ria, whflozing.and dys Plltii immtdiately.

Mon"rlor hfPiIIK status during dfllCj adminisuuion period (Filgrmim may

c,ustan tlf'l.tion in lim tnl)'l11l's.)

Instruct tht piltitm to It'port il lI)' signifium ikhing.~ellowing 01 ICl!orii

or skin,darkenrd uri~.or light or day-colored \lools.

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01 ...11, lS Oru9' for Hematopol"Uc 0"",<1""

NURSING PROCESS FOCUS

397

PATIENTS RECEIVING COLONY-STIMULATING FACTORS (Continued)

Implementation

Interventi on s and (Rati o nale s)

Patient lind Fli mity Edu clltio n

Stop iidminimation whtn WBC (ounts IN<h t~ IeYeI determi~ byt~ h~,1th
plO'lider.(FiIg,aniIlIllilY ~ nopped ....t.en neutrophil loom, ft'ath
lO,OOO/mm'; wrg ...nonim II\a)' ~ SIOp~d w~n n~l/Irophil (ounts ft'alh
20,OOO/mm' 0' u ordeF.d by the ~.kh laft' provider.)

(ii'"

Patitnt understanding ~f drug thf rapJ:

U,e opponunititl duril g .dministr,tion of medimion, ,nd during
.,msmenu to di!(ul' tht r~tion,lt for drug thmpy,d6ir~d thm~utic
Ol/llomts, mo>st (ommon .dverl<!' ~fftlts, pmmt tt rs for wht n to (ilil tht
health (ilft' provider, ,rd ~ny nt(6 Wry monitoring or pft'uutions. (U,ing
tim~ during nursing U ~ help, to optimize .nd ft'infon:t k~y ttl(hing

T~ath t~ patient.bout t~
~.

impon.nle 01 ft'tuming ft'gularly for bb

~ patien~ I.mily,or wtgil'!'r should ~~bIe to ,lait th~ reason br

t.1t drug,iPPropri.lI'dosl' and I(htduling;what a~~ tffem 10
dJ!t~ brand when to report;~nd t~antic:ip,ttd length 01
meditation t~"py.

~ft'.,.)

Patient selfadministration of drug tht rapy:

W~n iidministering mlitations, instrllU t~ p'tien~ family,or (ilrtg~r in
pro~r !el1-.dminist"loo ttdmiqU6 followed by ft'!Um dtmonmuion.
(Proptr iidminim,tion r.(ft'<lS6 tht tlf1~III'SS of tilt drugJ Proptr
thn~ indude:
Viallhould ~gentlyrotllN to miHomtou.nd nffll ~.k~n.Vi.tIs~ft' kept
under rtfrigtr.tion aid ~ould ~ genti)' w~rmtd in t~ hand.
All vi.1s aft' foro~tint U5<1'only and ~ny remaining ,mount should ~

T~ath t~ patitn~family,or UlI'9im in proper I<!'H-,dminimation

t!lhnique. Hin~lIing ,oft whettr (t.g.,lnsullon soft I.t~ter) ~
ifft in platt for injruion~ teath tilt patitnLf.mi~ or I.ft'giver thl
proptI(ilft' of ,itt, mhttt~.nd aO)' !(~rule for rotlling sites .
~avr t~ ~titm, f.mily, or laft'giver retum.oemonstratt th~
t!lhniqut until tilt proptr ttlhnique is !Md nd they .ft' (omforuble
Ijingtht injrdion.

dist.ardtd.
II indwt-lling lUocutntou, soft W~te1 (t .g. Insuflon soft mheter) is!Md.
tht patient should ~tau9ht ' ppropri,te sit~ ure, inlfllion \l!(hn~ u
'ppropriate,or I(iledule for rotating sites.
Evaluation of Outcome Criterill
Evaluat~ the ~ffeui'lelltssol drug

tht"py by (onfirming that ~titnt IjOiIs~nd"~ OlI(omrs hal'!' bfen mtI ( ~ Pt.nning1 .

Megakaryocyte activity is controlled by the hormone

th rombopoieti n, which is produced by the liver. Thrombopoietin 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 (N eumega ) . (Produced
through recombinant DNA technology, oprelvekin stimulates the production of megakllryocytes and thrombopoietin. Oprelvekin is functionally equivalent to interleukin-\\
(IL-IJ), a substance secreted by ntonocytes and lymphocytes 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 therapy generally continues until the platelet count returns to
greater than 50,OOO!mm' . Platelet COWlts will remain elevated 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 cardiovascular or renal disease. Visu,'Il impairment may occur during
therapy. Nun;ing care for patients receiving treatment with

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op relvekin is similar to care for patients receiving the

oolony-stimulating mcton; for WBCs.
In2008 two new plMelet enhancen; were approved .Romiplostim ( Nplate) and eltrombopag (Promacta) are approved
to improve platelet function in patiems with chronic immune (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 receptor 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 diminished 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

398

UnII4 TheC.,dklv.sc:ub,.oo Urinary Synefm

TABLE 28.2

Classification of An"mia

Morphology

Description

Examples

MamKytiI: - 1IOIIIIIXI'Iomic:

Lugt. abnonnally shaptd rrythrocyte w~h OOIInillltmoglobin (onanlra~on

i'fmiciolfi'ntmia, foI.t~fKimcy 'III'mi.

Mi(f()()1k- h)'pXhromi(

Small .bnorm.Jlly shaptd rrytlvocyte with lil'm'.t\td htmoglobin (OII(mtra~on

Iron~fKitlK' intmi . th.!Imtmia

Nonnocytic:- oormodlromic

0emKti0n 01 depletion of OOIInal rrythroblilSll 01 mat!R rrythlO(yte

A~ic illl'mi"htmoohigi('lII'mi"Ii!kl~

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 (macrocytic). Color is based on the amount of hemoglobin present 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 progresses, the patient often exhibits pallor, which is a paleness
of the skin and mucous membranes due to hemoglobin deficiency. Decreased exercise tolerance, fatigue, and lethargy
occur because insufficiem o."t)'8en reaches muscles. Dizziness 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

I"'. ,

ANTIANEMIC AGENTS
Depending on the type of anemia, several vitamins and
minerals may be given to enhance the oxygen-carrying capacity 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 minuscule amounts of vitamin B" are required (3 meg/day), deficiency of this vitamin is usually not due to insufficient dietary
intake. Instead, the most common cause of viI amin B" deficiency is absence of intrinsi: factor, a protein secreted by stomach
cells. Intriru;ic factor is required fur villlmin Bll to be absorbed from the intestine. Figure 28.2 illustrates the metabolism 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

Antianemic Agents

urug

lIOUie and Adult tJoos!! (max dose where rndlCatedl

qanocobillamin lCaloMi 5l, Hascobill)

"'"._30 ~, f. 5-10 ...""",

IOO-200rtKg/mo

folbdd (FoIvitd

roilM/lUooulII'ouS!1V; Ie! than 1mglda,

IRON SALTS

Adverse Effects

I-'~-'"
No~elftm

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

i! lII'fdedand toitrm d

QirdilWa!(uia, (01101118, aggr.l\\ltion 0( ~!!; U{ffi or

u(m~'tt(oI"f ~ htDali< fIN'?Iis, ~!Iil1hY!a!is (iron

~rlOlJllUlfate l~,othen)

PO; 7,0- 1>00 mglda, in 1- 3 dMdeddose

~lIIIIIlIytoI(Fmhf,RII'l

IV; ~ngledoll of S10 RIg followed by, !MIIId S10 RIg M

""""

ftrlOlJl fuma,att

(Fro!ta~othtrs)

~rlOlJl9kKonate (~rgon)

lt08da~l.ntf

ron dextran (OnftfTIIII)

1MIiV; doll il individUiliztd and delermined from i table

supplitd by the drug manufoKlII"tflhatcornlate,body ~t
to lItmoglobin \\Ilues (max: 100 RIg within 24 h)

Irdit< indir." rnm""", Mfmy offHr<;J..IldWi!iIIg.indir"... Yriou< .dVH",Hf'rI<.

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IF"

Inln15i~

factor

' '''-.,.,"" ~"

Th e QUfstion: Doe folic: add rmuu the inddl'nc:1' of ~ral rubt rll'fKts if
takrn prior to pregnancy? It has ~n ~ublishtd for s~rill rlrurll's that
folic: idd rll'fic:iI'n{1 ruring p~nil nq iOOl'iI~ th!o risk of Ill'Ural tuilt
rll'lKts in the IN'wOOrn,and that ~I'jyjng adrqua1l' amounu ruring
p~nilnq {.In rtduc:t th!o rill Ho-.e~doH folic: id e~n th~
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.
Nursin g lrnplitations: Hal/of all IRgnanc:ies illI' unplanntd.Thus, tht nurn
should ~ommrnd folic ildd supplemr mation for all womenwith a
lI'aIOnablr poIsibilil)' of pll'gnancy.
5aru: Wt>lI" l, irtiloKlrltJ> K. Allltl M.&5)f 5 (lOO9). (of{ k1fI
~rilfrr"'rMPrmMk1ItrlNt!lalllbf fJt/t(/',:Ai1 !IpOOII>I1fllrtErldtm
fwllrtll.i PrMIrlIw 5tntt! ill.tflm. Anrlilll OI'lnternat IMdIdtli 15IJ:6J1--6J9.

.. 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 affects both the hematologic and nervous systems. The
hematopoietic stem cells produce abnormally large erythrocytes that do not fully mature. Red blood cells are most affected, 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. Pharmaootherapy 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" deficiency, insufficient folic acid can manifest itself as anetnia.

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In fact, the metabolism of vitamin B" and folic acid are intricately 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 patients 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 disorders 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 deficiency 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 mitochondrial 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 hemosiderin maintain iron stores inside cells, whereas transferrin transports iron to sites in the body where it is needed.
After erythrocytes die, nearly all the iron in their hemoglobin 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

400

UnII4

Th<>(~ ,d""'.",ul.,.nd

.... Prototype Drug

U'I.... ry

Syne<",

I Cyanocobalamin (Ca/omlst,Nascobal)

Therape utic Class: Drugforanemia

Pha rmacologic 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, biWffkly, or monthly 1M or sulxui.ntous injtuions.Or.1 fit.min B" formul.tions
.~ milablt primarily as nhmin supplemtntation,.hhough thty af"! only dftctM 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 ~n ~no,~ by part nttral pf"!parilion~
P.rrottral adminim.tion rapidly rntrses mon signs ind 5)"IIIptorm of B"
defKitncy,lISwlly within. f~daysorWffb.lf tlltdil!'~has bttn prolonqtd,
symptoms may takt Io~ to f"!lOm,.nd IOmt neurologk damil9l' may bt
permanentln most (,Jses,t~atmtnt mu>! olltn bt m.inlaintd for the ~main
del ollile patient's Ii~.
ADMINISTRATION ALERTS
If PO ~r.nions a~ mind with fruit jukH, administtr qukkly btuUSt
mDrbic: acid .IIM tile stability ofvilamin B,,.
Prrgnanq rnegory A(C when ustd pa~nterally)

PHARMACOKINETICS
Onset: D.ys toWffks
Peak:8- 12 h (P01,1 - 2 h (intr.n.san,ind I h (IV)
Halflife:6day\
Duration: Unknown

INTERACTIONS
I)ug-l)ug: Drug il1noKtionl with cyanocobalamin indudt ~ dtouNII'" .bsoIptioo

wflen IJ'Iffi {OII{\I"rmtiy with aIat.oI, ami:.:6.Jk~ic:.oo. fIfOOI1<in,and *:hid~.

ona~oI fIIiI iIfMf withtllfr.!p@Utic:fE'IjIOIlI!'to<)WlO(obaIamil.
Lab 11511: lktlIOWIl
Ik>rbaVFood:Unknown

IINtment afOmda~: Na O'/trdo!..Jgt has bffilf"!ported.

RtI'tr III MyIUIInqQ fDI ~ Mnbrg /'ro(t']5 fuIsp/It: IIIIM Ikr!g.

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 childbearing 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 significant 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)

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ADVERSE EFFECTS
Adft~tflectl from 'Y~nocob~lamin a~ ulKommon.Hypokalemia is possitk;
thus. I!'IUm potas~um Itl'tk'f"! monitorecl periodic.lly. Asmall ~rcenta9t of
p~titml rt<eiving Bu ahibit ralhts, itching, ar amf r \igns of ~Iltrgy. Anaphylaxis is poISiblt,though ral!.
Contraindicatians: Comraindicatiom indudt \emitivity 10 cobak Jnd folk
~cid-deficien'Y .nemia. CYJnocoba Ia min is rontraind iuted in patitnu with It~t~ pulmoni ry diltal!'.nd !hoold bt ulI'd C.utioUiIy in patitnts with ht.n
dM.m btuUIl' of tilt pottntial for lOdum l!1ention (iusfd by the drug.

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 believed 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 depots. 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.

..

OI ... l<r lS Oru9' for Hemitopo""1< O""rd.."

Prototype Drug

Therap~tic Class:

401

I Ferrous Sul fa te (Feosoi, others)

Age-mfor anemia

Pllarmacolog ic Class: Iron supplemem

ACTIONS AND USES

Frrrous sulfilr is an iron SUppiMltnl {omaining 20% to 30% rkrmental iron.1t
ismilable in a widf variery of ONgI'lormsto prr~m or rapidly re'/rl\!' symptoms of iron--drrKirnq anrmii. Oth~ forms of iron indudr frrrous lumirate,
which contains B~ tltmental iron,and fen-ous gUo:Mite, which contains 129f.
rlrment.ll iron. Thr dose 01 thrsr various prepar;nions are basrd on Ihrir iron
contmlln gl'nrral,patirnB with iron deficitnc, I!!pond rapidly to thr idministruion of ferrous sulfall'. Although. positivr thrl1lprutic re5oponsf may br
i{hirwd in 48 houn, therapy may continur lor srmal months to rrpltnish thr
storagl'deplB for iron.
laboratory muation of hrmoglobin (Hgb) or hematocm (Hel) valurs is
conducWd rrgularly, is rl(rs! iron is toxic. Althoogh a positi!' thrrapMic rr!poIU may lit ach~ in 48 houn, thrrapy may rontinur for snrral months.

ADVERSE EFFECTS
Thr most frrqutnt~l'ffoo oIfo=us~tr isGI upld. Taking mr,drugwith
food will dininish GI symptoms but (an <trmi\l' mr, absorpti:m of iron b)' SO% to
70%.In iddition, an!aCids should oot br taktn with frrroui sulfatr brcao:M Ihr)o
also Itdt.Kt absorptiGn 01 tilt minml.ldtally, iron ~pal1tiMS should lit ministrrrd 1hou- brloreor 2 hounaftrr a meal.lron prepariDons maydarllrn stools,
M this isa harmlrss sidfeffra.Constipation is rommon;thrrrfo~ an ilKlNlr in
dirt.lry fibtf may br ildic.nfd. Ell:rssi~ dosrs d iron are vrry 1OlK, and patienB
sIKUd br advisrdto taq.thf mrdiation aKliy.s dirrctfd.
Contraindications: Iron salts druqs Ihould not br usrd in hfmolyti anemia
without documentation of iron derKirncy ~usr iron will not rorlr(t this rondition and it maybuild to toxic: 1eYeIs.Thr drug should not br adm inil1rffll to patienB with hrmochrornatosis, prpti ukrr, rrgional t nttritis, or ukrrativf colitis.

ADMINISTRATION ALERTS
When ad ministrring IV, ~ u rrlulto pre-Y!'nt inlikl1ltion, as iron is highly irmating totissurs.
u th. Z-Irl<k mrthod (dr.p mu.d.) whrn giving 1M.
Do not crush tablet or rmpry conttnB 01 upsukrwhen administrring.
Do not givr tablet;orcapsules within 1hour 01 bedtime.
Prrgnancy utfgory A

INTERACTIONS
Drug-Drug:.I.bsorp!ion ~ rtdlKfd "Ithfn 001 ion ...m an ~ (OIKU!Il'II~' with
MlUOOs, prOlonpump in~ibitoo, or <akium su~n. ~on drcrNII'! thf
ab>orption 0(1l'In<Jd ..... fi~inoIonH,"'" Midronar: .To pr...rl! ""'....
intflactioni, ~ i!iadvisabk> 10 00 iron ~1I1 to 1hcHn iIaoor after 0Ihtr

PHARMACOKINETICS
Bfcausr iron isa naturalsubst.lnce,it is difficuk to otcain pharmacokinrti
valurs.

I!II'dcation~

L1 bTests:fflrous suit... may dea&R!fII.WII <akium IewI and ioo&R lfIum

bii nm

Herbi VFood: Food, ~Iy dairy products, wi in~ibil absorption 0( frrroos

\Ufate. Foods ~ M11 in vitallin ( !lKh as oralMjO ~ and strawWrriI5 (;lI) iIotalf
thf abIorptiJn of iron.

Treat mem of D"ftrdOSl!: Thr ntidoll' for acute iron intoxication is defuroxaminr(Dtslenl). This parenteralagrm binds iron, which is subsequtntly rl'mOl'd by thr kKlneys, turning Ihr urinr ~ rrddish brown color.
III'ftrlJl M)Nu~mgm""QNrJrllnl} Pn::mJ FOOIIlpf(l/{lJIfIr/s~

NURSING PROCESS FOCUS

PATIENTS RECEIVING TREATMENT FOR ANEMIA (FOLIC ACID, VITAMIN Bn ,

FERROUS SULFATE)

Assessment
Basrline nsrssmenl prior 10 admin islr. tion:
o Undentand thr INIOn thedlllQ has ~n prrscribed in order tOillfSslor
tht rapruti tflrm (t.g., t)'pr of anrrnia:lfCondiry to inft.tmmatol)' ~I
disf.N,lack oIvit~min 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 vit~lsigns.AslfSs fat9Je boeI.
o Evakiatr i ppropriate labomoryfindings (r.g.,(B(,rltctro~tes, transferrin and
!e!Um f.. min ~Is, rrnal and liverlunction studir1.)

Potential Nursing Diagnoses

o lnefft~ rlSsue Prrlusion (mated to underlying disorder)
o Activity Intoirraocr (matfd to underlying disorder)
o Fatigur (rrlatrd to underl~ng 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)

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.
(Conr/nued)

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NURSING PROCESS FOCUS

PATIENTS RECEIVING TREATMENT FOR ANEMIA (FOLIC ACID, VITAMIN Bn ,

FERROUS SULFATE) (ConltlUed)
Planning: Patient Goals and Expe:<: ted Outcomes

The pilient win:

ExptneIKt tflefapeutic ttftS <!tptndtnt on the ~ason die drug is lItill!lgil'ft'l !t.g.,e.ptrienc:t inutue in IClMty 1MI,Im ~Iigue Ind shonntSs ofb~h
on tmUon),
BtfrttfMm.Of~minitn.lI,~tfftCls.
Verllizt an unr:lcmanding of the drug's ~,adverw th,and rtqIIirtd prtoutions.
DtmonWollt proper stIfadminimation oftht ~Iion !t.g.dme, timing. whtn 10 notify proicler).
Implementatio n
Inter ve nti o ns and (Ratio na les)

Patie nt and family Edu catio n

hsuring theripeutic effect s:

Cootinur mmmtnts ilSd&ri~ 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.)

nmur.~ adrquatt d~ry~.Hr of rartrinlt whentm JlOssib~. {ommr

iong-ttllll wwienMt.tion as ,pprojIMt.lM.lintaining. hNItIr)o ~t may
~ast the nted lor Iongrrrm suppltmtntatioft 01' win tIIh.IKt thtrapeutit
tffKUJ

FoIIowappropriatt .dministration gumlines. {Following .ppropri;rtl:

administration thn~ muimizes Ibsorption for tnhiMfd therapeutic
tffM,Oral formulllions ml1 requi~ specialldministrarion rtqUiremenu.}

inslRKt tilt ~tinli on W nfflilo return lor periodic lab work.

Tt~

the ~tirftl to in~se ~akr of folic Kid,. vitamin B" ~nd irm

richfoods sud! as:

Fo/'Kacid: Itafy~ ~<itJow !ruits..nddrifd bNru MId peal

'(rt.min BII: fi~ mNI, pouk~eqcJS.milk and milt produm,ind
fortified bltakfast enuls
lion: mms, fish, poullly,ltmils,.nd buns

Tueh the ~tirftt IpKiIic .dministrillion guidtlintl" ilduding:

folic Kid:~ 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 lIom~ , li:juid 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.

Mini.,izing 1m rw effKts:

Cootinur to mon~rx for oJdoimt tfffib, indOOing ~ rash, hypokilltmia,

nausta, vomiting, mnstipation, heanbum,staining of M, btadc stools (iron
pr~r~lions).or tllttgic I'9<tions. (llypokaitmw.nd subsequrnt ~nifiunt
dysrlTJthmiis may OfCUf with Viumin Blr ministrllion. Stailling of the 1Mb
fum liquid 0111 prt~raOOns 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, ~ramt'etS 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 s~'admini!tral ion of dlllg therapy:
When ~ministl'ring mtdiGtions, inruuctthe paUM!, family,rx ClltlJiYrf in

propn w:1f"!m iNstr.tion ttdln~as dtscn'btd nrlirr.nd of plllptl

intl1mu!QJ1ar injt<tion techniqUf forVit.min BII followed by ItIUm
dtmonmatio,dPropn administmion wiB in<rt.w: the efft<tiftntSS of the

d"",

~.H vitarnim.nd Iron prtp.ntims out oftht reW! ol)'Jung childrfn. (Iron

poisoning mi)' lit f.taI in)'OUJl9 childltfl.)

InslnKt iIIr patirnt 10 moIitrx lor s9ts and I}'IIIptDrnI of hypokilrmw

(t.~ rrusdt !taWs!" aitlflpirg,~!) and 10 rtpl ponfdJ.
TtKh the ~titftt 10 inertatt ftuid and fibtf iltakr as part of hi!alltiy
did whitt on iron p~parations and todilut~ rxailiquid fOl'mulations
and sip througil straw p&.ctd in the Nd of the mouth.
El'Kout~~ the patitllt 10 ItSt when fatigutd .nd 10 ~t actiritits

througllout tilt da,to allow for ideqllil~ ItSt periods.

The ~titn~ f.mil): orcartgiftr should lit abJr to lIill! ~ason lot
drug;aPPfOpMt dow: and Khecflllint; what l6ftrw rifms to
ob~ for.nd when to report; and lhe .nticipated length of
mrdlulion tbnapy.

The ~titnl should beablt todisaru appropNlt doosing and.ny

sptciil ~ministralion tKhnKjurs ~rtd rrLrt~ 10 drug t.krn.
Hnl' the ~titnt. f.mit,.or(~r rtlurn-Ormonstl1lt die
1t<hnicpJe until the ptoptr thn~ is used and thty.rt mmlorublt
giving the injMioll.
Tfidl the ~trnt 10 kttp iron p!l'parations and lliumim <onuiring
iroII, in iI SKUll! pL.ct if ~ng childrtft art prtSrflt in tht homt.

Evalu etion of Outcome Criteri a

402

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OIlfetr 11 Drugs for

1Wm~lopole(k

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 ~re not clear, refer to the numbered section within the chapter for review.
of platelets. Oprelvekln, th~ only drug In this class, Is prescribed for patients with thrombocytopenia.

21.1 Hematopoiesis Is the process of blood cell production that

begins wi th primitive stem ~lls that reside in bone marro w. Homeostatic control of hematopoiesis is maintained
through hormones and growth fadors.

28.2 Erythropoietin is a hormone that stimulates the production of red blood cells when th e bodyexperlences hemorrhage or hypoxia. Epoetin alfa is a synthetiC fonn of
erythropoietin used to treat specific anemillS.

21.3 Colony-stimulating fadors (CS Fs) are growth factors that

stimulate the produdion of J.eukocytes. They are used to
reduce the duration of neutropenia in patients undergoIng chemotherapy or organ transplantation.

2&.S Anemlasare disorders in whkh the())(ygt'Il.carrylng capacIty of the blood is reduced owing to hemorrhage , excessive 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 sy mptoms 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

2&..4 Platelet enhancers stimulate the adivity of megakar-

anemia and can he successfully treated wit h iron supplements.

yocytes and thrombopoletln, and Increase the produdlon

NCLEX-RNOREVIEW QUESTIONS

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. in~ 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 sustained-~ tablets in waler jf
they are too big to swaUow.
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. """"
The patient with a diagnosis of cancer is receivingepoetin
alfa (Eposen, Procrit) as part of the treatment regimen.
The nun;eevaluates tbe effecti~"t'IIess 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.

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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,'fedia rrhea.

lb best monItor for ther:apeutic effects from fiJ&rastim

( Neupogen ), the nurse will monitor :
1. Hgband Hct.

2. WBCorANCrounts.
J. electrolytes.
4. RBCoount.
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
p~.

J. periodic ECG monitoring.

4. intake and output measurements.

.. 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 indiClltions (or this drug.

2. A patient Is receiv ing filgmstlm (Neupogen ). What nursing intervtntions are approp riate to safely administer this
dmg and provide patient safety throughout therapy!

3. A patient 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'

~ew

mmnli!r and

f'lopiIf8 fw WC!:8SS wi th i1ildil'OOal ~-stYIe praWce

que!!liDns, IlIIerar:lIie 1!IS(1W!tentl! DnCI ectl'.tieiI. ..~ links, ellkMtlons

resoorces..

and videos. and morel

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Chapter 29
Drugs for Shock

DRUGS AT A GLANCE

LEARNING OUTCOMES

FLUID REPLActMENT AGfHTS 1U}tJI

Blood Ind Blood Products pt1/tQ
Crystalloid Solutions Jll9I'411
Colloid Solutions paJto

Mter re<ldlng rhls chClpt~ the Sfudtnf should be able 10:

(0) norm<Jlsefum lllbumin (AJbumlnar,

O ~tI'f'hr1nf!(I.MlphfodJ

INOTROPICAGENTS

3. Explain the initial treatment priorities for II patient who Is In shock.

4. Compare and cont rast the use of co ll oids and cry$tallolds In fluid

PlosbumJn, others) PIXJlf1

VASOCONSTRICTORSIVASOPRE5SORS

1. Compare and contrul lhe different types of shock.

2. Relate the general symptoms of shock to their physiologic c/l uses.

pogtO
ptJI4J J

ptl/tfIJ

o dopamJnt (Dopasflll,lnm:rpln) IJ1IiW}

AHAPNYl.AXJS , .41J
Q fPlMphrn.(Adrrno/lfl) pogtf/4

repillCement ther,p)'.

S. list the drugs used In the prn.rfTIKothe rapy of anaphyluls and discuss
IMir indiGlltiom.

6. Fo r eitCh of IIw dasses shown In Dtugs at a GI.mc~ know represe ntlltlve

O"ug e kaffiples, and explain their ITIKhanlsmof action, p!'lmalY actions.
.nd Important adverse effectl.
7. Use the Iepoflhe nursing process to care for patients who are
rece iving drug IherapyfOf shock.

KEY TERMS

anaphyla<rN; shod pDgI a

wdiogtliuhock ptJI4aj

crysuloids

hypoYOitI1icWKk pqo

stpticlhod pq );

<oIoiIk

inotropic~1 pl//t4ll

""'" ""''"

ptIIJtU

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poqtG

f\turo9!'nicshoa

(XIqtJiJ

u.,u Tho (a,d""'a5CU'a' and Urinary Systeml

406

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 emer9Qf\Cy;fa~UI'. 10 .."'..Sa , ... c ..... sas ~ symptoms o f .hock

may lead to irTeYenlble orgllf'l dllmllgt lind dellth.lhis chapter examinH how drugs lire used to aid In the treatment of
different types of shoo::k.

29.2 Causes of Shock

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 specific compLaints. Behaviorol changes are often some of the
earliest symptoms and may include restlessness, an.tiety, oonfusion, 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 immediate 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 inability of the cardiovaS(ular system to send sufficient blood to

Naurologi~

R..........
AAAiOlly
eo_

. """",",

"'"
.,..
0....,
' CoO

the vital organs, with the heart and bnJin being affected
early in the progression of the disease. Assessing the p~_
tient's cardiova!iCular st3tus will provide important clues for
a diagnosis of shock. Blood pressure is usually low and cardiac output diminished. Heart rate may be nJpid with a
weak, thre:ady pulse. Bre::IIhing;$ mu~Uy rapid ~nd ' hallow.
~ Figure 29.2 (page407) illustrates the physiologic changes
that occur during circu latory shlxk.

ewelj",,. ." " ...

T8Chycartb
ThrMdy puIM

Low card.., output

Low blood pruaI'"

Sbock is often classified by naming the underlying pathologic 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 present. Forexample,obvious traum3 or bleeding would suggest
hypowlemic:shock, related to volume depletion. [(trauma to the
brain or spinal co rd is evident, neurogenkmock, a type of distributive 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 inadequate 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 <II\lIp/lyl~tK lhoa,.
the most severe typt' I allergic response. The phannacotherapyofanaphylaxis 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 underlying caust' Followed by aggressr.e treatment, is essential, because
the patient's oondition may deteriorate ropidly without specific, emergency measwes.1t iscr itical to use the initial nursing

Reapi"'ory
Rapid bmalhing

ShrIUaw
respiration

Metabo.i....

Law tlKllpllra\u",

"'"'

' Acidoaia

Law uri .... output

PHARMFACT5

Shock
C.rd"""",K. " ... k, ~ it "'I""otb ...,...1, (U U~""IfIJ(,i:. ~~ "IU>(
!elh,1 ronn of shoc:k "Id h.H an ~ to 1~ moruli!, r~tt.
Hyporolrmic ihcxkarrieu 10'M01D31~mortalilY 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.
~

F1g1Ke29. J Symptoms of. patient In sl'lock

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( lIo",tll'

Drug. for Shoc:k

407

Blood voume co~erw.tion

Blood pre.s8Um compensation

Increased rani'"

Increased aldosterone

angiotensin """ration

"""mtion
Incmase<l antidiuretic

Incroasad
admnetgic
ltCtivity

Normal Homeostatic: Response

hormone (ACH) """",tion

r---!~------------------~--~
,.,........
Vaooconstrictora

Norepinephrine

Inotropic agenlo

Dopllmine

Crysialloide

.5".

dexlr<l....-t-!:p

Pharmacologic: Inlu rventions

Colloids

Albumin

Inc.... sed blood

,....,. "'"

Inc mased blood velu:ne

cer<liac output

,. Flgure29.2 Physiologic changes during circulatory shoc k:pharmacologlc Intervention

TABLE 29 1 I (ommon Types of Shock

Type of Shock

Definition

Underlying Pathology

Anaphybnil:

Arult alft9ic: ruction

~ ruction lOan al~n !UdJ .J I pmollil.nut~ WIIbh.

or .Jnimal prot~ns

Cardio9ffiit

Faillft of tilt heart 10 pIIIlP IlIfIitiffit blood to tiSllIf5

Lffi h~n fa~lft.m)'OUrdai isdIffilia.MI.~hmiH,

lois ofblood volllnt

Htmorrha.,.bums, n(!:lli~ dilftlis, or Sl'l'trt yorri~fI\I or

plAmon.Jry tIllboiism,or myocardial or pmyldi.!l infffiion

dianfIN

Vasodilation dut to O'mSlimul~ion of tilt pafjlY~tllttit nm'OIIS syIlffil

or undmtimulition oftlit lY"'pathetk ~ l)'IIffil

Tr.Juma to tlit !pinal lid or m~ul.J. !e'/ffI' mIO~onallll!lS

or pain,or drugs that dtprts\ tilt (tIltr.J1 nm'OIIS lY\ltm

Mu r tipl ~ organ dylfunaion a! i reuk of patoogt nit organilllll in tilt blood;

often i pr!'(II'lOftO i lW ~ratory diltrel\yndromt and cb!tlllilat~
intra\li!\Clllar (oagulation

Widtlpfrld inflammatory repollSl' to bamrial. fun~l.or

parilitkinft ction

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40 8

UnII4 TheCJrdkIY.",ubr ond Url",,'Y Syuem,

interventions of maintaining the ABCs of life supportairway, 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 monitoring (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 pharmacotherapeutic goals are to restore normal fluid volwne and composition and to maimain adequate blood pressure. For
anaphylaxis, an additional goal is to prevent or stop the hypersensitive inflammatory response.

flUID REPLACEMENT AGENTS

Various drugs are used to replace blood or other fluids lost
during hypovolemi, she<;k. fluid repla,ement therapy includes 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 conditions, including hemorrhage, extensive burns, severe dehydration, 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\

whol~ bb:>d
pIa!olna prolrin fraction
Ireh fr=n pia IIIU

JlKb'd ~ bbJd (1"11

Cd""'

plallllil prOirin friction IPla5lllW~ PI~PIt.x,

PLllmatrin,PPF, Protmat~)
dextran 40 IGrollan 40, Hyston. Rhtorn.Krod9) or
dextran 70 IM~)

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 specific 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 between the donor and the recipient. In addition, although it
is carefully screened, whole blood has the potential to transmit 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. Colloid 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 suspended 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 oncoli, pressure. Blood-product colloids include normal human 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 hemolytic disease.
Crystalloids are IV sol utions that contain electrolytes in concentrutioll'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 disorders is included in chapter 3100.

httaslilrm{H~)

oormal SfflJII altllln .., h!ll1an IAltlllnioa~Albutrin,

Bumioat~, Pli5burrin)
Crystalloids

oormal ;IlintIO.9% sodium dIIoride)

lanmd Ringer'1
Plalmal)"l~

hyprrtooio: ;Ilint 13% sodium dIIoride)

5%dextfO~inwatfiIDSW)'

Not Ull'd for \hod:;

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VASOCONSTRICTORSIVASOPRESSORS
In some types of sh<><:k, the most serious medical challenge
f~"illl\ tit" l'~ti"JJt i, I'Yl'u["Il,iuIl, wl,iul 1ll~1 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 replacement therapy have proved ineffective. These medicn tioll'i are listed in Table 29.3.

Cllopltll'

II~ Prototype Drug

Drug' for Shoc:k

4 09

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 placflltil human plasma. Albumin rmurallycomprim about 60% of all blood prot~in . lt< normal Nndion. ~~ 1<1 main"in plas ... olKotic pro"u,," ond to
Ihuttlt, ~ain wb.tance through tilt blood, inWding fat\)' acidl,ctrtain horOlOotSand a .ubnamialrurnoo of drug molecule.Afttrotraction from blood
01 pluma, albumin ~ nffilizfd to ~ pollibl!- cootlmination by tilt htpatit~ viO/\tS or HIV.
Administt~d IV, albumin ilK~astS tht oncotic presu~ of th~ blood and
(,lUstS fluid to I1IOVl' from tht Jj"ue to tht geooal ciKUlation. k ~!Md to~
stort plasma volumt in hypovolemic shock, or to resto~ blood prottin. in patienn 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 high~coo(flltrations mom mwly brcaust tilt risk 01 i Ia~, rapid
Huid lIlift ~ g~attr.
U~ i large"9<lU9l' (16- to 2O"'Jaugt) IV cannula lor administration 01
tht drug.

ADVERSE EFFECTS
BeuUlfalbumin ~ a mural blood prodlK~ the patitnt may havfimiborJies to
the dorm album in and i Ilfrgic ~actions a~ pos,ibl!-. HaMvel', coagulation lac:tors, ontibodie<, ond most oth~r blood protein ...... bHn removtd;tlltrflor~,
tilt in(idfncf 01 allflllK ~iCtioM from albumin ~ not high. Signs of alltrw indude If~~(hill" .. Ill, dyspnea, and po! libly hypott nlioo. Prott in overload may
OCQJr ij rnmive amoums of albumin i~ iofustd.
Contra indica! ions: Comraindications include It'YI'rt i ntmia or (,I rdiac: lailu~ in
the prmOU' 01 normal or in(INSfd inm'/il(ular wiullll',and allfrgy to album in.
INTERACTIONS
DIIII}-Drug: Unknown
l.i bTeru: Normal <;tItIII albumil may i"IoNsI' senJm alblint p/lospIaIR.
HerbaLlFood: lInkncwn
Treatmf nt of OYerdo,e: Therf ~ no t~atllll'llt 10rO'lfrdost.

Pregni nqc.tltgDr1(
PHARMACOKINETICS
kcau~ i lbumin ~ a natural SUbstllKf, it ~ not poIIiblf to obtain phar~netic 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 sympa thetic activity produces vasoconstriction, which mires blooo pressure and inc reases the
rate and force of myocardial contractions. The purpose of
TABLE29,3

these co m pensatory 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 indicated. Sympathomimetic vasoconstrictors, aIso known as

Vasoconstrictors and Inotropic Drugs for Shock

Orug

Routeand Adult Dose(max dose where Indicated)

Adverse Effects

dgoxinIYnaxin,~)11tl'~3.11

IV; d9ialiling dosf 2.5- 5IIKg Mf16 hotI"s for 24 h; maintmana

doll' O.IlH.5 mglday

Nau~ ~MIl<lhf,orHI ri5uo/ disruroooces

sudr al ho~ ~ )'fIIow/9fPffl ~rIgt, Of blurring

br~

Prototypflmj to; OO)

~rhl!tmia~ AVbb:k

dobutamioe lDobuun)

IV;infustdat i rate 0(2.5-40 IIKglkg/min for a muo( 71 h

dopamint (Dop.Jsta~ "tropinJ

epintplJine lAlRnain)

IV;2- 5m(gIkg/min initial dosf;may be D.1Ustd

to20- SO m'9fk9/min
Subalintousl O.I-{l5 mL 0( 1:100 f'lety 10-15min;
IV O.1-1US mL 0( I: lOOlMIY 10-15 min

O llOl"epintphrit~l~

lV:in~ial 0.5- 1 mcg/min, tin-itt

to reponll';l/StI.Il rang r

phenylephrine (tIeo- S)TIfp/M"ioe, OIhel1)

l~ pagf III for the Prototypl' Drug

S-lOllKg/min
1V;0.I- O.18 mg/min until prelU~ stabilize,tbm
0.04--0.06 mglrrin for mainttnalKr

"' ~I
11~1ks

inckattammoo Idvmf rfIf(\~ uodellining inckate 5triOll1advmf rflra~

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I\J4:>irQ~M\. mgNogOfwldnru~Wrtrlliries,
OO'KlUlMI~ dro~ in blood preswrt (hypotemion
(Jf hypttlmsion)

Ta!1!l':(,lrdia !i!bra!!:t!;ar<Iia !"erOOsfl

bypweOlj!Jl dyyhy!bmjn ntnmjul jnjrqjoo
Ijte I!'\T~ IwPWI'O)joo

410

Unll4 The CirdloYascu~ 100 Urlrlilry Systems

NURSING PROCESS FOCUS

PATIENTS RECEIVING IV flU ID REPLACEMENT THERAPY FOR SHOCK

Assessment

Potentilll Nursing Diagnoses

luelin assen mut prior to a.,iniilralion:

Ulldmland w ruson tht drug hil bm1 preaibed" onrr to as~ 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.
Ev.~te .ppropriate ~r.lOry findings kg.. Hgband HCI. WB( coun~
elKtrolytts rterial blood 9iSt's, lDul protein and .lbumin Imls,
aPT or
INII, blood MIUI!S, 1!Il.I.nd li'IfI function studies).

am

~astd Cardiac Output (ulliiowlrular)

Irdhor:til'l' Tisill!' hrMion (rardiopulmon..,. ~plic shod:}

l.rfdGuExch.nge(cardio~J

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 t~ Of
administralion)
Risk for UctsSWt flJid Vdumt (rtllted to drug therapy)

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 appropriil~.
AsItSS"" and prOOlpl1y ~ adw-BI' dfrcti:uchyurdia, hypMmsion,
IttWtthmias,~ling ~ of mnsciOlMfI1, e.sing ~plII' .. lung
congestioft. pink4in~ frot!rt sputum, lIKrt.std urinary output,or .lltJgic
I!actions.

Planning: Patie nt GOllls and b:pec ted Outcomes

1M p.ilitnl will:
ExptMoce ~apru1ic: ~IfKts dfptndtnl on 1M l!iI5OI1 thr drug is bfing gi_ (~.g... improvtd blood jlf('ISln.<aIliiac and u~ outpul witlWl no~1 imits).
B~ frt~ from,or nperimce minimal,aclYerw efkcts.
VMializr an Ulldmtanding of the drucis!M, a.:IvrM eIfrrts,l!Id f'rIIUirtd prKIutionl.

Implementatio n
Interve ntions and (Rllti onales)
hsuring therlpeutk effedl:
ContinU!' ~nt iI\eSIMnts IS alxnoe forthKapell'lic tffects drpmdtnl on
1M I!HOn tM drug lherapy isgMfl.(PuIst, blood pmw~.nd 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 ~mtI!rI.
(.rd'1aC output is witu. narnwl imilS and urine OUlp.ll has incrt~.)
Prome supponiYt nursing mmUftl;e.g., moistening lipsif patient is
im~ttd,~ 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, bypert~nsion,
tact.,.Citd ii, bounding pulst, confusion. IIKrt aling 1M Iof 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
~Ii/l(e btlWftfl Huid voIumt tJlUIl and deficit tmu. F~uenl asstsSmtnU
musl bt madr to drtKl: .nd.void adw~ rflem. Enema! alld invasive
monitoring dmce wil dftKl: early signs of ~ ~ffrdlal Wl'1! is
mon~oring for lhe-aptlllic effrrts.)

(ae.

Fl!qVtntly monilor
Mdroiyte.aPTT..nd aPT or INR ~.((rystalloid
solJUons nwy calM elrrtrol)'te imbilincts.{oIoid solutions may mlUCt no~1
blood roagulitioft.)

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PatIent and Fllmlly Ed uclltlo n

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

p.lin,d~u.or Madacllr immtdiat~ly.
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 ~nl monilOfing of lib voJluts.

(1101'1 .. 2'

NURSING PROCESS FOCUS

Drug,forShoc:k

411

PATIENTS RECEIVING IV FLUID REPLACEMENT THERAPY FOR SHOCK (ComlniN'd)

Implementation

Inte rventi o ns and (Rati o nale s)

Patient and Fa mily Ed ucati o n

Wtigh patient d.Jily and Il'port Might gain or lou of 1kg (approximately 21b)
or mOIl' in a l (.-hour pMod.lDaily Might ~ an a((urate mNWIl' offluid siaM
and takes imo mount imake,outpu~and irunsibit Iorm.Weight gain or
l'dem~ may signall'J(i'\sil'l' lkJid l!JiJlIII'.)

uplain to tilt patitnt!llt rationale for i ll eqJipml'nt lMd for

'Mighill9 me patitm and tht IIffii for frtquent monitoring.

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.)

lnstllKtthf patient to Il'port dyspllN, it(hing.. m-lings of throat

tightr.es~ palpitation~ (hfst pain or tightening..or headache
immodiml)o.

Patint understanding of drug therapy:

lIII' opponunities durill9 admin~mtion of meditations and during asm lmtnlS
10 disrus5 the rationait for drug therap)', dtsill'd Ihtraptutic: 01/101 rntS, and an~
nt<rssary monitorill9 or pll'(iution~ (Usill9 timl'durill9 nulloill9 (.;Ill' ht ipi to
optimizr and Il'i nfor{e IUpportiYl' drug treitment ind (.;11'1'.)

Iht patiem andlorbmiy Ihoukl heableto !latean lJIdtmindilg oftht

ll'olIOIl for !he aug. equipmt mwd, !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 ~rm (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 low1rtJr Ihtst 1lIIM9 <KOOIIS 1JIIII1.
Stl'1lAo MJIlingI'rocm fooJs l.tllt!,{oo{Xl111 fori1formriln rtltd !tl ~ltf'flfrykd1i(!l" ~),Qnd{III)l1'r 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 USE S

Norepinephrine ~ a sympalhom iml'lic: that iets dill'(t~ on alpha-ad 1l'III'19ic: 1'1'{epton in \\!I(\J1ar smooth mUl(ie to immedial~ rai5t blood PIl'"lIUIl'. To i
lesm degree, it allO ltimulites btta1-ll'(eptors in the hfar~ thul producill9 J
positive ioouopic: mponlr that may irKll'lIf cardiac output.ltl primary indications all' Jane shock and urdia( Ultl!. Norepinephrifll' ~!he 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 on~ Ito 1
minutes after tht infusion is tt nnimed.
ADMINISTRATION ALERTS
Sunan infusion only afterensurill9tllt patencyof tilt IV.Monitor mt llow
ra~ (ominoous~.

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

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)'ptrlenlion. Whtn first admin~tt ll'd, reflex bradpn:lia ~ sometimes txperitn(ed. h
alia has !lit ability to prodlKe I\!rious typtl of dysrhythmia~ ilthough less 10
than other v.J IOpll'Isors.1i nUa"liSation O!rurs, the drug may WIIf II'rious ~in
and 10ft t~SUI' 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 d~ to blood voiuml' derKits because \\!SO(on!lriction already exists in IlJ(h patients. Noft'pin~hrifll' may cause add~
tiona!. It"Vl're periplltral and vilaral '/aI()(onllrKtion with dt<reJsed urilH'
rotput. Norepinrphrint is oot usualI)' gwen 10 patients with munterk or ptripheral mrular thrombosis, hem llf tlltre ~ ~n 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 tril:yck~nl:l!lli'f po1fnti.JIt'~

effem. DigoIil,IIaIotIianf, ind qdopropalM' !IIi'f ilKfNlf 1M rilk of dyW)1hmi.l~

PHARMACOKINETICS

LlbTeru: Uni:nown

Onset : l ~lmin

Herba VFood: Unknown

~k: l ~lmin

Treal ment of OYfrdosr: Qilrontinuill9 the infusion usw I~ ll'Iults in a rapid reYI'~I of adYl'~ rifeal mh i l hyptnrnsion.

Halflife:Unknown
Duration: Unknown

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lifter Ie M}M!rJmgm for Q Mmirrq I'n:Im! forus lpf(1k Ie IIri5 drug.

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 organ 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 continuously monitored and adjusted to ensure the desired therapeutic effect has been achieved without significant adverse
effects. Thel1lpyis discontinued as soon as the patient's condition stabilizes. Discontinuation of vasopressor th"rapy is
always gradual, du" to the possibility of rebound hypotension and undesirabl" cardiac effects.
Vasopresson used to treat shock include dopamine
(Dopastat, Intropin), norepinephrine (Levophed), phenylephrine (Neo-Synephrine,others), and epinephrine. Because
dopamine also affects the strength of myocardial contraction, 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

29.6 Treating Shock

with Inotropic Agents
As shock progresses, the heart maybegin to fail; cardiacout~

put decreases, lowering the amount of blocxl reaching vital

tissues and deepening the degree of shock. lnot~icagen1s have
the potential to reverse the cardiac symptoms of shock by increasing the strength of myocardial contraction. For e.'Ulm~
pie, digoxin (Lanoxin ) increases myocardial ooml1lctility and
cardiac output, thus quickly bringingcriticaJ tissues their essential 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

I Dopamine (Dopastar, lntropm)

Therapeutic (lass: Drug for shock

i
,

INOTROPIC DRUGS
Inotropic agents, also called cardiotonic drugs, increase the
force of contraction of the heart. In th" treatm~nt of shock,
they are used to increase the cardiac output. The inotropic
agents are listed in Table 29.3.

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 dtptndent on tlltdose.At low dosn,thedrug !de<:tiYel~ slimulalesdop.miO!'r<jK re-c~torl, r5pKg I~ in lilt kidO!')"S, leading 10 mod iLllion and 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 incft'a~ng caroioK output. Anothrr beneficial ~l of dopamine whtn given in
higlltr dolrs is ill abili!)' 10 stimulate alph.J-adft'llt19ic ft'C~ton, 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 tlltdt~ft'd thtraptUtic Nrecl. alwl~ doub~-{htck dl\lQ cakulalions btfoft' giving tilt drug.
Ilo\ra'INtioo occun,adminisler phtntolamine 10 tlltalt<l of infikrilion
as lOOn .1 polli~.
Pft'gnancy cmgory (

ADVERSE EFFECTS
BecalM 01 its profound elffCls on tilt caroiolllsculil, S)"Ittm, patitnll rrceiving
dopamillt must be rontinUOl.JS~ monitoft'd for signs of dysrhythmi.u and h~
~nrnsion. Ad'ieBe ~lFfCls .ft' normally ~If-limiting bec.iUI!' oltllt lhort h.lflife 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.
Contraindicationl: Dopa mine is conlraindicated in patimts with ph_hromo
cytorn. or ~mtrirular 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
~1 \\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'\IeIsal 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 aMIsJnq Prors Foo/s spKl/Ic IIIIM /trig.

PHARMACOKINETICS
il1~t: 1- 2 mil

f'eilk: Unlmov.n
Hall~ i~:2 mil
Duration: ltslilian 10 min

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( ... pt .. zt

DIuc.I' for Shock

41)

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 inw~ase in cardiac output
assists in maintaining blood flow to vital. organs. Dabutamine has a half- life of o nly 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 peripher~l
vasoconstriction (a lph~, activation) and increasing the
focce of nl)'Q~... ,.dial contraction (bela, ~,,;val;on).
Dop~mine has the potential to cause dysrhythmiu and is
given only as an IV infusion.

Fest Mart fill.

o Decroa!l8d eordiae

COMPLEME NTARY AND A LTERNATIVE T HERAPIE S

Horse Chestnut for Venous Ins ufficiency

Hono!(htwu fAt1Mts~11IIIIIIII) 5. larqttm Illti10f IIlC11.11hmttm
Evropt dtu 5 _wUtd thl'JU9hout lMworicL nefruil of t!Iii 1m! (011IilinslftcklM art~ IIonfdtetnW,wbidI_wl!lfdicin.il Ptsofthl!
Im!.kt tilt UnWi ~ ~ Gulled. ~ 1rM.
TfaditW I.MS for ~ dltstrart indOO~ ~atmn of joint indO~f inlIMn 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 ~ ~fol(t may impn!'Ir ('IllYmptoml (Pinlef & Ermt 2(06). Rmxtioll in Irg swelling, pain
and itdti~1 oWJr I~ td.ing the druq for 2 to t6 Wftb.
50mf dltrniuh in hontdtetJtut ~Slrt 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 dosa.H~rb-ug intmcticm IflJ QUf l hotst dItstIIUI is uktft (llll(Ull!ftdywiltl ~ mcdifim .. h~ druqs.
1lRnIow,~indlildmt,u"bfbul.

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00,,",

M .....

odilalion
.,.......
V..

Hmamine

retell""

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 allergen 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 intlammatoryresponse. 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 difficulty 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.

.--

......

Sttondloconstridicn

~ F/gU'~ 29J

Symptoms of llnaphylaxls

.-

."""....,

29.7 Pharmacotherapy
of Anaphylaxis
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 necessary, the dose may be re~ated up to three times at 10_ to 15minute 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 bronchodilatorsuch~ s aJbuterol (Ventolin, ProventiI) is ofI~" ;oill,ll"~t~,,,0..1 uy ;,o..IlaJ~t;u" tv rdi~"" tl ... ~~ul~ ~hurt.u~~
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 sew ro] hours ~fter the initial evenl.
Nearly all drugs have the ca.,..bility to allJM' anaphylaxis..
Although this isa rare adverse drug effect, the nurse must bIi'

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 emergency cart. The most common drugs causing anaphylaxis
include the following;
Antibiotics, especially penicillins, cephalosporins, and
sulfonamides

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 desensitization regimen would involve administering an initial dose of
0.01 mg of the antibiotic and observing tht' patient for allergy. The dose may then be doubled every 15 to 20 minutes
until the full dose has been achieved. Desensitization has

NSAIDs, such as aspirin, ibuprofen, and naproxen

alsu u~~" a~hi",v...u [Uf pati""ls with a'piri" - i,,,.Iu~...u a,(hHla

ACE inhibitors

who require aspirin therapy for another condition.

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, anaphylaxis 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

&

COMMUNITY CONSIDERATIONS
-

Recurrent Anaphylaxis
Palifnn with a history of I!(UfI!nt ~naphyluk ma~ bt prtllJibNl epin~ phrin~
10 be ~H-administ~~ imramusruLul), ia.n .utomatic: injtct.bIIo rievic:t
(EpiPm).lnl1rud thfs~ patitou 1"t9.!ding .. ~"pm lIorq.nd dilposal.nd
lilt proper injection I~(hniquf. ElKourage patients to UI~ tilt medication-flff
"tr.int( .uto~njrll pm 10 proKtic:t tht If(hn~. Advist patitnu to fXptll
som~ mrdic:.Jtion to rtm.Jin in tht pm following injection and to report.ll
~s~ requiring pm lJIa9t to thtir lIt.Jhh (.re proYider. Advis~ patitnts 10
'M'ar. medic:aI.1ert br'(fltl or IIf(kLuf stating"allerq(.nd 10carl)'.J meditation .1Ierg)' list in walltt or purse.

I Epinephrine (Adrenalm)

Therapeutic (lass: Drug for anaphylaxis and shock

;<

HOME

Phannacologic (lass: Nonselective adrenergic agonist;vasopressor

ACTIONS AND USES

Subc:utalll'OlIS Of IV ~ntphrint is I drug of dJoic:f for .Jnaph)'lu~ bmlU it
can R'rot man~ ofthr dis~~ng symptoms within minutH.Epilll'phrinr isa
nom~lIiv~ .JdR'llflgic: '90n~t. srinwLning both alplY- and beta-adrenergic:
Il'ptors. AI molt im m~diately after injrllion, blood prrs~ re rnn dut 10 nimubtion oI.lpha, IfitptOrs. Atw.Jtion of ~t., 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 htut.ln addition 10 Ihr SC
and 1M roul~S, topic:.J~ inhali.tion,.nd ophtlYlmic: p~rations .re mil.blt.
The introKardi.( route is used lor cardiopulmonu"I rrsus(itation undtr fXlremeronditions, uswllyduringopm cardi.J( mal.. ~,or wh~n no othtr roult
iSpoisiblt.
ADMINISTRATION ALERTS
P.rmierall'pilll'phrinr is ~n irritam th.tlN)' (.lUll' tislUf d.mage if fXu''alalion occurs.
Plf9nanq categol)' (

ADVERSE EFFECTS
Tht mOSI (ommonadv~rll' effl'moftpintphrint are ne!\'OIMf"I5, trrmo~pal
pitations, ta(hyi.rdia, dizzillHs. hNdoKhe,.nd nioginglbumiog U lilt sit~ of
applic:.Jtion. Wh~n .Jdministt~ plrentt rally, hyperttnsion..Jnd dysrhythmia!
ma~ oc(ur rapidl)';thrrmrr, tilt pititm lhould he monitored wtlull)' following inj~ctiolL
Contraind i(ations: In life-threatening (onditions IIKh as.J n.phylam, th~re art
no ablOlute rontraindications forth t UIf of tpinephrint. Tilt drug must bt usf<!
with (aution, hown~~ in patitms with dysrhythmia!, U'l!brom(uiar in~lfi
(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 OtMS~imftiG.
MAOinhibbr\ tricydk antid@p"~~B, .Jnd. iOd bfli~ ....tI
iMibit thunions of rpilfplu..... Epilll'phrine will dfmR the HlHll of b@Ii
bIotb.>rs.~9l'IlI"aI~may~thehHrttotheeffKtlof

..,n,.trint.

PHARMACOKINETICS
Q,~t 3- S min (subruianeous); S- IO min (1M)
~. k:lOmin
HalHi~: Unknown
Dur. tion:l -4h

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Lab Tl5Is: Epirlfphrint may ~!fIIIII pot.mium IHl'I.

IIerbaVFood:Untnown
Tru tmmt of Oertbsr: Ovrrdost ilia)' bf lI'riw!,.nd alpha- and beta-.HRnergic:
bIodr.trs art incicattd. Hblood pressure remains tigh,. 'I<lIOdiator IN)' be adminintrrd.

 ~~ 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 sectIo n within th e 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,crystallo ids replace lost fluids
and electrolytes; colloids expand plasma volume and
maintain blood pressure. Whole blood may be indicated
in ca.ses of m assive hemorrhage.

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 cardiac 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.

NCLEX-RNOREVIEW QUESTIONS

The patient in hypovolemic shod: is prescribed an Infusion 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 ~ls.
4. maintain vascubr voIUIJlt'.

]. Unuswl bleeding
2. Hypeiilytemia
}. Anaphybctic reaction
4. Hypotension

The nurse eVlIluate5 the effectiveness of dopamine therapy

for a patient in shock. Which of the following may indicate 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
Dobutamine (Dobutrex) is used to treat a patient experiencing cardiogenic shock. Nursing intervention includes:
1. monitoring for fluid o~oad.
2. monitoring for cardiac dysrhythmias.
}. monitoring respiratory ~
4. monitoring for hypotension.

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Teaching for a patient receiving pluma protein fraction

(Plasmanate ) should include reporting which of the following possible aID'erse react:lons?

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.
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

416

UIIII.4

n-.. /J,dloY....:ulM ,00 UrlNry Symm.

CRITICAL THINKING QUESTIONS

1. A p.1lienlis on a norepinephrine (Levophed) dr ip for cardiogenlc shock with a blood pressure of 84/40 mmHg.
Why Is this palient on this medicatlonr What nursing as.sessments should occurr When and how should the norepinephrine drip be diSl;ontinued?
2. The health care provider orders J LofO.9'*' normal saline
(NS) for ~ 22-year-old p~tient with vomiting and diarrhea.
and a heart rate of 122 bpm and blood pressure of
102154 mmHg. Is th is 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 appropria te for
this patient? Why or why not?
See Appendix D for allSwers /ltId rationoles for 01/ oniv;ties.

OPlORE

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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.

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Chapter 30
Diuretic Therapy and Drugs
for Renal Failure

DRUGS AT A GLANCE

LEARNING OUTCOMES

LOOP DIURETICS

After reading this choprer; the studtn! should ~ able to:

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
/D}t42S

Carbonic Anhydrase Inhibitors

Osmotic Diurttks (}f415

,. bplllin the role of th e kidneys In maintaining fluld,elecl rolyte,lnd

add- base balance.
2. Explain the processes that cha nge th e composition of filtrate liS It
travel s through the nephron.
3. Describe the "djuslments In pharm"othefllp)' that mu st be co nsidered
In patients w ith 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 nur~'s role-In the pharma<oIogk rnlIIl~ment of renal
failure,and in diuretic therapy.
8, Foreach of the danes snown In Drugs a t a Glance, know representative
drugs, and eMpialn the mechanism of drug K tlon, primary actionl, and
important advene effects.
9. u~ the nursing process to care for patie nts who Ire re<elvl ng d rug
thel'ilp)' fOf renal failure. and diuretic therap)!.

KEY TERMS
diu~tK poIjf420

nfphron Jf1Jf418
rfablorplion ptJI}t4l!

fi~r.tf ~m

rmalf~ikn plJ/t418

mbonknh,drnt

ptlI}t414

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~rttion {1Jgt m

urinllylis

(!I19t4ll

418

U""~

TheCardlcHo"ubr oodUt11101ry Systeml

he kldne)'$ S('l'Vt' an amazing role In maintaining home-

ostasis. By filtering a volume equivalent toalllhl.' body's

ntracellular fluid 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 iKlditlonal 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 excretion. Although this is certainly true. the kid neys 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 (cha pter 2)00 )
and erythropoietin, a hormone that stimulat es red blood
cell productio n (chapter 2800). In additi on, the kidneys
are respo nsible for the production of calcitrio l, the active
form of vit~ min 0, which helps maintain bone homeostasis
(chapter 47OJ11: .1t is not surprising th~t our overall heaLth
is st rongly dependent on proper functioning o f the kidneys.
The urinary system consists of two kidneys, two ureters,
one urinary b13dder, and a urethra. Each kidney co ntains
more than I million Mphrom, the functio nal un its of the
kidney. Blood enters the nephron through the large renal
arteries and is filtered through a semi pe rm eable membrane known as the glomerulu s. Water and o ther small
molec ul es re:a dily pa5S through the glomerulus and ('Iuer
Bowman's capsule, the first section of th e nephron, and
th en th e proximal tubule. Once in th e neph ro n, the fluid
is called filtritte. After leaving the proximal tubule, the filtrate travels through the loop of Henle and, subsequently,
the di stal tubule. Nephrons empty their filtrate into common co llecting ducts, and then into large r 3nd larger collec ting s tructures inside the kidney. Auid lu ving the
collecting du.::ts a nd entering subsequent porlio ns of the
kidney is called urine. Parts of the nephron ar~ illustrated
in .. Figure 30.1.

Renal Disorders
A~hcugh mOl't tIIon 17,000 kidney trlnlf'lanb Irt perfonntd Inn~11):
mort thin 70.000 PfopIr arton a Witting I~t lor I rtplictment kidlle1.
Oneof f'lelY 750 ptOplt ~ bom with a linglt kidlle1.A~nglt kidney ~
largtr and mort \\llnrratk!O injuryfrom he,nyl.mct lpotts.

About 21,000 Amrriam wfftr from dUllnit kid~failurt, lnd SO,OOO

die innu..ly fnm (JIM! rNlftllO tIR ~_.
T)'Pt 2d.t~ iltht lNding rnM ofdwnK kidMy faiUe.~ting
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

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Many drugs are small eno ugh to pass through the pores
of the giome rulusand enter the filtrate. If the drus is bound
to p13sma protei ns, however, il will be too la rge, and will
continue circulating in the blood.

30.2 Renal Reabsorption

and Secretion
When filtrat e enters Bowman's capsule, its composition is
~rysimilarto that of plasma. Plasma proteins such as albumin, however, are too large to pass through the filte r and will
not be present in the filtrate or in the urine of healthy patients. 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 th rough 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 reabsorbed, leaving o nly \. 5 L to be excreted in the urin e. Glucose, amin o 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 Bowman's capsule may still enter the urine by crossing from the
blood to the filtrate in ~ process called tubular~mion. Potassium, phosphate, hydrogf.'tl, and ammonium ions ent er the
filtrate through active secr~ion. Addie drugs secre ted in the
proximal tubule include pm KilIin G, ampicillin. sulfisoxazole, nonsteroidal anti_inflammatory drugs ( NSAlDs). and
furosemide: Basic drugs include procainamide, epinephrine,
dopamine, neostigmi ne, and trimethoprim.
Reabsorption and secretion are critical to the pharmacokinetics of drugs. Some drugs are reabsorbed, whereas othem are """ reted into Ih cfih .... te. FOTexampie, approximately
90% of a dose of penicillin G enters the urine through se<:retion. \'/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 reabsorptio n and
secretion are iU ustratoo 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 o r the result of disorders in other body systems. 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
Befo re pharmacotherapy may be comideroo in a patif.'tlt
with renal failure, an assess ment of the degree of kidney impairment .. n~ ry. 11K' basic di agno:ltic to t i. a .. i."'~

(lIo",trIO DIJ'I'II(Thenpy and 0"'9' lor Renal F.llu.e

EtIo",nt

P9rmbwlr

'--~~"

GlomerU,,"

arta."

."o.m.

tubul.

--

F '" FiU.ation: blood to tlbule

R" Reabsorption: hbH to blood
S" Secretion: blood to tubula
E'" E""",tion:tubule to
_mal ""vi......,.,.,.,t
~

419

To blltdder and

To """,I
"";n

eldernal enviromant

FlgureJO.I Thenephron

which examines urine for the presence of blood cells, proteins, pH, specific gravity, ketones, glucose, and microorganisms. The urinalysis can detect proteinuria and albuminuria,
which are the primary measures of structural kidney damage. Although it is easy to perform, the urinalysis is nonspecific: Many diseases can cause abnormal urinalysis values.
Serum creatinine is an additional measure for detecting kidney disease. To provide a more definitive diagnosis, diagnostic 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 ftltrate 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 functioning nephrons. As nephrons "die," however, the remaining healthy nephrons have the ability to compensate by
increasing their ftl l ration capacity. Thus, patients with significant kidney damage may exhibit no ~ymptollls wltil
50% or more of the nephrons have"died 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 treatment 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 renal hypoperfusion, which is lack of sufficient blood flow

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 dehydration. 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
Indication
lof~nion

AmphomidoB

SySlmic:Jotiflllgal infffiioo

Angiotrnsin-<onl'l'rling ffil)'IIIt
lACE) iohi~lOO

HTN, lINn f~ilufl'

(i5pIa!inkarbopl~tin

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Viral iofffiioo
Nonsteroidal ~oti infliOTnJttwy

Inllimmi!ion

d'ugs INSAIIlI)
Prntamid~

RoIdiographic: (ontrJSI aogffil!

IliaoJIosi! of ItidfW1 ~nd n IeWr diIordm

4 20

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 failure may go undiagnosed for many years. By the time the
disease is diagnosed , impairment may be irreversible. In
end-stage renal disease (ES RD), dialysis and kidney transplantation 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 management is often necessary to prevent worsening of renal
impairment. Depending on the stage of the disease, dietary management may include protein restriction and
reduction of sodium, potassium, phosphorus, and magnesium intake. For diabetic patients, control of blood
glucose through intensive insulin therapy may reduce the
risk of renal damage. Selected pharm acologic 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 significant dosage reduction in patients with moderate to severe
renal failure. The importance of this cannot be overemphasized: Administering the "average" dQse to a patient in 5eVfTf

renal failure can have fatal consequencef.

DIURETICS
Diuretics are drugs that alter the volume andlor composition of body tluids. They are indicated for the treatment of
HTN, heart failure, and disorders characterized byaccwnuIation 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 particularly 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 Na ~ to the urine. Chloride ioru (CI- )
follow sodium. Because water molecules also travel with
sodium ions, blocking the reabsorption of Na ~ 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. Because of the abWldance of Na ~ in the f.iltrate within the loop
of Henle, drugs in this class are capable of producing large inueasesin urine output. Otherdrugs, such as the thiazides, act
by blocking Na ~ in the distal tubule. Because most Na ~ has already 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 minimal effect on potassium ( K~ ) 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

.....

Pathogenesis

Treatmrot

l<idntyl arr unablt tol)"lll~ mough

~~i1 for rrd blood (ti prtdJaion

Epottin alfa (Prouil, Ep:>gm)

H)"pt!blrmia

l<idntylarr unablt to~I~ly nUl'I~ pota'Jl,ium

Diml)' rrsuiction of pow~um; po/yItyrrrH' stMat~ IKaywlat~) with lab~ol

H~Im1ia

l<idntyl arr unablt to~t~ ~lUI'It 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 Mamtr(R~1

HypmoIrmia

Kid~art uoablt tou(rtl~ suflidmt sodum ,lIId

wmr,ltading 10 wattrrHffi~on

Comphcatlon

H)"pOUktmiil
Mmbolk addosis

Dittary rmklion 01 sodum; loop tiIRtKs in iM~ 'IIditions, thiazide tiUrttKs in

m~dror.ditiOlll

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)'

l<idntyl arr unablt to~I~ tlUl'tt mttabolic:

Sod!l11 bit.Jrbmatt or sodium citrate

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(lIopltllO

DIu'ell, TMnpy and ONg. lor ~ F~lluff

42 1

PHARMACOTHERAPY ILLUSTRATED
30.1 Mechanisms of Action of Diu retics
o.molic di_;'"
Act on the pruoojmaI tubu'" .00 !he ""'" of
Henle, to create an 0Im0Iic fore. thai pub
water ;"10 the
,Old i~ Ihe
aliiolectrolyl_

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

..

loop diuretic,
JIw:t on the ~ng Ii"*' of the loop
of Henle to block !he ~Iion 01
.odium, chloride .,d
Excretion
of ~ 1.1nc....M<i

w,'.

po~

....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

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 therap y are that the incidence of
ac!\'erse effects is docreased and the ph;lrmaoologic effects
(such 3sdiuresisor reduction in blood pressure) may be enhanced. 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 combinations that include diuretics in dude the following:
AldaC\3zide: hydrochlorothiazide and spiro nolactone
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

LibraryPirate

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 excreted by the kidney in a very short time. loop diuretics are
used to reduce the edema associated with heart failure, hepatic cirrhosis, or chronic renal failure. Furosemide and
torsemid ea re also approved for HTN. Doses for the loop diuretics are listed in Table 30.3.
Furosemide is the most frequen tly prescribed loop diuretic. 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 p0tential to produce serious advt'rse effects, including deh~ra
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;

422

UnII4

TheC.,d klv ..:ula, 00<1 Urinary SY'tem.

TABLE 30 3 loop Diuretics

DN'
bumetan ~

(Bum!'lj

Route and Adult Do5t> (max dose where Indicated)

Adverse Effects

1'0;0.5- 1fll9lday,1MI rrpti! at 4-- 10 ~h inrmai lif IItI'dtd

(max: 10 mgldar)
I'I'IIM;05- 1mg OW'I 1- 1min, ,~puttd MrY 1- 3 houl5 PRN
(max: 10 mgldar)

Mioor hypokoltmio, pI1WO/ hyportmioo, rmiflll,

lI<I~tfa"M4 dl1inru, /'Qrigw

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 mg fdo~)

f1n!ffil ~ (L1~x) (It!' pag!' 330

forttw, Proiotypt Drug boJ; OO )

I'O;20-BO mg in si"* ordi"lid~d <iNs (madOO mglday)

~0I5ffi1~ (Dmladu)

='

I'I'IIM; 20-40 mg in ~ng~ or djyjdtd dole !4ltO 600 mglda!'

-

POllY; 10-10 mglday (max:100 mglda, )

Ildio indicit~ {OOImon~ftf~m;~indicit6 ~.dm~eflem.

potassiwn supplements mar be prescribed to prevent hypokalemia. 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.

30.6 Pharmacotherapy
with Thiazide Diuretics
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

TABLE 30.4

tion. Their primary use is for the treatment of mild to moderate 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.
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 thiazides, although they are included with this drug class be
cause they have similar mechanisms of action and adverse
etfects.
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

Thiazide and Thiazide-Like Diuretics

Drug

Routeand Adult Dose (max dose where Indicated)

Advel"le Effects

1'0;250 mg- l glday

1'1';1.0 mq- 1gld>y in <inglt O< two diYidtd do ...

Mioorhypcko /mlio, ~

SHORT ACTING
Q

dllorothiilidt (Dillil)

h)'ltodllorothialilr (Mirroz~)
(5e~ piljt 304 for th ~ Proiotypt

PO;15- 100 fll9lday al~"* or rividtd dolt (m.x:SO mglday

forHTN; lOOmgfdayformu)

Drug boJ; OO)

INTERMEDIATE ACTlNG

btndroftLmelhWidt and oadolol (u.zidt)

mtiolu OIIt (Iaroxolyn)

PO; I ubltt{dar (40-&:1 mg nmIoII5 mg bmdIoIhrmtlhialilr)

1'0;1.5- 10 mg OIK~ d,iiy (max: 5mg/dol)' for HTN;1OfII9Iday
for ~dtma )

LONG ACTING

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

for~dema )

ind.Jpimidt (LmoI)

1'0; 1.15- 1.5 mg OIK~ d,iiy (max: 5mgldol)')

mtllrfdothimdt (Aquatm lm, EndJIOII)

1'0; 1.5- 10fll9lday (max: 5mgtdol)' for HTN; I0fll9lday for ~delllil)

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Signifi9nl hypobl..,io.
d~plelioo. dehydr.lfon

tIKi.

hypotension.

hmonatrrmj' byprodyCflllj.! ((())' blood

"""'"

Cll.1pt0l30

Na+, K+, or 0 - may occur with overtreatment. Concurrent

therapy with digoxin requires careful monitoring to prevent
dysrhythmia.<; due to potassium loss. Potassium supplements may be indicated during thiazide therapy to prevent
hypokalemia. Diabetic patients should be aware that thiazide 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 lea~ through the urine. When Na + is blocked,

~.

Prototype Drug

Dkl,"'I(Then py and 0"'9' lor Renal F. II",,,

423

the body retains more K+. Because most of the Na + has already 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 thiazide 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 potassiumrich foods to their diet. Intake of excess potassiwn when taking these medications may lead to hyperkalemia.

I Chlorothlazlde (Dlunl)

Therapeutic Class: Antihypertensive,agent for reducing edema

Pharmacologic Class: Thiazidediuretk

ACTIONS AND USES

ADVERSE EFFECTS

1M most (ommon indk,tion ior(hlorolhiuidt ~ mildto lIlodmte HTN.1t may

Ur:tssioss of w'ter and ~ledrolytfS can i)((lJr during chlorothi.uide phlN(otlil'rap)'. Symptoms ioc:Ude miBt, 'ftam~ I!>thargy, mUl(I!> (lamping. hypolfnsion,and tac:hyutdii. lieuUS!' of thf polfmially sfrious {onlf~t-! of
hypokiltmia, pltienn (ooc:urrrmly takillC) digoxin should be utclully mon~
tored. Thf intlke of polas~um-rKh foods should be ilKru!l'd, and K~ suppltmenll may be indicalfd.
Co ntraindi alli ons: This drug is (ontraindiutfd in ~Iifnll with anuria,
hypokaltmiJ, Sf"lfll' hepni( or II'nal im~irmfnt. and hYPf llensitiviry 10
sulfonamide-!.

br (Ombin~ with omf r Intihypertl'n~W1 in lilt mukidrug thtrap)' of !f"I'l'Ie

HTN.1t is also presaibrd to tINt lkJid rr1fmion dR to htan flilure, liYel" disfJIl', and (onic:ostf roid or rstltM}en mfrlp)'. Wlltn thf d",g is givfn orJlly, it
may II~ 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 ral~ of 0.5 9 OYer Smin when admin~tfring int~rminfl\tIy.
Whtn idministt rillC) IV, take speliil Wf 10 avoid ntrmsation, bK.iUIl'
Ihis drug is highly irritatinglotissurs.
PlI'9 nJ IKYUitgory(

PHARMACOKINETICS
On~ : 2h

PO;lS min IV

~k: l~h

PO;30 min IV
Halflif! : 45- 120 min
~n: 6-llhPO;2hlV

INTERACTIONS
DnJ}-D"'l: WhMg ..... ,onrmmtywilhotluor ilnlih)'lW'fl...u."\ odIiI .... PIfIorn
on tmd preIlln wil OUII".Wh@ndllonlthiazidfisadmir:i:lK>lHlwithMnphotflil:il

8or (ortic:osIl'loids, the risk for IIypolr.Jltmi: fll"em inaNlel. AntidiabetK

mrdutionsllKh j\ 511l1orl)hmsand inIu~n may bf ifss ~wIII'I1 t.Jkin with
(hIorO!hia!icko. OIoItstyramRand (~oo- theabsorption of
(hlor~ Coooirrto1l mnistralion wth dgon ~ (~t~1Iidty ~ to
inaN>;N potas ~um and magnesium lois. AkOOoI poitlltiates the Il)poltlllft anion
of \OIIIf thiazidlo dilnli:5,and u~may inaNsf durflis.
Ll bTfllI: OlIorothiazidf may iOOfH StIIIII a!l)"Ift ,aIue\ ind
1Uf000omophthalffi (SSP) Iflfntion. Ma, 00- proIMlboood iodi~ (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 IiIof, il iargl' amDlftS, may WIWII h)1lotalem.. When IMd wi!lt
(hlorothialide. gintgo ~ mayinaNsf IMIod pII'IllR.lIIf with IIawthom may
mu~ inaddiriv-.> ~poter6ivf eIIerts.
TlNtmem of OYt'rdose: TlNtment indudt>s Auid andelectrolytf infuliooslnd
drugs !Mel to ri ~ blood prtlsull'.
It!ftr Ie M)NUB InqnI for Q Nurlifll) I'rIKIn foals lp1k Ie IhII ~

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424

UnII4

TABLE30.S
Drug

The

(~,dloYaKub,.oo

Urinary Synefm

Potassium-Sparing Diur"tics
Routeand Adult IJosio (maxdo5e where Indicated)

Adver5e Effects

"mikHid. (Mi,,".. or)

1'0;> m~dlY (mu:lO rngIdoy)

M'"", !ry"''*''Itmio, htDdht, frlrigtH,

tplmIIOfN' (lmpra)

1'O;1,- SO mgOlKtdaiy [max: 100 mgldolY fof HTN;SO m9i'doJY for hun faiull')
1'0;1,- 100 mg 1-1 timffidoJY (mu; 400 mglday)
1'O;'iO-100 mg bid (mu; 300 mglday)

gynK0/I1Q5Iio

"

SjiItW'dlOllt (AldiClmt)

triamtmot (Dyrrnium)

lidifl inditit~ COIIIIOOII ~ tfl'ffls;.!.!:lli!!i!!m.inditite strioos ,dm~t/feru.

30.8 Miscellaneous Diuretics

for Specific Indications
A few miscellaneous diuretics, listed in Table 30.6, have limited and specific indications. Two of these drugs inhibit
carbonicanhydra~, 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 patients with open-angle glaucoma (chapter 4900). In addition to its diuretic effect, acetazolamide has applications as
an anticonvulsanl and in treating motion sickness and glaucoma. lt has also been used 10 treat acute mountain sickness
in patients at very high altitudes. The carbonic anhydrase

..,. Prototype Drug

I Spironolactone (Aldactone)

Therapeutic (lass: Antihypertensive,drug for reducing edema

i
,
o

inhibitors are not conunonly used as diuretics, because they

produce only a weak diuresis and can contribute to metabolic acidosis.
The osmotic diuretics also have very specific applicatio/lS. For example, mannitol is used to maintain urine flow
in patients with acute renal failure or during prolonged surgery. 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 intraocular 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

Pharmacologic (lass: Potassium-sparing diuretic,.aldosterone antagonist

ACTtONS AND USES

Spironolao:tone, th~ most frrquemly pmc:ri~ potmilm--sparing diurHic: is
prill\l rily used to 111'11 mild HTN,oftl'll in combination with oth~r antihyperttn
si"ltl.k molY bt lMIl to 1I'd(J(~ ~a aSICK;,ted with kidney orli!'rdism~i1nd
it is tfleo:ti'lt in mwing lhe proglffiion ofhean faikrll'.
SpiroOOW({ on~ IUS by inhibiting aldOlt~ront, lhe hormolll' mrHtd by the
adren,1 (OrreX thit is responliblt lor increasing the II'nalll'absorption of U!+
in 9(hangt fOf K~ ,thus (ausing watu II'tention. When lkiosimlll' is blocked
by spironol"tolll', N, ~ and wale, 9ClMion is incll'alfli and th~ 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 fixed~ combination with
hldnxhlorolhiuidt.

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 (OIKUl1l'IIt~ taking ACE inhibitors.. Signs ,nd symptoms of hy
ptrblemia include mus<1e Wt'aklll'ss, fuigut, I nd bridyu rdi'.l nm~n, spirooo
laaolll'un CilUgYlII'ComiStia, impot~n(t,and diminished libido. '&I11I'II m,y
uptfifnu IIII'IIItrual illl'9uiaritifs, himrtism, anc! bll'lSI ttnlierlll'lS. When
serum potassium levtls III' monitoll'd ull'ful~ ind lI\Iinrained within oormal
v,lutl,ad~ tffKtS from spirooow(tolll'ar~ ulI(ommon.
Contraindications: Spirooola(tolll' is romraindiuled in patitms with anuria,
significanl impairm~m of II'MI function, or hypmalemg. SpironoL!dont is
rontraindiuted during Pll'9nancy and LKtilion .

ADM INISTRATION ALERTS

INT ERACTIONS
1AlJg- 1AlJg: 'M1Hr~~~ MIlt ammonirn <IIIotiM,iICidoIis
m.Jf !KCUL Aspirin and 0IhH s.alicylar:1'I m.Jf droNse thr riu"flK ~lIea of the
mtdication. (oocUJltfllllll' with digoxin m.Jf dooNSf 1l1li' IIIi'm of digcl;i1. WIlI'I1
ubn with potlS~um ~ts,ACE 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

Gi"ir with food to inmall' tire ablorption of thr drug.

Do not gM- K~ supptem~nts.
PlI'9nallQ catf901l 0

"'~

PHARMACOKINETICS
iAlset: 1- 2days
Pl!ak;1- ldays

Lab lests:SpironoLKtOlll' m.Jf i KIUlf ~1fIIiI cortisol nlkli'l, and m.Jf n~1
wfth IffIIm gllKOIt dflHrllinalion.

Half~ifto:12-14h

Tll'iltmtnt of Overdose: Tl"Ntm~m is supportive and miY ill(ludt oJ9!'nts 10

II'pw(t' Auid and ~ro~tes lost through dilll'lis, and drugs 10 raM blood
PIl'SIUII'.

Ouralion:1- 3 days or mort

LibraryPirate

IlerbaVForxl: Use with hawillJrn m.Jf R'IU~ in adcim"lf h)'POlensl"lf ffIem.

(1101'1,,10

Dkl,,,,I<lhe... py and Dru9' lor RenoII F~lklre

42S

TABLE 30 6 Miscellaneous Diuretics

Route and Adult Dose (max dose where Indicated)

0""

Adverse Effects

CARBONIC ANHYDRASE INHIBITORS

iK~woIamidt (Oiamox)
metharol.Jrri~

(Neptll.Jnt)

PO;l50-l75mglday

fJrro/yrt imbolonm (Q~ fllllIStQ, M1mi D'ng. dizzirlfSS

PO;SI>-I00 mg bid-tid

QrhWlion. blood dysaas@s. paomop ~nia fludd p.m!y!is,

hrnIoIytil an~mia. alllalli!: aomlY

OSMOTIC DIURETICS

giyc:mn (CoIaa, OImoglyn)

PO; 1.1>-1.8 gItg. 1- 1 h brior~ ocuLar IU~

fJrro/yrt imbolonm (Q~ fllllIStQ, M1mi D'ng. dizzirlfSS

maoo~d (Ow~roI)

IV; 100 9 .. fused IWtr l--i. h

Hyponalltrllia

ulI'i(Uruphij

IV; 1.1>-1.S QI'kg IW~' 1- 15 h

NURSING PROCESS FOCUS

~i ronl'Jlsion~ @dMalliia

PATIENTS R'CEIVING DlURETICTH'RAPV

Assess me nt

Baseline assrssmrnt priort o administration:

Undt,mnd the II'iIson the drug has ~n prt'S(ribtd in onitrto iSseS for
thmpMic:effeds.
Obmin i lomplttt IINkh history ilKluding wdiova!<Uludilfiif, diabett~ and
pregn~nQ or breastffeding.Obt~in i drug hislOQ induding ~lIergit~(urll:'llt
prt'S(ription and OlC drug~ herbal plI'poIrations,IM of digoxin,lithium,OI
intihypMens~ dlll9l,and alcohol UII'.Bt iltn to pouiblt drug intmctions.
['/illuate appropriate IaborMO!), findings SUlh i Selearolytes, gillloll', CBe,
h~atK 01 Jl'llil fulKtion nudie,uric acid leYeh,and lipid profile.
Obtain ~leIint '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

Pote nt ial Nursing Dillgnoses

OefKitnt FluidVoume (relattd to a~1II' rflects of diurtlin)

Fat~
~lI'ased Card'1iK Output (relattd to i~1II' elleets of diurtlic:s)
o...lKitm Koowltdge (drug thmpy)
Risk for Falll, Risk for InjJ!)' (lI'Iattd to hypotl'll5ion,diuiness
moc:iattdwith~fif~m)

Risk for FulKtiolli IlnrononelKr (1I'1ated to diull'tic: use)

Risk for NOIKOOlprrallle (1I'lattd to idVflll' effects of drug therapy)

~Ianle.

Assess mrnt thro ughout ildministration:

A,~, /0, do<i...d IhrrapMK ~fff<n (. g., a<loquat. urill<'output.Iow.1I'd BP ~
gi~ for HTN).
ContinUl' pl'riodic: monitoring of ~(\ro~te5,gIlKOII', (Be, lipid profilf~ li'f!'r
limlrion studies, (II'iItininr, and uric ilid (eo,ocls.
Alses for and prompt~ rt port i~lII' elleeu:hypJttnsion,poIlpiUlion~
diuines~ mUI(ulosIceIetal ~a kn~s 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 1I'fIt~ tathYUldiil
dym.)'Ihmia~ de<lI'ised urinr OUIpu~ and weight9<lin or loss O\'ef 1kg
(approlimate~ 21b) in a 2Hoo, pl'riod Ihould be II'plntd imllll'diate~.
Plll nning: Patie nt Goal s a nd 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 miniO\i~ id~flll' eiferu.
Vtrbal~ 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)

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426

UnII4 Th"C.rdloY.<;(ubr.od Url",,'Y Syuem,

NURSING PROCESS FOCUS

PATIENTS RECEIVING DIURETIC THERAPY (COOUnuw)

Implementation

Inte rve nti o ns a nd (Rati o na le s)

En suring thf'il peutic effects:
CominUl' fre!p'M aS~Yntnu ilSd,,!(ribtd til rlitr for thtraPfUlic tffts: uriIII'
output ~ inc:lt'ned, blood p~SUIt' and puiS!' alt' within oormallimits or within
p.11i1mt1m!!'l by tht hNhh we providtl.(Diult'm may be rrodnal\' to
txtrt'llll' dl"ptllding on W 1)'pt of diJmic gi'll'll. BP ,hoold lit within nannal
limits without the prestna of It'ftex tachy{ln:I ii J
Daily ~ighn should JI'fllain at 01 do!!' 10 ba.tlilll' wright (An i~ in
wright Oftll kg perday may indic.!t" rmssiYt lkJid ljiIin. Adttlt'ilS!' ofOVff
1kg ptrday ma~ indicatt tllltS'Mo diult'l6 ilnd dth)dration.l

Minimizing ildft rse rifttts:

CominUf to monitor yj",l.iglll.Tilko blood prturtlyir.g.,itting.' nd "ilnding
to dtiKl onhoSlilric hypoil'llsiolL 8t wniour with tht tldtrty who art at
inc:lt'iI!!'d risk for hypottRlion.(DiJ~iu It'dKt circulating blood wlumt,
ft'IIlking in _red blood Pftssult'.Dnhostatic hypott lllion II\a)' ilKlNS!' the
riskoffalk.)

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

stud~~ (It'atinilll',and urit ilcid te-;m. (MOlt diult'liu {,IUS!' 1015 of Na + and K+
Ind may inc:lt'iIst lipid,gkKost, and urit acid ~J

CominUl'to monitor heiring Ind balanc:t, .. poning ptrs~iI'IIt tinnitUl or

~rtigo promptl,. (OlOtoool)' may ocru~tspt(ially with loop diurtliu.)

En lUre p.1I~nt saftl)', tspt<ially in the tIdtrIy. ObS!'1'fI' for diuilll'!5. Monitor
Imbulation until tlfttt.of drug alt' known.(Diuinffi from OrthoStltK
hypottnrion nwy oc(ur.)
Wtigh the p.1Iient dail)- and It'port significant ~ight ljiIin,or Io.~ Mt.tsurt
intlbo and output in the horpiulill'll p.tt~m.(Daily wright ~ an H(Uratt
rntiIsu .. of fluid ,tlIUI il nd ubos intoatcount inuk~ OUIpul,lnd in!!'lllibk
1os~.Diu~~ is indicated by outputlignirKilntly g..attr than intikt.)

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

tlenroiytl' imb.J iii IKts. (Be(\rol)'ll' imb.J b IKt, milY <KCU. with diu rtlin. Most
diJ .. tiu Glust Na+ and K+ 1os. PotmiJm-sPlring diu .. tia may ItsUh in Na +
10.. but K+ in{"'blt.)

Pati e nt a nd Fa mil y Edu cat io n

Tum rho
10 from lying o ining to "ilnding <lowl)- to
.woid
diuinffi or falls.
p"~m

LibraryPirate

Ttim tht pal~m. family,o,aregi'ltf how 10 IMnitor pu~ and blood

plt'lSUIt'. Ensult'w p!OpfI" US!' and functioning of any homt
equipmtnt obtained.
Havt tht p.1titm wtigh !til daily ilnd It'(ord weight liong with blood
plt'lSUIt' Ind pu~ measult'flltflts.

ri

In.trod tht p.1titnt to .top tlking tht mediution if blood prt'SUIt' ~

90160 mmHg or beIow,or palamtttrs It! by the htahh art providt~
and promptl)- notify the proyidtt
InstllK! tht p.1titnt on the ~ to It'tum ptriodiuliy lor bb work and
10 inform bbolalOry pmorIntl of diult'lic therapy when providing
blood or uriIII' slmplts.
Advi!!' tht p.1titm toa~ iI wallet idtntifiution card or Wl'iIr mtdiul
identification jtwtlry indiuting diuretic therap)'.
Havt tht p.1titnt rrpon pefS~ttnt tinnitUl, il nd balana or coordilliltion
probltrm immediattl)-.
Instruct tht p.1titnt to all for iII!istan(~ prior togening out 01 btd or
altempting lowllk alone,and Io.woid dri'ling or other adivitits
rrqJiring mtntll aleflntlS or physicll mon:linatiort umil thetffeo:tsof
tht drug art known.
Havt tht p.1titnt weigh !!'If daily, ideally at the SilIIIt timeof day.Havt
tht pat~m repln a weight 10" or gain of mort than 1kg
(approximattly lib) in .t lHtour ptriod.
Advi!!' the patitnt tocominllt to (Olllume tnouqh 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.
Ttlm tht pat~m that H(ts~!' htat ronditions (ontribul\' to 9(ts~!'
swrating and fluid and t ltctrolytt lOI5,and extra aution ~ warranttd
in tlltst ronditions.
InstllK! tht p.1titnt taking poulSium-wosriaq d'ure6u (~.gy thiazidts,
thiazidt.Jikand loop diurttin) 10 consume food! high in pom~um:
Ir!-rh fruits IlKh IS st,awOOr;" and ballilrw;dr~d fruits IlKh as
IpricO" t nd prunr.;.rgoubin ilnd kgum~'lU(h I.tomlton, b.rt~
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 IO~ with a heakh care Plll'lider befort
"'king ';lImn.nd mi""",1 ouppItrnmt. or 'pr<;'Iim! .porI> brvt"'9"~
(Typial ore sports ~f.g.,G.ttorade and ~ade,nwy 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)'.)

NURSING PROCESS FOCUS

PATIENTS RECEIVlNG DIURETIC THERAPY

(Continued)

Implementation
Interve nti ons and (Ratio nalu)

Patient and Family Edu ca tio n

Ot-w for Ii9nsof hypoUImJia or ~rUlmlw.USl' wlh cwtion" p.ltitnb

taking cortKoste!Oids, AlE inhibitors, Il\Cjiot~ nmff<tptOl' blodtn (AR&),
dig<*in,or lidlium.RtpOfI symplorns 10 tile hu~b Wf pmicltt pJmptl)o.
(ThW~ thiazide..lilo:t, ind Ioopdiurttics on uusr hypoulemw;potassium-

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 Iol~ 10
al'Oid hypoblrmw or hyperb~.

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 hYfll.'rblemw .CDncu~t 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 sof hyperglyumii. Ust with caution in patirnl5 ...nth di.lbetts.
(Thiazide, Ihiazide..lilo:t, ind loop diurtrics may aIIsr hyptl9l)'Ctmia,t~iilty
in cliibHics.)

InslRlct the patient to rfPOrI signs Ind symptoms of diabtttS fMllitus

(r.g., potydipsw,poIyphigii)or rlr-tnfd blood ~r 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.

Ob_ for symptOrm of gcuI.(OiurWa may c.Jusr hypmIricemia, whieh rna,

rtS4Jlt in goutlile conditio~ "cWl\Cjwirmth, pain, ttndernru, swd~ng. ind
~S around joints, irthriti5liR symptoms,and Flfllilfd ~rnrnl in
afftfd joints.)

ImlNct the patienl 10 pftllI1jlIly n'pOri sigllS and symploms ofgoullO

the lItilttl C~ prO'lidef.
k<Jdl tlltgoutlll1)1W ~tto incrtalt fluid intakt, wli'IQid
sbrIffish, orgin flll'ats {t.g., mr, bllIrJI), alcohol, and high-fructOst
bevtrlgM.

O~ for lll!lbuming if ptOlonged II.IfI CXpolUft has occumd.{Milny d-..n'oo

c.JlI5t photOst~itMty ind .m i~asrd 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.)

InSIMI the patient 10 wtar sunSl:rttn wi prote1vr dotting if

prolofI9'HI sun BpcI\.IIn' is I nticip.lt~d
InslMI the patienl to rfPOrI in, fluliu symptoms: shormns of
brt~h, IM~ sore mroil, ma~ioinl p,in,or profound f~iglle.

P.tint undt~"nding of dnrg tht rlllY:

Ust opporlunitie5 during administr~ion 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 p~atrtion!.{lkin9 timr during
mIning art helps 10 optimizt and rtinflm key I9d1ing Irm.)
Patint sftfadm inislrit io n 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

Tilt p.!tifnl, fimily,orcategi'lel should be ~bIe 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 ipproat~ clDsing

.Inc! adminirnation fIefds.

disruplion of sftpfromnocturia.(PropeI.inistrltionincrtueslllt
tffI1vrIltsS of the drug.)
EVlLluatlon of Outcome Criteria
Evalll.Jl~ tM

rfWti'lmtSl 01 drug IflrriPJ by ronfirmillll Ilia! patRnt 00i1l otrId Bpt(Ird out{om~11Y1'I' been flll'1(see1'lanninl(l.

Stt ra5JQ.1 thvuqhJO.4foffsIJ rt dNgH~ whidI rIef ~fiIin~.

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4 28

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 exception 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.
H OM~

&

COMMUNITY CONSID~RATIONS

Nutritional Therapy for Patients Needing

Diuretic Therapy
The patient lI'quiring diuretic: ther. py at hom!' nffils detailed Mrition~1
INChing. Till' nu~ should also pro'/ide tmhing with family membt~ 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 inlerPfI'ting food labels. Thffl' may be added 50dilm and po~sium 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.

COMPLEMENTARY AND ALTERNATIVE THERAPIES

Cranberry for Urinary System Health

NNrt,< tl'l'f)'Ont is familiarwith till' bright red (ranbtroo lhat all'filtenduring hoIidly time. MillM< Americans I.Md till' (olorfu~ ri~ benie to UNt
wounds,and to IU~ anorexia ilnd for othe<d~tNe (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 infKtions. 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 !U9ges~ Ihill "anbtnYs
can pK'I'I'Ilt I)'IIIPlomatic: urinary ""t infections in KIm!' Piltieon,~ially
in women who hal'!' re!UlR'llt infections. It is import! mto Mle that ("nberry
should bt taRn 10 prtl'l'lll,OOI ~at. 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 baoct~riil growth ,nd m,y bt (oomindicaltd in dj,~ic: patitnu. Som~ indjyidwk may plI'f~r 10 takt mnbtl!)' tapsuits, which illI'a"lailablt ill most drug SIOI!1.

. '; ': Chapter REVIEW

---

KEY CONCEPTS
The [Jumi.>t:roo k.ey

~u[J,""plli

provio.l"

~ su~d[J~1

SUflJHtary uf Ihe

iHlpur1~[J1

poi[Jls from lhe

~urr ... 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

30.5 The most emcaciousdiuretics are the loop or high -Ct'iling

acid-baSt' baianCt'.

agents, which block the reabsorption of sodium in the

loop of Henle.

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.

30.6 The thiazldes act by blocking sodium reabsorption in the

303 The dosage levels for most medications must be adjusted

in patients with renal failure. Diuretics may be used to

30.7 Though less effective than the loop diuretics, potassium-

maintain urine output while the cauSt' of the renal im pairment is treated.

distal tubule of the nephron, and are the most widely presc ribed class of diuretics.
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 bypoperfusion (mannitol).

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

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.

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

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(1101'1 .. 30

Which of the following clinical manifestations may indi ,ate the patient is experiendng hypokalemia?
I. Hypertension
2. Polydipsia
3. Cardia, dysrhythmias
4. Diarrhea

II

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

Dkl'l'!l<Th..npy and Dru9' for Renal F~IIu,e

429

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

A patient with a history of CHF will be started on the

potassium-sparin g 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

CRITICAL THINKING QUESTIONS

1. A 43 -)'\'ar-old man is diagnosed with hypertension following 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 ca re
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 ~ontbination 105anan ~nd 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?

J. A 17-year-old male patient is admitted to the ICU following 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 .. P!apar~ for S!ICC\!I&S with additiorl3l 11ClEX"$\yIe pr.u;li c&
QU!S1ilns. InteractM! assI g nm~ nts ani actlllltfes, web finks, anlrnatOO.

and iide05. and 1IlOfe!

f!oglSlo, YO"' 3<CO"" code frn m 1110 fro'" of )'OtJ' book at
www.myn ..u.gkilcom.

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Chapter 31
Drugs for Fluid Balance,
Electrolyte, and
Acid-Base Disorders
DRUGS AT A GLANCE

LEARNING OUTCOMES

FLUID REPLACEMENT AGENTS {1J9t41l

Crystalloids and Colloids plqt4Jl

After reading this chapter, me student should be able to:

Q dexrron40(Genlron40,orhl'f'5) pagtm

ElECTROlYTES PIX1f36

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.

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

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3.
4.
S.
6.

Compare and contrast the use of colloids and crystalloids in IV therapy.

Explain the importance of electrolyte balance in the body.
Explain the pharmacotherapy of sodium and potassium imbalances.
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
hyperkalemia PJI/I'4J8
hypernatremia po:JI437
hypokalemia pq438

filN}t4l1

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

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 chapte r will examine drugs used
to reverse fluid balance, electrolyte, or add-base disorders.

31 .2 Osmolality, Tonicity,

FLUID BALANCE

and the Movement of Body Fluids

Body fluids travel between compa rtments, which are separated by semipermeable membranes. Control of water balance in the varioIU oompa n 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 U)[", i~l. ur wale" w1,kh
serves as the universal solvent in which most nutrients, eleo::trolytes, and minerals 3re dissolved. Water alone is responsibl~ for about 60% of lhe total body weight in a middle-agt
adult. A newborn may contain 80% water, 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}<omparlntmt, 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-

-~
lnltlntilial
Iuid: 12l

Celt: 2S l

.......,
3l

"
"
"
,

""'
,, ,

,,

m
, ,
, "

,
m

"
m

C>OITIPI'Itrr...-.r:

a>rnpmrtmenI

body -...ighI
~ c/ body weigl!
FlgunJI.1 MaJor fluid compartmPnts In the body
M)'JI. of

lationship between these fluid compartments is illustrated

in ~ Figure 3 1.1.
A continuous exchangt and miring of fluids occurs between the various compartments, which are separated by
membranes. For example, the plasma membranes of cells
sepu":Ite the ICF from th. EC F. Th. """,Uary membran es
separate plasma from th e interstitial fluid. Although water
travels freely among the co mpartments, the movement of
large molecules and those with eieo::trical charges is governed by processes of diffusion and active transport. Movement of ions and drugs across membranes is a primary
concern of pharmacokinetic.s (chapter 500).

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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 significan t
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 so lut es, in 1 k~ (I L) of water. In most
body fluids , three solutes determine the osmolality: sodium,
glucose, and urea. Sodium is the greatest contributor to osmolality due to ilSabundance in most body fluids. The normal osmolality o f body fluids r:anges from 275 to
295 milliosmols j>eI" kilogram (mOsmlkg).
The term 100iOtJ is sometimes used interchangeably with
osmolality, althou gh they are somewhat different. Tonicit y
is the ability of a solution to ca u~ a mange in water movement across a membran e 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 arta s of high solute
con(~ntration (hi gh osmolality). lfa hyparon;c ( hyp erosmolar) IV solution is admini stered , the plasma gains more
solutes than the interstitial fluid. Water wiD move, by osmosis, from the interstitial fluid co mpartme nt to the
plasma wmpartmenl. This type of fluid shift removes water from cells and can result in dehyd ration. Water will
move in the opposite direction, from plasflUl to interstitial
fluid, if a h,paronic solution is adminis tered. This type of
fluid shift could res ult in hypotension due to mo'em en t of
water out of the vasc ular sys tem . Isotonic solutions will
produce no net fluid shift. These movements are illustrated in .. Figure 3 1.2.

4]2

UnII4

The

(~,dloYaKu b ,.oo

Type of

Movement of Fluid

infusion

~
:/- ~
.. .... 11' ..

l.o,rnw

------ .

io

plasms

Equal osmolality: No not ~uid change

,
~

R uR

.. '" solute

(a) Isotonic

Urinary Synefm

(b) Hyper10nic

I_MOO
"'~

I......... ,."ed osmoIaI;ty in plasma: W",,",

moW$ !tom cells and ;ntlH'Slitiailluid
10 pia""",

(c) Hypotonic

.'.

. "'"

O"C ..... sed osmolalitv ;n plHfTKI: Wate,

moves !tom pI .... ma to ;nt.... titiailluid

,
.. 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 beverages. Water output is achieved through the kidneys, lungs,
skin, feces, and sweat. To maintain water balance, water intake 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 hy~rtonic. 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 secreted by the adrenal cortex. Aldosteronecauses the kidneys
to retain additional sodium and water in the body, thus increasing the osmolality of the ECF. A second hormone, antidiuretic 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.

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Failure to maintain proper balance between intake and

output can result in fluid balance disorders that are indications for pharmacologic intervention. Fluid deficitdisorders
can cause dehydration or shock, which are treated by administering oral or intravenous (IV ) fluids. Fluid excess disorders are treated with diuretics (chapter J ()OO). In the
treatment of fluid imbalances, the ultimate goal is to diagnose and correct the cause of the disorder while administering 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 volume 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 administeringfluids via a feeding tube. In acute situations, IV fluid
therapy is indicated. Regardless of the route, careful attention must be paid to restoring normal levels of blood elements and electrolytes, as well as fluid volume.
Intravenous replacement fluids are of two basic types:
crystalloids and colloids. Crystall oids are IV solutions that contain 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 isestintated that two thirds of infused crystalloids will distribute
in the interstitial space. Isotonic, hypotonic, and hypertonic
solutions are available. Sodium is the most common crystalloid 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

01 ..11., lt

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 de~
pends on the solute (sodium) concentration of the fluid ad~
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 rnpidly expand circulating blood volume, care must be taken
not to create fluid owrload in the patient.
Infusion of hypertonic crystalloids expands plasma volume by drawing water away from the cells and tissues. These
agents may be used to relieve cellular edema, especiallycerebral edema. \'/hen patients are dehydrated and have hypertonic 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 compartment without causing a net fluid loss or gain in the cells.
As the dextrose is subsequently metabolized, the solution

.... Prototype Drug

Drug<; for Auk!

B.laoe... ElKtrolyte..OO Ack!Base Ol1ord .... '

433

TABLE 31 .1 Selected Crystalloid IV Solutions

Orug

Tonicity

Normal saiillf 10.9% NaClI

Isotonic

Hypl'rtonic: sa~1If 13% NaCI)

Hypotonir salilt 10.4S% NoJCn

I/ypI'rtorir
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

,% ootrw in lKtittd fliogtfJ

kotonic:
Hypl'rtonir
Hypl'rtonir

S% ootrw in ~{yt~ 56
* ~ ~111_ ~

mmbolized quid!): the \OIUlion i, _imts ronsidmd

Irjpotorir.

Dextran 40 (Gentran 4O,others)

Therapeutic (lass: Plasmavolume expander

Pharmacologic (lass: Colloid

ACTIONS AND USES

D~l~n 40 ~ j poIysrharide that ~ too Lt rg~ to pass through r.pilb ry w,lIs.1t
~ ymilar to deJmm 70, m t pt delllran 40 h" a lower moltwl.r weight OnIran 40 .ill by "i,ing tilt O>ll1otic: pl!"S!U~ of t~ blood, tht reby rausill9 f\Jid
to rTIOVl' from t~ int~r>tilial ,p-i{fS of t~ tiuUl'S to tilt intrava>cular spart
(bIood).G~n " ,In IV infusion, it has t~ (ipability 01 ~panding pia,m.i "IOJUnit within minutes.lter admininration.Cardiovallular I!"Spon>es ilKlude inclN,td blood pRSSurt, inllUled(irdiac outpu~and improvM W'nous rmlm to
th~ hNn.Dutrao40 is tllft'ifd rapidly by tilt kidn~~ Indiutiom ind:JdeftJid
rfP],(l'II"IPllt 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 .dhesiY~nt\5 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 ~mboli.
ADMINISTRATION ALERTS
Em~fgeIlC"/ .dmin~tration 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 btuu,~ deJmn romain, no pretrvuiYes.
PlI'gn.nqutegory(

PHARMACOKINETICS
OnW'!:wral minutes
PNk:Unknown
Halflife:Unknown
Duration: 12-24 h

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ADVERSE EFFECTS
ViLli sign! should be monitom:l continUOUlly during dau,n 40 infu!ions to
prt'I~nt hypMl'nwn WIsed by pla,m. voIumt npan>ion. Signs oIlIuid MrINd indude tar:h-,urdia, pl'riplltr.1 tdtma,distl'nded n~<k ''ins,~pnN,or
raugh. A>m.1I pMtntagt of palitonu.~ . n~rgir 10 dextran 40, with urtiuria
being the mo>l (ommon ,ign.

Contraindi"tions: D~IlI"n 40 is (ont"ind iuied in p-itients with rt nal failuft'

or ,tl't~ dehydration. Other (onmindiution, inrUde ,tl'tft' CHF and hyper"IOltmicdis~.

INTERACTIONS
Dru;rDrug: ThHtn nodiirMIy ~nbt intHaaions.

I.i bTI5U: Dextran .0 may p"oIoo9 bk>edill9linf.

HerlIaVFood: Unknown
TlNtmtnt ofDvrrdo~: For pi!~rm with oormal ft'n.1 funrtion,dis<ontirwtion oftht infusion will mull in rtdunionof .Mrse ~ffKH.Pati~nu wilh rl'nal
imp,irmtnt rrwy bellern from tilt admin~tr.llion 01 an osmotic: diufttK.
It!(pf ro M)Nunllrgm for Q Nunlnlj I'rfKnj fOOIllpKlk ro rIr/s dnJlj

4] 4

UnII4 TheCJrdkwasc:ubr.oo Urinary Syuem,

NURSING PROCESS FOCUS

PATIENTS RECEIVING IV FLUID AND ELECTROLYTE

REPLACEMENT THERAPY

Assessme nt

Pote ntill l Nursing Dill gnoses

Bilselin e assess ment prior to administration:

Understand the ~il50n the drug h" bffil PI&ribtd in order to n~ for
theraptUtK tfifcts !t .Cj., tepIao::~ment theraP'J', t~.tment of shoc:k}.
Obtain a complete health hillo!), including wdiol/ucular (including HTN,
MI),neuroiogic (inckiding (VA or h~id injury), bums,tnOxrine,.nd
hepatic or ~n.1 dimst.Obtain a drug hinOl)' ilKluding .1I~"lie,(\JlTI'm
plecription and Or( drugs, .nd herbal p~parations.1k iltn to pol,iblt
drug int~r~ions.
Obt.in bastlilll'~ht .nd vital ,ign" 1t~1 of Conlliou!.neS (LOC), b~ath
IOUndI,.nd urin.ry output "appropriate.
E..,luate .ppropriatt labmtory findings (e.g., eltctrolyle1, (Se. uriIII'
s~ilK glivity and urinal)'lis, BUN and c~.tinilll', tot.l prottin i nd
.Ibumin lnels,aPTT,.PT or INR, ~nal and Iml function nudifl).

Derlci~n1

Fluid Volumt

Dec~iltd Cardiac: tMtput

. ht~

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 (~latN todrug thflapy)
Risk lor In~ff~til'f Hfilth Mainteoan~ (~arding drug eflemand dittary
neeik)

Assessment through out administration:

AsstlS fol dtlittd therapeutic ~ff~n (f.g., tlectrolytt va 00 Mum to
within nooni Irange, 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 outpu~ mu!(1t we.me, or
cr.mping, or allergic ll'<Ktion!.
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, f1Ktro1yt~ v.lut!
within noonal fimits).
Be frtf from, or experience minifllill, .dvers~ tfftm.
Vtrbalizt an understanding of the drug's Ust, ad'Iers~ tfifcts,. nd Il'quill'd prKolution!.
Demonllrale prop!'r selh:fministration ofthf mtdication (f.Cj.,d=, timing, when to notify provider).
Imple me ntllt ion
Inte rve nti o ns li nd (Rilti o nil les)
En suring tht rapeutk effects:
Cominur frt~m a!stSVIlf nU a,dtlcribtd tarlitr for therapMic ~Iferu.
Aslin the patitm with obt.ining fluids and with ~.ting a, needN.(Urillilry
output i< within nollllllllimiu.OtctroIytf b.lllK~ i> ""tom!. Tho .ldtrly,
inf.nts, and patitnu who u nnot <KCtlS fluid! or tat by ihemSl'ives, e.g.,
poIt.(VA,aft'at ilKll'iSI'd risk forfluid.nd t ltctrol)'lf imbalanc:~J

Minimizing ildftlSe effects:

Monitor for signs of lluid ..oonll' m~ or d~fio:it, 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 inbalalK~ 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 ~ially if aooc:iated with \i(hyca rdia, dtc:ft'iSI'd !line
output..nd Il'izUft'l aft' Il'pOIItd immtdiat~. (Many fluid and tltarolyt~
inbalalKl"I h.M linilar 'ymptoms.When n!l"lSing the patient for adv~
~1Itct!,rol!licler pall h~tory, dl!lJ history, and rum-nt condition and
mtdiutionl to comate 5Yf!!PtomI to pcrssib~ calJstS.)

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Plltie nt li nd Fa mily Edu ca ti o n

T~ach the patient to cominur to COOIUnll' tnW9h liquid! to ft'fIIiIin id~ttly,

but not 0Yffiy hyd"ated. DrilkirJ;l when thirst): I'IOidrJ;l akDholic: btveli9fl,

.... 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 !bi~ and ft'(ord weight along with blood
pft'lSUft'.nd pulst mfiSUremtnls., .ppropriate.
Tta(h the palitn~ famil)-,orcart9mr how to monitor pulst and blood
pft'I\U~ if lII'edtd.Ensuft' proper UIf.nd fUnctioning of any home
equipment obtained

m.imainilg I

Inllrud the patitm to Il'port change in fllU!(lt lI~ngth or fulKtion;

numbnes,and tingliog in lip!, fingers,.rm! or legs: palpitations;diniIll'II;
naUIN or vomiting; GI cramping; or dtc:ft'asN urination.

NURSING PROCESS FOCUS

PATIENTS RECEIVING IV FLUID AND ELECTROLYTE

REPLACEMENT THERAPY (Continul!dl
Impl e mentation

Inte rventi o ns and (Rati o nale s)

Patie nt a nd Fa mil y Educati on

Instruct tht ~titnt on tilt IIffil to mum ptriodic.Jl~ for LIb worlc

F~~ monitOi (8(rIroro/yle,aPnand aPT OIINR 1tYek.((rystalloicl

IOUtionl may UUlt tltruolytt imbaLlOO'I. Coloid IOkrtionI may 1!d1K~
normal blood roagulation. f~ monitoringof tltarolytt ItY!ok whill'on
rtpiHl"IIII'm thtraJ11 m;lY bot lII'~d to tllllll' theraptUtic:dtl.)

(ontinUl' to monitor vital ~igns.Take blood plt'llUrf lying, ~ning, and

standing to dftfit ortholtatic: hypott nsion.Bfuutious with the~y
who irf at ilKrultd tilk for hypotf nsion. (Dehydration and flffirolytf
imbaLllKfl miYU!lSl' dizlintSland hypotf nlion.Orth05latK hypotffilion
may ilK~Uf thf rilk ofin;.lIyJ

Ensu~ ~titm life!)" f~ially in tht fldtrl)o.Oblf"lV!' fordiuilll'Sl and

monitOior umt with lI mbuiation as 1I!'eded.(DizzintSl from tlettrolytf
imbaLllKfl or orthostatit hypotf nlion m;lyour.)
Wri~h ~'f p4titllt d.iIy dllll ~rl' wright ~.in <II

kr."of 1kg
21b) 01 min in a 24hour period.(D~ily weight is an
i(urat. meilU~ of Auid status and takl's imo .({oom intake, OUlput.and
insensiblt Iolle. kight gain oredfmll may lignala{5~1If fluid tIUIlK'
ortlffirolyt. imbaLlIKf1..)
(applOlimatt~

CIas. 1y monitor for signl and l)1I1ptOIm 01 al!trw if {{Illoidsa~ ulfif.

(Colloids may (a!lSl' allt19K and anaphylutit ~adions.)
CIas. 1y monitor IV ~t5 dOl. 1y when infu~ng potmilm or ammonium.
Doublt--(h.d doIH with another 11111. btfo~ gi'ling.(Pota\~um,nd
ammonium a~ irritating to tilt Vffi. lind ph!tbitis may r=1t. Potas~um
is, "highaltn" medic.Jtion and doublt-<h.ding dam befOO'
adminiltfring prewn6 medic.Jtion MOil.)

Monitor nutritionalltllUl ind fll{ouragt , ppropriate lkJid intake to

prewnt . ltaroIyt. imbaLln(5.(EIt{\ro~~ imbaLlnm mi~ occur dJt to
inadf~t~ nutrition or fluid intakeu Wfll u from drug therapy,t.g.,
diureticl.)

Patint understanding of drug therapy:

lise opponunitifs during adminimation of mediulionl and during
Ulelmenll todi\(\J\S rationa!t fordrug tlieraJ11,dtsil!d tlieraptutit
out(omf~ and any III'msary monitoring 01 p~ution~ (!king tillll'
during nulling u~ ht lpl to optimi~and ~infOrcf IUpporci'ltdrug
t~atm'nI and (,ft'.)
Patint sflf.administriltion of drug therilPY:
Wlltn adminillffing th. rnedkation, instllKt th. patitnt, family,or
tartgivtr in propl'l s.lf-adminimation of drug,f.g., .~rly in theday to
pteffilt dilruption of Ittfp from IIO{lUria.(Proptr administration will
in(lUIf tht efle<ti"lenell of tht drug.)

Ttam tht patifm to tilt from lying or ~ning to standing slow~ to.woid
diuinm orfalls.

Instruct thf ~titnt to ull for ulistan{~ prior togming out of bed or
attempting tow,lk alolll'"nd to avoid dri'ling or other aaivitifl requiring
mental a!tnlltllor ph)"lilal (oordination if I"ftded.

p4titllt wrigh Idf d.il" 0011, 4tth... n", timf uf d. ".nd ....
H.ov.
weight along with blood
and
mmUren1ffill.Hallf tilt
~'f

urtI

prt\Su~

pu~

patitnt It'pon lignifiunt weight loll 01 gain.

Tudt thtpatitntthat ecssM 11M ronditi:mrontrhJleto~ _atilg
andlluid , nd ~IoIS,and txlr.t uution is wananted in ~HKitions.
Instruct tilt ~titnt 10 imm. diatdy ~port c/yspnea,itming, fedin9lof
throat tightll5~ palpit,tion~ ch.n pain or tightffiing,or headac:1It.
hl5lruct tilt ~titnt to rf port any irritation, pain, ~dlll'Sl,or IWflling at tilt
IV ~te or in theann whf~ tilt drug is infusing.

Ttam th. p,tifm to (onlumf . nough liquids to ~ain adeqUlltf"ly,but oot

OY!'rIy, hydrated.
InlNt the p;atitnt with h)'pokaitmia to consume foods high in K+:frrsh fruill
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, gr.t~fruit 01 prune;and W mea6.lnsrnKl tilt patitnl with
hyptdaltmia to noiI tilt foodl mtntioned fa dil'r (for hypokaitmia) aI wei 01\
sah substitutes (v.tli:h often (ontain poD ISi:Jm salts), and to ronsuk with a
hukhu~ prv.-idtr befmo taking vitamin and milll'lallUpp\fflIfIltlOi
IpKializtd !pOrts btffiagtl. (Typital ore IJIOrtI ilMroll)fl,f.I)., Gatoradt ,nd
Pov.o!radt.mav hal'!' ~ amwnts ofpotJl~um but hilYthiQhurbohydrate
allKUllI, which may INd to inUNItd dilrm, (brrllta, and ~potffitial for
dthydrati:1O from ~ h)"pMImlOlarity.)

The p;atitn~ family, or uregiVl'l should bt ablt to state the re,l\on for the

drug;appropnatf dcM and ICheduling;what adl'llf l'fffilS to oblf"lV!' for

and when to ~pon;and tht antiop;aied length of meditation tlltrapy.

Thf p;atitmand fami~ oruregmr'~ ablt to dilQJll appropnatf doling

and administration needs.

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 J1. 4 fDr 0Ii5rIf rht drugs 10 wNdlIhtst nIIIiDIJ IimI1JII1/y.

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436

UnII4

TheC~,dloYascul~,

,,00 Urinary System.

becomes hypotonic. This hypotonic solution then causes

water to shift into the intracellular space, relieving the deh ydration 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 beca u se
it can lead to expansion of the intravaswlar ( plasma) compartment 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 compartment; th~, th ese solutions are not considered effkient plasma
wlume expanders. Hypofoni<: crystalloids are indicated for
patien~ with hypt'm3tremia and cellular dehydration. Care
m~t be taken not to cause dtpletion of the intravascub r
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 normal saline; patients who are dehydratoo with fIOrmal blood
pres.sure should be given a hypotonic solution.
Colloidl are proteins, starches, or other large molecules th at
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 so lutions, drawing
water mole.: ules from the ce ll s and tissues into the plasma
through thei r ability to increase plasma osmolality and osmotic pressure. Sometim es called plnsma wlsmu:expnnders,
these solutio n s are particularly important in treating hypomlemk 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 syn thetk 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.

li

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

result in seriolL'l complications and must be quickly co r_

rected. Table 3 t.3 describes elec troly tes 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:uwhen 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 lev~
eIs are measuroo in units of mil1iequivall'llts per liter
(mEq/L).
Electrolytes are essential to many body functions, indud.
ing nerve condu ction , membran e permeability, muscle con~
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 resu lt . Although imbalances can occur with ~ny ion. N~+ K+ . ~nd 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 medical condition th~t 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 ra pidly deplete the body of sodium
and potassium. The thera peutic goal is to quickly correct the
electrolyte imbalance while the underlying oonditian is be
ingdiagnosed and t rea too. Treat menlS forelectrolyteimbalances depend upon the seveTity of the condition and ra nge
from simple adjuo;tments in dietllry intake to rapid elec.
lrolyte infWions. Serum elec trolyte Iev.:b mml bot ca reful ly
monitoroo during therapy to prevent imbalances in the
oppIJsite d irection; levels can change rapidly from hypo~
concentrations to hyper-ooncentntions.
amoun~

TABLE 31 .3

(Plasma Volume Expanders)

Electrolytes Important to Human

Physiology

""00

DNg

Tonicity

Compound

Formula

Cation

S%,lbumin

"'ro'

uki!Jltdl~

y~

yo.

Isotonic

llMdium~t~

""HPO.

Isotonic

Ptltmi!Jlt dIIorido!

'"

",itCO,

~.

~a

~.

0-

~,50.

",.

'N

Dmrom 40 in IIOITU siliM

Dm"n 40 in 05W
Dm"n 7Q in IIOJlU siliM
H~ ""innonUwIint
p],1ITY pnltein fIKtiGfI

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....
..

"'
"'
"'

--..

5Id!IIt biYrbonaIt

,.

",.

l(J-

HPOl"

0HCO,-

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"

IIyptrGikrrri.J

,11

Hypotoric ftuid or tlkitonin

<,

C.ki!lllll.Wltm~n1Sor wilMnil 0

'"-

Hypouknnii
Hyptrdllmmia

>112

Hypotoric ftuid

I/ypodlIlKflIIia

<95

Hyptrl00K 5ak IOIUlion

MilgnciJm

lIyptrmig~ia

"<"

Hypotoric ftuid

"
"

Ditta!)' phosphil~ relridion

Pho5phal~ IUppltmrrm

""

Caki!lll

H)'pOIIU9nNmii
Pho5phal~

Hypt~lt111ia

Hypoplmphillemi'
Ptu,si!lll

Hyptrkiirrnia
Hypobirrnii

Sodi!lll

H~rnanmii

Ilyponatrtmia

<1

<35

I >145

"'us

31 .6 Pharmacotherapy

of Sodium Imbalances
Sodium is the major electrolyte in extracellular fluid. Because of sodium's central roles in neuromuscular phy5iology,
acid- base balance,and overall fluid distribution, sodiwn imbalances 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 wnnected. As Na+ levels increase in a body fluid, solute particles accrnnulate, and the osmolality increases. Water will
move toward this area of relatively high osmolality. In simplest terms, water travels toward or with Na+. The physiologic wnsequences of this relationship cannot be
overstated: As the Na+ and water wntent of plasma increases, 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 aldosterone secreted by the adrenal wrtex promote Na + and
water retention by the kidneys, as well as K+ excretion. Inhibition of aldosterone promotes oodium and water excretion.
When a patient ingests high amounts of oodiwn, aldosterone secretion decreases, thus allow ing 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 abo~ 145 mEq/L The most wmmon
cause of hypernatremia is decreased Na + excretion, due to
kidney pathology. Hypernatremia may also be caused by excessive imake of sodiwn, either through dietary conswnption
or by overtreatment with IV fluids wntaining sodirnn chloride 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 glucorortiwids or estrogens also promote Na-+ retention_

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~nni!llllUppItmmB

Hypotoric ftuid.bufI'tfs,or ditlil1 pomsium Iffiriction

PoIi'~lRIl~U

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 hypernatremia include thirst, fatigue, weakness, muscle
twitching, wnvulsions, altered mental status, and a decreased 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 osmolality of the plasma to normal. If the patient is hypovolemic, 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 hypervolemic, 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 secretion or administration of hypotonic IV solutions. Hyponatremia 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 altered neurologicl function such as wnfusion, lethargy, wnvuisiollS, 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
cau sed 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.

4] 8

UnII4 TheCJrd kwasc:ub r.od Url",,'Y

Sy""'"'

I loa_sed K+ excretion I
~

Figure 31.3 Renal regulation of~lumand potas\lum balance

Hyperkalemia is a serum potassium level grealer than 5 mEq/ L,

which m ay be caused by high consumption of potassiumrich foods or dietary supplements, particularly when pali~nll; an: laking I'ul,,",-,iwll-'l'arinl': uiur~li~s ,ud, a,
spironolactone (chapter j OOO ). Excess K+ may also accumulate 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, paresthesias, 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, broccoli, and green leafy vegetables. If the patient is taking a
potassiwn-sparing diuretic, the dose mll'lt be lowered,or a thiazide or loop diuretic substituted. In severe cases, serum K+
I~ls 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 administered to ooWlteract K" toxicity to the heart. Sodium bicarbonate 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 potassiwn ion in the intestine, isgiven concurrently with a laxative
such as sorbitol to promote rapid evacuation of the potassiwn.
Hypokalem iil 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,tivity 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 possible consequences. Mild hypokalemia is treated by increasing 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

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 renal excretion. Like Na+ excretion, K+ excrelion is influenced
by the actions of aldosterone on the kidney. In fact, the renal 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 hypokalemia are associated with fatal dysrhythmias and serious neuromuscular disorders.

LibraryPirate

Adl'!'~ t ffts

of sodum chloride when gil'l'n is il n riectlOly\e f1'plaoc:t mrnt

p.nil'll ...tf_jndur~ 11)'1'"",,1II'1II;' II)' uking ... h ubi"". Iw>_
litYing they will f1'plil(f Na~ lost dJt to IWNting. Th=who IWNt plOfusrij
dUl' 10 wolking outdooB or aen:iling (iI navoid he.t-related probltms II)' oonIUming adequatf ilmoonu of watf l 01 b.tlilnud riectlOiytf SOlutiolll oonlOinrd 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 1IIiI~ 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 Sa
hyp.ertonit solution th" m.y palidoJiully (ilusr ill(fI'aIfd w"er /on. Inmooing athlrtH, especially (hildfl'n, to drink when thirsty and maimain a
urine the (olor of dur ~Ilow, oot dalk yellow or colorless, will help tlllUfI' 1101mal hyd"tion and sodium Iewk.
~r~ "If'. So .....

OI..,l<r 31 Drug' for Au ld Balan(e, Elec:trolyte, . nd Acld-Ba... Olso<der,

~ Prototype Drug

I Sodium Chlonde (NaCl)

Therapeutic Class: Sodium supplement

Pharmacologic Class: Electrolyte

ACTtONS AND USES

So:Iium {hloridt ~admin~lertd for hyporwtrrmi. wlltnstrum I~ 1.11 IItIow
no mEqIL Norm~ll.llilll' (onsiru of 0.9% HaCl..rod ~ wei to Ul'al mild hyporwlll'mia. When ,..rum sodiJmlalls bmw 115 m[q!l.. high~ {olKtntraltd
1% Na(lsolution m.y lit iofuSfd. Ollll'r {OII{~lrations 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' dI): inA.mt<! rw.J Iml'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

ADVERSE EFFECTS
P.tifnu Il'criYing /laCI infusions must bt monitortd frequenlly to p~m
symptoms 01 hypmlallt'lllia, which ilKludt letharg)', confusion,muscit 1remor
or rigidity, hypotension,and rtstltssnflS. ~UII' SOliii' of thl'lf symptoms . 1l'
.150 {ommon 10 hyponatll'mia, ~iodic lab oHlI'Ssml'nt, must bt lakt'n 10 bt
(I'Main sodium .J Utslie within 1M oorm.1 n!/t. When infusing 1% NaClsoiutions, tht flJllt m uld continuous ~ {hfckfor signs of pulmOllilry I'dtlN.
Contraindications: Th~ drug should 001 lit adminisll1ll'd 10 p.atients with hyptmUIl'fII Y, {oogesti'll' hurt failull',o. imjli irtd 1l'nallulKtion.
INTERACTIONS
Dru;rDrug: Thtrf aff oodi1icilily lignnl dfUl inli'fiKtions.
li b115ts: l.o!ium dl10ridf inaNsfs thf IfIIJIl sodiJm 1fflI.
HerliallFood: Unknown

PHARMACOKINETICS
~UII' sodium chloridt ~ a nalur.lsubstalKf, phillllloKokilll'tic dol1a
ul'diffiruk to oblain.

lIT Prototype Drug

439

Treatment of Omdo Sf: Iffluid accumulation occurs rut 10 a U'S, sodiJm, diUrtlin may bt admin~tell'd to Il'ciKl' pulmonary or ptriplltral tdtma.
.... ter III M)Nuflln9l for Q NurIifIIJ I'rrKm fIK1l'i JjItdk III rIr/s dfI!9.

Potassium Chloride (KCI)

Thera peutic 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,
powdtr~ .rod liquids, usually heavily flavortd rut 10 the unpleasant t.111' 01 the
drug. ~UII' 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'l l'rIoad lhe lItart and cau II' card iac '~l8t
caUIl' ph.rmolcothtr.py with loop o. thiaridt diull'oo ~ tilt most (ommon
QUII' of K ~ depletioo, p.ti. nu t.ki"'! th..,.. drug ~ usUoi11y pr..cri~ 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

~luII' liquid forms btlOR' gjying thfOl.l9h.J nasogastrK lUllt.
Ik-;tr admin~tfl' IV push or in cOlK~lIaled .mounlS,and do nol acete1
an IV ralt of 10 m[qlh.
81' n1rl'fllely ull'lullo 'l'Oid txuansation.rod infiltration.
Pll'<Jnancy megory A

PHARMACOKINETICS
StaUIl' potalSium {hloridt ~ . nalUlalsubstalKf, pha'IN{oi:inelic dati
.J~ diffiruktooblain.

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ADVERSE EFFECTS
Nausu arod I'Omiting a~ {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!' .J1l' ll'Iated 10 the POII~
bie acrulllJl'lion of m tsl K+. I-/yptrblemia molYoaur if thl' patient lakes
pot.ssium suppltments rolKU~ntly with potmum-sjliring diull'tiu. IkLJ!/lt tllt kidnl')'lptriorm mo~ thin 90% oflhl' body, potassium eJ(rttion,~
duct<! ~rwllunrtion can rapidly itad 10 hyptflcaitmia, p.rticularly in patients
uki",! potmiJm!Upplern~u.
Contraindications: Potas~um dlloridt ~ {oolfllindiulr<1 in palients with hyptrb itmia, chronic mloIl fi ikJll', s)'Itern ic oKidosis, !M'It dehydration, extl'nsm lissue b~.kdown is in II"I'fIl' burns. acill'nal insufficiency. or tilt
administration of a pol.ssium-spoilring diurttic.
INTERACTIONS
Dru;rDrug: Potas~um IU~lI imfl"iKlwi1h potaslilm-~1I9 dln!icli and

ACE inhibiloo 10incfNll'thf rill; for~ia.

li bTes1S:Poiassium dlloridfo iooN\eS Ihfo IfIIJIl potassiOOIIHel.
HerliallFood: Unknown

Treatment ofOverdOlf: When 0Yerd01l' ~ IUs~, polasyum-sjliri"'! d~

ur~ticJ ind all foods ind medications (ontaining signifiunt ~lMUnn of potassium soould bt withheld. TfNtmffil 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 admin~lered to I'fIhana polassium t liminuion .
.... ter III M)Nursl1rgl1l for Q NurIinl} I'rIKnl foors lfIKlk III rIr/s dfI!9.

440

UnII4

TheC.,dklv.sc:u b , aoo Urinary Synefm

LIF ESPAN CONS IDERATIONS

Laxatives and Fluid- Electrolyte Balance

Wnh aging. p~ristallis slow!., food inlakf diminishes, ,nd physiul "tivity de(~IIfS; and ~ fKton can (h,fI9I' ~I mo\'l'mem ~uLlliry. MIlO)' okltr
,dill; btlieft they must h.M a bowfI moYeIIIeIlI MI)' day and t,kf daily lax,oYeS. Chroni<: 1M of lautiYeS un ~uk in lkJid dtpidion and hypohiemia.
Stimulant lauti!'!, tlHo mon frr~~, pmuibeil(1aIs ofIaJ:alim,aktr ~lK

tro/ytt tr<lnspon in the irntllinallllKOsa.Thttldtrl)' <Irt ~pKially !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 adv~ 00e tfFfm, ,nd thi! these
,gent> should lit used onl, as dm trd by their hNkh ca~ PlO'lider. Tilt nullt
should JffOmmend that older patitots ilKlNM' rx~l(iM' (as toitrattd) and ~
insokJbltfilltr totiltdi(( to maintain timination ~larit\'.

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 carbon 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 normal acid-base balance.

31.9 Pharmacotherapy of Acidosis

ACID- BASE IMBALANCE

Acidosis (eKess acid ) and alkalosis (excess base) are not diseases 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 basic or alkaline, and below 7.0 as acidic. To maintain homeostasis, 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.

Ac:idosis occurs when the pH of the plasma falls below 7.35,

which is confirmed by measuring arterial p H, partial
pressure of carbon dioxide ( Pco,), 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 central nervous system, and include It'thargy, confusion, and
eNS depression leading to coma. A deep, rapid respiration 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
Nonnal plasma
Ammooium dlIoride
Sodium chloride
w~h pota&5ium
oN....

Ac id os is

Al ka los is

CNS depression

CNS stirrulation
Convulsions

C~.

FlgureJI.4 Acld- ba~

Imbalances

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OI..,l<r 31 Drug' for Au ld Balan(e, Elec:trolyte, and Acid-BaS<' Olso<der,

441

TABLE 11 S I Caus@sof Alkalosis and Acidosis

Acldosl,

Alk.alosl~

RESPIRATORY ORIGINS OF ACIDOSIS

RESPIRATORY ORIGINS OF ALKALDSIS

~li1ation or ihallow bruthing airwayoooruiaioo

Dama~

to !6piralory (tote' in rntdJ ..

METABOLIC ORIGINS OF ACIDOSIS

METABOLIC ORIGINS OF ALKALOSIS

SrW'r~ diarrbta

Cornlipation for proIongtd pffiod,

Kidllf'/ faikJr~

IlI9I'stion of mess lOdium biQlrbonot~

Ili.Jbtte mdlilUi
w e , akohol ingetion

Srm~ vomitiog

DlJrffin thot caUlf polOisium dtpIetioo

Starloltioo

~ Prototype Drug

Sodium Bicarbonate

Th@rapeutic(lass: Agent to treat acidosis or bkarbonate deficiency

Pharmacologic (lass: Electrolyte

ACTIONS AND USES

ADVERSE EFFECTS

Sodium bicarbonate is . drug of choic:~ for (olrening I1II'Llbolic oKidosis.After

d'mociotion, th. bic.>rbon.r. ion dirroly r.is<" tilt pH of bod~ A.iIk. Sod" mbi
carbonal~ may bt giYffi orally, if idosis is mild, or IV in m e of .rut~ dill'all'.
IV conmllatiom range from 4.2% 10 R49Uhhough lOdumbiurbon.le.1Io
neutralimgaltrK . cid.it is not UII'd to tre~ ~ptic uk~ts dJr 10 its tendencylO
caUll' uncomfort. bit giltric distension. T~ 0 ..1~pmtion of sodium bic.rbon.t~ is known al bokinqwQ.
Sodium bic"bon.te may.ko bt UII'd to .Ikalin~ t~ uri~.nd sPffilI~
tJ1rdion of .(idic: lubstalKe. This pnxffi is u,..ful in tht tre.tl1ll'flt of O'/~r
doII'S of .cidic: mNicationl SIKh ., aspirin .nd pherlobarbiLll.nd ., ad ;,JIId~
the'apy forct n.in ch~mother.pMic dIIJ9i wch as metholR'lolte.
Sodium bicarbonal~ may bt !Md in chronic ren.1 f.ilu re to nfUlr.lizr tilt
m!'t.boIic: ido\i, that O{(Uts when t~ kid~ cannot tJ1rde irydlO9!'n ion.
When IV lOdum biurbon.tf isgiv~n. it 1a!M1I~ urint to btcom~ more .Ikalint.LeI id is re.blOrOO:! in tilt ren.1 tubule, so more acid .nd idk mNicine is rl(R't~d This poxesl is known as ion trapping.

of th~ adW'rs~ ~fftcts of sod um 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. Simp~
discontinuing the sodium bic.rbonatt infusion olt~n ~rse the~ Iymploms;
ho_~ 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 gjy~ 1M to 1r;~lIIiItremi.J
and fluid R'1~mion.ln addition, high ~k of bic"bon.te ion passingthlOlJ9h
tht kidnty rubulM ilKlNs~ K+ If{R'lion, and hypob itmia is possibit.

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 ot~r
medications.
P~n.J ncyCill~ory(

MOSI

Contraindi cations: P.titnu who art ~om iting or haW' conlinllOUS Gllooioniog
will iose acid and chloride.J nd may bt in a ,tat~ of metabolic .Ikalosis;tlitrriore,
tlM-y lhoold not R'{~W' lOdium bicarbon.lt. 8K.JUII' of tire sodium contemof
this drug. it lhoold be USN Qlutiou~y in patienu with cardiacdiINlI' and renal
impaitmerll Sodumbicarbon.te il comraindiutfd in patienu with hyptrt~n
sion, peplic ukfr~ dianfrt.J, or vomiting.
INTERACTIONS
Druq-Drug: >ocilll! babonift maydfmalt tM.bIorplion of~and
may IiKll'Urininalion of duuoamphetim, rp/Ifm~, p\rooofplu..tiM, and
quinKW.T~ rilli!lilmnof~ium, ~kyI;l~ and le1raqdm rnay ~ OONW
L1 b11511:Urilaryand 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 llill;--aka~
~,.rond~iJndl.naHilfd Iryseriwl ~JlffUkfIW and possibIf Ioidnty

PHARMACOKINETICS

f.jkl~.

Onst'l: 15min PO;immNiat~ IV

~k: 2 h PO;unkna.vn IV
Half-life: Unkna.vn
Duration: 1- 3 h PO;8- 10 min IV

lrn tment ofOYerd~: 0Yerd0II' muhl in metabolic . Ikalom, which is IR'.Jtfd

by administeriH;J .cidic agerlU (Iff Xction 31.10).

31.1 0 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 central nervous system is greatly affected. Symptoms of eNS

LibraryPirate

IItfPf R1 M)NurJlngIJt for DNlm/III} PrtrmI fIlM lfIKl/{ III rIr/s d~

stimulation occur including nervousness, hyperactive refl~s , and convulsions. In metabolic alkalosis, slow, shallow breathing indicates that the body is attempting to
compensate by retainin g acid and lowering internal pH.
Life-threatening dysrhythmia s are the most serious adverse effects of alkalosis.

44 2

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, alkalos is 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 follows sodiwn chloride infusions. For these acute patients,
acidifying agents may be used. Hydrochloric acid and am

monium chloride are two drugs that can quickly lower the
pH in patients with severe alkalosis.

A VO IDIN G MEDI CATIO N ERR ORS

Aph~ian ordm digoxin (l.noxin) 1.25 mg. but mt. mto writt O. m. Tilt
nudent nurll' gim digoxin 1.25 mg. Who is ~iblel Tilt ph~ian?Tht
prim"., nUIII'?The nursing inlll\l(\oll TIlt nurse m.nager?
SIt J{IptndIxOAlrlhtIlJgqmM<IlSWeI".

.9j: 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.
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

(","~lIy 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 distributed primarily to the interstitial spaces.

31 .5

Bectrolytes are charged inorganic molecules that areesSl'ntial to nerve conduction, membrane permeability,
water balance, and other critical body functions. Imbal ances may lead to Sl'rious abnormalities.

31.6

Sodium is essential to maintaining osmolality, water bal ance, and acid--base balanCt'. Hypematremia may be corrected 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

Pot~~~il1m is"".enti~1 for pmp"" n"rve ~nd tnn""1,, fimc.

tion, as well as for maintaining acid-base balance. Hyperkalemia may be treated with glucose and insulin, or
by administmtion of polystyrene sulfonate. Hypokalemia 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.

NCLEX-RN " REVIEW QUESTIONS

Which of the following mechanisms is the most important regulator of fluid intakel
1. Thirst
2. Ele.;;trolytes
3. Renin-angiotensin
4. Kidneys

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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 arter~ll blood gases.

CJllfllfr Jt

The patient's serum sodium value is 149 mEq/L Which of

the following nursing interventions is most appropriate
for this p~tient? (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.
The patient complains of muscle cramping In the calves.
paresthesia ofthetoes,and the sensation ofthe heart sklpping a beat. These symptoms may indicate which one of
the following imbalances?
I,

Hypernat remi~

2. Hypen:alcemia
J_ Hypoglycemia

4. Hyperkalemia

Drugs for Fluid

811tllnc~, Electrolyte.lIOd AcId-8a~

Dl5orde.-s

443

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
Thenurse weighs the patient and fmds tha t 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. Con tact dielary to change the patient's diet to reduced
sodium.
4. Request a diuretic from the patient's provider.

CRITICAL THINKING QUESTIONS

1. A 72-year-old man with a history of heart failure presents
to the emerge ncy department complaining o f weakness
and palpItations. The patient has been taklng furosemide
( Lasix) and digoxin (Lanoxin ) at home. His cu rre nt ECG
reveals atrial fibrillation, and serum electrolyte tt'5ting reveals 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 low~ extremities and
slates that her hands and face are~5\\o011en.~The CBCreveals
an elevated hemoglobin and hematocrit. ThecerlifM.'d nurse
midwife diagnoses the patient with pregnancy-induced hypertension and orders all IV of OSW. In addition, she requests that the nuiSt' "push oral f1ulds."The nurse considers
whether the midwife's o rd~ should be questioned. Disrus.s
the app ropriateness o f this order.

3. An 84-year--old woman has recently returned home after

being admitted to the hospital for persisten t nau sea and
\Umiling and dehydration. Her past medical history in-

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eludes gastric reflux. hiatal hernia, GI bleeding. anemia,

and coronary artery disease. Her current medication regimen Is metoprolol (Lopressor), SO mg PO bid; pantoprazole (Protonix), 40 mg PO daily; furosemide (Lasixj, 20 ms
PO daily; an d betuloSt', 20 gOO mL PO at bedtime. Although this patient's nausea and vomiting has resolved,
she is still at risk for fluid and electrolyte imbalances seco nda ry to her medication regimen. Which dmg in particular 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 ~kIeos , anti flICIei

RegIster lOOr IICCI'!9$ eooe from the rlMI d vour IlMk lit
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UN ITS

The Immune
ystem

CHAPTER 3l

Drugs for Immune System Modulation

CHAPTER 33

Drugs for Inflammation and Fever

CHAPTER 34

Onlgs for 8acteriallnfections

CHAPTER 35

Drugs for Fungal, Protozoan, and Helminthic Infections

CHAPTER 36

Drugs for Viral Infections

CHAPTER 37

Drugs for Neoplasia

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Drugs for Immune System

Modulation

DRUGS AT A GLANCE

LEARNING OUTCOMES

IMMUNIZATION AGENTS PIl}HfB

Vaccines fUJt~8

After reading this chapter, the studmt shoold be able to:

Q hrparlf/S Bvaccine (Engem:-B,

RecomblvaxH8) )Q}t45J

Immune Globulin Prl!parations

IMMUNOSTIMULANTS
Interferons

paJt450

pajt451

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&

Cakinetlrin Inhibitors

poqtfSV

Q cyclosporlne (NlOffJ~ SCndlmmunej

,.,..w

, . Compare and contrast specific and nonspecifi c body defenses.

2. Compare and cont rast the humoral and cell-.mechted immune
respo nses.
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 pharmacologic manageme nt of
Immune di sorders.
9 . For eac h of the drug classes listed in Drugs at a Glance, know
representative drugs,and explain their mechanism 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
Imm une conditions.

KEY TERMS

ct.

plasma
{Q}t447
T(eU {Q}t4S0

Klieimmunity fklIIt449
nriboclies pt1J(441

immUl~ lespollst ~IItW

ntigen fXl}t # J

imlllUlO1lJPPltSsant pt:I}t451

tiW {XJgt449

~tft"felOO

tOlloid Pf1i1t 449

Bul

imm u lomod~ator pt:I}t447

fXTJf"'

biologic ~ponsemodifltl'l
calcinwrin n457

piXJtf51

~tHlf1Ikin {Q}t.fJj

tran~lant

.o-s~cifkdeknst systffll JlI)tW

~~atiOillill1munil.tion {Q}t448

pa!.Siw imllIunity

cytokint 17451
humo~1 imlllUnt'

1fJ1lt45J

mponse pt1I}tUl

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~tU9

r!jtction fkXjt.fJl

~cilt {XJgt44B

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 exteos~ 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 ~e patients, Immun omodulators afe used to stimulate body defenses so
that microbes or Cll ncer ce lls ca n be more effectively attacked . On other OC(asions, It is desirable t o suppress body

defenses to prevent a transplanted orga n from being rejected 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 lymphatic system provides the body with Ihe ability to
resist injury and protecl$ the body from pdthogcns. This system consists of lymphoid cells, tissues, and organs such as
the spleen, thymus, to nsils, and lymph nodes. The different
components of the lymphatic system a~ in continuous
com mun iC41tion and work together as a single unit to ac
complish dfeCl;ve immune ~urvcillance.
The first line of protection from pathogens is the
IIOIIspKilil delfnst sl'lolem, which serves as a senenl barrier to
microbes o r env ironmental hazards. The nonspecific defenses 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 defen ses, include physical barriers such as the epitheliallining of the skin, and the respiratory and gastrointestinal mucous memb ranes that are po tential entry poinls
for pathogens. Other nonspecific defense5 are phagocytes,
natural killer (NK) cells, the complemen t system, fever,
and interferons. From a pharmacologic perspeclive, one of
the most important nonspecifK defenses is inHammation.
Beca~ of ils significance, inHammation is discussed separately, in chapter ) }CX>.
The body also has the abili ty to mount a second line of defense that is ~rliculu to certain threats. For example, a specific 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 tfspon sr. The primary cell of the immlUle response thaI interacts with antigens is the lymphocyte.
Mkrobes and foreign substances that elkit an immune
response are oiled antigPm. Fo~ign proteins, such as those
present on the surf:K:e$ of pollen grains, bacteria, nonhuman cells, and viruses. are the st rongest anligens. It is estimated that the immune s)'!item has the ability to recogninand react to over a billion difft'f'ent an tigens.

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The immune response is extremely oomplex. Basic steps

involw recognition of the ant igen ,communication and coordination with other defense cells, and destruction o r suppression of the antigen. A large number of chemical
messenge.rs and inter.lctions are involved in the immune re~pon ..., many of whi ch h~ ... yet 10 be discovered . The two
primary d ivisions of the immune response are antibodymediated (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 ~spo.se is initiated when an antigen encounters a type 0( lymphocyte known as a B~. The Ktivaled 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 sec rele 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 produ ction of antibodies o"urs about 10 days after an
initial antigen challenge. The important functions of antibodies are illustrated in ~ Figure 32.2.
After the antigen challenge, memory B cells are formed
that will ~member the spific anligen-antibody inteTKDon. Should the body be exposed to the same antigen in the
future, the body will be able to manufacture even IUgher leYels 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 entire lifetime. Vaccines are sometimes administered to produce these memory cells in advance of exposure to th e
antigen, so that when the body is exposed to the actual organis m it can mount a fast, effective response.

PHARMFACTS

VaccinQS and Organ Transplants

Vxcines 11M r~ted SI'M8poI &om ditworid, andthr poIiorirus
from 1M 'Nmml1lem6phtrt.
V.cines ~thellll'nllerofdiplltlltn.(istS .. wlllli!NSt.Ie'!
from 175.000 .. 192110 ltIIIastIlWe 1980.
V.~ ~the IlIII\ber of rnmIt! gift .. tht Un~td State'! hom
mo~tlwn 501,000 in 1962 to onl)o ibout 100 ems annIWII)o.
Of thtvudne-preftntablt dististS. PlWIJmococcal pn~monw is tht
mollitthal, with 40,000 duths innwlly in thf Unittd S"te'!.
Mo~ th.Jn 7'!I.000 patients ittwa~ing for organ Ulnsplints. with 3,000
iddtd to !he lin rwfY month.
8fcallst oflidof millble tlinsplintt, many p.itirnu rflr fftty )lUI.
inWIing iP9~tIr 2,OOOtidrwy p.iIirnts, l,l00 Mrp.lDrnb,
450 lIN II p.lUmb, md 361 big p.ilirnts.
Tbr IIIMtmmOlllJanSplinctd OIgiMatt ~ Mr,lnd hNrl

448

UnitS

Th~

Immune SY"'-""
CEll.-MEOIATED IMMUNITY

Target. invaden outside ""II. (e.g . viru ..... Stimulate both humoral and ""II-mediated
bacteria. fungi. protist and toxins)
immunity by releasing cytokines

Targeta defective body celie (e.g . infected

celie an:! cancer ""lIa). tran.plant.

...... -Q ----------

viral ---~";"
antigen
~

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

B-cell antibodies bi.-.::l

to viral antige.. and
.timulate the B cella to
divide and differentiate

antibody

-! ~

T-cell re""pton bi.-.::l

to viral antigen.

' 0"

helper T cell

-t

-t
~

'\-

-1

.. .

-t

.'
-"'-;;.~'-''--:--7

Cytokines released by
helper T ",,11a .timulate B
cella and cytotClllic T cella

. ..-""

-! )( I-

"

Pia""", cella .ecrete

antibodle. into the blood
and extra""lIular fluid
~

:-t

-..oryll ...11

help..T ""II

Memory cell. oonfer

future immun~y to this
virus

Cytotoxic T cells rel_

pore-fonning proteins
that destroy infected cells

Flgurel2.1 Steps In the humoral and ceil-mediated Immune respon~

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 system. Vaccinations are oneofthe most important medical interventions for the prevention of serious infectious disease.

32.3 Administration of Vaccines

Va((ination, or immunization, is the process of introducing foreign proteins or inactive cells (vaccines) into the body to

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tri8B~r immune activation before th~ 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 destroy the pathogE"fl. \I/hereas some immunizatioll'i are
needed only once. most require follow-up vaccinations,
called boosters. to provide sustained protection. The effectiv~ness of most vaccines can be assessed by measuring the
amount of antibody produced after the vaccine has been ad-

'ho",tln
~

FIgunJ2.2

Dfug.fortmmu MSystEfn

Modul~tlon

449

binds 10 antibody

Funcnom of anllbodles

So!.Ke: 5INmhotn. I'Iur!\ln Physiobgy:An Integ~1E!d

AppIOaCI\Jndet C 200I, 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 activate the immune system but be modified 10 pose no significant risk of disease development. The four methods of
producing safe and effective vaccines include the following:
Attenuated (live) vaccines co ntain microbes that are
alive but weakened (attenU<lted ) so they are unabl e to
produce disease. Some attenuated vaccines cause mild
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 replica te o r cause d isease. Several boosters
may be necessary 10 prolong immu nity. Examples of

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or

inactivated vaccines in clude the innuenza and hepati tis

A vaccines.

. 1oxoids are types of vacc in es that contain bacterial toxins

that have bun chemically modified to be incapable of
causing disease. Exampl es include diphth eria and
tetanus tmwids.
Recombinant vaccines are those that co ntain 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 gener~tion of mem_
or y cells.
P.min immunity occurs when preformed antibodies ar~
transferred or ~donated" from one person to ano ther. For

450

I
j

"
t

UnitS

The Immune Synem

example, maternal antibodies cross the placenta and provide protection for the fetus and newborn. Agents infused to
provide passive immunity include immune globulin following "xposun: lu h"l'atili~, anliv"niu" fur s"akd)il~, 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 administration of antibodies.
Most vaccines are administered with the goal of
preventing illness. Common vaccines include those used to
prevent patients from acquiring measles, influenu, diphtheria, polio, whooping cough, tetanus, and hepatitis B. Anthrax vaccine has been used to immunize people who are at
high risk for exposure to anth.rax from a potential bioterrorism incident (chapter 1200 ) . In the case of infection by
the human immunodeficiency virus ( HIV ), experimental
HIV vaccines are give n after infection has occurred for
the purpose of enhancing tne immune response, rather
tnan preventing tne disease. Unlike otner vaccines, experimental 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 injection, and fever, minor aches or arthralgias; and for live vaccinations, a "sub-clinical" case appearance of the disease
(e.g., minor rash with measles vaccination). Although severe reactions are uncommon, anaphylaxis is possible. Vaccinations are contraindicated for patients who have a

TABLE32 .1

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 ofl"" ud~y"u in pr"H"~"l p~li .."ls wIlil an"r udiwry lu ~vuiu
any potential harm to the fetus.
Effective vaccines have been produced for a number of
debilitating diseases, and Ih.eir widespread use has prevented serious illness in millions of patients, particularly
children. One disease, smallpox, has been completely eliminated 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 vaccinated according to established guidelines. Table 32.2 lists selected 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 vaccinepreventable 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 respo nse involves Tlymphocytes, or T(tlls. Two major types of T cells are called
ht'lper T cells and '")'\:otoxic T (t'lls. These cells art' sometimes named after a protein receptor on their plasma membrane; 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 activating 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.

Immune Globulin Preparations

Drug

~ute

cy\OfIIt9ikwiM inm!ll~ globulin

IV; 150 mg!lgw~hin n h oImnsplanlation;thffi 100 m9fOl' 2,4,6,

and 8wk poII-trins~t;thffi 50 rn9fkg for 12and 16 wk poll.
tran~ ..

(C)"toGam)

hepatitis 8 ilmnrotgiobUin (HEIG)

inllal'e!lOUl immUlll' globulin

(Calim!ll~Gammaganl, IVlG,lktigamJ

and Adult Dose (rnaxdosewhere Indlcatedl

1M; 0.06 ml.J1o;g is soon 011 pos~bIt liter npolUre, prftera~y within
2( h, bI.c no I.!erlilon ] diY';repu,lt-lOdi)"l .fter "pol""

IV;I00-1oom9/mo
1M;11ml.J1o;gfollo\>i!,d byO.6ml.J1o;gMf'/ 1-4wk

labi!>s immuntglobutin (~Rilb.

Imogam Rabits--H, II)'perab)

1M; (giutulJ 20 un~l!lgiS i

RholD) inmun~ globulin (Ba)'Roo.O,

WinRho SDF, MKRhoG.i.M. RhoG,l,MJ

lMIlY;Ontvial 0I1oomcg il.pproximat~y 18 wk;folOWfd by ont vial of

miridOll' 01' 120 IIK9w~hin n h of~i"mY ifinfilnl is Rh-p&lili"l~

~nUl immune gIobuin (S;JyTet.

sifI\J~ do~with labits mont

1M; 250 !Il~1 for prop/T)'Ialis

H)1le!Ttt)

/ralia indjyt~ 001II100II adverse fti'erls;.I!l!!!:!!i!!!! indjyte strious Idverse fti'MS.

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Adve~

Effects

mxrkm ~ri~ fiTfi (poi", f/)"1hmIq.

m)'/gio), inf!uf,Ill1/ikf symproms (mdlli5t,
fmor, dilll hi?IldtIt

...-

' hlp"'!l

DtIIgs for Immur.e SYSII!fn MoOJlnlOn

45 1

PHARMACOTHERAPY ILLUSTRATED
32.1 Mechan isms of Active and Passive Immunity
1IocMt... V..:cine
AdrririotInd mcrrthe ... ~ aft.
m.I
aCcine. booster ......,a". ........ tt..
imrrKne eystem 10 maintiwl ...augh "*""'Y
c ...... to mount a "'Pid ~ to ..,
antigen.

u..

"~ lmm"My
AdrniI'ieu'J,bOII of

vaccine or eo.poeure 10
.. ..,tigen ,timlAat..
tt.. bodv tD~

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!.

RoopooH"""
.,tibodi..
(r~

T cells rapidly form dones after they are activated or sensiliud by an encounter with thei Tspecific 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
com muniC3tion. Some q'lokines kill foreign organisms dirc.:dy.

wh~r""s

others induce inflammatio n 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 therapeutically to stimulate the immune system, as discussed in
Section 32.5. Sm:JJ1 ~mounts of cytokines are abo sec reted
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 future, the memory T cells assist in mounting a more rap id
immune rt'Sponse.

IMMUNOSTIMUlANTS
Despite attempts over /Nny decades to develop effect ive
drugs 1113.1 slimul3 te the immune system 10 fight disease,

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but Iho<1-Wwd)

TREATING THE DIV~RSE PATIENT

Cultural Influ.nus on Immunizations

AIIhoughchidlllOd~hM~tobf_ofIheJnQII:~

rI ~ MId IIItII6Ig tht IfIUCl ddriM MId ~~

m.
klciinlAla!kiIUtM~Aru.fngIOCDCllitilIic!,791i.ofIIItio! z.)UI'"

~ IhouiMck of pmdIooI ~ ~not being ~ immunWd.

muninlian IMk Ir. ~ '11l0II\I Amc..n AmerQ\,IIis(Nnic,OIfId Arneriun

duldrmmmparm.,.,;m6ll'l(,of,l,&gft~itldlis(NnK2.,eIl.wlditilm

UIy 'Airwd in mrdIIw:t willi iMvIiution flidtline. Ouldml are

ooIy IIjf IJIIl'IIKmg so:IIicitnc irtmuniution.ln 1999,lis(Nnio m
Mriun Amrric.all'l iqi!'d 65 ~lIlnd older_1m 1-., tIwn White to !!pOll
b.wilg rmMd inbnza lind prwull'lOCO(U! wa<cine.limittd ICCN CO prnmtilof IlIVim Ind patirnt ~tic:Ml.lttiludts. ,nd rutlnl btlim itwt t.e.~h
ar.lIII)'contrbJlto III ~~iI~tirJ.
(ommunit~ outrtlCh PlO!lr~ms h'~lChit~ IOmt IUllesS,t r."hing
undermvf'd ethnic groups. Onto! the ~Is of HtclrhyPt6plt 1010, , set of
heakh objectives for the nltion tOlthie~ in the filltdtudtof the llstctntur~, ~ riiminuing racial and tthnic: dilparities in hNlth. Ricillud Ethnic
Approaches to Community Hulth (REACH) 2010Wle! none of the ([)('s
efforts to eliminatr the d~parities. u,unthed in 1999, REACHfunds community co.JlitioMdHignf!i to implement UIIique communily~rivtn 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.
I'm

!Ill tM

452

UnitS The Immune SY""m

TABLE n .21 Selected Vaccine5 and Their SchQdule5

Vaccine

ScheduleandAge

diphilltria, Imflll,incl ptlIUS~s{DiplaCfI, DPa~ Infirm. T~dia)

IM;05 ml 011aqtS 2 mq. mo,6 RIO,ancl 18 mo

haotmoplilus inftuenla type B(onjug,lI~ (AnH IB, HibTITIR, PrdvaxHIB)

Crown isa (ombilalion ofhamKiphiusanci htpal~is Bmuntl.

IM;05 mlil aqtS 2 mq 4 mo,6 RIO,ancl 15 mo;dikRn ~ 12- 14Il10 who 11m no!
btftl...oo...utd rta;" a ~ngIo: do",

hl'patitis A(Ha1Tix, VAQTA)

Children: IM;O.5 mlal i~ 12 mo, foIlowtd by a boosJ:tr 6Il10 10 12 mo laltr

Adrk~ 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\: 05 mlin thfN do~ wilh IhI' se(ond dOlI' 10 days alltr thl' mt. and !hi' final dOlI'
6Il10 after IhI' fiI'II

human papiliomaYiM (Girda~l)

Children (fmlaltsj: IM;05 ml wim fnl dolt at '91' 11 Of 121!ilS

htninintr I((l)[I(j rose 2 mortm ifltr m~ fim rose and till- mini dosr &months alltr !hi'
firndo", (itlN\! 24 Wffkl alltr!hl' fim dOII')

ilfhltrllj vj(m ~ (Alluria, AuarD:. FlulIIat A!Nirin, AUlOIIt)

Chidren: 1M twodo..s 1moipart;thm annual dolt

Adrk\: 1M single anrwl do", Of inuillHil (FluMin)

lIII'aIIei,mllllpl.and nmla(MMRUj
Proqwd is a (ombinalion of MId Rand varia-lia varniit's.

SlbMalltOlll;05 ml linglo: dolt at '91' 15 mo to poJJtny

FimdOll'ata~

12- 15mo

~onddOll'al"9l'4-6)'1

pMumlXoual. poIynlent (Pnrumov.lX 23). Of 7\\Ilent (Plnnar)

Adrk,(l'nrulllO\\lx 21 Of Pnummun ~ B):5UbrutillWJl Of 1M; 0.5 ml a,a !in9~ dOlI'

Chidll'n (Prm.-arj: lM;fourdOll'uugel2 mo,. mo,6 mo,and 12- 15 mo

poIioviru>,inaailllttd (lPQj
ltII .... irus (RoIirD:, RotaT~j

Chldll'n:>ib:uLJ1ItOIII;05 mlal ~ 4-8 'lit, 24 mo,and 6-12 mo

Childll'n:Ori~thrff

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

I'oong~r lhan

only a few such medications are available. These agents include interferons and interleukins produced by recombinant DNA technology. Inununostimulants are listed in
Table 32.3.

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, sufficient quantities have been produced to treat certain disorders. Sometimes called biologi(rt',pon,f modifiers, some of these
agents boost spe.::ifk functions of the immune system. Biologic response modifiers thai enhance hematopoiesis, such
as colony-stimulating factors, epoetin alfa, and oprelvekin
(Neumega), were presented in chapter 2S00.
lntrrferon, (IFNs) are cyto kines secreted by lymphocytes
and macro phages that have been infected with a virus. Mter

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12 mo:05 ml as a single dOlI'

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 functions such as increasing phagocytosis and enhancing the cytotoxic activity ofT cells.
The class of IFNs h.wing the grt'atest clinical utility is
th .. ~Iph~ int .. rferons, for which six diff.. r.. nt formul~_
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 inert molecule polyethylene glycol is attached to the int.. rferon. 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.

C""IU, n

~ Prototype Drug

Dw!!. fo,'mmUM S)"''-'''' MoWla''''''

45]

I Hepatitis BVaccine (Enger!x-B, RecomblVax HB)

Therapeutic (lass: Vaccine

Pharmacologic (lass: Vaccine

ACTIONS AND USES

ADVERSE EFFECTS

Hepatitis Bmulll' is used to provide activr immunity in indivwals who all' <II
riskforelpolUll' to hepatitis BviM(HBY).k is indilattd forinlan" bornto HBYpoIitiv~ mothe'l,~nd thOl~ <II high risk fomposull' to HBV-in~cted blood, inckiding nulVS, physici.ns, dtntist~ dtnttl hygitnists, morticians, .lnd
paramediu.8fulM HBY in~tion isutll'meiy diffiruh to tll'a~it is prudentfor
all hNlth call' wonm to 1l'Cei"l'l' HBV "I<lCci~ ~foll' btginning their clinical eduCiltion,unlts,conmindicated.The Yil(ci~ isako indiCilt~d for all ~rwM who
~~ in high-lisk tmlal practic6, wch as heterosuual activitywith mukiplt
panntn, femalt prOllitu~,or holllO\tlual or bisowl practicH or prISOns who
Il'p~atedly cont"' t \eil(Uilllytransmitt~d in~tions. HBY vacci~ does nor provide protfClion aqain \I UpolUll' 10 oth~ (non-B) hepatitis viru Ie. HBY VilCu~
is prodlK~d 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 firs~and the third doll' 6 months alimhefirst dos~.The drug
is lII'arly 100% effeai"l'l' in providing immunit-; to HBV. Theeffectivelll'u of the
VilCcilll' in prodKing immunity in adults dtdi~s with age.

The most tornmon adl'!'rse effects from HBY "I<lCcination all' pain ill the injtc.tion sit~ and mild to modtrat~ Ityer and thills.Approumall'ly 15% of piI1itnu
will experiente ')'Stemic eflecl!, usually fit9Jt,diuine~ ~~~ i nd hNcbche.
Hypersen~tivit)o ~idions such il urticaria or i lOlphylu~all' pollibllo.
Contraindi tations: This "I<lCd~ is comraindicated in patieml with h)'ptrsens~
tivit-; to )'I'all or HBY "I<lCcine. Pill~nts who demonmated \e"l'l'1l' Itjoptrsmsitiv-;1)' 'a ,.... r,,,, m.,.m' .....iIlrin. ,hnnlrl nn' rt'{.;.,. "'''''-1'''''' do"".Th. drug
should beadminismed with Cilution in patients with fever or actil'!' infections,
or thOl~ with tornpromill'd wdiopIJlmolOlry 'IiIIUS.
INTERAalONS

Drug-DIIJ!I: Unbiown
li bTesis:Untnown
Herbi VFood: Unknown
Treatmfnt of OW'rdOSf: OI'!'rdosrs hal'!' not ~rn ll'Corded.

ADMINISTRATION ALERTS

In ildullS,use tIle!\Maid rnlJl(i!' for the injection me, unlesiCOlilriIi ndicitro.

B~caus~ 110111' of the forlllJlas of RffOlOOivuJ HB contain a p~rvatN~
on' the single-dos~ vial 1m been pt~rated, th~ with(j.,wn vaccilll'
should be used promp~y,and the vial dilurded.
Epinephrilll' (1:1,(00) Ihoold be immediately milablt 10 tll'i11 a pos~bIt
alOlphyiactic reaction.
Pregnancy megory (
PHARMACOKINETICS

O. s.1: 2wk
Prak:6mo
Halfliff: Unknown
Duration: Sto 7Y

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, IF N gamma-lb, has limited clinical
application in the treatment of chronic granulomatous disease 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 stimulation of cytotoxic T-cell activity against rumor cells, increased B-cell and plasma cell production, and promotion of
illil~[mll~tiull. At l~""t 30 JiIT"n,,,1 Ik hav" Ut:~11 iJ"'"lifi~J,
though only a few are available as medications. Interleukin-2,
derived from T helper lymphocytes, promotes the proliferation of both T lymphocytes and activated B lymphocytes. It
is available as aLdesleukin (Proleukin), which is approved for
the treatment of metastatic renal carcinoma. AIdesleukin

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COMPLEME NTARY AND A LTERNATIVE T HERAPIES

Echinacea for Boosting the Immunll Systllm

EdrimKro purpurlll, or purplt colll'flowe~ is i popular botanicallOltivr to the
midwest~m United SIiIIH and cent,,1 (anad!. The 1IowerI, ltal'fS, and ,tem,
of this plant art lIalYeted and dried. Prtparatiom indudt dried powder, tinetUIl', lkJid nmrn, and trill. No singlt ingll'dient 5el'mI to be IflpDnsiblt for
the herb's ictivity;alil1}l' number of potential~ ictMchemic.iis W ~n
mmirlfd from the umm.
khillilCN Wi! used by Native Americans to tll'iII virious wounds and in~rirs.khina,a is btlieY~d to boost the immunr s)'Stem t:, inell'uing phaqa-C)'Iosisind inhibiting the b.icterialrnzyme ltjoaknonidur.Somesubstanee in
KhillilCfa apptilr 10 ha~ antiviral activity;thu~ the herb is lOIIl~imrs 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 supponiv~ tll'atm~m for any dill'i\e involving inflammation and to enhince the
immu~ !)'!tem.Sm ~ffKlIall' "1'1'; howe"!'I'r,it mayimerfell'withd~ that
w immuOOlUppIl'ssant efil'ct;.

TABLE32.1

Immunostimulants

Drug

ROUie and Adult Dose (max dose where Indicated)

Adwrse Effects

akle5latin (PtoItl.iln):lnttrltukJt.2

ri;600,ooo lII~sIkg (0.017 mgfl:g) t'ttJ 811 by I IS-min IV

infusion for 11IJt., of 14 dolts

fMil sympIfJIM (ff~ rJoIIf, MIlIaisl), fOlh, tl'ltmill,

/ICIIStII, M:IIW'~dkmhN, (tInMkll ogmlion, ~

!JUlia,.,U," bypgfmwn Wb't9ub

IIJ0000bocytopHi.l oIi!lJ1ji iDlrja R!!mwry cdmy

Badlus (ai'MtiH-ubin (BCG)

vilUilM' (Ti, ~1S)

kltracltrmal (Tlcf);O.1 ml as wacdIM'

kltra~1 (ThtlaC,sk bIaOdtl

ilstilation for bliddtr wmoma

f)jlikt symptfJfM (~ cN/1f, MIlia&), dyw,;"

hem.:rru~ anemiD
I!mI!ocy!Qpmy m@t UTI

INTERFERONS
Q

inttrftrm alfi.2b IIntron-A)

lMIstb:utaMOUS; ilaify cd lM~iiI: 2 milkfl uriMIII tlnf

FMit i)7I!~ mfl!f9ia.. fatigrJr,Modi!dJt. Q/J01I'Dl,

tim~

dillrrhfG

ll:lposi~ ~rwm.J: 30 millon lIliUlml3 tima'wt

Mnl~sion thfO!T!b!xyt!!proia ludd!! idl.'ation

seiZlRS (i'lIffltron beta! MI lintwtloo gamma)

Htpatilh:] milion ulitslm1tlm: timelwk Dr 18-24 mo

i'lterfcfon aHi(Ol)-1 (lnfel9tn)

SubW:IJ1fOUs:9 fTK91tlret timewk

i'ltufCll1 iHi-fil (Alferon H)

kltralMnll;O.OS ml (250,000 lUI ptr wart tMctlwk to/ up to 8'Nt

i'lterftron be~ 1a (A1'OfIa,Rtbif)

1M (AVOMJ~ 30 mcwwt

i'ltfritron be~ Ib(Bf~lffl)ll)

SubcWIM'OUS;O.2S mg (8 m~lion lIlits) Mr! 0I1Itr lSi,

pegimffitlOll iHi2. ( I'tgas~)

SubW:ilM'OUS; IIll mcgtwk for 48 v.t

Pf9imerfcfon ilfa-l1I (I'tg- rnlWl)

SUbW:ilM'OUS; 1.S m~/Wt

Inaplrttui5 hf1lMrogxjdty

SUbW:ilM'OUS (Rtbif); 44 m<g thIN ti~

~ 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 repon~ roodifier prtpared by ~ombinant DHA
Ihnology that is iPProvtd 10 trW ClnCfrS (hairy c~lIlfuklmia, maligll.lm
mfl.lnoma, non-Hodgkin'i IympbolN, AIDS-rtlalfod Kaposi~ Si/(OIN), lIS Wfll
II vifil inffCtions {human papilloma ..uus. chronic Mpatitis virus Band Q.Offlabel indi<AltionllNY inWdt mronic mydogeOOUl leuklmw., ~er Cinctt
h~rptllimpleJ: viul.ll'nil cell Clncet wriulw-zosterviM, and West NileviM.
It is ilVaiwble fol fI, 1M, Ind ~bruuneou\ administration.
Rebfuon in mrnbill.ltion dlUJ containing IFN illfa 2band ribil'irin,.in antiviral qrn. Rebttron is indicillfod in p/larrMOliheraP'l' of Mpatilii (in~.
Ptgilltlieron alfl-2b (Ptg-lmlOll) has a rnoIKule of PEG i1ttad1ed to 1M inltlftIon moIule, v.tIich gi'm t!lf drug an t:(ItJ"Ideod llalf-life. PegilltlM i11b-2b
is on~ aPPlOt<i1O Ifut mfOllic hepatitis (viM in~1iMs, although it may bt
used off-la~ tot~at dJ"onic htpatitis Binfections ind !le1lplilltic disea~.

ADVERSE EFFECTS
Afkdiu syndrorlM' of fMt mills, dizzin~ss, Ind fatigue OCCUI"I n S09G or patiMts, although this lISlJoIlly dimini~hei lIS Iherapy proglesse. Htac!ache, nlusti, vomitinll dianbfa, and anOrtxill art ldilively (I)II1mon. Dfprtssion and
wicidal iOtation h.'o't bHn ftPOrttdandmay bt stYt,ul"ICUgh to It'quift' discominuation of the drug. With pwlonged therip)', Sfrious toxicity such as imJlJJnosuppft'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 associated with an inutased incidtllD! of neurolo9ic ilnd other S4!riouI (omplications
in mtS4! agegroups..

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 ~omrnendfd for patieflu il rilli; for
b~ing (plartlet count lesllhan SO,OOOimmJj

11lm! is idcitin nr".oiosl4lPft'SSm with am neopIastiG. Zidcrrudioe moll' JnaNSl

hlmalologic loxidt,:
l.a~ T~s: 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
TINlm~nt of Owrdou: Ovtldosf mi~ caW' lethi'!IY <lnd {OIN. Trtillmtnl is
by gtnet"al support~ mtawrtS.

P~nancy c.all'gory (

PHARMACOKINETICS
tnset Unknown

Pe.U-12h (IMJ
Half.J if~:2h

Duriition:Unknown

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INTERACTIONS

1W:I-bu1;Use with ftllmlIN1GW mwdrowsi"ttss iIIId detijO"alion.

Rdfr III M'fMN19O ((If. Mnlngl'rtsS FufsptCMc to /IIIl1tug.

(hopltlll

NURSING PROCESS FOCUS

Drug. fo, Immulll' Sym'm MoWl.llon

45 5

PATIENTS .EeElVING IMMUNOSTIMUlANTTHE.APY

Assessment

Pote ntii!ll Nursing Di i!l gnoses

Baseline assessment prio rto admini stration:

Undtrmnd the INson the drug has ~n pr&ribtd in ordtr to mes lor
tlltr.pwtic: eifb.
Obtain I (ompittt IItl kh history ilKluding p~ history 01 acMI dist~
(t .g., chic:kenpox), ht patic:, rtnl~ cardiomsrular, ntUrologic:, or autoimmunt
distall', HIV infooion, lever or ad~ inltdions, prtgnallQ or brNstf<ling, and
prt'\'ious allt"lic: rtlponll' to immunizations or to produru (ontaintd within
immunization (t.g., ),!,ast stnsitiYiry,lI'n~livil)o 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 ~!eIint vitti signs, epteially tt mptraiurt.
['/;lluate appropriatt laboratory findilMJi (t.g., (&, platt lru, tit(troiytes, titm,
htpatic:.nd ft'nallabs).

Htahh Seeking IIt-'h.Jl'ioo (oprffitd dtlift' to obtain vaccinations)

lneffeaivt Ht.kh Maintt nalKf (ft'lat~ to Iliuft' to rompiete
immuniution !(iwdutr)
DtfKimt Kn~ ('/il{dnation !(htdJlt, It(ommendations)
Risk for Injury (mattd to drug ~ tfle(l\)

Assessment throughout administration:

Asses lor p.ltitnt Idhl'ft'nce to romllll'nded immunization !(h~utr (t .g.
n<llor ft'ptued immunization~ boosters in adults).
(ontinUl' ptriodic: monitoring 01(8(,lnd li~ Ind ft'nallimction Studitsll
appropriatt.
Asses vital signs, e.pttially tfmptruUft'.
Asses lor and immediatt l)' ft'"IKIn ad~ tfflS:fnt~diuiflffi,(onfusion,
mlJl(tr 'M'akne., IiKhyu rdia, hypotension, ')'IIro~, dyspnta, pulmonary
(o~stion, .kin r. she, bruising or bleeding, or anaphylactic ft'actions.
Pli!lnning: Patie nt 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 miniflli~ adW"ll' rfFb.
Vrrbal~ In undt,mnding oftlltdrug's UIf, adYfl"ll' eiferu, and ft'qJift'd plt(autions.
DffiIOn5lratt proptl stIfadministration of tht medication kg.,doII', timing, whfn to notify promr).
Implementatio n
Inte rve nti ons and (Rati o nales)
Ensuring tht ril pt utk rffects:
Conlinuo os=smmt> os dr><,il><d Nrlio, for tho .. prutK clfro,.(Th~ 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 ~te.)
Minimizing adftlle rftKts:
ContinUl' to monitor vital ~igns, rspteiilly trmpt,aturf,and ntUrologic: status.
(Immunizations and immunOllimul.nts may (.lUll' dtrmatologic,
cardiomsrula~and ntUrologic: la.tfSl' rifts.An ioclN.r in ft'm~r.wft',
Ioulizrd ukfr.!tions orYiJnsof infooion at injt{\ion lite, tach,,:ardi.! or
p.llpitationl,dizzint1l,or(hangrs in ~I of(onsOousne. molY indicatf
lignifiunl ad~f!I' tiflSJ
Rtport .11 sig nifKint aa.ef!I' tifb 10 lilt hNlth (irt ptoYidtr lor ft'porti ng to
VAERS---Vaccint Adversr [~nt Rtponing Symm.

Patie nt i!l nd Family Edu cati on

T~.{h th< potiml.nd fomily 0' wrgivr, 10 kp "",inolion rr<ord>
and to mnain rurft'nl with requift'd immunizations.
Eocoutagt older adults 10 hl~titeB d,awn 10 (onfinn immuniry.

Trl{h tilt patient to {onluh thf CIXTr~veIer'l Wfbsitf briOit' pl.Jnning

O'Itntas 1f1~llnd to (on!Uh with tht hNlth (.1ft' prol'idtr about riW
and requift'd immuniution~
Tra(h tilt patient to immtdiatrly ft'"IKIn art)' It'ltrOYfll0'' or u
inl1rud:ed by tilt htikh (ire providt~(hangrs in (lIOI(iousflffi wch
as d~nt11 or disorientation, dyspnti, or tac:h)Urdii or
pillpitltions.

(Continued)

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4 56

UnitS

Th~

Immune SY"'-""

NURSING PROCESS FOCUS

PATIENTS RECEIVING IMMUNOSTlMUlANTTHERAPY (Continued)

Implementation

Inte rve nti o ns a nd (Rati o na les)

Patient and Fa mily Ed uca ti o n

lR'at minor m~ ~lIecn symptomatically. (Mioor ~VI'M ~ffKls m.ay lit trmed
with ~mminoph~n or as ordloR'd Ir; the he~kh taR' providtrfor low-ilradt
fe\lellltss thn lOn, for localized tl'ndtml'u,orfor minor anhralgias and
malaist.Cool tornp~!eS to injer:tion .ruy help allt'/i.!tl' .rulaist, ft'/e~or
injer:tion ~te lOn'ne s.)

TNCh the patient to trm minor I)'mptomsas I"ftded but to Il"pOIt

<I~~ ellecn (as dtl(ribfd Nrlier).

Aslffi for plIIibilil)' of pR'gnalK)', pR'vious history of ol\}ln transplantation,

and hom!' tnvironment in(kiding signifiumly immunoc:ompromised patients
at ho~, ~.g., from (htnlotherapy, brfoR' giving live virus immunimions.(Some
I~ vattination~ rontinut to lit shed from the patiem in the posM(tination
Pfriod and may lit transmitt~dto immunoc:ompromised patients i nthe home
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' 'U(ti~ should (onlUlt thrir heakh u R' providtr.)

TNCh the patient to a!tn t~ir health me providen to ,lOy ho~

~lWtion that may lI'q.rill' dderral of li~ v~tinations before
vattination is g~n. Women who ~R' pR'gnant orwho br(OIlK'
pR'gnam within the first 1months after \\J(tination should (onlUk
with their health UR' provider.

Avoid or deft rimmunizations in any patient with a fr~~ autoimm u~ dista!(.

or tholl' taking cortic:osteroids. (~m.JY make it moll' diffrruk to disa'm drur;J
R'action \IeII~an infer:tiom plO(ffi.lmmu~ rtIpOOlI' to vattine ilia)' lIto~r
or unlltrtherapeutic <l nd an iIKrused risk of a~M effer:1I111a)' Irsult.J

uplain to the patient the rffi to defrrvminations unlltr teruin

ronditions and elllllR' that follow-up .I pplintmenn are made as
appropr;a1l'to maintain currency with immunizations.

Aslffi thf patiem for pll"lious use ofSCG 'U(d~and (onlUk with the health
taR' providtr beim giving PPD ("Mantoux1 !kin ttsting for 18.(8(G stimulate
immunity to th~ tulltrrulosis and II'Ctnt vaccination ilia)' caUSf an ~VI'rll'
R'action to PPD injection or II'sult in a f.J lse positive R'action.)

TNCh the patient thu prt"Vioos !M ofBCG may rrsult in a falll'positiVI' 18 test.an unusualll'action to the PPO ("ManlOUl1 testor
that other teting may br R'quired to tonfirm or refutt (urrent
infer:tion.

Monitor for lign~ of opportunistic: and suptrinfer:tiom,or an ilKR'aSf in bruising

or bleeding in patients IfCriving interf~ron therapy. (My~losuppresion may
o((ur, iIKR'uinl} the ris kof infrctions .I nd biffiling.)

InstrlKt the patient to immediately I!"porr ft'/e~ in(R'asing malaill'

and weams,gingivitis orwhite pat(hes in mouth, ~inal yeast
infer:tions, iIKR'~ in bruising. or prolonged or exmsive bleeding to

mt

Ihtprovirler.

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

interferon thelllPY. (Psycholis, dtprrssion, .J nd luic:id.J1 ideations aR' potential
arl~1!I' rffer:ts ofimerferon !M.)

InstrlKt the patienl,famiiy,or c.Jregil'el to immediat~ iy report

iIKlI'asing ietharw, disorientation, confusion,(hangtl in IIthavioror
mood, agitation or ill}9rrssion, ~ulTf<lsPfer:h, or atam.

Pati~t

undtrstanding of drug thera py:

Use opporrunities during .Jdministration of medic:.Jtionsand during <l lSmments
to dilCl/SS r~tiona!t fordrug thmpy,dnirtd therapeutic: OU\(OJlll'S, IIIOIt
rommon arl~rst effts. paramettrs for when to call the heakh UR' providt~
and any ne(esary monitoring or prtUutions.(Using time during nursing taR'
helps to optimizt and reinfon:e key tl'.Khing are.J~)

self-administration of drug therapy:

SptCific to interferons, when ~dministtring the medic:.Jtion, instruct the p.nient,
family,or call'giver in the pro~r self-adminismtion of the drug. (Proper
.dminimalion will inaNSI' thedrtttiv~oosof the drug.)

The patient should br <lblt to sta1l'the lI'alOn for the drug;appropMe

dOl~ li nd ~dleduling;and what IIdYmr tffer:ts to obmn for and
when to rrpon them.

Pati~t

TNCh the patient to take the medication as follows:

Rtconstitute the powdtr (if applic:able) with supplied dilutnt and
gmtly rotall' the yi.J1 brlWttll the palms. do not sha~~.Check
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 singie--us~
oniy).Singie--usf syringes Ihoold be dismded afttr U!I',~ 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 R'rum-demonmat~ the injection
ter:hniqut umil they aR' (omforuble with administtring dlll9.

Evaluation of Outcome Criteria

halu.J1l' the effer:t~ness of dlll9 therapy by tonfirming that patient goals and expemd outromes haft ~n met (_"Planning! .
"" TIIbIt 11.1 for ~ lis! (/ drugs re wIOCh rhest mnq ~rlionr gppIy.

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Chop", ll

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 lea~ the blood and enter the interstitial
spaces because ofuleaky" capillaries. Interleukin-ll, which is
derived from bone marrow cells, is a growth factor with multiple hematopoietic effects. It is marketed as oprelvekin
( Newnega) for its ability to stimulate platelet production in
immunosuppressed patients (chapter 2SOO).
In addition to int~rferons and interleukins, a few additional 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 certain 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 inflammatory 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 environment. 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 tril 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 occur months or even years after surgery.
Immunosuppressants are drugs gi~n to dampen the immune
response. One or more immunosuppressants are administered 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 immunosuppressant 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 immunosuppressant drugs differ,all suppress some aspect ofT-cell function. 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 nonselective agents will provide more widespread immunosuppression, but carry greatH risk of adverse effects.

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Dwg.forlmmu""Sys'"", MoWlat"'"

4S7

Because the immunosuppressants are toxic to bone marrow, they are capable of producing serious adVt'rse ~ffects.
During immunosuppressant therapy, the patient will be susceptible to infection from all types of pathogens: viral, bacterial, fungal, or protowan. Infections are common and the
patient must be protected from situations for which exposure to pathogens is likely. Prophylactic therapy with antiinfectives 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 immWlosuppress~nt activity in_
clude g1ucocorticoids, antimelllbolites, antibodies, and calcineurin 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 intracellularmessenger {.laneurin, cyclosporine (Sandimmullt, Neoral ) and tacrolimus (Prograf) disrupt T cell function. The
cakineurin inhibitors are of value in treating psoriasis, an inflammatory disorder of the skin (chapter 4SOO).
R~call from Section 32.2 tb.1t antibodies are proteins
produced by the immune system to defend against microbes. In fact, Section 32.3 discussed how infusion of antibodies can provide passive immunity. It may seem
puzzling, then, to learn that certain antibodies maybe administered 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 antibodies will attack T cells (or T-cell receptors). fuur of
thesf antibodies are used as immunosuppressants. For example, muromonab-CD3 (Orthoclone OKT3) is administered 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
auto immune disorders such as Crohn's disease and
rheumatoid arthritis. Note that the suffix ~ab 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 anhrit~. up"'in why tht nUJ1e Ihould
qut!lion th~ medimion ordtr.
Ste~/M'fId* DfrIIlht~_

4sa

ThelmmuneS~em

UnItS

TABU: 32.4

Immunosuppressants

"""

Route and Adult Dose (mall dose where Indicated)

Adverse Effects

ba~lilimab (SjmulKt)

IV; 20 1119 tint! two dow!5 (fil'5l do!e 1 hbdort 1lII)tfY;!KOIld

dose ~ IIqlilflf r trinspWntl

~izumib (ZeNp.xl

IV; 11l191k9 start fil"!t ~ no mort than 2. II priof to triMplant.

then Itpta' MIY U day; 101 foul mort dolts

loed fPfKfkm ilfriM liIr (pili,., tQffllmlt

mydgkr), inlbrrlo-/it sympfrms (molabf. fmr,
(hils), 1Itodwht, diIzint1!

iIlIDimab (RemiGldt)

IV; 3--5 m9fkg foIlowfd tr the !MIlt dose at 2 ~nd &wefts

lba~"ldmabl ~monarvfdrmi !muromona!).COJ

and Iymphoqrt ir!!I!\/!!!: qabuli'r l twn simplex or

IV; 10--10 mg/kgId.1y

rytnmma krdnl' Infmjnrn (roJJft'lmPluHm )

ANnBOOIES

r ; ;'Ioc)tt Immll'le gloIlJli'r 0r-

An. p!ndu k Iwpmcmjpn jnti:rtjoo< !may oulJrjn

IniIlY djfftrmt body MIf:!ml !U!iI inJ!imJml

inlithylTlOC)'ll: ~Jobtjin, (At9lfll)

mlftllllONlKD1 (Ortboclon!: OKTl)

IV; 5 rngfiWy i~irist~:lfOf 10-1. da)'s

ANnM ETABOLlTB AND CYlOTOXIC AGENTS

illikillfll (KiImt)

SWrutifltOOS; 100 1119 0I(f daily

/tjfiIII sire IffJCIionJ

11:(j~i Inf~ion!

wtlioprint (ImUlin)

cydopho5Jlhamidt (Cytox.ln)
(S!:f ~ 556 for tile Prototypr

..,,,.00,

POr1V;3--511HJ.tg{iWy In tially:INY bt.1lllf to rtduct to

1-3l!1CJ"kg1day

PO; lniti.ll: 1-5 11191kg1~.MalnttNlKt: 1-5 mg/kgMIY

HOday!
1V;40--SOm~m diyhkd~01!"2 S~'4Ito 100 mgi\g

NmI~

maHH 9:

l(lmrill!JMJIt.I'i:I

'im'rr N JM' and mrnjtjnn OOnr romw

:il 1 1lIlII:~lIIllllllmbl!l;:dIIi:mil ioftllkJm
fl\iJilmncy hfIHlOIo:J:icity
N4u~

MlIMing.aMlttb, 1IfIJ11OpI!1Ii4 4/opKi4

Anaphyli!lk. 'n;roenj .. Jimooa'Ytm lrglj jmrwjtja!

rdmpJNJY fibrmjl. tqpc cpjdmni! nmoIyit

Slmlll-Johnson 5~dromf Mm!!!b!!iil:!}stitil

n!l!!!Dtoxicity
fUIIH(ffII [ElIbttIl

SibruuMOOl; 2~ IrIIIMttwk 01 0.08 mgfkg ft SO I'II~ Ql\(UWI:

l()(dllmiMftll~tir#{pI1I,.,t/)fMm4

rnrd9iGJ, ,bdorrinolpGin, MlIMi/li hIadac/rt

Ickai!lOl IYDQ1Q1!m\')' Ml lKi!! (;)1~1!t bf:iltlllli~Ja:
~

IIII'tboIl!:liIt~ (Rh!:Ilfl\iuu, Tl!ull)

(S!:f ~ 558 for tile Prototype

PO:15-10 mglday rw 5 days; I!p!:."it~!:tf 12 wk forthr!:t COIInlS

HMd4d1t.gIoJsiris,"IiriJ,miId~/ltJMf/

UkmmslO!Ntjtjs m'lf'kl'illpprn'ign alllWk

antmli !!m!!k gnho!ls. nal!!2tomll 511ddtn

[)ugbox OO )

dram J!JknQoaryfibmS\M !!ft/!1 mlllji

~t!:

((!:IICtpt.Myfortic)

POI!V;720 mg bid in UHTbNtion willi (ortirouMlids Ind

C)'CIosporiIl!:, witlin 1. II of trampli M

PfIiphttrJ ldmI4lfGlriIN. /ItQdht., /7mXIf.

dyspfpsks, ttxbnilld pdn
yT1lM~a

iWlill1U! (R.Ipal1lll1~)

PO; Hnv loading dose Irrtrofdi.l!fly ifirf tr.In5p!ant. thltr 2 mglclay

antmla throntboM2I!:nla

'""""'"'

HypttehdtstmJmlil, 1II!h. ftrlilal9/tlilvilH,IIIIISla,

KlmilRj. ntIrriI, /JtXt pdll, llrijhlgdn.

/lypetfpidemia
HvprnrnSM IN*Q!!tria WEii !bmmlmtl"dl!'!lja
~~K'tooclarv

trmsillllimus {ToriseI)

IV; 251119 0!1C!: W!:dIy O'B" 3O-ro min

nt...mns Ill!lljg~OO'

IWSo\ ,llhtIli4I1XXMiliI,IIIIIJ~ fdtlflQ, 1JICmiII,

IIyptrv/7ffflliG.llyprrfpidtnU
AM/!!i,

alli~m. inftQioll!

dj'iUV gr mA Jronn

intmtilial l!!!!l

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

~!mm: Xllltll!s!:!liJik tJupll"D<ion nrutrnrtf'Oy

prripMr,! ntUropathr

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TAlI.E 32.4 ~ Immunosuppressants (COnltwro)

Routeand Adult Dose jlmM dose where Indicated)

Adverse Effects

PO:In~1a1 dose 14-1. mgIkg jv5t priorlo IIJgeIY;Mt~r 2Wftb,

111m 5-10 mlfl\9flb,

1hItism,1ImIOt Nniting

CALCINEURIN INHIBITORS

QIdosporinto ~'I.~ncinltrune)

H'!'Dt!!~

MI

nrphrolOm~J

Im!rrt.!ltmia

1fIl!'(ti INInthm hmuM91ridty

uaoimllS (Pro.jml

PO;O.lHJ ~lcb1 in two diYidtddows~ 11 h;rjrt In!:

cq/dose8-12hlftel di~ fl'therlPJ

~_,~M,~IItodJdt(

1'1; O.Gl-ll.05 l119J\g/d.Iy ,~oonlinoom Infrion; 1I1rt no !OOIIeI

t!Yn, h jflfr I1olIIIpIam .. daJnCinulo UIU~ pifm yn taV on!

Infrttjoo< hyl!!l! .......

' f t !lfl!m!..;y
ftr!:rnors.oart!thei.l lllJd!Wd Im!rrt.!lmia

tlbtttmind pdII, illSCllD\!, ptripIttId t(/frfl(J, ~

De"'"

!!!f!!!it

~ Prototype Drug

hypmtrmnit

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 TI: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
of a gkJaKorOCoid lOCh oft pINMoIII'. (~ is apprlIfd fa! t~ prophr\.ilis of kicInfy. hNre. MId 1M.
tfWplanl~: psoriisis; 1M JCt,ophth.lmil,ln ~ condition 0( diminisNd ttar pIOCbtion UIMd t.,. ow!.. inft.mllWlion.An IV loon is miWbR for
traIISplant~ ,md for~ morsel uftr"ift{oIimorCrohn's dismf.

omn lMd in mmbin.ruon will high dme

ADMINISTRATION ALERTS
Ntoral {rniuof,rookion}...d SandilllllUM' iI~ 001 biorqllinlmt omd tillI001 be IMd inwdiangrillll, wilhool: ckM supervision bJth~ health tiI~

ADVERSE EFFECTS
The primary ~ ~Ifm olQ'!bsporin~ Q((OO in the kid~ with UplO 7'fn.
of pil!itml ~lIptfimcing rtduction in urine autpUI. INtr hill" thf patitnu !akinog
tilt drug will ~Cf hyptrtension ilnd tmMr.Othtr <OmmOn ~f i!fft<ts
_ hudiJdle,ginginl hype!plasil,ilndmillfd Mj)itK ~.AIthougIr 0,portllninic: inftiono; oc:rur dUM9 (y(mporioJe thrra~ thry iI~ ff'ftr thin
with IOII1f of tM ocher immunosuPPffSSilnts. Periodic: blood (ounts irf IW'ISill)' to msu~ thIt WBU do not f4l1 below 4,000, or pIat~~ below 75,000.
lDng--tmn tlJeqpJ inrm~ tM mI: of miligniJrq,~ lymphomas illII
stiIIUl'(tJ'S.

Conlni ndiutiom: The only ronIr.Iinlic:, tion aprior hypmeMitiority totht drug.

.......

ON}-Drug: ~lhadfaN'it~lewIi~p/IfrrfUiII,

Pregnillq m~ory (

~iLl~arbiJnw:tpilf.iIIIII rif.Jmpin ........ tifi.ngallhljl,ACI in~ibi!or\

INTERACTIONS

t6AKk, iJnd IIWIIide ilnlibio!n r.ay iIcJNIe cydD\plri~ ImIl.

liJ' 1eru:~nwy naN'it SfI\IIl~ and lft.DI.k ma,

PHARMACOKINETICS

dfcrNIf hfpatic fIIl)mI5 ind lI'nary hMion ten ~

On~:7-14days

IIeIbIVFogd: ~juKe{iJnr.liw~IrwIs"'~2OJIi.1M1hj

hak: l-4h
Half.life: 16-27 h
Dur~lion: Unknown

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

il'ml)abanl~whidJllilJ inll'lifll'widlinn~

TrNllH'm of o-dose: Tilm is M

~ifK ~iltmenl forOftdose.

lUI II ~.b"QMmlI'IIJ1kIml fooriIpKllcll1fMsdrug.

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UnitS Thl'lmmun<>Sysll'm

NURSING PROCESS FOCUS

PATIENTS RECEIVING IMMUNOSUPPRESSANT THERAPY

Assessment

Potential Nursing Diagnoses

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
canw;ft~r or activt inftctions (nptlially htrpts, mkella,and CMn htPitK.
(tmt t cardio\l.Jl(ular,lII'umiogic. or autoimmunt dMa\t; dtrm.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 I~ 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, plattltl~ eitctro/ytn,
9U:OSt,hrpnic ind It'llilllabs,lipid Ie\oeld.

Anxittyor F8r (rtiiTed to conctrlll.bout condition, trtiltmtot)

lneffectil't Tlltr.ptutic Regimen Mamgemtot (~td to complexity
of dMalt, t~.tllll'ntl
Sor:iallsolation
DtrKient Knowltdqr (drugthelill'f)
Riskforlnltction
Riskforlnjury
Risk for Impairtd Oral Mucous Membr.ntl (malt<! to druglrUtmtM)

ASlelSlnent throughout administration:

Asltss ~r dtsirtd therapntic tfftcts (t,g.,no Siglll or symptoms ohl~nsplant
Itjtion, Itll!ft infl.mmatory rtsponlt or autoimmune Itsponsts art
suppresstd).
CominUl' monitoring of CBe,platelets, tlt{tro~te,9kK=,liwr.nd rrllill
function studits,.nd lipid it'Itls.
AsItIS l'iul sign~ npedll~ blood prnsurt.nd temperature,
AsItIS ~r and immtdiately Itport .cht~ tfft(ts:~ diilh, visible siglll of
inftction, n.UItiI, Omitinq. diuinn~{onMion, IIIlJI(It wraklll'S~ tlMlOO,
tach)'c.rd ii, h)'llfrtmsion,. ngi 1IiI, syncopt, d)'lplII'iI, plJlm onaf)' rongntion, ski n
ra~, blU~ing or bItIing.ol dtcrt.std urine OI/IplJt.

Planning : Patient Goals and Expected Outcom@s

Tbt patient will:
Expt'ritll(e thrraptUtic dftcts dtptndent 011 t~ ~ason tilt dlll(l ~ bring gi'lto (e.g., ~ from signs of mnsplant ~)tr:rion,tJC(tsliWautoimmune rtsponlt
limited a"d dtcrtasing),
Bt 1m from, or txptrience min imal. .dvmt ~fftcts,
Vtrbal~ an unclentandi"9 of tht drug's Ult, adverse tfftcts,. nd requirtd pttc.lutions.
DtmonlU.\t proptr stlf~mi"istration ofth~ mtdication (r-9,dost, timing. when to norif)' plO'/idtr).

Impleme"tation
intervenlionsand (Rationales)

Patient and Family Educati o n

Ensuring therapeutic effects:

Com inut ~ IStSSIlll'nt1 ~ sdtscribtci earlitr for thmpeutic effects, (Monitorifl!l
will t.. ."",irKlu ll4n>pLo n~~.y, 'n.inl~ndnc.~ 01 ",i". uulpllL Se..",
inlb mrnatory (onditions and autoimmun~ disordtrs should show 900wlly
Itm:ning inflamm.nion.nd pi in.)

AdYist tht patitm on the trtatmenticonditionsp~cifK monitoring

rtqUir",nt nl> (~Jj., ",i,,~ ,,"lpu~ i"'pn".,n,.",l Df rnumnt nl in juinl>
with lesstned lwelling).

Minimizing adverse effects:

CominUl'to monitor vital sign~ ~ially blood presSUft a nd temptrilUft.
(lmmunosupprrssant drugs may calM hypertmsion and illCrtillr the risk of
inftctiolllJ

T~ach tilt pititnt

how to monitor blood prtllUrt.ElllUft the proptr

USt lind functioning of any hoIIII' ~uipmtnt obtained. Tilt patitnt
!hook! ftporl blood prtlSurto~r 140190 mmHg [II' per parallll'trrs
let by tht heakh cart plQ'/idtr. (hen pain or presSUft !hook! bt
ftpDl'lN immediatt~.

Tram tilt pititnt to rrport ~ny ftRr OY!'r 101' [II' ~I instructed by tilt
health Wt providtr.

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NURSING PROCESS FOCUS

PATIENTS RECEIVING IMMUNOSUPPRESS ANT THERAPY

(Conrtnuedl

Pillt ient iIInd h mi ly EdU Cillti o n

ObSffi't for sicJns and symptOms ofin~tion. (lmmunosupp~SoInts inomt the

rnk of inftctiom., ~iill, witkoppal'tUnistic infections wck is ktrpft,
\OOceili. (My..nd full9'l inft1:tions.)

Ttadl tilt ~t to rtpOrt signs Ind symptomsliinftioft im~

st.dI H:wounds with I!dness 01 draioq, IK!eHilg toUgh, ioctising
filtigue. whitt-f)il\l:heson 0111mllCOUS memlHann orwhitt.nditl:1"tI
. 1 cisclwrgt,or itd!r blilltr-ib ~on skin.
1Mtrud: the patinu on inlNtion comrolllll"lUm,. indJding:
~tIwndWilshing.
Awiding ~rgt' crov.ds, uptcia~ illlloM..
Awiding ptOpko witk known infKtion oqooog childrffl who hn~
kightr risk of h.~ing an inftioll..
CDoking food thoroughl~,i1llowing f.mit, or artgiwt to prfPil!
r.w foods .nd to dun up afrlfWank. Tht pitRRlIhc:dd not
COllsumt IlIW fruiliOi ~ab~
Tud! the patimtto IfSlOrI .ny ftver pn- p.lwrll'ttrl ~ brth' hulth
(iIR' pmidt~ancl S}I11ptOIlll ofinlKtion.

Auess fol (~ in 1M! Ii wnsciousness,disorieoutioo 01 confusion,or

II!mori..(NtlllOlogic dJ'lIgfIlIIiIY indicatt.dl'rl\l' drug tfteru.)

Instruct the patient 10 'rll1~~tdy!!pOrt incrt~ng Ieth.IgY,

diioritntation,(I)nmon, dI.vtgts in irhmo.- or mood, WIred

Continue to monitof (II(, plattlm, tlectrtiytts,gU:ost.Iier and rfll.1 function

Instruct the patien! 011 the nffii 10 rHUm fl!quently for folow~p WI

~h,or trMlOl10rilt.uiill.

Itudits,.ncllipid Itnk.(lmmullOlUppI!ISoInll may (illM Itukoptnii,.lltmia,

throm~nia, hypftglycrmiil, and hyptrUlemiaJ

....

~ p.ltitnl to {illY. w.II,t identib:.!lion u.rd orWNI medical

idtntificiillion ;''M'Ir) indiGating inmuno!llflpre.lnt th'r'py.

ImpW oral IIII,ICDIII IIII'mlnnes Ind dtml hNlth. ~mmunolUppmlion
inc!eilsrI tht risk of or.lundidiillis.nd gingMlil.Ch.I . nl:ifulllJill rime may Ill'

,...;.dJ

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 ~

A~llhl' p.lbenl\ d~.nd <ol1lllmption 01 gl4ptfruit ;:&,. (Gtapl'flll~ juRt

iignif"rantly inclUStlcyo:losporint 1Mb .nclshould be mcIed wtrilt on
immullOlUpp~Qnt thtrapyJ

Too lhl' poUnt 10 4\Oid or flimin.~9rdptfruit 400 grd~ruitjuir.r

whilt on tilt dllJ9.~ ~ without juict.rt ptrmissibit..

AS5tS1 for plt'ljn.n<y.(~1K)' 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.)

Discml pI!g!IiIlK)' and bmily plilming with WOIlll'l1 ofdrid-lII'aring

age..Xplain tilt ,ff! of medKatiorts on prtqrIan<y and brNst"(~ing
.nd Iht III'td to<isrussany PIe9lMKY plans with tht hultll (irt

~Diswss till' rd kif JOjitiorwllmns of<OR!r~eption,

iKb:Iing barritrmdholh, with p.ltienIs tlking inmUIIDI~nts..

Auess for the deYtlopmtnt of hirwtism 01 alopeda. (Hirsutism is ~iblt
whtrl the drug isdiscontinued. AIopii m.lY indicattsignilicanl

~ me patient to notif, the providerof cballgfl to lwirgrow1h 01

tmurt.

immullOlUpp~sioo.)

Pillt iut oodtrstillrMI ing of dlllg therapy;

Ust opportUllitits during administrnion of mtdications and during ~sesSl1lfllIl

to di$ruIS r.tion.1t fo, drug therapy, deirtd thtr.l PftJtic OIrt<OIIIt!., most

common ~ rffKb, para~ 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!giftr in
pnlptl ~f-administtation thniqutS followed by IttUm cltmomtra!ion.(PIOpI'f
administriltion wi. inclfase the 1~~1ItU Iitht drug.1.

The patiellt.fam~ 01 (ilrtgivtr should be ablt to S!iIIt the If. SOII fat
tht dill!}: ilpplDpNte dolt and sdltduinj:wlwt idw~ rifu to
oIMrw forand ~ 10 If port ;.nd the anoop.ltfd Imgth of
rntcIic.tion thnapy.

Tud! the p.ilitnt to Llioe 1M rntdication as follows:

Ust enclosed ~uiplIII'nl 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. ~ilTing welL
After u king lilt drug. rifnl' tht rup wilh addition.l1iquid to rlllUlf
the rlltirt dolt is l.ikrn.

EViII lu illtion o f Outcom e 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 Istllf~ 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 aga illSt one particular microbe species.

32.4 Cell-mediated immunity involves the activation of spe-

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.

cluding interferons and interleukins, that boost the pa tient's immtulesystem. Theyare used to treat certain virnl
infections., illUllUnodeficiencies., and specific cancers.

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.

dfk T cells and thesecrdion of cytokinessuch as interferons and interleukins that enhance tht' inlmune response
and rid the body of the foreign agent.
32.5 Inununostinlulants are biologic response modifiers., in -

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.

NCLEX-RN" REVIEW QUESTIONS

A 55-rear-old female patient is receiving cyclosporine {Neoral, 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. transplan t rejection.
2. heart failure.
3. dehydration.
4. infection.
Which of the following statements by a patient taking cydosporine (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."
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

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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. ~nal 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'.
A 5-year-old child is due for prekindergarten immuniza tiollS.After interviewing ht'r mother, which of the following 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.

'ho", .. n

Dfug. for Immu .... S)"lem ",odJl.lIon

463

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. During the physical assessment, what signs and symptoms
should the nurse look for! What are appropriate nursin g
interwnlions?

2. A patient has been exposed 10 hepatitis A and has been reft'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 respond~

1. A patient had a renal transplant 6 months ago and is taking 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.

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ellapler review mar!!riab aM

lor succlln with addillonal IICl.fX"'-sl)1oe practice

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Drugs for Inflammation

and Fever

DRUGS AT A GLANCE

LEARNING OUTCOMES

ANTIINFLAMMATORY DRUGS fllX}t4ff>

Nonsteroidal Anti-Inflammatory Drugs
(NSAlDs) pGqt467

After reading this chapter, the student should be able to:

Q Ibuprofen (Act.1I,Mollln,othersj prq*l9

Glucocortkoids (Corticosteroids)

{XIJt470

Q prWnlJor/f! pagt411

ANTIPYRETICS pl1lJt41l
Q ocelamlnophen (1)"lenot olhfrs) {!OI}t471

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.mma tion.

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.

KEY TERMS
ilnaph-,laxis {8/t4(f,
antipyretic fklIi~m
Cushinljssyndrome M , 47I
tydooxygeniSf (COX) PI1fJl461

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histamine plljt4M
inflammation jllHjt4M
mast (ell f!II9t465

prostaglandins plljt461
salicylatt pl(}t468
salicylism {llq 468

'lIopl,,1l

he pain and redness of inflammation following minor

Drug. fOflnfl.mmaUon and

~r

465

PHARMFACTS

abrasions and cuts is something everyone has experi-

enced. Although there is discomfort from such scrapes, inflammation is a normal and expected part of our body's
defense against injury. For some diseases, however, inflammation 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

nelllr~li7oo_

33.1 The Function of Inflammation

The human body has developed many complex ways to defend against physical injury and invasion by microorganisms. Inflammation is one of these defense mechanisms.
Inflammation occurs in response to manydilferent stimuli, including physical injury, e."l:posure to toxic chemicals, extreme heat, invading microorganisms, or death of cells. It is
considered a nonspecific defense mechanism because inflammation 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 injury or destroy the microorganism. By neutralizing the foreign 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 redness 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, inflammation 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

Inflammatory Disorders
Anhritis, th!' most (ammon infiamm'tory disotdtr, is tilt lNtIing tilUS!' of
disability in tht United SUil's.
InA,mm'tory bowt l disust ,fftIU JOO,OOOto SOO,OOO Amtriuns
uth~ar.

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 m~ mortality than istilustd from
gutric:wKtr.
Worldwide, moft' th,n 30 million PfOplt (on",mt NSAlDs cWiiy"nd of
t~, 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 permeable. 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

I Chemical Mediators of Inflammation

Mediator

Description

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 {OOI~III' 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, t~\Ut sWl'iting. alditdJing

lMotrients

Siortd and relt..lsttl by mall (tlts;~(\S,fl' sinil.. to tholt ofhirumilll'

~di1l

Pretnt in most USwtl "Ill !Iortt1 ,00 ft'lmtd b)' m"t (tls;inuu~ upilla'l ptmIubitity,anroKl whitr blood (fils to silt of ilft,mmation"OO
YII~p.lil

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466

UnitS ThelmmuneSystMl

.- hiItarrine
b...tykifin

M. . ""

. . .alrienu

Sli....IIII""'oI

"""""endings
(pain)

.. FI9U'~ H.I Steps In acute Innammatlon

Source Poooon fdurorfOn/PM Co/l~.

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 result 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 person has an allergy to these substances. The pharmaootherapyof 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$, it may occur in virtu ally any ti~ue or organ system. When treating inflammation, the following general prindpJe$ ap ply:
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 ofth~
skin and mucous m~mbr.mes of the mouth, nose ,

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rectwn. and vagina are best treated with topical drugs.

These indude an tiinflammatory (Te;lms, ointments,
patches,suppositories,and in lr.masal sprnys. Many of
these are available over the coun ter (OTC).
The gool of pharmacotherapy with anti-intlammatory
d rugs is to prevent or decrease the intensit y of the infbmmatory response and reduce feve r, if present. Most antiinflammatory asen'" arc nonspecific; the druS will ahibit
the same inhibitory actions regardless of the cause of the in_
flammation_ Common diseases th at benefit from antiintlammatory 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 erythematosus, and ulcerative colitis.
The two primary drug classes used for inflammation are
the nonsteroidal anti-inflammatory drugs (NSAIDs ) and
the glucocorticoids (a lso called corticosteroids). For mild to
moderate pain, inflammation, and fever, NSAIDs are the
drugs of choice. Should innammation become severe ordisabling, 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 NSA IDs.
A few anti-inflammatory drug classes are specific for cer_
tain disorders. For example, s ulfasalazine (Az ulfidine) is
specific to treating inflammator y bowel disease, and
colchidne and allopurinol (Zylop rim) are u5('d for gouty
arthritis.

'lIopl,,1l

NONSTEROIDAL ANTI-INflAMMATORY
DRUGS
Nonsteroidal anti-inflammatory drugs ( NSAIDs) such as
aspirin and ibuprofen have analgesic, antipyretic, and antiinflammatory properties. They are widely prescribed for
mild to moderate inflammation. Doses for these agents are
listed in Table 33.2.

33.4 Treating Inflammation

with NSAIDs
Because of their relatively high safety margin and availability as over-the-counter (OTC) drugs, the NSAIDs are drugs
of choice for the treatment of mild to moderate inflammation. The NSAID class includes some of the most frequently

TABLE 33 2
On"

467

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. Although acetaminophen shares the analgesic and antipyretic
properties of these other drugs, it has no anti -inflammatory
action and is not classified as an NSAID.
NSAIDs act by inhibiting the synthesis of prostaglandins.
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.
There are two forms of COX, cydooxygenase-I (COX-I )
and cyclooxygenase-2 (COX-2 ). COX-I is present in aU tissues and serves protective functions such as reducing gastric

Selected Nonsteroidal Anti-Inflammatory Drugs

Route and Adult Dose (max dose where Indicated)

aspirin IASA ,lIld olhm) lit!' pagt

for th/, ProlOlypr Drug box 00 )

Drug' f... lofl.mmaUon and ~r

PO; 1so-6S0 mg evPfJ ( h (mal: 4glda:l) for pain or fM!"

PO; 3.6-- 5.4 glday in feu to ~I divided dolts for .rihriti( (onditions
PO;80-l25 mg/da:l for arut~ MI or pre'lmtioo of thrombi

Adverse Effects
SlOOIh pWfl.NQrmum 1XI6I'I!,
MlIIb'~rmiM,~bIfflmg
,~

5ryerr G( bJerdjoo broQ(bollNlID

initilvlailb,lItmo!yti(illl'mii, !!ms
syndrom~ in dlldll'n

mtlabolkiddosis

SELECTIVE COX-2INHIBI1OR
~oxibICfl~)

po; 100-100 mg bid (milx:800 I119lday)

DiorrMQ,ritlptl'fio,~

phQryrrs, fIIl/r
No Kfiouudyct\C ~ffrm.byt

IBUPROFEN ANOSIMILAR AGENTS

. ,"",

didofffiK ICataflam, SoIarm, VoItarrn,

.dillurisal

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)

u,noprWn INaIton)

~O;300-600 mg Ud-

ftlrliiprofm (Ansaid)

PO;~ 100 mg tid-

ibuprofm (MI~, Mouil,othm)

qid Imax: J,lOO mg/da,1

qid (max: 300 mglda,)

PO;400-BOO mg tid-.qid (max: 3,lOO mglday)

irmmtllladn IndcKil)

PO;l5-50 mg bid or tid (m.x: 200 mglda,) or 75 mg !Ul!iilll'd-lffif ~

to two times/da,

utoprofm

PO; 75 mg tidor 50""l qid (m.x: 300 mglda,)

melcJxicjm(Mobk)

PO; 75-15 mg ona' daily

nabumtlone

PO; 1,000 mglday (max:l,OOO mglda,)

naproxm IAk\>r, Anaprox, tiaprol}'n.

PO: 250-500 mg bid (milx: 1,000 I119lday)

ox.JpnIli1(Diypro)

PO;6(I(I..l,l00 mg/da:l (max: 1,800 mglday)

pi"o:Iic.Jmlfddtolll')

PO; 1~20 mg ont

toIme~n (TotKlin)

PO;400 mg tid (max: I,BOO mgfday)

.""",

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lOlWO tim6/da:llmil:lO mglday)

IIoUlM, clorrheG, romiring, obOOmiool

aumling, ritlptl'fio, dilJjflt'lj
I

468

UnitS The Immune SY""m

Arachidonic acid

I
NSAIDs block here

CycIooxyg&nasa-1
(COX-I)

CycIooxygenase-2
(COX2)

Prostaglandins
Thrornboxanes

Prostaglandins

inhibilors block

hm.

I
Gastropro19ction
(Decreased acid
production;
incroa.sed mucus
production)
Incmasad platelet
aggregation
Renal pro19ction
Vasodilation
Bronchodilation

S&Ioctiva COX-I

Inflammation
Pain

""",

Decreased platetet
a9l1egalion

,. figure 33.2 Inhibition of (ydooxygena~

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 reduces inflammation, the inhibition of COX-I results in
undesirable effects such as bleeding, gastric upset, and reduced kidney function. Most of the adverse effects of aspirin
and ibuprofen are due to inhibition of COX-I, the protective form of the enzyme.

SALICYlATES
Aspirin belongs to the chemical family known as the
sa licylat~~ 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 inflammatory 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 11day life span of a platelet. Because it is readily available, inexpensive, and effective, aspirin is often a drug of choice
for treating mild inflammation. Aspirin also has a protective effect on the cardiovascular system and is taken daily
in small doses by millions of people to prevent abno rmal

LibraryPirate

clot formation and strokes. The fundamental pharmacology 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 incidence of adverse effects, especially on the digestive system.
By increasing gastric acid secretion and irritating the stomach 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 antiplatelet 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 ibuprofenlikedrugs are NSAIDs that were developed as alternatives to
aspirin. Like aspirin, they exhibit their effects through inhibition 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 treating 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,

Chopltlll Drug' for Inflammal lon .1Id Fewr

469

TABLE jj.j I Forms of CyclooXY9"naSQ

..

Cydooxygena5e-l

cydooxygena~-2

"""

f'rt!tl\t i..llti' .... '

Prntntat >iI oI~, .... injury

Functions

Proiffis gUtrK mlKtN,suppocts ~ hlKtion, promOiti

plattl<t aggItgation

th~ blail

Undtsirible:ill(J!all'S risk of~\Uic: bIffiIilllj.nd ~ fllillfl'

Dtsirable: mUlS itll4lpre sion 01 inftamllliltion

hhibition II!' m~diutiom

ilflammaTion, II'n5itim pain Jt(epltn,m~iattl frm it

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 occasional 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.

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 particular drug. The choice of prescription NSAID is often
based on the dinical experiences and preference of the prescriber.
Most ibuprofen-like NSAIDs share a low incidence of adverse 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 assessments should be conducted periodically. Patients with signiticant pre-existing renal impairme nt usually receive
acetaminophen for pain or fever, rather than an NSAID.
Ibuprofen-like NSAIDs affect platelet function and increase

.... Prototype Drug

M~iat tl

SELECTIVE COX-2 INHIBITORS

Selective inhibition of COX-2 produces analgesic, antiin tianunatory, 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 adverse effects on the digestive S)'5tem and lack any effect on
blood coagulation. Upon their approval by the FDA, the

I Ibuprofen (AdVli,Motrm,others)

Therapeutic (lass: Analgl'Sic.anti-infiammatorydrug,antipyretic

ACTIONS AND USES
Ibuprofen is an oId~r drug thaI is pruribN for tht uutmml of mild 10 modtrat~ piin, feY~~.nd 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 indu~ piin i ~[I(iat~d with (hronic muswlosktlual disordm wc:h is rheumilOid ind OIt_ nhritis, hmladlt, ~nlil pain, and dysmenorrlrN.(Iltwa bit liblus, dropl, and sokltions all' ava iIa bit in low dasH for
idministration to children.
ADMINISTRATION ALERTS
GiY!' drug on an ~mpl)' stortlich as toltr.ued.lf naus~., I'Omiling, or i bdominal pain [I(CU~, give with food.
8~ aWife tlut paTients with i sthrtli or who haY!' alltl<Jie to aspirin 'Il'
moll' likft)o 10 ~xhibit i hyperunsitivity Il'action to ibuprofrn.
Pll'9 ni nqutog..,,8

PHARMACOKINETICS
Onset:11>-60 min
~k: 1-lh

Halflife: 2-4 h
Duration: 4-6 h

Pharmacologic (lass: NSAID

ADVERSE EFFECTS
AdY!'ll~ elfem of ibuprof~n all' gtnerally mild and indude naulu, lIranbum,
epigaslrK pain, i nd dizzines~ Gl ukrralion with [I(cuk or glOII biffililllj ilia)'
OC:aJ~ t1peo:iilly in patitnts laking high dolI'S for prolonged periods. P",itnts
with oKtive ptptK uk~~ should 001 likt ibuprofrn. Chronic use of ibuprof~n
may Itad to renal impairment
Contraindi citions: lbuprofrn hasan FDA blick boxwiming thit its use is(onuaindic.iled for trNtmenl of ptrioptritive pain in the lI'IIilllj of (orona ry artery
bypassgrah IUlgtry <kit 10 t~ potential for a suoktorMI.Thisdrug is i lso mn
uaindic.ited in patients with signifICant Il'nal or h~pitic impairm~m and in
thos~ who hiY!' 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 hypl'M~R!ion,or i history of nrolo:t or MI.

INTERACTIONS
Drug-Drug:8Kaw ~en (OIn alfen pIotelftflMion,iIs Ull'shcUd bf.rroidi>d
wIIfn !akilllj anticoagWnts and oth@rc<glllationmodfirrs. AsPrinlM lin
dMMe 1M iIII~-inn.nmatOl)' iCtion ofibuprofPII. lbul"ftrl mayillClNIf pIiIsIIIiI
IMIs of lithium,<aU~ng lithium toxirity.llII' iCtionI of certain diumics IIIiI)' bf
dimin~hN wIIfn taken COllCU1P11t1y with ~1'Il1Jst with other NlAlls,akohol,
or (OIOCO'imoidllllil)' utI\t ll'lious aml'lll' Gl_1S.
liI bTests: 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! IMriskof~

lINI ment of Oerdose: Thm is no Ipt(ific: tll'itment for oY!'n:ioIl'.Adminisuation of an aiblilll'drug rtliy illCll'i ~ tht urini ry 9lIl'Uon ofibupro~.
Ili!ftrlOM)MJrs/ngnr fllrQN1JnIfII} I'nxm focuslpKlk lOrlr/s~

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470

UnitS Thl'lmmu""Syst""'

C OMPLE M ENTARY A ND A LTER NATIVE T HERAPIES

Fish Oils for Inflammation

FiSh oiis,aiso known ~ marine oil~ arr lipm foood prifNrily iI coIdwn~ fish.
~ oils all' rid! !llUKrs oIlong~hain 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 am~inflammatory 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 ~pplrments and aspirin and otht r
NSAIDs. Ahhoogh rarr,mh intrrac:tions might be rrunifuttd by in(reasrd
~tibility 10 bruising. nostblfflk. hemoptysis, herruturia, i nd blood in tht
,,00[

selective COX-2 inhibitors quickly became the treatment of

~hoi~.. fur moderate to,~ i.nflammation.
However, in 2004, postmarketing data revealed that rofecoxib (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 colorectal polyps in adults with familial adenomatous polyposis (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 ~hililyto s"rp ...... s

TABLE 33 4
Dru,

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 adrenal cortex that have powerful effects on nearly every cell in
the body. When used as drugs to treat inflammatory disorders, the doses are many times higher than the amOWli naturally present in the blood_ The uses of glucocorticoids
include the treatment of neoplasia (chapter 3700),astltma
(chapter 3900 ), arthritis (chapter 4700 ), and corticosteroid deficiency (chapter 4300).
Like the NSAlDs,glucocorticoids inhibit the biosynthesis
of prostaglandins. Glucocorticoids, however, affect inflammation 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 severe 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 insufficiency), hyperglycemia, mood changes, cataracts, peptic ulcers, electrolyte imbalances, and osteoporosis. Because of
their effectiveness at reducing the signs and symptoms of inflammation, glucocorticoids can mask infections that may
be present in the patient. This combination of masking
signs of active infection and suppressing the immune response creates a potential for infections to grow rapidly and
remain undetected. An active infection is usually a contraindication for glucocorticoid therapy.
Because the appearance of these adverse effects is a ftmclion of the do.., ~nd d"rMion of Iher~py, IreMment is often

Selected Glucocorticoids for Severe Inflammation

Routeand Adult Dose (max dose where Indicated)

betamrthi lOIII' (CtltIlOllr)

PO;O.6- 71mg1day

...""-~-

POIIM; 20-300 mglrla)' il rivmd 00srs

IrJdllKortisonr (Conrt lI)'rtocortont. othm)

(w ~ 67) fa" thr Prototype Drug

bOi ool

1IIIlhir9. ~ irrwmtio,5IIdirJmrDi
IIlJid rmntiln, impoirFd \IOO/ld MdRj,

PO; 10-)20 mglday in thrte to four dividrd dosrs

'""""'-

IV11M; I, - 800 mglday il th~ to /ou" diYidrd doltS (rrul: 2glday)

l!il!lI1'llii!;l!~ baM fta{\y~loIs2lm!.!Kk

PO;OlHmgbid~id

mt'th~plt'dni!Obnt (Depo~totd, MMrol)

PO; 2--{,(1 mgiday in dividfd doles

pmtlisolone (Oraprtd, PII'IoM)

PO; 5~ mg onrto four timrs/rIa)'

Q prtdnisonr

PO; S~ mg onr to foor timrs/rIa)'

triarndnolonr (Arntospan, Kmalog)

PO; 4-48mg onr to foor timrs/rIa)'

Irdiainditnt rommon ad'/Mo! tfff(\s:~ inditnts s.rrioui idYftlftffrm.

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Adverse Effects
MoJ~ wtighl9CI~ ~UIt, (odol

PfQ~{ vlar

hypoY){fOlja (p\IfO!IOfO'ij!

mmdegfiltdQ!9W1h il dlildrm
Do!~ble malljoo o!'ilkoiOO!

Choplt,ll Drug. forlllfbmmallon.1Id Fewr

~ Prototype Drug

47 1

I Prednisone

Therapeutic (lass: Anti-inflammatory agent

Pharmacologic (lass: Glucocorticoid

ACTIONS AND USES

Predoisolll' is a ,YIlthttic: gl!Koconic:oidlt. Jctioos art the rauk 01 bting mrtabolizN 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 4to 10 da)'5. For long-term thenpy,akemuNbydoling
isulfd.Predoilont isocGHiooal1y used toterminatr iKUlr brolKoospasm in patitnu 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 ,~tl'lllic: inftion a~ prerm.
Whrollliog thedrug forlllOll'thao 10days,tlltdol!'mtIII btllowly taprred.
PlI'9nJIK)'(.iltgory(

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 I)'Od~ a (oOOition that in(kidts
h)1ltllll~fmia, lat redistribution to thr shouklrl\ ,00 facr, musclr 'Maklll'n,

bruising, JMbone that Nsily frxtu~. 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: ukf~uktliltivr (olitis,or diYl'flirulitis.
Contraindi u lions: Patiffitl with actiYl' yjra~ b"teria~ fuoga ~ or protOlOan iofections lliould oot take prednilOlil'.
INTERACTiONS
Drug-Drug:8Kaw barbitwilfl,~ iIOd ~n inmu jIIfOOisoM
mNaboM,incJNlfd~may 1M> ~IM {roamnt u'" with oIIIIpboIHicin SOf
diurMiG ilKlNl@';~ ~ which maybe I!'riouI fOf pMnlllAilg!igm:in.
OOIM prNlisoIII' yn raj", blood gluco!f t....eI!, diabetic pMnts may ~l ill
~u'illllPnt in 1lll'doIfSofminorOfillh~fmic .... ts.
l.i b1151s: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.

PHARMACOKINETICS
Onset:Unlrnowo
~k: 1-lh

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 patient'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 accustomed to high doses of glucocorticoids, patients must discontinue 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 ors~nistru; . M~ny . pecies ofb~cteria are
killed by high fever. Often, the health care provider must detennine 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 lifethreatening problem. Prolonged, high fever, however, can
become dangerous, especially in yOWl8 children in whom
fever can stimulate febrile seizures. In adults, excessively

LibraryPirate

Hm VFood: HHbaI ~B I!Khao;aIoi>,budthom. Ind IfIlI\a ma,inmu

poIaS~1IIt loss. Licm may IlOIffitil:! tIM> !lfw of ,00KlJtic00s. St Johrr"s WOO
may dKJNII' ~ IfflIs.

Treat ment of OYI'rdole: Theil' is 00 ~ific: 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 ~cu
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 temperature 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, entericcooted 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, including 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 fore~n by the booy and

472

UnitS Ttelmmu""Sysll'm
HOME

&

COMMUNITY CONSIDERATIONS

Ii tlielt' any I"Imnc:r to support the 1M of ahemating do~

of ibuproffo ard ~aminoplltn for (hildrt nwith ~rl
Th! Study: Miny hNlth (irr plllidm trNt ftbrill' (hildlt'n with ahtmatillCj
do~ 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 t~two drugs
is eithr r moll' rfil'l:tiYeorsaferthan usillCj tilt drugs individually. Nullt5
should ~crrtoin that poart'On undl"lSland thr plOpi'! doling sc:htdu~
forthe individlal antiPl'rttia,nd ad~ thtm not to (ombint or
alternile rntdkitioos withOUltlit ipplO'/al of thtir IINkh (ill' proYidtr.

Aspirin for Cardiovascular Event Risk Reduction

CulTl'nt pr,ctice relmd 10 (,Jrd~asc:ular and ne\JlO'/asc:ular nI'Ilt ~ntion
and lrt'atllll'lli may ind~ tht u~ of aspirin thtlllp)'. Tht bIood's dotting lion is m-:I by tht administllltioo of aspirin. This tlltlllp)' has ~n Il'Olmmt ndtdfor I11I'II 01derth,n4O ~mof age,postrnrnopausal WJIIII'II, and I11I'II
yoIJllCjl'llhan 40 )'!'ar.; of '91 and prt'lIII'nop,usal women who w high (ho~ttlO~ hypentnsioo,dia~lt"I,histol)' of a dOI-maled IllOkt or tllllllient is(hemic: ,niCk, or a histol)' of cicjilmt smoking. EYI'n though tht ~Utnl~
ustd dcM for thislhefap)'~l 1IICj-is nlrilabJ!o OYI'r tht counter, poatienu
should bf advised to (001011 Ihtir lItahh Lllt' proYidtr.; Wort initiatillCj stlfmtdiLllion wilh aspirin.

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

mood disorders can result in a high fever accompanied

by serious mental status and cardiovascular changes,
known as serotonin syndrome (chapter \ 600 ).

Th~ Question:

.... Prototype Drug

Conventional antipsychotic drugs: Drugs such as

ch lorpromazine (Thorazine) may produce an elevated
temperature with serious cardiovascular and respiratory

I Acetaminophen (Tyleno/, others)

Therapeutic (lass: Antipyretic and analgesic

Phanna(olog ic (lass: Centrally acting COX inhibitor

AalONS AND USES

ADVERSE EFFEaS

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 ~palion
of lINt Amamiropht ll, ibuprofl'll, ind alpirin ha~ equal elfKacy in relieving
poain ind rt'dlKing f!'let.
Atttaminophtn hils 00 anti~nllammatol)' propertits;thert'forl!, it is not tffK1i~ in tlt'atillCj anh ritis or poain caustd by oS!Ut s~lIing 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,indicated.ln tilt Irt',.mtnt of Sl"ltfe poain, fcamioophen may ~ rombined with
opioids. Thisallows thr dcM ofopioid to bf rtdUd, thus de<lt'a~ngtht risk of
deptndtnc:r and serious opioid tou.:it)'.1t is availabll' is rabltts, (iplets, soutioo~ and supposilorit-s.

Aretrminophen is 9fnt rally liff,and admt efletu alt' unrorrmoo at therapMic: dosr-s. Atttaminophen caUlfl 1l'1l CJilstric irrit.Jlion tha nalpinn, i nd does
nol affecl blood (I)igulation. k is not It'oommt ndtd in patients who ill' malnourished.ln SIKh lilts, iant IOxicil)' may I!"IUIt.ItadillCj to It'n.r1 fa iult', whic:h
Lln ~ fatal. Other signs of aartt toxKit)' inc:ludt naUIN, wmi:ing. chills, abdomirwl disoomfort,and fatal hepatic: nKrosis.
Amajor 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.

ADMINISTRATION ALERT

INTERACTIONS
I)ug-l)ug: A(flamioophen in~lJin Williann flll'taboism, UIIIiI9 thf
antK~ to ilmuoola!, to tOD: IfwIs. HiljJHlos.! or Iongurm oIa:Mlli"lophtn

Liquid forms lit' availabll' in varyillCj rolKtntratiolll. US(' tht appropnatt

strellCjlh prodlKl in childru 10 ivoid IOxicit~.
NeYI'f administr rto poatieou who (oosumr ,Icohol ~ularly due 10 tht poII'Iltial for IItpalOtOlicity.
Adv~ poalieO'.1 that iKttaminophto is found in many OTe produru and
that tX!mnt calt' must bf "letn 10 not duplicatt dosr-s by takillCj It'Itllll
of these prodlds (oOlUrrtmly.
Prt'9nanq cattgol)' 8

Contraindications: ConuaindiLltions inc:kJdIo

plltn or phtnaretin and chronic: akoholism.

hY~lII'IIsitivit~ 10

U\f II"Ia, rflWi: il elmlMl warfillillNeis and blffdillCj.lfI9'Ilioo 0( tIis

ttamino-

mug with

aklt.ol, or oth!f IIfpiII000Iit IinIIjs IlKh is ~oin or billlilurallI, ~ 001

ff(~ ~ 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 ~.JlydroxyiHlGeoK!tir:Mid (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
(oltsfoot, and (haparTai.

toIir:~ ilduci'"l <DfIIfr."

PHARMACOKINETICS

Trt'iItment of ()ytrdo~: Tht spt<ifit Ill'iItment for O'/trdol!' is Ite ora Ior IV ad-

()Jset 30-60 min

Pt,ak:O.S- 2h

ministration of H-amykysteiOl' (h:mdotr) as soon as possibltafttr the OYI'rdost. This drug pro1l1tU tilt Ii-It!irom 1Oxic: mttabolitflof iKetallinopiltn.

Half~i~:Hh

III'ftr /IIMytmmgXl (or ~ MlsJrtgl'rocllS Foo/l~ /111M <tuq.

Duration:1-3h

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'lIopl,,1l Drug. fOflofl.mmaUon and ~r

distress, called neuroleptic malignam syndrome (NMS)
(chapter \ 7CC .

Voiatileanesrhetic5 and depolarizing neuromuscular

blockers: Agents such as succinylcholine can cause lifethreatening 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 feverproducing 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.

NURSING PROCESS FOCUS

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 ~nzyrn!' ~lKiell()' that aflt<ts how they mmbolizt anain
ohgi.Morethan 200 m~ion ~rwOO:lwide aft' beIiMd to hal'!'ahtrNtal)'
deficierq d tht rfIl)'111t. ~~ dffi)drogrn~ {G6PO~ 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. HO'oWY!'~ beCilIIiI' ac:rtamioophen is 0IIl' of till' most cotrmon rh.ogs ingestN in intentional
~reahhcart~!hluldrffiH!lmmd1hatpatirrmwithG6POritfi.

drnq Mid th~ dMj.

PATIENTS RECEIVINGANTI INFLAMMATORY

AND ANTIPYRETIC THERAPY

Assessment

Bastlin! assrssmf nt priorto administration:

Undt~tlnd th~ J\'iIson t~ drug has bn prescribt<i in ol"lltr to alses for
t~r<lpwlK tfi"KIs.
Obtain a comprtt ~<l hh histOl)' ill(iuding htpatK.rtna~ rtlpiratol)'.
<~rd""'-'wt., <II rtnlruluojic. dM p~n.rl<'.'" b",~Hmlinlj. Obt.oirr drug
history iocluding alrflJir~ culltnt prrsr:ription and ore dlUlJS, ht rbal
~ruiom,caflein~nirotin~ and akahol us!.Bealento poI~bIe drug
intffiKtiolll.
Obtain b.Jselin~ ~itll ~ns aoel Wl'ight
['/<IluateapproptYtf laboratol)' findi"91 (f.g..CBC. coagulation j)a ntls,bWding
time. t lKtrolytes, 9kKO\~ lipid profir. ht patir: Of Ifnal funaion studifs).

Potentia l Nursing Diagnoses

Pain t~rut~ Of ChronK)

Hyptrthtrmia
FkJidVoIum! Il!'fKit (r~a!ed to fe\\'l")
Riskfor Injul)' (rtlate<lto ~\\'f\f 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 <ldft~drug tfftm of
gkKocortir:oKk)

Asstssm!nt thro ughout ildministration:

bellor desired thtrapMK effem kg.. temprratuft' rttums to oormal rangr.
pain isdt<l"Nstd or abstnt, signs <lnd symptoms of inflammation SIKh as
rtdllfll or IWI'liing aft' demastd).
Continue ~riodK monitoring ofCBC.roagulation nud~. bWding time.
eltarol)'l~~ gIIKOIf.lipidl.aoel hepatic ilnd rtnal full(tion studits.
AIleS vital ~m 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 2kg in 1Wl'tk.
ASles for aoel promptly rtport ildftrst tfi"t<tI:symptoml ofGl bIffiling (dar\!: or
"tallY" stools. hematemesis or cofffi!>-ground emtlis. blood in t~ 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.
PliInning: Patient Goal s lind Expected Outcomes

Th! pitirm will:

u:prrirrK~ thtrapwiK effKls (f.g.diminishrrl fe\\'r.dtCft'asN Of <lbsrnt pain. riMNSfd ~nl aoel symptoml of inflamllliltion).
~ fft'e from.or rxprril>lKt minima~ idv~rst tfi"KIs.
Vtrbal~ an undt~taoeling oft~drug's UIf.art;~rst tfi"tdI, and n'qJiit'd plfl:aUlionl.
Demonstratt proptr seIf-<ldminisuation of t~ medication (f.g . ~ timing. whtn to notify provider).
{Continued!

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474

Unit; ThelmmuneSyu,-""

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTI-INFLAMMATORY

AND ANTIPYRETIC THERAPY (Continued)

Impl"m"nt.. ti o n

Inte rve nti o ns a nd (Rati o na les)

Ensuring therapeutic tfl"t cts:
CominUl' alSmmtntl asdts<riiltd earlil'r for Ih~aptUtK tifecrs. (Diminished
fr'lff, !)lin, or SigM and symplomsof infedion should ~in aftrr taking the first
Ou and (ominur to im plOft. Thr heallh mr provider should br notified if fe'Ief
ft'maiM presem aftrr 1daysor ifilKrra~ng signs of infertion aft' prmnt)

Minimizing ildve r>e effects:

CominUl'to roonitor vital sign~ epKiall)' temperaturr iffe'lef is prrsrnt,and
blood prl'SSurt and pulst klr !)Itito!! on gkKorortiooids.(Ftvershould brgin to
diminish within 1 to l hour> abr taking thedrug.Gluu)(onQU)m may (.Iusr
ilKft'asrd blood pft'SlUrr. hypertension, and loKhyUrdia dJr to inrnasrd
ft'll'IItion of fkJids.)

CominUl'to monitor ptriodic: lab work: hepatic: and ft'nal furKlion teu, (Se.
eleo:trolytts,glurost, lipid le<iels. and roagulalion studies or biffiling Iimi'.
(Aspirin and "liql.1O< .!ftct platelfl.9'I"9"ion .nd ,hould br monilOrtd if
used Iong-trrm or if ml'SSiYt biffiling or bruising is ooltd.Armminophen tan
br hepalotoxit. CortKl>lteroids a!fed tht (SC,and i widr range of electrolyre,
gkKose.)

Monitor for ilbdomiOiI pain,blac:k or larry stools, blood in lhe 11001, htotalel1ll'Sis
or roffn-ground etnM, diuifltlS,and hypottooon,~iaOy if assorialtd with
loKhytaldia.(NSAIOsand giutocortic:oids may (luse GI bleeding.)

Monitor for tinnitus, diffirulry hearing.light -headednl'SS, or diffKUlr~ with

bilante and R'pCIn promptl)'.(NSAlOs and 1.l1ic:yla1l'S may brototOlit.)
Monitor uri III' output i nd ft'Oi Irunttion studil's periodiully. (NSAI Os and
salic:ylatfl may br ft'Oi Itoxic: during Iong-trrm or high-dosr thrra py.)

Patie nt a nd Famil y Edu Cllti on

0
0

Monilorelectrolyrr, blood giutOlf, and lipid le<irls periodiully in patients on

(onic:osteroick (Giutocortic:om may (lusr hypergly(emia, hyptlllillft'mia,
hyperlipidrmia,and hypokaiemia.lMbetio may requill' a (harogt in antidiabetic:
meditation if giutOlf ft'maiOl ele<iated.)
Monitor for signs and symptoms ofinfto:tion in patil'nt! on gluc:oconic:oidI.
(Gluc:orortic:oids supprrss me bodYs normal immulll' and inflammalory ft'Iponsr
and may mask tilt IigM and symploms of infection.)
Monitor for I>Iteoporl>lis (e.g., bonr drnsir>' tflting) ptriodiully in patients on
gkKocortitoids. ElKouroJgl' adequatr takium inlake. avoidalKr of carbonated
sorIa~and wtighl-braring oerdsr. (GIuc:oconKoichafien 00111' mmbolism and
may (ilUIf osteoporosis andhadurfl. Weight-braring oer(isr IIrl'\.Se 00111' and
elKouragtl oorrnal OOIlf rrmodrling.Extmi-;r or Iong-trrm (onsumplion of
wbonated IOdas has brrn linked to an in(ft'm risk of I>Itroporosis.)
Monitor for ufIJsual (hangrs in mood or a!fed in ~ieo!! on (Onic:l>ltrrom.
(GlUC:QU)nic:oids may taUS!' mood (hange,euphoria,drpft'lsion,or IeYt'rr
"""'t~1 in".biliry.)

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0
0

Tu(h thr patiem to supplemtnt drug thtrapy with nonpharmaroiogic:

musurr-s, r.g., ' RIC[' : Rest, hor(ool (ompres~,Compresoon
bandagr (r.g.,ACEwrap).and Ele<ialion ofinflamrd joinl or limb;
inaem fluid imake for fr~r, positioning for (omfon;diYmionary
distractions (r.g., trlevision or rrusid; ind ft'st for pain.
TroKh the patifm to immrdialriy ft'pon fe'lff lhat doe not diminish
brIow 1001, or per !)Iramell'lS sri by the health m t provider, febrile
seirurr-s, (hangrs in brhavioror le<itl of (oOl(iousoes~ ladr;wdia,
palpitations,or inuNsrd SP 10 lhe heakh Uft' provider.
Tei(h thr !)IIii'm on gkKlKortic:oids how to monitor pulst and blood
plffiUIt. Ensult the proper UIf and rurKIioning of any hol1ll'
~uipmem obtained
Inslrucr the !)Itil'm on the n~ to return periodiully for lab work.
Advisr lhe lliIIient laking gl\J(QU)nic:oids long Itrm 10 (.Iny a wallet
identiliution urd or_.r modiul idtmiliution it_I" indic:.ting
gllKQU)rtitoid thffapy.
Tri(h the pitil'm to abstain from ikohol while taking a(ftlminophen.
Mrn who (onsuOll' mort' thin two akDholit bfitl<lges prrday or
womrn who(onsum~ mo~ than one akoholit bfitrage ptrday
should not rakt a(ftlminophen.
Instrucr the !)Itil'm 10 immediatrly Itpon any signs ors~mploms ofGI
bftding.
Trath the patil'm to takt th f drug with food or milk to demasr GI
irritation and loswallow rnterit-<oaltd lablets wh* withool
UIIIhing or bltaking.Akohol UIf should br iWided or rliminattd.
Inllroo the !)Itil'm 10 imml'diatrly r~ pon any signs or s~mploms of
ringing.humming. buuing in Nr>,diffirulry with balantr,dizziorssor
vertigq.or nausea.
Inllrucr the !)Itil'nt on NSAlOs and salic:yla1l'S to promprly R'pon
mangel in quantity of uriot' ooiplll, darkening of uriIII', or tdema.
Tmh the patil'm on NSAIDs and salityiall'S 10 ilKrrase fluid imake,
epKially iffeverisprtsrnr.
InslrtKI thr !)Itil'm 10 Iflum ptriod"KaOy for lab WOrkil~.
Tram thr diabrtic: patifnt to Irll t~ blood sligar moft' ~ml)' and
notif)o the htaith (irt prOYider ifa (Onsistf nt tfevation ii ootrd
InSlrtKI thr !)Itil'nllo imfMdiatt ly r~ pon any signs or symploms of
infectiom (t.g., intft'uing tt mperalult or fe'lff, 10ft' throat, rtciorss or
s_lIing al si~ofinju", whitr !)IlIhes in mornh, Yelic:ular ralll).
Trath th~ palil'm to maintain id~ualt' takium in tltt dil'~ awid
wbonattd sodas,ilnd to do _ighl-braring enrtisfl al leasllhlff to
four tirors per week.
Tram the postmrnopausal woman to (onsuk with Ittr plO'lider about
the need for additioOiI drug lherapy (r.g., bisphosphonile) for
osteoporosis.
Tu(h th~ patil'm. famiiy,or(.lrrgiYtr 10 promptly Itpon o<l"lsive
mood swings orunusual manges in mood.

',,"plOI

NURSING PROCESS FOCUS

Drug. fD<lllfilmmatlon and ~

475

PATIENTS RECEIVING ANTI INFLAMMATORY

AND ANTIPYRETIC THERAPY {(onrlll/ed!
Impl e me ntati o n

Interventio ns and (Rati o nale s)

Patie nt and Family Edu catio n

W~ic.Jh palienl on guocorti<okk d.1ily .nd Jtpofl. o,wighlgiin of 1kg 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
ac:curat~ mealUf1' of Auid !lII~ and tilkts imo auoum inlikt,outlJUl,and
inwnsiblt Ios~. Patienn 00 ronicost~roKk will ~xp~ritrn 101M ftJid
retention.)

InsUUl:ltht patient to wtigh Itlf diily, idully at tilt limt time of~.
Tht patient should Jtpon signifK.lnt weight gain or ill(rt.sing
ptriplltral edtm .

Monitor'fision p~riodic.11y 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.)

'eilCh tilt patient on glucocorticoids to maintlin t')'I!eums twice

,wiy or mOl! lf1'qutntl, as inlt~ by the lit. ~h [.rt provider.
Repon any ~e pain, rainbow Iwlosaround light~diminishrd viIion, or
b"'rringlnd in.lbility 10 focus immediately.

4void tht use of llpirin or lalic~tes in childrtn under 18 unltss tlCplicid,

orde~ b, tilt heakh Uf1' providtr.{Alpirin hal ~n allO(i;r~ with .n
incll'asrd risk of RtyI"s syndrome in children under 18,plrticularly assoO.Jted
with tht ftJ vill/$ and vlric:rlla infKtions.)

Instruct pirtnl! to us~ NSAIIh or Icttlminophttr in(hildrtn under 18

for ft'ltr or p.in [ootrol,unltll othtrwilt ordertd by the provider.
rrac:h plrents to rud labm 00.111 DrC medication sand to iwid
formulations with IIpirin or Sllicylate on tilt label.

Do I\Ot !lop gkio:ocorticoiM Ibruptly. Drug must be llpell'd offif used

thitn 1or 1 wttks.{Adrrnal inlulficitlKY and (risis rna, occur with profound
hypotrnoon,tarn,uroia,.nd other i.Mr;etfiem if the drug is stopped
abruptly.)

noti!)' the htakh UIl' provider ilunable to t1kt medication for mOl!
than 1d.1y due to illnes~

Iong
-.-,---I-.-:T~:::::h::;:tllt patient to not !lop liking glucOlrticoidl.bruptly and to

Piliut undtrsu.ndlng of drug the rapy:

Ult opportunities during admilliUr.Jtion 01 medications , nd during mesmtnlS
to dio.[UII; Iht r~tiOn.l~ for dM} lherap)',drlirrd thmptUtic OIIIUI~,fIIOIl
common ad .... ~ effrct~ plfllfl!'ttl'l forwhrn tocall tht hNlth cart provider.
and all)' nt(tllaf'l mooitorin9 or prtcautions.(lJ!iJ19 time dUfi"9 nur~"9 Cift
helps to optimilund trinfon:e k~ tNching Ill'as.)

Tht patien~ 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 rtpOI'~and thtanticipated Itngth of
mtd~ion tht"p)'.

Pllien1 stlfadm inistration of drug thtrlPY:

Whtn admin~t~ing the mrdication,in!lllKt the patitnt, loimily.orull'gi .... rin
ptoptr sell-adm in~trltion of drug. e.g., with food or mill:.. (Proper adm in~trltion
will ill(ftjlt tht eflectimltss of the drug. Houlthold mNsuring dmm such j I
Itjlpoom differ signifiuml, in sillt ,nd amount Ind should not be UItd for
pedialJic or liquid dolts.)

rht pltien~ family,or clrtgi.... raf1'able to disnru ipproprial\'dosing

.nd admin~tri!ion 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
th~ ell(los~d 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.

Evalu ll 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

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rm Nuflilg I'rocrs.r Iixus rhart

476

UnitS Thl'lmmuneSyu,-""

rtr 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 release of chemical mediators that trigger the inflammatory
response. Histamine is one of the kry chemical mediators
in inflammation. Release of histamine produces vasodilation, 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.

13A NonstE1"oidal anti-inflammatory drugs (NSAIDs) are the

prinlary drugs for the treatment of mild to moderate inflammation. All drugs in this class have similar effective
ness in treating inflammation. The .selective COX-2
inhibitors cause less GI distress but have significant cardiovascular 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' druginduced fe;"\'r, which may range from mild to life threatening.

NCLEX-RN " REVIEW QUESTIONS

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

The patient has been taking aspirin for several days for
h.,~o.la~h~ . Duriu)o: th., a,.".";s,,,.,ut,
uur,., o.li,w.~" 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.

tI,.,

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.

The nurse is admitting a patient with rht'Umatoid arthri tis. The patient has been taking glucocorticoids for an ex -

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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.

A 24 -year-old patient reports taking acetanlinophen

(1)'I.,nul) r~irly r~l\ularly for h~~o.lad,= 11,~ 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.

The nurse is counseling a mother regarding antipyretic

choices for her 8-year-old daughter. When asked whyaspirin 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.

CRITICAL THINKING QUESTIONS

1. A64.)Y.lT-oid diabetic patient ison prednoone lOr meunutold 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 ~tlent?
2. A 44-year-old patient is req~in8 mI icat]on for a
painful tendinitis 01 the elbow. This patient has mJld hypt'rtension, a history of alcohol abust', and nutri tional

defklls. This j);llient has orders for atetamlnophen

(lflenoll , Ibuprofen (Molrin). and celeroxib (Ctleb rex).

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 I0 1"1'. She51ates tbe child is abo complaining oibeing tired and ac~ 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.

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EXPlDflE

~- - - - - - ,

~Kills

your O'1e . . lor ot*II cNIpl

.-alftls l'Id

~ MIl IddIkNl l,a.u4'-1ty18 pr1t1Ict

IS!igl'l'l'letltS n ICtIv*$, w!:b tw, Im!I!lDIS

ItWJrees. PIlIP' 101

~~

and vi:teo6. and

IIIIJI"

AeQISI~r 'PI'

IICInI COIle from me h'I1 rI \'IIIIf book at

_ .I\'IYfIUllirtgltilcom.

Drugs for Bacterial

Infections

DRUGS AT A GLANCE

LEARNING OUTCOMES

P{NI(llUNS

Aft" readjng this chepler; the ntJdml should be obIt to:

fA1iIt4!4

CO) pm/dl'n G SodlHn/Pl:)/asso\lm ~4ftJ

(EPHAlOSPORINS pq411S
Q ufotQKtne (Claforon)

m RAacuNES

~f!tj

ptJtW

Q letrocydtlf (Sumyctl, odlm) fJIl9tfBt

Plgt4i19

CO) trythromyc/n (E-Myc.t1, Erythrocln)

""

AMINOGIYCOSIOES tllgH89
Q gefllllmldn (Gllramydn, omm) JUlI'491

ftUOROQUINOlOHES paJtf91
CO) dprofloxacJn (Cpo) f>7!t~j

SUlFOHAMIDES

(XlJt491

Q llfmelhopl1m- sulfamerhacllzolf>
(Boc fl1m. ~Ira) pogt494

ANnruBERCULARDRUGS

3 . Compare and contrast the telTTls bacteriostatic and bacteriocidal.

4. Using III spectflc example, explain how resistance can develop to an antIinfective drug.

MACROLIDES

1 . Distinguish between the te rms pathogenicity and virulenc!!.

2 . E>cplaln how bacteria are desalbed and classlfled

IlIIJtf99

Q f50flJazld (lNH) pogtSCI

S. Describe th e nurs,'s role In the pharmacologic management of

bacterial infections.
6. Explain the Importance of culture and sensit ivity testing to antIinfective chemotherapy.
1. Identify the mec hanism of development and symptoms of
superinfections cau~ by anti-infective therapy.
8 . for each of the drug classes listed In Drugs at. II Glance, know
representatiVii' drug exa mp les" and exp lain their medlanism of action,
primary actlon s, and important adverse effects.
9. Explain howthe pharmacotherapy of tulxorculosis differs fro m thilt of
o ther Infections.
10. Use the nursing process to care for patients who are receilfi ng drug
the rapy for b;Kteriallnfectlons.

KEY TERMS
~qu irtd

ft;stan<e pogt481

bnIadspertnm u tibioti(

fWJt48}

padlogrl Nm
pathogenicity ptXJt419
Pflicilli n-bilding p!O(rin pogt484

.m!bi< paJt479

(uiturrandM'nlitirily tC&S)t~ n g

nat. Pqt}
iltibiotil: /XIgtJ
mijnftin P9Jl419
Iwclt'riocidoll j1JgtJ

9,ulnr9llti1ft bacteria {JIl1jt.fl9

N<ttriostMic {'A1gt46J

mtillions ptXJt481

luberdrs N4W

be1a-lactilll ri ng ~484
beta-laclin1st/ptnicillm- fO}tf84

_row-lpKtrumardliotic: pq4l!1

inknCf JX1IJl419

LibraryPirate

JX1IJl48)

9ll1mposl:irr bacteria pq .fl9

plasmid f!lJ741!1

~ostfiOfa pq-I8J

red-rnu syidromr

~'oUiYrI)HI {XJl}tm

~ nfrcticMI PU;lW

100000nU~frctiom

pq481

fWJt499

(hopm)( Drug. f","SKterlat Infections

he human body has adapted quite well to living in

II

world teeming with microorganisms (microbes). Present

in the air, water, food, and soil,mic robes are an essential component of life on the planet. In some cases, such as with microorganisms 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 la st 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. Human pathogens include viruses, b3cteria, fungi, un icellular
organisms (protozoans ), and multicellular animals. To infect 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 ingestion, inhalation, or contact with a mucous membrane
such as the nasal, urinary, or vaginal mucosa.
Some pathogens are extremely infectious and life threatening to humans, while others simply cause annoying
symptoms or none at all. The ability of an organism to 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 cau~of dtath io tilt
United State!, J nd first in tht world.
food.boml' iIIoess i'll'lJlOnsiblf for 76,000,000 iIIomes; 300,000
oo~taliutiom;and 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' u\OCilt~ with tilt i~rtion 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 ~Il' 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 anowl~ in tilt Unittd
Statts, with the mon common .ource ~ng ground~.

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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 l>~~i<. ",,,d,,,,,isms: inv~,jv"""Sb ur lu"";" production. Invasi"ft'nell is the ability of a pathogen to grow extremely 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 maydisrupt 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 bacterial 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 distinction between gram-positive and gram-negative bacteria is
a profound one that reflects important biochemical and
physiologic differences between the two groups. Some antibacterial 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 determined 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 " . ~ m)'g~n. Tho."" that thrive in ~n oxyg~n_rich
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 environment. Antibacterial drugs differ in their effectiveness in
treating aerobic versus an aerobic 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

480

UnitS Thl'lmmuneSyu"",

TABLE i4. 11 Common Bactti!rial Path09ti!nS and Disordti!rs

Name of Organism

DI5ease(sl

[)(>5C~ptlon

BlKillusiWlrlKiJ

Alllhw

AObt; apptaB in WLl~ and r~ratory forms

Borrri~ bagOOrft~

Lym~ disu~

A(qrirftlfrom tid:: bite

(h/omydio rnxhom~rif

'knffioal diwIr, f'lt infection

Most torOmoo taUll' of ~lUally trall\lllinftl diltillt in t~

UnittdState

&htridlio a:I

Trllelel"s dianllta, un, bictffl'lll~, meninljlis in dll<ten

Pin ofhosl ftOI,l of the iltl'llinal tr,a

IIotIOOflli/IIf

PIINIIOIIia, llIffiingitis in dikRn, baarremia, otitilllll'dia, silu~1iI

Some ~dts ire part of the oormalimt ftora oft~ LWtI'

repirattq tOO

KlfllJieiIo

PnellllOllia,Un

(ommon opjIO't!lliltit mitrobe

Myrobterom /fproe

Lepro!Y

.'"

Most all'S in th ~ Unittd State O(QJr in immigrant! from Afrita

Myroburom rubfrruli1>il

Tubft"rulo~s

M)ropIoS/ll~

PIIfIIIlOIlia

Most torOmoo taUll' of potUmooia il patiffilJ. 5~35

IilintriD gonorrl1oeve

Gonorrhta and OIhtr !BUilliy transmintd Ii 1tiI~\ !'IIdomt!riWi,

neonatll ~ infection

Some sptdts are part oftheoormalimt ftora

IiliJifflo mmingiridJ

Menil91i1 il dlildrffi

Some sptdts are part of the oormalimt ftora

I'MuI11lXlli

PneIlllOllia, otitis mtdia,lIII'oinis, biammia,ffidoc.Jrditis

Pirt ofoormal IIolillora il LWft" r~ralory trait

PrortrlS mirobilil

Un ~ inftctions

Pirt ofoormal IIolillora il GI tratl

l'lerJdomoooslltflJgiOOJ~

un skin inftction~ ~tir:rmia

Common opjIO't!lliltit mitrobe

RkkPwi~ ricterrJii

Rody Moon!ail spotltd fM!

A(qrirtdfrom tid:: bite

~lmoMloffirtriridS

Food poisoring

A(qrirftl from ilfKll'd aninil prodoos; raw rgg~ uodffi:ooked

mutordlitkffi

PIINIIOIIia, food poisoning. inpWlj<\ WOIIIIk, biaemria,

Some ~ il! part oftheoormilimt nora

5rap/ly/OCM (ljrtUs

IIItidtotr 'MY Iirjl in HIVilfKll'd patitnts

ffidoc.Jrditi~ tQIIK shodr 1)'IKtomt, O\IMn~~il.lfIl

5rfllplococCU5

....

Pharyng~i~ pot'umooia, ~ infffiion~ ~tkrm~, ffiIIourditi ~ otitis

anti-infective drug may be used to treat bacterial, fungal, viral, or parasitic infections. The most frequent
term used to describe an anti-infective drug is antibiotic. Technically, antibiotic refers to a natural substance
produced by bacteria that can kill other bacteria. In
clinical practice, howevtr, the terms antibacterial, antiinfective, 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: chemica! classes and pharmacologic classes.
Chemical class names such as aminoglycosides, fluoroquinolones, 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 therapeutic groups.
Pharmacologic classes are used to group anti-infectives
by the'ir mechanism of ([etian . Examples include cell wall inhibitors, protein synthesis inhibitors, folic acid inhibitors,

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Some ~dts irfpart of the oormil host ftora

and reverse transcriptase inhibitors. These' classifications

are used in this textbook, where appropriate.

34.4 Actions of Anti~lnfective 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 diffe'rences compared to human cells. Bacteria have ce'll walls,
use different biochemical pathways, and contain certain enzymes that human cells lack. Antibiotics exert selectiw toxicity 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' toxicity, dc>pending on the specific antibiotic and the dose employt'd, and adverse effects can be' expected from all
anti-infectives. The basic mechanisms of action of antimicrobial drugs are shown in Figure' 34.1.

(hopttr)( Drug' lor iIx!l'flalln/ealoo,

481

eel willi synlhuis

RNA synthssis
i'lhibit"..:
Rifampi'l

P",tein synthesis
i'lhibit"..:
A'Tlinoglycoside&
Ollo.ampheoic:ol
Oindamycin
Li>ezclid
Macrolides
S:reptogf8mins
Tetracyclines

inhObitof8:
Cs rbopen ......
Cephalo&pori ....
I""...... zid
PIInicilins
V.n~

t
t

mR~

DNA oynthuis

-----'It--I inhibitof8:
m
. '''"".''''~

~m::::::_~SCo::
,~,~."

,. Flgure34.1 Mechanisms of action of antimicrobial drugs

34.5 Acquired Resistance

Microorganisms haw the ability to replicate extremely rapidly. Forexample, under ideal conditions E. coli can produce
a million cells every 20 minutes. During this rapid replication, bacteria make frequent errors while duplicating their
genetic code. These mutations occur spontaneously and randomly throughout the bacterial chromosome. Although
most mutations are harmful 10 the organism, mUlations occasionally result in a bacterial cell thai has reproductive advantages 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 importance to medic;n~ ~re tho ... th~t conf.. r drug r.. _inance
to a microorganism.
Antibiotics help promote the development of drug-resistant
bacterial strains. Killing populations of bacteria that are sensitive to the drug leaves behind those microbes thai possess
mutations that made them insensitive to the effects of the antibiotic. These drug-resistant bacteria are then free to grow,
unrestrained by their neighbors that were killed by the antibiotic, and the patient develops an infection that is resistant
to conventional drug thernpy. This phenomenon, a{qui~d
~si,tan(f, 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!.

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It is importalll to understand that the antibiotic did nOI

errore Ihe mutation that caused bacteria to becomt resistant. 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 bacteria that have become resistant, not the patient. An individual with an infection thai is resistant to certain antibacterial
agents can transmit the resistant bacteria to others.
Thewidespread and sometimes Wlwarranted useof antibioticshas led to a large number of resistant bacterial strains. At
least 60% of Staphylococcus aureus infections are now resislant to penicillin, and r""i_mot strains of Entl'rOl"OCl1I' /aI'''''!;',
Enterococcus [oecium, and Pseudomonru oerllginosa h~,"\' berome 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 acquired in a hospital or other health care setting, called
nosocomial infrctions, are often resistant to common antibiotics. Resistant nosocomial infections are especiallr troublesome 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).

482

UnitS Thl'lmmu""Syst""'

1.loI8d:ion

, I Anlibiotic I

34.6 Selection of an
Effective Antibiotic
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

In most cases, antibiotics are given when there is clear evidence of bacterial infection. Some patients, however, receive 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 experienced deep pWlcture wounds such as from dog bites, or
those who have prosthetic heart valves and are about to have
medical or dental procedures.

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.

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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 treatment, giving the microorganisJJ1S more time to invade.
Prescribing ineffective antibiotics also promotes the development 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 ~h t~t~ m:l}' inch](le (>'(~min~tion of urine, ~tool. ~pin~l
fluid, sputwn, blood, or purulent drainage for microorganisms. 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 antibiotic is called rultul! and semitiYity ((&51 !tsting.
Because antibiotic therapy alters the composition of infected fluids, samples should be collected prior to starting
pharmacotherapy. However, laboratory testing and identification may take several days and, in the case of viruses, several 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, narrowspectrum 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.< ~ncl sympTom.<.

In most cases, antibacterial therapy is best conducted using 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 seveTal 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,

'hop1fll4

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 competing with pathogenic organisms for space and nutrients.
Removal of host flora by an antibiotic gives the remaining miccoorgani,lll.'l an opportunity to grow, allowing foc ovecgrowth 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 beoomes suppressed. Microbes that become pathogenic when
the inunune system is suppressed are called opportunistic organisms. Viruses such as the herpes virus, and fungi are examples 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 appears while the patient is receiving anti-infective therapy.
Signs and symptoms of a superinfection commonly include
diarrhea, bladder pain, painful urination, or abnormal vaginal 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' antibiotic is to be certain that the microbe is sensitive to theeffecls 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 natural 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 pro phylactic basis to patients whose white blood cell (WBC) count is extremely low.
Local conditions at the infection site should be considered when selecting an antibiotic beca u se factors that hinder the drug from reaching microbes will limit therapeutic
success. Infections of the central nervous system are particularly difficult to treat because many drugs cannot cross the
blood- brain barrier. Injury or inflammation can cause tissues to become acidic or anaerobic and to have poor circulation. 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

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Drug,fo<Sx!e,latlnf<'Ctlo",

483

listeria may reside intracellularly and thus be difficult for

anti-infectives to reach in high concentrations. Consideration of these factors may necessitate a change in the route of
drug administration or the selection of a more effective antibiotic specific for the local conditions.
Severe allergic reactions to antibiotics, while not oommon, 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 incident 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 without previous incident. Penicillins are the class of antibacterials having the highest incidence of allergic reactions;
between 0.7% and 4% of all patients who receive them exhibit some degree of hypersensitivity.
Other host factors to be considered are age, pregnancy
status,and genetics. The very young and the very old are often 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; aminoglycosides can affect the infant's hearing. The benefits of antibiotic 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 enzymes used to metabolize antibioties. For example, patients
with a deficiency of the enzyme gluoose-6-phosphate dehydrogenase should not receive sulfonamides, chloramphenicol, 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 similarities in their mechanisms and spectrum of activity, each
is slightly different, and learning the differences and therapeutic applications among antibacterial agents can be
challenging. Basic nursing assessments and interventions
TREATING THE DIVERSE PATIENT

Hispanic Cultural Beliefs and Antibacterials

emain ~thni: grwps,oo al H~niG,btI~that innm is("I~ b'f ,n inhl~

ara il hot ,nd roId.ln i hNhIl)' i1di'lidla~ hot ind oil irl' in hllalKf;whtn ,n
inb;lIaOO' oc:rul5, dloN\t II'IU~.
lilltlltl all' cblsifrd II fithtf hot or wkhl WflL For fJIImplt.!OII' throaund
di.lrThN n ~Jl'd hot distases;wkk, upper Jl'IjIil1liOl)' ilfooions. arthritis.
ind 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,
mtdi:"ionsorhtrbsron~rtd(oklaJl'wd.Formmplt.penidlilismnli:ltml
hot mtdia.t, but olIIIOJi:i~n is itslOOl Usilg aa'Ulmilophffi with 'rrmicil~n

make it rooItr.

48 4

UnitS Thl'lmmuneSyu"",

apply to all antibiotic therapies; however, the nurse should

individualize the plan of care based on the patient's condition, the infection, and the antibacterial agent prescribed.

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 miracle product by preven ting thousands of deaths from infections. 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 commonlyaffected by the penicillins, including streptococci and
staphylococci. Penicillins are indicated for the treatmem of

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 brtaI.<tam.ing. Some b~cteri~ 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 nwnbersofresistant bacterial strains have emerged that limit the therapeutic 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 molecule produced drugs offering several advantages. They indude 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

!ABLE 34 21 Penicillins
Route and Adult DoSf' (max dose whj>ffl Indicated)

Drug

Advflrse EffKIS

NATURAL PENICILLINS
pmicil~n GbtnzathiM (Bidlli1)

1M; 11 milioo uriu asa!oi1gtr dolt (mal:1.4 milioo lIlits/da,)

i/QJh, prunru~ dIorrilN, I!4IlfO, fMr,

pmicil~n Gprocaint (WUlin)

1M;600,0-11 milim lIl~sJday (max: t8 milioo uritslda,)

.towsi/ltSS

prnidlin Gsodiumlpot.mium

pmiciltin V(Pm-'ftor K. 'ftortids., VrMiIlin-KJ

1M/IV; 1- 14 million IIl~S divided MI'1 "-6h (mal:80 milion urilsJday)

PO; 125-150 mg qid (mal:71 glday)

PENICILUNASERESISTANT

doudlin (Cloxaprn)

PO; ~500 mg bid

didoxadlin

PO;m- 5OOmgqid (mal : 4g1~ )

nakilin

PO; 150 1119- 1 g qid (max: 12 glda, )

oxadllil

PO; 150 1119- 1 g qid (max: 11 g/da,)

BROAD-SPECTRUM (AMINOPENICILLlNS)

. morid lin (AnwilTrimox)

amoridt il-davwoa!~

(Augmm:in)

PO; 150-500 mg .."Y 6 h (max: t,750 mg/<b, )

PO;150 0/ 500 mg tabIrl (u(h with 115 mg dol'luanil: .dd) ~VI'ry 8- 11 h

ampidlin (Prindpm)

POIlVJIM;15O-S00 mg M!Y 6 h (max: 4 glday PO 011 4 glday IV/1M)

baYlI"pidl~n

PO;400-8OO mg bid

(Sprctrobid)

EXTENOEOSPECTRUM {ANTIPSEUOOMONALJ

Ylbtnid lin (Grodin)

PO;381-764 mg qid

pi~roKilin sodum

1M; 1-4 g 1id~id (mal:14glda,)

pi~roKilin wob.Klam

(Zosyn)

ticardlin (rKa')

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IV;B75gqidOW'rlOmin
1M;1- 1 g qid (max:14g1da,)

Aoaplwlaxis rnnpiOmt indudina

aogiotdrnla, drtulitort ?lam ind
cardiac a!lt!!; nrphrotollkity

'hop1fll4 Drug,/o<Sx!e.lalllll<'Ctlo",

o
II

485

/S,/CH,

J.
C - C- NH - CH - CH
\\//H.
II
C - N-

O~

C,
I CH,
CH - COOH

Penicillin G; p-Isctam ring givea

antibiotic actiy~y

Il-La.dam ring

- ,

Resistant bacteria: Penicillin *lactam...

o
II

/S,/CH,

!.
C - C -NH - CH - HC
\\IIH.
II
O= C
N-

C,
I CH,
CH - COOH

p-Laclam ring broken . antibiotic activity is toat

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 betalactamase enzyme. When combined with a penicillin, these
agents protect the penicillin molecule from destruction, extending its spectrum of activity. The three beta-lactamase inhibitors, davulanate, sulbaclam, and t3wooctam, are available
only in fixed-dose rombinatioJ15 with spedfl' penkilliJl5.
These include Augmentin (amo;ricillin plus davulanate), Timentin (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 contributed to their widespread use for more than 60 years. Allergy to penicillin is the most common advt'1'Se effect.
Common symptoms of penicillin allergy include rash, pruritus, 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 ReceivingAntibacterial 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

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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 tolerate 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 betaI~cl~m

ring IhM i< ""-"pnn<ihle fnr Their ~nlimicmhi~1

~cliv_

ity. The cephalosporins are bacteriocidal and act by

attaching to penicillin-binding proteins to inhibit bacterial
cell-wall synthesis. They are classified by their "generation,~
but there are not always clear distinctions among the gent'rations. 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

486

UnitS TtelmmuOI'S)"tl'm

..... Prototype Drug

I Penicillin G Sodium/Potassium

Therapeutic (lass: Antibacterial

"t

Pharmacologic (lass: Cell wall ilhibitor; natural peniallin

ACTIONS AND USES

ADVERSE EFFECTS

Simi!.r 10 penic:ilin V, penicillin Gis <I drug of dioe <lgaimt strt'ptoc:O(c~ pnwmoc:oai"nd na~hyIooxci Of'9iInisms thai do 001 produu ptnic:illinm ind art'
shown to lit su lC!ptibie by (&5ttlling. k is also a medication of choiu for gonorrllta and S)'phiil UUIN by Wl<tpliblt mains. Pmic:illin Gis milablt <II~
llltr a potmilm or SGdilm ~It; llltrt' is no difirrt'n(f llitraptutiully betwem
lilt two wits.
Only 15-10%0f an oral d= of penic:illin Gis ablOlbed. ~US!' of its low
oralabsorption,prnic:min Gis 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 Gberu:alhilll' (8ic:illin) and ptnicillin Gprouilll' (Wytillin)
Art' Io~ OCIing pl ...."""1 <.Ok< oftht drug.

PrniciUin GhiS ffW Ifflous adYerst effects. OianbN,nlUS!'a, an~ vomiting art'
tiMo most (ammon adYene tfl"ecu ind tan (aUS!' smous oompli:atiom in {hildlt'll ind oldtr idum. Pain it tht injrnion ~te miy oc:cur, ,nd !lIptrinrectiom
art' poI5iblt.Anaphylnis ~ tilt most W'rious ,dvtrSt tffect.
Contrai nd italions: The only contraindiution is ~nsitjyity to a drug in tht
ptnic:illin daIS. 8eo:.JUS!' penic:illin Gis er<reted flIensivtly by tile kidn~, tht
drug should lit UIfd with caution in ~tients with W"/ert' .... al ~~.

ADMINISTRATION ALERTS

INTERACTIONS

J)ug-J)ug: ","id~n Gmay dKiNlf the effKliv~ of oral rontoopliva.

~ taken with this rnMitiIioo will d@aNlfthei!blorptionofplidlin.

l'ou!Sium.sparilg diurMiG mayulM~iawhfn adminisrelldwith

peni:i~n Gpoli5!iOOl.

Lab Ttsts: Pl'ltidlil Gmay ij"lt poIitiu (rombs' tfII and Ial!.! positiVI! .linary or
W'l 00I prOieilll.

Afttr ~ .... telill administration, oblffi'l' for tm~bIt alltrgic rt'actions for
30 minut6,tspffially following tilt fim dost.
00 oot mix ptnic:illin ind aminogly(osoo in tiMo wme inlla_om soIulion. GiV!' IV n:edicatiom 1hour a~n to prt'~nt inter.Jnions.

Trtalmtnt ofDtrdow: Tlltll' ~ 00 sptcifK tlNtment for O"ItrWs.t.

Prt'gnalKY ~ry 8

RtI'tr III MyMIsIrtgR fur a MnJnq I'rortl! Foot! spKlIIi: 111M <tug.

Ik<rbaVFood: Urtnown

PHARMACOKINETICS

Il1wtRapid
~ak: 30-60 min PO; 1S- lO min 1M
Half~ift: 10-60 min
Ouralion: .~h

..... Prototype Drug

I Cefotaxlme (Claforan)

Therapeutic (lass: Antibacterial

Pharmacologic (lass: Cell wa ll ilhibitor;first -generation tephalosporin

Aal0NS AND USES

ADVERSE EFFECTS

(tWtaumt is a ttird"9flll'ration (~alosporin with i broad sptclnJm of activit"; 'gainst gram-negati~ olljanisms. k is tfftniV!' 19ainst many bitlt'rial
Speo:~slhat hiV!' df"/tloped rt'Sistanu to farl~r generation ctpha~rim <I nd
10 othtr tLmfl Ii anti-infectim. (tfotaIimt txhibits bamrioc:idal inivity t.,r
inhibiting (tll-WllIs)'lllhtsis. k is prt'S(ribed 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.

For most pat~nts, {ffotuillll' ind tht othtr {tpha~rim art' wft medilations. H~nsitivir; ~ tilt IMn (ammon ad~ tffl,ikbough S)'mptorm
ma, indlllk only, minor rilh and iUhing. Anaphylam ~ poIlbit. Glff!'trd
Iidt ffirm YKh as dianhei, I'Omiting. and nauIN may O(rur.Sane patienu fIptritlKt mmidmblt pain at t~ injtdion ~te.
Contrai nd ications:The only comraindication is hy~nsitjyity 10 a drug in the
tepha Iosporin das ~ ~USt (tWtaume is U(rt'ted ertt nsivtly by tht kidntyl,
t~drug Ihould lit UIN with uution in ~t~nu with Sfftll' rt'N1disNst.
INTERACTIONS

ADMINISTRATION ALERTS

Admio~ter IMinjeo:tiomdffp intOi

lalljt ~ malS to prt"lent iojuryto

sunounding tMutI.
Prt'gnalKY ~ry 8
PHARMACOKINETICS

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 ind Ib eIevationI of W'l 00I or Irinary Ufainiw lewis.

Il1set: 30 min (lM);S min (IV)

Ik<rbaVFood:lJnI;nown

~ak: Unkno\\ll

Trtatmtnt ofDtrdow: Thert' is 00 SptCifK Irt'atment for O"ItrWs.t.

Half~ift: 1 h
Duration: Unknown

RtI'tr II MytmbrgXI fur a MnJnq I'rortl! Foot! spKlIIi: 111M <tug.

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'hoplfll( Drug' fo< !lxtl'llallolealOll'

TABLE34.3 I Cephalosporins
Route and Adult Dose (max dose where loo lcall'd)

",,"

487

Advel"5e Effects

FIRST-GENERATION

madroxil (Duric:~

PO; 500 1119- 19 O!II' IOtwotimel/day (mad gfoHY)

ma/din (AAl:tt KtIzoI)

1V1IM;250 mg-2 9 tid (max: 12 glday)

aphaluil (Ktfttx)

PO; 250- 500 1119

PO; 250- 500 1119 tl'l'r)' 6h or 500 1119- 1 9Mf'! 12 h(max:. gfoH,)

,phOOi!ll' ('kW()

[JQrriIN,QImmilaluanpng. ~ (olii'll,

ro5ll. pruti~ pl!i~ or i"jtcrion sir/\ /XII or rogm

rQndidoJis

"d

IXudomrnlbranous (olili ~ oepI!rotoxidty

aoaphylax~

SECOND-GENERATION

mador (CtdOl)

PO;25O- 500 1119 lid (max:2 gld.y)

(tfolmn (CtfOtln)

IV/1M; 1- 2 9 f'leI} 12 h (max:6 gld.y)

a'foxilil (Mdoxin)

IV/1M: 1-2 9 f'leI} 6-8 h (miX: 12 gfday)

a'Iprozil (Ctflil)

PO; 250- 500 1119 O!II' to two time/day (miX: 1 glday)

a'I!roximt (Ctftio, ZNa'f)

PO;lSO- 500 1119 bid (max: 191oHy)

1M{1V: 750 1119- 1.5 9Mry 8 h (mad g/day)

THIRO-GENERATKlN
a'ldinr (Omnktf)

PO; lOO 1119 bid (.....:600 mg/di)l)

a'ItiIDml (Speara(tf)

po;.oo 1119 bid for 10 oH)'I (mn:&)) mgloH,)

a'fuimt (Suprax)

PO; .00 mgloHy or 200 mg bid (max: 800 mg/oHy)

~(Cefobid)

IV/1M; 1-2 9 f'I~ 12 h; 16 g/day in IWO 10 fotrdiloided Ibsfs (max: 12 gld.y)

Q (tfOtlxime (Clafonn)

IV/1M; 1-2 9 bid-tid (mil: 12 g/day)

a'IpDdoxint (vantil)
rntiZidim~

(ForuI, b1ir:d)

PO; 200 1119 Mf'/12 h for 10oH)'I (miX:&)) mgloHy)

IV/1M; 1-2 mg Mf'! 8-12 h (max:6g1oH,)

rntibulm (Ctdax)

PO; .00 mgloHy fOliO oH)'I (max: 0100 mgld.y)

rntiMximt(Ctfizox)

IV/1M; 1- 2 9 f'I~ 8-12 h, upto 2 9 f'I~ 4 h (max: 12 gldl1)

rntriaxo!ll'(Rocrphio)

IV/1M; 1-2 9 f'I~ 12- 24 h (miX:. g/day)

FOURTH-GENERATlOtl

~ (Malipimtcl--c_~I_"_'._:O.S-1.0 9 f'I~ 12 h for" 7- 10 d.y, (mad gldi)l)

Irolin indcat~ ammon .d'lml' ~m;~indcate ltOousod'/ml' ~fltas.

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-

LibraryPirate

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 allergic to the cephalosporin<;. Cephalosporins are contraindicated 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 penicillin In addition to allergy and rash, GI complaints are
common adverse effects of cephalosporins. Earlier generation cephalosporins caused kidney toxicity, but this adverse
effect is diminished with the newer drugs in this cla~.
S~ Nursing Process Focus: Patients Receiving Antibacterial 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

,
~

48 8

UnitS

Th~

Immune SY"'-""

TABLE i4 41 T"tracyclinti!s
Drug

Routeand Adult Dose (max dose where Indicated)

demtdoqdint(Dtdomym)

PO; 150 mg Mry 6 h or 300 mg r~ 11 h (mad. glday)

doxyqdinr (Vbramym,OII1rrs)

POny; 100 mg bid 00 day I, thrn loomglday (mal:lOO mg/day)

minoqdinr(MilHK in, 01hrB)

diarrM4 mild p!wlroraOdry. fI1fh, cflzinru,

stingill9fOOmirtg Vrirll fDliml oppIrorkm

POnV;1OO mgu ~"* do51' foIowrd by 100 mg bid

ltlri()'dinr (Stmydn. odtm)

PO;~500 m9 bid-"d (rnu:2 9/day)

tigrqdint(Ty~)

34.10 Pharmacotherapy
with Tetracyclines
Tetracyclines act by inhibiting bacterial protein synthesis. By
binding to th~ 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 adverse effects. Doxycycline (Vibramycin, others) and minocy-

Prototype Drug

IIlmiri"9. 0bd0mlM/(Jllmpi"9./linlmrt,

Aniphylaxi; gcondary infe<!iom.l!epi!loloxidtL

afoljatiYr drrmat~h

IV; 100 mg. fdlowrd by SO nl9MfY 12 h

against a large number of differ~nt gram~negative and

grnnqXlsitive organisms and have one of the broadest spectrruns of any dar.s of antibiotics. The tetracyclines are listed
in Table 34.4.

Jitr

Adverse Effects

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 bacterial strains that now limit their theT3peutic utility. Therare
drugs of choice for only a few diseases: Rocky Mountain spotted 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 acnevulgaris, 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. Because these drugs bind metal iOIl<; such as cakiwn and iron,

I Tetracycline (SumYCIn, others)

Therapeutic Class: Antibacterial

Pharmacologic Cia ss: Tetracycline; protein synthesis inhibitor

ACTIONS AND USES

Tetmydilll' ~ dfKti~ i9iiost , broad raogr ofgram-positiv~ ~nd gramntgzotivt olganisms, illCluding ChkJmydiD, Ri<ktftli4l, and My<cp/DfIIlD. Its use
hiS ilKft'aifd {f>It r thr past drude due to its effKlivtnl'ls iljiinst H. py/oIi in
lhr trutrneol of ~K uker dMm. Tttracydiot isgm orally, though it M a
soon hall-lijf !hit may rrquiR' admin~mtion four ti~ prr day. Topiul ind
oral prrjlruions i R' i'liilable for treating icnr.An 1M pll'piratioo isaYililablr;
injrctions may (aIM local irritation and lit Htremtly painfUl.
ADMINISTRATION ALERTS
Admio~ter oral drug with full gLm of water to dtUl'aIt tIOph.!gea1 aod GI
initllioo.
Admio~ter aotac:idund Il'troK)'dilll' 110 3 houlHjIrt
Admin~ter Intilipidrmic:,,-lIillran2hoursbefoR'or afw temqdior.
PR'goancy category 0

PHARMACOKINETICS
1l1'51't: 1- 2 h

Peak:2-4 h
Half~ifd-12h

Duration: 12 h

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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 niUIN, romitiog, tpiljistric: bum iog, and dia niIe.J. DiarrhN may lIt~R' tllOll9h !OUUst discontinuatioo 01 thrrapy.Olhrr common
side effKls in(1ude discoloration 01 thr tffih and pOOt<MnsitiYity.
Contraindications: Tetracydinr ~ (ontraindimed in patients with hypmtnsitili!)' 10 drugs in th~ eLm. Thr drug should not lit used during tht \fcond half
of prrgnaocy, in childrt n8 )'I'ars or yoongr~ indio jItients with 1f'IM' Il'oal or
hrjltic: impairlMnt.
INTERACTIONS
1Wg- 1Wg: Mil; jroIiKII.ion ~B, ~lIIKOIIlilining liIiIIi"ll'S,aod
antadd:! IftIlKf lht abIorplioo and If IOOIIMis of letriqd~ ~raqdilt ~1Id!
with the 1~.Jowfring mtgI (olestipoi and (OOItsiyrallliof, 1Mfir,' dKlNIing lhf
antitiolil:\ iblorplion.Th~o-lMJ dro~lhtffIK~ oforal romKtptim.
lab 115ls: May inlrfR the ~klMng Iab~~ UrN nitrogfo 18lMjJ,
aIpaftiIlf MIlinOlranlfmlf lAST), ........... aminOlrilllll'trillf wn, MIl)'W. biin.tlin,
and alaint p/IoIpIIaliIIf.
JIiorbaVhod: OdiIy ~ts irltrfmo with lfUilJdlll' ablorplion.
lINIment of Omdose: Thfre ~ 110 sprcifK trutmeot for OYl'rdo5I'.
1Itl(er.!:l MytmbliJKtl'or~ MnlniJl'rIKtsIi FooII'ipt(/It 1rI1M.:tug.

'''"pltr l4 Drug. fo< 8OC:I.... I.llnfe(Uon'

tetracyclines SllOUld not be taken with milk or iron supplements. 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 ~g" ~r" nol given t"tr~cyclin... b"c~us" 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 administered parente.rally or in high doses, certain tetracyclines
can cause hepatotoxicity, especially in patients with preexisting liver disease. Because outdated tetracycline maydeteriorate and become nephrotoxic, WUlSed prescriptions
should be discarded promptly.
The newest of the tetracydines is tigecydine (Tygacil), approved in 2005. Tigecydine is indicated for drug-resistant
intra-abdominal infections and complicated skin and skinstructure infect ions, especially those caused by MRSA. Nausea and vomiting may be severe with this drug. Tigecycline
is available by IV infusion.
See Nursing Process Focus: Patients Receiving Antibacterial Therapy on page 496 for the Nursing Process applied to
all antibacteria ls.

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 penicillin, 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 effective against most gram-positive bacteria and many gramnegative 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

A VO IDIN G M EDI CATIO N ER RO RS

Mr. Johnson is admitt~d for. snM' up~r ~r.tory inftion and dehydr.tion.D.Jring tilt nurs~'s initi.l ~\esml'n~ Mr. Johnson isqu~tiontd about a~
Itrgits and Il'poru being alltrgic to ~.ruts, ',pirin, sulfa, "Id ragMtd.
Followinq a history .J nd physiu Iexa mination,tht primary ca~ 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 ~~ier sw.JBowing.and gim Mr.JohnlOn his first!losr with a
Ia I1jI' gla IS of water. What should tht nursr haYe don~ diflerrmly?
5to'Apptllll/lOfllllhtJUl}9t'imiamm:

siding inside host cells, such as Listeria, Chlamydia, Neisseria, and Legionella. Clarithromycin is one of several antibiotics 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 erythromycin. 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 antibiotics. The shorter duration of therapy is thought to inCft'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 antibiotics, 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 Antibacterial 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 applications for the treatment of aerobic gram-negatiw bactt'ria,
mycobacteria, and some protowans. The aminoglycosides
are listed in Table 34.6.

Macrolides

"n"

azithrom,m (1ittromal,Z-Pak)
darithromydn 16i.11il)
diitl"romym (Dynab.K)
ft)'Ibrorny<in (Hotydn, Erythrodn)

Route and Adult Dose {max dose where Indlcatedl

PO; 500 mg for _dose, thm 250 mglday for 4 days

PO;M-5OO mgbid

PO;500mglday
PO;M-SOOmgbidor m mgtid

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489

490

..

UnitS The Immune SY"'-""

Prototype Drug

I Erythromycin (f -Mycm, frythrocm)

Therape utic ( lass: Antibacterial

Pharmaco logic ( lass: Macrolide;protein synthesis inhibitor

ACTtONS AND USES

Erythrom)'(in is irOOiv~ttd by 1I0mac:h acid ~nd is tills formulattd <II cOiIItd,
acid-~inant tablmorcapsulr1 that diuolvr in tlil'small im~lIi~.It; main~pplication is for patimlS who <I ll' un.JbIt to to~rate penicillins or who mJYholY!'
a ptnicillin-resisbm inleo:tion. k has a sptdrum ~milar to that oI!hr ptnicilli os
and is rfle.:tivr <lgainll mon gr~m1lClsm bacteria.1t is oft~n a prmmd drug
for infections by BllrrimJIQ pmuJIis (whooping cough) and Corynroocufium
dip/rdlfriat.
ADMINISTRATION ALERTS
Adminisll'f oral drug on an r mpty stomach with a fUll glass ofwater.
ForsuspeosKm,lhaktthebottkthorough~toen\Ull' thrdrug is~1 mied.
Do not giYl'with or immediall'ly befoll' or after fruit juices.
PIl'9n.J1K)' category 8

PHARMACOKINETICS
1l1~t: I h
Peak:Hh
Half~iM: 15- 2 h
Duralion:Unknown

ADVERSE EFFECTS
TIiI' molt frtqUtnt adYersr rflem from tr)1hromyr:in ~Il' n~UIN, ~bdominJ I
cramping,and vomiting,<lhhoogh t~ are rJreiy ~rious mough to wadisrominunion of tlil'rapy. COIKurll'llt administration with food rtdtns thI'st
l)'IIlpioms. TIM- molt ~Il' aMM dfd is htpatoioJicity c.Jutd bythe estolall' sak (lloIo ne) of tlil' drug. Hearing Iosl, venigo,and diuilll'Sl may be 9ptritncrd whl'n using high doles, particularly in older addIS and in thoJol' with
impaired hI'p;rtir: or r~naI 9aetion.
Contraindications: Erythromyr:in is rontraindiuted in patienu with hyptnen~til'ity to drugs in the macrolide dill,and fort"-taking terferudine,.ntemizoIe,or cisapridt.
INTERACTIONS
i)ug- i)ug: Ane\llwticJ,azolro oifltifu~Mld oiflticonwnll may "lfr.I(tto YIIII'
l'fllll druij Ifvm 0( erytIvOOlycinto 1M and rfIW " tolDdtJ. Tb~ Ihg n mcll
with qcIosporine, incrMilg tht risk for .000xicit~ It may iraNSI' iIIf !ffecll 0(
wilifann.Thr(l)fl()Jfffl\ UJoI' 0( fl)'thJOnin with Iov.!ruiin or~in ~ not
f!(0IIlIIfIICIfd becaIIIo! ~ may OONIoI' tht risk 01 mid! toIicity.Ethanol U\oI' may
dtoaUlol' tht abIorptioo 0( erythrorny<in.
Lab Te ts: Er)1hrom~ IIIa'f "tmlnwithAST ...-.:t gi"ll' fal\ol'urilar1c.1I~nt

.m

IlerbaVFood: ~t.km'l MIll mayd!crNlt!frlo!ffK~ 0( fI)'I~.

T~lmfnt of Derdolf: Tht~ is no Ipt{ifK tlNtment

iJr ove~.

Rmr II MyMfihlga for ~ MnJrtg l'reiI fools spt(itt III!tiJ ItiJ9.

TABLE 14

61 Aminoglycosides

Drug

Route and Adult Dose (max dose where Indicated)

Adverw Effects

amibdn lAmikinJ
gmUnici1 (Garamycin,OIhm)

1M; S.0-75 mg..tg is a loacting 0J\0I',then 7.5 mg/bj bid

1M; 15- 2.0 mgIkg iU loacling lbIoI',then H mgIkg bid- tid

dio,,1wl, tfniM, 60rirm

unamycin (Kanlln)

1M; S.0- 75 mgIkg bid-tid

A naphylalli~ n!:DlJp!oxidlY ilt'mliije ototoxicitv,

superjnk<!ions

neom)\in
piIItIfIIOII1ycin(Huma~n)

PO;4-11 g!day in divided ~

PO; 75-11.5 mglt9 in three dolt!

!Ill'p1omycin

1M;1Smg/bjupto 1ga!i ~,,* dw

tobr~mycin (NebcinJ

IM/tM; 1 mgIkg tid (max:Smg/bj/day)

Ponorin~QfI1II1Qtion Qri~ctionw,fDJIi. fmr, ~

hdkJ indiut~ 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, Proteus, Klebsiella, and Pseudomonas. They are sometimes ad ministered concurrently with a penicillin, cephalosporin, or
vancomycin for treatment of enterococcal infections. When
used for systemic bacterial infections, aminoglycosides are
given parenterally because they are poorly absorbed from

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the Gl tract. They are occasionally given orally for their local effect on the GI tract to sterilize the bowel prior to in testinal su rgery. Neomycin is available for topical infections
of the skin, eyes, and ears. Paromomycin (Humatin) is
given ora lly 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.

Chopltr l4 Drug' fo< 8K' .... I.II"fe<Uon'

II~ Prototype Drug

491

I Gentamicin (Garamyclfl, others)

Therapeutic CI ass: Antibacterial

Pharmacologic Cia ss: Aminoglycoside; protein synthesis inhibitor

ACTIONS AND USES

Gtnumicin is a broad-~trum, ~aeriocidillintibiotic u'Uillly p~ribed 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 5lQ~OWIf QUftUS
(MRSA).1t is ohm used in {ombimion with other antibiotiu.A topiul formulation (Genoptic) is '\\Iilablt for infffiions of ~ externil~.
ADMINISTRATION ALERTS

For 1M administration, gi-n d~ into ata~ musc~.

Use only 1M and IV drug IOlutions that 'R' c~. rand coIoMss or ~ightly )'1'1Iow.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'9 n.ncyc.ilegOl)'(

PHARMACOKINETICS
Onset:Rapid

ADVERSE EFFECTS
Ruh, nausra, vomiting. and fatigue 'R' the most frfll~nt adY!'~ effKls. As
with . r aminog~((IsidH, <Main idft~ ~rts mlly ~ !fn~.OtotOllici\)'
<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 ~igns of ototoxirit)o. Nephrotoxirit)o is of partirul.tr <on{ern to patinlts with p~~Jining kid~ imj)llinnnl~ and may limit phumac:o~r.py. Signs of mi"'M kid~
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 .. minoglycolidts has ~n II'portM.
Contraindimions: Genumicin is contraindic.itM in patients with hypel\ells~
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 ~.uisting
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, ~)"IIl)"Iin
B, 01 '/olIIComy<i1 inoUlfl ~ riIII of nephrotm:idty.
liI b11'Sts: Gfntamil:in may inmasl' value! of ~ folowilg: IoffiIm biirubin, IfIIIIII

~k: t-lh

uMiniM, IfllllllIacLltI' deII)'IIrogfna;r nD!), BUN, AS1; 01 All: may dKr&N valutol

Half-life: 3.... h
Duration: 8- I 2 h

[01 ~ IoIowing:SfI\Il1 <akium,IOIium,OI ~

HerlI<iVFood: Unknown
lrNlment of Overdose: T~ is 110 ~ifK tre.tlmtnt for OY!'rdosr.
III ftt Ie MyMJ"/ngfJI for Q MJrJi"'ll'rrKt.. fDan 1p11< Ie rIrtJ dfU9.

The clinical applications of the aminoglycosides are limited 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 perma nent deafness may occur, aminoglycosides
are usually discontinued when symptoms of hearing impairment first appear. Aminoglycoside nephrotoxicity may
be severe, affecting up to 26% of patients receiving these antibiotics. 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 Antibacterial Therapy on page 496 for the Nursing Process applied to
all antibacteria ls.

Fluoroquinolones
Ruoroquinolones were once reserved only for UTIs because
of their toxicity. Development of safer drugs in this class began 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 fluoroquinolones are listed in Table 34. 7.

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3 4.13 Pharm acotherapy

with Fluoroquinolones
Although the first drug in this class, nalidi..-uc acid (NegGram), 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 gramnegative pathogens; the newer ones are significantl), more
effective against gram -positive microbes, such as st3phylococci, 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 alternatives to other antibiotics. Clinical applications include infections 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 fluoroquinolones may be effecth-e against M. tuberculosis.

492

UnitS The Immune SY""m

TABLE i4 71 FluoroquinolonlO!s
Drug

Route and Adul t Dose (max dose where Indicated)

AdVl'l'seEffecb

dnoxadn (G~{j

PO;lSO- SOO mg bid-qid

/iQU5lll,dia~

naidixic:uid (NtgGrim)

PO;Arut~ thtriP1; I 9 qid

FIRST GENERATION

M1IIIiring, rash,hrodht,

n!S11tl~pi!in ~lIdinfl<lmmQrionor~"

sire, /0(0/ burring, uinJr19 ~1Id rorrwa/ irriloril/ll

(op/IlIIO/rrirJ

PO;Chronil: t~: SOO mg " d

,wphyli1!is. tm:bn !IJptll'( . \Uooinfwiorn,

SECOND GENERATION

Q dproftwdn(("pro)

PO;2S0- 7S0 mg bid

norIIoxicin (NorOlin)

PO;400 mg ~d 01800 mg OIK~ dolly

oIIoJOOn (Aoxin)

PO;200-400 mg bid (max;8O(I mg/da,)

pho!osrositiv~y, P!t!!dO!!lt!lltmous (oiJj~

!rizlll~ . ptrip!Iml nl'uroDalhy, hepalOllJl(idty

THIRD GENERATION

Ievolloxidn (L"iquin)

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 iflwtd~ up to fool time/diy
PO;25O-S00 mgfdoly [mal: 750 III9Id,,)

FOURTH GENERATION

gmlifloXidn (Firti'le)

PO;110 Ill9lday (max:320 mg/d,,)

moxifIoLJdn (AI'rIox)

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 fluoroquinolones 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 patients. Most recently, fiuoroquinolones have been associated
with an increased risk of tendonitis and tendon rupture, particularly of the Achilles tendon. The risk of tendon rupture is
increased in patients over age 60 and those receiving concurrent corticosteroids. Because animal studies have 6Uggested
that fluoroquinolones affect cartilagt' de~lopment, these
drugs al't'not approved for children underage lB. Use in pregnancy or in lactating patients should bt' avoided.
Set' Nursing Process Focus; Patients Receiving Antibacterial 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.

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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 gramnegative bacteria, the sulfonamides significantly reduced
mortality from susceptible microbes and earned their discovert'!' a Nobt'l Prize in Medicine. Sulfonamides are bacteriostatic 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 pregnancy. Bactt'ria also require this substance during periods of
rapid cell division and growth.
Although initially very effective, sE'Veral factors led to a significant 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 :tntibiotic 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

'hoplfll( Drug' fo< !lxrl'llallnlealOll'

Prototype Drug

493

I ClprofloxaCIn (e/pro)

The rapeutic (lass: Antibacterial

Pharmacologic ( lass: Ruoroquinolone,:bacterial DNA synthesis inhibitor

ACTIONS AND USES

Ciprol\olOl(in, . ,~rond"lffimlion fuoroquinolon~, wa, approl'fd in 1987 .nd
is th~ mOSI widely pr{'\(~d drug in this "'ISS. By inhibiting baa~ri.11lHA gy.. ~, dproflomin dfleo:ubaa~ri.l lI'pli(.l\ion . nd DNA II'p.i[ Moll' riflm
' g<linn gram-OOl.rtiW' thIn gram-po>itjy~ org.nilm ~ it is pll'sc:ribed for UTI. ,inusitis, pnwmonia, >kin, boot and joint inn uions, innctiou, di. rrlIed,' nd c~rtain e)'!' inffitions. As of 2007, th~ FDA 1I'(0mmendN thai ciprol\omin no
Iongtr be USfd to 1II'.t gonorrlrea. TIlt drug is rapidly .bIorbed aile.- oral adminismtion and is distribuled to most body li,rue,. O.. ~ in!llll'OOUS, ophth.lmic.
.nd olic: formulations 'll'i'I.iLlble.An tXlended 1l'1e<l~ form of the drug. Proquin XII, is administem:l foronly 3 rIa)'S and is appru;ed lor bladder inil'l:tions.
ADMINISTRATION ALERTS
AdminiSltr at lean 4 hours brfoll' . muids.nd ferlOUllUlfate.
PlI'9n.ncy(.l\~ory(

PHARMACOKINETICS
Onset:Rapid
PNk:I- 2h
Hall~~e: I --4 h

Duration: 12 h

ADVERSE EFFECTS
Gprofloucin i, ~II toierMN by most patierlll, .nd ~ious adYme ~ffe:n all'
un<omnon. NaH~d, vomiting. and dia rrbN may oc:rur in as many <I , 10%01 p.a-tiffiu. Ciprofloudn may be administtll'd with food 10 diminish <Im rie GI rIncts.l1~ patient >hoold no~ howt-W'l, taktthis drug with antacim or mineral
,upplellll'nt~ ,ill(e drug .b>orption will be diminilh~d Some Ilitien15l1'port
photolllXic:ity, headac:he, ind diuiness.The FDA hi , is5Ued <I blac:k 1m wi/ning
thai ci~ rofloucin m.y calM tendon inflammation or ruplUII'.Arty complaints of
difficulty with w.lking or pain in the fool or leg ,hould br Il'porled immttiatefy.
Contraindi u tions: (iprol\olOl(in is rontraindiulN in Ililients with hy~f'Stl\,ilivilyto drugl in the flooroquinolonedass. The drug should be discontiftutd ~
the p.Uent v:ptritnc:t l p.in or inflammation of a tendon, as II'Ildon ruplUIl'I
haYl' bttn Il'plrtN.
INTERACTIONS
DrurOrug: (rocullall m iniltr.tion with willfann may incrNlf iIIl!iroagw n
~iIIld Ii'lUk in bleNiIg. ThilO:ul may incrNlf lhfop/IyIine k>wk lS--J09ro.
Mudcb, ftmltll .. If.to. ar>d ...,/IIf. 1f dfo'........ ob5orption of dprol1.xodn.
l.i b Ti5II: GjRIIooon mIY incrrnf UUfS of ill,.IST, serum milinine. ar>d 8I.Jt.
Herba Hood: GprofkI:iKil can incrN" 'ifMllfvel! of CilffPilf: caflNlf
con~tioo IhorMI bf' rflui:ted 10 prMII ~~"ltflfl~iIIlxi@l~1JI
talhymlia.Dairy procluot15 fI' ooum-Iortififd .tintsGlO~ .... mrpticn of
ciprolloJaCil.
Treatment of OYerdole: Tberr is 00 ~ifKtll'.unenl for OY!'rdos~.
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)

1U1f.J(~midl' ((~midl',OIhers)

IUlfaduine (MiuoIUfoo)
IUlfadoxi~pyrifMIhamire

(FiIIllidar)

Opnhalmi:; 1-3 ~ of 100,15%,or m lOknioo into lower

conjunaivil QC fYl'IY 2- 3h
PO; loadilg 00..,:2-4 g
Miin!enanc:e 00..,: 2-4 glday il It.. to ~x dividl'd doltS
1'0; 1 2 gld.ly in IoIrdividod do ... (Jllilx:8 glday)

IUHi~(Ganlrilin)

PO; 2-4 g il~ial~ follo.oml by 1-1 g qid (mil: 12 glday)

trifMIhoprim-llfIfafMthoxazole (Saclrim, Sfptra)

ANpbyfaxk Slurn! Iobnwo

wndrom(,blood dVKlilias
IUminin! tAAa!i< rmrosis

PO; 160 mg TMP,BOO mg!IMZ bid

sulfonamide with anti-inflammalory properties that is prescribed for rheumaloid arthritis and ulcerative colitis.
Sulfonamides are classified by their route of administration: systemic or topical. Systemic agents , such as sulfisoxazole (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 sulfonamides are not preferred drugs because many patients are
allergic to substances containing sulfur. One drug in this
class,sulfadoxine-pyrimethamine (Fansidar) has an excep-

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NilUItll, I'Omitn;,QneJi~, IIIfll.

p/roffMmiririry, ~oIIurio

PO; lliblHWfftIy (,00 mg IliIidOline.2' mg p)'lWntlhamine)

1U1f... ~nc: (Azulficinc:1

Adverw Effects

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 reactio ns, nausea, and vomiting. Allhough not common,potentially fatal blood abnormalities, such as aplastic anemia,
acutt hemolytic anemia, and agranulocytosis can occur.
S~ Nursing Process Focus: Patients Receiving Antibacterial Therapyon page 496 for the Nursing Process applied to
all antibacterials.

"

,,,~

~
"
,,
0

"

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 ~ib~d for tht plwrmac:othtrapy of
urina~ tract infKtions. k is allO approftd for tht U"Nlment of PntumocyJtil
(~;,ii plltlJmonia,shigdia inftions oItht slllilll boweI,and for acute ~pisodtl
of chronic: bronchitis. Oral and IV prt parations afl' a'/ililablt.
Both SMl and TMP art inhibitors of th~ bacterial mmbolism of folic: acid.
Thtir aaion is )'lIffIjistic::A9fl'alt'lloo~rial kill isachif!'d by th~ futd rombi
mion thin would lit achR-vtd with ffllie-r drug ustd I~p.llitely. Btuuse hu
mans obtain thf pfl'CUrlOrl of folile in thfir diets and can 1M prrformtd fotale,
tlltse m~dic:.itionlare seiKtm for boaerid metabolism.Anotlltr advintqof
tilt combination is thai rleYrlopmem of ~isunu is lower thin is obserYtd
wlltn fflht-r of tilt aqenu is ustd alone.
ADMINISTRATION ALERTS

Administel" oral dowg~ with a lull glass ofwater.

P~nalK)' (a\~~ (

ADVERSE EFFECTS
NaulN and yomiting an' th~ 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
~ dise~ sira u)'!tliluria,oliguria,ind nonalfaikrn' h"e bfflJ fl'porttdPt,
riodic: tabor-alo ~ f\'aluation of thf blood is ulllilly peri:Jrmtd to idl'nt~ early ~ns
of agranulocytOlis or thromboqtopeniol. Dur to the po~tial for photosen\itivity,
tht patitnt !hould iYOid din'd IlIllight during thtrap)'.
Contraindi(ations: TMPSMZ isconmindic:.ittd in palitnu with hypersensitiv
ity to dllJ9S in tilt !Ulfonamidt (taIS. Patitnts with docum~mtd rnegalobbnic:
anemiol due 10 fobtt dtrKiency should not fl'Cem this drug. Prtolnut womI'n
it term ind nursing moth~rs should not tike this drug bec.iIM sulfonamide!
llUy uou the piacema and art' fan'ttd in milk and may Wile kemic:t~M.
TrimethQPrim rifcrt'i \eS pomsium eJCfl'Iion i nd is comraindilaltd in Pitients
with hyperlilemia.
INTERACTIONS
I)ug-l)ug:TMPSMl ma' fn~ncf tIltelfem of lfai n imaglUln. ThN rNjI
may ~ incJNse mfIhotfl'U1I' tolidty.By dMNsi'lll tilt hfparic metabolism of

PHARMACOKINETICS
1l1~t: 10-60 min
Pt-ak: 1-4 h
Half~ifd-12h

Duration:Unknown

pII~nytoil. TMP>Mlmay IilIIII' ~oin 10xicirJ TMPSMZ flfm a potl~

IpifQg fen on rIIf IK'pIwoo and lboukl lit IMd with GlllOOn with dixel~ IlKh ill

Ipironolao:OOf (A~) 10 prI"fflII ~pfli:alfmil.

Lab lets: lktnown
IWrbaVFood:~t.mium ~nlSlhcUd ootlJlo talmduring ihHap)',ooII5l

dlfC1\'d t., tilt IwaIth tart' proridfr.

llNtment of Imrdose: Tilt rt'nal elimination of trimrthoprim can be in

crt'al~ by acidification oftht urilll'.1f signl of bone marrow suppr~sion oo:ur
during high..:!ose thtrap)', Sto 1S mg oIltuoovorin should br gi!'n dai~.
P.M II MyturhIgKI fur ~ MIsIftiJ I'rt5.I fooIl spffiIt 111M <tug.

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 grampositive and gram-negative bacteria and is considered to be
appropriate treatment when less toxic alternatives are not effective 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, difficulty 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

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abscesses, gangrene, diabetic skin ulcers, and deep wound

infections. A relatively new usc is for the treatment of H. pylori infections of the stomach associated with peptic ulcer
disease (chapter 4(00 ). Metronidazole is one of only a few
drugs tha t have dual activity against both bactt'ria and mul
ticellular pa rasites; 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

TABLE 14 9 1 Selected Miscellaneous Antibacterials

Route and Adult Dose (max dose where Indicated)
Drug
IVI\M;O.5-2.0 9 biO-"d (mu::8glday)

~m(Azacum)

Adve~

Effects

Neulta, 1OOiting, dlorrllH,rtnh, fMr.iIsomti4 (fUJb

An~l!!:!J:laJ:ihsuoemf~o~

POllY; 50 Jt9I\g c;d

dWoimpbmkol

NoulIa, IOfIIring. lQrrlIH

6oum:lillis Sllm~iQ~ 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

R~~m!!!Mm!iIil.!!!!!2!I!!mJ~

iUplorTI)'tin (Cubitin)

1Y;.mgi'l;goncumy 24 h for7-14dlys

iWlulta, riarrfn, (0R51ipotion. ht.vdhf

6"anbwlilli< IIIm fra ipm rrrrona!by

RSftJdomeml!!i~

tlUpI'netn (mw)

IVr1M; 1gfdaV

t2im

NeulIa,riarrfn,lIlIIdhl
~~I!!!lli!ih WllHiIf~i~m. DItIIdommll!!i!ll1!l ~~nil.

PO; 1-11 SKhft !h~ in 3-4 Ol of water II a sir9f dcM

fosfomydn IMonwol)

NeUlIf, flarrhet!, IItpoh IIttIdtxhl

.w~ld!.H!mfroi!!rn

IV; 2~SOO mg tid-qid [max:. gfday)

Imlptlltm-<itastJtin IPrinwinJ

NdulIf, 1OfMing. dlorrllH,pdn III inJtctkmitt, hIdacht

ao,utlrtlillis !llI!ai:IftaiQ~ IliJ::udllmmlb[iIllllIiUtlilb

lincornydn (lincocin)

PO;SOOmgticl-"(max.:8 gilby)

Nc!/IltO, 1OOiting. dlorrllH

Anal!!rflaldi iYl!ttillS!io!!1, (,1fd~ arm!

pSftJdomemblanous roIiti1, blood dywlSias
lioooid (lyyox)

PO; 600 mg bid (moD:: 1,200 mglday)

NeulIf,flarrfn,lIlIIdhl
An~l!!rllald1. !UmffctiOrK

Il'..tI.Idommlbr.!1lOllS (oIi!:i1.

blood dyscmias

1V;1-2gtid

mtrOptIItI"ft (Mmml/V)

NoUlIf, 1Ornirfng. l<!rrlIH,pdn QII~sitr. hIdacht

&!il!!:ri:!ixl!.WDttiIf~i~n1. DStOdornmlb!J!l!I:!!i ",,Ii!.

IMIllmamlnt (M.vidtLlmint,
Hiprtl,UI6)

l<ilwl:!

IMlronicLuolt (~)

PO; I 9 bid (Hipral or "d ("""nd$mint)

Anal!!rflald!.mm1uria
PO; 7.S mglkg tm)' 6 h(max:4 g/iU,)
IV Ioaifng do~ 15 mgi'l;g
IV maintCMOO: dtJt; 7S mg/kg fmJ 6 h (1IIil: 4gfd.J)')

nitroliranloin (ftJJdintin, ~
MaoocIantin)

NeUlI/t _ring. dlorrllH,/flCfftlJMurFIay IJIgtIIC'J

PO;50-100mg qid (max:7 mgA!JIday)

Dillmru,htrJdocht, ollOfexiQ,aMJnirrd pdn, trlftali:

1M aid 1II1II5fIl. (atdd~ infraiom
k!~1!!!1!!!m1 ~I!!I ~k~~

NoUlIO, IOfIIdng, a~ ilDrtlliflf

~ciln/rt~lii l!~ilftaigCI

Ilr:nalil: IlI:mIlil iC!~D!i1i.l!

pnPIIOO!!i!b. Slrunrlohmon 1)'lIIkOOlt

-;;;;;il-dalfopristin {Smerddl

IV: 7S mg/tg infustd O'm ~ min "try 8 h

Pain and inl/lmmtJOOn ot iIjeaionshr. myo/lfo,

arrhrlllgil, ditmJJ

PO; SOO mg/da'J

NdUlIf, 1OIMing. dlorrllH

~n~i!!!!h D5tUd0m~I!rt!!Q!D coIttb

ltIitlram)'dn (~t.l

flS!il!liZ!l!l!ilKfi hMat....""kiI atl!r!:!!:mYi

nncornyrn (v..ncodn,OIh~)

IV; 500 mgc;dar I gbid

NeUIfII,IOOiti"9

PO; 125--500mgrvtfJ6h

ManhyijN, IIlQHi!ftaigm IlI:pIrp!griri,., g!!plgrjriTt

ltd-INn 8:nckom~

IrQ/ia Inci<ate common ~~ dl"tcts;.IIll!kdni!.a Inckatts stIIouSiclwtnttflu.

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496

UnitS lhelmmulleSyslem

NURSING PROCESS FOCUS

PATIENTS R,eElVING ANTIDAa'RIAl TH'RAPY

Assessment

Potential Nursing Diagnoses

Bntliu assessmnt prior to administration:

Understand the rwon the drug his bffiJ pr~S(ribtd in order to U~ for
It...r. po:uli< dl...l>.
Obllin I (Omplele heakh hinD!)' indudi ng lII'urofogic, (,)rdiov<tlruli~ ~irato!)',
hepatK or Iml dil~a)(. ,lIIeI the PQ15ibility of ple9nancy.Oblain , elrug hilw!),
illduding , Ilergies, illdudi ng 5pf(ifK ructions to drug~ QJlft"llt p=riplioo ,nd
OlC druql, httbal pll'p'r"ions,and akohollM. ~ alert to PQslibledrug
imf r.ldionl.
As~ liglll ind symptoml of QJ~nl inieuioll oolingiocation,(haraamtia,
pre~lK~ or 1I1Ienc:e of drai naljt Ind (ha roKler of drainlljt, durltioo, 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

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,diinhea (lU\fd by
adYen.~ drug tffem)
Rilk for Nonrompliall(f (Il'Iattd to adYers~ drug effects, ritlio:ieot
knowledge,or (Olt of medic:ation)

Assfss_nt throughout administration:

As~ for rleilfd therapt utic: efftcll (f.g., dimin~ htd Siglll and symptOllll of
inftction alldfel'l'l).
CominUl' ptriodic IOOllitOting of(BC, hepati( Ind r~nll fUnction, urinliyli~ C&S,
pt, kand trough drug ~k.
As~ for adYerSI' efffi:t~ nalMa, vomiting. abOOmin,1 (ramping. diarrhei,
drowsines~ dizzines ~ 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.
Planning: Patient Goals and Expected Outcomes
The palient will:
ExptritlKf lherapeutic ~fhas (e.C).,diminilhtd Siglll and Iymptoml ofinfectioo,dem.1td ft'ler).
Se /rte from, or ~(f 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 )

Patient and Family Education

Ensuring thtraptutk tfftctl:

CominUl' .lSflSments J I de(ribtd tarlier 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 imp~.The health (Ill' proYider should be 1I0tifitd if~
and Siglll of inffition rt'lllain after 1days or ~ !"Iltire (OUrSI' ofthe drug has bffiJ
taken .nd Siglll of infedion are Itill pIl'Sf01.)

Teich me pltiem to Il'pon a ft'ler that riots oot diminilh below

100'1' within 1days; 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 the t ntill'(oulltof Intibacteriatdo 1I0t!ha1l' doSI'I with
other family members with limilir sympIOI1ll;.nd rttum to the
healch (all' prwider if symptoml ha~ not ll'IoIvOO alter I"nlill'
r""N' of I ...... py.

Minimizing Jdft llt effKts:

CominUl'to roonitor vital siglll.lmmediatel)o Il'pOn undimin~htd k~~ changes
illiewi of (OlI\(iouIlII'SS (lOC), or k brile Il'izUll's to the health w e provider.
(mmhoold begio to diminish within 110 3days 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 pNkJ nd trough dlll9lt~1s. (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 1l'IOI~ 10 (ollfirm appropriate therapy. Drug IM-k will be monitolfd
withdrugs with known If~rt adYerse tfftm.)

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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 behavioror
UX to the he.1th (Ill' provider.

IlIItnJct the p'tient 011 the nffif for ptriodic: lib work.

C""pltr l4 Drug' fo< 8K' .... I.II"fe(Uon'

NURSING PROCESS FOCUS

497

PATIENTS RECEIVING ANTIBACTERIAL THERAPY (conrlnuPd)

Impl e me nta tio n

Interve nti o ns and (Rati o nale s)

Pati e nt a nd Fa mily Edu catio n

Monitorfor h)'pl'l'lI'n,itivity <l nd allergic ruuion',tspKialiy with lilt firs! dos~

of any ,mib.Kte rial.Conli~ to monilor for up to 2Wffn.fter (ompleting
antibmerial therapy. (Anaph)olactic l'I'actions <11'1' ~~bIe, panicularfy with tilt
fint doll' of an antib.Ktt rial.PMI-lIlt, rtYdu.J1 drug Ievek, dl!ptndtnt on Itngth
of half~ifr, may aus~ dl!wytd ruction~)

ContinII!' to monitor for IItparic, rena~ andlor ototoxicity.lAmibam ria k that al'l'
htpatic, rroal,orototoxic It'quil'l' flt'querlt monitoring to pl'l"lt'nt adv~1'!!' effects.
Inclt'<I ~ng Auid inta~ will plt"/emdrug ,(QJmulation in kidn~.)

Continuo to monitor for dollllillologic clkru induding ~ 0' P'Jrplish skin ,...h,
blineB, i nd sunburning.lmmrdiateiy It'pOn Itftlt' r.JIsIIes,tspKialiy mociattd
with blinering. (Tetr<lt),:line, IUif0na midts, <I nd fluoroqJiooion~ may caust
,igniflC.l nt dermatoiogic efftcts including Stt'lens- Joilnson ,yncllOlIII'.
Suf'l\{reens and protect~ (Iothing should he used for <l ntib.Kteria.k that cause
photosensitiYity.)

Monitorfor 1I'~lt'diarrhu.(SeI'!'l'l' diarmu may indicate the pI'I'SI'lKeof

antibioticmociattd psrudomembral'"llM mlitis,or AAPM(, a superinfection
caused by (fostridiumdifficiJt .)

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

inre.:tions. (Su ptrinre.:tions with opportunistic organisms may occur when
normil host IIora alt'diminishrd or killed by the antibuterial.)

Monitorfor signitKant GI fffeas.. inciuding naust., wmiting. ,nd abdominal pain

orcramping.G~ the drug with food or milk to de<~<1 ~ ad~ 61 efftcts.
(M.arr, .rrlibiulu ''''d>_i.n..t wilh .iyrrir... rrl GI dr.... b.Fuud III milk rr ..,
impair a~tion of 10l1li' antibiotics such as macrolidt~ but if paliem
complialKe with drug rtgimen can he ensurm with lesll'ntd 61 elfect~ g~ with
a snack and continII!' to monitor for thtrapeutic riferu.)
Monitorlor signs <l nd symptom! of neurotC\llicity, t.g.,diuiness,drowsines,
!l'Vtlt' hud<i{he,manges in LOC.and seizult'!.(Penicillins, (ephalosporins,
sulfonamidts, arninogl)\:osidts, <I nd fluoroqJiooiones hal\' an increastd risk of
neurotC\llicity. Plt'vious seizult' dilOroer,or head injurit! may increil ~ this riskJ

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

bleeding. bruising. ,nd significant fatigue. (Penicillin ~ dminoglymiidts, and
lIuoroquinolone! may cau~ blood dYStrasia! with reulting de.:1'I'a\tS in RBU,
WBC~andlor p~telets.Periodic monitoring ofCBC may he required.)

T~ach

th!o patitnt to immtdialeiy It'pOn any it{hing;ra,~;,W!'IIing,

pa nKularfy of face, tongut. or lips; unKari.J; llulhing; diuin~s;
sylKopt; wi-ftzing; th roat tightnes; or diffiruky brl'lthing.
Instruct the patitnt with known <I ntibact~rial aIltrg~s to wry a
walle! idtmitKation card or WNr m~dical idtntification itwt'lry
indicating allerg,.

Teach th!o patitnt to immtdiateiy It'pon any naust<l;wmiting;

~llowing of skin or sciera; <I bdominal pain; Iight or w)'"(oIortd
stools; diminilhtd uri~outP'Jt or darVning ofuril'l!'; ringing,
humming, or buuing in e<l n; ,nd diuines or I'I'rtigo.
Advise the pat~nt to ilKl'I'all' fluid intlu to 2 to II perday.

.u",,,,,,,.nd prottiYtdothing for !lin

v:posuretllo,ndpotiontto to woo,tinning
heds.lmmediateiy I'I'port 'OY !!'"Ieit'
T~;xh

<I~oid

sunburn or rashts.

Instruct the patient to It'pOn any diarmu that inCft'i!!'S in

flf<lUl'lK)', amount.or (ont.i", mucus, blood,or pm.
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 I~
<ltti~e QJkur~ such as kefir,yogur~or buttmnilk,to help I'I'Stort' <l nd
maintain ool'Tllill im~tin,llIor<l .
Teach tilt patitnt to oiulft brch.ngel in stool whill' pa\(~ in
mouth, whitish thickvagin<l ldischarge, itching in urogenitalalt'a,
blistering itchy rish"nd to immt'diate~ 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!!'
intl~of live-<ukure-rich dairy foods.
Teach tilt patient to take drug with food or milk but to awid acidic
foods and bt'Ierag~ or ca rbonattd drinn.
Teach th!o patitnt to oiulft brcominuing signs of improYl'lnent in
infmion.

Instruct the patient to imm~iatd)o It'pOrt in(lt'asing h~adache,

diuinffi,drowsil'l!'S~changes in hehavior or LOC,or seizult'!.
Caution the patient that drowsinell may OCQJr and to he cautious
with driving orother <lctiYitits It'quiring mentilalertnelS umil the
effml of the drug alt' known.
Teach tilt patient to I'I'pOIt ,ny Iow-<lrade ~~ sort' throal,rashes,
bruising or ilKl'I"std bleeding, i nd unusllill fatigue or shortnell of
bruth,~pecialiy alter taking an <l Mibiotic for <I prolonged period.
(Continued)

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498

UnitS

Th~

Immune SY"'-""

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIBACTERIAL THERAPY (Conllnlild)

Implementation

Interve nti o ns and (Rati o nales)

Patient and Famil y Edu cati on

Monitor for dnelopmfm of red-man Iyndromf in pilDenn ~fiving

~ Mom),:in. Repon any Ycjnifiumly IallJf 'R'a of reddening wc:h i1llrunk, lItad
or IIKk, limm, or gknNI arfa tlpffially ij ~wc:iilled with dt<R'a~ 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 ~mof tilt syncirollltJ
Monitor~roIyrtl,pulsr,and E(G ifindured

Inl1loo the p.!tienl to immediately R'pon unusual flushing.

I'IpKiillly inwlving i large body arN;dizziness;dyspnu; or
pillpitation~

in p.!tierru on peniciliins.(SoIllt
preparations of penicillin lIIiIy lit based in SGdium or potassium salts and rna)'
calM hypemat~mia and hyptrkaiemia.)

Ttach the patiem to promptly R'port all)' palpitations or dizzines~

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

Instroo thf p.!tienl to imllll'diately R'port any signifium or

inmo.tsing I-ftl, ~r leg or calf pain,ordiffirukywalking to tile
proidtr.

Aslffi lor tile possibility of pmjnancy or bR'~t-ferding in pilliems PR'l(ribtd

Itlracydint ami biotin. (Teuatydines affta fml bont growth and teeth
dt-itlopmtnl,(aUling ptrmantnl yellowish-brown staining of teethJ

bt<01lll'

Women of child-buring igt taking ptnicillin .Jntibiotics should lU an

,ktlllil1iYl' form of birth coonollO prt'lem pmjoancy.1 Penic:illins may reduu
lilt ell"fdiYl'fles of oral cooUJceptive!..)

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.

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 id-m~ rifll, paramtters for when 10 c,lIlhe lIt~kh (1ft' proidt~
arod an~ IN'Cl'lwry monitoring or pR'(.Iutions.(Using time during nursing tall'
IItlps to optimizt and reinfon:r uy teaching aR'J~)

The p.!tien~ famii)\ or caR'g~r shook! lit abitto stare the R'i50n for
lilt drug;appropriatt clost ind sclitduling;wlw adYI'rsr ~m to
obll'n'l' for and wlltn to R'port; ,nd the amic:ip.!ted lenglh of
mttlic,tion therapy.

Patimt selfadministration of drug therapy;

When administering mediutions,instruct lilt p.!ritn~ family, or caR'9iYl'l in
properstH-adm inimation If(hn~ IoIIowtd I:, return demonstration. (proptr
Jdminisuation in(1N1fS lilt ~(tiYmffi of Iht drug.)

AdYiII'women who aR' pR'gllinl,bR'~t-feeding. or atttmpting 10

pR'gllinlto adYiIe llitir heakh caR' plll\lider btioR'
~ffling any tttratyclint anribiotK.

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 ~nly !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 ort~ no Iongo. in us . R.......
medic:int cabinet twic:f i )'Nrfor old mrdic:.Jtion~

Evaluation of Outcome Criteri a

Evaluate lilt efff{t~IN'SI of drug therapy by (onfirming th~t patient goals and txptatd OUIrome\ hoM been mt! (see "Planning').

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effective as vancomycin again~1 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 necessar y in patients taking serotonin reuptake inhibitors, because 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 bl~ding,
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 aftet"bacteria haV(' become resista nt 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 uremia. Peak and trough levels are drawn after thr~ doses have
been administered. A reaction that can occur with rapid IV
administration is known as red-man ~drom@ and results as
large amounts of hi stamine are released in the body. Symptoms indude hypotension with flwhing and a red Tash most
often of the face, neck, trunk, or upper body. Other significant side effects include superinfections, generalized tingling after IV administration, chills, fever, skin rash, hives,
hearing loss, and nausea.
Daptomycin (Cubkin) is the fint in a newer class of antibiotics 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, St,..~rococrus 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 anlibiotics called carbapermru. These drugs a~ baCleriocidai
anti h:rw: ~mf' (If 'hI': hm...-les' 3nl;micmh;31 ~l'P.Clnm"", (If
any class of antibiotics. Of the thr~ 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 combination with cilastatin, which inc reases 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 approved for the treatment of st'riollS abdominopelvic and
skin infections, commWlity-acquired pneumonia, and
complicated UTI. All the carbapenems exhibit a low incidence of adv~ effects. Diarrhea, nausea, rashes, and
thrombophlebitis at injection sites a~themost frequent adverse effects.
In 2((, the FDA awTO\oo telithrom)Un (Ketek), the first in
a class of antibiotics knownas the hroIides, for respiratory infections. Its indio.tiorli include acute bacterial e:urbation of

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duunic bronchitis, acute bacterial sinusitis, and commWlity_

acquired pneumonia due to S. 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 b~(~IU'" I!arti<.ulady 00'''', via tI", lIluuU
or lymphat ic system. M. tuberculosis aCliv.ates the body's immune defenses, which attempt to isolate the pathogens by creating a wall around them. The slow-growing mycobacterj~
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, howevl'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 isola ted in the tubercles, therapy must continue 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- resista nt 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 because tht' 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 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 thr~ drugs,
ethambutol is dropped from Ihe r~en.

SOO

Un/l~

ThelmmurwSysum

TABLE3410
Drug

Antituberculosis Drugs
Route and Adult Dose (m~~ dose wnere Indicated)

Adverse Effects

PO; lH5 m9fday (nw: 1,600 mg for dolily lhtrolPY)

NIlu~a, KJmiring, heodoI:/It, rillirlru

FIRST-lINE AGENTS
tlhambutol (Myambutol)

!niR!!t~lb

Q Isoniazid (tlH,Hydmid)

lit,nlTB
PO;300 mgld.y or 900 IIHJ IWKf 'IIftkIy for 6-9 mortm
.I.ctln TB

Wis ~Iri~!

NIlUiM, Klmiting, diIIrrIIH, rpigmf//r poi"

~Dilltrdilb Rmllbtlill D~II!lI_ !lllliI: D~lIliIb

tml9!plidtv blood dyKruja!

PO;dailyl~rapy S mgltglday 300 mg/dar. W

glltn tr1 DOT.
15 mgitgor900mgtwKf wmly

p)'minamidt (PIA)

PO; ~ 15 mCJik9tid-qid (max:l glday)

Goolrl7~ iOOl't1li!m !trUmllriuxje( fIIlh

Al!illl:rdi!i11ai!9IWiW~ w.l1ImI2IlI~

hcmokdcanrml.
rifalrulin (M1lobutin)

PO;300 mg 000 daily (forprophyLu~) or5 mgftglday (Toc

actilt TB) (max:1OO mglday)

rifampin (Rlladin. R~t'!lfl

pony; 600 mglday iI a ~r.gltdostoc 900 mglWKf 'll'eekiy for

4monlhs

NIlu~, Klmiring, hto7~ t/igG!rrif: P<I~ Qoorrxio

/lawler/ft. dilJrriw, (fQmping, Ofllllgf' dilioltxorilfl

unlit !wel!tQlldrt1!1l

~ Klmmlllm~ wi!l~ illJQ~ ttll.ll filbltt

hp.1!o(oxiW~ try~rurkrmlf h!r.od

.twU!

rifaptOti'l~ (Priftinj

PO;600 mg twK~ a Wfft. for 1 rno;11Iffi OIKU Wfft. foc mo

Rifat~: com(jnation of p)f~i1amide

with Isoniazid and rifampin

PO;' ublet~d.y (f ~tltnts Wfig(j!l\l1211b ocfllOffl

(S~

.miUcin(.I.mikilJ

IV/lM;5-7.s rngIl:g.sa Io;Idi'lg doIt;then 7.> mgrtg bid

(~T.bI~34.61

.mlncr.alk)'lk add (lWrj

PO; 150 mgr1lgld".ln 14 equalydivlded doses

Glll'lloItJD!'Ifl, QrIOrblQ, dhrhfD, fMr

i'ldMduaI drugs)

SECONDLINE AGENTS

Hyw}r!l!ilivity i'lhibition ohitamin 8.1i fblOlIl!"on

~\otoxidt!
lIc!Ir,pdnOlld/n~Df!1fIIOrion ~r~(Jfl sir,

caprtOIl1)'cin 1C.~>lJI Sulfat~)

1M; Iglda1 (nol to ex<~ 20 mgr\gld.yl for 6O-120da)'S, then I 9

IWOIOthl'tttmest...1c

dprofloudn (Gprol

pony; 150- 750 mg bid

~Tabl~34.n

<yclostllnt~)Idn)

PO; 2SO mg ~NY 12h roc 2 wk:owl!'(lUW 10 500 mgf'/fIY

12h(maxlg1d1)'l

{)rowrinru, 1IfGdht.1fI~'0'

tlhionamid~

(Trt(oJlorsq

PO;05-1.0gld.lydivilltd E'Iff'! S-11 h(max: II)1.m gIv~n in

!hrH to fourdivided doItll

~122II1ttH[11iI~IlWlMIl! ~!.2!2!!~

t!2m:1~~jgDI

pm;1:I!Im OOlil:lllll

NIlU~D, KJmiring,

,/igmrir ~ diorrlrto

(Qm:ldliaOI b.1lhdoa!i~DI mtllLlIIkR!l:I~~D

bnolm)Kin (Kintrl'lj

IM;5- 75mgr1lgbid-tid

(SHlabldU)

oIIoMdn (FIoxil)

PO; 2IJO.4OO IIHJ bid

(SH labl~ 34.n

1I1!p1(1111)'cin

1M; 15 mgIkg!4l to 1 gldayas. Y!I\Iltoow

lil!ImO, Klmiring,[lQin~ri~ 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 indirn~ oomroon ~ tffoos;.I!l!!mi!i!l!I. indicolte SKiouI idwrse ftlem.

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'hoplfll(

.... Prototype Drug

Drug' fo< !lxrl'llall"lealOll'

SO l

I Isoniazid (INH)

Therapeutic (lass: Antituberrulosis drug

Pharmacologic (lass: MY'olic ~dd inhibitor

ACTtONS AND USES

ADVERSE EFFECTS

Isoniuid is I drug ofchoicr forilit irl'aDnl'mof M/UlHrruJosil btuu~ ~

of I'l~ritnc:f hiI!' ,hown it 10 hiI~ 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 ~rowing organisms bul baClfriostalic: for dOllna nl mycob.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
t~ating oKtil'l'di'!'''f.

Th~

ADMINISTRATION ALERTS

Gi!' on an I'mpry ,lolNch, 1 hour Ilrer or 2hours btioll' muts.

For 1M adminimalion,ldmini"erdeep IM,and rolale lirts.
Pll'9n,lIIcy mtgory (

PHARMACOKINETICS

Onset:lOmin
PNk: l- 1h
Halllifr:l-4h
Du.~tion: 6 8 h

mort common Idvrl!!' dfrm of isoniazid art' numbneu ofl11t hands .nd
11'fI. fiSh, Ind ~r. An FDA bIoKk boJi warning for isoniuid states tIlals~1l'
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 ~fI!ofj.Jun
dn, !.ri:)lIt, I'Imttd hepatic I'I!l)'DIf!, Of loss of appl'til~. Hrpati: et"Il)'IIIe test;
a", UlUIIy ptrbnned monlhly dJring Ihtrap)' to idrmify uri)' htpalolouar,.
Contr.indimions: Isoniazid is conmindic:,u td in patient; with hypernnsitivil)' 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 d lUftwn
is lilten w!th IHH, Qd; 0( <oordination or pI)'Chotic!NClionl III.!)' lI"'iult Drinijng
akoholllillllN HilKlNloel 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 w ~ h 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 IIO!t~

S)'mptomalic. Pyridoxine (vi(.Jmin BJ may bt infrMd in a doll' fqwl to thu of
the iIOniazid OY!'!dose to prt'fem seizull'5 nd 10 cOllea metabolic: a<idOl is. Thr
dost rnay bt ~Ptaltd IfVI'ral timl'l until thl' paliem lI'9'Iins (on!iousntss.
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
rapidly fataland 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
~re susceptible to infections bec~use they ~re immunosup_
pressed. Therapy usually begins immediately after a patient
receives a positive tuberculin test. Patients with immunosuppression, such as those with AIDS or those receiving immunosuppressant drugs, may receive chemoprophyla:us
with ~ntituberculosis drugs. A short-term therapy of 2
months, consisting of a combination lreatment with isoniazid (IN H) and pyrazinamide (PZA), is approved for tuberculosis 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

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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).
S~ Nursing Process Focus: Patients ReceivingAntituberculosis 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
inIll' tastern 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~nlfjjl is h)drastine, whic:h is rt'pOIttd 10 hm antibacterial and amilUngal
propmil'S. Wht n ulI'd topic:111y or Iool~, gokltnsl'il is diirned to bt of 'HUe
int~ating bam rial and IUngal skin infections and oral conditions such is gingivitis Ind thrush.AI anf)'I'W.sh,itcan roothl' inflirned ryes.Cofl!idr~ ... ~
for fIOIt PfOpie. it is mnrraindic:lltd in plfgn.!1K)' and hypertension.

,
"~

502

UnitS

Th~

Immune Sy"'-""

NURSING PROCESS FOCUS

PATIENTS R'CEIVINGANTITU.'RCUlOSIS DRUGS

Assessme nt

Potentia l Nur sin g Di ag noses

Bilstlin e assess ment prior to administration:

Understand t~ rNlOn tht drug hil been prfnriilfd in order to asSf'lS for
therapMil ffierts.
Obtain a (ompietr ~akh hillory induding IIl'IIrologic,cardiowrula~
~pir.tof)\ 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 prtparation~ and aloohol
=. ~ alen to pollibledrug imt ractions.
Asst lS ligns and Iymptoms of (u~m infMion Mting symptoms, dJration,or
all)' IfffOt (hinge.AI~s for colKurrmt inftions, panirularl)o HIV.
Enwtt appropriatr laboratory findings (t.g.,CBC,AfS C&S, ~~tic: and ft'nal
function \Iudifs).

Infenion
fatigUl'
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 ildft~ drug tll"K II. rltrKirm
knowlr<lqt, ltnqth of trNtrntnt ft'quirtd, or (ost of mfdilation)
Risle for Scx:i.lllsoiation (ft'latfd to disfalf,ltngth of tlN1ment)

AsstsslMnt th lll ugh out administ ration:

AsSffi for r1tsi~ therapeutic: tfffO:t\ (t.g., diminilhtd signs iI nd symptoms of
inffO:tion, fewor, nighHwt'ating.in(ft'~ing NSt ofbrmhing.~asN sputum
production, imp~td radiogri phic: tviritlKt of improving inftion).
ContinUl' ptriodil roonitoring ofCBC, and IItpatil and ft'IIiIllulKtion.
AsSffi for adYef~ ffiem: naUlfa, vomiting. abdominil l(ramping. diarrlltil,
drOWlines~ dizlines ~ p.1rtllhtsias, tinnitus, vuti4]o, blurred vimn, (hinges in
islul (olor 1fIlI<I', and in(ft'asing filtigut.E)-r ~in.ilrutr vision (uoge.suridtn
or ilKrNsing numbnes or tingling in otft'mitifs,rir<lNlrd lItaring or
~nifKant tinnitus, i nd intft'.N in bruiling or bleeding should bot immfdiatrly

""',,"

Planning: Pati e nt Goa ls a nd Expected Outco mes

T~ ~tient will:
fxp~ritlK~ thernptUtil: tifKtS (~.g., di minisMd signs and symptoms of infection, rlr<ft'ased f~tr and fatigue, inaust<l appetit"t J.
Sr mr from, or expMtn(f minimal. arlYmr rffrru.
VfflIal~ an undermndinq of tilt druq'1 Ulf, ad\'elSr ffieru, i nd requirtd prtUutions.
~monlmte proptr IfIf-admin~tration of thr milation (f-9,dOlf, timing. wlltn to notify provider).

Impl e me ntatio n
Inte rve nti o ns a nd (Rati o na les)

Pat ie nt Edu cat io nfDisc harg e Pla n ning

En suring 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'atmrmrtqJirtslong-tfim (om plialKt and mall)'
ft'alOOl o~t for nOll(omplian~. (Nonromplian(f m~y ilKrta~ thf rille to thf
~tirm's ~akh, family and (ommuniry lIt~hh, and prorootfS t~ dfwolopment
of rHistam otginisms. Monitoring o/drug administration may ~ rfquirtcl to
fll\Uft' t~rapy is contillll'd)

TN(h t~ ~tirnt to nolstop drugs whu"fet'ling bttttr"but to

(ontinUl' plfl[riilfd IU~ ofthffilpy;rIo not shaft' dasH with otlltr
family mrmbm with limilar symptoms;ilnd return to pKlYider ij
iI~ tifflts dMlop to ensurt drug thtrapy iI mainlilinfd.
Disruss with tilt patient (OOwnlilbout (OS~ family membotrs who
h.M similar l)'IIIptoms or may net'd prophylidil ~atmrn~and how
to lllanagf ~fffflt; to hdp fIKOUr~(omplialKr.

Minimizing ildft B f efft-Cts:

CominUl'to monitor vital ~n~brt~th sounrk,and spurum production ~nd
qJality.lmmiatfly rtport undiminishrd frl'fl,ilKft'i lfl in sputum production,
htmo~il.or incru~ in idftmitious brtath sounds to thf hNlth (ire
pKlYider.(IIKft'asingsigns of infwion may signify drug ft'Iiltan~orsignirK.im
MOOHIIpli.llKr with drug ~imfn.)
CominUl'to monitor ptriodil lab work: hfpatic: and ft'nal function tHIS. (Stand
spurum (uituft' for ArB. (Antituberrulosil drugs ~~ htpatil i ndfor rtOil Itoxic:.
Periodil C!lS test; may ~ordtft'd 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 srl'M'ad~ rffKts.)

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TN(h t~ ~tirnt 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 ~alth (ift' pro'Iirltr.

Inltrumllt patirm on tht neN for ptriodil lab work.

Cloiop"')' Drugl fOfBKtl!'l~ InfealOOI

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTITUBERCULOSIS DRUGS (COIllhuro)

Implementation

Interventi o ns and (Ratio nales)

Patient Educatio n/Discharg e Planning

Conrinut 10 moni\Ol'!of heJNtK, rm~anW'OI OfOtoxicity. tAmiwbl!lOllosis dfV9S

thit all' hepatir.ll'roal, 01 olDtoxic Il'~ fttq.Itlll mooitoring to pll'Ytfll
~ rfffm. llKIl'lIing ftuid intakr win pll'W'm drug KruUtioo in

Too the p.ltienl to report ~y 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 imnwdi~tly.
Advist tire patitntto ilKll'Hf fUel inlakt 10 2 10 II ptr liiy.nd 10
tlim"alt.1I Hoho! use.

'""""-J
MonitOl" lor ~s 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 gl~ in p.llifnts tamg iloOniuid.{bonioilid may inmiM'

giIlCOM' IMIs.DwbttK patitnts m.y II!qUft! a ~n9t in !Mir antidwbtiX drug

routine.)
MonitOl" II"II'IM)' rooUM in patitnb taoog isoniazid.{foods high in lyTamint (in

inttraCt w~h the drug Ind (i1M p.llpitations,lImhin!l-and hyptrte'lsioR.)

Instruct 1M patitnt to Il'pOrt dmnm, all.linm, numbnnl Of

tingling in ptl"iphml txtrmitits,and mion (hangtS.Eye pain, lrutt
blurring of ~ision OIlossof eIOI seflSt, Ind suddtn 01' irKl8sillg
numbntsS 01 tingIiIIg in trlltmi\in should bf rtporttd imllltd"littly.
ElI(w r . thf JNtitnt 10 ill(ll'lM' tilt inukr of ri\.imin B. ril:h bock
(t.g.. fortifitd (tl8h, biW ~I~O with skin on, balWlnll,.lI-an mtlu"
g.~nzo 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 ~nd pklStd fisIr,btft iII1d rfd win!',
biMIIa5, Ind cho<oIa!t Ind 10 rtPOII '-LKht. p.llpiutionl,.
U(hyCiiW,Of M immtdiiuly.

'alitnts u king riflmpin shook! bf (iUliontd thlt drug may tlllTllKdy IUds
(Inri, swu~ Slli'B,urirlf) lfddish~rlnqt.(Efff(\ is IIIrmitss bot mly suin 10ft,
hj'drophiil: (OIl!'" knses 01' dodringJ

Tt~ tilt patitnl to ((Insult: w~h drr tyt (ill! pllWidK btIo!t using
h)'llrophilir: (ontact 1t1lStS.Considtr wtaring nonwhillt ciodling or 1M
uodtl"9lrmtnl) if Swtilting is elltmiYf.

IIKWrigt infl!.:tion (ootrol mmul'tS ba5HI on tht alent 01 ant cond~ion.

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.}

Tt~ tilt p.ltienlidtlJlollt inftion(ootid and hygitne mtlSUltS

wc:h Mfrequent hand w.shing,. (O'Itring tilt mouth whtn (OIIg rung GI
sneexillg, and proptr disposal of loOiltd tissues.

Pat in t undtm alMfing 01 dnrg tht rapy:

lIIf opportunities IiJring adminiruuion of mtdications md <kIring MsasoltnlS
10 dinw ruion .1I- for dlU9 ~.dnirtd thellpMic OUI(OIIIts, most
(ommonly oIMrwd Irtwrw tfft<b, JNr'i!ldm lor wfHon 10 (lin tht health (ill'
pnMde~.nd .oy nt<HSlI'/ monitorill9 or prtCiutions. (lhing ti~ during
n!Mg till! htlpslO optimizt ind Itiniofct kty Itadling 11I!ii.)

TIll' patitntlollllily.or (MtgMr ihould bf able 10 "Itt the ftaSOl'l !of

the drug;lppr9piWlt ~ <lnd sdltduling;wlw idvt~tfftS 10
oIMrn fI:n oIIId w~ 10 1tpDft;lnd 1M anoopattd Imgth of
mfd'Kation thtrapy.

Patint ~adm inistrl tion of drug IhtrlP-':

WIltn ildmiMlering medicatXII'lS, instruct 1M ~t lamilY, orcartgim in
proptr sfll-administration tt<hniques followed by rttum dtmonstlltion.
(Proper .!minis union will ilKltast lilt tft'tctiventss of tilt drugJ

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! qu~t 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 Kidic~.1f
imtructtd to la~ tht drug on.n t RIply slolllKh, uktw~h 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* J~ IOfril~Jisl rXihqs "wIlOl'-nuMg.ams~ppIJ.

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50l

504

UnitS The Immune SY"'-""

rtr 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.

scribed ami -infectiw classes. CTOS.'i sensitivity may exist

with the penicillins in some patients.

34.2

Bacteria are described by their shape (bacilli, cocci, or

spirilla), their ability to utilize oxygen (aerobic or anaer0bic)' 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 ).

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 chlamydial infections.

34A

Anti-infective drugs act by affecting the target organ ism's unique structure, metabolism, or life cycle and may
be bacteriocidal or bacteriost~tic.

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 antibiotic effectiveness and is worsened by the overprescribing of these agents.

34.6

Careful seleaion of the correct antibiotic, through the

use of culture and sensitivity testing, is essential for effective pharmacotherapy and to limit adwrse effects. Superinfections may ocrur during antibiotic therapy if too
many host flora are killed.

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 prescribed sulfonamides to urinary tract infections and a
few other spedfic infections.

34.7

Host factors such as immune system status, local condi tions at the infection site, allergic reactions, age, and genetics influence the choice of antibiotic.

34.15 A number of miscellaneous antioocterials have specific

indications, distinct antioocterial mechanisms, and related nursing care.

34,8

Penicillins, which kill bacteria by disrupting the cell wall,

are most effective against gram-positiw bacteria. Allergies occur most frequently with the penicillins.

34.16 Multiple drug therapies are needed in the treatment of

tuberrulosis, since the complex microbes are slow growing and commonly develop drug resistance.

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

Superinfections are an adH'rse effect common to all antibiotic 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.

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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.

'hopttrl4 Drug. fo< Sx!e,lallnl<'Ctlom

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.
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.
A patient has been diagnosed with tuberculosis. While his
medicine is being administered, he asks questions regard -

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.."

A 32-year-old female has been st arted on ampicillin for a

severe urI. Before sending her home with this prescription, 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.

CRITICAL THINKING QUESTIONS

1. An IS-year-old woman comes to a clinic for prenatal ca re.
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?

J. A 66-year-old hospitalized patient has MRSA in a cellulitis 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 fo r all activiries.

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!

EXPLORE

aQ,ll!Iitilng!tlr------,

MyMlrsil1 gl(i! is )'OIJ ! one stop lOr onI"Je ehapter reVIew mill<'!lial:! and
resou rtes. Prepilrt tor SI.OXer.s witI1 additiooal rnD:~stvle 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
www. myml"Stllgkll~ .

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Drugs for Fungal,

Protozoan, and
Helminthic Infections
DRUGS AT A GLANCE

LEARNING OUTCOMES

ANTIFUNGAL DRUGS flD9tSM

Drugs for Systemic Fungallnfec:t1ons PIlIJ' 5/8

After reading this chapter, the Jludenllhould be db/e 10:

Q omphom;dn B (FungjZCJnf',o""'''i

1. Compar e and contranthe pharmacotherapy of superficial and systemic:

fungal infections.

O fluconazolf'rD/RucQn) Jll9f51J

2. Identify the types of patients who are at greatest risk for acquiring
serious fungallnfeCllons.

""",

Drugs for Supernd~ 1 Fungal Infections

jIIlIJt514

o nynorin iM)"".ralin,Nynop,o/hfo",
P1m

ANTI PROTOZOAN DRUGS p!JJt515

Antlma l~rlal rxugs J!IlII515
O (hloroquiM/Ara/lII} jIIlIJt5J/J
Nonrnalarl~1 Antiprotozoan

Drugs p!JIJt516

Q mtlro"d/u'o"IFlQgyIJ ptJIJ(5U

ANTHELMINTIC DRUGS

po!JtSIl

Q mtb<!n~IV<!~ fllll}t52J

3. Identify protozoan and helminthic Infedians that may benefit from

pharmacotherapy.
4. 8tplain how an understanding of the Plasmodium life cycle is import~nt
to the effective pharmacotherapy of malaria.

S.

Describe the nurse's role In the pharmacologic management offungal,

protozoan, and helminthic in fection i.

6.

For~ch 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.

KEY TERMS
iIlale f'I1J' 51]

derm.rtophytit

filii}' 'jQJ

dywntery JIIlT517
frgosterol JIIlI1'5IJJ
erythro()1intigf ~ m

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fungi fIIJIJ''j()J

mytlSI'S pogtsaJ

helmimh P'11d1J
miliary pogt m

polyene fllJlJ'515
protOIOil fllJlT5r5

meU\lo~es pogt515

1Nst pogt'j()J

OIoplfl n Drug. for fungal ProIOZO.n..nd Helminthic: Infection,

ung i, protozoans, and multicell ular parasites are more

complex than bacteria. Because of structu ral and func-

tiona l differences, most antibacteria l d rugs are ineffective

against fungi. Although th e re a re fewe r medications to
treat these types of infections, the avai lable d rugs are usuall y effective.

35.1 Characteristics of Fungi

Fungi aresingle-celled or multicellular organisms whose primary 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. Although 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 ~kin, mouth, and urogenital tract. YfiI.to, which include the common pathogen Candida aiMeans, are unicellular fWlgi.
Most exposure to pathogenic fungi occurs through inhalation 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 additional 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 b efore symptoms develop. Fungi cause disease by replication; only a few secrete toxins like some bactt'rial species. \Vith a few exceptions (such as athlete's foot),
fungal infections are not readilytransmil1ed Ihroug h casual
contac1. i n addition to causing infections, fungal spores may

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 H IV, 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 acquired 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 ~n

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
)'f~r, w~h an rstimaltd 2.7 million denhs dO!' to thr dill'_.
Chaogas'dill'asr,,,used by T~(ruzi,isthr 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.

TABLE 35.1 I Fungal Pathogli!ns

Name of Fungus

Disease and Prtmary Organ System Affi'CIed

SYSTEMIC

Aspenjlu, fun.y,rw, orhm

A5pmJ~Mi>: oppon ... i'Ii<; most <0II"fJl0I"iy .fftru lung but ~n

BIosromyrrs dmOQrilidi.

SIiInomyul\is;brgios in thr ILngland sprr.od! lOothl'r orgaos

spre.od 10 ochtr orgon.

oppn...isl:ic fillgal infruim; may affKl Of.lrty an, OI9'n

Cilr111idoiJlliam,oihrfs

~ndidialis; lIIO\I (OIllmoo

fsKddioidfs immiriJ

Cocddioidomycosi!: ~ios in thr lunqs and !plf.od! 10 OIhI'r organs

UyplOaKM ntOforlOQO!

(rypto{Ouosis; opporturillic; brgill in thr luogIM is thr most common cause 01 meriogilis in AIDS ~iffit!

Iinop/lllll"lQ(llpsuiarum

Hi>!oplumosil: bfgins in thf Iu~and spruds 10 othrrO"9ilOS

Pr!twnocy;ri. (Qrni (Pnromory;ti5 jral'M)

I'Mrimoqsri5pn1'11000g;oppor1II1i11ic;primariy catlll'S pnI'IIOoni, cillir kJng bul "n sprr.d 10 ochl'rorgan!"

SUPERFICIAL

Cilr111idoiJlljrar;,oihrfs

~ndidi.M;afftm skin, n,iis, 01",1

<aViJ:, (thrulh), vacjru

Epidfrrooph)'fOlllloc:W!IIm

Athl~r! foOl (1m pl'dis),jod ildt

.w{~!pKie\

Rilgworm cil(,Jlp (liOOl c.Jpitis)

SporolMx I(/im(kii

SporouidIosis; prinarily afirCIIW1 ,nd !U~llymph nodfs

Trichophyron sprOO

I All'K1i I(,JIp,skin,and nal!

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507

(tiOf.l m.ris)"ndothl'r!kin disonIm

UnitS ThelmmuneSysI""

Biologically, fungi are classified as eukar~ tes; 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 because of these d iffell'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 membranes. Whereas cholesterol is essential for animal cell
membranes,ergctft"Oi is present in fungi. The largest class of
antifungal drugs, the azoles, inhib its 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, f1ucytosine (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

t'I(~kmkOJ-15~infwdlMl

2-4 b (Il0l1 t.S ~daJ)

O .nphotman B(AbM~

"'"'

AmBI-.MIphotN,FungiIJ::Jnto)

. . . . . E_
I

Route and Adult DoW' (max do5e where indicated)

Drugs for SystemiC Mycoses

TABLE 15.2

35.3 Mechanism of Action

of Antifungal Drugs

Fungal infections are calltd myISU A simple and useful

method o( classifying mycoses is to consider them as either
superficial or systemic.
Superficilli mycoses a ffect the so::alp, skin, nails, and mucous 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.e nts with su ppressed immune sys
lem . Mycoses of this Iype rjuire aggr<$$ive oral or parenteral medications that produce more adverse effects
than the topical agents.
Historically, the antifungal drugs used for superficial in
fections were cle~rly distinct from those prescribed for sys
temic infections. In recent years, this distinction has
bl urred, ~s 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 superficial, but are often treated with or:i.l antifungal drugs. This
therapeutic division between s uperficial and systemic mycoses is still useful, however, since it separales the pharmacotherapy of relativel y benign infections (supetfici:i.l ) from
those that may be life threatening (sys temic).

35.2 Classification of Mycoses

508

_1HII1~fIIOftriI.lIftJd~

Neo/wt!!i!i!!J: !!m fllW lNDiWm, eriK i!m!

tlJmboa!oorrij lo'kppcniI .!ltJfJ'lpMmk jIld

.lOOIRlungili (bull)

u!pOfl.ngin Ketat~ [Clnc\dis)

fkK)1o~~ (Antobon)

t'I; Ioidilg dow 100 mg 011 dar Ilotlowtd I,,- ~ ~Idi,

Mi,.1I1ngi< rttiMs sudlas "'14111~,/WiIIg

t'l;70nIIJ i1fuwdcrm I hOllIli, 1,1oI~1,,- ~nIIJ

""""'"

iIlused ~tli b I:id 10/ 10 iii)'!

rhl!:mOOphltli!is

PO; SO-ISO mgi\9 in dividtd WS

""""'"

~hNdfIt,i!~lrNrtdpllltliril!nl

NQUltll, KlmiD~ htmht

!22!I2aSJiIliLIi'~iS 12!iSi!:I:

.miufingin (MJtmiM]

t'I; ISO IIlIJ/k4IlIir 0'lI'l1 h for 1M f6ndid11 inlKtion;

SO ~r:Iay IV _ t hfor Ctm.idG PfOPh)laJis

'AIde l~t . . . 1O! s)'SItfIIiI: inIt<!ionlm iIckIcW" tabIf 15.3.

halirJindim._ "'""" efle<U,~ lndiMtI...wr """".. efIfiu.

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rmat tlllU.

HtadXht,_,lIlIII.pNtliliJ

lMIefIii

~ I!!ml~ !.Ktions.litliri!!!!

OIoplfl n

(Abelcet, AmBisome, Amphotec, Fungiwne) and fluconazole (Diflucan) are drugs of choice. Selected systemic antifungal drugs are listed in Table 35.2.

35.4 Pharmacotherapy
of Systemic Fungal Diseases
Because human immune defenses provide a formidable barrier to fimgi, serious fWIgal infections are rarely encountered in persons with healthy body defenses. The AIDS
epidemic, however, has resulted in the frequent cli n ical occurrence of previously rare myooses, such as cryptococcosis
and coccidioidomycosis. Opportunistic flUlgal disease in
AIDS patients spurred the development of several new

..,. Prototype Drug

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 recently 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 systemic 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.

I AmphoteriCin B (Funglzone, others)

Therapeutic (lass: Antifungal (S)"5Iemictype)

Pharmacologic (lass: Polyene

ACTIONS AND USES

Amphotffic:in Bhas. broad spKtrUm of .uiity and is ~fff<lift . gainS! most of
th~ fungi pathogenic: kI hum~ns;thU5, it is ~ prdtrttd drug klr moot m~1l)' systt mic: rny<ose.1t may .Iso bI' indic:.n~d II prophylactic: .ntilung,1 ther.p)' tol
p'tienn with ~ell' immunosuppmsion. k .ds b)' binding to t rgost eroI in fungal {t llmtmbr,nes, (lusing them to bom~ PfITIINbie or Ie,k. B~uu ~ am
photericin Bis oot .bsorbl'd from theGI too.it is norm,11y given b)' IVinfusion.
Topic,1 pll'pmtions lit ,v,il,ble for supn-fic:iil m)'(<MI. Sever.!1 momhs of
pharm,ooth~llIp)' mily br Ifquired for a complete CUll'. Relislolnce to 'mphottricin Bis not common.
To ru~ th~toxic:ityof olmphol~ricin B, theoriginoll drug molecule !wI br~n
formul,ted with ~llipid molecults:

Liposomal.mphotericin B(AmBisomt): consist; of (Iosfd sphtric.J1mi(les.Amphotericin Bin inttgrilttd imo the lipid mtmbr'n~
Amphotericin B lipid {ompl9 (Abeled): (om,ins 'mphoteric:in B (ompined with two phospholipids in, 1:1 ratio
Amphotericin B (holtstt rylsulfut (omplex (Amphotec): conl;1I> of , 001Ioidal suspenlion of amphott ricin Bin, 1:1 ratiowith the lipid c~ttryl
sulf,t~ in mic:roscopk dislc-s/l,ptd partic:1es

ADVERSE EFFECTS
Amphotericin Bun procItn fIl'qutm and somtlim~s serious oJdverno riftas.
M~1l)' patienu develop ieer ard <hilk, Omiting, ~nd he~doKhe ~t tht btginning oIthmp)', whic:h subsidt., t~mem {ontinUH.Phlebitisis oommon during IV ther'p)'.SorMdtg~of III'phrolOJirity is ~rwd in80%ofthepatitnu
IoIking this drug ,nd t\fCtroiytt imbilllnces wc:h ., hypob lemii flfqtltntly DC(ur. (.n:liac 'rrH~ h)1lOleOlion,and dysrhythmill 'Il' pos~ble. ~use ,mphotericin B(In UI/Ie ototoxicity, the nu~ should .!Isns for huring loss, erligo,
unste,dy gait, or rinnitus.

Contraindi Citionl: The on~ rontr,indic.Jtion is hypt~nsitMty to the drug.

(,ution must br ~rved whenusing .mphotericin Bin patients with l"1'li.1 impairmem.
INTERAalONS

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 ~LlOU,.Jnd thiazd@
miIY potmti.!l~ 1l)lIOkilfmia.l!st with dilJOlin inaNSes tilt risk of digoxil toxicity in
Drug-Drug: Am~n 8 inlHiKtS with

p<fiefll> with prH1i1ting h)l101:ak>miil.

l.i blests:.I.mphotericin 8 miIY incJuIo ......." 01 tilt ~Iowing: IfIUIR GNtinint,

olUralilll' phoIphoJllSe, BlMj, ~e aminotransferN (AS n,.Jnd ,Ian .....
aminotransffrllf (AlJ]; Ny ~ 'IilIoes lor IfIUIR potas1ilnl, 1ilki1lm,.Jnd

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 dt~m plum. \mob of the drug.

..........

ADMINISTRATION ALERTS
Infus~ slow~, b~u!Murdiornculir(ollap~ mol)' Il'sult if the medication
is infused too rapidly.
Administer Pfl"medication to help rIKrN~ the risk of infusion ~.ctions.
Withhold the drug if the BUN mteds 40 rTI9IdL or ~rum uutinine rises
.bow.-l mg/dL

IIfI'8" /l) M)Nu1l1ngK1l A>r Q Nt!1li1l/j I'rIKm for11S lpt(1/{ /l) lin drrii}

Pregn.ncymegoryB
PHARMACOKINETICS (IV)

Onset:I-2h
~k: 1-2h

Halflife: 24-48 h
Duration: 20 h

LibraryPirate

HerlIaVFood: Un~
lINIment for O"ferdose: ~rdo~ may It"IUk in (lrdiort-spiratoty alll'lt.No
specffit: thtrip)' is mil.!bIt;p.nimllart tll'attd lymptomatic.Jlly.

510

U,* S Thelmm ...... Syu"""

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIFUNGAL DRUGS

Potenlhll NUl'$il"l9 01"9n05"

Bllrlinf I55fSS.,tnt prior 10 .dmini5tl'lllion:

Undel'ltand the luwn ~ doug has befn plf:S(ribfd in 111M to as~ b
the!apeutic tffKts.
Obuin a {~lItalth Mtol} induclill!llltll/OIogir,c.vd'lO'I<H{\Jw~
~ pir.tOfY, hepatM: or rfIIII diWiW, ind me possibi6ty of p~n.lIQ'. Obui nI
drug hislOly induding ~ inciJdil'lg spifK ~.mons to drugs,arnm
pm{riplioo .IIId or( dNg5, hffNl plrpirJDons, and limhoIlM. Be aIen to
poisibil drug intrf'a{tiorl1.
AsItSS signs Id s~mpklmS of (Ulltnt inffaion noting Ioution,
dIIr.lcttmoo, ~nc:t 01' ib!.mc:f of d~.nd mirJClel ofd~
4JrJtion,.meI plmlKl' Of aMcrof ifwrOf pain.
o &ilwtt ipptOpNtf 1ibor.lID/Y findi~ (t.g.,CB<,tltctrolyttt, urilll/r!i!.,
W~UIl'.Ind ~ty (&5), hepatM:.meI Il'IIillunc:tion studiH).
lIn.in b.m1Wle wrightlnd vital signs, ~11)' blood prtUUll' 100 p,iIst.

InfKtion (0lITtf( or riskfor(OIIoull'f1t ~I inft<tionl

Pain (reiatfil 10 infKtion)
Ifypt!thtrmia
llfficitm K~(drugdlf~)

RisUor In;"" (Mated to ~ drug rfftsI

Risl for Ilflicimt f\JidVolumr (Iflated to Rft( diarmn ciUIfd by.~
drug rifi5)
Ristfor DtaNstd Cardiac o.np.., 11IfftKtM! fisSIle Pfrlusioft (ttlattd 10
.mrl"lo!' rif~oflV antilull!lMs!
o Riskfor Noncomplianc:t (rflned to adYfl"lo!'dNg tffKts, dtficitflt knowltdgt,
c.ltftglh of~)

bHISmfnt throughout id.,inistrillion:

.t.s1tSl for dfs~ 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,
.lnd(&~

ContinUf to monitor Yiul sign~ ept<i..ll~ blood pltlSUlf Mel pulst, in

p,ltitn1:5 011 IV Itilun9iis.
AsItSS for ~ fffe(u; ftlUSU, vorn~ing.lbdomillil cri mping,diarrllfa,
m.lwi5t,musdtcrampill9 ",in, chills, dtowsintS~ 4IZzines~ ~
tinnilln,~ lkMing,Wn rash, urtiuN. Sfizull'S"h)'pOfmsion,and
tlf(tro!yw imbibnc:e {,.g..hyJO~lftN .. irfpomaglltWlllJ,).Hypo~ion,
tachyullfJ"dy1IfIylhmJ,~ dIInge in IMlof conSdouiMSl (lOC),
diminilhtd lRIe 0UIpYf,0I" s.rizu~ sInAcI lit Il'pCInfil inmtd~1fI,.

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
Interve ntions and (Ratio nales)

Patie nt and family EduItlon

hl,ring tMr.~utic effHtI:

ContinUf .ssns~nb.1 deoibtd tarlitr to..thmpeutic tffro:ts. (DiminiWd
~,p,lin,c. signs .oo Iymptormof infMioo shook! bt nottd)

1Nm ~ patieftt on OrJI.ntifu~ that IofWrII months of lreollrMnt IlIiY bt

Minillizing Iclftne effects:

CominUf ~m monitomg of Vitai ligns,npt(J,1Iy blood pIl'llIlIf IIId
pulst,aOO ItSpintory r.I~ IIId depth in pIlimu on IV .rwilongals.
1m mtdiateIJ Il'port dylthythmias, iOOf.1ing pulmonary (~tion,
irfpottmion, or tachyurdi.J.(urdiomuAr Ibnonn.tlitif! Ill' poisiblt
idvtl"lo!' rif~ of IV antifuRgiIs. (ardiac ind ~pirJ!Ofy alsesmrnl mtISl bt
monitoll'd dosrIy to obstfYf lor MIYmt tffKts.)

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lfqoIill'd."Jt,~ "'" p.nienton iDpKal .miluncj;Jls to <ompIelI! Iht rntitt CDIII"\o!'

of thtrapy and 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 ~1 uwd.

OIopltl n Drug. for fungal Protozoan,.OO Helminthic: Inlectloo,

NURSING PROCESS FOCUS

511

PATIENTS RECEIVING ANTIFUNGAL DRUGS (Conllnued)

Impl e me ntation

Inte rve nti ons and (Rati o nale s)

Pati e nt a nd Fa mily Edu cati o n

ContinUl' to monitor prriodic: lab work:h~!)atic:.nd !!1Ii1 fUnction trst~ (Be,

uri nalyl~ (UIN!! and I('n 5itivity, and ~rolytt lewis. (Antilull9'lk aft'
htpatic . nd II'nal toxic.nd labs ~ould be monitoft'd IIfQUI'Iltiy. Pfflodic: (&5
tesll m~y be orde~ ifinfl!diom ~II' !e''lf or ~It' slow to It'IoIYt to(onlirm
appropiUtt thl'rapy is being dtliv~ft'd. Antifungal~ particularly when giml
IV, rtIiIy cal/\(' ~~nrolytt imb.ilancfi, tspf(ially hypokalemia .nd
hypomagOl'll'Olia,and t lt1:trol)1t II'placemt nt may be I"ftdfd)

Tta(h tht j)<Ititnt about thl' nffil forfrequent lab telling.llon oral
antifull9'lk at hOlll!',inlU1J(\ thl' !)alient on th~ OI'~d br periodic lab work.

Wtigh tht !)atitnt d.ily and !!pOrt a weight gain of 1kg or moll' in a 14hour prriod.MNIUII' ima~and output in the hospitalized patitot.(Daily
weight is an auurut measulI'of fluid .tatu nd like. into ac:(ount intakt.
OUIput.and inll'nsiblt ~.Ex(tSW!ewtight gain or rdema II\a)' indicate
rt nal dysfunction.)

Monitor for h)1ltllto.itivity.nd allergic: lI'actions,t-!pt(ially with tht fir;t

dol!' of IV anlifungal.CominUl' to monitor the poatient throughout therapy.
(Anaphybctic: IN(\ion.aft' pollib~ 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 n~(rs SoIry to pm!'nt ft'ac:tions.)
[nsulI'adtqune h)dration in JlaIients on oral or IVantilungak.(Antilull9'll
dtugla!! lI'oal toxic: and adtquatt hydration hl'lplto pft'!'Ot a~1\e It'OiII
effecK)

HiM'!h~ patitm liking oral amifUngal drugs at hOlll!' Migh I('Hdaily,

0011)0 at th~ wmetimeof day, and ft'(oro w~ight along with blood
pI"r'SUII' and pul.~ rtII'alUft'rtII'nK Hoi!, the poalient rtporl5ignifiunt
wtight gain.

InstOJ(tth~

patitm to promptly ft'pon any (hilk, natJll'il, tll'mor;.or

hNdac:he.

Tea(h tht j)<Ititnt to incrul(' fluid inlike to 1l perday ilon oral

antifull9'lk. Explain the rationalt for in(lI'iI~ IV f\Jid hydrillion in
poatients on IV intilull9'lk.

ContinUl' to monitor for s.igns of0101OlCicity. (Antifungal. ilia)' calnt

olotOlCicity and lfQuill' f!!quent monitoring to pI"r!'nt adv~rl(' dtru.)

Teach tht j)<Ititnt to immrdiatt ly report any ringing.humming.or buuing

in rar~and dizzint ll; or vtrtigo.

Continue to monitol for he patK toool)'; e.g., jaundice, ROO pain, darkent<:!
uriOl',diminished uriOl' OO !pU~ tinniN~ v~tigo, in !)atients on IV or oral
antifungaltlltrapy. (Amilull9'lk may (il/\(' IItpatic toxicity and lfqUill'
flfQutnt monitoring to preY!'nt advtlll' ~I!d . )

Tmh the piltient to imm~diat~1y Itport jny naUI~a, yomitiog.~~llowill9 of

.kin or !(Im,abdominal pain, light or day..:olortd \look,or darktning of

Monitor tilt IV ~tt frtqUl'ndy for any signs 019tra'/ilSition or

thromboph~bitis.(lV .ntifungal medication is irritlling to !'in . UI!' a
(~rllralliOl' if pos5ibleor freqUl'lltly monitor tilt IV 5itt.lnfusion pump.
mint be used to tn.UIl' the properdosagt rate and pft'Yffit tx<fiSWt flow
ratd

urin~.

InstOJ(tth~ patiem to immtdiattly II'port any !)ain, buming.or ft'dnm at

the lite of tilt prripherallV. Explain tht rationale lor all tquipmtot UIl'd.

Monitor blood gluc:ol(' in pa!itm. taking ktloc:onarolt.(Kttocona.zol~ may

in(lI'iI.t gluc:O\f ~!'II. Diabttic: patienu may lfQuift' a (hangt in their
antidiabttic: drug routiOl'.)

Teach the diabetic patient to trstgkKos~ moft' mqUl'ntly,lI'porting any

(onlilttm elevations to the hl'akh (ill' proYidef.

Monitor for .ignificant GlI'fIKIl,including oaUll'i, wmiting.and abdominal

poain or cramping. Give thl' drug with food or milk to dKlI'iI'~ J~I\eGI
dfem. (Food 01 milk II\a)' dtclNlI' 61 effects but an antiemetic may also be
r~ift'd ij oaul!'a is l!"/~reJ

Tei(h tht j)<Ititm to toilet thl' drug with food or milk but to avoid ac:idic
Iood!and bM'la~. or caroonattd drinkl.

Monitor for .ign. ind .ymptollll of !fInclary infl!dion in topical olIN. of

fUngal inre.:tion, t.g. a!hlett'. foot Hsylttmic: adverst t~rts.1t oottd,
(ht.:k tht drug dol(' or administration roote tilt !)alient is lIIing.(lmens~
itching with !(ratching may imlOlluc:~ b.(\M.J into!h~ 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 (lI'at~
Iysttmic riff(\~)

Tta(h tht j)<Ititnt to Itport any inUUling II'dnes.,IOII'OI'I5 or pain,or

inclN.ing drainagt' from afie<1td .itt.

(conrlnued)

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512

UnitS ThelmmuOI'SY'tem

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIFUNGAL DRUGS (conlinuM)

Implementlltion

Interventi o ns lind (Rlitio nliles)

Pliti ent lind Flimil y Edu cliti on

Patient understanding of drug th erapy:

Use opportooi~durilg 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 p~aocl aO)' lIf(ess:a1)' monitoring orpreuutioM.(lking tint
ruring rming (')re helps 100ptimilr alii reinloru keytuc:hing areas.)
Patient se lf'il dministration of drug therapy:
Whenildministering mrdiutions, inltruct the patient. lamily,or wr<jivrr in
proper II'Ifadmin istration tKh niques. (Proper administration will inc:rei II'
the ~c:ti!'nffi of the drug.)

The patien~ lami~, 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 antic:i~ted length of mediution thmpy.

Teach the patient 10 take oral or IOpic:al i ntilungal medication ill 101101'15:
Complete the mtire COU~ 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.
D~oIvr oral antifunlj.llloungts (troches) in mouth or rinse with liquids
alter meals aocl at bedtime.lf dentures are worn, r~thrm 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 dll'lli~ when topic:ill i milunljills aft' UII'd.App~
a thin, ~n iaymo theafler:ted aIN.
Allow aflKled skin aft'aI to air dl)' and ww IooII'-fining aocl
"breilthable 1abrio: c:lothelto allow adequate ~ntilation. 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 ~tient goals and expec:ted outc:omes ha!' bffil met (~ Planning1.
SH T~ J5.41U,~oo' JHfor ~ lisltidr0g5 rcwNchrhtst mnqlims~ppIy.

Although rarely used as monotherapy, flucytosine (Ancobon) 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 important alternative to amphotericin B in the treatment of aspergillosis. Approved in 2006, anidulafungin (Eraxis) is
approved for invasive candidiasis. The echinoc::andins are
less nephrotoxic than amphotericin B and have fewer serious adverse effects.

AZOlES
The azo le drugs consist of two different chemical classes,
the imidazoles and the triazoles.Azole antifungal drugs interfere with the biosynthesis of ergosterol, which is essential for fimgal cell membranes. Depleting fungal cells of
ergosterol impairs their growth. The awle drugs are listed
in Table 35.3.

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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 hepatotoxic of the awles.ltraconawle has begun to replace ketoconazole in the therapy of systemic mycoses because it is
less hepatotoxic and may be given either orally or intravenously.lt also has a broader spectrum of activity tha n 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 similar to that of amphotericin B, are considerably less toxic,
and have the major advantage that they can be administered orally. Because of these characteristics,awles have replaced amphotericin B in the pharmacotherapy of less

IlIapurn Drug' 10< Funga~ Proto zo. n. ~ nd Helminthic: Inll'Ctlom

5 13

TABLE 35.3 AzoleAntifungals

"n"

Route and Adult Oose (max d05i' where Indicated)

AdwfSe Effects

butocooazolt (Fmlsm)

'bpilil~ 1 iw!ic.JICf introwagillily~ btd:ilM

dotrimazoi!, (fflII('ur, Gynt.\.otrinil.

Ft lfr,dills,nu.\ d;niflt5j, ~oou>t4

MyIM,OIhm)

'bpilill:ipply bid lor 4wk;kf va911i1 myalfS, illlffi I appIi<ator

ill~igi1ally ~ bdtint for 1 di)'s

t(~(Sprruzol!)

'bpilill;ipply bid lor 4wk

H~to\(o:iY!l:

HoconalOl ~ (DiflOOln)

~OOloazoit

ICf 3 diI)"

I'omilif/i d~rrIIN

i oal2!r!:lixil blood !!!:S<miaI

POIIV;lOO-400 mg on !Ii)' 1, then 100-10) mgldilyfor H wk

(Sporanox)

PO; 200 1119i!li)'; may ioou~ to 200 mg bit (max: 400 mgldily)

kt\O(~ (tim)

PO;200400 mgldily
'bpilil~ i PPIy OII(t

mkonazolt (M ic.J~n, Mooillat, (roo:, otllffl)

Cf twitr daily 10 ifftllrdall'a

'bpilil~apply bid lor 2~ wk

oxitonilat (Oxiltat)

'bpi1il~ iPPIy dilily in the ~tningfor 2 rno

!ft1.lcon.uoit (Ertaao)

'bpi1ill;29b uum bid/Of 4wk

IUkonazoit ritritt (Exeldern)

'bpilil~ apply OOI~ Of lWitr dilily rOf 2~ wk

tmonazolt (lbOzoI)

'bpilil~ 1 iw!ic.JICf intmaogillily~ btd:ilM IOf 3- 1wl:.

lioo:oniZOlt('hgism)

'bpilil~ I iw!ic.J1Of intmagillily~ btd:ilM fOf I dily

IV;' mg/bj MIY 12 h00 dily 1,lhen 4 mg,'bj MIY 12 h; may
II'dlKUO 3 mg/bj fflf'I12 hif oot loIffltfd

'IOri~ (~nd)

11~1io inciutt

Oril l i nd par!nt!rai routes:

Topltil route:
Dryir1ll ofJiin,5!irlgirrq ~Dr
DpIIimtion lirt, pruriM, urrimrio, (mr 1
dfflnQriD'1

Ug lI:IimIlalMlxfllt!l1

ammoo id>Imt 61tct~~inciutfS striOUSaIMlR tflta~

.... Prototype Drug

Therapeutic (lass: Antifungal

Fluconazole (Dlf/ucan)

Pha rmacologic (lass: Inhibitor of fungal cell membrane synthesis;arole

ACTtONS AND USES

Likt otlltr uole, lluc:onarolt ill!:> by interfrring with tht lymh~ of trgostt rol. Fluc:onilOlt,OOW!'I't\ offen le'Ieral advintl9l'S oYer other systemic: antifungals.1t is rapidly and (omplttt ly i blOrbM when gil'fll orally, and it iI
pirtic:ularl)o ~fft<t~ aganst (tndidQ aibironl. Unlikt itrac:onalOlt (SporallO.1)
i nd Utoconn * (Nizor~, lluc:onilO~ is ablt to penttratt IIIOlt bod~ mmlbr....... to rn<:h inft<tion, in t.... CNS, baM, <'l"', urioar~ met,.nd lI',pi lory

,,"'Amajor disadvantl9l'01 ftUiOrwOIt is itl ll't.t~1y IIIIrrow spt<trum of aitivity. A1thoogh it is tffffi~ against ComfIdD aibironl, it may oot be dfctift
against non- oRliam CoriMa spt<it!, whic:h i{((lunt for a lignifium ~=1i 9l' of opponun~tic: fungll inftions.
ADMINISTRATION ALERTS

Do not miJ IV AlKon.uolt with other drugs.

Pregnant)' uttgOl'1 (

ADVERSE EFFECTS
FIUloniz* laUlel 1M strious adv~1R tfiriU. NaUl!'a, yomitiog. and dilnhe.J
all" II'pon~d at high doles. Unlikt ketocorwolt, lIt~totOllic:ity is rart wlft flu.
lonaz*, although patimu with hepatic: im~irmtnt should lit monitorM carefully. Sttnns- JohnlOn lyndromr has bern II'portM in ()ititms with
im 1IIJ000uppresmn.
Contr.indi mions: fluronazott is lontraindkaled in Pititntl with hyptlWlll~
tivity III tilt drug. Coidmin~tration 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 ~with willfarin ma~(,J1III' ilKlNSfd rill: forblHOOg.
HypogI)"(fmia ma,~ ff~iI mnimll'd(OIKulIl'Iltiywith ooain orat
h)tlOl#fmc, n:Wng iflburiclt.fhItonazoIt ImIi may be dKrNIfd with
lonurnnt rilampit or dmmdiMo !/Sf.fhto fflffil of ffn1Ml)l, alfentan~, or
~ may bepiolongN with lOOOIrlaU olIirini!lrililn olftlJ(~.
Lib Tflts:YaiIlfS for AST,AI.,Mld illiillinP phosphat.l\i' may beilmud.

PHARMACOKINETICS
On5t"t :Unknown
~k: 2h

Halflife:2o...SOh
Duration: Unknown

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HerbaliFood: Unknown
Treal 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 ~I.
RPM Ie M}M!rl/ngIJ1 fr1f DNlmifll) Pn:m:I FOOII lpKlk Ie ~ drrii}

5 14

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 reduction or the concurrent administration of an antiemetic.
Anaphylaxis and rash have been reported. Fatal druginduced 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 irregularities, gynecomastia in men, and a decline in testosterone levels. Decreased libido and temporary sterility in
men are other potential side effects. The awles should be
used with caution in pr~nant 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 example, may be ongoing for months or even years before a

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 candidiasis at least once in their lifetime. Athlete's foot (tinea
pedis) and jock itch (tinea cruris) are two commonly experienced 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. Adverse 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 ointments.lfthe infection has grown into the deeper skin layers,
oral antifWlgal drug therapy may be indicated. Extensive superficial 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 ind icated for mycoses of the hair,
skin, and nails that have not responded to conventional topical 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

TABLE 35.4 . Selected Drugs for Superficial Mycoses*

Oru,

Rout.. and Adult Dn<P (m~x do,," wh ...... lndlralPd)

AdVPr... I'ff.... ~

butmafinl> lMffitax)

Top(,J~ ~ pply daily for4

wk for tiDl'aI

ddopirox atam, ~,wmpoo (loprox)

or naillac~ (l'ffiIoK)

Top(,JI; ~ppIy Ul'am bid

)( 4 w~~h for ti~iI

Orying of5kiJ, llingir.g llm/IOOn ~r opplkorion fire,

pruriM, ~'D'raio, (0011" dermo~ri5

griItofUvin lFulvidn)

PO;SOOmg 1li00li1! 01331>-175 mg ultr~ m~ dailyfor

ti~iI and OIl)'(homylle

Top(,J~ ~ ppIy

iHqutltonail x >l8wks foron)'(hornyc:ostI

naftifi~ (Naftinl

TopCil~ 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 ~!pffiIion (Nilstat);(,Jp!IR

(Bio-Statin); aum, ointmffit (M)'(OS1iItil,
Hystu )
terbinafnt (ulli~n

Intravaginal; 1- 1 tablttl daily for 1 wk

Top(,J~ ~ ppIy OIK~ daily orbid

)(

7wHorl~as

PO;150mgdaily x 6- 12wkforonyd\omy(ostI
bid for 4-6 wk

tolnaftur (Aftat~, nfll(\iI)

Top(,J~ ~ ppIy

oodrcyItnil: uid lFlllgi.fla~,

GordodIom,olhm)

Top(,J~ ~ ppIy OIK~ orlWiI:~ daily

'Azd~antiflJlgal drugs for wperfKiaI ilfffiioosafl' induded in Tabl~ 1SJ.

Irdi6 indil:it~ (011)1lI0II ~ ~fffis;.IIIdl:t:!i!i!Iindil:itts strious jdve"~ t/feds.

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r>lil!BIhxXIllR~DiiI (g!i!tSlfll():iDI ",,*,u!illla!illil~

(OIjlterbinafntl neutropenQ (0Ij( Tflbinafnt)

OIoplfl n Drug. for fungal Protozo.n,. nd Helminthic: Infection,

~

Prototype Drug

The ra p ~ti c

515

Nystatin (Mycostatm,Nystop,others)

CIass: Topical antifungal

Pllarmacologic Class: Polyene

ACTIONS AND USES

N~tltin binds to sterols in tilt fUngal ,lIlIItfIlbran~ uu~ng It.kagt ofinna
ctlkJlar ron~ts I I tht mtmbrant betOIlltl W!'iIkenftl.Ahhough it btlongs to
tht limt chtmical dall., .mphotffic:in B, tilt poIYi!flt s, n~tatin is availablt
in a willtmriety of formulations, inWding (fUm, ointmen~ powdn, tablt~
.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 cat~Of)' ((oral pl"I'j).Iruions) or A(topica l pl"I'p.rations)

ADVERSE EFFECTS
Wht n g~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
~itl found in somtoftht formuloitions.Wht ngWfnorally,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!/)

PHARMACOKINETICS
Onset:Rapid
PNk: Unkna.vn
Halflift : Unkna.vn
Duration: 6--11 h

clotrimazole are aTC drugs of choice for vulvovaginal candida 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
Proto..,~ 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 significant 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, protozoan infections often occur in patients who are immwlOcomprom.ised, such as those in the advanced stages of AIDS
or who are receiving antineoplastic drugs. Agents for malarial 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

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change fo rm and travel to infect distant organs. \I/hen faced

with adverse conditions, protozoans can form cysts that allow the pathogen to survive in harsh environments, and infect other hosts. When cysts occur inside the host, the
parasite is often resistant to pharmacotherapy. W"ith few exceptions, antibiotic, antifungal, and antiviral drugs are ineffective 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, wh ich is the carrier for the parasite.
Once inside the human h ost, Plasmodium multiplies in the
liver and transforms into progeny called mel"Oloites. About t4
to 25 days after the initial infection, the merozoites are released 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. ~lapses
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

516

UnitS ThelmmuneSyst"",

TABlE3S.S I S@I@cted Drugs for Malaria

Drug
art~lhtr~umefantrifM'

ICoartml

Route and Adult Dose (max dose where Indlcatedl

Adverse Effects

PO; 4lableu twier daily for 31Wyswith food

~dilzirltl~ ~n0::mi4 ftwI,orlhm/gi4

m)'f!9o._o

1tI1lI:I'>HIIiri'ti1l Qr RroInna.!tinn
alO\QQllOlltand progwrillMaiarone)

dKIroqUfM' IAr.llffij

Nometl, I'Omifing, abdomind pDin, diooIIfo.

POIol prophy\alis; 1t.JbIt'lIlily llirling 1- 2 IIIys btkn uavd,

aoll [OQlinuiog \Il~17 da~ ,fief rtlUm

IImxht, myII/giQ

PO IoIlrl'ilmmt;. labltlsJlIIy 1013 d.ys

HMrootri.!,m:I1'l!I'!!Wn

PO;600 mg in~ial dolt. thm 300 rogIwk

/JaIjSetl, I'Omi~fIg IJIJddiarrhto; mwldlll"9f\,

MJdiflg btJrrfII ri5ion, p/IorJphobio IJIJd diffiruJry

IrJdrmyd"joroqufM' IPiaqumin
I~ paoge 743 101 the Prototypt

For acute anads:PO;620 mg iritial dose,lhffi 110 mgal6, 18,

and 28h

","'PO

Forprophylaxii: PO;310 II'Ig Itlrti'lg 2wt bdoR lIam and

[ootinuilg H wt frAlowing rtum

meft<:qJilll'lLviaml

PO; P~tinn:btgin 250 mg OIICU wffl: for 4 v.k, tllm 150 mg

VomitiIJ!l. IlIIUlIQ, d~rrhN, m)'lllgio. dilzirll'U,

~eJ'!o!herWffk

~,abdomilllllpDin

Treatmml: 1,250 mg asa 5iogle dost

AVbkKk,llraIMirdia

prillliqufM'

-~

I!mIo!v!k anemia il P<ltimtl with GOPOdelic:itnOC

Mer~bI rlillil da~

~irdia

I!:molis

Vomitifl9, rnrullQ, d~rrhN, m)'lllgio.lItododrI:

For acule mad:s:PO; 15 mglday for 2 wk

For prophyIaxii: PO; 15 mglday foIlowilg Il'lIITl 10114 d.ys

~,abdomilllllpDjn

IImoIvIk il!!m!ia !:l ~Iimtll\'!l!l flIiE'lldeOOmll

p)'rillltlilamiIll'IDaraprim)

PO; 2~ mg on. WfH for 10wk

'hmiri"'J, "'U"4 d~"""", myolgio. fIbdomiMi p<Ji>

Mrgaloblalli<aormy IClltoprny
l!!!mlboMooenia
quinifM'IQuilamm)

ForoKUiUnads:PO:650mgtid X 3days

Vomitifl9, IlIIIIlI<I, d~rrhN

Forprophylaxid15mgbid X 6wk

Godlooism !tim~us ototolli<~ I'l'rtigCl frut visual

in~rmmtl hlli!!l:thmnia (oma,urdiO'mruiar

ro!!w N[jQuloCYUl'jil
11m indilite (OOIITIOII oJdom's! effects; !IIderIiriog indiYtes serious adtmse ~m.

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 (C DC)
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 chloroquineresistant 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.

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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 combination 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 properties for overa thousand years. Lumefantrineex\ends the halflife 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

Oi>plfl n

Drug. 10< fu~L Protozoon. ~nd Helminthic infection.

5 17

Int.ded mNquito

bOtft petaOn.

f) Plumocl"'n
tr..... IOw...

o "rGzoi,. <IiYide

Ineide MpelOC)1N.

........
"",",-

MtrGZoil......

.......
o
_r
and chiII..

..

MlrozoitM

r.cI blood oeII.

....,

O~uilObiI..
~inI..:ced

to

,_It cycIto.

o
~

FlgureJ5.1 Life cycle of PklsmodlUm

T REATING THE D IVERSE P ATIENT

G6PD DQficiQncy and Antimalarials

G6PO ~" ~I dtfU.orq iI ~ ciIordfr
bind .. ~ lQ900f AIrUi.l.meiicans lIId .. ~IO 10'1'of~idi:
~ ~ 1laiUns, FiIipino1, lIId
iI the IIIOIt (1)lIIII"IOII ~ fII-

nw-.It

in OIIff..oo miIioIl ptopIt ~ k iI bfJr.wI tIYt

~withthii ~ .. 1tW1!d
1N11u~_1IiIUIJI inrm-

l)mf drio!a, ~

blood"

IlitytonwimWidW:G6PQ(~wI.~ckugiinpM"'"

mNboiIm oflld bIoodoAsMld nwyUlMiMt ~ ~fdlii

driO!nly ii ~the pIIitnt lhoo.Ild betesled btbe IINtmenI is iiliitrd.
0Ihe-~ dwt shcUd beMided bJ ~ with Ci6P06ebncy ~ 1M
laoquimeilltiJioOl.llAfoNmides,lIId ~ (~).

areas. These infections include amebiasis, toxoplasmosis, giardias is, crypto$poridiosis. trichomoniasis. trypanosomiasis, and leishrrumiasis. Protoz~ns can invade nearly any
tissue in the body. For example, Plasmodia prefer erythrocytes, Giardia the co lon. 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. Drinking water may not be disinfected before consumption and
Illay [,t: ~olllamillalt:J wilh 1'~lllul!t:wi rrom I"ullall wa,It:.

In such regions, parasitic infections are endemic and contribute significantly to mortality, espedaUy in children,
who are often more susceptible to the pathogens. Several
of these infections occur in severely immunocompro-mised pa tients, Each of the organisms has unique differ-

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ences in its distribution pattern and physiology. Descriptions of common nonmalari~1 protozoan Infections are
giVl'll in Table 35.6.
One such protozoon infection, amebiasis, ~ff('(ts more
than 50 million people and causes 100,000 deaths worldwide. 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 abSCC5.'ies. The primary symptom of amebiasis is amebic
il)ntff)', a severe form of diarrhea, Drugs wOO to treat amebiasis include those that actdirectlyon amoebas in theintestine and those that are administered for their systemic effects
on Ihe liver and other orga n$. Drugs for amebiasis and other
nonmalarial protozoan infections are listed 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

5 18

UnitS

Th~

Immune SY"'-""

NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY FOR PROTOZOAN

OR HELMINTHIC INFECTIONS

Assess me nt

Pote ntilll Nursing Dillgno5es

Bilstlin e assess mf nt pri or to administrati on:

Understand t~ rt~50n 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, cardimKu!'~
I!"Ipiratory,hepatic or It'IIiII dill'all', and tht poSlibilil)' of p~naocy.Obtain
a drug history induding allergie~ 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 ~9111 and symptoms of (urrt nt infer:tion and IISI'IS family IIIl'IIltlm
or ot~rs living in the homt.
Obtain a travel history, noting dates of travel and nott when (ulKm
symptoms Slarred in ~Iillion to tra~1 (i.t., beIo~,during.or ilter travdl.
Enwtt appropriate !.ooratory and diagnostic: tfSt findings (t.g., (Be, C& S,
fal ova and par.l~tes, hepatic: and rrnal function studie, ECG U
appropriate).

Diarrhea

"~

DerICient FiJidVoiJlIII:' (related to diarrhN, wmiting)

Fatigut
Imbalanced Nutrition, ~s 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)

Assessment thro ugh out administration:

AsII'IS for dtsi~ thtra~tic: 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 1IfS~ dizrillfS ~ pafl'l!OOias, mttallit tastt,darken td uriIII',
dysrhythmias, and palpilollion ~ ~Yeff diarrhea, especially (ontain ing
mIKUS, blood,or pus;)'!llowing of sclera orskin;oietfl'iII'd urine output;
numbllf"U of ~tlt'lllities; lI'izufl's; dysmythmias; hypotffision; and
tal:hy(ard~ should br rtpOnM immtd~tely.
Plll nning: Patie nt GOlll s li nd Expected Outcome s

The patient will:

Uperitfl{f thtra~tit tfffi:1I (e.g.,diminished signs and symptoms ofinfffiion,oietfl'all'd ft'leri nd m~ laill').
Be mf from, or experience minimal,adYerse tfftcts.
Verbalizto an understandinQ of the drurts UII', adYerJe riff,cts, i nd rtquifl'd pttc.lutions.
~monsm~ proper II'Ifadministration of the mtd"Kation k g.. d~ timing. when to notify provider).
Implem e ntati o n
Inte rve nti o ns a nd Rati o nil ies

Pllti ent li nd Fa mily Educll ti o n

----t--

En suring theril peutic efffcts:

Cominut iSmSmtnll i sdfStriilfd earlier forthmpeutit riff,(\s.
(Diminished ft'lf~ pain,diarritta,orsigns of inkction should begin SCIOlI
after tlking the fint doll' and (ontinut to impro~. Thf heahh ca~ ptovidtr
should be notified ij signs 01 init(tion remain after 1days or ij the ffitifl'
roUIll' oftfl'~tmtnt has ~n takffi and signs ofinfffiion ill' still pl!"II'nl)

TNCh the patiffit to IfIIM i fem that does not diminish below l00"F
within 1days, ifl{~i~ng signs and symptoms of inkction, Of )"Il1ptoms
that It'IIlain prt"ll'llt alter taking thf emi~ (OUIII' of the drug.
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
fami~ mtmbtn with similar symptoms;ind f1'tum to the ptovidtr if
symptoms ha~ oot IfSCIlvtd after the f ntifl' rourSl' ofthtrapy.

--+=

Minimizing ildft rse effects:

Cominut to monitor vital !ign~ cspcci.Jllytemperaturt iffever iI prtll'nt.
Rfpon undiminished ft'leror(hange in level of connNllfSs to Ihe heakh
calt' ptoIIidtr immed~tf~. (mer should begin to diminish within 1 to 1
!bys aftef <uning the drug.Conlinuerlit~r may he i sign of wo~ing
inftction, i~rsedrug fifKtt, or amibiotic ffSistana.)

LibraryPirate

Teach tilt patient to imm~iately 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.

o..pur n Drug' lor fu"9"~ ProtOZOI", Ind Helminthic: Inlec:Uorn

NURSING PROCESS FOCUS

519

PATIENTS RECEIVING PHARMACOTHERAPY FOR PROTOZOAN

OR HELMINTHIC INFEalONS (Conllnued)
Implementation

Inte rve nti o ns and Rati o nales

Patie nt a nd Family Edu cliti on

(ontinUl' to monitor periodic: lab work:h~poatic: "Id ~nal fUnction ttst~(BC,

EeG, C&S, and fKilI ova and poarasites.(Hepatic: and ~n.lllab~ poanirularr,.
with IV Ihmp)', ~Id br monitortd to p~\'tnt MI'!'IIt ~ffKt.Periodic
(&$ ttsU orftc.1 oya and poarasit~, tests rna)' brordtred if infections a~
st'/~ft' or arr slow to II'IOM- to confinn appropriall' ~rapy. EeG roonitorillC)
mol, he required with Willi' antimalarial drugs.)

In\!roo tht poatitnt on the nffil for periodic: lab work.Provide a kit and
inslnICIions for homt 1M ifftcal sptdmem a~ requiiM
(ultu~ a~colltcted Irfforrdl\Jgth~rap)' is Stilted or if ,tlrt~d in an
rmtrgtrK' (~.g., OI'l'IWhflming infffiion with s.ig nifK.!nt body-widt
S)'mptoms),u 5QOIl U ftasibly ~~bIt, and ihertafll'f as ordertd b)- the
hulth carr pmridef.

Manitor for h)1ll'l~,itivil)- and allergic: rractions, fijlfCially with first few
doles of any dOl 9 tlNlment (Ana phyiactic: ~actions a~ pm ~bIt.
panicularr,. with tilt first doll'.As parasites dit, ill(rta ~1IC) dianhe.,
abdominal pain,or mills may occur.)

(ontinUl' to monitor for hepa\K or rtnal toxicity.(FrtqUeni monitoring is

r~ired to prrl'l'llt MY!'1It Ni"KU.lnmoasillC) lkJid intlu will prt'l'I'Ilt dlll9
accumulation in kid~.)

Manitorfor significant GI fffffi~ill(ludillC) naIMa, wmiting. and abdominal

poain or (lampillC).GiY!'drug with food or milk to dec~all' adY!'rs~ (;1 tfferts.
(An ant~lIK'Iic may he conliderrd if naUIN is s~.Akohoi UII', rsperiall,
in poatitnts on metronidazoif,maycalM a dilulfiranrlikt rraction with
ocessiY!' na!Mil, l'OIIliting.and possiblt Ir;pot~nIion.)

Manitorfor signs and Iymptoms of nftJrologic tffec:U~.g.,diuinm,

drowlilll'ss,and htadac:ht--and tniUrt' patitnt ~fet)o. 8t uutious with tiMo
tIde!Iy who IIY~ he at incft'iIItd rille for diuinessand falb. (ltach the
patient to rill' from ~ing or sittillC) to ,tandillC) gradually ifdiuiness ocrurs.)

Manitor pu~ and ECG as indicattd in pat~nll on anlimalari.tl trratmtnl.

(SoIM antimalarials may calM II,srhythmias and hypol\'nsionJ
Manitorfor signs and symptoms ofballl' marrow suppr~nion and blood dyscrasias, t .g.,Iow-grade ie--ft'rs, bltecling. bru~ ing. or s.ignifunt fatigUl'.
(80lIl' marrow wppres.sion rna)' caus~ blood dyscrasias with ~uking
decrrases in ROCs, WBCs, andlor piateltn. Periodic monitoring of (Be may he

Ttuh tilt patient to immtdiattly rrpon any itming.ralhts, s'ftlling.

partirularr,. of fac~ tollC)UI' or fu~, urtic:.Jri.t,lIuIhing.diuilll'ss, S)'lI(opt,
wheezing. throat tightnffi,or diffKUIty brrathing. Rtport signifiunt
in~a~ in abdominal pain,diarrhu,dlills,orfeverto tilt lItalth Wt
providtr.
Ttuh tilt patient to immtdiat~1y rrpon any naUlI'a, YOIIIiting. )'I'llowing of
skin or sdtra,abdominal pain, li9ht or cla)'-colored Itook, diminished uriIII'
outpul,or dlrkening of urint,.
Ad'IiII' tilt patientto ill(INS~ fluid intau to 2co II perday. ~kohol 1M
should bU"loidtd or t-iiminattd.

T~i(h tilt patient to tlU tht drug with food or milk but to avoid "idic
foods, he\'trlges or wbonattd drink~ and akohol 1M, ~specially in
patitnuon mtlroniduole.

Ttuh tilt patient to rill' from l,ill9 or sitting to stlndillC) sIow~ toavoid
dizzineslor falls and to awid driving or othtr activities r~iring mt ntal
alfflnffi or physical coordination until tllteffectsof tlltdrug aft' known.
InstrOO tht hospitlliztd pat~nt to call for a5Sistancf prior to gtning out of
bed or atlmlpting to walk alon~.
Ttach tilt patient to promptl)' rrport any palpitations or dizzines~

~T~uh tilt patient to rrpon any IO'N--gr.JdIo fIowrs, IOrr thlNt,rashes,

bruilillC) or ill(lNs~d bltecling. unuswl fat9Je,or shonnes ofblNth,
esperial~ aftt r takillC) drug thecap)' for a prolongtd ptriod.

~irdJ

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

TtachgtOeral hygitne measu~ to pft'l'ffit reinfestation with poarasites.

(Familie with)'OllllC) mildrm should practic:t thOl"OUllh handwas/ling.
proptrdispoNl of diapm,and nolif)' dI)'I~ or childurr pro'/iders of
infection.Assess for famil, ptts who m~y wry infffiion and also requirt
tft'atm~m.1 nt~mational traYl'ltrs should practic~ !(rupulous h)9ient,
esptcially in dIo\'tloping countries.)

Hal'f tilt patient ootif)' II'lWl p~nners for iSsessrrteclt and tlNlment

Ttach tilt patient and family or urrgivtr h)9ier11' mtasulfSand t ll(ourq

Y!'terinary iSsessrrteclt offamily pets. ~n if as)'mptomatK.

Patint understanding of drug the rap,:

till' owonunities durillC) administration of m~dic:.Jtionsand during

as II'Ssmenu to disC\J5S tht rational~ for dlll9 therapy, desirrd iherapNIic

OUI(om~~ mon common~ obll'lVtd am~eflecu, poaramtttrs forwht n
to call tilt health cart' plOl'ider,and any nKesSllI"j monitorillC) or
precaUlions.(Using timt rurillC) rursillC) ca~ Iltlps to optimizt and reinfon:~
ke)' ttachillC) areasJ

Tilt poatien~ family, or ca~giv~r should he ablt to stitt tilt ~ason for the
drug;appropriatt doll' and \(heduling;what aMIIt effec:U to obll'lVl' for
and wh~n to ft'port;and tilt anticipoattd ItllC)th of mtdic:.Jtion therap,.

(Continued)

LibraryPirate

520

Unit; ThelmmuneSyu,-""

NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY FOR PROTOZOAN

OR HELMINTHIC INFECTIONS (Conrlnued)
Implementation

Inte rve nti o ns a nd Rati o na les

Patient a nd Family Edu ca ti o n

Patimt selfadministration of drug therapy:

When admin~tering mtdiutiool, inrnuc:t t~ patim~ lamily, or Glr~iY!'r in
Propel' ~ K~m inimition thn~s IoIIowfd by return demonstration.
(Propel' administration inr:ru~ th~ ~ffliY!'OeSs 01 t~ drug.)

TfoKh t~ patimt to take the medication as follows:

Complett t~ eoti~ ( OUIW of therapy unbs othfrw~ inllnKled.
Awid or rliminuf akohol.Somt IIII'diutions (~.g., metronidazoit) uu~
signiliunt ~oKtions wh~n taken with akohol and akohol in{ful!1
ad~ 61 tll ts 01 many drug;.
Takt thedrug with lood or milk but avoid oKidit lIt~ra~I.11 instOKted
to t.!kt the drug 00 an empty stomach, take with a IuliglaSl oIwatt'l.
Takt the mrdituioo al M'OI~ SPited thlOllljhout tilh day as Ifasibit.
IlKlNs~ oel"aU lkJid intakt whiit taking tilt i ntibad~rial drug.
Disurd outdattd IIII'diutions or tho~ no Iongrr in 1M. Review
mtditin~ ubillfl IWKr i ~u forold medications.

Evaluation of Outcome Criteria

Evaluue the l'IiliftOl'SS01 drug therapy by{oofinning thu patient goalund aplrd outeDl1lI'S h.J~ ~n met (ste Planning").
5tI' iIlt/e:3H, 35.7, ~OO 3i8for~ IiIltid1i(llUlwhich rfItst oofling lKliom ~.

.... Prototype Dru g

I Chlo roqUine (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 lOlditrs in
the P ilie I!lands during World Wi rII, (hloroquinr hi sbffiJ the prototype mtdication for tht pro phylax~ and UN1mt nt of malaria for mo~ thi n60 ~ars.1t is
ffftjy~ in t~iting the t rythnxytit ltagt, but hn no mivity against lattm
Pll15trIIIdium. Both mioroquilK' and the do\eI)' ~lattd hydroxychloJOqJiO!'
(Plaqwnii) a~ also UIfd oll-lalltl for the trutllll'm 01 rbtumatit .nd inflammatory arsortiell, ilKluding upus t rythr matOlUs and rhfumatoid arthritis.
(hioroquilK' conr:~mratH in thelood \\K\I01ts olPfoJt1llldiwn l!'Siding in red
blood crill. Onr:~ in tht u (uoies, it is brlieYed to prt'l~m the lIIeubol~m of
h~ II1f, whim thm build; to tOlit IMoIs within the parasitt.
(hioroqui~ {an redU{~ tht high ~r of patients in tht arut~ sta~ in Itss
tllan 48 houll.1t also is ulrd to pmmr malaria by bfing admin~tmd 2 week;
~t he pol iom eotOR on todem it ~1N ~nd (oolillJiog ~ to6weKs oftt.r the
patient it<lV1'l.Ahhough {hloJOqJiO!' isa drug of moice. many other ag~nts a~
i"lailabit, al rt'limnr:e to ehloroquint is {ommon.

ADVERSE EFFECTS
ChloroquilK' txIlibin ftw serious .dvtlX' r1itm at low to moderat~ do~. MauIN and diarrhei may oc{ur. At higher rIoIft, (NS and cardiomrular toric:ity may
lit obstrYl'd. S)'IIlptoms ilKludf {oofusion, (oovulliolll, rt'rb:~d rtflOfl, hypotension, and dysrhythmin . (hloroquint u n U IM ~tinal tOliti!)" inr:luding.
blulrt'd yision, photophobia, and difliruity focusing.
Contrainditations: Bfuu~ mloroquin~ u n uu~ minal tOliti!)" it ~ {OIlmindicattd in p.lIiton with prt'~listing ~tinal orl'iswl rlfld dlang!1.k is also
contraindiuted in patients with rt'oal impairment i nd in !hOlt with hy~r>eo
IiliYit-; to tht drug.

ADMINISTRATION ALERTS
Pediatrit dosagt should bt monitort'd c~Iy, IItraIM{hildren all' sus(eptibit to aftrdOlf.
II administrating 1M, injtct into i ~p mus~ i nd aspirate prior to injting medication btuult ofils irritating effts to tht tissues.
Plf90anq Ulegory (

IlerbaVFoo:l: Uotncwn
lINiment 01OYl!rdose: OY!'rdose may bt fatal. S)'mptomuit trfatmeot may
inr:1ucIe anticonvukanu and m Opl!'SlOll for shock. Ammonium chloride may
lit used toidify the uriO!' to hastenellrWoo of {hloroquin~.

PHARMACOKINETICS
1At'\et: 8- 1Dh
Pf,ak:3-4 h
Hall~ile: 15- 2 days
Duration: Variabit (stYeral diYS to Wf~ks)

LibraryPirate

INTERACTIONS
1)ug- I)ug: Antacidland taxati"ll!l {ootaini~ aUnintnl and ~ uo
deauif {hkfoquillf atr.crptioo and mUll not tit 9i\opo withi1 4hoIn of 00 0!hK
~iN mayallo in!ml:n with tilt MpOOIf to rabifl 00111'.

lab Tell!: lktnowo

R#rt 10 MyMlsJflqr' (Of ~ tmbtiJ I're!I FooIl sp1(/tI( 10 1M iJ'ug.

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
fffilI-<ontaminattct water

fIIranoebo hiJto/yli(D

Primarily infffi' tht I.vgl' int eIIin to c.JUliJg 5oMI! diall'hu; rommooly tri'/ek to tiN' Ii ~r to form
~m iM11t\; rardy trMis to other OC9im sud! as tiN' brain, lungl,lX kidllt1

CryptolplXidOli!

lolffiltiN' intellint~ GtUling diarrhti; oftm Iffil in immUllO(ompromilrd pa1ientl

AmdNsis

fffilI-<ontaminattct water;

hllllilosand other anima!l

0~lpOridumpornJm

1_

lofffiltiN' intellints,GtUling maiablorptioo, li1ig~,indabdomilal pain

fffilI-<ontaminattct water

InIKt, ltd bbxI (d , toGtUltfrm,dJil~and fa.;5OIIIe i'lsmodQ in'li~ tiN' ~ ~r andotiH'r

tislUl's.

B~e offnnaif,Anop/ItIt5
mosquito

Trichomoniasis

Common STD that caUIe vagiritis in fnnal~and urethriti! in malts

Trammis!ion !hrOlJljh !t.IIIil

(OIIta(\ with iofffitct lkJids

TiH' Ammo form ~ChiI9a~ dilriSl') inl'idtscardi.Kt~ DI aUlOOOmK 9i09ii;tiN' Afric.Jo

form (~ng sidUlt llj QUIe filig~and CNS deprmioo

B~e of kis~ng 00;t (Ammo)

IXtset!e fly (Nric.Jn)

Giardiasis

GiorrlQ II!mb6o

Malaria

i'll1OOil1ll11variou! !pKitI)

~ iovadt any 019'10; c.JUs.tl a fatal too'phala~ io inmmoc:ompromiltd patimt!

klIopIosmo gondii

TOOIomI:nn ragilUll"rs
Trypanosooiasis
TrypDl105IImQ f!lIli (Ammo)

CongI'naal I~vnission; cal

'm

TrypIIl1OSOmQ bf!KellAfriYn)

areas lacking high standards of sanitation. Helminthic infections 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)

iockqJinot (Yodm:in)

PO; 63H50 mg tid for 20 dayi (mill: 2g1day j

Adverse Effects
NlWl#II, K>miring, htadQcM, tlnirlflS

!&:!Iofrision i!!I!aoY!!!mosis,~RiH'ral neur2lYt!rt

Q mttronidizol!, (FbgyI)

1'0;2,1)-750 mg tid

lIilline5l, hfoifht,~,aIxJomjr1d"an, mera' rront,

~"~
~l!rn.~m! ~~tl!t

rifunimox (l.Jmpit)

1'0;8-10 ffi9Il.IJ tllrel' tokutinWday for 90-110 di~

tramiml kutooerit

lID II\. dilzioru,. hlDiIhf, noolftllmrb'riIg

Sl'inm.'!Unl~iI! wi!!! !!!l:aliia I!!!egnia

paromom,un lHumatinj

1'0; 25- 15 m9fkg in !hrel' dvidl'd do!el for 5- 10di~

NIWlN, K>miring, htadQcM, dQffM, ol!domilol 0IIlIpI

pl'fltamidine (Peotam,
NebuPl'ntj

1'1' 11M; 4 rng./k9lday for 14-11 days; infu!e am 60 min

(rug" brmdiolpo5m, rnlUIl4 rmrrxiIl

sodilltl stboghKonate

1M; 20 tngtWday

I!Ig1axi>ilX IIfIIb~lilX
ll'ulioorria byoodvrnria abKmQr pain at iniraioo lhr
hlDOtmlion n~[l!~iIi!x

(PtntOltam)
tinidazoll' (Tilliamax)

NQlJltQ, Illmiri~diQrr/teQ, IIIOfaiQ, (Ojjgo\ !iIblrema /lllin

f&i dJan~ ~monia,btood !!Il!;rajia!

PO;ljardiali\: >0 mgik9 io ~~ dole (max: 2 g);ammasis:
2g/diy for 1- , da)'5

/ralt5 indic.Jte (OOT1lOlladYml' I'fII'a~ ~ indicates lI'riousarNl'!"SI' I'ffI'ru.

LibraryPirate

AniUliQ, mero'rront, QOO rJaJJeII

~/lm Rrdllbwlllt::llllllilm: I[jJD~rm Irui!lllrliol

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 t~ prototypr drug for mostlOlln! 01 am!'biasil, bting ~fIec.

~ aljainst both t~ int~tinal and h~patic IliIgtS 01 tht diSN!e. Reistam
forms 01 E. hislolyrKQ 11m not yet ~m~rged u a dinical problem with m~tro
nidaz* thtrap)'. Melronidazolt is a drug 01 dio~ lor two ot~ protoro.n infKlicm:giardiasis and trichomoniasis.
Metronidazole is unique among antiprotOlOan drugs in that it aka has antibiotic actiYity aljainst ana~robir: bacteria and thus is!Hed to mat a numbtl"of
I6piratory, bone, !kin, and eNS infections. Tapical forms of IIII'troniduoie (MttroGt~ MetroCrum, M~troLotion) a~ UIfd to ~at 1O\..J{U,a disu!e charmerized by skin rNdening and hyperpLuil 01 t~ !ehai:eous glanrk, particularly
around t~ n= and bee. Off-label lM5 indude th~ pharm"ommp)' of
psNCiom!'mbraoo!H cotitis and Crohn's di!e~. Helidaoc: is a combination drug
containing m~tronidazolt, bismuth,and t~triqdin~ that is used to ~radicile
H.p}k>ri infection modated with prptic uker d~a !e.
ADMINISTRATION ALERTS

The "tended-release form must bf swallowed who~ and taken on an

empty slOmac:h.
(ontraindKat~d rirring the fim trimester 01 prtgnanq.
Prtgnancy(a\fgOl)' 8

ADVERSE EFFECTS
Ahhough adRiII' efferu occur relatiYely

frfquent~, most are not serio!H

enough to CiU!e diKontinuation of t~rap)'. T~ most rommon adYers~ ~lfem
of metroniclazolt art anortxia, naUleil, diarrllta, dizzinelS, and headac:ht. Dryness of tk mouth and an unpltuanl mttlilic taste may ~ ~perimc:ed.AI
though rart, metronidazole (In (lU!e bolll' marrow !Upplt-ISion.
Contraindications: Mttronidaz* is rontraindicated in f)ititnu with tridJomon ia!is during tilt first trillll'"lter01 prtgnanq and thole with hypelll'nsiti'lityto tilt drug.Metronidazolt (I n(iUS~ bon~ marrow !UpprtlSion;thus, it is
rontraindicated lor f)ititnll 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 O'/~rdo!e.
HmfIlMyMfimgKt IIIr ~ /UJhlgl'IIXe\lkXIIIIpKlIII.1I UIIIIfI!9.

PHARMACOKINETICS (POI

()Jset:Rapid
Pt'.k:l - lh
Hall~ifd....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

exposed to contaminated soil without proper hand washing.

Enteriobiasis, an infection by the pinworm Enterobius vermicularis, is the most common helminth infection in the United
States. For ascariasis, oral mebendawle (Vermox) for 3 days is

TABLE 35.8 1 Selected Drugs for Helminthic Infections

Dru,
Route and Adult Dose (max dose where tndtcatedl
albfnduolt (Abtnza)

PO:oIOO mg bidwith m~ 1s (IIIiIJ:800llII}iday)

Adverw Effects

--.

Abootmd 6rfrillKoon rtm,oMomiro/ p4f1, rnrult4

~gLl1ld~Q:lt!:iij 1~1m-r;1I

ivffinKiin (SIromKlol)

PO: 150-200 IIKg~ as. single .me

rm, prorirus, "oms, orrhrulgi<!, lymp/IoiItoop:!fhy

AM~ allerg!!ior inflamllliltm: rt!Ron~

Q mtbtndarole(Vermox)

PO: 100 mgas i singit do~or 100 mg bid for 1 days

AbdroriroI po~ di<!rrIifo, fIJ5h

pruiquantrl (Bitriddr)

PO;S mgibl as a IiIglt doIr::, or i5mglkg tid

Headache, dlJiflfl.!, fflQ/Qili, ftllJ, oMrmirro/ poi!

aDtiwl~!IIi tIIIltlIl~1lIIl:

(Y~aillllml!tlIlIII:

p)'ranlel (Antiminth, Ascarrl, PirX,

Pinworm GJpleu )

PO: 11 mg~asa IiIgit .me(max:l g)

Irdia indiYte rommon advme tffem:.I!l!!mi!i!!!I. indiYtts 5oeIioui adve-If tffem.

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NoIllM, lerJfIII1UI. ~f1OI"tXi4 diorrlifo, fWl"!r

1:Iill:tWu1;m~w: ~tll::al

IlIiplfl n

the standard treatment. Phannacothernpy of emerobiasis includes a single dose of mebendazole, albendazole (Albenza)
or pyrantel (Antiminth, karel, Pin-X, Pinworm Caplets).
like protozo~ru, 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 intestinal 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 byextensive 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 (ontribu~ 10 the trammission ind reinfeuliln ofth~ wonm. lnllnKI pall'llUand family mtmhe!\ about wa~ to prevmt
I'Jposur~ to and sprud of helmimhs. T~ac:h dlildl!1l (oma ha nd washing tffilnique. fill phuizirog dun~ng under the niils and wishing befell' ~ating 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 ~ndboJ:H ooYeft'd ....-he-n oot in lM. Cltin!f all fruits and "ffIjttabies hefomNting.(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 U~atmffi~ partiallartj in households with s~YeraI )OII1g
(hildl!1l, ~onefamily lllflllber hasan infliln.

~ Prototype Drug

Drugs for fungal Protozo.n..nd Helminthic: Infections

523

intestine, malabsorption, increased risk for secondary bacterial infections, and severe fatigue. Pharmacotherapy is targeted 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 infKtioma~(ommon among(hildl!1l,with th~ IIitilllil ratH
highesl among dlildft'n Its! than Sy~arsof ag~.ln public health libl,!he mOSI
rommoniy diagoolfd intfllin,1 p,ruitf is Gardia. GiardiaUs lalHaft' moc:iuti! with swimming in oontaminattl! watfrways or drinking (ontiminattl!
groond 'ftll wat~~ ia (ontaminattl! diapen in (hiki-caft' mti ngs, and drinking watf!" or ronwming raw fruit; or Yegetotblts during int~mational uav~l.
Giordio inre.:tilm miY alia be difliruk 10 diagoos~ becalM lloolsprtillll'ns do
not always (ontain lhe lWoI or pa rasit~ althoogh llool ,migm I~sting sprtiIK
to Gilmia isavailablt.
(hildft'll adopl~d from (OUnlnn ouuillt of th~ Unittl! State alia ha~ a
high ra~ of parasitir: infection. Up 10 1S% of forfign-bom idopted (h i1d1!1l i Il'
Il'pOntl! 10 hi!' Giordio lamb/it!. Emrironmtnts in which t~ (hild~n hal'
he~n Iwing. pa rtiruli rIy orphanagtS, often plOl'ide favor! bit (onditilm ~r inre.:tious dis~~. The (DC ft'(omllll'llds that int~lIIiItionally adopttl! (hildr~n
undergo ~lIiImin.nion of at !fall o~ 11001 !.Implt, ,nd thlft stoolsimp1t5 ~
Gisymploms a~ pr~lffil Unforrunat~ly, rvilltnU' has shown that in (ommunitie wherto helmimh in/e(\ions aft' (Ommon. whrth~r in !he Unitm Stale or
om~u, poor nutritional lIaM.a n!'mia,a nd impaired growth and Itaming in
dJild~n

IHUIt

Mebendazole (Vermox)

Therapeutic Class: Drugforworm infections

Pharmacologic Class: Antihelmintic

ACTIONS AND USES

ADVERSE EFFECTS

M~nduole is lhe most willtly

BfloilM 10 littlt of th~ drug is absorbtd, mtbtnduole dots not gtlll'liIlly (ilM
mious systemic siclt rifrm. A; lilt worms dif, IOmt abdominal pain, dill~n
sion,and diarrllea may he uptriencrd
Contr aindi (ations: Ih~ on Iy (Omri indic:atiln is hypm~mitiyjty to the drug.

pft'sc:ribed anth~lmintk in the United Stat~s.1t

is UlI'd in the u~atmtnt of a wiclt range of hflminth inftionl,induding tlicM
('!IMd by roundworm (Al(orn) and pinworm (Enrlrolri<nis). As a broadsprttrum drug. it is particularly akwblt in mill'd helmimh imfltiom, which
a~ (ommon in aft'iI having poor an itatiln. k is ffre.:tjy~ iga inst both th~ adult
ind IalYilstage of the~ paruit~s. k is poorly ablorbtd aflfr oral admin~lra
tiln, which allows it 10 II'lain high (onU'lltroitions in the imHtilll'. For pinworm
infe(tions,a ~n9k> dos~ is uswlly ~ffir:itnt;other inie(\ions Il'qui~ loon!f(\JtiYedi~ of therapy.
ADMINISTRATION ALERTS
Thedrug is mOil eifliYe whrn dJewfd ,nd tak~n with a farty m~al.

P"'9n .nqca~ory(

PHARMACOKINETICS
Onsrt:Unknown
~k: 1-7h
Halfl~d-9h

Duration: Unknown

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INTERACTIONS
Dru;rDrug: UrboImmpiIll' and p/IM)1oin (0)11 ilKffiR tilt mttaboIism of

......"".

libTI'S1S:Unmown
HI'IiIi VFood: H~1at foods rna, inrrNlf the abIorption of the drug.
Treatm~nt of lmrdos~: ThM' is 00 !pf(iIK tft'itment for OY!'rdos~ .

fit'" ru M7N,mlng/!ll for Q Nom/nq I'rIKm foal< 1pf<1Ic ru mrs druq.

S14

Unit, Tho Immu,,",Syst"'"

~-=:J' Chapter REVIEW

' -~'--

KEY CONCEPTS
The nu mbered key concepts provide a succinct summary of the important points from the corresponding numbered section
wIthIn the ch~pter. If any of these points are not dear, refer to the numbered section wilhin the cha pter 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 (~f
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 cho ice for se rious
fungal infections.
15.5 The awle class of antIfungal drugs has become widely
used In the pharmacoth erapy of both systemic and superfkial mycoses owing to a favorable safety profile.

3,5.7 Malaria is the most common protozoan disease and requires 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 requires a different set of m edications from those used for
maLuia. Other protowan diseases that may be indications
for pharmacotherapy Include ameblnsls. toxoplasmosIs,
gIardiasis, crypto sporldlosis, trI cho mo niasis, trypanosomiasis, and leishmaniasis.
3S.9 Helminths are pa.rasitic worms that cause significant disease In certain regIons of the world. The goals of pharma _
cot hera py are to kill the parasItes loc~lly ~ nd to dlsrupl
their life cycle.

15.6 Antifungal drugs to treat superficial mycoses may be given

topIcally or orally. They exhibIt few serious sIde effocts
and are effective In lre~tl ng InfectIons of the sltln. nails,
and mucous membra nes.

NCLEXRN O REVIEW QUESTIONS

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.

A patient is given a prescription for quinine (Quina m m)

for treatment of malaria. Prior to beginning therapy, the
p.1 tiem 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.

A patient h~s returned from South America, where

malaria was contracted. A drug the nurse expects to see
used is.:
1. proguanll (P;lludrlne).
2. penicillin {Am pIcillin}.
3. ri:l<1triptan {Maxalt}.
4. chloroquine {Aralen}.

The nurse Is providIng com munity educatio n about pin worm.

~nd

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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roundworms. VVhkh of Ih" foll owing shol1ld

be included in this teaching? (Select all that apply.)

ct.Ipc...n

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

Drug5forFur.galProtozolf1,~nd

Helminthic InlKtlons

525

Metronidazole (FL1gyl ) is being used to treat a patient's

Gflmlill/mnblill inftion, a protozoal infection of the intestines. 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.

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 patient. What are three priority mmlng assessment areas for
patients on this medication!

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.

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. Identify priority teaching for this patient.

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Drugs for Viral Infect ions

DRUGS AT A GLANCE

LEARNING OUTCOMES

DRU GS FORHIV-AIDS fIlIJt519

Nudeosld~ and Nudeotlde ReYEni'

After froding this chapter, the student should be able to:

Transc~ptase

Inhibitors fIlIJt $J(J

Q zidol'lJdine IRelrovir,AZT! fJIJII/511

NonnudeosldeReer1e Transalpuse
Inhibitors

f1IlI}t5j}

fftNirtnz (5llSliva/ jIIXJI m

Protease Inhibitors p!JIJt5Jl

Iopino";, with rifOlIO>'i, /KolflroJ

fIIJi1511

FuslonlnhlbltoD

Pt1II5JlJ

DRU GS FORHERPESVIRUSES fIlIJt jJ&

Q acyckNir(Zovirax) p!JIJt5J9

DRU GS FORINFlUENZAVIRUSES p!J9t54IJ

DRUGS FORHEPATITISVIRUSES paJt S4IJ
Interferons Jlll9t54}

,. [)@scribethe major SlructU~5 ofviru~s.

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 manage~nt of pat~nts
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.

KEY TERMS
immunedef1tiencysyrdrome (AIDS)
JllXJ'5l&

.cq ui ~

antimroviral (JlJlJd18

,.psid paqr517
CD4 l'fCfptor fllXJ'518
hepat~ is p!XJ'54J

highlyactin

,.,."

anti~l rl1Yir .1 therapy (H MRT)

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HIV-AIDS fllXT5l1J
human immuoodencifnC)' virus IHIVJ fIIXT 5l1J
influellU fllJlJ'540
intracei lularpara~tf fllJlJ'517

latint phasf (If HI VinfK tionj fIIJIJ' 519

Pf9Ylation fIIXT 541

protNlli fllJlJ'5l1J
rntrSur ansaipl a~

yiraiload fllJlJ'519
f irion fllJlJ'517
yirus {JIJ1t 5lJ

fllXT518

CIIopltlK

iruses are tiny Infectious "gents capable of causing disease 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 increased dramatically In recent years bec.au1(' of resean::h into

the AIDS ~mlc,lIntlvlrals 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 deoxyribonucleic acid (DNA). that contain the neocess.ary information 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 trigger body defenses to remove the invader. A mature infective
particle is called a yir-ion. ,. Figure 36.1 shows the bask structure of the hrnnan immunodeficiency virus (HIV).
Although nonliving and structurally simple, viruses are
capable of remarkable feats. They in(oct their host by locating and entering a target cell and then using the machinery
inside that cell to replicate. Thus, viru~ are irlUacfiularpM<1sitts: They must ~ inside a host cell to cause infoction. Virions do, however, bring along a few enzymes that assist the
pathogen in du pliating its gentl ic material, inserting ilS
sen ... into the Ilo..t's chron"lOOnu, ~n,j ~e",bl ins nowly
formed virions. These unique viral enzymes $Ometimes
serve as important targets for antiviral drug action .

OIU9sf"'';'lr~lInfKtlons

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 hepa titis Bvirus 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 d r 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 immun e response {LmmUnOSlimulantsJ $0
that the virus remains in latency wilh the patient
symp tom free.

PHARMFACTS

Viral Infections
Appnxima~ 85\110 of Idulls hnor serologic Mden<:e of ~M by

HSV1.
About.5 million ~iclLns.~ infected with guiUI htJllts-Ontof
~ry 1M of tile toul.doitKmt.nd Idu~ pop.L~tion.
(;rnit.l Ilerpts is men [ommon in WOnItn th.n in men. .nd in Afriun
Amtrium th.n in other ethnic gJOUpi.
About900,OOO Amerium.~ [Urltnt~ living w~h HIV inftions,and
.bout 010,000 ntw infection LOUIJr N<h )'tar.
Roughly ~of ntw HIV infectiom occur in mu;tllt largest rish.tfgOry
is mtn who Iw~ 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
~induding4S0,OOOAmtriuM,lIMditdolthis~.

,. F1gun36.1 StJUctureofHfII

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528

UnitS

ThelmmuneSyu,-""
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 eventually 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 associated with the HIV DNA. enabling the virion to infect other

HIV-AIDS
Acquired immun~ defkiencysyndrome (AIDS) is characterized by profound immunosuppression that leads to opportunistic infections 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. Resistance to these drugs is a major clinical problem, and a
pharmacologic cure for HIY-AIDS is not yet achievable.

T4

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 surface of HIV fuse with the CD4 receptor. The virus uncoats,
and the genetic material of HIV, single-stranded RNA, enters the cell. After entering the host cell, the RNA strands are
converted to DNA by the viral enzymernersrtran~riptnf. The
viral DNA enters the nucleus oftheT4lymphocyte, where it

lyJJll'hu~rl"'.

0""" i>uuclillg UU.UTh, Ih ... iIJUJlUIJ~

Viral DNA enters tho nucleus

and is iocorporaled iolo

host chromoSOlTllls. II ..
transcribed iolo mANA
and mo ... ';ral RNA, which

Viral

~ 'o.~ ",".'~m.

Cytopl .... m

o
.. Figure 36.2 Replication of HIV

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'ysl~Jll

recognizes that the cell is infected and kills the T4 lymphocyte. 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 remove them. Knowledge of the replication cycle of HIV is
critical to understanding the pharmacotherapy of HIVAIDS, 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 characterized by gradual destruction of the immune system, as measured 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 certain level, the patient begins to expe-

Virus aliachN 10 ",coplor on hosfs

plasma membrana. ks core d""ni&gmles,

and';ral ANA enlers the cytoplasm .

OIIpttr36 Oru9,forVlr.llnfKtl"",
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
Thewid espread appe.mnce ofHIV infection in 1981 crea ted
enormous chalJengesfor public health and an unpredented
need for the development of new antiviral drugs. HIV-A IDS
is rullike any other infectious disease because it is most often
sexuaUy tronsmitted, is uniformly fatal, and demands a COlItinuous supply of new drugs for patient survival. The challenges of H IV-AIOS have remlled in the development of
about 20 new antirelfoviral drugs. Unfortunately. the initial
hopes of curing H IV-A I OS through antiretroviral therapy or
vaccines have not bft'fl realized; nOlle of these drugs produce> a cu re for this disease. Stopping an tiretrovinJ therapy
almost always results in a rapid rebound in HIV replication.
HIV mutates extremtiy rapidly, and resistant strains develop
!;() quickly that the crta tion of novel approaches to antiretroviral drug therapy must remain an ongoing process.
Although phamlacotherapy for HIV-AIDS has not produced a cure, il has rnulted in a nwnberof therapeutic successes. 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 H IV_infected another to her newborn has
been reduced dramu iaUy (see Section 36.7). AlOllg with
better patient education and prevention, successes in pharmacotherapy 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 ~ patients are asymptomatic and may not even realiu they are
infected. Once diagllOSis is established, however. a deds ion
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 treatm ent will delay the onset of acute symptoms and
the development of AIDS. Early therapy is especially critical
for infants younger tha n 12 months, because the progression 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 acu te stage evenluaUy develops, the drugs

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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 HIVAIDS include the following:

Reduce HIV-related morbidity and prolong survi~aI

Improve the qualit y of life
Restore and preserve immunologic function

Promol~

maximum supprc"ion of viral load

Prevent the transmission from mother to child in HI Viniected pregllillnt pa tients

T\'"O laboratory tests used to guide phannacothenpy are
CD4 T-cell count and measurement of the amount
of H IV 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 indiane 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> replicating and is conside red a more accurate predictor of cl inical outcome than CD4 ceO counts. These telts are
IWrformed every J to 6 months to assess the degree of success of antiretroviral therapy.
At onepoint, physicians recommended the routint useof
stru<lured treatment interruptions (STIs): periods during
whidl all antiretroviral drugs were withdrawn. This techniqu~was believed to reduce adverse effects, increase the patient'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 diseru.e progression. In all cases, viral load increases when drug
therapy is discontinued.
abso~ute

Tli! Qestion: WIwt t.crJn infl_ f pttIOIIlI bot IrSttdforllY inP.dionl

Tli~ Study: RnurdJmll1l~ two IeUnI Itudie tIIu mmined Ite
lining of HIV tnting .,.d demogf~phil; variablrs moc:iattd with tilting.
~ allil~ !ohowtd tNt INny ptOPlt Wlit to ~~ttd 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 ImpIicatiom.: 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
;1

S]O

UnitS TtelmmuOI'S)"tl'm

36.4 Classification of Drugs

for HIV-AIDS
Antiretroviral drugs target spe<:ific phases of the HIV replication cycle. The standard pharmacotherapy for HIV-AIDS includes aggressive treatment with multiple drugs concurrently,
a regimen called highlyactiwantiretroviralthfrilpy(HAART1. The goal
ofHAARfis toreducethe plasma HIVRNA to its lowest possible level. It must be Wlderstood, however, that HIV is harbored in Jocationsother than the blood, such aslymph nodes.;

therefore, elimination of the virus from the b!ood is not a

cure. The simultaneous use of drugs from several classes reduces the probability that HIV will beoome resistant to treatment. 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)

TABLE 36. 1 Antiretroviral Drugs for HIV-AIDS

Route and Adult Dose (max dose where Indicated)

Drug

Adverse Effects

NONNUCLEOS ~ DE

REVERSE TRANSCRIPTASE INHIBITORS

dtiaYirdillf IRecri,tor)

PO;400 mg tid (mil: 1)00 mgld.ly)

d"ilYirrnzlSullin)

PO; 600 mg/days (max:600 mglday)

h!f5!besja brojupqjd!y 5!fyf0\ lob(!oo IYn!U!!If

t1raviril~ (lnl~)

PO:1OO mg bid (max:400 mg/day)

CNSlOli!:ity fdavirmzl

III'Yir.pi"" (Vlr.m,,,,,)

1'0;100 mgld.,. In< 14 rby<;th ... in<""'" tohid

Rash, 1'tWj: mllIlM, dmllfO, I1eod~dtf, l!Im~riliI

NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS

abaulir (Ilagen)

PO;loo mg bid (1IIi1:600 mg/day)

didano~ot (\'"00,001)

PO;l1Hoomgbid

mltridtabillf ([moo)

PO;loo mg/day ]1IIi1: 100 rngIday)

Forriqw,~wrotntJl,myolgi~,flCU5t4~
abdomimll~il1, 1mIi~~ ~nomio, roll!

Bonf mar!pW IUWI'oon OMma MINDY

gramAI!MQpmy Jaqk addQlk witb 5!N1oubl'.J

IamivLdot (Epi'li",lTQ

PO; 150 mg bid (mal :100 mgfday)

!I&OIoxidIY Dftip/lffill !INON1hy (/,JI(~lbi'It,

lIawdot (1tri~ 00)

PO;.o mg bid (max:80 mg/day)

!la\'Udiot1 paOOl'lrtis flami'ludi!!)

tftlOfiwi (Vill'adj

PO;loo mg/day

1ido'I00i1lf (AlT, Rt,tnwir)

PO;1OO mg f'I~114 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)

PROTEASE INH BITORS

aliUnavi (R~aw.)

PO;400mg/day

1IoiIw, 1mIi~~ d~rrItev, obdmJirJI pan, lItod~dtI

darunavir (Pluistaj

PO;6OO mg taken with ritooavi" 100 mg bid

fMamprmavir (Lniva)

PO; 700-1,400 mg bid i1 (orrbina~on with l00-~) mg ritonavir bid

Aotmia ItukoDtnia,wP '/fin thrombolil, panWtilis.

IvmMooDj!lby b!IDgrrbagjc m(ml ocphmlj!hja~l

lmoll:1,8OO rngIday)
ildinawi ]Crilivin)

PO;800mgtid

PO;400/1oo mg (3 tlplUiflor 5 mL of llIIpfnsion) 1id;iOON~ do~ to

S33f1ll mg (4 tlpl\Jl's or 6.S mLl bid. wIIh (onaJlfl"llt d"IVRnzor

IopinaYir/ritor\lYir (Kaltlra)

floci"naYir) yl'diicalffl!lmuoni ) tluonWCYlOPfIlia

(!!Quinal'ir), paomopmia I!<lgl.inaYir)

otVirapi~

IIflfinawf lViraapt)

PO;750mgtid

ritor\lYir (Norvir)

PO;6OO mg bid (mal: 11,000 mg/day)

liQUinaYirlmiu~)

PO; 1g tid (rnal:l glday)

tpranaYir lAp~l'IIS:

PO; 500 mg taken with 100 mg of ritor\lYir bid

FUSION AND INTEGRASE INHIBITORS

toMirrm(fuuon)

SlDwtaotOUs;90 mg bid

llliravm: (SMntry)

PO; 151l-6OOmg bid (1IIi1: 1)00 mgld.ly)

rak~raYir (IItnt~)

PO;400 mg bid (1IIi1:800 mglday)

PIIin ~nd nIomm~rion ill irrjKrion Jill' (fflrNirridt),

rDMII,dUrhifJ, fari~e,obdJmiooi /1fi11,!0IIIJh,
tflzinru, nrusasIoJbltr~llymprll/lU, pyrlli~, 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)

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CNptfll& Oru9.lorvlr.tlnIKtlom

2.A nonnucleoside reverse transcriptase inhibitor plus

Protease inhibitor (PI)

Nucleotide reverse transcriptase inhibitor (NtRTI )
Fusion (entry) inhibitor
HIV integrase inhibitor
TIl~ last (hII' da"""" illdllU~ I~~~l1(l y ili""UV~I.,u a!!~l1l';
that act by unique me.:hanisms. Tenofovir (Viread ) is a
NtRTI that is structurally similar to adenosine monophosphate (AMP). After metabolism, tenofovir is incorporated
into viral DNA in a manner similar to the NRTIs. Enfuvirtide ( 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 antiretroviral 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

The rapeutic (lass: Antiretroviral

53 1

two NRTIs
Treatment failures commonly occur during antiretroviral
therapy. The primary factors responsible for treatment failure are inability to tolerate the adverse effects of the medications, nonadherence to the complex drug therapy regimen,
emergence of resistant HIV strains, and genetic variability
among p.1tients. Pharmacologic options available for patient> 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 available to treat HIV-AlDS. The therapyofHIV is rapidlyevolving; thus the nurse should consult current medical reference
sources for the latest treatment guidelines.
Drug manufacturers have responded to the need for simpler 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, emtricit.1bine, and tenofovir into a fixed-dose tablet. Approved by

Pharmacologic (lass: Nudeoside reverse transcriptase inhibitor (NRTI)

ACTIONS AND USES

lidovudint WIS first dil(_m1 in the 196O!, and itl antNiral auiYity was
~monmat~d prior to thl AIDS ~ic. Structural~, it ~mbl~ ih)Tllidint,
ont of tht four nudtolid! building bloc:h of DNA.A; tht reYl'f~ uanS(ripta~
tnzynlt bfgins to S)'IItheilll' viral DNA, it mi5l.krnly UIrI zidovudint U Ont of
thtmKltoIidt .. thuI(rearing ~ ~ftd~DNAmand.lidovudint illMd in(ombination with other .mirl lrovirall for both symptomuic:.nd uymptomuic:
HIY-i~tN ~tienu. as ~I U for poIltlpolU~ prophylnil in HIV-upoItd
health taft' WOrRrs (I SKtion 16.6). An importlm indic:.uion iI rmlKlion of
tht rilll of tranlOliuion r~of HIV from an HIY-politil'f mothtr to herftlus.
8~cauI~ of the dllJ9l' widtlprNd 1M sinft' th~ bfginning of the AIDS t pi~mic, resilt,nt HIV IlrailS h,1'f bfiornt (ommon. Most trtatment guideli~
do not ilKlude zidovudin! u ~ df119 of first moKf dUf to tht potl'fltial for reiltalK~. Combinuion prodKu (ontaining zidowdint indude Combivir (zidoYUdint and limivudint) ~nd TriziYir (zidoYudint, IimiYudint, ,nd abamir).
ADMINISTRATION ALERTS
Adminilt~ron an I mpt, stom"h, with wat~ron~.
!!!Ioid ~dminiltering with fruit jJK~.
PregnalK)' uttgory C

ADVERSE EFFECTS
Zidovudint has tht pottnri,1 for miolH adl'f~ tift"! and hal ~ril FDA
bla.c:k ~OII w,mingl. Thf df119 can (i!~ Sf'Itfl' htmatologK tOlicity at high
do~;inemia andnWlropeniaa~(Ommonand m.ylimitthfrapy.~(iIft

may Il'~ift' blood translusions.l.actic: ac:ido!is ~nd ~ft' hepatomtgal,> with

Itf'tolis h~1'f ~n repontd, inc:luding a few fatal ~ Prolongtd u~ hu
~ iI.ooated with m)'Op'thy ~ nd nT)'OIitil. Many patitnts HptritlK~ htigUf
and 9! ltI".rlll'd weakntls, anorui" nalHt~, and diarrhe ~. Htadadie willwr
in th~ najority of patil'nll taking zidol'Jdilll', and 1nOft' IfriouI CNS tfftc15 hal'f
bec-n I!porltd
Contraindications: H)'perItnlitivity to the dlUl iI the only (Ontr~ ildia.i)lL k
shooJd lit USN with cauti:m in ~titnlS with p~-elistilg 'lII'01i, or lII'~ia.
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 nm.U~'If
immUflflllJlPle\sion. TIl! folowilMj druglmay i"uMI' 1M rill; of All toli!itr.
oIiO'1aC[Ulne.am~n B,lIpiri1, dolllllDcin,ftjJ(onazoIe,~, iIOd

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

PHARMAC OKINETICS (POI

Onsrt:Unknown
Pfak: l- lh

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 ~wdlao; St..Iohn\ '11M,
which lIay(jkMa dMMe inaltil@!ro'liralmity.

Halflift: I h
Duration: Unknown

IItIlr to M',NrJlJIrIgIQ/ for Q NrJlJ/fII} I'rtml foM lpt(1k to rliHIrug.

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Treatment of OYerdolr: Therr iI no 5pt(ifK tll'.ument for OI'!'rdos~.

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 structurally similar to nudeosides, the building blocks of DNA.
This class includes non nucleoside reverse transcriptase inhibitors, which bind directly to the viral enzyme reverse
transcriptase and inhibit its function, and nucleotide reverse 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 transcriptase uses these drugs to build DNA, the viral DNA chain is
prevented from lengthening. The "unfinished" viral DNA

...

Prototype Drug

EfaVirenz (Sustlva)

Therapeutic (lass: AntiretroYiral

Pharmacologic (lass: Nonnudeoside reYerse transcriptase inhibitor (NNRTI)

AalONS AND USES

[fol'li~nz is gil'fl orally in oombimion with other antirwu;irals in thr 1rN!mrmofHIVinftion.Thrdrug ambyinhibiting ~rrll'tran\(rip!olII'.lt hasthr
advantlgr ofomr-dailydoling and penl'lration imoCSF.Hnilt'lll. isa ~frrrm
drug for thr initial thrrapy of HIV infrr:lion.
Rrsistlncr ran drftIop rapidly to NNRTls and (1O!:s ~istln(f among drugs
in this dm(an orrur.High-fat muls inaNlI' thrabsorption by u mIKhas5O'lb
and may "use toxic:it)'.Atripia is i fixed-dosr combination of three anti~troviral drugs: tfavi~nz. rmm.:iu binr. ,nd !rnofOYir.
ADMINISTRATION ALERTS

Administer on an ffilPty stomam.

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 depends 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 during 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,
~nd lipod)'!:rrnphy, ~ <ii~ordi'l" in which fur i~ 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

Administer al btrll:imr to limit lIIft~(NS rfftru.

Prtgnanq category (

PHARMACOKINETICS
il1setRapid
Pf,ak:3- 5h
Half~ife: 51- 76 h
Dur.lllion:24 h

ADVERSE EFFECTS
(HSaoM~ rffe(\S a ~obsrl'/~ in a! leoH! SO% of the patients whr-n fint initioiling thrra py, in(kiding sJrrpdisordrB, nightmarrs, dizzilll'l~ ~rb:rd abilit)' to
mnummt, and <!elusions. T~ Ymptoms gradually diminish afitr J--4
WffD of therap)'.likr other drugs in this das~ ruh is (ommon and musl bt
moni!~ camully to plrl'!'nt!he rIe~pmrnt of I>Mf"r blistl"ling ordrsquamation.
Contraindi(ations: Ef,virenz is a known trratogl"ll in laboratory animals and
rrust IlOl bt giftn to prrgnan! patienn. Patients in thr (hild-btaring ~m
!hould btadvill'd !o usr ~Iiable methods of birth (ontrol to avoid prtgnanq.

INTERACTIONS
l)ug-l)ug: Palifm who iftfKeimgan!~ti< mfdicatioollMaboliNd by thr

INI"I- soch ill ~nr.p/lfnytoin,anI PIIfnotwibitJI-mayrequill' p8iodic:

moo~omg of plasma IHH; ~ MliIKllIM)' irKrNIt thr incidenl:. of \l'illR\..
faWfIIl un de!rNst IfIIIIIIIHH; of!1If foIowing:sUlins, rMhiIIone.lf!lralile.
and YkiOOlIllarwl biodrn. ThfOlS ......MeetfKl! of mvirfllz .n ~ if
thr patifnt tal;es psydlol:ropic: 00J1I or ronsume\ akohol. L.wIs of warfarin may
fid\erillUNll' u~.
Lab Tl5l1: [/.wift'llZ maygMo filllf...posi!iw ~ for thr plNlKtofroaoluana.lt
1M)' irKrNIteOlm ~ \\1m.
lk>rbaVFood: St..km ~ won may <aUIf a dKlI'U i1 In!i"ftroWal iI(!W~ y.
T~tmrnt ofDrrdosr: Thr~ is 00 sprdfKtlN!men! ~r O'Iridoll'.
Rtftf 111 MyMl5/nqR ror ~ MnJnq I'rlXt5.I fooIj sp/II( 1II1M /J'ug.

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o..p!tr]&

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, slee p disor-

Orug,lorvr,.lInfectlo,,,

sn

ders, and fatigue, but these symptoms are rare in patients

taking nevirapine (Vimmune ). Unlike some other antiretrovirals that nt'Satively affect lipid metabolism, nevirarine actually improves the lipid profIles of many patients by
increasing HDL It'Vels.

LIFESPAN CONSIDERATIONS

Psychosociallssu"s with Antir"troviral

Drug Com pliance
Ont kf, 10 w((~lof an ,lOtirrt~iralll'gillll'll is ~t rompiian~with t~

pll'Kribed medication plan. Drug rompiialKf is diffiruk for most peoplt oo{f
thty frrl writ patifntl may ill' mon pront to ~ip do~ for various lI'.HOIIl
Ma ny factors "n mharKf thf probabilil)' that the patirm will adhm to tll'atIIIl'IIt.For rumplt, a multidiKiplillilY allfSllIIl'IIt (an \(1!'t'O p.ltirntl for dIopll'nion, akohol or drug aoolol', or negatiW' attitudes,.nd intt'M'ntion I ran ill'
initiatrd to minim~ 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 t~ medicatiorrs pliy in IKUring a polit~ oukomr. Developing trull
and oprn communication bttwrrrl the p.ltirntand t~ ~,kh call' proYicIrf is
nsrmial to improving thr {!worr-s of drug rompliaort and to lI'arhing common theraprutic goals.

~ Prototype Drug

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 pharmacotherapy 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 machinery of the host cell, and the structural and regulatory
proteins of HIV are ready to be packaged into a new virion.

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 (orrsid~1I'd Iht acbvt comflOl\~nt of th~ (ombination. Tht
smalilmoum of ritonavir inhibit! t~ hrpatir bll'akdo'Ml oflopi~vi~ 1M prrmitting ItIUm Irw-iloflopinnirto inCll'ils~ by 1lIOII' than l00-fold. k halan ntrnded haH-liftthat allows for OIlU'-or twirMai~ dosing.
Rr-listan(~ to lqJi~virfritonavir !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

PROTEASE INHIBITORS

T~ oral solution fonn lhould ~ ukrn with food 10 rnhalKf absorption.

Tablets may bt takrn with orwithout food.

PlI'9ni lKY utegoryC

PHARMACOKINETICS
Onset:Rapid
~k: l-4h
Halfliff:S~h

Duration: 12 h

ADVERSE EFFECTS
Kairul is 'MIl tolrratrd by molt patirnts, Ind the most fno~mly II'pOrtrd
prGblrm Kdianile . He~ and GI-reIat~d elleru art common, inckJdirog
oaum, wmiting..d)'lpepsia,and abdomillil pain. Hyprrglyrrmia hal been reponrd 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 ra ~ though potrmially fatal,adYtrw ~nt.
Contraindications: l'atirnts with l~r impainnrm, ~spe<ially thoW' with preexisting firal hepatitis, should ill' wclul~ mooitOll'<!. Htpatic rlll)'m!' 1r~1s
should br regulartyffalWlrd in t:hr!oI' patirnts to jlll'Vrm h~pnir failu~. PItirnts with diaill'tes should ~ monitored II'lJIlarl)o bruulol' K.iltm may uarfflIatr this condition.BII'III ferding is{oomindicatrd dUl' 10 th~ 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
~lofthfantRtnMralinWclfOf'lirapine,framnz.~

""'ill 0(

riIaqIin, riIabIlin,phfn)'loin, and OOamazePOf. Drugs thai II\a1 irmast

I(fin.wir in<Iudf aIOOIeuI;in, ~oIe, dHa'o'i"diOf, illlin.wi~ 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.
~!I1tia1l)' lilHlmtl'lling ltf\rI1)1Irnial rna, ouurifKatmilll\fd{onamrl\)'
";!h (~,<i<lp"ido, pi""""",,.and many antidy<rhytlu,i< OI)Mn.KaIoualllO)l
iooNSt adv~ ef1K1161Oda1ed with s.e4Ktivf loI'IOIorin rflllllal:l inhibitors
lSSR~), triq(ir antid!pressMlts,ancI p/IfnoJhiazinrs.
Lib Tests:1ot.Ji dloItstaoi and~ rna, inaNlf.

HerbaVFood: StJohn~ WOC!ma1G1US1'a~in antietroviral iK\ivityand iI

coouaioticatfd.
Treatmtnt of ImrdOSf: Theil' is 00 spe<ifK IlI'almrnl for OYerdosr.
1II!(pf Ie M)Nurllllgm IbrQ Nurlifll} I'nxtl.! fm Jjlt{1k Ie rNs d~

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534

UnitS Thl'lmmuneSyu"",

NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY FOR HIV-AIOS

Assessment

Potential Nursing Diagnoses

Bil st line aSSfssment prior to administration:

Understand t~ rtillOn the drug !ws bffiJ pr&ribtd in order 10 as~ for
tOOilpMK ~cts.
Obtain a (omplete he~lth hillory ilKludi ng lII'urologic, Qrdio"aSruli~
rnpif.tlllJ,hep.Jtir: or rt'IIal dilulI',ancl the pos,ibiliryof prtgn'IIC)'.Obtain
i drug h~lOry 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 (U~nt infe<tion OO1ing onll'~duration,
(!wracteristKs,ind prl'lfll cr or absflKt offewr or pain.
[valuate appropriate laboratory findings {t.g., (B( (D4 (ou n~ HIV RNA
iII.Jy,(ullUlf and II'n~tivity [(&5) for any (OII(Ufrt'llt inftctions, ~patic: and
Ifn.J1 function nudits,~pid IeYeis, 5e11Jm .J mylas~ and gIIKOIr).

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: RegimenMul.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
R~k for InjJry, Risk for Falk (lfi.Jtrd to adw"ll' drug ~cn ordill',u)
R~k foruregil'ff Role Strain

--+-=

Asstssment throughout administration:

klffi lOr rIt1iR'd tooapeutic: rfiem (e.g., (D4 (ounts and HIV RNA a l!a~
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 .JIsa~,lipid 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,
ftl'~ musc:1e or joint pair, pilfllhtsia~ ir;potflllion, S)TKOpt, and
~lyr:mlia. Sterr diant.e.J, jarrdic:t,rIttR'.J ltd uriIII' rutput or darUntd
iiiIII', purpl~hrtd 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 inmediate~.

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 (onrurrent infection, able 10
maintain ADu).
Br fnor from, or uperienre minimal, arhomr tfftcts.
VerlJalizlo an undemanding of the drug's Ulf, adYellr tffNts, and rtquilfd plffiutions.
o.monm.", proper !d/-admini.lrllion of tho modiulion ~t.<J.,do .., timing, when to notify hu kh "'''' pro.idor).
Implementation
Interventions a nd (R!ltion a les)
Ensuring thtril~utk 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 Iongtl'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.)

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Patient a nd Fa mily Educ!ltion

Te.l(h the pat~tto 001 nop the drug rtgimen whtn "feeling bffier"but to
continue to takf(ou~ of mfdiutions;do oot shalf dOlI'S with othtB;and
R'lUm to th t provider if adYl'l"ll' rfit<ll make rompiiance with R'9imf n
diffiruk 10 continue.

CNpttrlo6 Dru9,lorVlrallnlec:dom

NURSING PROCESS FOCUS

535

PATIENTS RECEIVING PHARMACOTHERAPY FOR HIVAIDS (continued)

Impl ementation

Interventions and (Rationale s)

Patient and Fa mily Educati o n

Minimizing ad'ftrse effed:s;

Continue to monitor vital signs,npecially tffi1prrarur~ if ~r is p~nl
Immtdiately report in{reasing ft'/~~diarrhu or vomiting, r/yIpne. ,
t"lr,urdia,diuinffi,I)'IICOpt,{hange in bfilavior,. nd letharw or lO( 10
tilt lItakh ml' plll'/idef. (lntreasing ~t !1pffially wlltn ac:(omp;lnied by
worsl'ning symptom~ m.~ be ~ sign of wol1!1ling in~tion, aderll' drug
f flem,ordrug l!"IistllKl'.j

Tea{h the p;ltitn~ family, or ""t<jwmo immtdiatei)' repln ~r that

enM 101'f,or per p;lramtl~ n;thang!1 in behavior or ~I of
{on!liouso!'Ss; shorlrlffi of~ath;inability 10 !Ninlain Ir;dr.tion or
nutrition; or diuilltS5 nd faiming to the heahh care prO'lidl"!.

Continue to monitor periodic: lab wor\I;;hl'p;ltic: and rtoal fUnction um, CBe.
C04 (ounl5, HIV RN~ ma)'~lipid ~Is, ~rum amyb~, C&S if(onrulll'nt
in~tionsil~ prt"IeIl~and gllKo~.(Drugs ulf<l for the lR'atml'nt ofHIV illI'
htp~tit: . nd 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 ~nd ICrum .mylase will k monito~
to asses for p;ln{lI'atitis and gkKOI~ Im-b chl'dtd for h)"lll'rgl)'lemia.j
Monitorfor h)1ll'l"~nsitivity ind ililergic: lI'"tions,tspttially with tilt first
~ of.ny ilnti~lIl'/iral or proteom inhibitor. Cootinul' to monitor the
p;lti!1lt as IIffiItd bastd on tilt drug usrd or tilt patieni's{ondition.
(Anaphy\olaic: I"I'<lctionsarf polsiblt,panic:ularly with zakitabiot. ~USI'
~.aioos milY not .lwil)"! bt prtdiuilblt, cilution ~nd fll'quent monitoring
art !1~ntial to l'OIUrt prompt trNtm!"Illj
Continue to monitor for IItpatit and II'IIiII toxitities.(AntirtirOOrab <l nd
prote. ~ inhibitors m.y be hepatic: ilnd lI'IIil toxic: ilnd ~uift' fll'qUtnt
monitoring to pll"<'tnt advers~ ~ffts.ln{lNsing fkJid intalct will pll"<'tnt
drug icrumulilUon in kidnl')"i.)
Continue to monitor for dermatoiogic: tffts ilKluding ft'd or purplish skin
ralh, blisters,or pr~ling skin, induding oral muc:ous ml'mbr'III'I ..wm oral
murous membriln!1 for signs of ltomatitis, i ldrug tffffil or
immunosuppl!"lmn may Il'IUk in thl' amgrowth of oral fIora.lmmtdiateiy
~port ~rt lilShts.!'Spttially ilSlCKiattd with blilll'ring. (Thesl' drugs may
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., drowsin~~ diniOl'l~

ml'ntal changt~ insomnia, delusions, pal!"lthflia~ hl'adadl~, change in
LOC,.nd ~izull'l.(Milny HIV-AIDS drugs UIM periphl'lill OI'uropathy and
h. 1'l' n~urologit .drr..... dftct>.)

InstllKt thl' p.tiem on tilt r--t for prriodK bb work,(orrNting iny

symptoms with OI'l'd for possible labs (I'.g., sl'rum amylil~ if the p;ltitm is
having upper abdominal p;lin).AdYM lab pmorlOl'I ofHIV status.

Tm htht p;ltitnt to immtdiately ~port.ny itthing;r.shes; 1'M'1Iing,

p;lrtirularly of f"f, tongue,or lips; urtiuria; fkJshing;diniOl'II; l)'IIropl';
wl-ftzing; throat tightOl'ls;ordiflic:ull)' brNthing.

Tm htht p;ltitm to immtdiatt ly ~port any naUSN, vomiting. yellowing of

lkin or !Iltr.,dbdomin.1 p.in, light or clay-{oiored llools,ilnd diminishrd
urin~ output or dlrkt ning of urillt.
AdI'M thl' patient to in{ft'~ Auid intillet to 2 to II ptr day.

Ttath tht p;ltitm to inlpffi oral cavity at 1t.1I on~ a day and maintain
II'9IJbr denull'tiIm1. Maintain good oral h)'gient .nd rin~ mouth with
plilin water or IOknion ill PlI'I(rib!1l by tilt hukh call' provider after
fating.U~ protfltil'l'(lothing for sun fllpOsure and immrdiatei)' repln
any signific:.m rashes or sunbumtd apptaralKl'.

InstllKt thl' patiem or cilll'givrrto immrdiateiy ~ ilKft'asing

headac:ht,diuiOl'l~ drowsinffi, WOIll'IIing insomnia, numbnts I of hands,
ffft or o:t~itit~ ilnd changn in IIth ....ior or LOt
Caution p;ltitm th.lt drowsin!1s may O(rul.nd to becautious w~h driving
orotlltr oKtWitits ~uiring 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 ma~ ltIt~n9 murile
temperiltuft' m~ diffic:ult
ElKourqsftp h)'gm mt.lUr6,f.g., I!"Itful rootin!1 befOll' b!1l and
avoiding largr mtab within 1or 2 houn of sleep. HiY!' the patient (OIIIUk
with the he.alth U~ p~ ifinsomni. u"' .. dayti ..... slt~piOl'I< or
(ontinues.

Monitorfor signs <l nd symptoms of blood dyscrasias, I'.g., tow.grade ~~

bletding. bruising. and signiflGlnt fat~. (BOllI' II\jrrow lUppll'lsion may
O(rur ilnd may CalM blood dyscrasia! with r~king clec:lI'all'l in R8(~
WBC~andlor plateltts.Pt riodit monitoring ofC8( will lit ~uired.)

Teach thf p;ltitnt to ~port <lny lowiJrade ft'/!1I,IOft' thrOil~rillhts,

bruising or incl"l'asrd bltl'ding, and ulR/IUal fatigueor shortrolofbl"l'ath,
!'SprOaIIy aftl"! taking t~ drug for <I prolonged period.
(commued)

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NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY FOR HIV-AIOS {COnltluPd}

Implementation

Interw ntlons and (Rati onales)

Patient and Family Education

Monitorfor signifiunt GI effis, idldiog_~. YOIIlirillg. abdominll l

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 ~ 0I~!td IImks, wiml mllYUIIIt S!omid! upstt.
Enr:our'9t the p,\itnt \(I try snwll, frequmt meals,.midl
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 ob~g , dittary
consultation ~ ~ if IIiUSti OIdiirrhu makes lnainuining intilkt

!)liin Ofcnmping. "Id ~,.Administ~ dru~ as pH guidtlinfi:Some

rtqUi,udministr.uion on ,ft tmpty stomadl. some wit!J food 01 milk.
AdcIiIion.lI p/"'_oIogK Iftatmtnt may bt IIKtslafJ to fimit mM GI
Ni"Hts.Emull' ~uatf nutrition.oo {,1liiie: nab.-. (.I.dwfw GI fifKh oft
cornman to most iIltitttroWals uld protme inhibitoIl. AIw,)'S (h~
,dminimation guidflillH bffoft' idmin~tfrincJ with OIwithout food
0Imil.)

N,

diffiru~.

MonilOrfor symptoms of !)li1Kft'ltiIis induing ItYeIt IbdomNi piin,

dislmtian.(5omt ,nIiIl'troviril drugs IIKh
IS didlllOSior ntl, UUIt piIl(ll'Ititis. Strum Irnylalt Ind ~pid !Mis should
bt monitorrd pHiodiully.'

I\aIMa, I'Omiting,.nd abdominal

Monitor blood gb:OSt in ~lients uking 'ntiret1Ovir.I!.(Thtst drugs may

Wist h)'p('rgtycmli.J.1Mbrtic piOOn may lfCJJill" dwll\Jf in thtir

Instruct the !)lititnt 10 !!port!Mr, _

.bdom......1paW\, fliustl,
I'Omiting"nd alxlominal <inrntion irnmrdia~.

TtJCh tilt GllbttK patient to tHt gkloose molt ~t1" Il'pOItiIlll ~

(onmlenl flmlioMlo the heillth Ull' pIO"fidK

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.)

Tor;h tilt plItitm ~uatt .. lrdian oontrol.nd hl9ienf IIlUSUfH wdI

.S frtqJtnt h.ndw~hing. Mlidiog (rowded indoor pLtces..nd adeqllilt
IIIItritioo.nd 1!11,~iilly if WlIl'rdy immunCKompromilfd.
PllaKe ibstinmct 01 itlwiYS ust b.uritf piotK1ian IiJring ~~I 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 9fOUps.An~t
multidis<iplinif)" iPPro.adL)
_ _ _+--'''''
:::c"=~ wilh ~t ~ 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 pititnt, family,Of {.regioItf should be .ble to ltaft tht rt~on for tilt
drug;i1J11lrt111rWtf dose ind KhtOJling;wlwt ~ tffHts kl obII'M" lor
.and when to rtpOrt;ilnd tilt inticipi~ length of mtd"1UIIion thera",.

the bu~h em pn:Mdt~ilnd i ny nKfWf)" monitorill!l 01 plt<autions.

(Using timf 6.mg IIJBing Uft' hdps to optinm ind ~fon:e key tor;hing
.!!~)

Piltimt n lfilciminiltr. iOll of dtllg therapr.

Whtn .dministtring mediutiom,."struct tilt p.atifl1l, bmiiy,or Ull'9ivtr in
Propel" ~K-adm~tration Tt<hn~ foIlowrd bt' Il'tumdtmon\\fMn.
(Proprr idmirmb1Iion incll"lfI tilt ~I of thtdrugJ

Tor;h tilt p.atitnt til ukt tilt mtdiutian il~:

Complttt the mtn COUM of thtr~lInltss otherwise ill$truct!d. The
duration of tilt rtqllirrd thtlolPYI1WJ be quitt length, but it is
nt(H~f)" 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 nwilli akohoL
Tau me drug willi food or milk but amd acidic btver.IIJH. KillStJuctrd
to ukt rill' drug OIl ntm pr, stOlllidl, takf with a fun gIas.! of Wilier.
Tau me mtdiutioft ' I fftIlly lpiCed throughout fach Iii, IS feMlle.
In':Il'i~OI'l'Ia/lfbd inulDtwhilelilking~drugs.

Evaluation of Outcome Criteria

E'lilluil~ thf ~t<tM1II'11 of drug

tIItrap)o by ronfinning thl! patimtgoals.Ind ~ ouI~ ha~ ,,",0 mt!: (lft,1'Ianningl .

Str TobW ~ I fllf alitlXdfIJlJlla .mi:hrhm 1U1inftilrzr

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o..p!tr]&

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 pre~nting the final maturation of the
virions. The virions 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 treat~
ment of HlV-AIDS.
The Pis are metabolized in the liver and have the potential to interact with many different drugs. In general, they
are well tolerated, with GI complaints being the most common side effects. Various lipid abnormalities have been reported, 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 Guidelines 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 intervals 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 optimistic that the spread of HIV infection would be pr","~nted
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 child~
hood, offering lifetime protection against the fllal disease.
After decades of research, scientists are still far from developing 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 VaCcines produced thus far only boost the immWle response;
they are unable to prevent the infection or its fata l consequences. 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 ~spect.l 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 gene rally poor; thus, the best approach to dealing with HIV infections in neonates is prevention.

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ONg,lorVI,. lInlectlo,,,

537

In 1994, clinical trials determined that perinatal transmission of HIV could be markedly reduced through pharmacotherapy. 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 infe~tion 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 essentially 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 congenital 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 zidovudine 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 infection from their HIV-A1DS patients. Fortunately, if proper
precautions are observed, the disease is mrely transmitted
from patient to caregiver. Accidents have occurred, howe~r,
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-careworker 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 demonstrate that PEP is successful in certain circumstances. For prevention 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 b~.Ieline 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 decided 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

53 8

UnitS The Immune SY"'-""

was sufficiently severe and the source fluid is known, or

strongly suspected, to contain HIY. Using PEP outside established guidelines is both expensive and dangerous; the
antiretrovirais used for PEP therapy produce adverse effects in more than half the patients. The basi, PEP treatment 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 increases 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 intensity 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-

L IFESPAN CONSIDERATIONS

HIV in thlil Pediatric and Geriatric Populations

(hildll'n infemd with the HIV viM appw to dtYelop opportunistic (onditions u a mlKh mOIl' rapid ra~ than do <ldult;.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 aII antill'tlOiral meditations can lit ustd in ptdiatric p<ltienn. Proplr;la<tit tll'<ltIIlI'm <lgiinn P. {~irJi 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 ime~ mtdKation Il'gimrn and also must he awall' of thr Nrlys)'IIIptOlllsofopponunistitdisri16.
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' {onsidmd high-risk bthavJlU. The gfflatiK palienfs I"ftd for <lmill'llOiral tfNlIIlI'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 00ciattd with <lgng ilKft'.N the pos ~bility of drug mity in this population. The
sodal faaoo must <1110 bt oonsidtll'd. btuIM these patients may lit rlYing
aloneor~ he the primary(aIl'lilRr d a dis.JbIed !pJUse.The ability of <I patient to lit Sl'XllilII~ <l(tivl' is not detennined b~ .;thell'fOll', it is I'!'ry importam 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 includes the following:
HSV-l primarily causes infections of the eye, mouth,
~nd lips, altho ugh the incidence of genital infections is
increasing.
HSV-2 causes genital infections.

TABLE 36.2 1 Drugs for Herpesviruses

DN,

Route and Adult COse {max dose where Indlcatedl

Adverse Effects

SYSTEMIC AGENTS
Q oK)'dlWi (lO'li"axj

PO; 400 mg lid

IV:" - to mg"'g ..MY 8 h 10< 7- 14.uy<

ddofcwi I'mtide)

1V;5 mgi1o;g ()II(e wMIy for 2wnltWli~ wk

famddoYir (ramlir)

PO; SOO mg lid fo< 7 dayslmax: 1:;00 mglda)')

foIamet lFolGllir)

IV;0-60 mgl\g infwdO'f1'l" 1- 2h tid {max: 180 mgl'gldl1)

~ddcwir (CytIWrnt')

NQlIlfo,lI1miring.diorrhM, irfOOhe,pllnooo
ifiecrioo fire! (ptnflftfllJ O9fIIrl"J

imlflmmo~OfIIX

PO;1 gtid
IV; 5mgJ1o;g nfusrd IWrr 1h bid

'fai<l(ydlWi ('hkll'J)

PO; 1.0 gtid (max:] g/day)

TOPICAL AGENTS

doc:osanoilAbrm)
idoxmlH' ([lrndid.lk!plrx)

TOjiul; 10% lJI'am applied to {old lOll' up to fi.". timel/day for 10 days
TOjiu~ 1drop in 00 ~ MIl hall" cUing ~mg hoo.n <lnd N~ 1 hr

dumg the night

pmddcwi (()malirl

TOjiu~<lppIy e'/rry 2 hwh~r awakr lor 4days

--

&mflg. ;';ro~oo. or sUrgn; at fill! ofoppirrxion.

PhoIophobia,k@op;Ithy,andtdffi\aofC'lrid}
(lKularagen!51

=,~,'c.::
drop in 00 ~ MIl 2 hdll"ing waking hoo.n (max:9 ctopsI
,="'
='_L___
triftmne lViroptic:) _ _ _-'-'Copc"

Irdis inditate{Oll1mon ~effem;.llldali!ing.ind iutes s.ffious adm~ elfem.

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Chaptfll&

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, o r emotional stress can promott' active replication of the virus and
appearance of the charncteristic lesions. Complications include 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 pati~nts for the remainder of their lives.
Initial H SV-! and H SV-2 infections are usually treated
with oral antiviral therapy for 5 to 10 days . The most commonly prescribed antivirals for HSV and VZV incJudt' acyclovir (Zovirax), famcicJovir (Famvir), and valacyclovir
(Valtrex). Topical forms of several antivirals areavailable for

~ Prototype Drug

OrugslorVlr.llnlectlorn

539

application to herpes lesions, although therare not a. efIeetivt' as the oral forms. In immunocompromised pati~nts, IV
acyclovir may be indicated.
RecurrenT herpes lesions are usually mild and often requ ire 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 experience particularly severe o r frequent recurrences (more than
six episodes per year) may bfnefil from low doses of proph ybcticantiviral 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 p ainful, 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 acquir~ ocula r herpes, they often experience recurrences,
which may occur years after the initial symptoms. Ocular
herpes is treated with local application of drops or ointment. Trifiuridine (Viroptic), and idoxuridine (Dendrid,
Herplex) are available in ophthalmic formulations. Oral
acyclovir is used when topical drops or ointments are contrairxlicated. Uncomplicated ocular herpes usually r~solves
after 1 to 2 weeks of pharmacotherapy.

I Acyclovir (ZOVlrax)

Therapeutic (lass: Antiviral for he!pesviruses

Pharmacotogic CLass: Nucleoside analog

ACTtONS AND USES

ADVERSE EFFECTS

A~

Therr.rr ffW idYl'~ f JfrcU to aqdovir whtn it is administf~ topically or

ora I~ .lleph rotoxicity is possible whtn th!' mt<!ic:ation is givtn IV. R~alKl' ha I
drYelo~d 10 Ih!' drug. panic:ularl)o in patients with HIV-AIDS.
Conmindimions: Aqdovir is (onmindic:.JIt<! in patitnll"';th h)'ptntnsitiYity toau!jS in !his dass.

by t~ fDA in H8l ~I 0lIl' of t~ finl ~mivirll drug~acycloYir is limitt<! 10 pliarmac:Ollierap)' for ~rpmillM1. for which it is I drug of dIoic:f.1t is
moSI eff~ 'gainll HSV-l and HSV-2, ~nd fffKtiYl' only at high do~
~glinll (MV and varierlla lOIter. By p~ting viral DNA s)'rllhesis,acyclovir dr(INSfS t~ duration Ind ltl'frit)' of aMf ~rpes tpilodrs. Whtn giftn for prophylaris. it ml YdKrNl!' t~ frequeoq of herprs appNranc:~ but it does not
<Urt tho pal;' nt It is "".ilobk .,. 5% oinl"",nl for opplic:.nion to .<lM: lesions.
in oral form for prophyln~,. nd u an IV for ~rr 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
~k: I.5-2h

Halflife: l.5- S h
Duration: 4-8 h

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INTERACTtON 5
Dru;r~rug: (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 BUNam !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.

54 0

UnitS The Immune SY""m

INflUENZA
Influenza 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 airborne droplets. In immwlOsuppressed patients, an influenza 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
th~n ~8e 65. Influe""" v~ccin~tjon i.
reconunended for
health care workers whoare involved in the direct care of patients at high risk for acquiring influenza, including HIYinfected 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 details 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
~ars. Chemoprophylaxis with amantadine or rimanladine
(flumadine) is indicated for Wlvaccinated individuals duringa confirmed outbreak of influenza typeA. Therapywith
these antivirals is sometimes started concurrently with vaccination; 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.

"'.0

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
"",ll~IIIivif (Rd"flZ~ ) ~re f~I'Url"U

Iu

~hurl"Jl

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, prevention 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 differt'fIt viruses, including rhinoviruses, cause symptoms identified 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, fatigue, 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 contaminated food.
Although approximately 20% of HAY-infected patients
require some hospitalization for symptoms related to the infection' most recover without pharmacotherapy and dewlop lifelong immunity to the virus. Fatalities due to
chronic disease are rare, and only a small nwnbt'r of patients

TABLE ~6 ~ I Drugs for Influenza

Drug

Routeand Adult Dose (max dose where Indicated)

Adverse Effects

INFWENZA PROPHYLAXIS

Jmantadinr (Synmeutll

po; 100 mg bid (ma1:400 "'9Id~1

rimantadinr (ALrnadinr)

PO; 100 mg bid (mal:lOO "'9Idiy)

INFWENZA TREATMENTT: NEURDAMINIDASE INHIBITORS

osekamivir(Tamifluj

PO; 75 mg bid foI 5 days

I.ouwmivi (Rtltnza)

Inhala~on;l

inhalJtiooIIday foI5 days

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leutoomia hall!KiDiljrm oWCP!U!jc byoO!emjon urinary

"""'"

Chopt.. )!; Oru9.lorVlrallnlectlom

develop severe liver failure. Thus, HAY is normally considered 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 trea tment for HAY is
prevention. HAY vaccine (Havri:l:, YAQTA) has been available since 1995. It is indicated for children living in communities 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:umatel), 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 recently exposed to HAY includes hepatitis A inununoglobulins (HAIg), a concentrated solution of antibodies. HAIg is
administered as prophylaxis for patients traveling to endemic areas and to dose personal contacts of infected patients 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 specific drugs are indiClted; in otht'rwise healthy adults, the infection 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 between men. Health Clre workers are at risk because of accidental 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, because 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 ~rs
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 cirrhosis. 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 vaccine (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 children 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-

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54 1

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 exposure 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 approved 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 medication 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 effectiveness as adefovir. Entecavir and tenofovir offer new treat
ment options for patients who have developed resistance to
oldt'r medications.

HEPATITIS CAND 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 gre~te'l clinic:\] imporhnce.
Transmitted primarily through exposure to infected
blood or bod)'fluids, hepatitis C virus (HCY) is more common than HBY. Approximately half of aU HlY-AIDS patients 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 prevent 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 includes several types of interferon and the antiviral ribavirin.
Combination therapy has been found to produce a moresustained viral suppression than monotherapy with either agent.
Conunercially available interferons for hepatitis include both
the regular and pegylated formulations. P!qylation is a process

542

UnitS

The Immune SY"'-""

TABLE 36.4 1 Drugs for Hepatitis

DN,

Rouleand

Adult Dose (mall dose where Indicated)

Adverse Effects

INTERFERONS

i1ttrfioroo oIHoIto;n.l ~lnfell1l'n)

i1ttrltroo .~.", ~Wtllftroo)
Q

inll'rfmfl altt.2b ~Inlroo A)

SlbartantOlJl;911K9 th~ t~ for 24 wi;

f1r1ikr J}'m~ myoIgio, fariquf, I1todoch(,

S!bcutantOlllJ1M;l milhn ... ~. thltt ~mn/wII for-l8w1!

alriUJia,dDrI!ta
M~

SlbartantOlllJ1M;l miItiOllIll~!/m' th~ ~~

Pf9intffi~roo oIH,-201 IPrljal~ j

SdKutintOlJl; 180 IIK9 of 1wk fOl48 wk

Pf9intffimn iH,-2b (PEG-lntlOO)

SdKutintOlJl; 1 rnt9fkgIwk for monOlhffiP'1; 15 g/bj/Wk

whtnlj'lffiwilhrWiirin

throrrbxytoprnia,wicid!:

id!:at"OII

NONINTERFERONS;COMBINATIONS

lIItfO'lir dpiYmi (Htp\e'oI)

1'0; 10 mglday

,(srhm'4 ht<!docht, MlI~ dilliMl'l, fQ!i~t,

ffittc.lVr (BariWdt)

1'0;05 mgld.Jr.l mgld.J,.!SoI ~fIIj~ 00Ie for patimn with

n<mldimJrOOOCPl (1omirudl"l/!J

hilltf)' oi'lami'lOOirll' rtlisLJrKl'

NffilltlloxKjty and 1KIk: 'tidosis (i!d!;foli(

Ii I

lamivucint (Epivr HBV)

1'0: ISO mg bid

ribalirin (R~rd)~nttrfioroo alf;t.2b

(Inlrd A):CombinatiOll ~ ulled Robtuoo

ribalim:PO;fi'I!' to ~x, lOO-mg ups*sd.Jily

inttrltron aHrlb:SubrutiOOlUl; 1 milion inl~maliooal units,
th~tifM!Iwk

tttiwdine (T)'lK.JJ

that attaches polyrthylene glycol (PEG) to an interferon to

extend its duration of action, thus allowing it to be administered less frequently. Whereas standard interferon formulations must be administered three times per week, pegy\ated

NURSING PROCESS FOCUS

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.

PATIENTS RECEIVING ANTIVIRAL PHARMACOTHERAPY FOR HERPESVIRUS

INFECTIONS

Asse ssment
Bilst lin e asessmrnt prior to administration:
Undrotand t~ rtillOn t~ 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 d~iI~,ilnd t~ possibility of Pll'9nilncy.Obtlin
,drug history indudifllj alltl9~s,intk.odifllj spedfK rN(tions to drugs,
(Ul!ffit pmtription ,nd OlC drugs, hmlal p~rations,and akohol UI~.lk
to possiblt drug intffiKtions.
AsIfS:i ~gns and symptoms of tUIll'M infection noting on~~duration,
dWri{\frinks,.nd prtSl'II(tor .bmKe offewor or pain.
Enwtt ,ppropriate laboratory findings (e.g., CB( ~patic: ,nd rmal
function lIudies, firal tulrures).

,It"

Asstssment throughout administration:

AsIfS:i for ~ill'd therapl'lltic: ~fft(1I (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 fifr(\~ n~UII'a, vomiting,.diallhtil, anorniil, fa~,
drowsines~ dizzintS~and ~oIr1at~. Dwtnd urint OUIput 01 rlarl:entd
urine. incll"std bruising or blt~ing,.,nd intINsifllj f~~ror symptoms of
inft(tions should be Il'pontd imm~diilttl,.

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Potential Nursing Diagnoses

lnfffiion
lmp,ill'd Oralll'lJo)us Membranes
lmpaill'd Skin lmtgril)'
FatMJie
Activity Imoleranct
SCKialllOlition

Oefi<iem Kmwltrlg!' (relattd to di~a\t proc:6S, tr~nsmission. and drug

therapy)
Risk for D~fKitnt FkJid Volullll' (Il'Iatl'd to diIN ~ process or oidl'ern drug
",<><lion.)
Risk for Imb:alancrd Nutrition, ~s Thiln Body iltquill'l11tnts (Il'latl'd to
d~a\t proms 01 aamJl' drug Il'adionsj

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIVIRAL PHARMACOTHERAPY FOR HERPESVIRUS

INFECTIONS (Conlflluea')
Planning: Patie nt Go als and Expe cted Outcomes

Tht~t~mwt

ExperitrKt ItImJPtUIic tffb (e.g.diministlf'il 01 ~ of sigm 1M symptoms ofinitdion,/II:IIf to mlintain rUrition 1M h)dRtion).
~!rl't' from,OIflptMnu' minillW~ iCIftrw tfftru.
Vt!b.llizt in undtrmnclirlg of tlltdrug's 1M, iltmse tftects, Ind ~ preuutions.
DmIonslrille proprr ~-Idministratioo of tilt medil<ltion (e.g.,~ timing, when kl notify proUr).
Implementatio n
Interven tio ns and (Ratio nal es)

Pati e nt and Fam ily Educati o n

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
immediate~ oin.m.bit.GrDwI impromnmt should be noted Ind tfw,
patient shOllld be eocourqd 10(omil'l\lf fiting meditation.)

Turn tht INtitm III not <iw:0II00U!' drug rtqimtn whtn~1ing bette(
on! to uke the fill (oolltof mecflUtioll.
[Moorq ilCItqullf nutrition, ~t..nd ~ IfflIs as impmtrnent is
Mol

Mi nimizing aCMm effects:

Continue III monitor vila! signs. lmll'lfliitt~ fl'port irKfI'ilYng ftlft,
cl"lUiness,.hNdKhe,or diminishtd UriM output to tht hN~h Wf pnMdtt
(klcfI'illing~, e~ wflrn i{(Dmpanied b)' worwning symptom!,.
1liiy be iI\ign ofWOBtning i1~ion OIIIMfWdrug tfftmJ

Tuch tht INtitnt, flmily,oru~ivtrto p!OIIIpIIy fI'IIOfI fI:omthat t1Cr('Ik

101'f, 01 per pirJmtlm; iII, biIiry 10 mainuin hydr Mion or l1li1 tiTian: 01
diuintss to 1M helkh u~ proidtr.

Continue kll!lOflitor ptriodic lab worHlK,llep.atk .lIld fI'IIll functiOll t~b,

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.)

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.

Continue III monitor for heopni( and _tOJkitit!.. (HepatM; ilnd fl'1IiII
tolic~itl trIoIyour Ind ~ frtqutfll mOfl~OIing 10 prmnt ~
rfttm.lnuming Auid ifIIakt mlY pfl'Wllt drug aCl:lrmuiltion in kiclnfrs.)

Tuch tht INtiefll to immtdiate~ 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.

Monitorfor signs.nd symptoms of nflllOl<lOOty, PlrtKulirly in paOmuoo

r'i iI(1(1oftt e.g., drowsiness. <illillfl~ IIfmOB, hudi<1w. (l)llfuIioll,
dlinges in I.OC. ind ~En",fI' p,lritnt Solftty ,nd 1Ia'fe the patient rise
sbNly from IJing or sitting It sllnding. (kydoyir, ~ wht ngMn IV.
may be 1IfOOI1I)lic.)

IrtStnKttht p,ltitnt, f.mi1',:01 u~i~r to irnrMIiat~ ~ inCIMSJg

hudac:ht,dciIn~ 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 11ow~.

Monitorforsigns.lndsymptomsofblooddrwasi.u,f.~blttding,~

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.
EIIIU~ acltquilt nutrition Ind caloric inQkt.(~IItGI tfiecBar.
common and tfw, pitient m.,-.iso h.M dis6\'HtIa~ tlfB, . g. moW!
SCRS. Milinllining idf<lllilt nutrition .nd Iirids is tsstntilho hti 6ng.)

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 ~titlR 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 (Ration a les)

Patient and Fa mily Educatio n

n(OlJragt infKlioo ronlrollnd good hygitne mealUll'S baIfd on disNs~

oondition, and follow th~ Ht.lbliWd prouxol in hOlpitalire:l piltiffits.
(Antiviral drugs de<rn~ tho! IMI of infectiGn but do nOl cure tho! dilta~.
En~lltm h)'9ien~ me.uull!! will limit ihechancf for Iondar, infrctions in
lhe immunocompromisfd piIIitnt.lnfKlion control mNwre ~m
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 advmefflect~ pilramtl~ for when to ull thf
heakh (1ft' providf~and any nKflWr, monitoring or prKautions.(Using
limf ruring nUBing Wf helpslo optimizf and reinloo:~ key 1N(hing
aR'as.)
Patimt selfadministration of drug therapy:
When idministfring medKltion~ inSifIKI the piltiffi~ fami~, or clR'gil'r
in thf plOpfl5elf-administraiion Ieo:hniqws followed by II'tum
ritlOOnstration. (Proper administration will implO'/f the f ffectiveflfS sof the
- ... >

Tfaoc:hthe pillient idtqwtf inftction conlrol and hygiffit mfi 5UrH 5U(h as
frtqUtnl hind washing. appropriat~ di~1 of dll'ssing material. and
arltqwte nutrition and 16t.~specially 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 isim~lm
Tfaoc:h the pillienllo practKf abstinence or to 1M barrier protfdion during
~I oKtivity mil if gtnital ~ionlarf 001 pres~nt.Gfnital HSV infruions
may bf traosmitted eY!'n in Ihf i symptomatK period.HaI'!' the patient
oomuk with their heakh !arf proYidfr aboot 5Uppres~ve therap)'.
Tfaoc:h the pillienl on oral aoc:ydovirto incl"f~ oral imake prior to LIking
oral aq<loYir and inclNlI' fluids to II pfrday thfOl.l9hoot therapy.

The piltienl, fami~,or(aR'giY!'r 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 ~tiR' {OUIIe of theraPl' unll'sl otherwilf instrudN.
Take the medi4:ation i S1'l'fl1y Spilled thfOl.l9hOUl mh day aliNsibll'.
In(ll'~ _rail fluid int.lkt.
If using oimmfnll orcreams, wash hands well btfm applying and
I~ 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 ~n 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.

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36.2

HN targets the T4lymph ocyte, using reverse transcrip tase to ntake viral DNA. The result is gradual destruction
of the immunf system.

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 (asymptoma tic) phase
of HI V infection.

16.4

Drugs from !lYe drug classes are used In various combinations in tbe pharmacotberapy of Hl Y-AlDS. The nucleotide reverse tranS(:riptas<> inhibitors and th... fusion
Inhibitors hnve retently befn dlS(:overed.

36.1

The risk of perinatal transmission o( HIV am be

markedly reduced by implementing drug therapy of the
mother during pregn~nt')'. and the newborn following
birth. Postexposure prophylaxiS of HI V infection is designed to pre"ent the accidental transmission of the
virus to health art workers.

36.&

Pbarmacotherapy can lessen thest"~rityof acute herpes

simplex infections and prolong the latent period of the
disease.
Drugs are available 10 preven t and to tren influenza in fections. Vaccination Is the best choice, as drugs are relativ~1y In~ff~ctive onc~ influenza symptoms ap~ar.

36.S

Tbe reverse transcript ase inhibitors block HIV replica tion at the level of the rewrse transcrlptase enzyme.
Th~ include the NRTIs.. NNRTls, and the NtRTIs.

36.9

16.6

The protease inhibitors inhibit the final a~mbly of the

HIV virion. They are alwll)'s used In romblnatlon with
other antiret rovira1s.

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.

NCLEX-RN . REVIEW QUESTIONS

When the patient Isstartedon antlretrovlral drugs for HIV.

nursing ed ucation 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

3. "You need to bevacdn:ttedonly If you are older

than 50.
4. ~'fhe Infectious particles are not easRy spread. and you
C1n mit 10 be vaccinated until there is an increase In the

popu1ation."

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

The nurse und erstands thai the laboratory tests th~t must
be a5&.'!iSed. while a p~tient is on drug thenpy for HIVAIDS ~re: (Selt'('t aU that apply.)
I . Csc.
2. clotting factors..
3. HIVRNA.
4. CD4lymphocyte count.
5. BUN.
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.
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 mOl\ths..~
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."

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A patient is started on efavlrenz (SustlV1). a nonnudeo

....

",,"

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.
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.

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
com plying 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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Drugs for Neoplasia

DRUGS AT A GLANCE

LEARNING OUTCOMES

AlKYLATI NGAGENTS

Arrer reoding mis ,hapler, rhe 5ru~nr should be able to:

plllJr551

Nitrogen Mustards paJt 555

Q cydopho<phamkk (eyr"".n)

pi1J' 556

Nitrosoureas I""Fm

1.
2.
3.

ANTIMETABOLITES p11l1,,5J
FoHcAdd Antagonists p m
fII11' 557

4.
5.

PyrimldineAnal ogs
PurineAnalogs

fIIlIJ'm
1'11'1<'555

Q dorotubkin (Mriall1ycin) poJr5'i&

Explain the significance of growth fraction and the cell cycle to the
success 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

'" vincrisriM (Oocovin) JllX!'56IJ

representative drugs,and explain t heir mechanism of drug action,

primary actions, and important adverse effects.

T~xa nes fIIl1'559

Topolso merase Inhibitors fII11'559

10.

(~ mptothed ns p 559

HORMONE AND HORMONE ANTAGONISTS

fIIlIJ' 559
f1l1"56IJ

Estrogens ~ nd Estrogen Antagonists

Identity the three primary therapies for cancer.

increase the effectiveness o f chemotherapy.

NATURAL PRODUCTS pDt}'558

Vln t.l Alkaloids JlIlIJr559

Q rall10xjfen

lif" styl"f.. ctor. ....oc .. t"d with a ,-,.duc"d ri.k of acquiring

6. Describe the nurse's role in the pharmacologic management of cancer.

7. Explain how combination therapy and special dosing protocols

paJt554

GlurocortkoldslCortkosterolds

D".cri~

cancer.

'" mf'thorruou /Rht um<J!ra, TraaN}

ANTITUMOR ANTIBIOTICS

Explain differencM between normal celis and cancer celis.

Identity factors associated with an increased risk of cancer.

paJt 56IJ

Categorize 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.

paJt 56]

Androgens~ nd Androgen Antagonists

BIOLOGIC RESPONSE MODIFIERS P!XT 56J

paJt56 1

KEYTERMS
adjUYilnt memoth<Ipy

plJ/}r55(J

. Ikyl.l i ln paJtm
alopfdil p<q m

aromatas. inhibitor

pajI' 561

{amptothfdn f1XJd59
can{l'Ifm linomii fJI1J' >I/J

dlemotherapy

jlIlIJd 49

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emetic potential jIQ}' 55<

growthf..<tion puq< m
metastuis jIQ}' 5#J

ta .. M 1'"'1"" 9
topoilomeril.1 fIIlIJ' 559

mucOlitis {I/1 Id5]

ni dir fIIlIJ' m
n@Opl.n m fllXT54Il

tumor fI1IJ' 54lJ

nsicant fI1IJ'5jJ
vinca alkabids fIIXT 559

palli.nion fIIlIJ' 55(J

S48

UIIIIS

The Immu"," S)"t""'

<lIneer Is one of the most feared diseues In society for <lI

(

number o f v<ll~d 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 ~fe.Thls chapter
eumloes the role of drugs in the tre<lltment of cancer.MedIGltlons used to treatthis dsease are Gllied onticoncer drugs,

B_ _ r

u..g ....

- Figure 11. ' Invasion and metUti)sis by cancer c~ls

ontintop/ostics, or cancer chemorhera~ric 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, suppreswr 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 controlling cell growth. Once damaged, the cell is no longer responsive 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 ch~r
acteristks of UflCe1' cells.
TUIJIOt is defined as a swelling, abnormal mlargement, o r
mass. The word neopImn is often used inttrchangeably with
tumor. Tumors may be solid masses, l uch as long or breast
cancer, o r they may be widely disseminated in the blood,
such as leukemia. Tumon are named according to their tissue of origin, generally with the suffu: oma. Table 37.1 describes 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 exampll', 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 associated with a hilther incidern:e of uncer in the workplace. In

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some cases, the site of the cancer may be distant from the entry location, as with bladder canar caused by the inhalation
of certain industrial chemkals. Some known chemical carcinogens are listed in Table 37.2.
A nwnbl'l' of physical factors are alw associated with cancer. For example, exposure to largl' amounts ofx.rays is as50Cialed with a higher risk of leukemia. Ultraviolet (LN)
light from the sun is a known ClIw;eof skin ca ncer.
It is estimated that vlr~ 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 n~ttd!!wot _!!won 1,400,000 lIN Ci/lCrf (ISH oaur ~h
I'N~ with _!halt Wi,OOO de.tta (~ l.soo ,",*00 lily).

Unc<'l'is the dIiri 00It of de~tft t.,. di~ in dJidrm ~!haIt

.,.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 2~ of.H
(llKfr deaths.
PlOItatf (jlKfr is tilt SKOnd ltading (aJSf of (llKfr deuh in TIl<'I'l.
Ihf hightst s.-~jr survrval ratHa~ 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 ~m.inWding t"'-ofthe lulllj, brNm,.1111
pfOnatr;~ 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,

TABLE 37.1 I Classification and Naming of Tumors

Name

Description

Examples

BffiilJl tumor

Slow growiog; ob I OOIlMiSLlIIzr ind rartly rrquile d1Jg Ul'..ummt

Adtoomi.~lilloma and

Cardnoma

Call(~of tpithtlial

MaIi!Jlint ml'lallOllW, mlal (til WOOOllli,

odMo<irOllOllli, htp>.ortilular aui ........
TtiangimuK ~iOllU, braillt!'fl! gbma

tissUl';mO\l(ommon I)'pt of mal~t ntOpIism;,WII

... picly.nd m."<ta<izg

Call(~of 91011 ~nll'rst~ial)

(til in tIM' brail,ijlinil (ord, pilll'al gland,posterior

lpom.1,olleoma,mmingioma

piRitary ~nd,or rttini

bIood-foming ttisin ~ marrow; may btarut~ or cMlnK

LN:emia

CaIl(~oftlM'

Lymphomo

.,-

Call(~oflymphoid

Mali9:lant tumor

Growsrapidi)\ be(~ ~l1.Ilt to treatm~nt and ~ i1 duth if!llUNtfti

mlUf

H~n\ dilta\e, IymphoblistK lymphoma

Call(~ of conllKtiv! ~ 15Ut; IJOWI utr!'fl!tiy Ii piIIy ind lMiSLl~m tarly

in tIM' pI'tqtIs.ion oftlitoNaII'

~ Bl! 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!

Tobi(m 1ID1la1l(6

lungandlkin
luog;hudarodoM

Vin)'ldl~

""'

Some cancers have a strong genetic componem. The fact

that close relatives may acquire the same type of canc:er suggests 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 associated with cancers ofthe breast, lung, brain. oolon, and bone.
Although the development of cancer has a genetic component, it is also greatly influenced by factor.; in the e nvironment. Maintaining or adopting healthy lifestyle habits can
reduce the risk of acquiring cancer. Following proper nutrition, avoiding chemical and physical risks, and maintaining
a regular schedule of health checkups em help prevent cancer 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.

LibraryPirate

MytiocytK ~utrmia, Iymphot)'liclfllkemia

Malignant mtlallOllla
OII~nk wltoma,fiblOlarmrno, Kapoli's WUomi,
Djosarmma

COMPLEME NTARY AND A LTERN ATIVE T HERAPIES

Selenium's Role in Cancer Prevention

is an 6l1'ntialtr.l(~ ~ltllH'm that is n~t!'Iwry to maintain litakhy
immulll' function.1t is a vitll antioxidant. ~Ipecially wh~n combilll'd with v~
tamin E. k protml tilt immu~ 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, ~(I )'I'iI1~ broc:col~ 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
th~ 1Oi1.1h~ loil of muth Aml'riun farmland illow in I~ltnium, rt'luking in
II'ltnium-dtikitnt produtf. Low ditta!), intake of II'ltnium il assoc:iotfti
with incrt'.J1I'd incidt'n(~ of II'IIml (ill(fB, including lung. (olort'ml skin,
and prol1ate. ~1tni.Jm IUppltlll!'mation has rt'SUk~d in ilKrt'aII'd nitural
killtr (til activity. and studits show its promilt as protection agailllt prostate
and (oloreml (inCfB,6pially among smokeI'!.
~~nium

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 ~hould receive a ~creening
colonoscopy, according to the schedule recommended
by the health care provider.
\I/omen who are sexually ~ctive 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 (h~mot hfrapy. 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

550

UnitS Thl'lmmuneSystem

blood-brain barrier to reach brain tumors. Others are instilled 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 removal 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 therapies. Examples in which chemotherapy has been used successfully 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 indude 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-

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 radiation 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 confined to a ,mall area. Radiation treatment. arc frequently
prescribed postoperatively to kill cancer cells that may remain following an operntion. Radiation is sometimes given
as palliation for inoperable cancers to shrink the size of a tumor that may be pressing on vital organs, and 10 relieve
pain, difficulty breathing, or difficulty swallowing.
Adjuvant rnemotherapy is the administration of antineoplastic drugs after surgery or radiation therapy. The purpose 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 developing. In a few cases, drugs are given as chemoprophylaxis
with the goal of preventing cancer from occurring in patients at high risk for developing tumors. For example,
some patients who have had a primary breast cancer removed 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

Teloph......

II.

, ,,

I MITOSIS I

,"

\
#
Non~Jl"Cffic

ID
phesa 01 cell cycle
o
o

AIkyieling egents
Anlitumot anlibiolics

~.""

,'.'.'

'.'

Anaphase

. "~

o HotmOOII inhibitofS
~

FlgureJ7.2

Antineoplastic agents and the cell cycle

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-- .

(110" .. 31 Drug' for Neap!",,",

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
~re Benerally more effective a8~inst cells th~t are replic~tinB'
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 G~ phase. Although
sometimes called theresting stage, the Go is the phaseduring
which cells conduct their everyday activities such as metabolism, impulse conduction, cont raction, or secretion. If the
cell receives a signal to divide, it leaves G~ 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 independent of the cell cycle. For example, mitotic inhibitors
such as vincristine (Oncovin) affect the M phase, which includes prophase, metaphase, anaphase, and telophase. Antimetabolites 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 undergoing mitosis in a tissue. It is a ratio of the number of
replicating cells to th~ number of resting cells. Antineoplastic 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 fraction; thus, they are less sensitive to antineoplastic agents.
Certain leukemias and lymphomas have a high growth fraction 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 bedetected on a manual examination. A drug that could kill 99%
of these cells would be considered a very effective drug, indeed. Yet even with this fantastic achiewment, 10 million
cancer cells would remain, anyone of which could poten-

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55 1

tially cause the tumor to return and kill the patient. The relationship 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 remaining 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 b~ eliminatoo 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

T "" Ia
''''''''''ng
remaining
cancer cells
.. Figure 37J Cell kill and chemotherapy

552

UnIIS

The Immune Sy>lI'm

37.6 Special Pharmacotherapy

Protocols and Strat egies
for Cancer Chemotherapy
Because of their nlpid a Udivision, tumor ceUs express a h igh
mutation r,!.Ie. This causes the tumor to change and become
moll' heurogenous as it grows, essentiaUy becoming a mass
of hundr~ o.r different clones with different growth rates
and phYSiologic properties. An antineoplastic drug may kill
onlya sm all portion of the tumor, leaving some clones unaffected. Complicating the chances for a cure is that canar cells
often develop resistance to antineoplastic drugs. Thus, a therapythat was very successful in reducing the tumor ma ss at the
start of rnemOlherapy may become less effective over time.
The tumor becomes ~refractory" k) treatment.
A number of treatment s trategies have bt>en found 10 increase the effectiveness of anticancer drugs. In most uses
multiple drugs from d ifferent antineopLa5l ic (Lasses ar~
given duringa ~U rle of chemotherapy_ The use of mulliple
drugs affects dlffer.e nt stages of the cancer cell's life cycle,
and attacks the I';I((OUS clones within th e tumor via seve ral
mecha ni sms of action, thus increasing the percenlage of
cell kill. Combina tion chemotherapy al.so allows lower
dosa ~es of each individual agent, thus reducing toxidtyand
slowlllg the development of resistance. Examples of combination therapi es include cydophosphamide_methoUeltalt_
Huorouracil (CMF) for bll'ast cancel" and cyt:lophospilamidedomrubicin -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 s ingle
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 tim e to recover from the ad verse effects of the
d~gs and 3H~ws tumor ceUs that may not have been replica tmg at the IJm~ ~ft h e first dose to begin dividing and Decome ~ore sensitive to the next round of chemothrrapy.
So~eumes t~e optimum dosing schedule must be d elayed
~nlll the ~a hent sufficiently recol'('rs from the drug toxici Ues, Hpecially bone marrow suppressio n. The specifK dosing sched ule depends on the type o f 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)

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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 poss ible dosages, so that the
greatest twnor kill can be obtained. Such high dosages alw:ays result in adverR effects in the ~tient. Tabl e 37.3 Iist5
typical adverse effect5 of anticancer d rugs.
No rmal cells that are replicating are most susceptible to
adverse effects. Hair follicles are damaged, resulting in hair
loss or aloprcia. The epit helia l lining of the digestive tr.lct
commonly becomes inflamed, a condition known as
mu,.,.iti . CoI).';equen,n of l1luc~ iti ~ include painful wcel ... _
!ions., .difficulty eating or swallowing, Gl bleeding, intestinal
mfecbons, or severe d iarrhea. The vomiting center in the
~.u1La 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]
agen t5, patien ts may be pret reated with antiemetic drugs
such as odansetron (Zo fn.n), prochlorperazine (Compazine), metoclopramide ( Reglan, others), or loraze~m
(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 contraindication to therapy with most an tintoplastics. Efforts
to minimize bone marrow toxicity may include bone mar_
row tramplantation, platelet infusions. or therapy with
~wth ~actors s uch as epoetin alra o r granulocyte colony_
sllmulatlllg factor (G-CSF ), filgrastim ( Neupogen), or
sargramostim (leukine ) (chapter 2SOO). The administra_
tionofG-CSFsoften prel'('nt5 or shortens the time period of
neutropenia, thus towermg the risk of oppo rtunistic infec_
tions and allowing the patient to maintain an optimum dosing 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 d ecreases all types of wh ite blood ceUs (leukopenia), neu _
trophil s are the type most affected. The nurse can calculate
the. absolule neutrophil count (A NC) by multiplying the
white blood ceU count by the percentage of neutroph ils.
This value can be ob tained by reading the patient's com_
plete blood count (C OC) 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

CIIopltll1

to an infection from f~mily members or health care

providers. If a neutropenk p~tient develops a fever. antibiotics are indicatt'"d.
When pos.siblt'", antineopl~stics art'" given locaUy by topical application or through dired instillation into a tumor
si tt'" 10 min im ize s)'$lt'"mk 10000city. Most antim!oIJlast ics,
ho.....l.'Vt'r, must be adminiSlt'"recl intr;lvmously. Many antilI""pI~~ti .... ~r~ ... ,,>/>ifi ...... ~~ ...Ii...."t .. iOt!.,,,b lhal ~aJl ~au..,
st'I"ious tiSliue injury if Ihey t'S(~pe from an artet"y or vt'"in
during an infusion or injection. Extravas;ltion from an injection site ca n produ ce .severe tissue. and net"ve damage,
local infection, and even loss of a limb.ibpid treatm ent of
ext ravasation is necessary to limit tiss ue (];Image, and certain antineop lastics have spt'"dfi( antidotes. For l'JGlm ple,
extr:avasation of carm ustine ( BiCNU, Gliadei) is treated
with injections of equal parIS of sodium bicarbonate and
normal saline into the extravasation si le. Before administering 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 whenever poSliible. Antineoplastk.s with the strongest vesicant
activity include busulfan, carmustine, dacarbazine, dactinomydn, dauno rubicin, idarubidn, mechlorethamine, mitomycin, plicamycin, streptolocin, vinblastine, vincristine,
and vino relbine.
Cancer survivors face severa l possible long-term consequences from chemother:apy. Some antineoplastics,
particularly the alkyl3ting agents, affe-ct the gonads and
have been a ..... ciat..d with infertility in both male ~nd female patients. A second conctrn for long-term SUrviWTS is
tht'" induction of .secondary malignanci es caused by the anti neoplastic agents. These secondary tumors may occur
decades aftet" t~ chemotherapy was admi nistered. Although many different sec.oocbry ma lignancies have been
reported, the most rommon is acute nonlymphocytk
leukt'"mia. 1n most nses, the immediate benefits of using antineoplastia to ( urt'" a 0II"Ket" far outweigh t~ SIl\OlU risk of
developing a .secondary malignancy.

37.8 Classification
of Antineoplastic Drugs
Drugs used in caI"Kef chemotherapy co me from di,et"se pharmacologic and crn-mica! classes. Antineoplastics have been
extracted from plants and bacteria, ~s 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 anhneopla stl cs IS quite vanablt'" 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 ~re not rompletely understood. A
simplt'" method of dassifying this romplex group of dru gs
includes tht'" following six ca tegories:

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DruglforNeoplal.la

55 3

. Alkyl.ating agents
Antimetabolites
Antitumor antibiotics
Honnones and hormone antagonists
Na tural products
Biologk respornt'" modifit'"rs and monoclonal
antibodies
Miscellaneous antineoplastk drugs

ALKYLATING AGENTS
The rlnt alkylating agents, the nitrogen musta rds, were d eveloped in secrecy as chemkal warfare agents du r ing
World War II. Although tht'" drugs in this dass have quite
different cht'"mical structur<'"S, all sha re the co mmon characte r 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 t~ 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, o r at le~st slowing t~ replication o f tumor ct'"Us. Al though the process of alkylation occurs indt'"pt'"ndt'"ntly of the.:ell cycle, the killing action does
nol occur until the affected ( ell allempts to divide. The alleylating agents havt'" a broad spe<:uum and ate used ag~inst
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 administr:ation, the numbers of erythrocytes, leukocytes, and
platelets begin to declint', reaching a nadir at 6 to 10 days.
Epitht'"lial cells lining the G I tr~" are also (];Imaged, r<'"S ulting in nausea, vomiting, and diarrhu. Alopeci~ 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 chemotherapy has been completed.

ANTI METABOLITES
Antimetabolites art'" antineoplastic drugs lhat chemically reM'mble essential building blocks of ceUs. These drugs interferewith aspects of the nutrien l or nudeic add metabol ism
of rapid ly growing tumor cel ls.

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

(b) Slrand braaks occuring

when DNA ntpIicat6S

during S pha.se 01 eel 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 nutrients, but they do not perform the same functions as
their natuml counterparts. When cancer cells attempt to
synthesize proteins, RNA. or DNA using the antimetabolites, metabolic pathways are disrupted and the cancer
cells die or their growth is slowed. The three classes of antimetabolites 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 structuraUysimilar 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 thymidylate, 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

LibraryPirate

arabinoside, Depot-Cyt) blocks DNA synthesis and is an

important drug in treating acute myelocytic leukemia. Approved 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 vitamin. ~ Figure 37.5 illustrates the structural similarities of
some of these antimetabolites to their natural counterparts.
Bone marrow toxicity is the principal dose-limiting advt'rse effect of many drugs in this class. Some also cause serious 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 antitwnor antibiotics are listed in Table 37.6.

TABLE 37 41 Alkylating Agents

RouU! and Adult Dow (max dose where Indica ted)

Drug

Adwrse Effects

NITROGEN MUSTARDS
bmdamllltillt (Trt.nda)

1Y;90-I20 mg/rrtl (Qrii~t sd!fdule)

Ntma, Kmiring,~riris,.~rash,

cNoramllWl (INmn)

PO; initiill doseO.H1 mglkg/dly; Ma1nltnaTKt dost;4-1 0 mg/d.ly

Ittt1dochf. doptciD, ~id Iftendon

" cydop/lo$ph.amkk: (Cytoxan)

PO; InitiiII dose 1-S mg/doly; Malnttnanct clost; I- SlIIg/kg t'VflY 7- 10 ~)'S

tUnmuUinr (ErBcytl

PO; 1( mglkgldiJ iIllhl~ 10 four diYidfd doStj

ifOlfDide (!fee)

IV; 11 IJ/rrtl/day for Soon!lll:ivt dayi

rMhloftth.imillt (Mu5UI'gIm)

1Y;611lCJ11111on~ 1 ind8c1i18-di1ycydt

mtlph.liln (Alman)

PO;6mg/diyfor 2- 1wk

Bonemarrpw S!,u)[I!fW (neytrpproia

iprmia tbmmbootpprflial SO'rrrOi'''fj
andyorri~!lg 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

NITROSOUREAS
afmllSlint (BiCHU,GIacStI)

1Y;1OOmg/rrtlMrY'wk

Iomustilt (CtrHU,(CNU)

PO; no rngImI asa siJ~ dost

urtptozOOn (ZaIlO5al)

IV; 500 mg/rrtI for S<OO!III:i~ ~

MISCELLANEOUS ALKYLATING AGENTS

buitJfan (Myltfilll)

PO;(-8 mglday

Qmopatin (P;wipla~n)

IV; 360 mg/rrtI 0I'lCt t'lfry (wk

cispQtin ( ~tinol)

1Y;20mg/mi/daylor 5 ~

!Yc<1rb.izine (OTl( -Oomt)

1Y;2.....5mg/kg/dly for 10days

oxalipla~n

1V;8Smg/rrtI for 2 hfor l wk

(8oxatiftJ

proGIrb.izillt (ManjaM)

PO; 2..... mgItIJ/diy for 1wk

IemOzoionide (lemodir)

PO; 150 mg/rrtl/day for 5oonstrutiYe diys

Ihiotq:y (llioPu. TSI',I,)

IY;OJ~AmgJkgMry

TABLE175 ~

I..... wk

Antlmetabolites

Drug

Route and Adult Dose (max dose where Indicated)

Adverse Effe<ts

N/ruJtO, KIffliring. stomoritis, aoomda,If1Ih,

lleada:he,aIoptda

FOLIC ACID ANTAGONISTS

" rnetllotre~te(RIleIna~ Trt~lI)

PO; 10-30 IlI!Vdayfor 5days

ptnIttrtud (Allmu )

1V;5OO mgJrrtI on day 1d um 21~ycydt

praialrt:late (Fdot)'n)

30 mgfm/ mli'lstertd Mf ]- 5minutes

PYRIMIDINE ANALOGS
Qptdtibint (Xtb:Ll)

PO; 2,500 mg/ml/~ for 2wk

C)Uribilt (Cyt()S;Jf,Cytosine inbinosidt,

IV; 100 mgJrrtI au contillUOUSinfusion (Wff 24 h

Ilfpot.(~)

ftoxwidine (ruDR)

~rHrttril~ O. l~.' mg/kIJ/diy IS I conti'lllous ~fusion

ftUOl'OI,I'~U

IV; 12 ~da, for consl/tiw da)'5

(Sru,Ad'ud,(.arac, Ehde!)

gmcitabine (Gtrnz,JrJ

IV; 1,Im mgJmI fflf'/ 1wk lor 1 wIo:

PURINE ANALOGS

c1mblM (ltustatin)

IV;O.09 mg/rrtllU1 as it COI1~nllJllS Infusion

cIofalabint (OoLII)

IV; ~1 mg/ml/day am 2 hours for 5 dayl

ftudarabile (Fludal'i)

IV; 25 mglm'/day for 5 COI1SKllli'fI! days

mtraplOflUritIf' (6oMp, Purinethol)

neIiIrabft (Manon)

1V;1.500 mg/mi on~ 1,1,'00 S,lfpeatfdt'lfry 21 days

ptnlOSlatin (H~nt)

IV; (mg/mi t'lfry othfr Wftk

lhioguariM (6oTG, labIad)

PO; 2 m4fkghlay

PO; B mglkgfday

IIQria incicatt common idl'l'Bf tfferu; unOO1ining imkates strious acIYme effKtl.

LibraryPirate

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
a~Dhy!ads) !It!I!!t!!!:idty(qwaIW
ftuorour.tdl tbiarabiM cI.ldrllintl

SS6

UnitS Tte lmmu""Sysll'm

~ Prototype Drug

I Cyclophosphamide (Cytoxan)

Therapeutic (lass: Antineoplastic

Pha rmacologic Class: Alkylathg agent; nitrogen mustard

ACTIONS AND USES

ADVERSE EFFECTS

iu {OInlMni)' pr.,,,ribod nit""!,,n mumm_h i!-"IM ,Iono.

or in (OInbinatioo with o1h~rdrugs, .gainsl a widt '/iIriet)o of wl(e~ in,kiding
Hodgkin'l diINl!, Iymphom., muhi~ m)'eloma, brust u n,"~ and OY.rian
caMrI'. C)'Ilophol.,h.midt.m by . tlathinglO DNA.nd diwPling replitation.
pa"irubrl)' in .. ~idly djyiding (ells.1t is 0111' of only. fM .ntiurw drugs thaI
art well ablOlbtC when giYell orally.
C)'Ilopho~nidt is powerful imm"nOlupprel.lnt. While this is (0000el!<! .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 rrythem'IO"1I (SLE).
()'doph",plu mic!~

,
iIi

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

eon.. ma","" IOppr~"ion is a p<>1~mially lifHhrutoning ,,,,,,,," ruction Ihu

oc:ruB during days 9-1 4 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 otheralkylaling 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'. Sto~rill
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 theraPl'.Ih~ drug mayausr ~rmanfflt sterility in ~ ,.titms.Unli!.?
other nitrogen mum rds, tydophospha mide dlibits little ntlJlttOXic:ity.
Contrainditations: C~dophosphamide is (oolr.iOOiuted in p,tHonts with hyptr5ellsitivity to the drug i nd for those who ha~ . clift inirtlions or 1fY~1I'Iy
Sl/ppr~~d 00111' marrow.
INTERACTIONS
I)ug- l)ug: Immu~tagt'll6 UlfdtorlCllffllly wim (~
wilirtr&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; ofd~xinOC:QI". lM

with inlUin may Ieold to hl"POlhtfmi.l.Ptrenobartital, pOOl)1oin. (f qhcOUflKOOI

PHARMACOKINETICS (PO)

Unmnwn
IINk:l h

OnV'!:

!Md (ooomnti)'mayleadto.nifl(reudr.\@of (~lIO'1iIboIilmby

Halflif!: H l h

,-,'C'C
'fuC
" :IO
C":: !..CI~:L-:-C\':'_______________./

tfwo bl'l.Thiazidf dilJlliG inoUll' 1M pcWJiIityofltu~.

Lab Tl5ts: Serum Lric: add ImII may OON ~. Blood (fli {OUn6 williillinilh duI' to
bonr marrow su~. FlJsiti'l! rMttioos tofllldNig,mumps,anO (lilHaiin liin
001 (PPO) f t IIIpJNfSSfd. PAP smNB may fjtf falll' p<>!itim.
IkorbaVFoo:t: StJem'l won mayiMIN!e iMlOIit Mlemof~.
Trt'iltment ofOmdo5e: There is 00 spt<ifll trt'.tment for OY!'~.

RtrI>r III MyMnJrtgR for ~ /UsJrti} I'ror.mfooll SjIK/II( 1II1M 1tIig.

Normal mlltabolile
0
0

,-<X'>

H,N A
Folic acid

N ......

GUlln;""

Antimet.bot~.

"'

",:X',>

,,,J...,
Melholra x.ate
~

Thioguan ....

figure 37.5 Structural similarities between anlimelaboilles an d their natural counterparts

LibraryPirate

"

"":J

oJ...,
,I
U-acil

o"J..,~'
,
Auorouradl

p,. Prototype Drug

I Methotrexate (Rheumatrex. Trexall)

The rapeutic (lass: Antineoplastic

Pharmacologic (lass: Antimetabolite, folic acid analog

ADVERSE EFFECTS

Mttoot~ute

(oIn lit I~ 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 a~ olten obstMd rb to low pbtelet (OUntl. Nausea, wmitilllj, ind
aOOIl'Xi ill' (ommon, and GI uktr,tioo may resuk in sffious intrstinal bleeding. Severe and potenti,lIy faul d!rmitologic ructions indud! Stelt'nsJohnscn syndromt and 9foliati~ dt rmatitis. Although lilt, pulrmnuy
toxi(it, ilKluding Iife..thruttning pIl!"Umonitis has bten ~ponro.
Contr aindi utions: The USt of mtthotrHite i s an antiOfOpb;tic is contlilind~
cittd il thrombocytoptnia, antmia,l!"Ukopeoia, COlKUITI'nt ~minismtion of
hepatttoxK d~,nd htmatopoietK wpprrswnts, ikooolilm, or lactation.
Metoolll'ute is ttritogenic and is contraindicated in preJoant patitrts. Pitiffits with ikooolism or other chronic lil'l'l disme should oot rt<eMmethotl6,te. ImmunOlUPPll's\td p.1Iitnu or toose with blood dyscmias
should not Il'(ti~ methotrexatt.

is ,n ,ntimrubolitt iIV,ibble by tht or.Jl p'~nter.ll. ,nd intratheul routH. By blockilg the S)'Ilthtlis of folic acid (vitimin BJ, mttootl6itt inhibiu replication, partirubrly in rapidl)o dividing (tlls.1t is pR'ICrilltd aloot
or in oombinuion with othtr d~ for ChorOOKinooy, o;ttogeni( san:oma,
IeukemioH, head and otdulKtB,brtmun:inoma,and lung CiKinoma.ln iddition to its role as in ant"metabolite, metoot~l:IIte hil poWl'rlul immunOlUppll'ssant thit "n lit Ulfdto t~it!n'M' rhtum,toid arthritis,uktr.Jlivt colitis,
upus,and psoriasis that OR unrt'lpOM~ to wfer lII!'dications.
ADMINISTRATION ALERTS
Avoid !kin HpOIU~ todrug.

Avoid inhaling drug j)lrlicles.

Dilute prior to IV ~mi1is1r.ltioo.
Pregninquttgor;X

M~too!lnate has many advern effect!, lOme ofwhich

INTERACTIONS
Dru;Hrug: 800e mallow wppressaoBsuth ~~;qon1l or radiMn
the!apyma, UUII' ioofNd IIIett!; th! patil>nt will ~fI alawn dol>! of
~_f. (orKIIJfI"l UIf wiII1 HS.IJ[Io; may INd to Ift'fIf IIIIIhoIrmtf toliOt~
.l.lpiin IOiY interl~wiII1 omtioo of ~lIitt,lHdi09to 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!.

PHARMACOKINETICS

Onstt: Variable
P!ak: 1--4 hPO;O.5-l hIMlIV
Halflif!: 1--4 h
Duration: Unknown

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 ~lII1f.&:hioacN IIIiI'f
irK_ th! rille ofhtpatot~xitity.

Treatment ofOverdoSf: l.!"Uc:a.orin (folinic acid},i rtduted form offolic ltid. is

somtti~ adminiswed with methottemt to "ll'saJI'" normal cells, or to prottct a91inlt se-Yl'lt' boot marrow damage. k is most tifectil'l' if idministtred is
soon 011 ~~bIe alter t~ overdole il discovmd.ln addition, the uriOl' may lit
alk,lin~ed to Pro\e(t the kidotyS from metoot~l:IIte tolicity.
111m 10M)MJ1l1nqm for Q NlJIlifll} I'rrxm forus lpf(1t 10 rln d~

IV;OlS-<l5 uri!/bj MfY4-7 ria)"!

daninornym (Actinomydo-D, (OII1II'getI)

IV; SOO IIKglday Itt a miDnum of 5ria)"!

dalllOlUbidn (Ctrubidot)

1V;*-60 mglm'lday Itt 3-5 days

dalllOlUbidn ~ po\omil (DaunoXomt)

IV; I mglm' MfY2 wk

I;) domnDcin (Adriam)'<h)

1V;60-75 rnglm' is i ~nglt dose at 21-day inltrVals,or lOmglm'

on Nm of lconseu.w! days (OYI:tOta! rumllati~ dose
550mglm')

doxonJIim I~I (DoJ:~ &actt)

IV; 20 mgIm' MIY 1 wk

~n(81tnte)

IV; 100-1 20 rnglm' is i

idanDdn(ldamydn)

1V;8- 12 rngIm' Irlayfor 1ria)"!

mitanydn (Mutimyan)

IV; 2rngIm' ~a IDje dose

mitoxantrorlt (tlovi mront)

IV; 11 rngIm'ldayfor 1 days

LibraryPirate

~nglt dose

"

ACTIONS AND USES

55 8

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 chemicals 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 similar 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 adverse effect of drugs in this clar.s is bone marrowsuppression.

..... Prototype Drug

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 after 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

I Doxorubicin (Adrlamycm)

Therapeutic (lass: Antineoplastic

Pha rmacologic( lass: Antitumor antibiotic

ACTIONS AND USES

Domrubicinattuhfi to DNA,diltoning ir>doublt Ittlicll stnKN~and p~m
ing oolTllill DNA and RNA s~nthtsis.1t iI adminiltt ll'd only by IV infusion. Doxorubicin ill blNd-spKUUm cytotoxic: .Jmibiotic, precribtd for solid tumors of
tilt lung. b~iSt.~ary,lnd bladdt~ and for various ltuktmias.Jnd lymphomas.
hiI 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 tlK~ in small lipid ml, or mide, Gliled
liposmnn. Tilt liposomal mic:1t iI dtsigned to open Ind ~ltast tilt antitumor
antibiotic:wlltn it ~ac:hes a (an(~r (fll.TIII>goal is todtlmr a higlltr (Onrtntriltion of drug to tilt (anr~ r cells, thus sparing normJI (tlls.An .Jdditiollal .Jdv~n
uge iI that domrubic:in liposom~1 has a half-lifr of 50 to 60 haun, which is
about twiu that of ~!Jlllr rIoxorubicin. Doxorubicin liposom.J1is ~pprv;td for
USt in patienl> with Kaposi's saKoma, refractory OII.J rYn tumors, and ~Ia!)led
mukipk myeloma.
ADMINISTRATION ALERTS
Extravas~tion (an calM ~I'Il' 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, ~trify (oncentration and ru~ of IV infusion with
tilt health GIll' provider.
Avoid !kin (Ontld with dnrg.1f nposu~ ocam, wash thoroughly with
soap and wattr.
PrtgllallQ category D

ADVERSE EFFECTS
TIll> man ~ clost-limiting adm~ tffed of doJ:Olllbicin is rardiotOllicity.
,\artt ~m inrkidt dysrhythmias; dtlayed tffrcts mly indudt in~rsiblt
IItln failu~.likf man, of tht .Jntiunrt r drugs, doJ:orubicin may profoundly
Iowfr blood (tll (ounts. Acut~ naU~J .Jnd vomiting a~ (ommon and oftt n ~
qui~ Jntiemttir therapy. Com~, though rf"lersiblt, hair Ion occurs in most
pat~rru.~ondary maligllan(ifi,ept<iJl~ JMt myflogtnous Itukemia, mly
occur 1- 3 )'I'ars following therapy.
(ontraindi(ations: Domnrbic:in is (ontraindicated in patienl> who J~ imlIlIoosuppresed orwho haw ~nsitivityto tlltdrug.
INTERACTIONS
I)ug-l)ug: If digoxin ~ lakin (OIKUlI!ntly,paliI>n( Il'IIImt5goxin Ir>v/'kwil
~.lMwith ~I may INdio im.MI plalmadNooa> of
ihona:i1 and deuMfd effO'ajy~s.lIItwith p/Ii'Il)1oil may iNdtodeuMfd
ph@nytoillffll, and possi~e seizin ar:tjy~y. Hepat~1llIIirity may amI" ff
mtlGlpIOpOm. ~ "ton <OO( ..... tIy.tktwith ..........1""I' ioawoo .......
ihona:i1 "''/ek,INd~ 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 wlOll.tim~
IIns woo IN1 dKrNIe the etlKtiveness of ikD:lfltlir:i1.
TINlment of ()rrdo~: The primary r=k of doJ:orubic:in O"/trdosagt iI imlIlIoosuppresion. 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.

PHARMACOKINETICS
Onsd: Rapid
Peak:Unknown
Halflife: 17- 32 h
Duration: Unknown

LibraryPirate

'1101'1,,37 Drugs(D<f\IeopLHIa

(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 properties were discovered. Despite being derived from the same
plant, vincristine, vinblastine, and the semisynthetic vinorelbine (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 t;wn~s, which include paclitaxt'l (Taxo!) and docetaxel (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 alkaloids have been isolated from the yew tree, and several
others are being investigated for potential antineoplastic activity. Like the vinca alkaloids, the taxanes are mitotic inhibitors. 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 usually the dose-limiting factor for the ta.unes.
American Indians described uses of the May apple or wild
mandrake (Podophyllum pe/tatum) long before pharmacologists isolated podophyllotoxin, the primary active ingredient in the plant.As a botanical, podophyllum has been used
as an antidote for snakebites, as a cathartic, and as a topical

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 carcinoma, 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 treating 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 androgens. In addition, several hormone antagonists have been

TABLE 37 7 . Natural Products with Antineoplastic ActiVity

"n"

Route and Adult Dose (max dose where Indicated)

VINCA ALKALOIDS
"tintUstint(Vdl~n)

lV;l7- 18.>mglm'~

Q Iinainile(OIKO'!'inj

IV; 1.4 mgtm' ~ 1wk (maM;2 mg/m')

iY;10fll9lm'MIllwk

"tinorelbint IN.rlelbintJ

lwk

TAXANES
mtaRl(laxOiert )

paditaxti (Taml)

1 1V;60-100mglm'MlYlwk
IV; 1l5- 175 mglm' MIY 1 wk

TOPOISOMERASE INHIBITORS
60p0sid!, (Ve~sid)

W;Sl)..l00 mgfml/day fo!)!bys

irinolKiin (Camplosar)

1V;1l5f119/m' MIl lwkfoc4wk

lerIiposide (Vumon)

IV; 165 fll9/m' MIl 3-4 days/or 4wk

topoll'(.Jn (1Iyum~n)

IV; 1.5 nM}/m'lday fo! >days

LibraryPirate

559

Adverse Effects

560

UnitS Thl'lmmu""Syst""'

.... Prototype Drug

I Vincristine (Oncovm)

Therape utic (lass: Antineoplastic

Pharmacologic (lass: Vinca alkaloid, mitotic inhibitor,natural product

ACTIONS AND USES

Vinuistine is a U'II.qo:Ir~ifK (M-phalr) agtm that kills unm c~ lk by pre\'eIlting their abilit)' to complrte mitosis. k ~rts this action by inhibiting microtubulr formation in thr mitotic spindlt.Akhough ilKmline must be giYen
intral'l'llously, it mlljor adn ntoll}!' is that it taUSeI minimal immunosupplftsion. k has a wider" spK\rum of diniul oKlwit)' than vinblastint, and is UlWIIy
preaibtd in mmbination with other antin~oplanics for thr trNtmffit of
Hodgkin's and non-Hodgkin's lymphomas, iruumias, Kaposi's !-armma, Wilms'
wmo~ bladder ultinoma,and breast umnoma.

ADVERSE EFFECTS
lhr most Irrious dose-limiting adYl'~ effects of in{mtilll' relate to ner\OUl
S)'ltffll toxicity. Children all' partirularty IUI(~ptilR. Symptoms include 111mb111'11 and tingling in the limb~ mUl{Ular ~akn!"ll, IoSI of neuralll'flrm, and
p,in. StYerr mnstipation is com man and paralytic ileus lIYy lXtur in young childlt'll.Rt'YI'fSiblr alopecia OCQJrs in most patients.
Contraindi{a\jons: Vincristine is (omraindica~ during pl!gnalK)' and lactation. Caution should II!' used whrn til'uing patients with hrp.atic im piinnent or
obstnJctiYl' jaundice.

ADMINISTRATION ALERTS
Extransation may r=k in Ifrious tissur da~. Stop injtction imrnedi-

I)ug-l)ug: .I.spaf~!Md cona.mntl1wilh .. bffOll' IiIKlil!inI' mayalM

~tely

ff eJ:llil'/awion I)(rurHnlhppl, local heat and injea hy~luronidm

as ordmd Oblfl'/e litt for sloughing.

A..,id ~1"lOnt.oc.~ whic.h y" y",. ,.,..~ inildtioll .00 lon ... 1<i"'HJr>.
PI!gIlaIK)' category 0

PHAR MACOKINET1CS

Onlet: Unknown
Peak: Unknown
Halflifr:ll1- m h
Durat ion: 7ct.ys

found to exhibit antitwnor activity. The mechanism ofhormone 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 section; for other indications and actions, the student should
refer to other chapters in this text. The a ntirumor hormones
and hormone antagonists ~re 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 debilitating 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

LibraryPirate

INTERACTIONS

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
llNtment of Overdose: l);erdoW' with vincmtint may {.1U1e life-thll'att ning
l)TllptOms or duth. Symptoms aII' "tensions of tht dtugl adYerse effls. Su pport~ trUlment lIYy ind~ 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 symptoms of Cushing's disease (chapter 43OC .

GONADAL HORMONES
Gonadal hormones are used to treat twnors that oontain
specific hormone receptors. Two androgens, fluoxymesterone (Halotestin) and testolactone (TesIac), are used for
palliative therapy for advanced breast cancer in postmenopausal women. The estrogens ethinyl estradiol and diethylstilbestrol (DES) are used to treat metastatic breast
cancer and prostate cancer. The progestins medroxyprogesterone and megestrol (Megace) are used to treat advanced
endometrial cancer. Leuprolide (Lupron ) is similar to gonadotropin releasing hormone (GnRH ), and is used for advanced 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 dependent on estrogen for their growth. Tamoxifen (Soltamox),

'1101'1,,37 Drug'(D<f\IeopLHIa

561

TABLE 37.8 1 Hormone and Hormone Antagonists Used for Neoplasia

Route and Adult Dose (mn dOle where Indicated)

Adverse effects

dwmmlOlll'jDeudron.oIhtrs)

PO;O.lS bid-qid

ditlhyl!l~bt!lrolID(s. S1il>tmol)

PO;f tr..lmmt of pro!lalt <1M.... ~ mg ~d;for polli.tion

1- I,lIM}Iday

We'qllrgoifl,momflio.abdJmif"IQl
di5lflHion.lwtllrl'f14 ftIlhif14 dQrrlIeG.

tltioyl tllradiol (El tin~. othml

PO;ft{ uutmmt 01 blffil (olfKtl, 1mg tiel for 2- 11llOltlnjlor

piliation of prostit~ UIK!'!; 0.15- 3 mgl~y

""'9
HORMONES

ftuoxyJllffimHll' jH alot~!lin)

PO;10mgtid

mtdrOX)'l!ltl9ffitro III' (Prw~a. DqIo-Proffii)

1M;400-1.OOlmgql wk

(w~

1Iffi1lU~ ~masri4liflUlijm

(ItlflmtrOlII',ltIlo/Q(/Ontj

Thrombophlrbitis. mUld!: wallioo

(prf!bMnr deumrI[Ia\Ollr) gru:gwolk
broatp!mjcih lll'm&ronr Ifllpliqporl

706forth/, Prototype Drug

!mOO1
~roIjM~lt)

PO;40- 160 mg bid--qid

prtdrilOlll' ~U5Olll'.olh~s) (II'~ pilje 471

for t~ Prototype Drug 1JoxOO)

PO;lO- I00mglm'l~y

testolinOlll'(T~)

PO;l,Omgqid

te5lOltmHll' IAnan,HistmHll', Ttsu!d,

DNtffi,othtrs) (~paqt 719 fort~
Prototype Drug boxOO )

lM;lOO-400mg M!Y 1-4wk

HORMONE ANTAGONISTS

anastrorok(Arimid9j

PO;1 mglday

bitJlutamitk I~x)
dt9amix (Firmaqon)

PO;50lII9Iday
StD:Ulilll'OUl; 240 mgloadilg doll' followtd Il)' 80 mg "~

Qffhtnio.l!QUJfQ

!Npby!axhl tblPmbq!b1rbki> (HE

l/ol~imm1lW..brfl)ff

UtmtstiUIt (Aroma~n)

18""
PO;2, Ill9lday ift... a IMal

ftutamitk (Eulain)

PO;250mgtid

lulwstrint (fa~odtx)

1M;2S0mgooa

gostI'Hn (ZoIadtx)

StD:utilll'ously;3.6 mg "try 18~)"I

hilt!!!in (Yantil)

Implin~ 1 implant "'Ill

ItUOlOit (Ftmara)

PO;2.SlIM}Iday

Ia.prdidt (Eli9ard.~. VOOur)

Subrutalll'OUlly; 1 mglday

HyprorositiYity runions (induding

Ibka!utimide.mr~rnl. htoalOuo:ility
(flularri4el !Utial dyllunnion (QOX!!in.

nilutMtidP. t~moifen1 oru~r uo:idlY

mo (501119)

niknami~ (tilincton)

PO;lOO IJI9fday for lO~)'Ii thm ISO mgI~,

raloxh (Evisti)

PO;60 1119 OIK~ daily

O timoxnen
ttmifmt(fareton)
triptorl'lin (TmstI)

PO; 10- 10 mg OR!' to two ~mes/~y (morning and Mning)

PO;&OlII9Iday
1M;17SmgOOO' monthly

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 tissues. The progestogenic effects have positive actions on
bone mineral density and improve lipid profiles (increase
HDL and lower LDL).
The antiestrogen class also includes anastrozole (Arimidex}.letrol.Ole (Femara). and exemestane (Aromasin). which
are called aromatal~inhibitors. These antiestrogens block the enzyme aromat:tSe, which normally converts adrenal androgen

LibraryPirate

mo~".in,hnld<Kht,dkJ""",.

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 progressed beyond tamoxifen therapy.

ANDROGEN ANTAGONISTS
Hormone inhibitors also include the antiandrogens bicalutamide (Casodex), nilutamide (Nilandron). and flutamide
(Eulexin). These agents are prescribed for advanced prostate
cancer. which is strongly dependent on androgens for growth.

S62

UnitS Thl'lmmu""Syst""'

L IFESPAN CONSIDERATIONS
-

Chemotherapy in Elderly Patients

Thr oIdtr lruk population hasa higher incidtn~of mon ~ of unw II I
R'wk of I gR'ltrr mumulation of (')Kinogrnic efm:u O'/rr ti~ and Ig~
R'lat~d ~uction in imroo~systl'llllunction.Studi<!1!how that hepuicdlll9
~l)'me .ctivity(P-450J is dK1N1fd by 30'11i in healthyoldtr adults, mulling
in dernilfd metabolism of drugs. TIll' glomerular filtration rate also dt
m'~ses, Jl'Suhing in dl'(l('~sed !'X(1Mion of dlUlJS from the kid~. Redoced
hematopoietic nem (rll mm and ~U{KI 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 <h~motherapy.
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 iwid aspirin products.
Bf{ollIIf older adulu olrrn haYrdefir:irm nutritional intalct,te.ch th~
patirnt and (,)lf9ivm about hralthy food choices,and as~s thr
patirnt', ability to ,w~llow foods and mediutiom. Nutritional
wpplrmenu may lit R'q.ri~.
Constipation may ocarrdut to I dt(R'~ in riiminuion. [ncoorilge tilt
patirnt to drink adequate !krichand to incrule dietary filltr by using
grainland ka/)'~egmbln.

.., Prototype Drug

BIOLOGIC RESPONSE MODIFIERS

Biologic response modifirrs (BRMs) alter body dd'enses to
enhance the destruction of cancer cells. BRMs include interft'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 alfa2a ( Pegasys) and interferon alfa-2b (Intron-A) are
approved to treat hairy cell leukemia, chronic

I Tamoxlfen

Therapeutic (lass: Antineoplastic

Pha rma(ologi( (lass: Hormonal agent, estrogen receptor blo{ker

Aal0NS AND USES

ADVERSE EFFECTS

Timouit>n is an oral anliestrogen thit is i ptmrred drug for tR'aring mewtatic blNlt UIK('I.1t is effliYr igainn brun tumor crils that requiR' estrogen
for thrir glOWlh, which a~ known as ~trogen receptor ([HI POlitivr {~Ik.1t
bloch estrogen fl'U'pton on brean u nm (elk, but tamOlifro actually twilles
~trogen l"t{eptoB in other pam 01 thr body, r~ulting in t)'piul ~trogtn-like
effects!UCh al rrduU'd IDllrv~b Jnd ilKrralfd mineral den!ity 01 bo~.
Auniqut futu~ 01 tamoxifu is that it is the only antineoplastic thit is ap.
p<OKi for prophyl.. is of bR'iI' UII('~ for high.ri<k pnirnu who Olf II riskof
drYrIoping thr dill'~.ln lridition, it is approved as adjunaiYr therapy in
women following lIY5If{tomy todrm~ the potemial foruncerin throppositt brtill

Othrr than n"UIN and vomiting, tamoxifen prodU{~ 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 hr~ !krid ~~ nlion, j nd vagini Idischjrgei i It relatiW'ly
common. TamOlifen uu~ initial "tumor liaR'"- an idiosyncratic ilKrfill~ in
rumor~, but this is an l'lpKtKl thrrapwtic M'n1. Hyptrtenlion and KlemJ
ocarr in lbout 1('% 01 patient> taking tilt drug
Can lr"; ndi<dlion>: (olll,.iooo..l"" 10 lilt u,", of 14,oolil. " in<.lude . n1ic.oagulant therapy, prMJiliing mdomnrial hyprrpl.lIia, history of thromboem
boIi! diINle, p~nancy, "nd lactation. Prrautionl shoold lit ob!l'lVfd in
p"tirnt; with blood dilordtB, ~I dilrurbanU'S, utJract~ hyprrukrmia,
Jnd hypen:oolrslrrolrmia.

ADMINISTRATION ALERTS

Give with food orfluick to drr:R'all' GI irritllion.

OonoHMhor{wdrug.
Awid antl{ick for 1- 2 hfollowing PO dOlaljf oitlmoxifen.
Plf9nancy category 0
PHARMACOKINETICS
On~:

Unknown

Peak: 3~h
Halflift': 7c1a~
Duration: Unknown

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INTERACTIONS

Dru g-Drug: NlKuagWnt; tM (ooo.mnriy with tamoIfIi>n rna, iootR the

rill; of blHding. (oocUrmlt !III' with C)'IotoDr: ~ s may ill(lNII' thr rill: of
tlu~ism.Es;trogl'nI wi. tIKINIl' the~KIi'lme!>loftJmoIifen.

IabTflU: >MIn (lkium ImIIIfIi)' OONlf.

IlerbaVForxl: Unknown
Trmtment of ImrdOlf: Stizurrs, neurotoxicity, and dysrhythmial
with OYI'rdo~. The patient is tR'aifd s)'Illptomatiuliy.
IIt/i>r 111 MyMnIngR fot ~ MnJrIg 1'rf'55 Foon lpK/It 1II1M atJg.

rna)'

our

(1101'10137 Drug,fD<Neopla,"
~108t'nous leukemia, Kapsoi's sarcoma, and chronic
hepatitis B or C
. 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.

563

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

TABLE 37.9 1 SC!IC!ctC!d Biologic RC!5pon5C! ModifiC!r5 and Mi5cC!lIaneou5 Antineopla5tic5

Route and Aduh ~ (mall do~ where Indicated)

Adverw Effects

a~rtlalliflt(Hwlm)

1'0;65 mglrn'/day

IiIIIJJe4 Kmirilg.Qnhmi~,nomalirk aHIftXiQ, rolh,

a~ triolid! (TrisfflJI)

1V;0.15 mg/k9lday [max:60 dolts]

a/cpi4 ~pmi{idemio (MQIOfmt)

~raginalt (Ebpn)

IV; 100 i l1enwlionil uo~!lkgldity

bo:arot_ (lugretioJ

1'0; l00-400III9Im'fdq;topical; 1% gtI applitd to ~ 0lIl' to

fourti~d.ty

hydroxyull'ol (Hydr61)

1'O;20-lOmg/day

iote-fffllO.!Itr1 (RofI>roo-A.lotroo A)
(w ~ 454 for tilt Pltlloty]N' Drug

S!t>anaotOUsl\M; 2- 3 m~lion 1Il~I/d.ty for ltukrmia; iOOl'u~ to

36 milion un~sJday for Kaposrs 5ita:Jrna

tm<X> 1
ilabtpilmt(lKffilpril)

Boor IDa]!9WMlD!Olioo (ol'ullgpmy m!IDia

thrombocy!oprri.!) gym niUI(~ and l'O!II~ing,
dia~i,pulmOlUry 1OXio:~y hyprorosili'li!v
!fiOkm (i"tdydjnganapbyWbl NouNliik
fJ\IIj!JtjNsr bl'mQlrof P!'W\lljrgasr)

hYDQ!lr1l2idi\ll) (bmrO!tOcl, hroatOlOJ:iQg

(JINraojru sr p~g.!!Nrga sr) bfiin ditmaqr
(m~OIin~)

1V;40mlJ/m'infllltdamlh"tf'! lwk

ImmilOk (Errjamisvl)

I'O;SO mg tid for 3 days

mitoufIt (l)'soho)

1'0; 1- &glday givtn in th~ to foor dividtd doIts;may ~

iOOl'a~ to 9-10IJ/dit~as tolerJt~

~rgaIt (OO(.up.!~ PEG-L-

1V;1,500 intenwtionallll~lIm' Mf114 dars

asparolginalt)
romidtpsil (lstodax)

IV; 14 mlJ/m'admioistl'R'd 0'/ff4 hroo ditrs 1, B,and 15

'IOrinostit (loIinu)

1'0;400 mg ona diily

IdMrooKJOO (1orneta)

1V;4 mglW~atlNlI15min

MONOCLONAL ANTIBODIES

aimtWlllloib (Camp.!th]

1V;3-lOIII9Iday

btYadzumab (Amlio)

IV;S m9Ib;i MI)' 14 days

bortnomib ('kk.Jdt)

IV; 1.3 mlJ/m'as ~ boIUllwK~ wMIy for 2wk

wuxinab (&binD:)

1V;400 mglm' IW~ 1 h;tIItn (ooti_ with 250 mg/rn' O'/ff

1 h Wl'ekIy

e-\oIioib (TaKt'loI)

1'0; 150 mg/day

gefninib(rnsa)

1'0;150-500 Ill9lday

9fflItuzumab ozogamidn (Mylota'lj)

1V;911191m'for2h

ibril!lIlornab tiuxetio (Zt'lillin)

lV;lSO 1II9Im' of rituxinab is infwd foIOWl'd by 5 mG of

unlin in a 10-llio IV push

imalioiJ m~ylit~ (Gitt'lKj

1'O;400-600lII9Iday

Idl"'lilib [Ty .... b)

PO; 1,250 my15 .. bh:,,)," ..~"" 11 un d.,. 1 II> 21

cmtilllOlllly in combinition with IilpMabi~

ofatumllllilb(Arll'lri)

1V;300 mg initial dos/, foIOWl'd by 2,00l mg wMIy for 7 dolts

p.!ZOp.!nib (Votriffit)

1'0;800 mg ona diily

ritlilin.Jb(Ri!uun)

1V;375 mlJ/m'/day ua (ootinllOUl iofusion

Ilinitinib (Suttnt)

1'0; SO mg ona daily for 4 Wffb followtd by 1 Wl'dts off

sorafmib (Neuvir)

1'0;400 mg bid

tositumomab (Bt'Dir)

1V;450 mg lW~r 60 min

trutuzumib (IIffi:tplio)

1V;4 m~as a !il~~ dos/,;tIItn 1 mgltg"tf'! 1wk

LibraryPirate

/iQlJIfO, ItIfIirilg.Qnlle1i~, lremoo (IIIfmllWmob),

QoorrxiQ, III Jh, d~f1IIetI, stomaliliJ, ft'll'r, {hils

Boo!: IDa!NW !!.OPm1ioo (ntlItroproia ~emia,

lhrombomop~oia)

seym: niu!!:i and \'OIII~inq

56 4

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 immunosuppres.si~ 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 adrenooortical cancer. Two of the newer antineopJastics, inmtinib
(Gleevec) and sorafenib (Nexavar), inhibit the enzyme tyrosine
kinase in tumor crUs. Lenalidomide (Revlimid) is an angiogenesis 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 patients with non-Hodgkin's lymphoma and multiple myeloma.

PHARMACOTHERAPY ILLUSTRATED
37.1 Monoclonal Antibodies and Cancer Cells
NOITTIIII cella 1\&.... no
IU"TIOI"-apec;fic antigena
of their auof...,....

TU"TIOI" cells with

tumor-apecific antig-ens.
The anliQ "" p,,,,,ent is
diff""",t for """" tYP" of
,~.

Adminis ter

.-

Adminis ter

Monoclonal antbod ....

(MAB) ""' crMted for
"""" specific type of
tumor antigen.

MAB

MAB

I
. '"",,,,,

TU"TIOI" celie die die to

p~,~oment

fixation, or induction of
apoptosia.

Exampln:
Rituzimab (Rituxan)

Alemtoromab (C~)

LibraryPirate

TU"TIOI" cells stop 9rtlWins

due to inhibition of 9rowth
factor m<:eptore.

........'

Cetu>.imab (Erbitux)
T.... tuz:umab ~ptin)

'1101'1,,37 Drug'(D< f\IeopLHIa

NURSING PROCESS FOCUS

565

PATIENTS RECEIVING ANTINEaPLASTIC THERAPY

Assessment

Potential Nursing Diagnoses

Baseline aSSr5!ment priorto admini stration:

o Undtr>tind th~ Il'ason t~ drug has ~n prec:ribfd in ordtr to use. for
tlltraptUtic: ~lferu.
o Obtain 1 (ompittt ~ahh history irKluding IIfIJroIogic. (.I rdi~~5(ular,
rtspiratol1, ~patic: or rt llil dutom, Ind tht pos~ bility of p!f9nalK y. Obtain
a drug history ilKluding alitrgifs, ilKluding spr<ifKIl'actions to drugs,
(urrent p=:ription and OK drugs.h~rbil pll'p"arions,and akohol ulI'.Be
alert to po!~bIt drug interactions.
o ~SIl'SS signs and .ymptoms of rulll'llt inffitions and for history of ~rptS
lO.ll'r or (hic~n pox.
o Obtain an imrruniurion history,rsptdally It(ffit momion, with li"I~
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 ~ifio: to t~ planntd typtof
antineoplastic: thefap)' (e.g., ludiology, cardiac testing, ECG, EMG).
o Obtain N5tline ~ight and vital !ign~Assns the level offatig~and tht
prrstn~ of pain. Assn , dttp tt ndon Il'flexrs (OTR,).

o
o
o

InlNtion
Activity IntolewKe
Fatigue

o Anxiety
ImNlanctd Nutrition,lffi Than Body Requill'menll
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 ll'9im~n 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 ~dftlll'drug efftct
o Risk for Injury, Risk for Falls (rtbted to adverse drug ~ffe(l\ or dill'm)
o Risk for Call'gi!'r Role Strain
o
o

Assellment thro ughout administration:

o AslI'Ss for dtsired therapMic rilecll (t.g., indicator>of trmrnem ilium or
palliation SIKh as ~owtd 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 ~uent monitoring of lab war!: (e.g., CBC, absolute ntutrophil
count [AHCL plattlet count, urinalysis. htpatic: and Il'nallulKtion studif~
uric .cid,~roIytrs, gllKose). (AN( = Totil WBC (ount multiplifd by t~
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 ~ifio: to t~ pbnntd
t~ of i minroplastic th~rap)' (e.g., audiology, (.I rdial: I\'StinQ. ECG, EMG).
o A.lI'Ss for the p~lKt of nause, or pain.
o AslI'Ss DTIb,and ECG as ,pffifk to th~ 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 ,(Onsti~tion. ft!'~ fatigue, diuiness, dysrhythmias, angina, dyspnea,
musc:1e or joim ~in, pall'Slhrsias, diminished or absent deep tendon rffbes.
hyptCension,hype~ia, bni.ing,and blttding.ftytrmtedng
pararneteB rstibl~htd b)' tilt provide~~ dianhN,jaundi~,dooNsed
urine output or hematuria, el(tuiYe bruising or bIffiIing. rrspiratory distrrss,
andd)'lfhythmia, or an.jna shoukl be rtpOrIrd inmediattly.
Planning: Patient Goals and Expected Outcomes
Th~

patient will:
upt"rir-rKt thera peul:ic tfffcts k g., Il'duction intumor flY" or dt (Il'.md progrnsion of abnormal cell growth, abll' IKt of signs i nd symptoms of (OlKUmnt
inlenion, able to maimain ADU).
Bf!lft from, or nperiflKt minima~ idv~1II' tffts.
o V~rbilizt an undfr>tanding ofthedrug's UII'"dvelll' ~1f1S, and rrqJill'd precautions.
o Demon!lrate proper seIf..administration 01 tilt medication (e.g.,doII', timing.. wht n to notify provider).
{Continued}

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566

UnitS ThelmmuoeSysum

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTINEOPLASTIC THERAPY (CorrtlrlUed)

Im plementilltion

Interverrtlons and (Ratlerra les)

Patient and Fam ily Educa tion

--+-

En suring Iherilpeul k effech :

Continut ill5mmtnts ilsdecribed earlier for therapeutic eiffc15:
radicJgraphic fYidtnc:e ofdiminisi'lfd tumor mas~dKrra~ production of
ilbnormal cell growth. ab~~ of signs of infection, milinte~ll(eof apptl~t
ilnd food and ftuid intake,nausN Ind 'oOmiting cOl'ltl'Ol1ed, .nd a~ to
maint.in ,mpubif ItveIs of AOIJ.(Antineoplistic drugs do not hal't
imrMdiately oIMrnbif J!Win and I!'IUIts will !If mtilsured ~r limt.
Thee drugs han many potentiill advt~ tfFlS.)

P~opla~tions for all t!'Sting ilnd trNtmt nts u~. ProY~geooal

inform ilion on the tllpKltd COUJlt of dJemothm py: rrqJill'l1II'nts lor
inYilliY!! lints (t.g . ptripherall'eJSus ~ntril ilCetSl ports). initial infusion or
dosing. I.eqUl'llCY 01 expec~ 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, inhoIpital W1US outpatient dinic loution~ and how to INCh oncology teil m,
~ially wring off.nouJ!.lnl'Ol\'t tilt family and ciI~i ....... in informnion
sesSlOn~

Minimizing il dft J!f effects: (ienffalCIIft

Cominut to monitor vital signs. Report incJNsing ttmptrarurr thit mreds
~rlmtlm (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 ftl't~ fI.'I"I Iow-grlde tt mperatuft's m.y lit sig nof inftion.
ImmlJflosuPPll'Ssion miyuu~ infKlions to occur il nd dil5eminatt ripid~.
61 tndothelial cells aft' affKted b)' chemotiltrapy and ft'dill muona may be
d.l1IIiIgtd if rt<l<ll ttm ptraturts art ustdJ

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 ~rlmtlm 1ft' ell(tede<i.
InslnKtthe p.lOtntthat ilmipyrttiu art not to !If used units! explkitly
JPp~ed by the oncology provider. (Antip)'ll'Iics may mask the symptoms
of an infl'(!ion,allowing rapid disll'Jllinuion of tht inff(tion.)

o Continut to mon~or fIl'~nt lib work:(O( ANC, pllteict coun~ hepatic ind
ft'JI II fundion tests, eifclrolytes, gkK~, and urinalysis. (Bone marrow
supprtSsion with I!'IUking blood dysunias is an opKIed idYfrIf" effKl
and will be monitorrd b)' AOC,(BC, and plat~1tt counn.)

o Teach the patient 01 the need for Irtquf", lab work. HaY!! tilt patient ilifrt
I<tb pmonnelofchemotht r.lPY ust.
If pt"riphtral ninlate!lled for phlfbotomy, KJUpulous cifilnsing of the ~tt
prior to stide and prolongtd pressurt may be Il'lJIill'd If a c~tralline
C-_ _+-_.C'C~C'Cis used, Krupulous cicansing of the pon is rtqUirtd.
Pro~ antiemtlic: the"py during ~minist"tion of drugs with high and
morlmte mtlic potential. If the patient has had prmous tll'atment with
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.
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,
inirrqUl'nt IlINls. Nutrition.1 su ppifmenn such iI SUtVury, Boos~ 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 ~ps of Cilrbonated ~rilgt~ !'Specially gingtr aif,
may provide ft'lief.1f GI efiKis predominatt (e.g, diarrhea), mid high
roughaqe foods.
o Encourage f.eqUl'llt oral h)'9~n t: rinSf mouth, tspecially abr tating; USf
lip balm;and 'l'Oid akoholb.~ moutliwdsh, ...mkh m be drying to Iht
mucosi.

Continut to monitor nutritio ...1and fluid intlke.(Naultii .nd I'Omiting all'

rommon Idve~ tfFfcts ilnd usually Il'lJIill' ilntitmetic therapy to man..
lliHJry consulution may be rrCJIirrd to main~in optimum nutrition.)

Continut to ilS~S forthe PJl'ltnct of pain and pKlYide for adtquate ~in
medication./Pilin may I!'IUk from ~anced 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.)

EnCOUr.lgf tht ~tient 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.

PJO'I ie1e for ~ftjwte rtst.(Fatigut related to anemia Ind adY!!JIf drug
Teach the patient tht importalKe of s~dng daily routifll'l throughout the
tflKls is common,tspf(ially around the nadir and immediately after:
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. Pro~
Itl!fal )'faJ! alter themothtrapy.)
_ _ _"--"
"=""',1,,to lOCiallfrmts IS netded.

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NURSING PROCESS FOCUS

Drug'(D<f\IeopLHIa

5 67

PATIENTS RECEIVING ANTINEOPLASTIC THERAPY (Continued)

Implementation

Inte rve nti on s and (Rati o nale s)

Patie nt a nd Family Edu cati on

Protttt t~ patient from inlKtion: t. 9. frequent hand wuh ing befD<t

patient (.Ifl';maimaining IUlJpulous inlKtion comrol mUlUfl'! for alllY
linrsor \'eIIOIIS puncture; tlKouraging t~ patitm to mainuin daily
hl'lient mmures to limit t rttlllilillora;and uln~ng lor,ymptomlol
opponuniltK inftttionland I{quiring tarly Ueatlll!'nt or prop/lylaJil.
(lmmunolUppr~Slion pbc:6 patient! at high riIk lor inlKtion. ProphyOOic
t~rapy with intifungll and anribac:ttrial mouth riOllS,ind prot~tjyt
isolation may be l!qtJirtdJ

Ttach t~ patien~ family, and (.I regiel" inre.:tion control mtalUfl'S u

follow!:
o o\void uowriM indoor pb.c:H.
o Awid ~with known in/euionlor)'Ollng childlt'll who haY!' a
higher rilk of having i n infection.
o Cook food toorough~, allowing t~ lami~ orcaregmr 10 prr palt' raw
foods.nd 10 dtan up:pati.nt should not ,onIUm. r..... fruit! or
vtgmblts.
o Repon all)' I~tr 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.

I'rovidt lor tmOliollill suppon for t~ patien~ family, and (.Irtgmr. (Can't!
rf"IUkl in profound . motionallt'lroOOlirom all inrolY!'d. EnWUri9f
di=ion of ,olUm ~ appropriatt It'I. rra II lor !O<ia Isupport or spirilwl
asliS!iIl(.,and ,1IIlnl t~ patient or family for dilufI! that may It'quilt'
m.ntal ~alth ~Ierral.)

ElI(ourag. t~ patien~ family,and cartgmr 10 di!WI1 {OlI(rllll or

quetionl ind 10 sm approprim spiritual or !O<ial support mltsilt'd
AI5f11 finan,ial (01I(em\ and providt approprialt .ooal lffi'ic:.lt'lerral u
n. tdtd.

Minimizing adft l!f ffl"Kls: Specific to Drug rherapy

Monitor DrRs, neurologic lIatus, and 1tY!'! 01 (OnI(iousnel~ UDO. lA/ky/mil19
agmn!lKh as c,dophoIphamideand norurol produa amnlClpa!lia!lKh
as vinailtine ha .... neurologic advmr .fft<ll.Changes llliy occur in orRs
that alt' not notiltabit 10 the patitm in tarly ltages but llliy alfm dmeril)'
or 1I.~dillfl! wlltn walkingJ

Ttlth t~ patient to be cautious w~n walking or ~rforminglllilnual tllks

rrquiring mra df,nerity. Promptly repon all)' lignifK.l nt diffiru Ity with
df,xt. rity, or duminfl! whtn I. rrying out ADLJ or when walking.
E()(ouragt t~ increal.d intakeoffluid! and modtrate fib.r in t~ diet if
constipation iI ~n tift" It'laitd to deul'lltd perillal~iI.Drug therapy may
lit lI'quilt'd if (Onstipation is IfYtre 10 pr~.m straining during dtlation.

Monitor(.lrdiolral(Ular ItaM i()(luding ECG, ~~rt and blt'ath IOUnm,

prl'ltllteof tdtma,and ~ngin~ or mflt-wall pain.lA/ky/mil19agmflllKh I~
cydophoophami df" antitumor QIIfibodies !lKh II dolOrubicin, na/uroJ
prodrxr oninroplll5lia !lKh as vinlriltine, i nd hormont and hofTrlOM
onloganim mh is tamoxif. n haY!' mdiomrular ad-mit eifls !lKh i~
pericarditi~ and effttts on tho cardiil conduction ~YSIffiI.)

Ttllh tiMo Pitient about t~ nw:! for flt'quent monilOring of "rdiil IUM.
Immtdiateiy repln any lhest-wall pain.angina, palpitatiom,~pnea,lung
longtltion, or dizzinell.

Monitor respirnor; SUM indudiog breath sourKb Ind pulmonary function

t6 11. Wkylatil19 ogmfl IlKh is cyciophoophamidf" antimHoboiirl'5 sum i ~
mtlootlt'ute, onriwmor omibodil! !lKh a~ doJOlU bicin, fIIlwroi produa
onOOeoplmria s",h as vinailli lit, and bioIogk mpomt modifiers !lKh 1\
inttrl"uon alphi-2 hal'f Jtlpiratory ad-;.B!' effls !lKh a\ interllitial
pnrumonitis.)

Teich tilt: Plitient ibout I~ nffll for fll'qU!'nl monitoriog of respirator;

lIaM.lm mtdiat. 1y repon all)' Ch6 t pa in. dyspnei,lung longetion, or

Ttlth tiMo patient pulmonary h)'9ienr mtaSUJtl !lKh II i()(lN~ng fluid

intakt to moisten II'Spiruory tl<ll~ i\lliding aowdtd indoor placfl and
proplt with known II'Spiratory dileasr,and avoiding Ulfol room or body
~pra)'S, which llliy be an irritation to tho Jtlpiratory tract.

Monitor hepatic and It'ndl staMand for urinary trill dysfuoclion.

(Amintopla~tic drug I may (.IU If significant hepatic and fl'na Itoxicity.
A/kyloringogmB IUdJ II cydopoo~phamidt may (.11M htmorrhagic

CYlliti~.)

Teach lilt: patient 10 immiattly repon any naulta, ~omiting, )'dlowing of

lkin or scltra,ibdominal pain, light or llay--cololt'd stooll,dimini~htd urine
outpu~darkening 01 urin. , or suprapubic pain or blood in t~ urine.
Advile t~ patient to i()(lN~e fluid intakt to 1 to II perday.

Monitor for ototoxicity.!A1ky/IriIg agmn s",h a\ I)'(lophospha mide and

onrmtrobolill! !lKh as mflootlHalt llliy (.IUIt otoUcil)',affKtiog hearing.
balancr,or both.)

Ttlth tiMo patient iboot t~ ntt<I for periodic monitoring ol~aring.

Immtdiateiy repln any diuillfl!, Vtnigo. naIMa It'lated to motion,
buuing.ringing.or humming in t m.

Monitorfor orulartoUcity.(l/ormontond honnontanlagonisn !lKh is

tamoxifrn may uu~. ocular toxicil)'.)

TtlCh tiMo patient about t~ nw:! for ptriodic ~ mm.lmmtdiattly

It'pon all)' bkJrmf vilion,.yt pain,or halo~ or other vilual disturba()(6
immtdiat. ly.
E()(ouragt t~ patitnt to wur ~ungla!st~ when in bright light.

dizzines~

(Continued)

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568

UnU The Immune System

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTINEOPLASTIC THERAPY (Corlflnvtti)

Implementatio n

Interve nti o ns and (Ra tiona les)

Pa t ient a nd Fa mily Ed ucati o n

MonilOrfor MllNloiogic IOllicity.(N1)"lti!9119l1'1U ~h IS

(){lophosphirniM ma, causr lignfunl U R'actions indJdill!l
StMM-Johnsonsyndromt.)

Tum tilt p.lDentlO imm~~teIy R'\IOI'tany unUSUiI (ha~ 10 skin,

I1IWs. ()' sunoom.ikt i PPfII1l00' promptly. RfIlOrt any purplish-ml
blisttlill!l fWl,Of pMill!l skin.

Monitorfor 1!U:00itis. {AnMplnn.: drugs IIIiI'I calM sigrlilkilnl l!U:osilis

ltiated 10 tfffft5 on 111.,..,. dividill!l GI tncioIhtliill [thJ

kICh the p.lDent 10 inspt(l mouth at IrlSt once oWy 1M m~tlin regWI
Mnt.ll wms.Miintain good onl tryqitnt and rinse mouth with plain
wate l 01 iOUion Ifttl eatill!l.Use anl~al 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 ~ny excHSM dia nbti,
rspecially lit (ootlm IIIIKlII Of blood.

Monitorfor hype~~tMty and i1lr.qK 19ttiom.. (AnIiMOplIln.: drugs

may YIM ~iOOnt IrfpmtnWvity and llIr19i1: R'lpon~ inckJdill!l
arwphylallis.Bfause ructions mry not a~ bt prtdirub!t.Q\ftion aM
frf!Jlffll monitoring <If! mfntiallO mIllR' prompt UfiltmtIIlJ

kICh tilt p.lDent 10 imm~~teIy 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.

Bt lWalt of qrq-~ polil:its and plllllJR'llfloIted 10

IntincottlastK Idministmion.!pillfliflagtmCfll. aM Itquirtd cWfWWOrk
btfo!t womng with or gm.,g (htmotlttr~. 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
~I!' HAZMAT intmmtion.(lnttmM t<kJutiln prognmSilR' ~i~
priof to administering vnicMJlS ilM othel (htmothmp)' drugs.'lI:IltCtion
ohhe IJJrs~phiinnaq pmonnfl, iIIId others inI'otffil in the ~l1Ition
aM administriltion of chemotherilJl1 is e$~tiaL)

PIIlYide tht iNtitn~ filmil"and ul!'giver rdocition ilM IUppofl when

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' PfC'I'idt~ilnd III)' nKe~1} mooitoring 01 prtUutions..(Usill!l
timt Wriog ~g 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 bmi~,()' c.JIlI'giver in
PIOpfI Ie K-m inistrllion Ie< hniques IoIIowfd ~ rtI\Jm MmollSlfation IS
I'ftdfd. (PlOptr adminismtion wiI Male the riflivmes of ~ drugs.)

gimg chemolhtfilflJ

The p.ltien~ fimiiy. ()' UregMor UIouId bf able tostatt tilt ItISOll for the
dlUlj;lppropr~tt 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 p.ltien~ 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 toiIe~
poortd in I drlin.Of thrown IW"I in the msh.)

Evaluation of Outcome Criteria

b,luil~ the Bf~ntss of drug

tMapy by (OfIfirmillg tltill patimt goals Ind eJjlKttdOlJlClKl'lellwve bten m~ (sH,1'I,nning1.

SrI' l1l*I17.1 rIrrIIHjI 17.'111 b /hfjl1wtKltl1lNlIIIMf

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Drug'fo<~

569

~~l' 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 clea r, 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 biologic. 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, palliation, or prophylaxis.

37A

H .S

The growth fraction, the percentage of cancer ceUs undergoing mitosis at any given time, is a major factor determining success of chemotherapy. Antineoplastks are
more effective against cells that are rnpidly dividing.
"Ib achieve a totat cure, every malignant cell must be removW 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 consequences 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-

raJ products, biologic response modifiers, and misceUaneollS 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 synthesis. 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 narrow 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 camptothecins.
37.13 Some hormones and hormone antagonists are antineoplastic agents that are effective against reproductiverelated 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 antineoplastic 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.

NCLEX-RN" REVIEW QUESTIONS

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 cancer.~
4. "One dntg will cancel oUi the side elfeas of the other."
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.

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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.
Which of the following statements by a patient undergoing 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 w~ek for her baby shots.~
5. "I am going to go shopping at the mall next week."

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.
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 provtdtT~
1. DimRea
2. DimInished bov.\>I sounds

Thl' n urse nOies tha t the patien t 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.

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 n urse to
teach a patierlt who Is receiving che motherapy at home~
1. A nurse Is takJrlg chemothel'apy iV medkatlon to a pa
tient'S room and the IV bag suddenly leaks solution (ap.
proximately 50 ml ) on the floor. What action should the
nurseta~

Sa "ppmila D foranswns and f'Il,ionaks for aU activitia.

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r::--'- ~"---.

EXPlOflE ~

Is YW' one _ I1lI' 0'*'1: d'll!PItr mIew materials and

Ie&WICH. Plllpae lor ~ MIh -'~0Ra1 ua .. w-st'p16 Practice
QlII$b1s, Interl/;1llle IISS~ aid aCIMIics, web tlnks, lIIi'mtlon!
arid ~ideoi. and morll
MyI''''~.-.go.

P.eg13l~.,ow IICI:tJiII

c:odIIlrom 1h8 1rm1 of)QIr DOOIr lit

www.mrllll.linilkitcam.

U NIT

l he Respiratory
System

(HAPTER 38

Drugs for Allergic Rhinitis and the (ommon (old

CHAPTER 39

Drugs for Asthma and Other Pulmonary Disorders

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Drugs for Allergic Rhinitis

and the Common Cold

DRUGS AT A GLANCE

LEARNING OUTCOMES

Hf RKIPTORANTAGONISTS (A NTIHISTAMINES)

Aher readiflt} this chopter, rhe sWdent $hould be obiI' 10;

",,,,

,.,,,,

diphMhydrD~(B~,OfhfflJ

INTRANASAL CO RTICOSTEROIDS

,-,511
<;) flu/mOtIf IfJMcose V"IImyst olhmJ

""w

MASHUl STABILIZERS f1J1I/56J

DECOMGSTANTS pq5MJ
.;)

o.rynfazol~c:Akifl,o!hffJl,.W

ANTlTUSSIYES

,.w

Q <h~fholpht>n (l:W.I)'fI1,IIobinmm.
olhm) pillJt511

EXPKTORANTSANDMU{OLYTI!3 1'11'584

1 . identify major function~ 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 proc~ to call! for patients who are receiving
pharfTliloCotherapy for i\lliergic rhinitis and the common cold.

KEY TERMS
ilHeIJI'Il fIIJ1t 574

mlKllJl:i:5

.nff1k minim ,.514

felloW (ongetiln

.nlossi'll5 JIIlIJ'5&J

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JIIlIF J!5
ptIJt 1II1

'"",If,31

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 provides 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 examines 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, conditions that affect the lower respiratory tract.

38.1 Physiology olthe Upper

Respiratory Tract
Knowledge of the basic anatomy and physiology of the upper respiratory tract ( URT) is necessary to underst.and the
ph~rm~coth~r:1o[lY of con<"lition.~ ~ffecting 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 sometimes referred to as the "air conditioning" function of the
respiratory system. The basic structures of the upper respiratory tract are shown in .. Figure 38.1.

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 systemic 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 autonomic nervous system. Activation of the sympathetic nervous system constricts arterioles in the nose, reducing the
thickness of the mucosal layer. This serves to widen the airway 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, administration of a sympathomimetic will shrink the nasal mucosa, 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 n:1o.~1 mncm;~ [lro<"luced <"I~ily. :1ond Ihi~ fluid i~
rich with immunoglobuliru that are able to neutralize airborne pathogens. The mucosa also contains various body
defense cells that can activate complement or engulf microbes. Mast cells, which contain histamine, also line the
nasal mucosa, and these playa major role in causing the
symptoms of allergic rhinitis.

InI...",.

"""""
Vestibule

Hard palme
a.alaM!y

11I.L\;':i:t---

Laryngopharynx

.. Flgure.J8.1 The respl.atory system

Sourt:e RIce, Medical Terminology with Human Anatomy, srh ro.,p.l9l, Cl lOO5. Reprlllroo /;)i permls5lcxl ofl\>Qf5a1

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fdocarJoo. tic, Uppe' SaddIe RIver, NJ.

ALLERGIC RHINITIS
o r hay fovtr, is inflammatkln of the nasal mudue to exposure to altergens. Although not tife threat-

AI~rgi<rhinilil,
(<=

ening, allergic rh initis is a condition affe<:ling minion<; o f

patients, and pharmacotherapy is frtquently n.ecessary 10
wnlrol sy mptoms and 10 prevent seoondarycomplications.

38.2 Pharmacotherapy
of Allergic Rhinitis
Symptoms of allergic rhinitis resemble thoSt" of the com -

mon cold:

h~arin8

eyes, snet'ling,

n~ 1

oongestion, posl-

na.loa] drip, and ilchingofthe throat. In addi tion 10 the acute

symptoms, polenti31 complications of allergic rhinitis ind ude loss of taste or smell, sinusitis, chronic cough, hoarseness, and middle ear infections in chil dren.
As with other allergies. the cause of allt"rgic rhinitis is exposure to an antigen. An antigen, also cal led an allergen, may
be defined as anything thaI is recognized as foreign by the
body's immun e 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 spo res; 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 rhinit~.
Some patients eJ:perience symptoms of allergic rhinitis
only at specific t imes of the year, when pollen levels are at
h igh le"els in the environment. These per iods are typically
in the sp ring and fall when piants and trees are blooming,
thus the nam e ~QS(}n(l1 alJergk rh in itis. Obviously, t he
"bloom ing" 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, an imal dander, o r
mold. This variation is called ptfennia/ allergic rhinitis.
These patients may requi re cont inuous phannacolherapy.
It is o ften not clear whether a person is exprriencing seasonal or perennial allergic rhinitis. P:itients withst"asonal allergies may also be ~rtSirivt to some of the perennial
aUrrgens. It is also common for one all ergen to ~sensitizew
the patient to another. For example, during ragweed season,
a patient may become hyper-respo nsive 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. Pati~nlS with allrrgic rhinitis con tain

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grea ter 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 inflamma tion o f the mucosa and
adding to the chronic nasal congestion expuienced by these
patients. Beause histam ine 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 occu rrence 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

AlIe'll' p I _ cell

reIe_ -.IIergy"

Bnmgoite
fo< ....rgy

-"-~''''~

Pelt"" binds to
allergy anlibociw,
CItU5lIOI hist ........

.......
~

Figure lB.2 A1ler!lIC mtnllt s

-\

Clllplfr 31 Drug<; for All<>rglc Rhlnltl. ~nd the Common Cold

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, receptor. 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 secretion, and nasal congestion. In more severe allergic states,
histamine release may cause bronchoconstriction, edema,
hypotension, and other symptoms of anaphylaxis. The histamine receptors responsible for allergic symptoms are
called H, Il'(fPtors. The other major histamine recepto r, H" is
found in the gastric mucosa and is responsible for peptic ulcers (chapter 4()00 ).
Antihistamines an drugs that selectively block the actions
of histamine at the H , receptor, thus alleviating allergic

TABLE 38.'

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 decongestants 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 effective when taken prophylactically to prevent allergic
symptoms; their effectiwness in reversing allergic symptoms is limited. Theireffectiveness may diminish with longterm use.
In addition to producing their antihistamine etfects,
these drugs also cause typical anticholinergic effects. Anticholinergic effects are responsible for certain beneficial effects 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

HI-Receptor Antagonists

"n"
FIR5T-GENERATION AGENTS

Routeand Adult Dose (max dose v.tlere Indicated)

Adverse EifKt5

alflutillt (,l.sttlin)

Intranilil; 2!pia)'! (It! IIOIIril bid

bromphtriramillt (~mttlpp, othffi)

PO; 4-8 mg tid-"d (max: 40 Jll9/day)

Dry moolh, IIetldlKiIt, dirzjrltlS, U~1H7Y

II'rmlion, l/icttning of bIoodiioI ftCII'!illl!\.

d"kIrp/Iffii"imi"lf ((blor-Tlinetoo, 01hffl)

PO; H mg tid-"d (max:24Jll9/day)

~mutillt

~ramillt

OOU~l'Omirn;

PO; 1.34-2.68 mg bid (max:8.04 mg/day)

(lavist)

PO; 4-20 mg tid 01 "d (max:0.5 m9Iday)

qproheptadilll'
(Drinran

PO;6mg bid

dud"orphtriramillt (DmrIor, PoIidfi,

PoLiramilll')

PO; 2mg Mry Hh (max: 12 mg/d~)

diMnlrfdrilal! (Dramamile)

PO; 50- 100 mg Mry 4-6 hr

Q tip/lffih)'1hmillt (Bmodryl,OIhffi)

PO; 25- 50 mg thr~ to four timrl daily (Jnax:lOO Jll9/day)

prometlwillt (PhfIII'~n)

PO; 12.5- 25 mglda, (max: 100 Jll9/day)

triprolidilll' (Zymilt)

PO; 2.S mg bid ortid (max: 10 mgld~)

SECOND-GENERATION AGENTS

miizilt(qml)

PO; 5- 10 mglda, (max: 10 mgfday)

dtsloratadin ~ (Oarilltxj

PO; 5 mglday (mad mglday)

iexom!adilll' (ldltgra)

PO; 60 mg bid or 100 mg onc:~daily

If\'ll(~tirizilll' (X)'lin

PO; 5 mg ntabltt or 2tmpocrnj OIK~daily

Ioratatillt (OariIin)

PO; 10 mglday

oIopatadilll' (Patanalf)

Intrallilil; 1 !pia)'! (It! IIOIIril bid

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575

Dry moolh, IIetldlKiIt, dilzirIm, U~1H7Y

II'rmlion,rlJJi'f1

ParadOJ(ital ~I(~ation hyprorosilil'ity

JI'!itjom,hyOOll'nSOO

S76

Un'"

Tte ResplfOlo<y Syst~m

TABLE 38.2

Selected OTC Antihistamine Combinations

Brand Name

Antihistamine

DecongMlant

Adiftd Coidand AI ~rqJ tabI~15

dIIorp/Iffiiamilr

p/IffiyIqtlriM

Adiftd(old andAl~

8tnidryl AllergyfCold Glplets

dIIorphtni'amilr
diphtrtlydl"DirM'

p/IffiyIqtlriM
p/IffiyIqtlriM

ChIorTrimeton Alkrgyf~SI.W ta~etl

~metJpp ChikRnl Cold and AI~91

dIIorp/Iffiiamilr
brompheniramiM

~iM

Sulbftd PE Sinusnd Alltrgy ta~15

dIIorp/Iffii'Jmilr

p/IffiyIqtlriM

Sulbftd PE tligh!tim~ Cold

diphtrtlydl"DirM'
dtmaSliM

p/IffiyIqtlriM

Triamiri( CoIdfAlItqf

dIIorp/Iffii'amilr

p/IffiyIqtlriM

TyIffioI AI~SirLHapieu

dIIorp/Iffii'amilr
diphtrtlydl"DirM'

p/IffiyIqtlriM

tJvi51 AI~tlblt;l

TyIffioI PM GtkapI

differ in int~nsity among th~ various antihistamines. The

older, first-gen~ration drugs hav~ the pot~ntial to cause significant drowsiness, which can bea limiting adverse effect in
some patients. After a few doses, tolerance generally develops 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-

..,. Prototype Drug

f.

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 membranes, which can lead to dry mouth,and urinary hesitancy,
an effect that is troublesome for patients with prostatic hypertrophy. Some antihistamines produce morepronolUlced
anticholinergic effects than others. Diphenhydramine and
clemastine prod uce the greatest incidence of anticholinergic

Diphenhydramine (Benadryl, others)

Therapeutic (lass: Drug to Ireat allergies

"

Analgesic

Pha rma(ol 09i( (I ass: HI-re<:eptor antagon is!; ani ihistamin e

ACTtONS AND USES

ADVERSE EFFECTS

Diphmhydramint is a fi~I..qtII~ation H,-rmplor Jmagonisl whole primary

usr is 10 tft'<II milor s,mptorm of JII~I9' and Ihr (ommon (old wc:h as I~l
ing. runny ~,lnd tNring of thr r)'I'I. ~phrnh)'draminr is oft~n (ombined
with n Jnalgtsi<, dKongestam, or txpf(loranl in OK (Old and!kJ produru.
DiphmhydramiM isJkoadminislerro lopicallyto IR'<II ruhes,and IMIlV forms
ar~ milable for I~R' allergic: rmliofll. Othrr indiutiom for diphfOhydramiM indude farkifllOn'l diINlr, motion ~,and inlOmnia.

Fim~nrration 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. AmKholin
tl9ic: effKts 5lKh a\ dry mooth, tac:hprdia, and mild hypolmsion O(QJr in
IOmI' patirnu. Diphmh)'d ram iM may causr phollXffilitjyiry.
Contraind ications: Hyperll'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 hypMh,llid~m.

ADMINISTRATION ALERTS

Th~re isan inC"N1e:i rilkof anaphy\.lcti[ lhock whrn Ihis drug is adminis
tmd parrmrwlly.
Whon .dministorirog IV, injro ~t ~ rolo of 25 mgfmin to rro~ tho .iskol

,hod.

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

Wh~n .dminr.l~rirog 1M, injKt drt"p into J largr mUlde 10 minim~ tislUl'

inhibitoo mayGIIMa h)1lf!1M1i"ll' aM.

irritltion.

Lab Test!: IlrIJlIhcUd br d&on!OOfd iIIlNst 4day5 prior to lkin~ ifill;

O!hfrwi\.!, f.J~~w te\II may r~

PR'gnallQ ~ry C

Ik>rbaVFoo:l: ~ filii')' [auII' OON5fd aOOdIoilll'rgK fll'KtI.

PHARMACOKINETICS
tl1~tl5-lOmin
~Jk: 1-4 h
Half~ife: 1 -7h

Duration:4- 7h

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TrNtment ofO~rdol!: Onrdo!l' may GlUSr fflhrr CNS drp=ion or mita

lion."Jhm is no ~ifio: IR'UmI'nl forOYelllo!l'.
Rmr III MyMnhIIJR for ~ MIsJfIg Procell fixIIl !pf!(1/1( IIIIM auq.

("",If,31 Drug>; fo, Allergic Rhlnltl' aJld the Common Cold

side effects, whereas the second-generation agents---loratadine, desloratadine, and fexofenadine---produce the least.
Although most antihistamines are given orally, two are
availablt' by the intranasal routt'. Azelastint' (Aslt'lin) is approved 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 because 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 allergic 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 o f 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.

.... Prototype Drug

Flutlcasone

Therapeutic (lass: Drug for allergic rhinitis

P~nalK)'mf9ory(

Intranasal (ortieosteroids
Corticosteroids, also known as glucocorticoids, may bt' applied 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 corticosteroids are very effective, their use as systemic tht'rapy is
limited by potentially st'rious adwrse effects. Intranasal corticosteroids, 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

Pha rmacologic (lass: Intranasal (ortiC05leroid

ADMINISTRATION ALERTS
IOIlIlKl tht p,tM<m to ""wily follow tilt di~(\iolll for 1M providtd by
tlMo manufa{\uftl".

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.

(Flonase, Veramyst, others)

ACTlONS AND USES

Fknkasont is typiul of tlMo intrarw..J1 mrtKosttroitis!Md to nut ~J !On.J1 JlItr<jK rhinitis. Tlltr,Pl' UllUIIy begin I with two Ip,a}'S io N(h oostril, twiu daily.
.lOd t\f(~J\eS to 001' ~ ptrday.Flutiu!OOI' am to ~alt local iolbmm,tioo io tilt mal pal~. thUI ~tb:ing mallluffiOl'lI.

ADVERSE EFFECTS
AdYel"5t rlffi:u of fkni<a!OOI' i ~ "'~. Swallowing large amounu in(~alts tht
pot~mial 10, 1)"I\I1mic: (ortKolleroid ,dvmr tfftru. Halal irrimion IOd~
uris oc:rur in a !In.JlIrumoo of patitnts.
Contr aindi w ions: TIMo only (ontlainal(.Jtion to flutiu!OOI' iI prior h~ptr=l~
tivity to the drug. ~Ir ronic:olleroich (ao mask lignl of ioftion. patitnts
with knowo bmtrial, vira~ fungal. 0' pmlitic: inn(1ions (rlptCialiyof tilt rtspi,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 ~awidfd.a5 m~ dru9

PHARMACOKINETICS
Onset:Unknown
~k: Unknowo

Halflifdh
Duration: 11- 24 h

~ntlyifl(!NItS plasma nutiG!loM 1Ml~

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 t~'tment 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

Potential Nursing Oi_gnoses

Anes5ment
BI5t1ift t tiStnmut prior toadmin istrMion:
UOOerstalld the re~so~ tilt dNg his betn preaibed ill otder to ~sstSS for
thmpMK ~cts.
Obuio ~ (o.~ ~Ith history including piMM histofy of symptoms
Ind a\soonion to ~1 5OOl.. took, or frwironmmloili HpOWfI'S; nisting
ca!d'Mrmcula(, ft'Spiratofy, lItpatic,ltnal. or nMOIogic d'~;9ial/Cl)ma;
PJOIt.ltK h)'ptftlOphy or diffi<ulty with urinition; pmtI1<t of r-r Of actM
inIKtiom; pregnancy or brea\t -lffiIing; ~kohoIl/Sf; or smoking. Obuin ~
dlUlj history, noting the t)'pe of aclvrlSe ItKlion or .nrrgy "prrienc~ to
Iny mf<licaliorts.
Ha~rw symptolll'l are of lIN on~I,i'S~ 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.
[v.~u "pPfOpMe ~mory findings (e.g.. (8(, hepatK~nd reJljj bbs).

IntftectM Aifw" (lrmnct

IntffectM BN!atlling P, UM!
CMturbfd SftpP.ntmtlNtedtoadversedlU!!fll'tcts)

F~1i9Jr

OtfKifflt K~1rdge {drug tII~rap'1

Risk fof In;..y,Risk for Falk (It~t~ to iclvr~ drug rlftctsl

bltss.ment throughout .d.,lnmr..ion:

As~!Of desired thmpt~tK rffts (e.g.,ciKrNsed nas.! (OrgHtion ~nd
dr~inagt. ciKN!ased fre Waltring or itmill9l.
Conrinur prriodK moniforing of(BC,1nd ~r.nd l!Oai ~nctioIlltudirs 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. ~ immedMtr~ any inuming !rft~ confusion, mUl(lr
wuknHS, tidryuldia. palpitations, hypottMioft, SyMOpr,dysp1U,
pulmonary congestiorl, urinary retention,.nd sudden ~I'tll! r,e pain or
r~inbow!lalos uoorod lights.
PJ.nning: Puient Go.ls and Expected Outcomes
Thr~lwiII:

Expr""oc~ ~apMic: rffKts (t.g..dKrea~ nalill (Ongmion and draina9f,dr<It~~ ~watffing.nd Aching).
Br frtr from,or ~ minimal. aclmst ~ffKts.
Vtrbaliz~ 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 ~l.
Implementation

EII.rin 9thtr, peutlceffects:

Cominllf iSStsSments ~s 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 ~atofy illYOlI'tml'flt

For trtatmtnt O'f ItISOflollI.allergies, dlUlj tlltripy should be n.lled btIott

the beginning of ~ i lle'9Y~iI$OII a!W;i appearilllCtof symptoms.
(Btginning drug therapy bHort tlltcirru~nng histamine irKrNse will
rt!UIt in grrattr tbmptutic tfftcts. 5t~rting drug IhrraP'l' afttr illttgy
symptoms'lI! ~lI!wm ~uilt It'lful doses IM!fort marked imp_t
of symptoms is oottd.)
Mlnhnlzing ,dftrse ffferts:
En SUIt patient safgy, tspeO~1 ~ in oIdtf adu k~ Obstrn fOf dizzintss..
MonitOI imbWtion um~ the tffts of the dlUlj Ire known.(DrowsiIltss or
dizmtsS from O'rtflonatK hypounsion may occur ~nd incre~Sts tht risk of
falls.Orowsillffi tmds to diminish om sf'l'tfal dosts..l

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read! the p.uient to suwlement dlUlj therapywith llOop/llrrrlKo!ogK

mtiSum sucha\ incrt.sed lkJid iIIuk! to Iiquefy . nc! assist to mobiflZt
rTJ.JCUS ~nd to reduct p;lOIUft to allr!gens wr- possib~ .
.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 tllttar!~ possible otpptar,nceofsymptoms for ~t tfftcts.

InstnKt tilt patitnt to Cililor assisulICt prior 10 grtting out of bed or

~Utmpting 10 walk ~1onr.1IId to iYOid drmng orO'thtr KliYitits rt<pJiring
ment.aI.1et1ntss or phy!K.l (OOfdioation until the effects of the dIUIj ~ft

....".

(""'lfr 31 Drugs for AIlerglcRhlnltl, and I"" Common Cold

NURSING PROCESS FOCUS

579

PATIENTS RECEIVING ANTIHISTAMINE THERAPY (Continued)

Implementation

Interve nti on s and (Rati o nale s)

Pati e nt a nd Fa mily Edu cati o n

Continue to monitor yital.igns,~p!'(ially pu~ ratt and rhythm fOr patitnn

with Histing urdiac dil!'~. EC(rt may bt ordmd ptriodiully for j)atitrru
with history ofdysrhythmias.(Histamint pla~ a rolt in cardiac conduction
and when bIockrd by antihimminr!;,1IIdY calII<' tttsrrr,thmias in patients
with history of urdiac di5elI!'.)

InstllK\ tht palitm to immtdiattly rt'port diuinffi, palpitations,or

sync:opt.
0 Ttach tht j)atitnt, family, or cart'9ivrr how to monitor pulst and blood
Pf1'S5Urt' " appropriatt. Ensure the pro~ rUI!' and functioning of any
home !,(!uiplMm obtaintd

Continue to monitor ptriodic: hej)atic and rualfunction Iabl,~pKi.l11y in

""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
antihi,tamin~.lmpairt'd rrul function will inhibit drug HCIt'tion and
prolong rifNn.)

InstllKt Iht patitm on the netd to rtrurn periodieally for lab woll

Monitor for pmistenl dry cough, ilKrt'asing cough 1!'I'I'rit)<,incINsing

congestion, or d~pfl!'a. (A ntihillamifl!'l art' ustd with tx1rt'11lI' caution in
j)atitnts with Histing rt'spirnory dMur, including COPD. Thidcmtd mucus
is a pottntial adYl'lW drtH} tlFect.A change in the sr~rit)< of the cough may
indie"t incrt'asing allergic: mpons,", wo~ning disNl!' plIXf"Is,or
rtspiratory infrction and should bt rt'ported immrdialrly.)

InstllKtthr patitm to promptly rt'port any change in tht ~ or

frequtncy of cough. Any cough accomj)a nied by , Ihortnffi of brtnh,
incINsing (ongrstion, ~,or mtst pain shoukl lit rt'porttd immediatt ly.
0 Encour<lgr the patitnt 10 incrNsr fluid intake to as~st in liqJifying mUCDUI
I!'Cretions i nd to NIt dry mouth tfftm.

MOOS for (NS tiferu including rnt~sfl!'l~ nervousfl!'lS, iMomnia,

hNdacht, 1rt'ft101""l, fatigue, or wt'aknes. RtpO/t 1fYert' s~mptoms or any
disoritnlalion orconlusion immedial~. (e NS dtprrssant effKtS such as
drowsin~s, fatigue,or mild wt'akn~s art common.Paraonic:a1 tnitemenl
ItKh as restlessne~ nmousnrll, or insomni.l may OCQJ~tlptcially in
chiklrt'ft.Akohoi consumption incrt'astI tht eNS dtprt'lsant rfleet> and
lhould bt avoidtd.)

Innlu(\ thr Piltirm, fimil~,or(<Irt'9ivrr to report in<re.J!ingleth<lrgy,

disorientation, confusion, chaogrs in behavior or mood,agitation or
aggrffiion, skJrrrd speech,or mJia immtdi.ltti}o.
InstllKt tht palitm to avoid or tliminatt akohol consumption whilton
antihistamilltl.

If ustd for s~p.~surt j)aUtnl safety on awakening.AI'Oid using

antihistamin~ fors~p for mort thin 1 Wl'rks and consuk the health cart'
proI'icIrr if insomnia continurs. (Morniog or daytimr dro'Mifl!'ls, a
"han90\'ef" rfftcl,ma~ occur in IOI1lI' j)atitnts laking antihistamine for
I~P ind ma~ imj)air oormal icitiYitirs.Patitms may btc:OI1ll' toltrim to
drowsinminducing tffrcts within 1 WI'~hJ

Caution the patitnt about polliblt morning ordaytimr !leepines and 10

Otr<M caution with activitil's requiring menial altrtfl!'lsor physical
coordination until daytimt tffrcts of th~ drug art' known.Do not kffp the
mrdiution al tilt btdside 10 prt'~nl ol'ffilosagr from ocQJrring if
additional doltS art' taken whtn drows~. Do nottakt the mtdieation
conQJlI\'Ittly with ikohol.

AsltIs for change"! in visual acuity, blurred vision, lassof ptriphtral fision,
sing rainbow halos around lighu,irutt f)'t pain,or iny ofthese
symptomsac:comj)anitd b~ naul!'a and vomiting arod rt'port immrdiatd-,-.
(lnc~,std imriocular prt'>5Urt' in paritms with narrow-anglt glaUComi
may occur with imihistamine.)

InstllKt Ih~ patitm to rt'port any fiswl rnangrs or ~ pain immedial~.

AsltIs for urinary rt'tention, ~pKi.l11y in malts 0'lrl400rwith i history of

prostatic Ityptrtroplt)<. (Antihistamine may causr urinary ~tention.)
0

Monitor for GI rffKtl.(NaUIN, vomitiog,~tric: dislrt's~anoruia,

(onstipation, or diarrlrra may ocrur and art treatrd symptomatically.)

Monitor for anlichoiintrgic:fflaltd adYenr tffrcts including dry mouth,

Ihic:kened mlKUl, nasal drynffi, ~ightly blurred vision,and htadacht. (Mild
antic:holinrlllic: tfftcn art' common and art' trt'ited I)Imptomalieally.
Significant synt ptom sas listtd prtl'iously art' rt'pontd immrdiattiy.)
Patint understanding or drug therapy:
UI!' opponunitits during administration of mrdic:ationsand during
'" ""''''''''''' 10 dim", Iht ,arinnat. for dnHJ Ilwora~. rlMilPd th"'p"'ttir
OUIcomt~ moll common adl'l'l"l~ tflKts, parametm for wlltn to ull thr
hNlth cart' ptoYider, and any fl!'(ffiary monitoriog or prt'(iUlions. (Using
lil1ll'during nursing urt' helps 10 oplimireand reinfolU' key Iraching

InstllKt th~ patitm to immtdiattly rt'port inability to l'Oid,ind incrt'i~ng

bladder pressurt' or pain.
Tmh tht p;ltitnt to takt the mtdieation with food or milk. Report an~
significant GlI~mptoml (t.C)., n<lusea with VOOIitiog,diarrlrra) to tht
health ca~ provider.
Ttach tht j)atitnlto incrt'al!' lkJid intau orltKk on hard candy to reiiewo
mouth and rrspiralory Ifact drynes.E=:il!' caulion if bkJrred vision
imj)ai~ normal ictivities and report signirKilnl viswl disturbance is
listtd prt'iousI~.

Thr patitm shoukl bI' able to staU the rt'ason for the dlllCj,ippropriate
d,w,~nd <rhNlulilll]. whit .r!....... ..ti"I'<1S In nb< ....... fotand wh." rn
rtportthem.

a~iI.)

(Continued)

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580

Unit,

TheR"'PIrotorySY'!em

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIHISTAMINE THERAPY (Continued)

Implementlltion

Interventi o ns li nd (Rlitio nliles)

Plltie nt li nd Fli mil y Edu cllti on

Patient selfildministration of drug thuapy:

Whtn ildministmng tht mtdiution, instruct t~ piltitm, filmi~, 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

T~ piltitnl and fami~ 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 (~ Planningi.
5ft Tab//> J8J flit ~ ~ofdnJ/}5 /t)wNd/ dIN mrlqlXlitm ~fy.

TABL[ 38.3 I Intrilnasill Corticosteroids

Route and Adult Dose (max dose where Indlcatl'Cl)
Drug
bfdmI!,thalOllf (BffilnaSl' NJ.Qml
(~ p.l9I' 600kt tht

Intrilnalil~ 1 spray in ~d!

IIOSIril bid-qid

Tromimlrmi1l imrQrioo,lMri~

Prototypt Drug

""'"

snmifH},oro:t)'fll'l.!
Hyproortidsm (only ij lamt amoonu

OOtIOOKR (Omnaris)

Intranalill;2 sprays in NCh noruil bid

Intranalill:2 spaysOlKe daly (max200 rrKglday)

flurisolidt (Nnalidt, Malarell

Q ftUtilil1Olll' (RonaSl', VtrilmySl,OIhm)

Intranalil~2 sprays in NCh noruil bid;may ioowo! totid ij!Wdtd

Intranalill; 1spray in u rn II05IriI aue (VrrilmySl) or twice (flonast) da~y

momtlillOlll' INaIOOO:)
triamdooiOlM' aatooidt (NuiI(O/t AQ)

Inuanalil~2 !plaYs in NCh nostril/day

Intranalill;2 sprays in u ch nostril daily

budtsooidt IRhiloc:ort Aqu.i)

Adverse Effect~

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 h ave 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-

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a(CwDowrdl

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 allergic rhinitis when given by either the oral or intranasal route.
The intranasal preparations such as oxymetawline (Afrin,

'"",If,31

Drug< fo, Allergic Rhlnltls and the Common Cold

581

TABLE 38 41 Nasal Decongestants

On"
SYMPATHOMIMETICS

Route and Adult Dose (max dose where Indicated)

~ot(PJfU-{l)

knlaMloJI (0.1,%);1- 3 !pIa)'5/rmuit oot more f'tqumtly min

InrroOORlI:uonIil'lJlrJOJOlim~orion.oo~

~my 4hll

JlWZing, 0Idr)nm, htodQcM

InllaMloJ~l ~ urn nOllrii MI'13~ h

Inlrarwl (0.05%);1-3 !pIa~OOl ooSlnl bid forup 10 3- 5days

PO: fIfrlI:lIIIW, in>OO1/1i4 hfadtxht, tty mourh

IIiphazolint: (lmiw:)

Q Ol}'meljzdirt (,11m 12 Hou~

Hto-S)TItphriot 11 HOII",othtrs)
phmJ~pllfiot

[Amn ~ Hoo~

Hto-S)TItphriot 4- 6 HIHI",OIhtrs)

. ,"'"

pItIIdot~tdrinf: (Actifed, Sudaftd.

.-

InllaMloJI (0.1%); 1-3 dlllp5 or ijKi)"l Nm flDllril"~ 34 h,

AdwI'5l! Effect,

l1uiulasal; rtbor.n:I (on!lmion

Q: mitJlion umI!!n.!b:!!Ir!!!!mii~ Iiml9f1h,
diffi cUly in voiding, !!:I'!'~ Yo! 5lKOOIuiction

PO;60 mg 4-611 (rnn:l40 fn9/day)

1f:uihydroldiot (Tyziw:)

InllaMloJI; 14 drop! or !play! ~arn flDllril MIl 3 h

xyIomrtllOliot IOtrivin)

InllaMloJI (0.1%); 1-1 !pIal" ~..m nostri bid (mn:thrrt dwsIday)

ANTICHOLINERGIC
ipritropiJm brom~[Atroml~
CorrbiI'mt)

Nilil ijKay;1 spray! in Nm flDllrillhrrtto fOIl" limrsJday upto 4da)"l

Tronlifnr nQSQ/ irrirooon, baniIg, WfZing. Of

dynru, rough, htodtxht
lkiroao: !!!rnl!m. worstni!!!l oIlIirrow ... ggr

IIQIia ilKkatr ammon idl'!'1>I' rIIetts;l!!l!t!!l!!i!!9intkatts sffiou!~1>I' ~1IK1s.

others) art' availablt' ore as sprays or drops, and produce

an effective response within minutes.
Intranasal sympathomimetics produce few systemic effects 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 characterized 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. Because of this rebound congestion, intranasal sympathomimetics should be used for no longer than 3 to 5 days.
Patients with aUergic rhinitis who develop toler~nce to the
effects of decongestants should be gradually switched to intranasal 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 intranasally, and they are less effectiw at relieving severe congestion. 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 insomnia and anxiety.
Prior to 2000, pseudoephedrine was the most conunon
decongestant included in oral OTC cold and allergy medicines. Pseudo ephedrine, however, is the starting chemical
for the illegal synthesis of methamphetamine by drug traf
fickers. Although still OTC, pharmacists are required to

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"""'"
monitor distribution of pseudoephedrine by kt'eping a log
of patient names and address, checking the photo identification 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 pseudoephedrine itself is a dangerous drug, but to limit the
availability of the drug to illicit makers of methamphetamine. Manufacturers have reformulated their OTC cold
medicines to contain phenylephrine rather than pseudoephedrine. A drug prototype feature for phenylephrine
is included in chapter 1300.
B<'C3USe the sympathomimetic< relieve only n~sal 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 (NeoSynephrine,Afrin,andVicks) may contain different sympathomimetics. 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 decreasing 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 ipratropium is in the pharmacotherapy of asthma, and a prototype feature for this drug may be found in chapter 3900.

"'" Prototype Drug

I Oxymetazohne (Afrm, others)

Therapeutic Class: Nasal decongestant

Pharmacologic Class: Sympathomimetic

ACTIONS AND USES

ADVERSE EFFECTS

Ct.ymmzolint..ai..tHalpha_.d""'"'9i< fN~"''' intt..<ympott..ti< ~

S~ltm. ThisQum arterioles in 1t..1W.i11W~ to (OMtrict, Ihus drying Iht
mlKOUS mffllbranes. Relief from n.ml (ongtStion CKwr; within miMtS ,lnd
last! for 10 or moft' hoor;.lhrmetazoli~ is .dministert'd with a mererrd spray
devKe or by IW.iI drops.
Ox)'metlloli~ (Y""i~ LIl) is also available al ~ drops. It QUIH moronmiction of !'S5tk in the eye and is used to ~Iint rednHI and proYidlo ft'li.t"
from drynHsand minor ~ irritation~

Rebound <O~tion is romlMll when o<ymtWoli.. is used In, Ion<jt, tNn 1

to 5 days. Minor stinging and dryness in IhI' IW.iI mlKosa m.~ beflperienced.
Systtmit adVt~ .t"ftm arl' unlikely, unless. 1o"1l' amounl of the mediti~ is

ADMINISTRATION ALERTS

Walh hands (aft'full)' d tet" administration to

~nt

anisocoria (blurTfd

mion ~nd intqWlity of PIlpil siz~).

Plf9naocy rnegory C

PHARMACOKINETICS

IAtset:S - l0min
Peak:Unknown
Half~ife: Unknown
Duration:6- 10h

H OME

&

COMMU N ITY 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 a~ "perien(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!(ommtnded doses, ootromethorphan is a lalto and tife(tive rough suppmsant
The nu~ shook! be .Jwareof the potential for abuse ofOXM and shook! (ounsel 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 us~r; mj~ ttkeom-lirge dos6 to t~perielKt the ~)dIotlQpit ~fftru
of DXM, add itiorY lantihistamint or dto:ongtStant doses may signifiumly in(lN se IhI' risks ofdmromethorphan abuse. Nurses ploy a vital role in p~id
ing p.tienn with wratt inforTlliltion about thl' dangen of .Jbusing
mtdK.ition~ induding those aviilable Olt

!Wiliowfd.
Contraindimions: Pat;'nts with Ihyroid disorder;, hypentnsion, diabete~ 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.
LabTem: lktoown

IlerballFoo:l: IJSI' with caution with herbII ~merlllsum <II St. John~ 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

A42-)'I'iIr-<l1d woman is admitted to the mediullIoor for obstrntion <liter

sufft ring \e'lffilfrmured ribs and dysp~a, SKOndal)' to SI'YM' (oughing
from .rutt bronc:h itis. knzonllate (Tffialon PMts) I00 mg tid is ordered. Tht
nu~ brings in tht meditition and the p.tient sta1e-s1 don'llhink I (an take
th.n.My(oughing is so bad,l don't Ihink Iun swallow it."Tht rlJrn pundurl'"l
IhI' ptrlt with a sterile ntedlt to triable tht pot;'m to swallow thl' liquid insm. Tht patiem uperienlf1signifiunt respiratory distrHl after sw~llowing
IhI' med K.ition and thl' rlJllt (alk forthe MltrgelKy reponse tea m. What trlOr did the nurit make and what shook! NVt betn do~ difleremly?
5tf~OAlrlhtsuqqt!lld_.

same drugs classes used for allergic rhinitis, including antihistamines and decongestants. A few additional drugs, such
as those that suppress cough and loosen bronchial secretions, 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.

COMMON COLD
The common cold is a viral infection of the upper respiratory 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

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38.6 Pharmacotherapy
with Antitussives
Cough is a natural reflex mechanism that serves to forcibly
remove excess secretions and foreign material from the respiratory system. In diseases such as emphysema and bron-

(""'1f.31

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

Drug' for Allergic Rhlnltl. and the Common Cold

to suppress the cough reflex are very low; thus, there is minimal 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 bronchooonstriction may occur. Op ioids may be combined with other
agents such as antihistamines, decongestants, and nonopioid antitussives in the therapy of severe cold or flu symptoms. Some of these combinations are listed in Table 38.6.

TABLE 38 S! Selected Antitussives and Expectorants

Route and Adult Dose [max dose where Indicated)

Adverse effectl

rodtilM'

po; 10-20 mg ~I'tr)' 4~ h pm (max: 120 mg/24 h)

Nwst~, KmiIi/ii romtipDrkII. coofusion, dilmrn,.

I1ydrocodont combi ntd wilh

homatropi1~ (lIyrocIin, otlltrs)

PO; llablu or >mL f'/!f14~ h011 ntl'lItd [max:30 mUday or 6

ubltu/di1)

On"
ANTTTUSSIVES: OPIOIDS

""'' '"

lIypo!~nsion. Stizuft\:,!!aOO,dia ,~pir.1I

!iepmlioo

orr

Wtre IOmoolroce

ANTITUSSIVES: NONOPIOIDS
bmzonalat~ (T~lilon)

PO; 100 mg tid pm (max:600 mg/day)

Pa(jdoxi(jl rujlatOO

dtllltmttholphan [Dtbym,

po; 10- 20 mg ~I'!'ry 4 h or 10 m9 f'/!f16~ h (max: 110 mg/da,)

'"""'"
PO; 200-400 mg f'/!f14 h (max: 2.4 glday)
En~ rflNSe PO;600-1,200 mg Mry 12 h (mB: 2,400 mglday)

MUCOLYTIC
ac~tykySlm~ [Ac~udol~

MlKomyst)

cuOOprja jQlOmnia

(l>IS depression. paradoxiYl mitalion, rtspimort

EXPEC10RANT
RobiIUI~n,otlltrs)

trl'mor;

I"JrowIirlt'l~ /leQdllCM, Glupm

RobiIUI~n,othtrs)

guaifmtsjn (MlKilM'l,

MOl; Inhalation: 1- 10 mL of 20% solution Mry 4-6 h Of 2- 10 mL of

10% 101100 Mry 4~ h

l"JrowIillffi, /leQdllCM, Glupm

Hosrnous~dkm

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
Ambtn)"l Cou91 Syrup

Oplold

Nonoplold Active Ingredients

codrillt

bromodip/lffihydramillt

codrillt

ulciLm iodm

HycoillSS bptctOfanl

h,.._
h,.._
h,.._
h,.._
h,.._
h,.._

HovahislilM' 011

codrillt

CaIOOi~ S)TI4l

CodamilitSyrup
Codioo, 011 Syrup
Codimal DH
Hycodan
HycomiM Compoood

P~nwllhCodthf

Robilus~n

A-C

T*TUI~n S)TI4l

TUllionn

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h_
"".

h,.._
codri~

58 3

phtn)"lpropinolami~

guanffirlin
phtn)"ltphri~ p)'Iiami1~

homauopilM'

_...

phtn)"ltphrillt,cblorp/lNirami~,ac~taminop/iffi

guanffirlin

pstIIIIotp/Itdi~,cblorpllffiiralli~

guanffirlin
p/Iffi)"ltphri~, cblorp/lNirami~

cbiorp/lffii,amilM'

584

UnU The R"'I'I tOfY Syst'-""

The most frequently used nonopioid antitussive is dextromethorphan, 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 dextromethorphan 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 numbing the mouth and pharynx. Adverse effects are uncommon,
but may include sedation, nausea, headache, and dizziness.

C OMPLEME NTARY AND A LTER NAT IVE T HERAPIES

Horehound for Rllspiratory Disorders

H~houOO 1m bttn ultd uan h~b.Jlrtmfdy YfKf theafKitnt fwptilnsand
wal popularwithAmMran IOOilns.ln fulkl~,itwasreplMtd toaid ina number 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 ofh~houOO are found thftll.lghout the fIowtring plant
T~ chit! conrututnt is a bitter IUbltllI(t calltd morrubirm thilt ItimulatHltcrelions. Formulations indudt tta, drifd or fresh ieilftS, and liquid mliKtI.
H~houOO hu an txptCtorant action whtn utatill9 midi and isi 110 avililable
as rough drops. k is daimtd to I6t~ norm, l!t{l!"Iions to iht lung and othtr
organs.

.... Prototype Drug

Expectorants and Mucolyti(l

Several drugs are available to control excess mucus production. Expectorants increase bronchial secretions, and mucolytics 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
hronchi~1

"",rel;on., Ihu . incr.. a. ing mllc". flow Ihal ClIn

then be removed more easily by coughing. The most effective OTC expectorant is guaifenesin (Mucinex, Robitussin,

The Quntion: Are medications tff~ in trMing children with chronic

cough?
The Studr. 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 ~9f 15. The ltudy fouOO no
evidmU' for using medications fur the symptomatic relitl of rough in th is
populition. TheaudlO~ 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 (]IXI6~ Wrltlrre5l1X~arooKalI9/1l1
I'rIbrtlNIPE~~ftDatt~ (h&

1l'J(1 ~JlfiJ5.l&ji

Dextromethorphan (De/sym, Rob/tussln, others)

Therapeutic (lass: Cough suppressant

Pharmacologic (lass: Drug for increasing cough threshold

ACTIONS AND USES

ADVERSE EFFECTS

ADMINISTRATION ALERTS

At thtr~ptUlic dose, aderst tiftds rut to dextlOlllflhorphan U~ rare. DiuiIM'II, drowsilM'ls, ilnd GI Upltl occur in !OIIle piltitm~ In iibull' lituations, the
drug can caUll' CNS toxicity with a Mde variHy ofs~mptoms, including IUlTI'd
IptfCh, ataua, hyptrexdtlbility, IIUPO~ rtIpiratoty dtprellion, lI'izures, {lima,
and toxic psydmis.
Contraindica\ions: Dmromtthorp!wn is cOlltr,iOOiUltd in t~ lreillmtm 01
chroniccoughdUl' tO tJl(~ bronchial~retions,sumas in althma, IIIIOking,
indernph)"ll'llla.Suppl!"lling t~cough reIIex is 001 ~ilible in thf2 patitntl.

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, inWding 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 t~ 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
~ml d~ytof therapy lhould II'f their hr.llth ca~ providtr.
Awid pulmonal)' initants, IIKh as vnoking or otherIulllt"l,btcaUll' thfst
agents miy cit<realt drug effedivt~.
Pregnancy rnegory C

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

PHARMACOKINETICS
Q,~t:IS-30min

f'eak:Unknown
Half~ife: Unknown
Duration: J~h

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Ik>rbaVFoo:l: Grip!fniI;:ie! can liill> SfI\Itn iefIs of d!J:uomKhorpllan ind <aII1f

1OJIidty.

Trfatment of Ovtrdo~: Thert is no lptCifK lreUmtnt loroverdoll'.

IIt/i>r 111 MyMnlngRfot ~ MnJrrgI'rf'55 FoonlpKl/t IrIIM <hg.

(""'lfr 31
others). Like dextromethorphan, guaifenesin produces few
adverse effects and is a common ingredient in many OTe
multisymptom cold and flu preparations. It is most effective
in treating dry, nonproductive cough, but may also be of
benefit for patients with productive cough. Nonprescription

cough and cold products (including those containing guaifenesin) should not be used in ,hildren under 4 years of age.
Acetykysteine (Mucomyst) is one of the few drugs available 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 becomes thinner, and can be removed more easily by coughing. Acetylcysteine is delivered by the inhalation route and is

NURSING PROCESS FOCUS

Drug<; for Allergic Rhinitis , lid lhe Common Cold

585

not available OTC. It is used in patients who have cystic fibrosis, 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 acetaminophen toxicity is presented in chapter 3JOO.

PATIENTS RECEIVING SYMPTOMATIC COLD RELlEF: ANTITUSSIVE, NASAL

DECONGESTANT, AND EXPECTORANT THERAPY

Assessment

Potential Nursing Diagnoses

Baselinr assrssmtnt priorto administration:

Undtrnand thr INson I~ dlll9M ~n presc:ribtd in orlltr to mesior
tlltrapwtic: ~ffls.
Obtain a (omplttt ~ahh histor~ ill(klding previous histOf)' i nd ~qth of
symptoms;~xisting mdionl(ular,mpiratOf)', h~j)alic:,or rmal diseall';
prtII'fl~ of~; 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 dlll9~
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).

Intffl~ Airway (!taralKf

Inclfffiivt Bre<llhing Panem
Disturbed Slet>p i'anfm (rrlat~ to advfl"ll' drug tfflom)
DefKitnt Knowltdge (drug therapy)
Risk lor Injury (rrlat~d to advfl"ll' drug tfflom)

AutlSmrnt throughout ildministration:

ASlI'Ssior dtlired Ihtripwtic: effeo:n (r .g., de<rras~d (0119 h, in(lNsed ~all'
in ~xpt(torating 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 adven~ tffls: dill.iness, drowsine~ blurrro vision, hNlbc:ht,
and t pistaxis. Rt porl immfdiatel~ ilny increasing fm~ tath)'lardia,
j)alpititionl, I)'1I(0pt, dyspll!'i, pul mona ry (ongestion, or (onrusion.
Planning: Patient Goal. and Expected Outcome.

Tht pat~m 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 ~lpt,",lKt minima~ adVfl"ll' tffKII.
Vfrbalizt an undtmanding olthtdrug's UII', advel"ll' tffrru. and reqJirro precautions.
Demonmatf propl'lll'lf-administr~lion oilhe meditation (f.g.,doII', timing, wht n to notif)' proI'idtr).
Implementation
Interventi o ns and (Rational es)

Plltie nt and Family Edu cation

Ensuring thtrilptutic riftds:

ContinU!' iIIltllmMII as dtscribM tarliu lor the rapwtic: tffls.Kough is
diminished, le(rttions are ihinll!'r and ~lpt(torition rail' is ill(reastd, llisal
j)aSsaqts are d~ar,ilnd brr<llh sounds are dNr.lmproftment in othtfsigns
and s~mptoms oflh~ rommon rold should begin aitfr tiking the first doll'.
Th~ health Wt plOl'idtr should br notifitd ~ symptoms ilKlNs~,epeo:ial~
~ respiratOf)' il1l'Ot;~mfm worstns or if ft-m is prestmJ

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 j)at~m to(ontaa tht htahh care providtr ~ symptoms WOIItn
or iffev!>r is prtll'nt or ilKrealing.
(Continued!

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NURSING PROCESS FOCUS

PATIENTS RECEIVING SYMPTOMATIC COLD RELlEF: ANTITUSSIVE, NASAL

DECONGESTANT, AND EXPEOORANT THERAPY (COlltlnue.:1)
Implementation

Interve ntions a nd (Rationales)

Minilllwng il liftne rffb:
[nSUlt patitnt w~t)',esPfCi~I~ fill older JduIts.Obsfflt lor diainm.
(Oltllninen or diz.zinm l1li)' Olwr; inu,,;ning mk of lab. ~s~11y in older

._,

Patient a nd Fllmily Educa tion

iIIllnKt the palitnt t.Hi1i for fililtance prior to getting out ofbed O!'
'~mpting ~ wall aIone"nd to mlid drioring Of ot!J~r ,ctM\irs ~
melltal ~ltrtnesl or ph~ic.l1 eooIinnion until the efFects of thf dlll9 11ft

....".

Cominut 10 moniflll vitil signs,tspiilly pulse r.le MId rhythm for P'litnlS
taking MtongrsuMS. incbfing rwwl dKOngetlnlS. (Srm p.thomi~til:
~tanu miY C.IM OO)'C.olnii and drsrhythmiil in patitnts with
h~IOI)' of c diINSofJ

1n11nK1 the pilitntlo immtdii ttly !!pOll diaiMlI, palpit.tions, or

Monitorfor pminul d!y(ough. incru~ng cough SoMrity,ilKlNsing

InllnKt the patitntlD rrpon ptOIIIptIy anr (hinge in tilt ~ or

~rqof cougitAff'/ cough accompi~ by shonnessofbr.!illh,
inmuill!llDfl9nliorl, feft~or det piin lllouk1 be ~td immrdi.!tly.
Encouril9f tile pilient to ill(rtHe fluid intlb 10 illlist in liquifying mucous
sretiolll,nd to moislen tilt upper mpiratory IRCt

congeslion,1II cIysjlnu. {Some of thtst drugs.r.! Ultd with QUlion or are

contraindic.ted in patitnts with emting ~orr~, incUling COPD.
.&. (~ in lilt !ofYeriry of the (DI,IIjh m.ly indiultwonflling diseillt
PfO(tlSlII iI mot! Itrious mpiralJ' iII~"ion.nc! should be teported
immeciiltelyJ

""'.,.

Tech lilt piOen~ f.mily,1II aregim howlO moNtO!' p.l1st.nd blood

p~RJre ~ ,ppropNle. E_ the proper 1M ard funclioning of,ny
borne equipmtfll obtiined.

k;sm tile colDr ,nd comiltmcr of anr upedDfJttd spuIIIm. {~uin9

thicknesl, c~ IItmoptyRs, or ~tity of sputum IIIiY indicatf i Itrious
~pirJtory inftion and Wluld be ~rttd immedwttl,oJ

InII!U<l the patitnt 10 ~rt anr sigmnt cilangto in the mIo~

mmisttrKy,lH quantiry of flputOrutd mucus to tilt hulthQte prowidrr.

Monitorfor GI tfFts. En<M~gt the pitielll: to like ~ or Qpsules with

Teil(h lilt patitnt 10 tale lilt mediC<1tiott with .dditionailluicl or food.

~rt anJsigniOOnt GI S)'!IIptoml (~.!J., I\aUSU with wrMing, diilrrhu)
to tht hNlth carf p!OVider.

, fulgLm ofwatrr.fTaking wdrucj with additionalftuichor food may

dKltiIt GI adenttflts.)
Hi~ the pititnt deu now before lISWIg ~t'nl nilliliprilf$ ilnd 10
waijl Smirotes befolt using iI stCond spray if OIderfd.1f rwsal
cortKQ!;lrroich or mast cfilu bilizm It also ordrrrd, IIIf , MtOll9fltant
nalil SptI)' fin(, Iollowed in 5 10 10 minUTes by Ihtgl.m:orticoid. 5jli1 out
, ny!'X(!'Slliquiddrug that m, ydfJin into lhf rroUTiL (Ourill!llfll' n'lIl
pillil9fl befoft ~ministtring the fWlil ~iI1 and .~ the MI of\Wo
Ipr.".tim~ 10 IXIfIItricllocalwlltinnd 11IUl0li win,lIow tilt If"!' 10
teach higbtr into pilligfS.UsingMtongrslMlt spray brloltother spr~
win optf1 rwlillllUCOU,iIIowing lilt other drug to r.!iCh molt W
m(J(QII.SwailowVJg additiorwl dtulj mar Di~ risk ofsystrmil: ~m~
efft<tlj

EnOltDge tile Ult of ~nglt-,;ymptom dtulj preparations whfn pMoIiblt.

(Multisyslem mmulilions inQ'ti5t the mk of .dftrlt tffects ..&.dditional
drugs not ~ in mulWst PrepaOOolll shoold bf noidtd.)

Patient ulderstanding of ~g thenP'1:

1kt opportunities during ,dministration of rnedicatiom and during
illltllllll'ntI co diirusl the miorwlt for drug thfr.lPY, deRd thtr.!peutK
OOKorrJe, most (Cfl'IIIIOfI ac!Yrrw ~ pifimttfn for when to ulltht
hfa Ith QIt prow icIt~ and ,ny nrcesSit} moniloring or pR'Colutionl.. (Using
time ckrring nuMlg Ute IItIpI to oplim~.rd leinmf Izy INCh inIj
, teasj

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~iI(h tilt patitnllO deilr fW\iIl pill'ges. then adm"iswthe

dKongtltlnl sprIJ. .&.fter a w..iling ptriad of S10 10 mirlllttS, UIt
idditionallpiay if ordtred or 10 low with addition,l nasal sprays 'I
O!dtttd. An, ~l((flS tII.t drains into the mouth should be I9f: cut lind not
sw,11owed.
~iI(h lhe paOentlO limit IMof dKOngeslinl rwwllpr. )'I to ) 10 5 dm.
unltllotbefwistonlered by 1M provicler,to , widtebound ron~ltion.

~iI(h tilt patitnllO COII$ideHymptoms wilen sffiting OK (Ijld temrdies

.nd choose jXtpir.tions bastd 011 runt. symptoms.
InIInJU the patitnt that multirst cold tmlt<i'lHcontaining
iI~uminophtn rrusl bf ulzfl in prtKriIIfd doses tuwid aauminophrn
O'ftI'dose.rd potmtiilliftr~.

TlIf patitntsllould be ilblt to stall' the ItlllOn for the druq..pproprialf

do!.r ard sdltduling, and wllilt adl<mf riffcll to obstM' lor and when to
~rtthmL

C"",lfr31

NURSING PROCESS FOCUS

Drug<

for Allergic Rhinitis and the Common Cold

587

PATIENTS RECEIVING SYMPTOMATIC COLD RELlEF:ANTITUSSIVE, NASAL

DECONGESTANT, AND EXPECTORANT THERAPY (eontInUffl)
Implementation

Interventions and (Rationa les)

Patient and Family Education

Patint selfad ministntion of drug therilPY:

Wh~n administ~ing th~ mtdiulion, iostOKt the puirm. family,oruregi~r
in lhe proper 1~If-adminismtion oltht drug. e.g., take thedrug btIore
alle19Y IUlon or before Iymptoms art' !e"'re. (Proper adminiltration will
inclI'iIl~ the tffeo:ti'leoeu of the drug.)

The !)atitnt and fam iIy orurtg~r 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 tffe(\~ 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 dPt.oni~Qnn: 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 !)atitmgoaisand H pKle<t oU\(omtSh",'f ~ met 1="Planning").
5tf T6Ne: 3"-3, 38.4, 3H , ~rrd .J.!.6 f,.. aliM 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
in g 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.

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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 effic~cious 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 Expectorants promote mucus secretion, IlliIking it thin
ner and easier to remove by coughing. Mucolytics directly
break down mucus molecules.

588

Un'" Thl'R"'!'I tOfySystem

NCLEX-RN OREVIEW QUESTIONS

The patient has been prescribed o)(ymetazoHne (Afrin).

The nurse understands that:
I. the mo~t serious side effect is ft.Wund collgt'Slion.
2. theaver;lgeusel.sfor IOdays.
3. th l.sdrug should not be used In conjunction with
antihistamines.
4. this isan OTC drug and maybe used as needed for
congestion.
A patient Is prescribed an intran~sal corticosteroid for allergi~ rhinitis. The nurse's tea~hing would in~lude; (Selel:l
all that apply. )
l. there ~re no known ~ide 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 ca n be used any time symptoms
increase.
A patient's history includes taking a first-generation H,-

re.;eptor

ant~gonisl.

Considering this history, the nurse

assesses for which of the following findings!

1.
2.
3.
4.

A history of heart disease

Anyrecent weight g.1in
A history of respiratory illnes.o;.es
A hlSioryofpeptic ulcer

v.lben teaching patients how to self-administer intranasal

corticosteroids, which of the following must be included ?
(5ele(;t all that ap ply.)
1. Prime device prior to Inltl31 we.
2. Clear nose before administration.
3. Clear nose after administration.
4. SWallow ~nyexcess that drains into the mouth.
5. Spit 0111 anyexces5 thM drolns Into tbe mouth.
Prior to administration of antlbista mines. the nurse usesses for.
I . prostatic hypertrophy.

2. Itching.
3. dryskin.
4. increased restlessness.
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.

CRITICAL THINKING QUESTIONS

1. A 74-year-old male p~tient Informs the nurse that he I.s
taking diphendydramille {Benadryll to reduce seasonal allergy 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 p~tient has bronchitis and has been coughing for several days. Of the two antitu~ive 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

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to lake flutlcasone and a week late r ca lls the provider's office 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

~.-----,

M)'NlIrslng~ is yoor aM SlOp fOf onHne d"I(>I~' review matflfWS.,d

resoo fWS. I'f!lllille b succuss Mth additional rlCLUS~ 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.

~eol.~er)OO1 IICce~

Drugs for Asthma and Other

Pulmonary Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES

BRONCHODILATORS fI1IJ' 592

Beta-Adrene-gkAgonlsts

Afrer reading this chapter, the sNdent should be able /0:

J1OIF591

Q I<>1m~M>I /'SI'rn'mI} J1OIJ' 59S

Antlchollnwglcs

plllJt594

o jprarropjum (Arrov.,,~ (ombMnl)

"",,,

Methylxanthlnes jllJlJt595

ANTI-INFLAMMATORY AG ENTS

ptJIJt595

Cortkosterolds 1"l1'595
Q b/><:lomnha.otIf' I8I'COfIQ~ AQ OIar)

""'~

l eukotrlene Modifiers fIIXF 599

Mast Cell Stabilizers

jlIJIJUi XJ
zafirlukast (Accolate) fI1IJ'6IJ1

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. Compa relhe 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 adve~ effects.

8. Use the nursing process to ca re for patients who are receiving

pharmacotherapy for lower respiratory traa disorders.

KEYTERMS
ar,1 _ '~ I

drypowd inhal .. iDPlj

il!thma

emp~ma p!JIJt6IJ 1

fllXY 591

bronmospivn

jIIJIJt 591

duonic bronchitis J'I'Il' 6(J1

chronicobnlll(\iv. pul lllDnar"/ dis"lf (COPD J
",, @

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leukotrienl5

_m

p!JIJt 599

metereddos. inhaler (MOl)

mM,ixanthin. _ 59>

n, buli,

p!JIJt 5~1

perfusion pa]'5'XJ
stat UI m hmatirus
p!JIJt 591

ventilatiln

p!JIJt 5'XJ

p!JIJt 59]

590

Unit,

TheR"'PIr~!o<ySym'm

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 pulmonary 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 seriou s consequences.
This chapter examines drugs u5ed in the pharmacotherapy
of two primary pulmonary disorders-asthma and ch ronic
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 rehxes and air leaves the lungs passively, with no energy expenditure 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

capillaries. An extremely thin membrnne in the alveoli separates 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 membrane, 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' receptors, commonly called bronchodilators, are some of the
most frequently prescribed drugs for treating pulmonary
disorders. On the other hand, drugs that cause bronchoconstriction maycause breathing to become labored and the patientto become short of breath .

Expired air

Trachea
Left lung
Left primary bronchus

""-"'

blood circulated
back to the heart

Diaphragm

.. Flgurel9.' The lower respiratory tract

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O~pltll9

39.3 Administration of Pulmonary

Drugs via Inhalation

The respiratory system offers a rapid and efficient mechanism 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 major advantage of aerosol therapy is that it delivers pulmonary 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 because 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 C NSdepression (chapter 1900).
Solvents such as paint thinners and glues are sometimes int"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 administered using a dr,powderinhale-r(DPI}. A DPI is a small device 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

third type of device commonly used to deliver respiratory

dru~. MDIs use a propellant to deliver a measured dose of
dru~ 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 measure 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 carefully instructed on the correct use of these devices. Swallowing 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 decrease the frequency of asthmatic attacks or to terminate attacks in progress.
PHARMFACT5

Asthma
Asthma is resplnsiblto [0, mOK than I.S million emrlge'KY drpanrnrnt
flits and more than 500,000 hospitalizations r~(h ~u.
iIIore than S,5OO patiems die of asthma N(h ~a,.
Till' inddrna of asthma has bten dramatically ifl(reasing e>Kh yr. ~ml'
lilSO in all age,grnde-r,and f1hnic groups. Thehigh~t 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 womenthan in IIII'n.ln
mildren,hOWfYl'f, thedisu~ 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.

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591

592

Unit,

TheR"'PIf~!o<ySym'm

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 considered a pediatric disease. Characterized by acute bronchospasm, asthma can cause intense breathlessness,
coughing, and gasping for air. Along with bronchoconstriction, 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 contributeto 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 exertion, a condition called exercile-illduced asthma. Status asthmatirus is a severe, prolonged form of asthma unresponsive
to drug treatment that may lead to respiratory failure.
Because asthma has both a bronchoconstriction component 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 bronchospasmsin progress and to reduc thefrequellcyof astluna

NORMAL BRONCHIOLE

attacks. Different medications are needed to achieve each of

these goals.

Beta -Ad renergic Agoni sts

Beia,-adrenergic agonists (or simply beta agonists) are effective 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 sympathetic nervous system, which relaxes bronchial smooth
muscle resulting in bronchodilation. Beta-agonist medications may act on either beta, receptors, which are located
primarily in the heart, or on beta, receptors, which are located in smooth muscle of the I=g, uterus, and other organs. 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

I
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

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O~plfl19

-.-

TABLE 39.1 I Common Triggers of Asthma

Cause
Sources
Ai'pjlutaou

....

lirrousand 11M.. o:Iidts

fI.mtI from duning lkJids or soMnU
Buminglu~s

"-

Polito from trfe,lJlIStI, and WffiIs

Animal dander
Housthoid dUll

"Od
Chtmitalsand food

DnI9s. indudng alpiin, i~ffi, and brtJ

""'"

Sulfir~ prNIVa!W~

Food ald Wlldinenr~ induding nut~ monosodium

glutamar~ 1M SG), shrllfuh, and dairy produru

Potspi'uory infffiions

Baw,rial, fIroga~and viril

.~,

Emotional S!~s/il'lliU1
umill' io dry,(oId dimar~

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 antiinflammatory proputies; thus, other drug classes are required to control tht inflammatory component of chronic
asthma.
A practical method for classifying beta-adrenergic agonists for asthma is by their duration of action. Short-acting
agents such as pirbuterol (Maxair) have a rapid onset of action. 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, however, 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 effects 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 intennediate and longacting agents are used in combination
with inhaled corticosteroids for the prophylaxis of moderate 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-

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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 indic~ted to
abort an asthma attack, taking a LABA instead of a shortacting beta agonist could result in lUlrelieved bronchospasm 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. Patients 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. Inhaled beta agonists produce minimal systemic toxicity becaust only small amounts of the drugs are absorbed. When
given orally, a longer duration of action is achieved, but systemic adwrse effects are more frequently experienced. Systemic effects may include some activation of beta, re.:eptors
in the heart, which could cause an angina attack or a dysrhythmia 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=peutic 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.
Se~ 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

&

C OMMUNITY CO NSIDERATI O NS

------------ -- -

Asthma Management in the Schools

Appmimilely 9 million {hildren )'OUllgl'lthin agt 18 ha~ asthm. litINnllt~ 5Ug9I'It that asthma a((ouou lor 14milIOO misled "hool dlfl ta{h
y~aland pot~mial misstd workdays Iofp,ill'Ots, making thisdM.Ncwoftlit
most romrooo (i!MS for sdml and work absmlffism.l ni typita Idall of 30
(hileRn. two students sulI!'r from asthmatic attl{b N(h )'NI whilt at "hooL
(hilC~n {aoMtlum whilt 9p1'ritnciog wh~ling,.{oughing,.ind sh:Jrtntss
ofb~ath.

.I5silling smoolslO dtv~1op asthma O"Ianagtllltnt programs ha, btc:OIlll'

tilt ixU! of ~rll fNl.'lal agenc:its and dozens of profes>ional and p,itieot
idYtcacy groups. Man-, "hools a~ adopting asthma manigtmeot ~Ians as
pan of a (oordinat~d "hool lItakh program. xhools with th~1I' programs
hm ~tlblishfd "asthmi-fritndly" polKH-~ wdI as allowing students !O WI)'
i nd Idminister quic:k-~ief asthmi mrd italioos. Additiona I~.tllt "hoJis routineljo maintlin a {OPY of tht studmt's asthma action plan from tht ,,~givel
or health { i If PfOllider. The rolt of tht I{hoolllJ~~ is to review tilt plan, determint tht stud~nt's !p~dfic: llffiIs,and be IU~ that the student ha, imnrdiat~
,I{<elsto quic:k-relief i sthma mrdiutioOl. Tht optimal plan lor _h l1Udem is
d~t!'lllliord {ill' by cast, with input from tht student. p,iIl'OB, heakh {i~
pfOlld ..... aod "hooi ou~~.lypiully, oId~lltudents a~ permitttd to {arry tilt
inha'er and s~lf-.idmio~ttr as nttdrd. The nufll' ofttn ktepS a b.JdlJP IUppIy
of tilt student's mtdiutioo. For youngtl dJ ild~n, a IUpl'fYised health aa~tlot
maybedeie9attd to admioister tilt m~ditation.

"

59 4

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, VoSpir~)

MO~ 2 inllalatioos Ml'/4-6 h as nrtdtd (ma1: 11 inhaiatiomldayl

HeiUim: 115- Smg ~~ 4-8 hasnffiltd

PO; 2- 4 m9lid- qid (max: 12 mglday)

En~ I!Irnr tabs:8 mg MIY 12 h (max: 32 miVday dividtdl
arformoltrol (8rOYan)
Ionnottrol (kmit Pfrforomi51)

IItodiKhf,dilzinw;,

rmoo,

1If~11roof

mlQ~oo.drug ltMrooct

ridrtyroia.dysrhythmi.Jt hYDoQ!!fl1ia.
hypmly(m1ia. paradoxical bronm!XOl!lIrigion

HeIPulim; 1SIII(g IwK~ daily (max: 30 mc:glda,)

DP~ 12 meg inllalitioo cap5U~ M!Y

12 h (ma1:14 mc:gIday)

HeiUiztr:lO 111(9 bid (mu:40 nKiVda,)

HeiUiztf;0.63 mg tid-"d
MO~ 2inllalatioos q 4-6 h

pirbuterol (Muair)

MO~ 2 itllalollioos "d (mil: 12 inhaliliomlliay)

inhalations bid or 1 pc:II\'dft' dilkus bid

Q !aimtlmll(SmI'mI)

DP~l~soI

tm..nalinr (~thinr)

PO;l5-S mglid (mil: 1S mgIda,)

SlbwtJnrous; 2SO meg (IrUY til' I'rpNtrd in IS nin)

Inhala~on;l

inh,iatiom(lOO m'9lspr.y) M!Y 4-6 h

A.NTlCHOLINERGICS
Q ipratropiJm (Al:flWm~(ornbi~tl

MO~l ithalaliool qid

(mil: 12 inhalations/day)

Nrbulim: 500 meg f'lB16~ h urftdlod

tiotropiLm (Spiriwl

DP~ 1 CipstH irhalrdlliay

METHYLXANTHINES

aminophyllilt (Truphylli1~)

po; 380 mgIda, in diridtd dosrs M!Y 6-8 h (ma1: 918 mglut)

t~)1~nr (n--Du~ othm)

PO:300-600 mgld.y i1 d'lidrd dcMs(nw:900 mglday)

IiHItII5I!tS\ Nl'mol\ dirlirlflj, htodiKhe, 00UIf4

Imlirilli ~rtOrrXiO
Tidrmroia. dysrhythmi.J\ hyDO!tllSion idnm,
cirwialory filure r@ralorurml

Anticholinergics
Although beta agonists are drugs of choice for treating acute
asthma, anticholinergics are alternatiw bronchodilators.
Only two anticholinergics are commonly used for pulmonary 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 similar 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

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adverse effects when administered by the oral or parenteral

routes. However, the rel.1lively recent discovery of anticholinergics 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 obstructive pulmonary disease (CO PD) and asthma. It has a
slower onset of action than most beta agonists and produces a less intense bronchodibtion. However, combining
ipratropium with a beta agonist produces a grea ter and
more prolonged bronchodilation than using either drug
separately. Taking advantage of this increased effect, Combivent is a mixture of ipralropium and albuterol in a single
MDi canister. Tiotropium (Spiriva) is a newer anticholinergic 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
(G I) distress, ht'adache, and anxiety are the most common
patienl complaints.

O~plfl19

p,. Prototype Drug

Drug' lor A,mma and Other Pulmonary O""rd .... ,

595

Salmeterol (Serevenr)

Therapeutic (lass: Bronchodilator

Pha rmacologic (lass: Betapldrenergic agonist

ACTIONS AND USES

Salmrtrrol isa LABA th~tlm by <ele.:tivrly binding to brta,-,drmt rgic ~fP
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 Iactivity, it u nplt"ll'llt txm:ise~nduo:rd brondmpasm. Salmetfltll is
<1110 iPPIV>'f<I for Ifllucing broncho!pasm in patifnu with COPD. 8euust silmell'rot liUS 1S- 25 minJ!!"! to Kt. it should n~r 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. O~ and instruct tht patifnt in Propl'I usr.
Pregnancy uttgory (

ADVERSE EFFECTS
Seriou:! Idvrnl' elfe.:u from wlmetMlI ~re uncommon. Some p,tifml uptrierl(f he.Hbc:hes,thro,t irrimion, Ul'lllO~ nrlVOUSlM'U,l nd rt5tir!5l1!'15. BrulM
01 ii, pottntial to causr !am)'(ardia, patifnts with hun disul!' should bf monitolfll regularly. S,ll1IEteroi hiS a bbc:k box Wilming that LABk mly ilDf<lll'
the rislof asthma-~lated dmhs.
Contraindi cations: Salmetl'l'Ol!III' is cOIltrairodiutrd in patifnts with hypersrmitml)' 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 patiMu with dysrhythmia!, hypertension, hu n failu~ or Il'izUItS.
INTERACTIONS
Drug-Orug: (rorurrent U\I' with ~Ii bIoclal wil

in~l!it 1M bfondlo!ilalion I'fIK1

ofsalmtlfll.
La b Ti5IS: ~mtlmI rna, {aU\I' hypobIi'mia.

PHARMACOKINETICS
Onsrt: lO-20min
P!ak: 2h
Halflil!: 3-4 h
Duration: Up to 12 h

The complete nursing process applied to patients receiving 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 corticosteroids. 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 prescribed 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, methylxanthines 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-

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HerbaHood: ~(OOt.Jining 1iI!f~ni'Iud1 a!collHIdtn may {aU\I'

~UflllOl;Ofp;ilpitalilm.

Treatment of IMrdosr: OY!'rdoII' ltSuhl in an Haggtratro sympathetic ICUvatio n,u.lling dylrhythmial, hypokalfmia,'rod hyptrgl)ocrmia.ln seY!'rt mrs,administmion 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. Because asthma has a major inflammatory component, it
should not be surprising that drugs in this class playa major 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 bronchodilators, they sensitize the bronchial smooth muscle to be more
responsive to beta-agonist stimulation. In addition, they red uce the bronchial hyper-responsiveness to allergens that is
responsible for trigguing some asthma attacks. In the pharmacotherapy of asthma, corticosteroids may be giwn systemicaUy or by inhalation.

"

.... Prototype Drug

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. Ih~ inhalalion form is applO'/~d to ~~ and preYellt the
brondiospasm that is dlilruristic of althma and (OI'D. Whrn(ombined with
albut~rol (Combirent), it is a prrfmed drug for liming bromflospums due to
(OI'D, ilKluding bronchitis and rmpll)'I~n"". Although it h.n nOI reuived FDA
approval for th~ 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 nperiffidng ~rre mhma rloKmmiom.1t is wmelimes (ombinl'd with brta
agonist! or ronKOIIeroidIlO plOl'irle additm- brondJodilation.
Whrn adminislrrrd vi, inMI,tion, ipratropirm un reI~ acut~ bron(hospasm within mirut~ ,!ltrr administration, although ptak~ffem 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
3Wffk~

ADMINISTRATION ALERTS
Tht proper In~ of the metered-doSl' inhaltr (MOO is imporuntto the effutiYl' drlm-IY oldrug. OWm!and instnKt tht patitnt in proper uS!'.
Wait2- 3 minutes bel'oYl'rn OOsagll.

ADVERSE EFFECTS
Bffi!M Yl'ry little is ablOrbed from the lungs. ipratropium prodKes ftw 1)'1tf mK adYI'ne ~ffKU.lnit,tion 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 hyptnensitwiry 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 1O~1iI'f
antKhoIil\el~~fffPm.

lab 115Is: Unl;oown

IlerballFoo:1: Unknown
T~tmrnt of OYerdos~: Ov!'~ 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 ~

Al'Oid (on\ad with ryes;othtrwis~ blurred vision may oc(ur.

P~nanq category 8
PHARMACOKINETICS
On5d: S- ISmin
~-1h

Halllilr: 1.S-2 h
Duration:34ih

TABLE 39 3 1 Anti-Inflammatory Drugs for Asthma

Route and Adult Dose (max do\e where Indicated)
DN,

MverS(' Effects

INHALED CORTICOSTEROIOS"

lII'domrthalOOr (Bfconu AQ,Qvar)

IHIdtlOOicie (Pulmirortl
dOOonicie (Atw,sro)

f1urisolicle (AeroBidl
f1utiulOlll' (ROYI'Ilt) (II'~ palJl' >771or~

MIX; 1-1 inhalations tid-qid (max: 20 inhalatiomlday)

OP~ 1- 2 inhalatiOlll (200 IIKg~nhala~on) Ijd (max:800 IIKglday)

HIa!fflI'!~ rty rnwrh, WIJ9II, SlIfe drool

Orpo/Iarynge,1 oodidm hyproortidW

inhal"ion; 1-2 inMlitKm/day (l204i40 IIKgl

MIX; 2- 1inhalations bid- tid (max: 12 inhalatiomlday)
MOl (<< IIKg):2 inh,latiom bid (mn :10 inMlitionllda,)

hyW'im litiYitY!f1jooS

PrototyprDrug boxOO )

momrlillOlll'(Almanl'l)
triamcinol~

(Mni(ort)

OPI; 1inhal"ion daily (mn:2 irhalations diily)

MIX; 2irhal" ions tid- qid (mn: 16 inhal"ions/day)

MAST CELL STABILIZERS

avmoIyn (Intal)

MOl; I irhalation qid

nedooomiisodilm (lilalle)

MOl; 2irhalations qid

NatMfJ, YlftJing, OQfIIlllingintJ. rlnr

irrirQ~oo, unjitllSQIlf roste

Anaphylaxis a!'!Qionkma, brond!o!palm

LEUKOTRIENE MODIFIERS

montrlubst (Singwir)

PO; 10 mglda, in moing

PO; 20 mg bid I hlII'forf IX 2h a1t~ IIINls

afirlwl! (A((oIitr)

lilruton (1y11o)

PO; 1)00 mg bid

"F dOSI'I at' systrmic: (ortkomroids, rdrt to d1apter 0 0110.

Ildio"indi<J1< <OIII1TIOO..mn. d'(<<1';~ indi<JI.... riouIld ...... tfltcl .

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IlI>pltll9

NURSING PROCESS FOCUS

0rug51o, Asthma and Other Pulmonary O""rd .... ,

597

PATIENTS RECEIVING BRONCHODILATORTH"RAPV

Assessment

Potential Nursing Diagnoses

Basrlinr a,srssmt nt priorto administration:

Under>tlnd th~ reason the drug has bn presc:ribtd in ollimo uses fo,
ther.J ptUlic: e1fls.
Obtain a (omplttt heakh h~tor)' including previous h~tor)' of symptoms
and .J ~ion 10 stasom. foods, or cnvironmt ntal O;POlures; existing
caroio'l<llwla~ re-spiratory, hf patic. rena~ or ntUrologic: dilt.J~; gla lKom.J;
prostatic: hypmroph)' ordiffirull)' with urination; pre~nct of ~, or mra
inleuions; P't9"' IK1 or brmt -feeding; akollal u~; or YIIo1:ing. Obtain a
drug h~tor" noting the t)'pt of adY!'r~ lI'action optricnc~ to any

Impaill'd GiIs Uc:hange

. lnrIfiMTr>sue F'fllusion
Allliely (rtlattd to diffirulty in breathing)

D~Nrbed Siefp PAn~m (reIat~d to adv~1SI' drug ~fflom)

ktiYity Intoltranc:e (1I'lattdto diseasr or inrffKtil'fdrug thmp)')

DerKitnt Knowledge (drug therilp)')

m~dic:.ilion~

If asthma s)'l11ptoms U t 01 new onsel.as~s for .J ny lI'!!'nt (liangf'S in dif~

soaps including laundry dtt~rgtm or IOftrlH'~ (osmetiu,iotions,
environm~nL or lI'<ent {arptl {INning (p.artirular~ in young (hildll'n) th.Jt
may (omlatt with on~t of symptoms.
Obtain ~ stlint vital signs, Mting respirator)' rate and dtpth.
Asses pulmon.ll)' function with pul~ oxim~er, pNk tlpirlloryflow mell'r.
and/or anfrial blood gam to rstabl~h ~srlilH' It~1s.
['/<Iluate appropriatf laboratory findi~ (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 i~ased activit)' IMIs, maimrnancfof normal rating
and sleep periods).
Continue periodic: monitoring of pulmonary function with PUM orimeter,
peako piruor)' flow mrtt~ andlor a,terial blood ~as appropriatt .
Asses vitalsigns,rspecially respirator)' rate and depth.As~ bruth
sound!, noting prrsen!!'of ~ntitious 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 flo~~ (onfusion, tJoc:hlUroia,
palpitation~ hypotension. synrope,dyspnN. or increasing pulmona I)'
(ongrnion.

Planning: Patient Goal s and Expected Outcomes

Thr patitm will:
uperience tlltr. ptutic: effects k g., i~ased t~ of bll'athing, im pro~ment 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 minima~ adVtrse efferu.
VtrIHIlize an undtr>tanding ofthedrug's 1M, advtrse tfferu, and IfqJired precautions.
DmIOnstratr Propl'l stIf-.ldmin~tration of tht medication (t.g.,dose. timing. when to notif)' provider).

Implementation
Inte rventions and (Rationales)
Ensu,ing the,.peutic dfects:
Continue as~smtnts as dtsc;ribtd t.J rlitrlor tlltra ptUlic: tffects.(In(lNSI'd
toN of bll'athing; lessened adY!'ntitious breath sounds; impJOVtd signs of
tislUl' oxygenation; and normal .J ppeUte, tilling.and sleep patlffiI sshould
o((ur.Th~ hukh Wl' providtr IMuId be notifltd ~ symptoms wornn,
f'Sptwlly ilrrspirator, invo/vemt nt in(lNsrs or fel'fl is plrsenl)

Patient and Family Edu cation

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 wllt~ pos~blt.
Advise the patient to tall, .J wallet identification uro or WNr mediu l
identification jMrll)' indic:ating tht prestnc:t ol .J llhma or ,rspil1ltOI)'
(ondition, any signifium allergies or ana phylui!., and usr of inhaltr
therap)'.
(Continued)

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598

UnU

The~...pf~tofySys!"",

NURSING PROCESS FOCUS

PATIENTS RECEIVING BRONCHODilATOR THERAPY (conrtJued)

Implementation

Inte rve nti o ns a nd (Rati o na les)

Monitor pulmOOif)' function periodically with pull!' oxim~te~ pNk

~Ipi"tof)' flow mell'r,indlor anerial blood gasn.(PtriodK monitoring is
flt(eluf)' to i ISf!1 drug efFI~l\eSs.)

To aron an Kute althmatK atu<k,inhaltr tOOapy !hould be nm~d at t~

fillt lign of respirator)' diffiruk~. For pr~tntat~ tOOa p~,long-term
blOlKhodiiation by inhaler Oforally will be ulf<l.Long-oCliI19MO, ogarilfs
(l.AiI/u) Qnd /ong-ocring In>ndrodiIQ/Of! In rIOllO be UI!'d 10 abort <IIII/Curt
OffQck. (Arutt i lthmatic analks all' managed with qtJKk-acting
brOlKhodilation wc:h.H beU, agonistl.For plt"lMting attuh,LARA!,
amKholintrgia, malt ctll Itabiliztn,and rorlKolitrOid therapy may be
wd.1t is (furial to know and rOgnizt th~ 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.
inefl'aling dylpMiI, ~ntitiJus bll'ath IOUndl. Ii9:Is of ti\\ut hypoxia, anxittjo,
ronfusion, and detlt'aling pJmona~ ftroions stu:lirs. (11KINIing d)\pllN,
idYtotitioul bfl'ath 1OUnds, timirishtd oxygtMion. Of ilKfI'asing anxifty or
ronfrllion may in~ iladequatt drug thtrapy, WOIItfing distall' pnxm,or
repillllOf)' iliM:iJn andYlouId be ~ftl immtdiattiyJ

Patie nt a nd Fa mily Educa ti o n

TNCh t~ patient tht Ul!'of t~ peak apiratOr)' IIoY.r mettr Of Ot~f
tqUipmtrlt ordtrrd to monitor pulmonary function.
In\lnKll~ patifnt 10 immftlialely It'pOn \)'I11p10f1110f dfteriofating
respirator)' llaM wc:h as in(ftas~d r/yIpnN, breathlf!ll\eSs with IP~lh,
ilKrmftl anxif~, andlor orthopnea.

ProideapiKit inltruction! on tht U\f ofqtJKkalting YmUS Iong-.KIing

inhatrn.TNCh t~ patitnt to USf qtJKk--acting inhalers at t~ earlitn
posliblt appearaIKt of lymptoml.llIng-acting inhaler; or oral therapy
I!IiI)' be ustd to maintain brondlOdiiation but do not dilUrd qUKk-alting
inhaltll if on long-term maintenaIKt thtrapy. The)- may !lill be nettled for
ptriodK arut~ itt1(k\.

InllnKt tht patient to immftlialtly It'pOn l)'I11ptOf1110f dl'ttriofating

respiratory SiaM wc:h.H iIKfI'astd dyIpnN,brmhlt!ll\eS\ with Ipttlh,
ilKlt'ilf<l anxiety, or orthoplli'a.

Monitor tating iI nd Ilttp patttrns and t~ ability to maintain functional

ADu. PlOYide lor lalorit-rith, nutrifm-den~ foork, fr~nt ttlt ptriork
betwrtn rating or actilrity,and iI root room fOfsftping.(Repiratory
difficulty and fatigue mo{iatftl with hypoxi nd tlltwork ofbr~.thing
may afftd i ppttite, and tht abili~ to ut dJring dyspnu and maintain
~ui~ AOl!.Maimaining adequate nutrition, Hum, ttI~ and Ittep all'
e~ntial to IUpport optimal htalthJ

TNCh t~ patient to suppltm~m drug thtrapy with nonphannac:oIogK

mealUttI iIKluding:
IIKINI~d Huid inta~ to liquefy and mistto mobilill' mucus
Small, frtqJent me~lsof alorit-and nutritnt-.densefoods 10 prevent
fatigue and maintain normal nutrition
Adtquatt rtII ptriods lletwffn tating and oKtivitiH
Deut'a~ room temprrarufl' for eale ofbrtathing dJring lletp.
Redu~apolU~ to illltrgtfll whert polliblt.
InllnKt thf patifnt to immftlialely rtpon any lignifiunt changf in
i ppttitt, an inability to maintain oorm al inta~, inadequatt Iltep ptriodl.
or n inability to carry out ~irtd ADIJ.

Bininat\' smoking.linit 6pOIUrt to lKondhand lmoke. and linit (afieilll'

inla~,ePfcially if taking methybamhines.(CigaR'tl\' smokt irritates
R'\Pratory mu:0IJI membrafll'l. r.c:lI'asing t~ risk of adYtrIt effll and
inertil ling blOlKhOOlllllriction. Ci~fII' I!IiI)' iOOl'aII' t~ risk 0/ liIdr,urdiL)

TNCh t~ patient about smoking CtssaDon programs, to al'Oid

t nvironments with mondhand lmo~, and to limit or t liminateullrifll'
inta~ whi~ taking brOfuhodilator thmPl'.

Mainlil in cornisl~m dOling of Iong-iCting bfOlKhodilatoll. (Rtguiar,

rofllisll'nt doling with LABA~antitholine"liu, ma\tallslilbilill'fs. and
rortKolteroid I is !lied to ~Yent or limit oKutt broIKhoc:on 51riaiYl' attalksJ

TNCh t~ patient the importllKeof lonsistt nt administration of

bfOlKhodilation Ihtrapy to prnfm KUtt allilcb.

Utilizt appropriate !paler betwttn inhaltr and mouth aI appropriatt and

ri= mouth after using in halt~ eptri.llly afttr cortitolttrom. (Sp alfll
betwrtn mHtrl'd-dol!' inhi ltllallist in thf roordination and tim ing of
inhaiation and pfl'Vtnt mftlit.ition being deiiYtrl'd to th~ bark of tht
phaf)'nx.Riming tht mouth afttr the USt ofinhalm pre~nts S)'StertlK
il1lorption or Ioulill'd fI'KlioM to t~drug IIKh i s ukeration.)

Patiml undtfllanding of drug thua p-,:

Usr opportunities during the administration of mftlKationl and tlrring
mtlSflII'nll to dilcuss tht rationalt for drug thtrap)'.desi~ ther<JptUtK
ookoflll'S, most (ommonly obl!'rvtd adYl'nf ~fftdl, parlmetm forwhtn
to call t~ health urt ptoYider,ind any flt(tlSilf)' monitoring Of
prautionl.(Using time during nursing tart htlp> to optimizt and fl'inlout
ko)' ~.xhjn9 ."'OIJ

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InllnKt tht patifnt in t~ pI"Operul!' of IpICUI ~ord~ followed by

fl'lUm-demonlllaDon.
TNCh t~ patient to rinl~ t~ mooth afttr tdch ulr of the inha~ and to
spit out afttr rinling.

Thf patifnt should be ablt to IUtt thf f1'ilOn for thf drug. appropriat~
dolt i nd IIhfduling. and what ad'R~ tff11 to oIurvt for and when to

report them.

IlI>pltll9

NURSING PROCESS FOCUS

Oruq< /0, Mthma and Other Pulmonary Disorder,

599

PATIENTS RECEIVING BRONCHODILATOR THERAPY (ConrlnuwJ

Implementation

Interve nti ons and (Rati o nale s)

Pat ie nt a nd Family Edu c~ti on

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., ta~~ thedrug at th~ first
appea,anctof symptom, before Ymptoms all' seY!'r~. (Proper
adminiruation in(ll'a~ the tiffdiY!'nfSs of the drugsJ

The patient Il'<09niz~ 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 mtl~reddm inllaltr and
_h.
Shake the inhalrr or load inhair, with tablet or powder as inllrumd
II using bronchodilator and cortKostrroid inhalen, usr the
bronchodilatorfir;~ wait 5 minu1l'5, then UII' the (ortKosteroid to
eIllUll' thilt the drug ll'iKhes dttper into th~ bronchi.
Rinsr the mouth aft~r lIIing all)' inlwll't

Evalu ll tion of Outcome Criterill

[ViIluat~ th~ ~~ti~1 oldrug

therapy by mnfirming that patirnt go;Ilsand oprdfd oUKomrs hal'(' bem met Isre PianninifJ.

5rf TOOIe5J9.1 tnJ J93 ku ~of~1lJ wNd! tht5t llllingacriml<Wlr-

Inhaled corticosteroids are the preferred therapy for

preventing asthma attacks. When inhaled on a daily s.:hed~
ule, corticosteroids suppress inflammation without producing major adverse effects. Although symptoms will improve
in the first I to 2 weeks of therapy, 4 to 8 weeks may be re~
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 their therapeutic effect and these drugs are not
effective at terminating acute asthmatic episodes in
progress. Most patients with asthma carry an inha ler containing a rapid.acting beta agonist to terminate acute attacks 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 corticosteroids for long term management.
Inhaled cortico<teroid.< He ~hsorhed 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 corticosteroids can produce significant adverse effects, including
adrenal gland atrophy, peptic ulcers, osteoporosis, and hyperglycemia. Because asthma most commonly occurs in
children, growth 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 corticosteroids are presented in chapters 33 and 4300.
See Nursing Process Focus: Patients Receiving Systemic
Corticosteroid Therapy, on page 674 in chapter 4300 , for

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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 thre~ 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 fiers 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

600

Unit,

TheR"'PI,~!o<ySym'm

.... Prototype Drug

Beclomethasone (Beconase AU ().tar)

Therapeutic (lass: Anti-inflammatory drug for asthma and allergic rhinitis

Pharmacologic (lass: Inhaled corticosteroid

ACTtONS AND USES

ADVERSE EFFECTS

B1o~haIGnt

Inhlll-'d bKlomethaIGIif protium few synemic adYt-'~ effll. Bffiulo!' 1111111

iroourrtl lIYy ill' swallaMd with U4:h dos~ tilt piIlitot should bl'obsmed for
<io)n. of InKo<lfroid ,,,,,icily whm '"king lilt drug for prolong'" p"riod<.locil tffll may indudt hwl\eOO~dry mouth,nd cha~ in tint .
As with all {ortKosteroids, It.. aoti~nflammatory proptrtits of bKlolIII'tha1001' can muk signs of inffilions, and tilt drug is coot"indicUtd if i noKlive infenion is pl"rSfOt.A <io)nifunt prnrntlgt of puients taking bKlomflMonf
on i Iong-teno basis will deYeIop oropltJryngeal candidiasis,alUngal infection
in the throa~dut to tilt Instant deposits of drug in the OIal cavity.
Contraindications: BlomethalOOI'is cootraindicated in t~with h)'pf~
litivit)o to the drug. The growth of ~iatric patients shoold lit manito...:! ""'fully btuusr inhaled Inicosteroids lIYy ...:!uce growth ~Iocit)o in lomf
childru

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. BlomtthaHIt 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
inh.Jlation~ two to thlff time prr day, USUiIIIy prOidt adeqwte proph)"luK.
B1o~haIGIif ms by ",dJ,:iog inflammuion, th~dec",uing tlltfrequency
of althmaatllcitl.k Koot 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 inlffchangubly.
PlfgOolIK)' calfgOry (
PHARMACOKINETICS
()Jlft: 1--4 wIu

Peak:30-70min

INTERACTIONS
I)ug-l)ug: lktoown

lab Tl5ts: lktnown

Ik-'rbaVFoo:t: Unknown

Half~ife:ISh

Trtatment ofOmdost:Ovtrdose dots notocrurwiltn tht dlll9 Kgiven bytht

inhalation route.

Duration: Unknown

Rdrt III MyMIsJnqKI rot ~ MIsbtq /'rtxeIJ FooIl5pf(/It: IIIIM <h9-

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 dysfimction or in chronic alcoholics, because they are extensively 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 inhibiting the release of histamine from mast cells, and their
doses art' listed in Table 39.3.

39.10 Prophylaxis of Asthm a

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 mediators 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

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therapeutic benefit may take several weeks. Both cromolyn

and nedocromil are pregnancy category B and exhibit no serious 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 MD I or a nebulizer, and an
intranasal form (Nasalcrom) is used in the treatment of seasonal allergic rhinitis (chapter 3goo ). Adverse effects include stinging or burning of the nasal mucosa, irritation of
the throat, and nasal oongestion. Although not common,
bronchospasm and anaphylaxis have been reported. Because 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. Administered with an MD I, the drug produces adverse effects simiJar to those of cromolyn, although the longer half-life of
nedocromil allows less-frequent dosing. Patients often expt>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 pulmonary 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.

IlIopltll9

II~ Prototype Drug

Oruq< /0,

Mthrna and Other Pulmonary DIsord.....

60 1

Zafirlukast (Accolate)

Therapeutic (lass: Anti-inflammatory drug for asthma prophylaxis

Pharmacologic (lass: Leukotriene modifier

ACTIONS AND USES

Zafirlubn is lI<I'I'l for r.... prnphyl..is of Jll'l'!is1l'l'l~ d""nM: asthmi _k r-<enl<
airway ~ and inflammation by bIockingltuko~ Jffi'II1oo in the ,irways.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
broochos~vn.
k is Itss tfftctiW' than inhaled corticost.roids It IlIhlllil prophylaxis.

ADVERSE EFFECTS
Zafirlukasr prod.:es few serious idve"" tff__ H ~i"""" is r.... """t<ommon
complaint, and naus~, ,nd dianhe. 'R' R'plnt<i by some ~titnts.
Contraindi cdions: Th. on~ contraindication is hy~""n~tivit)o 10 tht drug.
Ilfc.UIe a frw raR' castS of hepoJtic f.iklr. ha~ bffir R'plnt<i in ~titrru taking zafirlubst, those with pl!"-~listing hepoJti( impairm~m should ~ tR'att<i
with raution.

.rut.

ADMINISTRATION ALERTS
iM. ,sthlllil alli(D.

Do not UIe to rmnillit.

PlI'9 na lK)'mtgoryB

PHARMACOKINETICS
Onset:l wIr
Iflk: 3h
Halflife: IOh
Duration: Unknown

HOME

- --

&
-

COMMUNITY CONSIDERATIONS
- --- - ---- - - - - - - - -

Helping Patients Manage Asthma

Ont nonirl'miYe, inapmsiYe, and tasy-to-us. tool that (,In mist a ~titnt
with m'lliging asthlllil is the peak-flow mmr. The m(ter IlINSures king (,Iparity.nd gives I lNding.The ,~k un then be utfgorizfd on a (han to detennint if the patitnt is haYing <10)' manges, rnn earl)' breathing changes.
This will allow the ~titnt to seltd which Inel of tr. umen!,if iO)',IIIiI~ be
~ prior to yj~ting 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
th. ~titnt

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 (cigarette smoking accounts for 85% to 90% of all cases of
nonasthmatic COPD) and,secondarily, breathing air pollutants. In mronic bronmitis, excess mucus is produced in the
lower respiratory tract due to the inflammation and irritation 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 tolerance are additional clinical signs. Microbes thrive in the
mucus-rich environment, and pulmonary infections are
common. Because most patients with COPD are lifelong tobacco users, they often have serious comorbid cardiovascular conditions such as heart failure and hypertension.

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INTERACTIONS
Dru;rDrug: I.M with warfaoin may OOrnf prOlhromun tiM. Erythromyc .. may
decruSl'Sl'lUm lMokof i'ifi~ubst.
li bTests: 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 .t~se beins

. rnphysern After years of chronic inflammation, the bronchioles lose their elasticity, and the alveoli dilate to maximum
size to allow more air into the lungs. The patient suffers extreme dyspnea from even the slightest physical activity. The
clinical distinction between chronic bronchitis and emphysema 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. Various classes of drugs are used to treat infectiofl'i, control
cough, and relieve bronchospasm. Most patients receive
bronchodilators such as ipratropiwn (Atrovent), beta, agonists, or inhaled corticosteroids. Both short-acting and
long-acting bronchodilators are prescribed. Mucolytics and
expecto rants (chapter 3goo ) are sometimes used to reduce

L tFESPA N C ONStDE RATtO NS

Respiratory Distress Syndrome

iltspi,uOl)' dist~s syndromt (RDS) is i condition, prilllilril~ 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'lsion, tlltrrby ~nting 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 surf,{Un!,the alnoli (ollaj)Sl' and RDS results.
Surfactant mtdicnions can be deliW'rtd to tht newbom,tithtr as prophylactic therap)' or is 'fSUI!' therap)' aft~r s~mptoms 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' idministt rtd intratrac:heall~ ~ry 4 10 6 houB,
until the ~ titnt's condition improYf1.The only synthetic surf'{Un~ (oIiOKl'l'iI
(UOIUrf), is 00 Iongtr ustd in the Unired States bfcause it is Itss tffruiwo than
the natural surfarunts.

602

Unit, The RespmorySY'!em

the visoosity of the bronchial mucus and to aid in its removal. Long-term oxygen therapy assists breathing and has
been shown to decrease mortality in patients with advan ced
capo. Antibiotics may be prescribed for patients who experience 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 -

'';~~

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.

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 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 capillaries.

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.

39.2

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.

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.

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.
A.'lthma i. a chronic disea.., that ha, both inflammatory
and bronchospasm components. Drugs are used to prevent asthmatic attacks and to terminate an attack in
progress.

39.9

The leukotriene modifiers, primarily used for asthma

prophylaxis, act by reducing the inflammatory component of asthma.

39 ..4

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 occasionally used as an alternative to the beta agonists in
asthma therapy.

39.10 Mast cell stabilizers are safe drugs for the prophylaxis of
aMhma. Thq are I...... dfectiw than the inhal~d corticosteroids 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.

NCLEX-RN " REVIEW QUESTIONS

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.

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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.

o..plfll9

Patient teaching for patients on lon g-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.
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.

II

0rug51o, Asthma and Other Pulmonary OM,d ... ,

603

Nursi ng assessment for a patient on long-term oral corticosteroids 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.
Which of the following agents is .!!l2ll immediately helpful in trelting a severe acute asthma attack?
1. Bedomethasone (Qvar)
2. Zileuton {Zyflo}
3. Albuterol (Proventil, Ventolin )
4. Salmeterol (Serevent)

CRITICAL THINKING QUESTIONS

1. A 72-year-old male patient has recently been started on an
ipratropium (Alrovent) inhaler. What teaching is inlpo rtant for the nurse to provide!
2. A 45-year-old patient with chronic asthma is on corticosteroids. 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 assessment, the school nurse notes s.:attered expiratory
wheezes throughout his upper and middle lung fields and
a decreased peak m eter (Jow. The currt'nt therapeutic regimen 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-

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ing the child's technique in using the metered-dose inhaler

(MOI l, thes.:hool nurse wishes to reinforce thechild 'seducation as it relates to the administration technique of his
inhaL'lnt s. What areas should be emphasized!

See Appendix D for answers and rationalel fo r all activitiel.

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TI,is page intentionally left blank

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U NIT

The
Gastrointestinal
System

CHAPTER 40

Drugs for Peptic Ulcer Oisease

CHAPTER 41

Drugs for Bowel Disorders and Other Gastrointestinal Conditions

CHAPTER 41

Drugs for Nutritional Disorders

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Drugs for Peptic Ulcer

Disease

DRUGS AT A GLANCE

LEARNING OUTCOMES

PROTON PUMP INHIBITORS

After reading this chapter, me student should be able to:

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

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 ulce r disease.

KEY TERMS
Hrrutptorantagonist fllKlt6ll

ilntacid fl1I}'615
antiflatu lrnt (II1I'615
chirf(ells poqe6lJ8
rsophag~al reflUJ

HelicobQCttfpy/ori

intri nsidactor fIIKIt{l1J

milk-alkalisyndrome puJe61S

ftl'1l' 6lI!

gastroesophageal reflux disenf (GlRD)

H+ ,K+ATPalf paje611

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ty.TJe6(1)

fX1I}t(D;

mucosa la~ fIIKIt(iJ7

parietal cells {!all 6al

peptic ulcer fIIKIt{l
peristalsis page (iJJ
proton pump inhibitor page611
loll inger-8Ii~n syndrome jl!9I611

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-

tary canal, or gastrointestinal (GIl tract, is a long, continuous,

hoUowtube that extends from tht' mouth to the anus. Tht'accessory 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 provide 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 criticalto the absorption of nutrients and water and for the removal of wastes. If pt'ristalsis is too fast, nutrients and drugs
will not have sufficient contact with the mucosa to be absorbed. In addition, the large intestine will not have t'Ilough
time to absorb water, and diarrhea may result. Abnormally

Bile '"''' - - - - - -. ...

"
Hopa1ic II

,i

"

"

colon
colon

T,an5Ve," ,o,," -~,'-;-J -

". Flgure40.1 The digestive system

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.

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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 digestive tract are discussed in chapter 4100.
Tu ~h"lIliUllly i>r"ak duwn i" I!.,,,t,,d foud, ~ larg" Ilwnu"r
of enzymes and other substances are required. Digestive enzymes 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 additional infonnation.

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: uk~ dil~"~ aft' diagn&led
N(h~ar.

About 6,000 proplt die anrually of ptptic uk~- rtlatrd (omplic,lions.

~n pl'KfMof Amtricans wfrer from daily symptoms of GERD.

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 I5Ophag~aI~
fl ux. A second ring of smooth muscle, the 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 digestion. 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 secrete 1 to 3 L of hydrochloric acid each day. This strong acid

helps break down food, activates pepsinogen, and kills microbes that may haw been ingested. Parietal cells also secrete 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 thestomacb 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 defenses are shown in .. Figure 40.2.

1
_ Gastric juice 2
.-----;;:~-=u-"O~'h
'"~"
pH -

Bicarbonate barrier

neulralizes acid .

.. Flgure40.2 Natural defenses against stomach acid

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40.3 Pathogenesis of Peptic

Ulcer Disease

40.4 Pathogenesis of
Gastroesophageal Reflux 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:

GlIstro!sophageal rrflux 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, lUltreatoo CERD can lead to complications such as esophagitis, 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 i~ umally a weakening of the lower
esophageal sphincter. Tht' sphincter may no longer close
tightly, allowing the contents of the stomach to move upward 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 being to reduce gastric acid secretion. Drug classes include
antacids, H,-receptor antagonists, and proton pump inhibitors. Because drugs provide only symptomatic relief,
surgfry may become necessary to eliminate the cause of
GERD in patients with persistent disease.

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 cau~e of PUD is infection by the gramnegative 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. Secondaryfactors 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 stomach 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 blac k, tarry stools. Many duodenal ulcers heal
spontaneously, although they frequently recur after
months of remission. Long-te rm 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 yea rs, because a small percentage of the erosions
become cancerous. The most severe ulcers may penetrate
the wall of the stomach and cause death. \'lhereas duodenal ulcers occur most frequently in males in the 30- to 50year age group, gastric ulcers are more common in women
uv"r ~I!" 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 categorized as inflammatory bowel disease, are discussed in
chapter 41 010 .

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40.5 Pharmacotherapy of Peptic

Ulcer Disease
Before initiating pharmacotherapy, patients are usually advised to change lifestyle factors contributing to the severity
of PUD or GERD. For example, eliminating tobacco and alcohol 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 provideimmediate 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 asacetaminophen ora selective COX-2 inhibitor. This is notalways
possible, because NSAIDs are drugs of choice for treating

"

"

6 10

Unlt1 Thl>Ga'i!'oIm .. tln.1 System

PHARMACOTHERAPY ILLUSTRATED
40. 1 Mechanisms of Action of Antiulcer Drugs
Pmtoopunp
,mibil""

Proton pu m p in hibitors

~ind

H2-receptor antagoni.t. occupy

the h",tam"" reoeplOta and

to

the~ H~.

K+ ATP ... e and

prev"'" acid ""'" bftog ....,..,ted.

pn!I_

acid .ecrelion.

cellwilh

H,,-receptor

prolonpump

UIc&r with H pylori

0"

......0 .. ... _ _ J

Antibiotic

.~

'- + -
___
~.~

HCL-

water + salt

00
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 pharmacotherapy (see Section 40.9). Treatment using only antiulcer
drugs without eradicating H. pylori results in a very high re
currence rate of PUD.

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/\

Alka line antacid. chemically coml> ....

with acido to Iow<tr .tomach pH.

PROTON PUMP INHIBITORS

Proton pump inhibitors act by blocking the enzyme responsible 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.

CNplfl40 CInJ9' /0, Peptic: Uk.... [)I, ... ",

6 11

TABLE 40 1 I Proton Pump Inhibitors

",,"

Route and Adult Dose (max dose where Indicated)

Adverlie Effects

~(Ntxi!lll)

PO; ~010 mglday

IItOOodIf, dilJrrhto. OOIISN, 1I!!Ii. dirzirlflj

(f't!'Ii(id)

PO; 15--60 mglday

5Njoujadyerlr ~ fffm are rlre

linlOpr.lld~

0, omtpI'amit IPri.-:)

(Protoril)
.,btpnlOlr (AdplltxJ
pant~

PO; 2O--ro m9 m~ tolWO tim~day

1'0;010 mglday
pO;lOrnglday

IIQ/k! iOlkatr ammon mr;r tlftn~ uodelliniog iolkate strilM adYmt r flta~

4 0 .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 parietal cells of the stomach, this enzyme acts as a pump to release acid (a lso 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. Beneficial 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

trol of peptic ulcers and GERD; Th.. typical length of therapy is 4 weeks. Omeprawle and lansoprawle He usoo concurrtntly with antibiotics to eradicate H. pylori. The newer
agents esomeprawle ( Nexium) and pantoprawle ( Protonix) 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. He~d~ch",ahclomin~ll'~in.<linrrh"". 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

I Omeprazole (P"losec)

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 ifTl'~l"Iibli 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-wrrktherap)' of ac:ti!' ptptic: ukt rs and GERD.
Most patients al"l' S)'IIIptoll ~ .firr2 wrrks of therapy. k is wd for Ioogff ptriock in PiUients who ha~ (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(

ADVERSE EFFECTS
Ad!'m tffM aft' gtntrally mioor and in{kidt htadac:ht, l\alMa, dicrrht.,
ra~h, lid ilbdomina Ipain.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. ~sr 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
OIUl}-~rug;Crorulmltllll' willi diaztpam, ~oi1,iIId(HS~nu mil"1

00II' rom! blood It'II'II of thfsf d~ 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.

_w.

Lib TI5IS;~. mil")' i1crNst vaIut>s for AU, AST,iRlst'rumalbl~

HI'IiIiI Hood; Gioiato iIId St.1dVl~ won mil")' dKJNII' the pIaIrna ~uation of
~

.......

Treatment of Owmlose; Theil' is 00 sprc:ific: trtatmeot for O!'Idosr.

PHARMACOKINETICS
Onlt"t;0.5--l5h
Prak;5days
Halflife; O.5-1.S h
Duration; l ...4 days

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RPI'l'r Ie M)M!rliIIgKJIlbr Q Nlmlrll} Pn:m! fOOI5 Jjlt(1/{ Ie rills d~

612

Unlt7

ThI' Ga'ilrolnt.. tI",,1 Sy<!'-""

TABLE40.2

H2-Receptor Antagonists

Dru,

Route and Adult Dose (max d05l! where Indicated)

Adwrse Effects

dm~diM' (~met)

PO;300 1119 ~\'I'ry 6 h 01800 mg .It btdI~ OI400mg bid with food

fMrrIIeG, (lmMipmiOll, MliI<xilt, faligut, IJQU~

gynKOfflQl/iQ

!!art:Hepatitis. t+Jod d'l'l!OOi\, .naphy\a1:iI.!MrIrtlImin.

l!!i!l!oKtioo~!l!lactmhN {OOfuIiooOl' ~
fjmo~li~
nimid~

(Ptpdd, Mylointa AP I

PO;lO 1119 bid 0140 mgolt btdt~

1lwiKht; MUJtq. dry fOOIJIh

Ra-t: M~culOlkd N( P<lin OO)'Qrdia !IOOd dysqasia,

PO;l~lOOmgoltbtdti~

(Axid)

rinitidilll' (lanta()

~k!m'~rision

PO; 11-1SO mg bidor 300 mgat btdtim~

lldia ind~t~ (OI'llmon tdwnt ftfM!;lIII1l:I:Ii!ilIind~te ~ idl'fl~ ftf~m.

in the treatmem of hyperacidity disorders of the GI tra ct.

These agents are listed in Tab)e 40.2.

40.7 Pharmacotherapy
with H2 -Receptor Antagonists
Histamine has two types of receplOrs: H I and H,.Activation
of HI receptors produces the classic symploms of inflammation and allergy, whereas the H, receptors are responsible for
increasing acid secretion in the stomach. The H,.~(eptor antag
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

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, cimetidine (Tagamet ), is used less frequently than other
H,.receptor antagonists because of numerous drug-drug
interactions (it inhibits hepatic drug-metabolizing enzymes) 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 anta gonist will be diminished .

ANTACIDS
Antacids are alkaline substances that have been used to neutralize stomach acid for hundreds of years. These agents,
listed in Table 40.3, are readily available as OTC drugs.

I Ranrtrdrne (Zanrac)

Therapeutic (lass: Antiul cer drug

Pharmacolog ic (lass: Hl-It'(l'plor antagonist

AalONS AND USES

ADVERSE EFFEaS

Rinitidi~ ads byblodcing H,

rmpton in t~Slolni(h todfill'u!'ac:id prodlKlion.1t hal ol higher palm')' lhan d~tidin~ whim allows it 10 lit administt rrd
onc:t dai~, lI!Wl~ al bedtin"l!'. Adtqwtt htaling of tht ukff I.kes approxim'~ 4to 8Wffks,ahhough tho!~ at high risk for PUD may (ontinue on drug
m.imo ... nc:~ for prolongod po>riock 10 p....... nt IUrrrn.li.><trK u~n rrqJilt:
longer thmpy for healing to oc(ur.1V and 1M forms 'I! aY.ilablt for t~ n atmtmof ,nM, st~l-indtnd blt~ding ukm .Trit is i (ombination drug with
ranitidi~ ,nd bismum dtral!'.Ranitidi~ is availablt in i dissoiYing tablet form
(EFFERd=) fortlNtingGERD in (hildrenand infanrsolder mol n1 month of agt.

tffects art unc:ommon and mild. Rnitidint doe 001 (rol!! tht
blood-brain b.rrier 10 iny appJ!(iabl~ extt nt. so it OO!'! nOI {aus~ the (onfusion
and CNS d~p~sion obserwd with (imetidint.Ahhough rail', 1!'\'I'fl' rrdlKtions
in t~ number of red , nd whitt blood (l'lk ,nd plal~ltrs all' possible;thUI, peri
odic blood count< lniybe pcrformrd High do~ ""'y rnuk in impotolKo or 10..
oflibido in mt n.
Contraindirnions: Contraindicationl inc:kKit hypersmsitivity to H,.rt plor
oIm"90nist~ aMt porphyrit, ind or( administration in childl!n Ie! than 12
yursofq.

ADMINISTRATION ALERT

INTERACTIONS
1Wg- 1Wg: blitidM has Itw drug-d"ug il!l'I"actioos than dmttidirll'.
Raritidillf may redtn thf .t.sorptiOl'l of {efpG!m~, kMlKOIIiroIf,and
itrar:onarolt.AnIiKids Ihoo.Ml no! be gil'l'Owitllil 1hoor ofH,-rtcfPlOl oIntagonisrs
beao.MthfeflKriI'I'IIfII may bf di'<JNIi u to rflkKfdabsorplion. ~kilMl
dPaui.fI thf ffI~ of raoi!icine.

Administer after mtak and roonitor liver and lI'n.llunaion.

Pf!gniOCY rnegory 8

PHARMACOKINETICS

I),set Unknown
Pf,ik:l- l h
Half~ifto: 2-1h

DUrition: 8- 12h

AdR~

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: fnvi1lr1rMrl~ thus,

df/idfn(ymay OCtut no isalso bfUH absorbfd in ill oIddic: fmironlllfflt

lINtment of ()Y~n:lo!f: Tht~ is 00 Ipt(ific: tlNlmenl for OWOOI!'.

IWtf /II MyMIsIrtiJU fIJf ~ MnbIiJ Plrxl'S.! fIlM spt{1/I( /111M ItrJg.

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CNplfl40

NURSING PROCESS FOCUS

Orug;fu'Peptk:UIc.... DI' ... '..

613

PATIENTS RECEIVING DRUG THERAPY FOR PEPTIC ULCER IPUDJ

AND GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Assessment

Potential Nursing Diagnoses

a,smment priorto admini,tration:

Undtrstmd thr INSOO the drug has bn presc:ribrd in ordrr ro mes for
rhrrapMic: t1frru.
Obtain ~ (omplete hr~hh history ill(k.iding 61. hrpatic, K'nal. K'Spir~tOl)', or
(a,dicmsaJlar disr~; 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 curr~nt symptoms, ooting any cOll<'btions
~n 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 sum~sful to II'lifl't tht pain (e.g., tuing).
Obtain ~srlintyiul signs aod wtight.
Evaluall' approprWtt laboratol)' findings (f.g., CBe, platf lm, titctroi)1es,
htparic: or renal fulKtion Slodie).

~Iine

AruIl'Pain
Ak .. ,t<1 Nurrition,lffi Than Body RfqJill'l1II'nn
Derl(ient KnowIl'dge (drug thl>rapy)
Risk for 1~Iflivt Health Maimf nalKf (lodjyidwl or Family;dietary ,od
liftstylechangtl)

Assessment throughout iI dministration:

~ssrss 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 Itn~1
fiJoaion Llbs. Te ting for H.pyIai rna)' be nffiRd if symptoms fail to rrsotvf.
Assrs~ 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.
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 tl~ritlKe minima~ idvtrsr tlferu.
V~rb.Jlize an undtBtaodiog ofwdrug's 1M, ,dv~rsr flfts,and II'qJill'd plfCautions.
Demonstratt proper !eIf-<l dministration ohhr mtdiytion (~.g.,dose, timing. when to notify provider).
Implementilltion
Interventions and (Rationale s)

--+

Ensuring thtrilptutic effects:

ElKooragt appropriateli~~tyIe [hangr~ induding an ilKlNstd inrake of
)'OgUn and oc:KIop/lI1I1Honraining food~. Ha~ rh~ 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.)

Pilltient and Fillmily Educilltion

ElKoorq the patient ro <ldopt a healthylih,style oflow-f~t food choic:e

aod ilKlI'astd m-rdsr,aod to eliminatt <lkohol (on~umption aod
smoking.Prafldt for dittitian (oosulration or information on smoking
(ffiation programs iIIlM'tdtd.

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 H.p~ori.)
Monirorfor anylf"lfll' <lbdomioal pilin, wmiting, rolfft'-ground or blood)'
I'Omiting,or blood in stool or tarry stools ~ od report immediat~. (Drugs
used rotll',t PUD <l od GERDdem,sr 9iIItrK oKidiry, making t~gilltric
~vironm~t Itss f'l'Orablr for uker dtelopl1ll'Ot bur th~ do not heal
v:isting uker~ SorYert <l bdomioal pain 0' blood in t mrsisor \lools m<ly
indic,re a worstning of disN~~ or moll' strious (ondirions aod should be
reponed immtdiatelyJ

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
di~(omfort 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)

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614

Unlt7 lheGa'ilrolnt..,tI""ISymrn

NURSING PROCESS FOCUS

PATIENTS RECEIVING DRUG THERAPY FOR PEPTIC ULCER (PUDI

AND GASTROESOPHAGEAL REFLUX DISEASE IGERD) (Continued)
Implementlltion

Interventi o ns lind (Rlitio nliles)

Pliti ent lind Flimil y Edu clitio n

Conlirue to monitor pfriodic hepatic: and rrul function trill ,nd (Be.
platrlm. ,nd rledrolyir ~Is. (Aboormallrm- fUnction I..,U may indicatr
drugindlKrd adYe.n hepatic rffrds.~~a\ed 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. m-s~Ye UII' of anudds may
affect ritrolyir 1eW'1s.)
EnsoR' patinlt safrty. rspK~lt; 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

Instruct t.... patirnt on the need to R'lum ptriod iully 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 sor physical (oordination unlilthr rlln ohhr drug aR'

"""..

Pat ~nt

undt rstanding of drug th t ra p-,:

lJSI' opportunitiH during administration of mediGlDons and during
mrs,mfllU 10 d~<us, 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(rssary monitoring or precautions. (Using
time during nursing (aft-' help! to optimin> and rl'in/oKe ~ teaching
aR'asJ

The patirnt, famit;. or taR'9iYer should lit able tostalr Ihr ~ason 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.

Pat ~nt

stlf'il dministration of drug thrrapy:

Whrn administffing thr IIII'dimion, instruct the patirn~ fam it;. or
taR'giver in the proptr 1I'1f,dmin~tration oft .... druq. r.g.. ruring mning
IIlNI. (Proper administralion impl"l)Yel thr rfilil'l'llrss of thr d~.)

Tra.c:h thr p~tirm totaR t~drug 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 ~id.{OI11plrtr.
Proton pump inhibitoB: Tau 30 minutes btfoR' meals.lf onlN-d/ly
dosing ~ onirrrd, tak~ t~drug in tho morning bebR' blNkfasl
Antadds may lit tiled (OIKurR'ntly. 00 oot oontinUl' takill9tho drug
bryand 1 to4 months unless dirrord by t~ 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 scOOOJlRmly unless ava ita bit .J Sa
(OI11bination proO:Kt or dirrtttd to do 10 by tho health u~ providrr.

Ev aiuliti on of Outco me Criteria

E-Ialuatr the effectiveness of drug thrrap)' by (onfirming that patirnt goals and nptmd ou\(OIIII'S ha~ bet-'n mrl (1H P\anning1.
SH rli>lrl4IJ. ~ 4IJ.l.ooo ljf(K~ i1rridf'.llJllrl whidirirtst rNnirlgtimsopply.

LI FES PA N CO NSIDE RATIO NS

H2 Receptors and Vitamin B' 2 in Older Adults

H,.R'(tptor blockers demi~ 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 es~rll~1 itamin.
H,.reptor bkKurs aR' frrqurntly prrstribtd for older adults, who a~
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 fatto~ ,nd digtstil'!' rlll)'mrs pI09R'SsiYely diminishes. Thesf Ios~
can Irad to lower absorption r.llt-S. depletion of ~rve-s. and t"Vtmually B"
dtfKirnq. Thr nurw musl tdwN oIdrr adults taking thrsr d~ 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.

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H OME

&

C OMMUNITY C ONSIDERATI O NS

Over-the-Counter Medications for GI Disorders

Many patirnts pun:hast arc medicalions bastd on infoonation obtaintd from
the mtdia. Anudd~ H,.reptor agon~ts. and proton pump inhibitoB a~
av,ilablr as OK medic:ations. Alth01l9h fYrrY orc mrdiution indudes an in
form,lion r;hffl,m.Jny proplr do not ~id lhem. Soliii' do oot R'ad thom lit
(ausr lhey fffi that all or( medications aR' !.Ire, and othoB haYe dillkulty
~ading th~ small prim on tho information shws.Stili others may not ~ali~
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.

TABLE 40 3 Antacids
Adult

(max dose wh~r~ Indicated)

0""

Rout~ and

Q illlrinlJll hydroJlid!, (AIt~!IIoIGEL,othm)

1'O;600lIIIjtid- qid

CiJn5tipofiOfl, fI<ItI~wmlJ(h(fl!mp!

ukilJll urbonitt (Titrili<. Turm)

1'0; 1-1 9 bid- tid

CiJn5tipofiOfl, IIorultllCt

ukilJll urbon.J~ with Illi9M1ilJll hydI~

(Mylint.l GtI-<ip!, RoIiidsl

1'0;1 ups~~sorublets pm (!IIoIx: 11 tabltts/day)

migildrat~ (Riopan)

1'0; ~ 1,080 mg (5- 10 mL!Uljlffision or 1- 1 ublets) diiiy

(mil: 10 t.lblm or 100 mL/day)

Dos~

Adverse Effects
&Ulim~iIlo Irooooho'gl:yl~miol

Frql impilClion.me\ibolK ilt.Jlosi~

b)l!fWltfIllia DI:iIIUdi

mollJll'~lJIllrJdroxide (Milkof~)

1'0; 5-15 mL or 1- 4ublttsai rwdtd up to foor time diiiy

mollJll'liLm IrJdroxide with alLminLm hydroxide

(Mailu)

1'0;1-4 ubltts pm (max: 16 tibltts/day)

rTIolIJII'~Lm IrJdfllXidlo with alLminLm hydroxide

with ~mdl~ (M)'Iinti,Mulu PM,othtfS)

PO; 1~10 mL pm (!IIoIx: 110 mL1day) or 1--4 tabletl pm

(mn: 14 t.lblmlday)

\Odium biurbonite (AlkaSdtm, baking soda)

441 forth/, ProlOl)'prDrug box OO)

1'0;315 1IIIj- 1 9 on~ to fOll' timrllday

(~~

~ OOIlltO, K1mi1ing, ~bdomiool

(J(Jm{irll}
~nrlml~

mllrolrniil (wliffi

giYl'n Dartnterally)

Abdcmiool til/moon, bIc hing, IIorulmcr

Me!aboi{~lglosi$. ftuid rmn~on ~ckm.J,

hmmli!!!mli.!
I!QIk! indut~ ammon idvmr ~m;~in!kate sMousadwmr ~fIta~

40.8 Pharmacotherapy

with Antacids
Prior to the development of H,-receptor antago nists and
proton pump inhibitors, antacids were the mainstays of pepti' ulcer and GERD pharmaootherapy. Ind eed, nrony patients still use these inexpensive and readily available OTC
drugs. Although antadds may provide temporary relief
from heartburn or indigestion, they are no longer recommended as the primary drug class for PUD. This is because
antadds do not promote healing of the ulcer, nor do they
help to eradica te H. pylori.
Antacids are alkaline, inorganic oompounds of aluminum, 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 discomfort. For example, Mylanl3 contains simethicone, aluminum hydroxide, and magnesium hydroxide. Simethicone
is classified as an ntiflatu lrnl, because it reduces gas. It also is
available by itself in OTC products such as Gas-X and Mylanta 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

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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 recommended dosage range.
Antacids containing calcium can cause constipation and
may cause or aggravate kidney stones. Administering calcium carbonate antacids with milk or any items with vitamin 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 syndrome 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 cancer. To more rapidly and -completely heal peptic ulcers, combination 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 approp riately. Elimination of this orgaJtism

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

ADVERSE EFFECTS

Aluminum h)'droUde is an ioo~nK 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 ronnipalion. Unli~ cakium-N 5ed an!.icidl that can br ,bsorbrd and cause l)'Item KdIrm, dJminum compounds are miniml l~ I~rbed.iheir primary action is to
neutr,li~ stomlch acid by rlising the pH of the nomac:h contl'l1ll. Unlike H,reU'ptor ,magoni.1I ,nd prolon pum pinhibiton.' uminu mantlcids do 001 If"duce the voiullll' of acid !e<rrtion.ihey are mOlt efleo:ti'le~ 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 '\\Iiia~to ~at heartbum.

Auminum ntadds Irfquent~ 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.

ADMINISTRATION ALERTS

Administer ,luminum Intadds" Imt 2 hOUri befono or alterother drugs

because ablOlJltion (ould be a/fted.
PR'9nalK)' category (

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
(lIU"I,mmitl~.

Lab T.",: V.km f ....... op<lrin . nd oon ... , pit moy ilawst. \.or .... phosphO!.

\\Ik1e! may IiKINII'.

Ili!rballFoo:t: AUrin .... iIIUtim lNy inhibit IfIIo i!bsoIption of dtlify iron.
T~tmfnt of DYfrdoH: There is 00 lpt"{ifK tlNtment

lor u;e~.

R<ftr III MrImlrl9R till ~ MnJnq l'r!KeIS fIxrIs sp/It IIIIM /J"ug.

PHARMACOKINETICS
1Al1I:'t: 2Q--40 min

Pt-1k:30min
Half~i~:UnkMwn

Duration:2 hwhen t,ken with food,) hwhen !.iken 1 hafterfood

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 resista nce. The antibiotics are also combined with
a proton pwnp inhibitor or an H,-receptor antago n ist. Bismuth 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. Additional information on antiinfectives can be found in
chapters 21 and 2200 .

40.1 0 Miscellaneous Drugs

for Peptic Ulcer Disease
Several additio nal drugs are beneficial in treating PUD. Sucralfate (Carafate) consists of sucrose (a sugar) plus alu-

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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 ant~ity
in Indil ,nd Chirw. The K1if i-.gRdienu 01 gingt~and those 1M mate in spicy
ftil'/Ol" and prD}!'nt odor,lre louted i1 its IOOU or rIizornrs. k is sometimtllttndordized according to its IttiYt 5Ubstanm. gilgerok Ind shooiok. k is sold in
pharrnac:i...asdrirdgingerroct ~ataolle of250to 1,00> mg.and isreadi~ avaibble at roost groc:rry "o~ lor home cooki-.g.Gingtr is 0lIl' d ~ best
lIudied herbs. and itappeilri to be useful lor I number ofdigrniYt-~1IIed conditions. ~rhaPI iu widtst UII' is for 1ft'ating nauw, iKb:ling tIwt (.Iused b)o roolion Wmtsl, plf91'lK)' morning !i:kne~and postoperative proc:tduR'l.1t has
""111 shown to stirruw appetite. promote !II1tric: ~and incru.. perilubi!. ~r R'le~Kh 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
~GI trlt~ I<Ither than on tlltCHi Ginger hal 00 toxic:itywhtn used at rerommtndtddOle.AtIYrrII:'ellrmilKk.dtabdomirwldilCOmfortanddilrrhra.Om~ may lead to CNS dr~, inhibition d platelM aggrtgllion. and
(.Ird;;'tonK effrru ((Iu~kunaprulr. Nathiw.van.iffprakolbon, to l.ettalelllgooi.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.

Choplfl40 OnJg;Io,PeptkUIce<DI,,,,...
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

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.

{~~ \ C-h-ap-te-rR-EV-IE-W------------------

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.

40.6

Proton pump inhibitors block the enzyme H+ K+ ATPase

and are effectiv\: at redU(ing gaSlri, a(id secretion.

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.

40.7

H,-receptor blockers slow acid secretion by the stomach

and are often drugs of choice in treating PUD and
GERD.

4005

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 require longer follow-up.

Antacids are effective at neutralizing stomach acid and

are inexpensive OTC therapy for PUD and GERD. Although they relieve symptoms, antacids do not promote
ulcer healing.

40.4

Gastroesophageal reflux disease (GERD) results when

acidic stomach coments enter the esophagus. G ERD and
PUD are treated with similar medications.

pylori infections of the GI tract, the cause of many pep-

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.

40.10 Sewral misce1laneousdrugs, including sucralfate, misoprostol, and pirenzepine are also beneficial in treating
PUD.

40.5

40.9

Combinations of antibiotics are administered to treat H.

tic ulcers. A proton pump inhibitor and bismuth compounds are often included in the regimen.

NCLEX-RN" REVIEW QUESTIONS

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 developmem of what condition?
L Hypomagnesemia
2. Hyperkalemia
3. Hypermagnesemia
4. Hyponatremia
In the treatment of H. pyJor~ 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
W~"

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3. 1b increase the likelihood of eliminating redevelopment

of gastric ulcers
4. 1b decrease the cost of future drug thernpies

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. pre~ent diarrhea associated with GI drugs.

6 18

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

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.

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 increasing 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.

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EXPLORE

~~-----,

M~l"$in[ll(~ 1s)'OOI one !IMp ItIO" Mline ~haplef r..,..lew matenllIs MI1
reSOLKO!&' Plepare for ~uccess with addiuMat Ncr..ue-!;tyt~ 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 ~I ,.,... book 111
www.lItj ..... slngkltcorn.

Drugs for Bowel Disorders

and Other Gastrointestinal
Conditions
DRUGS AT A GLANCE

LEARNING OUTCOMES

LAXATIVES pagt611

After reading mis chapt~ the student should be able 10:

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

..

3. Discuss conditions in which the pharmacotherapy of bowel disorders Is

Indicated.
4. Explain cond iti ons in which the ph,umacotherllpyof nausea and
vomiting is indicllted
5, Describe the types of drugs us.ed In th e short-term management of
obesity.

dlpl!tnoql(Jtt with olropiflf (I.omoUI)

~,

sown

DRUGS fOR INFLAMMATORY

DISEASf:
AND IRRITABl.E Bown SYNDROME ptJgt6JS
'" wlftJ$DkJzne (AlII1fldkW) {#/t6Jr

AHnMETICS , .619

prochlorptf(J~ (Cotnpttl.hf)

pagt6JI

DRUGS fOR OBESITY pogtOf

Q sJbutromhf (Mttldb)

ptl9t6Jf

PAHCREATICEHZYM(R1PlAUMlHT

1. Identify major anatomic structures oftl'lt lower gastrointestinal tract.

2. Explain the pathogenesis of constipation and diarrhea.

{IfI1t6J5
Q JlClfIUf~ (CO(Ozym.I'I,",cr..,~

6.

Explain the use of pancreatic enzyme replllCement In the

pnllrmiKotherllp)' of pIIncrelltitil7. Describe th e nurse's role i"l the pnllrrnacologk management of bowel
di~rder s.nausell and VOmitll"l!:lllnd other GI conditions.
8. For eiKh of the <tug classes listed In Orugs" II Glance, know
repre sentative drugs, and explain the me<hanism of drug ItCtion,
describe primary iKtions, and identify important advene effe<b .

9, Usethe nursing process to ale for ~tients who are receMngdrug

therapy for bowel disorders, nausea and vomiting. and other GI
conditions..

OlhMJ ,.,636

KEY TERMS
anoroiam pI19t6JI
antifmttic pogt 619
bodymassindu(BMI)
Cilthilltic pqgt6}1

~6JI

d'of1norH@!ItOltriggtfzone(m)
UlIlSIipation ".6]1

ptl/t6J8

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Crohn's di srasr {XIqt61S

diarrma fXJ'}t 611
rlMsis pq .1S
rntrtiu fIIIIltUIJ
mrloqfnicpotmli.ll fl7jt 0l8
inlloJlTfllatOl)" boftI di_~ (IBn) fl7jt615

irritablr bowtl syndromt nBSI fi'J9t 6lS

lautiYr fXJ'jt611
~pa~i nhibitOl"S fXJ'jtOI
!lUstii

fJI'1t61S

l~iltOlthta fXl}t6JS

ukefatitulliitis p;gt615

620

Unlt7 The Ga'i!,oInt..,tI,..1 System

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 consequences unless drug therapy is initiated. This chapter examines 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

chyme, miXES with bile from the gallbladder and digestive

enzymes from the pancreas. It is sometimes considered part
of the upper GI tract bec~use 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 jejWlUm and ileum. The jejunum is the sitt' where most nutrient 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 peristalsis and speed materials through the intestine; the sympathetic division has the opposite effect. Tr~vei 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 vitamins and vitamin K. Disruption of the host flora in tht'
colon can lead to diarrhea.. With few exceptions, little reabsorption of nutrients occurs during the 12- to 24-hour journey through the colon.

Duodenum:
reoeOY85

chyme

I""" stomach

Jeiunum:
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.

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''''''lfr 41
PHARMFACTS

Gastrointestinal Disorders
Uktrati'lt rolitis 1m a peakOII!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 m~than $ll billion anfll);ll~ 011 OftightffdKtion
products and srrvim.
Thr in(idtlKt 01 motiolsic:knm ptab from ~ 4 to 10,and then
~illStorll'f:li~.
GalistOll~s auoontforW'lb 01 all Qlf"lol oKutf pan(lNtitis, whr~as
akohol (OIIIUmption iU!I;ociaud with 70% 01 all drronic: panm'atitits.
About lS,*, of Americans (m~ than 1 million adults) who all.' using
Wl'ight-losssuppll'melRl a~ oot Oft lWI'ighl

CONSTIPATION
Const ipation is a decrease in thf frequency of bowel movements. Stools may become dry, hard, and difficult to evacuate 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 distention and discomfort, and flatulence.
Constipation is not a disease, but a symptom of an underlying disorder. The etiology of constipation may be related to a lack of eJ{ccise; insufficient food intake, especially
insoluble dietary fiber; diminished fluid intake; or a medication regimen that includes drugs that reduce intestinal
motility. Opioids, anticholinergics, antihistamines, certain
antacids, and iron supplements are just some of the medications 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 hypothyroidism, 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 require drug therapy. lifestyle modifications that incorporate
increased dietary fiber, fluid intake, and physical activity
should be considered before drugs are utilized for constipation. Chronic, infrequent, and painful bowel movements,
accompanied by sewre straining, may justify initiation of

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Drug, for Bowel Olsorders and 0!1>ef GmrolmesHn . 1Coodltlorn

621

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, because fecal transit time through the colon slows with aging;
this population also exercises less and has a higher frequ ency of chronic disorders that cause constipation.

laxatives
laxaties are drugs that promote bowel mo~ments. 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 defecation,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 following abdominal surgeries. Such treatment reduces straining or bearing down during defecation- a situation that has
the potential to precipitate increased intra"abdom.inai, intraocular, or blood pressure. In addition, laxatives, in conju nction with enemas, are often given to cleanse the bowel
p riO! 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 oflaxa~
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
ou tcomes. Care must be taken to rule out acute abdominal
pathology such as bowel obstruction prior to administration because the drugs will increase colon pressure and possiblycause bowel perforation.
When taken in prescribed amOlU115, laxatives have few adverse effects. These drugs are often classified into five primary 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

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

PO;llJfdaypm

AbdomioolfrJ/nru1Jl (JQmpi~ frjn~f1IJ

methrl{du&ll' (Gtnnl)

PO; ltblp~d in 3- 10 Olw~ttr

[lIlIIblllll11tl r~ gl;UIIlUlislD ilLlKD ~Jb

jnwffiOOu "lid

Q psrllillll mllilloid lMtlamlli~tlallml,

PO; 1- 2 tIP it Sill Wiltrdaiiy pm

BULK FORMING
calwm poI)Urbopbil (Equaiactin,Fibmon,
othfrl)

othfrs)

SALINE AND OSMOTIC

migorsiJm h)'ltoxidf, (Mlk O(M~)

PO;lO~mUda,pm

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

DiIIm, ~biI<:mnaI uv"f!if1lJ

~~~~~rnm~~~
hydroJ:id~ (dys!I!ythmias, mpir.l!o!y fa~u!tl

STIMUlANT
bililodyl (Cor!tttol. Dukolax. othrn)

PO;IQ-I5mg/da, pm

GlSioroi (Emulsoil, HtoIoid.~)

PO;l5~mUdaypm

Abdomiool (fQmpirIIJ rDMII, filinrilg.

dQrrhto

AI!!!;! and ~ro!,!!~ lOIS

STOOL SOFTEN ER/SURFACTANT
dottM~

(CoDtt)

HERBAL AGENT

!trIoa/!trIoosidti (b .ul, StrIokot, othm)

PO; SO-SOO mg/da,

I
I

Abdooiool(fQmpirIIJ dQrrhto

I!o Icious idl'tl'!!: dlts

Abdomioolaompirli dQrrhto

PO;8.6-171mg1da,

It! strioo; film!!: tlftm

MISCELLANEOUS AGENTS
kJbiprOlioot IAm~iLl)

PO; 14 flK9 bid

mintraloil

PO;I5- 30mLbid

NMefl, di<rrl!fo, hfadoclle, dfJPhN

Allergic Wpm
aQ~OOU!eQ

Nutritional d~ fMion I1!]:IIIIOfia

/tal(! iodirn~ tommoo ~ tfltcls;~ iodititts strioo; i liwr!!: tlfttl!.

cause diarrhea and cramping than the bulkforming

type of laxa tives. 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 discoura~ed, because it may

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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 inuease 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, occasio nal diarrhea is often a self-limiting
disorder thai does not warranl dru~ Iherapy. Indeed, diar-

C"",lfr 41 Drug' for 80wel Disorder, and Otl>ef Gi nrolole';Hn. 1Conditio",

~ Prototype Drug

623

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 Iml~ plyllium is an illlOlu hlt fibtr that is indigestiblt
and not alMrbtd from the GI trau. Whtn Liken with a wffic:itnt ~mity of
watt~ psyiliumsOftlisand ilKll'a~ tht sUeoithefml mm.Tht Lirgtr the size
oflht ItullN!5, the mOf!' the ddtcation reflex will he nimul.ntd. tills promoting the pM!a9f of ,tool. Stftral Ous ol psyllium may bt IItfdtd O'/!'r 110
J da)"5 to ~ a thmptutic: tff~t. The drug may he Liken dai~ as a fibtr
9Jppltllll'm.
FlI'qutOt lMof p,yllilm(7 g/dayl may UlMa small rrouuion in blood {haIfSlerollt~I.8mlMof this tffrc~ psyllium may bt u,t<! . , part 01 a regiment
to rtdUCt the ri,k of rol"OOary lINn d~a\e.
ADMINISTRATION ALERTS
Mix with ilie.J,t 8 Ol 01 water, fruitjuic:t,or milk, and admini,ter immtdiak'ly.FoIIow mh doW' with an addition. 18 Ololliquid.
Obst~ oldtr . duln {iorely fur polliblt . spirMion.
Pregnancy uttgory (

ADVERSE EFFECTS
~yllium is a wit Ial0tift and raft'iy prodlKf"I adl'l'nt efl~ts. k uu~ Itss
o:ramping than stimulant-type laxati~ and ""ul" in a 100ft' natural bowel
IIIO'/ tllll'Olll Liken with in,uflkitnt wate~ it IIIil)' (,lUll' obnllKlionl in the
tsophagusor inrestiOl'.
Contraindiu tions: Plyllium should oot bt idministertd to patient! with undiagOOW'd i bdominal pain,intf"ltinal obllruction,or Itul impauion.
INTERACTIONS
Drug-Drug: f'I)'IIi:.m maydKr&R tfwoaborptionaod fffem ofwarfarin,.n,
nitrolll"artoin. oIO~aod wkyla!fI.
lib TI5I!:~~um mol)' ioofil\o! tfwo IfIIIIO glwrlf Ilvel.
HerbaVFood: Unknown

TlNt mem of OYerdo,e: Ovmiost from plyllium is unlikely.

III'ferlO M)NurslJrgntfrxoNurslnljl'rl:>!:m fooJ5spKlklOrlrls~

PHARMACOKINETICS
Dn'tt: 12- 14h
Ptak: l- Jda)"5
HalfliM: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 fluids, and pharmacotherapy is indicated. Prolonged dwrrhea maylead to fluid,
acid-base, or electrolyte disorders (cha p ter 3100).
Diarrhea maybe caused by certain medications, infections
of the bowel, and substances such as lactose. Inflanunatory
C OMPLEMENTARY AND ALTERNATIVE THERAPIES

Acidophilus for Diarrhea

liIcrobociJJw ocid:IpIriIus is i probiotk bacterium oormally found in the human
alimenLiry u nal and ~ina.1t 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 idcriIus 10 limit the growth olother ba{tmal IPfCits is the gtntration 01 hydl"09fll ptrw:idt, whidJ is toxic to IOOst ctlls.
The primary UII' of L IKidopIrlus is to ~torf tht normaillori 01 the inttstint following dia"hei, particularly from antibiotic: thmpy. k has i M ~n
shown to he tfftttiYt at shanming epirocIts 01 aMf inftiou, diarrhei (Tt itelbaum,lOO5).L lKido,ni1us may bt obtaint<! by drinking i(idophikJs milk or
by eiling yogurt or kefir oontaining liYt (or aaift) (Ultu~. Thost wi,hing to
obtain l.Qddoplr~U! from )09urt Ihould ft'ad the labtls ml'fully, btuUll' oot
all produc" {ontain ictift {ukuft'l; froil'll )09urt (ooLlin, no actift (uituft'l.
Suppltmtou in(kidt up,ults, tabl~tl,ind granules. 1lo!I's aft' oot ,tandardizfd, i nd tahltt dose ringt from SO to SOO mg.

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disorders such as ulcerntive colitis, Crohn's disease, and irritable bowel syndrome can cause episodes of intense diarrhea.
Antibiotics often cause diarrhea by killing normal intestinal
flora, thus allowing an overgrowth of opportunistic pathogenic organisms. The primary goal in treating diarrhea is to
assess and treat the underlying condition causing the diarrhea . Assessing the patient's re.;:ent travels, dietary habits, immune system competence, and recent drug history may
provide information about its etiology. Critically ill patients
wilh ~ [",Ju~",J in""un" "'''1'''''''' whu ~r" =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 severity of the condition and any identifiable etiologic factors. If
the cause is an infectious disease, then an antibiotic or antiparasitic drug is indicated. If the cause is inflammatory in

6 24

Unlt7 TheGaslrolnt..,tI,..1 System

TABLE 41.2 1 Antidiarrh@als

DN,
OPIOIOS

Routeand Adult Dose (max dose where Indicated)

AdwrwEffects

camphmttd opium tilKl!ll' (mgoric:)

PO;HOml~2hqidpm

diftnoxin w~h auopi'>. (Mot. (tn)

PO; 1- 2mg afttr ..." dianbta .pim (maltS mglday)

l1n7wJinm, lg/II.ooxtMM!~ rDMG,dilmm,ilry

moorh (frrIm Qlrop;,e), cmsripion

Q dP/ltnoxylal~ wilh auopiJlf [LomotiQ

PO; 1-2tabs oc ~ 10 mllid-ilid

loptramid!, (lmodiJm)

PO;4 mgasa !iJ9~ dost, liltn 2mg afitr mh daIThea ~

(max;16mg/d.y)

ool)'!K jleuswi!!l !~K ~mIon

doos5ion.CHS depmsion

~mlqo:

MISCELLANEOUS AGENTS
bismuth sailS (Ptpto--BilmoI)

PO;2 tabsoc 30 mlpm

(OfIIliporioo, OOIl!t4 rinrirtJf

SCIIV; l00-ioOO mcgld.y il lwo tofotrdiYided OOst,S

NIAAt4 di/lrrIieG,oMomillQ/ {Kin

Im~ion,Rm'Sl~n~
~OIidf

(Saodostatinj

'bolD~ iD II:IlID gllllgg IIiIBlIIlIIQ dllIlr:l!.1lil

.!!mi!1!il
Irdla inditit~ common adl'mo! tffffis;lIIIkdi!iog, inditite strious adm~ tff~m.

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 antidiarrheals are codeine and diphenoxylale with atropine (Lomotil). Diphenoxylate is a Schedule V agenl Ihat acts
direct/yon the intestine to slow peristalsis, thereby allowing

~ Prototype Drug

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 diarrhea because of the potential for dependence. Details on indications and adverse effects of opioids may be found in
chapter 1800.
OTC drugs for diarrhea act by a nwnber of different mechanisms. 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

I Dlphenoxylate With Atropine (Lomotll)

Therapeutic Class: Antidiarrheal

Pharmacologic (lass:

~ioid

ACTIONS AND USES

Tilt primary antidia rrilNl in glfllient in lomotil is diphenox)'late. LiR other apioids, diplltnoxylat~ slows peristalsis, lilowing iiIIII' for additional Witer ~d[).
wrptionhom th~ (olon nd mo~ solid stools. k 1m within 45 10 60 minute .1t
is ~ffKtiY<" for roodtrate 10 !tW'~ dia~a, but is oot Je(omllll'fld!,d for children. ~ atropiot in lomoti Iis oot added for its antKholinl'r9K ~fle(\. but 10 disCOUr.lgt patitnts from taking too m!Kh of th~ drug. At higher dos& tilt
dntic:holiJlfrgic: ff1fcts of atropiot may be obs~rnd, which ilKlude dra.vsinel,
dry mouth, and t.Kh,urdia.Diphrnoxylal~ is discontinutd as lOOn as tht diarrh~lsymptoms r!'SOI\\".

ADVERSE EFFECTS
Unlike most opioids,diplltnoxylal~ has 00 analgesic: proptni... and has an ntr~lIII'~ low pottntial foe abu~.Thedrug is'MlltoltruM at normal dous.Som~
palitnu apffiffi(~ diuines 01' drowsinffi, and t~ should oot driY<" 01' opt<ate muhilltr)' until tht ~fcts of tilt drug a~ known.
Contraindications; Contraindications include hypt~~tivity to th~ drug, s~
Vl'~ ~W'r distil~, obstructiW' jaundic:~, se'ItrI' dth)d ration or ~lKtrolyte imbalanc:~, narrow angl!> glaucoma, and dianhN aooc:iat~ with psrudollll' mbranous
wlitis.

ADMINISTRATION ALERT

l)ug-Drug;~pIIfnoxyIatt with atropint inlecam with oihlor (!j, dfpces~

including akdlol, to prodUCt id!i1iH Ifdaticn I'I!Ien IikM with MAO m tftm,
tiphrnol)lalt may cause hy)l@Hensiwai\is.

If administ~ring to )'lung childrrn, mNsurr tilt drug murately by using

tilt dropper !)ickaged with th~ liq,Jid form of th~ drug.
Plf9r1ancy category C

INTERACTIONS

LabTests; Ilipbrnox)lalt with atropilll' may iKmsIo ~um Mn)lalol'.

IkorballFood; Unknown

PHARMACOKINETICS
()twt 45-60 min

PmU h
Halfliff;H h
Duration; l-4 h

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Treatment ofllverdose; Dwd_with Lomotil may lit ltI'ious.Narrotic:i1ntagonim S!Kh as naloJ:on~ may readministl'rM par~nttrjl~ to rtVl'rII' rrspiruory
~prrssion within minute.
Rdtr IIIMyN/n1ngll (ora tmlniJl're\lFI/j~ IOI!ri! d'ug.

''''''lfr 41 Drug; (Of Bowel Olsoro..fS ,00 Otl>l'f Gamolm",Hn. 1Conditions

TREATING THE DIVERSE PATIENT

Cultural Remedies for Diarrhea

I!eaIu marrhl'a is in agMId rubdjo that afftds all pojUations, dilfmnt~
lIftS hiYr ~ed 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 wal\'r.Fortenturrs.lIIOthr~ ha'II' boiled rUand
giYrn the dikrted rU ~ttr to babits to ftat dianhea.1hI' riliJna~ bthiKI these
two thera~ is thatthl'y...m by absorbing mes Wiltr in the i~1IfI, thus
stoppilg the dianhea.AIthrugh a rationa~ wu not ~ifitd il NrlitrtimfS, propie Ii mall)' aftes frond mat NO"l grilted applt that had turned bruNn allMaI\'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 ~nt 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 G I
flora following a serious diarrhea episode.

41.6 Pharmacotherapy
of Inflammatory Bowel Disease
and Irritable Bowel Syndrome
lnflammat~ bO'M'Idiseall! (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 condition is often characterized by alternating periods of remission 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 abdominal pain, cramping, and diarrhea, which may have been present 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, methylprednisolone, or hydrocortisone are used in more persistent
cases. Particularly sewre disease may require immunosuppressant ~ SIKh as :rzathioprine (lmuran ) or methotrexate
{MIX). lnfliximab (Rem.icade) is a monoclonal antibody approved for Crohn's disease and ulceratiw colitis. A single infusion 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 interesting properties that allow it to be used as a first-line ther-

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625

apy for IBD. Entocort-EC is encapsulated to prevent signific..nt absorption in the stomach or duodenwn. The drug is
released slowly and reaches a high concentration in the terminal 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 antiinflammatory effect. In addition, when it is absorbed,
bu desonide is almost entirely removed by first-pass metabolism 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 pharmacotherapy of lBD. The tumor necrosis factor (TNF) inhibitor infliximab ( ~miaJde) 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. ~cently, a pegylated TNF inhibitor, certolizumab pegol (Cimzia), was approved that offers dosing
at 2- to 4-week intervals. Natalizumab (Tysabri), a drug previou>ly approved for multiple sclerosis, was approved for
treating Crohn's disease in 2008. The biologic therapies are
ex pensive and patients experience a much higher rate of serious infections due to their immwlOsupprer.sive actions.
Biologic therapies are currently recommended onl)" when
corticosteroid therapy is unable to control symptoms.
lrritabl ~ 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 diarrhea 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
im~ired without the presence of detectable organic disease.
It is not a precursor of more serious disease. Stress is often a
p recipitating factor along with dietary factors.
Drugs used to treat IBS do not alter the course of the disease 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
p rovide symptomatic relief for some patients include alosetron ( Lotronex), dig.domine (Bentyl), and hyosCYJmine
(Anaspaz, others). Tegaser<XI (Zelnorm) was once cOn<;idered a prototype drug for IBS but the United States and
Canada have suspended marketing of the drug due to the potential 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

is an unpleasant, subjective sensation that is accompanied by weakness, diapho resis, and hyperproduction of
saliva. It is sometimes accompanied by dizziness. Intense
nausea often leads to vomiting, or ~m~~s.

NaUIO!!l

"

"

NURSING PROCESS FOCUS

PATIENTS RECEIVING DRUG THERAPY FOR BOWEl DISORDERS

(CONSTIPATlON, DIARRHEA, IRRITABLE BOWEl SYNDROME)

Asseu ment

Pote ntial Nursing Diagn ose 5

Buelifte .ssen mut prior to admin istrat 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. \ ~tic, Of
It'II.Il dileolSt;pmJMoln(J;or bll'olSIAffding.Obt.Jio a dOl9Mtory inWding
.Iltrg~wm'nt pmuiption and OK drugs, htfb.al pltpolrations,uiffilll',
nil:01int,ind akollol IM.at .Ilert to possible drug inlt~tioM.
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 as~t (t.9-, ~I sooods, fi~~ disttntion,
prtstnct of tende-ntssL

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)

Aslessmtnt throughollt . chninistration:

AsSHS fat- dts~ thtrape~tic effts (t.g.,~.tt 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,lnd hepatil: Ind ll'IIal
funaion labs as .Ippropriatt.
~sforad-.mrefftds:RaIJIN,wmiting,d'loInhu.CD~ion,~
drowsiness, ind dizziMU. 5Mrt abdomillil pain, CDffft-lJOJnd or bloody
YOmit~Of!mod II stool orlirTYstoob shoYld be rtpOrted immtdiittly.
Planning: Patient Goals lind Expected Outcomes

The patient will:

up'rifnu thef<ipeutic rifern {e.g., ~rn 10 moll! norm.l ~ of elimillition,nolrOil 11001 voIumt and tonsistency}.
Befrt~ from,Of ~~ minimal,ilcM!w efkotts.
VerlIalizf anuodmtanding of tIw, drug's1M, a.:Iw!w tffKn.ilnd ~irtd prtuutioos.
IlfmDnltr.l1f prop'r stIf-adminiitration of the ~tion (t.9-,dOlf, timing, whm to notify p!tI'ridfr).
Impiementlltion
Interve n tio n 5 a nd (Ration. le sj

Patient a n d Fa mily Ed u cat io n

E.lurin g theril ptlltic effectl;

Ifa ~ (jU~ 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 Iiother lJIdfrtying OJIlditions

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..
nh alinftDns,~ttIkidOf6btrintakt,wm,Ofstdtm.ry~
=""
=I'-I-.,..._ _ _...,._...,._~

En<oufil~ appropril.te lifesty\t dlinqes. Hm the pltifnt kttp it diiIY

noting CDITI'btionl be!\ftfn symptoms and foods, btftri9f'l, IIJf\!, Of
~os. {El1IIIring ~tt .moufIls of daiy ftuidl and dittary fibet
.nd inOfiSing olCtiYity ~ i1Ssisu in encou raging normal ptriSlib:
activity. Smoting and lko~oI (/Sf i kel' norm.1peristalsis and shoold be
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 guicitlines.Oo not iJdmioisltr lautiYrs ff

bowel obstruction iI possiblt.Oo not adminisitf inticflolrrhtaldl1lCJ! if
inftion ii possible. (Ciuidltlints boatt mil:ing, fluid intakt.Of
.dminisllering with meals should be followed. If bowel sounds 'II!
hnmctiYf or ilb~"tcoosuk tht htalth CIII! plIl't'iOO befort idministtring
thtdrug.lf ink1:tion is ~si*(HJIe of dianht ., ccmult withthe IINlth
( .lit' pro<WicH,r befort giWlg .ntidianhN Idrugs IlruUlt cItm.ntd
ptrirulsi! II1oJ)' giw tile inftaion the opponuniry to ~.nd SPll'ilcU

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Encoufil9t t!If pnitm IW) adopt iI heiltlty &t)W ofiocmse<i dieQry

mlrr and fluid imale. iKrmed iMil" of YD!Jl" ,1nd txidopIilll'
(l)fltaining foods, ItIl'SS II\aIIoIgfmtnt te<hniqlltS, illOfasfd tRfCist,and
limiltd Of elimin.ted .kohol consumption ind smoting.Pn!1'idt for
dittitian comukition Of information on smoking crswtion PI'09UrTl'S . s
~d.

Tt adl the p.aOOlto t." tilt drug following appropriatt guKlt~nes or

label dim:t ions, pa rtirularfy for any add~iol\i Ilklid inQir.t Ifquiml, for
btltll!Wlts.
InstllKt the patient tlli! dilnflt. or cOIIstipation ilssociatfd with
increasing n'(/Sfa or yomiMg,tspKUl~ if i(cOlllpanied by .bdominal
pain, should be Il'pOrted to the hu lthcart prtMder WOIt' liking dIug.

(""'lfr 41 Drug' for Bowel Olsorder nd Othef G:onrDl"te<Hn.1 CDl\d1l1om

NURSING PROCESS FOCUS

PATIENTS RECEIVING DRUG THERAPY FOR BOWEL DISORDERS

(CONSTIPATION, DIARRHEA,. IRRITABLE BOWEL SYNDROME) (Conllnued)

Implementation

Inte rventi o ns and (Rati o nale s)

Patient a nd Fa mily Educati o n

Minimizing ad'ftrle effrcts:

ContinU!' to monitor abdominal"~lSlIII'm findings.Any signirlC.lnl
in(JNS~ or dK~' ~ in boJwd !OUnd"or n~worut or inc~.~ in discomfort
or pain YIould ~ ~pon~d promptly. (Any ,ignifiunt chan~ in ~I
!GUnd auivity or inmalfd discomfon or pain may .ignal tiMo deffiopmtm
of WOMning ~ d~..eorof ad'll'fU drug ~flemJ

Te.ch the p;ltitnt that some using of discomfort ~lated 10 constipation or

dianhr. rna)' be noticed soon after beginning drug thmp)' but t~ full
effect; may lallt s~~ral tb)'l or longer. If gillric diKomfort or pain
(ontinU!' or WOI1ffl, tilt lItalth,,~ pro'lider ,hould ~ notified.
Tea{h tht p.;Ititnt that se~~ abdominal p.in or any blood in ellll'lis or
!!ools 5hou1d ~ ~poned immtdialely to tilt hrakh,,~ pftll/ider.

Monitorfor an, 1f'Ien' abdominal pain, wmitilMj,rofl~ground or bloody

fflI!"Sis, or blood in Slool or t.my stook. (~~ abdominal pain or blood in
em!"Sis or Slook may indicale a wm~ning of diINs~ or mo~ miolJl
conditions ~ nd should be I"!pontd immediatelyJ

Ensu~ patitm!.I/ety, especially in older .dults. OillerYe for dininm and

monitor ambulation unlil tiMo ~Kt; of the drug a~ known.Obtlin
~roI)'Ie leYels if diuines, conlinUl'l.(Drowsifll'Sl ordiuiness from
opiojd..~!td or rNt~ .ntidiarrbNls mayour and ilKrN~ thr rille of
falk.Continued dizziness may indicate eler:trolyte imbaLlIK~.)

InstllKt th~ palil-mto "II for ' lSistan~ 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' u ~, .wid driYing or other miYi1ies
lfqUiring memal a!trtnes, or physic.i lcoordin.nion until lilt effK1S of lilt
drug a~ koown.
InstllKtth~

patil-mon tilt I"ftd to return pModic.11y for lolb woll

ContinU!' to monitor ptriodic hepatic and renal fUnction t6 t>,and

elearolyte Imls as ~.(Aboonnallrm function l!"Sts may indic.ill'
dfll9""ind!Ktd adY!'~ IItpalic t ffecK Exc!"Ssi'l~ Ull' of la.utim or
(ominued diarrhN may affKt eler:trolyte !t~k.)

Monitor'lital sign~ partirul<llly ~spir.l!ory rate. nd depth, on palil-m,

taking opioid or opiojd..rrIattd df1191. (Opioids may dK~. ~ rHpiratory r<lle
and depth.lntervention with n.notic.flIi9Onim may ~ nffilrd if
o~rdoll' OCQJrs.)

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.

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 u~ Pl(lllider,.nd any f1K!"sSiry monitorilg or prKolutions.(Using time
durilg 1MJ~i1g call' htlps tooplin~ and mnforc~ key teaching.~asJ
Patient selfadministration of drug thtrilpy.
Whl-n administ~ing th~ 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 tfftd~ness of tht

,,,,,I

Th~ pilil-nt, family,orwtg~r should lit i b!t to ,tall' tilt ~'lOn for tht
drug; appro pRatr dose nd scheduling; whllt adYfr~ effects to oblerie for
and when to II'port; .J nd the antici pattd length of medication tiMorap)'.

Te.{h th~ p;ltitmon 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 day.ln(ft'~ tht inlallt of dietary fi~r.
Excffiling l!rommmded doseor frequenl LlxaliY!' 1M inc~i ll'S tiMo
risk of ad Y!'fIf .nd dec~'1l'I oonnal peristalsis oyrr tim~, !"!Suiting in
' Iwti'lr depl'ndence:
Bulkfurrrrirrg Lo..(j .... :M,"a~'''rrr.,.j .... tiom 1huur ~Iul!'" 2lraurs
after thr LlxatiY!'.Powdrrro formulations should ~ mil:rd with a fUll
glm ofliqJid and immtdiately taken,loIlowfd by an idditional fUll
glill ofliqJid. Powders should nMI ~ swallowfd dl)' or l'IOphllgeal
ob>lllKtion may result.
Millffill oillaxatiY!'l:Do not take n nausea is p~m .nd do oot tallt at
bedtime to aYoid tiMo pos~bility of .. piralion.

Evaluation of Outcome Criteria

Evaluatr tht rffectiYeflt!s of drug thmpy bjo ronfinning that tilt patitnt gails and ~lpl'd~ outcome haY!' ~n IIII't (~'PLInning1.
5H TabIt5 H ll111d 41.1 ku I5t ofdrugI/O M1id! thtse fIIIffig oem oppIy.

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62 8

Unlt7 The G. sUoInt",tlnal 5ys!,-,",

.... Prototype Drug

I Sulfasalazlne (Azulfidine)

Therape utic ( lass: Drug for inflammatory bowel disease

Phannacologic ( lass: 5-aminosalkylate, sulfonamide

ACTIONS AND USES

ADVERSE EFFECTS

Sulfualazinr is ~ nora Idrug with ant~infla mmatol)' propertits that is approYed

10 11m mild to modtratt symptoms of ukm~ colitis. SulfiIS.Jlari~ is wd
off-Ia~ to tR'at CroIln's diswt.1t is approYf<l asan altemn~drug in tilt pharm~colhtrap)' of rhtumatoid ~rthrilis 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(t~ metabolitts.O~ ofth6t metabolitt-s,mtlalamint (Asil(o~(aoa.S.J,otllt~),
is availab~ .nan IBS drug.

The most frt~t ~d~ efiKtl of suHasalaziot aR' GI-R'lated: nausea, rom
iting. dianbtJ, dyspepsia, and abdominal pain. DiYidi09 tht total daily dOlt
tvl'nly throughout tilt day and using the entericooattd labirn may impro~
adlltR'OU'. Hrad,ullt is common. Blood dyscrasia! occur infreqUtrltly dJri09
thera~.Skin rash",art R'lat~1y common and may ~ a sign of a mort I!'rious
a~~ efFIsuch u 5tewns- bhnsoo syndromt. The drug may impair mJit
fMility, which revmtI when tht dlllC) is discoolirAlfd. SuHasalaziot (in caust
photostnsitMI)'.
Contraindications: SuHaS.Jlazi~ is ooMraindiuted in patient! with sulfon
amide c.- salicylate (a Ipirin or S-ASJ,) hyptntrllitiYity. Patient! with plH'urung
J ntmia, folatt,or othtr htrn~tologic disordm should uIt tilt drug with (iutian
btcau I!' it may wontrl blood dyscrasia!. Sulfasalazint should be ustd with (iUtion in patients with IItpatic impairmtM btcaust tht drug (in (iUSt IItpalo\OJicity.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 !U1f~ wlazint with (iutian
btcaultthe drug can incR'ut insulin I!'crrtion and worwo hypoglyctmia.

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

Ptak:15~h
Ha lf li~:5- lOh

Durati on:5- 10h

INTERACTIONS
t:rug.Drug: SlililSaWiM IOa1 'M)I';I'n bcrw IllimlW IUppmion cawd by
rnrthourulf and aso R'SUt in ~itivf hfpato!~~. Ab:Iorpiion of digoxi1 1Oa1 bt
dPcR'a\.td. ~ can displacr warfarin film its p-Olein ~nd~ ~eI, IiII11i1g
iOONlfd anocoaojlNnt tIKI!.
Lab T~ts: 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.

41.7 Pathophysiology of Naus ea

and Vomiting
Vomiting is a defense mechanism used by the body to rid it~
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 chtmolKtptc.-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 lreatmen t 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, cha n ges 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

LibraryPirate

abdominal organs, inner ear disorders, and diabetes. Psychologic factors playa significant role, as patients often become 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 oontinual vomiting, it may lead 10 hyperemesis8r1lvidarum,a situation in which the health and safety of the mother and
developing baby can become compromised. Pharmacotherapy is initimed after other antinausea measures have proved
ineffective.
Nausea and vomiting are the most frequently listed adwrseeffects for oral medications. The nurse should remember 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 antineo p lastic 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 tmetogtni c potential. Nausea and
vomiting is a common reason for patients' bckof adherence

("",If,41

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'
c~use~ ch~n8e 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 dangerous 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 ~nli~m~ti<> are available to I,",,~I n~usca and
vomiting. Selection of a particular agent depends on the experience of the health care provider and Iht' cause of the
nausea and vomiting. Patients seeking self-treatment can
fmd seVt'r~1 options ~vail~ble OTe For example, simple
nausea and vomiting is sometimes relieved by antacids or
diphenhydramine (Benadryl). Herbal options include peppermint and ginger, the most popular herbal therapy for
nausea and vomiting. Relief of serious nausea or vomiting,
however, requires prescription medications. Patients receiving 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 procedures. They art' usually given prophylactically, just prior to
antineoplastic therapy. IV, oral, and transdermal patch
forms are available.

Drug. for 80wel Disorder, and Otl>ef Gm ,oIntesHn .1 Condition,

629

nausea. The most common drug used for motion sickness

is scopolamine (Transderm Scop), which is usually administered as a transdermal patch. Antihistamines such as dimt'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 treating psychoses (chapter 17010 ), but they are also very effective 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 suppository 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 potential for serious adverse effects.

Other Antiemetics
Aprepitant (Emend ) is the first of a new class of antit'metics, 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 properties. 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 controlled drugs.
On some occasions, it is desirable to srimulatetht' vomiting reflex with drugs called em~ics. Indications for emetics
include ingestion of poisons and owrdoses of oral drugs.
Ip"~~<, ,ymp, giv~n ur.dly, ur ~puII1urphin", giv"n ,ub<.ul~
neously, will induce vomiting in about 15 minutes.

OBESITY
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

LibraryPirate

Obesity is a growing epidemic in the United States: II is estimated 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.

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

qdlit~(Marui~ )

PO; SO mg f'I!'rY .~ h (max:lOO mgfday)

dimmhydrinatt (ilramamint, othffi)

PO; 50-100 mg f'I~ 4-6 h(mn: 400 mglday)

diphmtl)'i"amilH' (Btoadryl,OIhm) (~
(Ii9C m for III!: ProtOl)'pC: Drug IJoxOOj

PO; 25--SO mg lid-qi d (mn: 300 mglday)

"'dfOX)'li~ (Ataru, Vimnl)

PO;25--loo mg lid-qid

,,",dli~(An~'Ifft, Broil~OIhm)

PO;25--SO mgldolY, taenl h btfo!! trav!l (mu:SO mglda,)

KopoiamiM (HyoIcint, Transdmn-Scop)

Transdmnal piltdl;O.' mg f'I~ 72 h

DlIIWlifl6~ dry meuth, bltJrrtd rilkI!

(!liCfIOIomiMJ
H'!IItIXOIiti'l~yru(\ion ICdatiQl). IrtmOf\
!!i&ur!j, hallu(iIa!mm.1!!!oooxiuJl ~)[(~ation
ImO!! (ammon in d1ihRnl.hypo!~nIiQl)

BENZODIAZEPINE
knlfpilm (Ati'l~) (~pilg!' 158 for tilt
Protot)'Jlt Drug boJ:OO)

IV; 1- 1.5 mg prior to dImIothtraP'f

lJzzjnm,d~lII<Di4 ~/igrIf,wrrrd5pM1l

~(jlDiI:ii(XliIillillD (1DIIIl: <mmOII ill dlilliml

Ifizu~ (If abw1fy(bamtiMdl.(OO\j

CANNABINOIDS
drooabilol (Marinol)

po;, mglrn' 1- 3 h bffO!! admini5b'ation of dItmothffiP'f

(m.u:15mg1m')

Dilmm" dlllWlinru, tlJjIhorio" (onfrJ5io~, QroJi4

nabilon ~ ((~m~)

PO; 1-2 mg bid

Pjra!!!y' !i!!;:al'altd moIor (ooroila1im

I1HhlDo,~lmSOryQWQrmm

""""'"

CORTICOSTEROIDS
dex.imt1ha1oot (DeYdron)

PO;O.l5-4mgbid-qid

""'thyl~drisolone (Medro!. SoIu-Mtdrd.

PO;4-48 mglday in dil'idtd dolt!

Mood~ wtighr~ Oml, frKi<lllWi~

OIhfn)

II<IU5f4 imomfia, wdium rnJ IIuid rrrtllfioo,

rnpoUdwormdhf06l1g,mtmffiJol
I1boomrQ/irits,irn:mnio
!'Wi!: u~r.hyplK.ll(tmia.ostNQ9l1l5i! with
~Ol~~~ I!!!:!!lloour~ Iosl of mm mas~
dl'W'il!'d!lOW!h jn dtUdrro ool'jjblr milkjng

NEUROKININ RECEPTOR ANTAGONIST

aprrptant (Emmel)

PO; US mgl h prior to dlmlOlhtrapy

Fati~ID~5lipofion,dilrrl!to"Q~ rnlUlf4

hkrup

t!d!!dratioo. oo!RIlrnIIlNOO!\m. !;!!ood

dl'l(la~a~ p!IN!Ionia

PHENOTHIAZINE AND PHENOTHIAZINELlKE

m<:todopromidc: (R<?i>n,othc:,,1

PO; 2 mg~ 1 h prior to chrmothc:f.py

perphtrwi~ (Phmilint, Tnlafon)

PO;8-16mgbid~id

prodtlorptruilt l(ompil1i~)

PO; 5- 10 mg lid-cjd

proolfIllil:iM (Phmtrgal,othm)

""",m.

Dry tyt>, bIomrd rilim, dry

(J)l1lliporkl\. drt:ltlt'IifH'J5, p/IolO5RlHiriYiry

E!;tral!):ramidal !)'!!!R!!!!!Th!m!~!k
maiiooant syJI!tpm!: aqilOuosytosis

PO; 12.,- 15 mg ~~ry 4 hqid

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 IIK~ 10 mil prior to chtrrothfrap)'

IlvIrIri!bmjaj QmqrumjdalwmptQmj

TrilO500mal pilldt: 1 paldt 1448 h prior to dlmlOlhtrap)'

G/ldinsron (Zolrin)

PO;(mg~dpm

IV; 31 mg Ii,,* dose orlhrte O. I, mgItg dose 30 miMe prior

to dItmothtriP'f
palOIIO!CIron (Aloxi)

PO;05 mg 1in9~ tIo~ I h priorto dttmothtrapy

IV;OlS mg 30 mil priortodttmothtraP'f

Ito/it< irodicou <OIIIrMn ~ .t'f.ct<;.!II!IaIiIiDg,lrodicot.. ..nou. adwr"

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""'<t<.

1ItoiIocM,~~ faligut,lDmripo~on,

(""'lfr 41 Drug' for 80wel Disorders and 0I1>et Ganrolme<Hn .1 Condition,

~ Prototype Drug

63 1

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 pr!'S<rib~d for !>Sy.
d,oltS. The pheoothiazi~ 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 do~mint rt<tpton in
the brJin, which inhibiu signals to th~ vomiting (fmfr in tht medulla.A. an
<I ntiemetk. it is ~Ul'OtI)' g~o by the rmlllllUtf, wOOe absorption is rapid. It
is .110 milablt in table~ Htended-relta.t (,Jp\U~.nd 1M formulations.
ADMINISTRATION ALERTS
Administ~r 2 houn btfoll' or aft~r antacid! and .ntidia""~als .
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 genetic, lifestyle, and physiologic factors. In a fewC<lses, weight
gain can be attributed to mediC<l1 conditions, the most common being hypothyroidism. Certain rare disorders of the
hypothalamus can also cause overeating. Drugs such as oorticosteroids are clearly causes of weight gain.
Lifestyle choices playa key role in the development of
obesity, the two most obvious factors being diet and physical activity. The fundamental shift in obesity levels in the
past three decades has likely been due to high-fat, caloriedense diets combined with less physically active lifestyles.
Despite an ongoing debate on the "best~ diet, the fact remains 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 imbalance 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

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ADVERSE EFFECTS
Proc:hlorpmzint prodlKtS doIt-lt"Iated antic:holilK'rgic: side efftru wc:h .. dry
mouth, sed.nion, (on ,tipation, orthostatic hypotrnlion, and tac:hyu rdw. Wllto
UIfd for prolonged periods at higher dole, extr.pyramidal symptOllll ~m
bling thOlt of Parkinson', distalt all' <I SfriotK Olll(t m.
Contraindications: Thisdrug mould not beUlfd in patientswith hypt~miY
it)' to phenothiazi~, in (omatolf p.tients, or in tilt prtIfII(f of profound CNS
depIl'Ilion.h is allorontraindiuted in(hiidren )'OUogerthan age 2orwrighiog
lei thin 20 lb. Patients with narrow-angle glalKOma, balK' marrow Illppmsion,or ~ hepatic orcan:li imp-aifOlfnt lhoold oot t.~ 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 ~erdlarbitat mttaboIiIm of p-odiIorpKazilf ~
inoNIfcLiM with tricydI: arlid@prrnanumayp-Olixtifl(rNlfdilltidiolinflgir:
.-.:IlIypoteflli'll' fflKII.
li biests:Untnown

HerbillFood: Unknown
TfNlmem ofOvtrdose:Overdose mavresuk in seriousCNSdefjlffiiM and ex
trapyramidal signl. Patienu m<ly be tll'~ted 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 entire 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 (ca rbohydrates, proteins, or lipids) does not matter. Of course, the source is indeed important in terms of overall health and wellness.
Hunger occurs when the hypothalamus reoognizes the levelsof 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, people often eat not because they are e:q'eriencing hunger but because 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 modest results and should be taken for only a few months. For
someone who needs to Lose 25 or more pounds, nonpharmacologic strategies must be employed. Secondly, maintaining 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 essential to losing weight and maintaining optimum weight.

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIEMETIC DRUG THERAPY

Asse ssment

Potential Nursing Diagnoses

Bilstlin e assess mf nt prior to administrati on:

Under>tlnd the ~,I!on the drug has betn pre(ribed in onIer to as~ for
therapMK tffrm.
Obtlin a complete heakh history indudi ng GI, wdioYascula ~ h~p-atic. or renal
d~m; pregnancy;or bll'ot-fr~ding.Obtain a drug histOl)' including
al~rgies, rufTl'm prf"l(ription and OK drug~ herbal preparations, (aff~ine,
nicotine,.nd akohol ulC.B~ tileR 10 ~ible drug int~OOioru.
Obtain ba~line ~ht 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., ~IIOUnds, finn~~distemion,
preell(e of tmdernrss).
As~ l'mfIis for amoun~ (oIor, and pIl'lmCfofblood.

Dl'fic~m FluidVolumt (~lated to 'fOIlliting)

Dl'lKitm KMW~~ (drug th~r.!py)
Risk for In~ry, Falls (~lated to dizzi~~adY!'~ drug effects)

Assessment through out administ ration:

Aslffi for desired therapeutic ~ffteU (e.g., nalllN is dtclNml, no vomiting
pre~m. able to to~ritf 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 pat~nt.
Monitor vitilsigns,fIp!'(ially blood plffiU~ and pu~,and IfIIOIl ill)'
hypotension ormhyurdia to the health (ilft' provider.
ContinlH' periodic monitoring of abdominal iII~>Smtnt 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, drowsintl~ diuiflfl5,dry mooth, blurred
ision, and fatiglH'.(ontirued wmiting. M'I'M' na!Ma,~is with blood
preemor (O~""9round appearan(f, h)"pOteMion, Udl)'GIrdia, or ronfusion
should be replned imm~diattly.
Planning: Patient Goa ls and Expecte d Outco mes
The ~tiffit will:
u:pe~lI(f 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).
Imple me ntatio n
Interve nti o ns a nd (Ratio na les)

Pati e nt a nd Fam ily Edu cat io n

En suring tht rilpeut ic effeds:

If ~ definitiY!' (a!Mfor the ru~m symptomlcan bt identified (e.g.,
inftetion, i.Ml1fdrug effKh),cOlTf(\ theUUl~ whe~ possible. (HallIN
and yomiting afl' often symptoms ofotherunderlying conditions sud! is
~d-;e~ drug tifl'(1\ or inffuiorn.)

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 ill(~i5f naUM'a orvomiting.

Encou.a wall alllOllltoffluih orKed!Pland dtcft'illitgac:tivity 1M! whit

naull'ated; eimitatilg akohoI il1ake, smoking ~ion, alii iKIwiIg intake of
~ and <l'iOOpIrius-<OOtaining foods after nauII'~ has (faled. (~
inteM'ntionIlIIi)' help fiIIe S)'lllptOllll rurilg Ihl' awte phu. Ensuring
idtqwte a~ oflkids, including intril"'llOUs flWs ijnflSilry, will ~
m.JiltJin tI oomuilluid bai<nre. SnJJking tlnd oIkoho1 tile (atI\f gastril: irritation.)

Encooragt the patiem to limit ph)'siullllO'/emtnt or ac:tivity ruring periods

of iMe IIiIlMii or vomiting. Enrouragf inmasing fluid imakegraduali'/, with
Kf (hipsor Imalisipsofwater.Ginger a~ may au al a naMal antinaulu
iltvtr'ge and may bt p-alaub~ for some p-at~nu.

Adminiltff ant~mtliu 11) to 60 minutf"l btfo~ anticip-ated nauseaindlKing

tr.!~1 or drug adminillr.!tion (f.g., d!tmother.ipy). Ensu~ adequate
hydruion priorto theOll\et of anticipated naUl~a. (Ant~mtOO aft' most
effK1iW'when taken btfo~ naulN O(rurs.ElllUring adequate pre/l)'dration
dtcft'asel the rilkof dehydration should wmiting O(rur.)

Teac:h the patient to take the il ntiffnetic btfo~ tra~1 ij IIiIlIIN iI antici~ted.
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 pat~nt on i\homl'(hl'm01heril py to take antiemeUa prior to
dtemotheraP\' dost or routintly al ordtrrd b)' the heahh (ilft' provider.

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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 pub~. l.b blood
prenul1' Iyinq. mting..md sundinglo&tat onhost.tic IIypottlllion.8t
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 h,po(flllion.wholi~ iWltiMtilllints, and
phrnolllW:inr or phenothiazi~kt dnqs may .w.cIt<l'I"~ blood

Tu(1I t!Ie ~nl to rise!ll)llllying 01 sittin9 to SIIoding slowly to l'IOid

diuinlssorAlb.

PIl!SIUI1'..)

ContinUt to rnonitor . bdomirwl olIltSSment findillgs.lmmi!diattly ftport

.oy signifi{;WI\ illm'.~or cit<I1'.~ in bowft sooodl,.distfl'ltion,. nrw on~
or Ull!ollt in dinornfort or pain,!oMrt abdomirwl p.lin,orvomiting t!wlt is
mffM-ground in HI~tf ncy or (onuins blood. (lncltiSing or !tI'fft
.bdomillill piin or blood in tm~ may inootf j WOfSfI'Iing of dist.stJ

Tudr t!Ie ~nt to report any intreolling ~strit discomfort or pain.

11IItnK1 the pat~t l!wIt ~re .bdomillill pain or ill)' blood in tmnis
should br I1'IIOrttd immediately to dre hNlth {~p~.

InstnKt the patitnt to all lor uSist'lKt priorto gttting out of btd or
atttmpting to wi11k .1oM if dizziness Of drow~nts.I 0111'. PJOYide iWI
tmts.is hilin neilby.m homt Ust,awid driYing or other .tMties
rtqIIiring lllfIIul.lfrtnns Of ~ coordination untillllf rlffru of tltf
drugomknown.

n1Uft p.ltiMt saftt); ~lIy in oldtf aduh ObstM fdizziMss and

monitor .mbulation until th! tflects of the drug .ft known. lIl1iin
~learolytt IMIs if diuintss (ooonufS. (DfO'NIiness Of dizziness from
&hydrltion or from .dvtrst drug cfftm ~y occur .nd Urt.1tS tht risk of
falb.Cootinutd diuinrss may indiurteleruolytt imbalana and tltmolJte
Itftk should bt asltSStd.)

CorItinUt to monitor ptriodic duo/ytt,gUost 1tvtb..IId hepatic IIld

1m.1 function rtll1 n netdtd.(loss of tltruulytrs IIIiI'f ocrurwith ~re
vomiting.Abnormalliwr flllKtion ttll1may india~ drug.i~ advtnot

1nstfU(t tire pat~t on thr nw:Ilor labwort

hep.ltic~)

MorWtor inukr <lnd output in thr hospitalizrd p.Jtitnt.lnitiatt IV IUd

rtp/M:rmflltwhtn indiatm Hold oral fluids unti aUrll! IIOmiting hll
(tast<! .nd then graduily Urt'!e IUd inub, beginning with smaisips of
Wittror itt chips. (Continuing olil inlalt IN, WOI1m IIiIlIsta iWld 'IOflIiling.
Grl~oIIy resuming fluids will for hydr~ion without stimulating
llilW'a.1V lIuid replic:ml!'nt may lit lequiml iflluid loss h<lslftn ~
and deIr)ldration prtIfIIl)

ImlnKt tire patifllt on thr netd to MthOOlcl tUds.wl food until vomitin9
h.s cused.fnitiatt illm'nk'IItal Ul1'aItS in intalt ~inning with srlliln
sips of wale. and dtit lIuids.
EqlIiin thr r.tiollillf lor illY IV hydrilion lequiftd and IllY equipmtnt

"""

Mth tht hellth (IR' pnwidti: (AllmJatM IntillillM. mtolIUII!S should bt

used 10 t.I!e nausea when possiblt.Tht drug's pltgnancy diss and
prt1jIUMY trimtSttl will bt mMldertd b, Ih~ he.1th WI! proWIel befort
prtl(ribingJ

Iftht p.lUfI'It is prt1jIlilnt.Of if prt1j1lil1'q is suspt(rtd. tt iJdr t!Ie patient to

(0fISU~ with tire htllth care p~ btfOft' tlking Ill)' antitmrtic: drug ilr
morning sickness.
EI'I(OIJ~ thr useof AOI'Idrug _
SU(h as dry and UflSWtttfl'li!d
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
.SItSSmfntslO discuss thr fuiollillf for drug thera~ desirltd therapeutic
outtOOlts, most common <Idverw tfftos, p.lramtters for wilen to aD the
helrth eM!' prtJYicIt~ and <I oy nt(tlliry monitoring or prtUutions. liking
timt during nu~ng WI! helps tooptimizt and ftinfortt kry ttM:hing

The patient. fimil1.or calegiftr should lit able 10 mtt the reuon for the
drug;. ppropriate dose .nd !Chi!duling; 'llftit .eM 1st effu to obstrvt for
and when to reportand the .nticipattd Itngth of mi!diution theraPl'.

If JII1'9I1iI'q is suspt(ttd orconlirmtd, hold thtintitmttic until COflSUIting

.1tiS.)

Patient sdfa~iniltrallion of dl'1lg therapJ:

When adminislt ring the mtdic.Jtion,instnxt tht ~~ Amil1.or
Ciltgil'fr in tht proptt stif-administllltion of the drug.t.g.. tal:l!n with
sips of 1'lJid. (Proptr administration intl!astI the efttctiwntss of t!Ie
d...J

sma.

Tilt patient .nd flmily or tiI1'g~ are ,blf 10 disarss ,ppropMe dosing
alld administr"ion IIfflk.

Evaluation of Outcome Criteria

Ewlua~ t!Ie tffKtivtnts.! of drug drtraPl' Il, confirming tht tht

Stt' TtIbIt4U ~.isl.1trNp rlllllllichlMtllldtlg~aiIm IfW.

LibraryPirate

p.ltirnt go.k.nd ecptCltd ou\(omt! hll'f IIftn IIItt (Ief "lalll'ling1.

6]4

Unlt7 TheGa,lrolnt..,tI,..1 Sy'tem

Drugs for Obesity

Despite the public's desire for effective drugs to promote
weig ht loss, however, there are few such drugs on the market The approved agents produce only modest results,

41.10 Pharmacotherapy of Obesity

Because of the prevalence of obesity in society and the difficulty most patients experience when following weight reduction plans for extended periods, drug manufacturers have
long sought to develop safe drugs that induce rapid and sustained weight Joss, In the 1970s, amphetamine and dextroamphetamine (De:wdrine) were widely prescribed to
reduce appetite; however, these drugs are addictive and rarely
prescribed forthis purpose today, In the 19905, theoombination of fenfluramine and phenlennine (fen-phen) was
widely prescribed, until fenfluramine was removed from the
market for causing heart valve defects, An
appetile sup pressant, phenylpropanolamine, was removed from the market 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 produce a hmagic pill " to lose weight has indeed been elusive,
Current pharmacologic strategies for weight management 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 -

arc

". Prototype Drug

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 decrease 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 shortterm ~ontroJ of obe..ity, In O~tober 2010, the manufa<:turer
withdrew sibutramine from the market because the drug increased 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, although 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 (BM I) of at least 30 or greater, ora BM I ofl? or greater,
with other risk factors for disease such as hyperlension, hyperlipidemia, or diabetes,

PANCREATIC ENZYMES
The pancr eas secretes essential digestive enzymes: Pancreatic juice contains carboxypeptidase, chymotrypsin, and
trypsin, which are converted 10 their active forms once they

Sibutramine (Mendra)++

Therapeutic (lass: Antiobesityagent;a ppetite suppressant

Pharmacologic Class: Anorexiant;SSRI

ACTIONS AND USES

Sibutlllmine is only oIpprored for lilt trulmenl oIo~i)' when combin~ with
a rmN-u mdietand 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 monthoflhtrapy lfqUil! an inuN,r
in OOS!'ordil(ontinWlion oh he"apy,Sibuuaminr thmpy is not ~ommendtd
for Iongmhn 1 ym,

ADMINISTRATION ALERTS
Allow at Irolst 2WffIu belwel'n dilcontinuing MAO iohibitonand staning
siOOtramine,
Thisdrug is not approwd for !lSI' in patients undtr ige 16.
Pl!ijnancy rnegory (
PHARMACOKINETICS

Onset: Unknown

ADVERSE EFFECTS

Sibutlllmine is gentlllily 'MIl toIera\fd, The most smous aU;tlS!' ~f(ts '~ 01 ninmud risk of strou <I nd III)'OUrdial infaraion. HeadM:ht,coostipali:IO, ifllOmnia,
0100 RIOStomia oI~ tM mon common romplaims reporttd durilg ~butramifll'
thtrapy,Wtight gain may wr <lfter ~butramint ~ d~(OminUfd k ~ a Sditdur
lVdnrgwithlowpolentialfor~,

Contraindications: Sibutramint is (OIllraindiuled in p;ltitnts with eating disordtrs (.J llOmOa III'rvou or bulimiaj.Jnd thole laking MAO inhibiton. Tht drug
!hoold be Ultd "';th ca~ in p;ltitnu with he.Jn diseaS!',dysrhythmias,or ,Iroke
bmu ~ it mayUUlt tadtyurdii.Jnd raist blood prtSlUlI',

INTERACTIONS
I)ug- l)ug: lIstwith ~n,~,and atlH9Y lIIKkation, may<aUSf

.w,.a\ed blood pr~'ilU, ~iOCOIIUdf iIIId erytInrny<in may ilhibit 1M mf~iIm

of Iibw.Ullint, (oocWlI'nt !III' with a lIICIIOiIIIiIf oIidR in~ibitor (MAa) or
1MIi'll' U'I1IIO nin rl'UpiiI:I' inhibitor (,SRI Irna, COlUII' Sfrotonill,oorOlll',

Iflk:Uh

Lab TeslS: tktllOWll

Half~ff: 14-16 h

Ik>rbaVFood:Unknown

Durat ion: Unknown

++ Sibutramint was rentO'ftd from lhe marUl in Oaobtr 2010

Treatment of OverdoIt : Tach)'UrdY and hypenension m.JYII'IUk from omdost, BetNdrene"lic blockers may be administerrd
IWfI llIMyMlIbrgKJrflJf ~ MnlngI'reIJFoo/s~ 101M!tug.

LibraryPirate

(IIIplfr 4t

Thr Qurstion: What<l~ the most effKl:ift Slrilltfgies for prodKing

lustaiord Wl'ight losl?
Thr Study: Tht authon (onrb:ted I)'Itrrnatic: !!'ViM to ~rrminr tyPfI of
Wl'ight-Iou intrrventions that (omribute to thl' mon luarsdiJl
ou\OOIlll'S. Eight typH ofWl'"ight-lolI intt rventions ~ ~:dift
alonr, dift plus r~, mn111' i11lo~, meal repbc:rment~ my..Jowelll'l9Y diets, weight-11m l!Il'dirations (oriistat iIInd libutramiOl'j, and
adYKr alonr.Tht most llJ((Hlful inter/Mtions Mff <I ~u(rd~rOJ)'
die! andlor Wl'ight-Ioll mrdiutioOl.i)Jring thl' first 6 momhl,an
a~rage 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. AdYic:~only and fll'rtM--alonr group! HptritrKed minil1lill
Wl'ight lou.The authors (onduded that the addition ofWl'"ight-101I
medic:ations so~hat enhalKrs Wl'"ight-Io!s maintenantr.
Nursi ng Implicationl: Nu~ 4Iou1d k'ac:h p-atifrrts that drug! (an be UII'd
to enhalKf weight lois, but ttr, mun be (ombinl'd with a Iow~~
diet to be most tfl"KI:ift.
M.11IIru.l
(lOOl).

~~A

CiIJIrr,J.8otK/ttr, llfllorr,1I! ~lBowlH1rr,N. 1'roIrt

~-I. Moolei:A S)1ItmQ/t RPI1twooo Ml'II!-ArnI~ar~-loii

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 disorders, 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 inflammation 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 alcoholism in men. Symptoms of acute pancreatitis present suddenly, often after eating a fatty meal or consuming excessive
amounts of alcohol. The most common symptom is a continuous 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 reduce or neutralize gastric secretions, H ,-receptor blockers
such as cimetidine (Tagamet ) or proton pump inhibitors
such as omeprawle (Prilosec) may be prescribed. To decrease the amount of pancreatic enzymes secreted, carbonic
anhydrase inhibitors such as acetazolamide (Diamox) or

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Drug. fo,OoweI011o,d<'r, aooOlIll'rG. nrolm",,"n . ICoodltlom

635

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. Pancreatic juice is prevented from flowing into the duodenum and
remains in the pancreas to damage cells and cause inflammation. 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 necessitate 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. Opioid analgesics, IV tluids, insulin, and antiemetics may be
necessary. Oral pancreatic enzyme supplementation is often
used in patients with chronic pancreatitis. Pancreatic enzyme supplements such as pancrelipase (Cotazym, Pancrease, others) or pancreatin (Ku-Zyme, Kutrase) help to
digest fats, and prewnt steatorrhea.

L IFESPAN CO NSIDERATIO N S

Psychosocial and Community Impacts

of Alcohol-Related Pancreatitis
Patirnll with ac:Uk' palKlNlitii a~ most often middle aged, <lnd moll' with
chronic palKrwitis a~ rtIMt oll~n in tiltir50! or 601. Patitnl! whost panaeuitil iI moc:iatro with 9'lllstonH II\a)' !fail'!' a diffrlfllt tyPf and amoum of
~ppon from ,ignifitant Olhl'rs, thl' (ommunity, and et'II from nurll'! <IS (ompa~ with thole who ha~ palKlNtitii mowted with akoholilm. NUIIf'
will nerd to eoxaminr thrir f~lingl and anitudl's rNird to akoholism in grnt ral and to patifnt! with akoholiun-a5Soc:ia1ed pancrNIitii in partiwla~ and
will nerd to adopt atlilUdrs to htlp tht p-atifntattain t~atmMt goals.
Patifnt! who abull' akohol often ntfd referral to (ommunity agrlKirs to
I1IiInagr thtir addiction andlor rtI1IiIin in ~ClMry. 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

&

C OMMUNITY CO NSIDERATI O NS

Educating Patients About OTe Medications

for Bowel Disorders, Nausea, and Vomiting
dilorders, Ool!lll'a,and vomiting a~ <l mong thf most common (omplaint! for which palimt! !edc medi(al (onluitation; therrfo~, they a~ also
thf most (ommon (omplainu t~uro 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' ~rf drug-1lrug interactionland adl'!'lIf efi"Ku.MolI of
thrsr OK mrdic:ationl imtrfe~ with thr rnetabolilm of pA'lCl"iplion mrdic:ations and Ihould be UII'd with caution in patient! with Mlarged proltatrs beUUII' thI')o can UU\e life..thrNtening ~a(tions.PatiMu also nerd to be.wa~
thanhrsr orCs can caulr drowsiness and hypotenlion. (.JIdul ro!Koltion iI required 10 that patienll understand that (ontirued!lll' of thHf mrdic:ations
II\a)' mollk a mo~ Ifff~ hl'ahh dilordtr.
~

636

Unlt7 lheGo'ilrolnleStinalsym'm

..... Prototype Drug

Pancrelipase (Cotazym, Pancrease, others)

Therapeutic Class: Pa ncreatic enzymes

Pharmacologic Class: None

ACTIONS AND USES

P'n(l~lip~ romains lipall', ~ 101911', and 'myW of parle origin and is UIfd u
rep1.KrllM'M t/itrap)' for palirnu with illluffkirni pan(lNtK oooinr II'{Ielion~ 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 rlll)'~ m locally in Ihr GIUoKt and arr not absorbrd Panaelipasr is milablr in powder, tablet, and delayfd-~lNsr upsulloformulatiolll.
On an ~ual~hl basis, pilKrrlipall' is mOl"l' paleM lhan palK~uin, with
12Ii1111'S th!o tlll)'mt activity. ~ aIso (omains 011 iea >I four tim~ as muc:h trypsin
andamylall'.
ADMINISTRATION ALERTS

00 IIOlUlIsh oropen r nterK-<oaled lablets.

I'owdrrformulations maybr sprinklrd on food.
GiYr t~drug 1~1 h brIortor with meals,or u dirtaed bt' the hr,kh Urt
provider.
Prtgnanq calf90ry (

ADVERSE EFFECTS
~IW rtrts of pn(~ip~ a~ unrommoo, sinct thr rnz)'llll's a~ 001 absorbed. Thr most frtqUrnl oIiMIW tife(ts an' GI symptoms of IliUll'a,wmiting,
and diarrllra .Vrry hi.;h doll'! 01 ~ moc:iated with a risk for hyptNricemia.
Contraindicationl: FalKrflip~ is (ootraindicated in patirnu allfl<JK to tht
drug or to pork produm. The delayed-nieolll' produru should not be giYm 10
pillitnu withoKUl\' pinae"'itis.
INTERACTIONS
1Wg- 1Wg: Porrnlipa;t inmru with i Ol1, whidlmay rflWi i1 dKrNSfd
absption ofiron.Nna:idI may~ the fife(! ofparmlipu.
lab Iflls: PanoripR rna, incrNlf \eIUm or urinal)' levels of uric add.
Ik>rbiollF.w:U" .......,

llNtment of Omdo~: High ~ of uric oIcid may oc:rur with o~rdoll'. Patitnts a~ UUled S)'ITplolNtiul~.
IIeI'lr III MyMnbtgl(l W ~ MnIrtg /'reIS Fo:us spKl/I( IIIIM <tug.

PHARMACOKINETICS
Ons!'!: Immediatr
Iflk: Unknown
Halflift : Unknown
Duration: Unkoown

{i::- ~ Chapter REVIEW

-

KEY CONCEPTS
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 nu mbered section within the chapter for review.
41.1

The small intestine is the location for most nutrient and

drug absorption . The large intestine is responsible for
the reabsorption of water.

'"
41J

41.6

Constipation, the infrequent passage of hard, small

stools, is a common condition caused by insufficient di etary fiber and slow motility of wasil' maleriallhrough
the large intestine.

Innammalory bowel disease indudes uicer.ltiw colitis

and Crohn'sdisease. Treatment indudes 5-aminosal.icylic
acid (5-ASA) agents or corticosteroids. Drugs for irritable
bowel syr.drome are largeled at symptomatic treatment,
dependin~ on whether constipation or diarrhea is the predominanlsymplom.

41.7

Laxatives and cathartics are drugs given to promote

emptying of the large intestine by stimulating peristalsis,
lubricating the fecal mass, or adding more bulk or water
to the colon contents.

.,.

Vomiting is a defense mechanism used by Ihe body to rid

itself of toxic substances. Nausea is an uncomfortable
feeling that may precede vomiting. Many drugs can
cause nal:Se3 and 'omiting asside effects.

41A

Diarrhea is an increase in the frequency and nuidity of

bowel movements that occurs when the colon fails to reabsorb enough water.

41 5

For simple diarrh~, OTC medications such as loperamide or bismuth compounds are effective. Opioids are
the most effective drugs for controlling severe diarrhea .

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41.9

Symptomatic treatment of nausea and vomiting indudes

drugs from many differenl classes. including phenoIhiazines, antihistamines, antkholinergics, cannabinoids,
corticosteroids, benzodiazepines, and serotonin receptor
antagonists.
Obesity has become widespread in the United States and
is associa~ed with multiple chroniC diseases such as hy-

("",If,41 Drug. fo, Oowel 0"",<1<>" aoo Ollie< G. nrolllle<"n . 1Conditio",

pertension and heart disease. Theetiologyof obesity is a

combination of genetic, lifestyle, and physiologic factors. A sustainable diet and exercise program should be
implemented before pharmacother apy is considered.

41.10 The pharmacothernpy of obesity includes the anorexiants sibutramine and the lipase inhibitor orlistat. Both

637

drugs are used for the short-term management of obesity but produce only modest effe.;:ts.

41.11 Pancremitis results when pancreatic enzymes are trapped

in the pancreas and not released into the duodenum. Pharmaootherapy includes replacement enzymes and supportivedrugs for reduction of pain and gastric acid secretion.

NCLEX-RNOREVIEW QUESTIONS

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 diphenhydrinate (Dramamine) how long before tht")' board an airplane for a trip?
1. 20 to 60 minute"
2. ] 5 minutes
3. 2 hours
4. 6 hours

The nurse assesses for one of the major precipitating factors in the development Iss, which is:
1. stress.
2. peptic ulce!>.
3. gastroesophageal reflux disease (GERD).
4. Helwhamr pyillri.

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.)

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 contraindication? (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 (Compazine) to a p.1tient for postoperative nausea . Before administering this medication, it is essential to che\:k the
patient's:
1. pulse.
2. blood pressure.
3. IWlgsowu!s.
4. temperature.

CRITICAL THINKING QUESTIONS

1. The patient has been ta king 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 phobic~
and wants all the medication in one syringe. What is the
nurse's response?

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 for Nutritional

Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES

VITAMINS pI1Jt 619

Lipid-Soluble Vitamins

Aher reading this chapter, the student should be oble to:

pI1Jt 5//

Q vltamJn A (AqUQ50/ A,. olhffs) f!I1I1t 642

Water-Soluble Vitamins

fCljt6-/l

Q foN, ocld ~(/n)

;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

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.

KEY TERMS
miuornin~ral (tlll(f

beriberi f'Jt}t64J
rarote~

pI1Jt 641

enteral nutrition JUje6S0

ergocalciferol M I641
hyperv~aminolil jXIgt 640

maaomineral (major mineral)

paljt648

LibraryPirate

minfral) nf,48
parenteral nutrition {!'Jgt6'lJ
IIfllagra JVjI f,43
IIfrnicious (rnfgaloblastid anf mia {tl~ 6-U
provitarnins fXl~ .39
Rf(omrnfnded Diftary Anowan(f (RDA) pagt&J9

SlJJrvy mrf,44
tOOlpheroi JXI9IfY/1
total parentrral nutrition (lPN) {!'Jgt651
undernutrition n65IJ
vitam ins pI1Jl6J9

0Iap1tl41 Orugs 10, Hutt~Ion~1 Ofsorden

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 th e
ne<l'ssary nutrients throug h

ill

b.1Ilanced diet, Once the

body has obtained the amounu o f vltllrnins, minerals, Of

nutriefllS it needs 10 carry on metabolism, Ihe elcess is simply 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, mine rals, and nutritional
supplements In pharmacology.

VITAMINS
Vitamins are essential substances needed to maintain optimwn wellness. Patients having a low or unbalanced dietary
intake, those who are pregnant, or those exper iencing a
dlIoni~ di,,,,-~,t 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 scienmls did n<M know the dlemical Slructures of thevitamins
when theywere d~ , they assigned letters and numbers
such as A, B'l,and C Thesenames are still widely used today.
An importan t characteristic of vitamins is that , wi th the
e.n:eption of vitamin D, human cells cannot synthesize
them. They,or their 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 d isease will result. However, the symptoms of the deficiency am be reversed by administering the missing vitamin.
Vit;lmins srrve diverse and important roles. For enmp le ,
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 regulated 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 includ e vitamins A, 0. E. and K.

LibraryPirate

639

The difference in solubility affects the w:J)' the vitamins

art' absorbed by the gastroint estinal (G I) tract and Slored in
the body. Thewater-soluble vitamins are absorbed with Water in the digestive tract and re:lldily dissolve in blood and
body fluids. When excess watersoluble vi tamins are absorbed, they cannot be stored for bier use and are simply excreted in the urine. Because they are not stored to any
significant dt'gTte, they must be ingested daily; otherwise,
derlCiencies will quickly d evelop.
Fat-soluble vitamins, on the other haod, cannot be absorbed in sufficient qua ntity 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 vitam ins if they are taken in excessive
aJno unts.

42.3 Recommended Dietary

Allowances
Bas<>d on scientific research on humans and animals, the
Food and Nutrition Boa rd of the National Academy of Sciences has established levels for the diftary intake of vita min s
and minerals called RtcommeRdrd Dietill)' AllowaJl<ts (RDAs). Th e
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 scientific ~rch. 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. Furthermore, 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
nillJrall)'~.

Vitamin Bu is pltlfnt only in animal pnx!!I(u.Vfgwriilns mily find

adtqu;lle amounu in fortir~ (fINis, nutritional suppltments, or ytil st.
Administration of folic acid lklring pregnilllCY has betn found to reduct
birth dtfts in t~ ntlYOUl system of the ~by.
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

.,...

640

Unlt7 TheGa,uoIm",tI ...ISym'm

TABlE42 .1 1 Vitamins

'D'

VItamin

Functlon(s)

Moo

ViIlI,1 P9:ntnt~~ilhdi'l (dl,

1,0001119 RE*

Bwmpi9:bioIin

Cotnzy~

Wo~"

8001119 RE

Common Cause(s) of Defklency

Proloogtd dtlay dfpffl,lion, p.lrtirubrly when
rU is the main food IOUITt; II'IKft'"kdiIN!I';
dnllOlis

qilr11XONbmin (Bul

in mrubolk rt', aions

~~,

lOnKg

~fid~ lrt' r'rt'

Cotnzyrnt in nudril: oXid ~taboIism

,~,

,~,

lido: ofinnimi( fKlor,i~tr intlu offoods

Cornzy~ in amilo.uid ind nudric.

1OO~,

16Q--1&Jmc:g

15-20mg

13-1Smg

..

/rom,nimaloric;jn
folic: ~id/folatr

(Bol

.xiii mriabolism

rioXin(BJ

Cotnzyrnt in OIidation- rrdJaion

ruction,
p.lntolheril:.xiII (8,)
pyridoJ:inflBJ

CotIIl)'RIr in mrubolk rt'iaions

CotIIl)'RIr in amilo ,dd m~boIism,
RBC produaion

''''
''''

''''
1.H.6mg

ribo/IaYin(B,1

Cotnzyrnt in OIidatioo-frdJaion

U- l.8mg

1.HJmg

11- 1Smg

1.0-1.1 mg

ructions
ttiaminf (B,)

(0ffil)'IIIt in met.lbolic: rt'.I<liom, RBC

formation

Pr~oq,

,koholism, (i1Kn-, or,1 roniri(rplift

Proloogtd dtlay drpi'i'lllion,lI'rtirubrly wh~n

Indln (OI!l (ma~lor mil~ is the main food
!OIU~; dlronic: diarrhN; i'lff di!l'a\I': alut.olilm
~fid~art'r'rt'

,l,koholilm, oral rontrnpli..,. U!I',

maiablOlplion distlltl
IlIidtquit~ (OOIUmplion of mit or Inimll
produ(l~ dlronic: diarrhN,live' Ii !l'alo!,
akoholism
ProIOIigN metal depri'l.llion, pirtiwbrlywhen
rU is the main food IOUITt; h)'pffihyroidilm;
pr~oq; i'lffdi!l'a\I';aI"loIi1m

C(aI(orbic:,dd)

,
,

CotIIl)'RIr and antioxidant

Cikium Ind phoophll.

60..,

~..,

S-10mg

>- 10mg

Antioxidant

IOTE**

8..,.

ColKlor in blood dorti'lg

65-80m{lj

5>~5mc:9

m~lboIi<m

IlIidtqun~ in.Jk~ offnits IndY~ffilbIt~

prt'IJIaoq,dlronic: innammatorydiSt.l1t, tum,

diarrhu,akoholilm
low diftl" into., inodtqUlIO fXJHIlUr. to
SIIllight
Prffilalllity, mabblorption di!l'aItI
NewbJm~ i'lffdi!l'aII', Iongtmn p.llfllttrll
IHllrition, rntain drug,lIKh as trphalo5pJrim
,nd saikyiattl

*RE = miooid rquivalent~ **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 dietary 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. HY]lfrYit~min osil, 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 actually 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 serious adverse effects.

LibraryPirate

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 deficiency due to the high growth demands placed on the body.
In addition, requirements for all nutrients are increased during pregnancy and lactation. VVith normal aging, the absorption offood diminishes and the quantity of ingested foOO is
often reduced, leading to a higher risk of vitamin deficiencies in older adults. Men and women can have different vitamin and mineral needs as do persons who participate in

vigorous ext'rcise. Vitamin deficiencies in patients with

chronic liver and kidney disease are well documented.
Certain drugs have the potential to affect vitamin metabolism.A1cohol is known for its ability to inhibit the absorption 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 phenothiazines, oral contraceptives, phenytoin ( Dilantin), or barbiturates. Vitamin D ddiciencycan be caused by therapy with
certain anticonvulsants. Inhibition of vitamin B" absorption 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 recommend 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 carefullyfollow the instructions of the health care provider, or the label
directions, for proper dosage. It is not unusual to find overthe-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 (uot~n!S. Carotenes are precursors to vitamin A

TABLE 42.2

",,"
o wililmin

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 molecule 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 affectingabsorption, mobilization, or storage of vitamin A, such as
steatorrhea, severe biliary obstruction, liver cirrhosis, or total gastrectomy.
Vilamin D is actu."llly a group of chemicals sharing similar activity. Vitamin D" also known as rrgocalciferol, is obtaimd from fortified milk, margarine, and othel dairy
products. Vitamin D, is formed in the skin by a chemical reaction requiring ultraviolet radiation. Vitamin D is nsed to
treat skeletal diseases that weaken the bones such as rickets,
osteomalacia (ad ult rickets), osteoporosis, and hypocalcemia. 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..

h~ving simil~r ~c:livily. Alph~

toc:opheml oonsli_

IUtes9O% of the tocopherols,and is the only one of pharmaoologic 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 cereals., 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 membeam's and other cellular structures. Deficiency in adults has
been observed only with severe malabsorption disorders;
howtwr, deficiency in premature neonates may lead to hemolytic anemia. Patients often self-administer vitamin E beca~ it is thought to be useful in preventing heart disease
and increasing sexual prowess. although research has not

Lipid-Soluble Vitamins for Treating Nutritional Disorders

A(A~!Ol A,o:hm)

wililmin O:cakitriol(CiI:ijtJ:,
RocaKroI) III'~ p.lg ~ 735 lonh ~
ProIotypr Orugbox oo )

Route and Adult ~ (max dose where IndIcated)

Adverse EffeciS

PO; 500,000 uriu/dayfor 3 day~ followrd by 50,000 uniufday for

1 'lit; tllm 10,000- 2O,I)XI !Il~lIday for 1 mo IM; 100,000 un~sJday
for 3 doJYs folowrd by 50,l)XIun~slday for 1 wk

Mwm tff!'I:r;olf UOOlIlIIl!OOOI rwmmmdtddosts

PO;015 mJglday;may br ilKlWl'd by 015 mJg/doJY rffiY 4-8 wi!

lor dialysis p.llimll Of MIl 2--4 wk fOI hypopilathyrold pa~rru~ If

Mwm tff!'I:nolf l/OOlfI1mi/f!olrwmmmdtd~ lMfalk

1IKl'1~f1

H!!J!! dc~:niU\ra, vomi~!l!I. fa!!!m ~idadIr.l!!!!:!!!ria,

wtigtu [1m balkJdNlioD! dMytbrri'luwlrand bonr

IV;05 meg th~ tinesiwk al thr md ofdiilysis;rnay nud !4l 10

3 m(glf"ffl timrslwk

~n E:tocophrrol

POJlM;60-75 lII~slday

(Aqwso! E, V"rtlP!us E,ot~~)

I'itlmin K:~ONdione
IAqwMEPHYTON)

Hg. dcleS:niul(a vomi~OIl fitim initabilitr. righ:

Im~l~a~ii drnkin
,~.

""

~wm tff!'I:Il01f1i00llllll!00Olrwmmmdtddostl
H!!J!! dostS:rvYl!:'

ponWsmtanroos; 1.5-10 mg lup 10 15 rng),may br IfPratrd

.fltr6-8 b n IIffiIrd

Iro/ia inootr ammon id"I!'~ rtIe(\~.IIIl!Ifdining.inckatrs 1rri0Ul~ ~fIta~

LibraryPirate

vorni!i!!lf4!!!JI!!:,he'~ll!urmlmi2n

FtxioIIlilhir9. pan 01 irrjKtiOOll"rt

IV rourr mlt rm!t in !b:IRnr. hll!Q!rosion

"'"

~, ~1iac

"

64 2

Unlt7 TheGa,lrolnt..,tI,..1 Sy'tem

.... Prototype Drug

Vitamin A (AquasolA, others)

Therape utic Class: lipid-soluble'titamin

Pharmacologic Class: Retinoid

ACTIONS AND USES

Vitamin Ais 6!e1lrial for g~ml9rowth and ~Iopmtm. particularly of rhe
bonrs,rem, and epithelial membranrs. k is n~essary for Pltlll" wound healin'!. is m~nlial for m.. bio<ymhesis of <lerni<k. ~nd is M. of the piglllt'llU .....
quirt<! for night vision. Yitl min Ais indic~ted in dNicitncy stares ud during
periods of ilK~lSed r"ftd !lKh as pR'9nancy,loKt.lIion, or undernutrition. Night
blindnrss and slow wound healing un be ell~tiYely In'a1td with as lit~t as
30,000 uninof vitamin A9i~m dai~ O'/ef a ~II is 1M prescribed for 61 diso~~ 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. Do~ of vitamin
Aall' IOmttimes mtasull'll in Il'rinoid ~uivalmts (RE}.ln ~~ ~fKiency
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

ADVERSE EFFECTS
Adft~ tfFeds art not obltlWd with norm.JI do~ of vitlmin A.Acure i~s
tion, howfm, prod!Kes serious CNS toxicir~, ilKUding ht ad<lrnt, irrirabilil)',
d"' .... illt'<~deli.i."n,.nd poibio mou. long_lmn i~<lion of high amrum<
UUIt! drying and scaling of tht skin, JIopia, fatigue, <Ir.orexi<l, wmiting. and
~1rDpen;'.

Contraindications: Vitamin Ain fllCffi of tht RDA is conrraindicated in Plfgnam parient\" or rho!!' who lIIiIy be<ome pll'gnanl Feral harm lIIiIy Il'IUIt.
INTERACTIONS
lWg- lWg: PI'opIt takill9litamin Ashould iMIid raki19 ninfral oil 0100
droil'll)'ramill@,bKall\!' both ma~ deouI,,1ht iIbIorpIiJn 01 vitamin A. (000I"i8l
II\!' with isorflinoin may lI!I,*in ~itift toxicity.

Lab Tests:Vitamin Ama~ inclNlt \MIll! G1kium and BUll.

IkorbaVFoo:l:lJnknown
T~tment of OnrdoSf: The~ is no

sptcifr tlNlmenr for u;erdol!'.

RM III M'fMlIhl9Kl till ~ MnJnq 1'roce\S Iixu! 'ipKltt 111M I'1InIn.

PHARMACOKINETICS
Onstt: UnkMwn
f'eak: UnkMwn
Half~iM: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. Vitamin 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 deYeloprntnt of Type I diabe!es and viramin Driefriency. 'frramin DrIeft:imcy has aM
bern ~td<lS I pormtial factor il tht ~lTI!'m of o~r chooi condlions SIKh <IS heart risNlt, hi91 blood prtsllft',UIKfI; T)'pI' II diabfre, <lnd auIoimrrunr cisonIe~ !ruhipl!' >tu:Jirs <Ill' being alIIdoord 10 conmn ~ linkl
in tht gtneral pIlII'Jlation and inspe<i.JI popUaiions such <IS oIdrr adUts and il differrnwhnigroups.
I'ropIt with darl<. skin hae glNrtr alllOllltS of I~ pigrntnt mtLlrin and ha'II.'
a ~m ability 10 prcdKevitamin Ofrom lun rxpoIull'.ln I study by tht USDA
HUlll<ln RrsNrchNutririonCmttr,AfricanAmtricaIllWl'~kuKJlOhMththigh
est rates of vitamin Dcll'1icimq 'Ihn comparrd with othfr AmtrDlIS. And .....
INrchbyt~AmtrDn DUbetrsAssoMion halSUlgrstmrhatAfrican Americalll
a~almost IWOtines moll' IRlyIO hlYl' T)'pI' Idiabfle than non-woo whiles.
Wrth strong fI'idm:~ trnerging that lII<Iintaining adequitf amctllll of viranin 0
may prMntrnlMic ilrrl~indu:Jing T)'pI' Iriabms, mamin 0 IUppitmentatiM
may bf <l Iow-<Ol~ Iow-risk pre't'fIl1ion option for Type Idiabeles,epa:ial)o in peopi!' with a high riskofdevrbpingt~ OINSf.

LibraryPirate

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 vitamins 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 different substances that are grouped together because they were
uriKi"~ll y u~riv"J [rullI y~~'l ~llJ [uuu- lh~1 ""wlkr~<.l~J
the disease beriberi. They have very different chemical
structures and serve various metabolic functions. The B vitamins are known by their chemical names as well as their
vitamin number. For example, vitamin B" is also called
cyanocobalamin. Medications containing waler-soluble vitamins, and their doses, are lisled in Table 42.3.

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'

IVnM;~IOOmgtid

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

l'itamin B,:niadn (Nirobid, NKoIar,OII1trs)

PO;ID-lOmglday
IV nMfsubcu!a1ll'OOl; 1,- 100 mg two to fiw tines/day

Ad'ftMtffem ~rt fll!mmon~rdozllltd for

viramin rlltropy

l'itamin B,:pyridoJo:illl' IHUoJ-8tt.l~n,

Htsirer, IIIhtn)

POIIMJlY; 1.5-10 mglday for 1 wk;thtn may rtdu(~ to

l.Hf1I9Iday

PonorirJjtioolilt

POIIMJlVI!lbrutantOUl;OA-1 mgfday

Ad'ftMlffem ~rtfll!mmm~r rKommrot/ed

dom

,"KrJ haM' oortwn rf/KXr!

High ~~l:!!'!:l!!r!!!lmias

witamin B,:folic:Kid (FoI.Kin)

High ~~nt\UIDolthy ataxia

~r~

PJ~nta:illl!!!ti'\; !I1k:!!i~ IrtDffitnl~i'I~r

l'itamin Bu:cyalllXtlNLnin (Betain l1,CoIJa,

Cynapin. othm) (~ pig!' 4OOfortht Prototype
Drugbox OO )
vil.lmin (:aso:orbic JOO (,i,s(ortiup, (~
Vit.J(,OII1trs)

IMf~~ subcUlalltOUs;10 fll(glday for , - 10 dar. thtn

lIXHOOfll(gimo

POIIVllMlsubcuLJntOUI; 1~,oo mqfday in _ totwo

dom

~lIl.diorrlil~

High dost~ thrombosis. hypokalemia,

ilYmona!l fdema,~!l!l fail!!!!:
Ad'ftM l ffem Qrt fll(Offlmm ~r rKomtIIfflII8/
do,.
~igb d!Mto;!m>~o ttromb~lb a~ f!!l!lrl

umalillia
/Jolin i"Ii"'I~ wn,"oo """""" "".u>;~i"Ii"'I" ...,.;""''''''''''''' .rr"'l~

Vitamin B" or thiamine, is a precursor of an enzyme responsible 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 berib~ri, is
characterized by neurologic signs such as paresthesia, neuralgia, and progressive loss of feeling and reflexes. With
pharmacotherapy, symptoms can be completely reversed in
the early stages of the disease; however, permanent disabilitycan 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 symptoms resoh-e by administering 25 to 100 mgldayof the vitamin 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-

LibraryPirate

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 drying 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 nicotinic acid, and doses are much higher-up to 3 glday
(chapter 2200).
COMPLEME NTARY AND A LTERNATIVE TH ERA PIES

Sea Vegetables
StJ v~gmble. or seawffd~ art J form of Il"IJrine algae th~t grow in tilt upP'" It.d. ofthi' O<e.ln, wh ... IUnlighl ron
wmpb ofthcs di
bit seawel'm inc:Udt spirulina, kelp, (hlo~lb, ararne, J nd nori, many of wh ic:h
a~ 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 mo~ minerals than most other food SOUK6, induding (akium,
magnesilm, pllosphoroos, iron, potassium, Jnd all ffi~mial mc:~ tlrmtnls.
kause the, aft' so ric:h in min~rals, seawel'm an as alkalizen for tht blood,
helping to rid tht body of acid (ooditions (acidosis). Spirulina, kelp. and
(hlo~1a are a\\lilablt in IiIpsult or 1.1 blet form, or u pan of a'grrl'ns-minontaining other nutritiou Iingred~nts.

proo"."'.

644

Unlt7 TheGa,lrolnt..,tI,..1 Sy,rem

.... Prototype Drug

Folic ACid (Folacm)

Therape utic Class: Water-soluble vitamin

PharmacologicClass: None

ACTIONS AND USES

Folic: ~dd is administl'fl'd to rm'Be symptoJM of deficiency, whic:h most commonly occur; in patirnts with inadequate imakt, such as with thIOnic akohol
alxM.BecalMthis vitamin isdemo)'edat high tempemure~propltwhoover
coole thtir food may optrien~ folate dtIKirncy. Pl!9nallC)' marUdly inc~.ues
tilt nffil for dirtary folic: Kid; folic: acid is g~n during pregnane)' to promote
normal fetalgrowth.BeulQ inwfficient vitamin B" mates a lackof ~ctivated
folic: acid, deficienc, s)'tnptDmsll'lI'mblt thoW' of vitamin B" deficiene)'. Tilt
megaloblastic alll'mi.l obll'~ in folate--defic:ient patirms, howevrr, dor5 nol
inckidr tilt smll' III'IVOUS s)'Stem symptoJM II'tn in patienn with Bu dtficitney.Administration of 1mglday of oral folic acid ofll'n IM'rws the deficirncy
symptoms within 5to 7d.J)'S.
ADMINISTRATION ALERTS

Pl!9nancy category A(calegory ( when laken in dolI'S above tilt RDA)

ADVERSE EFFECTS
Adftlll' effects during folic acid tlltraP\' are uncommon. P~tirnu may f~1
flushrd following IV inition~ 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: ~Mn)lOll,trrnrthoplilll-~,iOilO!hfl lMliOOons may

interfmo with tllf absorp!ionoffdic: add. ~ni:oI 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 B,~

Ik>rbaVFooo: lJnI;ncwn
Tll'atment of OYrrdose: The~ is 00 specific tlNlment ~r O'IeldoSl'.

PHARMACOKINETICS

Onset Unknown
P!ak: 30-1 min
Halflife: Unknown
Duration: Unknown

HOME

&

COMMUNITY CONSIDERATIONS

Vitamin B9and Neural Tube! Defects

It is now well dorumtmed that low vitamin II. (folic acid) ~s in prtgnant
Womffi m.ly contribute 10 the formation of _fal tullt delecn in tilt feM.

WomffiS health call' plOYidm.Jll' OOW suggtSting thal)OOng women begin

taking folic: ~cid prior to anempting p~nancy. 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 menstrunion btgins. To avoid poslibit OftrdOS!5, most lItahh U~ pnwiders 11'(ommend taking a daily mukivitamin th.Jt mnlains folic ~cid.

Vitamin I\" or pyridoxine, oonsists of sewral closely related compounds, including pyridoxine itself, pyridoxal,
and pyridoxamine. Vitamin B6 is essential for the synthesis
of heme, and is a primary coenzyme involved in the metabolism of amino acids. Deficiency states can result from alcoholism, uremia, hypothyroidism, or heart failure. Certain
drugs can also cause v itamin B6 deficiency, including isoniazid (INH ), cycloserine (Seromycin ), hydralazine (Apresoline), oral contraceptives, and pyrazinamide (PZA). Patients
receiving these drugs m ay routinely receive B. supplements.
Ddj"it:ll"y "YJlJl'lull1s jllduJ" Skjll aUllufJlJalili,..;, d",ilusis,
fatigue, and irritability. Symptoms reverse after administration of about 10 to 20 mg/day for several weeks.
Vitamin &" more commonly known asfolateor folic acid,
is metabolized to tetrahydrofolate, which is e~ential for
normal DNA synthesis and for red blood cell production.
Folic acid is widely dis tributed in plant products, especially

LibraryPirate

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 metabolic pathways. It also has important roles in cell replication, erythrocyte maturation, and myelin synthesis. Sources
include lean meat, seafood, liver, and milk. Deficiency of vitamin B" results in pernicious (mtgaloblastic! n emia. This vitamin is featured as a prototype drug in chapter 28 00.
Vitamin C, or ascorbic ocid, is the most commonly purchased OTC vitamin. It is a polent antioxidanl, and serves
many functions including collagen synthesis, tissue healing,
and maintenance of bone, teeth, and epithelial ti~ue. 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 forseveral weeks.

MINERALS
Minerals are inorganic substances needed in small amounts
to maintain homeostasis. Minerals are da~ified as
macrominerals or microminerals; the macrominerals must
be ingested in larger amounts. A normal, balanced dil.'l will

NURSING PROCESS FOCUS

PATIENTS RECEIVING VITAMIN AND MINERAL PHARMACOTHERAPY

Assessment

Pot entii!ll Nursing Di i!lgnoses

Baselinr assrssment priorto admini stration:

Undtrsund th~ Il'ason tilt drug has ~n prec:ribfd in ordtr to uses for
thtra ptUtic: ~IfKls (t.g., rfpialffllfnt theraPl' ~r dtrKitlKitl, pll'l'mtativt
hNlth maimenalKe).
Obtain, lomplttf lItakh histOl)' ilKludillC) (jIdiov'lI<uia~ nturologic,
endocrine, h~tic,or 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
rtdde~ gums ortongue, teodtncy to blt~d Nsily or rnmjy~ bruising.
n.JulN or fOmiting.rnmivr fatigue).
Obtain a dieta!)' histOl)' noting adeq~ of mrnti,1 viUmins, mintrals,and
nutritnts obtainfd through food wun:rs.
Note sunsuft'n UII' and the amount of sun ~lPOSUIl'.
Obtain ball'linr "ftighund vit,llign~
[1'<I1u.Jte approp riatf iaborato!)' findings (e.g., (&, ~trolytrs, hepatic: and
rf nalliJO(rion studits, ~nitin and iron ~).

ImbalanlN Nutrition:LfSs Th,n Body RtqJill'lIII'ms

Im~ill'd Health MaimfnalKf (reIat~d to dim!)' h,bits, dtfititnt knowlrdgt)
R~,dinrsllor Enh'IKN Therapeutic: Rtgimtn Maoaqrment
Defic:imt KnClWledge (drug ther.iP1)
Risk lor Inju!)' (reIatrd to adve~ drug rlfrm, h)'pfIVitamiOOlis)

Assess mtnt thro ughout ildministration:

Asses for drsi~ ther,peutic: effemdtptndtm on tht 1l"lOn lor tilt drug
(symptoms of dtlic:itnqo are diminishrd or ,bll'l11).
Continue monitoring of vit,1 ~gns,and prriodit lab alurs u appropriate.
~sses for and promptly Il'port ,~~ellto:ts:naUlra, Omiting. f X<flSivt
filiQut, tiKhytard iii, ~Ipitllion ~ hypotension. (onstip,tion. drows intss,
diuinrs~ disorientltion. hYpI'r-ll'flexia,.J nd tleurolyte imba Ia IKfS.
Pli!lnning: Pi!lti ent GOi!ll s ~ nd Expect ed Outco m es
Th~

patitm will:

b:pI'ritlK~ tlltra ptUlic: elfects (e.g., mainteo'lKf of overall

hfalth. symptoms of prrYious defititn'1 all' abll'ntl.

~ ~ from,or rlpl'ritlKe minim'~ idW"1I' riff(\!.

Verb.Jl~ ,n underst,nding

oftlltdrug's U\f,adve~ effects, and rrqJirro pll'uutions.

Demonstrate propl'lll'll-.ldministration of the meditation kg.,doII', timing. whfn to notif)' provitItrl.
Implement~ ti o n

Interve nti o ns and (Rati o nal 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, fibe~and rIIrnti,llfqUilflllenU not foond in vitamin ,nd miOl'ral
ruppiement,!ion.)

Patient i!lnd Family Edu cliti on

Review tlltdimry histo!)' with tilt ~tient and discusl food 1OUn:~ options
lor rormting anydelic:itlKits. [n(OlJr'ge th~ p,tient to adopt a healthy
lile\)'le of ilK ifilli'd l'<lriety in thediet.PlO'fide for dietitian (onsultation as
n~fdN.

~lSist tilt patient and f,milyor uregiver to betOInt ~ruutfd (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:flods.ad. nih.go).

Minimizing adft rse effKts:

RMew the dietary and supplemrm histofJ to (orrtct any o:~ting possibiliW
for hypervitJminosis and a~~drug rIiKh.(Ex{tSsil'f intakr of vitaminl
A, C, D,E. B" niac:in, and folic: acid may Itad to toUt ellto:ts.)

Oisrun the nrtd for nutritional rupplements if the normal diet is urwblt to
rupply these or if dista ~(onditions (e.g., pernicious aOl'lllil) Pll'Yfnt
ablorption or utiliz,tion.
Oiscourage tilt O'felllll' oIlUpplem~ntation and ptoYide information on
adverse rlfrmand symptoms relat~d to hypmitaminosis.
(conrlrruefi)

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64 6

Unlt7 TheGa,lrolnt..,tI,..1 Sy'tem

NURSING PROCESS FOCUS

PATIENTS RECEIVING VITAMIN AND MINERAL PHARMACOTHERAPY (comlnutidj

Implementation

Inte rve nti o ns a nd (Rati o na les)

Pati ent and Fa mily Educa ti o n

CominUl'to monitor prriodil: lab worlc lS ~.(lab tffiS appropriate to

rondition [f.g.,pernic:ious anemia and 11gb and Ikt Ievcls] will help toensurt
therapeutic: ~ru art ml'l With milll'ral replac:emenl,tifiuolytes !hoold
R'tum 10 norrnallfolflsJ

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.
En(ouliI~obtaining fat-1Olublr vitamilll from naM,1 !OUl{t"I sIKh I~
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!'9 r tabirs, grain~ nuts. ~rk, and forrified (tll'll!.
Vitamin K:gft'PlJl'fgtlabits SIKh IS turnip g~ns, lpinlm,{.1uliliower,
{ibbaoge and bro((oIi, and (fIlain vtgetabifoils induding !Oybtln oi~
{orron~ oi~{.1nola oi~and olive oil.

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
~k in toxic: Ievcls.Monitorlil'ff function stud~ 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 ~nanty.AsSl'ss 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

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 narr in the houSI'hoid 10 pmoent I({idrnlll poisoning.

[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
~ofvitamin ( nYy (iUIC rroal cal(uli.)

En(OUra~ tilt patitntlo in{lNst fluid imakt 10 llof lkJid pI'I" rby,dil'irlrd
throughout therla)o.

Patirnt understanding of drug thrra py:

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' provirlr~and I ny nKt"lwl)' monitoring or prKlutionl.(Using
timt rluring nu~ing (irt helps to optim~ and reinfon:t ~y INthing all'l!.)

The patient !hoold br Ibif to statethe II'l!On forthe drug;appropriatt doSl'

and nheduling; what adl'fBt ~m to obSl'fYf for and when to II'port; and
the antic:ipattd ifngth of mNi<alion theraP'1.

Patirnt selfadministration of drug thtrapy:

When <ldministt ring the mtdic:.Jtion, illltllKt the patim~ 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"lrntss of the drug.)

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 ~xpeatd OUt1OmtS havt bttn md htt' Plannin().
JH ToIIk< n.t4lJ,.fl.J. &41.4 fa nliJrd'*"'1< ro..mid! rhN ~<Iflio"'.....,..

provide the proper amounts of the required minerals in

most people. The primary minerals used in pharmacotherapy are listed in Table 42.4.

bound to organic molecules such as hemoglobin, phospholipids, or metabolic enzymes. Those minerals thai function
as critical electrolytes in the body, most notablysodiwn and

42.7 Pharmacotherapy
with Minerals

Sodium chloride and potassium chloride are featured as

drug prolotypes in that chapter.
Because minerals are needed in very small amounts for human metabolism, a balanced diet will supply the necessary
quantities for most patients.As with vitamins, patientsshould
be advised nOlto exceed recommended doses because excess

potassium, are covered in more detail in chapter 3100.

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

LibraryPirate

TABLE 42 4 1 Selected Minerals for Treating Nutritional and Electrolyte Disorders

On"
poIiIs~!III dlIoride jKDu~ MicroK,K1or.(on,
QIhm) (It!' paq!' 439 for I~ ProIOl)'ll!' Drug

Route and Adult Dose (max dose where Indicated)

Adverse Effects

PO; 11)-100 mEqlll in dividtd dosts

Noultl!, MlmiD"1IJ dillrrlifo, abdImirrd

mmling

"' ~ I

IV; 11>-40 mEqIll d~ulrd 113 al ~ast 11)-10 mEq/loo mL d

solution jmu 200-400 mEqlda,)

!Odium bicarbonate (Itt p.iIJt 441fa' w

PrOIQI)'II!' Drug box 00 )

PO;03-2.0g/dily--ijd or 1upol powder il j

91a1\oIWit~

Hypelka!tmia hYDQltoSion (oo/ulion

!!'!:!!I!l:!hmia!

Htotkxllt, ~iM:~MIIiIg. ~Qrulnr:t

IIIJlI:mmmioi bxIII:lI~Dlillo mu!d~
lwilchi!l!l dySlhrthmiai.oolmonary rdema
t1triphml

mma

CALCIUM SALTS
calci!lll oKrtalr (PhosLo)

PO;2- 4 t.lblelSwith rad! mnl (YCh labl~ (ootain! 169 mg)

calci!lll carbonil~ (Rwm, TIIIlI,OsCa~QIhmI

PO; 1- 29 bid-tid

ulci!lll dlIoridr

IV;o.S- 1.0g/q3days

calci!lll <itrail' (C~IiIUO

PO; 1- 29 bid-tid

ulci!lllgllKonale (Kakinatt )

PO;I- 2gbid-qid

ulci!lllloKt.ltt (Cal-Lx)

PO;32S mg- 13 gtid with lIII'ais

ulci!lll phosphate tribasic: (PosIu~)

PO; 1-2 9 bid-tid

I'IIffnff!fIIlroult:fMhi~ rDMG, ImII'D"1Ii

poi~injrioo Jiff!

Oro/ roorr: obdomi!1Ol "an, lass ofopptCiff!,

mIIltI!, 1'mliD'1IJ wIISlipolio!\. dry mourII,
iOOfflltd IhirWllifNlion.
IIvmGlkmi!l !!):lmtnsion,~i!"~
fltiw a!lOftXia (oofusion dOOythmiu

IRON SALTS
ferrous fumarate

(FrosIa~othm)

Noultl!, rllnJlipoliiJn fit diorrlifo, abdImil!l

PO; lOCI mg lid- qid

n:ntIUI ~!KOf\iIlt (Fflgon,O!Iim)

PO; 325-600 ""1 qid; may br lJadually iflCll'a ltd 113 650 mg "d
aJ ~ and toitfatrd

ferrous sulfale (f~,olhm) (It!' paq!' 401

for Itw: Prototy)ll' Drug 1HJxOO)

PO; 75(1.-1,500 mglday in ~r.gIr dose Of l'IIOlIQ thr~

dividtddosts

iron dextrin (Dexfmllm,Iim)

1MI1V;00Ic t indimwlirel inddetmnilrd from a UbltQ/

W1riitioos betwffn palirnt"s ~I and tw:moglobin
(O\il:l00mg (2 mll dirondmranwithin 24h)

poin,lfq(fQff1/Il(i'oo~

....

Anal2!:!ml~ ~ron OOlfjn!, !!):1!!!:2!emia,

Ilmat\'!Q6i1. tAAa\Q\oxidtY, metabole

MAGNESIUM
mJlt!i!lll rhlorido! (Chlormlig. SIo- Mag)

PO; m - 400 ~day

NoIlltlJ, MlmiIiIlJ dillrrlifo,flu5ling

flliCjllrli!lll hydfOJ(idf:lMilkof~)

PO; ~ 15 mL Of 1- 4 t.lbltlJ uptQ fOIl" Iimrs/da,

CinlllIl!I:ilia !flRi[j)I~!X!.Jilulf
hypgltDljQll d ~ cp lrndQll Irl\eI )fWQjoo

flliCjllrli!lll oxidr (M.l9.()J,Maol,OI~rs)

PO;400-1)OO mglday in dividrd dosts

Go) magntsium sulfatr IEpsom saks)

IVI!M;05- 3.0 g/da,

[<ldal DirOlhtOO,wnkness

PHOSPHORUS/PHOSPHATE
poIiIs~Lm/sodium phosphail'J (K Phos original

PO; 25(1.-1,(00 mg/da,

NoIlltlJ, MlmiIiIlJ dillrrlifo

KPhos Mf.KPhoJ 1"lMr00I,HMri-PhoJ K,

)ko.l(JlnMral)

lIvDtmhosR!!atl1llia ~ lBin,fr.Ktu!!l:,
mulde WN~n~; (QIlfusion

"NO
linr oKrtalr (Galm)

PO;50mgtid

linrgllKonail'

PO; 21)-100 mg (10 mgloIrnge\ may br tam. tQoI mal Qf lil

100m~day)

linrRMm (Oralinr,1inrate,O!Iim)

PO;IH1Omglday

NMrII1tfftrurn uocommooOI
fommfOOed 00JtJ

Hiqu!q\t1; II!lUltMooliting levrt

I immuoolUpprnion.aotmia

IrQ/ia inOOt~ ammoo idvelll' t1ftru;~ilKkatts striOl/ladwelll' rfIKI~

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.

LibraryPirate

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

648

Unlt7

TheGa,uoIm",tI ... ISym'm

potassium loss. Corticosteroids and oral contraceptives are

among several classes of drugs that can promotesodium retention. The uptake of iodine by the thyroid gland can be
impaired by certain oral hypoglycemics and lithium carbonate (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 calcium 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 contraction, ,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 calciumcontaining foods, lack of vitamin D, chronic diarrhea, or decreased 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, calcium citrate, calcium gluconate, or calcium lactate. In severe
cases, IV preparations are adminislered. Calciwn giuconate
is featured as a prototype drug for hypocalcemia and osteoporosis 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, phosphorus is a component of proteins, adenosine triphosphate
(ATP), and nucleic acids. Phosphate (PO.'- ) is an impor-

tant buffer in the blood. Because phosphorus is a primary

component of phosphate, phosphorus balance is normally
considered the same as phosphate balance. Hypophosphatemia 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 sewre malnutrition or an intestinal malabsorption disorder to
experience a dietary deficiency. Symptoms of hypophosphatemia 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 usually administered. Sodiwn phosphate and potassium phosphate are available for treating phosphorus deficiencies.
Magnesium is the second most abundant intracellular
cation and, like potassium, it is essential for proper neuromuscular function. Magnesium also serves a metabolic role
in activating certain enzymes in the breakdown of carbohydrates and proteins. Because it produces few symptoms Wltil serum levels fall below 1.0 mEq/L, hypomagnesemia is
sometimes called the most common undiagnosed electrolyte abnormality. Patients may experience general weakness, 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 ortenninate seizures associated with eclampsia. Magnesium salts
hav.. additional appli,ations as ,athartics or antadds (mag"
nesium citrate, magnesium hydroxide, and magnesium oxide) and as analgesics (magnesiwn salicylate).

42.9 Pharmacotherapy
with Microminerals
The nine micromioerals, commonly called tra(f miouals, are required 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

TADlE 42.5 1 Macrominerals

Mln ....al

."

Function

<al(um

800-1)OOmg

Forms bony matril;l!gwtf! IIfI'll' (onOJaion ,nd mU\dt(ontrauion

<h_

7. . .

Major anion in bOO! ftuids;p.lr! ofgawic:add (Ha)

magllelirm

Mffi:151>-4OO mg
Wornm:280-100mg

Corauor for many mzymf!; lIt(elSary for normalllfM oonduaion and muldt (ontrKlion

...,....
...
potJl~Lm
~

"".

700 ..

Forms bony matril;p.lrt of AlP and nudtK .od!

2.0g

"'''

HtCf"lSary for normal Om'! oondudion and muldt (ontraction; prindp.ll cation io i"ltriKtllu,r nuid; t5!fntial for
add-balf "nd dt(troIyt~ balitOO'
Ht"lsary for normal Om'! oondudion and muldt (ontraction; prindp.ll cation in utriKtilwr fkJid; t5!fnwt for
add-balf "nd dtnrolyu balitOO'

lIOIeIt"blilhtd

COftlIOIII'ot of JUIlti11, Bvitamir I, "nd other aitilal rnoIKultl

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IlI>pltl (l

II~ Prototype Drug

Oruq< /0.

Nutrn ional ~Isorders

649

Magnesium Sulfate (MgSOJ

Therapeutic Class: Ma(lnesium supplement

Pharmacologic Class: Electrolyte

ACTIONS AND USES

ADVERSE EFFECTS

Sevtll' 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 sindlllk 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 magnt~um-flff IOlutions.
Afttr adminismtion, magotlium sulfilt is distributed thJOlJ9hout tilt
body,.nd ther.~ tffl.s.1I' aboitrvedwithin 30-60 minutts. Oral iormsof
maogntsium sulf.tt art ul~ d as mharti~ 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

Patients Il'<ritinglV infusions of m,gllt~um sulfillt rtqUirt (,J rtful obsm.Don

to PreYl'Ot lo:lic:ity. E.rI)- signs of IJIjg~ium OI'!'rdosr indlllk flushing of the
skin, sedation. confusion, intt~ thirst,.nd mus(lr wt'.k~s. Extll'~ Ir~k
(,JIM oruromUlQltar bIoc:bdr with ~ltant repiratory par,Iysis, hNrt block,
.nd drrulillol)' rollapsr. PLism. maog llt~um IrYeIs should ill' monitored frtqumtly. Bffiull' of IhtII' pottotially fill.l idmw tfftm, the USt of migllfsium sull.lt is II'ItrKted to II'"Itll' magotlium derlCitncy: Mild-to-modera~
h)1lOl1li9ot\e11lia is lreattd with oral forms of mag~iJm IIKh as migotlium
ghKOnillt or mag~iJm h)droride.
Contraindi cdions: Magneium iscootraindiuted in patitnu with serious (,Jrdiac: d~ill'. Or.1 adminismtion is (oolraindiuttd in paOOlI with undi'gnosed .bdominal pain, intestinal obstruction, or 001 impaction. Iht dlllC)
should ill' UsM (,Jutious~ in patiffits with It'ul imp.irmtnt b.iIM tilt dlllC)
m.y pid~ list to toxic: 1rYeIs.

ADMINlSTRATION ALERTS
Cootinuous~ monitor tM patitnt during IV infusion far NrI)- signs of de(It'aIe<i (,J rdiac: fuoction.
Monitor ~rum m'glltsium ~k mry 6 h during pa.t nlml infusion.
When gJYill91V infusion, gil' lI'quill'd doll' O'/ tr 4 h.
PlI'9n.ncymtgoryA

F PHARMACOKINETICS
On~t: 1 ~2 h1'0; 1 h 1M
f'eilk:Unknown
H. Iflife:Unknown
Duration: 1-4 h1'0;30 min IV

INTERACTIONS
Drug-Drug: lJ5f with fIl'II"OIIlI/IIUar bIodHl may iocJNlf J@ijIiaICJ)'dfpm.lion
olOd .~. eooo.Jl'OI!Mof ~withakoholor other CN, dtpil'!wnI'; may
INdtoilKlNlfd Ifdation. ~ sam may IiKJNlfw abIorption 01" rntain
",ti~nIKtim such;>\ t"'raqdi ...
lib Tem:UoUlolrm
Herba VFood: MagneWn sam may deauwo W abIorption of (fI~n am.
inflouiv5llKh ill mracydilf.
Trrat mt nl of Imrdos!: Strious rr-spiralary ,nd cardiac: supp~sian m.y reuk
from ol'ffllole. CikiJmglucOn.J~ or 91uctptatt m.y ill' .dministt red IV iI. n
.nlido~.

9t!fPr Ie M)M!I! IngIJ1 for Q Nlml"9 Pn:ms f/KJJ5 lpKlk Ie ,iris mlMrlI.

TABLE 42.6 1 Microminerals

Func:don

Tr.ce Minerai

'DA

.....

0.05 - 2.01119

Potentiatrl inwin.nd iI OI'm~ for pl{llltf gixo" mtt.boIism

0.1 ""9

Cofactor for viI.llin Bu and If'Itr.1 oxida!il'l' tnzyme

Cofactor for htmoglobin S)Tltheis

dmnilln

"""
"'-

15 ~1.01ll9

ftuoriOl'

15-4.01119

;~

lSOmc:g
Men:lO-12mg
Worntn: 10-15 mg

.... ng.OI'"

2 -~

md""~

75- 2501119
Mtn:50-70meg
Womtn: 50-55 meg
12- 151119

ltim!lll

,.

""1

hflutllCf:! tooth ROKIlR.nd poI~bty .ffK!sgrowth

Corrponenl 0( thyroid hormone
Corrponenl 0( htrlUHJlobin .nd IOIIIt trIlYmrl of oxidativr Jiloljilorylation
Colan.. in '''''.. tnZyme 0( lpid, GlrbMy<irn .. ..,dprottin ,,,,,.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.
Iron is an essential micromineral thai is most closelyassociated 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-

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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.
Iodine is a trace mineral needed to synthesize thyroid hormone. The most oommon source of dietary iodine is iodized
salt. When dietary intake of iodine is low, hypothyroidism

650

UnliT

lheGisUolntfltl~lS)lstem

occurs and enl.oJrgement of the thyroid gland (goiter) results.

At high concentrations, iodine suppresses thyroid function.
Lugo/'s 5O/u rion, a mixture coo tlining 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 o f thyroid
hormone and is indicated for patients hav ing an acute thyroid ern;". Rodioac ti." iodi n( (1- 1)1 ) i, siv<: n to datroy
overactive thyroid glands. Pharmacotherapeutic uses of iodine 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 iothalamate and diatrizoat~ are very d ense and seT\'l' as diagIlO!it icmntrast agents in radiologic procedure5 ofthe urinary
and cardiovascular systems. The role of potassiu m iodide in
protecting the thyroid gland during acute rndiation u]>05ure
is discussed in cha pter JOO.
Fluorine is a t(:lce mineral found ab undantly in nature and
is best known fo r its benefidal effects on bones and teeth. Research has validated thai adding fluorid e to the water supply
in very small amounts ( I part per billion ) ca n reduce the incidence 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 to pialUy by dental professionals. Sodium
fluoride and stannous fluoride are components of most
toothpastes and o(:l.] rin ses. 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 enzym es, including alcohol dehydrogen3se, carbonic anhydrase, and alkaline
phosphata se. 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 imm unity. Because symptoms of zinc deficiency are often nonSpedrK, diagnosis is usually confirmed by a serum zinc level of less tha n 70 mCg/dL Zinc
sulfate, zinc acetate, and zinc gluconate are available to prevent and treatdefKiency states,at dosesof 60 to 120 mg/day.
In addition , lotenges cont3ini ng zinc are available arc for
trealing sore throa ts and symptoms of the common cold.

NUTRITIONAL SUPPLEMENTS
The nurse will enco unter many patients who are undernourished. Major goals in resolving nut ritional deficiencie$ are to
identify the specific type of defici ency and supply the missing 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

"t

~mutritiOi is the ingestion or absorption offewer nutrients

than required for nonn31 body growth and maintenance.
Successful pharm3cotherapy of this con dition reli e5 on the
skills of the nurse in identifying the sym ptoms and ca uses of
the patient's und ernutrition.

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Causes of undernutrition r:mSe from th e s imple to th e

complex, and include the following:
Advanced age
. HIV-AIDS
Alcoholism
Burns
- Cancer
- Chronic inflamma tory bowel d isease (180)
Eating disorders

GI d isorders
Chronic neurologic d isease such as progressive
d~phagia and multiple sd~ros is
Surgery
Trauma
The most obvious ca USC' 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. Oinka l 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 termin al disease, patients may be
comatose or otherwise un3ble to take food orally. Although
the etiologies differ, patients with insuffident intake exhib it
a similar pattern of general weakness, muscle wasting, and
loss of subcutaneous fat.
When the undernutrition is caused by lack of one spec ific
nutrient , vitamin, or mineral , the d isorder is more difficult
to diagnose. Patients may beon a fad diet lacking ooly protein o r fat in their in take. Cenain d igestive d isorders may
lead to malabsorption of spec ific nu trients or vitamins. Pa lients may simply avoid certain foods such as green leafy
vegetables, dairy products,or meat produc ts, which can lead
to specific nutritional deficieocie5. Proper pharmacotherapy requires the expert knowledge atld assessment skills of
the nurse, and sometimes a nutrilional consul l, so that the
correct treatment can be 2dmin " t~ red.

42.11 Enteral Nutrition

Numerous nutritional supplements are al'2iLab le, and a
common method of classifying these ag~ nt s is by their 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 co nditio n permits , enteral nutrition is
best provided by oral cons umpti on. Oral feedin g aUows n3tural digestive processes to occu r and requires less intense
llur,ill!! ""1[1:. It J""" IIU W"""', Idy Ull Valie"l ~uul"'r~tiuJl,
because it is not feasible for the heal th Clre provider to observe the patient at every meal.
Tube feeding, or enteral tube aJiment~ tion, 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 amoun t of enteral nu trition the patient receives ca n

CIIop1tr 42

be precisely measured and recorded. Various tu~ feeding

routes are possible. including nasogastric (nose to stom adl), nasoduodenal (nose to duodenum), nasojejunal (nose
to jejunum) ,gastrostomy. or jejunostomy (tu~ is placed di~
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 nasoduode~
naI and nasojejunal tubes are usually inserted by a radiologist o r 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 severa l different me!hods are used. A simple
method is to classify enteral prodUCIS ;IS oligomeric, polymeric, 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 fistul ...., 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-

"~.

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 failure. or a spific genetic enzyme
dt'ficiency. Sample products [n<:lude Amin-Aid, HepaticAid 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.1p' I!'I1te... l nutritiOl (TPN), or hy.
peralimentation, is indicated. For short-term therapy, peripht'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 candidates for centra l vein TPN. Because tht GI tr3(t is not being 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.

Modulllr formulas contain a single nutrient, prott'in,

Lipid.or carbohydrate. While not designed to serve as a

NURSING PROCESS FOCUS

PATIENTS RECEIVING ENTERAL AND PARENTERAL NUTRITION

Assessm ent
Btitlint aiKliment prigrtgIdminlitrlllOl'l:
Undtnttnd the ~tiOO lilt drug hiS bttn p~ribed in ordtllD ilSSHS fol
thelilptUlic: tIIeru (t.g.. short- ollo"9'tetm thela~. undtllyu'o!l heillth
d~onlm).
o

o
o
o

Obtain iI complett hNlth h~tory induding Cilldicwi\Cular,~roIogic,

!'I1dor:rinr,hflHtit, Of Itnal distast.Obtain iI dlU9 h~tory in(kiding allergirs,
currmt pm<riplion .nd OK drugs. herbal prtp"'tion~ akobol LIst.or
smoking.Be illtrt to possible drug intef.(!ion~
Obtain. dietary h~tory noting the.bility to"t ilnd tlk~ ~dtqJilt~ flum.
Obtain b.iselin~ height, ~ight.and vitll ~ns.
['fiIllIol~ i1ppropriollt lilboratory findillgs {~.g" (B(, ele<t~ff, gluclKf, BU II.
hepitiund rm.J1 funo;tion studin,. total p!Ot~in, 5ef\Im libumill,ipid ~Iofile.
stMn iron 1rIttb).

Po tential Nu rsi ng D1IIg no5es

Imbaiano;rd Nutrition: L~s TIIIn Body Rtqui~ments

Defici!'I1t KnowIedg~ {drug the!i1pyl
Risk for Imb.ililnttd FkJidVolume
Risk for Infr(!ion

{COIIrInutdJ

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6 52

Unlt7 TheGaslrolnt..,tI,..1 System

NURSING PROCESS FOCUS

PATIENTS RECEIVING ENTERAL AND PARENTERAL NUTRITION /Conrlllu~J

Assess ment

Potential Nursing Di agnoses

Assessment throughout administration:

Aslffi lOr desirtd therapeutic: rfftcts dependent on thr INson for thr drug
(r.g., weight is maintaintcl.rlearolytrl,gllKo~, protein~ lipid ~k rrmain
within normal limits).
Cominur monitoring of ~itJl ligm,.nd periodit lab I'iIlue! al appropriate.
Weigh dai~ at thr same lime mh day and rrcord.
Aslffi lOr and prompt~ re-pon adl'!'~ effras:~~ nauIN,vomiting.
tadlyun:li.l,palpitation~ hypoteosion,d~u,drowsinrss, diuinrs~

disorientation, hypJ. or hyprl9l){emia, and electrolyte imbalaMrs.

Planning: Patient Goalsllnd Expected Outcomes
Thr palient will:
ExpeMlKe therapeulic rifrcts (r.g., maimenalKr or improl'!'lllemof 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, and rtquirrd prruutions.
~monmue 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
~rrneolAsSl'ls all ac:{rss sitrs (r.q.,~IIric: tuhrsitr,lVor pon sitrs)
frrqurmly for rrdnes~ streaking, swrlting. or drainagr. Rrport any leI'!'!,
[hilk,malaill',or [hangrs in Inrmal status immrdi.lttl~. (Entrral and
pareotml nutritional rrpla[emeot [onlains high gkKose, protrin,and lipid
IOUKfI that may stlvr ilIa rrlffilOir lor infection.M(rss ~tes may also stl'le
as a poinHI-rntryfor inieuion.)

Patient a nd 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 patieo~ lami~, orurrgiYer to immtdiatr~ rrport alTj Itve~

dJiII~ unuswl dJangrs to thrac:{rss IiR.or{hangrs in tiM' IrI'I'I of
mllS(iousness to thr iM'ahh (lire providrt

Usr mid ilSl'ptK ttchniqur with all IV tubing or bag [hangr~ and sile
drrs~ng (hangrs. Relrigeratr thr TPN IOknion until 10 mirutrs !lfloft' using
ind st~ riIIlra emml formula in thr rrlrigerator alteropeoing. (Infusion
and ac:(rss ~tes ilrr at high risk fordtvtlopmrnt ofinieuion and must hr
monitorrd frr"",ntly. Soknions ,md mrafonnula must hr ft'frigeraltd to
inhibit baurri.llgrowth.)

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.

Monitor blood gU!:osr Itvrls.Obsern for ~gns ofhyperglytrmia or

h)<poglyt:rmia i nd obtain u pillaI)' 91(1[OSl' irI'I'k is ordrrrd. (Blood glll[OSI'
Ir~k may hr affratd ifTPNoremeralldingisstopped,tflrratr isrrdlKrd,
or is depeodem on other mrdic:.IIions tiM' patient is ta I:i ng. Supplrrnrmal
insulin, !Ulxutanrous~ or added to thr IV IOknion,mayhr ft'qJirrd)

InslnKl Ihr patient on thr III'rd for frrqueot gl(l[OSI' monitoring.Tud! the
patirm, la mill', or Llrrgi~rr to IfIIOn signs of h)<pergl){rmia (mrssiYe thirs~
mpious urinalion, and insati.blt hungrr) or h)'poglyt:emia (nervousness,
initabilil~, and diuinm) promptly.
InstnKt tflr patieo~ lami~, or urrgiYer in thr tKhniqlK' to monitorupillary
gUmsr, IoIlowrd by rMUrn-demonstration, ij tiM' ))aIirnt will hr on nutrition
rrplai:rmrot at home.

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 prrswrr,d~ra,orrrlrrna will assist in qJiddy noting advrrst
rffKtsJ

InstnKt thr patieo~ lami~, or urrgiYer to immtdialrly rrport shonnrs! of

brrath, heart palpitations, I'M'lting, decn'aSI'd uriIII' outpu~ disorientation, or
mnfusion.

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IlIopltl41

NURSING PROCESS FOCUS

OruqslorNutr~"""'IO""rd<>"

653

PATIENTS RECEIVING ENTERAL AND PARENTERAL NUTRITION (ContimJedJ

Implementation

Interve nti o ns and (Rati o nale s)

Patie nt a nd Fa mily Edu cati o n

Monitor ren,1 lIalUS.(intae and output "tio,cIaily wfigln,and I,boratory

lIudies sIKh <IS ~rum (J('atinin~ <lnd BUN should he mOllitOlfd.)

Maintain a(ruratt ffit~ral 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! precis~ rontrol OY!'r ffitl'l,1 fe~ding 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 ~emtnt btIore adminiltrriog ~ny

fffiiing.!Propl'l" ruhe illSfrtion Ihoold he confirmed racliog"phiully before

any fffiiing is initiatN.COIIfinn,rion of plac:rmem by obll'lVing th~
(haroKtemtiaof thegaltrK .!Spirat~ or pH may he uS!'d to (Ollfinn

ImtnKt the p,titont on home therapy to'Migh ~f 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 ~qJipment US!'d and the nI'~d for
frequent monitoring. If using homefquipment,enlUft' the proper iull(tioning
of fquipl1ll'nt and th~ proper US!' by the patitn~ family, or ufl'gi-m.

Explain the ratiolhlle for (heciing tube ~rllll'nt priorto m hiecdingto the:
patien~ family, oruregiY!'r.lfhol1ll' enteral therapy is ordtrtd, teoKh the
patien~ family, or ufI'giYl'l the appropriate m~thods ior(hecking pIoKffiIerlt
prior to fffiling.

...- 1
Patient unMrstanding of drug therapy;
US!' opportunititol during administration of m~diutionsand during
.!S!eSS/mtts to discUlS the rationale for drug therapy, ~fI'd 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 th~ patitont, f,mily,orureg~r
in the proper Sl'1f...Jdminismtion of the drug. ~.g., taken with addition,1
tkliIh. (PIQptr administration.an impWlt the tf'le(tireneHOlthedrugl.)

Tht p,titont, family,orwtg~r should lit ab~ 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 ~ngth of medication therapy.

The p,titont and f~mily or ufI'giver aft' ,bit to discussappropnate dosing and
administration nl'l'ris.
The patient, family,or.areg~r is able to ~rurn-dernollStrate appropriate
dosing. ,nd administration and mr of mtlssiltl ,nd IUb~s prior to home
us~.

Evaluation of Outcome Criteria

E'/aluat~ the effectiYerltu of drug

-r- -

~~~" ~

therapy by confinning that ~titont goalland fXpKted OU\(om~ haY!' bten met (~"lanning").

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. Deficiency 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). ~quantities oflipidsoluble 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.

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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 occur 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 indications for pharmacotherapy with water-soluble vitamins.

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.

42.11 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 supplying nutrilion to patients via a peripheral vein {short
lerm} or central vein (long term).

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

An older adult has been diagnosed with pernicious anemi3 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

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

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

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
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

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 historyofrenal calculi. The only medication the patient lakes is a daily

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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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UN I T

The Endocrine

System

CHAPTER 43

Drugs for Pituita ry, Thyroid, and Adrenal Disorders

CHAPTER 44

Drugs for Diabetes Mellitus

CHAPTER4S

Drugs for Disorders and Conditions of the Female Reproductive System

CHAPTER 46

Drugs for Disorders and Conditions of the Male Reproductive System

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Drugs for Pitu itary, Thyroid,

and Adrenal Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES

HYPOTHALAMIC AND PITUITARY DRUGS p!XJ'6(iJ

Afrer froding lhis chapter, the sNdent should be able /0:

HYPOTHALAMIC AGENTS fIIlIJ'6(iJ

Anterior Pitull~ry Agents p]'66iJ
Q dwnop~in (DDAW,Slimar~

1. [)@scribethegeneralstructureandfunctionsoftheendocrinesystem.

pIlIJtM I

THYROID DRUGS p!JIJ'66l

Th)Told Agents ptJIJ! 66]

o ItvorhyroKin. (~VOIhroi4 Synrhroid,

ofhoon) fllJl/'664

AntHhyrold Agenls !"9"66J

o propylrhiouroc:iI (PTU) fX1I}t661

ADRENALDRUGS fXkJ' 667

feedback in the endocrine system.

3. Cl@scribethedinicalapplicationsofthehypothalamic and pituitary
hormones.

4.
S.
6.

Glu(ororticolds p!JIJ'6J(J

o hydrocorlisOM ((orlPt HydrocorrOM,

olh<>nl {JIJIJ' 67J

Antiadrenal Agents

2 . Through t he use of a specific example,explain the concept of negative

7.

Explain the pharmacotherapy o f diabetes insipidus.

Identify the signs and symptoms of hypothyroidism and
hyperthyroidism.
Explain the pharmacotherapy of thyroid disorders.
D.!scribe the signs and symptoms of Addison's disease and Cushing's
syndrome.

8. Explain the pharmacotherapy o f adrenal gland disorders.

9. Dt>scribe t he nurse's role in t he pharmacologic management of

fX1Y 611

10.

11 .

pituitary, thyroid,and adrenal disorders.

Foreach of the (lasses listed in Drugs ata Glance,know re presentative
drugs, and explain t he mechanisms of drug action, primary actions, and
important adverse effects.
Use the nursing process to care for patients who are receiving drug
t herapy for pituitary, thyroid, and adrenal disorders.

KEY TERMS
Addison's disuse fX1IJ'611

diabftes in~pidus p!l1'66 1

adenohypoph~is fX1J'657

fon i: ular ~lk p!l1'66i

. dr. II.lOlliu l in,.mu.n<,

G' . ... di

fII1!' 61IJ

adnono(oniu tropir honnone (ACTH(

.lntidiuretir honnone (ADH ) poqt661
bualmetaboliuat e poqt661
Cushing's synd rome fIIlIJ'6n

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fIIl1'61O

[1JIJ'66J

hormone fllXT 657

rnyxedf ma p!l1'66J
neurohypophysis p!l1'657

parafollirularcells [1JIJ' tiS l

rt'leasing hormone p!l1'657
, IHr,I . ldlu ", p!l1'6'~
~matoUl)pin fII1J' 659

thyroid storm fII1J'66l

thyroxin~bindin9 globulin (TBG) p!l1' 66J

IlIoplfl41

0nJ9' 10, P~ulury. Thy,oId,.nd Ad .......1Ol..,rder,

657

ike the nervous system, the endocrine system is a major

controller of homeostasis. Whereas a nerve exerts instanPineal gland

Hypolhalam.JS
Pilu~ary gland

taneous control over a single muscle fiber or gland, a hormone 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 endocrine 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 ofhormones 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 normal. 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 oxytocin, 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 hormone. For example, as serum calcium levels fall, VfH is released; VfH causes an increase in serum calcium, which
provides feedback to the parathyroid glands to shut off PTH
secretion. This characteristic feature of endocrine homeostasis is known as negative feedback. Negative feedback
helps to prevent excessive secretion of hormones thereby
limiting their physiologic responses.1t is important to unden;tand that when a hormone is administered as pharmacotherapy, 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 hypothalamus sa:retes rrlrasing hormonfs that travel via blood vessels a
short distance to the pituitary gland. These releasing hormones specify which hormone is to be released by the pituitary. After secretion, the pituitary honnone travels to its
target tissues to cause its biologic effects. For example, the hypothalamus secretes thyrotropin-releasing hormone (TRH)

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,. Figure 43.1 The endOCrine system

source: IWr!JJfl Erumr/oiVPHCDlIge.

that travels to the pituitary gland with the message to secrete
thyroid-stimulating ho rmone (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~li7...-l

a. an integratedllni!.

The pituitary gland comprises two distinct regions. The

anterior pituitary, or .denohypophysis, consists of glarldular tisme and secretes adrenocorticotropic hormone (ACfH ),
thyroid-stimulating hormone (TSH), growth hormone, prolactin, 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 female reproductive truct are presented in chapter 4500. Selected hormones associated with the hypothalamll'i and
pituitary gland are shown in ,. Figure 43.2.

An~erior

pHuilluy

.....

~~:~---f L_,~::~""1
Ad ..... lgland

Thyroid gland

Ii=>

G"."' . . . . ,GH}-/

Bone, mu.de,
ot.er ~iuues

,,,.,,"',,,,, ~ ~

......., .......
I

---~ Testo5Ieltlne
185105

Ovari...
,. Flgure.fl.2 Hormones associated with the hypothala mus and the pitui tary gland

Sour(/': PearsonEducaf/oo/PHCalege,

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Dopttr (I

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 quantities of their own endogenous homlOnes. Examples of replacement 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 functioning. 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 ar~ used in cancer chemotherapy to shrink
the size of hormone-sensitive twnors. Examples include
testosterone for breast cancer and estrogen for testicular cancer. Exactly how th~ hormones produce their antineoplastic
action is largely unkoown. Vthen hormones are used as antineoplastics, their doses far e."Keed normal physiologic lewis.
Hormones are always used in combination with other antineoplastic 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 action 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 of~an
tihormones." These hormone antagonists block the actions
of endogenous hormones. For example, propylthiouracil

AVOtDtNG MEDt CATtON ERR ORS

A Ift",","rr

inf~nt

weigh. 2,000 9- Tbt ookr is fur

,hlor.mph~ni<oI

((hloro~in) lS mg!kg.'!lay i dministerrd in twofqwll)'dividtd ooln.The

nurst administers SO mg iorlhe 10:00 a.m.oost.l'l !hit th~ ((IIIK! dos~l

5tl'AppmdIx DfllllIIt suggtlltdlllSlll'l'.

I:lr\'9' lor PRulmy. Thyrold..nd Ad....,.t OMIde"

(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
canc~rs (cha pter 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. Furthermore, 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 (G nRH). 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 advanced prostate cancer. Two pituitary hormones, prolactin
and oxytocin, affect the female reproductive system and are
discllssed in chapter 45 00. Corticotropin affects the adrenal 8land, and is discussed later in this chapter. Of the remaining, 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 hormone from human pituitary glands, which severely limited
the amoWlt available for pharmacotherapy. Human GH, somarolropin (Ao;; retropin, Genolropin, HWl1alrope, other~)
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 .. ~

AntialRnal~1I

Hypostu~ion:Addi5on~di~

Qurorortiroirk

Piwilall

Growth honnon~

l/ypost(rtIion:Yl\a1 SliJture

Somatmn (Protropin) and somatotropin (Gtnotropin)

Hypmtmlion:oKKIIl"ItO}Ily (adulI)

Ortrrotid!' (mdosLJtin)

.,...

An:idill"~ir hormonf

Hypost(rtlion:diabufS ~Ul

VasoprrSiin, dtsmopm~n, and Iypmsil

Thyroid honnont (T, andTJ

l\ypI'~ion:GrMs" di~a~

Propylthiouool( PlU), methimazolt (Taparole), and I-H1

Hypostuelion:m)"ll~ (olduks)

Th)TOid hormont, Itoiothyroxr.t, (TJ

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659

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

StD:UlintOUS; 100- 600 m(g/dily in two to fool dMdtd dose; may

switch to 1M drpcl! inj<ction , fir< 2 wht20 mg <Wry . wIc for 2mo

injt<1io. ,;r~ pdn, </.ekiirlUa>if

HYPOTHALAMIC AGENTS
octre01jdf, (~odo statin)

1iou5ltl, I'Omirilg,dit7rhto, ~ fluslir.g,

.......

~!!r!!tmID.(OI)IJffiiv h~!1 fiillfl'

pfgYiIorunt {Somivmj

StD:UI.ntOUS;40.mg Ioadng ~ tlltn 10 mgldily

(madOmgldiY)

linin

NaIl5tll,~rrfII4i~tcric:tJJilf!pain,flllfiktl~
L~r dilmag,!f'litrd nnloaminilt!MI!

ANTERIOR PITUITARY AGENTS

rortkotropin (ACTH)

IV; 10- 25 intma1ioni1 un~s in SOO ml OSW infUltda.'n' 8 h

50diJm and ~lPflffemion

roIYntropin (Cortrol)'ll)

IIMV;015 mg injKt~ Oftf 211in

(ushi!!!U~

lJIet.lsmnin (Inml9,lpluj

StD:UI.ntOUS (:;e:l yrund okirr): 05 mgIkg 000' diliIy, up to

1- 2 mglkgldily,ljl'ffi OIK~ diily

Inilionfire ~ iron de6(ffl()'oflmlkl.lJOirer,

ontibody dm/opment helldoche, hyptrrrophy of
Ildeooidl ~nd IOmiis

somatotropin (Aur~tropin,
Gffiotropin, H!lllittropt,
Norclitropin, tlnropin, Srrosim,

StD:UtintOUS;dostS M~ higtly individuililrd,baltd on. mile!'!

IJ'OWIh r.t~

IVn or ifJirion Jirr, hyPfrylytPmi4 r./hdrjo. m)'l1lgi~,

obckrnilol P(jn, oom mtI6o,. headache, l:Irrahilis,
hyporhyroidi5m, hyperfmlion, &J1ikt l)mpl'cml

HiI!Q!1!:!:(ffilY inuNlI'd intrac:rariil ~1I'!\u1I'

~ilrn,Zorbtil'f)

Ii
.
~
'j

TlrJrotropin (IIrJKI9ffi, thyroidlIimwting hormOlll' (TSH)

1M15UlKutJrItOUI; 10 interna~onallll~!/dily for 1- 3 diI)'!

NaU5ltl, htododt4: Q5!henio

Ug il:ligiIUItaIlll: lWiIlm

POSTERIOR PITUITARY AGENTS

Q

d6mopll'l~n (OOAVp'Stimat~ )

vasopm~n

InTrin.saI;O.I -<1.4 ml (lo-40nKg) in _ ToTh~dividtd 00sts

IV lStb:utin~; 2-4 nKg in t'M) divided doItl

1ItodtKhe, mua cmqmion or irrirorioo, oouseo

:tii!fr: ilWiWiIlo 1!I!IIi Iblllmwllllli, djlllllfl;

PO; O.H . mglday

hypolHlrtmii

1M l5UbtWrItOUI; 5- 10 uriu Iqueous soknoo two to foos Tim~!/day

I IV; O.HI. III~!/mill upTO IIIIit/min

rrtmor,pd~

mOil

MlmiriIg. WVrtrrtWllm

!.I( 1IoI!IIIIfIIf IIDIIlllxdnil;

*Hyporhalimk and pil!ilirY ~u ultd forrondiTionsofTh~ ftmal~ fl'productiv~ S'f5lffil.r~ pr~T~ in mapler 45 00.
Irdla indit.lT~ common adl'ffSt ftf~m;lIII1Wili!III. indiciT61trious idm~ ftI~m.

have closed. GH agenTs are usually well tolerated, although

patients must undergo regular assessments of glucose tolerance and thyroid function during pharmacotherapy.
Meas"rmin (Increl" x, Iplex) is" newer "sent,"pproved in
2005, thaT has the same actions as growth hormone. Mecasermin is indicated for the long-term treatment of growth failure 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 subculaneous roule. Adverse effects include hypoglycemia, headache, 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

LibraryPirate

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 parents 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 hormone, octreotide promoles fluid and el.ectrolyte reabsorption
from theGI traer and prolongs intestinal Transit time. It has limiTed applications in treating acromegaly in adults and in treating the severe diarrhea sometimes associated with meTastatic

cm:inoid tumors. Acromegaly mayaiso be treated with pq0somant (Somavert), a growth honnone-receptor antagonist.

lecting tubules to increase their permeability to water, thus

enhancing water reabsorption. Although it acts within minutes, vasopressin hal a short half-life that requires it to be
administered three to four times per day. Vasopressin tannate is formulated in peanut oil to increase its duration of
action. Vasopressin is llSually given 1M o r IV, although an intranasal 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.

ANTIDIURETIC HORMONE It is essential that the concentration 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, AD H conserves water in the body.
AD H 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 AD H secretion stops. ADH is also called vasopressin, because it hal the
ability to constrict blood vessels and raise blood pressure.
A deficiency in AD H 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 treatment of diabetes insipidus: vasopressin and desmopressin
(DDAVP,5timate).
Valopressin is a synthetic homlOne that has a structure
identical with that of human ADH . lt acts on the renal col-

.... Prototype Drug

43.5 Normal Function

of the Thyroid Gla nd

The thyroid gland secretes hormones that affect nearly every
cen in the hody. Thyroid hormone io" rea ." ", ha ..1ITN'ubnl ir
rate, the baseline speed at which cells perform their functions. By increasing cellular metabolism, this hormone increases body temperature. Adequate secretion of thyroid
hormone is also necessary for the normal growth and development in infants and children, including mental development 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 secrete different homlOnes. Parafomrularcflls secrete calcitonin, a

Desmopressin (DDAVP, St/mate)

Therapeutic (lass: Antidiuretic hormone replacement

Pharmacologic (lass: Vasopressin analog

ACTIONS AND USES

D~MIIO[llffiin is ~ s)'IIthetic analog of human ADH lhat aru on tilt kidllt)'S to in(INS~ th~ rrabsorption of water. It is USfd to (ontroltht Uti' S)'m ptom! of dia~t~s insipidus in patitnt! who hav~ inlUfficitnt ADH mrrlion. Tht oral rout~
is plt'f~rrft!, akhough inmnua~ thinaltu~ naSiI spray, and parrnteral folllll
<l rt avaiiabit. k hu a ruralion of action of up to 20 hoo~, wherm moprffiin
(Pitll'Ssin) hal a duration of only 2- 8 hou~.
Dtsmoprrnin (~ (mlfaction of smooth mU\d~ in tile "lal(uiar 1)"I1I'm,
uterus,and GI tfiK1.1t also produc:~ an inO"NW' in (lotting factor VIII <lnd on
Willebrand"! factor, and is thUl indicated for tht rnanigtl1ll'nt ofbftding in Poltitnll 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 ~ministerrd IV for diabrl~s insipidus, desrnoplI'Ssin is givtll undilutt<! 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

AOVERSEEFFECTS
~opmsin (an cau W'symptormofwater intoJ:ication:drowsi~~ hNdac:ht,
and listitlllll'ss, proejll'Ssing to (OIIl'Ulsions and (orna.Otlltr ~eflem indUlk transitnt lItadacllt, nauW'a, mild abdominal p.ain and mmping, facwl
llulhing, hypertension, p.ain, or ~Iing at injection site. Intranasal forms can
(aIM nasal (ongtltion, rhinitis,ind epistuis. Toltrancr oieYmpslO th~ e~m
of rlesmopmsin wilen it is administered rnorr frequtnlly than ~ry 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 WO~ !\rid rrII'ntion and o..moad It is uW'd with (aution in palitnlS with (oronary irtery disN il', hyptrtensiOll,and in p.atitnts al mk for hyponallt'mia or thrombi. Young
childrrn and thtolder aduhs should ~ trrut<! with caulion beciIM thm 11'1titnu <lit' mort' pron~ to wner intOlicalion and hyponatrrmw.
INTERACTIONS
Drug-Drug: lnarnfd antid~retic: oKtion can OU\I" with GlIbammpiIll',
(hlor[l~,dofibrate,and nonlleroidal iIl~~nllammator,OOigI IHS.I.IDsI.
OKlN5edan!i~ntKac:tion

GIIl o((llrwith lithium,aklilol.ht>parin,and

epineptri~.

Li bTi51S:Unmown

PHARMACOKINETICS
On~:lmmt<!iale IV; I h PO
Prak: IHOmin 1V;4-7h PO
Halflift:75min
Duration: lh 1V;S-lO h PO

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HN VFood:Unknown
Treat ment of OVfrdOS~: Ov!'rdos~ may (,JIM W'Y!'rr Wilt r intOlication.Trratmtnl ilKludei water rrstriction and osmotic diJrrtKs.

662

Unlt l The Er.docrl .... Sym'm

hormone that is involved with calciwn homeostasis

(chapter 47 00 ). Fdliculan~lIs 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 protein malnutrition or liver impairment, can lead to a larger
percentage of[reethyroid hormone, with subsequent symptoms of hyperthyroidism.
The secretion of thyroid homlOne is regulated by the hypothalamus and anterior pituitary gland by way of a negative feedback loop, as shown in .. Figure 43.3. When blood
levels of thyroid hormone are low, the hypothalamus secretes thyrotropin-releasing hormone ( TRH ). Secretion of
TRH stimulates the anterior pituitary to secrete thyroid
stimulating hormone (TS H). TSH, then, stimulates the thyroid to produce and secrete T, and T. As blood levels of thyroid 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.

o
e

"

NeUlOsecretDtY

cells ot hypothalatnl5

anterior

....

Neg"" ""

, "

THYROID AGENTS
Thyroid disorders are common and drug therapy is often
indicated. The correct dose of thyroid drug is highly individualized and requires careful, periodic adjustment. The
medications used to treat thyroid disease are listed in
Table 43.3.

o./
tncreased

metabolic .ate

in moot body c ..11o

". 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
PHARMFACTS

Thyroid Disorders
Hypothyroidism is 10 times mort mmmon in women;hypenhyroidism is
Sto 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: ~nk.
Ontof ~tf)' 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 oId~1 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.

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43.6 Pharmacotherapy
of Hypothyroidism
Hypothyroidism may result from either a poorly functioning 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

TABLE 43.3 1 Thyroid and Antithyroid Drugs

Route and Adult Dose (max dose where Indicated)

0""

Adwrw Effects

THYROID AGENTS
dtsir:Gilttd th)fOid (ArInoII', 8j,). Thyroid, ThyKid

Wtiglrrloss,lrtodhf,~

usp'othtrs)

mo~htorinroltrooce,

~oth)'l'OliM ~lforoIhroid, S)'nthroid,othn"s)

liotlrjronilt (C)'IOmrl, Trio5tJl)

imomnio, mfmrrod MytJ),m'rits

PO; 11-400 mOlfday

IlnrIMbmjal byptOernioo

PO;2>-75 mOJlday

IV; 2~ 100 III(g/day

lioiril IThyrdar)

PO; 125-30 mOl/day

ANTITHYROID AGENTS
m~himu. (lapuol~ )

PO;H,mgtid

potJl~!In ioddt and iodllt (LugoI'l Soh.-ion, PiIN,

PO; 250 rng tid

NilUltll,rasI!.prurilrJ~ Wl'i9hrgoirr,
hfadochf, fm! oomblltSJ in /ingtfJ,

lftj~dklfrOOl

SSK~ Thyro.8Iod:)

propylthiouracil (PTU)

lidioacti~

iodide (I. Bl,lodoIopI')

PO;300-450mqtid
PO;O.s-150 mG la Gor (I.-it iu lI"I~ oflidioa.ajy~,)

results generally reveal elevated TSH with diminished T,

and T. levels. The etiology of myxedema may include autoinunune 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 content. 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. Desiccated thyroid gland from beef, pork, or sheep sources (Thyroid USP) is an inexpensive option, although it is rarely used
because of the possibility of allergic reactions to animal prott'in. Liothyronine sodium is a short -acting synthetic form
of thyroid hormone that can be administered IV to individ-

LIFE SPAN CONSIDERATI O NS

Shih Workers, Hypothyroidism,

and Drug Compliance
Many bod, proc:ffirlllKh <IS tftllptratu~, blood plrllU~,1tft1s of certaio
honnonrl, biochemical pnxm~s,andalennrlS fludwteon a 24.flour Khtdule MaNn as th~ drradia! rbyllrm. Cirtadiao pnx~~ <I~ thought to br 1f9ulated b)o daylight. Normal ciKadian C){1rs Ina)' br imflTUpttd io tholr ptOple
who 'M)flmrird Ihift~ Thertfo~, mtdicatiom that mUlt br given at a sptcirtrd timr to t nhalKe t~ir potrmial elF! (.10 bra <OlKrm for Ihift ......nns.
for enmple. thyroid mrdiution is brll gmo at the I.lme time Nch rIa)o,
usua I~ on .!Wakffiing. br<aul!' it (.I ndisrupt slerp if ta~n later in the da,. But
for Ihift worms who rota1~ Ihilt:i, <lnd t~rtfOft' awakffi at diff~rent timrs,
this conlistent dosing Khtdule Giln br <I dlallenge. Advisr patients of this chal
1I'ngt. and hal' tflrm work with the ~akh (.1ft' providl'r to ~<I{h <I mtdication IChtdult that allows optimization of th~ drug effNn.

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uals with myxedema coma. The short duration of action allows 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
~SO low and go slow,~ because there is a risk for inducing
acute coronary syndromes in susceptible individuals. Replacement therapy for most patients is continued lifelong.

ANTITHYROID AGENTS
Medications are often used to treat the cause of hyperthyroidism 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: increased body metabolism, tachycardia, weight loss, elevated
body temperature, and anxiety. The most common type of
hyperthyroidism is called Graves'd ilrase. Considered an autoimmune 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 between the ages of 30 and 40. Other causes of hyperthyroidism 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.

664

Unlt l

Th~EOOo<rI .... 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 synt~tK form ofT, thlt ~ I drug of ,hoice for ~plamlll'm
tlltra py in patients with low thyroid fulKtion. Action s a~ 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 ~","SI' ~ts,dom of ImIthyroxine I~ highly individwlizfd for
each pa~nt. When gim by tilt oral route, 1~1 weeks may be rtqUirtd to obtain full theraptUtK btntfits. DOlts for p;ltitnts with prHx~ting cardi.l{ d~
tom a~ uswlly ilKl"Nlofd at 4-6 week intervals to mlid triggering
d),!mythmi.lsor angillil att.Kks.Strum TSH leYelsa~ rtgUlarty monitoml todetmnine whttht r the patitm ~ m:riviog suHKitnt ItYothytOJine-high TSH
IeYeis usull~ indiott t!wt tht dos.aqeofT, rftds to he ilKrulofd.
ADMINISTRATION ALERTS
Administef the medication at the Sollnt hint el'tf)' day, p~mbly in the
morning to dKlUse tht pok'nti.ll for insomnia.
P~oalK)' cattgOry A

PHARMACOKINETICS
On""l: 3- 5 I" (ordl), 24 to (IV)
Pea k:3-.4 wk
Half~ife: 6-7 cia)'!
Duration: 1 ~3 wIc

ADVERSE EFFECTS
Attlltlil peutKd=s, adl'ffSe ~Is oflewthYlOJ:ine tlltr~ py a~ ra~,~ hhough
U~ must he taktn to avoid OYertnoatmt nl Ad"mSl' tl~cts a~ thOSl' of hyperth)oroidism and inc:lude p;llpitaDoos, dyvhythmi.l~ ~ruo:itry, iOlOlllnia, weight
Ios~ and h~at intolel1lKf. Men!tnJal irR'9ulariti~s may OC{lJr in hma~ and
Iong-tt nn U\I' 01 ImIthyroxine !ws bft>n aslO(i.lied with osteoporosis in
women.
Contraindications: l.tfOthyroxine ~ contraindKatfd if t~ patient ~ hyperSl'llsitive to the drug, ~ optril'lKiog thyrotoxKosis, or h~s sel'm (ardioval(ul~r
conditions or arute lIl)'ocardial inlarrtion (Mil. If gmn to p;ltitnts with ad~MI
insu/frc:itncy, th)'Jllid hormone may (~lM a serious ~~oa krisis; thus, the insufficiency should bt {ometed prior to ~minimation of Ievothyroxine.1i should
he ulofd with (aution in pa~nts with urdiac: dM~ SI', h)optnt osion, oIdtr
~duhs, and impaimi kidney function. Symptoms of di~bttH mellitus ma)' bt
WOMned with ~min~mtion of thyroid hormone ~ nd dole of ~ ntidiabttK
dlllCJS may ~ui~ ~justmtnt. L.ewthyroxint has I bIad boJ warning t!wt it ~
illl'iftctift for wtight miudion and can bt potrotially IOIK wlltn ulofd with
~nom:tK drugs.
INTERACTIONS

"""""ion

1:nJg_1:nJg:(hoIoItJ""flli"" ~nd aoIo.mpoi dorrN<t tho

of ~)O'o,; ...
(QiI(lIll'Ot mniruation of I'piIfpIIrWMIII ~ilKrN115 thfriskol
W i( in!itfidflKJ Lmiltyroxi.. inmasfs tJlf ff1Kn 01 mOt, resultilg in an
illUN!fd risk 01 tw!iog.

tab Te ll: tktoown

HerbaVFood:\.o)tIean IkIII" anlant formula), coctortsefd mNI,walnuts, 0100 diftary
filfr may bind Ind d@muthoiblorptiooollM>iltyroxi.. lOdiumlromthfGl
100. ~mOfi"oo ~fm@Il!l!houkl ~ token it lPiII 4hem ift., utilg
k.roiIt)'roxiw to prMOt ill~.,.,;m drllll ~bsorption.

smous

T~tment ofOmdoSl': O\'!'~can caUSl'

th)orotOXKOSis, whKh may
not pR'Sl'muntil !e'Y!'ral da)'S ~lttr the OYtrdose. Trutllll'm~ symptomatic, U!U~I~

wgetfd at prevroting (Iidiao: toxicity with bttHdrtne"lK ~ maqon~ts

IU(h as propr~nolol.

RtII>r 10 MyMIsIniJD (llf ~ MIsJfIg PrIKts5 froIl spnt: 10 1M It!!g.

Very high levels of circulating thyroid hormone may cause

more readily than propylthiouracil and is contraindicated

thyroid darm. ~ mre, life_thr...Mening form ofhyp .. rthroidi.m .

in

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, progressing to coma ). Thyroid storm is treated with supportive
measures, efforts to reduce body temperature while trying to
avoid causing shivering, fluid, glucose and electrolyte replacement, and beta-adrenergic blockers. Antithyroid drugs
may be used to decrease thyroid hormone production.
Tht' two primary drugs for hyperthyroidism are propylthiouracil (PTU ) and methimazole (Tapazole). These rued
kations act by inhibiting the incorporation of iodine atoms
into T, and T. Methimazole hasa much longer half-life that
offers the advantage of less frequent dosing, altho ugh adverse effects can be more severe. Both drugs are pregnancy
cat"'!!ory D agents , but methimazole crosses the placenta

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 destroys 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 thyroidectom y. Sodium iodide may be administered IV (along with

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pT<'8n~nl

pati .. ot.<.

NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY WITH HYPOTHALAMIC

AND PITUITARY HORMONES

AH,u m, nt

Pote ntia l Nu rsing Diag noses

Baseline ~stSSlMllt prior to 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
noctun\iI~J.

Olll"in iI (ompR1~ t.e.kh histOly iMt.Jding ~t~trointtsIifII~

h~DI' mwI ~;p~r.OI blMt-lffdingJ)buin iI drucj listory
iKbIing ~0IntIIt prtSCriptiot'I illId OJ( drugs,ht!b.1I ptrp.llitiam,.
.oId lM,W wokiIg.8e.1eft to posWit drug in~Ktions.
miu.lw, ~k 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 b.~1/Ie heigllt ~i9/rt.ind viulligns.OWin u EClion pititn6
uking growtlJ hormone ilnI.gor.ists.

~t fU:I 'kIIImf
DUrrhea
DdirrdGrowtb.nd~
SitwlioNlLow SeIf..s1mn (INttd II MigI1c, ~1U!t)
Impairtd lIrinary EimiNtion (nortumll mmis)
Dmmt~(drugtbmpy)

ASStlllllfnt thRllghout ulmi nistr. tion:

A\~\ for dnired IherilpwlK tffe(Ud~dent on the rusan thr drug it
~ng givm kg.. _ r, blt ifKJtue in htigh~ slowed diurtSis, JtNrn to
norm,l urioe ootput and strum osmoltlity, rtturn to normal ~I iKtjyi~).
Continue ptriodic: monitoring of urint 1M IfI'Um osmolality, urine lPf(ifK
gravity. (BC,tlKtrolyt~,gkKost,ilnd htpatk and JeIlill function studits.
Continue monitoring viul signs.htighlilnd wtight.Monitor the ECG for
patim~ ukiog gJ<JWth hOfl'nont iI~nists.
oIdleSs for ildYmt flff<U: 'IMt1, wmiting.d~rrhea,loo 1\t.IILubf. HypoOf bypertfl1!ion,tadl)umi "dysmythnVi,Of ingilll ~ bf, rtpOfItd
immtdiatf t,.
Pla nni ng: Patie nt Goals a nd Expected Outco mes

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).
~M'fm.n.Ofnpmm;t min_~tftu..
Ymilirr In undfl\lindirlg of the dN(s 1I\t,~ tftu.and ~ p~.
Dnnomtmf p~ 1fI'1dminim-1rion of tile ~tion (t.g.,dost,m. .... wh~n II noIif1 pro"YicIrr).
Impl ementation
Intervention s and (Rational e s)
Ensuring tMrlpNtk ftfffiS:
PoritnIJ fIltinggrowflthormotlf: Monito! ~iIjIl iOO weight II 00 {~nical
visil.Repor\ Iict of groowth tothe llN~h (irt p~.(~k of groowth ,tiff
a jlfliod 01 mm~tent grllWth m11 matt tht dffllopmtnt 01 antibodifs
again! GH.)
PatitntJ rQkinggrowflthormOllf antQgmjsn: Monitor ,"tis of strum GH.
Monitor boweIlOUrm 1M for 1dtcrt11t in dianht,.(GH ,nugon~ts art
giwon for acromfgi t" Itwort di1nhN un respon ~wo 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 Pit~rrts"";th diabet~ imipi.:M,
monitor urineoulpul,uriflt 100 strum osmo"lity,100 urint sptcifio: gr,vity
for In/m 10 nonnallimits. 1f gi-ltn fo, OO{~ 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 ~mits.
W-tMg has)(owtd or slO9ptd.1

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Pati ent and family Ed uIti on

kid! m~ patitm. f, ...,., Of U"9Mrlo mnSlllt'oo It(ord height ind

wright wctkly.1Id bring tilt: ~nlto fKb dinial visit.
Imtnxtmr pilifnt on tht nmI to l!I:um periodiully for .. b
Imtnxt thf pilifnt to monitor output, pmidr mnsu,ing rquipmrnt ~
1ftded,Ind to kffpa It(ord 01 diily"ftigbt lnd output aoo bring t~
rt<Droto Nch prwider v~it.
Tta(h tht p:atifn~ f~mily,o, ('ffgim to urp' dial) of night-timt Iip
habits Ind any btdW!'tling. Limit ollilluicis within 4110urs ofbtdtimt.
Ad'iM tIlr plritnt of tilt: drug'lcost btfo~ br<;tinni"9 therapy.&plo~ t~
ability to moiinuin drug tIlmpyfo, tilt dU'iltion ol tllt trtatment
prtS(n"btd. NstSS filllnc:iaI {Onulm Ind providt 1pPIllpri.n~ social ItIYKf

won.

""'" """'"

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TheEr.doar .... SyS!,-""

NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY WITH HYPOTHALAMIC

AND PITUITARY HORMONES (Conrlnued)
Implementation

Inte rve ntion s and (Rationales)

Patient a nd Family Education

Minimizing ild'ftBf riffCts:

Monitor for il ny [omplaims of musdt,joint,or bont !)ain,!)arlKularly in thf
kn~ or hip, or aO)'(hanqtJ in gait(Awwlar ~lOIis is il na.dl'llf drug
tffKl of growth honn~.Inc:lffiiog or~tft' pain injoinuor(hangts in
gait should be rt porte<l promptly for follow-up evaluation.)

IMtnKt thf patifnl, family, oryrt9M-r to ft'pOIt any (hangtS in walkiog.

di\[omfon or !)ain in knefor hip joints. roOf !)ain,or(onlisttmmUl(it
!)ain oYer joint artill to tht hfilhh Wl' ptovidlor.

Monitorgl!Kolf tevm,!)artKUlarly in diabetK !)at~nts. Replrt [onsistl'flt

tlmtions to tht hfilhh wr providlor. (GH and GH antlgonisu may caUSt
inc:~illtl in gl!Kolf IewI. Diahftiu may ~ altffiltiolll in their normal
~Kation rootines ifhyptrgl)'[l'f!Iia O[ruB.)

IMtnKt the p.atifnt on thr IIfI'd to ft'lUm periodKally for lab work.
Tra.c:h thf diabetK!)at~nt to monitorypillal)' gkKOI~ IMIs m~
frtqUl'ntl~ during therap)'. Replrt an~ {onsistrnl Mvillion s in blood
gkKosr to the health (art provider.

CominUl'to roonitor vital iigns,fSpfflally pullf and blood plffiU~ for

!)at~ntI 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 rrttmion Itlndilry to ADH t~illmtflt may
Iud to inc:~illrd intrililsrular voIumr and hyprrtrnsion.)

IMtnKt 1~ p.atifnllo immrdiateiy IeplM pounding ~adac:hf,diuiness.

!)alpitations,or synmpe.
T_h thf patitn~ family,or [a~givef how to monitor pullfand blood
pIl'lSU~ ~ appropriatr.Ensurt thr proper UII' ilnd fimctioniog of any home
rquipmrnt obtairwd.
IMtnKt 1~ p.atifnllo monitoroutpul,providlo mrallJriog rquipmtfll IS
lIffiItd,and to borp a rffilrd of daily wright and output and bring tht ft'(ord
to ra.c:h provider visit

Monitor for Ygns of periphfral iso:hrmia or il ogina ind ~port immrdiately.

(VillOOlMtriction causrd by \\Isoprffiin may caUlf mdia( or periphfral
iso:hem ia, angina, or infarnion.)

IMtnKt lhf puifnl to immrdiatel~ IeplM any [~11 !)ain,!)ain Of

rumbnffi in tOl'S or fingers,or {Iampiog whfn walkiog to the hfahh [iI~
provider.

For pIItitnu takiog intranasal mMiution~ monitor nilsal tmlil9fS.RrPOrt

thmpy may atilt
naIiIl irritation and ukrration.)

Tra.c:h thf patitnt to Ieplrt niwl (ongtstion, irritation, in(INIf in nasill

di\[liarge,or nasal blrtding to thr health we provider.

CominUl'to roonitor nutritional ind fluid intau.(ChronK,lfVffl' diarrhfil

~uiriog tft'atmrnt with a growthhonroOf antagonist may l'fSult in
nutritional derlciu and dehydr.ltion until the diarrllea is (onffiM. Dietal)'
[oOlUkation may be ~qJi~.)

Enc:ouragt inc:rm ed fluid intabo,up to 2l per day, taun in ImjUl'nt small

'0)' aroriarion or bletding.(longterm imranalill ADH

Patient undtrstanding of drug thmp-,:

lIIf opponunitifS duriog idminimation of mrdic.nions ilnd dJing
ill SfS5l111'ntslo disulIS thf riltionait for drug ther.lp)', dfSi~ therap!'UIK
0UK0rTII'S, most romroon adver!f rifKIs. pIIramelrB for when to ull thf
hNhhyll' ~~and 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 puierr~ 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.)

.~~

Enc:ouragt ~al~ high-ulo!ie. Mril'fIt-deo!f meals rillhfr than largt,

infrequent mNts.
T~ p,l1ifnt should be ilbit 10 statr thf ~.I50n for l~drug.approprialt
dolt ilnd I(hfduliog.and whill ildvrn.r effls to obstrve for and whl'fI to
Ieplrt thfm.

Too tht p.lli.>rU t:I laizo thed~ a.:rording toappropMegu~~ blbM:

R onl1ilUte the j).Irrmml drug ~iI[tly per !)a,ugt dirrctions and do
oot shaR thf vial but rotalr gtmly toavoid b~lking down drug.
(lift'(! nasalsp~ high illo thf nasaiuvity rather than hack to thf
nasopharynx.Do IKt !hau thf nawl !prIY ~ using WI ro!alfgtnlly.
St~ any ullJlfd ft'(onllituted solutions in ~or. Nasill !prays
may be k!'pl at room trmperil1U~ but avoid tl[fSsive ~at ~r 8O'f.
Disurd any 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 Irhythms.
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 ha~ ~n mt! (s~Planning1.
5tf ~4J. l & l ,rorQIiIr!tutp III wIir~ rheltIlllMgocOOns~.

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Dl>p1fl41 Drug; /0, P~ulury.Thy'oId.~odAd"""'1 0"",<1<>"

propylthiouracil) to manage thyroid storm. Potassium iodide (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 affect every body tissue. Adrenal disorders include those resulting 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% epinephrine, with the renlainder of its secretion being norepinephrine. Adrenal release of t'pinephrine is triggered by
activation of the sympathetic division of the autonomic nervous system. These homlOnes are described in chapter 1]00.

.... Prototype Drug

667

The adrenal cortex secretes three classes of steroid hormones: the glucororticoids, mineralocorticoids, and gonadocorticoids. Collectively, the glucocorticoids and
mineralocorticoids are called corticosteroid5 or adre,lOcortiC<lJ hormones. The terms corticosteroid and glucocorticoid ue often used interch~ns""bly in clinical pr~ctice.
However, it should be Wlderstood that the term corticosteroid implies that a drug has both glucocorticoid and mineralocorticoid 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 secreted 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, resulting in hirsutism and masculinization, signs thai are more
noticeable in females than males. The physiologic effects of
androgens are detailed in chapter 4600.

I Propylthiouracil (PTU)

Therapeutic Class: Drug for hyperthyroidism

Pharmacologic Class: Antithyroid agent

ACTIONS AND USES

Prop)'lthioorlcil ~ idmin~tmd 10 patitnu with hypenhyroidiml. k am by inItrfering with the synthes~ofTl and1, in the thyroid gland.lt j llo prt'ltnll the
(oovenion ofT, lO TI inlhe l'rge\ MSU!'S.1ts Inion lI"Iiy IItdelaytd from SM'r,1
dI~ 10 U long as 6-12 M~In.EffKt; indude, 1I'1urn to Mrmil thyroid function: Wfight gain, II'dKtioo in inxiety,!t1S illlOOlnii, ind !JaMr pu~ 11I1e. Br(,lUll' it hu " short half-life, PTU ~ usually idmillisterrd ~ml timrs " rIajo.
Prop)'lthiourlcil ~ the pll'ferrrd intithyroid drug for liming thyroid starm.

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. Asmall
peKrnt'9t ofpatitnunptritrK~ iljrinulocytosis, which ~ its mosl serious 1rJ..
~ rilKI. Periodic Iabol1ltary blood (ounts and ISH value '''' rte(rsS.J ry to rsublish proprr~.
Contraindi (iltions: Propyithiourj(ilshouid not lit giYen during pll'9nancy or
Ij(tltion or to p.ititnts with koown or wspeard hyplthyroidism.

ADMINISTRATION ALERTS
Adminillerwith m!'"luo rrduc:r Gl d~tlffi.
PlI'9nillqutrgoryO

INTERAalONS
Dru;rDru;!: Prop)1IIiooool MHlf'i1hf iCIionI of antk~ whidi ~ri@I
ill OONIfd r~t of~dirlij.lodilf..l:on1iining iHj@flts ~iocIironf, potaIsiOOl
1CJIjdt, lOdium 1OIidf) and U,roKIlIcrnIJnts (0)11 naqooill' tIIf ~KIi_s 01 tIJS

dlllg.(IM~~ya({\Ir;"abou(~of)lil1ifntswhohiwf~i

h)"pflWllliti"Oily INffion to IIIfIhimazolf, Ihf otlM>r rn<4(f mtI!yroid mfdiatm

liI bTell:PropyIthioor.Kil mq ioofN protII"ombin titrE;nj irmR 1l'l000lMis

PHARMACOKINETICS
Onset: 30-40 min

of iSpiIlil! aminotronlfHalf IAlTI, m~ ilminor,amfflilSl' (ALD, and ilblilf

Iflk: 1- 1.5 h
Halflife: I- 2h
Duration:1-4 h

HerlJiIVFood: Unkncwn

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~Wl.

Treat ment of Overdou: Dvt-rdosr will WM signs of hypothyroid~m. T,e"'IIIfIIt indudfs a thyroid igtn~ "'ropilll' far brad)Urdia, ,, OOS)'lll ptomuic: tll'iIIIIfIIt as III'(rssary.

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Th~EOOo<rI .... Sy<!"",

NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY FOR THYROID DISORDERS,

THYROID REPLACEMENT AND ANTITHYROID DRUGS

Assessment

Potential Nursing Diagnoses

Bilst line Issessmtnt prior to administration:

Understand t~ rt~!On 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 dist~; pft'9nancy;or brtaMffiling. Obtain a drug history
inc:luding alltl9~, rurr~m pmcription and Ole drug~ hmlal pft'Polrations,
akohol USI', or smoking. ~ aim to plISiblt drug imtraaioos.
Enluatt appropriatt laboratol)' findings (t.g., T" T~and fSH 1tveIs, (8(,
platt ltts, fltctrolyte,. gllK=, and lipid It~k).
Obtain baltlilll' heigh~ weigh~and filal signs.Obuin an KG as nffdtd.

Activity IntoteranU'
FatigUl'
Constipation
De~t Knowledgf (drug tht r.lP,)
Riok for Infedion (1I'1attd to aomllfdrug effeds)

Asstssrntnt thro ughout administration:

Aslffi for dfsi~ thfraJlflltic: eff~1I dtptOdeot on the INIon t~drug is
bting gil'fO (f.g, T~ T"and TSH ~k 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, ~igh~ilnd weight Monitor t~ KG ill

""""

Aslffi for adYmr t!ff,m: nilUSN, VOln iting, diarrlltii, tpigastrK distres~
skin rillh, it(hing.lltadoKlIt, umymdia, palpitatiolll,dysrhythmial,
S"M'ating. nervotJllIl'IS, par6t~sias, tll'moJ1, in !Omnia, lItat intoleranc:t,
and angilY.Hyp~ CH hyptntnsion, tac:hlUrdia, 6 pt(iillly mooattd with
angina, \hoold bot II'pOntd immtdiattly.
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 (~.g., dOlf, timing, wlltn to notify pJO"tider).
Implementilltion
Interventions and (Rationill les)

Pilltient iIInd Family Educ ill tion

----II--

Ensuring thtrilpeutic tffeds:

Monitor vit~1 signs, appttitf, Wl'igh~ 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'
meoHu~ to oHSfIS thtr~pwtic: II'sponse to drug thmpy.)

AdYilfthe patient that tht drug will help to ltabililf thyroid hormone
Itvtls quKkl~, but lull t!ff(l\ maytakt a Wffkor longer toocrur.
InllnKt tilt patient to maintain (OOsistfOt doling during this initial period
to illiow t~drugto ft'ac:h thtrapeutic: Itvels.
InslI\Kt the patient 10 Wl'igh ItH t'NOto thref time! per Wl'ek and to
record t~ puhe rate.Bring tht lI'(ord of Wl'ight and puhe to eath provider
visit.

Monitor diet for iodinf<onta ining foods (e.g., iodized salt. roy sall<f, tofu,
109ur~ milk, llrawberrie,. tggs). (inuf,l\ing CH dt(ft'aling normill iodint
intake may ft'IUlt in ad'lme drug fflecll.)

Pl\lYidediet.iry iostllKtion on foods toavoid.Provide dietitian {Onsuitation

.n nffiltd.

Monitor thyroid IulKtion \I1I!s. (RfSUhl httpdttenninethtt!fedillfOtlSof

tilt drug thtrapy and tilt IIff<I for do\ige mangel.)

InllnKulit patient on tht IIff<I to II'IUm ptriadic:allyfor labwork.

Minimizing ildft rse rfftrts:

Monitor fCH II'IUm of original symptorm and II'port (onsistfnt oaurft'lKf.

(O~ily 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.)

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TN(h the patient that lInilll dail)' ilOOUilionl may o((u~6pf(ially ruring
ptriod\ of Itrffi or illlIl'Is.Any signifKilnt or inc:reilling d\a09fl in pulse
rate. weigh~ 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

o..pltl43 I:lnJ9' /0, pnult.,y,Thy,oId, ao<l Ad", ...1Disorder,

NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY FOR THYROID DISORDERS:

THYROID REPLACEMENT AND ANTITHYROID DRUGS (Continued)
Implementation

Interve nti o ns and (Rati o nales)

_ _ _+ patie nt a nd Family Edu cliti on

Monitor for signs of inlKlion, (Be aocl platelet (aunK (Antithyroid drugs
ma, talMaogranulocytomJ

Instruct the !)at~nt to I!'pon I_r, ra!he~ SOIl' throa~ (hills, malaise, or
weakness to the lItahh (1ft' provmr.

Monitor symptoms in olde, adults mOIl' frequently.(Older arulu al!' moft'

Itnsitioft' to thyroid I!'pla(l'II1ent tlltrapy. Minor (hangl's indaily thyroid
ieYels II\a)' cause <I significant mangl' in symptoms.)

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
chan~ in symptoms should ~ Il'portl'd to tilt IINlth care provider
prompd,.
-

Monitor serum gl(J(<m ~ls,nPfiially in patients with dia~tes.Diabetics

should monitor capillary !ems mOIl' freqUl'n~y. (Thyroid aocl antithyroid
drugs may tallll'{hangtl in gu.:osr Ie-Irls.)

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

[n!llft' !)at~ nt !<IfN)" rspecially in older adulu. Ol!sere lor diuin~SI aocl
monitor ambulation until tilt rflem olthr drug aft' known. (Dizzilll'SI may
~ 5f(oocIaf)' to (hanges in pIIl\t or blood ~!uI!'. Efircu of thyroid
hormonr on bone l\'IIlodeling II\a)' piau the !)at~nt at risk for frmu~J

Instruct the !)atienl tocall for mistalKe prior to ~ning 0lII of bed or
atll"nlpting to walk alone if dizzifltllO({II~
Assess tilt salety of the h~ environment and distun modifK.llions that
mi)' be IIffiIed with tilt lamily "ft'9il'l'f.

[nsul!' P<it~nt aocl uregiver ~fety if radiomNr iodinr is UIM (RadioactiYt

iodilll' provides Iow--Ou radi.ltion but prolonged contatt by IINlth cal!'
providers or visitors !hould ~ iWided.)

Trich tilt patienno limit wotan with fjmily to I hour perday per person
until the tl!'atmenl period is ~r. Young mildrrn aocl PlI'9nant WOflK'O
should avoid (Onia(\.
Advise the patienl to ifl{lNsr fluid intau and 10 void fre~mly to ,wid
irradiation 10 gonads from radiomil'i!)' in the uriIII'.
Instruct the !)alieni oot 10 expedorat~ and to co~r the mouth when
<oughi"'l.AnyconllmiOlt.dti....,. !hauld b< dispoord of pert .... protocol
of tilt hNkh carr provider.

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
OlII{omr~ 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

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.

al!'i~)

Patint selfadm inistriltio n of drug tht'ilpy:

Wlltn administer'ing thr medication,ioslOKt the patien~ 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.)

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 hofTll(l~ 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 !)at~m ~Isand "peded ouUomes haYl' been met!1fe Planning").

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6611

670

Unit. Thl'EIIdoaI .... Sy.lem

MINERALOCORTICOIDS
Aldosterone a.:COWlts for more than 95% of the mineralooorticoids secreted by the adrenals. The primary function of aldosterone 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 preferred drugs for treating hyperteru;ioll and heart failure
(chapters 23 and 24 00). Certain adrenal tumors cause excessive secretion of aldosterone, a condition known as hyper~1d05teronism, which is chm"lKterized by hypt'rtension and
hypokalemia.

Circadian rhythms

51.......

~
; -.
Hypolha1am.J5

e
(

Anl ... ior pitu~ary

Negaliva
Ioodback

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. Glucocorticoids affect the metabolism of nearly every cell and
prepare the body for long-term stress. The effects of glucocorticoids 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 hypothalamus. CRF travels to the pituitary where it causes the release of ad~n()(ll"lirotropic hormone' (ACTH). ACfH then truvels
through the blood to reach the adrenal oortex,causingit to release 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.

LibraryPirate

e
Adrenal corlex

G', ""'

Biological ellocto

51imulalion ~

Nag&live
tee<lba.d<.

!!!!!!)It-

,.. Flgure4J.4 Feedback control of the adrenal cortex

Lack of adequate glucocorticoid production, known as

.drtnocortic.l insufficit ncy. may be caused by either hyposecretion 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 challenge; the cause of the patient's adrenocortical insufficiency 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 patients with adrenocortical insufficiency and to dampen inflammatory and immune resporu;es. The glucocorticoids,
listed in Table 43.4, are one of the most widely prescribed
drug classes.

o..plfl4l Drug; /0, P~uIUry. Thyrold.~od Ad""",1 DIsoro.-"

671

TABLE 43.4 1 Selected Glucocorticoids

0""

Route and Adult DoSE' (max dose where Indicated)

AdverSE' Effects

PO; 20-300 mglda,

Sodumltluid rtr~_,
/JClN',lIllier~iIsomll4 mood

SHORT ACTING
{OItisoo~

hydllKortilone [(on~ l/yItoconone, o!htn)

PO; 10-320 mglday in tlvte 10ftiii' divided doII'l

IVI1M; 1,- 800 IJl9lday in th~ to fool diYidtd dos6
(mal:2 glda,)

INTERMEDIATE ACTING
meth)'lprtdni!Ol~ (~M~roI.Med'oI,othtB)

PO; 1-60 mg ~ 10 fOll' lintl/day

prrdrilOloM

PO;,-60 mg ~ 10 fOll' lintl/day

prrdrilOlle [Ite PJ~ m for!ht ProIol~ Drug box OO)

PO;,-60 mg ~ 10 fOll' lintl/da,

tri)mdn~ [AriltOIpin. Ktnalog)

PO; 448 mg ~ 10 IWO lim~day

LONG ACTING

ooolmethillOlle ((MIIon~ ~loKor~ 0I1Im)

PO; 0.6- 7.1 mg/day

dwlMihalOlle

IM;O.HlJl9lday

ll+irlql,iOCltllml~pptrilf,

weighrgoill, fD<i~llIrIlIif1l}

knNirtdwwnd h~)ling,
!N1kinq of ink(\iom.~lmai
aU!lI!hl h~~mi.!,l!mil:
YRn gl.:!IKOOU OID'ppormjl
musd( w)S1i!IIJlMablrn.
CHF
'IIOOffling of

mrrn,

"""""

PO; 0.2,-9 mg bid-qid

Ir~1k! inOOt~ ammon iodvmr tfI~(\~~inrkat~ Iffiousadoimt ~fltas.

43.10 Pharmacotherapy
with Glucocorticoids
Symptoms of adrE'norortical insufficiE'ncy include hypoglycemia, fatigue, hypotE'nsion, incrE'ased skin pigmE'ntation, and GI disturbances such ~s 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~as!, is quite rare and includes a deficiency of both glucocorticoids and mineralocorticoids. Autoimmune destruction
of both adrenal glands is the most common cause of Addison's disease. Secondaryadrenocortical insufficiency is more
common than primary and can occur when corticosteroids
are suddenly withdrawn during pharmacotherapy.
When glucocorticoids ~re taken as medications for prolonged periods, they provide negative feedback to the pituitary 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 abruptlydiscontinued, the shrunken adrenal glands will not be able to secrete sufficient glucocorticoids, and symptoms of acute
adrenocortical insufficiency will appear. Symptoms include
nausea, vomiting, lethargy, confusion, and coma. Immediate administration of IV therapy with hydrocortisone is essential, as shock may quicldy result if symptorru remain
untreated. Acute adrenocortical insufficiency can be prevented 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.

LibraryPirate

For chronic adrenocortical insufficiency, replacement

therapy with glucocorticoids is indicated. The goal of replacement 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 replacement therapy usually must lake glucocorticoids their
entire lifetime, and concurrent therapy with a mineralocorticoid such as fludrocortisone (Florinef) is necessary.
In addition to treating adrenal insufficiency, glucocorticoids are prescribed for a large nwnber of "nonendocrine
disorders. Their ability to quickly and effectively suppress
the inflammatory and immWle responses gives them
tremendous therapeutic utility to treal a diverse set of conditions. Indeed, no other drug class is used for so many different indications. Following are the indications for
pharmacotherapy with glucocorticoids:
H

. 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)

672

Unlt l Thi> Er.do<rlJW'YfSlem

PHARMACOTHERAPY ILLUSTRATED
43.1 Corticosteroids (Glucocorticoidsl and Adrenal Atrophy

1.

Norm~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

Sudden Discontinuation

4. Suddan wilhdmw ot
corticosteroids I....ds 10 awe
IKire nai insufficiency
' hypot_ ion
lethargy

",,,,,Itailura
asthenia
""u"""""""'mog

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 mineralocorticoid activity that causes sodiwn and fluid retention;
others, such as prednisone, have no such effect. Some glucocorticoids are available by only one route: for example, topical
for dermal conditions or intranasal for allergic rhinitis.
Glucocorticoids interact with many drugs. Their hyperglycemic effects may decrease the effectiveness of antidiabetic agents. Combining glucocorticoids with other
ulcerogenic drugs such as aspirin and other NSAIDs
Illark<:<l.ly im;r"""",,, lit" ri.-k ur l'''l'li~ uk"r ili,,,a,,,. AJmiuistr:ltion with non- potassium-sparing diuretics may lead to
hypocalcemia and hypokalemia.
High doses of glucocorticoids taken for prolonged periods 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

LibraryPirate

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 (alternateday 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 injectiorl'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
(u~ing's 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

o..pltl43

I:lnJ9' /0, pnulu,y, Thy,oId, ao<l Ad", ...1Disorder,

673

TABlE415 I Adv"rs" Eff"cts of long-T"rm Glucocorticoid Th"rapy

Type of Adverse

Event

Description

mmun~ ~

Supprrs!ion 01 tilt immu~ Jnd io/lammatory mporlltS ilK/UltS pa~ftlts' IlJI(tplibility to ioftaions. lhrir ao~-ilnammatOlY
actions may!M II:: till' signs 01 an o illilg infection,

i'rpIi(!HtrS

..""""

DtYelopmmt of ptp~1 ukm ~ Q(ul',rsptdaliywhtn oombilll'd with nonsttroidil aolHnflammatory drugs (NSAIDs).

Bthavioral d1angtS

Pt)'thologit man~!MY til' nin, W JlntI'/OIIIIlrn or moodilll's~orm~ i!1l'Ol'l t halliKNtiom and OONttd lliddal
ttndmdrs.

EytdlanlJl's

Cataoosand opm-anglt giaocoma ar~ modill!'d with ionq-tmn tllffi!11.

Metabolit d1an~

Thn h)'IIffiJlytffilit tfka railtS serum ghKOII' and can caU\e ~!KOII' ilt~~I~. Mobilization 01 lipids nwy uU\e ~pffiipidtmii
and abnormal lat dtposit~ ElKIrOI)'It mangtS indude h)'pocakffilii, hypobltnia. and hyptmatrrmia. ALid r~l!'n~on, W!ight gail,

Up to SO% of palims 00 IlHI9'tmn tllffi!11 willsuflrr a foo!ll' rut to ostropoollis .

il)'ptllmlion,and ~art oommoo.

Myopathy

.... Prototype Drug

Musdt wasting UUltS Wl'akOl'lI and fatigut; m~

mOOt oU.... or rt~atory musdrs.

I Hydrocortisone ((ortel, Hydrocortone, others)

Therapeutic Cl ass: Adrenal hormone

Pharma cologic Class: Corticosteroid

ACTIONS AND USES

StllKturaliy idtmi loll with tile naturJ IoormoOl' (ortilo~ hjdrocortisoot is a S)Tlthetic corticOSlrll)id that is the drug of cMKr for liming adrtnocortia I insuflidenC)'. When !Md far rtplaten1ft1l therapy, it is givrn <II physioklgit doltS.
Oll{~ properdoliog isoKhirYfd,its th~rJpwtic: rlfrmshould mimic:t~ofen
dogtnous {ortitosttroitk. H)IIrocortisoot is abo iYJilabit for tile U~atllll'nt of
inflammation, allelijit disordtB, and mJny olhtr londitions.lnuNnic:ular injtaions mi y br givt'n to dtcrull' St~rt inflammation in all'Itd joints.
Hydrotonilone is available in YJ diftrlt'Otlonoulations. HjdrotoniloOl' bu
(kr=b-HC, Alp/mit no, (('latOn, oillen) and hydrotortilo~ oKetatt (AnUlOI
HC, Cortaid, Conti' Au-Iatd ar~ iYaiiabit as oral plt'pafations,~Jms, and oint1III'On. HydrotortiwlII' typiona1l' (Contl'FkJid) is an oral SUlptnsion. Hydrotortilon~ todium phosphate (Hydf\XortoOl' Phosphalt) and hydrotortilo~
todium I!Ktina1l' (A-Hydf\Xor~ So/uumtfj ar~ for pa'~nttral USt on~.Hydro
(ortisOIll' vaitfal~ (Weslron) isoniy far topital applitations.
ADMINISTRATION ALERTS

Adminilltr9att~ as pr&ribtd and it tilt sam~ lillll'm!fY day.

Administtrolliionoulations with food.
PlI'gnilK)'Ui<'9ot)'C

ADVERSE EFFECTS
Wh~n UIfd allow dom for reploK~menltherapy, or b)' tile topital or imranasal
raft. HoweYt~ ygrrs of Cushing'l

routt!, Jd'itllt tflKn of h)'drocortisont art

synd,allll' un dev!'lop with high dOltS or with prolongtd ulI'.lf taktn lor Iongtr
than 2 Wl'tks,hjdf\Xortisoot !hould bedisrononurd graduil~.Hydroc:onilolll'
posltSm IOIIlt milll'lalotonic:oid Jctivity,w todum and fluid rttention may be
ooted.A widt ratH}!' ofCNS Hfern hom been rtporttd, ilKUling insomnia,ilUiety, huda{lIe, ~rtigo,conMion,and dtpression. Card'lOYaI(ular tliecl'l mJ, indude hyperlension and tathlUrdia. IlIng-ltrm therapy may resuh in peptK
uk~rdMJse.

Contraindimions: Hydf\Xonisone is loolrainditaltd in jlitirnu wha alt' hyperwnsit~ to th~ drug or who have known inflion~ unless tilt patirnt is bring tr~att<l lonrun~mly with imi-iniettives. Patients with diabrtH,
OIteoporolis, psyo.:ho~ Ii'm' dis9I1', or hypothyroidism shoo Id br tJNtt<l with
"ulian.
INTERACTIONS

Dru;rDrug: Barbinl'atn, phMytoi1. and ~n may i1trNII' hPpatit lIIfIaIQiIm,

thus doofi'iing hjd!1l(ortiloM ltvftl. EstrogmI poWItiatf 1M fllKl! of
h)'dromrlisorw.l.M with OOIIIHOidaI iIII~ ... ftornmalory d~ (NSAIDS) iooUlfl
thf rMolptplit LkfB.~1II' and ~ IlKJNII' hyQ-otortilOOI'
absorptitnDl.fem and a~HUl8 RJNII' thfrisl::"~pokaIi>mia.

PHARMACOKINETICS

Onset: I- lh PO;20 min 1M

Antitl'd~agt'OlSmay~Ie'II'R'II'flkneII.~ma,caul4'

a dHr&u il im01llllfrelpOOll' to'/il((ooand IOIllidi.

~k: lhPO;4-8hIM

li bTesll:H)II!1l(orti\orM> may ilmfifl4'lum 'IikIt'i for ~,thoIfs1!'roI,

todilJll,lIit add, or cakium.lt may deaNIt' IoffiJO vallII5 01 potalsilm and Tilt

Halflife: 15- 2 h
Duration: 1- U days PO or 1M

H~ VFood: lII4'''

""rocortisone with WOIIiI, t.i<;Cill1, or budthorn may aM

potaI~um dftitimty with dl'ooit 1M.

Treat mf m of O~rdOSf: Hjdrotonilone has no ac:ul!' tOJicil)' and dtaths art

ralt'. No IPHifK therapy is mi labl t i nd p.uirnll ar~ IrNttd symptomatitally.
.... fe' mM;rNurJlngI(1! for Q Nurllfll} Proo1! fm Jjlt(1/{ millis ~

LibraryPirate

NURSING PROCESS FOCUS

PATIENTS RECEIVING SYSTEMIC GLUCOCORTICOID THERAPY

Assess me nt

Potentilll Nursing Dillgnoses

Bilsrlin r assrss mrnt prior to administrati on:

Undffitand the ~iI!On tilt drug his ~n pr~ribtd in order to as~ lor
therapeutic riferu (t .g., rtplawnent theraP'J', trutment 01 spt<ifi<
ronditionl SIKh ill autoimmun~ di!Ordt~or alier9ic 1!"IjI01I\lS).
Illtain a romplru huhh history in:ludl"f;l urdimIaAI~ lepi-i1oty, neurok9<.
htpatic. or rmal~; pr!9nancy; or brNlI-fredl"f;l.llKain iI rirUl history
indJ:Iing allei9M. current pre!(ription and OlC drug!, Ilerb.JI ~paratM.
~, nKo~D:I alrohol u~.~ iltnto poI~drug inttOOiom.
llKain ba~lillt vitilligni and weight.
h'~ln~ appmpriM~ l.lhn.. lnl)' finding' (.g.,CR( pl.lI~IPI\I'''''''nlyt''\
gUeosr,li pid profile, hepatic or renallunction stud its).

DrfKitnt Knowltdgt (drug !ht rapy)

Risk for FluidVolum~ Ucffi (rt lattd to fluid retfntion propenits 01
gluc:oconicoids)
Risk for Injul)' (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 ilrt;~BI' drug tifrclI)

Assrssment thro ugh out administration:

Aslffi for rIe-li~ therapeutic rfft(B (~.g.,signs and symptoms 01
inflammation such as ~nm or IWt'liing i ~dt(rNsed).
CominUl' periodic monitorill9 olCBe, pbteletl, ~lectro~te,gluc:=,lipid
profile, and hepatic or renallulKtion lIudits.
Aslffi viti Isig ns ind weight periodiu I~ or if symptoms warram. Obt.i in
tilt Wfight daily ilnd ~n any~ight gain 0YrI1 kg in a 24-hour period or
mo~than 2 kg in 1 Wffl
Aslffi for and promptly!!"pOn ad~ B1Kts:naUIN, vomiting.symptoms
01 GI bletding (darlc or"tlrry' ItOOk, htrnatr mesis or (ofiet.ljround _is.
blood in thellool),abdominal pain.diuinesl,(onlu!ion.~itltion. euphOOi
or dtplt'l!ion, palpitations, tac:hyurdia, h~n!ion, ilK~asrd respiratol)'
ratf and dtp!h, p11lmon'lIycon~stion, significant ~ight gain.tdrma,
bkJITl'dvision, ~~~and infectiolll.
Pl anning: Plltient GOll ls a nd Expected Outco me s
The patient will:
UperHolKt therapeutic tfftcts (t .g., dtmilstd liglll and Iym ptom s 01 inflammation or ~Ilergic lePOnse).
B~ Irr~ from,or experienuo minimal.ildYefSt tfltas.
V<rbol~ In undmtar.ding of I .... drug'. u"",adven. dfrru, l r.d ~uired pr.tution .
~monmate properlfll-adminimation ol!hl' mication (e.g.d=, timing. wlltn to notify plO'/idtrl.
Impl e me ntllti o n
Inte rve nti o ns a nd (Rilti o nil les)

Pllti ent li nd Fa mily Educll ti o n

En suring thrril peutic dfects:

CominUl' i SmSmtnts il SdfSCribtd earlier for thl'rapeuticrifeclI.
(Diminished infl~mmillion, allergic responsr, and ilKrei std fr~lill9s 01
~lIl1fSsshould begin alirr takill9 the first do~ and rontinUl' to impl"O\'e.J

Teach the patient to ~ any rt'tum oIoriginal symptoms or inert'iI\!' in

inflammation, illlfrgic ft'Iporllf, or ~lII'raliZ1'd malaisl' to the hNlth Cirf
prwider.

Minimizing ildft rsr effects:

CominUl'to monitor yitil signl,fSpt<ial~ blood plesurund puke.
Immediately II'pott tachymdia or BP (Wr 14OMO mm Hg.or per
par.tmelen ilS ordtrrd, to the htahh ure ptoYidrr. (CortKolieroick may
mJ~ in(rt'iJstd blood prffiUrt, hyptn~nsion, ilnd tadtjUrdia dUl' to the
ilK~i std retrmion 01 fuidsJ
ContinUl' to mon~or periodic lib work:CBC, tledro/yttl,gluco\!', ~pid Ie\lek,
ilnd htpatic i nd renallulKtion tfffi.(Corticostfroids affect theC8(, i nd mily
(iiUS!' hyperg/yr:emia, hyptm i1rem ia, hyptrlipidtmia, and hypoU It mia.
Diabetics may tequirt' a (han~ 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, ~nd hypotension, t5pe(ial~ if
llsociatedWith tadt)Urdia. (GI biffiill9 is an adYml' drug tff~l)

LibraryPirate

Tl'ilCh the patient how to monitor the pIIM and blood prt5MI~. [nsurt' tilt
proper lilt and lunctioning 01 any home equipment obtliMd.lmmedi~teIy
~n tichyurdia, palpitations. or ilK~ilstd BP to th~ 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 ~ry ind"uull9
corticosteroid theraP'J'.
Tl'ilCh thediabeti< patient to tel tilt blood gk.lt= mo~ 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.

o..pltl (] Drug; /0, p~uln,y, Thyroid. and .<.<1",...1O""rde"

NURSING PROCESS FOCUS

67 5

PATIENTS RECEIVING SYSTEMIC GLUCOCORTICOIDTHERAPY (Conllnued)

Implementation

Inte rve nti o ns and (Rati o nale s)

Patie nt a nd Family Edu cliti on

Monitor for signs and Iymptoms of inreuion. (Corticosleroids rupp Il'II th!o
immune and inflammatory Il'sponm and may mask thesignl 01 inreuion.)

Instruct the patient to im~illte~ ,epan any signs or Iymptoms 01

inftions kg., in(ll'asing temperaturt or ftl'el, lOll' thlW~ redlltll or
swtlling ~I siteolinjury, whitt p;l\(1\es in mouth, ~icul.Jr rash).

--+-~
Monitorfor osteoporosillt.g., bonedenmy testing] periodic.Jl~ in patienll
on Iong-ttrm (Of!i<osttroids. ElKourage adtqwte "kium intakt, al'OidalKt
of wbonated sodas,and wflght-bearing nen:~. (Corticosteroids alft
bone mttabolilm and mol)' GlIM osteoporosis i nd "'dull'!. Weight-bearing
I'J:trtM st~1e 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.)

Tu(h the patient to maintain adl'~le (akium in til!- die~ i\Olid

"roonated sodas,and to do wtight-buring tlertMs ai lust Ih,~ to four
time ptr wttk.
Tt,(h the pallmt nop,U\i1 woman to conluh with II!-r proYidI'r about til!nted for ~itiooal drug thmpy (t.g. bisphosphonate) for osttoporosis.

Monitorfor unusUilI (hangtl in mood or afreu.((ortitosttroids may mu

an ilKll'utd or drNstd mood.l'Uphoria,di'p'ffiion,or ~re mental
inltability.)

Ttath the patien~ famii)o,orta't"9i'1l'r to promptly It'pOn l'J:cr\si"fl' mood

swin9l0r unUIWI tha~s in mood.

Wtigh tht patitnt daily and It'pOn wtight9'lin or in(lming peripht ral
edema. Me.!IUft' the inti kt and output in the hOlpitalill'd patient. (Dai~
weighl is an rurate mNSUll'of fluid status <l nd tlkts intoi((ounl intlkt,
outPU~<lnd inll'nsible IolmJ

Instruct the patientlowtigh leifdaily, ideally at III!- I<l~ li~of day.TII!patitnt should It'pOn a wtight gain of moll' lhan 1kg (approximately lib)
in i 14--hour ptriod or more than 1 kg (approlimate~ 4-5Ib) ptrWffk,or
in(ll'asing periphml tdtma.

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

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.

Do oot stop til!- drug abrupt~.Tht drug nlJst be laptll'd off if LISI'd longer
thiln 1or 1 Wffks.(Adll'nal insulfitienq and (rM may o((ur with prolound
hypoten lion. ta(hyurdill, and othtr <ldYtr>e efi11 if drug is Itopptd
abrupti)oJ

T~ath the

patienl to not SlOp (orticosttroids abrupti)o and to notify tilt

pftl\lider if unable to tlkt tht ~ic.Jtion for I1IOIl' than 1dol)'
due to mnffi.
h~akh (ill'

Implementation
Inte rve nti o ns and (Rati o nale s)

Patie nt a nd Family Edu cliti on

Patirnt understanding of drug tht rapJ:

1M opponuoities wring admioisuillioo of mrdic.Jtionland wring
asleSmtnlllo disnru tht ralionalt for drug therapy, dtsill'd therapNIit
out(om~1, 0l0I1 (om mon~ obsft"vtd ~dRl"It ffiU. pa r~mtltll for when
to tall the health (ill' p~ and any ntaSSilI)' monitoring or
pll'uutiolll.(Using lime ruring riming tart helps to optimill' and rtinfon:r
ktyttathing areas.)

Tht ~tient 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' tlfts to obSl'lVl' for
aod whtn to Il'poI"t thtm;and t~antitipattd length of ~ication
therapy.

Patirnt stlfadm inistntion of drug thtrapy:

When admioinering thr mrditillion, illltOKt thr paliem, f,mily or mtgiYer
in til!- proptr srlf-admin~tration oIdrug, f.g., with food or milk.(Proper
adminiltralion will inuulI' thr tffecti"fl'nffi of thr drug.)

Til!- ~titnt and fjmi~ 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.

Evalu a tion of Outcome Criteria

halUiltt the rfieui\'elltll of drug th!orapy by ronfinning that patient gNlsand I'J:prded outtomrs h,~ bern met (= Planning").
5H Tabit4H forQ htliltr!ljHnwlidi rhe5t ooflillljlKtioJIl ~

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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 include adrenal atrophy. osteoporosis. hypertension. increased 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 allul'~r","alily ~h~lll!""" flJ~y U~~llr. 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 adrenal twnor or perhaps an ectopic tumor secreting ACTH,
surgical remova l is indicated.

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,,, ~JltirUlll!al urug klu~u flal.Ul" ( Nizural) h~, l.>~~UfJl" ~

preferred drug for patients wi th Cushing's disease who need

long-term therapy. This drug T3pidly blocks the synthesis of
gluoooorticoids, lowering serum levels. UnfortWlately, patients often develop toleT3nce to the drug and glucocorticoids 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 gluoooortiooid receptors; it does not block the synthesis of gluoxortiooids or decrease their amounts. Although it has antiadrenal
actions. its primary use is as an abortifacient: The drug is pregnancy 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 .

~~: 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 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 response to changes in the internal environment. Negative
feedback prevents owr-responses by the endocrinesystem.
43.2

43J

43.4

43.5

The hypothalamus secretes releasin g hormones, which

direct the anterior pituitary gla nd to release specific hormones. The posterior pituitary releases its hormones in
response to nerve signals from the hypothalamus.
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.
Only a few pituitary and hypothalamic hormones, in duding growth hormone and ACfH, have clinical applications as drugs. Growth hormone and ADH are
examples of pituitary hormones used as drugs for replacement therapy.
The thyroid gland secretes thyroxine (T.) and triiodothyronine (T,). which control the basal metabolic
rate and affect every cell in the body.

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43.6

Hypothyroidism may be treated by administering tbyroid 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
ca rbohydrate, 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 Adrenocortica l insufficiency may be acute or chronic.

Glucocorticoidsare prescribed for adrenocortical insufficiency, 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.

NCLEX-RNOREVIEW QUESTIONS

The nurse=gniusmat drugsfrom which of the follow-

2. Hyperthyroidism

Ing classes ClUse illCreased risk for peptic ulcers, decreased

3. CUshing's syndrome
4. De>dopment of acromegaly

wound healing, and increased capillary fragility!

I. Gill(OU)niooids
2. Antidiuretic honnones

3. Growth homlOIlt'5
4. Antithyroid hormemes

When administering hydrocortisone (Cortef, hrdrorortone, 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

When hydllXortisone use is disrontinuf'd abruptty, the

nurse must assess for which side effect!

I . Development of myxedema

2..

CiftU~tory 0lIbpse

3. De>dopmentorOlshing's~
4. De~ntofdiabetesimipid\lS

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 indication ofwhu hormonal co ndition!
1. Addison's disease

What preoullons should a patient who Is receiving radioactive 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, r~Ie. and anxiety.
4. v-.wa mask if.round children and pregnant women.
5. Signs and .>ymptoms of hypothyroidism indude general
weakness. muscieaamp&. anddty skin.
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 intranasally. 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" F3. 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.

CRITICAL THINKING QUESTIONS

1. A S-year-old girl requIres trutmenl (or diabetes Insipidus
acquired IOUowing a ase of meningitis. The child has suffered serlouscompllallons Induding blindness and menIal 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 adolescen t with a hIstory of severe asthma is
admitted to the intensive care unit . He is comatose. appears mud! younger than his listed age, and has short
stature. The nurse notes that the asthma has been managed with prednisone for 15 days, until 3 days ago. The patient'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!

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J. A 9-year-old boy has been diagnosed with growt h hormonedefkiency. His puents havededded to proceed with
a presalhfd regimen of somatotropin ( Humatrope).Out]jne the basic information the parents need to know reguding 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 1tCl~-$\y!B practice
(JleSIiom. I~ 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 ....

Drugs for Diabetes Mellitus

DRUGS AT A GLANCE

LEARNING OUTCOMES

INSUUN

AftprrNflingthisclKJpl, rhenudMrshouldbf'ablefO:

ptJIJtfillJ

o humon . 0 ' ",wM(HlImu/j" R.

NCNNnAj prI9Ill4l

ORAL H'l'POGLYCEMICS

ptJIJt6aJ

mtrfotm ... (FoffOf'flft.GlucO~

G/urMUG,othmJ pr19168'J

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 ma~enl of
diabel:es mellitus.
6. Identify drug cla~ used to trNt type 2 diabetes mellitu s.
7 . For each afthe drug d asws listed in Drugs al a Glancl'. know
representative drug "xamples,and explain the mecMnisms of dtug
act ion, primary Ktionli,. and impo rtant otdvefW effects.
B. USl:'~ nursing process to care for patil!nl'l receiving drug wl3pyfor
dlabel:es mellitus.

KEY TERMS
cU,,"i: ketOiCidosis (DM )

ptJIJtfJlJ

-,.,~
gkonHgenris ptJIJt619
IIyptIQl)'lemic tffKt piJJt619
lIypI'rovnolar t.,pKf)'temK S1iJlf (HHS) Pl'6a1
IIypofJumktfIKt ptJIJt619

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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

OIoplfi,,", 0"'9s for DI.beles Mellitus

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 epidemic.Diabetes can lead to serious acute and chronic complications, including heart disease,cerebrovascula r accident
(eVA), blindness, kidney failure, and amputations. Because

nurses frequently care for patients with diabetes, it is imperative that the di sorder, its treatment, and possible complications 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 digestiveand endocrine systems. It is responsible for the secretion 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 remain 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 gluco.e hilt

Ihey~re Iln~hle

to ""e it IIntil in."lin

~rriVf'_'.

It

679

porting glucose inside cells: no insulin, no entry. Thus, insulin is said to have a hypoglyl~micffffll, 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 adequate 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 relationships 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 glucose be periodically monitored in patients receiving medications that exhibit hypoglycemia or hypoglycemic effects.

Low blood glucose

High blood glU00B8

m~y

be helpful to visualize insulin as a transporter or "gatekeeper." \'/hen present, insulin swings open the gate, trans-

~ )J

P"ncr....

ins~

ALPHA CELL
seaeting
Glucagon~,

i~~~t~~~~~
"

BETA CELL

--'C-- -

Insoi n-

,,,.,,'

LBng..maM

seaeting

Cell. take
up glucose
,~""'"

in pane""",

~,

GUcegoo-raiS85 blood glU00S8 level

Insolin-loWllTO blood glU00B8l.......t

.. Flgure44.1 Glucagon- and Insulin-secreting cells In the

Islets of Langelhans
Source: Pearsoo fducat/oo/PH CoIlege.

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Blood gluooae risM

'")

(0)
.. FlguTf 44.2 Insulln,glucagon, and blood glucose

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 increased to 300 million. The etiology of OM includes a combination 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, increasing consumption of highly caloric foods with resultant
obesity, and increased longevity.

44.2 Etiology and Characteristics

PHARMFACT5

Diabetes Mellitus
Ofthlo 16 million Allltriuns who hal'edilbms,5 million probab~ a~
unawalt' thu thry hav~ thf dileas~.
E,ch day, mo~ than 2,000 proplea~ diagoosed with diabel!-!.
Gestational diabetn Iff!!. about 4% of all pregnant womm in tilt
United Statn ~a.c:h ~r-about 115,000 m~s.
Diabms CiI!MSalmost 200,000 d~aths~a.c:h ~ar;it is t~ siuh !tading
wuofduth.
Diabms is thf !tIding talM of blindnl'ss in adults;uth )'rar 12,000 10
24,000 ptopIt ~ their sight beCiluW' ofdiabrt~.
Diab~~5 is I!1plMib!t for SO% of nontraumatir Iowt'r~imb ~ mputltions;
56,000 imputations af"! prrformed NIh yw on p~liM1S with diabetn.
Diabetes is the leading CilUW' 01 ~nd-stagt ~nal disuW', mounting for
about 40% of new meso

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, because it is often diagnosed between the ages of II and 13.
Because approximately 25% of patients with type I OM develop 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, immunologic, and environmental factors. Because children
and siblings of those with OM have a higher risk of acquiring the disorder, there is an obvious genetic component to
the disease.
The signs and sym ptoms 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 degeneration, or neuropathy, is common, wilh symploms ranging
from tingling in the fmgers or toes to complete loss of sensation of a limb. Because glucose is unable to enter ceils,
lipids are utilized as an energy source and ketoacids are producrd as waste products. These ketoacids can give the patient's breath an acetone-like, fruity odor. More important,
high levels of ketoacids lower the pH of the blood, causing

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diabrlicketoacidosis{DKA), which may progress to coma and possible 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 con trol 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).
R"c~Il.<e norm~1 iO.<lllin .ecrelion ""ri,,_< gre~lly 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 consequences 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. Administering insuli n when glucose is not available can lead to serious
hypoglycemia and coma. This situation occurs when a patient administers insulin correctly but skips a meal; the insulin is availablt' to cells, but glucose is not. In another

01..,1<,4-1 0"'9' for Dial>.. MeUitu'

example, the patient participates in heavy exercise. The insulin 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. Patients 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 glucose is available in the blood. Without insulin present, glucose 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 outcomes and patient compliance with therapy.
Many types of insulin are available, differing in their
source, time of onset and peak effect, and duration of action. 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 because it is more effectiw, causes fewer allergies, and has a
lower incidence of resistance. Pharmacologists have modified human insulin to create certain pharmacokinetic advantage5,such as a more rapid onset of action (Hwnal og) or
a more prolonged duration of action (lanius). These modified forms are called inlulinanalogl. The different types of insulin 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 patients require two or more injections daily for proper dia-

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 important for nurses and patients to know the time of peak action
of any insulin, because that is when the risk for hypogl~mic 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 boluses 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 overtreatment; 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. H ypoglycemia
may occur when the insulin level peaks, during exercise, when
the patient receives too much iltsulin due to a medication error,or if the patient skips a meal. Some of the symptoms of hypoglycemia are the same as those of diabetic ketoacidosis.
Those that differ and help in detennirting that a patient is hypoglycemic 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

"n"
i!IIUin ~ !pirt (Novolog)

i!IIUin lilpro lHumalog)

imuin glu~!i~ (Apidra)

""""

.'"

Onset

10020min

""'.

1- 3h

5-15min

.'"

15- lOmin

lD-60min

1-5 h

12h

..

isophi~ 1lI1J11HPH,

kll~RII'diatt

AdmtntsUatlon
andTlmtng

1-5h

sw.:utantOOl; 5-10 min

~fulum~al

.'"

i!IIUin rtgUar lHumuin

R,HowinR)

Duration

1-1.5 h

Hh

sw.:utantOOl; 5-10 min

~forl'i m~al

1h

Hh

SubultantOOl; I, min

Compattbillty

Can 9MWith NPH;draw

alpin !4l fim and g~
imllltlhtdy
(an 9M- with HPH;draw
lilpro upfimand <jI~
imllltlhtdy

~foream~al

(an 9M- with HPH;draw

~ui~~!4l frn and gift
imllltlhtdy

6-10h

SubcutantOOl; 30-1 min

btforu m~I; 1V

(an miniih tlPH,lImil'

wat~,or 1IIIIINllililt;do

6-14 h

16-24h

,...",

(an mixwiih alpin, liIpro,

or II'gu~r; do not miIw~h

."""

'-Oh

102H

SubrutantOOl; 1/day
or2/~

Do MI mixwith any othtr

illlUlin

1.1h

Hoptak

SubrutantOOl; 1/day,
iiIIII' tim~ mil day

Do MI mixwith any othtr

illlUlin

Mlmilrwith~~

HlJIlJlil H)
i!IIUin deimir llfo1mirj
i!IIUin ~~ lli!ntUl)

"'"
"'"

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102H

SubrutantOOl; rrix

~19i~

682

Unlt l The ErdoallM' Sym'm

L IFESPAN CONSIDERATIONS

Psychosocial and Cultural Impacts

on Pediatric Patients with Diabeus
For the child or adoll'sc~t who hll diabetts, t~ art psychosocial and rul!utili considerations of (ompliaOC:f with mtdication and dimry regimens.
Enn if diagoosN tarly in l~ (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, ~d nip!, and afterschool snack time, whtll' SWffl trNts all' tht norm, II'~ II a physiul and
psychologic tempmion. During adoll'sctnU', when tht tn wants to rn in
with 01 peetgroop, tilt diabttic regimt nun ilfoome mIlft' difficultlt is during
this time thilt fililull' to til~ 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 II'K~tffm.

'*

,.. 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 elevate 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 diabet~s meHitus is the more common form of OM, representing 90% to 95% of people with disorder. Because type
2 OM first appears in middle-aged adults, it has been referred 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 asymptomatic and may have the condition for years before their
diagnosis.
The primary physiologic characteristic of type 2 OM is
insulin ~siltancf; larget cells be.:ome wlresponsive to insulin

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1111<': to ~ lI<':f~ct in in.~lllin r<':c"'!'tor f1lnction. P.~~<':nri~lly, 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 dyslipidemias, 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 complications as patients with type 1 OM (e.g., retinopathy, neuropathy, and nephropathy).
Hyperosmoiarhyperglycemicstate(HHSI is a serious, acute condition with a mortality rate of 20% to 40% that occurs in persons 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 mortality rate than diabetic ketoacidosis.

0I~r4ol

... Prototype Drug

683

Human Regular Insulin (Humulm R.Novoim RJ

Therapeutic (I ass: Antidiabetic agent; pancreatic hormone

Pharmacologic (lass: Short-acting hypoglycemic agent

ACTIONS AND USES

Human ~ular insulin is!Md to h~lp maintain bIoodgUcoW' ~k within oormallimits."Iht prim"~ tifrds ofhuman ff9ULtr ill\Ulin al"!:to promot~ crlluLtr
uptake of gUcoSl', amino adm, and potmilm; to promotr protrin 5)'nth6is,
g~ogen formation and storiljr, and fatty acid 510ragr u triglturides; ind to
(onsrrn ~nergy stor~ by promoting thr utiliution 01 glucosr lor rlll'l9)' nmk,
and inhibiting glu<onrogrnesis. BffiuW' ff9ULt rinsulin is shan "tin 9. it is most
oft~ !Md in mmbination with intrrmrdiatr or IoIlQ-actillQ in",lin to achm
24-hour gUcoW' rontrol.lndic.ilions for insulin include the following:

0"'9' (or Olabete, Meliltu,

Asmooothet"apytolowfrbloodgkJmselnn in patirnllwith typr I diabrtes

In combination with ",ali midiabetic agrnts in patirnts with typr 2 d"labe~s
For thefflll'rgerKy trNtmrmof diabetic ktioaddosis
For 9l'Itationai diabetts

ADMINISTRATION ALERTS
En",rr that the p;ltirnt has ",fficifnt food and is oot hypog~mlic brio!"!
administffing ~ular insulin.
Rrgular in",lin is thr only typr ofin",lin that may be!Md for IV injection.
Rotat~ injKtion ~tts. When thr patirnt is hospitaliml, US~ Sit~1 not oormally!Md b)' the p;ltirnt when at homr.
Administer approximatrly 30 minut~s brfo~ mrak w ill\Ulin will be abwrbrd and available when the patirnt begins to ut
P~nalK)'megory8

PHARMACOKINETICS
Onsrt: 30~ min subrutanrous; 15 min IV
Peak: 1-4 h lubcutanrous; lO~ min IV
Halflile:Upto 13 h
Duration:6-HI h subrutanrous;30-60 min IV

ADVERSE EFFECTS
Thr most (ommon adverW' efiro 01 ill\Ulin thrrip)' is hypogly~ia. Ifypoglycrmia may mult lrom taking too mum insulin, not properly timing the insulin injection with food intau, or skipping i mral. Signs of hypoglyc~mia
indud~ 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 Irssen~d with rotation olinjection SitH. Wright ~in is a
possiblr ~dr tffra.
Contraindi m ions: Insulin is!Md with uution in pregnane,: !"!1IiI1 impairmrnt
or lailul"!, !tvrr, thyroid disNsr, an d among oldrr adults, childl"!n, or inlann.lnsulin 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 ""~frric: fffKII: conicoruroidl, thyroid 00r1llOOf, and tpiIfpImf.
Sl'l"00I ijlUClISf k>mI may ~ inclMll'd with furwrnidf or thWidt dUMino
s,mptorns"'~r&KtionmaybellY\l:edwith~bIod!l\.

li b1l'1": III\~in 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 1e"I'!'~ rpilodrs al"! truled with pal"!ntrralgiuugon or
inlril'Ilous glucosr.

s.... RtfI'I" III MyMlsJni}Kl (Of IIUlIng /'reII Fool! sp11Ii: 111M ttug.

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 disease progresses, insulin may become necessary for type 2 diabetics, 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 classified by their chemical structures and their mechanisms of action. These include sulfonylureas, biguanides, meglitinides,
thiazolidinediones (or g1itazones), alpha-gluoosidase inhibitors, and incretin therapies. Therapy with oral antidiabetic agents is not effective for persons with type 1 DM. All
oral hypoglycemia;. have in common the action of lowering

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Th r Question: Oors Iowrring blood lipid IeYek help to improve the

therapeutic outtomrs of diaooic patienll?
Th r Study: RrsNrrhr~ analyzed 12 srudirs ttYt ~mined the ben~rllS of
lipid-lowering drugs in ~tirms with diabete. [ad! study lasted lor 3
~mand looked at the inc~n~ol i<M~cardiowcul"r"lrrru in
diabnia ve~us nondiabetics.AIthough both groups ~lI!'rned from lipidIowrring drugs (OY!'r 10'1(, irWl'rurdiOlla!ular adverse r"lrn~l,diabetic
p;ltirnts ipprirm to brnrfit mo~ than nondiabetiu.
N u ~in g Implications: Nurm should Itach diabetic patirnts thr imponancf
of managing thrir blood lipid 1~ls,as well as blood glueoW' IMis.
Slutt: CoIm,J., BIlfges, M, Lhn101 C & !<!mfIn;A.V. (1OO6).Etrll:1K111f1lfN ~
Ml!gllNlmml'tMr1Id/)ttJ(QM 1IolII-~{I<lIIlM:llllt~ot'rlfIdCmJZM
ronUOltlt IDIIi. 8rItiIII1MdIul.iou mall Jl: 1115- 1114.

68 4

Unlt l TheEr.doar .... SyS!,-""

NURSING PROCESS FOCUS

PATIENTS .EeElVING INSULINTHE.APY

Assess me nt

Pote ntilll Nursing Dillg noses

Bilstlin e assess ment prior to administrati on:

Understand t~ rtilson the drug hu betn pre.:ribtd in order to aslnS for
t~ .. peuti< tff.rts ond 10 pbn forl_hing nH<k (t .g., new onS<'t of
diabttts with hypergl)'(tmia pr!"S<'Il~(h,oge in imulin I)'pe/'moun~
sliding IYIt u)Y!'ri9\', trtatmenl of hyptfk.Jltmiil).
Obl,in a (Ompltlt ~alth history ilKluding endocri~,(lrdioYiI\(ular,
~palic. or rt n.1 distal<'; p~n'lKY; or brtil st-fre:ling. Obtain a drug hislory
ilKluding alltrgies,rurrtnt prtKription and OT( drug~ hffiIal plt'pilmions,
(.fffi~, nitoti~, i nd akohol ust.1k ,ltn to pcrs~blt 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 Io~rnlremitits for polSiblt uktr.ltiorrs.
Obtain a dittl ry history induding {alorit intJ~ if on anAOA din. and the
numbtr of mI'iIls il nd m,ds perdily.k!es fluid intaR i nd t~ I)'peof
nuilk (Ofllumtd.
Obt,in bastli~ vital sigrrs, htigh~and ~ight
Enltwtt .ppropriatt labor'lOry findings (f. g., (Be, tlectrolytts, glumII', A1(
Itvtllipid profilt,omloiality,~patK ,nd rt nal fuoction nudits).

Imb,l,n{t(j Nutrition, ltsl Than Body Rrquirtmenu (I)'pe I diabttt~

fl'bttd 10 b<k of insulin ""oibbility for nannol "",toboli<m)
Imb.l,n{t(j Nutrition, Mofl' Th,n Body R~uifl'llltnu (type 1 diabtte,
fl'lattd 10 imulin ~tanU' and intaR mOfl' than body nttm)
Oefic~m Knowlt~ (drug thtr.lp)')
IfII'fit<tNe Thtrapeutit Rf9imt nMil nagtment (fI'lattd to defit~m
knowIedgt or alttfl'd (ompliafl(t with pres(ribtd lIt'atment)
Alttrtd Complian~, NolKompliafl(f (fI'lattd to mmplexil)' ofutatment
plan, dtlK~m knowledge)
Risk for DtrKitnt FkJidVolume (related to polyuria from hypergly(tmi.)
Risk for In;"'1 (fI'lattd to adY!'lSt drug fKed!, lack of stflliltion in
t((rfmit~1 from nfUropathies)
Risk for Infe<tion (fI'lattd to hyperglyremia,imp,ifl'd cirtulation 10
flI~mit~l, fll'urop,thies)

Assessment th ro ugh out administ ration:

Asst\S lor dtsirtd thtrapeutit tfftm dtpendent on tht INIon t~drug is
ONtn (f.g.. gIutOll' Itvtk. eItruoIyttS and osmolality f1'main within normal
limiu,Al( ItYl'ls dtmonstritt id~uilt (ontrol of gIutOll').
Asst\S lor and promptly ft'pon any idvtrv tfletl~ 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. flUl~d,dr-, skin,poirJria, poIyphagia,poIydipYi,
drowsine~91y<:0\Uria, knonuria, i~to~ bruth),lipodyltrophy,and
inft<tion.
Pl ll nning: Plltient Goa lsllnd Expecte d Outco mes
Tht paritnt will:
Ex~~fI(t 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.
~mon mite pro~r selh:lministr,tion of tht medit.tian (t.g. dOlI', timiog. wht-n to notify provider).
Imple me ntlltio n
Inte rve ntio ns li nd (Rllti o na les)
En suring tht rilpeutic effects:
Cominllt iI IStsSments ~ ! de(ribtd tarl~r for thtrapeutit tffr(15.
(~p~ndent on the IMrity of hyptrgiy<:emia,bIood gkKOIf IMIs ~hould
gradually ~turn 10 normal.)

Adminilter in sulin mrrt(~ yand ptr t~ sc:htdult ordtfl'd (t.g., routi~

dosing with or without Iliding-sc:.ilt (_ragt)'planning irrsulin
,dminimation nd ~ak ti~ ,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 e nt li nd Fll mily Edu clltio n

Ttilth tilt patitnt to fI'POn any Il'Nm of original5)'mptorm.
Ttilth the patitnt tilt l)'IIIptoml of hyper-and hypogl)'(fmia to obll'fY!' lor
.nd inllnKt tht pat~ntto mt<ktilt (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.
Ttilth tilt pat~nl,family,or (a~iY!'f appropnatf ,dminimation
ttmniqll('l for all types of in lui in ull'd, folla.re:l by rtlUmmomtr,tion
until tM pat~nl,family, or {a~Ner 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 pat~nl,family,or (afl'giY!'f tilt imporun~of ~,k 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
pcrs~bIt.

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NURSING PROCESS FOCUS

PATIENTS RECEIVING INSULIN THERAPY (CooUnuedl

I mpl ~ ITI4ffitatio n

Int~ rv~n tion s

and

(R ationa l ~s)

ElIWrtdinilJ.-Is art mtI ~Ied on lilt JIefd to iost.tain, Of mainuin

CIIntnt wtight ~nd gluaM 1M1s. Comull weh a dittitiln II nffiled.L:imit
or~iminm Ilcohol 1M. (ldfqlWtl!' raion.: amounu and ptO{~n,
Cbo~11n, Ind fs SUflPOf\S tht insuIiII ~imtn !of gIucost con\llll.
Activity Ind &ftjtylt wiR lbo be fletoM no dietary lI\I~t Alcohol
rail r.iS!' and w.. prtcipitwslr Iowtr blood gluroS!' ~ .Icohol is
mtt.boliltd,rai!ing tht risk ofhypogf'tum~.)
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
~p~(D.ilyglu~~,~befortmtlb.wmanistin

lJIiintiining wbit blood ~.nd wil lid in .~ tilt

IClPIOprilttlltll of tht currtnt inlUlin legimtn.)

Pat i~ nt

a nd Family EduUltion

Rtvitw (Ur~t ditt.liftlt)le.and Ictivit)' IMI with the patitrlt.kratlgf I

dittitiln romull hmd on tIlt"HI! to I~trdift ()J foodrhoUi. 1m" dIt
paUmt to limit Of~min.Kt .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 ~lifnt on blood gb:~ 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.

Continue 10 _tor periodir lab work:(l!(,tltrtro~ gU:OIt,A Ie 1rfeI,

IiJ.id profile,osmollliity, ~ btpuic iI"Id rtNI funclion It~.(Ptriodic
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.)

lni1JU(tthe ~lifnt on lilt nmlto return pniorI"K.11y for lib worl

Mstsl for symptoms of hypogl)'":tmia, ~11y .round timt of iniUlin

puk ~iYity. 1f Iymptoms ofh)'!lOgl)'C_lIre nottd. ~11 quitl-Kting
Cbohydr.l\t IOUrtt (t.9-,jui(t or othersimplt ~r),uld IIltn cW
capinary guOit 1t"lt1.1ltport I) th~ IwIth w~ prtl"fidtr if tilt gU:o!e IMI
is Itn thin 70 ~dl or IS ordtrtd If meal ~mI! is not mmtdiatt,~,
Ionger~g PIIlt~n _ I ) ~nlUrt that ~ypogl)'":ttnii ~ Mt rt(U[
(Ifypoglytrmia iI fipt(iaIIy ~\rly to OCQll" IlOUnd pt<lk illulin IttMty,
espt(ilily iffood SOlUtes I~ ..,dtquatt. PnMdi"9 a quid:..ai"9
CMbohydt<ltt IOUrtt and thMchtcking Ittt apill,..,. ghKost 1M! wi!
rmurt that gt.Jroit dots IlOl dKrelS!' iJnhn whilt IorJting 1M gU:o!e
ltlting tqUipllltrll When in doubt, t~ I)"mptoJIII for SUlPKttd
~)'!lOgI)'C_ is $,Iter dwn .wing fufthtr dKrellts" glucoS!' and
pouiblt lou of rOfllCiouIntsl with .J<Mrst tffKb. SIIIIII additionll
iIIlounuof Qlbohydrufl wil nOI drillliliully irK~ase blood Illgif if
ItIting shows I hyptrgty.:emic tpisodt.)

"lurn the ~lifnt to alwa"tl wry I quirk--aaing wbohydralt MlIlKt"

use lymptOOlI of h)rpoglrtfmia O(rllr.1f UIIIUft vdltthtr IJII14ItornS
indKite hy~ Of I\ypt'lllycemii. tJtat 15 hypoglyttmia and thtn dttck
capillary g~. If.ymptoml ~ not rtliMd in 10 to IS minultl,or if
blood I~I is below 70 mgldl (or p.1ramttllfS 15 ordtrtdl, notify tht
ht.lth are pnMdtr immtrfiattly.

Monitor blood g1uroS!' more ~lItrltlyduring pfriock ofillnessor Stml.

(Insulin nffih mlY irKrelst ()J dKre~ during pfriock of hs or SIlts5frelJlfnt monitoring during tlJrst times "'!pi to ~ ~tt gkKoSI'
(ontrol.)

iJl'I1JU(t the ~titnt to rhKk g/urOit Itvtk JIIOR' ~UtrltIy whtn ill Of
IIndtr ItI!! s.11nts1, tsptCillly I5lOCiattd with <I nortllia, 1IIUIti, Of
lOOIiting. may dKrnst inscAin JII'fdI. No(jy tilt h~.1th ~ pnwidtr- if
llllabit tOUI JIOI"IfIII mull dwing ptriodiof iIInt!.s or .Iltss lor I pouibIt
dwl\9f in insulin dv..t.

ErKourigt ~d ph"tlKII iCtiYily Iu monitor blood gb:~ btfore Ind

aftt rexmiSI'JIld btgin II1J _ or inoNmI9m:ist IOlIint gr.J<U.,.
Continue to monitor for hypogIy~ia up 1t~8 hOUB afttr ~eist. (Wrciit
~1is1l m~ ID 1M guOie mort' efliOtndy and iOONSfl in!Ulin 1K~p1()J
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

"lurn the p.1lifnt 1M bentIi8 ofinr~.J1ed lICtirity but!O be9in Iny JII'W
routintor inauSI' in ~ gradually: ExHist ihoold rut I hour .alt~r
.a mfal Of .aft~r al()" ()J 15-g Cbohydratt IIW<l to prf"mII. hypogl)'(trnii.
IffltMt is probJgfd. .rniI.~1 Qlbohydr.ate Irwrb an ~
rOlllUmfd f'H'1J 30 minute during ~XtrtiSI' It lJIiinllm blood 111gB.
IJlltnKt tht palifm to rhKkglurOl~ Itvtk JIIOR' ~lItrltly, briore Ind
amf~.

(Conrlnued)

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686

Unlt l

The Er.docrl .... Sym'm

NURSING PROCESS FOCUS

PATIENTS RECEIVING INSULIN THERAPY (ConrlmJed)

Implementillt ion

Interventi o ns iII nd (Rillti o na les)

Patient iII nd Fill mily Edu cilltio n

Rotat~ inwlin administration ~t~ Wffki\'.lf hoIpitaliztd, 16~ ~1l5that aft'

If" used or diffKUk !O rNCh by tIM> patienllnsulin pump wbanantol6
mhtttr, mould lit rnaoged eYl'fY 2 to 3 days.(Roming ini~(\ion sit~s
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
~podYSlrophy.lfllUlin in an unul~d sitt may lit absor\wd moft'quicidy lhan
a lite wilh lipodyslroph~ I"fWlting in hypogl)\:~mia.lnsulin pump
wbc:Utllll'OUS (a!helen should lit chaoged ~~ry 210 3 days 10 pft'l'Mt
infttlions altht sitt of insffiion.)

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) ~ery2 10 3 days.

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
prttipitat~ forms, discard tIM> vial.)

Tth !he patient methods for proprr ll000geofinsulin and for s!Oragr
ruring tral'l!!.

Patimt undtrstanding of drug thtrap-,:

U,e opportuni1ie during oIdminimation of medications and during
a!~mrnB 10 discus, !he rationalf for dflllj Ihffilp~ de>ired thffilprutic:
OIJlcom~, mo!t common advffle~flect!'[)aram~t'l for when to {.111 tM
lItoikh taft' pro'IidI'~and oI ny nttn sary monitoring or prKautions.(Using
timt ruring nur;ing tare IItlps 10 optim~ and I!'inkllu uy INthing
aft'asJ

TIM> p.atien~ famii\', ort.lrt<jil'f should beablt!O stltr tilt INIOn for lilt
dflllj;oIppropriate~and schtduling;what oIoM~ rllem to oiufft for
and wlltn !O report;nd any Ipt<ial fI'I1uin>mrml of medication tllrrapy
(e.g., ifllUlin nted! during ntf(~ iIInffi J.
InslnKttlM> [)alient to tarry a wallet idl'miflt.ltion card or Wl'ar medical
ide mifiulion jroMlry ind it.Jting diallt1I5.

--+--

Patimt stlf-administration of drug therapy:

When adminisltring 11M> mtdit.Jtion, inslnKl tIM> patien~ famii\', orurt<jim
in tIM> proper 5eif-iidminisuillion of lilt dflllj.(Proprr administration
inc:ft'a II'Ithe ~ffectivrnrss of lhe drug.)

TIM> p;lIien~ famii\', ort.lrtgiYl'r is , blf!O diswss appropriat~ dosing and

administration neecls, inc:luding:
Proper prepar~tion of inlUlin: Rotate vials grotly and do nOI sh~kr; if
ifllUlins aft' mixr<l, draw up tht qJicUsI acting ifllUlin and then longeratting ifllUlin ij tilt ifllUlins aft' (om~tiblr.1 nlu lin glargine or inlulin
drttmir should not lit miud with any otlltr type ofinlUlin.lM lilt
appropri~te syrin~ (100 unit) unlrls !III~II 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 (lfa~ lit~ with
rotation fflf'IWI'~k.lnjt(\ at 9O-degr~ angle, applying pad 10 lilt lite
~fttr injto:tion but do not massa~.
Proper us~ of all fquipmrm, inckiding blood glutOlf monitoring
rqJipmrnt and inlUlin pump.

EVillluilltion of Outcome Criteriill

halu~te lilt effKlmlll'1I ofdflllj lhera~

by (onfirming thn patient goak and tllpr(ltd ootrome hoM ~n mrt (Iff "Planning1.

5to r.bh H. ! ("'. 1;(<<d"'1J< r~ whid> rJoos. OIJf<ing.aitJm ."pIy.

blood glucose levels when taken on a regular basis. Many

have the potential to cause hypoglycemia; therefore, periodic monitoring of blood glucose levels is necessary. Doses
for the oral hypoglycemics are listed in Tab le 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 hypoglycemic 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.

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SULFONYLUREAS
The first oral hypoglycemia available, sulfonylureas are divided into first- and second-generation categories. Although drugs from both generations are equally effective at
lowering blood glucose. the second-generation drugs exhibit 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

TABLE 441

Oral Hypoglycemics

Drug
ALPHA-Gl UCOSlDASE INH IBITORS

RoutE' and Adutt DoSE' (max dose wN!re Indlc:atE'dJ

Adverse Effects

ik<lrbost (Prt<ost)

PO; 25- 100 rng lid (madOO m~day)

mkjitol(~t)

PO; 25-100 rng lid (max:300 rnWday)

RIlfIj!fn<t eI,rrlw, Q/IdomhII

dilfllMio~

IImlIlb:WIlii!irmllm Ihlll!ilniml~

BIGUANIDe

mtefonnil

mmtdiut rtlf:ast (Glumplligr, RiomK)

&tmdtdrtlmt(Fort'md,GlU(~

XR.GlI.II'IK:UJ

PO; SOO m~ two IllIItsiday or &SO RIg OtI(t d.lily;lnot~st 10 1,OOl---25SO mg

in two to tlHfI! dividtd dowday (mal: 255 g/day)
GlllTlflza: 1,lXO-lOOO mgOllCf d.lily (mal: 2g/day) GI~ XR:
sao 1119 OII(t daily (max:2gJd.l,J

RrJIlIJm<t dnrlw, 1lllUSttl. orllWlict

abdcnri7d pdn, bit/If ormnolk Imfll
IMIkirjdmk

Fortamtt: l,(m mg met delly (mn: 2.S gfdiyJ

MEGLrTIN IDES
nattgtinidt (StatlilJ

PO;6.0-120mg 1id. 1-30mln priortomNh

~iridt

PO; 0.5-4.0 RIg bid~kll- JO min pfioI'tomtils{mn: l' mgfday)

(Plilncln)

~Irl.l)'mplOm.\. upptr lt5ji".ory

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: 1g/lUr)

Iwdht, iJrrJOrwss

loIbtn~ldt{~tl

PO; 2SG-I,SOO mg _ 10 two tlmti/d.l, (max: J ~/diYl

HlI!!ISb:\m!Y (11P11'1M Ri!l!ililillm.

!,Nrati!'!!!) d!GltSlatic Wnd!ct blood
~

SUlFONYLUREAS, SECOND GENERATION

gl~ridt (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)

gl)buridt miauniltd tabldS (Miaoo,st)

PO; 0.75-12 mg _ 10 rMl tlrMslday (max: 12 mg/day)

THIAZOLI DINEDIONES

piogIilalOM {Ioctos]

PO; 15-30 mgtday' (mn:4S mg/day)

rosicJlitazorlt (AYiIlCN)

PO; 2- 4 mg ont 10 (I) Iimtslday (nw::' mg/dayl

!!m2!I!):ePm~ (IrmlOn. ~!I!!!al!!lm.

lWPati!'!!!1 dlof!:j!j!!k @lIndkr

blood

""""'"
Uff'IJ repfflfOly 11fto(tiln, ~9tl.
IIN1ht,tdIJIIII, wright gail

WmtnilgtfCHfdmlt!l li'm

ma!!la. bmt!2!2!!i:!! I!!l!!~

......

fwl!tS hfjnfill!! I!MXjrdyl

MISC EUANEOUS DRUGS

bfomocr1lI:int (CJdoseIl

PO; OJ-4.8 rngJd.ly upon.waktning

mn.JUdt (SyKU)

SubcutalltOU5; S-10!IKg ont to two times/day 6(1 min prior to i mfal

NaIMq fmigut,tfziMl.\. KlIIIiting.

-'"

~!l!!:i!m i!liti!i!m l!ilgg!!i!i!m!

1ItMEv,l'I1miring,dialr~_

Um:tl1b:WIlY II~ Rillli!ol!i!)m

primlintide (Syrnlin)

SubcuJalltQlS;1ypt 1OM: 1HAmcgpriorlOmtais;l)'pt 2 OM:

(,(I-11Omcgp!iorlo muh

"""'"

IfIIIISfO. ..,mlrilWJ, QlI(Ittxl~, tlzmes~

mugh.fQIigut

H)l!2!l;!):tm!l (!rmlOn. ~!I!i!ilMn.

....,.".
iwgliptin (liMia)

PO; lOOmg meedaily

Ralrilm. tla., o/ldomhll

disttntion
Um2Ilb:'~mii (1 rml1m

Ihlllli!ol!kim
(CmtlnUJ)

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The Er.docrl .... Sym'm

TABLE 44 21 Oral Hypoglycl!mics (conrlnuro)

"n"

Rout e and Adult Dose (max dose where Indicated)

Adverse

gipizilk-'!rnf,tlonnin (""'ta~ip)

1'0;1.5/250 mglday (max: 10 mg glipizid/, and 1,000 mg mmormillday)

Sf! p~iouI pagtfor i'ldil'idJal drug

glytuilrJrnfifonni'l (GilKovanc:~)

1'0; 1.15 mg/l50 mg 0lIl' 10 IWOti~da, (mll:1O mg glyburid! and

"'~

Effects

COMBINATION DRUGS

l,OOOmgmNfomioJ~)

PO; 15 m~500 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 mg.0I.mgl4mgfixtd-dwrosigl~1
gimepride daily (max:S mg ro!i9itiron~and 4 mg gimepirid/,fday)
rosigi~tfonnin (Avanda'~
='_~L
"C
'~
='=
~ do!C' (max:S mg ro5i9itiron~and l,<m mg metforminlda,)

IIQIk! indQt~ WIllmon id.".rlC' tfI~m;.IIlIIk!Iining,indQte!C'rious~ 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 ex~rience 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 uconeogenesis) 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 promotes 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
dela~d. 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
a1phagh,,;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 su o
crose. Concurrent use of garlic and ginreng may increase the
hypoglycemic action of alphaglucosidase inhibitors.

LibraryPirate

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. H ypoglycemia
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. H ypoglycemia 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 increase 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 ~J""lua'"
amounts, thus disrupting an important glucose control
mechanism. Drugs may be used to modify the incretin system 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

0I~r4ol

... Prototype Drug

Oru9' (or Olabete, Meliltu,

689

Metformln (Fortamet; G/ucophage, G/umetza, others)

Therapeutic (Iass: Antidiabetic agent

Pharmacolog ic ( lass: Hypoglycemic agent; biguanide

ACTIONS AND USES

M~nnin is. p",f~"od orAl hypogl)o:~mK for mon.ging i)'p" 2 DM ~"s~ of
in tiflo(tiVl'1ItSS .nd safety. It is UIN alo~ or in combin.tion with other orAl hypoglytemic:.or insulin. It is appl"OYfd for "sr in {hildlt'fl.gr 10 or abo'll.'. k is
milablt as ~ularffINlI' tlblrb, solution (Riollll't), And wstlintd-rrlr~
forms (Fonallll'~ GllKophagr XR,. nd GlUOII'w).
Metfonnin ~lKn falling .md pOllprandiolgllKOII' Ievrk.A major adwntageof thr drug i5 that it don not talM Ilypoglycmi . Thedrug actions do not
dtprnd on lIimuliiting insulin rrit~.10 it is .bit to mr gUcosr levm in patients who 00 longer srrlt insulin. In addition to Iowrring blood gluc:OIt levt is. it lowers triglywidt and total i nd Iow-dtnsity lipoprottin (lDl)<holtst~rol
Itoiris. and promotes wright Ios~
Metfonnin is UIN ofi-t.btl to urn womrnwith poiy<ystic ovary syndrollll'.
WoOll'n with this .yndromr havr insulin ft'IistalKt i nd high II'IIIm insulin I~
rls. Mrtfonnin rtduc:rs inlulin rrsisun~, which in tum IowrB insulin .nd an
drogtllltffis. thJ. ft'Itoring oormal mtnllrual cy<ltsand arolation.
ADMINISTRATION ALERTS
Sustainro.rrit.u tabitts must bt swallaMd wholt and oot {rushed or

,""".

Strum gu.:osr Ieffis shoold lit obtaintd ~try 3 months,i nd tht, clost adit/llod a{cordinqly.
Oiuontillll' lIII'dication imrntdiatr~ if signs of "idosis orr prrsenl
P~nalK)'<.iIegory8

PHARMACOKINETICS
Onset: Its. thdo I h
~k : I- J h (regular rriNlI'); 4~ 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

LibraryPirate

ADVERSE EFFECTS
Th~ most <om ..... n . <MIW .ffom orr GI ... latod And in<kId. na",~ .. """iting.
abdominal disc:omfon, mmlli< taSit. diarThta, and anorexia. k may .Iso <OUII'
headacht. dizzilll'S~ <lgitation, and fatigut. Unli e the IUlfoo~ull'as. OII'1form in
.. rrly {alMS hypogl}o:t mia or wright ~in. Tht most
ad!,M tffed is
lactic:acidosis,whim is i "II', though plttntiallyfatal,condition.The riskfor lactic: icidosis is ilKrr.1N in patients with renal impainnrnt, liYer dista~,s~~
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 faikJ .... history of Llctic: "idosis, or {onrurrrnt
miolJ! infK!ion.1t i5 contraindicated for 2days prior to and 2days .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 prrgnancy and Iact.tion.

stnous

INTERACTIONS
Dru;rDrug: AkohoI inmns iMrist forlao:tic: ao:idosis.Captopri~f~,and
niWp~ ma>f ~ tht> r~t 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, ~i1,oo~idt,lIlicIoctiIt,
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.

lINi ment of Dftrdose: For ~rdost or ~Iopmfnt of lactic: acidosis, hemodialysis <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 synergistically with insulin in glycemic control. Pramlintide slows
gastric emptying time and increases satiety, thereby leading to
reduced calorie intake. Pramlintide is administered subcutaneously immediately prior to each meal, using U-IOO iru;ulin
syringes. It cannot be mixed with insulin, and must be injected into a different site than insulin. When initiating treatment, 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 approved in 1978 to treat Parkiru;on's disease, pituitary adenoma, 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 exact mechanism by which it improves glycemic control remains undear. The most frequent adverse events associated
with bromocriptine are nausea, fatigue, dizziness , vomiting,
and headache.

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TheEr.doar .... SyS!,-""

NURSING PROCESS FOCUS

PATIENTS RECEIVING ORAL HYPOGLYCEMIC THERAPY

Assessment

Potentii!ll Nursin9 Dii!lgnose s

Bilseline assess ment prior to administration:

Understand the reilson the drug hu litton pre<ribtd in onIer to as~ 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 prtSeIl~oral 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 drug~ 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 orfM}.M~ 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 ~Iinl' vital signs, heigh~and ~ighl
Enlwtt ippropriate laboratol)' findings k g., (8(, Murol)16, glumII', Al (
It~llipid profilt, hepatic ilnd R'nal fulKtion srud~s).

Imbalanced Nutrition, MoR' Thin Body Rrquilt'mtrm (typt 2 diabtlt'S,

It'lattd to insulin R'listan~ and intake mon than body n~lk)
Oeficirm Knowlt~ (drug thtl<lp)')
lnefienr.e Theraptutic RegimenM.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 adY!'~ drug elf1\, lack of sellliltion in ellR'mities
from IIfIJropath~s)
Riskfor Infection (relattd to hypel<jlycemia, impailt'd cirtulation to
f1{tlt'mities, neuropathies)

Assessment throughout administration:

MIl'S! for desirft! ther~ptutic: ~ffn (~.g., gkKDlt ie\'els It'rruin within
oormallimits,Al( Itvels dernonstr<lle adequate (ontrol of gllK_).
CominUl' periodic monitoring ofhe~tic 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, li9:1I-htidtdnes~ ~nQety, deeR'~I!'d IevfI 01
(OIIS{iousnesSo Also as~ 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.
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, and rtlJuired prfUutions.
~monllr~1t' properseihdministration of the mication (t -9.d<M, timing. when to notify plO'/id!or).
Implementi!ltion
Intervention s i!l nd (Ri!ltio nales)

--+

Ensuring thfrilpeutk t lffds:

CominUl' aIStI>ments aI d~ribtd earlier fur thrraptUlic dftCI5.
(~pendeot on the se~rity 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 tlimioatt 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 d~tal)' man~9fmenl
Alcohol tiln raill' and then plI'(ipitOlJlIy IoWfr blood sugar as akohol is
IIK'tabolizrd, l<Iising the lis kof hypoglyct mia. Patients on IUlfonyluR'as
should awid or tliminate akoholtntilt'~ to pl"fffnt a disufiram-like
R'adion.)

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Patient i!ln d Fi!l mily Educi!ltio n

T~ac:h 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 glum~ IIovel (~
"Min imizing idvt-~ eff !"I"later in this table) rootinely ilnd if sym ptorm
aR' prestlll Prom ptly R'pln any OO1iceabllo symptorm and concurrent
capillary gllKose ltvel to the heahh Ult' provider.

Re>iiew cumnt diM, lifestyle, and adjyity Itvel with the pat~nt.Anill9f a
dietitian {onsuh bill'd on the I'ftd to alter dirt or food choic:es.TNth the
~tirnt to limit or t liminalt'akohol ulI'.lf ilkoholic ~verages are
mmsumed, limit to On!' per day and take i long with i complete mtal to
enlUre that intake balaoces akohol metabolism.
Imtrutt the patient on sulfonyureas (t.g. glyburide) to avoid or t liminalt'
almholull'.

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-

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.

NCLEX-RNOREVIEW QUESTIONS

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.

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.
The nurse is initiating discharge teaching with the newly
diagnosed diabetic. Which of the following statements indiCltes 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."
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.

3. Exercise may increase insulin needs.

4. Withhold insulin prior 10 engaging in strenuous
exercise.
5. Take extra insulin prior to exercise.

A type 2 diabetic has been NPO sinU' midnig ht for surgery 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 administration 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.

A 63 -year-old patient with type 2 diabetes is admitted to

the nursing unit with an infected foot ulcer. Despitt' previous good control on g1yburide (Micronase), his blood
sugar has been elevated the past several days and he requires 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.

CRITICAL THINKING QUESTIONS

1. A 28.yt'ar-old woman who is pregnant with her first child

3. The patient has insulin g1argine (Lantus) and regular in-

is diagnosed with gestational DM. She is concerned about

the fact that she might have to take ~shots." 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 g randfather talk about his pills to control his ~sugar." What
should the nurse explain to this patient~

sulin ordered for every morning. Explain the implications

of administt'ring these two types of insulins.

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?

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Set Appendix D for all5weTl and rationalel for all activitiel.

EXPLORE
M)'ttJrsinyKit is \OOr Me

tor oolite cha pter [/!\liN! mat~iais aM

resolKcu. f'l1lIl'we fa' ~U:C8S$ 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.

Drugs for Disorders and

Conditions of the Female
Reproductive System
DRUGS AT A GLANCE

LEARNING OUTCOMES

ollAt (ONTRACEPTIVES ~695

After reading this chapter, the studmt should be able /0:

Estrogen -Progestin (~tlons

~lmdioI 000 nonrllindroM

(Ortho-NovumJ

,.695

,. Describe the roles of the hypolllalamu5" pituitary,and oyar~ in

,.XXJ

Progestl rKlnly Agents

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 symptom s.
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 e~plain 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.

,.fiJt,

DRlJCiS FOREMERC>ENCY CONTRACEPTION

ANDPHARMACOlOGIC ABORTION pq JrXj
HORMONE REPlACEMENT Ttl.ItA PV pq lIH

Estrogens and EstrogeniPfOOtstin

Combilliliom /llI/' JIJI

o COI1jugatN ","'gnu (C~~Ii...

...

EnjuviQ,I'mrnI,;,,/

IIfti\lS

DltlHiS FOR !lTSfUNCTIONAl unRINE BlEEDI NG

~

Progeltlm IIIfti'OlJ

...

Q m~t.I .-aaral.",",""Q)
~

UJ1RJt~E STIM UIANTSANDRIlAXANTS ptlftlf1l

Oxytodo ,.u
Q oxyrodn(Pirodn)

fJIIIJ'}QI}

&got Alkaloids ptqiU

Prostaglandins , . JOI
TIXoIytics fIIIIltJr1l,
DR\JCiS FORFEMAU INFERTIUTY
ANOENOOMETRIOSIS

,.m

KEY TERMS
(OIpIIl luteUIII fJIIJ'695

h_

cl)'sUKtionalltl'fine blHding , . JIJS

.lIdtmtri:lsis , . m

inffrtililJ piq 7Il

lutfrimt honnorw (lHj

eIIOtfn fIIJ1'69J

IIIfMIYNO jIIlIJt;t\l
o.,.1I1iMl fII1J' fiIj

JoIid@'itilllWlinlitormOIll![FSII)

jXkT695

gtnHOtropilHtlrning hor_IGnRH )

... m

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II'pla(HlfQ\ lII~ra P1 (IIln 1""J'lf)4

111)1000 JlDIT lW
p rog f~ fII1J' 695

piZ/t695

prosuglMlilil

piq lfJ(J

IO(olyt!( fllJll'lW

OIop1fl45 D"'9' lor Dbord<>" aM Condition, nftl>o Female ReptOducdve System

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 vlrtuaMy every body syllem Including effects on cOiIgulation,
blood vessels, bone, musdes,overllli body metabolism, and
behaviOf. Hormonallherapy of the femille reproductive system is used to achieve II variecy of ther~lc goals, ranging
from replacement therapy, to prevention of pregnancy, to
m ilk production.Thlschapter examines hormones and drugs

used to treat

conditlon~

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 hypothala mus secretes gOl"llldotropinrele,sing hormone(GnRH ), which tr.lVe1S a short distance to the pituitary to
stimulate the secretion of follicltllimu l"ing hormone (FSH) and
lutein izing ~lI"mone (lH I. 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 hormones create two interrelated cyd es that occur on a periodic, monthly basis: the ovarian and uterine cycles. The
hormonal changl.'S tha t occur during the ova rian and uterine C)~les are illustrated in ,.. Figure 45. 1.
Under the innuenceofFSH and LH ,seven l ovaria n follicles begin the ma turation 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 mens~ btfoIt '9t 4O,ind S of 1110 womenwil

(O'Ioo..~.6I.

About half the U~ 01 :ly$functiollil ~ltriM blttding irtNgrlOSfd in

wollltn older tMn 45; ~~ mol USfS oco.rr ........ in !hOSt
younger th.n 20.
T~ most common It.!:>n wtr,-womtll bfcomt prtgn1nt while on or.l
{onrfiCf1l\rnS i! skippilg. dolt.
Anonsmoking wo~n lIItd 25 !(I 29 hna 2in 100,000 chancrof dying
from {omplic.llionsdulto or~l 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; il&mm~toJ)' distue
10.000 hospitaliutions for Kiopic prtgnincy
27,000 fAstS of imn-delicitll()' MfOI II
20,000 hospitaliutiOl1i for ~in typtS of rtOOIrlilignint brost distoM

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695

tbe ovarian cycle, a surge of LH secretion causes one follicle

to expel its oocyte, a process called ~ulatiOi. The ruptured
follide, minus its oocyte, remains in the ovary and is transformed 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 u terus. If conception does not occur, the outer lining of the u terus 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 hormoCll.'S estrO!lfrl and pT09tflHOIM'. Es trogen is actually a generic

term for three different hormonn: est(;lodiol, eslrone, and

estrio l. Estrogt'fl is rnponsible for the maturation of the female reproductive organs and for the appearance of secondary sex characteristics. In addition, estrogen has numerous
metabolic effects on nonreproductive tiss ues, including the
brain, kidneys, blood vessels, and skin. For e.lample, estrogen lowers blood cholesterol levels and fadlitates calcium
up take 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 secrete, a class of hormones called proge5tins, the most abundantofwhich 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 beoomc:s vascular and thickens in preparation for receiving a
fertilized egg. H igh ~terone and eslrogen levels in th e fi nal third of the uterine cycle provide nega tive 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:acologic useof the female sex horm onl.'S is 10 pre\enl prerl;lncy.
They are also prescnbed to treat dysfulKlionai uterinebleeding, ~vere symptofl"L<; of menopause, alld certain neoplasms.

ORAL CONTRACEPTIVES
Oral contraceptives (OC) are drugs used in low doses to
p revtnt 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 commonestrogen used for contraception is ethinyl eslradiol, and

696

Unlt l

The Er.docrl .... Sym'm

Ova rian
cycle

Ova rian
hor mone
cycle

1
1

Me nstrua l
(ute rine)
cycle

I
,,
,

];

",,

Secretory phase

Days:
0
7
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, differing 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 estrogen contained in ()Q; have declined from 150 mcg,40 years
ago, to about 20 meg in modern fonnulatiollS. This reduc-

LibraryPirate

14

"

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 encourage the patient to take the pills on a daily basis. Some of
these placebos contain iron, which replaces iron lost due to
menstrual bleeding.

IlIopltl45 Drug; 10< DI"" ...... ' arod (oodlliom 01 I"" F""",'" Reproductlw SY;lem
Releaw

ot GnRH

C"

""

OvUBlion

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 contraception. If two consecutive doses are missed, two tablets should
be taken on the day the missed doses are remembered and

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697

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 feedback to the pituitary, which suppresses the secretion of LH
and FSH. Without the influence of these pituitary hormones, the ovarian follide ~annol 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 contra~eptive fun~tion, these drugs are sometimes pres~ribed to promote timely and regular monthly cydes, and
to redu~e the incidence of dysmenorrhea.
The three types of estrogen- progestin formulations are
monophasic, biphasi~, 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 treatment cyde. All three types of OC formulations are equally
effective.
The progestin-only 0Cs, sometimes called minipil&, prevent 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. Min ipills 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 patients 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 available. These e.'(tended-duration fommlations are equally effective 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 medroxyprogesterone acehte that provides 3 months of oontraceptive
protection.
_ Implan ts: 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

700

TheEO>dornn ~ Sym'm

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 6trogtn (0.035 mg) and progesterolH' (1 mg) for 21 days,1011aMd b)' ploK~bo
ublm for 7 days. k iSlH'arfy 100% effective.n prrftnting (o'Ktption. OnhoNoyum is.Jlso mililblt in biphasK and triphUK pll'pmlion~ All Pfl'Pilrillions
pIl'YI'nt O\"IJlation by JH'9iIt~ fttdbadc rontrol tilfl1eted at the hypothalamus
and the pituiury gland Whm th~ 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 oyulation.Off-lab~ indimions 10. the dlll9 inc:kKitac:ne \"IJ1~ris(in Iemalts who have ac:hitY~d m~naKh~), endometriosis, hypermenorrbN,.Jnd
dysfunctionill uterilH' bletdil"l(j. HonrontroKep~ bmefilS 01 Ortho-Novum indudt implO'femellt in m~nstlllill tydt ll'9ularity and deu"a\fd inc:idenc:e of
Onho.H~um

d)'lll1~OOIrht.J .

,"

ADMINISTRATION ALERTS
Tilblru must be uun ~dly U dill'tled
II a dol!' is misstd, tallt as soon as remembeml, or ullt two tabltn th~
III'lttday.

Peak:l mo
Halflifr: 6-45 h
Duration: 3- 27 h

antit~

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 ~fIem and oompliutions. EmphasUr to the patient theimportlnc:tdukingthtmedlations.ndill'ed.~itionofOOetf
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 Pf09I~m. betaull' smoking ilKft'.lll'l the risk 01 IOIIIplications, rspt(ially in WOIIII'I1 older than 3S.injJrm ~titnlS that hormone thrraP'J' for ffiII'I"gene:)' (OIlUoKeption or II'nni ... lion of pll'<JIanc:y may Il'SUt i1 ~lm5iY1' Rgilal
blerdil"l(j. This ommnc:t InJII be reportfd to the he~ hh Ull' proYider. 110Il1I0III'
therilP'J' may be UI!'d to tll'at (enilin millignam rumors in IIIiIIt ~nd female patients. Admst tffetts inc:kKit deYebpllll'm 01 (ha.actfflstin of the opposite
gtndrr.For mro,that incUIesgylH'romastia,changt in libido,and testlula. atropIr;. For WOIIII'fI, that indudes. inc:rmrd IKial hail and drt'ptnil"l(j of the Oitr.
ThtSI' changes may have drYasuting flIIOtilnal ~fIKtS on the patient and lamily. Enc:oorage the patient to IftIc III*ssional help ifsymptoms 01 depll'lsiJn o.
i... biity totopi' O(QJr.Familycoool!'liIg ma~ also be ~vilfd.

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INTERACTIONS
I)ug-l)ug: ~n,1OIIII' i~tibioOO,harbituritel,antitorMHam.DI
anlifl.ngik dKIl'u1lll' ~ ofOCs, ilcrN~ng tilt riIk of~ blefdi09
DltMpos~uit,of~.~mllli)'dKIl'N1III'~lofOlill

P.egnalKY megory X
PHARMACOKINETICS (PO)
Olllf"t: 30-60 min (I month 10. (ootra(eption)

ADVERSE EFFECTS
Tht mOlt iIl'~m ila.rrll' ~ffe<ts of Onho-Novum a.f naUll'iI, brem tfnde.IH'IS, Might gain, and bll'ilkthoough bletding.lrss (ammon ~(I\ indude
edema, (hanges in ision, gillbbdde. dill'.m, nausu, ilbdominal (rimps,
(hanges in urinar; function, dysmenorrhra, brmt fulllll'lS, falicjut, skin rash,
imr, hNdoKh~, "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 (00ditions: QJlTI'm o. past history 01 thrombotmboll disordel5, strou, 01 roronar;
anl'rydill'~ lI';hepatic: tumors; known OIsuspt<lfd un:ioolllil of the brNst,endomtlrium, 01 oth~r ~strogtn~ndem tumOl; ilbnormal ulI'rilH' bletding;
dIoIfSIatic jaundlt of Pll'9ni IKY 0r jaundn with prior oral rontr.Krptil'l' UII';
known OIlUIpt(ted pfl'9l\ancy.

Lab Tem: ViUes of 1111' following Ina')' bt inc:1NSed: jnIInwnbin iiIIII', tfrtlin
<Ngwtion Iactoo, thyroidbindiog~in,P8I, T.. plalrlel ~tion,ind
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

.kIhn~wOll

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 implantation 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;
"V~ll OG h~v" ~ [~ilur" r~ t~ u[0.3% tu 1%. Erll"rl!~"'.Y LUlltraception 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

NURSING PROCESS FOCUS

PATIENTS RECEIVING ESTROGEN AND PROGESTIN THERAPY (ORAL

CONTRACEPTIVES, HRT, ANDTREATMENTOF DYSFUNCTIONAL

UTERINE BLEEDING)
Assessment

Potential Nursing Diagnoses

Baselint assmmtnt priorto administration:

Undtrmnd th~ INson the drug has ~n prescribtd in ol'lltr to mes for
thtr~ ptUlic: ~ts (f.g., oral rontroK~ption, UtUllK'IIt 01 dysfunctional
uteriIII' ble!ding. hormone repioKfment ther.!p)').
Obtlin a (omplete heahh hiuOl)' iMk.iding (jIdio'alrula~ peripheral
mub~migraint htildad-.e, th)TOid, h~pnic:, or ml,1 d~m;di,belf"S;
prt'9l1i1ncy;or bll'an-frfding. Notf peoonal or family hislol)' of
thromboembolic: dilorden; (~.g. MI, CVA. PVD) ,md of II'procilKtiYl' (all(m
(t.g., blNl~ uttrint,or ovatWn WKtr).
Obtain i drug hinol)' induding allel9~(lJrll'nt p=ription ind orc drugs.
htrbal plI'pmtOOs,akohoi ust, ind Imoking.B~ ilen to possible drug
inttroKtiolll.
[valu~1I' appropriatf liboratol)' findill9l (f.g., CBe, pbtt leu, tle(trolylf"S,
gllKOSl',lipid,ind thyroid function Ie\'ek, Pap If"SQ.
Obtain balflin~ heigh~ Wl'igh~and vit.ll signs.

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)
Dtf~nt KoowIedgf Idrug therapy}
Rille of Injury (lI'bttd to adwr-SI'drug ~ffn)

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 m~oopauSl' 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' v~t.
Asses for advmt t1fts: lIiIusti, 'IOmiting..headoKhe, weight gain, blNn
tendtmes,lkin lish,itnt, fluid ~~ntOO, 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.
Planning: Patient GOcIIls and Expected Outcomes
Ih~ pat~rn will:
Experience theraptUlic: tffts It.g.tfffitin birth rornro~dlI'aSl' in lymptOms of meoopaust, dyslull(tOOal uterine ble!ding is dimini\htd).
~ ~ from, or 9penrIKI' minimil, id~~1SI' t1fis.
Verbal~ In undtrmndiog ofthedrug's ust,idv~1SI' tifll, and II'qJill'd plI'{autionl.
DmIonmate proptl stII-idministration of the mtdi{iltion (~.g.,doSI', timing. whf n to notify providtr).

Implementation
Interve nti ons and (Rationale s)
Ensuring thtrilptutic rffects:
Monitor iPPropriall' m~diatOO administration for optimum 1!"SlJ1ts.10Cs
all' lI!'arly 1m effffiiYl' whrn ta~n ilS lI'quill'd Skipping dam ilKr~'1e
the risk of PlI'9nilllty. Mainta iniog (olllilltllt daily dole! for lII'atmern of
m~nopaual symplOtm or dysfunniollill ut~rint ble!ding will ensull'
hOl",oo.In.1> r. nldin ,ldbir .nd ',"'plo"" "SI'J

Patient and Fam il y Education

Inmu(\ thr pat~rn 10 t.l~ thedrug at the am~ tim~ daily 10 .... Ip
rf mtmber to ti~ tht pill. Do oot omit d~or ilKll'iSl' or dl!i Sl' thf
dole without ronlulting tht he,1th {ilrt p!QYidt~
For etrogen-progestin (ombination OCs:lf a doSl' is milltd, t.lke it al
IUln., it ~ r."'..m~red .IId l.k the "".1 pill.l il' oolllldll, ... h.dultd
ti~.1f two ronmuti"l.dole ill' mis>fd, two tablets lhould be t.l~n on
both th~ day the miu~d 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 ~mted in the nm momhiy [)tie.
For progestin-Qlliy 0Cs l"mini-piIl11: If a dOlI' is miurd, ta~ th~ pill il
lOOn as rfmembtrl'd but ust an idditional form of (ontroK~ption until
the II!'I:i cycle of pills is St.lrttd.
For hormone rl'ploKtllll'nt ra~ the pills on i lI'9ulir \{h~ult.Omitting
dose ill(lNII'S th~ risk ofbrNk-through ble!ding.
(Continued)

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702

UnII l

The EocIottrne SySWI'l

NURSING PROCESS FOCUS

PATIENTS RECEIVING ESTROGEN AND PROGESTIN THERAPY (ORAL

CONTRACEPTIVES, HRT, ANDTREATMENT OF DYSFUNCTIONAL
UTERINE BLEEDING) (COI1UIll!ffl)
Imple me nta tio n

Inte rventi o ns li nd (Rilti o nil les)

Minim ld ng . dytnt d'f~:
o Monitor for symptoms of thromboembolism.Monitor blood plfllUrt at Nth
dinial vilit(Thromiloembolic ~nts iI~ ,n ,dIom~ eflKt of
~1lI\)qtn/progtstin drugs. The rilk inmilll's with agt'0YeI' 35, in womm
with a prfYious history of urdiov'lCUlar dMI~ , nd in wof1ll'n who

wok<J

Pa tient li nd Fll mily Edu clltio n

o InllflKt the patient to immediately ~rt:
IlyIpON,dltlt !)lin, or blood in IpUlUm (poI~bIe pulmoouy mlbolism)
He,~iOl'S~chest !)Iin,or oYelWhelmiog fffling of f,tigut and w~akness
1(Ompanitd by na~ and diapholfSis (possible Mil
Suddtn, stlm he~he,tlpiilly if mociittd with dizziness;
diffirulry w~h ~h; numbnesl in Jrm or Ieg;dilliculty w~h vision
(ponible (VA)
Warmth, rfdflt'i~ s~lIing.or teodemm in ralfor pain on walkiog
(pouible mrombophlebitis)
TNth the patient to monilor blood prellUJt periodialty and ~rt any
blood prmurt ilbolot 140190 mmllg or per pilr,f1II'ters iIIOrde~ by tht
heahh (ilrt provmt

o Enoorlgt smokiog ctSsation ilnd pfOllm information about smokiog

ctSsation progrilms.(Smoking glutty incrta!ts mt ri~ of ad~erst tllt<ts of
hormone meripy.)

o Advist the p.ltient of risk of smoking while using tstrogtns/progestins.

Pro-iidt rtftnal to appropriate IUpport groups and Ikmrurt on smoking
ctSsation PfOg"ms.

o Monitor blood gUOSt levrls in diilbftic: patient> f1Im irequently.(Estrogens

may affta u rbohydrlte mWbolism,ltading to inc"alfd glur;/M itvtls.
Progestins may all t tndogtnoos iMulin It'Itls.)

o Ttach the woman with diabectS to monitor Cilpillary blood wgar f1Im
frtqUenliy while on drugs contai niog tsttogefl iI ndIor progtstin iI nd rtpOrt
consistent tlt'lations to tht huhh Uft pro"Iidtr.

o Monitor htpiltit fulKtion tests nd symptoms of liwr dysfunction, lipid

profile studit~and th)TOid IMk periodic:ally.(Estrogensa~ iISIoc:i~tfd with
, lUI! risk of ben~n liver tUIMf'I and may adl'fRrly affta (holtlterol
synthtsis, lipid It'Itl~and thyroid ~nction in Itositivt patients.)

o ImtflKt the patient to IWJm ptriodic:~lIy for lab ttst>.

o Tfol(h the patient to immediately ft'port any symptoms of , bdominal or
right upper quadrnt discomfort or pain, ~Iowing of tht d:in or 5Clera,
fat~ut, anoft'~a, d.lrtentd uriflt,or clay-colo~ nools.

o Monitorconwmnt drug thfiapy.(M,fIy drugidtutast or alter tIM:

tfft<tivenm of tstrogens ilnd progestins inckidiog drugs in the penitillin,
b.Jrbirurate,ilmMizu", oInti.deprtsum,and IItnzodiil'l'pilH' clauH.Chrdl
fordrug intt roiCbont thlt may afft hormofltrfftNtOtsS briort il OY ntw
prHcription is SUrltd.)

o Tfach tIM: patient to alMst all heahh calt providtrs of the ust ofalrogens
aodlor progtstin I for contf<Ktption orfor hormont replactffltrlt therapy
bfiofl' btginniog 'fly IH'W prtSCription.If' pmcriptiorr is Ifqui"d, discUls
the nrfd for ah('fllati~t utatme:nt or birth control mtISU"S as oI ppropriollt.

o Monitor yt.lrly Pap ItsIS ,nd In,st eums.(AnOUolI Pap tests and b"alt
t:urm, inckidiog mol mIMgraphy 's appropnatt, will monitor for the
dMloprnrnt of brtast tumors or of cfrvic:al (anerr or HPV infection.)

o TNth the patient haw to perform b,,~ts~lfflilmSilnd rnc:ouragt

monthly rurm. For worntrllM'r 4O,advist th~ Piltitnt on the r'ftd for
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

contifllOU~ unU\lsa1. or heoII'y bIe~ding. (SO\iIII amoun" of"spotting" mily
oc(ur,tspially with 1ow4st hormont therapy"t midcyde.Any
contifllOU~unU\lsa1. or heilVY bletdiog may indicate ildlomt tffB or
distasr oInd should lit Jtporlfd.)

o Ttol(h the patitnt that ~ight sporliog mily occur midcydt while on
hormolH' drugs but to rtpOn any uOlIIU,1 chiflCjfl in tilt ilmount or if
blttdiog continUts.

Patimt understanding of drug th trapy:

o us~ opportunitifs during . dministfiloon of medications ,nd during
'SItUf1II'nts to discUl stile rationille for drug therapy, dtsirro therapeutic:
outcomrs, most common adYffsttfftcts, paramrtm for when to ull the
hea hh (jIft' prol'idr~and 01 oy ntssary monitoring or prffilutions.(Usiog
timr ruriog nursing urI' htlps to optimizr ilnd rtinfon:r key tuchiog
ilR'ilSj

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o Thr patient should lit ,ble to state thr Jtol lOn for thr drug,appropriatr
dolt ,nd 5Chrruliog,and what ildIotBl' tffts to obitlVI' for and when to
rtpOn thrm.

IlIoplfl45

NURSING PROCESS FOCUS

Drug; 10< DI"" ...... ' arod C""dlliom 01 I"" F""",'" Reproductlw SY;lem

703

PATIENTS RECEIVING ESTROGEN AND PROGESTIN THERAPY (ORAL

CONTRACEPTlVES, HRT, ANDTREATMENTOF DYSFUNalONAL
UTERINE BLEEDING) (Conllnued)
Implementation

Interventi o ns and (Rati o nale s)

Patient and Family Educati o n

Patirnt St!lfadministntio n of drug tht rilPY:

Wlltn admininffing th~ rntdiution,imtllKt th~ p,.itm, family,orult9~r
in thl- proptr s~lf-adminismtion ofdrug, ~.g.,(omillently" l.imt tim~
~.l(h day to h~lp Il'mtmbl'r dosr.(Proptr adminismtion inc:rri~s tilt
effeui'lrnessoltlltdrugs and 1It1p! 10 rtinion:Hra,hillQJ

Trach the p;ltitnt to like IhI- drug following appropriate guidelin~

Or,l drugs should be taken " tht samr timt NCh day 10 htlp Il'mtmbtr
thl- rIo~.FoIlowthlo inmlKtiom if, rkM is missrd (mi:nsuring
lherapMic: ~ts' disrusSfd ta rlitr in this ta~J
Intra'ligillill rings all' ploK.-d in tilt l'iljina ,,-.:I Il'movtd alter 1Wffks for
1WffI: beIort a new ring is irun~d
U:tt nded formulations (~.Ij.,SeiloniqUl' or SNsonalf) art laken for
approximiltd)o 3 momhs (84 dilys) and tlltn loIiowtd t, 1 days of rith~r
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 1Wffl

Ev aluation of Outcome Criteria

Evaluatt tht rf~tienl'ls 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, Pre~
ven, co~isted of a combination of ethinyl estradiol and lev~
onorgeslrel; Ihis regimen is no longer available in the United
States.

TABLE 45.3

Plan B must be administered as soon as possible after lUIprotected intercourse; if taken more than 72 hours later, it
becomes less effective. By 7 days after intercourse, it is ineffective at preventing pregnancy. The normal rate of pregnancy 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,

Drugs for Emergency Contraception and Pharmacologic Abortion

Route and Adult Dose (max dose where Indicated)
Adverse Effects

"n"
EMERGENCY CONTRACEPTION
1e~(PlanB)

PO;2 ubltUwithin 72 hof IIIprotKltd imff(oo~ followro b'f

2tabitts 11 htatfl (0.75 nI9 in mh pin

1IMtl, mnili"i fDli~e, /lNdQdrI, mfIrStfUIll

rhafl9t!,brwrrtndlfflflS
Ho~!idvelll'~!

PHARMACOLOGIC ABORTION

urbopoll trommamin~
(IItmabatr)

lM;initial:l5O maj (1 ml) ~atrd at 11l- 111lh inltrlill! if

indicaltd b'f utm rtspon~
IlosaqI> may be illCll'.ilstd to SOO maj (2 ml) ifuterine (ontoolity is
i~ttaftfllt'lff'al dosts of 250 mOl (1 mil, not tou(ffiltotJl
rIosr of 11 rng or (ontinuousministration for 1mo

diioprostOlll' ((trlidi~ l'Il'pidi~

Prostin E,l

hUaviginal;illlffl wppository high in Vigna, ~i1 ~1'l'IY 2-5 h urtil

abortion OCQUS or mflllbranes ~1IIl' (max: IOtal rIosr 240 rngJ

mtthotrnatt with misoproslol

lM;mtthotrnal~ (SO II\9fm') foIowtd 5daystalffb'f intravaginal

800 roo;J of milOplOltoi

miftpristOlll'(Miftpll'l)with
misoprostol

PO;1Hy 1:600 rng of miftprillone;lHyl(ifabortionhasootocwrred):

400 roo;J of misoproslol

IIQIio inOOt~ ammon id'1mI' tffi>m;~inOOle striousadl'l'lll' ~ffKl\.

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1IMtl, IIrni!irli dorrllev, fern

Utmn~ Qcfl~li!1!!.!!!I1!!.!l !1!:htrnMh~

NaMG, mni~rIi dQrrIIev

='

NaMG, mniri"i dorrllev

~bIllllillllll!iiD !W:D!II: bl:mllliIYlI:

70 4

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 l~ter 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, mifepristone aborts the implanted embryo. Misoprostol is a
prostaglandin that causes uterine contractions, thus increasing 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 offer women a safer alternative to surgical abortion. The primary adverse effect is cramping that occurs soon after
taking misoprostol. The most serious adverse effect is uterine bleeding, which m3}' continue for 1 to 2 weeks after
dosing. Pharmacologic abortion must always be conducted 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 dinoprostone 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 cessation 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 theNlt~m United
Stneund pailS ofCmda.UsI' ofthe IN-'rb h.n been Ifforded byNniYe WIieanl for IIIO~ than 100 yun.1t is uled .n , hormone b,l,ncer in perim.nop,Jusal WOmM. gl.o<k <oh ... h hos bHn ,hown to b~ ~""'ti"" 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 <oho~ ,~
IOmehmes I"nd,rdire<i by the amount of the <hemical 27-deoq,rtein,
which is ,n a<live ingitdienl At)'pi,,1 doseof bla<k cohosh I'nges from 40
to 80 mg of dried herb per day. {Approximately 1 mg of 17-d~OX)OOein is
p~m 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 unknown.~ effem indudt hypotension, uterine stimulation,
and GI complaints such.n nau~,. Blac:k cohosh Gin ill<ru~ tIN-' action of ,ntihypertensivrs,so mnc:unent 1M should be avoided.

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disorder, but is a natural consequence of aging that is often

accompanied by unpleasant symptoms that include hot
flashes, night swe~ts, irregular menstrual cycles, vaginal dryness, 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 preve nt the long-ternl consequences of
estrogen loss listed in Table 45.4. In 2001, more than 66 million 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 clinical study, the Women's Health Initiative (WHI) were analyzed. The results of the study depended upon whether the
HRT consisted of estrogen alone or an estrogen/progestincombination. 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
cardiovascul~r 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 potential 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. Thedat~ 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 history of cardiovascular disease or cancer. Topical preparatioru; 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 ovarian failure, and as replacement therapyfollowinJ:l su~ical re-

a..p1fl4S

Prototype Drug

Therap~ti c Class:

Drug; 10< DI""""" arod (""dlliom 01 Il>e

f"""'''' Reproductive 5y;lem

705

I Conjugated Estrogens (Cenestm,fnjuVlQ,Premarm)

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(~nrstin) and(ooj:Jgaltd ~stroqtll B(EojtMa) contlin a min ull' of9- 10dilfmm s)'lllhetic plant rstrogtns. The primary indic.Jtion for oonjugolttd Htro~M hu bt~n 10 UNI modmte 10 Sfflll' symptoms 01 menopaus~ aus~d by
diminished truu9!'n 5e(ll'tion by tht ovaries. Othtr replaument th~apirs inckKlt treatmenl of lema It hypogonadism and lISt after oophorlomy. The drug
is applOYtd for the paliiatiW' IlNtmenl af inoptl"able prostl~ ancer.
Conjugattd rstrogeM 6ft1 It'Iffill positi~ mrubolic tffts, induding an
incll'awo in bone deOlity and a Il'duction in LDL choltsterol.1t maya110 IooMr the
riskaf coronary artery distawo 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 rruogeo~ reconniMt by fiBI
Il'm~ing approximattly S ml of air from thedry-powdervial, then slowly
injea the diluent imo the ia~ aiming it at the sKIt af thf vial. Gently ~i
lait ta disft;do not shake.
Adminin~1V push !IowIy,ata rateof5mgfmin.
8othall'p~nanqcattgOl"1X.

PHARMACOKINETICS (PO )
On~ : Unknown

ADVERSE EFFECTS
~~ effects of conjugattd estlO9f1n ilKludt n~USI'a, Huid Il'temion,
t<itma, bll'ast tendernrss, abdominal era mps and bloating.. anne palKreatiti ~
apptlitt cliaogrs, acnf, mental dtpl!1sion, dtclNW'd libido. headache, fatigut, nt IWusness, and wtighl gain. HfKts art dos~ dtpeodtnl. [!IIogen~
when ustd alolH', haW' br~n associated with a hightr risk 131 ultrilH' canm. A~
though addinga progestin may txert a protlivt tfl"rct b)' IooMring the risk of
uttrinf cancr~ salll!' studirs suggest the progtltin 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 patients 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! i1d~ a ~ .ffKlolt.lmOmfO, enharKed
cortKOIIl'loid Iffl'ttS, 0100 dKrNIfd . frem of an\i(oagU.n~ l'IpKiaIy wirlaril.
The !ilKI'! of l'Wogeo IOi)' bt dl<lUed ~ takfll with bartitwles or rifamjin, and
thffi' is a pos~twin(JNll'deflKt of tricyd"K Intidrprl!lsam I t.lbowith ~

l.i bTl5ls:YatUK of thf loIowilgma:o' !If incrNlfd: promrombin tirM, eMail

c~lolCIOI\ myroid-biJKing gIoIUit,f'8t, T~~!tWt aggreg.!lioo.and
uigl)ttrides. Ya~ of thf fotlowilg lnay!lf dKre.ud: antithrombin ttl, T~ foLll~,
and , itamilB"

Herba VFood: Red dovn and blad cooOlh IOi)' n!Hffno w~h HtrogIO tll5.,.
EIIlns of l!llrogtn IOi)' bt ert.anced if cOll"lJinfd with ginlfllg.

lINI ment of Imrdase: Thtn' is 110 sprcific Ill'almeol lor O'II.'rdos~.

P9k: Unknown
Halflife:4-13h
Duratian: Unknown

lifter Ie M}tII!rllllgm"" Q Nlmlnl} I'rIKm fools ljItCl/{ Ie rlrls d~

~ distUrb.Jncrs,dtpIl'sWl,irritabiity

....

" lOmnia

"'

ITtgular menstrual (ydrs

Hfidicbtl
Vaginal au~~ incrtill'd nftnion~ p.linful
inttl"lJlI.rII'
Skin atKljtly

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 progestin 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 secretion. 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.

SUffi winary incmtilH'nce

SexUoJI dsintemt
Cirdio....uculilrdiltall'

..""""

Allhtimtr'riR dtmtntia

Colon cancer

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UTERINE ABNORMALITIES
Dysfunctianal uterin~ bleedin g is a condition in which hemorrhage occurs on a noncydic basis or in abnomlal amolUlts .
It is the health problem m ost frequently reported by women
and a common reason for hysterectomy. Progestins are the
drugs of choice for treating uterine abnormalities.

706

Unlt l

Th~EOOo<rI .... Sy<!"",

45.6 Pharmacotherapy
with Progestins
Secreted by the corpus luteum, endogenous progesterone

prepares the uterus for implantation of tht' embryo and pregnancy.lf implantation does not occur, le~ls 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 limits 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 lu teal phase
Postmenopausal bleeding-hemorrhage following
menopause

Dysfunctional uterine bleeding is often caused by a hormonal inlbalance betw,n estrogen and progesterone. Although 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 continuing forthe next 20 days can sometimes reestablish a normal,
monthly cyclic pattern. Onll contraceptives may also be prescribed for this disorder.
L IFESPAN C ONSIDERATIONS

Estrogen Use and Psychosocial Issues

~!ISI' und~ir~ble .J~rw ~m

may oc:(ur with ~trogen usr, t~ nurw

lhoold{ommunK.iil'th~r priorto implementing drug ther'py.The nu~can

apiait' ~ patient'l INdian 10 thrll' pott ntial rilks.An~lllmltofthepa

til'ms t motion.J1 Wpporls)'Sttm should also bt made btioll' ini~uing drug
ther~py.Hirsulilm,kn5 of hair, or a deepening of ~ voKt (an oc:rur in the frm.J1e ])atirnt Men may deY!-lop IffiIndary fl'lll,1e (hmctrrist~ 5IKh .JS.J
higher YOU, lI(k of body hai~ and inCll'ilsrd blt'all sill'.lmpoirrur m,y , 110
~p 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/ ~lIoqrn ther'py.1his
kmwltdgrnwydow both Iml andwomen patieontolt'lllainWllpiiamwhnt
adYme tfl"tru ouur. Duril"f;l therapy, paMrm may nerd tmOtional !UppOII to
~I in dtaing with tw body illll9l' is5Uel. The nu~ LIn fIKOII"agr this suppon,disruss IW issurs with f,mi~ mtmbm,and rmr patients for romseIing.
Forlhe irmaII' patirnt, the nu~ 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 M~ surrounding impotrlKr and iu ellrn on Ihrir r&tionship.

Endometrial carcinoma--cancer of the endometriwn

.... Prototype Drug

Medroxyprogesterone Acetate (Provera)

Therapeutic ( lass: Hormone;agent for dysfunctional tnerine bleeding

Pharmacologic (lass: Progestin

AaJONS AND USES

ADVERSE EFFECTS

MrdI"tlq'PIOQI'II~1OIIl' is .J

The most frrlJlrm ,dvr~ rffrm of medrol:)'Plogrsttronr alt' brtm troderIII'SS, lmoakthrough blrtding. and other menllru,1 irrfgularitits. Wright gain,
dtpJl'Soon, hyptnt noon, n'lIIN. yomiting. dysmt norrlle.J, and 'I<lIginal LIndidialis 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
may Ll!lSl' a Ion of bont mineral derJ~1)'.
Contraind 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 dill'~ hrp,tic im])ailllll'n~ or undiagllOled vaginal bftding. Tht drug shoold br usrd
Lltnious~ in patienu with a histoll of psychic: drpll'Soon and thr drug discontinued at t~ fillt sign of IKUrrill9 dtpr~oon.

synthetic plOQI'Itin with a proJolIQrd duration of oKtion.As with its natural (oumt rpart, the prim,ry t'''ltllissur lor mtdrol)'progrstrrolll' is the t ndometrium of ~ U1l'M. k inhibits t~tffr(\of estrogen on
the U1tru~ thus restoring oormal hormonal balinft'. Applications indudt dysfunctional U1t rine bIte:Iing. Sf(ondary amtnorrhu, and (ontroKrption.
Mrdl"tlq'progestflOlll'mayalso brg~n 1M forthr ])allialian of mmstatic:tnerint 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 abs{t";~ plt'SflKr of lump <l nd discolor,tion oftissUl'.

Prtgnanq rntgOry X

PHARMACOKINETICS (PO)

il1S!'t Unlmo'Ml
Peak:2-.4 h
Half~ife: 30 da~
Ouration:Unknown

INTERACTIONS
])ug- ])ug:Strum I@ve/sof meriroxyprogl'lletOOf ~", deomPd by
amiooglutflhinidt, barbinratH, jHnilonf, rifampin. rifabutin, and topiramatf.

tab Teu: loIfdng~ogNfIOIII'lIIir1 ina&lie TM for alblirw ~ti'if,

gIumII' toteraMf !f51IGTn,and HOI..

Ik>rbaVFood:St..kmi wort Illa)'dI<:rl!Rw etfKliI'~ of

mtdrox~ogNfIOIII' and (iW' abnormaIlIIfIlruuai blffcing.

Trtatment of Onrdost': Theil' is 00 sptCifk IJeiltment for 0Vl'~.

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

In cases of heavy bleeding, high doses of conjugated estrogens 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 tranexami<: acid (Lysteda) for the treatment of cyclic heavy menstrual bleeding. If aggressive hormonal therapy fails to
stop the heavy bleeding, dilation and curettage (D & C)
may be necessary.
Progestins are occasionally prescribed for the treatment
of metastatic endometrial carcinoma. In these c~, they

~tridio! (Oiman, E5irldmn,

EltIl',Vi~~,olhen)

f"""'''' Rep'oductlve 5y;tem

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

Several agents are used to manage uterine contractions and
to stimulate lactation. Oxytocia are agents that stimulare uterine contractions to prom ote the induction of labor. Torolytiu.
are used to inhibit uterine contractions during premature
labor. These agents are listed in Table 45.6.

PO;05-2mgdaily
Tranldmnal ~tdl; I ~Kh titlltr onc:~ wmJy (Oimari) ortwia 'IoftkIy
(0.025-0.1 mgltlayj
Intril'ilginal ~am; nstrt 2---4 glda, for 1 wk.tllffi Iflb:r to Y:.tll! iI~ial dose
for lwk, thtn UII' I 9 _ to th~ tinel/wffl;

(ypionatt

gallbladde(

disorlIrn,iOONIN yom rill!

1M; I- Smg ~1'tf11 -. wi:

Midio! valflat~ (Deltstrogm,

Du"igen-10, VoIlqen)
~strogtn,(on)Jgat~

HyQffi~Dljoo

djIwr tbmmbPflnbg!j(

Topical gtl;ApproIinatrly 11S glda,

~lIIIdio!

707

(Ctntltin, fnjll'lii,

1M;lo-1Omg~1'tf1 4 wk

PO;OJ-1.2S mgiday for 21 days 00 month

Prrmarin)
l'S~te(Ckjen)

PO;0.74mgidayforll daysudt month

PROGESTINS
Q ~trOIIt(~Prv.'i,
~f'Ivffl"i,f'Ivffl"l,(,mn)

PO;~IOmgdiilyonday; 1 - 12ofm~nstrllollqdt

BIfotlIIroogh blfflling. 5pOIfiIg.

1M iIltpo--PKl'lffil); ISO mg daily 10, 1 months.Givt til! fi~ dose dJlilg ttw, firs!
Sdays ritht lllfflSlrual period or withil til! fi~ Sdays postpanum if not
brffil-fffililg

S!.tKuta!leOlll (depMlbQ-Prom"lit 104 mg !!aMy for 3months. GiYe the first dose
dlling til! rrll 5days of til! menllnJill pffiod or at ttw, 6th WffI; postpanum if not
brulIfffililg

iwMllffllitml'lJ, wtighrgDin

AmmorrIIN dl'll!ltllOl!!ltt,
*,,'6~on

Ihrombornlbolic:

""""

PO;03S mglda, ~innil19 on day 1 of menstrual '1'l~

procjI'neron~ ((rtIorIt. Endomtirln,

ProdtiM, Promtlrium)

NMnorrhtl or fIIKtIonil UIl'rlne bIffiIl1g: 1M; S- 10 mglday

,l.s5isJ:~ rtprochKtM ttdtnolog)': Intr.l'i(jinil; 90 mg gel 000' daily or

1(J().mg ubltis

IWOto th~ tines/day

ESTROGEN-PROGESTIN COMBINATIONS
Q

(onjugat~ MogtnS (tquine)1

mrdrOX)'procjI'neron~ (Prrmpha~,

-",)

PO; Prrmphast:~strogen 0.615 mgidaily on days H8;idd Smg

rnedllJX)1l109tltffiHll' da~,on da)"lI~28
PO: Prrmpro:~strogen 03 mgand m~rmyprogtllffiHll' 15 mg da~,
Intravaginal ~.m:illlfl1 'I, to 2 gdai, for 1- 6 months.
PO; ll1b1ti of 1 mg fSU"adid for 1 days, 1oI0000d by 1 tab~t of I mg ffi,adol

combined with 0.09 mg lIOfgeIIinate for l day;. Rt9inrn isrepe't(([ (ontilUCllSly

without ilterruption.
~thilyl MidiolillOl!lhildrone I(etat~

(Aail'elli)

PO; ll1b1ti daily, wIidt (ontains 05-1).1 mg of ffiOOioland 05- 1 mg

noretlind!orlf
Tranldmnal ~tdl; I ~Kh,IWKe wMIy

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~ ibcw~ for adYmr ~flffi:sof

ffiJOgffiSand procjI'S~ns

70 8

Unlt l

The Er.docrl .... Sym'm

TABlE4S.61 Uterine Stimulants and Relaxants

DN,

Route and Adult Dose (max dose where Indicated)

Adverw Effects

To ronuol postpartum blMIIg: 10--40 urill ptr infulion pump

in1.lmmLoflVI\Jid

lioll5ill, Klmiring, mQltmaldylmyr/imios

OXYTOCICS
Q

oxytlKi11Pitodn)

To induo:~ labor: IV 0.5~1milli:Jllit~min.lJidually iOOl'a ~ng tiN-'

dolt 110 gfNter than 1 ~1 milliurinlmin at 30-60 mirut~ iltffials
until (ootrKtioo panml is6Ublishtd

Em) 1tu1b:1ilu1io IIlI:IiD~ 1II1l1W: [tloIl iollilWDioIl

htf!lOllilaot. Witt!" intoxiylion. f(taI brain htmoo!laoe

ERGOT ALKALOIDS
trgOIIOI'il~

maleall' (Ergotrale)

meth)"lft9OOO'lint maiNte
(Methm;int)

1'0: 1tabltt 101 mg) lid-ijdall~ thilitJirth for a maximLm of I wi;

1'0:0.1--1).4 mg bid-iJid

Iiwlfo.lOmiring,umint CTaI1I'1'f1g

lM;initial:lSO IIK9 (1 ml) repeall'd at 1111~ 1111-h iuervak ff

iodiulled by uteri1e 16JHHI~
hualllgillil; 10 mg

liawo. 1Omiring, diall/rto, hfIlIIocllt, d1Ilh, ultIiflt

mrmpirlq

S!!2!:~ !m~ m:11!:!lenlion,dvIrlMhmias

PROSTAGLANDINS
~st(HffilaM:~)

dinoprostorle (Cm-idl, Prtpidl,

Promn E,)
misoprostoilCytottt)

1II~Ii[lf 1oill:1iIIiIlD! ~[1IWlI1iIIillll ibI~ III ill"""

huavagillil:15 meg (1/4 of 100 111(9 tablet);may ~at ~ery 1--6 h

TOCDLYTICS
magntsi:Jm !Ufat~

rifedipint (AdaIa~ Prowdia)

ttlbutaline sulfalt (BrethiOl')

IV; 1-4 9 ill 5% r1e1lrOlt byskM infusion ~riliil max dolt = 10-14
gld.y. tiH-'o 110 mOl! tlwllo-40glrlay at oJ max ratt of 1 ~1g"')
I'O:lniliai dosage of 10 mq. foIowtd II)' 20 mg orally all~30 min
HcontrKtions pmill, tiH-'raP'f un be cortiooedw~h 20 rng Dlaly
Mf'/ l~ 8 h for 48 ~n hw~h a maxinum doItof 160 mglday
Aller 71 hoIn, if maifteDilK is u~lll'quirro.lonoJ-Kting
nifedipillt 30-60 mg daily un be used
1V;1.5~ 10 II\(glmill; irKru~ MI1102fj minUles;dll"Jtion of
iofusioo = 12 h lmax: 17.5-30 II\(glmin)
I'O:mailttnallll'riosI':1.5 IOmgMf'/4-6h

Ruslirrg,fMQring,musdt wfaknru
Coml!!~t~

hea!] bI!l!!, (i1:uiaJID: colla!!! !nRira!o[!

""'""

=" ".. ,

Ruslirrg,lliI'Qring,musdt W!atnru
I

, ;,

IiffI'lJlJlMJ,lrPmot;~J

8foothocoo lIrittion, dy\!!rt!hmiat ak~td mat~maI and

[tioIlb!:oII1Wf

Irdb iodiute (OO1mon oJdvmt di'ttlS; !llderliri!l!! indiute serious adm~ 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 increasingly 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

LibraryPirate

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 breasl~feeding 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 intense 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 softening and dilation of the cervix that must occur prior to vaginal delivery. The prostaglandins may also be used to induce
pharmacologic abortion.

IlIoplfl45 Drug; 10< DI""..... ' arid (""dlilom 01 I"" FE'ma'" Repmductlw 'ytlem

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-

Hypothalamus
sends impulse to

~~u,~

po!lt""'" p'tu~ary

"-

NetVe i"""'l .....

~,

Muscles contract,

squooza out ,",Ik

"""'~~

Milkproducing coil.
Flgure45.4 Oxytocin and breaslfeedlng
~ Prototype Drug

u[ l'ul~"li<oJ

~<.lw""~ ~rro:<.l', lh~y

,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 ineffecti~ 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 manufactured for use in the United States. Calciwn channel
blockers such as nifedipine (Adalat, Procardia) and betaadrenergic agonists such as terbutaline (Brethine) appear to
be effective but are not approved for this indication.

/thalam.m

Milk

709

I Ocytocln (Pltocrn)

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 th~ posterior pituitary that is a drug
of(oou forinduc:ing Iabor.fuytoI:in isgiml by!l"lefal diffrl\'lll ltIUIe~d
ing on its inlendfCI iction.Gil'!'n inlepanum by IV infusion,ol)'loc:in indum labor by in(rt'asing t~ ~UI'nC)l and Ioru of uterin~ (omraction,. k is timtd to
Iht final st. of prtgllllncy,alt~rthe (ffi'iJ ha, dilated, mmbrilW1 ha-;~ rupturt'd,and prt'll'nution oftht fetus ha, oc:(urrtd Do!I'S in an IV infusion aft' in(IN,td gradwlly, ~try 15-1 minu1l'l, until a normJI labor pan~n is
fiublishf<l.
Oxytocin II'\a)' also lit mministe..:'d postpartum to ..:'din htmo~ ~lttr
"puloon of the ploKenta, and to Jid in rt'Iuming normallllJl(ular tont to the
uterus.lmranasal form I on~ used to promote milk letdown aft' no Iong~ available in the Unitf<l SUtts.
ADMINISTRATION ALERTS
Dilutt 10 unit, ol)'llXin in 1,000 mlIV lkJid prior to administration. For
postpartum mminislluion,mayadd up to 40 units in 1,000 mL IV Huid.
Imidt nu of allergic: ft'Jctions is hight r when lJi~n 1M 01 by IV in~(\ion.
rathe, than IV infUoon.

PlI'9nancy uttgory X

PHARMACOKINETKS
Onset: Immf<lialt
~k: Unknown

Halflife:1- 5min
Duration: 1h

ADVERSE EFFECTS
The m05l (ommon adl'l'~ 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 tflt fetus. IlKh a>dysrhythmia I
or intriKl1lnial IN>monhage. Striou> romplic:ation, in the motlN>r may indUiX
utt rine ruplurt', ~izlll'l,OI roma .Ri,k of uteriII!' ruptuft' ill(lN!I'1 in womtII who
ha-;~ delil'!'rt'd fl'l~ 01 mOrt' midrtn. Though nperirnu has mwn tIN> u~ of
ol)'loc:in to lit quitt ,aft,labor Ihould lit induc:f<I by tfI~ drug only whm theft'
art' demonltritf<l ri>ks to the molher orfetus in (Ominuing the PII'9IWIIC)I.
Conllaindi u tions: Antepartum us~ is (ontraindiulf<l in the following: signifKant (fpllaloptlvK disproponion; unfavorable fetal position, that are und~ljy..
erable withoot (olMrWn btfoft' delrmy;oblletric:al ~lI(its in whic:h t~
btnefit-to-rilk ratio for the felUl 01 moth~, fawB IU"lKal ime~mion; fetal
distlffi when delivrl)' is not immint nt;whtn idequat~ uterin~ actjyityfaiis to
oKhieYl> satisfactory PI09rt'ls;whfn th~ uterus is alrt'idy hyperactil'!' or h)opertonK; v.t.en vagilWl dtl~ry is (om,aindic:ate<i, >lJ(h as in~jyt cerYic:a1UK~
noma, aniVI' gtnital ~Ipfl, total placmta prt'Yia, '/.H.l prffia, and (ord
prt"!I'f1tation 01 prola~ of the (Old.

h_

INTERACTIONS
Druq-DIIJ!I: Yol\IXOIISlIinor U!I'd (OII(UflflliIy witl1 oxytocin may (iU!I' W'Il'II'

lJbTesll:UnkrocJrwn
Herba VFood: HI1M' known
TlNt mem of O'ffrdo,e: (Mo,dos~ (aUStlllrong uterine (Omractiolll, whic:h
may lead to uteriII!' lac:eruions orruptuft'.lmmtdiat~ 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! ~

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710

Unit. TheEndoal ..... Sjr.t"'"

NURSING PROCESS FOCUS

PATIENTS RECEIVING OXYTOCIN

Assessment

Potential Nursing Diagnoses

8it~ine a55tSi.,nt prior to admin istrlltion:

UMtrmlld the ~~lOn 1M dnIg hilS been pres<ribt<i in CIfdef to ISseIS (of
thtJapMic ~ (t.g.,labor irlliKtion,lfltroi of posIJIaftum b~.
Dluin a {~healtlt Mtol} induclintj a.mm Imgdt of pregfllncy
4J,.tion;pltStllCt of pfH(lamp~ 01 t<limpu.; J!<tltt IabOl;t)'pl! of
livtry; hist3!y of ~bors Of urwrt~ n Stiom; {ilrdicmwulu, ntUlVlogic,
hepatic,or ~fIIl tflStaSl';dybt!:ts;alld IRm-ftding.
Dltlin ~ drug hillOlY indlltflllO 111tf9it's. wrrtnt prtSCfiptiolt and OK dNgs,
he!bal ~txms,akohollM, alld smoking.8t altrt to possible drug
iIItractions.
&Iullt appropriate labontol} findifl9\ (e.g.CB<. pIilteltu, coagulation
stlltfltS,eIedrotytH,911K~ l1119t'leSiJm IeftI. ~il.oo m1~1 fun<tioo
sllldits).
Obuin ~Iine beight, weight, llId yital sigIIS.
Obtain htal IINrt r~te alld inlr.luttfine positioning.
Chec.k for !be pmtrKt of (trWai diLition alld tffl(tmrnlMonitor~
.1Id dUrMion of 11'1'1 nisting (ontrilClions.Mo!titor fetailfSponlt to
mntractiom,noting an, sign of letal~.
Ched: for postpartum blttdintj.wld nolf the IIlmbtl' of pills \MurMtd.

P.in (~OJtt. tdittd to strong uttri lit (OfttrKtiolll)

IneflfttiYr B_tfrtding,Pottn!yl for EffKtM Brtut-fffding
I)r,licitmKoow~(drug~)

Rist oIln~1} (pititnt or ftM), ~littd to ilMne drug tffKts.IUOntj

utfflrtt (00 tliClion:!

Rist for ImbiLinctd Fluid Volumt (tx(~~ rtLittd to wIIt1' inrOJication

from the drug's jf\tidiu~tic ho!mone tfftS)

---+---------------------

bl-rss~nt throughout

.d.,inlstfillion:
AsIHS iJrdtsftd tlttrapeulir tffn *pmrlt!tt 00 1M IUSOfl wdnJg is
g;..rn (t.g. stlOfl9, ~guI.Il conI/actions supportr.t of..,).
Continuously monitor timi ng. qllillity, and Ibllion of {ontr.lctions.
kII rnediatrly ~port SllStiintd IIIt rine {ootractions to 1M hHhh (,J ~

.......

Continuously monitor tilt Iml heart rorlt oIIId ~I'M to mntractions..

m rnedytrly ~port 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 frr~ alld immediately ~pon 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 {a~ pnII'idtr.
Continue to lIlOII~or postpartUm bleeding and ~ COUnlNotify tilt 1It~1th
(,J~ providtf if molt thin two ful~sW! pads.It \Mtnttd in 2hOOJB' time.
16\l'15 iJr.dmr ~ niUW, omiling, and he~dadJr.JoKh,urdia,
palpitations, ind hyptnfnsion.tIPf(idy ~Yttd will Il\gini,_~
hHdlche,OI d')ospne. s~ bt ~porttd mrnediMtly.lmmtdiatt ly ~poIt
11'1'1 RVI'~ iibdominil pail. SllStaine<i uttrint (ootlKlion, dimi nishtd urW
OIIIput,diuinn~ 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 libor,~t milk IHdown sUPlXl~of bfNIt-~ poslplfMII blttdill9 is
diminillttdj.
8t frre from,or~Cl.' minillloli. idwnf tffrru.
Ikrbalizt, iIII Ulldmtancing ofw drug's 1M, ~ tfIem,ind requftd prfUUtioM.
Dtmonltri~ proptr !tIf-administration ohllt mtdio:.Jtion (t.g.,d<M, timing. when to notify plll'Vidfr).

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OIIpler 4.

NURSING PROCESS FOCUS

DJU9S for DllOfden , r.d Conditions of tile

FHnaIe Reproductive System

PATIENTS RECEIVING OXYTOCIN (CDnrJnuf!d)

Impleme ntation

Inte rventi o ns and (Rati o nales)

Pati e nt a nd Family Edu cati o n

Ensuring tht r, pt utic effects:

Monitor ~ pproprialt m~diation ~dminimation for optimum ~ks.
Intrml'lOUSo~odn must be giftn yja an inM.ion pump to ,11ow for
pm:ilf dming. (Infusion pumj ,11ow for rapid doI'gf ,djustments to
maintain Uleri~coomdiom supportNe of labor and cffi'Kal dilollion 1m
~Ichfd approlimatl'ly Sto6cm.)

Innruet the plltiem aboutlht ratioroaif: for .11 IV and monitoring

equipment and the nwl for ~utnt monitoring, to .1I.y anxiety.
Teich the patient that laborcootr.diom willgtldually incrNse , nd that
the drug will bt dt<~11td or stopped oo~comractions f'N(h an optimum

.'"

Encourilgt the patient in labor to use p.in..:ootrol mmufts (t.g..

ther4ptUlic brt41hing) or lBt pain (ontrol dr~ dl needed and ~d

Minimizing ad'fttlt rfflKts:

Monitor the timing. quality. and duJltion of {ontrlctions CDIltinucusly.
Immediately ~poJl <lny IUn~ined UI~rine contriKtions to tht hNkh c.~
pIO'Iidtr.Stop tltt infusion. infusing norm.1 s.alin~ 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 rupru~. Uterine contractions
must bt cootiroously mon~ortdJ
Continuoudy monitor feu Iheart I'iIte and ltiponlf to conttlctions.
Immediately ~pon signs offml distlffi to the health {,Ire proYicltr.
(Utrrinr{ootr.ctiom (,n all'fCI the ,moum ofblood flow through the
p!acenti with diminish~d oxyge~ion to the fetus.(hanges in Itti Iheart
rate may sign.1 fml dis~ and the paumt should bt placed on htr side.
o~n ,dministtrrd. the inrusion stopptd, and the heakh ca~ provider
notifltd)
Monitoryiul signs ~nd urinroulpUl fJtqllelltly and ~port any BP .I11oe
140190 mmHg or less thIn 90/60 mmHg,.~specially ~ accompanied by
t,dryeardia. or diminished urint: outpu~ to the health ure pnrtidtr
immediatf Iy. (Oxytoc:i n has YIIIoconstrictiY!' proptJtHoslnd wattt-~tention
prop~niH. 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 ~tp'rtum bftding and pad
count (Oxytocin may ~9iY!'llto{ontroi postpartum bleeding. lochia that
in{~asts,or if \W(I or more plltisalt' S.tUfl!td O'Ifr a 2-hour ptriod, should
be It'port~d to the h~lIkh c.Jrt proYidtf immtdilttiy.)
Palirnt understanding of drug therapy:
1M opponunitirs during administration of medic.Jtionland during
as ~StnffiU to discuss the fltionale for drug therapy. desired thmptUlic
outcomel,tnoSt commonly observed ImJ'lf eim:tl, parameter! forwhtn
to {,IlIthe health (.J~ pnrtidt~ ~nd all)' nmslal)' monitoring or
pm:aUlions.(Wng time ckJring riming (,Ire helps to optimize ,nd reinforu
keyttlChing areas,)

TeICh the patient that laborconmdiom will incrtl lf in st~ngth and

durMion and will bt monitored throoghout.lnnruet the p~tient to
immediately report Ill)' sustained (ontfl(~on 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)' htidiKht.dillinrs~

disorientation or confusion, pi Ipitltions, OJ chest prtsSY~ or pain.

Imtruet the p,tirm to ~port 'Il)' sudden inc~ast in lochia, dizzintss or

light-headednrss,or if more than two pads.l~ saturatrd alter 1 houn.

The p,tirnt should ~able 10 state tIM- rNson for the drug,lppropria~
dolfand ICheduling, monitoring n<ls, and wh.t . mJ'lffim:u to
ob!erY!' for and when to ~pon them.

Evaluation of Outcome Criteriill

Evalua!~ the eim:t~s 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 ofttugs /01+1ridr fhrst OOM9 lions 1JIfiy.

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712

Unlt l

The ErdoallM' Sym'm

FEMALE INFERTILITY

"
t

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 experiencing difficulty in conceiving children at some point during 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 infections, physical obstruction of the uterine tubes, and lack
of ovulation. Extensive testing is often necessary to determine the exact cause and it is not Wlcommon to find multiple etiologies for the infertility. For women whose infertility
has been determined to have an endocrine etiology, pharmacotherapy may be of value. Endocrine disruption of reproductive function can occur al the level of the
hyrolh~l~mlH. rintit~ry. or ov~ry. ~n(] phHm~rolher~]'>y i.~
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 successfully treated with drug therapy. Clomiphene (Clomid,
Milophene, Serophene) is a preferred drug for female infer-

TABLE 45.7

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 ra te of patients 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 pregnancy, 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 (G nRH ) may
be indicated. These therapies are gene rally indicated only after clomiphene has failed to induce ovulation. Also known
as menotropins ( Pergonal, Humego n ), 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), bromocriptine (Parlodel), and HCG.
Prem~ntre oVlll~rion. Ihe e'C]'>l1l~ion of ~n oocyte from the
ovary before it has fully matured, is another cause of infertility. GnRH antagonists such as ganirelix (Orga lutran) and
cetrorelix (Cetrotide) suppress LH surges, thus preventing
ovulation Wltilthe follicles are mature.
Endometriosis, a conunon cause of infertility, is characterized by the presence of endometrial tissue that has implanted oUl5ide the uterus, in locations such as the surface
of pelvic orgaru; or the ovaries. Being responsive to hor-

Agents for Female Infertility

Mechantsm

Drug
br~illl'lP,l1lodd)

domiphmt lCIomid, M~ophme. ~)

danazot lDanooin~)
FSH AND LH ENHANCING DRUGS

chorionic: gon.Jdotropin-HCG (tIoYarti. 0vi1Rt. ~)"I)

Rfduction of Iiojl prolactin IMIs

Promotion of loIid1' maturation and owlation
Anaboi( IIm1id; 5l.ppIelion of FSH (OIltro1 of ffidometriW!

Promotion of loIid1' maturation and owlation

IIII'noIropns (HLmI'IjOO. RtproIII'x)

foIitroPn IHI (GonM)
loIitropn lIN Ifdliltim)
OOlfoltitropin ( 8riVtI~))
GnRH ANTAGONISTS

a'tromil '(~ite (CMrotidt)

I P~tion

of prtmaturt Owtion or (ontro1 of~rio~s

g,Ilirtlil oKttltt (~IUb"in)

GnRH ANALOGS/AGONtSTS

goItItliI a(l'\,Jte (lolidex)

~dt{l!."ron.~Orpot)

nafirtlin (S)nar~)

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S!.pprelion of FSH and (ontro1 of ~rio~1

o..pur45

Drug; 10< Ill"" ..... ' ar.d Condltlom 01 the

monal stimuli, this abnormal tissue can cause pain,dysfunctional bleeding, and dysmenorrhea.
Leuprolide ( Lupron) and nafarelin (Synarel) are GnRH
agonists that produce an initial release of LH and FSH , followed 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.

f"""'''' Rt'p.oductlw S)'Item

7 13

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.

i . ~:~ Chapter REVIEW

KEY CONCEPTS
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 secretion 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 available 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

stimulate uterine contractions to expel the implanted

embryo.

45.5 Estrogen-progestin combinations are used for hormone

replacement thE'rapy during and after menopause; however, 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.

NCLEX-RN OREVIEW 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.

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

The nurse's assessment of the patient receiving an IV infusion 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?

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1.
2.
3.
4.

Administer oxygen via face mask.

Monitor the patient for water intoxication.
Position the patient on her left sidE'.
Discontinue the infusion immediately.

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 medication! {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

714

Unlt l

lhI'Er.doo1""S)lmm

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 wou ld become pregnam
wh Ue on oral co ntraceptlvt'$!
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.

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 first
J. There Is less risk of multiple births with clo miphene.
4. Her past history of oral contraceptive use has prevented
ber from ovulating. domipbene is given to stimulate
ovulation again In these Ilmditions.

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 mechanism of action of Ie nproli de in managing the patient's en do metriosis. What Info rmation should be Included in a
te~chlng 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
con tractions, and the nurse notes late decelerations on the
monitor. The nurse flu shes the drug out of the patient's
vagina with saline per hospital protocol. What is the use
and action of misoprostol!

J . A nurse is assessing a 32 _year_old postpartum patient and

notes 2+ pittin g edema of the ankles and pretibi al area.
The patient de nies havln g" swellin g" prior to delivery. T he
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 reg imen and
the patlent'scur re nt pres.m t~ tion ? What additional assessment s should be made?
See Appendix D for answers arid Ttltionales for all activities.

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tJJestioos. i1tela:trve as.sIgnmenlS aM lJC1iYi!ie!l, well i rlkS, anil11/l!IOOS
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www.mynursi-lgkitcom .

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Drugs for Disorders

and Conditions of the
Male Reproductive System
DRUGS AT A GLANCE

LEARNING OUTCOMES

PHARMACOTHERAPVWITH ANDOOGENS JI'19'116

Afrl'r re<lding mil c/loplef, rhe lru~nr should be able to:

o ~IIOSltfOne fIIJII/ 719

DRUGS FOR MALE INFERTILITY ".m

DRUGS FOR EREalLE DYSfUNCTION

fIIlIJ'lf9

Phosphodiesterase-S lnhlbltors nlil

o sJ~""m (V"oogrl ptJIJt m

DRUGSFOR BENIGN PRDSTATKHYPERPLASIA

""no
AlpharAdrenerglcBlorurs

pagtm

S-Alpha-Reductase Inhibitors fIIJII/ li5

o finQI/f rnH (/'r()KQlJ

,.127

1. Describe the lOIeSortnl' 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 o f 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.

KEYTERMS
anibolin teroids fDIF 717

follid.. ~ imulating honnonf (FSHI fIIXJ' 716

androgl'l"5 fllXJ'716
u oospermiil fX1IJ' 718

h)'pOgonad~m piJIJt 716

libido ptJITlIl
oligospermia fIIXJ' 711

impoten~ fllXJ'719

t ~t osterone {JIJ1t 716

benign prostitic hyperplu iil (BPH) fIIJII/ 7U

corpori (avernosil fJIJIT 719

If ulfinizilll hormone (LH) fIIXJ' 716

irililition fIIXJ' 717

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716

Unlt l

Th~EOOo<rI .... Sy<!"",

s in women, reproductive function in men is

r~ulated

Ret ....se

ot GnRH

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 chapter examines drugs used to treat disorders and cond itions 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 m en. 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 reprod 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. Beginning in puberty, testosterone production increases rapidly and continues to be mainl3ined at a high lewl until late
adulthood, aft",c which it slowly declines. If the lewl of testost",rone in the blood rises above normal, negative feedback to
the pituitary shuts off the secretion of LH and FSH. The relationship between the hypothalamus, pituitary, and the
male reproductive hormones is illustrated in .. Figure 46.1.
Testosterone has profound metabolic effects in tissues outside the reproductive system. Of particular note is its abilityto
build muscle mass, which contributes to differences in mll'icle strength and body composition between men and women.
PHARMFACTS

Male Reproductive Conditions and Disorders

Ermiledysfunction ilffem 10to 15 million American mtn~.Jbout Ollt
in four mtn oI~rthan 65 )'Nfl.
Smoking m~ 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 tIIuiskby 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

-~.

ApproQmu~

30% of men aftsublffiile, and u lean 2'l(, of men aft

totally infertilt.

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""

Secmt"'" cI \estostl!,..".,.,
Stimulation 01 spermatogenesis

.. FlguTe46. 1 Hormonal control of the male reproductive

hormones

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 hypogonadism and certain cancers. These agents are in Table 46.1.

46.2 Pharmacotherapy
with Androgens
Lack of sufficient testosterone secretion by the testes can result 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. Examples of disease states that may cause primary testicular

(hopltl46

Drug. IOf 0110,<1<>" and Coooltian. 01' the Mak> Rep'oductlve 5y;tem

7 17

TABLE 46.11 SQIQctQd AndrogQns

On.

Route and Adult Dose (max dose where Indicated)

Adverse Etfl!.cts

dalluol (Danoo:ril~)

PO;200-400mgbidfor 3~mo

AuIt, fJ)'rIK001Q5lio, hiwlism ~nd molt !fl"

ftUOX)'Jnffitronr (H alol~ lIin)

PO; 5 mg 0IIt to fOIl" tim~day

meth)"ltffio'teroo~

PO; 11)-50 III9Iday

c.JpsOO (Android, Tffiltd.

Vinoo); m~"'kffiomKlllt tabItIs (Mtllilffi)

-""'-

morrxrtmOO (i" womt"!,sodimorr/

wur"rtumrion,~rWtmi~
AnaphyLD:i~ tffiiniar alrophy and
oiQ!J!Dt!mia at high dolts

Bu:c.JI: ~-25 mglday

lM;50-200mgIwI;:

oxandrolorit (Oundrin)

PO; 15-20 mgltlay djyjdtd two to 1011" lim~day for 2-4 wks

oxymrtholonf (Androl-SO)

PO; 1-5 mgltglday

Bu:c.JI; 30 mg ~ 12 h

IffiomfOM (Striant)

(Tffiodffin TTS, Androdffin, othm)

T!an!dfflna~ Ttltodtrm TTSpault: apply

1 daily;Androdffin

patd1:opply 15-7.5 mg patd1 daily

(AnItoGtI. Tffiill)

Gd;apply 51J1arn, daily (mall0 lJIam,)

It'ltOItffilfll' cypionat~ (Dtpotw, AIIdfO..(yp.

1M; SO-4OO mg el'tfY 14 wi::

Dtpo--TeltOltmmt)
It'ltOItmmt ~anlhal~

(Andro L.A. 0tIa1ffi,

1M; 50-400 mg el'tfY 14 wi::

OtIatetryl)

failure include mumps, testicular trauma or inflammation,

and certain autoimmWle disorders.
Without sufficient FSH and LH secretion by the pituitary,
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, in~
cluding Cushing's syndrome, thyroid disorders, estrogen~
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 subcutaneous 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. Non~
specific complaints may include fatigue, depression, and reduced muscle mass. In yOWlg men, lack of sufficient
testosterone secretion may lead to delayed puberty.
Pharmacotherapy of hypogonadism includes replacement therapy with testosterone or other androgens. Within
days or weeks of initiating therapy, androgens improve libido and correct erectile dysfunction caused by low testosterone 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 increase the risk of adverse effects. Testosterone is ava ilable 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

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profound anabolic effect on skeletal muscle, which is the rationale 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 athletes 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 psychologic dependence. The use of anabolic steroids to improve
athletic performance is illegal and strongly discouraged by
health care providers and athletic associations. Most androgens are classified as Schedule III drugs because of their
abuse potential.
High doses of androgens are occasionally used as a palliative 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 possibility of prostate cancer has been ruled out. Patients with
prostate carcinoma are sometimes given a GnRH agonist
such as leuprolide (Lupron) to reduce circulating testosterone levels.

718

Unlt l

TheEO>dornn ~ Sym'm

TABLE 46 1 Androgen Formulations

"'""
Implantabll-' ptlru
(5lbrutantOUS)

Drug

Advanlages

DI!iadvantages

r~stoprI: 1-1> pdiell f t imiUnlrd on thf

antrrior abdominal wall dtpffiding upon

Dose IiIIl-4 mil

InlLlmllliltion or inlrnion may octur

aroundinSffiionsitr.

Dose 1i112--4 wi;

Strum IrstOSl\'ron~ IMIs will vary

widdy iflr! admiri 5llalion,IiIU1ing
~ p.ltiffitto e1ptrit1Kr
ftuwmions in thrir ibido and

thfOOsr~Rd.

Intramu5(IJlilr(lM)

tffi05l~ cypionalr (.TffiOllrrtlllt)

and trstOllrrone tflinthalr IDdalt 5lry!1

rnMJ)',and rxpffitrKt mood

\Wings. Patitnls II'IHI to (OIlliUin 01
SlKrotSl 011 thf ~tr ofinjKtion.

",.

TtllOltffiHll' buc:<al

Sirianl tablet isapplifd 10 tilt gum"N

jUl1abM ~ ind5or, hoIdif19 ~ in plac:r
for ~ SKonds.

f'nHkK~ a ron~noous lUpp/J of

~ mtfIl!qJR lWia-dai)' doling.

Irstomron~ in th~ blood.

Lool irritalion to tht blKul mlKOIi

mayoror.

Tramdmnal
tffi05lmr gd

AndroGtl and Tffiim arr applird OIKt

daly 10 ~ upprr arms, shoUdtrJ. or
abOOmrn.

lilt drug il ablCKbrd intothf skin in about

lOmilU1~and rrlusrd ~owIyto tht
bIood.CaUlrS 1m skin iritation lhan

Gr!liIn ~ transfrrrrd 10 anothrr

prrson II)' skirHo"w.. (on\a(\
uu~ng l'iriliza~on oflrmaie
(Ofltulland lrul harm.

Transdrrrnal
tffi01lmr p.llm

Androdmn p.llm isapplied daily 10 Ihf

ilytO~

Rash may 0((\1" atthf sittofp.ltm

appi<ation.

""".,

upprr arm. th91,had or abdomm,

rOl.ti"'l .pplirnion !.itt!.

L IF ESPAN C ONSIDERATIONS

Human Chorionic Gonadotropin (hCG)

Abuse by Athletes
Most hNkh (aR' P~II art' familiar with tht ~rious probltm of anabolic:
lk-'roid Ul~ by athletes and Iffill. feo.m, ho_~ IR' familiar with abo.M of
tilt pla!:rntal hormon~ hCG in thil population. hCG il notan anabolic: steroid
Why would anuhltte lakt a plac~ntal hormone? TIIm aR' l~ra IlI'a\OO ~
Mtn taking anabolic: ltl'lOiIk nprritnu a natural negat~ frtdba(k pileIIOllH'lIOn. Tht high Itoiels of anabolic: stt roidl providt fffil~k 10 thf h)1lO ..
thalamus and pituitl ry to !hut down production of tellmtt rone by the l~stn.
Whtn theath(tttnops taking thentroids the testMr"ftd sMr.l(Wftbtore(Ol't~ and t~ man maysufft r from km of m~ strength,tn tic:ular atrophy,
loll of libido,and impottnu. Taking inj~da,* hCG duringthil rillH' immtdi ..
at~1y raises tilt man's teslO1t~rone lewl bKaUIl' hCG rNmbltsleuteiniling
hormone, the natullllstimui.Js for t~ltol1eront 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 th~ amounts, that mow up on Iabor.llOry
t~m (ondKted by athlttic organizationl.
The nurse nffils to tta<h ~~tnts taking th~1t iIIega( subnallCH that hCG
and anabolK stt roicb both haw major idYer"lr tffe(B.1 heir tffetlS.u~ tholt
of rIIt~sie test01t~rone ItYels: testicular atrophy, femin iznion (ml'Sstrstost~rone il mttabolizfd to estf09l'llJ,stunting of growth (~doses rpip~ in
young tel'm),1 il'rr damagt, and ~rious psyt:hiatric: di IOrdrn.

"t

MALE INFERTILITY
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.

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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. Ol igolp~ rmia. the presence of
less than 20 million sperm/mL of ejaculate, is considered
abnormal and can lowt'r reproductive success. Azoosp~rmiil,
the complete absence of sperm in an ejaculate, may indicatt' 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 dysfunction must be considered and treated, as discussed in Section 46.4. Infertility may occur with or without signs of
hypogonadism.
Tht' goal of endocrint' pharmacotherapy of male infertility 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 spermatogenesis. 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.
Other pharmacologic approaches to treating male infertility have bet'n attempted. Antiestrogem such as tamoxifen
(Nolvadex) and clomiphene (C lomid ) have been used to
block the negative feedb:lck of estrogen (from the adrenal

Choplfl46 Drug . fOfDhorde" .nd (oooltion. 0( the M.", Reproduc!lV1' System

...

Prototype Drug

7 19

I Testosterone

Therapeutic (lass: Male sex hormone

Pharmacologic (lass: Androgen;.mabolic steroid; antineoplastic

ACTIONS AND USES

Tilt primary therapMK U~ 01 Il5tost~roll!' '1'1' fur tht tlMmI'nt 01 dtlay~d
pubmy and hypogonad~m in malts.lht drug promot~ 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)' ~ dtrKitnt 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 ulKerin womtn.
T~tOlttrone "15 by Itimulating RIIA I)'flthesis and protein mttabolism.
High do~ may ~ppmslptrmatogellfSis. Tetolleront ba~ 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 di~d
Alternate pa\{h site daily. rotlting site tvrry 7days.
Give 1M injtction into ,luINI mUl(its.
Pregn.nq mrgory X

PHARMACOKINETICS
Onl('\: Unkna.vn
Ptak:Unkna.vn
Halflife: Unkna.vn
Duration: 1- 3d.J~ (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 aromatase inhibitor, has been administered to block the metabolic 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 reactive intermediates. Unfortunately, these and other therapies 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. Beca use of the expense of pharmacotherapy and the large
numbt'r of injections need ed, other means of conception
may be explored, melt as in vitro fertilization or intrauterine insemination.

ERECTIlE DYSFUNCTION
Erectile dysfunction, or impotence, is a common disorder in
men. The defining characteristic of this condition is the

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ADVERSE EFFECTS
An obY<M, dl'l'Mei'fe(tol Il5ta>ttroll!' therap)' is virilization. whKh is uwal~
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, akhough it is a potentially ~rious ioMf\e tffHt
with 1OIII!'01 tlltorally administtlt'd androgens.Aclll'and skin irritation i;common during therapy. ~male may experience supPfffiion of owlation or mtnstruation. [xtreml' do~ in men (.naboiK I1troid abu~) rna)' talM
kmin~ation ratlltr than virilization bt<iIM ums ~tOlterolll' is ml'ta~oIire:l
to estrogen.
Contraindications: T~tOltffOlll' is (omriindicated in men with kna.vn Of WIpK\ed blNlt or prostatic can:ioomas ind in women who all.' or may bMome
prf9~t (talrgory X).lhe drug shoold ~ uled with uulion in patients with
pre-fX~tinq 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 [ai~r~. f\@patOlOlicdrugsslKUdtltiMliderlbtutM!II!'wi:h
te'iIOIIeJOMun tilUlfaddm'lfli\ti~.
La b1i511: YalUfS of 1M foIowin9 may tit deu!Nd:14. 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, although it may occur in a adult male of any age. Certain diseases, most notably atherosclerosis, diabetes, kidney disease,
stroke, and hypertension, are associated with a higher incidence 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 impotence as an adverse effect, including thiazide diuretics,
phenothiazines, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), beta- and alphaadrenergic 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

720

Unlt l TheEr.doar .... SyS!,-""

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANDROGEN THERAPY

Assessment

Potential Nursing Diagnoses

BUfline l zess mfnt prior to administration:

Understand the ~J \On the drug hil been prfnriilfd in order to as~ for
thor~pwtic dftm (~.<J.,""uk 1"'tieu"', filiu"", ""byrd puborl)' in boy>
1Wt'I1S, hypogonadilml.
Obtain a complete health hillol)' induding wdiollasc:ula" peripheral
va sc:ular, thyroid, h~atic. or renal diseale; diabetes; proltltic hypertrophy; 0'
promtic or b~i ll tanCfl".
Obtain a drug hiltOl)' ilKluding al~lIlie, aJrTrm presc:ription and OK drugs,
herbal preparations,akohol use, and smoking.Bealen to poI~bIe drug
imerJcticm.
E"lawte appropriate laborato!), findings (e.g., C8(, Mctrolytes, glucose,
lipid IeYels, PSA).
Obtain baseli~ heigh~ weigh~and vital signs.

Oisturbed Body Imagf (rt'lated todrug rfif<tl. oIgill9 plO(m)

Sexual Dysfunaion (lI'Iated 10 drug rfif<tl)
Fuid Volu~ Excess (related to ad\'el"lr drug eflem)
[lefidem Knowledge (drug therapy)

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 ~~I!.
Monitor filal signs, heigh~and ~ht at u{h heakh W I' visit.

dIl"",. ..

As~ fur
n.,l" rrdU","", Y"nrnir'I,L h....!""' ~hl 'l"irr.lluid
ft'~ntion.rdrma, ioomed blood pl!"IWJe,changel in mood, irritabilit"and

agitation. Allo ilses5 for tachymdY. palpitations, or hypenenlion.

r!pl'(iall)' is!ociated with angina or d)"spnea;abdominal pain; or ligns of
hepatotoJicity.
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.
~monmail' proper selhdminilu"ion ofthr medication (e.<J. dose, timing. when to notify plO'/iderl.
Implementlltion
Inte rve nti o ns li nd (Rlltio nalesl
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 ~ight and for the
preelKt of edema. (Androgens (au If \Odium and water ft'tention with
ft'IUking ilK~i lfl in weigh~ blood prt'!1Urt'. and poslib~ f!1ema. Report
promptly any BP O'I!'I" 1401'JO mmHg, periphtral edema.or lignifitant
Wl'ight gJin o~ a Ihort amount of time.)
CominUl'to monitor elKtrolytes, lipid le<iris,ind hepatic fuodion labs
prriodic:ally. (AndrogeM mav in(mll'ch~ttrol arod akium Imk.
H~pOloto.ici1)o nd h~patic noopb "'" .r~ 10ft' but polfmi.ol adwrs~
rfff<tlJ

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Patient li nd Fll mily Educllt io n

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 dirtued by the health ta~ pra<ider. Report any
Wl'ic;rht gain o~ 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 quadr~"1 discomfort 0' pain, ydlowing of (h. skin or Kina,
fatigU!'. aoort'Ua. darkened uri~ or cLly-<oIorrd stool ~ W!'~knes<, ~thargy,
naulfa,or omitill9.

(hoplfl4/; Drug' (Of Dllorde" and Coooillon, 01 the Mali> Rep,odunlw S)'5lem

NURSING PROCESS FOCUS

721

PATIENTS RECEIVING ANDROGEN THERAPY (Confinutd)

Implementation

Inte rve nti o ns and (Rati o nale s)

Patient a nd Fa mily Educati o n

Monitor blood gl(l(oll' Ievcls in diabttic: j)atitnu fll'quently. (Androgens

mly IffKt wbohydrillt metlboIism,ltlding 10 irK~I ltd gllKOII' ItYeIs.
Mtn with diabttfi ,hoold monitor their(apillary blood gl(l(OII' mOIl'
frequently.)

Ttl{h IIII'n with diabetfi to monitor {ilpillary blood gluc:O!I' more

fll'quently whileon drug Ind Il'pOn {on~ttm tlmtions to t~ hNhh
(a~ prOYider.

Monitor height Ind growth in {hildren and adolt:KenU. tAndf09l'll

adminisuillion may (aUSt pmniliUrt (Iosureof t pip~and !as,of
nannll growth pillII"fns.)

Tt.t{h the pillitm. f.Jmily, or mrgimto lIII'illU~ htight OrKe ptr month or
at dir~tM. Return for dinical at!emll'nts at I"ftdtd approximately M'f)'
6 momh, to monitor bo~growth.

MonitorlM do~ in iIdolt!(ent patiems.(Abuse of arodrogtns arod

anabolic steroids mayo{{u~along 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', dt~~d t~raptUtK
out{omt~ most {ommonly o~ ildvtlll'riIe<lI, pilramtten for when
to (all tiM' health ure provide~ and all)' nKtSsary monitoring or
prtlautions.(Using rime during riming (are ~Ips to optimize arod reinfon:e
keyttil{hing iIIeatJ
Patint ~If.administlilt io n of drug thflil PY:
W~n administ~ing the mtdicillion,instrun the patient. family,oruregim
in t~ proper self-adminismtion ofdrug. e.g.,comillently ill t~ same timt
eil(h riayto help ~lIII'mber tiM'dose. (Proper .tdministration will incft'ast
t~ rffectMlII'II of tht drug.)

Tta{h tht idolescent patient to m.J imain riaily do~ng at instructed and
not to incft'ast dos.igt unltu in ,lnKted 10 do so by t~ htalth Cilft'
providtr.T~ 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 w~n to
~por1thtrn.

Tmh the piltitnt to take t~ 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 ~onds.Rotate 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 m.J~ rub off
and UU!l' adYtr-st effects.
Transdtnnal pelitts.Jre implanted in t~abdominil wall M'f)' 3 10 6
month!.
Injections should begiven into deep glulNlllIII(lt.1f t~ 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 pilt~m 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 dysfunction may include damage to the nerves or blood vessels involved in the erection reflex.
The development of sildenaftl (Viagra), an inhibitor of
the enzyme phosphodiesterase-5 (PD E-5), revolutionized

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the medical therapy of erectile dysfunction. \'/hen sildenaftl

was approved as the first pharmacologic treatment for erectile 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 implanted into the corpora. As an alternative to prostheses,
drugs such as a1prostadil (Caverject) or the combination of
papaverine plus phentolamine were injected directly into

722

Unlt l

Thi'Er.doa1neSym'm

TABLE 46.3 1 Drugs for Er"ctil" Dysfunction

Drug
(0)

~1dma~1

(V"IJ'J)

udalilfil (G.!I~)

Route and Adult Dose (max dose where Indicated)

Adwr'll' Effl!cts

PO; SO mg J pprtllinat~1y 30-60 min briOfl' intmGUBt (mn: 100 mg onw'day)

MllQ/ rmgt5OO~ hfodxh(, fodd flwJing, dzzilltJ5,

Iilioo abnorrmlBriff, mydgi~

PO; 10 mg Jpprtllinattiy 30 rrin briOfl' inltr<tWt (max:20 mg OIKt/da,)

IIypotPlKinnwh. n IObn w;m ";lm... nriapillll

0ncHiII1)' 00sIng:25- Smg dilly

'lal'llmafil (lni\ra)

IINring19I~ nonan~1i!: anterior iscllerri{ optic

PO; 10 mg ipprtllinattiy 1h ~for~ intMOII'lt (max:20 mg onw dily)

lidifl indicit~ {l)ItI1OOIt ~ ftfffls;.!.!:lli!!i!!m.indicite

smous adm~ ~ru.

the corpora cavernosa just prior to intercourse. Penile injections caw.e pain and reduce the spontaneity associated
with pleasurable intercourse. These alternative therap ies
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 E5 inhibitors have no effects on female sexual function, and
these drugs are not approved for use by women.
Two other phosphodiesterase-S inhibitors have b~n
approved by the FDA. Vardenafil (Levitra ), acts by the
same mechanism as sildenafil but has a faster onset and

,.. Prototype

Drug

"""""

slightly longer duration of action. Tadalaftl (Cialis) acts

within 30 minutes and has a prolonged dura tion lasting
from 24 to 36 hours. Drugs for erectile dysfunction are
listed in Table 46.3.
The three phosphodiesterase-S inhibitors are equally effective at promoting erections in 60% to 80% of male patients,
and adverse effects are similar. The most conunon adverse effects are nasal congestion, headache, facial flushing, and dizziness. 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, ho,,~ver, this blood pressure change may produce symptoms of hypotell'iion. Phosphodiesterase-S inhibitors are contraindicated in patients taking nitrates.
TadaIafil produces less blood pressure d ecrease than the other
drugs in this class.

I Slldenafil (Vlagra)

Therapeutic (lass: Drug for treating impoten{e

Pharmacologic (lass: Phosphodiesterase (PDE)-S inhibitor

AalONS AND USES

ADVERSE EFFEaS

Sildenafil iru by ~Iuing smooth musdts in W{orpori lal'MlOSi, thus allowing inaNst<i blood flow imo tilf penis. Tilf in{lNI~d blood flow rtlUm in a
firrntr ind Iongrrlasting maion in about 700M. of IIItn taking the drug. Tilf onsd of lion is 1I'1a1~~ rapid, less than 1 hour,and itstifrcts bst up 10 4hours.
Sildenafil bkKks 1h~ myrtle phosphodif,strrast-S.
Si1denafil ~ also UI~d for the trutrm~nt of pulmonary irt~rYl h)1ltlttlllion.
Blod:ing phosphodietm~-S in pulrrooary mrulu sroooth musd~ Glusts YoIsodi Lnion and rrouaion in irteri,l hyptrt~nsion. Tilf drug implO'/~s ~1Im:~ (apali!), in 1h~~ patient~

Sildlonafil is well tolerated and adYmt tfflods a~ uswlly transient , nd mild.

Comrron adYeB~ tfFIs indudlo h~adh~, diuines, flushing, rash, and nas.il
{OnqtStion. Tilf most serious adv~~ tffe(~ hypottn mn, ocrurs in p.ltienl! (onrurrenl~ ukingol9inK nitr.rt~s for angil\j andGln rI'Iuk in MI and suddenGlrdia( dIoath. Sildtoafil u n prodlK~ blurred vision, in{lm~d sensitWity 10 ligh~ or
{hillCjl'S in (lIlor ptfuption. Priapism, a sustained ~rroion lasting longer than 6
hoofS. has be~n ~ported with ~ldtl\jfil use and th~ may lead to prnnanent
darN9!' 10 ptnile tis!Ul's.
Contraindkations: Sildenafil is (omraindilllted in patif,nts taking nitrates and
in tho~ with hyptfunsitivi!), to th~ drug. Thfs~ '9!'n!s a~ (ontraindiut~d in
patif,ms with ~~~ urdiomruLtr disea ~, I!(tnt Ml, stOOR, heart fai1ur~, dysrftythmias" nd in thl> ~(t of anatomillli dtfonnitits of the pen~.

ADMINISTRATION ALERTS

Ayoi;I adminismtioo of ~ldeoafil with m(.!is, (~II~ high-fat mtals,

bt<aus~ i b50rption is dfc~asM.
Al'Oid graptfruit juic:~ when administering sildenafil.

INTERACTIONS
1)ug -1)ug: ("rnetidi~, H)'IIIromyc in, and~ew~l il:rNSe,..".m~of

PHARMACOKINETICS

IAtset: 20-60 min

f'f:.k:30-11Omin
Half~ife:4 h
Duration:14 h

sidmJfil and tlKl'lWlt Iowfr drug ~lkewith nilrilles wil trlUt in

twotfl1licn I'fotease itibitor; ltitooa~a~f,fl1toM) will aust iooNsfd
sidmJfil lfwis, whidt may iEOOto toliritJ Ri/aqIin Ina\' deuue WtleMi lewis.
leadingto rieaf<tlfd !If~.
Lab Tl5ls: Iktnown

IlerbaVFoo:l: GralM'fnir: j.ict ilKfNlfl thf plasma (OfI(t rlraticnl of IidmafiI and
mayaustad~ llIf!CtS.

Tl9tment of tNerdose: Tht~ is 00 Spr(ifK tlNlrtlelt for overdose.

Rmf lIIMyMnJftqKl(oj" ~ MlsJnqPrOCell" fixfIl sp1/I( 1II1M1tlig.

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(hoplfl4/;

NURSING PROCESS FOCUS

Drug. IOf DllOrO<>rs.oo Cor.dltlom of the Mal<> Reproductive Synem

723

PATIENTS R.eElVING TR.ATM.NT FOR .REaIl. DYSFUNCTION

Assessment

Potentia l Nursing Diagnoses

Baselinr assrssment priorto admini stration:

Undtrsund thr IN.on the drug has bn prescribtd in ordtr 10 me. lor
llitra pwlic: effts kg., inability to obui norillStain .n M'ction).
Obtain a {omp~tt lIt.hh h~tory induding {oirdiov,u<ula~ peripllt.. 1
vaswla\ thyroid, hepatic:, or rtnal di~wt; di.rbrlri;.nd PIV~tatk
hypertrophy.
Obtain. drug h~tory 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.
E~luate appropriate I.boratory findings (t.g., e&, eieulViytes, gluc:ou, lipid
itl'els,PSA).
Obtain bistlint vital ~ns,rspt(ial!)' blood presSUrt.

SeJwlOysfulKtion
DisturbtdBodyl~
Dtr~nt Knowledge (drug

lherapy)

Rilk for Injury (rtlatM to <Idvtllt drug ~ffKtt)

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 nt rffiion).
Monitorviul ~ns,espt(ially 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 d~pne., should bt rtported im mediattly.
Planning: Patient Goa ls a nd Expecte d Outco mes
Tht patient will:
ExperielKt llitrapwlic: effts k g.,. biliry 10 ac:hitvt and maintlin an M'(tion).
Be ~ from,or txptritnc:t minima~ 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 e me ntatio n
Interventi on s and (Rati o nale s)

Patient I nd Fa mily Edu cati o n

Ensuring therilptutic effects:

Monitor appropriate mtdiation .dmin~tration for optimum ft'IUlts.
(Appropriatt administration will optim~drug absorption .00 thtr.lpwlK
t l'fe<K)

Teach the patient appropriate administration tKhniques (_ ' Patient lelf

administration of drug thtrapy"l.Jttr in th~ tabid.

Minimizing adftrsf 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. {Phoijlhoditst~a ~
inhibitors (aIM Y<lsodilation and may rtlUh in lignifKant hypotenlion.)

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
9Of60mm Hg.
InstllKt Ihe palient to 001 takt tht drug if (UlTtntiy taking nitralts for
(hest pain.~ 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.

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 ~ts.
(Phosphodieslt. - inhibitors may .ffect tilt abiliry 10 let mlors,tlpt{iilly
blUI' and gr~n, .nd may cau.t blunM lilion. Optic: nl"Urit~ ~ a raR' bul
Ieriou,adYflSf efftd.nd .ignitiGinl visual changtsorf)'l' pain should bt
r~port~ immedialtlyJ

Caution lilt patient to tmcile caution when driving orwith oKtivitits

inwlving visua Iaruity until tffts 01 tht drug aft' known. Pitienll who
pilot ain:raft shoold chtdwith thtir tmployer 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 ~tS to tht ht.kh ca ft' provider.

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

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)

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724

Unit .

The Er.doc:.l .... Sy.tem

NURSING PROCESS FOCUS

PATIENTS RECEIVING TREATMENT FOR ERECTILE DYSFUNCTION (Contlnuw)

Imple me ntation

Inte rve nti o ns a nd (Rati o na les)

Pati e nt a nd Fa mily Edu catio n

Patitflt undt rstanding of drug thrra p-,:

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, p;ar~melel> forwhen
10 call I~ hralth (a~ prOYidtr,.tod any newu!), moniloriog or
preuutions.(Usiog time during nUBiog ca~ ~Ips to optimiH< and ~nfoKt
kr, leaching arl'ols.)
Patitflt stlfadministrati on of drug tht rapy:
When idmin~trriog t~ mtdiution,iostllKt t~ p;alien~ family,orurt9~r
in t!lf proper !t1l...Jdmin~tr<llion oft~ drug, t.gv(Ons~lently at t!lf samr
lime each day to help II'membtr ibedost. (ProPf'r administration inma!f1
the eli"fdiY!'Olss of the drug.)

T~ 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.
~.od

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 ~ightly longer dJrition of
action.
Tadalafil may be liken 1 hour btfoII' intici pited Itlllil inlet(oul>e but
dJration ~ up to 16 houl>.

Eva lu atio n of Outco me Crite ri a

Evalu.Jte the efffdiwOl'sS of drug looar; by ((Infirming mit p;atiertt goals.Jnd l'Jpl'(led OUICOmes h,J\'(' betn met(~PI.Jnnintf).
';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 ~OO' 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 to tyiwtr thedrug'I~

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 ~tiem did
notNilheplE"t'NdlU] w.JSas~.JShew.Jmed.k 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 ill' 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 disease, 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 outflow of urine by ob-

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structing the urethra, causing difficult urination. Symptom.. indud e im:reased urinary fH'quen~"y (usually with
small amounts of urine), inueased urgency to urinate,
postvoid leakage, excessive night-time urination (nocturia ), 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 surgical 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 enlargement 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 excessive 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 disease, 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 Pharmacotherapy Illustrated 46.1.
Certain frequently used medications can worsen symptoms of BPH. Alpha-adrenergic agents, which include decongestants such liS pseudoephedrine and phenylephrine,
may activate alpha,-adrenergic receptors in the bladder
neck , restricting urine flow. Drugs with anticholinergic

Choplfl46

Drug' rot DllOrrler. and (oooillon, of the Mal<> Repmductlw 'ytlem

725

TABLE 46 4 Drugs for Benign Prostatic Hyperplasia

ROUM and

0""

Adult Dose (max do5ol' where Indicated)

Adverse Effects

ALPHA,-ADRENERGIC BLOCKERS
alfuzo~n (lkwual)

PO; 10 rngItiay (mil: 10 rngIday)

daxalO~n (unhn)

PO; 1- 8 m9Ida:I (mad rngItIa,)

daxalO~n XI. (unhn XU

Ext~r*all':4-8 mgftla, (rnax:8I1191da:1)

......

Fi1IjIolI' pheoomrnoo (sum byoolfDjjoo and WDrgpr)

tarrIIlbin (Flomil)

PO;OA mg]O minafi~ a meal (max:0.8 mg.ItIa,)

teralO~n (Hytrin)

PO;!Ia1 with 1 mg at btdtifM, then 1- 5mgld~ (rnax:lO mgftlay)

5-ALPHA-REDUCTASE INHIBITORS

duta5lmdt(Avodirt)

PO;05mgltla,

Q fina5lmdt (PrOlCilr)

P0;5mg/tiay

wal dys(rmcrioo, dtcrfQ~ b"bido, d!N!#II tj/KIJIQ1e

1WImf, gynomosrio
No IfflouS idl'l'fg tfftg,

italia intkau ammon id'Ime t1f~n~~intkate Ioffiousadmslo ~flKts.

~~' ---"!s-ll

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 elderly men .
The goal of treatment for patients with BPH focuses on
minimizing the urinary obstruction and preventing complications. Drug therapy can only treat symptoms; it cannot reverse or cure BPH. Patients who are asymptomatic or who
present with mild symptoms generally do not receive pharmacotherapy. Not all BPH is progressi~, and many patients
never experience moderate or advanced symptoms. Patient
education such as avoiding caffeine or alcohol intake, eliminating drugs that worsen BPH, and restricting fluids dose
to bedtime may be sufficient to achieve symptomatic improvement. The patient is re-evaluated at 6- to 12-month
intervals to assess for worsening symptoms.
When symptoms ofBPH worsen, pharmacotherapy is indicated. A1pha l -adrenergic blockers are often drugs of

.....,
U';M'Y

,..,.
Natrow<ld'-_--';:-1'1I
urtllhra
Hypertrophied

,.,

True proslale
~

,0,

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.
~

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726

Unlt l Thi> Er.do<rlJW'YfSlem

PHARMACOTHERAPY ILLUSTRATED
46.1 Mechanisms of Action of Antiprostatic Drugs

Static fa ctor.:
Gland . ,laogee under the
inA""""" of t _ _
Enlarged gland creat ...
~.AI_k>odinn '"
0,"",.

Alph ..... duct ... inhibitor.

interfere with t ....IOOIt...,.,..

melaboliom.

choice for treating moderate symptoms of BPH. The selective 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 ad~rse
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 reported with tamsulosin. Reflex tachycardia due 10 stimulation of barorect'ptors is common with alpha blockers.

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Dyn .mic factor.:

~,-ad""""llic 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.

C OMPLEMENTARY AND A LTERNATIVE T HERAPIES

Saw Palmetto
Saw palmttto (Sm:m rtptm) is ~ bulh, palm that ~ i1 t~ CNILllrrgions
of the IWIhrm Unittd SLlta The portion Uitd i1 ~pplemml> is t~ btrm of
thepl, nlMoll'ttun 2mili:mmtnlMl.lwpalml'uo in theho~thatitwilltft'at
BPH.likr fin.tn~ride, I.lWpilmttto is thought 10 btlp stop ~ usadt of proltill'd'fNljing tIIl)'mtI that may ClNj" BPH.1t also O(~ bilding ~l'I on the
proStlll' thataft' typical~ 0Upird by dilljdrotl'ltostelOOl' (DIU), an enzyme
that rna, trigger BPH.AItIKuj! ~I clinitalstudies have Suggtlll'd that I.lW
pammo is II~ as fillll\l'rid" i1 trrating mikllO moderate BPH and pr0duce ffo.m idvr~ eflKts, rww II'lNlth i1dkatl'l that it tu s00 brnefn in tINting BPH (~~ Kane. Shinotur.J, Neuhaus, Hudl'S, Goldberg, &AIvim. 2006).
5.iw~lmetto may (,JIM damage to the liver ~nd panuus,1G it is vital thu
1~ nu~obtain , thorough hNlth , nd ~pplrmtnlUII' history, .J ndadvill'lbt
~jient of in potential ad ..... rll' effect!.

Chopltl46

~ Prototype Drug

Drug' rot Dllorders.OO Coooillon, 01 the Mali> Rep,odunlw S)'5lem

727

I Flnasterlde (Proscar)

Therapeutic (lass: DrugforBPH

Pharmaco logic (lass: 5-alpha reductase inhibitor

ACTIONS AND USES

Finastt ride am by inhibiting S-alphHed~ 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 Mlargtmtnt 01 tht gland. BtcalM it inhibits tht mt tabolism of ttdosttront,
fin.lI1l'ride is sometimt1 u lltd an anriondf09/'fl Finantride prorro!tS !ohrink'91' of Mlarged prOn<ll6 and sublfqutnt~ 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. Do~ of fin<l'1l'ride all' ~
timt. higlltrwlltn prr!(ribed for BPH than whtn prescribed for baldnrSl.
ADMINISTRATION ALERTS
Tablet! may bt Ulllhtd for oral <ldministr<llion.
Tilt pll'gnanl nu~or pharmacist Ihould avoid handling (rushtd mtdicalion, as it m.tybt 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 tffrets.)

ADVERSE EFFECTS
Fioalleride is well toleral~ and side ~ffemall' 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 ~ula!ory d~
function.
(ontraindi cations: Tht oo~ (omraindic<llion is hypmtOSitMt)' to tilt drug.
INTERACT10NS
Dru;rDrug:IIIf with an tidIoIiIfr9iG may dKrNsf tIMo ~lIects finaruricIf. Ust of
fillilltlidewith 1!'I!lI:I1m1nt wil ~ in a rmtion in 1IIP ~lIects both ~
La bTI5II: 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

PHARMACOKINETICS
Onset: Maximum effrm may loll- 3~ mo
PNk: l- 1h
Halflift : S- 7h
Duration: 5-7 da~

Additional information on the alpha blocl(t'rs and a prototype feature for doxazosin are presented in chapter 2300.
Some patients are unable to tolt'rate the cardiovascular effects 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 pathway, 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 ..

size of the prostate; thus, they are not appropriate for severe
disease. The 5-alpha-reductase inhibitors produce few adverst' rlfects, alth ough 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 symptoms but does not cure the disease, these medications must
be taken for the remainder of the patient's life, or Wltil sur8"ry i. indicated.

KEY CONCEPTS
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.

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46.2 Androgens are used to treat hypogonadism in males, and

br..ast cancer in females. Anabolic steroids ar.. frequently
abused bya lhl.. tes, and can result in serious adverst'eifects
with long-term use.

72 8

Unlt l

The Er.docrl .... Sym'm

463 Malt' inft'rtility is difficult to treat pharmacologically;

medications includt' HCG. menotropins, testolactone,
and antiestrogens.

46.5 In its early stages, benign prostatic hyperplasia may be

treated successfully with drug tht'rapy, including finastt'ridt' {Proscar} and alpha, -adrenergic blockers.

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

3. "Haw you ever had an allergic =ction to dairy

productsl"
4. "Haw you ellerbeen treated for migraine headadJes?~

Which of the following nursing assessments would beappropri~te for the p~tient rec~ivins testo.teronel (Select ~ll
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.

II

Which of tht' following nursin g assessment findings may

be evident in a patient who has undergone testosteront'
tht'rapy?
1. Virilization
2. Electrolyte imbalances
3. Hepatomegaly
4. Precocious puberty

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

Tht' patient with a history ofBPH is complaining of feel in g 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)
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,

espec~1Uy if it is crushed
4. blood donation should not ocrur while taking this drug.

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 TH INKING 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 performance. 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 junior 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?

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 compare it with that of saw palmetto.
See Appendix D for answers mId rationales for all activities.

EXPLORE

~~------,

MylkJlYIgKd ~ iwr one st~ !of onl ine chapter reoiew matenals I!I1d
resouroos. Preporo for success with ad!ilflnll NCLeo:-style ~ice

QuestklnS, tntenctl ~ assignmentS In:!

aClMtl~,

wee *lKS, ! nlmatklM

and i idoos. and mIn!

Aegiste r your a.;c! !I!l CMe from tne from of your ~ 81

www.mym."'g kill:om .

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U NIT

The
Integumentary
System and
Eyes/Ears
CHAPTER 47

Drugs for Bone and Joint Disorders

CHAPTER 48

Drugs for Skin Disorders

CHAPTER 49

Drugs for Eye and Ear Disorders

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Drugs for Bone

and Joint Disorders

DRUGS AT A GLANCE
PHARMACOTHERAPY OF HYPOCALCEMIA
CalciumSupplemenu fJt1Itll4

LEARNING OUTCOMES
Alrer reading this chapIn', the student should be obit to:

pqJtJJJ

1 . Describe the role of calcium In the body In malnu.lnlng homeosta~s In

Q caklumsolts (l!JgtlJ4

the nervous,muscular,and nervous systems.

PHARMACOTHERAPY OF METABOLIC BONE

2 . Identify the rec ommended dietary a ll 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 arthrltl~ 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 listed in Drugs at a Glance, know
repre-sentative drugs, and explain their mechanisms of action, primary
actions, and/or important adverse e ffect s.
7. Use the IlU"sing process to care for patients receiving drug the rapy for
bone and joint disorders.

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 co~III(1fIe (CoJcryt) ,.'44

KEY TERMS
mrtegoutyarthritis (XI/tJ44
utoantibadies fJII9f741
bisphosphonates /#It 136
bone df,po~tion Ili9t JJ1
bone morption (IIl9t l1J
GJkiftGol , . J1J
Glkitoni. p!IIItlJJ

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nkitriol ~7Jl
cholKaldMroi tuJf 7Jl
diINIP-rmdif-,ing i ntimfumatic drug (DMARD)

""m

9001

piI}t UJ

~,pfnricfmi.J 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

CNplfr47 0"'9' for Booe and Join! Olsordl'l'

73 1

he skeletal system and joints are at the core of body

47.1 RoleofCalciumandVitaminD

movement. Disorders associated with this system may

in Bone Homeostasis

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 important 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.

Calcium is the primary mineral responsible for bone formation 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 nervous, muscular, and cardiovascular systems. To maintain
homeostasis, ca lcium balance in the body is regulated by
parathyroid hormone ( PTH ), calcito nin 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

Paratt.;roid gl ands

Parathyroid glandli cause:

o
a
o

Ael ....... of calcium from bone

Incnoued calcium "'absorption

from kidneys

'"",,,,,sed absorption 01 calcium

in small intestine (with help 01
calcitriol Or vitamin OJ

Lowe, lewis 01 calcil.m

in the bloodstream

'"

Hig>er levels 01 calcium

in tho bIoodst",.m

Thyroid gland

Thyroid gland causes :

Addition 01 calcium to bon"

o..c",ased absorption of
CIIIciIm in """,II intestine

H~I"" I"""", uf ....J.. y'"

in the bloodstream

Low" , lewis of CIIIciIm

in the bloodslrMm

'"

.. Flgure47.J (a) Parathyroid hormone (PTH) and (b) calcitonin action

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732

UnII' The Intequmeomy SY'tem ar.d EyI>"Em

bonr ~sorption, demineralization that breaks down bone into

its mineral components. Once bone is broken down (resorbed), 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

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 synthesized 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.

~akilulli".

... FiKur" 47.2 illu,lral"" [h" ",,,[abuli,,,, uf vilami" D.

\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, kidneys, and gastrointestinal (Gl ) tract. The Gl tract is influenced mainly by parathyroid hormone and involves
vitamin D. Vitamin 0 and calcium metabolism are intimately related: calcium disorders are often associated with
vitamin D disorders.

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. Patients with extensive kidney disease are unable to adequately
synthesize calcitriol and thus frequently experience calcium
and vitamin D abnormalities.

r
Skin

Calcilediol
(inlermedialelorm)

PT"

Parathyroid glands

Calc~r iol

(ac~ve

vitamin 0)

Increased absorption
01 calcium in

the small intestine

... Flgure47.2 Pathway for vitamin D activation and action

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CNplfr47

The primary function of calcitriol is to increase calciWll absorption from the GI tract. Dietarycalcium is absorbed more
efficiently in the presence of active vitamin D and parathyroid
hormone, resulting in higher serwn len~ls 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 excitabil~
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 hyperex~
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 hypocalcemia 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 eas ily reversed by nutritional therapy. If hypocalcemia occurs with normal dietary
intake, GI causes must be examined, su<:h as excessive vomiting 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 diseased 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 "overshooting~ 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 corticosteroids, which is a very common cause of hypocalcemia and
osteoporosis. To help prevent oorticosteroid-induced osteoporosis, patients should receive daily supplements of calciwn
and vitamin D.
Signs and symptoms of hypocalcem ia 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 abnormal behavior may be obserwd.
Unless the hypocalcemia is life threatening, adjustments in
diet should be attempted prior to initiating therapy with calciwn supplements. Increasing the consumption of calciumrich foods, especially dairy products, fortified orange juice,
cereals, and green leafy vegetables is often sufficient to re~
store calcium balance.

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0"'9' for Booe and Join! DIsord ...,

733

If a change in diet is not practical or has not proved adequate for reversing the hypocalcemia, effective and inexpensive calcium supplements are readily available over the
counter (OTC ), in a variety of formulations. Calcium supplements often contain vitamin D. Severe hypocalcemia requires 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 bloodstream. The greater the ability of complexed calcium to rele"se element,,1 c"lcium, the more potent i. the .upplement.
Table 47.1 lists calciwn supplements.

PHARMACOTHERAPY OF METABOLIC
BONE DISEASES
M~tilboli,bonfd il~I!(MBD) is a general term referring to disor~
derscharacterized by defects in the structure of bone. MBDs
are caused by abnormal amounts of the minerals or hormones 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 calcium 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 hypocalcemia, 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 consists of calcium supplements and vitamin D.lnactive, intermediate, and active forms of vitamin D are available as
medications. Drugs used for these conditions are summarized in Table 47.1.
The daily vitamin D needs of people vary depending on
how much sunlight is received. After age 70, the average recommended 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,

734

UnII'

Th~ IntequmeotorySY't~m

arid E)o'''Em

TABLE 47 1 Selected Calcium Salts and Vitamin 0 Therapy

Route and Adult Dose (max dosewhere Indicated)

Drug

Adverse Effeds

CALCIUM SUPPLEMENTS (ooSES ARE IN TERMS OF ELEMENTAL CALCIUM)

calw mc.ubonat~ ( RoIiid~ Tums,olhtn)

PO; 1-1g bid- tid

(OfIlIiporioo, nDlI1& Klllliring. rom/Ik lOla>

calw mchlorid/,

IV; O.H g byslo.v infusion (1 mUmin)

Sf riwI adyrnr; tlfMj a rt oWrvtd 000 wjth IV

calw mdtratt (Gtraul)

PO; 1-1g bid- tid

calw mgllKonatt (Kalonatt)

administooion.HYDma!rnii (!WN~nm.
Inhargy hNda(iIt inortlia.oau~Hnd
vomit"ng,ioomtd uioation and tliDtl
wrtrabmbj y rdjKam! roohnjpn delirium

--

PO; 0.5- 29 bid- tid

IV; O.H 9 by !law inMions (1 gIh)

calw mlKtatt (CaI..LJo:)

PO; 100- 100 mg Iidwith rntals

calw mphosphitt t rbi5k (F\Jst!Jl'J

PO; 1-1 g bid- tid

VITAMIN 0 SUPPLEMENTS

Q uldtriol (Cildjft,Roultrol)

PO; O.lS IIKglday

Side dfem In 001 o/Mrtlld i1I oormoI diMs.

dIoIKaIdftrol (DtluD)
dih)'ltotadlysterol !OHT, H)"literol)

PO; 400-1,1XKI irlelnationallllits daily

PO; 0.15- 15 mgfday fOilMlal dayll~n 0.1- 1 mglday

0vtnI0g Dl9dlKts mns ofhmykrmi.,boor

pain le!hugyano,uia !IilU<eiandvomitioo

doJo:t.lkifffill (lIKtorol)

PO; 10 lIKg.tl"ffl timm k (mu:60 m(gIwt)

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)

IV; O.OH.l m(g~ rmy otherday (max:14 mcg/tg)

c:-~cc:Irdia inditit~ oornrron oJCI'imt tfl'Ms; lIII1aIiliDg. indicitts smous adm~ ~~m.
pH;Jldtoi (lmipiM)

many supple'm~nts 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

OTC mediOltioll5. Excess vitamin D will cause calcium to

leave bones and enter the blood. Signs and symptoms of hypel"Clkemia, such as anorexia, vomiting, excessiw thirst, fatigue, and confusion may become' evident. Kidney stones
may occur, and bones may fracture' easily.

I Calc!um Salts

Therape utic ( lass: Calciumsupplement

Pha rm aco logic ( lass: HypoU1lcemia agent

AcrtONS AND USES

ADVERSE EFFECTS

For mild. (hronic: hypookerniJ, ine!pensiYr c.kium suppltments art tfirail'!'

and rtadily anilt bit OK. in y.~\)' of forrrulations. Calcium U1rbonatr .nd
ukium citr.ll~Ar"lh. two mo<l rommon ",In. for rouli"" ,upplernentation.ln
addition to prty~ming or lI"I'.ting hypookrmit,(.kium salts 011"1' administered
for osteoporosis, Pagr(s di ~.~, osteomalacia, chronic: hypoparathyroidism,
ric:kn~ pregnant)', lactation,and r.pid childhood growth.
For!f"Yffl' m~ of hypouktmi., muhi~ inlusionsof ukilm salts may br
nt<elsary to mum smrm "kium 10 oormalievels. Constant monitoring of
~rum u kilm is required during IV administration 10 prewnt thr dmloprntnt
of hyperuktmia.

0r.J1 U1D1n products JI"I' sale when ultd as ml"l'('(m ~ most oornmon . dYe!w
~t 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.luIN and vomiting. nc:1N1td urioation, and thi~t.lV 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'tntriruIt r fibrillttion, meu stttic: bont (.rx~ ~ 1"1'001 I "kuli, or hypertak:tmia.

ADMINISTRATION ALERTS

GiY~oral(akium !Uppltmrntswithmtaborwithin 1hourfollowingrnealI.

Administer IV slowly 10 .wid h)1lOtrnsion, dysrhythmia!, .nd u rdia.c: amst.
Prrgoall()' ut~ry 8

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 rniI'f.nagon~ tbfffftm ofukUn manntl bIcKIIfo.

lab Tet!:Ukium may iIKrNIt Yalues for blood pH and ~urn cakium.l! may
d!oau\.! IffIIII ~f iOd poIiI\!iiurn lMk,and~mand urilarymagnNJrn.

IlerballFood: lill(rkh foodlmq detre.e the absorption 0( talcUn. AkohoI,

Gltfeint, and carbonaIed ~ages .fIK! tbf absorp!ion of cakiurn. Oxak ~ in
SJinidt, rlUltrb, sm d\ao"d, and bfeu can \l.Wfll ull:Un absorplion.

PHARMACOKINETICS

Ihr pharmJroki""tiu of "kium sa hs yari6 b)' tIlr route of .dministration

and the spedfKforrrulation.

LibraryPirate

Trmtmfnt of O~rdosr: Mfasu 1"1'1 ma~ 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.

..

CNplfr47 0"'9' lor 8001' ~nd Joint O""rd ....,

Prototype Drug

73 5

I Calcltrlol (Calc/)ex, Rocaltrol)

The rapeutic (lass: V"lIamin D

Pharmaco log ic ( lass: Bone resorption inhibitor

ACTIONS AND USES

Ca kitriol is tht activto fom of vit,min D.1t promolts tht inlt,tin, Iab50lJItion 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 ~ion ,nd is Ull'ful in U"uting rieken. Tht tffectiYl'ness of ukitriol!ltprndl on ,n ,!ltqJ"t ,mount of ukium; th~, it is usually pl!"ICn"brd in
combin,tion with ukiull supplements. k is 'lIIil,1* as oral ublets ,nd 5010tions, ,nd b)' tile IV rou~.
ADMINISTRATION ALERTS
ProtKt UPIUits from light ,nd htU.
PlI'9n,IKY mtgory (

ADVERSE EFFECTS
Vitamin Dtht"py m,y Ut/Sl' symptoms ofh)'ptluktmidllel~ indudt p.llp~
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~,1I'<i urin"ion,and mUldt or bone p,in.
Conmindimions: This drug should not be giYen to !!'IimU with h)1ltKalcrmia orwith MIltner of vi/,min Dtoxicity.
INTERACTIONS
DrurOrug: iliilidt lilntiG may eoIIanao 1M ffftm of"IiUmiIl D, OOIing
h~ Too mlKhvitamin Dma)'GIUIf d)Vfl)1hnin i1 patimts rtcei"lilll]
digolin.~antacidsoc~ts!hcQd not bf 9NerI <roaIIIfIltly dJt
10 tIw inoN\.ed rill; of~permag~

"

,,0

~
0

"

lib il5ts:VILJmi1 Drruyilmu!fl\lO cholelrtrol, ~f, magne\Un, II'

PHARMACOKINETlCS (PO )
Dnll't:2- 6h

cMcJum\\llUl!I.tt ma)'dmNlf"lilklls lor akaIiof ~tN .

HerbaHood: I~ oflOlgfamoootsoflilkiulIHi:h foodswith vitamin DIIII'f

~k :ID-12 h

(lUll'

Halfl ife: l~h

Treal mfnt of D-nrdolr: Vit,min DOYI'rdoII' rrsulu in hyptfukrmi" hyptKa~

Duration: 3- 5 da)'i

ciuria, and hyperphosphatrmia. Tht p,timt is Irr"ed symplom,tic,ly ,nd

placed on, Iow-<alcium dit! until symptOllll rr!O~.

h)'pI'IakfllN.

IItI'tf rc M}NurJlIIgKJ/ fr1r Q NurlIrrtj I'rDm.! fooJs lpI(lk 11/ rills drug.

47.4 Pharmacotherapy
of Osteoporosis

(a.) Nocmal cak>um intaka

Qel106ij.i:>r,

...

Osteoporolis, the most common MBD, is responsible for as

many as 1.5 million fr3ctures allllually. This disorder is usually asymptomatic until the bones become brittle enough to
fracture or for a vertebrae to oollapse. The following are risk
factors for osteoporosis:

Normal bone
homaotaois:
Ooposilic:n"
msorpbo~

Menopause
High alcohol or caffeine conswnption

f:lasorQ'.~

Anorexia nervosa
Toba cco u,e
Physical inactivity
Testosterone deficiency, particularly in older men

To body
(b) Low calci..., inlake

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 osteoclasts, 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 density.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.

LibraryPirate

tl depoSifbq

Inl ... tine

...
Os1eopor<ltio bone:
Resorption exceeds
deposition. Bone
beoo"", ~ Iragilo.

,~
i

0:

;0 """
~

F/qure 47J

Calcium metabolism In osteoporosis

"~

736

UnII'

The InteqJ~tarySY'tem ar.d EY""Em

BISPHOSPHONATES
Many drug therapies are available for osteoporosis. These
include calcium and vitamin D therapy, estrogen replacement
therapy (ERT), estrogen receptor modulators, statins, slowrelease sodium fluoride, bisphosphonates, and calcitonin.
Teriparntide (Forteo) is a newer drug for osteoporosis produced through recombinant DNA technology that resembles
PTH. Some of these drug classes are used for other bone disorders or for conditions wtrelated to the skeletal system. Selected drugs for osteoporosis are listed in Table 47.2.

The most conunon drug class for treating osteoporosis is the

bi~holphon.tes. These drugs are strucrural analogs of pyrophosphate, a natural substance that inhibits the breakdown 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 corticosteroidinduced 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 oftherapy, 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 benefits as daily dosing because of the extended duration of
drug action.

PHARMFACTS

Osteoporosis
Ihttoporolil is tht most prevalent bOIII' di50rotl" in Mttriu.
On an annual ba~,28 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 t~trytwo womt n.nd oneof t'ltry t ight mtn
alt' likely to dtl'flopa Iri(tult' R'lattdto os1topOrosis.

TABLE 47 2 Selected Drugs for Osteoporosis and Other Bone Disorders

Route and Adult Dose (max dose where Indlcatedl

Drug

Adverse Effucts

HORMONAL AGENTS

Hyptraktmia: RiKllliUltOlJIIIM; . illfmarionallllitlikg tid

oro

Rliniris, 1Iu5hi1lg uf rhl' (IKe QOO h~oo~ poi" ~r rhl'

OIItop01"OSis: intr.lnlsal; 1 !pray/day

inttmationalllliu) in
OIIC nosuil,aHematiog rmtri~
day

i"irionsire
Aniph'llaxi!

PO;runwith 30 mg 0IICl' ddr. may i1Ifl'N tl'fr)' 24 Wffkl

ulfil taJgel iPIH of 150- 300 P91mL lmax:300 mglda,)

n~lIl'14 tmrtrio, hyl'lKl1/wni!l, m)'lllgi~

tit"

Villilll'll, OOOC~(ht5l ~ hyptrrtmion,

HvpOQI(fOlia, ltinrm

Brml !MjD

Rainal blttdjDQ.Qnrumgo@ dJOI

~
Subwtallfous;20 mC9fday

Diui~ de,:nWon, immrnio, 1rr~9I> rfriniri~

irt&/Ii#dcoo~ ~ OI1m~ f1ulM, ..rlrolqio

Synwpt angina

BISPHOSPHONATES
OIiNpOr01i1: PO; , - I0 I119iday

Q altndronatt lFosamax)

hgtfl dilt. II':PO; 40 mgfday for 6 mo

1'0:,- 10 mg/day for 6 moor 11 - 20 mglkgldayfor 3 mo
bandrooail' lBoninl

I'O;B I119iday orone 1,IHng ubltt ]1ft" mo, tal:.m on tht samt
dar~t.dJmo

panidronatt l,lndia)

1'1'; 1,- 90 mg i11,OOO mL ramal salinl' or D5W om 4-24 h

....

riltdronatt (,l,aontl)

1'0;30 I119iday at Itast 30 mil befort tht first drink ormeal of

tiudronatt lSWd)

1'0;0100 I119iday takm with 6-8 ozofwattl" 2h btforI' or after

foodforlmo
1'1' (lomN);okTig lingltdost i1fwd om at Itast 15 mil

~--c'c'
::c(::::"); ~mg ~ngIt doll' i1fwd Irm at INnIS min'--_ _--'_ _ __

Ildiaindic.Jtt (OItImon adl'tl"Sf tffffil;~indic.Jte Iotrioui adve"1I' tllem.

LibraryPirate

Choplfl47 0"'9s10l B""" and Joint O""rdl'lS

Bisphosphonates are also drugs of choice for the pharmacotherapy of Pagets dis~as~. Therapy of this MBD is usually
cyclic, with bisphosphonates administered lUltil serum alkaline 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 pharmacologic 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 vitamin 0 in the diet or as supplements, on a daily basis.
The most frequent adverse effects of bisphosphonates include GI problems such as nausea, vomiting, abdominal
pain, and esophageal irritation. Because these drugs are
poorly absorbed, they should be taken on an empty stomach, as tolerated by the patient.

SELECTIVE ESTROGEN RECEPTOR MODULATORS

Srl!'(tive estrogrn mrptor modulators (SE RMs) 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

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, decrease bone resorption; thus, it increases bone density and
reduces the likelihood offractures. It is most efftiveat preventing 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 treatment of osteoporosis in women who are more than 5 years
postmenopausal. It is available by nasal spray or subcutaneous injtion. Calcitonin increases bone density and red uces the risk of vertebral fractures. Adverse effects are
generally minor; the nasal formulation may irritate the
nasal mucosa, and allergies are possible. Because the parenteral form causes nausea and vomiting,it is rarely used. In

I Alendronate (Fosamax)

Therapeutic (lass: Drug for osteoporosis

Pharmacologic (lass: Bisphosphonate; bone resorption inhibitor

ACTIONS AND USES

Altndronatt Io'ft~ smlm alkalifll' pholphmW', t~ ffll)'llII' 0I 5S0(i.n~ with
bolll' turllO'leT. r~ 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
rreatmmt of (onicosttroid-induc~ osttoporosis in roth womfnand IIlI'n
rreatm~ntlO i!l(~oIW' 00111' mm in IIII'Il with osteoporosis
rft'atm~nt ofsymptomatic: Pa9f\'\ disease in both wornt nand IlII'n
Seoirrallf9 illll'nl for altndfOnat~ aru'Iailablt:o!l(t daily (1 0 mg), twic~ I'm'kly
(35 mg), Of on~Wff~ (ill mg).Although thto!l(ew~kly is moft' con'/ellirn~
higher dol~ un produc:t mort GI-related !ide rflem. All doW'S must bt Iolken
on an ~mptv nomad!. prrfrrably in 01 folltiog Ilate 2 hou~ btfM' bft'akf'll
T~apeutic ffm:1I of altldron.te molY tike 1 to 3 months 10 appear and may
contintll' for I>t'Y!'r al months aft~r therapy is discominutd. fosoI max plus Dcombines altndronatr oInd 'liumin Dintoa lioglt tabltt.

ADVERSE EFFECTS
Adl'fll! tfIf(1S of .ltndronate a~ diarrllta, ronstipation,lIatultlKf, nlusra,
wmitilg, mmllic: Iastt, hypouk~mia, hypophosphlltt mia, abdomin.1pain,
dyspepsia, anhralgia, myalgia, ~adoK~, and fillh. Pathologic: frac:turl'l rray oc:cur if tilt drug is taken Iongmhan 1 mornhlor in mesof mronic: O'/erdoW'.
Contra ndiu tions: Contraindication I indude patitnts with ol1M1maooa, abnormaitirs of th~ l'IOphagus, or who have hyprrsfnsitiYity to the drug. Cau
tion IlIouki bt UI~d in patienll with ft'nal impainn~n~ htan failurt,
hyptrp.osphat~mia, lim diW'.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
ninrr.1I~ n me..ewithtlw abIorption of alMdronatr ollld h.m tIw
pounti.ll to ~ i6 flf~s.lNwithikohol!lla1 incrNsr tIw rill: of
osteopcrosil...-.l (;!(M IjNriI: ilitoiHn

libTI51I:Unmown

ADMINISTRATION ALERTS
rake on an tmpt)' ntmach with plain wate~ pft'ftrabl)' 2 hours btfoft'
breakfast.
Rtmain in i n upright position for at Itm 10 minutl'l aftrr 01 doW' and until aftt r the first food of t~ day 10 !!duc:t ~lOphageal inilollion.

Herbi Hood: The dirt mtIIt haveidfquat! amounts of '/itarnil D, cakium, oIIId
phosp/utl'S. ukium oIIId food (~Iy da' ypro.ilml rfducralMdronate

Plf9nalK)' megCIT)' C

IIfftr Ii1 M)Nurs/srqfJI/i:lf Q Nurlifllj Pn:m! fOOIllpt(1/{ Ii1I1r/s d~

PHARMACOKINETICS
OnSl"t:1~wk
~k:l~mo

Halflife: 10 yr jdut IOsiow ~ltal>t' oft~drug from t~ Iktltton)

~on:

737

Uwkorlllm

LibraryPirate

_'m

Treat mr rn of OverdOlO!: Hypoukt mia is an

t~.n~d with or.1 or IV calcium salts.

e1p1'lt~ tfI!'(~

and rray be

"

738

UMit The InltgumenurySyslfm;nd E)ft'E.llt)

NURSING PROCESS FOCUS

PATIENTS RECEIVING PHARMACOTHERAPY FOR OSTEOPOROSIS

AND OTHER BONE DISORDERS

Assess me nt

Potential Nu rsing Diag noses

8.ltll"t ISSfiIIl1UI priOf' 10 .dmin bttMion:

Undtn!.JI.I the ,mon tbedrug hilbeom pRMribed inonitfloll\e1 for
thtfapMic: rffts ( .g.. replM:tment tlwnPl' for dtfKirrlcie or OIlHSf,
~tntltivf hullh mainttMllCt).
Obt,in a (~hralth hiIto'l inducing mU\(\J~
9'nroin~anlioVJICUIa( nfUroloqi(.tro:io<rinr.1wp.aIio:, 0' rmll
mult.Obuin a drug histOl)' irdiding~. 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
~lh.9''' and nolt '11'1 polin or diKootort on mamnml or ,I rtSt.
Obt,in boMcIm~ty 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 '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, ~1, ,nd riYl sigm.
[y.~tt i1PP'OpMt iabonlO'l findi"91 (e.g..(8(;f~;(akium.
pbolfjhorus..nd m.gntSium btl!; lltp.ltit.nd rtnal irnction 1tucSits).

Awl, or (hrmil P,in (bontOl' jginll) (rtli~ todi!tutcondition)

Dclilitm KlI(lW~ (drug WI39Y)

Risk for In;..y, Risl for Falls {lflittd 10 disusr a>ndilion, ad'IMt drug

"""l

c..

AsSf1sment throug hout ad.,inist ration:

AsItIS fordeiRd lheripeUlil tfftcll (t.g.,ukium, p/Iospt..tr, and
lIY9~lJm Inm art within normal ~mib;bolll' demitysu.d~ !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. tlOp~1itritltion, N'I!tip.ltion 01 dia rrfIt".nd tltctrol)'lt
ilIbalalKrI. Sntrt GI i nitation or pain should lit rtpOfItd immtdi.l1fl,.

Plan ning: Pat ient Go. ls and Expected Outco mu

p.titmwin:
UptritllCt thtfij)tUlic tfftcts (t.g" m.WfNllCt 01 Jdtquate bonrdtruity, It!Sfntd n.clUrt risk).
~ frtt from,Of~ce m..imal,.ct/mt rifKIl.
Vtrbalizt an undmtanding 01 thr drlllfs 1M, idIIfflt tfWm,.nd rtquftd prwuCom.
Dcmonm.1I! proptr IelHdmin~lr'lion atw mtdic.tioft (t.g.dost, timin!l, whtn to notify plO'ficltf).

Implementatio n
Interve ntio ns and (Ra tio na le5)
hl,ring lberl~utic effeds:
Rtvi~ tilt diNry hiltorywiththt patitflund discu~ food _Itt optiom
for{orrtaing IIIr ak:iJrn or mmin OdtficirllC~ Enmurigt tht ""titnI: 10
~t . hNItIrf ~irltylt of _lItd physil.1 I<IMty,~tt ~
txjIOSurt, limitd (. fftinr.and!Oda incaR,Jnd limiMd Of~imioal~ .mhol
mmumption.(Adtqllillt .mount! 01(., ri1amin O. il.l M9Jrt nmItd for
bont hr.Ith.Any dtficitocits sIIould IItmlfKttd btfort bispholphollilft
irt laM ~It lUll txpOiUrt m'r mill in vit.nWJ 0 formation.
ElKmNt !Oda Ofaffloiot inul::t may inuNsrthr risk ofO!it~rosii.)

Pati e nt and fami ly Educat io n

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
WlIJ(~. Prol'idt oltliti.ln rtfrmlll nmItd.
ErKour.gt 1imi1rd mou Illi of wn txpollft 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 a~lt I<IMty,t!pi.lllyftighl-iltarin9 tlItfri!t, thrtt' 10
fitttimtlptfWHl

LibraryPirate

CNplfr 47 Oru9' lor 800e ~nd Joint O""rd""

NURSING PROCESS FOCUS

739

PATIENTS RECEIVING PHARMACOTHERAPY FOR OSTEOPOROSIS

AND OTHER BONE DISORDERS (Continued)
Implementation

Inte rventi o ns and (Rati o nal es)

Patient and Fa mily Educati o n

Follow idminisllaDon guidl'lillH for optimum rmlu. (u ~ppltllll'nt>and

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 pati~m should ~main upright for 30 mirutts to 1 hour.
Bisplmphonatftand ukiJm preparatiom mould b. ukon 1 hours a])art)

Tta{h tht ])iItirm appropriate .dmin ~lration guidrlines. Ensu~ that the
patifllt is. blt to rf main upright.fter .dministration il bi.pho!;phon. t..
.~used.

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.)

ImtMt the patirm to immediat~1y ~port ill)' nrw onSfl of naus~. or i ll)'
ilKl"N,ing or !eI'm dlrSt or ilbdominal discomfon or pain.

Continue to monitor periodic: lab woR:.~prcially u,Mg,phosphorus 1tYfI~

and (lNtininr as III'tdr<i.Asses, far lign,or symptoms ofhypo- or
hyptrrak~mia. (C., Mg,ind phosphorus levels 5/lould ~tum to, and ft'm.in
within, normillimit~ Inue.sed (~atinint Itftls milY ~uired
di!(ontiruation af mtdiution,.)

ImtMt th~ 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).

IIK~ise lkJid in!akt,avoidiOC) ufltinr or soda.(ln(rNstd Auid imako

detft'.ses lhe rille of ft'nal (alculi formation.!

ElKourq til!' patitntto ilK~ut fluid intake loll offluid per diy, divided
tfJroughoUI lhe day, but '\'Did highly {,)f!tin.ttd btvrrages and ~l{~sivt
soda inuke.

Monitar .dherelKt ta ~ommended ~imfn. (Bolli' ~modeliOC) oxwrs ~r

It'Iml momh,' tillll'.Tht patitnt may dinontintJl' drug bm!Mof peKtiYtd
lac:kof 16pl1lSf.)

Tei{h the ])iItirnt to{ominue uking the drug therapy rt'!Jllarly to fIl'U~
fUll tfit{u. Therapeutic: ft'Sponse maytake 1 ta 1 momlrs . nd tfleru
(ontinue after tht drug has bet-n discontinued.

Pationt understanding of drug the rapy,

1M opponunitir5 during adminisuillion of mrdiYtions.nd during

as ses'lIII'nu to disWlS the rationalt fur drug therapy, rItsi~d tlltrapeutic
CHII{omt<,moli (ommoniy absftwd ~mrse tfINu. ])arimrtr rs farwht n
ta ull tilt health u~ plOY~ and . 1l)' nmssary monitoriOC) or
prt'uutioll5.(lking timt rluriOC) rursiOC) u~ help, to optim~ .nd r~nfon:e
kl'ytri{hiOC) areas.)
Patitnt H lfadministriltion 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 efIK1~nes, of tht

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 imic:ipat~d itngth of mtdiution therapy.

Ihr patirm is ablelo dis~s ilppropri.ttedo~ng and administration needs.

."",1
Evaluation of Outcome Criteria
haluatt tht rfito:tie0e5' of drug ther~py 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, calci~
tonin is less effective than other therapies and is considered
a second~line 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 calcium by the parathyroid glands. When the drug is present,

LibraryPirate

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 comm on during therapy.
T"ripu"liJ" (Furl",,) i,,, fUTm uf hWllall PTH, pruUu~"J
by recombinant DNA technology. Theactions ofteriparatide
are identical to those of endogenous PTH.lt is the only drug
available that will increase bone form.1tion . The only approval indication for teriparatide is for the treatment of osteoporosis in men and postmenopausal women. The drug is
usually reserved for patients with a high risk of bone fractures.

74 0

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

Joint conditions such as osteoarthritis, rheumatoid arthri~

tis, and gout are frequent indications for pharmacotherapy.
Because joint pain is common to all three disorders, anal~
gesics and anti-inflammatory drugs are important components of pharmacotherapy. A few additional drugs are

specific to the particular joint pathology.

\\bmen of Caucasian and Asian Anman de!!mt haY!' a hi9:"otr ~~ 0101teo~ than !host of African American de!!m~ ahhouijl po!Imenopal/l<ll
women ,lI"e ~ ~higlwst rilkin allethni:9roups.hisimportlnttomnem~th~
men also an dtYelop this dwse.
MIl though mNi:atDnS <Ill' n-ailable to hah bonedtttmmion,pmoention
u,.f1tablilhingand maintaining a healthy liflostyleis the Uyto~og 0\tI10pomis.L\Jring dliklhood ilnd ~1Ke. the 10m Ihwkl be on llIikling bone
mass.Chikllt'fl s/wld be erJ:lUaged to Nt bods h9J in akUn and vitallin 0.
~ ~1iIrt,<, and avoid !IIIOkiIg and mmiYe UII' of akohol. [).ri-,g iduhhood,tIr f00/l5houki beon !Nintlining bone mmand rontiruing hNhhy Iimry ardemcis.e habits.Vitamin ~ maybe tlktnon theadvicf,ofthe
heahh rare proYidtor. ~tmmop;IUliI WOIIII'n shtUd forus 00 pIl'YI'ntmg bone
ms.ln aO:lition to maintaining a hNlthy lifestyle. patienn !hd:l haY!' bone dtn>itytfSUandmoukidisrussthepossibilityolukingmediutilOto~ortll'at
osteoporol~ with their health (,lll'

prom

~ Prototype Drug

JOINT DISORDERS

A VO IDING M EOICAT I Or~ E RRORS

The M"Oing nurse on drty <ldministm mediutDns at 10:15 p.m. When <I
nuBl' mten~. Brown's room,Ms. Brown is alll'ady in bed and falling ilftp.
The nuBl' gent~ shakrs her <l nd says, ' l h.M)OOr 10 p.m.mediutDn~ Ms.
Brown. Ahhough the pilient awa bons, she is not fully <lwa 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 ~.(rown, who is in a room down
the hall from ~.Brown. Wh~ should the nuBl' 11m dollf dilFell'ntlyl
Sn~xOAlrll1tjjjljl}t!ltrlalllm.

I Raloxlfene (Evlsta)

Therapeutic (lass: Drug for osteoporosis prevention

Pharmacologic (lass: Selective estrogen receptor modulator

AalONS AND USES

RiIoQ~1If 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 postmeoopausal women. Ahhough the drug rMures nrtebral frictU~ 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, I1Iloxilf~ 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.

ADVERSE EFFEaS
Tht most {ootmon adveBf e1fecu of ralol:ifme therapy all' hotllashel, leg
{ram pi. and Wl'ight gain. ~s {ommon effects in{kidt feYfl, archralgia, dtpll'lsian, insoot nia,dlet pain. peripht ral edtma, declfased IfIIIm {holl's1flOl naulI'a, vomitin~ flatulen{e, {)'Stili!, migr<li~ lItada{~ IkJlibo symptOlll~
endometrial disordlo~ brNSl pain, and 'liginal bletrling. Ralol:jff llf has two
bla{k boxwamings.FiBt it may iOUNII' the risk fordeepvtin thrombosisorpulIOOnaIY 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'9oaocpnd in WOIIII"O who may bt<OIIIe Pll'9nam.Patitnu with a history ofvtOOIIS throm botrn bolism and thOIt' hypeBl'ositil'l' to ralolifflll' should not take
this drug.

ADMINISTRATION ALERTS
GiYt wilhorwithoutfood.
Pregnancy category X

I)ug-l)ug: (OOOI"lI"Ot 1M with willtarin !Ny dPoUSl' proOvOOlbin ti~.

PHARMACOKINETICS
Onset 8 Wl'eki

Ptilk:Unkrnwn
Hall~i~:27-33h

Duration:Unknown

INTERACTIONS
Dtamfd raloDlI'fII' ibIoIptioo wil ~k from (OOQIIfi( Ulfwitha~lin
dJJIeItyrami~. list of raloml'lll' "";!h othtr higbt, proIm.boIIid druos fi~/@fl.
indornethacil, dimpam,etc.) may intelfflf with bindi"lg sites. Pilients should oot
t.Jkf {boItsteroI1owHi1llj dnq; IJ I'IIrOljl"O rtpI.t!:flllfllt1llfr~ {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 (a), ukim,~t.. total protein,
andalbumin.
~il,

HtrbaVFoo:J: 8Iid at.o\h has I5IroC]I'I1ir: flfeas and IIW1 in~ 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.

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CNplfr47 0"'9' for Booe and Jornt Olsoml'l'

741

PHARMFACTS

Arthritis
8~twefO 10 and 40 millioo propl!o in t~ Unit~d Slates ,1I~ aflectrd by
OIteoarthritis.
After igr 40, m~ than 9O'Jj, of th~ 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. Womenart thr~
to rll'f times roo", likt-ly to dtvelop rlwumatoid arthritis than men.
a..-. 1"" .nd 3~of 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. Coutyarthritis is presented in Section 47.7.
Nonpharmacologic therapies are som etimes 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 therapies commonly used to relieve pain and discomfort include
thermal therapies, meditation, visua lization, distraction
techniques, and massage. Knowledge of proper body mechanics and posture may offer some benefit. Surgical pJ"O(;edures such as joint replacement and reconstructive surgery
may become necessary when other methods are ineffective.

OSTEOARTHRITIS
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 enlargement, 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 normal 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,
JluJlskruiJ~1 ~Jlti-iJln~llmJ~tury w-uK"' ( NSAIDs), illduJillK
naproxen and ibuprofen-like drugs, are usually given. Because 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

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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 combined 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 patjent~ 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 deteriorated because of the inflammation of osteoarthritis. Treatment consists of one injection per week for thret' to five
injections. By coating the articulating cartilage surface,
H yalgan helps provide a barrier that prevents friction and
further inflammation of the joint.

RHEUMATOID ARTHRITIS
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 complement and drawing leukocytes into the area, where they att~<.k th" ""US uf th" 'y"uvial JJJ"JJJUrdlJ"" ~llJ uluod. TIll'
results in persistent injury and the formation of inflanunatoryfluid 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

74 2

UnII' The IntegumeomySY'tem ar.d EyI>"Em

of metabolic dysfunction such as fatigue, anorexia, and weak~

ness. A patient with RA is shown in ~ Figure 47.5.
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

Patient with rheumatoid arthritis

Smith.

Flgure47.5

Sourc~ Coorte>yofDf. .Jason L

TABLE47.3
Dru,
ab.Jtac.~

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. Acetaminophen is effective at relieving pain and fever, but has
no onti _inflontllUltory .ctions. Although these onalgesics re_
lie~ symptomatic pain, they have little effect on disruse progression. 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.
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 reduce 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 several 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.

Selected Disease-Modifying Antirheumatic Drugs (DMARDsl

(CRno:g)

Route and Adult Dose (max dose where Indicated)

1V;500-I,1XKI mg~ 000, 2, aod. wk~then MIl 4wbtooufter

~~mumab(Humira)

SubrutJ~ I mg Mf'/ other wtdr

anakirn (KiImI)

Subuna~ 100 mglday

mtolizumab ~ (GmLl)

SubrutJ~ 400 mg initiall)' aod at 'IIftks

l/KoI~~rmjrioofire(poin,e~

",y.Igiq), ~'JQ1Ophorynqiti>

hod . ,followtd by

200 mg Mf'/ orherwlr

tiJIM'KrpI(&lbrrI)

Adverse Effects

SubrutJ~ 25 mg twK~ WffkIy;/KO.081119ik9 or SO mg 000

Oppommj5li<infrajons Ijnd:!djngIB Ifpti

hrNtiti! BI'OOMtion and ilYiI~I'tf!ma1 infffiioml,
1!I!!!l~k~l . .ndrohi~ tumor!I!i! l!ndrom~ (mUl(imabl
WOlll'ni ng of hl'an fJilufl' ((wolizumab. inffillimabl
Stmm Iobn\9D syndrome hrp,ugtpxjd!y
Ildlllomidtinlbimabl mJlignJlKirllmtiah

goIim.mab (Sirrponi)

-'"

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 day~ then 20 mglday

ri\Ul(imab (R~uun)

IV; 1,000 mg ~I'tl)' 1 wIr for a total oflWO dOIfl

alilhiopilM' pmuran. Aman)

PO; 1 mgJkgIdayOlK~ or in dividtd 00st1 bid 11K 6--8 wi!

(max:15 mgJkg/day);

(hils, (PM'! maIorist, myrrlgio

Miintenarn 00st is 1- 1.> mgfcg/day.tl J ~ngledo~ ordivided

disord~n

PO;400-600 mglday 11K 4-11 wk. thm 1OO-400mg IHK~ dail)'

Anomi4 00UlN, IOmjrinq,~pmmoIiry d/o"9fl

Miintenarn 00st: Il>-20 I119iday

Rffi!lWitblmn!l!Qro~~},ii!!!!i1 j~jj, sriru~

PO; 75 mg onWwIr or 15 rug ~1'tI)' 11 h for !hIM OOstslHKr/Wk

(max:20mglwk)

IIeJId~cIrf, g/oJ'iitis,

Q hydrox)'dJloroquil~ (~I)

methotrmtr (RhNmilUU, Tfl'ull)

SubrutJ~ SO mg onc:~ lJIOIthl)'

M~!!!RI1!nli2!l,~tOJ:!!;i!y.!):mm!!rulfrr~t!\'~

1"9ilitH, mild Ifl!koprIio. rrouJeII

Ukera~Y$ gomalKlt mmoJUptm~oo,aNs!k

anemia. htpali!: drrhosiJ. !@hrotoxicity.suddendrath.

]lI.i!ll~OJlIX 6~llZIil allioullllXlllliI bfmllbJi~ aormia
apia 11K jnemii, fl'naJ fa~ufl', tt@lOQe!il:itv
lIMa5alilzilM' (AlLlfKiilM')

PO; 500-1,000 mglday (miX: 3 g/day)

IIeJIdQcIrf, QlICflXi4l1DulM, K>mi~ng

AOiobylaxis 5tmm JOhD\90 smdmme

mn!l!2OOol!t lruI;~njj,[t)'!!Ii!!!~ !1!~lI!m!IY
lIo1kJ iodilitr rommon advtrJ.! ~fffiS: !llderiiniog iodilitrs striouI idver~ rfIlom.

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CNplfr47 oru9' for Booe and Jorn! Olsoml'l'

(Enbrel), anakinra {Kineret ), and the recently approved certolizumab pesol (Cimza ) are newer therapies that block
steps in the inflanunatory response. The biologic agents appear to be effective and relatively nontoxic, although they
are more e.lpensive than first-line therapies.

C OMPLEMENTARY AND A LTERNAT IVE T HERAPIES

Glucosamine and Chondroitin for Osteoarthritis

GllKosamilll' iu nalurallUbstllKf thlt iun imporhm building bIoc:k of urtilaoge.With aging. glucOSolmint is Ion with the natural thinning of mtillgt. As
unilagt Wl'ars rIown,jointslost tlltir normal QJ~ ioning ability, r=king in
the pain and inflammation of onroanhrilis.Glua.Jmilll' IUHall' is <I~ila~
aun orc dittalllUpp!emfnt. SoIM studits hm shown it to lit molt' rife<ti~ 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' un~
It'pai[ k is a nltur<lllUtntllKf that forms pan of tilt mauu bflWl'tn clnilage
II~ Chondroitin i, ,"k Ind limon rr.. of ~dr rfkct>. Atypiul dolt is 400 to
1,500 mgfday for 1 ~1 months. Chondroitin is u~11y combintd with glucosamilH.' in !pf(ific anhritis formulas. Rf"ll'iln:h fuM that giucosamilH.' and
chondroitin may lit flfectift only for modtrall' to ~It' ostfClilnhritis pain
(Clfgg ml.,lO(6).

The choice of specific DMARD depends upon the experiences of the health care provider and the response of the
patient to therapy. Therapy often begins with hydroxychloroquine (Plaquenil ), methotrexate (Rhemnatrex, Trexall ), or sulfasalazine (Azulfidine), because these drugs have
the most research-based evidence for reducing morllllity
due to RA. Gold salts, o-penicillamine (Cuprimine), azathioprine (lmuran), cyclosporine (NaHal ), and cyclophosphamide (Cytoxan) are used as second- line drugs because
they are more toxic. Biologic therapies such as etanercept

~ Prototype Drug

743

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 tissues, causing inflanunation. These crystals are the result of
increased metabolism of nudeic acids or the reduced excretion 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 cla~ified 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 excreted 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,

I Hydroxychloroqulne (Plaqueml)

Therapeutic (lass: Antirheumatic drug;anti malarial

Pharmacologic (lass: Disease-modifying antirheumatic drug

ACTtONS AND USES

ADVERSE EFFECTS

H)':IlOX)'(hloroquilH.' is an older drug that is ~ribed for rhfumnoid anhrilis

i nd kJp~ ~ryth~ rnato\us in p.ltitnts who hal'!' not ft'spondtd wtll to oth~r
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: inIKtion ((haptfr 3SGlQ). H~droxy(hioroquilll' It'litvfs the R"Itft' inflammation
characteristi< of these disorders,iI hhough its mt<hanism of <Iction is not known.
For lull effe<tivtlll'S~ h)':lroxyt:hloroquilll' is most often prtSuibed with SilKyLItH and giucocortic:oids.

AdYelSf elferu ilKludt aooft'm, GI dilluroalKf"I, loll of hair, headacht, Ind

moodand mental changfS.POIsi~ocul.Jr tfIKts in{k.idt blurrm YKion,phObphobia, diminished ability to ru d, and bladced-out Ift'as in tilt visual field. With
high dosts or prolonged therapy, tllesf (dinal chilnges may lit i~rsiblt in
IOIllf patitms.
Contraindications: Patitnu hyptrsensitivt to the drug or who u hibitlftinal or viscy Ifi~ Id ChingH m ociatfd with quinoline drugs ~ould not If(eivt
hydroxyc:hloroquine.

ADMINISTRATION ALERTS

INTERAalONS
Dru;rDrug: AnOOds rontairing aUrinlll1 or crrq.nium may prt\'au abIoIption
01 hydrorydlloroquillf. Hydroxychoroqvinf may OOUlf tilt ri!Ir of Ij\'fl to~
wIIfn minisleI!CI with ilfpatorOIil: drugs:ilkohol U\f sboUd be eliminatPd during
thtrapy. TIii ~ aID may N:t to inmastd dgmcin k>wk. iOd mayintalm with
tlltp.atil'Ofire\jlOO5C' 10 riiM!! voKCillf.

ra~atthes.i lll!'tilll!'f~ryday.
Administerwith milk to dtclNSf GI up!et.
Slorr drug in saft place,as it is l'l'IytoxK to children.
PlI'gnillK)'U1egoryC

liIbTl5u:Unknown
PHARMACOKINETICS
On~ : 4~ weeks for Imirntumatic

rf"lllOIU

~k: l ~lh

Halflift: 1l- S2 cia)'!

Duration: Unknown

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Herba VFood: IkMown

TlNt mem of OverdOSt: ~rdOlf may lit I~ thlt'illl'ning. f"IjIf(iil~ in chi~
d",n. Th .... py with . ntKORYub'n!"."oprH IDrs,and . ntid"rhythmio .....,. bee
IIf(~IIl

744

UnII' The Integumeotil'ySynem ~od 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 obtain~ from thr autumn (fUS that has been
thr trlditiorul or,1 drug of dlOicr for thr trNlmtnt of <lrult gouty arthritis.1t
hn ~n lMd forc~nturifs. ,rod was appro.'td by the FDA in 1919. k is molt riflive ~ 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, 1U~lular Itructu~ ~ponlible for helping whitr blood (rlls
infiltrate an arN.Although <okh ic:iDl' has no anllgtlit properties. patitnts fIptritn ' pain ~Iiel dut to the red uuion in infl.1 mmation.lt m<ly ~ tI ktn to pit\'tnt or trut acute gou~ often in combirution with other uric: <lad-inhibiting
ilgtnts.ln 2009, cokhicinr brarne thr first druglppflfl'ed by thr FDA to t~'"
II milialMrditerTall!'an ~, (FMf ), I hered itI ry disorder ch<l r<ICterizfd by <lCute
inflammuion loci arthritis.
AOMINISTRATION ALERTS

ADVERSE EFFECTS
Adwrv rfieru SIKh <1\ nollrl~, I'Omiting, di,rrhe", 'IIO~Ua, and abdominal
pli nart cornmOlllt thr begin ni ng 01 thrr<l py. The drug m<ly (ILIV boor mlrn:M

tOl idty, and apllltic: all!'mil, Ifuo:openia, thromlxKytopenia, or ag~nulocytosis

lNyour.
Contraindi(ations: This drug is contraindic,ted in patients with a known hyprn.rnsitivity to mkhicinr,an d in tt-.u with seriou IGJ, ft'"IIal. hepatic:, or mdiac
impairmtnt. flatirnn with blood d~rasia lshould IIOt IfNf mkhicill!'.

INTERACTIONS
i)ug-On.og:eona.rftII!6r wkhHSAIDs n-..y 100_ tilt risk olGls~oms.
WdidDl' may fnlit additM bont INIIIl'II' tuxidty with (Jdo!.poriflf,
phefl)"looWOOf,MId othrr lkug!;tlwt~ atlKI bofIfmarrow.El)'\I"Iomtcin
may imaIt serum (okhidDl' Irwell.loop di.ntics lNy !lrcrflllf (okOODI' KIt<!\.

T.1ce OII.n empty Itoma<h, when symptoms first .ppur.

P~gnanq CoIIfgory C. Parmter.l l dotH mUlt not be givrn to pregnant

AkdlOl or prodoos that COIItail akohollNY QUSf Win r.sllts ~1Id rfSIJI ln ~itNt
INtr damage.(okhidnt 1M)" InuNlt SffISitl"lity to (NS di'pm:slts.
lab Tets: {okhKi"lr may In1Prlt~ with Iriny lIeroid detHm ina!;oos, am rn.y

~-

gi'/f laISf-positi'If ,akIrs lor uinary ff)'throcytelMld ~

PHARMACOKINETICS
On'itt:l1h

ow rich In ptJines,locIlKlng akot.ol~ 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,

IItrbaVhod: (okhidflf rM)" nMft' with tilt Iblorption of l'itamin

~a k:O.5-1h
Hal f~ ift:l .HOh

Dmtion: Unknown

aspirin, cydosporine,and alcohol, when ingested o n a chronic

basis. Conditions that can ClUse second~ry gout include diabetic ketoacidosis, kid ney failure, and diseases associated
with a rapid ceJl turnover s um as leukem ia, he molytic anemia, and polycythemia.
Arult gouty uthritis occurs when need le-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: termination of acute attacks and prevention of future episodes.
NSAlDs are the drugs of choice for treating the pain and inflanunation 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 symptoms are in a single joint, and the medication can be delivered intra-articularly.

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au. rODds that

and bating lOdo!.

Tru tmfllt of O'/froos.: Ovrrdose (induting lCCidfIlul ifl9tStiln d autumn (10CUI) may<JI.M _~GI d~trffi, shod, pa~ttsis. delmm, rtspi"<IIorY fiikt~,and
<!Nth. Tre.lIment ~ l)TI!p~ticloci lNy Jd.degutric Llvagelrod htmodialysis.
IIt(rf S/MyMIJIngK' fot~ tmJrIgl'rol:sfoonsptc~ S/ 1M /trig.

Pro ph ylactic therapy of go ut includes drugs that lowe r

serum uric acid. Pro phylacti c therapy is U5ed for patients
who suffer frequent and acute gout attacks. Combination
thef3p y using uri c acid inhibitors such as colc hicine and
antigou t medications suc h ~ s probenedd (Benemid ) and
allopuri nol (Zyloprim j are the mainsta y of go ut prophylaxis. Colchicine reduces the accumulation of uric acid in
the blood or uri c acid crystals within the joitlls. Probenecid
inneases the exc retion of uric acid by blo,king its reabsorption in th e kidney. Allopurinol blocks xant hin e oxidase, 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, alcoholic beverages, mru;hrooms, and oatmeal, because nucleic acids will be formed when they are metabolized.

CNplfrol7 0"'9' lor Bone and Joint Olsord .... '

TABLE 47.4

Drugs for Gout

"n"
alopurinolllqlt1in.I)'loprim, olhm)

Route and Adult Dose (max dose where Indicated)

Adverse Effects

PO (primary); 100 mg/day;may itam~ by 100 mg/wk

(max:SOO mg/da,)

llrowlinm, !kin roll!, diarrhttJ

PO (wrondary); 200-800 mgld,., for 2 1 ~or longtr

Q

(okhicin ~

745

(Cokrys)

PO;05-11 mg. folWd by O.S- O.& mg MI)' 1-2 h !Illil p.lin

iiltlm(lIIu:Ullll}lddy)

S:mu: lIIio Il:j!.lillll' ttIlIIr: IIIIlIllllfl d~R[f:..illll

hepato!oxi(ily Itllillfil!u
MwllO, I'Omi6ng.d..meo, Gll!jIJff
Boor millpwdl'Plf$~oO ,JQlii5licaormia

ltIioomii Ihf!!!!lt!o;!ro~,",a!!!ljgranuIoMOIis.
~ere diarrhea. fS!hroloxidty
friHlXOItlqulorK)

PO;4G-SOmgOlKedaiy

MwJlfl,rr15ir

lill:l bmai~o .~o~IIlb1It1i1:5

r-

probffiKid (Bmmrid, ProbaIan)

PO;2S0 mg bid for 1wk. tIIffi SOOmg bid (mil: 1 glday)

MwllO, I'Omi6ng.htodiKhf,Qoo~ fltJWdflKl!

.w2!!'!:y!!i~ !!:l'ere2jn fNction~ h~IOIollkil~

suffinp)'l<ll_ (MIUlallt)

PO; 100-100 mg bid (or I wk.lhffi inuu\e 10 ZOO--4QO RIg bid

I.ildi5Im!,roJir

Blood !I'!:!!i[alii~ neRhrolil!!iasil

IIQIio ilKkale ammon id'lm~ tflect~ ~ilKkale seriousadvmr ~ffKB.

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIGOUT THERAPY

Asse ssment

Potential Nursing Diil gn oses

BiSfline assrSl mrnt priont o administrat ion:

Undel'\tand liMo rNlOn the drug h" bffiJ pltS(ribtd in order 10 "Iffi for
IherapMK tifKls le.Cj.deuusing aWlr inflammalOry S1a9l',pr~enling
!t(ulTI'IKe).
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 al~njtJ, um'm pmuiption alii arc dlUljJ, htlbal
prt'p.lration~ akohol UJI', or smoking. lit alert 10 pol~ 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 lymplom~Allffi fluid intake.
Illiain baltlilll' weighl and 'lital sigm.
E'/awl\' appropnatr laboratory findings (e.g., un.: ac:id ~YeI, (B(, hr patK
"Id rrnal function lIudits, urin,lysiJ).

Activit)' IntoieralKf (relat:rd to joim pain)

Disturbed Body Image (mated to joint inflammation and swelling)
DefKitm Knowled9l' ldrug Iherapy)
Risk for In;"., (~latrd to aWlr inflammatory (ondition)

Assessment th ro ugh out administration:

Allffi for deirtd therapeutK tife(H drpermnt on tilt ~ason 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, p.l~~dinirilhrd urilt rutput. ft'Ie~alll infei:m.
Plilnning: Pilt ie nt Goa ls il nd Expecte d Outco mes
TiMo palitnl will:
~ritlKt tiMorapeuti( tfftl {t .Cj.,diminishrd inflammation, dr<lturd or ab~t 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, and ItqJill'd prtUutions.
Dtmon IIrate proper Jelfa dministl1llion of liMo mrdK,lIion (r .Cj., dole, timing. when 10 notify provider).
(Conrlnued!

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746

UnII'

The IntegumeotorySYltem arid

NURSING PROCESS FOCUS

Ey<>"rEars

PATIENTS RECEIVING ANTIGOUTTHERAPY ICOnrlnutd)

Implementlltion

Inte rve ntion s lind (Riltionilles)

Plltient lind Fllmily Educllt ion

Ensuring therapeutic effects:

RnifW tilt dietary history, noting ~ny (orrel.Jtion beIWffn ditl and
<ymptoll'll, PI p.. iolfy .11.. ingPltion of puri .....(om.ining food<. Avoid I.rge
Ousofvitamin C.(Gout molYO((U, ~ 10 O'frrproduction or
undernc:rl'lion of uric atid or a rombination of both. Correlating symptoll'll
to imake of highpurinr foods assisu in detennining tilt most efi..livr drug
therap)'. Luljt do~ of vit.amin ( II\a)' ac:idily tilt urinr Itading to formation
oIuric ac:id nollH.)

Entou,aljt thr patiem to kpa food diary, noting any OIrurrrntr 01

irKr..,ing of 'ymplom. ret.t.d to food or wr>g. im.l<..
Trac:h thr patientto limit imakeofhighpuri .... bods (f.g., Sillmon,
Silrdi~, organ mrats, akohol, mUShfOOlI'II,ltlJlme5,OIItmraO and to limit
or eliminate akohol consumption.

Inm'.m Huid intake to 2 to4l porr day.Monitor urinr output and obtain
porriod ic: urinalysis. (llKft'a5f<t fluid imake in(INs~ uric ilid t);{rtlion and
prMnll urinary uric: add (rystal formation or rmal (akuli.)
Continue to roonitOi !fIUm <lnd urinary uric acid ItYrls and Mtt
improl'tl!ll'llt in I)'mptom ,of arult inflammation, gouty toph~ and
improYed mO'femrrtt with Itss pain 01 afittled joinu. (As uric <lcid ItYeis
decft'alt, inflammation due to uric acid crystals ,hould improvt.)

Minimizing ild"ffBe effKb:

Moniklr ItlUm and urinary uric I(id IeYeis jnd !ymptorm mo(iated with
aM. infLImmatol)' period.(Cominued 01 in(ft'.!Iing inflammation II\a)'
inditatt thr IIffii for adciitiou Imt<lic:ation.)

Monitordaily ~ight and urina l)' OUIput (Uric acid mrMion may (.11M
urate ayml formation in the kidnt)'! with IrIUlting rl'nal impai,mtnt Daily
wtight is an muratr mNSu~ ofOYefall body fluid wkJmt.)

0taN1t the intau of purint.wntaining foark.Avoid Llrge doltS of vitamin

t (lntakr 01 highpurint foods Jnd akohol may ilKrl'a~ production of uric
ilidlirge do~ 01 vitamin ( II\a)' inclNst the fomtiltion of urit uid

IlIItnKtthe patient to repon any IDntirmd infLImmation, pain, ioomed

joint inwlYellltfl~orgentral ~ning of 'ymptOIll! promptly.

Teac:h tiMo pat;'nt to immt<liateiy ft'pon anyflulik. 5)TIIptorm, ff'/t~

mouth irritation or 1O~IIt\.S, 01 wn rasht-<.

Trac:h tiMo patitntto ilKlN!r fluid intake to 2 to 4l prrday, taken

throughout thr day.
Entouraljt tht patiem to maintain consislrnt drug dosing to .nsu~ uric
aoo 1t~ls arr diminilhing.
IlIItnKt tilt patient on thr nted to ft'tum for ptriodit Lib trlting and
urinal)'!is.

IlIItnKt the patienllo repon any diminished urintOUlPU~lhaoges in

urintappearantf,OI flank pain,and to rrlu,n prrioditalfy for urinaiylis.
HaYe the piltient 'Migh ~fdaiiy at thIo Silmt timt nthday and ft'POn any
wtight 9.in of O"o'tr lib (1 kg) in. 24-hour ptriod to It.. h..lth carl'
provider.
Teac:h thIo patitnt to awid foark with a high purine (Omen~ de<m~ 01
rliminatt a/lohol consumption, and avoid ilKrl'a5ed vitamin ( intal<. or
supplemrntation. Pmride a dietitian consuk as needed.

ItO~.)

Obst~ fo, ,kin rash .., floVff,lIomatitis, IkJlil<. !ymptoms,or Ijtntfal

malaisr. (Bone marrow supprtlsion may O(rur with <I migout drugs and
ft'IUk in Itukoptnia and in ilKrrJ 5ed 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
.llltI5mtnu to discus, t~ rationalt for drug thffilpy, de! ired theraprutic:
ou\(omes,lIIOIt (ommon adm-seefiens, paramttrn for when to ull thIo
hrahh tift' ~r,and i ny nKtslal)' monitoring OrprKautions.(Using
tim. dJring nursing w r 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
(aft'gil'l in tho proper stlfadministration of tilt drug. r.g., taktn on an
tmpty stom<l{h or with mr aIs, with additionallkJids. (Proprr administration
ilKrl'JIts theefle<tiv~~sof the drugs.)

The patient should lit ablt 10 state tilt rl'.IlOn for thedrug;approprialt
~ and ItlltdJling;what adYmt rflKl! to obSl'M' for and wiMon to
ft'pon;and liMo anticipated length of mtditation tiMorip)'.

The patient is abltlodiscuslippropriatr doling and administration IIffiis

ilKkJding taling mt<lic:atiolll at tho fiBt sign oIgout attatk.
Cokhic:int ,hould lit taken on ~n empty stomac:h. OtiMor antigout
mtdiutions lhould lit taun with food or mtJk.

EVlllulltion of Outcome Criterill

haluate tiMo efitdmntll of drug therap)' by (onfinning thu f)atitnt goals and rlpf(\td outlDlIII'S h.M ~n mfl (1ft "Planning1.
5H TiIbIt 47. 4f1lf ~ liM IfdfIJljS ril whidI rJrm IIOOirrq ~aM ~pIy.

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OIIpwr41 DNg. for Bone and Joint Dl5Ord~s

--

747

Chapter REVIEW
-

KEY CONCEPTS
The numbered key concepts provide a sucdnct su mmary of th e Important poin Ts from the corresponding IlUOlbcrt.-d section
within the ch~pter. If any of points these are not clear. refer to th e numbered sedio n 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 immediate therapy with calciu m supplements, often concurrently with vitamin D.
47.1 Pharmacothernpy of osteomalacia includes calcium and
vit amin D supplements.

47.4 Pharmacotherapy of osteoporosis includes bisphosphonates, estrogen mo dulato r drugs, and c;alcitonin.
47.5 For osk'OO rthrltl s. th e main drug thernp)' Is pain medication that includes aspirin, acetaminophen. NSAlDs, or
stronger analgesics. Drug therapy for rheuJrultoid arthritis includes analgesiC$, anti_inflammatory drugs. glucocortlcolds, alld disease-modifying a11llrheum.1tlc drugs.
47.6 Gout is characterized bya buildupofu r icacld in either the
blood or the joint cavities. Drug therapy includes agents
that inhibit uric acid buildup o r enhance itsexcretion.

NCLEX-RN OREVIEW QUESTIONS

The nurse completin g a physical exam on a child diagnosed 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.

1. Cardiac dysrhythmia,<;

2. Patl8lle
). Bone fradures
4. Increased muscle strength
5. Hunger

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 (Posamu) fo r treatme nt of osteoporosis. The nurse would be
concerned aboUllh ls order If the patient Tt.jXIrted: (Select
all that apply.)
1. she enjoys milk, yogurt, and other d.1 iry 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."

T he patlent's ca lciu m 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.
The patient r&eiving allopurinol (Lopurin) for treatment
of gout asks why he should avoid consump tion of alco_
hol The nu rse's response Is based o n 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.
The patient is admitted with a diagnosis ofhypercalcemia.
The nurse would assess for which of the following? (Sele<:t
all that apply.)

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748

u.. ,

n..lnt~rySY'temMldEyeolE ...

CRITICAL THINKING QUESTIONS

1. A young woman calls the triage nurse In her health care
provider's office w ith 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
moth er may not be taking the drug correctly and asks for
information to minimize tile potentia] for drug adwrseeffects. What information should the triage nurse inmrponul' in a teach lngpJan regardIng tile ora] administration of
alendronat&.
2. A community health nurse hasdedded to discuss the benefits of oral adciurn supplements with an 82year 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 ~just can't get interested" in her meals.. She refuses to drink milk. What considerations must the nurse
make before recomm ending calcium supplementation!

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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 extremely 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 fo r Imswtn and mtionaies fo r all activities.

EXPLORE

~l1!la::1lili!!fir'------'

t.I\'f.l.JJmgKl 1s)'OOt" ane stDp !or enloe chapt .. l!!\flew mate r~ and
resources. f'repa.t ftr $UCCe$lI with ad~OII<lI ItCU:x -$tyle practlQ!
QUeliti:Jns. inlln:tive ~s ..: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 .

Drugs for Skin Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES

DRUGS FOR SKIN INFECTlDNS J'4ltW

Aher f?Qding this chClpt~ the student should be Qb~ to:

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! (J01tl~
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

1. Identify the structure and functions of the skin layers and ilS$OClated
structures.
2. Explain the process by which superfid al skin cells are repla ced.
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 dass~ listed In Drugs at a Glance,know representative
drugs, and explain the mechanisms of drug action, prlm~ry ""tlons, ~nd
import~nt ~dverse effects.
7. Use the nursing process to care Jar patients who li fe receiving drug
ther~py for skin di50rders.

...

DRUGS FOR SUNiURH AND OTIIER MINOR BURNS

",

SlIlbbb fJI1I1IJ6J
local AnestMtics ptJtlO

KEY TERMS
minoid pogtl56

trytMlN pilI}/'l'lJ

kfratolytic ~756
nits pq 75J
pfdirulicidf,s pi1Jt 751
pruritlK JIII1I7'lJ
psoralen pi1Jt 76J

fxmriation PIl!/t lS9

psor~is JIII1I76D

IIfIKW

ac:nnulglris pqllS
romfdone pa)f 156
d!ormat~il
Knrnl

PIl!/t7S9

,..1S9

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rhinoptrym~ (jt 157

rosKfa

{A1It m

~ (Xl9tlSJ
~bonhN {!09f 755

(llJlltl5C

UnII' The IntegumeomySyl1~m ar.d Ey<>"rEars

750

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

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 nutritional status and heredity. Sonte sources consider the sub"
cutaneous layer as being separate from the skin, and not
one of its layers.

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 necessary 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 injected 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 germinativum).stratum spinolUm, stratmn granulo5um, stratum lucidum, and the strongest layer, the UTatwlI corneum. The
stratum corneum contains an abundance of the protein
keratin, which forms an effective barrier that repels bacteri.1 and foreign matter: Most substances cannot penetrate
this barrier.
The deepest epidermal sublarer, the stratum basa.le, supplies 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 ultraviolet rays. The nwnber and type o f melanocytes determine the overall pigment of the skin. The more melanin, the
darkfr the skin color.

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"essory structures such as hair and nails. Most sensory nerves
that transmit the sensations of touch, pressure, temperature, pain, and itch are located within the dermis, as well as
the oil glands and sweat glands.

48.2 Causes of Skin Disorders

Of the many types of skin disorders, some have vague, generalized signs and symptoms, and others have specific and
easily identifiable causes. Urti(.ria is a hypersensitivity response 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 impairment. A substantial number of drugs have urticaria or pruritus 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 classify 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 disease processes o"urring in other body systems. Skin abnormalities such as changes in skin turgor and in the color,

TABLE 48.1 Classification of Skin Disorders

"'"

Infectious

fIrogal infwions:riror-m lh~~s foo~joI:k ~dl,and nai

ilfedion
Para~tK ioftaioos: ticks, mill"!, and IK~

Y"nl ioftaions:roId lOR"!, fev bIislm (hptS simpln).

dJidrn pol. wa1~ llioglts {ht!pes ZOIlI. rnN5I~1
(rubtolal. and Gtrmao 1IIN~6 (nftlla)
Inftarnmalory

DERMIS

Beneath the dermis is the sub cutaneous layer, or hypodermis, consisting mainly of adi-

SUBCUTANEOUS TISSUE

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Example5
Saamal infenions:boiI~ inptliljC\and ilftclf<i hili
folidts

10)1ry and 6p&IU1! 10 1~!UO

Combinalion of O'ffi'.ai"l~ gland!, iKru~ 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,
susi!dmna~~~and psoriM

~ltic:

Skio (,Jocm:~mOUl (til urdoorna.baQI cell ta1:illOllU,

and maWgnanl mNilorna
Bffii9n o~lmsiod~ ur.losiland rnalOilunlhorna

Chopl.... Drug' fotSktn O""rd .... ,

size, types, and character of surface lesions may have systemic causes such as liver or renal impairment, cardiovascular insufficiency, mE1astatic twnors, recent inj u ry, and
poor nutritional status. The relationship between the integumentary system and other body systems is illustrnted
in ". Figure 48.1.
The pharmacotherupy of skin disorders mar be conducted with oral or topical drugs. In general, topical drugs
are preferred because this route delivers the medication directly 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 indicated. Some conditions such as lice infestation or sunburn
with minor irritation warrant only short-term phannacotherapy. Pro longed and extensive thernpy i< sometimes
required of eczema, dermatitis, and psoriasis.

Endocrine syatem
Hotmones influence
glandula. activity, calcium
homeostasie, and skin h.... llh.

PHARMFACTS

Skin Disorders
An estimated 3 million ptOpIe with ntW me oIlic:t infestation art
tll'itfd t<Kh ~ir in tIN> Unilfd Statrs.

Ntul)o 17 million ~ple in !hi> Unitfd States hae <Knr,making it tIN>

roost mmmon ~in disraSor.
Moll' than 15 million proplr in t~ Unitrd SliIlrs haff symptOIlll 01
rlrrmatitis.
Of inlints and 100119 (hiidll'n, 10% ~perienct symptollll oIdenn.nitis;
roughly 60% oltllesr inlants cominUl' to haff symptollll imo idukhood.
Pwr,",i>~rr",b 1% to 2%ur tlo" U.5.pupul.olim. Tioi. diwnlrr unun in.1I
agr glOO[II- adJits mainly- affoxting about thr Iol~ rumoo of mtn
aswomtn.

The integumentary

ay.tem

Nervous syatem
Emoliomo sfteeI skin
coIoralion. The skin is a
sensory organ.

Cardiovascular s yatem
The blood canies oxygen
and carbon dioxide, 1ae\ore
1h&t influance skin health

Muac ula. ayatem

The &kin and ....,...,les a re
importanl lot proper body
movemenl and expression.

and ooIotrllion.

Reapinotory syatem
The lungs provide
oxygen 10 all

celie
in the body.

Lymphltic syatem
Helps fight disea .... s and
inteclions 01 the &kin.

S keletal syatem
II. stora.ge site
Ier calcium. an important
"';""ral connecle<l w;th
vita"';n 0 lundion.

The bonaa are

Digestive aystem
Prope. nut,~"", is imporlan\

to. healthy skin.

Reproductivs ay.tsm
Urine. y s y.tem
The ao:um.Jlation 01 Io>cic
54.bslar>c:ola in the

bIoodslream willllfac1 the

skin advorsely.

The skin oovers eld""",1

Fo. all sy.tems

The &kin larms a p>teetive
ba .....r a9"inst hazardous
cond~iona.

". Flgure48.1 Interrelallomhlps of the Integumentary system with other body systems

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75 1

genitalia. Sex ho""""""

innue""" skin

health.

752

Un'" The Int~meoUfy System ~r>d EyKIEm

SKIN INFECTIONS
The skin is normally populated with microorganisms or
flora that include a diverse collection of viru.ses, fungi, and
bacteria. A5 lo ng as th e 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 m icrobes. Although perspintion often provides a
wet environment, its high salt conU'nt disoourage:s microbial growth. Furthermore. the outu layu is continually being 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 punc~
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 infections of the skin are caused by SlIIphyl{J({J(ClIS and
Strept{J({J(cus, which arealso normal skin inhabitants. S. aureus is responsible for furuncle:s (boils), carb uncles (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 Str~'PI(J(OCCUS.
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,affects large regions of the body. or has the potential to become 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 pJurm~cothtrapy with r,.,'() or more
antibiotics. Some of lhe mort common top kal an tibiotics
include the following:

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 (G"'-III~" 1II~41>I",,). U~ .....llr. thn~ i" ("'"t io,,~ ~r~ ~df_
limiting and IX)flspecific.so treatment is directed at controlling the extent of skin lesions. Viml infections of the skin in
adults include herpes zoster (shi ngle:s) and herpes simplex
(cold sores and genita l lesions). Pharmacotherapy of severe
o r persistent viral skin lesions may indude topical or 01"3 1
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 pubic 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 cont~ 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

Bacitracin ointment
Erythromycin ointment (Erydtrrn, others)
Gentamicin cream and ointment
Melroniduole cream ~nd lotion
Mupirocin (Bactroban )
Neomycin with po lymyxin B (Neosporin), cream and
ointment
T~tr~<.ydi,,~

FlUlgal infections of the skin or nails such 35 tinea pedis

(athlete's foot) and tin~a 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
antifungal agents such as unde.;ylenic acid
(Cruex, Desenex, others). More serious fungal infections of
the skin and mucous m embrane:s,such as Candida albiCil/ls

arc

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Figure 48.2 S,.blei

SouIl:O':CwltelY ofDr. JO:ion L Smrlt

ClIopl .. 4I Drug'/OfSklnDIsom...,

753

ing followed by vigorous scratching. Secondary infections

can result from scratching.

48.4 Pharmacotherapy
with Scabicides and Pediculicides

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 human 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 ~s
Phthirus pubis. The pubic louse is referred to as a crab louse,
because it looks like a tiny crab when viewed under the microscope. lndividuals with pubic lice will sometimes say that
they have ~crabs.~ 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

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 infestation is located, as well as factors such as age, pregnancy, or
breast-feeding.
The preferred drug for lice infest~tjon is permethrin, a
chemical derived from chrysanthemum flowers and formulated 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 chrysanthemum plant. Permethrin and pyrethriru:, which are also
widely used as insecticides on crops and livestock, kill lice
and their eggs on contact. These agentsareeffecti~ 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 alternative for resistant organisms.
Permethrin is also a preferred drug for scabies. The 5%
permethrin cream (Elimite) is applied to the entire skin surface 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
remo~d from the skin. Crotamiton (Eurax) is an alternati\'e
scabicide available by prescription as a 10% cream.

I Permethnn (AcrICrlt Ellm/re. Nix)

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 Iic:~ and
miln,<lnd to~adic:ate thtirova.A 1% lotion is a~ lor Iic:t and a S% lotion
lor mitH. Tht mtdic:atioo shoold bt <l11owtd to rennin on the h<lir and stalp 10
minut~ 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
hi~ ~n killtd.
Suc:ttlsful ~imination 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 ~m.

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

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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 (<ltions: Contr<lindiutions iIKludt hyprrll'nsitivity to p)'II'thrins,
chrysanthtmurm, IUlfites, or othtr plI'SfrntiYH. Pt lll"ll'thrin !hoold lit uSfd
(iutious~ 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 bTesll:Uoinown
Herb<lVFood: Unknown

Tll'at ment of Overdose: No sprcilK trtatmmtloromrdoll' is <lnil<lblt.

/II11i>r Ie M;MJrJIngIJ/ A>r Q NiJrJill9 I'n::mJ fOOl! JpKtk Ie IN! ~

754

Unlit The Intt9UmeI'lt~ry S~tem aod EyeslE~11

NURSING PROCESS FOCUS

PATIENTS RECEIVING THERAPY WITH SCABICIDES

AND PEDICULICIDES
Potential Nursing Dia9no~s

Assessment
Siseli.e assessme.t prior to administration:
Undmtand the rmon the drug hn been pr~ribed in order to iS~ 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
hai~ ~ed
artas hetw~ wtbs 01 fingtB,around belt or elastic
fines), irritation. enoriation, or driinage.
Illtainbaselineheight, weight,u.d vital sign~

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)

tnc.

Assessment throughout &dministration:

Asstss for desired therapeu tic rffKts <leptndent 00 tht ft'asoo the drug is
given (e.g., visible inltstation is gone, nits arl' rtmoved.~in haling is
visible).
Assm for ad'ttfSt tfftas: IourlZtd tingli~ pruritus. stingi~ or burning.
SP'ltrt skin !factions or ~ma should be ft'poned promptly.

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 (e.g~dOSf, timi~ whffi to notify proyided.

Implementation
Interventions and (Rationales)
hSiring thfnptutk effects:
Monitor appropriatt medication adminillrlltioo for ojltimum I'tSlIl1S.
Monitor the .ffected area .after treiltment DYtr the following 1to 2wNI;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 1to 2 weeks.ReinftStatioflS
may appear within 1wetk and need to be retreated ilt th~t 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.J1ob;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 s~n 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 plt(.llJtion~ (Using time
d.Jfing I'A.lning cart helps to optim~ and reinfortf Ry teaching arn~)

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Patient and Family Teaching

Teach the patient appropriate adminismtion trchniqUtS (set"Patient stlfadministration of drug thmp(lattr in this table).

Instruct tile patient. family, or caregiver to (ootinue to asstSS tht illN daily
for 1to 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, ilnd combs ilnd brushes in ~py 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 rtdne5s,swelli~
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 (MWli~ and what advelst tffects to obstrn for and when to
rtpOrttiltm.

ClIopl .. 4I

NURSING PROCESS FOCUS

Drug' fo< Skin Dl1Ord ... ,

75 5

PATIENTS RECEIVING THERAPY WITH SCABICIDES

AND PEDICULICIDES (Continued)
Implementation

Interventio ns and IRati o nale s)

Patient and Famil y Tea ching

Patint selfadministriltion of drug thtrilPY:

Wlltn administtring thl medKation,instnKI th~ patitm, fimily,oruregi~r
in lilt proptr s~lf-.admiristration of the drug, !.g.,IM waly" dilro~d or
per p;lckagt direions.1 Proptr administration ilKlNSti tilt elm:ti'l~1ItII of
IlltdrugsJ

Teilch th~ 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 ti~ (lIIUIIlly approximately 10
minute). Most paoc:u~s (omain enoogh drug rorone IlI'illlIIfIlt
athough alf({lnd paWge maybt lI'qui.ro if th~ hair is long.
DI)' lhoroughly aflrr shoWl'ring or shampooing tilt drug OUI of Ih~ !lair
ollkin.
Ccmb through hairwith the smalltoolhed (omb providtd 10 II'mO''
ary rffluining dtad IKe, nits, or nit {asings.
If ~hts illI' inftslrd,appiy alhin (Oill of perroirumjelly to ~hts
oru . dory fur t w ... k.Cornh Thmugh II.i"'l . 1IM1I.'PIW)!' ramn
(trd hai~ webbings offingenand tOts,and btlt or ~1.utK lints for
I~ns of lI'inftstation O'/rr tht oo:t WI'~k.1 f1Iffiitd, a lI'{ond ipplKilion
ofthedrug (in bt tMd after 1 Wl'rk.

Evaluation of Outcome Criteria

[valuatr the ~ffectil'tlll'ls of drug llitra py by ronfinning that p;ltit nl gN Is and OpKte<l ow:om~s have bffil mel (Ite Plannin(].

The traditional 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

& COMMUlllTY CONSIDERATION5

- --- - - -

HOME

------~

Psychosocial and Community Impact of Scabies

and Pediculosis
Childll'n and p;l1I'I1I~ paniWrty tt-.u illl'lariYrl)o afflutnl all'lS, IIW)' apress
fe.!.ing LlKiran or that Ihti- se/f~teem has betn IaNtnd whtn thf, all',jag
~ with IUbier or prdinAosis.Somt patienlS thinkthat only horntItss ptrwns
or PfOII~ allow inrome gettll!5l' disordm. dK;atr tht patitnt .md fami! IIII'm
ben abrut thtw~in 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 hyije~!t.ppIits or hm bodily({lllixtwith othm.
Subits or IKf un r.Jpidly Ipll'ad in a \(hoo~ nuning ho~, lI'Iidtmial
Ufnroolt=I~,orhOlpinland bKomea(ommunityhukh probirm. School
nurstl mUI! a\ srss tilt pl~mial fur studtnu or patitnu (onuding SGlbirs or
IKt and ,ake pll'"/~mive mmurrr. This may ilKlude fll'qutm .J!SI'ssmems of
the hili~SGlll'and 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 t~ nunt should be tll'iltrd in an at
(tptiog. prWsliorw~h!lptJl manner.

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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 Wlusual 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.

756

UnII' The IntegumeomySyl1~m ar.d Ey<>"rEars

TABLE 48.2 1 Drugs for Acne

Drug

Rl!!T1arks

idaJlalelll'lootmo)

Rtlinoid-ik~

imait uid (Azdex, Finaa'a,othm)

Fm~d to lIICIdtfit~

bmzoyI pl'rOlidt (~lilin. FoIiex,othm)

\(mtinolytkaviila~ ~OTC :someti ~ (ombinf<i with ft)'throm)'<in (~mydn)

(ompollld UItd tOUNt aaM' 10000000tion

ilflallll1ita} iOI~
or dindamydn (SMuClin) lor

oKIIt t.lUltd by P.Q(ntf

diodolmydn and uetiooio (Dina)

Combination product with.lO oIntibiotitand j retiloid in 01 gel ba!t;for mild 10 rnOOeralt oIUlI'

ethinyl ~ltridio\ (Eltirr,1l

Oral (ontroKtptive ir~ !OIII~~ lI!ed for oKJlI';wmp\t:~il1'!l etratiol pkII norgtIIimat~ (Onllo TrHydtn28)

iIotretiooio (AaUtiIll'J

F !f'Im' oKJlI' with 'Ysn or lItnt forTntd in Ynall, IOIIIdtd rna\.Se; prtgnaocy <at~ X

5Ufitmmide (Cetamidt, K1aron, othel!)

F !l'n~tM skin; somd~s (ombined with 5UI1l' 10 promot~ pl'd llg, ~ in t~ tonditioo roSoKN; illO U!I'd lor
(onjllotti'litil

tmrotrlll' (T.uor.Kj

Areliloid ttug that may allO tit UItd lor plaq~ pIOIiaIis; MI antiprdi/eritiv~ and aotHnftammatory ~fffflS

tetraqdioes

Amibiotiu; rtfettodwplet 3400

O trrtinoin (R~o-""o1hm)

To prt'Imt dog4jing 01 porr loIlidts; allO u!I'd for t~ ummmt 01 aM\' promytlotytit IetJkemii ind wrio~

As a result, small inflamed bwnps appear on the surface of

the skin. Other factors associated with acne include androgens, 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. Blackheads,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, resulting 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 regimen 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 peroxide 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-

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tolytic agents used for severe acne indude resorcinol, salicylic 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 inflammatory 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 medication 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 associa ted with a risk of
suicidal ideation. Therapy with retinoids may require 8 to
12 weeks to achieve maximum effectiveness. Common reactions 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 inflammatory 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

Choplt... Drug. fOf Skin Disorder,

II~ Prototype Drug

757

I Tretlnoln (AVlta, Retm-A, Trentm-x. others)

Therapeutic (Iass: Antiacne agent

Pharmacologic ( lass: Retinoid

ACTIONS AND USES

T""inoin ;.~ n~tu,,1 d. ... 0!~ ohiumin Athal ;. iMiuted forthe"ArIy lI..t_
mtnt'M mntrol of mild 10 moderille oK/I!' vulg,ris. Renm ;. Atopic,1 form of
tretinoin 'PPlO'fed to liNt fi,", i.lCi,1 wrinkles 'M hyptrpigmmtnion associated w~h photodamaged skin.Trriiooin has antinroplu1K <lrtions;,no"llorm
(Ve-\aooid) ;. appWled to ~iII <lMe promyelorytic itukemia ,lnd Ina)' be Pll'I(ribed ofF.Jabei for skin m,lignanr~.
Symptorm t,kt 4-8 Wffb 10 improYr, aM maximum therapeutic b~OOit
ilia)' take S~ momhs. Bffilu," of potfntialiy II'nous adYers~ dfe<ts, this drug
is most olt~n 1l'1I'rYe<! for ryitic aorne or II"/~Il' 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 (th~ product contains
rlSh protti ns).
Pll'9nanry Ulfgory (

ADVERSE EFFECTS
N.~rIy All p-atienu using "'pical twinoin will ",.;...... re:I~. =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 miy bt n~cl'llolry. Otrmatologic adYersr elle.:ull'solvt ooce th~rapy ~ dil(ootinue<i. D"ltooapy un
also(ius~ \kin olIIYenerifms.
VrfY high or~1 doll'! u n Il'SIlIt in ~ adY!'M efle(\~ including OOIlt
p-ain, '""', headoKhe, naus~a, yom iting, ra 5h, stomatitis, pruritu ~ I'Mating, aM
orular disorders. The oral drug has ~"l black 00. warnings, inckJding the p0tential for rapid d.-;~Iopm~m of k-ukorytosiland the polIsibility of S~1l' reactions in ~titnts with promyelocytic leukemia.
Contraindicdions: Com"irKiutioos for tapinl admin~tratioo iKUIe rmma,
elpolUll' 10 sunlight or IN raY', sunburn, hypmrn ~tMty to the drug or vitam in
Apreparation, and children !tss than 12 )'u rs of age. This drug is comr~indiratN
duringlaaation or prt'9nancy. Oral minoin is cont"iMinied in p-atienB who
haYe hepatic disem, !tukoptnia or neutroptnia,or who a~ hypl'Mnsit~ to
the drug.
INTERACTIONS
Dru;rDrug: T~ arnt kfr.Itinolytio~, rflOlCoo,bfnzO)"I pl'IOlide. and
sak)1ir iddl may incll'R inllammation and PfMng;lopnl tro1KB (OOtainiog

PHARMACOKINETICS
On~t: Unkoo'Ml
Pf,ak:Hh

_OhOI or IIlfOthot 1M)' rauseSlillQinq.Addili"ll' phoIOIOIidty IiIII ouII"ifUMiooi1 ~

II!I'd (OII(IJIflltlyWithotllfl pI\o!OImOc drugsSU!h ill tetrarydioH,

Half ~fe: 0.2- 2 h

Ll bTl5ts:NOOftmwn

Duration:Uoknown

HI'IiIiI VFood: ED:~~'II' all"llUllB of vitamin Aor Sl. John\ '/IOCIIM)' II'IUk in

ftuoroqu~orsWfonam~

pho\oII'nIiI:ivily.

Treatmf nt of ()mdo~: D-muse of the topical drug will lead to eJ(tlsiY!' sl::in
drying and ~ing. Symptoms of oral OtrdOl~ all' oornptrifk and resol"l'!' with
symptomatic treatrroent
IItftrlO M)MmllrgmfrlfQNlmlnl} I'nxm foaTispKlk lOrlrlsdrui}.

proved ineffeclive. For Ihe actions and contra indications of oral contraceptives, see chapter 4500 .
ROSACEA Rosa(fil is an inflammatory skin disorder of unknown etiology with lesions affecting mainly the fa ce. Unlike acne, which most commonly afffCts teena gers, rosacea
is a progressive disorder with an onset between 30 and 50
years of age. Rosacea is characterized by small papules or
inflammatory b umps 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 includin g alcohol, spicy foods, skin care prod ucts, 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

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.. Flgure48.4 Rosacea
Source CourfqatDr. Jaw n L Smlrh.

(Finacea). Benwyl peroxide maybe applied as needed.Alternative 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).

NURSING PROCESS FOCUS

PATIENTS RECEIVING ANTIACNE MEDICATIONS

Assess ment

Potentl.1 Nursing 01'9nOstS

Billtlilt .S5tIl IlUI prior 10 adminiltr.ion:

Undmtandtllt rmon IfIedrug IlisbmJ preuibed inonltrto.s~ fOi
tl!trapeutk tfft<u (~.g., ~tmelll of I(nt, ligns of ~(omponent of
cilnmtrutrnoent).
Olltil" iI (()mpie1t he~1th history induding dtmIiltolog"hf~tk.or ~nill
diltillt;ps~ dilordM; plf9ll.il"lC)';or brull-fding.

Disturbed Body Imilgt'

Im~il!d Sbllmfgril)' (rNM to sllin wndition ldvtlSf drug efffCbl
Defw:itn! KIXIW~ (drug tlttrajly)
Rist for in;"" (rNitd to ~ drug tfI"ts)

Illt.l" iI drug ~OI~ including illIr:'IIirs,~nl 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, ht~tk 01
~nill function ~).
Illtilin biitlinuiul signs.
AsstlS/Mftt thlllughout "'lIinistration:

As_ il, dtsirtd Wr~ tfffCb (ltg.,stin is dtMing of atilt Itsions).

Cominuf Pfriod"l( monitomgof(lIC.~pid profilt,gl!KOSf,.nd IIfpitk
funtion tem if on oral drug.
MonitorYitalli9nlilmdalitalth(,J~mit.
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 ~Iing lkin,ck)' mouth,tyft,OIIIOSf milY ouur.~ in mom.
tspKiil/ly ~presion or suicidil thought~ lhouid be It$IOIted immediately in
~titnll on oral iIot~tinoin.

PI.nnlng: P.tlent Go.Is.nd Expectt'd Outcomes

Thf ponnt will:
Ex~JI(f Ihtrapturic ffffCb (e.g.. arnf Iniom .~ wring. appt.lnao of WTin kIes 01 skin dal1\i9f is imprwing).
BeffftIroIt\Of~ceminimilll.~~s.
V~ an lRim!ancliJg 01the drug'1 !M,.dYme tffrts,lnd mjuirtd jRc.Jutiom.
Otmonstru~ proper IeIf-adminisuiltion 01 !Itt IIltdkiltion (t 4- dose. timing. whtn 10 notify pfOYidtr).
Implementation
Interve ntions and (Rationales)

p.tient li nd Fllmily Education

--+-

E.I uring I htr .pt\l1 ie tffe<t I:

Monitor i1ppropNtf mtdication idminilmtion foropMium rrwIts. (Topiul
trUlmtllt iI_ shoold s'- signs of imp_ent widlin 2-( ~b.OfilJ
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 or~r-drJing of 1bt skin miIY make tfw, (ondition wolII'.1

Monitor patienlSon isouninoin b """tion.1 hfakh 01 manges .. mood.

(Otjmsion,induding with wkidil ideation, llis bHft noted ill MI 16itnt
tfff(l..)

ltac:h ~ paOOJupproprialudminilmOOn ttdllliqurs (~"P.timl IflfIdminiltmion of drug thrrip(t.w in this tablt).

ltac:h the paOOJt 10 9tfIIly dtilflSf tilt skin usirlg iI nonoily SOolp and
noidilllJ rigoJOlJllCJUbbin<J.II9(~lMdrynesl O(lJJ\ lilt I nonoily lotion
tUJUsof drynesl..
Instruct tilt patient l.imii)", 01 wtgiYtr II) immf~ml)' rtporI.ny ligns of
~td

mood,ilfffl:t dtpltSsion, 01 rxpItSsed suicidillthoughts 10 tfw,

- ,_ _f-c'='=
~=(,Jrt provicIK.

Monitor (Be, lipid Itvrh,and hf~ric function Lib! ptriodiu li)"1or pi!itnu on
0Ia! mtdiciItion.{Lipid !Mil may incrt.1f in up to 7(19(, of Piltieflts on OIl!
.(IIt Ibtrapy: Hepatotoxicity is In ~If rfft of orill drugsJ

Instruct tilt patient to IrtJm pm,dk.Jllyfor Lib !eh.

ltac:h patitflt to rtport Iny symptOms of ibdominill 01 right IJIlPfr<lfJldlitot
!b:omfort or pain, ~ing 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 ltCJuLlr~ 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.

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(lIoplOl41 Drug,ro<SklnDMrd...,

NURSING PROCESS FOCUS

759

PATIENTS RECEIVINGANTIACNE MEDICATIONS (Conllnuw)

Implementation

Interve nti o ns and (Rati o nale s)

Pati ent and Family Edu cati o n

Monitortllt !)oItiem's tlpOwrt to tIl~ wn 100 UV light (Drying. ,kin

I!'nsitiYity,aOO pttling ,kin all' possibtt, adYmr rifrc.u,~ially for
~titnll on Ill'1iooin.Proledion from sun expilSUIl' is ~sl!'mial.)
Monitol(omplia IK~ with ' iPItdqt' Il'qU ill'll1tnl! for !)oItienu on isotft'b noin.
(iPItdqt is Il'quill'd of all palilom. on isotrttinoin btfoft' ~tiving I
pIl'!{ription or Il'filk of the drug. k requill'S tht patient to tmurt that all
ll'qIIirtllll'flu 10 pll'~m leratogenic tfffm 11m betn m~l)

Tt-i{h tht- !)oItienl TO un sunl(ll'tlllofSPF 15 or higher and to ~ar

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 th~ patilom on isotft'uooin of tht Il'qJimn~nu 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 ha~ two n~gativ~ pll'gnancy tests
Oil!' month brioIl',ckJring..aOO after drug thffilpy,condKted at certified

'''.

Matt, patienll mustffnry that thty will UI!' a barrMor melhod of binh
comrol and 001 donate blood whi~ on lilt drug.

--+--

Patint understanding of drug thtrapJ:

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

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.

all'a~)

Patint selfadministrilt io n of drug therilPY:

Wlltn administtring tilt mic.ilion,in'lfIKt tht patilom, family,oruft'9i~r
in tllr prop'r ..If...vlmini,trllinn Df th~ dnH). P.g.. TOpiul dIU] i. lKf<I
appropriatr~. iPItdqt program is folta-l.(Proprr administration will
in(rtast tilt ef!e<tiventSs of tilt drug.)

Tta{h tht patienl TO takt- tilt drug following appropriatt- guidelint-S:

Gtmly (~an5l' 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 tffe.:li~s of drug thtrapy by mnfinning that patiem goalsand aptCled oukomrs haYe betn met (~Planning").

C OMPLEMENTARY AND ALTERNATIVE THERAPIE S

Aloe Vera
Alor mol is deriYl'<i from the gel inside tilt- ~af of tile alor plim, which is a
mrmbtrof tilt lily family.~ I'ffiI romains ~r 70~wbslalKrs,ilKkid
ing amioo iKids, mint-r~1s, vitamins, and enzymrs. ~ wbsialKrs aft'
dilimed to kill a 'f<IrMol)' ofmicroorglnisrm.de{ft'i\!' ~in.and Il'duc:t- localized
inflammition.Alorvm 011,0 has yallll' for ill moisturizing ilnd woond IItlling
proprrtits.1t has ~n used m~dicinally for lhousanm of yrm. Tlltft' art numerous alor prodJru .nrailib~, in{kiding ~ps,lotions, {Il'am~ ind sunbIoc:ks. Theil' ha~ 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

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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 symptoms may differ dependin8 on the cau.alive a8"nt. The thr"e
most common types that respond to topical pharmacotherapy are atopic, contact, and seborrheic.
Atopic dermatitis, or rrnoma, is a chronic, inflammatory
skin disorder with a genetic predisposition. Patients presenting 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 introduction of other foods. In infants and small children, lesions

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 response, resulting from exposure to specific natural or synthetic allergens such as plants, chemicals, latex, drugs, metals,
or foreign prote ins. 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 infections, nutritional deficiencies, and immunodeficiency states
are associated with the disease. Seborrheic dermatitis presents 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, blepharitis, otitis externa, and acne vulgaris.
Pharmacothe rapy of dennatitis is symptomatic and involves lotions and ointments to control itching and skin
flaking. Antihistamines may be used to control inflammation and reduce itching, and analgesics or topical anesthetic); m:l}' he ]lre.~crihe(] for p~in relief. Ato]'>k dermMiti.~ Cln
be controlled, but not cured, by medications. Part of the
management plan must include the identification and elimination 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 therapy. The moderate-potency formulations are for more prolonged 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. Highpotency 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 discussed in chapter 4300 . To avoid serious adverse effects,
c.<ITeflll

~tlention

mllst he given to the

~mOllnt

of glllCOCOT_

ticoid applied, the frequency of application, and how long it

has been used.
Several alternatives to corticosteroids are availa ble. Patients 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 calcineurin inhib itors pimecrolimus 1% (Elidel) and
tacrolimus 0.03%,0.1 % ( Proto pic ) are available for p atients
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.

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TABLE 48.3

Topical Corticosteroids

Generic Name

TracK> Nam1'5

VERY HIGH POTENCY

buam~thaOlll' IIpropional~ auglllffill'd, uum

dOOelald propional~
difioralonuii(~liIt~

HIGH POTENCY

amdoonidlo
ftuodnon~

haldnoriill'

MEDIUM POTENCY

bctamcthasone bcnzo.JI~

~""

bctamcthaOlll' valtr.u~

Val~

doconolone
ill'Wlimtl~,lJNm

""""

ftuodnolOlll' '(tlon~

S)"nalal

Topilon

fturandl!llOiill',aNm

Cordlan

ftutiu lOlH' ~onal~(fl'~m

U/lMlt

ItydllXorti!Olll' \\Iltral~

W~(on

~liIOIII'rulOill~

",,00

triamd~ arnon~

Ari5fO(0I~Kmalog

LOWEST LEVEL OF POTENCY

aklomelalon~ d",opional~

...."

Ado'o', le

.....

DtsooaIl',DeIOwm,

...

Cortizm~ H":OII

PSORIASIS
Psoriasis is a chronic, noninfectious, inflammatory skin disorder 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 covered with flaky, thick, silver scales calledplaqlles, as shown in
~ Figure 48.5. These plaques shed the scales, which are sometimes 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,a nd occasionallyarolUld the nails. Thevar"
iow; forms of psoriasis are described in Table 48.4.

(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 conducted in a stepwise manner. Psoriasis is lifelong, and there is
no phamlacologic cure.

TOPICAL THERAPIES

~ Flgure48.5 P'sorlu's
Source: CooneI)' afar. Ja!Of"l L Smirh

Although the etiology of psoriasis is incompletely understood, 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 condition, 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 infections can trigger flare-ups. In addition, certain drugs act as
triggers, including allgiotensin-=nverting .,nLym~ (ACE)
inhibitors, beta-adrenergic blockers, tetracyclines, and nonsteroidal anti-inflammatory drugs ( NSAIOs).
The goal of psoriasis pharmaootherapy is to reduce skin
reddening, plaques, and s.:ales to improve the cosmetic appearance of the patient, leading to more normal lifestyle activities. This is accompfuhed by reducing epidermal cell turnover
and promoting healing ofthe psoriaticle:sions. Choice of therapy depends on the type and extent of the disease, and the history of response to previous psoriasis treatmE"l1t.A nwnberof

TABLE 48 4

Topical corticosteroids are the primary, initial treatment for

psoriasis. These drugs are effective, inexpensive, and relativelr safe. Examples include betamethasone (Diprosone)
ointment, 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 (Tawrnc},a vitamin A derivative gel or cream. These drugs provide the same benefits as topical corticosteroids but exhibit
a lu,,t:r iI1~i<.lt:I1~t: uf auvt:r"t: t:frt:~ls. Cakipulrit:ll~ ""Y product' hypt'rcalcemia if applied over large areas of the body or
used in higher doses than recommended. This drug is usually not nsed on an extended basis.
Other skin therapy techniques may be used with or without 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 ronsidered seoond-line therapies.

Typesof Psoriasis

Form of Psoriasis

OescrlpUon

MOSI Common Location of lesions

Comments

(dropliu) or
mtp~ft psori.tsis

IrionSlnlilitr thin lhost of psoriilsis

UpptrU\JnkatM! utremitie

MOIl' (OfIlmon in wly~l ps3fUsis;

can ippur ,nd resoM !pOIItlfP.(llJs/y
, few Wffksfollowing i strepto:ox<al
~!atOl} inftctioo

Guttal~

vul9aris

Psoriasis v!Jgaris

Irionsare papule lhilr form inro

ftYiIH'marou, pIique' with llid, Ioi'lff,
<II g"'Y pioqll!'< rhor lit....:! whM
retr"lllftd;plique in darto:~kimtd
ildivilWl, oftffi oppeir purpIt

So. ~n- salp,tlbow5,and ~';Ieions

possibllo inywhm on lhtbody

MOIl (OfIlmon form; r~rn Iotg.

ltrlll spttialind~l

Psoriaric iUlvitis

Rermble rlraullitoid lrthr~is

Fingtl'! indtotl it riml inttrphalill9t'l

joinll:L1Il iflKlSm loci nails

About 10% of patients with psoiasis

,Iso hav ~ arthriLis

Psorialic ~rythrodenna or
ufoliiltil'l'rlffinalitis

Gmrrlliloo sca~ng; ~rythtma W~houl

All body Suriiffi

lNII oommon form

Pustuir psoriasis

Eruption of pustule; preffi(~ of ft'In-

TDllkand tnrrrn~ie; <an ippur on

palm~!OIt5, ,nd nail bed,

kln-'ge 'ge of 0IlItI is 50 ~ir'

"'"

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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

Route and Adult DoSl! (maxd05~ wiler. Indk:ated)

Adv~rSl!

uI~rifllf(Dovol'lu)

Iopic.1I:AwtI thin ~erto ~s one 10 two tlmtSldlY

8UnVlg,stlfI9IfI9, fo//kiJ6ti1 irflli"19

(Ojltir 18illltlir,(uta~ othm)

lopital:AwtllO i ffffird irffiOlK~ qid

Drug

EffI'CIS

TOPICAL MEDICATIONS

HI! Il:d~lIl.m:r:ar: ~Ifm~

Fo/IiwIi~~ irlirorioo, p/1orclffifirir~Y

!:!r! &iR!IH!!~!lUfffSll
~Ikyljc~ ~IaJc, NMJOgmI,OIhm)

lopic.1l:AppIy lOilftrd IIUS tid-qiclln (OIKtrltr"iom ranging

from2-10%

UliKlit'1H' (Tazorac)

w: Apply Ihil fikn 10 d~in, d'y a~ !blly

PlaqUl' psoriasis:Applylhin film !blly Intlle Mring

[~pr!Jritr4llingingM"" skin
IIowi!M~~!!m!

ProriM, oomi"4- stirlt}irlg, sU! irlilarioo,

r~WJffl"19 ofpsqjjs

tie &i2VSMfottnrrffrQ!

SYSTEMIC MEDICATIONS
acitrtlil (SoriaUnt)

PO; 25-50 mg/!bywith ihI' main mHI

I>ry mourII, I1Ioptdo, (htiIi~l, rty!ki~ rty

_lIII'm/lrQlIt$

h'Kill ltd rrigMnjdn and d'!QIffitr91

IIjrtl!!!~:i!i !I!1!llu1!!r!!siY ~j~ Rm!!!!I.
Pil:Ildnlumgr ,rrtbri dmrmjoo donN!
Ijye! hmajnn I'll< tmtggerjrjry
id.J~mlJllab IHumlra)

SulxUUIH'OIIS; 40-&:1 mg f'/ffY OIhtr wm

Upptr rrspifllfllfY inf~OIl, 6Jjt<rion silt

IfIXri()/)lllNdQdtt fDih
Miljg~!IdtI

altfactpl (Arnt'iM)

1M; 15 mg OIK~WffkIy for 12 wffiH

Il:IiII!D ~!iIlDI

P/gyngili~dzzinru, G31Jt}h, IlQUW. Prurifli1

myolgi~, (N11 irriotI silt rtoonr
Millglli~~ il:Iill!D ilItI:!iPDl

bW!O\9Xkttv Iympboptnia
qdolpCllilH' (SindimmulH', Nrorall (w
pag!' m for Ille Protorypt DruIJ box OO)

PO; 1.25 mglkg bid 11IIiI:. mglkglday)

Hirwliilll, IrtffiOl: K1mirin~ hNdodtt IWriM,

_ , Imliting. diorr118
Hypt'lm#oo II!' onP9!gri,jIy
il:YRI:i:UlUDii gi!l\linl mluV:tIDmi
parrsth~'iias h~paI9101Ii(iIy inf~<!i!H!

tlalH'~ (&lbrrI)

SuixutalH'Olls; 25 mg lWicf/Wk or 0.08 mgfl:g or 50 mg 1IIa'lwk

llK~lrtQ{tiamol ~Iirt (poin,

......

t~~Ig/DJ,Wdomill<lpoi~ I(IIIIjrifl9,
Ink!!!!!!l~ par" ,IOD<:lii M~I!!:Il!lfjilll!!:

ilfliJirnab (Rmlicadt)

IV; 5 mgfl:g wilhadditional dostI hnd 6 wk afttf lhf iI~ial

ilfUlilll,thtn e'lery 8wk IhtrUfttf

I/aJh,mioor nfriam
Infi!!l!t!l::tt~!!:!1 BUI!m1;

gg 11lIf:ai2l!r

maigna!ld!:s. WSIlng 0/ heart falhrrt

hepjUolfl1!irtty

metholrm!f (Rhtumaun, Trrxall) (!I'~

pag!' m for I(w, ProtOlyp~ DruIJ box OO)

PO; 1.5- 5 mg bid for thfM dolI'S mhwm: (mu:15- 30 mg!wkJ

IM/IV; 10- 25 mg/wk

llfadtxht, gl()5jiti~ gifl9lrilh ~Id Itl!kopeni~,

!1I1~!i'!:~ rumnWlllBd~~lll9Wlilm

,plank .oroja bMI d!rho~l

ntphrotMic~, !!!ddffi llh D11lmonary
fibrosi!

umkinumab (Slmra)

SulxutalH'Olls;45--90 mg iI~ialy and 4 Wffb latfl; fdlowfd by

45- 90 mg f'If!Y llWfl'b

lItMp/I<ryngili1!Jpptf rtspifll/"Y /rOO"

infKtiOl1, 1wdIxhf, foligut
~tW!1l ilkllillDlllliltiglliDdti

48.1 for lopical (ortkosteroid! forplOlialis.

Irk indicil~ OOIIImon arIw5f effects; !lldcr!inioo indicilts !I'rious idm!l' efil'ds.
"St~ la..

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SYSTEMICTHERAPIE"S_ _ __
5011ll,' patients have severe psor~si5 ~t is rd istlntto lopical therapy. BKau.se the5e drugs have the potent~llo cause
more serious advSe dfecu, they are generally only U5td
when topical drugs and pholotherapy (ail 10 produce an adequate rdponse. ln $Orne cases, systemic drugs may be used
for a few weeks 10 produce a rap id improvement in symptoms before beginning topicalthl-rapy.
The most often prescribed systemic drug for severe psoriasis is me thotrexate. Methotrexate (Rheumatrex. TrelGlll ) is
used for a variety of disorders, including camr)()lnas and
rheumatoid arth ritis. inaddition to bei ng used for the treatment of psoriasis. Methotrexate is presented as a prototy~
drug in chap ter J700.
Othe r systemic drugs for psoriasis include acitre tin (5oriatallt), which is taken orally 10 inhibit excessive skin ceO
growth. Cydosporine (Sandimmune. NeoraJ). an immunosuppressi\'l! agen t. may be used for severe condi ti ons. The
newest psoriasis therapies include biologic agenlJ such as
a1efacept (Amevive). adalimumab (H llmira). usttkinumab
(Stelara ). etanmept (Enbrel), and inflillimab (Remic ade).
These drugs :act by suppressing specific aspects of the inDammatoryand immu ne responr.e:s.Several of these arealso
used to tr~t rheumatoid arthritis (chap ter 4700). A major
disadvantage of these biologic drugs is that theyare very expensive and not availab le 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 me~len, a
d rug from a che mical family known as the psor.Jem. The co ncurrent use of UVA and the drug is called PUVA therapy.
Psoralensareoul or topical agents that produce a photosensitive reaction when exposed 10 UV light. This reaction reduces the n umber of lesions, but un pleasant 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
w~vdength of UVB usimilar 10 sunlight. and it reduces le5ions covering a laflll' area of body tha t normally resist topica l tr~tments. With dose su ~rvision, this type of
phototherapy can be administered at home. Keratolytic
pastes art often applied betwetn treaunenlS.

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SUNBURN AND MINOR BURNS

Burnsare a uniqUt t)'pto! stress that may affect alIl~yerso!
the skin. Minor, first-degrff burns affect only the outer layers of the tpidermis. are ch~raClerized 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 th e
more hazardous hours of the <lay ( 10 a.m. until J p. m .), and
lack of protective clothing when outdoors. Chro nic s un exposure can result in serious conditions, includ ing eye injury,
ca taracts. and $kin cancer.

48.8 Pharmacotherapy of Sunburn

and Minor Skin Irritation
In addition to producing local skin d~mase. sun overexposure releases toxins th~t may produce s~temic 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 treatmen t for sunburn is prevcltWn. Sunscreens
are liquids or lot ions applied for dtemical or physical protectio n. Che",iaU IUNCIftOS absorb the spectr um of UV
light that is respomible for mOlt sunburns. Chemical sunscreens incl ude those that contain benzophenone for protection against UVA rays; th05e that work against UVB rays
indude cinnama tes, p-aminobenzoic acid (PABA). and saIicylates. Physical SUnKTns ,uch as zinc oxide. talc, and tit:anium dioxide reflect or 1Cll1ler light to prevent th e
penetration of both UVA and UVB rays. !'alSOl is another
sunsc reen product tha t 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)'dra tion, an d
topical anesthetic agents, if lleC'ded. Treatment is llS ually
done on an outpatient buis. Topical anesthetics for minor
bums include bmlexaine (5olarcaine), dibucaine (Nupercainal). lidocaine (Xylocai ne). and tetracaine Hel (Pontocaine). Aloe vera is a popula r natural therapy for minor skin
irritations and burns. These same agmts may also provide
relief from minor pain due to insect bites and pruritus. In
mOrl.' Sl'\-ere cases. oral analgesics such as aspirin or ibuprofen may be indicated.

Chapter REVI EW
KEY CONCEPTS
The numbered key concepts provide

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. su nburns, Infections.dermatitls. and psoriasis.

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] gJucocortiooids, wh ich are claSSified by their potency.

48.3 When theskin inlegrityiscompromised,n;.cteria, virU5eS.

and fungi can gain entrance and callS<' infections. Anli
Inf~cti\'e therapy may be Indicated.

4&.1 Both IOpical and ~emic drugs, including cortico_

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.

4&.1 The pharmacotber.lpy of sunburn Includes the sympto-

steroids, immunomodui.acors,and methotreJUlte, are used

to !rut psoriasis.
matic relief of p~in usIng soothing lotions. topIcal anesthetics, and analgesics.

NCLEX-RNe REVIEW QUESTIONS

The patient is treated for head tire with permethrin (Aetleln, Ellmite, Nix). following treatment. the nurse rei nfolU'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 w~ter and bleach.
Careful atten tion to directions for application of permethrine (ActJdn, lImite, Nix) Is emphasized by the nurse.
Signs of inapproprhte over-~ppUcatJon include; (Select
aU that apply.)
\. nausea and vomiting.
2. headache.
J. ~ irritation.
4. diaphoresis.
5. resde:ssness.
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 ~can't 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:

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] . hlgh-potencywrticosteroid creanlSshouid be amided

In the neck or bee beClIuseofthe J106SIbiUtyof
additional ad~ effects.
2. an CJl'llIl1$ sl\Quld be discafded after the initia l 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.

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.

ClIopl .. 4I

II

A lS .yea r-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 switchin g to a different type."
2. "Some improvement will be noticed quickly but full
effects may take several weeks to a month or longer.~
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."

Drug. fOf Skln Olsord .."

765

After trying many other treatments, a 28 -year-old female

is started on isotretinoin (Accutane) for treatment of severe acne. While she is on this medication, she mll'lt follow 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..

CRITICAL THINKING QUESTIONS

1. A senior nursin g student is partidpating in well-baby

J. A 37-year-old woman is referred to a dermatologist for in-

s.:reenings at a public health clinic. While examining a 4month-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 ointment and wonders how she should a pply the creanl. How
should the student nurse respond!

creasing redness and painful " acne~ 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?

2. A 14-year-old girl has been placed on oral doxycycline

{Doxy-Caps} fo r acne vulgaris because she has not responded 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 ~so 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 th~r:lpy that takes into eonsider:ltion
the major side effects of this drug and the cognitive abilities of this patient.

Su Appendix D for answers and rationalel for all activitiel.

~-~'----,

EXPLORE

M~rs"'~l'.it II )'0<1' "" . <fOp lor onti .... erlal>\Of .. "' .... ",. lor1. lS.rIC!

resources. Pnpale tor SUCC~ 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 fiont cI yoor book at
_.myntlilflgkllCOI'II .

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Drugs for Eye

and Ear Disorders

DRUGS AT A GLANCE

LEARNING OUTCOMES

DRUGS FOR GLAUCOMA {l'J9t169

Prostaglandins )ll9t169

After r~ding this chapr~, the student should be ablt to:

knaooprost (Xa/aran)
AutonomicDrugs /it169
Q

{IJ9t m

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

1 . Identify the basic anatomic struc tures of the eye.

2. Describe the major risk factors aSSOCiated with 9'111,1(00'1,01.
3 . CUIllp"'" .mY cunlrd~l 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 v~~s,or moiste n eye membran~.
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.

KEY TERMS
Iqueoushumor p<1Jt761
doSfd.angle glalKOITIII fJ09f loa
cydoplegkdrug1 pqjtJ74
melTWlotiris I#ItllS

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gluromil

pai/tl6iJ

l1altoidit~ pu;t176
l1ios~ ptl/fll'J
l1ydrias~ pu;t ll'J

mydriaticdrugs fJI1Jfll4
optn-anglt glatKoma ",.l~
otit~ media (#It l7S

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
disorde rs, 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. Important structures of the eye are shown in ~ Figures 49.1
and 49.2.

A fluid called aqueous humor is found in the anterior cavity

of the~, 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 circulates 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 venous system, thus completing its circulation. Under normal
circumstances, the rate of aqueous hwnor production (inflow) is equal to its outflow, which helps to maintain intI"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.

Ante,io,

and ....in

dlambe ,
Co,nea
Ed~ot

~~

pUp'1

......
'"

Visual

Post..,;."

~.
,. ~

I,;,
Conjunctiva

~ Flgure49.1 Internal structures of the eye

5v.Jfce: PeaSOfl EducarkxlJPH CoIlegI!.

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,-

&m_

Bony orbit

768

UnII' The InteqJ~tarySY'lem ar.d EY""Em

,~.

c.~

Slowly Ming
intraocular
press ure

Anterior

,-

Flow 01 aq"'"ous

Notmll a/\Iorior
ct.amber angle
Posterior
chan-ber

,.j
Rapidly

rieing

intraocular
preseure

Canal 01

~---"""

ClD&8d anterior

mmmb", anglo

Trabecular
meshwork and canal

;~;~;'aN~ J '~
(b)
"
~ 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 advancing to blindness. This disorder is usually accompanied
by increased intraocular pressure (lOP). Glaucoma mayoccur so gradually that patients do not seek medical intervention Wltil late in the disease process.

49.2 Types of Glaucoma

"t

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 abnormal 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 because they are associated with permanent vision manRes.

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Some patients of Asian descent may experience glaucoma at

"normal~ 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 persons 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, tumor, or cataracts. Some medications may contribute to the
development or progression of glaucoma, including the
long-term use of topi cal corticosteroids, some antihypertensives, antihistamines, and antidepressants. Other major
risk factors associated with glaucoma include high blood
pressure, migraine headaches, high degrees of nearsightedness or farsightedness, and normal aging. Glaucoma is the
leading cause of preventable blindness.
The two principal types of primary glaucoma are closedangle 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 increases, 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 dosedangle 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 accounts 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 acconunoda tion 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 aql1"ol1~ 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 outflow is totally closed, dosed-angle glaucoma constitutes an
emergency. Laser or conventional surgery is indicated for
this condition. Options include iridectomy, laser trabeculopLasty, 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 intraocular pressure developing over years. It is called "open anRle"because the iris does not cover the trabecular meshwork;

CIIoptor49 ON9!10I E)'und Ear Olsorder!

PROSTAGLANDINS

PHARMFACTS
Glaucoma

WOrlclwi.lIlCe lII'n 5mi50n ptopIt IIiIII! lost lhervision"" ID

gIaucomi.~ tNn 50,000 oftlltse people Ut in Iht Uniled StiffS.
0"" SO'Kof the peofIle withgIMO!I\i m ,~~ tlut they
thr

.....

"'W

Thf irKidHKr of glMlHN in people of A~ h~is tk~ ID fiw

timts higbrrtlwn in ,,,,otlltl" ttbnic 910'"
GIiulIHN is most 0Hnm0n in JNtienboldertil160yuli..
.o\nnglauronw isollrnUlMd byhNd triMlllli.UW~,tUIIIQIS,or

"""'-

Chronic simple gIIuu!nw ~covnt:s 1or9O'ilo of ~ gl.il.l((llll,l gosH.

it remairuopen.lf discovered ea rly, most patients wi th openangle glaucoma can be succtsSfuUytreated with medications.

49.3 General Principles of Glaucoma

Pharmacotherapy
Some health care providers initiate gla ucoma pharmacotherapy in aU patients with an 10)"1 greatcr than 21 mmHg. Because
of the expense of pharmacothero py nnd the potential for adverse drug effects, other health ClIre providers will instead carefully monitor the patient th ro ugh regubr follow- up e.'UlI11S
and wait until the lOP rises to 28 to 30 mmHg before initiatingdrug therapy. [f signs of optic nerve d amage or visual field
changes are evident, the patient is t rea ted regardless of the TO P.
When beginning glaucoma pharmacotherapy, a target
TOP is established. Durin g therapy, revaluation of the TOP
and the exten t of visual field changes is performed after 2 to
4 months to chKk for th er.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 medication, it is common 10 add a se<:ond drug ftom a differen t
class to the regimen to produce an additive drtase in lO P.
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: increasin g the o utl1ow 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 n ervous system (chapter 1300 ).

49.4 Antiglaucoma Drugs

There are many drugs available to treat gbuco ma. Although
topical drugs are most frequently prescribed, oral medications are available for severe disease. Drugs fo r glaucoma,
listed in Table 49.1 , include the following classes:
Prostaglandins
Autonomic age nts, including beta-adrenergic blockers,
nonselective sympa thomimetics, alpha1-adrenergic
a~mists, and cholinergic agonists
Carbonic anhydnlse inhibitors
Osmotic diuretics

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769

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 Iongdurationso f :action and prodoce fewer adverse effects than drugs from
other classes. They m ay be used as m oootherapy or combined with beta -adrene rgic blockers to "roduce an additive
reduction in lOP in pdtienls with resistant glallCOm a.
Prostaglandin analogs decrease lO P by enhandng the
oull1ow of aqueous humo r. Latanoprost (Xalat.;ln) , available
as an eye drop solution , is o ne of the most frequently pre_
scribed prost.;lglandin analogs and is a prototype drug in
this ch apt .. r. Several other ocular prostaglandins have been
approved, including bimato prost ( Lumigan ), travaprost
(Travatan), and UllOprostone (Rescula ). An CKClsional adverst' effKt of these medications is heightened pigmentation, which turn s a blue iris to a more brown oolor. This
change may be irreversible. Many patients experience
thicker and longer eyelailies. These drugs cause local irritation,slinging of the eyes, and redness during thefirst month
of therapy. BKause of th ese effects, prostaglandins are normally administered just before bedtime.

Autonomic Drugs
Several structures within the eye receive signals from the
sympathetic and parasympathet ic divisions of the 3utonomic nervous system. As suc h,a significant number of au_
tonomicagents have been used to trea t 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 glaucom a. These d rugs act by decreasing the prodoction of aqueous hu mor by the ciliary
body, and can lower lOP by 20% to 30%. Beta-adrenergic
blockers generally produ ce fewe r ocular adverse effocts than
other autonomic drugs. In most pa tients, the topiCllJ administ ration of beta blockers does not result in significan t 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.
AlP~A. _ADR~N~RGIC

AGONISTS Al[">h ~ ,_Ad'f'"nf'"rsir Asn-

nists act by dreasing th e producti on of aqueous humor.

Only two alpha,-adrenergic ago ni sts are currently ap_
proved for open-angle glaucoma, and neither of th em 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 muco SOlI membranes, blurred vision, and
irritated eyelids.
CHOLINERGIC AGONtSTS Qwlinergic agonists are autonomic drugs that act ivate cholinergic receptors in the eye

770

UnII'

TABLE 49.1

The InteqJ~tarySY'tem ar.d EY""Em

Selected Drugs for Glaucoma

Route and Adult Dose (max dow where Indicated)

Drug

Adwrse Effects

IrvmW /engrII mdlhidnrulXtytlolhtl,. dorkmmglX

PROSTAGLANDIN ANALOGS

bimatopmt (lIIIligan)
Q)

litanop""1 (XIliun)

tral'(ljlfOll(T!a\'llan)

1dropofo.o391> 5durim da~y in lilt fflIlilg

1dropofO.OOS% >oIurion ddy in lho: ~ffililg
1dropofO.00491> 5durion da~y in lilt fflIlilg

M~ lfIIS4rionoffoflliQII ~ in rhtfl'!

XOouI idvt!}C dftm lhat may Q![ with systtmic:

abso!p!ioo;~pira!o!y inlt<tionlflu ~ogin~, muscle or
~

BETA-ADRENERGIC BLOC KERS

betaxolol (BtI~ic:)

ItIWunoIoI (Brogan)

mtlipranolol (OptiPranolol)
Q

~moIoi ~~mol,llI.lIoI, Tmoptic:)

1dropof0591> >oIurion bid

1-1 drops 01 O.15-{1591> Kllution 0IIt to 1'IIOllirltslday
1dropof0J9I> 5durion bid
1- 1drops 01 0.2'-{l5 91> Kllutoo 0IIt to t'llOllirltslday
Gd (~):aw1Y daily

ALPHA,.AORENERGIC AGONISTS

apradonidiM (lDpidilll')
brimonidilll'lAlph'gan)

1dropofO.5% 5durion bid

1dropofOl% 5durion lid

local i/rhilg 000 bumif"4 blimrd "lion, dry mouth

" Ii

",_.

CARBONIC ANHYDRASE INHIBITORS

a(eQzoLimidt(Diamoxj
brinrolamidt (Azopt)
dorzoLimidt (T!IIIOpI)

md harolamidt (NepI.WIt)

For ropKol ~gmII; b/urrtd IiWn.. birm rOile, dry t)f,

PO; 250 mg OIItto ku timwday

1dropof1% 5durion lid

bltphon"ri~ /0(0/ irdiilg. 5eJuoOOi IX fr.nign body n

1dropof 2% 5durion in affecl~ ~s) tid

PO; 5(1.-100 mg bid-tid

1M

&r QIiII roult:diU!t!il.tkro!m imbilarm ijood

dnlmia:!, fta(od p.!ra!ysis.lltpa~(impiirmml

CHOLINERG IC AGONISTS

Glrbidlol (Mioltatj
M:lthiophit~

iodidt (Phospholin~

1- 2drops 010.75- 3% Kllution in ~ (onjuoai'lill !a( MIl

4htid
1dropofO.03-0lWo 5dution 0111'10 twotillll'S/day

lodidt)

IrIdurrd ~ rtdIJmJri5ua/aruiryinlowlighl, l)'t

mlfItS~ lleadache

XOouI idymc dftm IIIaI INY OIIwith systtmit

abso!p!ioo:sa!i"la~on,tadr1Yrdia,hyDWmSion.

piloGlfpin~ (lIopIo Cirpilll'. PilopiIII')

...(U\~ ~lKom.J:

1drop of 1- 1% Kllutim fflI} 5-10 min for

I:tonmowalm IWr-a1i!l!l n~u~a

"IOm~i!IQ

3-1i OOstS

(hJorlkgla\KOllla: 1drop 010.5-4% solution Mr,4-12 h

NONSELECTIVE SYMPATHOMIMETICS

dipivefrin IKI (Propiflt)

1dropofO.l% 5durion bid

loco/ oomil9 Qoollingif"4 /IIurrtd "lion, IIeodQdiI,

p/rJIOSfMifiriry
Ychl'OOii,!lI'tIwnlioo

OSMOTIC DIURETICS

iIosoJbidt (kmotic}

PO; 1- ] g.1cg 0IIt to two tillltliday

mam~oI (O!m~roI)

IV: 15-2 m9as a 15- 25% 5dution o~r 30-60 min

OrtirOltoti( ilypott11lim, flrdol fluIhing, iItododlf,

paltilori/1m. ~rWery,_

Xvm !\rididi!:, dl!'Olytt imbalarm tdema

IrajcrindiGll~

(ommon advMo! df~m;~indiGltH!ftiouI ~tfftm.

and produce miosis, constriction of thi' pupil, and contraction of the ciliary muscle. These actions physically pull open
the trabecular meshwork to allow gri'ati'r outflow of aqueous humor and a lowering of lOP. The cholini'rgic agonists
are applied topically to the eye. Pilocarpine (IsoptoCarpine, Pilopine) is the most commonly prescribed
cholinergic agonist. Mversi' effects include headache, induced myopia, and decreased vision in low light. Because of

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their greati'r toxicity and more frequent dosing requirements, cholinergic agonists are normally used only in patients with open-angle glaucoma who do not respond to
other agents.
NONSELECTIVE SYMPATHOMI METICS Nonselective sympatho-

mimetics activati' thi' sympathetic nervous system to produce mydriasis (pupil dilation ), which increases the outflow of

C/up!fr49 ON9' lor E)'" .00 Ear Disorder,

II~ Prototype Drug

771

I Latanoprost (Xalatan)

Therapeutic (lass: Antialauroma drua

Pharmacologic (lass: Prostaalandin analoa

ACTIONS AND USES

lataooplOSt is a prostaglandin analog thllt I'I'~ lOP by ilKrta ~ng tilt ootflow of aqu~us humoc It is lMd to Ut al open~nglt glau(oma. TIlt rommtndtd doN i, Olll' drop in tilt <lfffited 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 ~r
15minutts.
lII'oid touc:hing tilt ~ or ~1a5hts with any jlan of tilt tytdropper to
,,'Oid clOSHontamination.

Wait 5 minutt s btfowalttr instillation of <I diffeft'nt ~ plfScription to

admini5ter t yedrop(l).
Pll'gn<lnquttgoryC

ADVERSE EFFECTS
AdYerst tfFeru indudt orul.r symptoms wc:h <IS con;.JIIctiYal tdt rna, tearing,
drynffi, burning, pain, inila!ion, iuhing, ~nsation of Ioft'ign body in ~ pliotophobg, andlor visuil disturNmf5. TIlt l)'tlashes on tht trtaltd fYf may
grow th~ and da~r. Changrs may O((llr in pigmtnUtion of tilt iris of tilt
tft'attd ~ ,nd in tht ptriocular \kin.
Contraindication!: Contraindiutions ilKkide hype~nsitivity 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 dostd-anglt
glalKorna.
INTERACTIONS
Dnq-Drug: Lmnop-OII inlfroKU with tilt P-Nf"Iati'll' thirnProla~ II UIfd
(ooumn!ly with 0IIti e)'f.tops (oouiling thilllfllM, PfKipiUtion may Q(OI".
liIb Ti5IS: Unknown
HerlIiJVFood: Unknown

PHAR MACOKINETICS
Onstt3-4 h

TlNtmt nt of Imrdose: Ow-rdosr with ophthalmic solution is unlilo:el)o.

~ilk:8-12h

III' ftf I!I M)M!rslrlg/f1l for Q NwI"9 I'n:>:m fOOI5!pf(1k I!I rIr/s ~

Hilflire: 17 min
Duration:Unknown

.... 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 ophthalmic Ionnulations. 8etimol and Timoptic art 0.15% or 0.5% ophthllimic sokllions taun !Wict dail)'. TimoptK XE i nd Inalol aft' Ioog-ting solutions that
allow for olKr daily dosing. Timolollowers KIPin 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
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 inlan:tian,and migraillf5.

ADVERSE EFFECTS
Tht mon commonadvr~ tflem art 001 burning and ninging on innillation.
Y"rsion mi~ 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 ((IrI'I'ctl)'.11 absorption [l(all!, hypott nsion or dysrhythmgsart possiblt.
Contraindications: Timalol is rontraindicated in patirfm with asthma, Sr'ltll'
chronic obslruct~ pulmona!)' distasr, sinus brad)'Cardi., !e(ond- or thirddtgrtt atrioYl'ntrirular block, hurt lailurt, cardiogeoic !hock,or hyptrsrnsitiYi!)'totlltdrug.

ADMINISTRATION ALERTS
Proprr administration Its~ns thr dangrr that the drug will be absorbrd
SYSlI'micall~. Systrmil: absorption u n mollk symptoms of hypog1yc:tmg.
Pll'gnanquttgoryC

Drug Drug: Drug inlln<tions may 1M" if lignffia,u syu.mi< absorption 01"' .
fmolollhoWd brused with (;1M in ~lItakinllllhfr brIa bIockM ~to
odditWf cardoK fffI>m. (mURalt U\I! with anticho1i1frgicl, niUitrs, rNrpilf,
1MhyIdopa, III wrap.!llil (OUd Iud 10 h)"potmlioo and brad)Uf(ia. pinPJhft

to.

LNTERACTIONS

U\I!(<UdlNdtoh)1lff!Mlionfolowi>dlrf_~ia.

PHARMACOKINETICS
Onstt30 min
Prak: 1- 2 h
Halllilf: Unknown
Duration: 12- 24 h

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liIbTi5Is:Unmown
HerlIiJVFood: Unknown

Trmmfnt of Imrdos~: OY!'rdosr with ophthalmic solution is unlil<el)'.

Sir IWtr 111 My/UsJnqKI for ~ MnIng 1'rt5.! fo:uI sp/It 1II1M Itr!g.

772

UnII'

The IntegumeotorySYltem arod Ey<>"rEars

NURSING PROCESS FOCUS

PATIENTS RECEIVING OPHTHALMIC SOLUTIONS FOR GLAUCOMA

Assessment

Potentilll Nursing Diagnoses

BUfline assessmrnt prior to administration:

Understand the ~JlOn the drug his been prtnriilfd in order to as~ for
thor~pwtic dftm k'l.,op"n ~n91< or dosI.nglo, =or.d.1!)' 10<")'0
trauma).
Dbtain a complete health hillol)' indudi ng ophthalmologic. ~spiratol)'.
caidio'lalwlar, and f ndouill!' disN~.
AlSfIS viSUilI acuity and vi5ualfields. AsltIslor the p~nce of ~ !XIin,
yilwl disturbaIK~ 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 allel9i~, wmm prl'llription and OK drug~
herbal preparations,akohol USI', and smokillCj. Be alen to possible drug
imt ractioM.
Db"in baltline vital signs.

rAsturbed ~nlO!)' Ptl(t ption (Vilwn

AnIitt)o (,.,lat<d to """am. of los. ofy;';"n,.,.. pain)
Pain (di~a;r condition, tll'iltment adYl'lSt efftm)
Delicirm Knowl~dge (drug th~IlIPl')
Risk for In~!)' (~lated to 'liwal acuity derICits)
Defi<itnt Self.u~ Ability (relat.d to impaired vision)

Assessment throughout administration:

AlSfIS lor dtsirft! therapt'utic rfft<:u dependent 00 the ~ason thedrug is
givtn (f.g, intraoorlar pre SW~ remains below 20 mm Hg or it target value,
improvemffit in yilual Jruity or fields).
Allffi for ~ tflrm;(onjuncti'f<ll edemt, tNrinidryoo~ burning,.
p-ain,irritation, itchini srm.uion oflo~ign body in e~,or photophobia.
s.~~ visual disturba""H or.~ pain "'auld be promptly rt'pOn.d to tho
heakh ca~ ptO'Iider.
Plllnning: Patient Goals lind Expecte d Outcomes

The pat~t will:

UpeMIK' therapeutic tfftas (f.g,f)'f plfSsu~ his normal~ vimlawity.nd vilwl fitlds rem.in st.ble).
8. 1m from. or txptrience minimal. .dvers. tflrcts.
VerlJalino an understandin 9 of the drug's u~, .Jdo.m. tflrm, and fftlui~d prtautions.
Demonstrall' proper self-administration ofthr medication (f.g.,d~ timing. when to notify provided.
Implementlltion
Inte rve ntion s li nd (Riltionilles)

Ensuring thfriptutic tffects:

Monitor yilwl acuity, vision lieId~and imraoarl~r .~ presu~. (E)'f
presu~should ~m.in Itss than 20 mmHg or pt'I" paramttrn Id by heakh
(j~ proyider. Vilual .Jwity and fields ~main int.ct)
Minimizing .Jdft rst rffKtli:
Monitor ~ppropriatt administration of dlll9 to noid rxtraoorlu tflrCI5.
(E)'fdrops should be instil1ft! into the conjunctivall.Jc.nd tht lacrimal duct
a~a htld with gentit prtSSU~ for 1fun minuteto prtl'tnt dllHJ lu~ into
the nalOphi!),nx with poI-Sibit s~lfmic rfiKII.j

Patient li nd Fllmily Education

lnstMt the patient to immediarel-; II'pln changrs in vision, f)'f pain,

light -Itnsitivity,hilos .round lights, or head,uM to tho hkh ca~
provider.
Trac:h the patient plOpt'l" administration tt<:hn~s for e~ drops. Oral
flll'dicatioM should be t1ken as regularly throughout the day.s possible
and with (Oosistent dosing.

Monitor intraoc:ular presu~ period"KaIIy.(Consisttnt ~adinqs .baft thf

Lll9ft value molY indicalf wofll'ning dMu. or improperuSl' of drug
thera)))'.)

InstMt the patient of the imponaIKf to ~tum for and maintain regular

Monitor for inclUSing eye mfllfl~pain,light sfllsitMty, or dlilngtS in

visual .Jwity. (Ey. (haOljfl or pain may indicalf wofll'ning dis .. ~
inft<:tion,or acIft~dl\J9 eff.as.)

InstMt the patient to .Jwid IOIKhing the f)'f drop tip to the conjunctiYal
sac: when instilling f)'f drops.lmmedi~1I'I)o II'pln any iIK~asing ~n.s~
')'f p-a in, r~ drainaljf, or (hJ ngtS in yision.

Remol't contact itnltl btfo~ administf ring ophthalmic solutions.(Cornact

lense may hinder the f)" solution from fully ~ac:hing all t)'f surface or
may absorb solution, rrsuhing in higher than e'Xpt<:1I'If amounu in ~0'/eI"
tiflll'.)

InstMt the patitnt to renJa<. (001.1(\ itnlfS priorto administering e'$'

drops .J nd wait at least 15 minut~ beloit ~insening thmt.

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')'f.xam~

C/up!fl49 DN9' lor E)'" .00 Ea. D""rde"

NURSING PROCESS FOCUS

773

PATIENTS RECEIVING OPHTHALMIC SOLUTIONS FORGLAUCOMA /Conflnu~!

Implementation

Inte rvention s and (Rati o nale s)

Patient and Family Education

Monitar viul ~n' ptriodiully lar ~gns al systemic: allsorption 01 topical

~rations. (Ophthalmic: drugs SIKh u betJ bkKkersor(holinergic: drugs
may r=k in hyp:ll~nsion Of bradyardia il tilt drug is absorbed
systemic:ally. ERlUIt' the patient isadministering drops appropriately if
changtS in blood pr!"SlUrt 'R' noted.)

Tt,{h tht j)<ItNont to rttum ta the htalth cart prOYider ptriodically lar
rronitoring. As~1 blood PIffiUR'OllCt ptf week and repln any aoo
bs than 90/60 mmHg or ptr paramtt~rs. ImmNi,J!~1y R'port '11)'
diuines~ headache, palpimion~orlyncope.

Providt lar f)'~ comlan IlKh aI ,rieqwtely lightN room.(Ophthalmic: drugs

SIKh I. brtl bIocktrs!Md in th~ lJ. .t..... mofgtlucOlllO <In <lU'" mio.i>
and diffKUky Iffing in low light ItvrkJ

Caution tht palNont about driYing or other activities in low-light conditions

0.11 night untit th 1Iff" of tho drug 1ft known.

Monitar adhmnct to the tR'atm~nt R'9i ..... n. (Nonadhertnc~ may rf"IUh in

tilt totalioss of visionJ

Tt.ch tht p.iltNont 01 the imporunct in adlltring ta tht mtdication

Kht<iJ~ 's PIfI(ribf<i.
Addrffi i ny (onc~ffI! tht patient may haw.' about mst and discomlan
rt latN to drug thmpy and providt appropriate R'~rals (t.g., social
II'IYic:t ,gtncy) aI I"ftded.

Patimt unMrstanding of drug therapy:

UII' opplnunities <iJring administration of mNic:.ilionsand <iJring
alll'lmltnll todimll5 tht rational~ for drug thtrapy, dtsiR'd thmpMic:
outcom~~ most (omrron adYerst t!fem, p,rameters for when to (all tilt
htillth caR' prOYider, ' nd any flt(tsury rronitaring Of precautions. (lking
time during nursing caR' IIeIps to optimi~and rti nfolU' kty t~"hing

Tht pariem should ~ a~ to statt tilt 1I'aI0Il for th~ drug.appropria~

doseand srnNuling.,nd what adw.'f'" rfl"tcts to ob!m'e for and wlltn ta
rtport them.

a",, ~)

Patimt selfadminilitntion of drug thfrilPY:

Wlltn administtfing tht medic:ation, instruct tht patient, famii)o,or
cartgm r in the proptr II'Ifadminimation 01 tht drug. t.g., appropria~
instillation 01 ~ drops. (Proper ,dministration inclNsI"I tht tifediYl'lltl5
ofthedrug.)

Tmh tht j)<ItNont totakt tilt drug following tilt guidtlillH provided bytht
htalth cart proYider.

Evaluation of Outcome Criteria

Evalua!~ tht ~lIfftiYeness of drug tlltra py by (onfirming tM

p..ItNont goa Is and txpKIN outcomtS h,w.' bten mtt (= Pianninif).

St<' TobIt 49. 1(llf ~ Ii5lIf ftu!p re whKh riel lUling ~aiom QPPIy.

aqueous humor, resulting in a lower lOP. Theyare not as effective 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 epinephrine in the~; thus, its Effects are identical to those of
epinephrine. If t'pint'phrine reaches the systemic circulation, it inneases blood pr~sure and heart ratt'. Be,ause of
tht' pott'ntial for systemic adverst' effects, these are rarely
prescribed for glaucoma.

Carbonic Anhydrase Inhibitors

Carbonic anhydrase inhibito rs (CAIs) may be administered
topically o r systemically to reduct' lOP in patients with
Up~JJ-~JJgl~ glau~uJJla. 11,,"Y ad \'y c.I"~H,asiJJK th" pruc.lu~
tion of aqueous humor.
CAls art' grouped into topical or oral formulations. Dorzolamide (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

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than photosensitivity. Oral formulations such as acetazolamide ( Diamox) are very effective at 10wt'Ting lOP, but are
rarely used because they produce more systemic adverse effects 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 lOP quickly, serwn electrolytes should be
monitored during treatment.

Osmotic Diuretics
Osmotic diuretics are occasionally used preoperatively and
pu,tup"nliivdy wilh u~ular sUfll"r y ur as ~JJlrIl~JJ~y tr~at
ment for acute closed-angle glaucoma attacks. Examples include isosorbide (lsmotic), urea, and mannitol (Osmitrol).
Becaust' they have the ability to quickly reduce plasma volume (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

77 4

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 examinations. 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 se~re blurred vision and loss of
near vision. The response to mydriatics and cycloplegics can
last 3 hours u p 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 lining of the eyelids. Topical corticosteroids and nonsteroidal
a"liinflamJllalury ~K"I1ls (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 decrease the redness and itching associated with allergic con
junctivitis. Topical mast cell stabilizers, with or without an
antihistamine, are the preferred treatment for allergic conjunctivitis because they do not cause excessi~ drying of the
eyes. Two more recent drugs, olopatadine (Patanol) and
pemirolast (Alamast ), provide for daily dosed treatments
for allergic conjunctivitis. Azelastine (Optivar) and epinastine (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 maintenance 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)

MYDRIATICS: SYMPATHOMIMETICS
phtnMhint (M)'Ifrin,tIeo-S)"n~ntl
III let the Prototype Drug box 00 )

1 drop 2.5% or lC1l1l IOhnion briorr ~~ wm

(~paocj~

Adverse Effects

--

[ )It ~in, p/rorlMlHirifiry, f'yr irrifQrjo~,

!b:1!!!!~nIOO,IIl'~!b:!!I!!!tmial

CYCLDPLEGICS: ANrICHOUNERGICS
~lropilH' (lsoplO Alropil~OIiIt~) (~ pa~ 1
letJlw, Proiotype Drug box OQ )

1 dropofO.5%soIUlion mhday

cydopffitolatt (C)'dogyI, Ptntoliir)

1 dropof05-2% lOIution 40- 50 min ~fort "'ft t Um

[)It irrilalion 000 rtdnru, d,., mou!h,/orol

bumil9Ofni~ IIlIld~rM, bllJrrwI
ri~ p/lorrMmirWiry, KlIImo!oid
dermoritiJ (llopo/aninf ~OO U!J!icanidej

homarropilH' (Isopoo Homatropint, olhm)

1- 2dropsof 191, or S% IdUlOO btfOll' f!"It. wm

lCopobmilr hydrobromidt ~IopIO HyoICilH'j

1- 2dropsof0.25% lOIution 1 h briort t'jt tUm

mtn!!l( d!t!lQl:~ Wan~i!llru~

tropicamidt (M)'dciacy~ Tropi<acyl)

1- 2dropsof05- 1% soknOO btfOll' f!"It. ~um

inlr.JO(W[ PR$llR /homalrwiod

5gmngltnct t.ubWa (DQYu!sioos.

LUBRICANTS ANO VASOCONSTRICTORS

lioolinakohol (OOiIhbtj

Awly athinfilm IOlilt ~ofJlw,f!"lt.lid

flH'lh,!ll'luw (Melh~. V"1II:WIr.OIi1tfll

l- 1drOPlprD

naphilolint (Alhalon, Altrts!, O""~ olhm)

1- 3dropsofO.l %lOIution t'mY 3-4 h pm

QX)T11eQmlinc (O(l!(IN~ Visinc LR)

1-1 drops of 0.025 9(, !OIution qid

poIy'Ii"ll akohol (Liquifilm, OIhtrsl

1- 2dropsprn

ttl~dlW.Olilr (Collyrium, Murint Plu~

1-1 drops of 0.05 %solution bid- tid

Vi~nt,olhm)

Ildb iod~ttCOCllrron ~tfftm;.IIII1aIiliDg.iod~tts Itrioui advtrl>! dltm.

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Ttrnparary oomiflg or lmging, f'yr irdiflg IJf

rtdE~ IIlIld~drt

t!o!(liou! idl'tl!(dltds

He lix - - - -.,
, - - ,~,.'o, "','." cenels (e quilibrium)

Anlihelix ---~

hc!-{ ?-' r-G" ". ot the vestibule , ne,ve

Ca,lilege ---~C-~-

Concha (bowl)

. .":~~T'~e;;:S~

------~

'J';..--. n . -f"-'--- Cochlaa

Stapes (stirrup)
(hearing)

Exte,nal acoustie ___ _ _ __ _ _ _0

meatus

"",+,;-_" Vestibule

Mastoid process -----,~_'T

L -'\;__

Lobe ----,~

Tympanic

L ___ Eustec hian 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

CO~PLEMENTARY AND ALTERNATIVE THERAPIES

Ophthalmic Drugs in the Home Setting

BilbQrry for Eye Health

In modem Amrriun QJku~, oldtr adults ilia)' lift alo~ or with other rldtrty
family 01 friends. Th~ 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. Hrffied. ~ INsonabir i krmati~ wm as ~p from a
neigh bar, family mrm iII'~ or (')l!giYt r.
T~.Kh ing is critiu Ifor j:OIitiYt OUKOmrs in this POpIJlation. ~ oIdrr adJk
nHCk to uncWrsund th.t lOIKhing 01 rubbing the f'jf un ~k in infedion or
damal}!' to the f'jf. BeraUSf vision may al~idy bt (ompromiSfd, the older
aduk ilia)' rxpffltn~ bkJIIN vision that shoold dear in a lNIonabir timr iftt 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 ilK~astd risk for falls. A~ssthe
homr and IIIiIkt suggrstims 10 improll!' safety. Ca~ should ill' taktn to label
f)'r mrdiutionsto indicatl whic:h is fo, the Itft t)'~ and whic:h is for the right
~r. xht<kJling mrd ic:ations '!!Iund a muti~ SIKh as mr.1s, ako ilia)' hrlp the
oldtr adJk Il'ml'IlIbtr to t.Jkt tht ophthalmi( mrdic.tions as Pll'l(ribed, in(~olIing nKesary rompiianU' fo, hraling.
PNiatric: ~titnts aR' ala tft'atN at homr for ~r disordtrs. Cal!gill!'rs in
thr homr aR' rrsponsiblr :Or administrating and rnsuring thr patiem's (omplialKf with thr drug thrllpy. Thr limr mministration in!lructions apply to
both geriatric: and pedialrK populatiorlS.Caution against IOIKhing and rubbing
thr ~.In 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.

Bilbtrry (Voccinium myrtiHlIl), a pint whOl~ lravfS and fruit a~ UIfd m~dic:
ilal)", i; foondin(flltralaoo nonhtm ~Asi.J,and NonhAmtria.lthis btrn
5hown in dilic:al slIKits to iKft'il1t ronj.JfJ:tival (apillary ~tancr 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.nab~~ing rfffl:lln(ll'astd synthf"lis of (onnmlve tilW!' lilKluding (ollagrn) it O~ of
thr (ontriooting factors that ilia)' Irad to blindne-s5 (aUlfd by tiabttic
'rtino~thy. Silbtrry has also ~n 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

& COMMUrllTY CONSIDERATIONS

---- - - -------

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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.
z

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, inflammation of the middle ear, is most often associa ted with upper

"

776

UnII' The IntequmeotorySyslem arid Ey<>o;,IEars

TABLE 49.3 1 Otic Preparations

ON,
j(~ic:

,J(id and Ilydroo:ortisoM (VoSollK)

Route and Adult Dose (max dose where Indicated)

AdwlW Effects

3- 5 drops ~1tI)' 4 h qid for 24 h, 111m 5 drops tid- qid

fGrirririon.lrxQlllir19ing fI(
blmirrg. diIIintlJ

lKruociilll' and anlipyrilll' lAuraigan)

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.

dprofloxadn and dr:Jl.imelha5Olll' ICiproDu)

Childrtn to aduk:4 drops in affffied ~I bid for7 days

dprofloxadn and hyd rororti5Olll' (Cipro)

lltops oflht IUIptnSion inltiled ilto m bid for 7days

poIyfll)'lin 8, lII'OIIlydn, and hydroc:ortisolll' lCortisporin)

4ltops irlNrlid-"d

Ala

tuctiom (wibiolja\

Iralio indjyl~ (OOlmon ~ ~ffffis; Lnde~ini!IQ indjyle smomadvme trfffiS.

RM alsolo dlapltr 3 'Pril~ of Drug AdminiSlration,"forproptr ad"ninistra!ion tffiln~ for ur!tops 00.

respiratory infections, allergies, or auditory tube irritltion.

Of aU ear infections, the most difficult ones to treat are innerear 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 systemic 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 combined with antibiotics or other drugs when inflammation is
present. Examples of these drugs are listed in Table 49.3.
Acetaminophen or NSAIDssuch as ibuprofen are used to relieve pain and reduce fever.
Mastoiditis is frequently the result of chronic or recurring
bacterial otitis media. The infection moves into the bone

and surrounding structures of the middle ear. The treatment of acute mastoiditis involves aggressive antibiotic
therapy. Intravenous gentamkin or ticarcillin may be used
initially; thenlpy may be adjusted once culture and sensitivity results are obtained. Therapy is continued for at least 14
days. If the antibiotics are not effective and syntptoms persist, surgery such as mastoidectomy or meatoplasty may be
indicated.
Cerwnen (ear wax) softeners are also used for proper ear
health. \.\'hen cerumen accumulate.., it narrow~ 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.

Chapter REVIEW
KEY CONCEPTS
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 understanding 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.

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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, carbonic anhydrase inhibitors, nonselective sympathominlt'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 earwax buildup.

Chopllr49 ON9' lor Ey<' ~nd Ea, 0"",<1<>"

777

NCLEX-RN" REVIEW QUESTIONS

A patient with a history of glaucoma who has been taking

II

The patient is pres.:ribed timolol {Tintoptic} for treatment of glaucoma. The nuTSl' assesses for which of the following 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 therapeutic 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

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

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 teachingplan1
1. HYJX'rtfnsion
2. Loss of lashes
3. Dilation of pupils

4. Brown pigmentation of treated eye

Beta-ad renergic 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.

'Y'.
4. leavtngcontact lenses In to be sure the eyedrop Is
maintained in the eye.

The nurse emphasizes to the patieDi with glaucoma the

importance of notifying the health care provider performing 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 ~stethoscope." 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?

3. To determine a patient's ability to administer glaucoma

medications. the nurse asks the 82 -year-old mlman to instill 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

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reooolCOlS. I'f~ 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 ~ideos. ;lOO morel
Regllller 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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Appendix A
ISMP'S LIST OF HIGHALERT MEDICATIONS
High-alert media.tions are drugs thaI bear a hrightened risk
of causing significant palient harm when they are used in
error. Although mis takes 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 lis t
to determine which medicatiOI15 require special safeguards
to reduce the risk of errors. This !my intlude stl'1llegies like
improving access to infonmtioo abou t 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 employing redwxlancies such as autolruUed or independent
double-checks when necessary. (NOll': manual independent
double-checks 3Tt nOI always the optimal error-reduction
strategy 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 agen ts (anticoagulants), including warfa rin,
low.molecular.weight hepari n: IV unfractio nated he
parin, Factor Xa inhibitors (fondaparinux),direct thrombin inhibitors (e.g., arg;lIroban, iepirudin, bivaJirooin),
th rombolytia (e.g., aJ leplase, reteplase, tenectcplase),
and glycoprotein IIbIIIIa inhibitors (e.g., eptifibatide)
cardioplegk w1 utions
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 liquid concentr.ues, immediate and 5usbined-release formulations)

LibraryPirate

"

,.

".

":~

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
me thotrexate: 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 (excluding pour bottles) in containers of 100 mL or more

Background
Based on error Il.'pOrts submilted 10 the USP ISMP Medicatio n Errors Reporting Program, reportsofharmful errors in
the literature, and in put froln practitioners and safety experlS, ISMP created and periodically updates a list of poten
tial high-altrt medications. During ~ebruary-April 2007,
no praclitioners responded to an ISMP survey designed to
identify which medications were m05t freq uently considered high.alert drugs by individuals and organizations. Further, 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 poItntial li.sl. This list of drugs and drug categories reflects the
collective thinki"8 of all who provided inpul.

tSM P~0Il. p.".... hoion io InIIltd 10 ~roduu .... 1fti.aI1or

inte. nal ncwde'\tn or a>mtR,.nk;n;on. with propr. Imibu,ion, OlhfT
~"""-'<tion 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
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.
s..trtC

, Appendix B
TOP 100 DRUGS RANKED BY NUMBER OF PRESCRIPTIONS
Top 100
Rank Generic Drugs

,...

..,.,.
,.

I.,do

' D. w/APAP

SI.
52.
53.
S4.
55 .
56.
57.
SolI .

litinop<il

.un.......,.
......,....~

.mo:clcill.in

.:cltbromycin

.... ........

hydrocblorothiuido
.Ip......u.m

dinycydine
tlriooprodol

.lIopouin<>l
m<lhy!prl"is<JIon. ..,,,

moloxlc.,.,
omlDdipif>f/bmaupri1
potuIoium cillo,;""

clonidine

59.

prt>m<th.zm.. ..1>0

W.

ioooorb;& ....,"""il .....~

,I.
62.
63 .

folic tcid
opin>nobctono
&Iimcp'rido

6<1.

pan!<>prU01<

om<pruol.

&5.

~uridt

....pidmJ ",rtnk
o:<ya>dono w/APAP
ibuprohn
prlnioonr oral

".

_"""m~SR
.... ' .... Inobuliuroolution
tridi<!ni,

"-

ft~

n.

~""'"
c:q>hakxin

70.
11.

H.
U.

...
".,.
".
...
H.

".

D.

,..
D.

JDftformin
metoprolol .lKcinato
furo .. mi"'onl
metoprolol tan ....
_ofu.

67.
611 .
69.

.....,...,

_....

b......pril
d..
cJinchmycin .,.mmJc
ramlpri
IMlronidaJOielaN

dulopnm

D.

p bopattin
cipl<>floucin
p~ ... w/APAP
lisiaoprillHCTZ

78.
79.

U.

...
~.

".
".D.
~.

,.
D.

n.
~.
~.

"'.
...
u.

n.

trbmto~CTZ

kmfftladi_

86.
87.
sa.
89.

<Idof""""
grmlibroril
p"'J'rlDOld HQ
vitamia D
quinapril

promed>.>:in</<O<Irino

91.
9<1.

.qd",jr

~.

.mitriptyli_

9';,

m.wzm..

"~

96.
97.
941.

.
fi.

>0.

ft,,,,,,,,,,,,
tnabpri1
<.....dilol
roni. idin.

Syntluoid
Pr~cid

A<lvair !)i,k..

-"
_
.
.
U.

VytOfin

..

Pro-AirHFA

64.

"'.,,",

65.
66.
67.

fulymagma PLaln

6&

Evi
AodoJ:

E/kmrXR

".
"
". ,
,.". "-D.

n.

,.
D.

rno...nHCT
Lcnquin

~
"'"
.""

n.
74.

Vi.J1'

.,...

9'}.

100.

Add.r:oll XR

v"m.

potassium chloride

nllrofutontoin

tulbmcthoumldt,imt1hop,im
f'.1II.nyI ,~01
bwpUoI><

Topamu

,~

,.n.

".

.,

u.
U

."".

,....

n.

N..o",",
Premarin_Tabs

D.

69.
70.
71.

CrIrb...

,." ""'.,
,.n. ,-

u.

pr....... in

.".

AbUlfr
V mln 2&
81>d<prioa XL
Ni."I'""

A.... pro

,_.

. m aminophenJ<Odtin<
lndron'l~

v.

Pmwntil HFA

55.
56.
57.
58.
59.
60.
61.
62.
n

o..nliI

H.

donzooi.
mUtaupi ...
&IipiDde ER
pbentr.mine

90.
91.
92.

.u..,....

Sf.

"".
" "'""
-
",." c"-.,.

8<1 .
85.

trim<thoprimlou\f.r.
!but....! Krosol

Slnguloir
PI ...ix

m ..odop<amXk

h)'d=rz;illf
.mphctamu. WI c:ombinalioa

~roIU.

51.
52.
53.

. . radioI .... '"

SJ.

Top 100
Rank Brand Name Drugs

Up;to
N..ium

l1li.

.mo:clcil~nJ davul.n.tt

p.an>n!tine
lon... tin

,.,...
,
,.
.

n.

cydobr=princ

R..ne_ ... IIR

w ..

-.

Rank Brand Name Drugs

dipJin

81.
82.

."'""'-

p"aiciD.in VK

""'""""
m<lformin HCl ER

D.

cl""'orpam

'""'uq>Om
.riamcinoiont aC1Ol<>nido. ropial

n.
71 .
7<1.
7S.
76.

,.

Top 100

Top 100

Rlink Generic Drugs

..

Amblm CR

Spiriu
Bonicu

""'m

CombiwDI

la mn';"

Bonin
TriNeosa
Nu.. Ring
Risperoal
Ro\oftlt HFA
[m~,"",onl

~rER

Pmtollix

Avalido
Liodtrm

15.
76.

Z1l'r<:U
N..-nd.
l\usiono::<

n.

Thyroid ...... mDII.

78.
79.
80.
81.
82.
83.
84.

Humaloc
Vipmo:<

85.

86.
87.
88.
89.

TomilI:u
Bl>d<prioll SR
Suboooo ....
Lano:lin

Loeotrin 2~ Fo
A...ian
Cownodin ,abo
Wtll>utrin Xl

Endotct
Sbluin

90.

N ..."". AQ

AcipHu

91.
92.
93.
0<
95.
96.
97.
98.

J:q>p ...
Allqro D II hr
SIr OlICl" '
.....
Avandi.
Octl[
Vynnoe
Toprol Xl.

~-.
lamkbl

99.

lrvitno

100.

A"din

BolliclrHCT
Ariorpt
Onho Tri .c,dtn La

..

.",.

Tri-Sprint

a ",

o.,c-m

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 2~, 2009.

.
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,

"-

Appendix C
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General R.f.rances
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LcMo~, P~ " Burkt, K. M. (2008). Akdir.'IlIJ~" nll";nt=Criliall
rII;t!k.m, III c/imu/JU (.lh N .). Uppc'f Sadd.k RiWt, NI : ~nlkf

1M
Mlrtln~

F. H. (2001 ). FII1IJalMnl#b o/lultlw"'....., .....,.Ilnd

pI!,llo1<lf1 (6th rd.). San Francisco, CA; Iknjamln Cummings.

MtdlOiI EoollOm a (Ed). ( 2004). P/ryJi<:illll'j dtlk rr/trtnct for /wbal

_diri"tJ (3rt! ni l. Mo nfYllle,NI: AaJ1hor.
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.. II,riri,,,,,,, iupplnMnfS. Montv41c. NI; Author.

Medkal Economics (Ed ). ( 20(6). Phr"'rillll ~ delk w/nt"u

(6(lth cd ). Montmc,NI: Aulbo~

MulvihlU, M. L~ hLmaIl, P~ Hokbw,y, P~ Tomp;1l'1, E., &:
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s.n

Chapter 1
Moort, T. J~ Coht:n, M. R.. r-urbr11o c. D. Q ..... rterWalCh 2008
quantr 2. Rc1rkvN from InMit ... te for s"ff Medication Pr.KIKC1I
wmsile: hnp;l/www.iomp.o.io..QlYrkrWalCh/20090I .pdf
Newton,G. 0 .. Pray, W.s.. &: PopnYk:h. N. G. (2001). Nrw OTC
dr\IP and ckvices 2000: It Kkcti~ mieW. "'~nW oj Iitt Amnirllll
PltanrtQMltiaIJ ~ 41 (2), 273-282.
Na. R. (2004). Dn<~ F..,." cIiscavrq "' 1IJIPI'f1"III. Hnboktn,NI: W'~.
o,.ta, j. A. ( 2006). 1b. Kknof dnl& thenPr. In L L DruolOll,
I. S. ~ Ie K. L PaM (Eds. ), GPordItNlII o-CoJlfII1,(, TM
phil~ k,;, oj.ltuaprutia (11th ed., pp. 117-136). Nno>
'fnrk. NY: M<:GrawHill.
OlKn, D. P. (2000). The p.1lient'1 rt'l)Qnsiblllty for optimum
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Chapter 2
Bond, c . It. , Raehl, C. L,Ie Fnnb-, T. (2001). Medication won in
United SI<ueshoopitab.. PMrmMVtNrIIp1, 21 (9 ), IOH-I036.
Br-. E. P. (200 I). Oru, therapy: Chan,IIllIM $I<U .... of drup from
prncriplion 10 ()\'ft'IMrounter Inibbility. Ntw EntI.IlflIoIl'tUJJ

of Medirbw..us, 81O-1Hi.
Brown, So 0 .. &: landry, F. I. (20(H ). Ro&nlzin" rtpOrIing. and
mlLICinc IWfwrvdrug roctions. SPllrllrm Itkdool/ /ottmal, 94(.).
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N~"'ltg Admilti,"lIrion, J6( I ) 34-41.

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GaitMr, C. It. Kirkina. O. M" AKiorot', F. J., Ie \\~at', L 5. (2001 ).

Consumen' vkwI on gflleric mcdicotionL }otmuU of'M Ammrarr
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PhiUips, " . It. , Vemstn, 0 . 1.., Oren, E ~ 1., 1. K., 8t s,,1"IIft, W.
(2001 ). ~cntlal role of pl\armalD8"nomics in reducing advme
drug reictlons: II &)'$IelNlic r~kw.}ou'~llloflkt AItNTkllll
MaJitlll AnItJ,i<ln, 286, 2270-2279.

Chapter]
Armilaat', G~ Ie Kn..plNn, H . (2OOJ). AdYCTK fnn\J In drut
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~,,". 11 ( 2), I30-I40.

Ikrman,A. I. SIt,.r, S., Kozier, 8., 8t Erb. G. (2008). I(ow 6- Erll,

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xal. R. (2000). How 10 promOltdtU(l compiillll;e in the eldtrly.

c......

Q,mmurrlry N~IY, 6( I), 4' .... 2.

Smith, 0.1 . (2001). T.lllt&control ofro"r mcdldnes. NewsicUtr
I( I). Q ""'mtr Hr.llir 1II/orrtl4rio" CorporiJriI1II. Iil'triewd from
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Smith. 5., ~n, D., 8t Manin, B. (2000). amkAl ltlln l.., M-i/b: /J&si('
10 /IJ... ncrrJ JUb (Sth td ). Uppn- Saddk Riva-, NJ: JOn,ntltt H.n

""hI>.

WOOI:m, J. ( 200I ). lbxic~klermal nrcroI)'liI. Nllru.., 2001 64( 10),

J5-l8.

Chapter 4
Bateman. D. N. (2001 ). Introd ... ction 10 plu.rntacokinclicJ ,nd
p~rmOKOdyn,mlc .. Jowmnl olTwlicology: Qinkal TQ\'irolotr.
JI'(3),207.
Bhlr.tlarml, V. B"Gtild'e, U, Kohlen,C., Vril. M., &: IXrrndorf, H .
(2002). ~Ia and ~bilil y oflxrbl.l mcdkln.ol
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Brunton. L. L , Luo. j. S~ 8< PaM, K. L (Ed .. ). ( 2006). Goodmatl cIGilman', 1M pftIIr~1tJ IwU oj rhtTnprutia ( lllh ed.). Nrw
'fort, NY: M((i...wHin.
8&aton, l L 0. (2006 ). PhlnlllUlkineti<::sand pharm.cod)'Mmkl:
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Good""." cl- Gilmn"j 1JIt PMtm/1ICoJogkal /HuiJ P{lkmlpru,/n
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ikrcoff. E. (2002). Puventabl~ and nonp",,,,,ntable risk factors for

ad,."""drug .-vrnts ",lat<d to hospital admission in tl>. dd~rly.
CIi"kal D"'8 IMW"ig<l'"'~' 22(6). 385--392.
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update part 3. Pharmacokin.tics: M ~tabolism and =r~tion.
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Ad,""", drug effee" in dd~rly prople - A disparity bc:tween
dinical """mination and adve"" dJ~cts ,..If-reporled by th~
pati~nt. Europe"" IOIl,.,.,,1 ofOmiml Pharm<>Cology. 63. 979--'.1SO.
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Chapter 5
ikrg. M. J. (2002. August 31-Septem],.,r 5). Do> H:X ",at",r! Pa",r
p"'s<nted at the Congress oft h~ 62nd [nt~rnational
Pharmaautkal Federation. Nk~, Frana. Mf<ISftlp~ Pharrr.aci>t5,
3(2).
Bottle .. K. ( 200I }.A remlution in 8'nrtk.: Changing medicine.
changingli...... Phy,ki"" &.>ru.i ..., 17. 5lki3.
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Th~ dynamics of drug absorption. distribulion. action. and
dimination.ln L L. Brunton. J. S.l.azo, & K. L Parker (Ed . ),
Goodma" 0- Gilman', The pharmacological basisofth"'''/><Iltic.
(lIth ed . pp. 1-40). !*wYork. NY: McGraw-Hill.
du Soukh. P. (2001).ln human therapy. i. the drug--drug interaclion
orth~ adver,.. drug r"'Clion the issu.1 eamuJ/an Jollrnal "f
Clinical Pha1"1tl<lro/ogy, 8, 153-161.
Ginwurg. G. 5. & McC.rthy.l. J. (2001). Per50naliud medicine:
R~",I"t;"ni7.;nE ~nlZ

<li.m",,'Y ~n~ p ....n. OI~. T",..J. ;"

BiOl"chrwlogy, 19. 491 -496.

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India: B. Jain.
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Kuo. G. M. (2(0 3). Pharmacodynamic basis of herbal rnlidn~.
Anr.als cfPh~rmaroth.rapy, 37(2). 308.
Ma. M. K. Woo, M./o... & McUod. H. l. (2002). Grn.tk ba.i.of
drug rn~taboli.m. America" lourM~1 of Heal.h-Sy,,,,,,, Phant'~CY.
59(21),2061 - 2069.
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A",i",icrobful pharmacodynamics iM .heory and cliMical practin.
New York, NY: Maral Dekker.
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J. S. Lazo. & K. L Parker (Eds.), GoodmaM o-GU",an, Th~
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York. NY: McGraw-Hill
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Pa.hology. 119(1 ).26-36.
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thrnoprotk drugs. Clinim Chimica Acln, 315, 137- 155.

St.im~r.

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Techtwlcgy Review. 72- 78.

Chapter 6
ikrman. A. J. Snyder. S. Kozier. B.,& Erb, G. (2008). Kozkr 0- Erb',
Mlnd"","M'''!. ofNllrsinS OmrPt5, f'rI:>a ... and Practia (8th ed.).
Upper Saddl~ Ri,."r. NJ: Prentia HaU.
DAmica. D. & Barbarilo, C. (2(07). H ... lth and physical a.,..ssrn ~nt
in nursing. Upptr Saddle RiY.r. NJ: Prentic. Hall.
Gardn~r. P. (2003).Nwrnns pro<:"" in ac,;""'. New York, NY:
Thompson Ddmar Learn ing.
HOj!)ID. M.A., Bowles,D . & "''hit~,J. E. (2003 ).Nu"ing
fimd~m""tal" Revitw' 6ratimtale,. Upprr Sadd.l~ Ri""r. NJ:
Pmllia HaU.
Jahrau .. D. Sokolo>ky. S. Th urston. N . & Guo. D. (2002).
EYaluation of an education program for pati~nts with br ..."
c.a","-", ,,,,,-,"wing rMlia'"m .h"",I'Y. r.anc...... /oI1l"i"/I. 24(4).

266-275.
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diagnow: DefinitwnsaMd c1a"ijka.im. 2003--2004. Philadelphia,
PA:Author.
Smith. S. E, Duell, D. J. & Martin. B. C. ( 2004). aiMical MU"mS'Wt.
(6th ai). Up",r Saddl~ Rh."r. NJ: P",mia Hall
Wilkin""n. J. M. (2005). Nursing di<lgrwsi, handbook: NIC
iM.e"""";"',, and NOCou.eomes (Sth ed.). Up",r Saddl~ Ri""r,
NJ: Pr~ntic< Hall
Wilkinson. J. M. (2007). Nllrsi~sproce.., and m.i",1 thinking (4th
~d.). Upper Saddl. Riv". N J: Puntice" Hall.

Chapter 7
Am~rican A.cad~my of

Pediatrics, Commin on Drugs. (200 1). The

lran.f" of drug. and other chemical. into human br~ast milk.
PrdiatriC!l, J. 776-782.
Andrade. S. E. Gurwitz. J. H . Unis. R. L. Chan. K./o... Finkelst. in.
J. A. FOllman. K . t al. (2004). Prescriplion drt18 us< in pregnancy.
Am~riCtm Jo"",al ofob.tetric. ~"d Gr"""Iogy. 191(2). 398-407.
Anwar. A. (2007). Prescribing in p"'gnancy and lactation: Factors to
consider. Nul'll< Pmcribing, 5(6). 245-249.
full.

J. w. . .." Rin<ll.".. R. r.. ( JilOl). Prdia.rit: nil";,,!!' r.arinS/nr

childr"". UpP"r Saddl~ River. NJ: P"'ntic< Hall.

ik . ... M. H . & ikrkow. R. (Eds.). ( 2000). The Muck manllal of
seriatric> (3rd I. ). Whit.hou,.. Station. NJ: Merck &
Company. Inc.
B",.sler, R., & Katz. M. ( 200J ). GeriD,ric pharmacology (2nd ~d.).
NtwYork. NY: McGraw-Hill Professional.
Briggs. G. G. (2002). DruS dfectson the fetwand breast -fed infant.
CliMical Obstetric, attd c,..,oecoIogy, 45(1 ). 6-21 . 170-171.
Hale. T. W. ( 2004). Maternal medication. during br~a str.Iing.
Clinical Obstetrksand Gyft""ol"8)', 47(3). 696-711.
Leipzig. R. M. (Ed.). (2003). D",spracribingforolderadul", AM
evidence-baud appmarh. Philadelphia. PA: American College of
Physicians.
Ol~n. C. G . Tindall. W. N . & da~n. M. E. (2007). Gt-rilllric
pharmacc'herapy: A 8"ide for .helulpins profe,,",nal. Washinglon.
oc: Am~rican Pharmacists A.sociation.
S",nc". J. P.,Gonzalez. L S. , IIl. & Barnhart, D. J. (2001).
MIications in th~ bmlst -fe<ding motl>.r.A",erkaM fumily
Phy,icum,64, 19-126.
U.S. Food and DrugMministration. D.partment of Health and
Human ~rvi=. (2005). R.oSl'/a.km, rrQwiriM8 manufacturers to

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"""'" th~ UIfoty and ~ffoctil'et1rs> of new dl'llS' ~nd bW/ogk~1

produCN in pediat'ic pati,nt>. ~trieved May I. 2008, from
hnp:llwww.fda . .iPv/<d~rI8uidance/pedrule .htm

Chapter 8
Andru" M. R., & Roth, M. T. (2002). Health literacy: A revi~.
Ph~,",~cl"herapy, 21(3), 282- 302.
Chen, J. (2002, Oc!ober 20-23). Th. rokoferhnidtyill m.dk:~rUm
U.IC. Papc:r presented at the Amcrkan College of Qink.iil
Pharmacy 2002 Annual Mting, Albuquerque, NM.
Davidhi1.3r, R. (2002). Strat~ies for pro\"iding culturaUy appropriate
pharmaceutical care to th~ Hi..,..nic patienL Hospital Phanna<y,
17(<;).

<;O'>-~lO_

Franconi, F., Brun eUe5Chi, S.,Steardo, L. & Cuomo, V. (2007).

Gendrr diff.",nce, in drug response,. Pharmaw/ogical R ..arch,
55(2),81--85.
Gallaghtr, R. M. (2002). The pain---tkpres,wn conundrum: Bridging
th.body~"d minJ. Mcdscapc clinical updale based on .... ion
presented at the 21 st Annual Scientific Meeting of th~ American
Pain Society. Retrie\"ed from hnp:l/www.mcdocapc.ooml
\"i~wprograml203O

Humma, L M., & T~rra, S. G. (2002). Pharmacogenetk. and

cardiovascular disease: Impact on drug n:sponse and applkation.
to di"""" management. American Jowrnal ofHealth-Sysum
Ph~rm~cy, 59(13), 1241 - 1252.
Kudmta, E. C. (2001). Cultural competence: Cardiovascular
medication . Frog"", in Catdiova.!rolilrNut:Sil1g, 16(4), 152- 160, 169.
Martin, L., Mirade,A. w., & Bonder, R R. (2001). Culture in clillical
carc. Thorom"" NI: Slad:.
Richardson, L G. C2(03). ~social i"""" in patients with congcsm'C
h<-an faUrne. Progmsi",Cardi"","",ulil, Nu"ing, I~I ) , 19-27.
Salimbene, S. (2005). Wh~t Iil"guag< docs yowr patirnthurt inl A
prat:tic~1 gui<h to ",ltu",11y rom/",trnt patino, e~rc (2nd ed.).
Anlhrrst, MA: Di''Cr.!ity Resources.
Simpson. R. J. (21)lS). Challenge.o; for improving mrokation
adherence. Jo..rn~1 of the American Mediall "",,ociarion, 196(21),
261 4-2616.
Sleath , B.. & Wallace. J. ( 2002). Providin~ pharmaCCllticaJ caR to
Spanish-speaking patient . Journal of rhe Amfrican Ph~'mac""irol
A.s.!ociario .... 42, 799-801.
Spector, R. E. (2004). Cul",,,,1 diversity in ht'tllrh and illn"" (6th cd.).
Upper Saddle River, NJ: Pr~ntke Hall.

Chapter 9
Bates, D. w., Clapp, M., Federico, E, Goldmann, D., Kamhal. R.,
l<rndrigan, C., & McKenna. K. J. (2001). Medication ~rrors and
adverse drug event. in pediatric inpati~nt . loum~1 of the
American Medical AJsod~twn, 285(16), 211 4-2120.
Berman.A. J., Snyd~r, S., Kozier, R, & Erb,G. (2008). Kczkr& FIb.
Fundamentals ofNut>in8 Conup .... p"",tsJ and Practice (8th ~d. ) .
Uppcr Saddle Ri,'Cr, NJ: Prentice Hall
Burn.,I. P., Mitchdl, C.,Griffith, J. l., & Trung, R. D. (2001). End-oflife ca", in th~ pediatric int~n.h.., ca",: Mtitudes and pnct ices of
pffiiatric critiml care physicians and nur.... Critical C.r~
Medicine. 19(3}. 658-664.
Comminee on Drugs and Commiu on Hospital Care. (2003 ).
P",vcntion of medication ~rrors in the pediatric inpatient .. uing.
PediaJrb, Ill, 431-436.
Fedrral DrugMm inistJ"3tion. {200 I, (ktober I). Mod error
"'pons to FDA show a mixed bag. Drug Topics. Rotri.,..d from
www.drugtopics.com
Ghaleb, M.1\., Bar ber, N .. FJ"3nklin, B. D., Ycuni',. V., Khaki,Z. E, &
Wong, I. (2006). Systematic r.vicwofmedication errors in
pffiiatric patients: Suggestion. to preyent mcdkation erran; in
chUdren. TheAn",," ofPh~rmaco,he",py, 40(10), 1766--1776.
Goldman, E. ( 2006, May I ). PDA- ba .. d drug dose calculator ,lashe5
NICU med rrro .... Family Practice News, 55.

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~rrors with rekrence to older adult . Nu"in8 S,andi",!. 20. 53--57.
Kane-Gm, S.,& W.-bcr, R. J. ( 2006). Principle, and practice, of
medication safety in th~ leu. Crirical <Au Clillics, 22. 273--290.
Koczmara, C.,ldincic. V., & Pmi, D. (2006). Communicalion of
medication order.! bytdcphone---"writing it right." Dy""mics, 17.
20--24.
Meadows, M. (2003) Strat~gi e. to reduce medkation rrro .... Howth.
FDA i. """,lUnS to impro"" "",dic . tion .. fety and what l"'U <an
do to hdp. FDA Camu""r, 37(3), 20- 27.
Mitchell, A. (2001). a.aUen~ in pediatric pharmacothenpy:
Minimizing medkation erro .... Mm.capr Pharmad"s,l(I ), 1-8.
National Coordinating Council fur Medication Error and Reporting
(Na::: MERP). RecommrnMtio .... to ,nhance ac""""J' in
preu:riptwn wriling. Adop1<d Scptember 4, 19%. Rcvi...d June 2,
2005. R<tri...ed from hnp:I/www.nccm~rp.orWcoundV
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..fdy. Oklahom~ Nwr... 51, 16.
Page, K., & McKinney,1\. A. (2006, luly II ).Mdressing medication
error>: n.. role ofund~rgnduat~ nurseeducation.N"rse
Edurotwn T",u,y, (rpub ).
PhiUips, I.. Beam, S. , Brinker. A., Holquist, C., Honig, P., Let, L Y., &
Palmer, C. (2001). ~trospti'" analysis of mortalitie.o; associated
with medication error .. Amcriam 10u,,,,,1 ofHralrh-Sy''''m
Pha,,,,~<y, 58, 1835--1841.
SanteU J. P., & Cousins, D. (2004j. Pr~""ming mrdkation ~rro" that
occur in tho home. U.s. PI,~,maci't,19(9).~.
Shuttleworth, A. (2006). How to kp up to date with practice.
Nursing Times, 102, 54-55.
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",com"",ndation . Quality Review, 7.

Chapter 10
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rommi.,,;"n E monograplu. Austin, TX:Am~rican Botanical
Cound!'
Ebadi, M. (2002 ). PIt~'maccdynamk btI,is ofhcrbal ,nedidne. Boca
Raton, FL: CRC Pr....
Fontaine. K. L. (2009 ). Camplemen"'ryand alternarive the",pu./or
nu"in8 ptactice ( 3rd ed. ). Upper Saddl~ River, NI: P"'ntice H.iiI!.
Fost.., S.. & Hobbs, C. (2002}.Afield S~idc ti' We""", meJicin~1
plan" and herb.. Bo.ton. MA and NcwYork, NY: Houghton
Mifflin.
Goldman, P. (2001). Hrrbal medicines today and the root. of
rnodrrn pharmacology. Antlals of /m.,,,,, / Medicine, 135(8),
594-597.
Marcus, D. M., & Snodgn ... W. R. (2005). Do no harm:Amidan<cc
of hrrbal medicines during p"'gnancy.
6- Gynerolo8)',
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and Comparison "", Publisher.
Scott, G. N., & Elm.r. G. W. (2002). Upd,teon natural product drug
int~rdction . American Ja"rn~1 of Hral,h-Sy,rem Pha,macy, 59( 4),
339-347.
Si~rpina, V. S., Wollochl .. ger, B., & Blu"",mbal, M. (2003 ). Ginkgo
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sub,lance" .bust.l'fJiatricJ in Rem,,", V( 4), 123-131.
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Fraochini, E, Dcnunini, G., & Esposti, D. (2002). Phannawlogyof
silymarin. Clin;c,,1 Drug ],M"Stiga'WM, 22(1), SI-{iS.
Fr~ ... , T. E., Miotto, K., & Roback, C. J. (2002). Th~~ff~cl.and
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Gabl~, R. (2006). Th~ toxicityofr",ational drugs.Am""k~1I
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g<netic. of .... bslance" abuse. American

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H.ndrrson, D.Io.., ]ngbby, T. V., & OTool., T. (2002). Bwrerrori,m:

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ronc~ming chemical and biological terrori,m: Continuing
education implications.lollmalofContinlling EduCluwn in

N.";,,t, 33(6), 2~J-2:;S.

Salazar, M. K., & Kdman, B. (2002). Planning forbiologicaldi .. "m.
Occupational h~alth nurse. as "firsl .... pond..... America"
Association of(kcuf"'tk",,,1 Hroldt Nur..., J"""",I, 50(4), 174-181.
S~ncrr. R. C., & Lightfoot, N. F. (2001). Puparedne" and ""pon ..
10 bioturori.m.jou"",loffM[ecrion, 4J(2). 104- 110.
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Medical Al.!ocirltion.189(6), 68~86.
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biological ,.,."apon: Io.n old di ..... that po ... a new th",at. Critical
CtI", Nllrse, 22(5), 21 - 32, 34.

Chaptlr 12
Bartlett, I. G.,Sifton, D. w., & Kdly. G. l. (Ed . ). (2002). PDRguid.
hi biological aPld chemical warJt!", "'spen",. Montval',NI: M.dkal
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BI.udon, R. I.,~' Roches, C. M., Ben""n,l. M., H.. rmann, M. I.,
Taylor-aark, K., & Wddon, K. I. (2003) .
public and t h~
smaUpox th",al . New England lOI4mal ofMedie~> J48{S).
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Bouman, W. P., Dil!>.ro, D., & Seh:m!>.n. I. l. (2002). Biologic and
ch.mjcal1"lt~pon~ of nWl! d~str\l~tion. Emergency Mrdkal Oinie,
ofNoNh Am,ri~a, 20(4), xii. 975-993.
Cansemi, C. W. (2002) . =u!"'tional ""pon .. to '~rroru;m.
Am,.,.ican A,,,,cuuion ofOcrup,uwnal He.al,h Nwr..., lou,nttl. 50(4),
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Chyba, C. F. (200 I ). Biological sccurity;n a changro ...urld. Scim<:..
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Crupi, R. S.,A,ni., D. S., Ltt, C. C., Santucci, T., Marino, M. J.. &
Flam., B. I. (2003). Mttting tho challrng. ofbioturorism: ussons
learned from WeSI Nile virus and anthraL Amerimn lournal of
EmergeII<)' M~diciM, 21(1), 77- 79.
Donn. Uan, C. (2002). Nrw law funds nursin8" rol~ in biotrrrori,m
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Muocarinic ",aptor .ubtypt. and managt"m~m of thr o...,,""li....
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Chapter 15
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Chapter 18
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Chapter 19
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""'i,

Chapter 24
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T""

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David, p, S" Boatwright, E,,,-,, Tozer, B, S" V~rma, D, p" Blair,
j, E" Mayer,A. P"et al. (2006), HOfDlonalrontra<<ption update,
M~yo Clinic Proctdings, 81(7), 949-955,
ErUola, R. (2007), Recent advance. in hornlOnal contraception,
Cur"'nt Opinion in Ob'tNri &Gynecology, 19(6), 547- 553,
Han .. n, L 8., & Portman, D. (2006), Hormone thet'apy update:
Current recommendation. rorm.nopausal symptom" US
Ph~rn'~ci!"

31(9), 119--')6,

Lttman, L" Fontaine, p" King, V" Kldn, M, C, & Ratcliffe, S, (2003),
natun: and management oflahor pain: Part II, PharnIaCOlogk
pain n:lid,American Family Phy.icultl, 68, 1115--1120, 1121 - 1122,
Loo .., 0. S" & Stancel, G M. (2006 ), Estrogen., In L L Brunton,
j, S, Law,and K, L Par~r (Ed,,), Goodman ... Gilman'. Th.

n..

794

AppeoolxC

pharmlll"e/egirol ba.i. ef,hN'apellrlc. ( 1Ith..d, pp. 1541- 1572).

NrwYork, NY: McGraw-Hill.
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., Ladowi~, P.A., & Davidson, M. R. (2008).
Matenlal.....<"Wborn nu"ing and ""mfn', heal,h
(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. ~nd G,..,..,rology, 105{5 pt I), 1074-1083.
Prine, L. (2007). Em<~ncywntraccvtion: 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.

"Ir"

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 "" ~<J' 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. r..nc~ 361(9351), 6(ki2.
Kltastgir,J.,Arya, 10.1., S~rgill,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.
Snyd~r, 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 errctil~ 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., & Fj~rald, G.A. (2006).
Analgcsic-antipyretic aunts; Pharmacot~rapy of gout. In
L. L Bn..tnton, r. S. Lazo,and K. L. Parhr (Ed . ). Good",~" ...
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., ... & W~liam H. J. (2006). Gl"", .. mine,
chondroitin sulfate, 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 min<r~l 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" eftherape~tic,
(] 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.

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~,c.

(2003). Dietary nrrels for bone health and t~ 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 ofMedicine, 35/X2] ), 2167- 2179.
Qa_m,A., Snow, V., S~kelle, P., Hopkins Ir., R., Forded, M.A., &
Owens, D. K. (2008 ). Scrning forosleoporo,is in men: A clinical
practice ~uidrline 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
Ph~rmlll"ology,

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 . r..nce~ 361. 1]97- 1206.
Leung, D. Y.,& Boguniowicz. M. (2003 ) .Mvan,~s in allagic skin
disca .. s.Jo~rntJcf A/Jersy ,,,,d QiniaJ Immu~ 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 ot~r skin d;,.a ....
361, 13.J.6-]344.
SmoUnski, K. N., & Yan,A. C. ( 2004). Acne update: 2004. Curren,
Opinion in ~ditJt';,;" 16( 4 ),385-391.
Snow, M. (2007). Thelruth about "",bie. Nursing, 37(2), 28- JO.

La""",

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 doGilm"n:' The ph,,'macologic,,1 00.;. ef th"",pe~t;'-' ( 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 updat~.Ameria", Family Physician, 74(9), 1510-1516.
Schw.nz., K.Io.., & Bud. nz. D. B. (2004). Current managemmt of
glaucoma. Curr~n' Opinicn in Oph,lwlmcltJsy, 15(2) , 119-]26.
Tripathi, R. C., Tripathi, B. J., & Haggc:ny, C. ( 2003). Drug-induad
glauwmas: M~chanism 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.

Appendix 0
cologie; an oral contraceptive is therapeutic; a laxalive is
therapeutic; a folic acid antagonist is plulrmacologic; an
antianginal agent is thenpeutic.

ANSWERS
Chapter 1
AnS\<l'~rI

to Critia l Thinking Q UHtion5

The patient may choose OTC drugs nth"" than more ef~

(<<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 seeing a heoalth care provider, the patie nt saves lime and
monty.
drugs art obtained much more easily than
pres<:ription drugs. Patients often think they can rife<:

ore

lively Irtat themselves and that OTC drugs do 001have as

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 remember. However, because gmenc drug formularies may
be differen t, the inert ingredients may be somewhat different and, consequently, m;ay affect the abili ty of the drug
to reach the target cells and produce an effect.

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 ineffective drugs off the market. Another of the agency's
goals is to improve the heoalth o f Americ:ms and ensu re
th at drug infonmtion is clear and uoSily understandable.
Ove r 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 autho rity to recommend civil penalties if the guidelines 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 app roval process. In this phase, the drug
is monitored for harmful effects in the larger population.
The FDA hokb public meetings 10 receive feedback from
pa tients and organizations reg.;mijng the safely and effectiYt'I1CS5 of new drug therapies.
4 Nunes are responsible for the safe administration o f medications, 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, $O rne nurses may administer medications to patient~ participating in phase II and III clinical trials, but all
nu rses participate in phase IV p05tmarketing surveillance
by reporting adverse drug reactions.

4 Schedules refer to the poten tial for abuse. Theseschedules

help the nurse identify the potential for abuse and require
the nurse to maintain com plete records for aU quantities.
The rugher the abuse potential, the more restri ctions are
plated o n the health ca re 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 Q uestions
I Amwer:'

Rationale Tbe primary responsibility of the n urse is to en

sure patient safety when admin istering prescribed medica.tions. Pa ti ent complia~ includ es much more than
wa tching th~ p.1lient take medica.tions.Accurate health care
provider ordeN a re a p.1rt of ensuring safe medication ad~
ministration. Cog"ifive Le.'tl: Comprthension. Nursing
PrCH:dS: Implementation. Patient Nerd : Health Promotion
and Maintenanc~.
2 An.fwrr: J

Rationale: The enteral route involves the process of swallowing by definition. Cognitive Le.'eI; Comp rehension.
NUNing PrCH:eu.: Assessment. Pali~tli Nerd: Health Promotion and Maintenance.
3

A/U~r:

Rationale: This question :lSks for the highest priority; thereChapter 2

Answen to Crit ica l Thi nk ing 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-

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nre, all the answers al't correct. but one should stand oul as
the first action the nurse should take. Think about patient
safe ty. In this example. the d rug luis been nMY p rescribed;
thel'tfore, notifying the health care provider of the patient's
reactio n 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.

796

AppeoolxO

4 NtSWer: 2

Rationale: STAT means immediately. ASAP orders should be

administered within 30 minutes. Cognitive woe/: Applica tion. Nursing Process: Implementation. Pa tient Need: Physiologicallntegrity.
5 NtSWers: 2, J, 5

Rationale: Enteric-wated tablets are designed to dissolve in

the alkaline environment of the small intestine. Sustainedrelease 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. Pa tient
Need: Physiological Integrity.
6 An.s ....,,": 4

\'lhile a patient who is NPO for surgery is not usually allowed 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 additional orders are needed. Cognitive Level: Analysis.
Nursing Process: Implementation. Pa tient Need: Physiological Integrity.
Answers to Critical Thinki ng Q uestions
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 enablcs 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 effect. \'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" Rev iewQ uestions

I Answer: I

Rationale: Some medications can be affected by foods, bewrages, or other drugs. The effect of calcium, iron, and magne.iwn on ~ tetracycline ~ntibiotic i< an e""mple of a food-drug
interaction thM OCCllrs in the ah_<Clrption pm"""' _

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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. Pm ien t 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 bycirrhosis, will require reductions in drug dosage because of the
decreased metabolic activity. Cognitive Level: Analysis.
Nursing Process: Implementation. Pa tient Need; Physiological 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 Le~'d: 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 because of decreased excretion. Tht' patient must be aS5eS&ed
for drug toxicity. Cogn ith-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. Cognith-e Ln'd: Application.
Nursing Process: Implementation. Pil tient Need: Physiologicallntt'grity.
Answers to Critical Thinkin g 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 membranes of the mucosal cells of the gastrointestinal tract
and the capillary endothelial cells to t'ntt'r the bloodstream. To leave the bloodstream, it must again cross capillary 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 digestive enzymes.
2 The plasma half-life is the time required for the concentration of the medication in the plasma to decrease to half
its initial value after administration. This value is important 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. Th~ half_lif"

Appendix D

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 relationship 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 metabolic reactions. Alternative routes of delivery that bypass
the fin;t-pass effect (s ublingual, rectal, or parenteral
routes) may need to be considered for these drugs.

797

patient safety. Cognitive Level: Application. Nursing

Process: Implementation. Patient Need: Physiological Integrity.
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 endogenous substance from acting. Antagonists compete
with agonists for binding sites. An antihistamine would
most likely be an antagonist.

Chapter 5

Chaptllr6

Answers to NCLEX-RN" ReviewQuestions

Answers to NCLEX-RN" ReviewQuestion s

I Answer: 2

I Answer: I
Rationale: NANOA classifies a nursing diagnosis as a clinical judgment about individual, f~mily, or community responses to actual or potential health/life processes. Per
NANOA, nursing diagnoses provide the basis for the selection of nursing interventions to achieve outcom... for which
the nurse is accountable. Cognifile Lewl: Analysis. Nursing
Process: Assessment. Patient Need: Health Promotion and
Maintenance.

Rationale: Unpredictable and unexplained drug reactions

are labeled idiosyncratic. Cognitil-e Lnel: Analysis.
Nursing Process: Implementation. Patient Need: Physiological Integrity.
2 Ans"",r, 1

Rationale: An antagonist occupies a receptor site and prevents endogenous chemicals from acting. An agonist produces 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: Application. 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: Physiological 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.

2 Answer: 2

Rationale: Goals f(X;us on what a patient should be able to

achieve and outcomes provide the specific, measurable criteria that will be used to measure goal attainment. ~The patient will demonstrate self-injection of insulin (what should
be achieved) using a preloaded syringe, inlV the subcuranams
tissue of the thigh prior to di5charge~ (specific, measurable
criteria used to measure goal attainment). Cognifile ul-el:
Application. Nursing Process: Evaluation. Patieut Neelt
Physiological Integrity.
3 AnSlwr: I

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.

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,wthis patient has identified a lack of knowledge 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 administr~tion techniques. Coglrifil-e
Lelel: Application. Nursing Procrss: Intervention. Patient
Need: Psy,hologiQ[ 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,,). Extra caution should be taken with drugs with a narrow ther~peutic index to ~void giviJlj,lan exce&6ivedose ~nd to ensure

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 medic~tion. 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. Cognitiv e Le,'el: Application.
Nursing Process: Assessment. Pa tient Need: Health Promotion and Maintenance.
6 Answer: J

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

~pt'cial

r"'"luir""'''lJi.'; lJ.,.,u.,u lu "'lSur"

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.

ChaptQr 7

Answers to Critical Thinking Questions

Answers to NCLEX- RN" ReviewQuestions

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 assessed 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 assessment for adverse effects should also be ga thered. Cost issues 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 recommended because weight loss is a symptom of uncontrolled type I diabetes. The nurse would also explore the
patient's and her mother's understanding of the diagnosis, their npectations about the treatment plan, and any
previous teaching given, correcting any misWlderstand ings or misinfonnation. Noncompliance asswnes the patient has made an educated decision about the treatment
plan. If insufficient knowledge about the condition, treatment plan, or care needs is the reason behind the healthseeking 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 treatment routine)
Ineffective Therapeutic Regimen Management (related
to deficient knowledge or altered compliance with prescribed treatment)
Risk for Infection (related to implanted subcutaneous
catheter used for delivering insulin via pwnp)
Risk for Injury (related to adverse drug effects, hypoglycemia 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

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Ih"rdl'<"uli~

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 provides the patient with an opportunity to ask questions
about the medications or the treatment plan.

1 Answer: J
Rationale: Isotretinoin (Accutane) is FDA pregnancy category X and is contraindicated during pregnancy. It should
not be used at all during pregnancy. Cognitive Level: Application. Nursing Process: Implementation. Pa tient Need:
Physiological Integrity.

2 Answer:4

Rationale: Administration immediately after breast-feeding

allows as much time as possible for the medication to be excreted 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 medication 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 poisoning. 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 children if desired. Cognith'e Lewl: Analysis. Nursing Process:
Evaluation. Patienf Need: Physiological Integrity.
4 Answer:4
Rationale: Toddlers may resist taking medications. Short explaruotions 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. Cog nifi ve Lel-el: Analysis. Nursing Process: Implementation. 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 newborn. The middle third of the rectus femoris is an alternate
site, but its proximity to major vessels and the sciatic nerve

Appendix D

requires caution in using this site for injection. Cogn ithe

Level: Comprehension. Nurs ing Process: Implementation.
Pa tient Need: Physiological Integrity.

6 Answer:]
Rationale: V-.'ith each visit, the nurse should take a medication history of aU OTC and prescription medications, noting 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 Le~el: Analysis. Nursillg Process: Implementation. Patiell t Need; Physiological Integrity.
Answers to Critical Thinkin g Q uestions
Pyelonephritis is frequently associated with preterm labor 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 during the first trimester. The nurse should also look up the
pregnancy classifica tion 01 the antibiotic. Selected agents,
such as tetracyclines, should not be used during pregnancy. 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 assess 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 fatsoluble drug; thus, because elderly patients have increased
total body fat, the drug has a much longer half-life. In addition, numerous drugs decrease the metabolism of diazepam and may contribute to an increased half-life and
enhanced CNS depression. If sedation is deemed necessary, 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 ora1 cavity. Therefore, the nurse may not need to repeat 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 acetaminophen. The nurse should consider using an oral syringe to
accurately measure and administer medications to infants. 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 absorption because of their effect on peristalsis.

ChaptQrS

799

ditional medicines. The nurse should examine bow these herbal

and alternative therapies will affect the desired phannacotherapeutic 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 medication interactions. Cogll ifin~ Level: Assessment. Nursillg
Pracess:Application. PatielJl Neett Physiological Integrity.
2 AnswerJ: 1, 2,]

Ratianale: Writtt'n materialsallowtht' patient and fumilyto review information on additional occasions at borne, but up to
48% of English-speaking patients do not ha~ 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 literacy level and take appropriate action to ensure that information is understood. An assessment of visual impairmt'nt
should also be made and large-print matt'rials provided when
necessary. Cognitive Lel'f~l: Assessment N ursing 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; however, women are one and a half to three times more likely to
develop the disease. Cognitive Le~el: Analysis. Nursillg
Process: Diagnosis. Pa tient Need: Health Promotion and
Maintenance.
4 AIIS",er: 2

Rmiollale: When patit'nl5 have strong spiritual or religious beliefs, these may greatly influence their perceptions of illness
and their preferred modes of treatment. III health and spiritual issues can have an impact on wellne:ss, nursing care, and
pharmacotht'rapy. Coglliti~e !.n-el: Analysis. Nursing
Process: Assessment. Pafien t Need: Psychosocial Integrity.

5 Am",er: 1
Rationale: Slow acetyiators experience a delay in drug metabolism in the lher. This can caust' the drug to build to
toxic levels and result in drug toxicity. Coglliti>-e u~el: Application. Nurs illg Process: Evaluation. Pa tient Need: Psychological 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 activities. These determinations help to develop a plan of care
specifically tailored to individual patient needs. Cogn ith-e
!.nel: Application. Nursing Process: Assessment. Patie nt
Need: Safe, Effective Care Environment.

Answers to NCLEX-RN8 ReviewQuestio ns

1 Allswer: 2

Rationale: Many cultural groups believe in using herbs and

other alternative therapies either along with or in place of tra-

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Answers to Crit ical Thinkin g Q uestion s

The primary concern for this patient would be the potential
for drug-food interactions. Warfarin (Coumadin ) achieves

800

AppeoolxO

its anticoagulant effect by interfering with the synthesis of

vitamin K-dependent clotting factors. The antiooagulant effect 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 related to the dietary intake of these foods. It is conunon for
rural people to "eat out of their gardens" during the growing 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 patient'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 management 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 leading to his condition. Further holistic assessment of the
patient will help the nurse determine probable reasons for
his present condition.

Analysis. Nursing Process: Assessment. Patient Neetl: Physiologicallntegrity.

4 Answer:4
Rationale: The Foodand Drug Administration (FDA) and the
National Coordinating Council for Medication Error Reporting 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 physicians 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 ~ Incident Report 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. Vital signs should be assessed dependent on the medication
given. Cognithe Le,e/: Analysis. Nursing Process: Implementation. Patient Need: Safe, Effective Care Environment.
H

6 Answer: 2

Rationale: This approach best ensures a ooUaboration between 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.

ChaptQr9

Answers 10 NCLEX-RN~ ReviewQuestions

I Answer: 4

Rationale: Nurse pract ice acts encompass all aspects of nursing, including the definition of professional nursing, medication 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 medication errors and completing an incident report for review
by the facility's quality assurnnce personnel. Cosniti,e
Level: Analysis. Nursing Process: Implementation. Pa tient
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:

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Answers to Critical Thinking Questions

The nUTre should be well organized in preparing for drug
administration. The MAR must be assessaI at the beginning 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 minutes after the assigned time. If administered within this
time frame, the drugs are considl.'red to have been given "on
time.~ 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 asswne that the healthcare provider meant for the palienllo
have one "Tylenol #3" tablet by mouth. Prior to administering the dose, the nurse should consult with the healthcare 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-

App<>ndlx D

tient. The prescriber could have assured that the appropri~

ate dosage for the weight of the patient was ordered. The
nurse may have checked the KFive Rights of drug administration 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 checking the drug against patient-specific variables. In order to
M

I'[".. di~" ... r" amI "rr.,..uv" <.Irug a<.IIlliJJ.i~tratiull, all Ill"Illbers 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 medica~
tion errolS.

80 1

tients are taking two or more drugs, one of which is a selective serotonergic medication. Synlptoms include agitation,
dizziness, sweating, and headache. Patients should discontinue use of tht' medication and seek medical care immediately. Cognitive Lelel: Analysis. Nursing Process:
Assessment. Patien t 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 supplements and their claimed benEfits is unclear and the body
may already have sufficient quantities of the substance. Taking 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: Implementation. Pafient Need: Physiological Intt>grity.

Chapter 10

Answers to NCLEX-RN@> ReviewQuestions

I AnslI"er:4
Rationale: Some herbal products contain ingredients that may
se~ 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 consid~
ered less potent than prescription medications, but whensimilar drugs arc taken together, there is the potential forodvcrsc
rea,tiofl'l. Cogrrifhe woe/; Analysis. Nursing Proem: Implementation. Patient Need: Physiological Intt>gl"ity.
2 Answer: I

Rationale: Natural products contain many active ingredients, many of which havt' not been tested or identified. Patients with known allergies to food products or medicines
should seek medical advice befort' using herbal supplements. 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: Implementation. 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: Implt'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 lifethreatening medical condition that may occur when pa~

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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 because they are taking a SERM, estrogen replacement is indicated. 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 ~natural~ soy 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 ha~ 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 important that the patit'nt stop taking St. John's wort at least
3 weeks prior to the surgery, be'3USt' it ,an pott'ntiate sedation 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 addiction when U'ied according to aa:epted medical protocols. The
risk of addiction for prescription medications is primarily a

802

AppooolxO

function of the dose and the length of thernpy. Ct>gn ifin~

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. CDgltitil~ 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 fo r
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 d~prc:;sion. C rack 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 ca uS(' rnpid heartbeat,
sweating,dilation of the pupi!s,and an elevated body temper
ature. Large doses ofb,arbitur:lles drugs suppress the respiratory centers in the brain. The uS('r maystop breathing orlapS('
into a coma. Cognithoe Le.oel: An.:Ilysis. Nursing Process: Assessment. Patient Need: Physiological Integrity.

4 Allswer: J

malignant hyperthermia, which can lead to muscle damage 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. extreme irritability. delusions. and impairtd judgment.
Other symp toms are extreme mood ch.a~ and maniclike symptoms, even when the user (tports feeling "good.~
3 The principal danger associated. with prolonged use of
barbiturates is tolernnce and physical addiction. Barbiturates generatl y lose their effectiveness as hypnotics
within 2 weeks of continued USt. This patient is demonstrating signs of developing tolerance. H e needs 10 discontinue the drug gradu.aJly to denease the risk of
complications associated with sudden withdrawal. These
symptoms include severe anxiety, tremors, marked excitement, delirium, and rebound r~pid eye movement
(REM) sleep. Today, nonbarbituralts are usually prescribed as firstline hypnotics.

Cha tllr 12
Answers 10 NCLEX-RN" Review Questions

Rationnle: Patients eJlpl'l"imcing alcohol withdrnwal typi -

] Answers: J, 5

cal ly experience tremors, fatigue, anxiety, abdominal

cramping, haUucinations, con fusion, seizures, and delirium.
Cognitn'e Lenl: Analysis. Nursing Prouss: Asses.sment.
Patient Need: Physiological Integrity.

Rationale: Anthrax affects therespirntory system . Fevl'!", peTsisknt cough, and dyspnea are all initial sym ptoms of inhaled. anthrax.. Cognitwe Le"el: Analysis. N urli"g Prouu:
AMessment. Patielft Nud: Physiological Integrity.

S Answers: J, 2, "

2 AlfSlO't'r: 2

Rationllle: Symptoms of nicotine withdrowal indude irritabil-

Rorionale: The potassium iodine prot ects only the thyroid

ity, anxiety. restlessness, hea<:bches, increased appetite, insomnia, inability to ooncentrnte, and a decrcaw in heart rnte and
blood pressure. Cognitil'e Leve/: Applkat ion. Nursinf{ Process:
Implementation. Pntient ~d: Physiological Integrity.

gland from 113L No other body orpns art protected by

this medication. Coglfitil'f! ~I\'l: Analysis. Nu"i lfg Process:
Implementation. Patient Null: Physiological Integrity.

6 Answer: 1

Rationllle: Overstimulation of the oeurotransmitter acetylcholine causes convulsiol15 and loss of consciousness within

Ratiollllle: Phpical dependence and psychological dependence may occur together and r~sult in drug-seeking behavior. But physical dependtnce occurs as the body adapts to
the substance such that withdrawal sym ptoms 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 neurotoxic agent. When taken in high doses it ca n produce

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3 Answer: I

seconds. Cognitive Level: Analysis. Nu'sillg Procell: Assessment. 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 ofbiologic terrorism is to cause widespread casualti es. Cognifi.oe
un/: Analysis. Nursilfg Process: Asses.sment. Patient Need:
Safe, EffectiveCare Environmmt.

App<>ndlx D

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. Participating 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 keeping up-to-date with emergency management protocols are
all ways a nurse may benefit the community. Specific medications, antidotes, vaccines, and supplies are kept in strategic locations by the federal government and are available
quickly for emergency use. They are not part of an individual's disaster preparedness strategy. Cognifive w-el: Comprehension. 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 effectiveness of these vaccines.
2 KI t~hl~I.~. ifrnken ]'>rior to or immediMely ~ft~r 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 com munity 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 affected community within 12 hours of an attack. VMI
packages are shipped if necessary and require identifkation of the type of chemical or biologic attlck. Theycontlin 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 emergency medic.:!1 corp_,

m~int~ining

Cllrrent knnwledge nf

resources, and in the early detection of possible emergencyconditions. Through educating their patients, families, 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-orfliJl,ht response. Nausea, vomiting, nervousness, bronchial

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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 bradycardia because they suppress the effects of acetylcholine
and stimulate the sympathetic nervous system. Anticholinergics 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: Physiologicallntegrity.
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 potential side effects related to the use of bethane.;:hol.
Bethanechol is used to treat nonobstructi~ urinary retention. Cognifil"e Level: Application. Nrmi"g Process: Implementation. 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 (cholinesterase inhibitors) may produce excessive sweating, drooling, 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 originall), prescribed for the treatment of asthma. Terbutaline
promotes bronchodilation and therefore reduces bronchospasm 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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Appendl~O

2 Bethanechol is a direct-acting cholinergic agt'nt that

works by stimulating the par.asympathetic nervous system . 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.asympathetic 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.gement (related 10 side effects and precautions of using
cholinergic agents)
3 Benztropine (Cogentin ) is an antichol inergic. Blocking
the pansympa thetic nerves allows the sympathetic nervous system to domina te. 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 nu rse should
monitor for decreased heart rate, dilJted pupils, decreased peri stalsis, and decreased salivation in addition to
decreased muscular tremor and rigidity. Many of the side
effects of anticholinergic; are dose dependent . Adverse effects includ e typical signs of sympathetic nervous sys tem
stimulation.

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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 btuperiencing relief from insomnia and reporting feeling rested
when awakening. Cognitil~ Ln'e/: Analysis. N.ming
Procns: Evaluation. Patient Nd: P~iologic:.\l Integrity.
3 N .n .... r:J
Rational" F1umneniJ ( Romancon) is a benrodia zepine-receptor blocke r which may be used to reverse CNS depressant effects. Nalo.wne ( Natan) is an opioid antagonist.
Cognitive Lt.-e/: Analysis. Nursing Pro.:el$; Evaluation.
PIlfie,,' Netll: Physiological integrity.

5 A nswer: 2

Rationllle: The state ment 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: Analysis. Nursing Proceu: Evaluation. Patient Need: Physiological Integrity.
6 Answer:4

Counseling or behavi oral techniques such as stress reduction 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.:uelf or cardiovascular effects may occur. Cognitive LntI:
Analysis. Nursing Proc.. ,,: Evaluation. Altie .. t Need: Physiological Integrity.
Answers to Critical Thinking Qunlio ns
Pain is empha5ized as being the fifth vital sign. The assessmmt 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 narcotic. Secobarbital is a short -act ing barbiturate. Barbiturates are not ~<'C1ive 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 appea rs 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 agen t 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 wh en 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 before bedtime,a nd a\'Oidanc~ of MOlV)' meals,alcohol, and
caffeine befo re bedtime sho uld also be considered. In
older adults, the total amount of sleep does not change;
however, the quali ty of sleep dNeriorates. Time spm t in
REM si'P and stages 3 and .. NREM sleep shorteru.
Older adults awaken more often during the night. This
sleep dilurban ce can be compounded by the presen ce of
a chronic illness. Th e alten tion 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 scuss age related issues, health concerns, and environmental factors that may be affecting the quality of sleep.

4 Answ.-r; J

crn.

Rlltionnle: Benzodiazepines should

Answers to NCLEX-RN. Review Qun tio ns

iuluKi~al l"t ~KritY.

Rarionale: Seizures nlOlY be caused by inflammation, head

iujuc;"", uc luw lIl........! .u~al k .."i>. Rapid-KWW;UI!. 'I'~~"-

not be s topped
abruptly. The health care provider should d ecide when and
how to discontinue the medication. Cogniti" e Lt ..tI:
Analysis. Nursing Process: Evaluation. Patient Nd: Phys-

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Appffidlx D

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: Evaluation. Patiem Need: Physiologiallntegrity.
2 A 'ISIver: J
Rationale: The influx of sodium into a neuron enhances
neuronal activity. The delay of an influx suppresses neurotransmitter 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 influx of chloride ions into the neuron, leading to the suppression of neuron firing. Cog"ithe LeW!/: Analysis. Nursi"g
Process: Assessment. Pa tiem Need: Physiological Integrity.
4 A "Slver: J
Rationale: Valproic acid may produce an idiosyncratic response in children, including restlessness and psychomotor
agitation. Cognitive Level: Analysis. Nursi"g Process: Assessment. 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: Implementation. Patient Need: Physiologial Integrity.
Answers to Critical Thinkin g Q uestions
Carbamazepine (Tegretol) is the second most widely prescribed 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 laboratory reference manual. The therapeutic drug level of
phenytoin (Dilantin) is 5 to 20 mg/dL. Patients may become drug toxic. and demonstrate signs of CNS depression. Exaggerated effects of phenytoin can be seen if the
drug has been combined with alcohol or other agents.
Phenytoin also demonstI'3tes dose-dependent metabolism. 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..!.

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3 Long-tenn phenytoin therapy can produce an androgenic

stimulus. Reported skin manifestations include acne, hirsutism, and an increase in subcutaneous facial tissue-changes that have been characterized as ~Dilantin fucies.
These changes, coupled with the risk for gingival hypertrophy, maybe difficult for the adolescent to cope with. In addition, 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@> ReviewQuestio ns
1 Amwer:4
Anticholinergic effects such as blurred vision, dry mouth,
and constipation may occur during the first weeks of therapy. ToleI'3nce to anticholinergic effects tends to develop after 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, tachycardia, hypertension, increase in respiratory rate, and tardive dyskinesias are potential adverse effects of TCA
antidepressants but are not related to anticholinergic effects. Cog"iti,e Lnel: Application. Nursi"g Process: Assessment. 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: Application. 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: Physiological 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: Physiological 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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AppeoolxO

6 Allswer:3
Antidepressant drugs such as the SSRIs may not have full effects for a month or longer but some improvement in mood
and depression should be noticeable after beginning therapy. Anything less than a month is too early for filII effects
although some improvement may be noticed. Cogniti~e
Level: Application. Nursing Process: Assessment. Pmient
Need: Physiological Integrity.

that the drug is swallowed. Never leave medications Wlattended in a patient's room. If there are concerns that the patient 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 energy to carry out a suicide plan.

Answers to Critical Thinking Questiolls

Chapter 17

Methylphenidate (Ritalin) therapy is usually administered

twice a day, with one dose before breakfast and one dose before lunch. A child in school would be required to visit a
school nurse to receive a dose of Ritalin bernre IWlch. Amphetamine (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 Erikson's dev..l0l'm .. nt~1 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 person 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 decrease 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 established. Thehealth care provider must weigh risks and benefits 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 patient 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 permissible 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 removed with the food tray or taken by another patient. Always supervise all medication administration a nd be certain

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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 therapy. These are severe muscle spasms, particularly of the back,
neck, tongue, and face. Cogniti~e 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 mental disorder. A decrease in delusional t:hink.ing,lessened hallucinations, 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 hypotension, reflex tachycardia,or sedation are potential adverse
effects. Cognithe Level: Application. Nursing Process: Assessment. Patient Need: Physiological Integrity.
4 Answers: 1,2,4
Rationale: Alwninum - and magnesiwn-based antacids decrease 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 Parkinson'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: 1mplemenl3tion. 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 Le~"el: 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 anticholinergic activity. Pacing and squirming are signs of akathisia, and
bradykinesia and tremors are symptonlS of pseudoparkinsonism.lnvoluntary lip-puckering and wormlike movements

808

Ap~r.dlxO

medications. Poss ibl 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.

R~viewQ ues tio ns

1 Answn: I

Rmionnle: The

th~t 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 pa in , abili ty to
stand, and ability to urillOl te are not priorities.. Cognifin~
uw': Application. NUrfing Procn.: Assessment. Putient
Need: Physiologica l Integrity.

2 AnsIO'er: 4
Rationalf: Solutions of lidOOli ne con tai n ing preservatives or
epinephrine are intended for local an est hesia o nly and must
never be given IV for d ysrhyt hmias. Cognifil-e bl-e/: Analysis. Nursing Proct'ss: Implementation. Pafiem Nfe/I: Physiological Integrity.

An ....er::J
Rationale: Th e first step of th e nursing proCe$S is assess -

ment. Assessment of prior know ledge provides the basis for

the development of a t.::aching plan. The other o ptions take
place after a thorough assessment. C~"itj,-e 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 ca using analgesia. It does not produce complete 10iSS of consdousne$s or profound relaxation
of skeletal mUlKle$. Nitrous oxide does not induct stage 3
analge$ia or ca~ a loss of consciousnli'Ss. Cogniti...! Ln-e/:
Analysis. Nursing Proceu;. Implementation. Ptitient Ntelt
Physiological Integrity.

Answers t o Critical Thinking Qutstions

The nu!'l;t' 5hould questio n the health care provider regarding 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 areasof~fi ngm.
nose, ~,and toes,~ 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 pa tient is
on digoxin (Lanoxin) and has renal fa ilure, and therefo re
is not a good candidate for this drug because of the potential 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$ia and opioid s in the
patient's system, ca using depression of the eNS and rli'Spiratorysystem. The patient should al$O be monitored for
postoperative bleeding related to the use of ibuprofen.
TIle digoxin =nooentratioLl ~hould be ~ t 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, beca~ symptoms may become worse. CognilM w-el: Analysis. NII"ing Proctss: Im_
plemI.'ntation. Pritknt Need: Physiological Integrity.
2 AnSWl'r: 1

5 AnsK'ers: I, 4
Rationale: Succinyh:holine (Anectine) ClIn ClI~ oomplete
paralysis oCthediaphngm and intercostal muscles. BradYCllrdia and respintory depression are expe<: ted. Medunical ventilation 5hould be avaiUblt. Cogniti,-e Lel'tl: Analysis. Nursing
Process: AssessmenL Ail it'" t l'-Jcul: Physiological Integrity.

Rationale: Pharmacotherapy dotS not cure or stop tht disease process but dotS im prove the patient's ability to perform normal activities 5uch astating , bathing, and walking .
Depending on th e drug thenpy, EPS m ay be an adverse ef_
feet. Cogllitile UItl: Analysis. Nurl ing Proc..u: Implementation. Ptoli~,,' Need: Phy5iologicaJ Integrity.

6 AnSIO'er: 4

3 AnSlO-er: 4
Rationale: A decrease in kidney and liver function mayslow
the metabolism and excretion of the drug, lea ding to over_
dose and to:ucity. Levodopa does not cause th e 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
Anal ys is. M'Ning Pro(tu: Impl ementation. Patint Need: Physiologicallnttgrity.

Rationale: Neuroleptanalgesia drugs su ch as ketamine do

not re5u1t in full loss of cOl1S(:io usness but ca use disconnection
from events occurring. Co nfusio n, 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 assessme nts above thost required for pa tient sa fet y increase senso r y stimulation and may result in
extreme patient rtac tions. Cognitivt Level: Analysis.
Nursing ProCf!ss: Im plementation. Patit nt Nud: Physio
logical Integrity.

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4 Answer. I
Rationale: The cause is unknown; however, str uclUrai dam_
age consisting of amyloid plaques and neurofibrillary tan_

App<>ndlx D

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 receptors . Cognirive Level: Application. Nursing Process: Implementation. Pll tien t Need: Physiological Integrity.
5 Answers: I,)

Rationale: Symptoms of overdose include severe nausea and

vomiting, sweating. r.alivation, hypotension, bradycardia, convulsions, 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 muscle twitching are early signs of potential overdose or toxicity.
Orthostatic hypotension,drooling, nausea, vomiting, and diarrhea are potential adverse effects unrelated to toxicity or
overdosage. Cogniti,e Lend: Analysis. Nursing Process: Implementation. Patient Need: Physiological Integrity.

Answers to Critical Thinking Questions

The patient should rea~ess with a health care provider
the need for regular Mylanta. This drug contai/lS magnesium, which maycause increased absorption and toxicity.
The patient needs teaching on decreasing foods that contain 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 i~ues related to postural hypotension.
2 A patient on benztropin (Cogentin) has a decreased ability 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 patient 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 medication (this is not a nursing function). Thecoupleshould
be educated regarding safety issues su,h as postural hypotension and bradycardia that may occur with this medication. Anorexia is also a potential problem; this patient
has diabetes and thus may have glycemic issues.

Chapter21
Answers to NCLEX-RN8 ReviewQ uestions
I Answers: 1,2,5
Rationale: Adverse reactions to cyclobenzaprine include
drowsine~, dizziness, dry mouth, rash, and tachycardia. Because medication can cause drowsiness and dizziness, ensuring patient safety must be a priority. Usually, patients
experiencing back pain have orders for limited ambulation

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until muscle spasms have subsided. Cogn itil-e Lewl: Analysis. Nursing Process: Implementation. Pa tient Need: Physiological Integrity.
2 AIISwer: 4
Rationale: An adV\'rse effect of botulinum is pain. The drug
is injected directly into the muscle. Pain associated with injections is usually blocked by a local anesthetic. Treatment
with botulinum helps improve muscle strength, bUltherapeutic effects are usually del~d by a few days. Cogniri,-e
Lewl: Analysis. N ursing 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 antihy~rtensives such
as propranolol may increase the risk of hypotension. Cyclobenzaprine 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 effects 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 effects such as muscle weakness, drowsiness, dry mouth,
dizziness, nausea, diarrhea, tachycardia, erratic blood
pressure, photosensitivity, and urine retention. Until effects 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 therapeutic outcome of the medication. The patient's report of
pain or oontinued spasms should be oonsidered an accurate
account. Cognifivt Level: Analysis. Nursing Process: Assessment. Patient Need: Physiological Integrity.

Answers to Crit ical Thinking Q uestio ns

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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AppeoolxO

improvement in 45 days, the medication regimen is usually 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.

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 levels. Cogn itive Level: Analysis. Nursi ng Process: Evaluation.
Patient Need: Physiological Integrity.

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 before responding to this patient's concerns:

Rationale: One adult-strength aspirin taken 30 minutes before 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 medications 1 hour before or 4 hours after the drug are guidelines
reconunended for bile acid sequestrant drugs. Cognithe
Level: Application. Nursi ug Process: Implementation.
Pa tient Need: Physiological Integrity.

\'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 receptors in the parasymp.1thetic nervous system. This allows
the ~ctiviti ... of The symr~thetic

n~rvOll.' "Y't~m

to dom_

inate. In this case, the result has been a decrease in oral secretions and relaxation of the smooth musde of the GI
tract. Decreased peristalsis and motility can result in constipation. The anticholinergic effect is also responsible for
urine retention because of increased constriction of the
internal sphincter.

Chapter 22
Answers 10 N CLEX-RN~ ReviewQ uestion s

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.

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3 Answer:4

4 Answer: J
Ratiouale: The nurse teaches the patient with a diagnosis of hyperlipidemia about lipids in the body. The nurse informs the
patient that the major storage form of fat in the body is triglycerides. Cognifh-e l.ewE: Analysis. Nursing Process: Implementation. Patient ~d: 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: Implementation. Pa tient 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 coenzyme QIO. Grapefruit and grapefruit juice may inhibit the
metabolism of the statins and lead to potentially toxic levels. Cognifive l.e,eI: Application. Nursing Process: Implementation. Patient Need: Physiological Integrity.
Answers 10 Cr itical Thinking Questiolls
Photosensitivity is a major problem with atorvast~tin
(Lipitor), so the patient must take precautions such as using sunscreen, wearing sunglasses and protective clothing,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 advice before self-medicating--especially because this patient has diabetes, and many drugs affect hyperglycemic

~b<D

,tt

Answer to Avo iding Med iCoi tio n Errol"$

The nurseshoukl h';l\eadministered molestyramine alieasl
4 bours before or 2 bours ~fte r digo.'(in and tetracycline be~
cause the ll' is decreased absorption if they are adminislered
together.

of treatment with direct-acting v~sodilators. Giving two an_

tihypertensive drugs together may ~Iso lower blood pressure
further but the ~ta-blocking 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 ha ve
effects in p reventing lu pus and is not adiuretk . alt hough judicious d iuretk 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: Implementation. Adient Need: Physiological Integrity.

Chapter 23

Answers to C rit ical Thinking Q u estions

medications and blood g1uc06e levels. Niacin can ca use

hypergl ycemia in this p~tient, so S('r um glueQse levels
should beevaluated. The flushing and hOI flashes all' normal side effects of this mediation.

An5\\ers to NC LEX- RN. Rev iew Q uestio ns

I A.nswer: J

Rationale: Furosemide was prescribed as an adjunct treatment for hypertension. Blood pressure within norma! limits indicates thatlTeatment has beffi effective. Absena- of
edema, weight loss, and frequency of vo iding is ll'lated to
fluid status. Cognit io'e Le.'e/; An al ysis. Nursing Process:
Evaluation. Pat ient Need: Ph ysiological Integrity.
2 Answer: I

Rationale: HCfZ is a thiazide diuretic. II acts on the kidney

tubules to decrease the re~ bsor pti on of sodium. \\fhen reabsorp tion is blocked, more sod ium issent into Ihe urint'. Tht'
most common side effect of HCTZ is elec trolyte sodium
and potass ium depletion. The patient's potassium level is
decreased at 2.8 mEq/ ml. Administering HCTZ eQuid further deplete the p~tie nt's po tassium level. Cognitiw Lew ':
Analysis. NIl"i ng Prouu: Diagnosis. Alti'"t Nud: PhysiOlogical Integr ity.
3 Answer. 2
Rarionllle: The advantage o f using two drugs is that lower
doses of each m~y be used. resulting in fewer side effects.
Compliance will iocll'ilSe due to fewer u nromfortable side
effecls. Cognit ive Lew': Appliation. Nursing PrOctu: Plan ni ng. Putie nt Nd: Physiological Integrity.
4 Ans....er: J
Rationale: ACE in hibitors block the effects of angiotensin II ,
decreasing blood pressure through two mechanisms: lowering peripheral resist ance and de<:reasing blood volume.
Cog,.iti,e Le.e/; Appl ic ati on. Nursing ProceS$: Assessmen t.
Pafienf Need: Physiologic:ll iotegrity.
5 A.u .....rs: 2, 3, 4, 5
Side effects of ACE inhibitors include pers istent ,o ugh and
postural hypoten sion. Hyperkal emia may occur and can bt'
a major concern for those with diabeles o r renal impairment and in patients taking potassium-sparing diuretics.
Though rare, the most ~ rious adverse effect of ACE in~
hibitors is the development of a ngioedema. Cogfl itivt Lele':
Analysis. NllrJillg Proc:eJS: Assessment. Pa tiem Need: Phys~
iological Integrit y.

6 AIIsw.>r. 2
Ratiunillc Propranolol and other ~ta-blocking drugs are
used to preven t ll'f1ex tKhycard ia that may occ ur as a reo;uJt

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TraditionaUy, if the patien t has a systolic blood p ressure of

less than 110 mmHg, the dose should be held unless verified with the health ca re provider that the dose should bt
given. The patient is on a low-sodium, low-protein d iet.
which may oontribute to hypotension. Beause the pa_
tient has mild rena! failure, the excretion of the drug may
be prolonged and also co ntribut e to the hypotensive effects. If the health care provider wan ls th e patient to re_
ceive the benuepril (Lotensi n), then th e blood pressure
should be rechecked at 30 minutes and 60 minutes after
the mediution is given. The patient sh ould be cautioned
about postural hypotension.
2 Atenolol (Tenormin) is ~ beta, -~dre nergic blocker Ihal
works directly on the hea rt. The nurse and the palient
need to be aware that the patie nt's hea rt rate will rarely go
above 80 beats per minute beca use of the action of lhe
medication. Tachyardia is one of the adrenergic signs of
hypoglycemia that would not be evident with this pa tient.
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 ~ evident 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 o f a case in whim t2Q/80 mmHg is
not necessarily an ideal blood pressure readi ng. Typically,
the blood pressure is not lowered below 160 mmHg systolic. 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> ReviewQ uu tioM
I Amwers: J, 4
Riltiollale: Digoxin helps increase the contractility of Ihe

heart thus increasing ca rdi ac o utput. The heart rale will decrease with the use of d igoxin . Cogni,;.'f! Level: Analysis.
Nursing Process: Evaluation. "",ient Nud: Physiological
Integrity.

812

AppooolxO

2 NISWtr: 1

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.

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. N llrsing Procns; Im plementation.
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/: Anal~is.
Nursing Process: Implementation. Patient Need; ph~io
logical Integrity.

This diabetic patien t needs 10 be educated about the importance of regular glucoSl' checks, bKause this medication may cause the blood suga r to vary spoooiolly.
Typically, hypoglYCl'mia is more of a problem. so the patient Deeds to be especially aware of the symptoms and
treatment of hypoglycemia. Safety should be emph.asized.
especiaUy regarding postural hypotension.

4 Answer: 1

Rntionnle: Po tassium levels should be closely monitored.

Encouraging die eating of foods rich in potas.5ium could
help maintain potassium levels. Cogn;ti"" Le."f: Ap plication. Nursing Process: PLanning. Pn'ien' Need: Physiological 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 diarrh~, nnd hypotension. Hyperka lemia
may occur, especially when the drug is taken concurrently
with potassium-sparing di uretics. Ccgniti''e Le l'el: Analysis.
Nursing Process: Assessment. Patient Need: Physiological
Integrity.
6 Nlswer: J

Rationale: Digoxin and other positive inotropiC drugs increaS{' myocardial contractility, allowing the ventricles to
ejed blood more forcefully and maintaining orga n perfusion. In hean failure, blood pressure may be lower than normal o r hypotensive due 10 decreased cardiac o utput and
urinary output dKlines as renal perfusion decreases. Therapeutic 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. Posith"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: Implementation. Pa';enJ Need: Physiological Integrity.

Answers to Critical Thinking Q uest ions

The nurse shou ld 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 patil'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

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Chapter 25
Answers to NCLEX-RN- ReviewQuest io ns
1 AnSloO'er: 2
Rationale: At the initial onset of chest pain, sublingual nitroglycerin 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 shou ld seek medienl 3s&istanee.
Cognitive uw/: Application. Nurs/llg Procell; Impl ementation. Patient Need: Ph~iologic:al lntegrity.

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: P~iologicallntegrily.
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 relax arterial and venous ~mooth 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 transdermal patch for 6 to t2 hours uch day or withhold the
night-time dose of the oral medications to delay the development 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 drugfree interval. Cognitive uve/: Appli~tion. 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 p~tient is hypotensWeor if th l' heart rateis below 60 bealS per minule. Once nitrates are administl'red, blood pressure must be monitored,
because hypotension may occur. Documenl~tion of interventions and outcomes is essential to the patient's health history.

Appendix D

Cognitive Le~'e/: Application. Nursing Process: Implementation. Pat ient Need: Physiological Integrity.
6 Answer: 2
Rationale: Erectile dysfunction drugs such as siidenafil (Viagra), 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 recognized as useful for the treatment of anginal pain. These
drugs do not oontain nitrates and do not lead to nitrate tolerance. Cognitive Lel'el: Analysis. Nursing Process: Implementation. Patient Need: Physiological Integrity.

Answers to Critical Thinkin g Q uestions

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 postural 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 (Ca rdizem) 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 monitorwith frequent monitoring of blood pressure.

Chaptlu 26
Answers to NCLEX-RN'" Rev iewQuestions
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. Patient 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, noting any changes. The nurse should also teach the patient to

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8 13

monitor the pulse for rate and regubrity, before sending the
patient home. The nurse is monitoring for the therapeutic effects 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 related to the type of drug given and any effects on cardiac output, but frequent output monitoring is not indicated in
routine antidysrhythmic therapy and will not assess for therapeutic drug effects. Cognitil-e Le~-el: 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 weakness. Cogn itive Level: Anal)l5is. Nursing Process: Assessment. 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 hypertension 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: Imple~
mentation. Pat ient Need: Physiological Integrity.
6 AlI5wer:4
Ratiol/ale: Potassium channel blockers such as amiodarone,
like other antid)l5rhythmics, may cause significant bradycardia 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: Assessment. Pa tient Need : Physiological Integrity.

Answers to Crit ical Thinking Q uestio ns

Propranolol (Inderal) is a nonselective beta-adrenergic
blocker, which means it acts on both the intended system (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 propranolol.

8 14

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."cicity 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 (Cordarone) slow the heart rate, the patient must be monitored 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 verapamil (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 ,onsciousness. The patient needs to be taught how to recognize 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 Iidocaineis I to I.:; msfkg IV every) to:; Llunutes up to a maximwn 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 bolus dose. Nurses should never proceed with drugadministration 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 thrombin. 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; AHlj""agul~llls du Hul ~hallg~ Ih" vi,~u,jly 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, including 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 medications without first consulting the health care provider
and recognizing the signs and sym ptoms of bleeding.

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Enoxaparin is given to prevent development of ovr. Patients should be taught signs and symptoms of ovr to observe for and should contact their health care provider
immediately if these develop. Cognitive Le~-eI: 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 adequate 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 rapidly 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 respirations, and temperature elevation of lOO.8F are not symptom.,> of adverse eff""t~ dir""t1y attributed to thrombolytj~
therapy. Cog nitive Le~-e/: Analysis. Nursing Process: Assessment. 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 antiplatelet and anticoagulant drugs do not prevent emboli
formation. Thrombolytics dissolw existing blood clots.
Cognitive w-e/: Analysis. Nursing Process: Implementation. Palient Need: Physiological Integrity.
Answers to Cr itical Thinkin g 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 hemorrhagic; 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 patient 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 formation of a large (and often initially occult) hematoma in
the abdomen.

AppendlxD

Answer to Avoiding Medication Errors

Most health care providers recommend that mothers not
breastfeed while taking warfarin (Co wnadin ). 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 preparations are used. In addition, extra fluid and fiber will help prevent 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: Implememation. 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 erythrocyte prodnction. The primary signal for the increased
secretion of erythropoietin is a rednction in oxygen reaching the kidney. Cognitive Le~e/: Analysis. Nursing Process:
Assessment. Patient Need: Physiological Integrity.
3 Answer: 2

Rationale: This medication does not cure the primary disease 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; Analysis. Nursing Process: Evaluation. Parie"t Need: Physiological 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: Assessment. Pa tient Need: Safe, Effective Care Environment.
5 Answer: 2

Rationale: Filgrastim stimulates granulocytes (\'/BO;). Filgrastim does not stimulate RBC production or enhance/
replace electrolytes. Cognitil-e Levet. Application. Nursing
Prouss: Implementation. Patient Need: Physiological Integrity.
6 Answer: 1

Filgrastim stimulates grannlocytes (W BCs) and is used in

the treatment of conditions such as cancer and in HIY. The
patient remains at risk for infections nntil WBC counts increase. 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: Im plementation. Patient Need: Physiological Integrity.

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815

Answers to Critical Thinkin g Questions

Patients with chronic renal failure often have decreased
secretion of endogenous erythropoietin and therefore require a medication such as epoetin aIfa (Epogen) to stimulate RB C production and reduce the potential of
becoming anemic (or to decrease the effects of anemia).
Teaching points should include the importance of monitoring blood pressure for hypertension. Side effects such
as nausea, vomiting, constipation, redness/pain at the in
jection site, confusion, numbness, chest pain, and difficulty breathing should be reported to the health care
provider. The patient should also be instructed to maintain a healthy diet and foUow any dietary restrictions necessary 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 potential for GI upset. Constipa tion is a common complaint of
patients on this medication, so preventive measures need
to be taken. The patient needs to ensure that this medication has a child resistant cap and is safely secured, because 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: Implementation. 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: Physiological Integrity.

8 16

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 difficulties. Cognitive Level: Analysis. Nursing Process: Assessment. 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: Assessment. 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 congestion may occur; changes in level of consciousness may
indicate increasing intracranial pressure due to increased
cerebral volume; and an increase in daily weight may indicate fluid retention. Crystalloid solutions may affect electrolyte 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 th"e Level: Application. Nursing Process: Assessment. Patient Need: Physio
logical Integrity.
Answers to Critical Thinking Questions
A major action of this vasoprer.sor medication is its positive inotropic effect on damaged myocardium that is having 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 pressure is well maintained, normally a systolic blood pressure 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 patient, 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.

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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 Le~el: Analysis. Nursing Process:
Implemenrntion. Patient Need: Physiological Integrity.

2 Answer: 1
Rationale: Potassium is a serious side effect of loop diuretics, and this is a serious concern for patients being treated
with digmin (Lanoxin). Cognithe Le~el: Analysis. Nursing
Process: Evaluation. Plltient Need: Physiological Imegrity.
3 An5'i"er:.J

Rationale: Rapid excretion of large amounts of fluid predisposes 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 diuretics. Diarrhea can be associated with hyperkalemia.
Cognitive Le~"el: 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 decreases 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 (Di~mox) is used to
decrease intraocular fluid pressure patients with openangle 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 Le~"el: Application. Nursing Process: Assessment. Patient Need: Physiological Integrity.
6 Aflswer;4
Rationale: ACE inhibitors or ARBs taken concurrently with
potassium-sparing diuretics increase the risk of hyperkalemia. NSAIDs are used cautiously with aU diuretics because 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 antagonisi =mmonlr pre:s.:;ribed for hypertension. Because

Appendix D

some patients do not respond adequately to monother~

apy, a drug that offers combined thernpy, Hyzaar, is
added. Hyzaar combines losartan with hydrochlorothi~
azide, a diuretic. This combination decreases blood pressure initially by reducing blood volume and arterial
resistance. Over time, the diuretic is effective in maintaining 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 measurement of hourly outputs. Daily weights should be obtained. Edema should be evaluated and documented, as
well as status of mucous membranes and skin turgor. Because 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 surgery. 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 promote 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 in~
take. Cognithe Len/: Analysis. Nursing Process: Assessment. 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-

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817

fied of any elevated lab values. Cognitive uw/: Analysis.

Nursillg Process: Implementation. Patient Need: Physiological Integrity.
4 AlIJwer: 4
Rationale: Hyperkalemia, a serum potassium level greater
than 5 mEq/L, predisposes the patient to cardiac and musde irregularities such as cramping in the calves, paresthesia 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: Physiological 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 assessment is needed to determine other signs or symptoms
that may be present. Checking dietary history may be considered after the nursing assessment is completed. Changing
diet or medicatioru is part of the collaborative treatment
plan with the health care provider. Cognitive Level: Analysis. Nursing Proccss: Assessmcnt. Patiellt Need: Physiological 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 dysrhythmias. KCI is indicated for patients with low potassium
levels and is preferred over other potassium salts because
chloride is simultaneously replaced. The nurse administering 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 assium oVl'rdose include mental confusion, weakness, listlessness, hypotension, and ECG abnormalities. In a
patient with heart disease,cardiac monitoring may be indicated during potassiwn infusion. Students should consult 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 institutions require that any solution containing KCI be administered using an infusion pump. Prior to beginning and
throughout the infusion, the nurse should assess the patient's renal function (BUN and creatinine levels). A patient with diminished renal function is more likely to
develop hyperkalemia.

8 18

AppeoolxO

2 The patient may be considered dehydrated despite her ap pearance as indicated by her elevated hematocrit and hemoglobin (~hemoroncentrationn ) . 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 instructed to take oral potassiwn sup plements to prevent
hypokalemi~.

Answe r toAvokiing Medication Er rors

Student nurses are held to the same standard as nurses
holding a license. Like the student nurse, the nursing instructor 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" ReviewQ uestions
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 hypertension are adverse effects of cydosporine therapy.
Cogni tive Lnel: Analysis. Nursing PrOU5$; Assessment.
Pa tient 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 interstitial fibrosis. The serum creatinine test is a good indicator
of renal function. Cognitive 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 immunostimulant drugs. Infection, immunodeficiency disease, and cancer

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are indications for use of these drugs. Cognitive Lewl:

Analysis. Nursing Proce5$; Assessment. PariI'm NeeiC Physiological Integrity.
5 Answer: 1
Rationale: Active immunity occurs when the p.1tient has received the vaccine. Passive immunity is achieved by directly
administering antibodies to a patient. A titer is a measurement of the amount of antibody produced after a vaccine.
Cognitive Le~e/: Application. Nursing Pro,e5$; Assessment.
Pa tient 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 immunosuppressant 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, assessment of her immune "Ystent 'M>uld h~ve been compteted at
that time. Soreness of the injected arm is a potential (mild) ad verse effect of immunizations and can be managed "Ymptomatically. 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 bleeding 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 patient 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 formofimmllllity 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 patient'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 regularly (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 Avoidin g Medicatio n Errors
Methotrelate is given for rhewnatoid arthritis in smaller doses
than when used in cancer chemotherapy. It is thought to block

AppendlxD

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"

ReviewQue~tions

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. , urin~, or .toot.; fev~r; chill. or
signs of infection; increased thirst or urination; fruity
breath odor; falls; or mood swings. Cognith'e Lel'e/: Analysis. Nursing Proc.ess: Implementation. Nursing Process:
Physiological Integrity.

8 19

current concern is the hyperglycemia- an adverse effect

of the prednisone that can become serious when the patient is diabetic. Blood pressure mltst be monitored for
potential hypertension, which is related to sodium rett'ntion and, tht'refore, increased water retention caused by
the prednisone. The patient is also at high risk for infection 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'ntialliver compromise secondary to alcohol abuse. The patient should not take ibuprofen (Motrin ) because of the
potential for gastric bleeding. The patient's stomach is aIreadyat 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 children YOlUlger than age 18. These drugs have been implicated 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.

4 Answer:4

Rationale: Monitor for development of Cushing's syndromt'

(adrenocortical excess) with signs and symptoms of bruising 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 consumption of alcohol may increase the risk of ht'patic toxicity wht'n acetaminophen is used. Rt'nal damage, thrombotic
effects, and pulmonary damagt' are not adverse effects associated specifically with acetaminophen. Cognitive Lel'e/:
Application. Nursing Process: Assessment. Patient Need:
Physiological Integrity.

.,r: '

6 Ans ...

Rationale: Aspirin and salicylates are associated with an increased risk of Reye's syndrome in children under 18, especiaUyin the presence of viral infectioru;.Acetaminophen is not
quantifiably different than aspirin or salicylates for the treatment offever. Use of aspirin or salicylates should not increase
fever although maycause nausea or vomiting related to GI irritation 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

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Chapter 34

Answers to NCLEX-RN@> ReviewQuestions

1 AnSlwr:4
\'lhen normal ho~t flora are decreased or killed byantibacterial therapy, opportunistic organisms such as viral and
fungal infectioru; may occur. The other options are not definitions of superinfectioru; although they may be adverse
drug effects of antibacterial therapy. Cognith'e Le~'e/:Appli
cation. Nursing Process: Assessment. Patit nt Need: Physiological 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 peniciUins (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 breastfeeding. Cognitive uw/: Analysis. Nursing Process: Implementation. 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 appropriate for children younger than 8 years of age. Tetracyclines have ont' oftht' broadest spectrums of the antibiotics
and are .contraindicated in pregnancy. Cognitive u~-el:
Analysis. Nursing Process: Implementation. Patient Need:
Phj1Siological Integrity.

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 medic~tion is t~ken. Fluoroquinolone. h~ve 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.
Pa lienf Need; Physiological Integrity.
5 Answers:l,2,J

Rarionale: For the 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 therapy 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 successful therapy. Cognitive Level: Analysis. Nursing P rocess:
Implementation. Pa tie'" Need; Physiological Integrity.
6 Answer: 2
Penicillin antibiotics may significantly decrease the effectiveness 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 Q uestions

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 infections 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 secondary priority is hearing assessment. because ototoxicity is
common for patients on gentamicin.
Answerto Avo iding Medication Errors
The nurse should have questioned the health care provider
regarding Bactrim, which contains sulfamethoxa.wle. Because the patie nt 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 ~nd result in symptoms such

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asa rash or hives. In severe cases,bronchospasm and cardiovascular 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 NC LEXRN* Review Questions
I Answer: J
Rationale: Systemic antifungal drugs have little or no antibacterial 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. Pa tient Need : Physiological Integrity.

2 Answer: 2

Rationale: The patient needs to be assessed for pre-existing

cardiovascular disease. and an ECG should be done. Quinine therapy does not require a consent to be signed, but education is needed. All medication should be continued
wtless otherwise specified. Cogniri,-e Level: Analysis.
Nursing Process: Imptementation. Pa fiem Need: Physiological Integrity.
3 Answer:4

Rationale: Chloroquine (Aralen) is the classic antimalarial

for treating theacute stage. Proguanil (Paludrine) is the prototype antimalarial for prophylaxis. Rizatriptan (Maxalt) is
used in the treatment of migraines. Cognilhe Level: Analysis. Nursing Process: Implementation. Pa fie m Need: Physiological Integrity.
4 Answers:I,2,J,4
Rationale: Play habits and hygiene of children can contribute 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 sandboxes that are left uncovered. Children should also wear
shoes when outside playing to prevent skin invasion.
Cognifive Lew:l: Analysis. Nu rsing Process: Implementation. Pa fient 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 excessive 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 metronidawle. Cogn ifhe Levtl: Application. Nursing Process: Implementation. 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

sexual partne1'5 do not usually require treatment for Giardia

infections unl ess they are also expe riend ngsymptoms. The
entire COUl'5e of metronidazole therap y should be completed, even if sym pto ms are diminished or absent, to ensure adequate treatment . Cognitiv, uvel: AppliC3tion.
Nursing Process: Imple mentation. Ptllienr Nud: Phys iologiad Integrity.
Answers to Critica l Thinking Qu~tio n$
A5 always, the ABCs are a priority for any patient and
mustbe considered. Thenu rse must monitor the pa tient's
airway for evidence of bronchospasm or d ecreased 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 priority. The patient"s renal status (urine output, serum
BUN, and creatinine) also must be dosely monitored because approximately 30% of patients o n this media tion
suffer renal dama ge.
2 This patient has vaginal ca ndidiasis.so it must be stressed
that her partner be treated co ncurrently or reinfection
may result. Alcohol mu st be avoided while on this medication to prevent profound vomiting. It is important to
stress that alcohol is found not o nly in alcoholic drinks
but also in products s uch as cough medicine, vanilla extmct , 3nd "",en in perfume that is absorbed via the skin .
3 This drug can have profound adverst elfe<:ts, and the patient 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 pressure aMeSSment, liver and renal funct ion tests, and a hearing and visual assessment screening. B:aUSl!' the patient
may suffer permanent organ damage while taking this
medication, Nseline inform ation is crucial.

sis. Nursi"8 Process: Impleme ntation. Pulien! Netll: Phys iological Integrity.
4 Ans"'1Ir: 2
Rilrionale: Oseit3mivir (Ta miflu) and unam ivir (~ lenu)
are availab le and may preve nt the flu or if taken within
48 hours of symp toms, may limit the length of the d isease.
Immunity begins approximately 2 weeks after immuniuoon. Vaccination is recommended (or high -risk populations
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.
AnSh'1lr: J
RatioMle: Neurologic adverse effects may occur b ut dizzi_

ness, sleep disorders, nightma res, and diffi cul ty thinking

dearly tend to improve after } to 4 wks. Neurotoxici ty ma y
occur and increasing confusion, delusio ns, or seizures
should be reported immediately. Drugs for HJV-AIDS help
limit the viral load and maintain a longer symptom -free period. All drugs used for HiV-A1D S have significant ad vel'5e
effects. Taking efavirenz (Sutiva) with a high -fa t meal may
increase its absorption by as much as 50%, leading to to){icity. Cogni,ive Ln'd: Application. NUrl;ng Process: Implementation. PIl,ie,,' Need: Phys iological Int egrit y.

Answers: I, 2
Rationale: Acyclovir ca n be renal to.tic and fluids should be

increased throughout the mp y. Neurotoxicity may occur

and increasing dizziness, tremors, o r any confusion should
be reported immediately. Fluid intake soould be increased,
not dec reased , and the drug must be taken consis tentl y
throughout the entire (()urse of ther.lpy. Suppress ive thn_
apy may also be ordered. Cogniti."t' Level: Application.
Nursing Process: I.mplementa tion . Putient tktd: Physiological Integrity.
Answers to Crit ia l Thinking Qu estions

Chap ter 36
AnS1o'>'ers to NCLEX.- RN. Review Questio ns
I Answer; 2
Rationale Drug th enpy 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/; AppliOitio n. Nursing Process;
Implt'mentation. Pu,iell' Need: Ph ysio logiOlJ Integrity.
2 Ans"'1Irs: J, 4

Rationale: Two laboratory tests used to guIde pharmacotherapy are an absolute CD4 co unt and an HIV RNA
measurement. Clotting factor3 and a CBC do not provide
information for guiding HIV-A IDS therapy. Coglli, ive
Level: Anal ysis. Nursi"g Proc:t,,: Imple mentation. Pmie1lf
Need: Physiological Int egrit y.
3 Answer. I
Riltiorlilir. The medi cation should be take n on an empty
_tom.:ldl for m:u:imum abso rption. C"8",,;r;... L.vel, Anat y_

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The best approach to inOuenza infec tion is prevention

through annual vaccinatio n . Those who benefi t greatly
from vaccinations include res idents oflong-tenn care fa_
cilities. The drug amantadine (SynunetreJ ) is used to prevent and treat influenza. Th e nurse sho uld work with the
health care provider to obtain an o rder and make
arrangements to administer the medicatio n.
2 This medication may cause bone marrow supprCS$ion.
This patient is alreJdy immunocompromised, and the potential for leukopenia is high. The patient should be taught
to watch for any evidence of infection, monitor temperarure, 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 ca re 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 ho ur. Th. IV _it.

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 Questions
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 combination dlemotherapy is reduced ind o
dena of drug rt$istance. Cognitive
Application.
Nursing Process: Impl ementat ion. Pelt;en, Need: Physio
logical Integrit y.

un!':

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.u cerbation or a more pro
nounced episode of chi cken po~. The patient should also
avoid crowds. Cog ni,i.'e
Analysis. NIINing ProceJJ:
Implementation. Patien, Nud: Physiological Int egrity.

woe':

4 Answer: J
Rarionnle: The nurse should monitor for blood d)'Krasias
rt$u1 tingfrom bone marrow suppression by monitoring the
eBC with differential and platelet count. Cog"iti.'Ct w'Ct':
Analysis. Nursing Process: EvaI~tion. 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. Pellien l 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 alw~ys takeantiemetics
1 hour prior to chemotherapy, eat small frequent meals,
drink high-calorie liquids if unable to eat solid food, and
increase nuid s if diarrhea occu.rs.

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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 abou t 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 to 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 shou ld not be
used for longer than 3 dar.; and shou.ld be used only as di
rected. Cognitive Le.tI: Appliotion. N ursi ng Process: 1m
plementa tion. 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!;ten l.lI5e of 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 ca use 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 ~dministration, not af
terward, so that medication remains in the n:J5al cavity. Any
excess that drains into the mouth must not be swa llowed
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 sho uld not be used in patients

App<>ndlx D

with a history of prostatic hypertrophy. Cognitive Lele/:

Analysis. Nursing Process: Assessment. Pmie", Need: Physiological 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 calcula ted to provide precise dosing for age and
symptoms. Antibiotics may Ix> required for serious infections 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/: Applicatio n. 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 effects 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 passages, 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 (capsules) must Ix>swallowed whole and not be chewed or pUIlCtured 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 arrest. 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 delivers medications to the immediate sites of action, thus re-

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823

ducing systemic side effects. The main disadvantage is that

the precise dose receiwd by the patient is difficult to mt'asure 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 bronchodilation that lowers airway resistance and makes breathing 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 instructed to seek medical attention if the drugs become less effective 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: Implementation. 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 diarrhea have no relationship to the use of ipratropium.
Cognitive Lele/: Analysis. Nursing PrCKess: Implementation. Patient Need: Physiological Integrity.
5 Amwers: J, 4
Rationale: If taken for longer than 10 days, oral glucocortiooids can produce significant adverse effects, including adrenal gland atrophy, peptic ulcers, and hyperglycemia.
Long-tern} oral glucocorticoids can cause osteoporosis.
Changes in level of consciousness rna)' be related to oxygenation lewis and need to be reported to the health care
provider. Cognithe Level: Analysis. Nursing PrCKess: Assessment. Patient Need: Physiological Int egrity.
6 AlI5wer. J

Rationale: Beta-adrenergic drugs such as a1buterol

(Proventil, Ventolin) are most often used for rapid bronchodilation. Glucocorticoids such as bedomethasone,
leukotriene modifiers such as zileuton, and long-acting
beta agonists such as salmE1:erol may be used for maintenance 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 Thinkin g 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

824

Ap~r.dlxO

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
sid e 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 001lapse. lbe patient nefds to be instruCloo on the dosa~
regimen for prednisone, which tn;Iy indudean incremental dec rease in the drug dosage when discontinui ng the
drug. The patient should be monitored for hyperglycemia, peptic ulcer d isease, signs and symptOIll5 of GI
bl~ing, 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 ~ter after exh U5I!' (especially
after U5ingsterold ml1.alers,De<:ause thedrug may cause
fungal infections of the mouth and th roat).

Chapter40
Answt'r's to NCLEX-RN- Rev iew Quest io ns
1 Allswer: J
Rationale: Antacids are generally oombinations of aluminum hydroxide and magnesium hydroxide. Hypermagnesemia 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 complicatio n of renal
failure. Hypernatremia can occur with use of antacids.
Cognitive Levt/: Analysis. NIJ"ing Proreu: Im plementation. Patient N~'ed: 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. N ursing Process: Implementation. Pillien' Need: Physiological lntegriry.

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3 Answer: 1

Rationale: Simethioone is used along with other GI drugs or

alone to decrease the amount of gas bubbles that accumulate with GI disorders or indigestion. Simethicone will not
affect the acid-fighting ability of medications, or prewnt
constipation or diarrhea from developing. Cog"iti ~e Level:
Application. Nursing Process: Im plementat ion. Patient
Need: Physi01ogicalln tegrity.
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"it;.-e Le.'tl: Analysis.
Nu rsi"g Process: Implementa tion. Patien. Need: Physiological 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 su pplements
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 stomach. For the TFF2 protein to reach its maximum
effectiveness, the person n~s a minimum of 6 hours of

AppendlxD

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 drowsiness in combination with ranitidine. 1his patient should
IX' advised to stop smoking and drinking alcohol if PUD
is to be resolved.
Chapt8r41

Answers to NCLEX-RN~ ReviewQ uestions

I Answer: 1
Rationale: When contents lost from the stomach are
strongly ~cidic, vomiting m~y ch~nSe the pH of the blood,
resulting in mt'tabolic alkalosis. With severe loss, acid- bast'
disturbances can lead to vascular collapse. Patients' respirations may increase with prolonged vomiting. Esophageal
tears with prolonged vomiting occur rarely. Cognitive Le~e/:
Analysis. Nursing Process: Assessment. Pm iellt Need: physiological Integrity.

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 hypoteru;ion (i.e., reflex tachycardia). Prochlorperazine does not
directly affect llUlg solUlds or temperature. Cogn itive l.el"el:
Application. Nursing Process: Implemenilltion. Pa/ient
Need: Physiological Integrity.
Answers to Crit ical Thinking Q uestio ns
A priority for the nurse is to assess the potential for dehydration. The nurse should assess the patient for possible
hypotension and tachycardia. The cause of this ongoing diarrhea 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.

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.
Pa tient Need: Physiological Integrity.

3 This patient needs to take a contact laxative to stimulate

the nerve endings and fJcilitate a bowel movement. A
bulk-forming laxati~ promotes bowel regularity. The liquid stool may be a result of fecal impaction, in which only
liquid seeps out. If this patient has ongoing bowel irregularity 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.

3 Answer: 1
Rationale: Stress is one of the major factors in developing
IBS. HelicoblKter pylori is associated with developmem of

An swers to NCLEX-RN" ReviewQ uestions

2 Answer: 1

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. Loperamide (Imodium, Kaopectate) and diphero:tylate (LamotiI)
are antidiarrheals. Cognitire woe/:Analysis. N ursing Process:
Implementation. A llient Need: Physiological Integrity.
5 Answers:l,1,J,4
Rationale: Sibutramine (Meridia) is a CNS agent that iscontraindicated 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. N ursing Process:
Assessment. Patielll Nted: Physiological Integrity.
6 Answer: 1
Rationale: ProchJorperazine may cause decreased blood pressure or hypotension as an adverse effect. The blood pressure

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ChaptQr 42

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. Perniciou, anemia affect.. vitamin D" absorption. Cog"i/;. ....
Le~el: 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 receivingmagnesium 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 aperiencing hypomagnesemia may experience general weakness, dysrhythmias, hypertension, loss of deep tendon refiexe;,
and respiratory dt'J'ression. Cognifive Level: Analysis. Nursing
Process: Assessment. Patient Need: Physiological Integrity.

826

AppeoolxO

4 NISWtr: 4
Rarionale: Alcohol is known for its ability to inhibit the absorption 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-

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: Physiological Integrity.

pro~

3 Answer: 2

6 Answer:J

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 deficiency. Myxedema is related to hypothyroidism. Cushing's
syndrome is caused by excess gluCQCortiooids. Cogniti\'e
Level: Analysis. Nllrsing Process: Assessment. Patient Need:
Physiological Integrity.

clotting. \Vithout vitamin K, abnormal prothrombin

is produced and blood clotting is affected. Cognitive Lewl:
Analysis. Nursing Process: Implementation. Patient Need:
Physiological Integrity.

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 dra inage and all tubing
and bag for signs of cracks, cloudiness, or precipitate. Glucose le~ls 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 Pr"C~": 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. Vitamin 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 contraindicated in patients with a history of renal calculi because the vitamin may exacerbate the problem.
Chaptllr43

4 Answer: 2
Rationale: The patient may have the hormonal condition
hyperthyroidism. Symptoms of hyperthyroidism include
diarrhea, stress intolerance, and weight loss. The other disease processes are not related to the thyroid gland. Cognith...
Level: An~lysi . 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. Radioacti~ iodine is used to permanently decrease thyroid
function. Patients may experience hypothyroidism, including signs and symptoms such as general weakness, muscle
cramps, and dry skin. Ruids do not affect radiation levels.
Cognitive Lewl: Application. Nursing Process: Implementation. 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 present, 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

Answers to NCLEX-RN~ ReviewQuestions

1 Answer: 1

Rai1onale: Glucocorticoidscan incre3S(' the risk of pepticulcers, 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: Implementation. Patient Need: PhysioloJ!;icai InteJ!;Tity.

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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. Desmopressin is a synthetic analog of ADH. It may be administered intranasally and therefore maybe better tolerated by
a child. With pharmacotherapy, there should be an inune-

Appendix D

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 indicate that the kidneys are concentrating urine. The caregiver 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 instru, 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 regimen 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 fmancial 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 cellular size.
b. Instructions for reconstituting the medication, site selection,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 opportunity 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 u~'e/: Applica-

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827

tion. Nursing Process: Assessment. PtlIienf Need: Physiological Integrity.

2 Answer: I

RatiO/wle: Humalog is a rapid-acting insulin that is administered 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 sufficient food intake. The medication can be mixed in one syringe. Cognitive Le~er: 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 followed 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 Le~"el:
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 insulin, 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 medications 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 condition.lt is not within the nurse's scope of practice to independently 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 carried out. Cognifh'e Le~'e/: Application. Nursing Process: Implementation. 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 discharged. 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. Immediate changes in response to an oral hypoglycemic drug are
not known and diabetics may continue to take all-oral medications while in the hospital. Cognitil"e Levtl: Application.
Nursing Process: Implementation. Patient Need: Physiologicallntegrity.

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 diabetes 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 pregnancy. These complications can range from fetal deformity
to fetal macrosomia and its subsequent sequelae. Someauthorities 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 placental membranes and have been impliClted as teratogenic
agents. Their use is not reoommended during pregnancy.
2 Beta-blocking drugs such as propranolol have the potential to affect type II diabetics on oral hypoglycemics byaltering the way hypoglycemia is perceived. In recent
studies, hypoglycemia was perceived differently in patients taking concurrent beta-blocker therapy than patients who were not. Diaphoresis was a common
symptom when blood sugar decreased among those patients 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 normally 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 recombinant hwnan insul in analog. It must not be mixed in the
syringe with any other insulin and must be administered
subcutaneously. Insulin glargine appears to have a constant 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 administered every morning.
Chaptlilr45

Answers to NCLEX-RN~ 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. Cogn iri~-e 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

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cause water intoxication in patients with prolonged IV infusion 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 include intolerance to contact lenses, abdominal cramps, dysmenorrhea, 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 common cause of pregnancy in patients using oral contraceptives is skipping two or more doses. Cognirh-e Le~e/:
Analysis. Nursing Process: Implementation. Patient Need:
Physiological Integrity.
6 AIISIWr:

Ratiollale: Infertility may result from physical obstruction,

pelvic infections, or endocrine-related reasons resulting in
lack of ovulation. If a fertility workup suggests that infrequent or anovulation isa primary cause, clomiphene may be
tried to increase ovulation and is approximately 90% effective for patients with ovulatory-related infertility.
Clomiphene will not be therapeutic if the causes of infertility are other than lack of ovulation. The risk of multiple
births is higher with ovulatory stimulants with approximately 25% resulting in multiple births. Contraceptives do
not continue to suppress ovulation after they have been discontinued. Cogllitile Le~e/: Application. N ursing Process:
Implementation. Parient Need: Physiological Integrity.

Answers to Critical Thinking Questions

The student should be able to use this example to help illustrate neuroendocrine control of the female reproductive system. Leuprolide acetate is a synthetic GnRH
agonist that acts by stimulating the anterior pituitary to
secrete FSH and LH. The pituitary receptors become desensitized, which causes a decrease in FSH and LH secretion. Consequently, estrogen production, which is
dependent on ovarian stimulation, is diminished and the
patient"s menstrual cycle is suppressed. The goal 01 suppressing the menstrual cycle is to decrease hormonal
stimuli to abnormal endometrial tissue. It isexpected that
~menorrhea 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 therapy for approximately 6 months. Menstrual periods usually resume 2 months after the completion of therapy.
2 Misoprostol (Cytotec) isa prostaglandin that maybe prescribed as an antiulcer agent. The drug also has two offlabel uses, which include cervical ripening prior to

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 demonstrated with the vaginal application of prostaglandin E.
Misoprostol is a prostaglandin E analog that has clearly
been demonstrated to produce uterine rontractions. In
this exam ple, the fetus was not tolerating the uterine rontractions and the nurse used correa judgmenl in quickly
acting to remove the drug.
3 Oxytocin exerts an antidiuretic effea when

adminis~

tered in dosesof20 milliunitslminor greater. Urine outpu t decreases, and fluid retention il'l(reases. Mon
patients be-gi n a postpartum diuresis and are able 10 balance fl uid volumes relatively quickly. However, Ihe nurse
should evaluate the patient for signs of water inloxica
tion, which include drowsiness, listlesmess, h.-adache,
~nd oliguri~.

Chapter 46
An swers to NCLEX- RNe RevitwQ uestions
I AllsIi'ers:2,J
RatiOlwle: A side effect of testosterone therapy is fluid retention. Testosterone is also used to increase muscle mass and
strength. The hem~tocrit usually increases with the use of
testosterone, because it promotes the synthesis of erythropoietin. Cogn itive Le"d: Analysis. Nu ,.,in8 ProceJS: Assessment. 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: characteristics or viriliution also occur. o,gniti>le Level: Analysis.
NUN'''g Proceu: J\ss<,ssment. Pat i<,n l NeM' I'hylIiological
Integrity.
3 A"s....er: J
Rationale: In men, some medications such as phenothiazides, thiazide diuret ics, SSRls, TCAs, propranolol, and di
azepam cause impotence beause of low testosterone
secretion. Cog"i'ive Level: Analysis. Nu rsing Prouss: As
sessment. PIl';en' Nttd .' Phys.iologi~J 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: Assessment. 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 d~func~
tion. Testosterone is used in the treatment of hypogonadism. Cog"i.iv, le1'd: Analysis. NurJi"s ProcesJ:
Implementation. Altie"t Need: Physiologkal!nlegrity.

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.. 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 trade
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 Q uest io ns

This patient's age puts him at risk for a variety of health
problems. Conditions such as renal o r hepatic dyfunc tion
mayaJter the manner in which the drug is metabolized or
excreted. The poten tial 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
effective in initiating co nversations about sexu~[ity. Studies have shown that p~tients are often forthcoming with
concerns about sexual performance when an interviewer
is open and professional.
2 A.:oording to Erikson's theory of psychosocial development, this young man is in the stage of identity versus isolation. 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 ~n increase has been docu
mentedonly in mature men. In addition, testosterone can
prod uce premature epiphyseal closure, potenli~Uy affect
ing this )Qung man's adult height
3 Finasteride (Prosca r), an androgen inhibitor, is used to

shrink the pros tate 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 d ivide.A regimen of6 to 12 months may be nt'Cessary
to determine patient response. Saw palmetto is an herbal
prepa mt ion derived from a shrublike palm tree that is na_
iive to the southea~tern United States. This phytomedicine co m pares 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 significant adverse effeas of saw palmetto e.'ttract and no
known drug-drug in teractions. Just as with fin.asteride,
long -term use is requi red.

8 30

Ap""O>dlxD

Chaptlr47
Answers to NCLEX RN_ Rev iew Que~tio n s

] Answer: J
Rationale: Osteomal3da, referred to as r!eke" in chi ldren , is
a disorder characterized by softening of bon es without alteratio n in basic bone structure. Classic signs o f rickets in
child ren include bowlegs and a pigoon b re4lst. Shortness of
b reath, crutch walking, and finger and toe deformities are
not associated with 05toomalacia. Cognitive wei: Analysis. N ursing Process: Assessm~nt. Patien, Nud: Physiological lntegrity.
2 Answer: 1

Rationnle: A normal ~rUln caldlUn level is 8.5 to 1]5 mgJdL

Sigru; of hypocalcemia ioclude ~izures, mu.sde spasms, facial
twitching, and paresthesi;l..s. Anorexi.a, headache, and drowsi
ness may be associated with hypercalcemiol. Cogn ilive Le ..r l:
Analysis. Nursing P rocrS$: Assessmen t. 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! cavities. Alcohol increases uric acid levels. Although long ternl
alcohol use ma y affect the liver, it is not related to uric acid.
Alcohol does not affect th e absorption of antigout medica
tions. Alcohol increases urine acidity. Cogn itin : L ..el:
Analysis. Nu rsing Process: Assessment. Pt,tient Need: Physiologicallntegrity.

4 Allswers: J, 2, J
Rationale: Signs and sym pto ms of hy~rcalcemia includ e
anorexia, vomitin g, excessive thi nt, fatigue, and con fu sion.
Kidney sto nes may IXcur, and bones may fracture eas ily.
Cardiac dysrhythmias may IXcu r, because calc ium ions
influena the elICitability of all neurons. Whenever calcium
concen trations are too high, sodium permeabilityd~reases
:Kross cell membranes. This is a dangerous state, because
ner..-e conduction depends o n the proper influx of sodium
into cells. Cognitive Lew/: Analysis. Nursing ProUfJ: As
....... tn~ n t. Pat;~n t Nd: PhY3iologkallnt egr ity.
5 Answer: 2
Rationale: Sodium hyalurona te (HyalganJ is administered
by injection directly into the knee joint. This med icatio n reo
places or supplements the body's ru.tural hyaluronic acid
that deteriorated be,ause of the inflammation of osteoarthritis. AU other routes are incorrect. Cogniti,-e L"e/:
Analysis. N urs ing Process: Implementation. Pa lient Need:
Physiological Integrity.

6 Answers: 2, 1, "
Rationale: Bisphosphonates such ll5a lendrona te require the
patient to tau th e drug on an empty stomach and remain
upright for 30 minutes to J hour. Adequate serum calcium
levels should l>econfinned before starting bisphospho nates
and adequate calcium and vitam in D intake should be encouraged while on drug therapy. Any narrowi ng of the

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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.
Nu rsing Process: A.s.sasment. Pat;ent Need : Physiological
Integrity.
Answers to Critical Thinkin g Qut$tio ns
A1endronate ( Fosamu ) is poorly absorbed afier oral ad ministration and can produce significant G I irritation. It
is important that the patimt be educated regard ing sev
eral elements of drug administration. To promote ab5Orption, 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 ea ti ng
for 30 minutes or more, the pa tient is promoting abso rp
tion of the drug. Additionally, the patient sho uld be
taught to sit upright afier taking the drug to reduce th e
risk of esophageal irritation. Alendronate must be used
carefully in patients with eso phagitis or gastric ulce r. If
the patient misses a dose, she should be told to ski p it and
not to double the next do~. 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 physicallimilatioru, and is not able
to g<'l out of the house into the sunshine without assistance. Orally administered calci um requires vitamin D
for absorption to take plxe. Because this patient does not
coru;ume milk, the most recognizable sou rce of vitami n
D, she needs to be encouraged to increase her intake of
other dietary sources o f th is vitamin. Foods rich in vita
min D include canned salmon,cereals, ~an 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 o f
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 calc uli ma y also be predictive of acute gouty arthritis. The nurse sho uld 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 nur~ should obt ain informat ion
about prescribed drugs and the use of OTC drugs co n
taining salicylates. Thiazide diuretics and salicylates can
precipitate an attadr.. The nurse shou ld :also ask about reo
cmtlifestyle events. Stress, illness, trauma, o r strenuous
exerci~ can precipitate an attack of gouty arth ritis.

App<>ndb<O

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 respond to calling them by name. When there are two patient:!
with similar names, it is particularly important to doublecheck 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, patients 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 isolation. Linens should be washed with hot water; bleach is not
required. Cognithe Ln-el: Analysis. Nursing Process: Implementation. 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 convulsions. Eye irritation does not occur with over:lpplication.
Cognirive !.nel: Analysis. Nursing Process: Implementation. Pmirnt Need: Physiological Integrity.
;, Answer: I
Rationale: High -potency corticosteroid creams such as fIuocinonide 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 temperature until the e."lpiration date unless there are signs of discoloration 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 antigenic material and the body's reaction depends on the antigen-antibody response, not necessarily to the antigen itself.
Cognitive Lele/: Application. Nursing Process: Implementation. Patienr Need: Physiological Integrity.

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83 1

4 AnSlwrs: 2, J, 4
Rotionale: Washing the face gently with a mild soap and using 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 ~evere , kin irritation or pain , hould be
reported. SWl exposure should be avoided unless specifically instructed to do so by the health care provider.
Cognitive Lele/: Application. Nursing Process: Implementation. Patienr Need: Physiological Integrity.
5 AIIS"",r: 2

Rotionale: Initial drying of the skin caused by benzoyl peroxide 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 antibiotic 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 treatment, 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 effects, 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 normal daily intake is usually sufficient to meet the body's
needs without supplementation. Cognifh-e Level: Applic~
tion.Nursing Process: Implementation. Patient Need: Physiological Integrity.

Answers to Critical Thinkin g 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 b~ a t~mptation 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 ~rea to weight compared with that of
adults. The student nurse should ensure that the health

832

Apper>dl~

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 understands 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 development. A young person in this age group is :l.ble to think
logically and make dedsions regarding health care problems and take co ntrol 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'$l' should reoosnize that this patient is l'Xperiencing GTsidl'effects that are oonunon in ~line:l.nd all
tetracycline t reatmenl. Recent studies have dl'monstrated
cast$ of tsOphagitls in teenage fXltienls. Todl'Vdop :l.n effective teadiing plan, the n urse 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 reduce 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 m eals 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 deCrl'3Se5 the absorption of the drug; therefore, other
remedies for GI irritation will need to be discussed
with the health ca re provider
3 This patient's presentation is typical of ro5;lcea. To preventlong-term changes in the skin, therapy should be ag_
gressive despite the fact thai this patient is also of
child-bearing age.lsotrelinoin (Acc ulane) is a pregnancy
category X drug and has a picture of a fet us overlaid by
theKNo~ symbo l on the package. Reported teratogenic effects indude- severe CNS abnormalities such as hydrocephalus, microcephalus, cranial nerve deficits, and
oomprornised intelligence scores.
Thi s p~tient needs 10 understand that she must use contraCl'ption while receiving drug therapy and for up to 6
momhs 3fter therapy is discontinued. She should nOI begin therapy un less she first demons trates a negative pregnancy test. In lIddition, she should be laught to begin
therapy on the second or third day of her norrnal menstrua/ cycle. Teenagers whoareon isolrelinoin should anticipate monthly pregnancy tests.

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Cha tllr 49
Answers to NCLEX_ RNII Rev iew Q u esti on s
I

A,nSh~r:

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. Pa tient Need. Ph~iologicallntegrity.
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 symptoms such as f1ulike symptom s, nuh, or headache may occur. Loss of lashes, hypertension, and dilation of the pupils
do not occur with the use of prostaglandin!>. Cogn ;t;,'/!
uvel: Analysis. N ursing 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 administration and to notify the health care provider if l'Xtremes occur. Beta-adrenergic drugs do not affect urine
output, respiratory rate, or glucose levels. Cognitivr u''e/:
Analr-;is. N urs ing Prore$S: Implementation. Patien' Neell:
Physiological Integrity.
4 Answer:4

RaNonair Some drogs are- speciflC~lIy 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 mydria tics,
because these drugs Clln worsen glauooma by impairing aqueous hwnor ou tflow and thereby increasing intraocular
pressure. Cognitive LeI'd: Analysis. Nursing Process: Implementation 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, bradycardia, cardiac failure, CHF, or COPD because timoloJ may be
contraindicated for J>lltients with these oonditions.lf thedrug
is absorbed systl'lllically, it will wo~ 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. Cogn itiOT l.e>-rI: An.aI~is. Nursing
Prouss: Assessment. Pa llent Nt'ffi: PhpiDIogicallnlegrily.

6 ,4"SWl"r.4

RJltronlllr. Conuctlenses should be nrnm'N before instiUing 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 the~ are all appropriate IKhniques to use
when administering eye drops. Cognitive Lncl: Application. NUN;nKProceu: Implementation. Ptuil.'n( Netd: Physiologicallntegrily.
Answe rl 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-tipped applica tor. Any unusual odor ordraina~
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 promote 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

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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 ~ithout aprlYins pressure. lbe cotton ball can be
removed in IS minutes.
2 limoptic. a beta-adrenergic blocking agfnl, is contraindicated in individuals with COPD. This agfnt has
been known to produce brondlOspasm by blocking the
stimulation ofbetaz-adrenergic receptors. When beta z receptors are stimulated. relaxation of bronchial smoo th
muscl es is facilitated. Timolol is contraindicated in
COPD, an air- trapping disorder, and may be contr.1indicated in chronic asthma. In bolh cases, the beta adrenergic
blocking effea of timolol could be pottntiallylife threatening. 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 conj unClivai $aC. The cornea is highly innervated, and direct
applic:Uion of medicatio n to the cornea can result in excessiVl' burning and stingi ng. Tke conjunctival sac normally holds one or two drops of solution. The patient
should be reminded to place pressure on the inner can_
thus of the ~ followin8 administration of the medication to prevent the medication from flOWing in to the
nasolacrimal duct. This maneuver helps prevent systemic
absorption of medication and decreases the risk of side
effects commonly :wociated with antiglaucoma agenl5.

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 no tations.

Dose o n hand (2.5 mg)

Des ired dose (20 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.

1: 10 means 1 part of drug A to 10 parts of

sol ution/solven t

fl. CALCULATING DOSAGE BY WEIGHT

In drug adculations. ratios are usually expressed as a

fraction:

Doses for pediatric patients are often calculated by using

body weight. The nurse must use caution to convert between pounds and kilograms, as ne.;:essary (see Table 3.2 in
Chapter 3, page 2 1). Use the formula:

I part drug A
10 parts solution

10

Body weight X amountlkg = X mg of drug

A proportion shows the relationship between two

ratios. It is a simple and effel.:tive means for !;lIkulating

certain types of doses.
Dose on hand

Desired dose

Quantity on hand

Quantity desired (X)

Us ing 'TOSS muitiplkation, we can write the same

fonnula as follow:>:
Quantity desired (X) =
Desired dose
Dose on hand X quantity on hand

E.J:am ple 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 shou ld

the nufloe adm inister?

To calculate the dosage, use the formula:
Dose o n hand (250 mg)

Desired dose (500 mg)

Quantity on hand (5 ml)

Quantity desired (X)

Then, cross-m ultiply:

25Op(gXX=5 mL X500pfg

Exa mple 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 o f amiodarone. The JXltient weighs
I 10 pounds. How much of the drug should be
administered daily?

Step I: Conve r! 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 =

Therefore, the dose to be administered is 10 mL

weight (kg) X height (em )

>600

The formula for BSA in household units is

B. The same proportion method can be used to solve

solid dosage calculations.
Exam ple 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?

."
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BSA=

\\-eighl (Ib) X heighl (inches)

3\3 1

Exa mple 5: The health ca re provide r 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?

Ap~IxE

835

Example 6: The health ClIre provider o rders 1,000 mL

Sttp I: CaJcul~ te the !!SA of the child.

of 5% normal Jalior to infuse over 6 nours. What is the

flow rate?
].OOO~ X IOglt/ .
28gt!
6 j( x 60 minf)f
min

30 X 24
3\3]

rna
BSA - "rut

BSA _ VO.2JO = 0.48 ml

Other IV convenion formulas ~ u may use include the
following:

Step 2: Calculate the drug amount.

\0 mg/m2 X 0.48 m l

mcg/kgl h ..... mL/ h

TIle nurse shou ld administer 4.8 mg of the antibiotic to

the child.

.. X -"""..
hX

IV. CALCULATING IV INFUSION RATES

mcgfml/ h ..... mLfh

~re

administered over time in units of

mllmin or gu/min (gil: drops).lbe basic tquation for IV
drug calculations is as follows:
Intravenous Buids

"'"
mL = h
mL
\,00094
X J7g

mLofsolution x gtt/mL

glt

h ohdministration x 60 minfh

min

pi

"""pi

mL
mL
P7s
= h

mcg/kgfmin ..... gil/min

kg x~x
min

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"'"

X - - h - X 1.0009>4 X

1,000 p;;?g

A..o fiben I'Ien\'$thlttnnsmlt sensations of sharp pain

Absence u izure seilurewlth a 1055 or reduction of flOfll1al attNity. inciudlngsurln& and tnm4enlloss of responsi.vm.~
Absorplto n the pr0ces5 of ll10Ying a drug KlOSS body
mombn~

Acetylcholine primary neurotransmitter of 1M pansympathc'lic IltO'OU5 system; also present .1 somatlc neuromuscular
junctions and at sympatMk pregangllonk otrvtS
Acetyk holinestel"1lSle (AchE) enzyme thai degrades atttyldJoIjot ",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 musdeor nel'l'l' cell due 10 changes In membranepermeabiUty
activatoo chaK(t;olI short_term treatment (withln60 minures) after 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
Mu te 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 resultIng 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 disease hyposecmlon of glucoconicoids and a1dosterone 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 tha t releaSl! norepinephrine or epinephrine
Adrenergic . ntago nbt druS that blCKks the actionsof the sympathetk n.ePiOUS system
Adrenoconical insuffICiency bek of adequale corticosteroid 5ecre!ion by the adrenal gland
AdreOOCOr1 icolropic hormo ne (ACTH) hormone seemed by
the anterior pitultary that stlmuJares the release of sJucoconlooids by the adrenal rorlex
Aerobic pertaining to an 0X)"8t!l envlronrnmt
Aerosol 5U5pC'llSion o( minute liquid droplets or fine solid partides in a gas

'"
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Affmity chemial allrxlion that impels cenaln Il10kcules to

unite ~ith 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 hormo~ 5t(f('Ird by the adrenal cortex that InQ'elI5t'S$Odium reabsorption in the dlsultubuJe of the kidney
Alka losis 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 defense 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"posure to allergens
AI~cia 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 neuronal <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
re~ction

Anaphylaxis acute aUersk response to an antigen that rewJ.1S In

severe hypotension and rTllI)' lead to Il(e-threatenlngshock If untreated
Androgens steroid sex homlones that pronloce the appearance
of masculine characteristics
Anemia lack of adequate numbers of red blood cells. or decreased oxysen-carrying capadty of the blood
Angi na pedoris ~cute chest pain on physiOll or enl<Mional ex_
ertion due to inadeqwte Qi[fgtn supply to the m~rdlum
Ansiotensin II chemical released In response to f.alIinS
blood pressure that ClIU5t5 vasoco nstrlction and release of
aldosterone
Angiotensin.convrrti ng enzyme (ACE) enzyme responsible
for conwrting angiotensin Ito angiotensin II
Antons negali~ challed Ions
Anore:t:aa 1055 o( appetite
Anorexiant drug. used to suppress appelite

Gto.... y

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 antigen; 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 neurotransmitters in the brain, norepinephrine and serotonin, to I'l'duce depression and anxiety
Antidiuretic hormone (ADH ) hormone released by the posterior pituitary gland when blood pressure falls or when the osmotic 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
Antipy retic 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 humo r fluid that fills the anterior and posterior
chambers of the t're
Aromata se 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 characterized by airway ob struction
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

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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 precedes 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 spontaneously generate an action potemial
Autonomic nervou s sy~tem 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, cau se 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
p~~

Basal metabolic rate resting rate of metabolism in the body

Baseline data patient information that isgathered before pharmacotherapy is implemented
basic ~upportive care one of the first elements of toxicity treatment 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 developing seizures; and management of acid-base disturbances
B cell lymphocyte responsible for humoral immWlity
Benign prostatic hyperpla sia (BPH) nonmalignant enlargement of the prostate gland
Benzodiazepines major class of drugs used to treat anxiety
disorders
Beriberi deficiency of thiamine
Beta-Iactam rin g 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 specific functions of the immu nesystem
Biologks substances that p roduce 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 ~reme and opposite moods, snch as euphoria and depression

838

Glo".ry

Bisphosphonate5 class of drugs th~t block bone resorption by

inhibiting osteoclast activity
Blood-brai.n barrier anatomlc:J.l structure that prevents certain sublitalK:es from S;Unlng access to the bf;Jln
BodymaSli index (BIIoU ) me~suremelltof obesItydttermined by
dividing body weight (in kil0Vo"ns) by the sqlUf(' of height (in
""'~)

Bone depo.oition oppo:lil~ 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)-irinesia difficulty Initiating movement and C()lItroLling
Hm.' mlKle lIIO'I'ements
Broad-5pect rum an tibiotic 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 ~hemical that helps nulnuln normal body pH by neutralizing strong acids or bases
Btmdle branch elect rical conduction pathway In the heart [{",jding
from the AYbundJe and through Ihe waD ~n the ventricles
C fibers nen-es that transmit dull, poorly locaHud p;!in
Calcifediol subst.'1nce formed In the first step of vitamin D fornutlon
Ca lcineurin intracellular messenger molule to which immunOMlppreM.Ult. bin.!
Calcitonin hormone secreted by the thyroid gland tnat in~reases 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 b o f caldum
ions into m)UQrdlal cells
Calcium io n channd pathway In a plasma membrant" thfOll8h
which calcium ionsenter and leave
Ca mptothecinl class of antineopwtlcs that Inhibit the enzyme
topoiwmt'r.lSe
Ca ncer/ca rcinoma malignant disease characterlwd by rapidly
gru.ving, invasive cells that spread to other regions of the body
and l'VCfItually kill the host
Ca psid protein coat tholt surrounds a virus
Ca rbonic anhydra ~ eruyme that forms carbonic acid bycombining carbon dioxide and Willer
Ca rdiac output amount of blood pumped by a ventricle in
I minute
Cardiac remodeling change In the size, shape, and $Iructure of
the myocardial cells {m~} 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
Ca rotene dass of yellow- red pigments that are prerursoTS to vitamin A
Cat echola mine! class of lIgenlS.scatted In response to \ri'SS
that ilK:lude epinephrine, oorepinephrille, and dopamine

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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
Ce ntral 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 Applied O!emiWy (IUPAC)
<llemoreceptor trigger zone{CfZ) location In the cerebral COfrex ",hid!. sends sensory signals to the vomiting center
Chemoreaptors nerves located in the aortic arch and carotid
sinus tnat sense~hanges in oxygen content, pH, or c~rbon dlox
ide levels in the blood
Chemotherapydrug treatment of Clncet'
Ch ief 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 (co rD) generic
term used to descrihe several pulmonary condItions characterized 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 decreased 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-stimulatin g factors hormones tlut regulate the
growth and maturation of specific WBC populallons
Combination drug drug product with more than one aClI~
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 (CA M) treat
ments that consider the heahhofthe whole person and promote
disease prevention
Complementary and alternative thenlpi es treatments oonsidered 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 over-th~-rounter
(arc) ~ foUowing the instructions on the label

GIoss y

Conjugates 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 in ternal mammary arteryto 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 tolera nce 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 secretion 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 interleukins, 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 ingredient 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

LibraryPirate

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 feelings 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 intended 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 excess of ketone bodies, most often occurring when diabetes mellitus is uncontrolled
Diarrhea abnormal frequency and liquidity of bowel
movements
Dietary ~upplement nondrng substance regulated by the Dietary 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 number 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 unavailable 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 focu s pacemaker cardiac tissue outside the normal
cardiac conduction pathway that generates action potent~1ls

840

Glo....y

Eczema abo called aroplc dtrmmlrlr, ~ skin disorder with unexplained symptoms of in flammation, Itching. ~nd scallng
Efficacy the ability of a drug to produce a desired respomje
Electrocardiog ram (OCG) devke that reoords the electrical activity of the heart
Electroro nvulsh,,, therapy (ECI) treatment wed for serious
and life threatening mood disorders In patients who are UIU't'sponsh-e 10 pharmacothenpy
Electroencephalos,n m (HG) dJ.asoostk test that records
bnin"'";lu.'Slhrough electrodes auachlto the scalp
Elect ro lytes dlalt'd substance5 [n the blood such as sodium,
poIaMiwn, calcium, chloride, all<! pOOspha~
Embolus blood clot carried in the bloodstre~m
embr)Vnk period period oflife from 3 to S weeks poslmnct'p,,,"

Emesis mmiting
Emet ic drug used to induct mmiting
Emelic pote ntial usually applied to antlnooplastlc ~gents; degree 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
Ilmphysem a 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 nasogastrk or gastrostomy tubes
Entericcoated referring to tablets tmt m"", a hard, waxy coating designed 10 dissol\-e in the alkaline environment of the ~
intestine
Enterohepatic recirculation recytUng of dross ~nd other substances bythedrrubtion ofblle throush the Intestine and liver
Enzym e induct ion process in which a drug changes the func~
tion of the hepatic microsomal enzymes and Increases mmbolic
activity in the liver
Epilepsy disorder of the CNS dlar~!zed 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 mero~,()ltes and causing fever and
chills
Erythropoietin hormone secr~'1ed by the kidney that regulates
the processofred blood ct'U formation, or erythropoiesis
esophageal reflux baddlow of stomach contents into the esoph .g~

E.!iter type of chemical linkage found In some local ~ni'!5thelic:s

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 herita~

LibraryPirate

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 Inflammation of the outer ear
ExtnceUular Duid ( ECF) compartme nt body liuJd lying outside 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, manufactured, and med.
~brile se izure tonic-donic motor actlvlty lasting I to 2 mInutes with rapid return of consciousness that OUTS In conjUll(tion "ith eleYated body temperature
~rritin 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-p lacental 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 action of thrombin in the blood ooaguiation proces/i
Fibrinolysis rt'lTlovai of a blood dot
Fight-or-flight response characteristic set of signs and symptoms 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; o n principles toot offer slm
pie and pnctical guidanct' ror nurses to use during drug preparation, deliWI"}', and administration
rolic acid/folat e B vitllmin that Is a coenzyme In protein and
nucleic acid metabolism
rollicle- stimulating hormon e (FSH) hormone secreted by
the anterior pituitary glan d that regulates sperm or egg
production
rollicular ct'lls cells in the thyrOid gland that secrete thyroid
hormone
Food and Dru g Administration (FDA) U,s, agency responsible for the evaluation and approval of new drugs
rormulary list of drugs and drug recipes commonly used by
pharmacists
Frank-Sta rling law the greater the degree of stretch on the myocardial fibers, the greater will be the rorce by whleh they mnmct
Frequency distribution cur'"" g.raphical representlltlon th3t il_
lustrates interpatient variability In responses to drugs

Glosmy

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 neurons located outside of the (.tntral nervous system (CNS), when'
uon terminals from the first neuron make oontact with cell bodw..and P.'<f............ nf' .... .<KI'M1od """mn
gastric lavage and Ispiration oourse of treatment (within 60
minutes) after the patient has In~ a potentially life-threatening amount of polson: this Is performed by washing out the
stonuch with Slerile water or a saltwater solution followed by removal of the Huid or l1'Illt'd substaoces
Gastroesophageal nnuJ( distll~ (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 so rder (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 .sel~ures 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 coagulalion
Goal any ob;ect or ~Ive that the patient o r nurse seeks to atuin o r achieve
Gonadotropin- releasing hornlOoe hormone secreted by
the hypoIhaiamUSlhat stimulates the socretion of follide-stimulating 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 respon~ 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 purp~ because they
h:ive nO OUler I'Ill\'lope
Graves' disease syndrome caused by hypersecretion of thyroid
homlOne
Growth fraction th~ 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 thall5Stlm\~3ted byhlstamine to produce
bronchodilalion and vasodllatlon
Hr receptor antagoni $1 drug that Inhibits the effects of histamineal its receplOrs in the Gllract
Hallucination St't'ing. hearing. or feeling something that is not

""
LibraryPirate

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 percentage of peptic ulcerdisease

Helminth typf'ofHal, round, or segmented worm
Hematopoiesis proct'SS of I'f)'throqote produdion that begins
with primitive ~U'm 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
~0I1.'S 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 th e dot In place for a
longer period
Hepatic microsomal enzyme S)'$lem as It rela\t'!!S to phaTITl<lcotherapy, 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, lim bic system
Hi~tamine chemical released by mast celli In miPOnse 10 an
antigen that causes dilalion of blood vessels, bronchoconstrktion, tissue swelling,and itching
HlV-AIDS acronym for human !mmunodeflclency virusacquired illllllUlk' defldmcy syndrome; characteriud by profound inunullOMlppression Ihat leads to opportunistic Infections and rnalignancies not (J()mmonly found In patients with
functioning immUIll' defenses

HM G-CoA reductase primary enzyme In the biochemical

pathway for the synlhl'sis of chQkosterol
Ho listic viewing a pelliOn as an Integrated biologic, psychosocial, cultural, communicat ing whole, exi~lng 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 collSisting of estrogen and progeslin combinatiOnS; used to treat symptoms associated with menopause
Host flora normal microorganisms found In oron a patient
Hou sehold system older system of measurement that uses teaspoons, tablespoons, and cups
Humanimmunodclicit'ncy virus (HIV) the causative agent for
AIDS
human integration pyramid a conceptual framework for dealing wilh patients in a holi!Olic manner
Hum oral immune response a spKific body defense meclunlsm
involving the production and releaseofantibodles
Hypercholestero~mia high levels of cholesterol In tile blood
Hyper&lyumia hi9,h st1umse leveIln 1M blood

842

Glo".ry

Hw rhkmia serum potassium

le~

above 5 mEq/L

Hyperlipidemia ew'$S amount of lipids in the blood

Hypernatremia high sodium Ievtlln the blood
Hyperosmolarhyperglycem lc $late (H HS) acute complication
set'n in persons with type 2 diabetes, that is characterized byatreme hyperglyumla, hypero, mobrity with dehydration, the
absence ofh-toocidosis. and CNS dysfunction.
Hypertensi o n 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[ borHypokalemia serum poIas.slum lewl below 3.5 m EqlL
Hyponatremia low sodium level III the blood
Hypovolemic sh ock type of shock Olused by loss offluidssuch
as occurs durins hemorrhage, extensive burns. or severe '"Omiting or diarrhea
Idiosyncratic respon se unpredictable and unexplained drug
reaction
Illu sion distorted. pe:eption of actual sensory stimuli
Immune response spedfk reaction of the body to foreign
agent. involvins B ~ndJor 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
Implem entltion phase when the nurse applies the knowledge,
skills, and principles of nursing care to help move the ~tiem tnward thedesired goal and optimal weOness
Impotence inability 10 obuln or sustlin an erection; ~lso 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 o r anligen
Inflammato ry bowe1 d[~ase (I SO) disease charllcterlzed by the
presence of ulem; in th~ distal portion of the small intestine
(Crohn's disease) or mucosal ero6lonsln the large intestine (uIcerativecolitis)
Influenza common viral Infection, often called fin
Inotrop ic agent drug o r chemical th~t ch~nges the force of contraction oftbe beart
Inotropic effect change [n the strength or contractaity of the
h~art

Insomnia inability to fall asleep or stay asleep

In Sillin 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 decreases, less effect is amleved

LibraryPirate

Interferon type of cytok[n~ 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 ~tem
Int .. rmittenl ,b"dim t ion rondit ion caused by inmffidoent
blood flow [0 skeletal muscles in the icM"r Ilmbs, resulting in isdll'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

m='"

of medication into specific

Intravenou s (lY) administration of medications and tluldsdiredly into the bloodSiream

Intrinsic factor chemical substance secreted by the p.1rlet~1 cells
in the stomach tbat is essential for the absorption of vitamin Bu
Invasiveness is the ability of a pathogen to grow el.tremely rapidly 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 a ble bowel syndrom e (IBS) Inflammatory disease of the
small or lalB" intestine maracll.'riud by Intense abdominal
cramping and diarrhea
lsI.el5 ofLangerha ns cell clusters In the pancreas responsible for
the secretion of imu1in and glucagon
Kappa recepto r 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 released by mast cells;effects are similar to those of histamine
Libido in terest in sexual activity
Limui<; ~yo l"m ~r"'4 ill the ur4lll re~ll.llole fOI ""lotlun, I.,.... uing, memo ry, motivation,and mood
lipaseinbibitors drugs that block the enzyme that br...~k5down
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

GIoss.ry

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 (LMWH s) drugs clost'ly resembling 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 th~r:l.peutic 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
Ma st cell connective tissue cell located in tissue spaces tll.1t releases histamine following injury
Ma stoiditis 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 specific 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
Menopau se 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 millions 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 distant 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 measurem ent most common system of drug
measurement that uses grams and liters

LibraryPirate

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 oxida se (MAO) enzyme that destroys norepinephrine in the nerve terminal
Monoamine oxida se 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 bipolar 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 muscle, alrdiac muscle, and glands
Muscle spasm involuntary contraction of a muscle or group of
mllS(;les, which become tightened, develop a fixed pattern of resistance, 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 tissues in the brain and spinal cord
Myasthenia gravis motor disorder caused by a destruction of
nicotinic receptors on skeletal muscles and characterized by profound 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 coronary 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 contradiolts 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

844

Cilo"''Y

Narrow-sp ectrum 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 age nt chemical used in warfare or by bioterrorists that
can affect the central nel"\Uus sysiem and cause death
Neurofibrillary tangles 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 surroundings
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 he~rtbeat,=d muscle rigidity
NeuromuKUlar blo<:ker drug used to cause total muscle remation
Neuropathic pain caused by injury to nerves and typically described 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 system d ef en se defense such as inflanumtion that
protects the body from invasion bygeneral hazards
Nonspecifi c cellular respo nse 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 cellular pumps
Norepinephrine (NE) prilllllry neurotransmitter in thesympathetic nenuussystem
Nosocomial infection infection acqui .... d in a health CIT<.' setting such as a hospital, physician'softice, or nursing home
Nursing diagnosis clinically based judgment about the patient
and his or her response to health and illness
Nursing process five-part decision -making system that includes assessment, nursing diagnosis, planning, implementation, and evaluation
Objective d ata information gathered through physical assessment, laboratory tests, and other d~1gnostic sources

LibraryPirate

Obsessive-oompul~ive disord er recurrent, intrusive thoughts

or repetitive behaviors that interfere with normal activities or relationships
Old er adulthood person older than age 65
Oligomenorrhea infrequent menstruation
Oligospermia presence ofJe... than 20 million "perm in an ej~c

"",,

Open -angle glau coma 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)
Osteoarthritis disorder characterized by degenerntion of joints;
particularly the fingers, spine, hips. and knees
Osteomalacia rickets in children; caused by vitamin D defi ciency; characterized by softening of the bones without alteration of basic bone structure
Osteoporo~is condition in which bones lose mass and become
brittle and susceptible to fracture
Otitis m edia inflammation of the middle t'3r
Outcom e 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
Parasympathetic nen "ou s system portion of the autonomic
nervous system that is actiw during periods of rest and that results in the rest-or-.... laxation response
Parasympathomimetic 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 la~rs
Parietal cell cell in the stomach mucosa that secretes hydrochlo ric acid
Parkinsonism having tremor, muscle rigidity, stooped posture,
and a sbuffiinggait

GIoss y

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 ~aker, or less efficacious, respollSt' than an agonist
Passive immunity immune defense that lasts 2 to 3 weeki; obtained 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 ~r 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 related 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 nervou s 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'harmacoge netics 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
Phosphodie sterase enzyme in muscle cells that deaves phosphodiester bonds; its inhibition increases myocard~11 contractility
Phospholipid type of lipid that contains two fatty acids, a phosphate group, and a chemical backbone of glycerol

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845

Photosen sitivity condition in which theskin is highly sensitive

to sunlight
Physical dependence condition of experiencing unpleasant
withdrawal symptoms when a substance is discontinued
Planning pha se linkage of strategies or interventions to established 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 antibodies
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; precursor of plasnlin
Polarized condition in which tht' inside of a cell is more negatively dJarged than the oUl.'lide of the ~U
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 disorganized 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 stress disorder type of amiety that develops in
response to reeq>eriencing a previous lift' e'.,ent that was psychologically 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 information 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 postconception
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 form~ of
Multiple Sclerosis named for gradual advance of the disease
from onset and with no superimposed reillpses (new or r...urfacingsymptoms) and remissions (periods of recovery)
PRN order medication is administered as required by the patient's condition (L:ltin: pro re nata)

Prodrug drug that becomes moreaclive aftt'f it is mernbolized

Progesterone hormone secreted by the corpus luteum and placenta 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 immed~1telyfollowinga 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 H~ , K ~ .
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
Pruritu s 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
P~chedelic 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', ~y,.hutul\k"l 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 medica tion 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 d~ 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

LibraryPirate

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)
Relea~ing 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
Renin~ngiotensin aldosteron e 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 cerebral 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 tran scriptase 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
Sca bicide 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 misuseorabuse
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

Glomry

1&47

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 messe nger caSColde ofbiochemltal events that init iates
a d rug's lIctiOO by either st imulating or inhibit ing a Il()rmal 3(livityof thecell
Seco ndary hypertension hypertension having a specific identi-

Somatic nervou s ~tem nerve division that provides volun_

tary control o\'er skeletal muscle
Somatostatin synonym for growth hormon~ 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

fillb!... cause

Spast icity inability of oppo6ing m\lS(le groups to ITIO'o't' in a coordiruued manner

Specialty supplement nonherNl dietary product used to enhance a wide variety of body functions
specific antidotes direct remedies to counter the effects of poisons or totins in va riouo; OI~ including heavy metals, radioactive agents, and o\\'rd05ing of pharmacologic subsunces
Spiritu ality tM OIpacity to love, to convey compilSSion and empathy, 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 ord er any mediCll tion that is needed lmmedJ,nely and Is
to be gi~n only once
Status asthmat icus condition characterized by repeated sel~ures
or one proionPtd seizure attack th.lt continues for at least 30
minutes
Status epilepticu s condition characterized by repeated sei)(U,es
or one prolonPtd seizure attack that continues (or at least 30
minult's
Steato rrhea 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 ho rmones and drugs
St erol nude us ring structure common to all steroids
Strategic National Stockpile (SNS) program designed to ensu~
the- immediate deployment of essential medical materbls to a
axnmunity in lheeventof a large-sale chemlcalorblologk att~k
Stroke volume amount of blood. pumped out by a ventricle in
a single beat
Su bcu taneous medication deli\\'red beneath IhesJdn
Subjecti~ d ata information gathered reguding wh3t a patifonl
states or perceives

seco ndary-p~ h'e MS one of the rour ft'COgJIl:t.ed forms of

Multiple Sclerosis named for gr.lduaJ advan of the dlsea.sr; superimJXN'd relap5t'S (new or resurfacingS)'nlploms) and remissions (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 yp notic drug with the ability to produce a calming effect at lower doses and to induce sleep at higher doses
Seiz ure symptom of epilepsy charaClerlzro by abnormal neuronal discharges within the br.lln
Selective estroge n receptor modulator (S ERM ) 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 selectively inhibits the reuptake of serotonin Into nerYe terminals;
used mostly for depression
Septic shock type of shock u used by se~e infeaion In the
bloodstream
Serotoni n synd rome 5d o( signs and symptoms as.soctiltOO
with o>t'rmedicatio n 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 s ta tu~ height below the fifth percentile for aPt and gender,or mo~ thall two st~dard deviations below the mean (average) for age and gender
Sho rt -tu m o r ~h.iIiond insomnia lnJb\l!ty to sleep that is
often attributed to stress uused by a heal, Ufenyle or the inability to re;o"'e day-ta-day conflicts withln t he homeor work-

pbu
Silm t angina ITl}'OC3rd iaJ ischemia that occurs In the absenceof

1"'"
Single order medication th~t 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 numberofbe~ts per minu te normallygenerated
by the SA node
Situation al aru:ictyanxiety e..~p..'1 ienced by prople faced with a
stressful environment
Sleep d e bt lack of sleep
Social a nxiety fe~r of crowds
Sodium ion cha nn~ l pathway In a plasma m~mbr.lne through
which sodium ions enter aoo !e<l\'e

~I""-ifi~

LibraryPirate

Sublingual rout e administration of medication by pladng it

under the tongue and allowing it to dissolYl! slowly
Substance a buse self-administrntton of a drl1& that does not
conform 10 the medical or social norms within the patient's
g iwn culture or society
Substance P neurotransmitter within the spinal cord involved
in the neural tl1lllSmission of pain
Sub5tantia nigra locatio n in th.e br.lin where dopamine is syn_
thesized that is responsible for regulation of unconscious muscle
movement
Su perinfection new infection caused by an organism different
from the 0Ilt' causing the initi.1l intection; usually a side effect of
anti-infectM.- thel1lpy

848

Glomry

Su rgica l a nesth esia stage 3 of anesthesia, In which m05t major

surgery occurs
S u ~tained r elease tablets or capsules designed to dissolve slowly
owr an atended tlme
Sym path et ic nervous syste m ponlon of the autonomic system
th.lt Is :lC!lve during periods of stress and results In the fight-ortlight response
symplilholytic a drug that blocks the actions of the sympathetic
nervous system
Sy mpa tho mimet ic drug that stlmuLltes or mimics the sympathetic nervous system
Synap se junction between two neurons consisting of a presynaptic nerve, a synaptic deft, and a postsynaptic nerve
Synoptic t ra nsmission process by which a neurotransmitter
reaches receptors to regenemte the action potential
Syrup of Ipecac remedy primarily used to induce vomiting following 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 d yski nesia unusual tongue and fuct' movements such
as lip smacking and wormlilw motions of the tongue Hut occur
during pharnucotherapy with cenain antipsychotics
Tax an 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 ceUmediated immune response
Temion hea dach 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; secreted by h.'Stes
Therap eutic cl assificatio n method for organiling drugs on the
oosisoftheir clinical usefulness
Therapeutic ind ex the ratio of a drug's LDIII to its ED~
Th erapeut 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 ra t.io n in conjundion
with the five rights, these ascertain patient safety and drug effectiveness
Thrombin enzyme that causes dotting by catalyling the conversion of fibrinogen to fibrin
Thrombocytop enia reduct ion in the nWllM of circulating
platelets
Thromboembolic disorder condit ion in which t he patient develops 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

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Thyroxi ne- bindingglobu lin (TBG) a plasma protein produced

in the liver
Tiss ue pla sminogen 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 spa sm 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 ~cross a membrane due to osmotic forces
Topo isomera se 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 adverse 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
Trad e n am e proprietary name of a drug assigned by the manuldurer; 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
Tran splant rejection re;:ognition by the immune sr,;tem of
a transplanted tissue as foreign and subseq uent attack on the
tissue
Tri cyclic antid epressant (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
Tuberc le cavity-like lesion in the IUl1gcbaracteriSlic of infection

by Myc:oll<lcterium tuberculosis
Tumo r abnormal

~we]]j ng

o r mass

"TYPe 1 di abetes metabolic disease characterl~d by hyperglycemia 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
~uch 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

GIos, y

Urticaria hypersensitivity response that is .:haracterized by hives

and is often accompanied by pruritus, or itching
Vaccination/immlUlization inoculation with a vaccine or toxoid to pft'llent disease
Vaccine biologic material that confers protection against infection;

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 coronary 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 (enravasaUon); many antineoplastiG are ~j,ants
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

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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 ingested 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 entericcoated 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

Pag~ num~~ blJowed by /lndica~ figures

aod those foUow~ by, indkatt tables,
boxes, or special fe,lIurts. The title' o f
'pi<tl k~lU," (e.s., Home 1nd
Community Con.iderations, PharmFa~1s,
Treating the Diver.., Pau.nt ) are abo
capitalized.,

i'rotOl)'pf drua;sapptar in bold faa, drug

cbsiir1.cation, :are In SMAl.L CAPS, ~nd tl1lde
names are -..pit<lliud and cross-n:f=ted
to mrir grnerk name. Disease, disorders,
and condition. a", in red type.

A
AAPMC (~ntibiol:it~KIt"tro
pscudO .... mbnl\OllS toliIU), 494
aN"",i 5301
aNtatept.742.
abbreviations:
toan>id.20~871

dfU(!; administration, 20t

abcixlmab, 349, 379.
AbeI, John J~cob. 3
Ahekn. Su Amphoterici n 0
Abilify. Su Aripipl1l101,
abortion. pharmacological. drugs for:
earboprost trO!llethamiJlt, 7OJ~ 704
dlnoprostone, 703., 704
methotrexate with mi5Oproilol, 703., 704
mifrpriilOn, with mi5Oproiloi. 703., 704
Abreva. Su Docosanol
absl'Ilcc {pdit mal) "';zure, 168~ 169., 112
ab50rptlon:
d.finition.37
fa~IOTs aff<'C1ing. 38. 39/
mechanisms. }7~}3. 381
In older adults, 7J

In

p~ancy.64

acamprosatt cakium. 108

aarbo5c:. 687., 683
Acroialt. Su Zafl rlu\<aj;!
Atcrdropin. Su Somatotropin
Atcuprll. SuQulnaprU
Atcurnic, 302.
Accut<lnt. Su bOIn:1inoin
ACE inhibiIO~. Su ANGIOTaiSIN
CONVEITINC I'.NZYME (ACE)
,~~

atebutolol:
actioll5 and uscs.I36.
for an8ina ~r>d myocardial
inf~rdion. 343.
for dyYhyt/lmlas, 36(h
effecu durln8 bmutf<lin8, 67.
for bypc:rtension, 315.
/It;(01L Su PerindoprU
aCorIamin ophrn . 4721
aclions and wes, 472.

'"
LibraryPirate

administl1ltion alm 4721

~r'" . 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. 770~ 773
for pancreatitis, 635
for renal bilure. 424, 425.
aertk addand hydrocortisone, 776.
acetylation. 81
amykhoJine (Io.ch):
bIotktr$. S- NOJlII1t!1CUL\~ J.t.(l(Xllt:S
physiology, 130, 139
r=pto~. Stt Chollntr8k !'KeplOR
acctykholinestcrase (AchE), 131,264
1cctykholine:stcrase inhibitors. 5t'r
OiQUNUGlQ
( PAAASYMl'lI.11lOMIME1lCS). IN DlRf.CT

.en""
aCftylcysteine, 123

~nzoy1 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 Trd in oi n
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

""(WI.

Mlkin. St~ 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

472~ 583.

amylsalkyJic acid. Su M I>i rin

acetyltl1losfen ... 81. 811
Achromydn. Su Td racyclil1c
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
inter~ntion' and I1Ition~lrs.
7SS-59t
patient and family nlucalion.
75S-59t
pl~nnlng: pati,nl goals and apectcd
outromrs. 753.
potentia! nu~ingdiagnOlts. 758.
pbarm.acoth,rapy
adapaiC1le. 756. 7561
ud.J.k acid. 7561

activ4trd dOlling time. 372r

1cti"u,d partiollthromboplaslin time
(aP'IT). l?i. 372.
acti~ immunity. 44'1, 45if
acti~ transport, 37
Atti~Ua. 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,
~r.Y effI5,538~ 5391
inltractio!l5,539.
pharmacokinetlcs,519r
I'O\Ite I nd iiHluJt d05t, 5381
for viral $kin It~ion .. 752
AdaLa!. s... Nif~ipi ne
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

Indn
addiction, 14, I().I , SAo 11110 SubslaD<C' abu ...
AddiJon's dlsnst, 659" 671
adtfovir, >II, 542,

tI..a (tI.-ddu ) fibers. 220

Ad~noard.S A~nosin~

admobypopllysis, 651
tI.d~noscan. SAo i\dtnoiinc
ad~nosin~,

360" 366

AllIlENIllCIC NWlON I LO<:XIIS:

JillH. SAo An~ktiu'etic oormonc

JillHD. Sn "'um~lon ddkll-hyperaclivily
dllOl\Jer
adh~""ne~. mNlQa~lon,1a,

adjuvant eh~moth~rnpy, 5SO

adol",",net, 71-72
adolroant" SAo Chlkl""n
JillP lCPTOl .lOCXDIS:

drll&' clmintd IS
clopklosr~L Sn Clopidogrd

pnl$uarcl, 379,
tioclopkliM, 349, 379,. 3110

rung,

runclion,667,670f
production, 65J1f, 6721
gluclXOetlcoids. 670, Sa..Jso

hormon~

GlUcocomCOlI

gonarirxortiroids. 667
mln ..... loroftkolds.610
adrtnal mWulb. 130
Adrenalin. SAo Epin.orhrino
ad""n'''aic, 130

AIJ'HA_.
BFrA_.

AC1'OBid Sn Runl!Olid~
591

a~rosol,

affinity. 'W

Afluria. Sot I nflumu, v~ine

Afrkan Amcri<:anl:
ACE Inhibitor e/ffCts. 31 It
angln;llnclden"'. 341 1
cane~r Incidence, S4&
dt:prtJ5ion trtatmont com.d ..... tions. 182,
G6PD deficiency, 517,
belrt failure Inddo""" 325,
tntn,'" IUroess t~tment, 205.
pain maniliemmt, 220,
~ use and mortality rnles, 1I 2t
Afrin. Sot OlymetllZOlino; Phmr"phrin~
Afi.ote. SotToinaftate
afi~'lO<Id,

In,

So. AU'!IA-AllIlENERG1C AGONISTS

S Bln'A-ADltENnGIC~[m

mhanlsms of Ktlon, 132-33

Nursina Process Focus
_.... _"t,IH,
tvaluatlon of OlI\OOmo aiteria, 135.
Impktntntation
int~ntionsand 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,

LibraryPirate

akohoI.buw:
adverw heoltb ~fkcu, 108
chronic panc""alitis and, 635, 6J5.
vitamin B, ddkioncy and, 641
wilhdtaWll symplOms, 106., ]08
Aldacwld~, J02~ 42]
Ald<lClOnc. S Spironolacton.o
aidalnrkln. 4541, 563
Aldom~t. See Methyldopa
aldosterone, 310, 423, 670
aldosterone antagonist. 329, 423. Sot ~I...
Silironolacto lle
aldoSlerone reuptor bloi:kc:r. SN Epler~no.,.
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, 151~ 252,
N. s... Interferon alfa-nl
a1l'mosin, 125,

tl.lf~ron

A]imta, SuPomet",Ied
;tlblin~ phos['h;ota .. (ALP), 737

........

ClIu .... 44I'

dffinltlon.441
phumacoth ..... py, 44]-42
Alkenn. Sot Melphalan

325, J26f

,,,,.,

a~.on .. t dJabd....

ADltl'.NIJl(;lCAGONlm (SYMPATHOMlMFJICS):

action s. nd uses. 131, 132-33,

rcstrpint, 3 15" 318

adrmergk r~ptOrl:
Jcx:atlon ~nd rtspon ..s, 131,
types. 130, 130f, 1l]1
adrtl'lOCOI'llaollnsufncio:ncy, 670-7]
adrtnotortltotrovic hormone (ACTI-I), 670
Adriamydn, Sot Doxorubicin
Adrucij. SAo R oolOurodl
Advilr Dlskus. Sa FluliCluone; Silmomol
AdvilS Ibuprofm
a~rubic, 4 79

mrchanism,of acllon, 380

otl"",al "",!>/>y. "'71. "'11
ad""nal si.;lnd:
disorder,
Addlsonsdisult. 659t. 671
ad",norortlQallnsuffklency,670-7]
Cu$hlng'llyndrom~. So. Q ..

""'-

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.

Sot Oi;obolt. md.l.itus.

A&gn.\!at. Sn Tiroliban

busulfan. 5551
carboplatin.555,
dsplatln,555,
dacarbazino, 555,
ni"~n mlUto.rd.

AIDS (ac.qulrtd ;mmun~ deficiency

.,..ndl'OClW), 116t, ~28 . See "''''
HJV-AIDS
abthld .. 206, 207.
Akin.oton, Sot Biporiden hydrochloridr
Ala"",.\!, S I'emlroLut
Albalon. Sot Napl'wollne

bMdomU<ti .... 555,

chlorambucil, 555.

cyclop/>osphamide, Sn
Cyclopho.phamide
ntrarnustillO,555.

albmduo". S22~513

Alboma. Sn Albenduole
Albuminn. Sot Nonnal .. rum albumin
Albu~dn. 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,

~dvorw elfects. 553, 5551

dru8' classified

agonlSl, SO

Ifosf..mido,555.
mrcillordhamin.o, 555.
melphalan,5551

nlttOlOl.U:oas
cumusti ne, 553, 555,
lomustln~. 5~5,

Slrq)torocin, 555.
ox:aiipl.1in, 555,
procarbazine, 555,
tomozolomide, 555,
thiot~55S1

t06~

15 1

mhanllmS of action, 5so, 553, S54f

p~htropywith,SS3

alkylation . 55), S54!

852

Index

All.sra. Sa I'rxof.nadin.
Allrr.st. SN Napharolin.
allrr~n. 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.

Se~G..,.lk

allopurinol. 744. 745.

almolriplan.233.
alor. drug int.ractions:
amioduon 3651
atropin 143.
chlorothiazid 423.
p",dnison 471.
alor vera. 759~ 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.
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 ... Se~ DlOONGESTANrS
mhani,m. of action. 30 If. 31,
for .~dfk condition.
glaucoma. 769. 770.
hyprrlcmion. 315. 3151
n...1con~stion. Sa DECONG!SfANI"S
o ... rvirw. 1321. U3

no.

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&. 725~ 726
teraro.in. 1361. 315 725.

LibraryPirate

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.
~luntinum hydroxid 6161
actions and ""'. 616.
administration alerts, 6161
ad..rr.. rffls, 615 6]6.
intrraetion 616.
pharmacokinrtics. 6161
routr and aduh do ... 615.
Alu~nt. 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. 258~ 540. 540.
Am.ryl. SN Glimepirid.
ambenonium. 140.
Am~nyl Cough SyruP. 5831
Ambirn. Stv Zolpid.m
AmBisolJll.'. See Amphotericin B
ameinonide.760.
amrbia.i 517. 521.
a,",norrh .... 706
Amr'W. Se~ Naratriptan
Am ..icaine. See Beru.ocainr
Amrrican Pharmacrntical Association
(APhA).6/
Amrvi.-.. See M.racrpt
Amicar. Sa Amin ocoproicadd
Amidate. SN Etomidato
amid.s, 242. 243f. SNalso I.ocAJ.
ANESlHEl1Ci

amikacin. 490 500.

Amikin.~Amikadn

amilorid 303 423,

Amin -Aid,6 51
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. 490~ SOO.
lobramycin.490.
pharmacolherapy with. 490--91
aminophyllinr. 594 595
amino .. licylic acid. SOO.
amiodaronc, 3651

Index

actions and u ...., 365,

administration al~rts. 365,
adyer ... dJm 67~ 360,. 364. 365,
for dl"rhythmia>, 358f, 359~
364
hypothyroidi.m and. 663
interactions. 100,. 365,
o,,,,rdo ... treatm~nt. 365,
pharnIaCOkin~tk5. 365t
rout~ and adult do .... 360,
Amitiza. See Lubiproston~

360,.

amitriptylin~:

adyer ... ~fflS. 155t, 186,. 233t

~n~tic po1ymorphi.m.affting
metabolism.81r
rout~ 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 diaz~pam o""rdOS<'. 41
amobarbital:
a. goneral anesthesia adjunct. 252,
for stdaHon and in",mnia. t59t
for ... izu",>, 171,
for statuHpil~ptku ] 71
amox.apin~. 186t
amoxkmin:
adyer ... ~fft5. 484,
for ear infroion>, 776
for H. pylori. 616
m~chani'm. of action. 484
rout. and adult do .... 484,
amoxkmin- davulanate. 484,. 485
AmoxU. Su AlIlOXicmin
amphetamin~"

abllS<'. I1Q.-II
ad,.r .... fflS.67 ~ 198,. 199
drug. daSllif",d as
D- and L-.1mphetamin~ racomil:
mixtur 198,
dextroamphetamine. Sa
Datroamphotamin.
m.thamphotamin~. 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 .. ~fflS. 508t. 509,
interactions. 509t
pharnlarokinotics.509,
pharnlacothorapy with. 509
rout~ and adult do ... 50s,
ampicillin. 484. 484,
amyl nitrit~. 343,
amyloid plaque 263. 265f
aml"trophic lat.ral .duo.i>, 256t

LibraryPirate

Amytal. See Amobarbital

anabolicst.roids,IOO',717
ana.rob'c. 479
Anafran il. See aomipramin~
anakinta. 458" 742,
anal~.i<5:

ddinfion. no
nonopioid
au:aminophen. See Acotaminoph en
comtaUy-acting
donidine. Sa ehnidin.
"an"dol, 228t
nonsteroidal anti-inflammatory
drugs, See NON;"fEROID.u
~.NTI - INFLAMMAroRY

DltUGS

(NSAlDs)
opioid. Set OPIOlD (NUaJTIC)
}.l.AIJ3ESICS

anaphyloctil: shock. 406. 407,

" naphylwo:
ddinfion.18. 4 13
drugscaming,414
inflammatory mediators in, 466
pharma.cotherapy
rpilrphrine. Sff Ep inephrine
tt...rap<>utk approach, 413--14
p",Yention.4t4.414,
run~nt.414,

5pI1ptom,,18. 4 13, 4 13f

Anapro:I. Set Naproxon sodium
Anaspaz. See Hl"scyamin.
anastro",l., 561. 561,
Ancobon. See Flucyt""in~
Andro LA. Set ThstOSl~ron~ .nanthat.
Andro-Cyp. Set Testost.ron~ cypionate
Androd.rm, 718,. Sua/", Tcstost eron~
AndroGd., 718 . Set a(", Tes t ost~ron e
ANDIOGIN ANTAGONlm:

ad"" ... effects. 561,

bicalutamid~. 561. 561,
lIutamid 561, 56lt
nilU!amid~, 561. 561,
rout~and adult doses, 56lt
AND10GINS:

abu ... 717

ad,,,, ... effects. 561" 717, 717t
for ca~ur ch.motherapy. 560. 561,
drugs classified a.
dar.awl,717,
fluoxymesteron . 560. 561t, 717,
me;hylt.stosteron~, 717.
nandrohn~, 717,
oxandrolon.,717t
teslOlactone. 560. 561.
t.. lOst~ron~. Se. Testo. t ~ron~
I<slO't.ron~ cypional<, 71 7t
t.. lOst.ron nanthal<. 717,
formulation 718,
function 717
nOll"'Productiv. dr.ct .. 717
Nursbg Proc... Porus
....... m~nt. 720,
evaluation of outcom~ criteria, 721,

853

implem~ntation
int~""ntions

and rationales,
720---21,
patient and family tducation,
720---21,
planning: patient goal. and ~t~d
outcom .... nOt
pot.ntial nursing diagno ... s, 720t
production. 667
route and adult do .... 561~ 717t
Android. Se< Methyltestosterone
Antin~. Se. Succi nylc holine
anemia:
cau .... 397
cla.. iflcation, 398. 398,
d~flnition. 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 failur~,420,
anesthetics:
g~neral.

See GINERAL ANISTIlrnCS

local. Se< lJxJJ. ANFSllIrncs

angina poetoris:
d.flnition.339
~thnil:/ .. cialconsid~ration .. :J.4lt
g~nd~r con,iderations, 341,
indd~nc<, .l4Ot
nonpharmarological manag.m<nt.
M0-41
pathophysiology, 339--40
pharmacotherapy
bota.ad"'n~'8ic antasonist . Sn
BIITA-ADINEItGIC ANTAGONISTS

calcium clt.annd blockers. See C.UOUM

DMNNEL BWCUJ..\
m~chani'm.ofaction, :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,
~prmartan , 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

8 54

Index

ANGJOTI:NSIN II lI:CIYl'Oi BLOCKER,

(ARB.), (conI,)
impl~m~ntation
int~rv.ntion'

and ralionales,
313- ]4.
patimt and family iucation,
313- 14.
pl.nning: patient goal. and exp<'<tOO
out.ornc~ 3131
pot.ntial nursing diag no .. ~ 3] 2.
for .~cific condition.
h~arl failu"" 327, 3281
hyp<rten.ion, 3021, 3] I
angiot~n.in -conycrling~nzym ~ (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
fo.inopri~ 3111, 328,
lbinopril. Me Li ' in opril
moaipril,3]II
perindopril,3111
quinapril, 32&
ramipril,311~ 328.
to"..mid~. s..,To"..mid ~

trandoiapril, 3] I,
~thnk/racial considerations,)]],
mrchani.m. of action, 30 I/. 3lO,
326,327f
Nursing Proce.. Foeu.
" ..... ment, 3\2.
....aloation of oulcome criteria, 3]41
implementation
int~".. 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 .~cific condition.
hearl failu"" 326-27, 3281
hyp<rtm,ion, 3021, 3lO- 11
m)'X3rdial infarclion, 351
anidulafungin, 508~ 5] 2
anions,436, 436,

anomia , 609
anorexiant., 631
sibutramin~. s.., Sibulr.. mine
An<aid. Me Flurbiprofen
Antabu",. Sa Di.mlfiram

ANl"MJDS,6]S
adv~".. dfects,

6] 5,

drug. da .. ifii as
aluminum hydroxide. Su Alumi num
h ydroxid e
calcium carbonat~. Sn Calcium
carbonate
caldum caroonate wi th magnesium
hydroxide,6lSI

LibraryPirate

magaldral<,6]5.
magnesium hydroxid~, 615,
magn~sium hydroxide and aluminum
hydroxid~, 6]5,

magnesium hydroxide and aluminum

hydroxide with .im.thiconc, 6] 5.
sodium bicarbonal ~. s.., Sodium
bicarbonate
inteJ";lction with H,-rretptor ilnt.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
impl~mmtation

interventions and rational ,

""",
""",

patienl and family education,

planning: patient goals and ~xpIi
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 acidJfolat~
iron. Me [ION SAm
vitamin Bu. s.., Vitamin B"
Nursing Proa.. Foeu,
assessment, 401,
evalualion of outcome.riteria, 402.
impl. m entation
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
carba~n<1ll'
erta~n.m,

49SI, 499

imipen~m -cilastatin,

495., 499
4951, 499
c~ph.l",porin'. ~ CI'PHAW'POI1NS
chIoJ";lrnphcni,ol, 49SI,776
dindamydn, 494, 495,
c)'dic lipo~l'tid
daptomydn, 4951, 499
Uuoroquinolon ... Su
FWOIOQUINOWNE>
fosfomycin, 4951
mero~nem,

utolid~,

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
impl.nt~ntation

inte,,mtion, and rationales, 496--98,

pati.nt and family 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 B~ nztmpin e
biptTiden hydrochloride, 260<
c)':lo~nlola{e, 143~ 774,
dkydomine, 1431, 625

Index
diph~nhrdramin .

Sn

Diph~nh rdramin e

gl)alpyrrolau, 143.
homatropine, 774,
ipratropium bromide.Sn
Iprdtropium bromide
oxybmynin, 143,
procydidine hydrochloride, 260.
prol"'nthdin~, 143.
scopolamine. Su Scopolamin~
tiotropium, 594. 594.
trihexyphenidyl hydrochJorid~,
143~ 260.
tropicamide.774.
mechani,m.of action, 143, 259, 259f
Nursingl'roct .. Focu.
aN.I!mcnt, 145.
impltmentation
"""1,, ion "f OIl'CO..,.,. crit~ri 14Ii'
intervention. and rationales, 146.
pationt and fantilyffiucation, 146.
planning: I"'ti~nt 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,
m~chani'm. of action, 373, 373., 374f
Nursing Pr~ss Focu,
asses,ment, 376-77.
evaluation of outcome crit~ria, 379.
impltmentation
int ervention, and rational ...
377- 79.
pationl and famiiyffiucation,
377- 79.
planning: pati~nt soal,and expected
outcom... 377.
potential nursin8 diagno..", 376-77.
phamlacotherapy with, 373-75
for spifk condition,
m)'OCardial in farction, 349
thromoo..mbolic di .. a .., 373-74, 374.
Amm<:PRE~

adyer .. dlect,. Sa .pocifj< drugs and drug

cia"""

LibraryPirate

black box warning, 183

drugs d.ssififfi a,
atypical antidepr~ ... nt . Sa !.TYPlCAL
~~~

monamine oxida.. inhibitors. S

MONOMlIN OXIDASE INIIIBlTORS

.. lecti'... serotonin

reupt~

inhibitors.

&~ SEIKl"IVE IEl uroNlN REUI'JAKE

INIIIBITORS

tricyclic antid~pr .... nt .. Sn Tllcru.Jc

ANTIDEPll.ESSANTS

mechani,m. of action. 184, 185f

Nursin8 Process R>cu,
a ... "m ~nl. 191.
evaluation of outcom~ criteria, 193.
implementation
inlen~ntioO!

and ralionaki,

191- 93.
[>'It i~nt

.nll f.mily MllC.lItion.

191- 93.
planning: patient goal, and apected
outcom~ .. 191.
potential nu .. ingdiagno .... 191.
for 'pec ifk oondition.

J\.IzlIeimtr'sdiseaSl'.266
anxiety syn-tptom" r~st.l ..'ne... and
d~p",,,ion, 154-56, 155.
d~pr=ion, 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.

diphenoxylat~ with atropine. &
Diph ell oxylale w ith alropi ne
Lxw/",dllOl5adiWphi/u., 100 623,
Nursing Process R>cu,
,...... men', 626<
evaluation of outcom~ eril.ria, 627.
implementation
inter""ntions and rationale..
626-27.
pati~nt and fantily ffiucation,
626-271
planning: pati~nt goal,and ~Iffi
outcom ... 6261
pot~ntial nursing diagno ..., 626,
nursing pro<:ess foeu .. 6271
pharmao::oth~rapy with, 623-25
rout~ and adult do ... , 624,
antidiuretic hormone (J.DH ):
in blood pres",,,, control. 299
in Huid balance, 432
pharmaroth~rapy with, 661. See also
Vaoopr..,in
production,658f
antidotes, 122, 123,

855

ANI11JYS11ITIHMla:
Amiding Medication Errors, >65,
d as,ifkation, 359, 359.
drug. dassififfi a.
ad~no,in~. 360 . 366
beta-adrenergic anla8Ollist . Sn also
BEfA-ADIINEIGIC ANTAGONISTS

actions and indications, 359,

ad..er.. effect., 360t
C1hnic and racial co",id~ration ..

"',

mechanism, of action, 35Sf

rout~ and adult do .... , 360,
th~raptutic 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
rout~

and adult do ..., 359.

approach, 365
digoxin, 359 . J60~ 366. s.., alw
Digoxin
pota"ium channel blocurs. Sa aha
th~raptutic

ParA"IUM CHANNEL Il!..OO:OO

actions and indications, 359 ,

adver... ffects, 360.
mechani,m, of action, H8f
rout. and adult doses. 360,
th~raptutic approach, 36.J.-..64
sodium channel blochrs
actions and indication., 359.
adYer.. effect .. 3601
mechanism, of action. 35Sf
rout~ and adult do ... , 360,. s.., at",
SoDIUM atANNEL BLOCKIlIS

th~raptutic

approach, 359
N uning Process Focu,
a .... 'm.nt, 361,
evaluation of oulcomecriteria, 363,
implenl~ntation

int.""'ntionsand rationales, >62-63,

pati.nt and familyffiucation,
362-6),

planning: patient goal, and expect~d

outcome.. >62,
pot~ntial nursing diagno .... Mil.
ANI1~M!."f1CS, 629
.oh..... df~ct .. 630,
druS' dassi/lffi as
antihistamines and anticholinergks. 629
cydizin~, 630.
dimenhydrinil~, 629, 6].0.
diph~nhydramin~. Sn
Diphe nhydramin e
hydroxyzin.,6)o,
meclizin~. 629, 630.
scopolamine,629,63O,
benwdiazepines
lorazepam. &~ Lor.u.q>am
cannabinoids
dronabinol.629,63Ot
nabilon~, 629, 6301

856

Index

ANI1EMITIcs, ("'~t.)

~u<ocortkoids
dcxam~thason~.

See Da:amdhason~
Sa
MethylprinisoJon e
neurokinin r=ptor antaeonist
ap"'pilant, 629, 630.
phenothiazines
chara{tnislks,629
metoclopramid.,63Ot
perph~nazin . See P.rpb.nazin~
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
m~thylprednisolone.

ANI1FUNGAI.I:

azol
adver ... ~ffts, 513., 51 4
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.
""ri""n.ml~.<;ll.

m~chanisms

of action, 512
pharmacotb.rapy with, 512
rout. and adull do .... 513t
tchinocandins
anidulafungin, 508~ 512
caspofungin. 508~ 512
m""hani,m, of aclion, 508
Nursin g Process Focu,
""SSllYnt, 510.
n'alnation of outcome criteria, 512t
implem.ntation
int.rwntion.and rationale.. 511}...12t
patient and family iucation,
510-12.

LibraryPirate

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, 51 4.
grbrofulvin, S14, SI 4r
n.rufin., 514t
nystatin. See Nystatin
ttrbinafin~, 514, 514.
tolnahal<, 514, 514.
und.-cyl~nic add, 514, 514., 752
pharmacoth.rapy with, 512
route and adull dOS<"., 514.
systtmic
ad,~ ... 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.
brimonidin~, 769, 770t
btta-ad",nergic antagonist.
bttaxolol, 770.
cartrolol, 136t
l.~bunolol, 770.
m<tipranolol,770.
timoloJ. Sn TImolol
carbonic anhydra .. inhibitors
acetazolamide. 770., 773
brinzolamid.,770t
dorrolamide, 77Ot, 773
m.thazolamidl', 770t
miotic. (choline~ic agonist.)
c.. ..ruchol.77fl.
hothiophal. iodide, 770t
physoslismin~, 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.
~\I3luation of O\Itoom~ criteria, 773.
implem.ntation
interwntions and rational..,
772- 73.
patient and family~ducation,
772- 73.
rlanning: patient go;Ib iUld txp<C1C"d
outcomes,772t
pot~ntial nur5ing diagnosts, 772.
routtand adult do .... 770.
ANI1GOUf DRUG!;:

allopurinol. 744, 745t

colchicine. Sa Cokhicine
Nursing Proce.. Focus
JSSI'ssmtnt, 7451
~V".. luation of outcom~ criteria. 746.
implem.ntation
interv~ntion.and rationales, 746t
patient and family~ducation,
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.
~\I3lu.tion of outcom. criteria. 520.
implem.nlation
im",,'entions and r~lional..,
518-20.
patient and family~ducation.
518-20.
planning: patient goals and ape<1ed
outcom .... 51llt
pot~ntial nur.ing diagnosts, 518.
roureand adult dose .. 522.
ANI1HlITAMlNJ:S. See H,-ROCEI'fOR
.NT..."""'''''': H.... ..., .vm.
ANTAGONlm;

abc Hyperl<nsion
drug. classifil'd as
adrtn.~ic agonist . Su ALPHA

ANI1HYFI:RTI:NSIVO. Set

ADRENERGIC AGONlm

adn:n.~k

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

Index
ANTI- INrncrlVl'.l:

acqui",d resista nce. 48 1-82. 482!

all~rgy TO. 483
amibaC!~rial . See ANTI!lACIT.ItIAl.\
antifungal . See ANnFUNGAI.\
amihdminThics. See Ir.NTIHELMlmHlO
amimalarials. See Ir.NI1MALULUS
amiproTozoal . See Ir.NTIPROTOZOALS
amitu~n:ulosis drugs. Sa
ANnnJlll;RCIIWm DRIIGI

defmition.479
for H. pylori. 616-17
hOST fa<lor., 483
mrchanisms of action. 480. 481!
prophylacTic u"". 482
.tl~C1iOll. 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
H ydroxrcl!loroquin.
mefloquine.516.
primaquin 516t
pyrimethamine. 516.
quinine.516t
pharmacoTh.rapy with. SIS
rouT~ 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
fluorourad~ 550[, 551. 555 556!
gemdTabin e.555.
m~chanism.of 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.

LibraryPirate

rrovatriptan.233t
naraTripTan.233.
rizatriptan. 233,
SUmaTripTan. See Snmatript an
zolm itriptan.233.
Nursing Proce.s Focus
a ... ssm~m. 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 diagno~. 235.
route and adult doses. Z:J:Jt
AntiminTh. See PyranTd
AN11NEOPlASTICS:

administraTion co",id~ration .. 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 CAM~lU'tfr.UN'
bormon. antagonists. 561 . Sa alw
HORMONE AlIT!oGON!STS
bormon 561 . Snalso HOlMONE5
hydroxyurea. 563.
interferon alfa-2b. See lnt. rf.ro n
alf..- 2b
ixab.pilone.563.
l. nalidomide.564
levami'lOk.563t
mitot .. ne. 563.
monoclonal antibodi ... 563t. Se~QJsa
MONOCLONALAN11I!OD!F.I

p<ga <parga ... 563,

pl.rix.afor. 564
sorafenib, 563.
taxan .... 559,. See ~I", TA.lANES
topoisomera .. inhibiTors. 559 . S alsa
TOP01SOMDoASE INHlBrroRS

vinca alkaloid .. 559 . See~lsa VINCA

AILAWIDS

""rinostat. 563,
,.,l.dronk add. 563t
8fO">"1h fra<lion and
of. 551
II1tchanisms of ~C1ion. 550[, 551
nadir.55Z

,11<,"'''

857

Nursing Procts, Focns

a, ...,menl.565,
evaluation of outcomecriT.. i., 568.
implementation
inle"",ntion. and raTionale., 566--68,
patimT and family education.

"'-'"

planning: paTi.nT goal, and

<XpC"I:T~d

outcom .,565r
potential nursing diagno .... 565.
in older adulT .. 562t
pharmacotherapy proTocols and
str~lfgi... 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,
e pTifibaTide. 379t
penToxifyllin 375. 379~ 380
prasugrd. 379 380
lidopidinr. 349. 379 300
Tiroflban.379.
mC"Chani,m.of action. 373 380
for myocardial infarction and
prevmTion.349
Nursing~" Focu,
a, ...,menl.381,

"rou

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 McIronid azol.
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.. 51 8-20.
paTknT and familyeduCiltion.
518-20.
planning: paTimTgoals and <XpC"I:lfd
outcome .. 51St
pot.ntial nursing diagno ..., 518t
roUle and adulT do .... 521

858

Index

ANIlPSYUlOfIa:
ad"""", dfem, 206-7, 1fJ7I, 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 actio n , 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 in~ra .. 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,

LibraryPirate

ritonavir, 530~ 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
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, 17~
lamot,igine. Se~ lamonigine
I ...,tiracetam, 173, 1731
o",arhazerine, 173, 173,
valprok add. See Va lproi c acid
7Onisamide, 173-74. 1731, 174
.ruccinimides
ethosuximide. Sa Elh o.uxi mid e
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,

,,,I>..

planning: patimt goals and oulcome..

177t
pot. ntial nur.ing diagno ...., 1771
for specific conditions
bipolardioorder, 193, 19~,
suicide risk and, 167~
ANl15PASMODlQ:
.d""r.. df""ts, 274,
characteristics, 273, 275
drugs classified as
botulinum toxin type 10., 273,
274',277t
bolulinum toxin type' B, 27 4, 274t
damrolen. sodium. Sa Dantrol en e

""'=

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, 663~ 664
potassium iodide, 120- 21, 650,
663t, 667
potassium iodide and iodine, 66),
propylthiouracil. Se~ Propylthionracil
radio.eti..., iodin., 650, 663t, 664
Nursing Process Focus
a ...ssm.nt,668,
.valuation of outcom. criteria,6691
implem.nlation
intervention. and rational ..,

"'-'"
"'-'"
planning: patient goals and expected
palient and family education,

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

Index

rifabutin, SOOt
rifampln, SOOr
rifaP<'ntiM,SOOr
Rif.tn,SOOr
second-liM ~ts
amibcln, SOOt
;unlOOAllcylk add, 500<
al'rwmydn,5OOt
c;prot1oadn. S(r O proflo:u dn

",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
roul~ 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
Ocxtrome toorphan
hydrocodont . Su Hydroco<bne

pb.rm:oCOlherapy with. 582-84

route and adult dosn, 583,
Antiv<rt. S Mcdl1lne
AmMlAU:

for hcrpcsvirusct
Nunln~ Procns Fc-<:uJ, 543--45,

srSl.mlc aae nu
acyclovir. S Acr<lovi r
ad .... rKdJu.S38'
cidofovi 538.
famclclovlr. S381
foKarnct.538.
pnddovlr.538t

LibraryPirate

lOUt. and adult dosn,538,

''alacyclovir, 538,
thl:rapnrtk approach, 5J8.--39
IOJical'8mu
~fW 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 Sulfinp)'l'ZlOn~
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 managtm~nt.

151-52. 1521
Nursb8l'rocull'oru.
'!S<lIm(nl.161,
lmplemmtatlon
I ..~lu;ulonof outwn.. cri .... ia, 1631
In ........ ntions and roulonal..,
16~3,

90liml .nd family tducation.

162-'3t
plalnlng: p;ltlmt goal.and apccted
outromn, 162.
potent~ 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

C/SODnA~AHL\GONISn

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 .. 152 .~" al$oAnxidy
Anumct. ~ Dollostlron
Apldr . ~t Insulin ~luJisine
A.P.L Stt Hunun chorionic gonadotropin
apomorphlllO:
ascm~\I;.629

for pakinJOOism. 257. 258.

apoprot<ln.283
apothtary system nfm",,,,rm>mt.
<t,21'

859

appdhe,6JI
appdh~ MlI'P,,"saRt.. Sa AIIoruiam.
apraclonidint. 769, 770.

apr"Pitanl. 629. 610.

Ap~suld(,

421

Ap~tnlitW:. SN

Hydralazin .
>proNrbital, 159,
>protlnln, 386.
!.ptlvus. STlprallitvir
aP'TT (."ivat(d panial thromboplastin
llmcl,J71
AquaMEI'HYTON. ~Vitamin K
Aquasol .... ~t Vita min A
Aqu:.osol E. Stt Vitamin E
Aquat(nson. St~ MethyclothW:ide
aqueous humor, 767

Aralm. Stt Chloroq uillf

Aramlne. SN Mrunminol
Aranesp. Su l)a.bcpo<1:in alfa
ARBs. ~ AI'IQ(l'T[N:ltN II mH'lOR
.~

Arduan. S Pipuronium
A~ia.

S P~midron.t.

.rformolerol.594,
.rg~lrob.n,

3n. 3nl

AricC'l't . ~ Don "P'>.i~ Memamine

Arimldex. S Anastrozol.
ariplpr.uok, 194 213,. 216
ArlstoSp;ln. Su Triameinolom
Arlx, .... Sa Fondaparinux
Armour.Stt D~trd 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.
ATta n( . Su Trlhayphrnidyl
aTtemetherllum.rantrine. 516, 516t
Arrt'r~isi<lun"".SI6

aTthritlf, 7~ \, 741,. SN~IsoGout;

Osteoarthritis; Rt..umatold .rlbrilla
Anh~n.

S Cbnlin.

oaJicyIa~

anlaitW:. U2.

ASA. S A~pirin
AAOOl. Su Mt$alamine
ASAP order, 20
ASCilrd. Sa Pyrantd
A5Olr;, I"",bricutd~ 522
ascorbic Kid. SttVilamin C
Ascorbic.p. SttVilamin C
AKndln. SAmox:apin~
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.
A~U"I fomiJir"'o, 507.

860

Index

.'pi rin, 2301

actions and uses, 230t, 380, 468
administration a1~rt .. 230,
ad"""", df~ct .. 228t, 2>()~ 379., 467t, 468
b",ast-feeding and, 67.
int~raction .. 100" 2JOt
",..,rdOst treatmtnt, 41, 230.
pharmacok.in~tk.. BOt
rOUIC il nd aduJl dQllt, 228r, 379~ 467.
for .~dfic condition.
Qlrdiovas<ular ~yent risk ",duclion,
472t
f.....,r, 471
m)'>QIrdial infarnion, 349
a'..,..m~nt pitas..:
ddlnilion,55
",laltd lodrug administralion, 55- 57, 56t
A<1.lin, See Aulastin~
a't.mizol~, 20,
."luna, 592
causts/trigg~rs, 593.
indd~nc~, 591,
man.~mrnt in "bools, 593,
Nursingl'roa.. Fo<u.
3Ist=nl.5971
n-a1uation of outcon", criteria, 599t
implem~ntation

intuv.ntions and rationales,

5'J7.J)9,
patient and family eduQltion.
5'J7.J)9 ,
planning: patirnt goals and expected
oulcomes, 597.
pot~ntial nursing diagoo .... 597,
pathophysiology,592.592/
pham,acoth.rapy. S.,.
BiONOlODlIATORS
anli-infl.mmatory agonts. Se~ INHALID
GWCOCOmCOIDS; LWWll1IENE

MODIFIERS; MAS[ c a l STAIlILIZI:&S

Astramorph PF. S Morph in . sulfate
.. Irin~nt df~ct, 25
Atacand. See Omd.sanan
AtaraL See Hydroxyzin~
atazanavir, 530t
alenolol, 3471
actions and use" IJ6. 136t, 347.
administration a1~rt .. 34.7.
~<lVf'cy ~ ff~ct<,h7 . It\O . n~,. 147.
inleraclion .. 347,
mechani,msof action. 136,
"""rdOst treatm~nt. 347,
route and adult dost. 16Q,
for s~dfic conditions
angina and m)'>QIrdial infarction, 343,
anxi<ty. lrot
hypertrn.ion.315,
migrain~, 233t
Atgam. See Lymphocyt~ immune globulin
athermel""",i .. 283, 339, 339f
athl~te androgen abu .. by, 71 7
athlet< 's foot, 507 ~ 514
Ati",n. Sa Lor.....l'.. m

LibraryPirate

AlOlone. Sa Triamdnolone
.tomoutine, 198t. 201
.tonk .. izUK. 168,
.Iopied.mtatiti.. 759. See ulw Lkrmatili.
a lorvastalin, 2901
anions and u ..s. 290,
administration alert.. 29(},
adverst df.d .. 287., 290,
int~/';IClion" 290r
pharmacokin~tiC5, 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 Atropin e
A!ro-ITn. S Atropine
atropine.l44r
actions and U>fl. 143r, 144. IHI
administration aI.",.. 144,
adyer.. eff..:t .. 144,
int~ractiO/ls, 144,
Oy.rdo.. "eatment. 144,
pharmacokinetics. 144,
for .o;pedtk condilions
as cydOJlI~gk, 774,
a. nerYe .g~nt.ntidot~, 120
.tropine ",Ifate. ] 23.
IUropi",,!. Sa Atropine
At"""'nt. Sa I pratropiutll bromide
Atryn. See Antithrombin
an~m ion defic il-hypera<:tivity disor<kr
(ADHD):
characteristia.197
Nu"ing Process Focus
assessment, 199t
impl~m.ntation

...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,
methamphetamin~, 198t
methylph~nidal<. Su
Methyl phen idate
th~ra~uticapproach, 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
duloxetin~, lS6t. 188
mirtazapine, lS6t. 188--89
ndawdone. 1861. 189
traz.odon~. ISS., 186~ 189
venlafaxin., ISS" 186~ IU
Nursing Proc ... Rxus. Sa
Anlid.pr~ssant .. Nursing Process

"""'

route.nd .dult dose .. ISS., 186t

fur .o;pe<ilk condition.
ADHD.200
anxiety .ymptom.. K.tle.. n~ ... and
depression, 155r
d~p,",,,ion, 184, IUt
A1YPlCAlANTII'!;'!UlOTIC5:

ad .... r.. dfects. 212, 2]3,

for bipolar di""rder, 193, 194,
characteristics, 212
drug. classified ..
aripiprazole, 213~ 216
dozapint.2UI
olanzapine,213 . 266
quetiapin. fumarat . 213,
ri!p<'ridon~. Sn ai'perido"e
zipra,idon 213,
mechani.m. of action. 212
Nursing Process Rxus
. .....m~nt. 2U.
impl.ntent.tion
n-a1uation of outcome criteria, 2]5,
intervention. and rational~ .. 214- 15t
pati.nt and family ~dU<'"tion.
21 4-15,
planning: palient goals and <Xp<ctC'd
outCOIllC., 214,
pot~ntial 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
~m~. ~ff..._
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) bundl~. 356
},V (atrim.. ntrkular) nod~, 356
Ayalide.302.
},vandamet. Se Ro.iglitazone/metformin
},Yandaryl. Sa R",igJitazon~/gJimepirid<
Avandia. See Rmiglitazone
AYapro. Se~ [rbesanan
},v.stin. S Be",cirumab
},ydax. Sa Maxitlox""in
},.... ntyl. See Nortriptyline

Indn

Amdart. See Dutast~ride

Amiding MNication Errors:
anticoagulants, 379,
antidysrhythmk.. 365,
dosag~ calculation by w~ight. 659,
drug a]]",gy. 489,
lipid-Iow"'ing th~rapy. 19Jt
m~dicationddivery. 184,
most common "'u .... 19,
patient idtntification. 740t
","ponsibUity for. 442t
rout~s of administration. 582,
Amna. Su Int",feron beta-la
"",,,rt. See Almotriptan
Axid. &. Nizatidinc
Azactam. &. Aztrconam

A.zaS3n. S A.zatbioprin~
azathioprine.457. 458,. 625. 742,
az<lak add. 756. 756,
azela'tin~.575,. 774
AIelex. Su ARlak acid
azithromydn. 489. 489t. 501
Azmacort. Set Triamcinolon~
azol~. 512
azole antifungals. Su AN11FUNGAll. Jzoll'S
azoos~rmia. 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.... Calm.n~-G""rin (BCG) vacdn~.
454; 457
bacitracin ointm~nt. 752
badofcn. 271. 272,
bact".mia. 480t
bacteria. 479. 479,. 480t. & a/so .pocifit:

bacteriD and dj..-a5e'

bacmioci""l. 480
bact~riostatk. 480
baking soda. Sa Sodium bicarbonate
BAL in au. &.Dimerraprol
bal.ncN ane"b.sia. 246
Salndar. Sox Coal tar
Banflex. See Orph~nadrine
Baraclude. Su Entecavir
IV.J.BrrtJV.TI'S:

ad'<J>< <rr",,( 159,. t 7 tr

d.".nd~ncy risl:. 158
drug. classified as
int.rm~diat. acting
amobarbital. &. Amobarbital
aprobarbital. 159,
butabarbital sodium. 1594 252,
long acting
m~hobarbital.159,. In l7lt
pb.nobarbital. Sox Ph enob. rbital

LibraryPirate

short acting
~ntobarbital

sodium. See
Pentobarbital sodium
sc<obarbital. &. Secobarbital
grndk polymorph isms affecting
melabolism. 81,
h",b-<irug int~ ractions, tOO,
rout~ and adult doses. 159t
for specific conditions
as adjuncts to anesthesia
amobarbital. Set Amobarbital
butabarbital sodium. 252,
~ntobarbital 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 m~tabolic ratc. 661
ba.. lin. data. 55
bask supportivecar~. 121
basUiximab, 457. 458t
BayRab. &e Rabies immune globulin
BayRho-D. See Rho(D) immune
globulin
BayTn &e Tetanus immun~ globulin
BCG (Badll.... CaJllYlte. Gutrin ) vacdne.
454,.457
beclo mdhaso ne.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 Beclomnh aso ne
Becona.. AQ. See Bcc1omdh ..o ne
bchavionl (ohon. term) insomnia. 153
belladonna. 143
Benadryl. &. Diphenhydramin e
BenadrylAll~IVICold caplet .. 576,
benaz.cpril. 311,
lxuda,uu>!iue.555.
bendrollumethiazide.422<
Brn~mid. See Probenecid
Benicar. See Olm~sartan mtdoxomil
BcnicarHC.J02t
benign. 549,
benign pro5latk hypcrtropby (BPH):
inddence.7lfu
natural th~rapy with saw palm.tto,
726.

116 1

pathophysiology. 724. 725f, 726f

pharmacotherapy
alpha-adr~ncr8ic 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,
finast~rid~. Su Fina.leride
mechanism. of action. 726f, 727
therapeutic approach. 725- 26
symptom!. 724
benign tumor. 549t
Bcntyl See Dkydomine
benzocaine. 242. 242t. 763
benzoca ine:
otic pr~paration. 776.
benzocaine and antipyrine. 776t
B<Nz.oDIAZ.I1'I~

abuse. 107
ad.... "".ffw .. 157t.17I'
drugs dassifiN a.
alprazolam.157,
chlordiazepoxide. 157,
donaz.cpam. See Clonazcpam
d.)ra zepat~. 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,
rout~andadultdo .... 157t
a, intra""nous an~sthffics, 251 ,
.. izurrs
ad,m.< <rre~( .. 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 ~ro:xide. 756. 756t

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) :

adv~r.sc 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,
norepin ephrine. 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, 315~ 343t
pindolol. 315t
propranolol. See Propranolol
sotalol. ] 36,
timolot SlY Timolol

LibraryPirate

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,
pla~nin8: patient go.ls and exp:li
outcome 138,
potential nursing diagnoses, 137,
for specific ronditions
an~ina 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 .... 328~ 330-3]
hyptrlension
Nursing ProctSS Rxus, 3]6-18,
overview. 136
rout. and adult doses, 3 ]5,
tb.::raprutic approach. 31 4
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
BiDil, 311~328t
BIGI1ANID~

ad""r .. df ts. 687,

characteristics. 688
metformin. See Metformi n
roule and adult do"". 687,
bilberry. 961, 775t
B!I..E ACID 1~1N\:
ad""r .. tffu. 287~ 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 IESI'ONS~ MODlFU'lIS. 452. Sa

~I>"

H~MATOPOIITIC CIOWJ1l FACTOl.I;

IMMUNOSJ!MIJLANP.i

for cancer m.motberapy. 562-04. 563,

biological-ba..d thmpies. 961. Sn~!so
Herbal therapies
biologks, 4. See a/so BIOI.O(;IC R!".5I'ON.\~
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

IndH

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 dJ~ti, 736t, 737

drug.dassifled as
al~ndronate. S Al~ ndronat~
etidronate disodium, 736t
ibandronate,736t
pamidronatc,7J&
risedronate,736t
tlludronate,736t
1.OlMroni<: add (wIMronate),
563; 736t
m~<hanism.of 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
BI~uomyCf' 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 ~Isc Hypet"tension
faaors affecting, 298, 29S/
physiological regulation, 298-99,
299f, 300/
BI.OOD PROD\.TCn:

to, ." ",,".k. 40 R

'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 companm~nt .. 431, 431/
body rna .. index (BI>II),631
honedeposition,732
bone disorders:
osteomalacia. Sa O S(~omalada

LibraryPirate

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
botulin~m tm:in typ< B, 273, 274f, 274,
Bowman'. capsul~, 418
BPH . Su Benign prostatk hy~nrophy
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 Terbutalin~
Brevibloc. Se Esmolol
Brevital. Se Methohoxital sodium
brimonidine, 769, 770,
brinzolamide,770,
broad-'ptrum antibiotia, 482. See ~Isc
!&NTIMCIl'.R1A1S

broad-sptrum ~nicillins, 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, 594~ 595
ipn'mpi"m hmmid~ . .'in

Iprat ropiullt b romid~

phumaroth ... apy with, 595
route and adult do",s, 594,
tiotropium, 594 ,. 595
btta gonists/.ympatoomimdia
ad""r .. effects, 593, 594,
alb~tero!. 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,
rout~ and adult doses, 594t

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
implem~ntation

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 Bum~tanide
Bumi""I~. Se. No nn al ",rum albumi n
bundle branche., 356, 356/
bundle of Hi 356, 356/
bupi,""caine,242t
Buprena. S.. Bup"'norphin~
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.51 4 ,
Butiso!' S Butabarbital
butoconazole,5Ut
buto'1'hanol tartrat~, 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

864

Index

Calan. Sa "erapamU
Calcidrine Syrup, 584,
calcifediol. 732.732f
Cakikrol. Sa Ergocalciferol
Calcijtx. See Co.lcitriol
calcineurin. 457
CALaNFUJllN INHIBITORS:

cydosporine. Se~ Cydo"l'orine

pimecrolimus, 761
tacrolimm . .se. Tacrolimu.
calcipotrien<. 761. 762,
calcitonin:
functions. 732
forosteoporosi .. 7)6,. 737
for r.gd.di ...."". 739
calcitonin~mon. 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, 437~ 648. Sa ~I",
H)"p<J<alcemia; Hyp<><:alcemia
in myocardial
358
in OSlwporosis, 735f
pharmacotherapy with. Sa CALCIUM

con..

Mm
ph~iology.

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,. 343~ 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

LibraryPirate

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 magn~sium
hydroxide. 615t
calcium chloride. 436r. 647,. 7.l4,
cakium citrate. 647,. 734t
cakium gluconate . .sreG!lcium
gluconat~

drugsclassifi.d ..
irinotecan.559. 559,
topotan. Ssw. 559. 559,.
pharmacoth.rapywith.559--60
OImpwth,,",,,,,,mmata, 559
Canada:
drug approV"~1 and regulation process.
9.9,
regul,niom mlri'ting drugs of ~b\l&t.
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
Marijuana
characteristics. 108-9
drugs dassified as
dronabinol. 629. 630,
nabilone. 629. 630t
o.M""hi. "'tiva, lOS. s.., ~I", Marijuana
Capamll Sulfat~. Sa Capreomycin
capitabine.555t
Capoten. Sa Captoprll
C.pozide. 30lt
capreomycin. 5((),
cap.. icin.741
o.psi<llm "MMum. Sa Cayenne
capsid. 527

"I>"

capsul~s:

administration guideline.. 22. 23,

t~s,22

calcium lactal<. 647<. 734,

cakium phosphate tribask.
647,.734,
interactions.734t
pharmacokinetics, 734,
route .nd adult doses.647t. 734,
",lfactant. 601 t
Cal -Lac. Se~Cakium bct.1<
Calomist. ~ Vitamin Bll
(cyanocohalamin )
Calphron. Sa Calcium acetat~
CAM (compl<mentary and .lternative
medicine). 95. Sa ~Iw
Complement.ry and alternative
therapies
Campath. Sa Alemtuzumab
camphorated opium tincture. 624r
Campral. Sa Acamprosal< cakium

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. 4 95t. 499
mrropen.m. 495,. 499
carbenkUlin. 484r. 485
carbidopa-levodopa. 257. 258 ,
Carbocaine. Sa Mepivacaine
carbonic anhydra ... 424

CAM!'fOTIlEC1NS:

CARIJONIC ANHYDlAS[ lNHlBrrolS:

characteristics. 559

adver .. dtects.425,

Index

drug. dassifled a.
a~lazolamid~. Sa Acetazolamid~
brinzolamidc.770,
dorwlamide. 770,. 773
m~thazolamid~. 425 770,
forglaueoma. 770 773
for r~nal faUur 424. 425,
carboplatin.555'
carboprost trom~thamin~, 703~ 704,
708.708.
cardnogm 548-49. 549,
carcinoma, 548. 549,
Cardene. s.... Nkardipin~
cardiac drcompensation. 326
CAJtDIAC GLlC()l;IDES:
adyer ...ffts. 328,
drugs dassiftcd as
digoxin. Sa Digoxin
f",h~~ r1 f:oi1",~. n~,. H()
nursing consid.ration,
client t.aching. 336
m~chani'm.of action. 327f
cardiac output. 298.199 325
cardiac ",mod.ling. 326
{3rd~nk ~hock. 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'
carnitin~. for hean failu",. 335,
carot.nes,64 1
caneolol.I36.
Cania XT. Sa Dilti az.m
Camol. Sa Carttolol
carve<laol. 136~ 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
ca~nne. 273.
CBER (Center for Biologks Evaluation aud
R.... n:h ).5
a::B,. See CAlCIUM rnANNEL IlI.OCUti
a::N U. Su Lomustinc

LibraryPirate

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.
ce farolin, 487.
ccfdinir. 487.
cofdito,"n.487.
ccfcpimr. 487.
ce flXimr. 487t
ccfopc"razon 487.
cd"otaxim e. 4861
486t. ~ S8.
aetiOT..! and u ..s, 466<
admi~i.tration al.rt 486t
.d,... ,... r.fi"t"C' .<. 4R~,. 4.'171
interactions, 486.
rout. and adult do ... 487.
ccfotetaA. 487.
ctfoxiti", 487.
cofpodo:rirne. 487.
cefprozil. 4871
ccftazidimr.487.
ctftibutm.487.
coftizoJ:irn~. 487t
ceftri;m,n 487t
cefuroxi:nc. 487.
Cdebrn Sa Cdecoxib
crl.coxib. 228t. 467.
c.l.stor.~. 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 Co njuga t~d cstro8~n '
Centrr f~r Biologks E.-aluation and
h ... n:h (CBER). 5
C""'<r f~, Dru8 Evol" ion and Re<earch
(CDER).5
Crntu far Food Safety and Applied
Nutrition (CFSAN). 5
central r. emus >J"lt~m (CNS):
drgrnerathe di .. a .... 256. 256 . Sa ~I",
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,
aml'h~amin~s. Sa Amphetamin~.
caffcin~.81 lll

cocaine. Sa Cocaine
m~thylphcnidat~. Sa
M~ h ylph~nidate

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.
charact~ristk 485
founh-grnrra.ion
fepim~. 487.
chara(teri!tics. 485
.. cond srnr ration
c~f:od",. 4~7,

ce fotrtan. 487.
cefm:itin.487.
cdprozil. 487.
ce furoxime.487.
characteristics. 487
third-generation
cddinir. 487.
cdditorrn.487t
crfiximr.487t
cefopcrazone. 487.
fotaxirn~. St. Cd otaxim.
crfpodoxim 487.
ccftazidim~. 487,
crRibutrn. 4871
crftizoJ:irnr.487t
<rftriamn~. 487t
characteristic 487
pharmacotherapy with. 485. 487
route and adult do .... 487.
cephradin~.487.

c=bralpalsy. 27It
G:rebyx. Su Fo'ph.nytoin
certolirumab 1'<"801.625. 742.
cerum.n.776
cerumen <often ..... 776

C.rvidil. Sa Dinoproston~
Ctsam.t. Sa Nabilon.
C.tarnid~. Sa Sulfawamid~
cetirizine.575.
,"'rorcli>: acetat 7l2.
C.trotid~. Sa C~rordix ac~tate
cetuximab, 563 564f
crvilllC"lin. HCI. 140t
CFSAN (Center for Food Safetyand
Applied Nutrition). 5
dt.ag.u' di ....... 521 ,
charnomile.158~ 174 212.
Chrm ... Sa Suaimer
chrmical nam~. 13-1 4
chemoprophylaxi .. 482
chemoreceptor triggrrzonr (crz). 628
'hrmon:ceptors, 298
chrmotherapy.549. Sa ~b"
ANrrnwPlASTIcs

865

866

Index

chief cell" 608

childbirth, d~r~ssion after, 182
Childhood Vacdn~ Mt, 6f
childr~n:
al!~mation

of ibuprokn and
in, 472t
dia~tes in, psychos<xiaI and cultural
impact, 682.
drug idrnini,tration d1a1knga, 191,
59,90.
drug administration guiddines
adoleK~nt. , 71 - 72
pr."hool child, 70
ochool-aS" child, 70
school-agt child"n, 7If
toddl .... , 69-70
dysJipid~mias in, 286t
Gw,dja infection., 5BI
HN inf~ction, 5>8t
medication errors in, 90~ 91.
ophthalmic drug administration, 7751
pain exprossion and pelUption, 2231
para.itic infections, 523.
"";zur~ <1iologies, 1671
a(~taminoph~n

ClIMmydia ""dumlatil, 4801

chloral h)<lrat~. 159
chlorambucil.5551
chIoramphenicol, 4951, 776
chlordi=poxide, 1571
chloride (Cn:
functions, 648.
imbalances, 437.
recommended dina~ 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
chlorothiazid e, 4231
.ction. and uses, 4231
ad""""dfe<ls, 4221, 423.
interactions, 4231
"""nlo... t"'~tm~ nt. 4B,
pharmacokin<1ics, 4231
route and adult do"". 303 . 422.
for .~cific rondition.
",nal failu"" 423.
chlorphenesin.272.
chlorpheniramine, 57St
chlorpromazine, 2071
action, and
2071
administration alert., 2071
ad"""",dfe<ls, 206-7, 206., 2071
interactions, 207.
overdo"" t",alment, 207.
pharmacokinetics, 2071
route and adult do"". 206.

U""',

LibraryPirate

chlorpropamide,6871
chlorprothixtne, 209.
chlorthalidone, ,l.()3~ 422, 422.
Chlor-Trimeton, Sn Chlorpheniraminr
Chlor-Trim<1011 Allergy~nS"stant
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
Ezetimi~

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
cbolin~rgic 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

Belhan echol
cevimelin~ HCl, [401
pilo<arpin~, 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 Don epail
Mm[lhoninm, lMl.

galantamine hydrobromide,
] 4 0~ 264,
nrostigmine, ]39, loWl
physo.ligmin~, 139, [40., 770t
pyridostigmine, 139, t4O,
riva'tigmin~, [40., 264, 264.
tacrine, ]401, 264, 264t
mechani.m, of action, 139
MIOTICS (ANTIGUUCOMA DR\JG\)

drugs classified a.
carbachol, 770.
ochothiophatc iodid~, 7701
physostigmine, 770.
pilocarpine, 770 . 771

Nursing Pro<~ ss Focu.

a=ssment, 1411
ewluation of outrome crileria, 14 3.
implementation
int""'~ntions and rational..,
[41--43.
patient and famay ~ducation,
[41--43.
planning; patient goals aJId ap1ed
outcomes, 1411
potential nursing diagno..s, 141.
cholineura.., See Acetylcholinesterase
cholinest~ra .. 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, 379~ 380
cim~tidin.,6]2, 6]2., 635
Cirnza, Sn CertoJizumab ~go[
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"" rlfects, 492~ 493.
int eractions, 493,
pharmacokin<1ics, 493.
route and adult do"".4921
for "piflc conditions
~nth"'n'

[lmphybxi, .ntl '",alm""t,

1]9,49t
ear infections, 776, 776f
tu~n:ulosis. SOOt
drcadian rhythm,663.
cirmo,is, [08, 108.
ci.,lracurium, 278.
cisplatin, 555.
dtalopranl, [55., IS6t. 266
Cilanest, Se. Prilocaine
Citr""al, Sa Cakium dtrat~
CitruL Sn MothylUulose
CK ("ratine kina",, ), 3491
a - , SN- Chloride
d.dribine, 555.

Index

darithromycin, 489,4891, >01,616

aaritin. Sn Loratadin~
clavuJanate,48S
aearE~s. ~ N.phazolin~
d~ma'tine,

575" 576
aeodn. Su Clindamydn
aeocin-T. See aindamydn
d~vidipine, 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
c~nkal phaSl' trials, in drug dt\tlopment, 6-7
ainorU. Sn Sulindac
aoar. Sre Clofarabine
dobetasol, 7601
docortolone,7f1J,
dofarabin~. SS4, SSS,
dofibrate, 287~ 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,
rout~ and adult do ... 3791
doraupau, 157., 171/
dosed-angle gla\l<:Oma, 768, 768f
Clo>,rid;~m bolli/inurn, 273
C/m,ridium dijJirik, 4971
dotrimazole:
actiOll' and use .. 5 12, 51 5, 752
adversedJecls, SUI
rout~ 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, 2 13,
aozaril. Su a02.apine
CNS. Su Contra! nervous sysum
coagulation, 370

LibraryPirate

867

ANI"JC(W:;\JUNfI; AN1U'lATElEf

Collyrium. s.-. TetrahydrozoUne

rolon. 620, 620f

AGEIITI; HEMOSTATICS;

OOI.ONY- .\"T!MUL\.TING FACIOIlS (CSF. ) :

THROMllOlTIlCS

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,
pot~ntial nu ... ing diagno .... 395,
pharmacotherapy with, 394
ronto and adult dost" 391,
combination druS-, 13, 13,
CombiYent. Se< [pratropium bromid~
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,
pot~ntial nu ... ing diagnose .. 5851
pharmacotherapy
amihistamin~'. See H , - RECIl'l"OI

modification of, 373, 3731. Sre also

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 D H 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 S.-eCol~stipol
colestipol,237,
408
characteristic.. 436
for specific condition,
fluid and dectrolyt~ r~plaum.nt,
436,4361
,hock, 408, 4081

OOLl.OIDI,

'n>"
5% albumin, 4361
dextran 40. Sre [)alran 40
dextran 70, 408, 4031, 436,
b.tastarch, 408.408" 436,
nomlal ...rum albumin. Se~ Norm.!
... rull1albulI1in
pla,ma protein fraction. 403,408"
436.436,

ANTAGONISTS

amitus'i.... '. Se~ AN1TTIJSSIVE.\

combination druS', 583,
decons""tant,. Se~ DEOONGESTAN15
expectorants. Se. EXPF.CroIt.'oNTS
Compazin~. Sa Proc:hlorp. r....m.
Compkat "'gular, 651
compl.ment, 465,
complem~ntary and alternatiye m~dicin~
(CAM),9S
Compkm~ntary 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 faUur~, n51
ca~nn~ for nlUKular tension, 2731
d o"", tor dental pain, 242,
cotnzyme QIO for hrart di .. a .., 2901
cranbtrrylor urinary ,)"t.m btalth, 42St

868

Index

Compl<m~ntary and Alt~mati"" Th~rapi~s,

(cont.)
~chinaua for

immun ~ syst~m

~nhanco .... nt,

4 53t
~""ning p.imrost oil for pain, 234,
flsh oils for inflammation, 470,
garlic for aordionscular h.,.]th, jl!,
ging~. for gastroint~Slinal disord~.s, 616,
ginkso fordem~nlia, 258,
ginseng for m)'X'lrdial ischemia, .l49,
gluwsamin~ and chondroitin for
osteoarthritis, 743,
gokl~n",al, antibacterial p.oprnies, 501 ,
gra~ ",I ""tracl fo r hyp<rtension, 303,
hor~hound for respiratory disorders, 584,
hor",ch~stnut for ""nollS inrufflciency,

413,
for insomnia, 153t
kava for anxiety and insomnia, 153t
ulogtnic diet fo r .. uur.., 169,
melatonin for insomnia, 153,
milk thistle for alcohol liver damage, lOSt
saw palmetto, 726,
"'" ""g~lables, 643,
selenium for cancer prevention, 549,
S!' )ohn"'M)rt ford~p ..ssion, 188t
val.rian for anxiety and insomnia, 153,
compl.m~ntary and alternative therapies:
attitudes toward, 96,
cultural and ethnic influences, 79
deflnition, 4
h~.bal, Su H~.bal th ..rapks
types, 961
com pia partial.,im.e, 168t
compliance:
d~flnilion,19

facio" affecting, 19---20

COmprehensi.... Drug Abu", P... ''''ntion and
Control"ct,14
Com,,"x,452,
conduction pathway, h~art, 356, 3%/
conll"SliYe hun failu .. , 325, See ~OO ]-kart
failure
conjug.l~d ""t~ ns, 7051
actions and ""'s, 705t
administration al~rt .. 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:
d~flnition,621
indd~nco,62I'

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

emerg~ncy,

LibraryPirate

implants
desogesml.698
[mplanon, 697
)adell~, 698
lemnorgemd, 698
Norplant, 697--98
NUYalting,6'iH
oraL Se. ORAL CONTlACEl"lWES
Ortho-Evra,698
contractiUty.325
Controll~d 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
cop~r, 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, Se~ Polymyxin B, neom),dn,
and hydrocortisone
Cortrosyn, Sre Cosyntropin
Co ...... t, SN Ibutilide
Corzide, 302~ 422,
cosyntropin,660,.670
Colazym, Stx Pancrdip""e
Coumadin, Se~ 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, 96~ 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 n""form~n.s, 507t

Cfypt"'poridio,l., 521,

Cryptospcridi.m p~rw"" 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 saline, 433t
5%dextro", in Pla,malyte 56,433,
5%dextro", in water (D5W).
408t, 433t
hypertonic saline, 408., 433.
hypotonic 5i!lin~, 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 ~lso Ethnic/racial
consid<ratiom
culm ... and ... nsitivily (C&S) t.,ting, 482
Cuprimine, Se~ 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
cydo bcnZilprine, 272.
aclionsand u ..., 272,
adrniniMration alerts. 272,
ad"" ... effects, 272,
int.ractions, 272 ,
OY..dose treatment, 272.
pharmacokinetics, 272,
Cyclofiex, SN CydobcnZilprin e
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

IndH

<y<lopho.phamide, 5561
action, and uses, 55&
administration al~rt" 5561
adverst dJect., 5551, 5>6,
interaction',556,
m~chani.m,ofaction,

550f

phamIaWkin~tk., 5561
rout~ and adult do .. , 5551
for :;pifi, ronditiom
canca, 5551, 556,
immunosupp",ssion, 458,
aUOPLfG1C5:
a tropin~, Sre Atropi""
charact.ristiC&, 774
cyd~ntolate, 774,
homatropinr, 774,
=polamine, 7741
tropkamide, 774,
CJ'doserin~, SOOI
Cyclooti, Se Bromocriptin~
cy<:losporinc, 4591
action. and u"'s, 457.459,
admini,tration al~rt" 459,
.dver", ~ffect" 4591
inU1'3ctiom, 201, 1001,4591
phaml"",kin~tic" 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,
cytarabin~, 550{. 554, 555,
CytoGam, Se Cytomrgaloviru, immune
globulin
cytokines, 451
cytomegaloviru, immune globulin, 450,
Cytomd, See liothyronin.
Cytosar, Se Cytarabin~
Cyto,ine arabino,id~, See Cytarabin~
Cytot= Se Mioopro,lol
cytotoxic T cdl', 4 50
Cyto'..,n~, Sa Gancidovir
Cytoxan, Se Cyclopho.phamide

actior.. and u"'s, 2Uf, 275,

admimi,tration alerts, 275t
ad"" .... ffects, 275,
int.ractions, 275,
pharmawkinetiC&, 275,
Daptaen, Se.e Diphlh~ria, manus, and
~rtus'i' vaccine
d.ptomy<;in, 495" 499
Dilraprim, Set Pyrimethamine
d.ro.poetin alfa, 391, 391,
darunavir,5JOt
Darm<:<l- N 50, 223
Darmn, Set Propoxyphen~ hydrochJoride
Darmn-N, Seo Propoxyph~n~ 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 Dr""mdhason~
Declom~in, See Drmedocydine
decoctirn, 98,
DICONGISfANTI:

ad""nc effects, 581,

combinations with antihi,tamines, 576,
drug, classified a.
<p~_~drine, 581,
iprotropium bromide, Seo
Ipratmpium
naI'hazolin~, 5111,
oX)-lllctawline, S.,. OxymdllZOli""
phenylephrine, Sn Phenyleph ri ne
pseudoephedrine, Se
P",udocphedrine
tfIJah)'drowline, 581,
xylomctawlin~, 58],
pharmacotherapy with, 580----81
rout. and adult do",., 581,
d<ql ,,,,b thrombosi. (DVT), 371" 372
defecation, 621
def~roxamine, IB,
ddlbriU.tion, 357
dcgardiI, 561 1
Drl.test Se T.. to. terone
Drlate.>tryl, 7]8" Se a/so T.stost~rone
enanthat~

D
D- and L-amphdamine rac~mk mixtu"',
198~ 200
D4T, See Slavudine
D5W, Su 5% dextro", in wat~r
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

LibraryPirate

ddavird,ne, 530,
Drlestrogrn, Se Estradiol ,,.].rat~
delirium tremens (DT), ]08
Drlsym, Sn Dcxtromethorphan
dclta.9-t.trahydrocannabinol (THe) , 109
Drlta- D, Se.e Otol.cakif.rol
Drltasone, Se~ Predni "" n ~
deltoid 'ite, 32
dclushns, 204
Demad= Sn Tor"'mid~
d<meclocyctine, 4891
dementi. , 258" 263, Se.e a/so Alzhrirner',
uiotaK
DemeroL See Mcperidin~
[)mavir, Sn Pmcidovir

669

Drndrid, Sa Idoxuridine
d.ngu~ f~'..,r, 116,
Drpaken~, Sn Valproicacid
Drpakote, Se.e Valprokadd
Drpakole ER, Sec Va! proi< acid
Drprn, Sa PC1licillamine
d~prndonce, Sn also Substanu abu ..
d~finition, ]4
opioid, 1061, 227
Drp-MedroL Se.e M.th)'lprednisolon~
Drpo-Cyt, Sn Cytarabin~
d~polarization, 58
d.po]arizing blockers, l7S, Sn ,,/so
NIUROMUSCUIAR BWCKfltS
Drpo-M edroL See Methylprednisolone
Drpo-Provera,697, See ,,1<0

MMtoxyprosesterone acetale
Drpote't, See Te;tosteron~ Crriona!.
Drpo-Te.>tosterone, 718" See ,,1.0
T~sto't~rone cypionate
d'p",ssion:
a ... ssm~nt, ]83
characteri,tiC&, ]82---113
d~finition,]82

tthnklradal considerations in trutmtnt,

1821
indd~nce, ]82, 1831
natural th~rapy with 51, lohn'. wort,
188,
nonpharmacological therapy, ]83
Nu"ing Proces, Focu,
a ....,ment, ]91,
...aluation of outcome criteria, 1931
implem~ntation
int~rvC1ltion'

and rationales,
191---93,
patient and family education,
191---93,
planning: patient goal. and expected
outcomes, 191,
r-:>t~ntial nursing diagno", .. ]9],
pharmacothCTdpy
atrrkal antid.pr.... nt .. Se ATIPtc.u

="~
monamine oxida ... inhibitors, Sn
MON(w'UNE (llIDASE lNHlBITOlS
",l~ctive ",rotonin

uptake inhibitors.
Seo SIll:CI1VE SIltOfONIN llUYrAXE

lNH!IlITOlS

tricyclic antid.pr .... nt .. See TlIC'lUJc

ANI1DIl'RE>SANn;

d.rmatitis:
charact~ri.tic ..

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"",
d~rmis, 750
DES, See DiethyistUbrstrol

870

Index

De.. na. Su Undccyl~nic add

d~ .. nsitization. 414
Desfual. Su Defcroxamin~
d~s/luran 246,
d~siccated thyroid. 663. 663,
d~.ignu drugs, 104
d~sipramine, ISS., 1861, 200
d~sirudin, 374, 374.
d~sloratidin., 575,
desmop ",... in,6611
actions and use.,661<, 662
administration alens, 661,
ad"""", dfecls, 66Ot, 661,
interaaions, 661,
"""mo.. t",atm~nt, 661.
pharmacokinetics, 661,
route Jnd adult dOloI', 660t
Desog~n, 698t
d.SOSC'strel,698t
de""nid~. 760,
d~SOJ:imetason 760,
Desoxyn. See Dextr""mph.tamin~;
Methamphetamine
De.yrd. SeeTrazodon.
Detrol. SetTolterodine
de""lopment. 64
d.umelhason.:
ad,,,,,,,, effects, 470t, 671,
for spedlk conditions
adrmowrtica] insufficitncy, 671.
cancor ch.moth~rapy, 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. Se~ Datroamphetamine
Dex/"errum. See Iron dexlr.m
d~xmedetomidin. HC], 132., 160,
dextran 40, 4 331
actions and uses, 4331
administration al~ns, 433.
ad"""", df~cts, 4331
charact~ristics, 433~ 436, 4361
interactions, 433t
pharmacokinetics, 433t
for .hock, 408,
~u' ... n 70 . .tOM. 4011 4'"",
dulran 75, 408
d<J<troamph~tamine:

for atuntion defidt- hyperaclivity

disomor. 198~ 200
u .... 110
forw~isht comrol,634
dextromethorphan, 584,
abu .., 582,
actions and uses, 584,
administration al~rts, 584,
ad,,,,,,,, effects, 5831, 584,
int.ractions, 5M,
pharmacokinetics, 584t
route and adult dose, 5831

LibraryPirate

5%dextro.. in 0.2% saline, 433,

5%datro.. in lactated Ringer's, 433,
5%d<J<t""'" in normal salin~, 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 chUdr~n, P'l"'hosocial and cultural
impact, 682t
complications, 680,
gestational,680,
inddenao, 680, 680,
lipid-lowering therapy in. 683.
pharmacotherapy. Se.IN'UL!N~ ORAL
HYP()(;LYU.MlU
r~nal

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,..... ~ffts, 1571. ]71~ 174,
.xcr~tion. 41
gmeti< polymorphism. aff~cting
metabolism, 81,
int.ractions, 174t
"""rdo.. tr.. tm~nt.41, 174,
pharm.cokin~tics. 174,
rout. and adult do .... 1571. 171.
for "",dlk conditions
anxidy.157,
"' ;n,,..",,",,,,,,,,, . n ~_"h"'k, ]SI.
..izu..... 169,. 17]1. 172
a, sk.ktal musd~ ... laxant, 272.
diaroxid~, 319
dibucain 242~ 763
didofenac, 2281. 467.
didoxaclllin. 4S4,
dicl"'Jomine. 143~ 625, 635
didanosine, 530,
Didronet See Etidronate disodiurn
diet, cultural.nd ~thnic in/lumces, 79
dittaryfiher,621
Dietary Rrl~ren", Intm (DRl),639
dietary .ruppl~ment(.):
ddtnition, 98

herbal. See H~rbal therapies

medication errors and. 57
for old.. adulls, 97.
,,%ulation. 98- 99
Dielary Supplemenl and Nonpr~scription
Drug Con.rum~r Protection Act. 99
Dielary Supplement H~alth and Education
Acl. 5, 6 98
dkthyl>tilhestrol, 560, 5611
difenoxin with atropin~, 6241
diffusion. 37
dillorasone,760t
Dillucan. Su Auco nazol.
dillunisal. 228,. 467t
digestion.607--8.620
Digibind. See Digoxin immun~ Fob
digitali, Blycosid~s, 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.
ad;"tr~ tffem. 109/. 3281. 3311. 3601
inl~raction., 100., 331t. 34&
Nursing Process Focus
a..., .. m~nt, 332.
.... Iu.tion of outcome crileria. 333.
impl.m~ntation

int.rvmtion. and rational~s, 332- 33t

patient and famlly~ducation.
332- 33
planning: pali~nt goals and exp<aed
outcomes,332t
pot~ntial nursingdiagno .. s, 332.
o"ordo.. tr~atm.nt, 331,
pharmacokinetics.331.
for spedfic conditions
dysrhythmias, 360 J66
heart failure, 328~ 330
shock, 409t. 412
digoxin immune F.b. 123~ 331t
dihydroergotamin~ m~.ylat~. 233 234
dihydrotachyst.rol,734.
Dllacor. Se~ Dilti ..... m
Ollacor XR. Se~ Dilti .....",
Dilantin. Su Ph enytoin
n;l.t~t~ ..<;." I .".",h;~ ~ ~ ;n;1 ,..I~
Dllaudid. See Hydromorphon~
hydrochlorid~

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
dimmhydrinat~, 575,. 629, 630.

Index
dimucaprol, ]23,
Dim~tapp. See Bromph . niramine
Dim~tapp a,Udrm's Cold andAJl~r8Y, 576t
DIN (Drug ldmtification Numbtr), 9
dinoprostone, 703" 704, 708,
Diown. See Valsartan
Diown HCf. 302,
Di~ntum.

s.x OI...Jazin~

diphrnhydnmin(,576f
action. and uses, 5761
administration alert 576,
adYer,", ~ffts, 575t. 576. 576,
interactions, 576,
ph.mlacokin.rk. 576t
for spifk condition.
aU~'Ek rhinitis. 575,
anaphylaxi~

413

extrapyramidal side ~ffts, 257

insomnia. 161
nau .... and vomiting. 630,
Parkinson's di .... '"', 260,
diphenoxylate with atrop in e, 6241
actions and u,",s, 624,
administration al~ru. 624,
adwrse efff(:t~, 6U.
interactions.6Ut
o,..,rdO'lt t .... tm.nt. 624,
phannacokin~tk., 624,
rout. and .dult dO'lt, 624,
diphtheria, tetanus, and ~nussis ,,,,,,,ine, 4521
dipi,.. frin,770t.773
Diprivan. s.x Propofol
dipyridamole. 379,
DIItECf THROMBIN INHIBITORS.

s.x ~r.o

ANT!OOAGULl.lmi

drugs cl.ssifled as
argatroban. 374, 374,
bi-;alirudin, 374, 374t
desirudin, 374. 374,
lepirudin. 374, 374,
m~chanismsof action, 374
dirithromydn , 489t
Disaldd. s.x Sal...Jat~
D1'EA.'iE- MODlFYlNG ANTIIHnJMATIC DRUGS

(DMARDs),742
adver .. ~ffts, 742t
drugs classified as
abat=pt.742,
adalimumab,742,
anakinra. 4Sg" 742,
azathioprin~, 74 2t
certolizumab pogol, 742,
rtan~rcept, 742t
golirnumab.742,
hydroxychloroquin . See
Hydroxych lo""l uine
infliximab, 7421
l.flunomid~ . 742,
m~thotruat. s.x Methotrn.l te
ritw:imab, 742,
rulfasalazine. See Sul fa",Ja zi ne
phamtaeotbtrapy with. 742-43
rout~ and adult do,"" 742t

LibraryPirate

disorlium phosphate. 4361. See also

Phosphoruslphospbat.
disopyramide phosphate. 360t
distribution:
ddinition.39
facto .. affting. 39--40, 39/
medt.anisms, 38f, 39-40
in old~r adults, 73
in pr( gllilflcy. 64-65
disulfrram. 108
Ditropan. See Oxyburynin
DlUJ.FnCS:

carbonic anhydr ..... inhibitors. Se~

CAitooNlC ANHYDl,\Sl; INHlBrroltl

combination drugs, 421

home ca ... consid~rations, 42St
loop. See Loop DlVIUIT1CS
mechanisms of action, 298. J.Olf, 327f,
420-21.4211
osmotic. Sa O>MonCDlURlITlCS
potassium-sparing. See PorASSlUMSPAltlNG DlUJ.ITICS

for specific conditions

hean failu .... 328,. 329
hypertension. 303-4, 303.
Nuroing Process Focus. 305- 7t
rrnal failur~. 422t. 424" 425t
Nursing Process Focus, 425- 27t
thiazid . See TJiL\.ZJDE DIURETICS
DiurU. Se~ Ch lorothiazi de
diwlpron sodium. See Va lpmk ad d
DKA (diabttk kotoacidmi.). 680
DMARD .. Sn DIS.\,E- MODIFYING
ANTIRHEUMATIC DlUG,
dobutamin~:

actions and u,",s, 132,

ad,.., .... effects. 409,
mechanisms or action , 4 t 2- 13
for specific conditions
hean failu ... , 335
.hock, 409,. oj 12
DOOurrex. See Dobutamin~
docetaul. 559. 559,
docosanol.538,
docusate.622,
dofrtilide. 36O',.l64
dolasetron, 629. 630t
Dolobid. Sa Diflunisal
Dolophin . Sa Methadon~
DaM. 110
do nep<Zi J,2661
actions and u,",s, 140,. 145. 265f, 266,
administration al~rts, 266,
ad,.., .... effects. 264,. 266,
classification. 140,
int~ractions, 266,
mechanisms of action. 2651
overdo.. t ... atment, 266t
pharmacokinrtic., 266,
route and adult do ... 264,
dopamin e, 4 121
actions and u ..s, 132t. 412~ 413
adminimation alerts, 412t

871

am ...... ffocts, 4]2,

interactions, 412,
ovrnl"'" t .. atm.nt, 412,
pharmacokindks, 41 2t
for .pecific conditions
heart faUu .... 335
shock, 409" 4 13
OOPAMINE SYSITM STABJUZE.It\.

aripipril7.ok.194~

215

2]3" 216

dopamin~

type 2 (D,) ... <epto ..,

204.2051

OOPAMINERGIa.:

am..... effects, 258,

drugs classified a,
amantadin~, 258. 258,
apomorphine. 25&
bromocriptin . See Bromocriptine
carbidopa-kmdopa,258t
~nta<:apone, 258,258t
In-odopa. Se~ Levodopa
~f80lid~, 258, 258,
pramipaole.2591
pramipomle dihydrochloride, 258, 258,
ropinirol. hrdrochlorid~. 258.
258t.259/
..l.gilin~ hydrochloride. 257, 258,
tolcapon~. 257. 258,
mechanisms of action, 2591
Nnr.in g Process Focus
as.s.essment.26It
n-aluation of outcomecritftia, 262t
implem.ntation
inl~"..ntions and rationales,
261-{i2,
patimt and family education.
26 1-{i2,
planning: patient goals and <Xpt~d
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
Dotiglut~. See Glut~thirnide
dorna,", alfa. 585
dorsogluteal site. 32
donolamide.77Ot
dose-respon,", r~lationship. 47-48, 471
Domna. Sa Cakipotriene
doxacurium,278,
donzosi n,3161
actions and u ..s, 136~ 3]6,
administration al~ns, 316,
adv~rsedflS, 3]5 316,
intera.ctions, 316t
",..,nlo,", t .. atm.nt. 3161
pharma<okin~tks, 3]6,
for 5pecific conditions
btnign prostatic hypertrophy, 725~ 726
hypenm,ion.315,
dox~pin. 155" ]86,
d""~rca.kil~rol. 734,

872

Index

dmorubkin,553t
actions and uses. 558t
administration a1~rts, 558,
ad"""", dfects, 558t
interactions, 558,
"""rdo.. tn:atm~nt. 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
doxylamin~, 161,577
DPaT. See Diphth~ria, tetanu . and ""nm.i.
vacdne
DPI (dry powder inhalrr). 591. 591/
Dramamine. &. Dim.nhydrinat~
Driodol. See Ergocalciferol
Drimral. See [kxbromph~niramin~;
P..,udoepbedrine
dronabinol, 629, 630t
dron~darone. J60" 364
drop at\llcu. See Atonk 5I"iml'l'
dro""ridol, 248, 252t. 629
drospin:non~. 698,
dru8(S):
administration. &. Drug administration
administration ~rron. &e M..dication
errorhl
Canadian approval P='s, 9, 9,
ronsumer spending on,S
cost, for old.. adults, 8,
ddinition.4
d~dopment cost., 8
FD" approval pro<e..
nurses' panidpation in, 9
n:cent changes, 8--9
'\lIg~s, >-8, 7/
time l~ngth, 8t
timetin 7/
inl<'raction.
with grapefruit juice. 20t
"""r-tbe-counter. 4
pa ... ~ through pla.ma membran ...
37- 3S. See also Pharmacokin~tics
pn:scriplion,4
reaction . See Drug reaction.
"'iulation, and standards, 4- 5. Sf
drug administration. Sualso
Pharmacotherapy
abbn:viation.,20,
compliance and. 19--20
.m~ral

buccal. 23- 24, 23" 24/

di .. dvanla~s, 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,

LibraryPirate

guidelines
Ii>.., rights, 19
overview. 22
thn:cchecks, 19
inhal..d. 591
lifespan consideration.
childn:n. See Childr~n
infants, &e Infants
during lactation. &e B",ast-fn:ding
older adults, Su Old~r adults
in pr~gnancy. 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
pan:nt~ral
guiddin~s,

30-31,
2S. 29/
intramuscular, 29, 31 - 32, 32f
intrnvenous, 32, 33/
subcutaneou 28-29. 31f
pediatric. See Childr~n; 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 df~ct .. 24-25
transd~rmal, 25. 25/
'YI~s, 24
vaginal. 27, 28f
transdermal, 25, 25/
Drug Enforcement "dmini"ration (DEAl.
14-15
Drug Jd~nlifk"tion Number (DIN). 9
drug im~raclions:
absorption and. 38
with grapefruil juice, 20t
with hcrb.tltherapies, 100.
drug--protcin compl=s, 39, 391
dru~ ",aclions:
anaphylaxis. See IuIaphylaxi.
Ste""ns-johnson .yndrom~, 18t
toxic q>idermal necrolysis, IS,
dry powder inhaler (DPI), 591, 591f
DTIC- Dome. &~ Dacarhaz.ine
Dukolax. S.. Bi .. codyl
duloxetin~, 186 188
duod~na1 ular, 609
duodenum, 620, 620f
Durag.n- l0. See Estradiol val~rate
Duragesk. Six Fentanyl citral.
Duralith. See lithium
Duramorph. S Morphine . ulfate
intrad~rmal.

Durancst. See Etidocain.

725,
Duvoid. Six Bethan ""hol
Dyazid~, 302 . 422
o,.:lone. See Dydonine
dyclonin~, 24 2t
Dynabac. Su Dirithromycin
DynaCir<:. Stx Isradipin~
Dyrenium. &~ Triamterme
dysentery. 517
dy.functional uteriM bINding:
cau .... 706
ddlnition, 705
pharmacoth.rapy
~strog~ns, 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
dutast~ridc.

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

Index
efovi",n., 5321
action, and uscs, 532,
administration al~rts, 532,
adversc dJect., 530t. 532,. 533
interaction,. 100,. 532,
pharmacokin.lics.532t
rout. and adult do ... 530t
Effexor. Su V~nlafaxin~
elJka,y. 48{, 49
Effi~nt. Su Prasusrel
Efudex. Su Fluorouracil
Elavil. Su Amitriptylin.
Eldepryl. Su .sc1"8ilin~ hydrochlorid~
dderlydient'. Su Oldu adulUl
d~ctrocardiogram (ECG). 356. 357/
el~ctroconvulsive therapy (ECT). IS3
tltClroeno:tphal08ram (EEG):
in diagno'i' of sleep and .. izure
disord~rs, 153.166/
normal V5. abnormal. 166/
d~ctrolyt :
dermition.436
diuretic .ff~ct, on. 304
function .. 436
imbalancts, 436, 437 t. S& also spedf/{

e1ec,,,,ly,,,.
important in hu man 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 Perm et 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 ~stradiol and l~""nor~strd.
703.703,
levonor8~strd. 700. 703. 703.
.merg.ncyprepandness. nur ...' role.
117- 18
emesis, 625. See ~'''' Nauoea aoJ
""mitinll
emetic.629
emetk (rnletogen ic ) pot~ntial. 552. 628
emphY""ma. 601
Empirin with Codeine No.2. 223
emtridtabine. 530,. 538
Emtriva. Su Emtricitabine
EmulsoU. Se~ Castor oU
E-Mydn. Su Erythromycin
~nalapril. 319
enaldpril .312t
actiOll' and usc .. 312,
admini'tration alert'. 312,
adver .. dJect,. 31lt. 3]2,. 328,
interactio",. 312,

LibraryPirate

owrdosc trratmmt. 3]2,

pharmacokinetics, 312,
for 'pecific condition,
heart failurr. 328t
hyp<rten,ion.311,
Enbrd. See Etan.n:ept
endocardilil, 480,
endoerin~ syst~m.657. 657/
endogc:nollS opi<Jids, 220. 220f, See alw
Opioid(s)
endometrial ,,".dnOll' . 706
Endometrin. Su Progesterone
endometri ... t .. 706. 7tZ
Enduron. See Methydothiazide
eniluran~. 246t
enfuvirtid 530,. 531
Engeril- B. See HqJilliti s B vacci nt
Enjuvia. Su Conju gated estrosen s
en"""parin. :J.49. 374t
E",ute- Plm. 651
entacapon . 257. 258. 25&
En,~nweba histolytic", 517.521'
enteca"ir. 542. 542 t
enteral nutrition:
dtfinition.650
formulas. 651
NU!':'linS proc~.. 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
Drug
enteral route. 22.
admini'tration. ent~ral
emeric-coated tabl~t .. 22
enterobia,; .. 522. 523
En",,,,bilu ''i'mlu-..lmis, 522
En",,,,,,,",,, fatx~lis, 481
Enrerot:O<'CU' Jiv'<iull~ 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
epinephrin e,4141
action'''ndu ..... 132t.133. 4t4'
administration alerts. 414,
ad,..,,,,,, dfe<l,. 409,. ~14,

Sua""

int~ractions,414,

OYeTdose trratment. 414,

873

pharmarokinetic .. 414,
for .pecilk condition,
anaphylaxis. 413- ] 4
heart faUure. 335
'hoek.409,
epinephryl borau. 770,. 771
EpiP~n . 41 7 t. See also Epin~ phrin ~
epirubidn. 557t
Epival. See Valproi~~cid
Epi"i . See lamivudine
epl.rmon~. 303~ 311. 32S,. 423. 424,
epooetin alb. 3921
actions and uses. In,
administration alen .. 392,
adv~"", df~ct .. 39],. 392.
intera.ction .. 392t
Li~span Consideration,. 391.
Nursing Process Foeu .. 392--94,
o~..,rdose treatm~nt. 392,
pharmacokinetics, 392,
route and adult do ... 391,
EpDgfn. Su Epo"'in alf~
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 Ergotamin~ with caff~ine
=elile dysfunction :
cau .... 716t, 719
ddlniti<Jn,719
indd~nce. 7]6,
Nursin g Proces, Focus
a, ..ssment. 723,
....aluation of outcome criteria.
723--24,
implem~ntation

int."..,ntionsand rationa~s, 723--24,

patimt and family education.
723- 24,
planning: patient goal, and cxpect~d
outcomes, 723,
pot~ntial nU!':'lin8 dia&/lo .... 723,
pathophysiotosY. 719. 721
phamIacotherapy
alprostadil. 721
pap....erine plu, phentolamine. 721
selection of appropriat~ agent. 724,
,ilden~fil. Set Sild enafIl
tadalafil. 722. 722,
vardenafil. 722. 722,
E'W'misol. Sa Levami",l~
ergocalcif~rol (vitamin D,), 641. 734,. Su
ar", Vitamin 0
ergonovine maleate, 708,
Ergo'taL See Ergotamine
ergo't~rol. 508
I'lIGOT AI.K.l.WlI)!;:

dihydroergotamine m~sylat~. 233t. 2>4

e rgotamin~. 67t. 2B., 2M
u gotamine with caffeine. 233,

874

tndex

rrgotamin~,67~ 233" 234

"sotamine with caffeine, 233,
Ergotrate, Sa Ergonovine maltale
rrlolinib,563,
Ertaczo, Su ~rtaoonazole
"ta~nml,495" 499
mlpti...., psoria,ilI, 761<
rrythema, 751
Erythr<xin, SIT Erythrororctn
erythrocyte sMim.mation rate (ESR),
349,
rrythrocytl' stage, malaria, 515
~rythromyd n, 4901
for acne, 756
actions and uses, 490,
administration ol.n .. 490,
advl'~ d~ct .. 490t
interactions. 2Or, 490,
ointment, 752
pharmacokinetic .. 4'.1Or
rrythropoil'tin, 391. Sa ~I", Eroet in alfa;
Hematopoietio: growth factors
E",herid,;a col~ 479~ 4S01
esci talopr-a m onlate, 1561
actions and U~, 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 s~cific 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
F.<lJ'a~nm.

sO', F"'TA~;,,1

estradiol, 7071
estradiol cypionate, 707,
estradiol val.rat., 707,
estradiol/drospi.. non., 707,
estradiol/norgestimate, 707,
estramustin~, 555,
E5T1OGENS:

adv~"" dfect .. 704, 706,

con><q ... n",s of loss in menopau .., 7051
drug. classifii as
oombination drug.
conjugated estrogl'n .. iuine/
medroxyprogestl'rone, 7071
~stradioVnorgestimat~, 7071

LibraryPirate

ethinyl.stradiol/no.. thindron.
acetat., 707,
conjugated estrogens. Se. Conjugated
.. trtlllen
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

m~~

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.. eff~d .. 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 no,..,thindron~, 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,
healthcar~ . cc .... 791
in immunization. 451,
mental illn .... 2OS1
osteoporosi., 7401
pain expr~ssion and Jl<""ption. 220,
pharmacotherapy, 78---79
tobacoo U". 1121

etho.uximid~,

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. Se~ 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, 187~ 234,
Evista. Sa Ralm:ifel1e
awriation, 759
cxuetion. drug:
definition, 40
facto .. affecting, 4 1
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
extended-s~ctrum p<'nicmins, 4841, 485.
Sn ~Isu 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"'.'

~i""" ... ,

2S7

ey~:

anatomy, 767, 767/

glaucoma. See Glaucoma
ht~s inftion .. 539
natural therapy with bilberry, 7751
pharmacotherapy. See Ophthalmic drug.
emimibe. 287" 289 291 - 92

F
5- FU. Sn FluorouracU
Factiv~. Sa GerniU"""dn
falls:
benzodiazepines and. in old.. adults,
1581

Index
famddovir, 538,
family t~aching. See P~ti.nt and family
..ducation
famotidin~,612'

Famvir. Se Famd dovir

Fansidar. &. Sulfadoxine--pyrim.thamin~
faociculation . 275
fat-so1ubl. vitamins. See Vitamin(.), lipidsoluble
FDA. Se Food and Drug
Administr~tion

FDA Mod~rniLation Act, 6[, 8

FDA's Critical Path Initiati"", 6, 6/
febril~ "'''ure, 166, 168.
F..d.ra1 Bureau of Ch.mistry, 6/
F.. n-a_Mint. Se Phrnolphthal~in
fdhamato: , 1731
Fdhatol. Se F.lbamat.
F~M~n~ ..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
domiph~n~, 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
femal~ r~productive function:
hypothalamic and pituitary r<gUlation,
695,696/
infertility. Se F<1Ilal. inknility
owrian control, 695
Femo ... S.., 1.<1ro2.01.
FmtCa",. Se Clotrimal.Ol~
F<mstat. Su Buto<:onal.Ol~
frnfluramin~. 634
frnofibrate, 287.
frno/lbrk add, 287.
frnoprof~n, 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
FC"rah<1ll~. Sec F.rumoxytol
Fergon. Su knOllS sluconate
Fer- Iron. Su Fcrrouss ulfate
ferritin, 399
Ferronyl. Sec Iron carbonyl
ferrou.rumarat~, 398t, 400,647.
ferrousgluconat~, 3981, 400, 647t

LibraryPirate

ferrous su Ifate, 401 t

actions and u ..s,401,
administration alerts, 40],
ad,,.r.. cffts, 398., 4Olt. 647.
interaction .. 40 I.
nursing
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.

P""""

f~""rf~

drug interactions
aspirin,230t
"'"p ....fe.n.4I;9,
oyervi~w, 100.
warfarin, 376.
fexofonadi n~. 575,
Fi~rCon. See Caldum polycarbophil
HBilC ACID AGENn:
3d,'!'r5l' effens, 2871
drugs d""ifi..d as
dofibrate, 287t
knofLbrate, 287.
knofLbrk add, 287.
~mfibroLU. 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/
filara,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,terid e, 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 .. ~ff""t, 40, 40/
fLshoils:
for inllammation, 470,
uses, lOOt
fLve rights of drug administration, 19
Flagyl. Su Metronidal.Ol~
flaXSetd oil, lOOt
lIainid<, 3591, 360,

875

A.et Pbospho-Soda.!in Sodium

biphosphate
AeurU. See Cyclo~nl.<lprin e
Aexon. Su Orphenadrin<
Aomax. SuTamsulosin
Aon ..... Sn Flutic.so"e
Aorinef. Ser Fludroronisono
Aov<nt. See Autiar.so " c
Aoxin. Su OOoxadn
1I0Xllridin~, 555t
Auarix. See Inlluenza ..... ((inc
lIu conaz.olc, SUt
actions and u .... 513,
administration alen .. 5131
am.... df.ct .. 513t
interaction .. 513,
pharmacokin~tic .. 513r
route and adult dOS<". SIlt
1I",:y'o<in~.

'>fill.. ~OR,. ~t2

lIudarabin~,

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 exp<"<t~d
outcom .... 410.
pot~ntial nu,..ing diagno .... 4 IOt
for shock
Nursing ~'" Focus,410-11,
th .... peutk approach., 408
lIuid !>alan",:
body fluid companment .. 431,431/
d~pl.tion, cau ... of, 432
intau and output "'gulation, 432
mov<1ll.nt of lIuids. 431. 432/
lIuk ... 521
FluLavaJ.

s.:llnflu~nza, ",,"ine

Aumadine. See Rimantadine

lIum"",nil. 123 174,
lIunisolide, 580., 596.
lIuo<:inolone. 760,
lIuo<:inonid., 760,
lIuorin<,6491,65O
FWOIOQUINOIONi:S:

am..-... ~ffcct .. 492, 492.

drugs da ..ifi..d as
first-grneration
cinoxacin,4921
nalidixic add, 491, 492.
fourth-~n~ .. tion
gemifloxacin,4921
moxifloxacin,492, 4921
.. cond- g~neration
ciprofloxadn. See Oprofloxldn
norfloxacin, 4921
olloxadn, 492t, 500.

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.
fluollllJ.-.ctI,5~f. 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.
Folic Kldlk>bu
I'OIJC foCID AtlTACONIST$. Sa abo

s..:

""""'~

melhottUot( . Sa Mcthotraote
pemtlr~, 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,. ~19t, """,
recommended dlctar, allowance, 6Wt
5OutCeJ,644
structure,5S6/
foUideslimulatlng hormone (FSH ):
for f.male Infertility. 7[2.
in female reprodU<:ll~ function, 695.
697/
in male reproductl~ function. 7[6
sccretion,658/
foIliwLlr ctIIs, 662
FoIloom.Sa FoUltropin beta
roIlilropin a1fa, 11:!l
foUitropin bda, 712.
Foivile. Set folic add/folate

LibraryPirate

forn.pIz.lle, 1231
fooo.parinux, 374,
Food an~ DlU,Adminmratlon ( FDA):
medlcotion ([!'Of rrponing, 87
Med~';tICh,87,91

new drug approval process

. tnl ehanges,&-9
staces,s-&' 7/
timdinc,7/
prcgruncy '~t('jOrl". 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 Akndronat~
fosampreru.vir, 530.
foscamn.538.
Foscavir. Su Foscamtt
fosfomydn.4%.
fosinopTil, 311" 32&
fosphenrtoln.I73.
~no/' 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
fungall~ftion5.

Su Myrooc"

fungi, 507. 5(17 Sa also Mrcos.es

Fun&.iNir~, Su Undyl<nk odd
Fungizone. Sa Amphotericin B
furwm.ld.,3.\Ol
ac:tior.und uws. 330.
admilistntion alert$, 330<
advme effccu, 303., 12!l~ 130., 422.
;n , ~ ...... i<>n .. lV1.
overlhs-e trC'<ltmcnl , 330.
pharm;acoklne.ju, 330.
for 5plflc oondhion.
heart f.ilure. 328.
hrvcltnlion,30J.
rerul f~ih.lre, 42], 422.
Furosldc, Sa Furoonnide
Fu roxont. Sa l'urawiidone
FlJSI)N AND ~ tNHIBlTOlS. Su rilio
,~~

G
G6PD (g1ucott-6.pOOsp .... te
dehydrOi'"na ... ) ddkiency, SOt.
47)',517.
g;aboptntln:
adv~neeffu.. 171t

for 5tizu.cs, 169 ]7].

Gabltrll. SuThrgabine
GAD (gcncralitro anxiety disonkr), 1SO
galantamlne hydrobromide. ]40., 2641
G~l1.ln. 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 ~.te, 7 12.
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.
~rfarin., 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,$63.
,nnclt3bine, 555.
gnn6brod l,2921
action, and U'l($, 292.
odmlnhu",ion al<n s,191.
Id~rs-e effl$, 2:87~ 292.
inleraction 292.
p .... rmacokinctico., 292.
rou(cllod adult do .., 287.
gemIOonc!n, 492t
gcm(ULumah omgamiein, 5631
Scndor, lnnucnc on pharmacoth.rapy,81
gomoral.nesthr$ia:
chiInCt([;stics, 240, 246
.tI,n,2~'

enfu-tinkk, 530., 531

rrR .... lroc,

5lO.

rali<'Jt1lvir, 530., 53]

Fuzcon .Su Enfuvinide

adjunctl
borbituratn
amobarbital Su Amobarbital

Index

butabarbital. 1591. 252t

pc1Itobarbital. See Pentobarbital
oodium
...cobarbital. See S:obarbital
bnhan,""hol chlorid~. 252
droporidol.252t
opioids
alfemanil hydrochloride. 252t
f~ntanyl. lS2t
fentanyl/droporidol.252.
remifmtanil hj<lrochlorid~. 252.
suf~ntanll citrat~. 252 .
pharmawthe rapywith.25] - 52
promethazin~. See Prormthazin~
succinykholin~. Su Sucdnylchol in~
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
ketamin~. 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: pati~nt goals and ",po(t~d
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.
... mfluran e.2461
g~nuali=l anxietydlsordrr (GAD) . ISO
g~n~raJi=l..;:rure. 167. 1681
gen..ic drug .. vs. brand-narm drugs. !.J--14

LibraryPirate

gmeric name, 13
genetic poLymorphisms. SO. 81.
gmetics:
influmces on pharmacotherapy. SO. 8] I
.. izu", etioLogi.. and. 167.
~notropin. See Somatotropin
~ nl amkin , 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
~mran 40. Su IHxi.dn 40
~ntran 75. See Oatran 75
~ociUin. Su Carbenicillin
~odon. Sa Ziprasidon.
GERD (lla5l:"",sopha~1 ",flux di .... ..,J. 609
gestationalag drug therapyand.65
lIestational diabet~, mellitu .. 680.
GFR (glomerular mtration rate). 419
GH (growth hormones). 659-00
Gi~rdw "'",h/i<l, 521t. 5D.
gianlia~i~. 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
.uma l 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
ouma l riptan.234,
warfarin .l49t
for myoc;ardial is<hmtia. 349.
standardization.97.
use 961

877

glatiram .. acetate, 267, 267.

gLau.:oma:
diagnosis. 768
incidence. 769.
pathophysioLOSy.768
pharmacoth..apy. 769. See~lso
AmIGWJOJMA DIlUGS

ri!l:: factors. 768

type 763. 768/
GI...-vC"C. SN lmatinib mesylat~
Gliadel. See Carmu5line
gLim.piride. 687.
gLioma. 549.
SLipizide. 687 t
glip;zide/metformin.68&
8Lorn~rular mtration rat~ (GFR). 419
glucagon. 123',679. 679[.682
GWCOCOItl100IDS:

adrenal ...<relion of. 670. 670[

am..-..... ff~ct .. 470-71. 470,. 671 I.
672,673t
drugsclassified ..
aldorn<:tason~. 760.
amcinonid 7601
beclomethasone. Ser Beclometh asone
betam~thason. Sa Brlamethason.
bud.sonide. 580 596,
cid.sonid~. 596t
dobrtasoL.760t
do<onolon. 7601
cortisone. 470 6711
desonide.76O.
desoximelasone.76O,
doxamelhasone. See Dexamethasone
diOorason 7601
flunisolid~. 5801. 596,
floodnolon.,76Ot
fluocinonidr.760.
flurandr~nolide. 7601
fluticason~. Sr. Flulkason.
haldnonide.76O,
hydrocortison . See H )drocorti .on.
methylprednisolon~. 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.

878

Index

GWCOCOJtTJCOIDS, (ront.)
for .~cific condition.
adrenocortical insufficiency. 671. 671,
a11.rgk rhiniti . Su lNTlANAMI.
GWcocomCOIDS

asthma. See INHAI.W G!U:OCOItl100IDS

can~r. 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
Glucovan~. 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. lOO~ 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

LibraryPirate

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. 51 4,
growth. 64
growth fraclion. 551
growth hormones (GH). 659--(,(J
guaifenesin. 583~ 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
crtirizin~. Ste. Crlirizin.
drsloratadin 575,
fexof.nadin 575.
1'''''''''irizin 575t
loratadin 575,
olopatadin 575,
Nursing Pr""ss Pocus
a' ..... ment.57S'

.valuation of outcom. 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:
ad""r~ 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. 61 4,
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,
halor~ridol. 208,
actionsand u ..... 208t. 266.629
administration alat., 20St
ad""r ... effects. 208,
~nrtk 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.

Index

hay r.,,,,,r. See Allugk rhinitis

HBlg (hrpatiti. B immunoglobulin).
4 50~ 541
HCG (human chorionic 8On.dotropin).
712.718
HCfZ. See Hyd ro, hl o ro t hi azi d~
HDL. &e High-density lipoprot~in
h~dacha, 230. 230t. &~~Iso MiH .. in~
heallh beliefs, ,ultur41 and ethnic
influ."ces . 79
H~alth Canada. 9, 9,
h~lth history .,...,ssm~nt. 55. 56t
H~alth Product. and Food Branch
(HPFB).9
h~al!h statu com munity influ.n~.. 80t
h~althca", ""ces.:
wmmunityinf]uen(~s. 79
minority stam. and. 79t
Maring impairmem 74,
htan attock. See Myocaroiallnwaion
h~art block. 355,
ht-~rt failu", (HF) :
definition. 325
diology.325
hypmen,ion an d. 299
indd~n~. 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. 328~
330-3l. Sa 11/'" BE."fA- ADJENEJG[C
ANrAGONlsn
<aroi"" glyco ,ide .. 328t. 330. See"lso
Oigo.-.in
diuretics, 328 t. 329. Sa "Iso D1UJ.ETICS
m~d"'nism. 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
H~ctoroJ. Sa DoRrcakifcrol
Hdicobucterpylod. 609. 61Of. 615--16
hrlminth .. 507,. 517. Sauoo
ANI1HEIMn;rn[CS

hdprr T cell,. 450

Hemabalr. &e Carhoprost tromr1hamin~
hemat"",,;'si .. 3'Xl. 390f
HEMATOPOIETIC GJ;owrn w.crOlS:
drugs classified a.
",lony-stimulating factors. Sa
CoLONY-snMUl.\.TING w.crOlS

LibraryPirate

darhrpor1in alfa. 391. 391,

~tin alra. Sa Epodin alfa
platd", ~nhan=s. Sa 1'lATEI.ET
rn~=

Nursing Proce.o;s Focus

a ... ssm~nt. 323- 93t
<Valuation of out"'m~ criteria. 394t
implementation
imerl'l:ntioD! and rationalts.
393-94,
pati~nt and family education.
393-94t
planning: patient goals and apted
outcom~ .. 393t
potrntial nu",ing diagno .... 323-9),
pharmacotherapy With. )91
hffilO\lhilia. 371r. m
hemo,iderin.399
hemosta.is:
definitio n. 370
di,..,. .... of. 371 - 73
mrdunism. of modification. 373. 373,
pnx:rs .. 370-71. 370f
HEM05TATIC<;:

am'trSof .. ffe.:t5. 31161

definitio n. 373
drugs daSliflrd as
aminocaproic ""id. &~Aminoa proic

od d
apro!inin.386t
tranexami< add. 386,
IIlhanism. of action . 373. 373,
route and adult do..., 3,0,6,
hepa rin, 375 t
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. 452~ 541
hrpatiti. B. Il6t
charactrristks, 541
pharmacotherapy. 54l. 542,
hepatitis B immunoglobulin (HBlg).
450 ,.54 1
he patitis B vacci ne, 4531
actions and u .... 453t
admini.tration alerts. 453,
ad"" ... df""". 4531
interaction .. 453,
pharmacokinr1ics, 453,
5Chtdul~and
452,. 54 1
hrpatitisC :
characteristic.. 541 -4 2
pharmacotherapy.542t

.gr.

879

Hrplock. Sn H'1"' rin

Hrp .. ra. Sa Adrfovir
hrrb.95
hrrbal th.rapies. Sa
Compl~mentary
and Allfmati,'t Thrrapie.; ,pedfic

"I..,

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 ~ffrcts, 68,
hrrpcs .implex. 752
hrrprH.oster.752
hrrprmr~.:

d assification.538-39
e~ infrctions. 539
in cidtnct.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. &~,,'so
Am~

Herpla. &~ Idoxuridin~

hrlastardt, 408. 408 ,
H"",,-Brtalin. Sa Vitamin B.
Haalen. Sa Altretamin.
H E Sa Hean f.ilu",
HibTITER. Sa Haemophilus type B
conjugat. weein.
high- d~nsitylipoprotdn (H OL):
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 Methrnamin~
HismanaL See A'irmizole
HispankAmcrican.:
d~p",,,ion t",alment considerations,
182,
hot and ",Id throryof illness, 483,
mental iJln~ .. t",atmrnt. 205,
pain management. 2201
hiSiamine. 465. 465~ 575
histamine rrptor antagonists. Sa
H,-RECEP"IOR ANrAGONlSn;
H, -RECEYIOR ANrAGONlSU
hiSiaminr r",tor .. 575.612

BBO

Index

Hist~ron~. Seo T.. to.t ~ro n c

Histoplllm", CII/"ukl",m. 507t
histoplasmosi .. 507,
histrclin. 560. 561,
HIV ( human immunodm.c~ncyvirUll ) .
Seo HIV-AlDS; Human
irnrnunoddic~ncy virus
HIV-A1DS:
in child~n. S38r
ddlnition.528
indd~n~. 527,
mortality rate. 527,
Nursing Proce.. Focus
a ..... m.nt.534'
tvaluation of outcome criteria. 5.l6t

implem~nt.tion

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
~harmacothtl"a~y

antiretroviral . See ANnIFI1tOVU...l.I

cla .. ification of drug .. 530-31
th.rapeutk approach aud goal 529
postClPOru~ prophylaxis foUowing
occupational exposur 537- 38
p~ ... ntion of perin atal transmi .. ion. 537
stago 529
HMG-CoA ~dudasc. 287. 2S8/
HMG-CoA ~ducta .. inhibilors. S.. SrAJINS
HNKC (hyptrosmolar nonkelolk
coma).682
holistic, 77
homatropin 774,
Horm and Community Co",id~ralions:
Alzhtimer's disc ...... 263,
anaphylaxi .. recurrent. 41 4,
anticoagulant th.rapy. 373t
a'pirin for caroioV"aocuJar ....nt risk
rluction. 472,
asthma managoment
peak- flow meter for. 60It
in ",hooJs, 5931
autonomic n~rvou. "Y"t~m agonl . safety
with. 1 4 ~t
dalromethorphan and drug abu ... 582,
~ducating pati~m.ahout OTC
mlications for howd disoro~rs,
nausea. and ""miting. 635t
uc:ctile dysfunction drugs. 724,
hear! disea ... CPR and othc:rtducation
for. 341,
heart failur~ treatm~nt.p'J'<hosocial
i"ue 335,
hormon~ th~rapy. sid ff.ru. 700,
hypcrnat",mia in athletes, 438,
mtdication errors
o ... r-th~- counter drugs and. 91,
pr~ ... nting, 87t

LibraryPirate

mu.d~ rdaxant th~rapy, 277,

neural tubt dekcts and folk add l~ ... ls in
pr<gnancy.644 ,
nutritional th~rapy for patirnts taking
diurttics, 428,
ophthalmic drug . 775,
oye r- th ~ -counter drug.
for howd disord~rs, 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 foJlow- upcar~ , 248t
ocabi~s.psychosocial and community
impact,7SSt
viral inkctions. 539,
ho",hound, for ""piratory disord ..., 584,
HOlMONE ANI"AGONISTS:

adyer .. dJ~d .. 561,

for can~r ch~moth.rapy
anastrozol 561, 561,
bicalutamid~, 5611
dftartlix. 561,
cxrmestan~.561, 56lt
fuJ ... strant.56I,
8o..",lin, 5611
histrclin, 56],
ktrozol., 56lt. 562
kuprolid 56],
rmdtanisms of aClion, 550/
nilutamid.,56],
tarnoxif~n. 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 th~ral'Y (HRT). See

abc EsrIOGENS
ady...... ffocts, 7Il4- 5
benefits, 704
NUr>ing Proct" Focus, 701 - 3,
HOlMONES:

ady.,... ~ffts, 700,

andr"8'"n . See ANDROGENI
for ""n~Tch~m"th="y
d.""m~thason~. 56lt
di<thyl'tilbtstrol. 560. 561,
.thinyl estradiol. 560. 561,
lIu0J<YIll"5teron 560. 561,
mechanisms of action, 550/
DYdroxyprogest.rone. Seo
Medroxyp r~.t.ron c acc:tatc:
mego.trol, 560, 56],
pharmaroth~rapy with, 559--60
pn:-dnison . Se~ P rcd ni .on.
t~stolacton~, 560. 561,
t~st""t~ron~. S<: T.. I",tc:ro n.
for contractption. Sox CoNfUCE!'J!VE.\
.. nog.n,. Seo Esl1lOC[l~

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. r."lacc:m~nt therapy
HTN. See Hypcrlrn,ion
huffing. 106,
Humalog. Seo Insulin lispro
human chorionk gonadotropin (HCG).
712, 712t. 718. 718,
human immllDOlkficic:ncyvirus (HN ). Seo
~Iw 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, influ~nct.on. 529,
transmission, 528
human in!t2ration pyramid cart mod.1.
77,77/
human papillomaYiru. Yacrin., 452t
hum an "'Sul ar in . ulin, 683t
aaions and uses, 683t
administration alerts, 683,
ad ... r.. dfects. 682" 683t
im. raction.,683,
o\"erdo5C tr~atmrnt. 6113t
pharmacokin<1ics.683,
rout. and adult dOS<". 682,
Humatin. See P.romomydn
Humatrope. Seo Somatotropin
Hum<gon. Ste M~notropin.
Humira. Seo Adalimumab
humoral immun. r.. pon ... 447, 448/
Humulin N. Seo [sophan. insulin
.uspension
Humulin R. Seo Human rc:gul ar in sulin
hungor,631
Hunling!on', chorea . 256,
Hyalgan. Seo Sodium hyaluronat.
Hyrodan.584,
Hywmin. Compound. 584,
Hywtus. Expectorant. 584,
JIYrnmoINS:

ad .... .. dfects, 173,

drug. cla.. ifl~d as
fosph.nytoin.I73,
ph<nytoin. See Ph<nytoin
mechanism, of action. 172
roul.and adult do5Cs, 173,
for stirur.., 173-74
hydral azin e. 319,
aerion. .nd u ..., 319t
administration al.rts, 319,
ad".r .. dfects, 319,
gonetk polymorphism' affecting
m~taholism, 81,

Index

interaction" 319,
o""rdos. tmU ntrnt, 319,
pharm"",kinr lk&, 3 ]9,
for spifk condition.
hean failuJ't , 328., 334
hy~rte",ion, 319t
Hydrwti.! """ad.",;., SeeGolden....1
Hydrea. Sec Hj<lroxyuJ'ta
h~hIo rothiitz.id ~, ,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.
hy~nension, 303t
",nal failu ... , 422.
hydrocodonr:
adYersc Iffrcl . 222t, 583.
asamitur.siYe, 583, 583,
for pain manag~ment, 222<
routl and adult do ... 222t, 583.
hydroco rtisone, 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
inflammation, 470.
Hydrocorton . Sec Hydroco rtisone
H)droDlURIl. Sce H)'drochloro1hi azidc
hydrogtn cyanide. 121t
hydromorphone hydrochloridr, 222t
hj<lroxydl lo roq uine, 7Hr
action. and uses, 743.
administration alert., 74 3.
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
H~rab. Set Rabies immunr globulin
hyprraldosteronism, 670
hypen;alcentia:
ddinition, 437.

"""I't

LibraryPirate

suppon;ye treatm.m, 437.

spI1ptoms.648
hy~",hJo .. mia, 437.
hy~",holest.rolemia, 285. Sn aJ", Upid
dJ""rdu.
hy~l'tmc:<is &f"dvidarum . 628
hy~rglycnnia. See Diabc:te. mellitus
h~r81)".mic dftet, 679
HYJ'frirnm pfrjimllum. See St. John's wort

primary, 299
secondary. 299
hyprrl<1lsi,.., emergency, 319t
Hy~rTer. Se~ Tetanus immunr globulin
hyperthyroidi.m:
cau .... 662
inddrn"',662t
pharmacotherapy, 663-64. Sn ~Iso

hy~rkaJrmia:

h)'P"nonic solutions:
cltaractrri.tics, 431, 4 321
uystalloid, 433, 433 . Se~ "/.,,

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
hy~rmagn~mi . 437t
hy~rnat"'mia:

in athlerl., 438.
cau .... 437
ddinition. 437,437.
pharmacothrrapy, 437, 437.
hy~rosmolar hyperglycemic statr
(HHS), 682
hy~ro'molar ",,"utotic coma
(HN KC) . 682
hy~rpho,phal<mia, 420 . 437.
hy~nr",ion (HTN) . Se~also 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,INCONVEItTING 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

88 1

hNTITHYlOID t.G!Nf~

CRYSTAllOIDS

salinr.408.
hypcrtrigl~ridrmia,

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
dlfinition, 437~ 438
pharmacotherapy, 438. 4 39.
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

882

Index

carn, (amI.)
OClrtQIide, 6241, 660, 611

HYPOlHAv.MIC ...

~nl,6601.661

hypothalamus!
in anIitty, ISO. 151/
dioordM"S,6S9
borm<)R( production. 54&, 653/
in hunll..,.,631
hypo!hyroidlsm:
.miod.uone~nd, 663
inci<;lenct, 662,
pharm.cOl hCTapr, 663. Su "Iso THnOID
~~

gmclic polrmorphlsms afkcting

Intl"illbolism, 811
interaclions. 1811
ovcrOOselatrnent,1811
pru.rruroklnetics. 187,
roUI,nd adult dose. 155~ 186.
for splfIt: conditions

ADHD,200
arulrlr symptoms, 1551
depKsslon, 186,
mi, .. ln., 2331
lmitra.Set Sltma tript~n
IMMUNE Gt.OlIUl.II<fo:

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<

cyto{1l~loviNI

immune globulin. 450,

Immu ... globulin, 541
I><pollb immWl~ 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
l><po~tl sA

passi~,

11J] !ktRadIo~cti...,iodlne
ihandron.te, 7)6,
ibritumomab tlmetan, 5631
Ibul"""f... , 4691
lClions.nd I.IK"S. 468-69, 469t
adminlltralion alerls. 4691

lMMunOST1MUL\.~

lMMunOSUJlI'RDSANn

~dfms.12i11.~.~1

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

"""'rn"'"

449, 451/

immuniUltlon, 448. 50: ul.., Vaccin~.

immuno&looulin!, 441
IMMUNO'oIOUULATOIU. 447. S "Iso

.wo

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,. 187~ 233,

LibraryPirate

for mJltlpie sdnosis

ptlnmtr ;Ke\ale, 161, 261.
inlmm>n ~]a, 261,261,
Inlmm>n bmIb..261,261.
tMloIlJI<IO>TlMIJI..M'TS:
adVCTM' dfls. 454,
drugl dassified as
aldesJeukin.454,
Il;i(Ulu.CalmrnrGu~rin

(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 f.un~yeducation,
455-56,
pla.,nlng: palienl goals and expr<:lro
oltl,omes,",55,
pot.nllal nUriing diagnose!, 4551
pharmaoothcrapy with. 452- 53. 454,
rouleand adult doses, 454,
IMMUNo;UPPl~:

.dvclW cffKls. 457, 4531

eha.... Urlslla,4S7
drUJlSdusifotd as
.n~bodlts. S MoHOW>NAl.
~~~

an~mtubolitft

and q1010Dc agenl<

utaklnra, 4SSt. 142,

,ulhioprine, 457, 458., 625

cydophosphamide. S
C)ocIO(l/lospru.mide
etan~rctpl,4531, 762., 763
mrthotrnate. Set Melholrcn lt
mycophmotilt moktil, 458.
slroUmu!, 457.45&,
Itmsirolimus,458,
Ihalidomide, 458,
cald nenrin inhibitors
cydolporine. See C)ocl osl", rin e
lacrolinm . S Tacrolimm
glucocorticoid . Su Gwcoconrcotus
mbanl.mlof ;Ktion, 457
lOr multiple Id~msis
m;tOIantron~, ]fj7, 267,

NUl1h" I'rocal; Fows

155esUI1rnt,460.
Impkm~ntation

"al""tion of OUIOOlll( c,it..,.ia, 46 if

Inte,....,mion. and rational..,

...... "

patient and filmily education,

460-61,
plannIng: patient goals lnd UJlKIM
outcom~ . 460,
pountial nu..ingdiagno,",,!, 4601
route and adult doses, 458,
10. Ir4nsplant rt;a;lion prnoemion, 457
lmD(tium . Su Loptrrntidc
lmopm Rables-HT. S Rabies immun.c
globulin
imptl\aO. 152
Impli.oon,697
ImpLlnWllc cardioo-on..,. ddibr~lator
(lCD).3S7
implm.nlation pru.~. in drug
~dminiMration. 53--59
also Ertclae d}"functlon
ImpoltnQ:, 719.
lmuran. Sn Azathioprine
in.monon., 3281
lnapsln . !k< Dro~ridoI
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 ]ndorn~th",in
indomethacin. 2281. 4671, 744
[nran.lr. Sa Diphtheria, tetanu!, and
perlussis va<cinc
inranu:
drug adminiMralion <hallcngr ..
19,,59
drug admlniltralion guidelines,

s..

68-69,69/
InrilSUri S. Calfactanl
Inrtlousa",nts., 1111
lnkcr!ouJdista ..... 1]61
Infuatn. s Inlerfm>n a/fawn. ]

IndH

infertility, 712
fcmal~. Stx F""",1e infertility
m.al~, 718--19
infiltration an<"Sth.osia, NO/, 241,
inflammation:
dt~mical miiators, 4651
classification, 465
d~f,"ition, 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 bo\\"~l di!ol'a~, 615
inflammatory disord .... , 465, 465,
infliximab:
adver ~ ~ffts, 45S,
as irnmunomppressant, 457, 4 58t
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,
va"in~. 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:

ad"er~ ~ffts,

5%t
for asthma. 595. 5%" 599
~lometha"'n . See B edo~tha.on e
bud"""nid~, 5%t
dde",nid. ,596t
fluni",lid~. 5%,
flutica"'n~. Set Flutkaso ne
monlda"'n ~, 5%t
triamrinolon~.

s.-. Triamdnolon~

Innohep. Me Tinzaparin
Innovar. Set l'entanyVdroperidol
Inowr. See Inamrinon~
lNO"mOPlC AGlNI"S:
drugs classified a.
digoxin.. Me Digoxi n
dobutomin~. Stx Dobutamine
do""mine. See Dorami""
m ~ chanism. of action, 4 12- 13
inotropic effect, 325
in ,omn;':
anxiety and, 152
d.fmition,152
indd~n"~, 153t
insulin ""i.ton"" and, I 53t

LibraryPirate

Iong-1et"m,152
natunl th.rapi~., 153,
pharmacotherapy
antihistamines, 577
antiseizur. drugs, 160. Set aoo
AN"I1SflZUlE DIUG.
harbiturates, 159,. Stx ah.,
iWtBmJII.l.ITS

ber.zodiaz.epines, 157r. Se~ IIlw

BrnzoDl.l.ZEPlNES

b.u-adr~n~,%iI:

antagonist., 160t. Set

aoo BIIT.I.-ADIINE1G1C .l.NfAGONISTI

noab<nzodiazepin., nonbarbiturat~,
160,. Stx ,,00 NONBrnZODIAZEPlNI'.,
1I0NMRBITUlATE CNS DIl'ItF..>S.I.NI"S
r~boll1 d, 153

ilionterm (I~havioral). 152

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 ~lulisine.68I'
insulin lspro, 682t
insulin pnmp,681, 682f
inwlin ~.i>tan"'. 153.,682
insulin- d~p"nd~nt diab.:! ... Set Diabo"l",
"",Uitus, typ" I
INSUUNs:
adve ... . ffects,681
herb-.drug interaction., 100,
Nur. bg Process f'<x:us
a ... "m~nt, 684,
evaluation of outcom~ crit. ria, 686,
impl~mentation

int. rvention. and rational .,

"'-'"
pati.nt and family iucation,
",-",
pla~nin8: pati~nt

goal. and upti

outenm ., 684,
potential nursin g diagn"",., 684.
pharmaroth~rapy with
principles, 680-82
route. of administration, 681,
681~ 682f

preparations
human r<"8ular in.ulin. Sre Human
~~uJarin .u lin

insulin aspart, 681,

insulin d.t~mir. 681,
insulin glargin~, 681 t
in.ulin glnli.in., 681.
insulin lispro, 681,
i",phan ~ .uspension , 681 1
Intal. Set Cromolyn

1183

Intd. n"". s". Etravirin .

intorforon lllfa-2b, 45-1,
actions and uses, 454t
. dministration alert., 454,
am'e"" df~ct., 454,
for cancer, 562-fi3, 563,
for htpatitis, 542,
interaction., 454,
]lltarm.cokin~tks, -1541
routo and adult do ... -154,
int. rkron alfaenn -I, 454,. 542,
interkron alfa-nl, 542,
int.rferon alfa-nj. 454,
int~rkron beta - la, 453t
for mnltipl. sd.ro.i., 267, U,7,
int~rkron beta- Ib, 454,
for multiplf "lerosi., 267, 267,
lNTElH:RON. (IFNs):
ame "" .ff~d., 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.454 542~ 562-fi3
r<%int~rkron alfa-2b, 454" 542t
mechanism. of action, 452
Nursing Process Focus
assossm. nt, 455t
n-aluation of outcomo criteria, 4561
implenl~ntation
int~rventions

and rationales,
455- 56,
pati<nt and family iucation,
455- 56 ,
plannins : patient goal. and exp:t~d
outcomo., 455,
pot. ntial nursing diagnose., 455t
pltarrnacotherapywith, 452- 53
for .peciflc conditions
cancer, 562-fi3, 563.
htpatitis, 541-42, 542,
lNTEl LEUllN. (ILs):
ald~sl~ukin , 454" 563
d~flnition,453

mechanism. of action,453
oprdvekin, 391" 397, 457
intermin~nt daudication . 379" 380
intermittent infu.ion, 32, 33f
Int. mational Union of Pur~ and Applii
Cb.mistry (iUPAC ). 12
interper",nal th~rapy, IS3
int~rstitial space . 431, 431f
int. rventions:
in miication administration, 60,
int ..""Uularfluid (ICF ) companm~nt,
431,43lf
intrac~Uular parasites, 527

884

Index

inlrad~rmal

(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
mom~l.son. furoate, 5801
uiamdno!on~. See Triamcinolone
imraocul.rpr ..... '" (lOP), 768. See ~lso
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 N~ 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. S~1.sc
Glauwma
ipecac, Ill. 629
Iplex. See M.ca .. rrnin
IPOL See Polioviru.vacdne
ipratropium bromid., 5961
action. and uses. 1 43~ 594, 596t
administration al~n .. 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. ~sirudin
irbesartan, 311,
Ir..... See Gmtinib
irinotecan, 559, 559,
iron. 399--400,649,649,. Seealw IIION .... 1J"S
iron caroonyl, 400
iron dextran, 398~ 400, 647,
iron poisoning, 70,
IION5AIn:
ad"."" dfeet .. 398t
drugs elassifii as
ferrous fumarale, 398~ 400,647,
f.. ron. sluwnat., 3981, 400, 647t

LibraryPirate

ferrous sulfat~. See FerroUll sulfale

ferurnoxytol, 398,. 400
iron dextran, 398" 400,6471
pharmawth~rapywith, 399--400
routo and adult do .., 398,
irrigations. 14
irritable lxMd "I"'drome (IBS), 621,. 625
[salol. Set Timo!ol
[.. m",ss. S RalI~gra"ir
i.l~ts of Langerhan .. 679, 679f
[,mo. See lsosorbide rnononitrate
[,motk Set lsosorbid~
isocari>oxazid, 186,
iso!luran., 246~ 247
iso ni azid, 501 t
aetio~. 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
ir.ophar.~ insulin m,~nsion. 681 t
isoprot.",nol:
aelim.and me., 1321, 133
for heart failor. , 335
[soptin.See V~rapami!
[soptin SR. Se~ V'''dpamil
[sopto Atropin. See Atropin ~
[sopto Carpine. Se~ Pilocarpine
[sopto Homatropine. ~ Homatropine
[sopto Hyos<in~. See Scopolamin.
[sordil. Sa [sosoroid. dinitrate
isosorbede, 770" 773
iso""rbede dinitrat.:
ad..., .. ~ffts, 328" 3431
for angina and myocardial infarction,
342,343,
for heart failure, 334
isosorb:de mononitrat . 343,
isotonk crr.;taUoid .. 433, 433t. See ~lso
CIYSTAUD1DS

isotretinoin, 756, 7561, 757

i.radipine. 3071
[suprel. Su Isoprot~"'nol
itraconuole, 2O~ 512, 513,. 514
IlJPAC (l",~mati"n.11Jni"n "f PIlT~
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 immun~ globulin
ixai>epilon., 563,
[xcrnpn. S [ui>epilOll'

"".-I

J
JadeU., 69S. Se~ alw Lemnorgest",l
Januvia. See Sitagliptin
jejunum,620,620f
jock ilm, 5071, 514

Joint Commission onAccriitation of

H~althca ", Organization (JCAHO ),
di ... t~r 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 c h!orid ~
Komadrin. See Procydidine
hydrochlorid.
Konacort. See Triamdnolon.
Konalog. Se~ Triamcinolone
Krppra. See levetiracetam
keratolytic, 756
Korlonc. See Iktaxolol
Kttalar. See Kotamin
ketamin~, llO.24S.251,
Kttek. SeeTelithroml"in
ketoacid .. 680
ketoronazole,513,
ad .... r.. effects. 5131
for Cushing'. syndro""" 676
int ~ ",cti"n<. 20',100.
route and adult do .. , 512. 513t
ketogenic diet, 169,
nTOllD!'.I, 499
tdithromydn, 495" 499
ketoprofen, 22SI, 4671
ketorol" trom~thamine, 228,
KI (pota .. ium iodide), 120-21,650, 667
kidneys:
disord~rs. See Renal failure
drugs toxic to, 419,
function .. 4 18, 4191, 438f
transplants. 4\8,
Kin~ret. See Anwnra
KlclJsiellll. 480,
Kalcinat~.

Index

Klonopin. SuClonaupam
Klor-Con. s.., Pot~ ... ium ch lorid~
Konsyl Fi~r. s.., Calcium polycarbophil
K-PhosMF. Su Monobasic pota"ium and
sodium pho,phat~.
K-Ph05 nfUtral. & . Monobasic pota"ium
and sodium phosphate.
K-Phos original. s.., Monobasic pot ~ .. ium
pbosphat~

Kutra ... & . Pancreatin

Ku-Zyme. Su P~ncr~atin
Kytril. s.., Grani .. tron

L
la~talol.

315t

lact~ .. d~hydrogtnase,

349,
lactalro Ringer's, 408r
lactation. See Breast-f.eding
I ar:ttlbarU/u.'

"";Mpltilu.~

100

fin.

Lamiclal. &.Lamotrigin~
Lami.U. Sa T~rbinafin~
lamivudin~,530t. 538, 542,542t
lamotriginr:
~dvasedJI5, 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
larg<"-volum~ infusion, 32, 33f
Lariam. &e Mdloquin~
Larodopa. See L",nd"""
Lasix. &e Furosemide
lalanoprosl, 771 t
action. and uses, 769, 771,
administration al~rts, 7711
adver .. dJu, 770t. 771,
intaactions,77I,

poly<1hylrne glyrol, 622,

sodium hiphosphat~, 6221
stimulant
bi .. codyl,622,
<astor oil, 6221
charact~ri'tks, 621 - 22
stool soft~nerlsurfac;tant
charact~ristic., 621
docu .. t~, 6221
fluid- el ~arolyt. balance and, 4401
Nursbg Proces. Focus
a ..... m~nt, 6261
muation of outcom~ crit~ ria, 627,
implermntation
inten'rntions and rational~., 626--271
pati~nt and family education,
626--271
pla~nin8: patient goalsand oxpted
outcome., 6261
por.ntial nursing diagno ..s, 626,
LD .. (modian l~thal dost ),46
L-Drprmyt. &. Sd"8ilin~ hj<lrochlorid e
WL Sn low-density lipoprot~in
L-Dop.t.Se< Ltwdor a
lo:cilhin~

2&3

lenalidonide,564
lepirudin. 374, 374,
l<pro<y, ~80" 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,""" 465~ 599

pha rmacokinetia, 771.

I,uprolid ~ :

rout~

for canc~r ch~moth ~rapy, 560, 561,

forfemaldnfmility, 712" 713
1",-albut.rol,593,594,
1..... mi5(l1~, 457, 563,
~quin. Sa le\'Ofloucin
l.evart~rrnol. See Norq>in"1'hrin~
lev.",ir. See Insulin d.r~ mir
l.wtiraatam, 169~ 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 ... ssm~nt. 261,

and adult dose, 770,

latent pha ... HN inftion, 529
laughing ga . Sa Nitrous oxid~
LUATIVES,621
drugs dassif.. d as
bulk forming
caldum polycarbophU, 622,
charactaistic., 621
m<1hylcellulose, 6221
psyUium mucilloid. Se< Psyllium
mudlloid
h~rbal a&'"nts
characteristic., 622
senna. Sa ~nna
lubiproston~, 622, 622,
min~raloU, 622, 6221
salin~ and osmotic
characteristics, 622
magnesium hydroxide, 622t

LibraryPirate

as5

....aluation of outcom~critaia, 2621

implrnl~ntation
int~rvrntion.

and rational ...

261--{i2,
patient and family education,
261--{i21
planning: pati~nt goals and cxpe<t~d
outcome., 261,
JXltential nursing diagno ..., 261,
",..,rdose treatm~nt, 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,
u""ph~d. Su Nor"1'in"1'hri"e
lemrphanol tartrate, 2221
le..,throid. s.., levothyrminc
Itl'Othyro.rine. 664.
actions and use., 664,
.dministr-~tion al~n., 664,
~me ..... df~ct., 663" 664,
interaction., 664,
"""rdo.. treatm~nt, 664,
pharmacokinetics, 664,
route and adult do .., 6631
u-=yl. Set, kmthyrmi nc
lcwisit~ mixture, 121,
Laapro. See Esdt~lopram OXJ.lat~
Lai..... St.. Fosamprtnavir
uxxd,J02,
LH. s.. Lut~inizing hormon~
libido,717
Lihrium. Set: Ch!ordi=poxide
lice:
characteri'tics, 752- 53, 753f
pharmacotherapy. &" PEDICUl.lClDES
p<y<hooocial a nd community

impact, 755,
licorice, 423" 4711
lid",.i" e, 243.
actions and use., 243.
administration al~n., 243,
adve "",dr~ct .. 242t. 2431, 3601
ch~mical structur~, 243f
intaaction., 2431
"""rdo.. tre.tm~nt, 243,
pharmacokinetics, 243t
for .pedllc condition.
dysrhythmias, 359~ 360t
as local ane.th.rk, 2421
for sunburn, 763
Lifespan Considerations:
adve"" drug ~ff""ts in older adult .. 41 1
.g<"-rtlated issu ~, in drug administration,
."
.lcohol-rdated pancreatitis, 635,

886

Index

llfespan Consid~ration S, (ront. )

antirrtroviral drub complian~, 533,
botulinum toxin type 10., 277.
,h~motherapy in oldu adults, 562.
didary supplem~nlS and th~ oldu adult,

'"

~~Iin

alfa a. th~ new "blood doping,"

3911
~strogm u~ and rsy(hosodal iffil~s, 7061
H, r<~ptors and vitamin B" absorption
in oldu adults, 61 4.
HN in th~ pMiatric and g<"riatric
populations, 538.
human ,horionic J\Onadotropin abu .. by
athlet~s,

7]8t

iron poisoning, 70t

l.uatr.es and !luid-~~ctrolytt balana',

"",

living withAlzMim~r'sand Parkinson',

di ..a .., 257.
methylphenid.t~ u .. in oldu adult., 20],
pain a)'"ssion and ptrception, 223.
parasitic inf"'lions in child",n, 523.
pMiatric drug administration, ]9.
pffiiatric dysHpid~ mias. 286t
p",scription dr'41 costs, df~ct. on .. nior
citizens, 8.
psy<hosocial and cult ural impacts on
pffiiatrk patients with diaooes, 682.
.. spir~tory distress syndrom~, 601 t
.. izur~ etiologies ba,~d on gmetk.. and
ag~ - r<latN factors, ]67.
shift workers, hypothyroidi.m, and drug
complianc~,663.

volatile inhalants abu ... in child"n and

adolescents, 106.
limbic .yst~m. ISO. lSI!
llnrocin. S.. llncomydn
lincomycin, 495t
lindane, 755
lin~lOlid, 494. 495t, 499
Lio",...t. See Badof~n
liothyronin~, 663, 663t
liotrix,663.
lipa ... inhibitors:
orli.tat,634
lipid(.), 39, 283, 284f. Sa also Cholesterol
lipid disordm:
in chilclhoocl. ? AAt
incid~nC<". 283t

laboratorywlu.s, 285, 2Mt

nonpharmacologkal tr<atm~nt, 21\6-.87
pharmacotherapy. Su llpid-lOl'.'<ring
tb.rapy
lipid-IOl'.'<ring therapy:
bile add r~,ins. See BILE =0 ROINS
in diaoo~s, 683.
n ..tim~. 287t. 289[. 291
flbrk add ag~nlS. See F1Bl!CN:1D t.GENT.
niacin.SuVitamin B,
Nursin g Proa .. FO<lI.
as ... ssll1tnt, 292.
implcrn~ntation

LibraryPirate

~uation

of olltcorn~ criteria, 294 .

interwmion. and rational~s,
29 3-94,
pati~nt and family education,
293-94,
planning: patient goal. and ~xpled
olltcom.., 293.
""tmtial nursing diagnoses, 292.
statin . See STATIN'
lipid - solubl~ vitamins. Su Viramin(s),
lipid-soluble
Lipitor. See AtoTVa5tatin
lipodystrophy, ,32
li""prot~ins, 283. 285f. Su "t..IlChol~terol
liquid . admini.lration guid elines, 22, 23.
Liquifdm. Su Polyvinyl alcohol
li sinopri~ 329r
action. and u ... s, 329.
administration aluts, 329,
adver.. dJects, 311 328t 329t
interaction',329,
",.. rdo .. trratnlC"nt, 329.
ph.rmacokin~tics,

329t

for "",dlk rondition.

heart failure. 318t
~rt~n.ion,3]].

myocardial infarction, 351

lit~racy, hralthca", and, 7<)....8()
Uthium, 1941
action, and " .... , 194t
administration alerts, 19.tt
ad"", ... ~ffects, 67., 194,
for bipolar disordtr, 193, 1941
int~raction., 194t
Nur,ing Process Pocus
a,,,,.. ment, 195,
impl~mmtation
~uation

of outcom~ criteria. 196.

interwntionsand rational es,
195-96t
pati~nl and famUYMucalion,
195-96t
planning: patienl goal. and expecled
outcom~s, 195t
potrntial nursing diagno",s, 195.
overdo.. trratll1tnt. 19.t.
pharmacokin~tics, 19.tt
rout~ 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..... ~ffls, 242<. 243
classifICation, 242--43
drugs da"iIlN as
amid~s

artiCiline, 242.
bupiwcain e, 242.
cb.mical .truCiUr<, 243f
dibucaint, 242,

lidocain~.

Su lldocai n~
242,
ropivacain~ . 242.
dydonine, 242.
prilocain~,

~st~ ..

benzocaine. See Iknzocain~

ch~mical5troclu""
chloroprocain~,

243f

242.

procain~,

242, 242t, 243f

242,
prarnoxin~. 2421
m""hani.m.ofaction, 240-41, 24 1f
Nursing !'roce..
a .... ssm~m, 244.
trtracain~,

R>c".

implem~mation

n'aluation of outcome criteria, 245t

interventions and rationalc,
244--45.
patient and family ~duCiltion,
244--45.
planning: palient soolsand exp<ctN
outcomes.244t
""t~ntial nur'ingdiagno ...... 244.
l.odin~. Su Etodol ..
Loestrin 1.5/J.OFe.698t
l.omotil. Su Diph~noxylat~ with atmpi ne
10ml15lin~,

555t

lon8't~rm

inOOJJUlia, 152
Loniten. Se~ Minoxidil
lOOP OIUlmc.l:

ad""r .. dT""ts, 303~ 304, 328t , 422.

drug, d."ifi~d as
buntttanidt. Sa Bumetanidt
~thacrynk add. 422.
furo ...mide. Su Furo.~mid ~
torst"mid~. See Tor ... mid~
m""hani.m, of action, 304,420, 421f
for "",cilk conditions
h~art failur~, 328~ 329
hyperumion, 303., 304
renal faUure, 4.21 - 22, 422t
l<>p<ramide.624,6241
Lopid. Su G~mfibroz.i l
Lopidine. See Apradonidin~
lo r ina vir lri Ion . vir:
actions and m .... 533t
adntinistration alerts, 533.
ad""r .. dT""ts, 530., 533t
inl~raclions. 533.
pharmacokinetics, 533.
route and adult do"" 5301
Lop",,,,,r, 302 . Su also Mfioprol ol
Loprox. See Cidopirox olamin~
Lopurin. Su Allopurinol
loratadine, ,75.
loraupam, 1581
action. and UstS, I).S,
administration alerts, 158.
ad""r,"" df""ts, 157~ 158t
int~raction . ]58.
overdo ... treaunmt, 158.
pharmacokinetics, 158.
for sprdfi, condition.

Index
anxi~tr, 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
low- d~n5itylipoprot~in (WL ):
dtaracttristiu. 2S3, 2S5/
laboratory yalu~s, 286t
ratio to HOt, 285
mbdasses, 2115
lowrr gastrointestinal tmet:
anatomy, 6()7f, 620/
di",rd~..
constipation, 621. Sa ~f", L\..UTlVH
diarrh~a, 622- 23. Sa~bo

ANI1DIMRHF..\.1S
incid~nc~,

621,
normal function, 620, 61fJi
low"" r~spiratorytmcl, 590, 590/
WW-MOIRuv.Jt-WEJGfIT HEPARIN,
(LMWHs):
adY~r .. dJu, 374,
dtar~ct~riotiu. 373- 74
drugsda"m.d as
dalttparin, 374,
.nox.oparin, 349, 374,
tinzaparin, 374,
m~chanismsof action, 373--74
rout~ and adult do .. , 374,
for spifk condition.
myocardial infarction, 349
throm~mbolic di .. a.., 373--74.
374,
lox.opine sucdnat~, 209,
Lro:itan . Sa Loxapin. sucdnat~
Lowl. Sa Indapamid.
Il'ROSTAGlANDlNl:
drugs da"m.d as
mi"",rostol,617
LSD, 109-10, 109/
L-tryptophan, 188,
lubipro'ton~, 622, 622,
WIIIICANT.>, OPHTHAlMIC:
lanolin alcohol, 774,
m~thykdlulo .. , 774,
polyvinyl akohol. 774,
Ludiomil. Sa Maprotiline
Lugol"s solution, 650,663~ 66-l
Lumigan. Sn Bimatoprost
Luminal. Sa Ph enobarbital
Lundk Su M~droxyprogestnnne ""<I. t~
Lun~.ta. &, Eszopidone
Lupron. Sa Leuprolid.
Lupron Depot. &, l.=prolid~
lutnnizing hormone (LH),658f, 695. 716
Lu",,""- Se. Flumxamin.

LibraryPirate

lyn .. di ...... , 480'

l)1llphatk syst~m. 447
lympho<yt~, 447
l)1llph<><yt~ irnmun~ globulin, 458t
lymphoma, 549,
lyrica. See Prtsabalin
lysodreJI. Se. Mitotan.

M
rna huang, drug int~ractions:
digoXn, 331,
loraz<:parn, 158,
pb.ndzin., 190,
Maalo,," Sa Magn.,ium hydroxide and
aluminum hj<lrru:id.
Maalox Plus. Sa Magn~sium hydroxide and
aluminum hj<lrru:id~ with
simtthicone
MIr.C (Mycohacteri~m ~vi~m 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 Phosphorus,lphosphat~
pota,,;um. Sr. Potassium
rODUI1~nded di~tary allowanas, 648,
sodiu:n. Sa Sodium
sulfur.648,
magaldm~ ,615,

magnesium:
functions, 648, 648,
imhalmas, 437<, 648. Sa "/,,,
Hl'P"rmagn.sernia;
Hypomagn~ ..mia
pharmawth~raPr with
ma~~'ium chlorid., 647,
m~n.sium hj<lrru:id . 615" 622t, 647t
ma~n~sium hj<lrru:ide and aluminum
hj<lroxid~ , 615,
ma~~'ium hj<lrru:ide and aluminum
hydroJ<id~ with sirn~thiron~. 615,
ma~nesium oxid~. 647,
ma~n~sium sulfat~. Sn Mlgnesium
.uJfate
rODUI1tnded di~!ary allowam,.. 648,
magnesium chl()J'id~, 647,
magnesium hydroxid., 615" 622" 647,

masn~sium

as7

hj<lroxid. a nd aluminum

hydrru:id ~, 615,

ma8ntsium hydrru:id. and aluminum

hydrru:id~ with simtthioont, 615,
masn.,ium oxid~, 647,
magn esi um sulfate, 6491
actions and uses, 649, 649,
administration a1tns, 649,
~dHrK~ff~~ts, 647r, 6491, 708,
interactions, 649,
"""rdo.. tn:atm~nt, 649,
pharmaookin~tks, 649t
route and adult do,"", 647t, 70&
as tocolytk. 708t
Mag-Ox. Sa Magnosium oxid~
maintrnana do"", 43
major dtprtssi'il' disorder, 182. Sa "/,,,
lHpn:ssion
major mineral. Se, MACROMINElALI
malaria. 116t
indd~na, S07t, 515
pathophysiology.515--16, 517f, 521,
pharmacotherapy. See Ir.NTIMAlMlIA15
pn: .... ntion, 516
Malaron~. Set. Atovaquon~ ~nd proguanil
malalhion.753
mal~ InfmiUty, 718- 19
mal. rcproducti.... function:
disord ....
antkholin~l'%iu and, 144,
~r""tilt dysfunction. Sa En:ctil~
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 d~rc:"ion . Se~ Bipolar doonkr
mannitol, 424,425~ 773
manual hraling, 95,
MAO (monoamineoxida..), 130
MIr.Ols. Sa MONOAMINE OXIDASE
INHIBITORS

Maolat. Sn Chlorphen~sin
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

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
Mat~ria Medica, 3
Matulan~. See ProGlfbazin ~
matu"'"Kn~, 755
maturity..,n ..1 diaoo ... See Diawl~.
mdlitu .. typr 2
Mavik. Se~ Trandolapri/
Manir. See Pirbut~roI
Maxalt. Sa Rizatriptan
Mayapple, 559
MCT Oil, 651
MDA,IIO
MOl (metered do .. inhalu), 591, 591/
MDMA, llO
m~ .I.., 1161
measll'S, mumps, ~nd rubeUa vaccine. 4521
m~su .. m~nt systems, 21 - 22. lIt
Mebaral. See Mephobarbital
m~b~IJdazol., 5231
actions and u ...s, 522, 523, 523,
administr.nion al~ns u ..... 523,
ad"..... dfects, 522t. 523.
interactions, 5231
pharmacokinetics, 523t
rouU and adult dru<, 523t
mecamyl.min~, 278
meao ... rmin, 660, 660t
m~chanism of action, 12
mecltJorethamin~, 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 ....', r~sponsibUiti.. for, Ig, 19

cate""ri ... 89. 891
in child.. n, 9Ot, 91,
di~tary supplern~nt. and, 57
faclors contributing 10, 85
in th~ hom~, 85, 87t
impact, 85-86
OTe drugs and, 91,
r'"""rtins and docum~nting
documenting in pali~nf, miiaol
r"""rd,87-8-8
.. poning to national databases, 88
writins an incid~nl report, 88
strategies for reducing
d~nt education, 90-91, 90.

LibraryPirate

in hmlhcar~ facUities, 91
nursing p=ss in, 88--89
tracking,91
m~dication uror index, 85, 86/
m~dication reroncUiotion, 90
MEDMARX , 91
Mtdrol. Me Methylp .. dnisolone
m edro"YP ro8""t~ron~acdat~, 706,
action. and u ..s, 706,
administration alerts, 7061
ad..rr.. effls, 561., 706~ 707t
int~ractions, 706t
pharmacokinetics,706t
for sp<dfic conditions
cancer, 561,
dysfunctional ut~rin~ bl<ling,
707,707,
inj""tion for contraception, 697
MedWatch,87,91
mefenamic add, 228.
mdloquine,516.
Megace. See M~.trol
mellalobla,lic (p<midou.) anemia, 399,

M'

mmbolk bon~ disea .. (MBD), 733

metabolism:
alcohol, 108

dru,
faclors aff'""ting, 40
m,""hani,m, lS/. 40
In olde r adults, 73--74
in pregnancy, 64"";5
Metaglip. Se~ Glipizidc/metformin
M.tamucil. Sre Psy llium mu cilloid
Meland .. n. Sa Methyltestosterone
metaproterenol, 132t
metaraminol, 132,
metastasis, 548, 548/
metaxalone,272,
rn<trrido .. inhaler (MOl), 591, 591/
m~tfo rmin,689 f

actions and u .... 689t

administration alrrts, 689.
ad...,r.. cff'""ts,687~ 688, 689,
interactions,689.
m""hanism.ofaction,688
oyrrdo ... treatment, 6891
pharmacokinetics,689.

megestrol, 560, 561 ,

methadon~

MEGl.JfINIDE.\:

foropioid d~[J<nd~n"~, 107. 227

for pain manascmen!, 222,
methadone maim~nanc~, 227
methampooamine, 110- 11, 198" 200, 581
methazolamide,770.
meth~namine. 495,
Methergine. See Methylrr8<lnOYin~ m.. l~at~
rnrihimazok, 6631, 66.J
M.thitest. Sa Methyh",!ost~ron~
methocarbamol,2721
methohexital sodium, 251.
m~thot .. xate, 5571
actions and u ...,557t
administration alerts, 557,
ad...,r .. effects, 555,. 557t, 742.
interactions, 100., 557t
mechanisms of action, 5so!
overdo .. tr~atment, 557t
pharmacokinetics, 557.
for sp<cilk condition,
aoncc:r ch<:moth~ra py, 555,
immuno.<uppr~ssion, 458t
inflammatory bow.l disea ... , 625
poori",i . 762 . 763
rhrnrnatoid arthrilis. 742t
stmctu..,556/
methotrexate with mooprostol, 703~ 704
methoxyflurane. 246.
methsuximide.174,
M.thulo .... See Mcthykellulo ..
methyclothiazide, 303., 422t
methykeJlulOK, 622" 774 .
methyldopa, 132~ 315.
methylfl"WJnovine mal~te, 708t
m~thylph ~llida te, 1981
abust, III
action. and u ..., 198t
for ADHD, 200

adyrr.. effls, 687,

charact~ristics, 688
drugs classified as
natfglinid~, 687t
rtpa&linide. 687,
rout~ and adult do>es,687t
mdanin,750
melanocytes,7so
melatonin, 153,
Mollari/. &. Thioridazine
mdoxicam, 228~ 467.
mdphalan,555.
memanlin~, 264"";5, 265/
m~mory B ceUs, 447
meningitis, 480.
m~n"""me:

definition, 704
estrogen 10... in, 705t
hormone replac<m~nt therapy in. See
Hormone .. placc:ment thaapy
nalural therapy wilh black coho'h, 704,
menorrh"l!ia, 706
m~ notropin', 712, 712t, 719
M.nta>:. Sa But~nafine
me[J<ridin~, 222., 635
m~ph~nytoin hydroxyl .... , 81 , 81t
mephobarbital, 159',171,171,
meprobamat~, 159
mercaptopurine, 5so/, 554, 555~ 558,
M.ridia. Se~ Sibut"'min ~
meropen~m, 495~ 499
merozoit~s, 515,517/
Me""m N. Se~ Meropenem
m~salamine ,625, 6281
m~SGlline, 110, IIOf
Mf.<tinon. Sa Pyridosligmine
metaholit: acidosis, 420" 44 }.

IndH

administration al~rt., 198,

adya .. df~d., 1981
im .... ction., 1981
mechani,ms of action, III
Nursing Pr"", .. Focu., 199--200,
in olda adult., 201,
o'-"'rdo .. tmtm~m, 198,
pharmarokin~tk., 1981
methylpminisolonc;
for ad",nocortkal insufficirncy, 67 1,
adva .. ~fft., 4701
.. anti~mrtk, 629, 6301
for inflammatory bowel di .. a .., 625
for ..""'" inUammation, 4701
methylt~.>t""t.rone, 717,
MmIYIJlANTHINES:

aminophyUine, 5941, 595

characteristics, 595
pharmacotb.rapy with, 595
theophyUine, 594" 595
methysergide, 233,
metipranolol,770,
metodopramide, 617,630,
m.tocurin. , 278,
m~tolaz.one, 3031, 422, 4221
Mdopiron ~, Soc Metyrapone
mdorrolo~ 3341
action, and u .... 136" 334,
administration al~rt., 334,
adva .. effts, 3281, 334" 3431
&"n~tic polymorphism. affecting
metaboli,m, 81,
jmfractions, 334,
o,,,,rdo .. tmtmem, 334,
phamIaCOkin~tk., 3341
for specific condition.
angina and myocardial infarction, 3431
heart failure, 328,
hy~rte",ion, 3151
migraine,2B,
metric system of meaSll"'m~m, 21, 21,
MmoCmm, Se< Metro nidazole
M~trodin, Se~ Urofollitropin
M~t~L Su Metronidazole
mdronidazol e, 522,
actio", and u .... 522,
administration al~rts, 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, Se~ Lowstatin
mexll~tin~, >601
MaitiL Sn Maildin~
MJ. Soc M)"Xardial inf./'Ction
Miacakin, See CalcitoniJl-salmon
mibtfradil,20,

LibraryPirate

mkafungin, 508,
Mkardis, SecTdmi.. rtan
Micatin, Sn Miconazole
miconazolt, 513" 514, 752
MICRhoGAM, Se< Rho(D)

immun~

~Iobulin

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, 649~ 662
iron, 399--400, 649,6191, Sa abo [roN
~

mangJneS<,6191
molybd~nnm, 649,

1189

imeractions, 3361
"""rdo.. t",atm~nl, 336,
pharm.cokin~tk.. 3361
route and adult dOst, 328,
mind--body int~rventions, 951
min .... l oil, 622, 6221
mineralocorticoid .. 670, 671
minerals:
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:

romm~ndl di~tary allowa",,, ..

649,

stleni:.tm, 549~ 649,

zinc, 649" 650
zinc acotate, 6471
zio, &!uconn., 6471
zinc 5ulfat~, 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< Mif~pristone
mi&prh;ton~, 7031, 704
for CIt.<hing'. syndrome, 676
mi&!itol,6871
migraine:
ddln~ion, 230
incid,"co,2J.Ot
pbarmaroth~rapy, 232, 234, Sn

aoo

ANnM!GfJJNE DRUGS

propJ:ylaxis
btta - adr~nugic blockers, 2331
calcium cbanne! blocurs, 233,
methJ'S<rgid~, 233,
riboUavin, 2331
topiramate, 2331
tricydic amid~pr~... nt .. 2331
,;olprok acid, 233 ,
MigranaL Su DihydJ'Ort'gotamine mesylat~
Milk of .\lagnesia, See Magnesium
hydroxide
milk thhtl~, 96" 97t. 108,
milk--.an:a~ syndrome, 615
Milontin, Su Pb.nsuximide
Milopb.n~, Su Clomipb.ne
milrinOIl e, J36t
actior.. and u .... 336,
admimi,tration alal5, 3361
ad"" ... effects, 328" 3361

,arbachol, 770,
pilocarpin~ , 770,770,
MiraLax, See Polyethyl~ne glycol
Mirap<x. SIX Prami~lDle
Mi/'Crtt~,698.

Mil'etl3, 698, Ste ah<) ~\'Onor&tst:rtl

mirtal.apine, 1551, 1861, 18S--89
misopro,tol, 703" 704, 7081
for p<ptic uker pre..ention, 617
mitomycin,5571
milotane, 563" 564
miloxantron~, 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
",cdn~

Moban, Sn Molindon~
Mobie. Su Mdoxicam
modular formula .. 651
motXipru, 311,
molindone, 209,
molybd~nnm, 649,
momerasone, 580" 596" 760,
Monistal. Sec Miconazolt
monoamin~ oxidase (MAO), 130
MONOAMINBoxtru.IE INHIBITOl.\ (MAOb):
.dve.... df~ct .. 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
Nursin g l'rocce.. Focu., Su
AntidC']l""sams, Nursin~ Pro.: ....

"""'

for specific conditions

antitty symptoms, 155,
dC']lr~ssion, 1861, 189
monoba,je potassium phospbat~,647'
monobasic potassium and sodium
pho.phat.., 6471

890

Index

(MASs):
ad"""", df.. ts, 458" 473
for amoimmun~ dioord~rs, 457
druss dassifil ...
al~mluzumab, 5631, 564
ba,iliximab, 457,458,
b..vadzumab,563.
hortfWmib, 563.
~tuximab, 563,
dadizumab, 457,453.
~rlotinib, 563.
gefitinib, 563.
gomlu:rumab o~micin, 563.
ibritumomab tiuutan, 563,
imatinib rntsylate,563., 564
intliximab, Su In(iximab
lapatinib,563.
lymphocyt~ immun~ globulin, 458.
muromonab-CD3, 4 57, 458,
rituximab,563.
ocinitinib,563.
soraf~nib, 563~ 564
tositumomab, 563.
trastuzumab, 563--fi4, 563.
m<'Chani,msof a<lio~, 4 57
for .~dfic conditior.
cancer chemoth~"'I'Y, 563--M, 563., 564/
immuno>uppression, 457, 453.
Monom. See lsosorbidr mononitrat~
Monopril See FminoprU
monosodium gluumat. (MSG), 230
monldukast, 596~ 599
Monurol See Foofomydn
mood disorder, 182. Set ~Jso Bipolar
disord.... ; Dtprasioo
mood stabUizers, 193. 5eealso Uthium
mominH skkn~... 628
morphln~ . ulfat., ll31
action. and uses, lllt
administration alul5, 223.
ad"""", dr.cts, 2221, 223.
H~n~tk polymorphis:ns afi'eaing
mdaholism, 81t
int~raclions, 223.
in mJ"'Xardial infarction, 35 I
"""rdo.. tn:atm~m,123.
pharmacokinetics, 2~3,
rouuand adult do ..; 222.
motion .kkneos. 577,621., 1\2'1
Motof~n. Set Dif~noxin with atropine
Motrin. Su Ibuprofen
moxil\oxadn, 491, 492, 492,
MarobU. See PI~rixaror
MSG (monosodium slulamatd, 2].0
mu n:cC'ptors, 221, 22 1t 221 .
Mudn.x. Set Guaif~n .. in

MONOCLONAL ANIl90DIE,

MUCOLYTICS:
act1ykyst";n~, 583., ,85
characteristics, 585
dorna .. alfa, 585
pharmacothrrapy with, 585,601
Mucom)"l. Set ~tykj"st~in.
mucosalaycr,607

LibraryPirate

mucositis, 552
Multaq. Set Dron.ru.rone
multiple tdaosi. (MS ):
characl~ristks, 266-07
classifICation, 267
di .....-modifyin8 drug.
immunomodulators
glatiram.rac .... at., 267, 267,
int~rf.ron beta- la, 267, 267.
interferon beta- Ib, .67, 267.
immunosuppressants
mitoxantron., 267, 1.67 t
indden~, 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
U~

muscl. rigidity, 256

mUKk spaJlm s:
causes. 271
definition, 271
home care consideralion>, 277.
incid~n~, 27l.
natural therapy with cay<:nne, 273t
nonpharmacological tn: alm.nt, 271
Nursing Proc<ss Focus, 276--77.
pharmacoth.rapy, 271 , 272,. Seea/so

Mylanta. St. Magnesium hj<lJ"OIid~ and

aluminum hydroxide with
.irntlhicon~

MylantaAP. Sre F.molidin~

Mylanta Gas. Su Sim.thicon.
Mylanta ~l-<:ap . See Calcium <arbonate
with m.gn .. ium hydroxide
Myl~ran. See Burulfan
Mylol.rg. See Gerntuzumab o7.0~icin
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
pharmacoth~rapy

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

SKll.ETAL MUJ.Cl IIElJ.XANTS

Mustarg.n. St. M<chlomhlmin~

mutations, 48 1
Myambmol. See Elhambutol
my."h.nia gf1lYis:
characi<ristks,139
cholin.rgic agonts for, 13~
nitrous oxid~ 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., 4 ~. See
ali", Thberculo.i.
Myoobulin. Su Rifabutin
mycophrnolat. moktil, 45&
Afycoplru".a pn~umll";ae, 430.
my<:<>..s:
mmmnnitY.""'1nirM, <;(17

definition, 508
incid~n~, 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 Ph ~n~krhrin ~
MyFortic. Ste Mywphenolat. mof.... il

N
N. ' . Su Sodium
nabilon., 629, 63(1.
nabum.lone, 228., 467.
N-a~tylcyst.in., 472t
N.a. See Sodium < hlorid~
nadir, 552
nadolol,I:J6~ 315., 343.
nafan:lin,712.
N.fcU. See Nafcillin
nafdllin, 484.
nalliflD . , 51 4.
Nallin. Set Naflifin.
N.HCO,. St. Sodium bk.rbon.l~
nalbuphin. hydrochlorid., 222.
Nalfon. Sr. F.noprofen
n.l ioi ixk Add , 4'11, 4'IIt

nalmefrn. hydrochlorid., 222.

n.loxon . hydmehlori de, 226t
action s and U=, 123., 221, 226" 227
administration alerts, 226.
ad,.. r.. effects, 222~ 226,
int.ractions, 226.
o""rdosc tr.atm~nt. 226,
pharmacokinetics, 226.
route and adult do .. , 222.
nalnnone hydrochlorid., 2221, 227
NANDA (NorthAm.rican Nur.'in8
Diagnosi. Assoo:iation), 57
nandrolon.,717.
naphazolin~, 581.,774,774,

Indn

Naprdan. Su Naproxm
Naprosyn. Su Naproxm
naproxrn. 228,. 467t
naproxm sodium. 22&
naratriptan.2B,
Narcan. SN Nalo:ml1~ h}o:Iro<hloride
narcotk. 220. 221
narcotic analg~iC5. SN OP[OID (NAJtCO"I1C)
t.NAI.G<.S!C5

Nardil. SN Ph~ ndzin ~

Naropin. 5I:~ Ropivacain~
narrow-'~trum antibiotk 482. SN also
ANI1MCfEllAlS
narrow-'~trum

prnidllin .. SN

Pl:NICIllINS

Nasacon AQ. Sa Triamcinolon~

n.l!>JI drug administration. 25. 261. 28f
Nasalid~. Sa Flunioolid~
Na!>Jrd. SN Auni",lid~
Naorobal. 5I:e Vitamin B"
(cyan ocobalamin)
naoogamk (NG) tube, 23" 24
Naoona. Su Mom.taoon~
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 ... Am~ricans:
m~ntal ilIn~ss tnatm.nt. 205,
Natncor. Sa N ... iritid.
Naturacil. Sa Ps}llium mudlloid
Natural Hoaltb Products Di=torat~
(N HPD ).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";
Navan~. Sa Thiothiun~
NO" .mew. 7
NE. Sa No,""pin.."hrin~
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. 5I:~ Castor oU
neomydn. 490. 490,

LibraryPirate

neomycin cream/ointment, 752

neomycin with polymyxin B cream/
ointment. 752
neoplaSJll. 548
Neoral. SN Cyclosporin~
neostigmine, 123" 139. 140t
Neo-SJ"TIephrine. 5I:~ Oxymelazoli nc;
Phenylq>hrin~

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,
207~ 473
neurol.."tics, 206. Sre ~!SO ANnPSYUlOf!c";
NEUIOMUSCULU 1I!.OaE1.\:

d<p<>Jarizing
,uccinylcholine. Se. Succinylcholin~
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 Se~Potassium and sodium
pho.phates
Neuttogrna. Sre Salicylic add
n ... irapine.53Ot
administration alerts. 533,
New Druglo.pplica tion (NO",. 6;; 7
Noxa,.,.r. Sa Sorafcnib
Nexium. Sa Esomeprazole
NF (Nmi<m~/ 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

891

nif~dipin~,

308t
actions and u .... 307. 308,
administration alen .. 308,
am..... .rf.ct.. 233t. 307,. 308~ 708t
interanion .. J08,
mechanisms of action. 307
ovrrdosc trtatmem, 308,
pharmacokinetics, 308t
for ,~jfic 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 ~Iso "UJ!A.l1NG
~,~

bc:ndamustin 555,
chLorambud~ 555,
cydophosphamid~.

51:.
Cyclophosphamid e
estramustine.555,
ifosfamide. 555t
mechlortthamine.555,
mdphalan.555,
nitrogl yce rin, 344,
action. and u .... 344 t
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

892

Index

Nitrostat. Sn Nitroglyc~rin
nitrous OIid~, 2471
actions and u,"" , 247,
administration al~rts, 247.
ad""""d&cts, 2471
int ~ ractions. 2471
"""nlo.. t .. atm~nt, 247.
pharmacokinetics. 2471
nils, 753
Nix. Sn P~rm..thrin
nizatidin~, 6121
Niwral. Sn ~oconazol~
NOC (Notice ofComplian<C"),9
nockepti"" pain, 219
nociceplor, 220, 229f
Noct..:. Su Chloral hydrate
Nohad~x.

Sa Tamo.tif~n

NONBJ:NWDIAZEPINE. NONllARBITUIATE CNS

DEPRESSANTh:

for anxiety and insomnia, 1601, 161

mechanisms of action, 161
Nursing Pr~ss Focus. 161-631
drugs dassifiro as
buspirone, 16O~ 266
dexmooNomidine He!., 1601
esropiclone, 1601, 161
ethchlorvynol, 1601
zaleplon, 160.
zolpid~m. Su Zolpidem
noncatecholamine drugs. 130
nondepolarizin~ blockers. 275. &e a/$o
NruJIOMlJSCULl.R BLOCKIlIS
non-English-s~king 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,
ziconotid ~. 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 Halop~ridol
loxapine succinate, 209.
molindonc, 209,
pimozidc, 2091
thiothiunc,209,
Nursing Proceso; Focu.
.s"ssllYnt,209,

LibraryPirate

implemmt.tion
rvaJuation of outcome criteria. 211,
in~rvcntions 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, 228~ 4671
f1urbiprofm, 228 . 467.
ibupro&n. Sn Ibuprofen
indom ethacin, 2281. 467., 744
kctoprofen, 228., 4671
kctorolac tromethamine, 228,
mefenantic acid, 228,
mdoxicam, 228" 467.
nabumetone, 22S~ 4671
naprmm, 228., 4671
naproxen sodium, 22S,
oxaprozin. 22S~ 4671
piroxicam. 2281. 467.
sulindac,228,
tolmetin, 228t, 4671
salicylates
aspirin. Sn A.pirin
cooline saJicylate, 228,
saJsaJate,2281
scJ~C!i,.., COX-2 inhibitors
cdecoxib, 22S" 467t
herb--drug int.,..~'tion., 1001
mechanism. of action, 227
Nur,ing Process Focu,
assessment, BII
~.,.aluation of oulcom~critcria, 2321
implementation
intorvcmion.and rationales,
231 - 32.
patient and famUyC"ducation ,
231 - 321
plannin~: patient &
oal, and expccll
outcom es,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
no"rinq>hTin ~ (NE), 411 r
action. and u..., 132., 411.
administration alorts. 411,

ad""r ... dfccts.,4OSI~ 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, 698~ 707,
NorfleL Sn Orphenadrinc
norfloxacin, 492.
norgostimate,69S.
norgo.>l ..1,698,
normal ..line, 4081
norm al .... rum ~Jbumi", 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 . Se~ Labctalol
Noroxin. See Norfioxacin
Norpac ~. See Disopyramide poo,pha~
Norplanl, 69S. Se~ also Lc""norg~.>Ird
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.. Nalbuphin~ hydrochloride

NUCLEOSIDE AND NUUEm1DE REVD.,';I;

nAN>CR!!'fA.lE INHIBITOR>' S. .
~~~

abacavir.5>O.
didanosine, 5301
emtridtabine, 5>0., S38
lamivudine,53Ot
'iavudine, 530,
tenofoYir. 530 53]. 538
zidovudine. Sn Zidovudin.
Nu~n:ainal. s... Dibucaine
Nu~r""ine. &. Dibucaine
nur... (. ):
drug appro,.... l proces.s and, 9

al50

Index
nursing di~gnoses:
ddinition, 51
in dnIJ odmlnl~""tion, 51, 5&.
nuning proass:
defUlition, 55
in d"" odmlnl~ntlon
...wment p~, 55-57, 56r
cvalU<ltion ph.lIt, 59-60

implemc nlal ion phut, 58-59, 601

nursing diagnoKS, 57, 58.
planning phase', 57-511
in mNicallon error n:duction .nd
p~!Iof1 , &3-89
phases, 55/
NuninH ~5S Focus;
ACE inhibilornnd ARB bIockrn,
)]3-]4,

amc mf<iicalions, 7S8-~.

ADHOand AOD thnopy, 199-2OOr
adrmc.rJk aJOnlm (J)'IIll'"thomimelks),
1J4-lS,
adrmc.rJk antaJOnlsu ( symp.tholytics),
131-39~ 316-18.
androgens. 720-2 1.
~nlianm1k aa~nu,401-2.
anlian~ielylhcrapy. 1 6 1~)'

anlibacterials, 496-98<
antichoiin. rilcJ (choiin.l"gk-blacking
agoents),1 45-46.
antico;!&uI~nU, 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.
antin~laSllcs, 565~ .

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,
wlony-~imuLlllnB f3e1Qrs, 395--97.

diJaxin,332-33.
diuretics
hyperlm,lon, )05-7.
for ",nal failun:, 425-27.

ror

LibraryPirate

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 sulf~t., 401-21

fluid IDd tllrolyt. replacement the""py,
43 4-35,

fluid lfpJa>tment for !hock, 4 10-111

o
obftity:
elloioaY,63 1

health risks. 629

Inddmc.,629
phar~ u~,"ment,634,6J4.

object!Yc dlola, 5S
obttsJiYe-compubj", doordcn ( O<D ~ 150
Ocu gam, Sa lntra-,,:nous imrnWl~ globulin

folie add. 401 -2.

oclr~ide, 624 ~

generll ~n(5'helks, 249->0.

gluoocorlicoldl. 473_75., 674-75,
H,-n:cqltor anugoniw, 571!-11(1,
h... peIVirul p..... rm""oth.rapy,

OcuClear. ~e O~rmelazo ljn e

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.

!42-141
HIV-AiDS p..... rma<OIMrapy. 534-36.

horroont rtpbc"~nllhenP!'. 70]- 31

hypollW;lm k: In<! pituitary hormones,

".....,

immunostlmu]ant.. 455-S6t
immunosuppn:JSOInls, ~It
,n",lil Ihctapy. 634-86t
levodopil or levodopa-a.rbidopa,
:<61-62,
lipid-lowering IhfU PY, 292-941
loca] . ne5,h.lie.!. 244-45.
nilro"yurln, 344-4&
non"~foktal ,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,
symp!Om~Iic cold ",Ii.r, 585-87.
thrombolyllcs, 384-115.
thyroid hormone ",plac.m.nt,

"'-'"
235-36<

660, 660.

d.... administration <haIl~"1t"", 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
~n,73

dISlribution,73

= relion,74
melabolism,73-74
polyph2..mxy in, 90
pn:scrlptlon drugcmu and, 8,
oIillOmcnorrhe., 706
oligomeric formulas. 651
oIll1Ospam~

718

olmesarhln mrdommU, 311.

n4

tript~~s,

oIop.itadln.,575~

vasodilators. 320-22,
vitamin and min.ral pbumacOlherapy,

ols..l.zin., 625
omtil-3 f,uy acids. S Fioh oib

".....,

vitamin 1",401-21
nutritioaal Jupplcmmt'l'
.... t.ttI. S Entaal nutrition
indicl lion s. 650
!otaI9an:nlcral nutrition. S Toul

rlrtnleral nutrition
Nutropb. S. Soma,otropin
Nuv. Rin8,698
N}'lrazid . ~ hnnl.!zi d
n)'Jtatln, 5 15'
acliou and IISOIo. SIS.
admi.lstratlon alert .. SIS.
ad.-erlt tlfta, 5 14., SIS.
p/1;IrmiKOkinelk:s, 515.
routnnd adult dolt, 51 4.
Nyslcx. S N)'Slalin
N)'Stop. S N)'Slatin
Nytol. S Diphenhydramine

Bill

omepfiuoIe,6 11t
llClionnnd 113<'S,61 I~ 635

administration al.n s,61 I

adv\>rw dINts, 61 I.
Inl<'l'''''llons,6 11,
pharmacoklnel\cs, 6 1 II
mule and adult dOS(', 61 I.
Omna r;" s acl.sonid.

Onca5p<lr, ~e ~gaspargalt
ondlonse',ron. 629, 630.
opm-ansle ~l,uron .., 7611, 7611/
nphlh.lm!r <I,ul\"
adm lnistntion , 25, 26., 27/
.ntlglauco..... S ANTJGl.\l!CCW" [)1UG5

C)tloplcak$
a'ropine, n4,
dIIf'ilCtmSlIa, n 4
cydopentolau,
honull'OJ""', n 4,

n,.

894

Index

ophthalmic drugs, (conI.)

scopolamin~. 774,
tropkamid 774,
hom. car~consid<rations. 775,
lubricants
lanolin alcohol. 774,
m~thykdlulo... 774,
polyvinyl alcohol. 774,
mydriati"
characI~r;'tic.. 774
ph<nyl~phrin~. ~ Phenyl"1'hrine
natural u...rapy with bilberry. 775,
pemirolast. 774
vasoconstrictor.
naphazolin 774, 774,
oxymda70lin~. ~ Oxymdozo line
tflrahydrozolint. 774. 774,
opiale, 220
opioid(.). Sn~Jso OF!OID (NAI1OOTIC)
ANALGESICS

combination drug. for ..,....,r~cold

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. 251~ 252,
.ufentanU dtraie. 251 252.
rrceptor .. 221. 221f, 221,
opioid agonist 221. ~ ~&O 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
butorphanoltanral~. 221f, 222,
charac1<ristics. 221 . 22lf
dezodn~. 222,
nalbuphin. hydro<hloride. 222,
pmtazodn~ hydrochlorid~, 22 1.
22 1f, 222,
opioid a(lOnist.
characleristics. 221. 22lf
codeine. Su Codeine
hydrowdon~. See Hydrocodone
hydromorphone hydrochloride, 222,
lomrphanol tanral<. 2221
m.peridin~ hydrochlorid. ~
Meperidin.
methadon~. Su M",hadon ~
morphine sulfate. See Morphin e
sulfat.

LibraryPirate

oxywdone hydrochloride. 222,

oxywdon.t<lrphthalal~. 222,
oxymorphone hydrochlorid~. 2221
propoxyph~n. hydrochloride. 222,
propoxyphene napsy!al<. 222,
herb--drug int<raetion 1001
Nursing Proc",-, Pocus
........ m.nt. 2241
~Iuation of oulcom~crileria, 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:
charaC1~riSlk . 221 . 22lf
drug. da .. ifial as
nalrnefene hydrochloride. 2221
nalonme hydrochlorid. Sn Naloxone
h}'dro<hlorid e
nalt",xone hydrochloride. 222,. 227
pharmacotherapy with. 226-27
opportunistk inftions, fungo!. 507
opponunist;': organism . 41U
op",lv"]<in, 391t. 397. 457
OptiPranolol. Se~ Mdipr.molol
Optivar. &e AzclaSiine
OIAL OON1lIAumvES, 699f
for acne, 756. 756.
administration. 697
adv.... dfl .. 698. 699,
benefit .. 695,
~51lOli1rn. and PlOlilestin. a . 697--98. 6981
extended regim.n
Seasonal. 698
Season ique.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 Tri- 1.)'cI~n.6':1H'

Ortho- Novum 7/7/7.6981

Triphasil.69St
interaction . 699
N ursing Proce.. !'oeu.
a"", .. mem.70I,
implem.ntation
evaluation of outcome ",it<lia. 70).
intrr.,..llIion.and rational... 701 - 31
pati~nt 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,
pioglitazon~/m<lformin. 6881
rosig)itazon./g)imrpirid 688.
rosiglitazon./metformin.688,
mC'(llitinid~s

characleristics.688
nat.glinid~.687'

rtpaglinidt.687t
new.. ag~nt.
char""leristics.688-89
cx.nalid~. 687,. 688-89
prarnlintid 687 ~ 689
sitagUptin. 687 689
sulfonylurea.
charaeleristics. 686. 688
chJorproparnid~. 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: pati~nt goal. and rxp<aal
outcomes. 690,
pol<ntial nursing diagnoses, 690,
pharmacotherapy with. 683. 686
roule and adult doses, bl!/-8HI

Index
Orap. Se~ Pimozid.
Orap ... d. Se. Prrdnioolon~
Orazinc. Sa Zinc ""Ifat~
Or.ncia. Sec Abataccpt
Orgalutran. Sa Gani ... lix a"'t3t~
organ transplants:
frequency. 447t
"'j<"Ction.457
ORGAN!C NlnATI.S:

drug. dassiflCd a.
amyl nitriu. 343,
isosorbid. dinitra~. Sa lso.o mid.
dinilral.
ioosorbid. mononitrat 343,
nitroglycerin. SN Nil roglyctrin
m~,hani.m.of action. 341 -.4 2. 342f
nUllling process focus, 344-16t
rout. and .dult do .... 343t
;n <",!"c'M m~ni;.1 ;nfardkm. l'i()
therap<lltk approach. 341 -.42
Orinase. See ToJbutamid~
orli.tat.634
orph~nadrin 272t
Ortho Tri-Cyd.n.698t
Orthoclone OKT3. Sa Muromonab-CD3
Ortho- Cyd~n. 698.,
Ortho-Evra.698
Ortho-Novum 7f7 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
ur~a. 424. 425,.

773

m~chani'm. 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 ):
charact~ristics, 74 1. 7411, 741,
incid~n"'. 74 1,
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
~thnic/racial co",id.rations, 740,
indd'D<'~. 736t
lif~styl. consid.rations. 740,

LibraryPirate

pharma.cothr:rapy
bi,phosphonates. Sa B!'PHOSPHOOAThS
hotmonal ag~nts
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 hydnxortioon~. 776t
ber:zocain. and antipyrine. 776t
carbamide ~roxid~. 776t
cip:oflox..dn and d.xamethasone. 776,
cip",floxacin and hydrocortisone. 776t
polymy:Iin B. ntomycin. and
hydroconisone.776,
"ru.rmac.nth~'""l'Yw;'h. 77(,
miti. ,",dia. 480,. 775
Otrivin. Sa Xylom~ta70line
outoomts:
ddin~ion. 58
in dr~g .dministration. 58
o\"er -thHOUnler (OTC) drugs:
ad ..... age. and disad""ntages, 4
for oowd disord~rs. nausea., and
,"miting.634,
ddin~ion. 4
for gallroint. stinal disord~rs.
int ....actions, 614,
n .. di(ation ~rrors and. 91,
Oyidrd. s... Chorionic gonadolropin -

HCG
Ovr~tt~.698,

ovulation.695
oxacillin, 484. 484,
oxaJipl"in.555,
Oxandrin. Sa OxandroJon~
oxandrolon 717,
oxaproz:n. 22St. 467,
oxazrpan.157,
QlAZOllDlNONl'S, 494
linezolid. ~SL1 . 495 499
<m:arba;:tpin~. 169~ 173. 173,
ru:iconarole.513,
OxistaL Set Oxi<onarol~
oxybutynin. 143.
oxycodon. hydro<hlorid~. 222,
oxycodOlletOT~phthal.t~. 222t
OxyComin. Sa Oxja>don~ hydrochlorid.
oxynl <1, ro lin 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. hydro<hlorid~. 222t
QlYTOC!a:

defin~ion.

707

895

drug. dassifird a.
carboprost trom~thamin~. 70},.
704.708,
dinoproston 7031. 704. 708,
~rgonovin. maleat 708,
m~thyl.rgonovin~ maI.at 708.
mi5Oprostol. 617. 703t. 704. 708,
oxytocin. &. Oxytoci n
oxytoci n,709t
action, and uscs, 708--9. 709,
administration al~ns, 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
;n'~T\"en,ion< .nel .... ion.I ~_,. 7t t.
pati.nt and familyrducation. 711,
planning: pati.nt goals and expt~d
outcom~s, 710.
pot~ntial nUllling diagnoscs, 710t
"""rdo.. t .. atm~nt. 709,
pharmacokin~tics, 709t
rout. and adult do ... 70S.
secmion. 658f

P
p53 gm 549
paceJ1"laker.356
Pa'OTon . Sa Ami odaro n.
Pa,ific~.

559

packed red blood ceUs.408,

paditaxd.55O(. 559.559,
P.lget'.disca ... 737
poin:
a.essm~nt. 219
cla.. ification. 219
ddlnition.219
exp .... ion and pcrCtption
age and. 223,
~thnic/radal con.id.rations. 220t
;ndd.nc..219.
mechani,ms
n~ural. 220. 2'lJ.Jf
nociCtptor Irwl. 229f
nonpharmacologic manag~ment. 219
pharmacotherapy
.C<taminoph~n. Sa Actlam inoph~n
donidin~. Sa Clonidin.
nonsteroidal anti- inflammatory
drugs. Sa NON'n:R01DAL
AN11-1NFV.MMATOn DIUGI
opioid. s... OPJOID (NAi.OOTIC)
ANMGEI1CS

.. Ikylat~.
aspirin. See Aspirin
cholin~ salicyJau. 228.
salsaJate.228,
tramadol.228.,
palliation. 550
palonooetron.629.630,

896

Index

Pamdor. Sa Nortriptyline
pamidronau, 736.
p-aminob.nzok add (pABA), 763
Panaxgi""ns. Se~ Gin ... nE
I'Ilnaxqu;nquefoliu . SeeGinsmg
panc~a.s, 679, 679f
Pdnu~ ... See Panc~1ir ..... e
panc~atk enzymes:
ilctions wd US<"i,633- 34
drugs classified as
pancreatin, 635
panc~lira",. Sa Pancre lira.e
panc~atin, 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,
pharmacok.in~ic.. 636,
pancuronium, 278,
panic disorder:
deflnition, ]50
pharmacotherapy. 154- 55
pantoprazole, 611,6] I.
pantothenic acid (vitamin 8,),640,
papa""rine,721
Paracmldohyde. Sa Paraldehyd e
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

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, 490~ 521.
pamutine, 155" 1S6t
Pdr""I, 763
partial a80nist, SO
pania! (focal) seizure, 167, 168~ 169t
P.ser. See Aminosalicylic add
passi"" immunity, 449, 451 f
passi.., transport, 37
P.tana .... See Olopatadine
Patanol. See Olopatadine
pa~n, 479

pathogenicity. 479
patient and family education:
acne, 758-59,
ADHD and ADD pharmacotht-ra py,
199- 200t
ad~nergic agonist. (sympathomimelics),
1>4- 35,
adrtntri;ic antaitOnim (sympatholytics ).
138- 39t
androgen., 720-21.
amian~mic 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.

I".arhymid h"nn"ne (PTH). HI

h;<ph",pMn ~<. 71l!- Wt

Paregoric. Su Camphorated opium tinctu~

parenteral nntrition, 6>0. Secal", Total
pa~nteral nutrilion
parenteral route. 28. Sa a/", Drug
administration, pa~nl.ral
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

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,

LibraryPirate

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, 29 3-94,
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.
lindan~, 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,
7~4-5"

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 impac~ 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

Index
~gfllgra'tim,

391 ~ 394
alfa-2a, 454., 542.
~gimaf""m a1fa -2b.454., 542.
P~g- lntron. Su Prgintaf~ron alfil- 2b
PEG-L-a'paragin ..... SN Prga'parga'"
~gvisomam, 660~ 661
~gylation, 542
~gin!afaon

~Uagro, 643

~mctr=d, 554, 555.

~mirol.,t, 774

PIm Tscw, 3
~nddovir, 538.
~n~trat~calcium

trisodium, 123.
trisodium, 123.
~nidlaminc, 123.
~nkillin G b"nza!hin~, 484.
~nkillin G procaint, 4S4t
penicilli n G sodium/potassium, 4861
action, and u ...s, 4861
administration al~rt" 486.
adY~r ... dJcet" 484" 486,
ima.ction',486t
pharmacokin~tk., 486t
rout~ and adult 00.... 484,
penkilUn V, 4Mr
~nidlUnase, 484. 485f
~nkiUinasc-resistant ~nkiUins, 484, 484 .
Su a/s" P!N1C1LUN.
~nkiUin- binding prot. in, 484
~n .!ra!~zin"

PE.NlOLLlNS:

ad= ... ~ffl5, 484" 485

all~rgy to, 485
dru8' cI.ssif..d a.
broad-.ptctrum (amin"P"nkmin.)
amoxkillin. Su Arnoxidllin
am""icillin-davulanat~, 484" 484
ampkmin, 484, 484,
bacampiciUin,454.
charactaistk" 484
CXI~nd~d-sptrum

(am ipseudomonal)
caro..nidllin, 484., 485
charactaistk" 485
pi~raciUin sodium, 484; 485
pi~racillin lazobactam, 484,
IkarcUlin, 484t
natural ""nkUlin.
pmicillin G Mnzathin~, 484,
pmicillin G procain~, 484.
~nkillin G sodium/potassium.
Set ~nkillinG so dium /
potassium
penicillin V, 484,
pmicmina ... -ro.istant
charact.ristics, 485
cloxadUin, 484, 484,
did""""min,484,
nafcillin, 484.
oxadUin, 484,484.
m~chani'm. of aClion, 485
pharmacothtrapy with, 485
rout~ and adult do .." 484,
P~ nlac. Su Cklopirox olamin~

LibraryPirate

Pentam. SN P~ntamidin.
pentamidin.,521.
Pentasa. Su M<"SaIaminc
J><ntalOdn~ hydrochlorid~,

actions and uses, 753, 753,

administration al~ns, 753.
am'c""df~ct" 753.
intaa.ction" 753.

221 ,

all. 222.

pharmacokin~tics, 753t

Penthran~.

Su M<1hoxyfl.uran~
pmtobaroital sodium:
as sc""ral anesthesia adjunct, 252t
for ... 4iuion wd insomnia, 159.
forscirur." 171.
Pentolair. Su Cycl"P"ntolal.
Pentostam. See Sodium .tibogluconal.
~ntostatin, 555.
Pentot .... l. Su Thi op< ntal
J><ntoxilyllin., 375, 379., 380
Pen- V~. K. Su P~nkiUin V
Pepcid. SN F:irnolidin.
I'rplamm Liquid. 651
J'qIUC ULel" di .....-:
ddln~ion, 609

herbal th ~rapy, 616,

nonpharmacolosical th"",py, 609
Nurshg Proces. Focus
..... ssm.m, 613.
e<.'3!uation of outcome criteria, 614r
impl~mentation

~rrnitil.

See Fluphenazine
(m.-galobla.tic ) an<rnia . 399,644

~miciow

~rph.nazin.:

gen.tk polymQrphism! affecting

m~taboli'm. 8] t
for nausea and ""miting, 6J.Ot
for psycho..., 206; 207
~rtofran~. SN D... ipramin~
~tit mal. See Absence ( ~tit mal ) ... illl'"
pH:
d.finition,440
~1J~ct on absorption. 38, 39f
pl ma.440
pharmacodynamics:
cdlular r<plor" 49--50, 49f
cuslontization of drug therapy, 50- 5]
d.finition,46
dru8-r~ptor int"",ction., 50
dkacr, 481. 4 9
gradl'd dose-response relationship,
47-48.47f

inter.-.,ntion. and rational~"

613-14.
pati~nt a nd fantily education,
613-14.
pla~nin8: pati.m goalsand .xptcted
O\Itcom~" 613,
pokntial nursing diagno ..., 613.
pathophy.iology, 608' 609
pharma.cothc:rapy
anudd . SN ANTAOns
H,r=ptoranta80nim. SN H,-

imerp,ati . nt yariabmty, 46, 46f

pot.ncy, 48-49, 48f
second m .... ng<r~.-.,nt., 49
theraprntk index.46-47. 47f
pharmacog~netk., 5], 80. Su ~I,,,
Genetic>
pharmacokinetics:
absorption. 37- 38, 38' 39f
d.finilion,37
distribution, 38f. 39-40, 39f
drug pla.ma conc<ntration. 41-42, 4 3f
~xc"'tion, 38j. 40-41

iKEI'IOR ANTAGONISTS

mo:hani.ms of action. 610f

mi"'pro,tol, 617
pr.-on pump inhibitors. &e

897

Per~222

loading dOS<", 43-44, 4Jf

maint~nanu 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:
d~finition, ]2
exampl., ]2t

Parocet 5. SN Oxycodon~ !a.phthalat~

Percodan, 223
pct"cutan~ous tran.luminal coronary
.ngiopla,ty (PTCA), 340
pct"iormiUlce anx;'ty, ] 50
Perforomi'l. See Forrnotcrol
~rfu,ion , 59(jf
persolid., 257, 258.
Prr80na!. See M.nolropins
pct"indoprU.311'
pct"iph~ral n~rvoussyst<m (PNS), ]27f
~riph~ral r i,tanu, 298, 298f
~ri.talsi . 607
~riwinlJc. 558-59
p. rmetbrin, 7531

pharmacology:
d.finition,3
history, 3
y. th~ra~utic>, 4
pharmacopotia,4
pharmacoth.rapy. See ~151> Drug
admini'lration
community and enyironm~ntal
influenu .. 79--80
cultural and ("[hnk influences, 78-79
d.finition, 4
g.nd~r influ~nu" 8]
8.n~lk influences, 80--81, 8],
holi.tic. 77
psychosocial inlJucnc~" 78-79

PwroN

lUMP INHIBITORS

sucralfutc, 616
thcraprntic approach, 609--10
risk frctors, 609
symptom,,6JY)
Pepto- B:Smol. See Bi,muth ",b.. licylat.

89 8

Index

Pharmacotb.rapy UJustr-~ted:
activ~ and passi..., immunity. 451f
Almrimd. dis<:a"" drugs, 265f
angina drugs, >42f
antid~p",s .. nt therapy. IS5f
antihypert~nsiv~ 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 rre~ptor--<hlorid. channd
mole<uI. ,170{
heart failure drugs, 327{
limbk system and reticular ""tn'.ting
syst~m,151{

local anestooks, 241{

monoclonal antibodies and canur un

'M,
".

Pharml'acl>:
ahmati..., th~rapies, attitude. toward.
ane'th"ia and an.sth~tics. 242.
angina, 340,
anxiety disord~rs, 1511
arthriti .. 741,
a.thma, 591,
attention def"'it-hy~r""tivity disord~r,

,,,.

bact~rial infection .. 479.

canur, 5481
dotting disorder .. 3711
community health 5tatistics in the
U.S., SO,
d~g~n.rati"" distases of the central
n.rmu, syst.m. 256.
d.p", .. ion. IS3,
diabtt~. mellitus. 680,
dysrhythmia .. 3551
.pil.psy, 168,
femal. r.productive conditions, 6951
f.taleff~cts of drug uoe during
prognancy.68,
fungal infection 507.
gastroint ~stinal disorders, 621 ,
glaucoma. 769,
,ra~fruit juke and drUJ, interactions.

".

headachu and migrain~, 2301

h. althca ... ""uss among minoriti.s, 79,
hoan failur., 325.
helminth infection 507.
h.matopoietk disord.rs, 390,
hi~ blood ,holest.rol. 2831
h~ne ",ion, 2971

inflammatory disorders, 4651

insomnia and insulin resistanu. 153.
insomnia indd.nu, 153,
male reproducti..., disord~rs, 716.
musd~ spasm., 271.

LibraryPirate

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,
vilamin~. minerals, and nutritional
supplement,,639t
pharyngitis, 480,
Ph~nazine.

Siie ~rphenazin~;

Promethazin~

ph enelzine, 190.
actions and ...... 190.
administration alerts, 190,
adv~r...ff.d .. ISS., 186~ 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.
ph enoharbital,I 721
actions and U""S, 172.
administration alerts, 172,
adv~... effts,67/, 159t, 17lr,I72.
interaction I72t
Oy~rdo .. trratment, 1721
pharmacokin etics.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
chlorpromazin~. See Chlorpromazi nc
Oupb.nazine. 206.
~rph~nazin~. Sa ~rphenazine
promazine, 2061
thioridazin~, 206. 206t
trifluoperazine. 206. 206,

mrcbanism, of o<tion, 206- 7

Nursing 1'rO<:<.. ""'us
a ...ssment, 209.
e""luationof O\Itoom~ criteria, 211,
implementation
inte,,'entions and rationales.
1l0--11.

patient and family education.

210--]].

planning: patient goa), and <XpCcted

outcomes.210t
potential nur,ingdiagnose .. 2091
pb.nsuximid~,174.

pb.ntermin 634
pb.nlolamine. 136., 721
ph~nyl "l' hrine, 13JI
actiOn! and UIO. 132" lBI
administration alert.. 133.
ad...,r .. dfects, J33~ 409t
in cold/allergy combination drugs, 5761
interactions, ]33.
oyerdosetreaunrnt.IBt
pharmacokinrtk., l331
fur specific conditions
e)'l' irritation, 774. 774 t
nasal congestion/allergic rhinitis,576,
576t, 581t
shod::. 409.
pb.nylpropanolamin e. 634
Pb.nytek. s"., Ph ~nytoin
ph~nytoin, 1751
action. and u .... 175.
administration alert .. 175t
ad...,r.. dfrcts, 173~ 175., 360.
interactions, 175/, 187t
o..erdo""trratm~nt. 175t
pharmacokinetk., 1751
for specific conditions
dysrhythmias,360.
seizures. 169t, 173,1731
PH' NYJOIN- IlKE !.GENTI:

drugs cla.. ified a,

carbamazepin~. See

Carbamazepine
174
lamotrigin . See lamotrigin.
valprok acid Stx Valprok~cid
zonh,amide. 173-74,1731, 175
phobia .. ISO
ph",ge n~ oxime, 12],
I'hosLo. Siie Caldum aulal~
phosphodi.ot~ra"", 335
f<lbamat~,I73I,

PHOSPHODl~

lNillBITORI:

adver.. dfects, 328

drugs classified as
i"amrinon~. 328t, 335
milrinon~. Stx Mi lrino n~
mrcbanism,of action, 327f, 335
route and adult doses. 3281
therapeutic approach. 335
PHOSPHODl~ - 5INHIBrro~

adver.. dfects, 722. 722.

drugs classified as
,ildenafiJ. Stx Sildenafil

IndH

tadalafil, 722, 722t

vard~n.fiI, 722.
NUr>ing p =.. Focus
assessment, 723.
n"aluation of outcome crit~ria,
723- 24.
impl~mentation
int~rventions

and rationales,
723- 241
patitm and family education,
723- 24,
planning: pati~nt soaJsand exptct~d
outcom"',711t
potential nursing diagnoses, 723t
Phospholine Iodide, &e Echothiophate
iodide
phosphoUpids, 283, 2Mf
phosphorus/phosphate:
functions, 648, 648,
imbalances, 4371, See. at.o
Hyperphosphat~mia;

Hypophosphatemia
for nutritional and d~<lrolyt~ disord~rs
monobasic potassium and sodium
pho,phate ,6471
monobasic potassium phosphate, 647,
potassium and sodium phosphates,

..."

potassium phosphat~, 647t

",commended dietary aUowance, 648t
photo""nsitivity, with t~tracydines, 489
phototherapy, 763

Phm;rw p~bis, 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
p~ocarpine, ]4Ot, 770, 770t
Pilopine, & Pilocarpine
pim~crolimus, 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, 228~ 467t
Pitodn, &eOxytodn
pituit ary gland:
anterior, Sn ANI1:J.IOl PlnJITA lY!.GENT~
disorders, 59t
hormon~ production,65Sf, 659
post~ rior, See. PruTIltlOR PfI1JlTAAY AGENTS
Placidyl, See. Ethchk'''')'I101
Plan B, 700, 703, 703t

LibraryPirate

plannintphase, in drug administration,

,5--56
plaq....:
corornry a rt~ry,)39
in p",riasis, 760, 761f
Plaquen~, & Hydroxychloroquin e
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 prot~in fraction, 408, 408,
plasma "'Ium~ expanders. Sa COUO[D:\
PlasmalJ1~, 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],
pl.td~t ""unt, 372t

1'1..\.= ENHANCEIS:
drugHla .. ifled as
t1trombopag, )911, 397
opJ~h;ekin, 391t, 397
romiplostim, 391" 397
pharma.coth~rapy with, 394, 397
Platinol.Sn Ci.platin
Plavix. SocClo pidogrd
Plendil. See. Fdodipi"~
pkrixafor,564
Pletal. Ste Cilostazol
pneunto.:OC<al infections, 47<;1,
pnewnooxcal vac.;in .., 4 52t
f'!1""m",,"~ 480t
f'!1eum,,:v,,;, carin;; (PMumocysrk prowd),
,07,
pneumonia, 4SOt
Pneumovax 23. Sn Pnrumococ<al vac.;ines
pNS (peripheral nervous .ystem), ]27, 127/
plJdophyl1~m peI""um, 559
poisonir_B:
inddrnce,7],
iron, 70.
prev01ltion,69
top 2S substance. invotv.d in, ]22,
t ... tm~nt fundamental., 12t- 22
Poladex. Su DexffiJorphrniramine
Polararnine. &e D=hlorph~niramine
polariztd,358
poUo',ins, 1]9
poliovirus ""ccine, 452t
Polyco .. , 65]
polyc:thllen~ glycol, 622t
polymeric fommla, 65 I
polymyxin B, neomy<in, and
hydroconisone,776t
polypharmacy, 73, 90
pol)'Styren~ sulfate, 420t
polyviJl}1 alcohol, 774.
Ponstel. & ~Mfrnamk add
Pontoca.n . Su Tetracain~

899

P",;';or. Su M~fradil
positi..., inotropic a8~nts, 325
positi..., symptoms, 204
posteriorchamber, 767, 767/
POSTIlIIOR PfI1JlTARY AGENTS:
d~smop", .. in. Sn D""-lno pr .. sin
Nur.ing Pro<..s Focus
as ...smont, 665t
cv;a/uation of outoomc criteria, 666t
impl""'~ntation

intervrntion. and rationales,

665--M,
patirnt and familylucaHon,
665--Mt
planning: patient goals and CXl'<'Ct~d
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
chlorid e
recommended dietary aU"".. nee, 648,
renal regulation, 423, 438, 438/
POTAS'illM CHANNEL Bl.OCKEl.I:

drugs classified as
amiodaron~. Su Amiodarone
doktilide, J60t,.l64
dronedaron~, 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 al~ns, 439,
ad.,.."" df~ct .. 439., 647 t
interactions, 439,
ion,, 4J.6t
"""rdo.. treatm~m, 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:

ame""df~ct .. 303., 304,328.

drugs classified as
amilorid~, 303t, 424,
eple",none, 303t, 311, 328~ 423, 424,
spironolactone. &. Spironolactone
triamt~rm~, 303., 424,
mechanisms of ""tion, 42If, 423
for specific conditions

900

Index

(amL)
faUu",. 32&. 329
hyptrl<nsion. 302,. 3031. 304
",nal faUu",. 423. 424,
potency. 48--49. 48/
PPF. St. Pla,ma prot~in fraction
pralidoxime.IDI
pramiP=lI~. 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 a1~rl .. 137,
ad,..,,,,,,./hcts, 1371. 315,
classification. 13fu
int.ractions, 137,
",..,rdo.. trtatm~nt. 137,
pharmacokinetics, 1371
for s~dfic condition.
I'OTA.SSIDM- SPARING DllJRFllCS,

h~art

btn~n

prosutic hypertrophy. 725,

hyptrtension. 315,
fucia. S Dtxmod.tomidin. HCl
preclinical inVC":'ltigation. in drug
deyelopm~nl.6. 7/
fuco ... SN. Aalrbo ..
pmlnisolon 470.. aI,
predni so ne.U I,
action, and uses. 471,
administration a1~ns, 471,
ad"""", dft" 4701. 471,. 561,. 671,
int.ractions, 471,
pharmacokinetics, 471,
for 5~dfic conditions
"d..noconical insufficioncy. 671,
cancer. 560. 561,
intlammalory bowd di .... se. 625
intlamrnalory disorders, 470,
fukst. St. Estradiol/norg~'timat.
pregabalin.169,. l7I,
preganglionic nruron.129
pregnancy:
antisei Lur~ drug, during. 167
oornplications, 167
d~p",<";,,," "f'~r, 1~}

drug r~gi.'ries, 66
FDIo. drug cat.-gori. s, 65-66. 6fu
folic add supplem~nts in. 3991. 644,
gestational age and dru~ 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 trometham in~. 7031. 704
dinopro,'on 7031. 704

LibraryPirate

mt1hotraale with misopro'lOl,

703,.704
mif<priston< with misoprostol.
703',704
P"'gnyJ. Sn Chorionic son adotropin -HCG
p",implantation period. 6,
p",load. 325. 326/
P",lon~. St. Prcdnisolon~
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.
equin</m~droxyprogesl.rone

P",mpro. Su Conjugati <mog<ns,

equin./medroxyprogt'sleron~

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 equi\"lll~nts,
13--14
consumer spendillion. 51
di,~nsing. 4
ffect of costs on okl~r 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
prilo.:ain~. 242t
Prilo.. c. S Ornept""dzole
Primacor. Su MUrinon.
primaquin 5161
primary hyptrt~nsio", 299. Ste,.]",
Hypertension
primary-V"'ll ..... i.." multiplo. .. lerosi 267
Primaten~. Su Epinephrin~
Primaxin. St. Imi~n<1ll.dla'tatin
primidone.671, 1691. 17lt
Princi~n. &~ ILmpicillin
Prinivil. Su J.isinopril
p,.;"7.nl~,"I'., (""""-'p"<fkj ~nzin". 140..v,
abo Angina ~clori'
Privin . St. Naphazolin~
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.. ~ffts,
361,
for dysrhythmia,.3'Sf. 359,. 360,
genetic polymorphi.m, .fk<ling
m<1abolism. gl I
int~ractiOlls. 361 I

J.6O'.

o,..,rdo .. treatment, 3611

pharmacokinetics. 361,
proc.in~. 242, 242,. 243/
Procan. St. Procainamid.
Procanbid. Su Procaina mid.
procarbazin., 55"
Procardia. Sn Nifedipin.
Prochi""". See Progest~ron<
prochlorp(razi.IJe.6311
action. and u .... 631,
adntinistration alerts, 631,
ad""r.. df<cts. 630~ 631,
interactions, 631,
Oyerdo.. tr.atment. 631 I
pharmacokinetics. 631,
rout nd adult do ... 630,
Procrit. Su Epoetillilfa
procydidine hydro<hlorid~. 2601
prodrugs.40
progest~ron~. 695. 706. 7071. Suolso
PROGFSfINS
PIlOGESTINS:

action, and u .... 706

drug, classified as
combination druiS
conjugati estrog~ns,
.quine/miroxyproge't~ron~

7071
<strad iol/dro'pirenon 707,
estradiol/n0'1l"51imate.707,
~thinyl ~stradiol!norfthindron~
acetat~,

7071

miroxyprog~st~ron. acetate. Six

M. d roxyprogcsteron. """t.'e
no",thindron 698~ 7071
progest.ron 707,
functions, 695. 706
Nursing Proce.. Focus
a ..."ment.701,
implem~mation

evaluation of outoomecriteria. 703,

inurYCntion.and rationales, 701 - 3,
pati.nt and family~ducation. 701 - 31
planning: pati.nt goals and exp<Cled
outcom .... 701'
pot~ntial 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. Flupbenazin~
Promacla. Su Eltrombopag
promethazine:
a, adjunct to g~n~ra1 an~sth<,ia. 252. 2521
for an~rgic rhiniti,. 575,
for nau\oeO and mmiting. 6301
Prometrium. St. Prog.st~rone
Pronestyl. Su Procainamid.
propaknon 36O,
propanthdin<, 143,
Propin<. S Dipiydrin
Propionw,,<1erium acrr"" 755

Indn
propofol,251t
propoxypt.tM hydrochloride, 222l
p~ 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. ~~..Jso
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 ~ilk conditions
as emergency contraception, 703.
.Jauroma, 769, 770/
pha.macologlc~1 abortion, 7031
as tocolytlcs. 708, 7M.
p""tate. S Iknl. n prostotic hrpertroplty
Prostigmln . S NeoSliQmine
Prostln E,. ~(Dinoprostone
prot.mlne :sulfate, 123" 375
protealt,528
I'ItOTTASE tNlUlitlOltS. S.
Nml.lnOVllALio

;ad...,,,,e dfKIS. SlOt

drup wstiflt<.l IS
ataunavir, S30f

LibraryPirate

daroruovir, 5301
I'osampunovir, 5301
indinavlr,S301
IopiMVi.!litonavi . s
lopi,uvir/ rilooavir
ne13D<1vlr, S30f
rilolUvlr, S30~ 537
saquinovif,530t
tlpml~vlr,

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--1 41
pharmil)th~ ... py With. 6] I
Pmtonb:, Sa J>~nlOpruol~
ProIOPUI, S Prali<kWm~
ProIOpk. See Tltcrolimus
pMOIy!" drua. 12
pnMo-.Sl5
pfO(OW,&J lnfKtiOf1s:
incidence,5IJ7/
malolti;t. S MaI~ria

nonmaiarlal,S21.
prot.ipMlnc, l&a., H31
Pro""ntil, S Albuterol
Pro""ra. ~e Mcdroxyproge. tcronc acd~tc

provita.mlnl, 639
ProU(. ~e 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&.76 1
rtloloiy, 761
nonpUntlilCOlogicallherapy, 763
pharmKOlhelllPY

.,..mk
KiIMin,7621,163
adalimllmab, 7621, 763

901

~lefoC<pl, 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 artlvilil, 7611
(Wriatlc ~rythrodcrllll, 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 rn udUoid, 6211
acllonnod ....... 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, ~t Propylthiouracil
publc 11, 152-53
Public Heallh Service AC!. 6/

Pulmlcort. Stt! Budeoonide

PuImocI.u,651
Puu Food and OrugAa,5, 6/
Pu~,sCasto.oiI

purine, S~
PVlINE .o.NALOGS. S . ANTlMEl'AIIOUTlS

cbdtiblne, SsSt
dGf~r.bine, SS51
fi\ld.:lr.bine,5S51

mCTC'optopurine, 550/. 555,

nel;!r~blne,

5551
j)('ntostatin.5551
thiogu<lnine, S55~ 556f
Purklnje ftben, 356, 356[
push ( IV bolus ) odminiit",tion, 32, H/
push pltaage, 113
pwlU];Ir ptOritiis, 76lr
py"'ntc~ 522" S13
pyrulnamide, SOOt
pyrtthrin.. 753
pyridost.i.m'M,IJY,I4U.

902

tndex

pyridoxine. SuVitamin
516t
pyrimidin~, 554

S.

pyrimethamin~,

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,
g~mdtabine, 555.
pZt\, See Pyrazinamide

Q
quazepam, 157.
Qudicin, See SUc<in ykholi ne
Questran, Su Cholestyram ine
qudiapine fumarale, 194~ 213r
Quin.mm, S.. Quinine
quinapril,328,
quinidine glumnate, 360r
quinidine sulfal<, J60r
quinine,516t
quinupristin--<lalfopristin, 494, 495t
Q""r, See Bedomdha'lO n.

R
rabeprazole, 6]],
rabi~s immune globulin, 450r
radal wnsideration., Sf< Ethnic/radal
consid.r~tions

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 al~rts, 740.
adv."", dkcts, 5611, 736~ 740.
inl<'ractions, 740t
pharmacokinetics, 740t
route and adult dose, 7)6,
raltegravir, 530., 531
ramiprU, 31lt, 3281
Ran~xa, 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
R~betroL &. Ribavirin
lkbif. See Int~rferon beta la
rri>ound congation, 5S1

LibraryPirate

",bound insomnia, 153

"'ceplor(.), 49---50,49f
"'ceptor theory, 49
Rccomb;..'iX HR Sre H'1'atitis Bw cci 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
R~Hudan, See Lepirudin
",frac:tory""riod,358
"'gional ane"he,ia, 240
R~ilin., 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
R~miaode, &~ InHiximab
"'mif~ntanil hydrochloride, 251~ 252.
R~minyl, &. Galantamine hydrobromide
R~na~L &.Sr,eJam er
",nal failu",:
causes, 4181
classifICation, 4 19
definition,418
diasnosis,418--20
drugs causing, 419t
incidence, 41St
pathophysiology, 4 18, 4 18,
pharmawth~rapy

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, 4 18.--20, 4201

thiazid~ diuretics, S THIAZIDE
DIURETICS
"'nin-an~iotensin

system:
in Huid balance, 432
",nin--an giot~ 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

Repron~x. Sa Mrnotropins
lkquip, Sa Ropinirole
Rescriptor, Sre Delavirdine
Rescula, &. Unoproston~
Resear<h Shows:
alt~mating dose. of ibuprofen and
acetaminophen for child"n, 4 Ht
folic add supplem~nts prior 10
pr~8nancy, 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 lif~style,
to5r
_ight loss strat~i.., 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
adapaLen~, 756, 7561
isotretinoin, 756, 756,
t"'tinoin, See Tretin oin
lktrovir, See Zidovudine
r...."'" ,holesterol Iran sport, 283
rn'e ... lranseriptaS<', 52S
l=~ TItANSCIt!l'fA,E lNH!I!ITOIS,

-~~

Rnex. See Nalmd~n~ hydrochloride

lkYia, See Naltremne hydrochloride
Rf..iimid, &. Lenalidomide
Reyataz, Sre AIazanavir
lk:zulin, Sa TroglitaI.On~
rhalxlomyoly,is, 288
Rhromacrodex. Sre Dcxtr-dn 40
rheumaloid arthritis [RA}:
characteristics, 741 -42, 742f
indd~nco, 741,
pharmacotherapy, &. DI,EASE-MODlFYlNG
AN111HEUMATIC DJlJGS
Rheumatr"", See Mciliot rexate
Rhinown, &. Budesonide
rhinophyma, 757

IndH

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 Risperidon e

risperidon. ,266
risperidon e:
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 rfero n 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

LibraryPirate

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 Ram r henn
rTMS (""",titi.., transcranial magnetic
ltimulation),183
rubella. 752
rubeola, 752
RUbeL ~n Doxorubicin
RythmoL Stx Propafenon.

5
SA [sinoatrial) nnde, 356, 356/
SAD ( ~ISOnal affectM disoroerl, 182
SaiLen. ~n Somalotropin
SalOL S", Salicylic add
SAL!CYLIIT.S, 468, 741, 763
a.piri~. &e Aspi rin
choline .. licyla". 2281
salsa],te, 228,
salicylk acid, 7621
salicy\i~m, 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.po ri""
Sandostllin. &~ Octreotide
San,.rI.See Methl""'rWde
saquinaYir, 530,
.. rcoma. 549,
Sarrop/t"S'lCabie~

752

sargranlJstim, 391" 394

Sarin, t~l,
saw palmrtto, 96" 97" 7261, 727,
SCABlQIU:

characteristics, 753
drugs da .. ifi..d as
(rotamiton, 753
lindane. 755
penn~thrin. See ~rmrthrin
Nursbg Proce .. 1'ocu.s
a"''''m~nt, 754,
evaluation of outcom~ crilrria, 755,
implrmentation
int .....entions and rationalr ..
754-55,
patient and family ..ducation,
754-55,
pla~ning: patient goal. and upect..d
outcomes. 754,
por.ntial nursins diagnoses, 754,

903

pharm.cotherapywith,753
scabies:
charact~ri'tics, 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, 205~. &e al5c
ANrIPS'lCHUJ1CS

atypiLal antipsychotics. See AITJl[CAl

AN11PSYCHOTICS

dopamine ')'Icem "abiliuro , 2 t6

mechani.m.ofaction, 205/
nonphenothiazin~s. 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
school-a~ child, 70-71. See al50 DlUdrm
scinitinib, 5631
scopolamin~:

actions and uses, 143~ 14 5

asantiemrtk,629,6301
ascl"lop~ic, 774,
ocurvy, 644
sea ..,~tabl ... , 643,
seasonalaffti,,,, disorder (SAD), IS2
Seasonale. 698
Seasonique,698
seborrhea, 755
seborrh~kdermaliti' . 760
secobarbital:
as genua! anrsth~sia adjunct, 252,
for ..,J...ion and inllODln;", 159,
Seconal ~ Secobarbital
second me;senger ""ml" 49
secondary hypen~nsion, 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

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. SN Tam""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 .~dfic condition.
anxirty,
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:
~d"" .... 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 hop rim ul fameth o:<aZO Ie
Serax. Se~ Oxazepam
5rt"...ent. Se< Salmetero l
SElU.t S. Set S!llECl1V[ ES1l!O(;EN- RECE!'fOI

"'.il....

MODlFlEb

S<:rom)'l"in. SN Cydo.. rine

Serophen . Set Clomiphen.
Seroqud. Su Qurti.pine fumarate
S<:rostim. Set Somatotropin

LibraryPirate

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. Se~

, I.e 1irYl'lCAl. ANT!DEPlI.""ANTS

S<:rpasil. Su lkserpin.
.. rtaconazole, 5]3,
... rttaline, l88t
actio~.and
1118" 266
ildmiDistration alerts, 1881
ady..... eff~ 155" 186,. ISSt
interactions. ISSt
""e,,:b .. lreatrn<nt, 188,
phannacokinetics, 1118,
mnt~ .nd .dOlIt dn ... I",
for specifIC ronditions
ami.ty symptom .. ",.tle..,n... s, and
dtpression,15Sr
dq>re .. ion, 186,
..""lam.., 420t
.. voflunn~, 246,
Sherley Am.ndment, 5, 6f
shin&l"' (~<T), 539
mock:
defin~ion, 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,
4 1(1....11,
pla~ning: patient goals and exp<eti
ootcom", 4 IOt

U"',

potenti. 1 DUrlins diasnou<, 4[0.

pathophysiolo8Y, ~07f
pharmacotherapy
eff<ets, 4071
fluid replacement agents. SN flUID

-,

MID ELECIWLYrn JEPL\.CEMENT

inotropic agents. S.. lNOTIO;OPlC ACENTs

"""""onstricto.... Se~
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, 20~ 2S7,
Sin"",et. See Carbidopa. levodopa
Sinrquan. Sa Doxrpin
single order, 20
Singulair. SN Montduk.o51
sinoatrial (SA) nooe. 356, 356f
sinw brad~rdia, 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,.clo benz.aprine
diazepam. Sa Di azq>am
lorazepam. Su Lo f"Ll"l'am
mrtaxalon . 2721
mrthocarbamol,272t
orphenadrine, 272,
tizanidin., 27 2t, 27 3
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

Index
n~plastk,

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
~~uym:'INH!!rroll), 186r, 188, Set
alsc A TYl'ICAL AmID!:PI!!'5SI.NTI
,~NS (StT"'~Bk N",;on~1 Stod"n~),

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, 359~ 360,
lidocaine, See Lid ocaine
maUetine,36O,
phenytoin, s.., Ph enytoin
pro<:ainamide, s.., Procainamide
propafenone,360,
quinidine gluconate, 360,
quinidine mlfate, 360,
fordysrhythmias, 3581, 359. 359" 360,
.. local anesthetics, s.., l.ocAI. ANlSlHEllO
sodium chlorid e (N.O ), 439t
action. and u ..... 439,
administration alert., 439,
adycrse dIed" 439t
intera<tion',439t

LibraryPirate

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 Diph enhydr-dffiine
Somoeri ph~nom~non,
Sonata, Stx Zaleplon
""rafenib, 563t, 564

~1\1

Sorbitratr, s.., lso.o mide dinitr-dtc

Soriatanr, See "dtretin
""talol, 136" 360" 364
soy, 961
spasticc%n ,625
spasticity:
cause~ 273
ddin~ion, 273
homrcarecomiderations, 277,
non pharmacological treatm.nt, 273
pbarma<:om.rapy, Sa aJ..,
ANTI' PA.lMODICS

mo;:hani,m.of action, 274/

Nursing Process Focu~ 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,
'P irilla ,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,
'werd~se 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 u;hencki~ 507t
sporOlrim.o.is, 5071
SSRls, St. SEUCl'lVE SEJ:OTONlN REUl'I'AKE
l'<IlIBITOLI

905

St, john', >rort:

for dfpr.ssion, ISS,
drug interaction.
chlorpromazine, 2071
efavirenz, 532,
esdtalopram, 156,
<Ihinyl.stradiol with norethindrone,

"""

imipramine, IS7t
medroxyprogc'trrone ac~ate, 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 ~wreu"
di ....... , caused by, 480t
methkUlin- r.. istant, 481, 498
tesiSlanU' to ~nkiUin, 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 I0 and, 290,
drug. dassifii a,
atorva'tatin, s.., Aton....t.tin
Huvastatin,2871
lon'tatin, 20~ 287,
pra'''statin, 287t
roSllva'tatin, 287,
.inwa".!in, 20" 287t
mechanism. of a<:tion, 287-83, 2S9/
NUr>ing Proce.. Focu~ 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 Dcsmop~in
stimulants, central ncrmu ystem:
a mph.tamin .., s.,., Amphetamine,
caffein., 81" III
cocaine, See Cocaine
methylphonidate, See Meth ylph enid ate
stoma<:h, 608, 608/, See a/so Upper
gastroint.stinal tract
Strat<gic National StockpU. (SNS), 118

906

Index

Stran~ra.

&. AlomORlin~
75-0
cornrnm. 750
granulmum. 750
luddum. 750
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.
T.. to't~ro ne
strou mlum<.198. 298/. 299/
Slrom~ctol Su [vermectin

stratum
stratum
stralum
stralum
stratum

basal~.

Su,,"o

subcutaneous drug administration. 28-29.

30dl!
sub.k<;livedata.55
Sublimau. Su Fentanyl citrat~
sublingual route. 23. B,. 24!
Suboxone.227
sub,tanu abuse:
androgen .. 717
dtfinition.104
d=rometborphan.582,
indd~nu and extent, 14,
neurobiological and psychosocial
compon~nl'. 104- 5
nur...rol 1I2
opioids
cltara'l~ristk.. 106,. 107
treatment. 227
withdra.....al symptom,. 1061
overvi~. 104
physical . ctivityand. lOS,
physical depend.nu. 105
psychological d~~nd~nu. 105
stati'tics. 104,
terminolosy.1 4--15
lol~ranu. 106
volatUe inhalants. 106,
withdrawal syndrom ... 105. 106,
sub,lanu ok~nde"",. 105--6
.ubstance p. 220. nO!
substantia nigra. 257
sucdm~r. 123,
S\JCCINIMIDO:
dme<d~<.iflM

"'
Su Etho. uximide

~thosuximide.

m~thsu.ximide.174'

ph.nsuximid 174,
mechani,ms of action. ] 74
pharmacolherapywilh, 175
sucdnykholin~. 2531
actions and u", 253,
administration alert .. 25 3,
ad,..,,,,, dfccts, 2521. 253~ 278
interaction .. 253,
overdo", tn:atment. 253 ,
pharmacokinetics. 253,
sucralfale. 616
Sudafl. Su P.. udoophedrine

LibraryPirate

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
.ulfa.oo:.mid~. 493~ 756,
sulfadia;:in~. 493. 493,
sulfadolinc--pyrimethamine. 493. 493,
.ulfamethoxarole. Su
Tri mcthopri m-sulf~metho.uzol e
,ulfasalazine:
adv.,... effects, 742,
for rheumatoid anhritis. 7421
. u]f",. lazin e. 6281
aClior., and u.-s. 492- 93. 6281
admimistration alen .. 6281
adva .. ~ffects, 67,. 62St
for in~ammatory bowel disea ... 625
interactions. 6281
overdo'''' Irratm<nt. 628,
phallllacokinttic.. 6281
,ulfinpy;awne.745,
sulfisoxazolr.493. 4931
IUUONA.\I~

ad.-a .. effecl .. 493,

drug, cla"ified as
SIllfacetamid 493~ 7S61
sulfadiazine. 493. 493,
sul:'adoIinC'-pyrimethamin . 493.
' 931
sulfasalazine. & Su]f",alarill e
sul jl~zole. 493. 493,
trirlelhoprim-oulfamethoIalOle. Se~
Tri methopri m-sulfal11 ct hoXlzole
mec .... ni'm' of action. 492- 93
pharmacoth~rapy With. 492--493. 497
rout~and aduh do.... 493,
IULFONY"..uRl'AS:

adv""",, effects, 687,

characleristics.686
drugs classified as
chlorpropamide. 6871
glimcvirid 687,
glipizid . 687,
elyhmid,. ~A7,
tolazamid~. 6871
tolbutamide. 687,
route and adull do .... 6871
sulfur. 648,
.ulfur mustard. l21t
,ulinda.. 2281
. um alriptan,2341
aclior_.and u"' .. 23 4,
admimistration al~rts, 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 ~"o Complem~ntary and
Allanatm Therapies
dietary. See Dietary .uppl<ment{.)
htrbal. 5 H~rbal thmpi~s
specialty. 1001
Suprane. Su D .. Uuran~
ruprawntricular.355
surfaa anesthesia. 240
rurgk.. l anesthesia. 246
Surmontil. Se. Trimipramine
Surv.nla. Su Beractant
Sustlcal Po~~r. 651
5UStainl-n:leasc tablet .. 22
Sustin. Su FIavin:nz
Sutrnt. See Scinilinib
Symlin. Su Pramlintide
Symmetn:l. See Amantadine
synlpalhetk ner~>u' "ystem. 128. 128!
SYMPArnoITI1CS. See IillRINE1GlC
ANTAGONI!i1ll

SYM001l0M!MErICS. Sa ADRENElGIC AGONISTI

synap",.129
synaptic transmi.sion. 129
Synan:l. Se~ Nafarclin
Syn~rcid. Su Quinupristin--<lalfopristin
Synthroid. Su l.r\nthyroxine
Syrup of[pccac. ] 22
systemic mycosis, 507,. 508
systolic pressure. 297. 297,. Su
Blood
pressun:

""0

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. Se~ 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. 7 18

Index

tamsulo,in, 136" 725" 726

Tanace,u~, P<'rfhmium. See F.....erffW
tapnoourm., 521
Taractan. See Chlorprothix<ne
Tarct"Va. s... Erlolinib
t.rdj,..., dyskin~ia , 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:

chanm eristiC&. 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
TCA~. Se~

TR!acuc ANI1~

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, ]36~ 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 Trifluo~razine
t.. riparatide, 736~ 739
Teslac. Sec T..,tolactone
Tessalon. Su Benzonatate
Testim, 7]8 . 5"lso Testo,terone
T..tod.rrn. Su Testostero ne
T.stoderrn TIS. Sec Testosterone
testolactone, 560, 561., 7]9

LibraryPirate

Testopd. 7IS . Sa al", Te,tosterone

testostero ne, 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, 717~ 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<:lin e
tigteycline, 488" 489
facton affecting absorption, 38
pharmacotherapy with, 488--89
tetrahydrozoline, 581~ 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.
thera~utk d ... ification, 12, 12.
thera~utk index, 46--47, 47[
Therapnnk Products Directorate
(TPD),9
thera~utk range. 42,43[
thera~utk., 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.

907

hydrochlorothiazide. See
Hrdroc: h lorothi az id~
indapamide, 303t, 422.
methydothiazide, 303~ 4221
metolarone, 303" 422,
mechanisms of action. 420, 421[
for 'prdfic condition.
heart faUure, 328" 329
h)'l.'tnemion, 302~ J.O.l--4, JOJ,
rtnal failurt, 422- 23, 422,
TIlIAZOLINEDlONE5:

adve""dfe,ts, 687t
,haracteristic&' 688
drugs classified as
pioglitawne,6871
rosiglitazone,6871
rout~ and adult doses, 6871
thioguanin . 555" 556[
thior~ntal , 2511
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 Chlorpromazin e
thrtt ch<-cksof drug administration. ]9
thrombin. 370
thrombin time, 372.
thrombocyto~nia, 372
thrombocytopoie.is,394
thromboernbo.lk disordtrs., 37]
TIlIOMBOLTIlCS:

definition, 373
drugs classified as
alt."la .... See Alt~rla.e
rtt."la ... Su ikt."lase
strtptokina..,383t
tenccr."la .., 383~ 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.

90 8

Index

THYJ.OIDAG~

(",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
disordrrs.659~ 6621. SN:~lso
Hyperlhyroidism; Hypothyroidism
functions. 662. 662f
thyroid storm. 664
Thyroid USP. Sa ~skcatrd thyroid
thyroid-stimulating hormone (TSH ).

6581, 660.
Thyrolar. See Liotrix
ThyroSafe. See Polassium iodide
thyrotropin. 6581, 6601
thyroxine. 662
thyroxine -binding globulin (TIlG ). 662
tia~bin . 1691. l71,
Tiamate. Se~ Diltiaum
Tiazae. Sa Diltiazem
Ticor. See TIeardUin
tkaremin.4841
Tic. See Haemus Calmen.-Gu~rin (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
1361. 771,
administration alrrt .. 7711
adv..... dfrct .. 315 343~ 771,
inleraclions, 7711
pharmacokinetics, 771,
for .~dfic 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

U""'.

LibraryPirate

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. 272~ 273
tobacco u .... Se~ 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. Se~ 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,. 171~ 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 rational~s, 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 (Th~ raptutic 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>
Br~nd- nam. 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. 186~ 189
Trranda. Su Brndarnustin.
Treating the Diverse Patient:
Ir.CE inhibitors and ethnidty. 311,
acr"laminophen metabolism. ethnk
diff... nces in. 4731

IndH

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 ddic~n(y 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. Se~ 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 ~nofibrat.

(TCA,):
adv.... effect"~ 155t. 156, ]861
contraindications, 156

11lICYCUCANfIDEPI!ESSANTS

LibraryPirate

drugs classiflla,
amitriptylin . Su Amitriptyline
am=pine,I86,
do,"ipraminc, 155/
desipramine. ]55~ 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 sp~ifk 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,
143~ 260,
triiodotbyronin., 662
TrUaron. Stx Perphrnazin.
TrUoptaL &. Oxcarba"'pine
trimethoprim--1lulfamethOJQlZole,
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

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 AminophyUin~
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., 54 1
Tyga,U. Se.Tigecydine
Tyuro. See Lapatinih
Tylenol. Set Acetaminop hen
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 ~tlurane
Uhiva. Set R<mifenlanU hydrochloride
Ultram. Se.Tramadol

910

Index

ulu ..;oki lighllMrapy, 763

Unasyn.485
und.cylenic add,514~ 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
di~5Iiv. process, 607-11
disord.r>
gast",",sophagm ,eHIlI di,..,. ... See
GJSlrot'SOpha~alll'nUI disease
indd.n~, 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 Potassium 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:
dysfunclional bleeding. Se~
Dysfunctional uterine blding
rdaxant . See TOCOLYTICS
stimulants. See 0xrr0cJcs

v
vaccination, 448. See a!so Vaccine.
vaccines:
administration, 448--45O
ad,.... dfects, 450
anthrax, 119
cultural influ<uce. on administralion,
451t

LibraryPirate

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 ~dminimJtion. 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 . 4<j~t. 499
",ncomycin-re.istant enterococd
(VRE),481
Vam .... Se< Histrelin
V.... QTA. See HepatitisA vae<:ine
Yardenafi~ 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 rin e

napharoline HCI, 774, 774t
norepinephrine. See Norepi nephrin e
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. 318~ 328t

drugs classifi.d as
dia:zm:ide,319
hydralazine. Sn Hydralazi" e
isosorbide dinitrate, 328,. 3>4
minoxidil.318,
nesiritide, 328~ 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, 328~ 3>4
hypcrl<:n<ion. 318- ]9, 3\8t
",,,,,motor~nter. 298
Ya""p"""in, 66Ot. 66]. See a/", Antidiu .. lic
hormone
"'''''p",,,,,,rs. Sn
VA5CKX)NS11tIcroRS";o.so~1S

,",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
""nl~f.x;n~, l~~t. IAA~ lR~

vrnlilation,590-91
Ventolin. See Albuterol
""ntricular fibrillation, 355,
vtnuicula r fluner,3551
""ntricular tochycardia. 355,
vrntrogluteal .ite, 31
Veramyst. Se< Flulicaso ne
'''''''d pamil,3661
aCiions and u ..., 366t
administration al .. ts, 3661
advrrse dfe<t., 233~ 307t. J.O/
J60t. 366t
int eraction . 366,
mechanism. of action. 307

Indn
o""rdo .. treatm~nI, 366.
phamlarokinetks, 366t
for 5ptCifk condition.
angina and nI)'>GIrdial infar<tion, 343.
dysrhythmia., 358 359~ 360,. >65
hy~rtemion. 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 Sild~nafll
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
rout~ and adult do .. s. 559t

Vinca "'_ 559

vin cristin e, 560.
actions and uses, 550{, 551. 559. 56(1,
administration aler". 560.
adver .. ~ffts. 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<>
Amw~

viral load. 529

Viramune. Su Nevirapine
Vir~ad. 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 Tetrahydr07.Olin~
Vi,ine LR. Su Oxym<lazoli".
Visk~n. S. Pindolol
Vistari!. Se. Hydroxyzine
Vistid~. S. Cidofovir
visual impairments, 74t
Vita-C. Se~ Vitamin C

LibraryPirate

vitamin(.):
characteristics. 639
classification, 639
ddki.ndes.641J-.41, 640t
<XU>$, 640
functions.640t
lipid- solubl~

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 r.ltional~s,
645--46,
pati.nt and family education,
645--46.
planning: patient goals and expted
O\Itrorn~s. 645t
pot~ntial nursing diagno .... 645.
rDmm~nded 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.. dfts.64I~ 642t
interactions.642.
route and adult do ... 64I'
rDmm~nded 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.

9 11

for h)1l'<rlipid.mia
adver .. effects. 287t, 290
m~chani.msof action, 289/
pham13cotherapy with. 290--91
rout~ 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. 390~ 640t. 644
function 64(),. 644
pharmacoth<Tapy With. 643., 644
lecommendcd dietary aUowanec:. 640.
vitamin B,.. See Foli< .ddJfol . t~
vitamin B" (.-yanorobalamin l.400r
dtficifncy. 3901. 398. 640., 641
fun<tion . 64()t. 644
H, -re"'ptor blockers and. 61 4t
metabolism. 398--99. 399/
pharmacotherapy with
a<lion. and u .... 400.
administration al.rts. 400.
adver ...ffts. 398~ 400., 643,
interactiom. 400,
route and adult do ... 398t. 643.
recommended dietary aUowanec:. 640,
source 644
vitominC:
d.ficiency. 64()~ 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
d~ficiency. 640.
dia~le. 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. 64O~ 641
functions. 64(),
pharmacotherapy with. 641. 641.
romm.nded dietary aUowanec:. 640.
sources.641
vitamin K:
d~ficiency.64O . 642
functions. 640,
pharmacotherapy with. 641., 642
recommended dietary aUowanco. 640.
sourcc:s.642
a. warfarin antidote. ID.
Vita- Plus E. S. Vitamin E

912

Index

Vivactil. Sn Protripl)lin~
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 ~lso Antiemotks
""miting cmter,628
""n Willdmond', di~s<, 371., 372- 73
""rioonazol. ,5l3.
""rinostat, 563.
VoSoI. See Acetic acid and hydroconisone
VoSpire. See Albuterol
VX,I2I.
Vytorin,292

Xenkal. Se~Orli'tat
Xopen.L Sa Uvalbuterol
Xy!ocaine. See Lid ocain.
Xy!ocard. Sn Lid"". i".
xylom.talOline, 581.
Xyzal. See u,..otirizine

y
Yasmin, 698,
yeast., >07
Yodoxin. Se~ lodoquinol
yohiml>e,223.
young adulthood, 72
Yutopar. Sn Ritodrine

Z
zlfirlukl~I,601t

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., lOO~ 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 immun~ globulin
withdrawal, 14, lOS
withdnwal.yndrom..{J l, 10>-6, 1061
Wl"'illin. Sa Penidllin G procain.

X
Xalatan. Sn !.alanof'm,1
Xanax. Se~ Alprazolam

LibraryPirate

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
r~,i'tance, 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, ~':I6t, ~~
zinc, 649., 650
zinc acetate, 647 1
zinc gluo:onat., 647,
zinc oxide, 763
zinc sulfat. , 647.
Zincate. Se~ Zinc sulfate
Z;ngiber ojJUitr~lu. 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, 160~ 161
administration alert .. lro.
ad .... rS< <ffeelS, 160~ 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 lISOI~ 21 and 28, 698t
Zovirax. Se~Acydcw ir
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

"

Special Features
A VO ID IN G M EDICATION ERRORS

H OME

&

C OMMUNITY C ONSIDERATIONS

Actdophilus for Dia rrhea, p. 623

p. 759
AntIbacterial Properties of Goldenseal, p. SOl
Bilberry for Eye Heal th, p. n5
Black Coh06h for Menopause, p. 704
Carnitlne 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 In flammation, 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 Osteoarth ritis., p. 743
Grape Seed Extrad fOr Hypertension, p. 303
Horehound for Respiratory DIsorders, p. 584
Horse Chestnut for VenOll5 lnsuffitiency, p. 4 iJ
Kava,p.153
Milk Thistle for Alcohol Liver D~mage, 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
Aloe Vera,

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
Educa ting 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 Relaxan t Ther3Pl' in the Home SettIng, p. 275
Nutritional Therapy for Patients 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
Pa tients Taking Anticoagulant T hempy, p. 37J
Posunesthesla FOllow-Up Care, p. 248
Preventing MedicatIo n Errors In the Home, p. 87
Promoting Safety with Medications That Affect the AN5,
p.145
Psychosocia l 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

LibraryPirate

.~

C OMPLEME NTARY AND A LTERNATIVE THE RAPIES

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

TREATIN G THE DIVER SE PATIENT

Asia n Patients' SensitivIty to Propranolol, p. 363

O!ltunl Dietary H.1bits, p. 286
CUltural Influences and the Treatment of Depression, p. 182
Cultural Influences o n Immunizations, p. 451
Cultural In fluences 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

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 lie~rlng 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 C ONS IDE RATIONS

A~ 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 New~Blood Doping." P. 391
Estrogtn Use and Psychosocial Issues. p. 706
F~U RIs .... in Older Adults and 8tnzodlazepin~ p. 158
H: Rectplors and Vitamin BI1 in Older Adults. p. 614
HIY in the ~iatri' and Geriatric Populations, p. 533
Human Chorionic Gonadotropin (hCGj Abuse by Athletes,
P. 7 18
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 CUltur~llmpaclS on Pediatric p.~tJtnu 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

LibraryPirate

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 Path~y, po 259
Cortlcosterlods (G lucorortoldi) 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 "5 1
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. 59 1
Attention Dendt-Hyperactivity Disorder. po 196
Bacteria! Infections, p. "79
Cancer, p. 548
Chapter 45, p. 695
aolling Disorders, p. 371
Community He~Jth 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