Brief Contents
Unit 1 Fundamental Principles of Pharmacology 42 Immunostimulants and Immunosuppressants 741
43 Immunizing Agents 762
1 Introduction to Pharmacology: Concepts and Connections 2
2 Drug Regulations 13 Unit 7 Pharmacology of the Respiratory System and Allergy
3 Pharmacokinetics 26
4 Pharmacodynamics 45 44 Pharmacotherapy of Asthma and Other Pulmonary
5 Adverse Drug Effects and Drug Interactions 55 Disorders 786
6 Medication Errors and Risk Reduction 70
7 The Role of Complementary and Alternative Therapies in 45 Pharmacotherapy of Allergic Rhinitis and
the Common Cold 810
Pharmacotherapy 84
Unit 8 Pharmacology of Infectious and Neoplastic Diseases
Unit 2 Pharmacology and the Nurse–Patient Relationship
46 Basic Principles of Anti-Infective Pharmacotherapy 834
8 Pharmacotherapy During Pregnancy and Lactation 98 47 Antibiotics Affecting the Bacterial Cell Wall 848
9 Pharmacotherapy of the Pediatric Patient 110 48 Antibiotics Affecting Bacterial Protein Synthesis 868
10 Pharmacotherapy of the Geriatric Patient 123 49 Fluoroquinolones and Miscellaneous Antibacterials 887
11 Individual Variations in Drug Responses 133 50 Sulfonamides and the Pharmacotherapy of Urinary Tract
Unit 3 Pharmacology of the Autonomic Nervous System Infections 900
51 Pharmacotherapy of Mycobacterial Infections 915
12 Review of Neurotransmitters and the Autonomic Nervous 52 Pharmacotherapy of Fungal Infections 934
System 142 53 Pharmacotherapy of Protozoan and Helminthic Infections 952
54 Pharmacotherapy of Non-HIV Viral Infections 975
13 Cholinergic Agonists 155 55 Pharmacotherapy of HIV Infection and AIDS 996
14 Cholinergic Antagonists 170 56 Basic Principles of Antineoplastic Therapy 1020
15 Adrenergic Agonists 185 57 Pharmacotherapy of Neoplasia 1036
16 Adrenergic Antagonists 201
Unit 9 Pharmacology of the Gastrointestinal System
Unit 4 Pharmacology of the Central Nervous System
58 Review of the Gastrointestinal System 1074
17 Review of the Central Nervous System 218 59 Pharmacotherapy of Peptic Ulcer Disease 1082
18 Pharmacotherapy of Anxiety and Sleep Disorders 227 60 Pharmacotherapy of Bowel Disorders and Other
19 Pharmacotherapy of Mood Disorders 253
20 Pharmacotherapy of Psychoses 281 Gastrointestinal Conditions 1103
21 Pharmacotherapy of Degenerative Diseases of the Central 61 Vitamins and Minerals 1130
62 Enteral and Parenteral Nutrition 1147
Nervous System 304 63 Weight Reduction Strategies and the Pharmacotherapy of
22 Pharmacotherapy of Seizures 330
23 Pharmacotherapy of Muscle Spasms and Spasticity 358 Obesity 1162
24 Central Nervous System Stimulants and Drugs for
Unit 10 Pharmacology of the Endocrine System
Attention-Deficit/Hyperactivity Disorder 375
25 Pharmacotherapy of Severe Pain and Migraines 392 64 Review of the Endocrine System 1176
26 Anesthetics and Anesthesia Adjuncts 422 65 Hypothalamic and Pituitary Drugs 1183
27 Pharmacology of Substance Abuse 447 66 Pharmacotherapy of Diabetes Mellitus 1200
67 Pharmacotherapy of Thyroid Disorders 1229
Unit 5 Pharmacology of the Cardiovascular System 68 Corticosteroids and Drugs Affecting the Adrenal Cortex 1245
69 Estrogens, Progestins, and Drugs Modifying Uterine
28 Review of the Cardiovascular System 474
29 Pharmacotherapy of Hyperlipidemia 488 Function 1262
30 Pharmacotherapy with Calcium Channel Blockers 510 70 Drugs for Modifying Conception 1287
31 Drugs Affecting the Renin-Angiotensin-Aldosterone 71 Drugs for Disorders and Conditions of the Male
System 523 Reproductive System 1307
32 Diuretic Therapy and the Pharmacotherapy of Chronic
Unit 11 Additional Drug Classes
Kidney Disease 539
33 Pharmacotherapy of Fluid Imbalance, Electrolyte, 72 Pharmacotherapy of Bone and Joint Disorders 1328
73 Pharmacotherapy of Dermatologic Disorders 1364
and Acid–Base Disorders 561 74 Pharmacotherapy of Eye and Ear Disorders 1389
34 Pharmacotherapy of Hypertension 582 75 Emergency Preparedness: Bioterrorism and Management of
35 Pharmacotherapy of Angina Pectoris and Myocardial
Poisoning 1409
Infarction 602
36 Pharmacotherapy of Heart Failure 622 Appendices
37 Pharmacotherapy of Dysrhythmias 641 A Answers to Chapter Review 1425
38 Pharmacotherapy of Coagulation Disorders 661 B ISMP List of High-Alert Medications in Acute Care Settings 1457
39 Pharmacotherapy of Hematopoietic Disorders 691
Glossary 1458
Unit 6 Pharmacology of Body Defenses
Credits 1477
40 Review of Body Defenses and the Immune System 714
41 Pharmacotherapy of Inflammation and Fever 723 Index 1478
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Pharmacology
Connections to Nursing Practice
FOURTH EDITION
Michael Patrick Adams
Adjunct Professor of Anatomy and Physiology
Hillsborough Community College
Formerly Dean of Health Professions
Pasco-Hernando State College
Carol Quam Urban
Director, School of Nursing
Associate Dean, College of Health and Human Services
Associate Professor
George Mason University
Rebecca E. Sutter
Assistant Professor, College of Health and Human Services, School of Nursing
George Mason University
330 Hudson Street, NY NY 10013
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or implied, with respect to its contents.
The authors and publisher have exerted every effort to ensure that drug selections and dosages set
forth in this text are in accord with current recommendations and practice at time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of
information relating to drug therapy and drug reactions, the reader is urged to check the package
inserts of all drugs for any change in indications of dosage and for added warnings and precautions.
This is particularly important when the recommended agent is a new and/or infrequently employed
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Library of Congress Cataloging-in-Publication Data
Names: Adams, Michael, author. | Urban, Carol Q. (Carol Quam), author.
Title: Pharmacology: connections to nursing practice / Michael Patrick
Adams, Carol Quam Urban.
Description: Fourth edition. | Boston : Pearson, [2019] | Includes
bibliographical references and index.
Identifiers: LCCN 2017026174| ISBN 9780134867366 | ISBN 013486736X
Subjects: | MESH: Drug Therapy—nursing | Drug Administration Schedule |
Medication Errors—prevention & control | Nursing Records |
Pharmacology—methods
Classification: LCC RM300 | NLM WY 100.1 | DDC 615.1—dc23
LC record available at https://lccn.loc.gov/2017026174
10 9 8 7 6 5 4 3 2 1
ISBN-10: 0-13-486736-X
ISBN-13: 978-0-13-486736-6
About the Authors
Michael Patrick Adams, PhD, is an accomplished and has worked with Dr. Rebecca Sutter to open three
educator, author, and national speaker. The National Insti- nurse-managed health clinics, academic–community part-
tute for Staff and Organizational Development in Austin, nerships that care for uninsured patients and provide edu-
Texas, named Dr. Adams a Master Teacher. He has pub- cational opportunities for Mason nursing students. She has
lished two other textbooks with Pearson Education: Core published the Pearson textbook Pharmacology for Nurses: A
Concepts in Pharmacology and Pharmacology for Nurses: A Pathophysiologic Approach with Dr. Adams and Dr. Holland.
Pathophysiologic Approach.
To my daughter, Joy, an extraordinary and resilient
Dr. Adams obtained his master’s degree in pharmacol- woman who continues to change the world for the better,
ogy from Michigan State University and his doctorate in and in memory of my son, Keith, and my husband, Mike.
education from the University of South Florida. Dr. Adams
was on the faculty of Lansing Community College and St. —CQU
Petersburg College, and was Dean of Health Professions at Rebecca E Sutter, DNP, BC-FNP, is Assistant Profes-
Pasco-Hernando State College for over 19 years. He is cur- sor in the School of Nursing and one of the directors of an
rently Adjunct Professor of Anatomy and Physiology at academic nurse-managed clinic within the College of
Hillsborough Community College. Health and Human Services at George Mason University
in Fairfax, Virginia. She has been on the nursing faculty for
I dedicate this book to nursing educators, who contribute over 15 years at community colleges and universities, and
every day to making the world a better and more caring has practiced for over 20 years as a pediatric ICU nurse
place. and a board-certified family nurse practitioner.
—MPA To my husband, Lee, and my parents, Jane and Ellis, who
have given me the foundation to reach for my dreams, and
Carol Quam Urban, PhD, RN, Associate Professor, is to my amazing children Andrew, Sarah, and Emily, who
the Director of the School of Nursing and an Associate have made me stronger, better, and more fulfilled than I
Dean in the College of Health and Human Services at could have ever imagined. I love you to the moon and back.
George Mason University in Fairfax, Virginia. She has been
on the faculty in the School of Nursing for over two decades —RES
iii
Thank You
First Edition Contributors
We extend a heartfelt thanks to our contributors, who gave foster our goal of preparing student nurses for evidence-
their time, effort, and expertise so tirelessly to the develop- based practice.
ment and writing of chapters and resources that helped
Diane Benson, RN, EdD Denise Marie McEnroe-Ayers, RN, Janice Lynn Reilley, RN, C, MSN,
Humboldt State University, Arcata, MSN EdD
California Kent State University at Tuscarawas, Widener University, Chester,
Chapter 29 New Philadelphia, Ohio Pennsylvania
Chapters 67, 72, 75, 76, and 77 Chapter 63
Rebecca Boehne, RN, PhD
Linfield College, Portland, Oregon Mariann Montgomery, RN, MSN Luann G. Richardson, RN, PhD
Chapter 74 Kent State University at Tuscarawas, Duquesne University, Pittsburgh,
New Philadelphia, Ohio Pennsylvania
Jacqueline Rosenjack Burchum, Chapters 66, 67, 68, 75, 76, and 77 Chapter 60
APRN, BC
The University of Tennessee Health Kim Alexander Noble, RN, PhD Roberta Shea, RN, CCNS, MSN
Science Center, Memphis, Tennessee Temple University, Philadelphia, Indiana University School of Nursing,
Chapter 73 Pennsylvania Bloomington, Indiana
Chapter 46 Chapters 9, 66, 67, and 68
Pamela Evans-Smith, RN, MSN
University of Missouri–Columbia, G. Elaine Patterson, RNC, MA, Pat Teasley, RN, MSN, APRN, BC
Columbia, Missouri FNP-C EdD Central Texas College, Killeen, Texas
Chapter 57 Ramapo College of New Jersey, Chapters 22, 23, 24, 25, 57, and 58
Mahwah, New Jersey
Geralyn Frandsen, RN, MSN, EdD Chapters 10, 11, 12, 70, and 71
Maryville University, St. Louis, Missouri
Chapters 26, 27, 28, 30, and 44
Third Edition Reviewers
Our heartfelt thanks go out to our colleagues from schools Practice has reaped the benefit of your collective knowl-
of nursing across the country who have given their time edge and experience as nurses and teachers, and we have
generously to help create this exciting new edition of our improved the materials due to your efforts, suggestions,
pharmacology textbook. These individuals helped us plan objections, endorsements, and inspiration. Among those
and shape our book and resources by reviewing chapters, who gave their time generously to help us are the
art, design, and more. Pharmacology: Connections to Nursing following:
Wanda Barlow, MSN, RN, FNP-BC Dearborn, Michigan Trinity Valley Community College
Instructor Kaufman, Texas
Winston-Salem State University Staci M. Boruff, PhD, RN
Winston-Salem, North Carolina Professor Katrina Coggins, MSN, RN, CEN
Walters State Community College Assistant Professor
Carole Berube, MA, MSN, BSN, RN Morristown, Tennessee Western Carolina University
Professor Emerita Cullowhee, North Carolina
Bristol Community College Sharon Burke, EdD, MSN, RNC
Fall River, Massachusetts Assistant Professor Tamara Condrey, DNP, RN,
The Pennsylvania State University ACNS-BC, CCRN, CNE
Sophia Beydoun, MSN, RN Abington, Pennsylvania Assistant Professor
Instructor Columbus State University
Henry Ford College Judy Callicoatt, RN, MS, CNS Columbus, Georgia
ADN Instructor
iv
Thank You v
Rebecca A. Crane, MSN, RN, CHPN, Chattanooga State Community Vanderbilt University Medical Center,
CLNC College School of Nursing
Assistant Professor Chattanooga, Tennessee Nashville, Tennessee
Ivy Tech Community College
Bloomington, Indiana Susan Growe, DNP, RN Elizabeth L. Law, MSN, NP-C, RN
Lecturer Assistant Professor
Lynette DeBellis, RN, MA Nevada State College Ivy Tech Community College
Assistant Professor Henderson, Nevada Indianapolis, Indiana
Westchester Community College
Valhalla, New York Jeanne Hately, PhD, MSN, RN Connie Lawrence, MS, FNP-BC,
Owner DNP
Debra Dickman, MS, RN, CNE Professional Nurse Consultants, LLC Director of RN-BSN Program
Assistant Professor Aurora, Colorado The College at Brockport
Blessing-Rieman College of Nursing Brockport, New York
Quincy, Illinois Antonie Hiemer, MS, RN
Assistant Professor Dr. Euphemia Marlene C. Lazarus
Teresa Dobrzykowski, PhD, APRN, Morrisville State College Professor
BC Morrisville, New York Camden County College
Assistant Professor Blackwood, New Jersey
Indiana University Susan Holland, MSN, APRN,
South Bend, Indiana GNP-BC Carol Isaac MacKusick, PhDc, RN,
Clinical Assistant Professor CNN, CNE
Deborah Dye, RN, MSN Sam Houston State University Assistant Professor
Department Chair and Assistant Huntsville, Texas Western Carolina University
Professor Cullowhee, North Carolina
Ivy Tech Community College Molly Jackson, RN, MSN APRN, NP-C
Lafayette, Indiana Instructor Shayne A. Mason, RN, BSN,
Case Western Reserve University PMHNP(BC)
Nancy W. Ebersole, PhD, RN Cleveland, Ohio Instructor
Direct-Entry MSN Program University of San Francisco
Coordinator Sara K. Kaylor, EdD, RN San Francisco, California
Salem State University Assistant Professor
Salem, Massachusetts The University of Alabama Vicki McCalmont RN, MS, ANP-BC,
Tuscaloosa, Alabama CNS, CCTC
Anita Fitzgerald, RN, A/GNP Professor
Lecturer, Director, Learning Center Amy Mitchell Kennedy, MSN, RN San Diego State University
California State University Adjunct Faculty, RN and PN Program San Diego, California
Long Beach, California ECPI University
Newport News, Virginia Bethany Mello, DNP, MS, NP-C
Suzanne Franzoni-Kleeman, MSN, Assistant Professor
RN, CEN Alice Kindschuh, DNP, RN, University of Jamestown
Assistant Professor APRN-CNS, CNE Jamestown, North Dakota
American International College Adjunct Instructor
Springfield, Massachusetts Nebraska Methodist College James Mendez, MSN, CRNP
Omaha, Nebraska Adjunct Instructor
Lola Goodson, RN, MSN, CRNI Villanova University
Instructor Vicky J. King, RN, MS, CNE Villanova, Pennsylvania
Ivy Tech Community College Nursing Faculty
Sellersburg, Indiana Cochise College Toby Nishikawa, MSN, RN
Sierra Vista, Arizona Assistant Professor
Amy C. Graham, RN, MSN, FNP-BC Weber State University
Assistant Professor Julie Ann Koch, DNP, RN, FNP-BC Ogden, Utah
James Madison University Assistant Professor and DNP Program
Harrisonburg, Virginia Coordinator Nola Ormrod, RN, MSN
Valparaiso University Department Chair
Crystal Graham, RN, CHSE, MSN-Ed Valparaiso, Indiana Centralia College
Simulation Lab Director/Instructor of Centralia, Washington
Nursing Angela M. Koller, DNP, MSN, RN
Francis Marion University Dean Mechelle Perea-Ryan, MS, FNP-BC,
Florence, South Carolina Ivy Tech Community College PHN
Indianapolis, Indiana Associate Professor
Yolanda J. Green, RN, MSN California State University, Stanislaus
Associate Professor Stephen D. Krau, PhD, RN, CNE Turlock, California
Associate Professor
vi Thank You Sabra H. Smith, DNP, MS, FNP-BC Florida SouthWestern State College
Clinical Assistant Professor Fort Myers, Florida
Beth Rowlands, DNP, GNP-BC University of South Carolina
Clinical Professor Columbia, South Carolina Diana White, RN, MS
University of Massachusetts Professor
Boston, Massachusetts Rebecca E. Sutter, DNP, APRN, BC- Tuskegee University
FNP Tuskegee, Alabama
Janet Czermak Russell, APN-BC Assistant Dean and Assistant
Professor Professor Carol S. Whiteman, MSN, RN,
Essex County College George Mason University CCRN
Newark, New Jersey Fairfax, Virginia Assistant Professor
Ivy Tech Community College
Jennifer Brindisi Sipe, MSN, Nanci Swan, RN, MSN, CCRN South Bend, Indiana
RN Instructor
Assistant Professor The University of Alabama Toni C. Wortham, RN, BSN, MSN
LaSalle University Birmingham, Alabama Part-time Instructor
Philadelphia, Pennsylvania Madisonville Community College
Valerie Taylor, RN, C, MEd, MSN Madisonville, Kentucky
Michelle Taylor Skipper, DNP, Assistant Professor
FNP-BC Lorain County Community College Benson Kar Leung Yeung, MSN,
Clinical Associate Professor Elyria, Ohio RN
Director, A/GNP and FNP Full-time Instructor
Concentrations Angela Trawick, MSN, RN California State University
East Carolina University Clinical Coordinator Los Angeles, California
Greenville, North Carolina
Preface
Pharmacology is one of the most challenging and dynamic drugs. The role of complementary and alternative thera-
subjects for professional nurses. Each month new drugs pies, which are used by many patients, is included in the
are being introduced, and new indications are continually context of holistic care.
being developed for existing medications. Some medica-
tions that were considered preferred drugs only a decade Unit 2 connects pharmacology, the nurse, and the
ago are now rarely prescribed. Current knowledge of drug patient, with an emphasis on positive patient outcomes.
actions, mechanisms, interactions, and legislation is man- The four chapters in this unit recognize the essential role of
datory for nurses to provide safe and effective patient care nurse–patient interactions in providing optimal patient
in all healthcare settings. Pharmacotherapeutics remains a care throughout the lifespan. The fact that individuals vary
critical and ever-changing component of patient care. in their responses to drug action is an important theme
introduced in this unit.
The subtitle of this text, Connections to Nursing Practice,
has guided its continued development. At a fundamental Units 3 through 11 provide the concepts and connections
level, pharmacology is a series of interrelated essential con- that are necessary to understand the actions and adverse
cepts. Some key concepts are shared with the natural and effects of individual drugs on different body systems. Many
applied sciences. Prediction of drug action requires a thor- of the units begin with a chapter that briefly reviews relevant
ough knowledge of anatomy, physiology, chemistry, and anatomy and physiology, which is a useful feature for the
pathology as well as the social sciences of psychology and student when studying drug actions. Each chapter clearly
sociology. This interdisciplinary nature of pharmacology identifies the concepts and connections necessary for safe
makes the subject difficult to learn but fascinating to study. and effective pharmacotherapy. Pharmacology is intimately
related to the study of disease processes. The connections
However, the discipline of pharmacology is far more between pharmacology and pathophysiology are clearly
than a collection of isolated facts. To effectively learn this established for each drug class in every chapter.
discipline, the student must make connections to nursing
practice and, ultimately, connections to patient care. Resources for Faculty and Student
Patients expect to receive effective and safe medication Success
administration from a nurse who is competent in the study
of pharmacology. Pharmacology: Connections to Nursing Resources for Faculty
Practice identifies key pharmacologic concepts and mecha-
nisms and clearly connects them to current nursing theory Pearson is pleased to offer a suite of resources to support
and practice for providing optimal patient care. teaching and learning, including:
Pharmacology: Connections to Nursing Practice recognizes • TestGen Test Bank
that pharmacology is not an academic discipline to be learned • Lecture Note PowerPoints
for its own sake but is a critical tool to prevent disease and • Instructor’s Resource Manual
promote healing. This connection to patients, their assess-
ment, diagnoses, and interventions supports basic nursing Resources for Students
practice. Like other core nursing subjects, the focus of phar-
macology must be to teach and promote wellness for patients. Online Resources for students that are available include:
Structure of the Text • Making the Patient Connection case studies and
answers
This text is organized according to body systems (units)
and diseases (chapters). Unit 1, the first seven chapters, • Additional Case Studies and answers
identifies fundamental pharmacologic principles that are
applied throughout the text. Although new drugs are con- • Answers to Patient Safety Questions
stantly being developed, these chapters build the struc-
tural framework for understanding the applications of all • Suggested answers to Connection Checkpoints, and
more!
vii
antidysrhythmic. It is considered a broad-spectrum The potassium channel blockers are a small but diverse
viiia nPtirdefyascrehythmic because it is effective in terminating both class of drugs that have very important applications to the
atrial and ventricular dysrhythmias. It is approved for the treatment of dysrhythmias. After the action potential has
treatment of resistant ventricular tachycardia and recur- passed and the myocardial cell is in a depolarized state,
repolarization depends on removal of potassium from the the ECG.
cell. The drugs in Class III exert their actions by blocking Route(s)
rent fibrillation that may prove life threatening, and it has
A Practical Approach to Learning Pharmacologybecome a preferred medication for the treatment of atrial
dysrhythmias in patients with HF. potassium ion channels in myocardial cells. Although there
Amiodarone is available as PO tablets and as an IV are significant differences among the drugs, all have in
infusion. IV infusions are limited to short-term therapy common the ability to delay repolarization and prolong the
U(2N–I4Td4a ys). APhltahromuagcholoitgsyoonf sthete oCfenatcrtailoNnemrvaoyustaSkysetesmeveral refractory period. This action is reflected by an increase in
CCw4HHtAAeoePP8kTTswEERRwe eh11ke87sn atfhPRteehervamtrihemewedadicocorfauttthgihoeeirnsaCdipesiynsgctoirovfaneAl ntNninPxeuirOevet,doyiutbasseneScdfayfSusetlcseeteemspitc ahn2a1sl8aasnt the QT interval on the ECG. Automaticity is also reduced.
extended half-Dliifseotrhdaetrms ay22e7xceed 100 days. Amiodarone is
Most drugs in this class have multiple actions on the
heart and also affect adrenergic receptors or sodium channels.
CaHAstPrTuEcRtu 1ra9l aPnhalaorgmaocfotthhyeraopidy ohfoMrmoondeD. iTshoredtehrse ra2p5e3utic For example, in addition to blocking potassium channels,
CCsHHeAAruPPmTTEERRle v22e10l foPPrhhaaamrrmmioaadccaoorttohhneeerraaippsyy1ootoff PD2s.e5ygcmehnocesgre/astm ivLe2.8D1iseases of the Tsoh◀tea lpoDol ti(aBsseesatiauspemaaccenh)dainsBncoeoldnbsyliodSceykreesdrtseamarbeeAltiaps-tpaeddrorieannceThra.gbTilceha3en7to.a4rg.goannisizt.a-
CCMacHHocAAtmeiPPcoTTphnEEleaRRixsn 22ani23sco tmtiocSPPCnopohhesmaaanfosrrtpAtmmrnialcceaalitttthccNyeiooeol ettyhhrnhv3eeke:5orranaa8uroppstAwyySamyoonnffsid.otSMIedinemtuiasza rsueodcxrln3deea0esiSc4t etpioxam3nes3rme0ttcosshmabannluodilcstmkipinloegf,
CpHoAtPaTssEiRu m24i onCcehnatrnanleNlse,rsvoomuseSoyfstthemis Sdtriumgu’slaancttsioannds relate tioDnrubgys binodthyisscylasstesmhasve(ulinmitist)edanusdesddisueeatsoespo(tcehnatpiatlelyrs)
to its blockadeDorfusgosdfoiurmAtitoentciohna-nDneeflisciat/nHd yinpheirbaicttiinvgitysym- sepriloaucesstothxeicditryu. gLsikine coothneterxatnwtiidthyshrhowyththmeiycsa,rpeoutsaesdsiuthmer-
pathetic activiDtyistortdheer he3a7r5t. Repolarization is delayed, the chaapnenueltibclaolclyk.erTshsilsowortghaenhizeaarttiornatec,ornensuelcttisngpihnabrmraadcyoclaorg- y
CCCIriHHHnneAAAcfrarPPPaedTTTacdEEEtsRRRoiet rsi222yot657hnp eetPorMPPAiRhhonpiaagderirrnrsommapttlhieornaaeronccevtlooisgoac ltisolhnngaaeg3grynn9eadd2dtoph,fAyweSanoiunQdefbdseSTstnehtaaviseunnestttcrihoeaeeemrAPAvQaadabitRjluniu,cSsnaaietcncm yotdsmi4r oe4pdd74la2uer2xcoeondne. diaanadndpaptohsospibhleyshiyoploogteyntsoionnuirnsainsgigcnairfeic.ant percentage of
M37_ADAM7t3h6e6_E0C4_GS.E_C37.indd Page 653 28/10/17 1:44 PM f-0046-new
patients. These drugs can create or worsen dysrhythmias,
especially during the first few doses. Older adults with pre-
existing HF must be carefully monitored because these
patients are at higher risk for the cardiac adverse effects of
potassium channel blockers.
Pharmacokinetics: PROTOTYPE DRUG Amiodarone (Pacerone)
Route(s) PO, IV Classification Therapeutic: Antidysrhythmic, Class III
ChaptePbrlh3oa7crkmePrahcaormloagcioct:heProatpaysosfiuDmysrchhyathnmnieals 653
▶ UApbdsaotrepdti!onPrototype ACpopmrpolaectehl.yTahbseovrbaesdt bnyumtheber of
drugs that the practicing gnausrtrsoeinmteusstitnlaela(rGnI)istrsatcatggering. Therapeutic Effects and Uses: Approved in 1985,
To fDacisiltirtiabtuetlieoanrning, thisWteidxteluysdeisstaripbruotetodt;ycproesasepsptrhoeach amiodarone is the most frequently prescribed Class III
in wdhyiscrhhyththemmiaossitncrleupdrienpsgleanscuetanpttpiavr;eessesmciroeentdedoicfainetxiboernrecsaisiten-mineildakcu;hced antidysrhythmic. It is considered a broad-spectrum
classtiafcichaytcioarndaiar,eaitnritarol dduycscorenhdcyetinnhtmrdaietaetsda,iilvn.eTtnhhteriislcuuenldgai,rtkidoidynnsfreehyays-,th- antidysrhythmic because it is effective in terminating both
turesm1i9a4s, pprroetmotaytpueredvreungtssrpitclheuaeltna,rinacncoldundatrdeaicpdtoeiosteanitslie,sdsauniednfdorigmoax-in- atrial and ventricular dysrhythmias. It is approved for the
t i o nPirnoidmnuacrteyhdme rteaatcpahbeyoudltiyiscsmrheyfHftehecmptasit,aicsm.toPeracochptiavrnaeinmsomleotal obeofxlhiatiecbsti;itos nf,ew treatment of resistant ventricular tachycardia and recur-
- odpvrhuearPOgrsabpdrmenneaiiornmdtstaisaieoteecaeb-tu.noarrrosyadotkfscanrieatndecmxicnheovctartoeeniieoyrrssctsgnp,sieeioa,pxcesnpramfaefedneg.rcvtniPtaeesargnsiPPronnaooscOrptchmeeinrmy:tiaihbe2senacier–tfetraora3sfniiatledlnosedtypceyoglaetCrbcmiosyuosiah,rlstherifiy;aadececCI,prpaoVidyYaattan:oeu;,ntP2trssirhdrc4oeeha1y5sdmrt6i0.pernA.aeceoedisTantftreeicathzhcmcunyiiapeslsgmsaetrihioodtnoeitnodtrsnou,nootsgy;Hsf,epFises,, rent fibrillation that may prove life threatening, and it has
become a preferred medication for the treatment of atrial
Dpurergantiaonncoyfcaactetigoonry C.PO/IV; 10–150 days dysrhythmias in patients with HF.
ACdOvNeNrsEeCTEIfOfNecCtsh:eckPpooteinnttia3l7ly.2serious adverse effects Amiodarone is available as PO tablets and as an IV
infusion. IV infusions are limited to short-term therapy
limBoiththaelpuhas1e bolfocakmerisodaanrdonbet.aA1 mbloiocdkearrsonareemusaeydctaoustreeantaHuT-N (2–4 days). Although its onset of action may take several
sebau,tvoonmly itthinegb,eatan1obreloxcikae,rsfaatireguaen,tiddyiszrzhiynthemssic, sa.nFdrohmypwohtaet ny-ou weeks when the medication is given PO, its effects can last
M37_ADAM7s3i6loe6na_r0.n4Ve_diSsEiun_aCCl3hd7a.piinstdetudr r1Pb6aa,genexc6pe5l4saina2r8we/1h0cy/o1thm7e1ms:4eo4lenPctMiinvef-p0a0alp4th6ie-ann1etbwslotcakkeirns gare 4 to 8 weeks after the drug is discontinued because it has an
thniost udsreudgtoftoreratedxytsernhydthemdiaps.erAinosdwserasntodCionncnleuctdioen bClhuecrkrpeodint extended half-life that may exceed 100 days. Amiodarone is
viqsuioesntiodnuseatreo acvoarilnabelae donepthoesfiatcs,ulptyhroestoopurhcoesbisait,e.xPelreoassteocmonias,ult a structural analog of thyroid hormone. The therapeutic
cawtaithraycotusr, inasntdrucmtoar.cular degeneration. Rashes, photosen- serum level for amiodarone is 1 to 2.5 mcg/mL.
sitivity, and other skin reactions occur in 10% to 15% of M◀e cUhpadnaitsemd! BoflaAckctBioonx:WaArmniinodgsa.roTnheeelxaetretstmbulalctikplbeo, x
cwomarpnlienxgascitsiosunesdonbythteheheUa.rSt. aFnododitsanexdaDctrmugecAhdanmisinmisotrfa-
6mp5aPe4tdioeincUtatanstiistota5snki;iutPnhhgmuatrsmh, eaaCcddovhrlouegargysn.eoCfnetefhefreetlacCitBansrdmtliioosavsycauskbecseuelcasrorlsoSnw:ycseCttneomtlrraaetsseostlvhIeiIs,I NtmNioprtpauauoetncaocrifrtsootsitristhaintoafsnhseiocnbngstaertiilorrciugpoPasermacarpynckacRtyiltcoapeieeiotdfvtnaeiosncietcrrtrpselioyocyoDroAmhftdeiyoanspcdpsnopetpselrdhinerhlnvioeiietbyicutellnihatsoilmfhgy,tleinieimasoagitkdoronmiietnmane.fdofisoRsoeoc,.wreh:rdaopanaanPflon.rdaltKolnIhtpannieaeirerselyuionaszdtadttaanoosrrtdnemuuitRodiygritaennpsi’itcosicneiiennlschauimgivcditdtbtyioeeiieniomldtdargbineniylpcisPdognealhcrduitsteckai,chyolairteamen--hndtgees-..
In addition to prolonging the QT interval, amiodarone
pe3r7s.i9stinPgotlaosnsgiuamftecrhtahne nderlubg lhoacskbeersenprdoisloconngtitnhueed. DirnucrgesasSesimtheilPaRr itnoteArvmal iaonddawriodnenes (tPhae cQeRrSocnoem)plex on
BlraecfkraBcotxorWyaprneirniogd(oorafltfhoermheoanrlty.): Amiodarone causes OtherECClGas.s III antidysrhythmics include dofetilide, drone-
darone, ibutilide, and sotalol.
dmswpaericpTtcrpiosooretleanshehangdplmseaseleaoy.assutnrelepsmmTmyaoinrdochrfheitotitoessandyzoandhnatodtrsxihaoutsdafoirircimcgu-oflouilktusngithdnimk,yncsteeydoehg.iamsrceamnsrcfhptyAhuatyCaehniyyVnoonnladtcancdbnhvbrtsaoiesmeelasorolmnodvfnIicbaaIndeiekIaatlsr.oari.lrymeneMlecAxc,mikaeetmefbihyerlltsoladetrepsvcssrietolsaalehnuiatrlulvheittnrinoaisieneegarnefrealsaatap.ib.cancAadosBrttnpjmiateiuemoadoppdcrnsanilaoyyspoilsucliplcdeuaiaasbsobrramterytiuiifrdoeoztrothbnifeendnardlqdetsioo,eiciuapmtccvshoelakauteanahsrittlrnsht---htasegeees, Pharmacokinetics:
Cpoontatrssaiuinmdiiocnacthioannnse/lsPirnemcayuoctairodniasl:cellAs.mAilothdoaurgohnethiesre DoRfeotuiltied(es)(Tikosyn): ApPpOro, IvVed in 1999, dofetilide is an
coanrterasingdnicfiactaendt idnifpfaetrieennctes swaimthosnegvetrhee bdrraudgysc,aardlliah,acvaer-in
M38_ADAM7366_04_SE_C38.indd Page 675 28/10/17 10:09 AM f-0046-new
Preface ix
Chapter 38 Pharmacotherapy of Coagulation Disorders 675
Table 38.5 Antiplatelet Drugs
▶ Updated! Drug Tables. Easy-to- Drug Route and Adult Dose (Maximum Dose Where Indicated) Adverse Effects
understand tables reflect the latest FDA- anagrelide (Agrylin) PO: 0.5 mg qid or 1 mg bid (max: 10 mg/day) Nausea, vomiting, diarrhea, abdominal pain,
approved drugs and provide average aspirin (ASA, acetylsalicylic acid) PO: 80 mg daily to 650 mg bid dizziness, headache
dosages for most medications. Unique to dipyridamole (Persantine) PO: 75–100 mg qid as adjunct to warfarin therapy Increased bleeding, central nervous system
this text is a listing of the most common vorapaxar (Zontivity) PO: 2.08 mg/day (CNS) effects (dipyridamole), anaphylaxis
and the most serious adverse effects for (aspirin), interstitial lung disease (anagrelide)
each drug or drug class. This allows the ADP Receptor Blockers PO: 75 mg/day (max: 300 mg/day for life-threatening cases)
student to immediately recognize impor- clopidogrel (Plavix) PO: 60-mg loading dose followed by 10 mg/day Minor bleeding, dyspepsia, abdominal pain,
tant safety information regarding the prasugrel (Effient) PO: 180-mg loading dose followed by 90 mg bid headache, rash, diarrhea
drug(s) he or she is administering. ticagrelor (Brilinta) Increased clotting time, GI bleeding, blood
dyscrasias, angina
Glycoprotein IIb/IIIa Receptor Antagonists
Dyspepsia, dizziness, pain at injection site,
abciximab (ReoPro) IV: 0.25 mg/kg initial bolus over 5 min, then 0.125 mcg/kg/min for hypotension, bradycardia, minor bleeding
12 h (max: 10 mcg/min) Major hemorrhage, thrombocytopenia
eptifibatide (Integrilin) IV: 180 mcg/kg initial bolus over 1–2 min, then 2 mcg/kg/min for Dyspepsia, nausea, vomiting, dizziness,
24–72 h (max: 180 mcg/kg bolus, 2 mcg/kg/min infusion) myalgia, headache
Tachycardia and palpitations (cilostazol), CNS
tirofiban (Aggrastat) IV: 0.4 mcg/kg/min for 30 min, then 0.1 mcg/kg/min for 12–24 h effects (pentoxifylline), heart failure, MI
Drugs for Intermittent Claudication
cilostazol (Pletal) PO: 100 mg bid
pentoxifylline (Trental) PO: 400 mg tid (max: 1200 mg/day)
Note: Italics indicate common adverse effects. Underline indicates serious adverse effects.
membranes and their functions are complex. Chemicals require special medical or nursing interventions, such as
such as epinephrine, thromboxane A2, thrombin, sero- suturing or applying a sandbag to a venipuncture site that
tonin, and fibrinogen can bind to these receptors and mod- does not stop bleeding.
ify coagulation through their interaction with the platelets.
Following vessel injury, platelets become “sticky,” PROTOTYPE DRUG Clopidogrel (Plavix)
Connections to Nursing Practicebind to exposed collagen, and release substances that Classification Therapeutic: Antiplatelet drug
recruit additional platelets to the site. One of these chemi- Pharmacologic: ADP receptor blocker
cals is ADP, whose function is to promote platelet aggrega-
tion. The ADP receptor blockers comprise a small group of
drugs that irreversibly alter the plasma membrane of plate- Therapeutic Effects and Uses: Approved in 1997,
/207/PH03350/9780134867366_ADAMS/ADAMS_COleNNtEsC.TFIOoNSr_TtOh_NeUMRrS2eI4Nm_GA_aPDRiAAnMCdT7I3Ce6Er601_o_0Sf4E__tS9h7E8e_01iCr.2..4li.ifneddspPaagne,38th9 e30a/1f0f/e17ct8e:d05 pAMlaft-0e0-51a clopid/2o07g/PrHe0l3i3s50u/9s78e0d13f4o86r73t6h6e_ApDAroMSp/hADyAlMaSx_iCsOoNfNEaCrTtIeOrNiSa_lTtOh_NroURmS-ING_PRACTICE01_SE_97801 ...
M24_ADAM7366_04_SE_C24.indd Page 375 23/11/17 8:01 AM f-0037
lets are unable to recognize the chemical signals required boembolism to reduce the risk of stroke, MI, and death in
Making the Patient Connection is a feature thatfor them to aggregate.◀
patients with acute coronary syndrome. For patients with
Ticagrelor (Brilinta), clopidogrel (Plavix), and prasug- ST-elevation MI, this drug has been shown to reduce the
opens each chapter with a quote and a photo of arel (Effient) are ADP receptor blockers given CPhOapteor 2p4revCeenntrtal NervroiusskSoysftedmeSattimhu,larnetisnafnadrDcrtuigosnf,oroArttsentrtioonk-eD.efCicilto/Hpypideroacgtirveitly hDiasosrdseirmi3-89
Understanding Chapter 24rtnheecrwoenemrtbdtihrufroogrmsmibnaottehiomisnbcoilnalsicsp,aettivcieeanngttrsesluwoppcrhhahaonatadhsirapesvrmtnareosutekax.gecproeIoelrrt,liaMeocnrtIgce.meTyidonhraeemfourlocasnretcaesCna-dtliloatcwipoolyiadgadoutyoghlasrsineenltgbai.sscIetntgivhuioivitbeydninttieooPtnnaOhsotpefairpntinldphatbaheaulatettstiisefttuhmnhneocteatr.iedovTenfxaomopnectaanyudgsiepsvreeior.vf-oef
“The school nurse recommended
we consider Adderall for
Jonathon. He’s just doing poorly
in school and hates to do his ortehafffprebeicledDetildervyduretuighnagsagnsnatasifcthrfhleeoocruspotiilimmnddgobitlgohapr2Ktrelie.4aclpe.t1aeeaynlftefidaCeetClceneaatnrtc.ogttnhrsAganeuirlseddwtescnvhv,tgeaeueeerainiivratnpthscosiomahuettennsrsioecadsmefriyucfnSetsemhrtccceaeuproitmaeastmtnaobosiasistrlcitmireimsmthuyttatoeunahtannellodaegntrncetyaortsrtstinhnghsitcdnokeemaicnnrtreraaetksteepspMsi,oirosasnietsnfoasdcgfrioghbttrolhaeee7s,nexucthiloroesg2cpo1m4erhi0.r4dmcydaooitgaSssopfeyyeremveas,Atelvpserasctoatfh.olhirttdmoeniToruoeseinlnotxshdshfctp:ieaebmertseatduseseCdnirltavevutiliniseogetcinspbqosni-aildsnedriueettedtofiedineiecgfwsiiuftrndces/eecoghttdlhni.yviaitapeonoitentihrnlnuaeiitcetabrtssdeshiivatt.ist5eitaiWynnAdgsheaDtseyrnPnisosdt-
homework. Why would he need
a drug for that?”
Patient “Jonathon Hogan’s” mother
dental or surgical procedurdeesl.ayTthheesseymdrputogmssaorfefastoigmuee.times receptors on pladtiseolredtesr. and prolongs bleeding time by
Chapter 24 the student to apply the content learned in the chaptergiven concurrently wi2t4h.2anAticttoenatgiounl-adnetfsic,itw/hhyipcheraccatniviftuyrdtihsoerrder isirreversibly24in.5hiNbiatricnogleppslyaitseclheatracgtgerrizeegdabtiyoenx.ceCssliovpe iddaoytgimreel
Central Nervous System Stimulantsincrease
to a realistic patient scenario. An additional case studyinjection
obrleveedniinpgunrcistku.rePsrciiomthelaposrunamlcgstieaevrydeizbebdedehibraryeveicqiontrua.ptitrerenedtsisotuno,rcheoypnoetvrreaocrltivity,iaatcsntedilvfehmaseltiatbtloeliatcesstlyiievsnetipettmiyhn;eesshtsilmoiavwnuedleranvitsthestrrrae,onaiutdtegidashnwtcieihdtxheatpncerengensestsirdavanlettnosf.eirarvsohtu-igps haslys
and Drugs for Attention-Deficit/ is also included for further application of knowledgebleeding. Bleeding l2a4s.t3ingPsmychoorsetimthualannts10aremceinnturatlensermvoauys systemmetabolism2.4.6 Methylxanthines are central nervous system
stimulants indicated for the treatment of ADHD stimulants used for their ability to increase
Hyperactivity Disorder learned.and narcolepsy.
alertness or their effects on the respiratory system.
Chapter Outline Learning Outcomes CASE STUDY: Making the Patient Connection
c Characteristics of Central Nervous After reading the chapter, the student should be able to: Remember the patient “Jonathon school nurse suspects he may have ADHD. She has recom-
System Stimulants Hogan” at the beginning of the mended an appointment with Jonathon’s healthcare pro-
1. Describe the general actions and chapter? Now read the remain- vider and told his parents that Adderall may help Jonathon
c Etiology and Pathophysiology of Attention-Deficit/ pharmacotherapeutic applications of central nervous der of the case study. Based on focus on his schoolwork.
Hyperactivity Disorder system stimulants. the information presented
within this chapter, respond to Critical Thinking Questions
c Pharmacotherapy of Attention-Deficit/ 2. Identify the signs and symptoms of attention- the critical thinking questions
Hyperactivity Disorder deficit/hyperactivity disorder and narcolepsy. that follow. 1. What is ADHD and why would Jonathon be experi-
Psychostimulants encing more difficulty as he becomes older?
PROTOTYPE Amphetamine and Dextroamphetamine 3. Compare and contrast the central nervous system Jonathon Hogan has had trouble at school beginning in
(Adderall, Adderall XR), p. 380 stimulants and nonstimulants in treating attention- kindergarten and for the past year. His teachers have con- 2. How might amphetamine sulfate and dextroamphet-
Nonstimulants deficit/hyperactivity disorder. sistently reported that he is easily distracted and wanders amine (Adderall) help Jonathon with his ADHD?
PROTOTYPE Atomoxetine (Strattera), p. 382 around the classroom even during a lesson. Getting him to
4. Compare and contrast the different do his homework after school has been a struggle. Jona- 3. What caregiver education would be appropriate
c Pharmacotherapy of Narcolepsy pharmacotherapies available for narcolepsy. thon loves art and does well at video games. Because he is regarding dextroamphetamine and amphetamine
PROTOTYPE Modafinil (Provigil), p. 384 a happy-go-lucky child, his parents have assumed that sulfate (Adderall)?
5. Describe the nurse’s role in the pharmacologic Jonathon’s right-brain dominance has created trouble with
c Methylxanthines management of attention-deficit/hyperactivity left-brain logical work. With more homework now in sec- 4. What are other nonpharmacologic treatments
PROTOTYPE Caffeine, p. 386 disorder and narcolepsy. ond grade, Jonathon is struggling to keep up in school. The for ADHD?
6. For each class shown in the chapter outline, identify Answers to Critical Thinking Questions are available on the
the prototype and representative drugs and explain faculty resources site. Please consult with your instructor.
the mechanism(s) of drug action, primary
indications, contraindications, significant drug
interactions, pregnancy category, and important
adverse effects.
7. Apply the nursing process to care for patients
receiving pharmacotherapy with central nervous
system stimulants.
375
Additional Case Study 2. What teaching will you provide to the patient
regarding this medication?
Anna Steinmetz has graduated from nursing school and is
working nights. She is having difficulty adjusting to her 3. The patient reports feelings of lightheadedness with
night schedule. Her healthcare provider suggested she uti- position changes. What interventions will assist in
lize a medication to assist with her adjustment to shift maintaining patient safety?
work. She has been prescribed modafinil (Provigil).
Answers to Additional Case Study questions are available on
1. What effect does modafinil (Provigil) have on the faculty resources site. Please consult with your instructor.
the patient’s ability to maintain alertness during
shift work?
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x Preface
/207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...
546 Unit 5 Pharmacology of the Cardiovascular System
CONNECTIONS: Preparing for Advanced Practice
▶ New! Connections: Preparing for Chronic Kidney Disease and Prescribing Considerations
Case with CKD and AKI therefore require more thought, especially for
AdvancCehdapPterra6c7ticeP.haDrmraamcoathteicrapcyhaofnTgheysroiidnDisorders 1235Nolan is a 71-year-old African American man who was admitted medications that are renally excreted. For prescribing purposes,
CKD is divided into three grades:
the delivery of healthcare have placed an to the hospital for altered mental status. His daughter Renee
• Mild: GFR 20–50 mL/min; serum creatinine 150–300 μmol/L
reported that her father had become progressively confused
- inlciorteraisxeodveemr lpehvoasthisyoronxdineev.eIltospaicntgiotnhse, acrdivt-erse and had been having visual and auditory hallucinations, seeing • Moderate: GFR 10–20 mL/min; serum creatinine 300–700
67.6. μmol/L
effects, andand hearing people and animals that were not really there. In the
- iccaolntthraininkdinicgatsioknilslsaraensdimcillianrictoalthdoesceisfioorne-ndogenoupanasdstst2hh4ehyboe-ucrasm, Neomlaonr’es symptoms had become more persistent • Severe: GFR less than 10 mL/min; serum creatinine more
and more concerned. Nolan has a 9-year than 700 μmol/L (GFR above 50 mL/min does not usually
mraokidinhgoramboinliet.ieTshiosfdrnuugrissepsreagtnbanocthy ctahteegory A. history of HF and type 2 diabetes, and was diagnosed require any dosage adjustment.)
10 months ago with stage V CKD, thought to be primarily due to
Drugs to which particular attention should be given include
nassTutidTttcoiuhnorchhovbahrrdcnyenatostay-etaretentumiroarigecsocngiigd.iiaendfeehdrodksdtsPa,irhisTdmdancpfty3lrahergrureuotsasaaosaimilecntsscicatdtkdcuteippstaiciliohuTltrtesaleuonera4sradnemdsnidnuno(iaaadroAerfonntittssethrlddeaee,ddmgesdnehhittrotrvhrthwahaauinaesfesodyrhonalnrbucortetoachumelsaeiuiaeyisrdntdustnrareriheollgcearppiopallpedtalirraliraper,noasoibedvlTdcndpaplteehu,escoiaclyaecstrocrsiodpreet--o.fioponbpinrdtyioesgUnv.lseeDtS.vdtTPeohh)sita:nihe3bws(rcahOcnraioie0sldsinotyct1gnt0idheooadDsu pasrnmd9tiRiOnladhiarynotuebg9ernyp3eu,)reners;6rsnoixaeetcns9ir%ecidfdgecesga,a---gs,.sm.lnlcafpauNoWeiniebisrurropexdaashmNlhataipaowotromnehtonraalnyaepp,iwcsntnarhtiueanaa?ht1anshttte33eariiyomtt6t.n’awtnesi/aukm,,8aiPcrn6shseionhgees1lasmo84dpruwgmm1arlbiiaacinHlmrscyDe,fgtgaaf.isaot;ctilrnoohreeptdosfnetvuh/arepilmesehssryweapidshnbedihior;waduionsabratup,nehesalaidctidtsirat7ceeoolt2mninuhnxstoyteesebl,ygluadoetherbiealsoc,inslattapeasamst.bat/rioamotteHhtrebnduviyidness---. histamine H2-receptor antagonists, specific antibiotics, anticon-
inignet.oItwiosrukswedithoinnlyspfeocriaplatytiepnrtasctwicheosehta- ve ta ken it forDiscussion vulsants, digoxin, and NSAIDs. Prescribing any medication that
tiynegasrasn—dnwewithlyvudlinaegrnaobsleedpocpauselastioofnhs.ypothyro Kidney disease, both acute kidney injury (AKI) and CKD, affects increases potassium levels, such as potassium supplements and
body. The number of patients with potassium-sparing diuretics, is potentially very dangerous.
idism areevery organ system in the Additionally, methotrexate, enoxaparin, and metformin should no
AKI and CKD has increased due to the aging populations and longer be prescribed even with a mild grade of CKD. With cardio-
treated with synthetic thyroid hormone. medical advancements. Prescribing considerations for patients vascular (e.g., atenolol), antidiabetic (e.g., glibenclamide), or anti-
convulsive (e.g., gabapentin) drugs, the recommendation is to
use alternative medications, such as metoprolol, gliquidone, or
carbamazepine, that are not renally excreted or are independent
of kidney function. Drug dose adjustments should be considered
with antimicrobial (e.g., ampicillin), antiviral (e.g., acyclovir), and
some chemotherapeutic and cytotoxic drugs (e.g., cisplatin).
Products with a high sodium content (e.g., antacids) should be
avoided because they may cause sodium and water retention in
patients with CKD (Carville, Wonderling, & Stevens, 2014).
M60_ADAM7366_T04h_eSEra_Cp6id0.inedxdcrPeatgioe n11o22f l0a8r/g11e/1a7m2o:0u1nPtMs of-f00f3lu7 id has th/e207/PHp0r3e3s5c0r/i9b7e8d01f3o4r86p7a3t6i6e_nAtsDAwMiSth/AmDAoMdSe_rCatOeNtNoEsCeTvIOerNeSf_lTuOid_NrUetReSnIN- G_PRACTICE01_SE_97801 ...
potential to produce serious adverse effects, including tion, such as acute pulmonary edema, or when thiazide
- dehydration and electrolyte imbalances. Signs of dehydra- diuretics have failed to achieve therapeutic goals.
- CONNECTIONS: Treating theD11iz2z2ineUsnsita9ndPhfaairmntaicnoglogcaynofrtehseuGltasftrrooimntesthtinealfaSlylstienmblood
pressure caused by the rapid fluid loss. Potassium deple-
4 and tion include thirst, dry mouth, weight loss, and headache. PROTOTYPE DRUG Furosemide (Lasix)
-
DHImoipvrmreoovrnesedeRKPeidpanlateicyeeFnmutenncttion from Thyroid iimd epCnotoirnftyanngetcemtnidoonedrsi,f:iceTurrsletuoatfriadnlr,guagtnhdaecetDitohinivc.earlsienfPluaetinecnets ftehaattuareresBeemtotthhhvaledayyeescrreyneooaor.hiiulddpsdaSsilaesivhegetmreoihvetaretnphmmdrtyrcasouoarhlolfyn(taotLiehdnhupuegano,thohevdpGoeresuiureresmlaiofasnfipget,oiyenoctLnhxitnimfeuseiisscs,,a.taa&eyanRamsftZhspefoeeehcetucflaeocpfnteoniatcw,pntltlo2reyshrefe0aysiosnr1celnety6irrhtavc)hcy.areuherclSollrharouviebdtebninsonricaucrydgellgiynkypacpsodftsdlmwmotSsstiotcpbmtac(zafghoiinorhrShuauaceyhitxiiovnoyiocinaeeoclhodnheausrnencaueroepouimeatnasletriannntpuoginueeeoyrneuasarsmpoylfiacnstcserAcsr)nahntmptfltedncgcichlebtnlawd,aoestslsmhndraoeetoytoeoutorolieuoi.cbibutinmwcoatnmgsgsntithttfianicussntlIybhisoholsehtlniivmmeiiooeocnloaeaerhiuniadibeevsycoutemeltttnnescft,oymtanumamteodnesrhuen2rgbosipattuncarehxouobSi,antild0s(omgvryeenaspcntsaie,eian5panueso1tedseneauecrhsosasiyitarhtea-dcadst4aynnsr.snuuceatitoH(dd--nhhet,itosnneid,rtviWr-AovhncgepofidneoradeteimatidnoeeTlreonyusfouhuiaullgiruitpdterrtonoesP)ttpd3negodesesirscastsihd,oy)frcxttioO,avehsodaiueatntaooctcsomeoesirheamclelkcolhausc)tontxttexacsonaneuh.ymuo)asesosedparmidithrccecofdeTcpetuldirecgnnwtefetopieeeanempi,ihpebrdooahrmesdtipcpnamnlrrgnoeaccnysinmkaaoeneeroandtodaniostsiiavtiisarnsnosl◀savdssouirpiinranoiasoumeceolestea,uctreueef.teltastguosrtsmtnushtppniahcrmweloisTtaprturpeosucboetirheerpiiorteseonsi,oaphssanmnreeteiecoipt,eadtnrvnaadeialtsbieardhddspaoccntandlmpdinse.esatleiaousiinu(fv(oigiggreoPwrfatsayulclAeonbZrditrfldueyoerpnomiosnosmyiwreebnldsrooiodgndgarienonottotcumiupdvfmthaaofotin.g.zosucitogivAacrartltoreycsyie,seuenrtoCoeenltahdekvosaxmaaottstyknmersitndisnihchysniovemrafgriturcyn.stnctae:iiciepr,mntem.eeo.mohdtcanmrSiguesirnrireDlttZnlsaiLtnreeizaniaoeeeis)sbariitnrandTsanauo,eipudlecstnlestughtyesesoycrthfiohsuesohgpyeeg.rndg.etneeesopaadepiospeeorlaFw.(oPsfaaetcdtfsetapffdutionf,asonoeusxfTaooffmeiodhunineeatasssrefsmoirtttrtsrchtnieieencz.uhrooilnicaeearheutobossoutearUeit)dssxmgdntna1eafeerei(i,nttnyc.ssobivoLisestho9t,anvtpcioeuoaadtaTrsohetertua9nttegaaiecifamlisninmoihnhhtesnoos0cmltocgerirezaeryykdodnnyeeeeseseessfr--f----t-,,Classification Therapeutic: Antihypertensive drug for
improves renal function, including improvement vinomcitiangrdcaiausced by highly emetogenic chemotherapy. rectal, and parenhteeraarltrfoauiltuersetahnadt aeldseomhas significant anti-
effect nPohisnetns)vo: tahsTiahczeuinp-erismaanrdy related drugs (dopamine antago- cholinergic propePrthiaesrm. acologic: Loop- or high-ceiling-
status, improvement in dyslipidemias, or the indication for phenothiazines is the Benzodiazepinetsy:pe Tdhiuerpetriicmary indication for benzodi-
Tazheeprianpees uistiacnExfifeetcyt.sBaenndzoUdsiaezse:pinAenseasrtaebilnisehfefdecdtiiuvreetaics
lar endothelium (Hataya, Igarashi, Yamashita, & trKeaotmmenattosfups,ychoses (see Chapter 20), but they are also aapnptireomveedtiicns 1w96h6e,nfuursoesedmaisdemios nfroetqhueernatplyy.uHseodwinevtheer,ttrheaety-
2013; Rhee et al., 2015; Shin et al., 2013). IndinvveeirrdygiuecfafreelcictzeivpeetdoarnstiienmtehteicCs.TPZh,eannodthtiahzeinseesveinrehinbaitudsoepaaamnid- mreelanxt tohfeapcuatteieendteamnda adsescorceiaasteedthwe iathnxliievteyr acsirsrohcoiasitse,dCwKiDth,
ochr eHmFobtehcearuaspeyitahnadstthhee aanbtiilcitiypatotiorenmoofvseelvaerrgeenaamuosueantasnodf
evdoemmitainflgu.idLofrroamzepthaemp(aAtiteinvtainn) aissthhoertdtrimuge.inWthheisncglaivsesnthIVat,
disiumreossitsfbreegqiunesnwtliythuinse5dmasinaunteosf,fp-lraobveildainngtiermapeitdicrealdiejuf fnrcotm.
dCiastnrnesasbiningosiydmsp: toCmasnsnuacbhinaosiddsysaprenedar.uUgnsltihkaettchoentthaiianzitdhee
dsaiumreetaiccst,ivfeurionsgermedidieentisaasbmleatroijuinacnrae.aDserounrainbeinooul t(pMuatreinveonl,
wSyhnednrbolso)oadnfdlonwabtoiltohneek(iCdneseayms iestd) iamreingisivheend,PwOhitcohrmedaukcees
iptoosft-pcahretmicuoltahrevraapluyenianupsaetaieanntds wvoitmhiltoinwg,cwaridthialceossuetpuupthoor-
CriKa Dco. mIt pisaarelsdo taopmpraorviejudafnoar. HDTroNn,aabltihnooul gishailtsios ninodt iacaptreed-
ffeorrrethdedtrruegatfmorenthtiosfinadniocraetxioian abnedcawuseeigohf titlsosshs oinrt phaatlife-lniftes
awnidthpoAteIDntSia.lCfoarnsneariboiunsoaiddvsearsree enffoetctass. effective as other
antiemetics.
Corticosteroids: Dexamethasone (Decadron) and meth-
ylprednisolone (Solu-Medrol) are used to prevent chemo-
therapy-induced and postsurgical nausea and vomiting.
They are reserved for acute cases due to the possibility of
serious adverse effects and are most often used in combi-
treatment for subclinical hypothyroidism should btvreoematcietdoinwng isathsisdtoh-ceiaseteddruwgitsh. Saonmtieneoofpthlaestpichethneortahpiayzianreesomfteany nation with other antiemetics. Dexamethasone is used for
ered in older patients. the treatment of delayed nausea and vomiting, which are
cause sedation, and extrapyramidal symptoms (EPS) are a common problems with certain antineoplastic drugs.
concern with long-term therapy. Promethazine (Phener- Other drugs: Aprepitant (Emend) belongs to a class of
gan) is an older phenothiazine that is available by the PO, antiemetics, called the neurokinin (NK) receptor antagonists,
CONNECTIONS: Complementary and Alternative Therapies
Probiotics for Diarrhea
▶ Connections: Complementary and Description Evidence
Alternative Therapies features present
herbal therapies and dietary supplements Probiotics are live microorganisms that are taken in specified Most of the evidence supporting the efficacy of probiotics is
Assesstmheanttmay be considered as alternatives to amounts to confer a health benefit on the host. Most commercial related to their effects on the intestinal tract. Both Lactobacillus
conventional drugs. These features include probiotics are bacteria from the genera Lactobacillus and Bifidobac- and Bifidobacterium are normal nonpathogenic inhabitants of a
a description of the herb or supplement, terium; however, the yeast Saccharomyces is sometimes also used. healthy digestive tract. These are considered to be protective
history of use, standardization of dose, and flora, inhibiting the growth of potentially pathogenic species such
brief description of the scientific evidence History and Claims as E. coli, Candida albicans, Helicobacter pylori, and Gardnerella
supporting (or not supporting) the use of vaginalis. Probiotics restore the normal flora of the intestine fol-
the product. Although probiotics have been used for thousands of years, only lowing diarrhea, particularly diarrhea resulting from antibiotic
in the past 20 years has research begun to confirm their health therapy (National Center for Complementary and Integrative
benefits. Probiotics are claimed to improve immune function, Health, 2016). A 2015 systematic review indicated that probiotics
decrease cancer risk, lower blood cholesterol, reduce blood do in fact reduce symptoms of IBS in patients (Didari, Mozaffari,
pressure, and prevent vaginal infections. Probiotic supplements Nikfar, & Abdollahi, 2015). Probiotics have also been shown to be
are available in certain drinks, yogurts, and tablets. Although effective at shortening episodes of acute infectious diarrhea and
probiotics are safe, care must be taken not to exceed recom- may be considered an option for increasing eradication rates for
mended doses. those with H. pylori (Dang, Reinhardt, Zhou, & Zhang, 2014).
Standardization Although probiotics have been used for many years, they
are not without risk. Infections (including sepsis), lactic acidosis,
Supplements include capsules, tablets, and granules, as well as and other serious adverse effects have been noted (Doron &
cultured dairy products that contain the probiotic bacteria. Snydman, 2015). Because of these, probiotic supplements
Doses are not standardized. Tablet doses range from 50 to should be used with caution in critically ill patients.
500 mg, and not all dairy products contain active cultures.
use sites that have been less used or are difficult for the patient to wrAaedlleeynkoolscyicnuberr(aAinsdgiesnnuotcocalerpdo,sriAeddeveetnhnoasttcaatncist)i:vsauAteedsepdnooatsamisnseaiuigsmaecnhoaatrun--to romortaafriitbleyriulslsaeutdiobtncoautrnetdaatPnHSeVFo,Tiutbissecaalsuoseproefscitrsibaebdilfiotyr atrial flutter
reach. Insulin pump subcutaneous catheters should be changed every to decrease
2–3 days or as recommended by the healthcare provider. (Rotating cnaetlhs eintethresSiAteasnd(inAsVunliondeps,ucmaupsisng) ethveeproyta2ss–iu3mdtaoys.automaticity of the SA node and slow conduction through
injection sites weekly helps to prevent lipodystrophy. Use caution if leave cardiac muscle cells. When given as a rapid 1- to Preface xithe AV node. The drug is not effective against ventricular
using a new site, especially if the previous site used by the patient 2-second IV bolus, adenosine blocks reentry pathways in
dysrhythmias. Because excessive levels of digoxin can pro-
▶ Coemnxonhriebeitqcsutsiicigoknlynstshoaf: nlipNionduayssrtistreoipwnhigtyh. IlniPpsourdlainycsitntroiapcnheuynoAurstepisdspusleiteiccmhaaatnyigaoebsns, osrbfea- the AV node and terminates the tachycardia. It is usually duce serious dysrhythmias, and interactions with other
tures crbeoesnuclhtcianingsgeienldyhyepvceoorgynly2cn–e3emcdiata.ytIsnhstoeulipnnrepuvuermnstpininsfugebccptiuortnaosnceaeot utshssectsaoittehetohtef rienssmsehrtoaioujnlod.)r
dru•g cElnassusre(eprso)pienr setoaracghe odfrinusuglincthoampatinetarinamnadximinucmopropteonrcay.te out- followed by a 1- to 5-second period of asystole. Patients medications are common, patients must be carefully moni-
comes(UfnroopmenetdhiensQulinumalaiytbyeasntodredSaatfreotoym Etedmupecraattuiroe,nbuftoarvoNidudrirescets
(QSENrsou)onmlicghotetmmanppdereeaxttucereenssfcoivireeushpetaoot.f1Omppoeanntteihde. nIinf sntu-ocltiniceevnaiabtlselemrceahdyanbgeceasitnroerseo,dlutateitoanm- should be laid supine prior to adenosine use and warned tored during therapy. Additional information on the mech-
work oacncudrs coroifllparebcoipritaatteifoornm,s,pdaistciaerdntthesvaiafle.)ty, and evidence-
bceansP•etaedtriaUeesspnsdeterosuaspnacmpdntoeeirdnrctsutsetnai.titonniedEdsciinalsducgucurdhoisnsfegdtnsahrdeuumtgrrhaistnthieoiisenntrraragalteapioytfino:inrootdfnermuargevldteheicenaratationpinyods, ndaenasdisisredsduopricnagitaiteendt that they may feel faint. The IV site used to give adenosine anism of action, adverse effects, and nursing responsibilities
patienpthtaeraraamnpeedutetrifcsaofomurtcwiolhmyenetste,ocacocamlhl mtihnoenghlye.aoClbthsocearlvrleeadpbraoodvrvideaertsr,ieoaennfdfecawtnsyi,tnheceostshareyr
discipmlionnietosr,ingsuorcphrecaasutisonosc. i(Uaslinsgutipmepdourritngsneurrvsinicgecsareohrelpdsiteotary should be antecubital or above, and an 18-gauge angio- for digoxin may be found in Chapter 36, where the drug is
servicoepst,imisizeaalnsdoreininfcolrucedkeedy teianchtihngeairneatse.)rventions. Important
lifeP•spataiWennhteansenaldfd-maidndmisitvienreiisnrtgrsatehtieopnmaeotdfiidcearnutiogtntc,hionesrnatrspuicydt: tehreaptaitoiennt,sfaamriley, onroted catheter or larger should be used. A rapid saline flush featured as a prototype.
throucgahreogiuvetr.inTthhe eproNpeur sreslfi-andgminPisrtraatciotnicofetheAdprupg lfoiclloawteidobnys are
organhtiezealepcsdh-tbotaorcekihn.f(eoUrltcpileizitsnetgauctihdmineegnd.)utrsinlgenaurrsne taodmtihniisntraktiolnikoef thaesneudrrusges as • TCeOaNcNhECthTIeONpSa: tNieUnRtSImNGePthRoACdTsICfEoArPpPrLoICpAeTIrOsNtorage of insulin and for storage
they take students through the processes of drug admin- during travel.
Patients Receiving Pharmacotherapy for Dysrhythmias
istration, nursing care, and teaching that are necessary
Assessment
in pharmacotherapy.
Baseline assessment prior to administration:
• Obtain a complete health history including cardiovascular (including previous dysrhythmias, HTN, MI, HF) and the possibility of pregnancy. Obtain a drug
history including allergies, current prescription and over-the-counter (OTC) drugs, herbal preparations, and alcohol use. Be alert to possible drug interactions.
• Obtain baseline weight, vital signs (especially blood pressure and pulse), ECG (rate and rhythm), cardiac monitoring (such as cardiac output if
appropriate), and breath sounds. Assess for location, character, and amount of edema, if present.
• The patient, family, or caregiver should be able to state the reason for• Evaluate appropriate laboratory findings: electrolytes, especially potassium, calcium, and magnesium levels; renal and liver function studies; and lipid profiles.
the drug, appropriate dose and scheduling, what adverse effects to• Assess the patient’s ability to receive and understand instructions. Include family and caregivers as needed.
observe for and when to report them, and any special requirements ofAssessment throughout administration:
• Assess for desired therapeutic effects (e.g., control or elimination of dysrhythmia, blood pressure and pulse within established limits).
the• mCoentdinuice faretqiuoennt mtohniteorrinagpofyEC(Ge(.cgon.ti,nuionussiuf hloisnpitnalizeede).dChsecdk puurlsienqgualiety,xveolurmcei,saend roegrulailrlitny,ealsonsg)w.ith ECG. Assess for complaints
• Instruct the patient to carry a wallet identification card and wearof palpitations and correlate symptoms with ECG findings. Assess for changes in level of consciousness (LOC).
• Continue periodic monitoring of electrolytes, especially potassium and magnesium.
medical identification jewelry indicating diabetes.• Assess for adverse effects: lightheadedness or dizziness, hypotension, nausea, vomiting, headache, fatigue or weakness, flushing, sexual dysfunction,
or impotence. Immediately report bradycardia, tachycardia, or new or different dysrhythmias to the healthcare provider.
Implementation
• ThIEenntsepurvraientngitetiohnenrsta,apnefudati(mcReafitflieyocn,tasol:esr) caregiver is able to discuP• astTiseonatal-leCpvieapntetreporoespdsibrClieaaraetnexietdy, oteascihnthge patient, family, or caregiver the
and administration needs including:• Continue frequent assessments as above for therapeutic effects. rationale for all equipment used and the need for frequent monitoring.
(Dysrhythmias have diminished or are eliminated. Blood pressure and
• • aPphEnreunoalcdslotephuscrdaheagoroereulpdaprpnobpvreoriedoweptpirrt.hi)saaitnehrnlaiaofertsmktiyoaelleln;imchiitafosniogfnreiswsn:itluohsiwnluienprlaeisnrdamf:aateRtirneetroaskstmeea,tinbticxyeretehavesdeiad, ldsrga• weEnnutclopyurabtgheetehtewqpaeutieeincnt,kfatemhislye,torpaccaartelmginivegsr to adopt a healthy lifestyle
insulin and then the longer acting one if insulins are compatible;exercise, limited alcohol intake, limited caffeine intake, and smoking
cessation. Provide for dietitian consultation as needed. (Healthy lifestyle
of low-fat food choices, increased exercise, reduced caffeine intake,
decreased alcohol consumption, and smoking cessation.
inchsaungleisnwigll sluaprpgortinaned moinrimiiznesthue nlieneddforedtreugmtheirrapsy.h) ould not be mixed with any
other type of insulin; use the appropriate syringe (100 unit) unless
small amounts of insulin are ordered, then obtain syringes with
smaller volumes to ensure accurate dosing.
• Proper subcutaneous injection techniques: selection and cleansing
of the site with rotation every week, injecting at 90-deg angle, and
applying a pad to the site after injection but not massaging the site.
• Proper use of all equipment: blood glucose monitoring equipment,
insulin pump.
CONNECTIONS: Patient Safety College of Endocrinology (2015) are designed to target an A1C
level of 6.5% or less with an FPG of less than 110 g/dL. In gen-
Incorrect Insulin Dose ehlorowawt◀l,euera vrlACeler1oo,tCfinhntlanheletovenecaplgtnsri-toeitinedsnrietmashnb:etecPssothaincaottidrretobrntulre.tgirFemsSofraa.prTefeexahastteyimirmee,pniaallatreQe–r, ndsiSnoruEumtrNghseseedicirniosfafcmtebheriepenlintteayhctreietiasono-, ctyh,aist a fea-
illus-
A patient with diabetes has 30 units of Humulin R (regular)
insulin ordered for the morning dose. There are several patients zoltidrainteedsiponoetecnlatsiaslappiptefaarllstoemncaoinutnaitnergelydcbemy incucrosnetrsotlhfaotr can lead to
with diabetes on the unit and the nurse has given many doses 5 tom6edyeicaarst,iownheilrertohres.suMlfoosntyslucreenaasrpioeaskenatd6wmitohntahsquanedstion asking
of insulin that morning. The nurse prepares the insulin but slowthlye dsteucldineenitnteoffiicdaecyn.tTifhye wadhvaetrswe eefnfetctws orobsnegrv, ewd hfoart the nurse
draws up Humalog 30 units instead. The patient begins expe-
riencing symptoms of hypoglycemia within 15 minutes and is eacshhcolauslsdddiffoeri:nSotmhee csaituusaethioynpo, gwlyhceamt itah,ewnhuerresaes sohthoeursld question
treated successfully.
cauasbe owuetigthhtegaoinrdoerrG, Iocromwphlaaitnttshseunchuarssedisahrrohueald. Bdecoaudsiefferently in
AinntshweWefruhstautotreeP?rartoiersntoScacfuetryreqdueasntdionhsoawrecaovualdilabthleeyonbteheprfaecvuelntyteMd 44_AgatDhcuAehiorMdieere7vidd3see6dnb6roy_bt0pyot4eh_trpheSfreeEeec_ixtvnCpded4erni4urvit.gieindmnfduocdearePldstyapiopgcafeaetitt7e2hi9noed5tni.paA2bra7eedc/s1tocem0mrs/i,1ibpc7nehairo1rsi1tiascr:no1eand7otiAfotohtMfnhetehFerr-eaer0spr0auo5ny0lrttiisss-.
resources site. Please consult with your instructor.
diabetic drug classes is presented in Table 66.4. Doses of the
individual medications are listed in Table 66.5.
medications used to treat type 2 diabetes require some Therapy for type 2 diabetes is usually initiated with a
degree of pancreatic insulin secretion. These antidiabetic single drug. The AACE recommends metformin as the ini- Chapter 44
medications are not effective in treating type 1 diabetes tial therapy for most patients with type 2 diabetes (AACE &
because these patients have a total lack of insulin secretion. American College of Endocrinology, 2015). If glycemic con-
Treatment goals recommended by the American Associa- trol is not atochiCntiheOvePetdNhrweaNriatchpEtemuCicotinTceorItehOgeriNmapeSyn, .a:FsUeacilosunridenmtgoedaRicchaeiteisovneearch
tion of Clinical Endocrinologists (AACE) and the American is added
▶ New! Connections: Using Research in Practice features Early Exposure to Allergens May Reduce injectable
illustrate connections to nursing or pharmacology research Asthma Risk receptors.
and discuss the short- and long-term directions of pharma-
cotherapeutics. A critical thinking question is presented at Allergen exposure has been noted to increase the risk for and
the end of each feature to challenge the student to connect severity of asthma in both children and adults (Custovic, 2015;
scientific evidence to nursing practice. Sheehan & Phipatanakul, 2016). What is not as clear is what
roles the timing of initial exposure, ongoing exposure, types of
allergens, or amount of exposure play in the development of
protection from conditions such as asthma and anaphylaxis
(Sheehan & Phipatanakul, 2016).
Lynch et al. (2014) noted that cumulative exposure to
allergens in the first 3 years of life seemed to decrease the risk
of recurrent wheezing and allergies and that such early expo- 44.6
sure may be beneficial. A subsequent study also noted that
there was no increase in allergic rhinitis or sensitization to
indoor allergens such as dogs, cats, and house mites due to
such early exposure (Schoos, Chawes, Jelding-Dannemand,
is necessary to ensure continuous anticoagulation. During abnormal clotting factors (Patel, 2016).
- xitih isPrterfaancseition, risk of bleeding increases, due to the addi- Arterial thromboembolism may deprive an area of
tive anticoagulant action of the two drugs.
blood flow and is a medical emergency because tissue
CONNECTIONS: Lifespan hypoxia and cellular death will result soon after blood
- Considerations pti◀dippsoovt errhopeCdonypucetopApeairlnfasdnhayrtngduataieioeerrrmsre.ecnmtitsTeaMspian.lhoioncItentrovhaptsmtaonrl:haonldoLvecmtsieirstncfmtabeorsgpioseneyparkansirenaitotdi..ndeunTersirChetaaameholtryeitnpboemsuornoiinlasdlaidcyletcteoturaohralrmerstenoaiosmomdsosnuuourbsrnilocegtlfheiyesnamaaaanrtsfbteudeeosaraulnfepirnslgsoetmdimdcoflregideoatfrahifmtaserre--lciyc-
heart. Emboli are common complications of mitral valve
Miscarriage Prevention with Anticoagulants
Miscarriage in pregnancy is devastating, and recurrent miscar-
riage even more so. Autoimmune diseases are related to
poorer obstetric outcomes than that of the general population,
especially in mothers with undiagnosed thrombophilias disease, prosthetic heart valves, and atrial dysrhythmias.
(genetic hypercoagulability disorders) such as antiphospho- Emboli originating from the left side of the heart may lodge
lipid syndrome (APS). Antiphospholipid antibodies are present in any organ in the body.
in 15% of women with recurrent miscarriage, and there is a
potential 90% risk of future fetal loss in those women if left CONNECTION Checkpoint 38.1
untreated (Chetty & Duncan, 2015). Other obstetric and neo-
natal complications related to APS include apnrdeelocwlapmlapMtse3ilae3t;_ADAM736yCo6o_ua0gl4eu_alSarnEtieo_dCn 3ion3c.CicnuhdrdaspPtbaeygr ei2n58tr6,i5nwsh2ic8ic/ah1n0pd/1a7ethx2wtr:0ian7ysiPicsMpafac-0tthi0vw4a6tae-yndse.wwFhroenmbwlohoadt
eclampsia; hemolysis, elevated liver enzymes,
count (HELLP) syndrome; early delivery and subsequent pre- leaks from a vessel? Which is more complex and takes several min-
maturity; intrauterine growth restriction (IUGR); and placental utes? Which results in the formation of fibrin? Answers to Connection
insufficiency (Begum, Ganguly, & Islam, 2015; de Jesús, Checkpoint questions are available on the faculty resources site. Please
Rodrigues, de Jesús, & Levy, 2014). consult with your instructor. Chapter 33
- Due to discrepancies in the research on treatment rec-
ommendations for the use of heparin, LMWH, or aspirin for
recurrent spontaneous abortion before 10 weeks of preg- CoBnlonoedctpiorondCuchtsecmkapyobine tasdamsiknitshteresdtutdoernesttotorerdeceafilcliepnatst◀
nancy, it is recommended that a woman experiencing such
loss discuss the situation with her provider and whether cnounmcebpetrssforof mblopordevcieollussocrhparpotteerinsst,hoart taoreinrcerleaatseedftlouicduvrroel-nt
genetic testing should be conducted. If genetic coagulation
abnormalities are found, heparin or LMWH may be considered sutumdey.dUepneiqnudeintgo othnisthtexctl,inthiceaslesrietuinaftoiornce. Wmahtoelreiablloleoadrniesd
as an option (Andreoli et al., 2013). ininpdriceavtieodusfocrhathpetetrrseathtmatehnat sodf iarceuctea,pmplaiscsaitvioenbltootdhelocsusr-
r(ednetpclhetaiponteor.f more than 30% of the total volume) when there
is a need to replace plasma volume and to supply erythro-
cytes to increase the blood’s oxygen-carrying capacity.
M30_ADAM7366_04_SE_C30.indd Page 513 28/10/17 9:15 AM f-0046-new PharmFACT
▶ PharmFacts connect relevant statistics to the presented In the United States, over 13 million units of whole blood and
material. They add interest to the subject and place it in red blood cells are donated each year. About 36,000 units of red
perspective with other nursing concepts. blood cells are needed every day (American Red Cross, n.d.).
CONNECTIONS: Community- ChapterT3h0e aPdhamrminaicsottrhaetriaopny wofithwChaolclieumblCohoadnnheal sBlboecekenrslar5g1e3ly
Oriented Practice
iasnrroeabdnprelecylnaalyecrofdeanidcideaimacbslyppifneroticehrsiltefopeiacruadetscdieoaemfrnooetfprsnboswoelnotveioatenhdfrtfaemcilcnortyemeboadlpscooaboornynddse,di.natIrthfluseti.ghsrWsceehipinhesaomtntlhieioeiasnb.ntclVeolnaeeoesdidensd.tsioss
Calcium Channel Blockers and Effects
on Minerals Eeffxepcotsse othne tphaetiemnyt otocaurndnieucmess: aryMcoosmt pCoCnBens trsetdhuact ecotuhled
foproceteonftimallyyotcraigrdgiearl acnonatdrvaectrisoene.fTfehcits. Tnheegastuipvepliynoftrbolpoiocd
Patients may be concerned about taking calcium supplements efpfreocdt oucctsurdsebpeecnadusseotnhehsuemdarnugdsorneodruscaenthderienqwuiarreds mcaorvefeu- l
for osteoporosis prevention while taking CCBs. Calcium and mcernotssomf Catac2h+indgurtiongenthsuerpelcaotemaupaptihbaislietyofbtehtwe eaectniotnhepdotoenno-r
magnesium supplements may actually help maintain a normal tialn.dThthise dreeclaipyieednte.ntry of Ca2+ prevents the release of Ca2+
blood pressure or a lower high blood pressure, and as long as fr◀refosu umCslitooiTinnthsgneisneimntccotlofuiresoadwtngeceesorf:medaCbcemrotpiomlnoen–tmsmncoouiymnnnohpisttehilynimec-caOosrtlaoiryorsitnecsiocsnbpotraefilndadwdsgmhPecosrhialcaieclnlrbt-dierlcotiaegiocoddufreiltmaurraetimunnacrs-,e-- s
normal doses are taken, do not appear to affect the antihyper- ipsthrioeodvnisfd.oerTcihemeopfpocarottinaentnrtaticnetixfoopnrem.riaetnicoensthsyamt nputorsmess noefeadntoalcleorngviecy
tensive effects of CCBs. More recent research suggests that toretahFceotiiror nvpeatrhtaiaeptnaitmnsctillouadennedsbudarcielkttihpazaetinmtha,entyhderleoncweeig-vgaertaievdfefeeicfnetoivvtereroppahnicadr-
CCBs may affect the body’s mineral content (Suliburska, emfcfhaecciltolsits.hDecrliezaazpriylnyeasafstp,epurarlrteieacnvatriniaagt, tathhnederahpoeeasudptaiitcahldeoomrsecasly.inToihccaeulrrseedmtutairniinng-g.
Bogdanski, Szulinska, & Pupek-Musialik, 2014). CCBs, along deorr oimf tmheedCiCatBelsywaifltleornthlye etrxahnibsfiut sthioisn.eSffyemctpattohmigshaerre dgoenseesr-
with other antihypertensive drugs such as beta blockers and oralilnyomveilrddoasnedsittrueaattieodnsw. ith acetaminophen (Tylenol) and
angiotensin-converting enzyme (ACE) inhibitors, were found to EfdfiepchtTeshnoehnymdcoarsartdmsieianrcieoc(uoBsneanddauvdcertryisole)nae:sffneIcentefgdreeondme. raadl,mCiCniBsstreaxtihoinbiotf
decrease serum zinc levels. Because depletion of some min- a wnehgoalteivbelocohdroinsoatrnopacicueteffhecetm: tohleytpicrotprearntsyfuosfisolnowreinagcttihoen.
erals such as zinc may have long-term effects on glucose and spTeheids oocfceulresctwrihcaenl ctohnedpuacttiieonnt arcercoeisvsinthgetmheyotrcaanrsdfiuusmio.n
lipid metabolism, adequate mineral intake through diet or sup- Udnedveerlonporsmaanlticboonddiietsioangsa, itnhset SdAonnoordereadutbolmooadticcaelllly(gReBnC-)
plementation should be considered when a patient is taking eraantetisgaennsa. cAtiBoOn pblootoednttiyapl beeicnacuosmepoaftiabniliintywiasrtdhemmoovsetmceonmt-
CCBs or other antihypertensives. ofmCoan2+ctahursoeuogfhtchaislcriuarme, cthhaonungehlss.oBmloectikminegs cfaatlcailu, mdiseonrtdreyr.
caAunsoetshtehreuSnAconmomdeonto, tgheonuegrhatseerfieowuse,raadcvtieornsepeoffteecnttifarolsm,
N-type channels in the spinal cord to ease severe, chronic thwuhs odleecbreloaosidngisaturtaonmsfautsiicoitny-raenladtesdloawciuntge hluenargt irnajtuer.yS.imThi-is
pain. Although the drug has limited applications, in the
Treatment of Overdose: Overdose may result in seri- Preface xiii
ous adverse effects, and close monitoring of cardiovascu-
lar and renal function is necessary. No specific therapy is
available.
Nursing Responsibilities:
• Notify the prescriber prior to administration if the
patient has a history of leukemia, multiple myeloma,
or other myeloid malignancies.
• Monitor for and immediately report signs and symp-
toms of fluid overload, hypokalemia, and cardiac
dysrhythmias.
• Monitor patients with preexisting fluid retention con-
ditions carefully, such as HF, pleural effusion, or asci-
tes, for worsening of symptoms. ◀ Nursing Responsibilities specific to some prototype
drugs are provided in a bulleted list format. Nursing
• This drug has a black box warning for possible anaphy- Responsibilities include important lifespan and diversity
considerations and patient and family education needs.
- laxis. Promptly report any signs and symptoms of aller- When a prototype drug does not have a correlating Nurs-
gic reaction to the provider and discontinue the drug. ing Practice Application, a more complete Nursing Respon-
sibilities section follows the prototype drug section.
- Lifespan and Diversity Considerations:
- • Tachycardia, cardiomegaly, papilledema, conjunctival
- redness, and bone changes may occur more frequently
in children taking oprelvekin than in adults. Carefully
monitor heart rate and heart sounds, changes in visual
- acuity or eye pain, and for complaints of bone pain or
changes in gait. Further cardiac testing (e.g., echocar-
diography) and frequent eye exams may be warranted.
- Patient and Family Education:
• Do not take any other prescription or nonprescription
- drugs, dietary supplements, or herbal products with-
out the approval of the healthcare provider.
- • Immediately report shortness of breath, swelling of
feet or ankles, rapid weight gain, chest pain, unusual
fatigue or weakness, irregular heartbeat, fever of 38°C
- (100.5°F) or higher, unusual bruising or bleeding, orM34_ADAM7366_04_SE_C34.indd Page 586 28/10/17 10:10 AM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...
- blurred vision.
Learning Through Visuals• For self-administration, follow the procedure demon-
strated to prevent contamination of the vial, syringe, 586 Unit 5 Pharmacology of the Cardiovascular System
or medicine. Never touch the rubber stopper of the Pharmacotherapy Illustrated 34.1
vial or the needle of the syringe with your fingers. Dis-
pose of needles and syringes as directed by a health- Mechanism of Action of Antihypertensive Drugs
care provider. Alpha2 agonists
• Do not drive or perform other hazardous activities Decrease sympathetic
impulses from the CNS to
until the effects of the drug are known because this the heart and arterioles,
causing vasodilation
drug may cause drowsiness or dizziness. Arterioles
▶ Updated and Expanded! Pharmacotherapy Illus- a2 Alpha1 blockers
trated features visually present the mechanism of
action for many of the prototype drugs, showing stu- Inhibit sympathetic
dents specifically how drugs counteract the effects of activation in
disease. 2 arterioles, causing
Sympathetic vasodilation
nervous system
a1 2
2 Direct vasodilators
Act on the smooth
muscle of arterioles,
Beta blockers b1 causing vasodilation
Decrease the heart Ca21
rate and myocardial
contractility,
reducing cardiac 2 Calcium channel
output blockers
2 Block calcium ion
channels in arterial
Heart smooth muscle,
causing
vasodilation
Angiotensin II Angiotensin
receptor blockers
Renin Prevent angiotensin
II from reaching its
receptors, causing
vasodilation
Kidney
Diuretics ACE inhibitors
Increase urine output and Block formation of angiotensin II, causing
decrease fluid volume vasodilation, and block aldosterone
secretion, decreasing fluid volume
– = Inhibitory Effect
causing vasodilation
Eleven different drug classes are used to treat HTN, as Drugs for Initial Hypertension
shown in Table 34.2. Each class has specific benefits and Therapy
characteristic adverse effects. The mechanisms of action of
the major classes of antihypertensive drugs are summarized The JNC-7 report recommended thiazide diuretics as initial
in Pharmacotherapy Illustrated 34.1. Although many effec- drugs for the management of mild to moderate HTN.
xiv Preface
-
Platelets and fibrin deposit
on plaque and initiate clot
formation ◀ Vivid, Colorful, and Effective Illustrations help students review
Smooth muscle M24_ADAM7366_04_SE_C24.indd Page 389 30/10/17 8:05 AM f-0051a
the anatomy, physiology, and pathophysiology of a body system toM24_ADAM7366_04_SE_C24.indd Page 389 30/10/17 8:05 AM f-0051aPlaque /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...
better understand the impact of disease on that system.
Chapter 24 Central Nervous System Stimulants and Drugs for Attention-Deficit/Hyperactivity Disorder 389
Chapter 24 Central Nervous System Stimulants and Drugs for Attention-Deficit/Hyperactivity Disorder 389
Understanding Chapter 24Moderate Understanding Chapter 24
narrowing
Thrombus Thrombus
partially completely
of lumen occluding lumen occluding lumen
KFieguyreC3o5n.1cAetphetrsoscSleuromsismin taherycoronary arteries. Key Concepts Summary
2C4O.1NNaCleEenrCttnrTaelsIOsn,eNernvhoCauhnsceseyctskhteepmaobsiitnliimttyut3loa5ncot.s1nicnecnrteraastee, and 24.1 Central nervous system stimulants increase 24.4 Several nonstimulants are effective in treating
24.4 Several nonstiamleurtlnanests,aerneheaffneccetitvheeianbtirleitaytitnogconcentrate, and
symptoms of datetleanytitohne-sdyemficpit/omhyspoefrafactigvuitey. symptoms of attention-deficit/hyperactivity
From wdehlaayt ythoeuslyemarpnteodmisnoCf hfaatpigtueer.28, predict what would happednistoorde2r4. .2 Attention-deficit/hyperactivity disorder is disorder.
2th4e.2caArdttieanctiwono-rdkelofiacidt/whyhpeenrapcltaivsimtyadvisoolrudmereisis increased b2y4.a5 raNpaidrcolepsy iscchhaarraacctteerriizzeeddbbyyienxactteesnsitvioend, ahyytpimereactivity, and 24.5 Narcolepsy is characterized by excessive daytime
Understanding the Chapterinfusiocnhaoraf cnteorrimzeadl bsyaliinnaet.teWnthioant, ehfyfepcetramctiigvhitty,tahnisd have on a patsielenetpiness andimispturelsaitveedbwehitahvcioern.tral nervous sleepiness and is treated with central nervous
system stimulants and antidepressants.
Th2ow4eni.t3hthmCeiPmAfosayDpcscuu?htlltosyAicsvtnroieesmsbwmoueeulharrpasncvettrisosoearCs.rhietoecne.ennPnetlcesrataiilosvneneecCrvohconeushcuskalsptyopwsintittehtemqyruoeursretiinovsntsireuacwrt2eo4ra..6vianilaMsyibetslettsehmycl2xsl4atain.m3sthusilnsP!atesniymUstcsauhranleonasncddtetimasnentiurnrtaildsdalinetncptaaesrtreenavdsrosedufaocsniertsnnsty.htsrgetaeltmrnteehartvmeoeunCstsohyfsaAteDpmHteDr beg2i4n.6s wsMtiemitthuhylalxnaatns tuKhsienedesyfoarrCethcoeeinrntaracblielnitepyrvttoosuinsScsryuesatsmeemmary,
whichastniqmduunaliarcncotksleilpnysdyi.ciadteednfotritfhieetrseattmheentnofuAmDHbDered key sactlieomrtnunlecasnestopsruttshseaednifrdfroenofrfatermhccetosilreotapnhbstiyehl.ietycrethospianircparteotaresyers.ystem. alertness or their effects on the respiratory system.
- Pathophysiology
of Angina Pectoris-
C35A.3SEASngTiUnaDpYe:cMtoraiskiinsgchtahreacPteartizieendtbCyosenvneerectionCASE STUDY: Making the Patient Connection he may have ADHD. She has recom-
Remember the patient “Jonathon school nurse suspects
n▶e ecAchMmntesgosaittntkihapoienpanieasgnclttuostbhtrdrrioseeeusinPssgcRHdt.aahheeocatrtmtgupoioaettoefneemtrntn”h?bchaetNehbtercetoCayhtswhspeteoeprbpsaepnehtaauatgdtynidiiinneeytshenn.niceitBccna“traatgueJsiolmepsoondefearadntioxthnehnee-bsorrnyeetnimcootynesvmfnoociddhceoc-unoearsrdorlaeodndnniduaharltnisoselasdscpuhhpsoiopsoiepnlcwattmrsoerhenknet.stmtwhaaiytthhAaJdovdneeaArtahDcdHtlohlHhenomearD’gpsiaoan.tyfhneSfetrhoh”h?areeaelmlNttphhcatoaacJhtswosaieoenrreernbasectetpoaphugrdmordioennyt--shn.eeiBnnratgeesdmeodfatiohnne-
TitanibhckJiiastoosinoihnnentcptoduahthteetheuaehntrerselmgoistdttoanpeeehirusratoHrspece.cdsnaoaThetngeapiiehennandrnsennaid,taopc.tshftrlrroioTcaaoretisymsrhcoltsnphheioeieaetecitrttwttcadhhhidaa’pipaicmsaeercsatttrlthrsiacilenodchnfetyirsonutilf,soysertelohbietltwencwrholahatgeametwrinehlaa.sliiaa.ottHttctttdhdhiichnihhoiinosisanhedncsanopthkhkcelratpoioicoeaeniirtofrmcfprmsegn,tulhiasrtoeotqabnefsegoroeneruvhsgsnmgptrereriiheitsonnaynqda.tunraignvoIlodaupiteapnndspwtmcsegneoediocaenasanidtnetrsy-ontedatrispaiitoatsnlitoasooinCiog12snlrtr..tssh-se.ihiaWeHttexnieenmctohajceawilatiadnnenhwtleygfdmeiTt,,s(mAihAgodihDJksnrdotiieskHnneatdirdmeaDnainteflphgfrtlail)ghoncyQahneudrtreluateHtlweypmpenohoasJigyonrasttanneiewhnodadseotnuhhfbtuloshaofelraasdncttotehJwhmhoaeaeiwttndnethhpahsidiaestattohthhrsdceolofitirdaesonuinysxetAlbiiettlrblcrhola?DyeeaowrilH.asdea.mtHxictDhsphiptis?serancharpthkeice-toittaen-eocrdg,lhreqbaerneussgdpehisonwatninvoadiennntdcsgooenirns- mended an appointment with Jonathon’s healthcare pro-
absaiosnteudnttilnytrsheopemoretsedpcatehtnaiet anhetrsiisothe.aesiTplyahdiniisstirsaacetelxdlpoaenwrdiewsncaaneddperipsnltihcea3e.-pWighaatsc-areagriovuerneddtuhceactliaosnsrwooumldevbenapdpuroinpgriaatleesson. Getting him to vider and told his parents that Adderall may help Jonathon
focus on his schoolwork.
Critical Thinking Questions
1. What is ADHD and why would Jonathon be experi-
encing more difficulty as he becomes older?
2. How might amphetamine sulfate and dextroamphet-
amine (Adderall) help Jonathon with his ADHD?
3. What caregiver education would be appropriate
atrroiuunmd tohre calbasdsroomomineavlenardeuari.nAg cacleosmsopn.aGneyttiinngghtihmetodiscomfreogratrdisingddoexhtirsoahmompheewtaomrkinaeftaenrdscahmopohl ehtasmbineen a struggle. Jona- regarding dextroamphetamine and amphetamine
- ctihoanpteorf. knowledge obtained in thetadsihmoeohvnahppeilesoprnvehydeo-egsmionmae-rglwtouadotcnikreodkyandtachafohtle.eilsrTddwsh,icsehehtlirlorseeaoptslisavshri—audesnesaotubseagfehealnlameyvaleeipsns.atagrBsluseloogucagrfm,ulepeds.deayJhnostenhpicaains-tweaitwh4i.ftheWfsouarchlr fAyaatotaDeaf-Hr(AeDodaJt?hotdhnoheenaarrtaphlnloploo)vy?nne-’pgsshoar-airgltruhmactnk-abdcyrodaclioohngeilsiddcow,tmreheliialnstaamptneavcnreidethsneaotssgcharamevaetees.daBstserucoaumubesldee he is sulfate (Adderall)?
- that 4. What are other nonpharmacologic treatments
with
lJonteonifnootd-asbntgihrsrAaoa,oinddnnr’eisgl,aoreiJpgonimginhachaaolottl-rhbtpweoiraosanoiinrsnniks,a.dstilWtaosrmcueiuhtgxihsnygcualmciinnaatocegrlreldmetyhoihaekpos,nemraceetrnpe—ecwdauitpopeeeridvilktneaetvnrstnooceauthwdtsboelodibenal.ywbssTselihptocohe-hocdyiasptifAcearancedusslwlstewyuexrrrsieeetstr.hoo-uCrrcieoltesinfcstdai-ltbgeTr.rahPaiidnlneekal,isonJegogcinocQanautlshuewoslttnoiowrinksist.shaWtrryueoitguahvgralmiiinnloasgtbrreltueochotknooemrte.hpeewuopriknnsochwooinl. for ADHD?
sec-
The Answers to Critical Thinking Questions are available on the
faculty resources site. Please consult with your instructor.
increased myocardial oxygen demand. Angina pectoris
episodes are of short duration. With physical rest and men- Additional Case Study
Atadl rdeliatxioatnioanl, tCheawseorkSlotaudddyemands on the heart diminish
and the discomfort subsides within 5 to 10 minutes. Anna Steinmetz has graduated from nursing school and is 2. What teaching will you provide to the patient
ADnensacSrtiepintimoentzs hoafstghreadfuoauterdbfarosmicntuyrpsiensg oscfhaonolgainndaisfollow2.. What teacwhionrgkwinigll nyioguhptsr.oSvhideeistohtahveinpgatideinffticulty adjusting to her
regarding this medication?
3. The patient reports feelings of lightheadedness with
position changes. What interventions will assist in
maintaining patient safety?
Answers to Additional Case Study questions are available on
the faculty resources site. Please consult with your instructor.
◀ An Additional Case Study gives stu-night schedule. Her healthcare provider suggested she uti- 3. The patienltizreepaormtsefdeieclaintigosnotfoligahssthisetawdeidthnehsesrwaidthjustment to shift
working nights. She is having difficulty adjusting to her regardingnthigishtmsecdhiecdautiloen. ?Her healthcare provider suggested she uti-
dents another opportunity to apply theirlize a medication to assist with her adjustment to shift
work. She has been prescribed modafinil (Provigil). position chwaonrgke.sS.hWe hhaatsibneternvpenretisocnrisbwedilml aosdsiasftininil (Provigil).
Mm2a4_inAtDaAinMi7n31g6.6p_Wa04thi_eaSntEt_esCfaf2ef4ce.ttinydd?doePsagme o39d0af3i0n/i1l0(/1P7ro8v:0ig5 iAl)Mhf-a0v0e51oan
knowledge to patient care.1. What effect does modafinil (Provigil) have on
the patient’s ability to maintain alertness during
shift work?
Answers to Additiothnael pCaatsieenStt’usdaybqiluiteysttioonms aarine taavianilaablelertonness during
the faculty resourcesshsifitte w. Polreka?se consult with your instructor.
390 Unit 4 Pharmacology of the Central Nervous System
▶ Chapter Review prepares students for Chapter Review The world would be better off without me.” Which
course exams on chapter content and action would the nurse take for this patient?
gives exposure to NCLEX-RN®-style 1. An elementary school nurse is providing education to
questions. Answers and rationales are the faculty on the use of central nervous system stim- 1. Tell the patient to stop taking atomoxetine
provided in Appendix A. ulants to treat attention-deficit/hyperactivity disor- immediately and not to take it until checking with
der. Of the following, which is most important for the the provider.
nurse to convey to the faculty?
2. Assure the patient that these are normal symptoms
1. Have the child bring the drug dose in a lunch bag because the drug may take 3 or 4 weeks to work.
and come to the office to take it to avoid being
teased. 3. Alert the family or caregiver that immediate
attention and treatment are needed for these
2. Request that the parents leave an extra copy of the symptoms.
prescription at the school in case the dose runs out.
4. Have the patient increase intake of caffeine by
3. Suggest that the parents have two prescriptions consuming cola products, coffee, or tea to
filled, one for home and one to keep at school. counteract the depressive effect.
4. Keep the drugs in a locked drawer, clearly labeled 5. An office worker has made an appointment with a
with the student’s name and only the number of
doses allowed by school policy.
4. Dexamethasone (Decadron) 1. Have a glass of wine with dinner.
2. Eat a chocolate bar at bedtime.
M24_ADAM7366_40.4_ASEh_iCg2h4.sincdhdoPoalgset3u9d1en02t/1ta1k/1i7ng1:4a8toPmMof-x0e0t5i1nae (Stratter/a2)07/PH03350/937.80T1a34k8e6t7h36e6d_AruDgAMbSe/fAoDreAM4Sp_.CmO.NNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... Preface xv
for attention-deficit/hyperactivity disorder visits the 4. Switch to decaffeinated coffee.
school nurse’s office and confides, “I am so depressed. See Answers to Chapter Review in Appendix A.
References Chapter 24 Central Nervous System Stimulants and Drugs for Attention-Deficit/Hyperactivity Disorder 391
MNPCHCeaay&n(wfceetarnrrianncawsAaFAnbooew.fthDnrttidcen,mfatteewrcedbttwlHt.eaeoorree,)iidwlmssld.nnnsfh.lL.onetd,iINtteDtff.i.raanpiciitooHcd-mnooAgpandiisssrrnn/mnnrdot:y,c.eic/DDi--,ao-.ens.Btodd,ehpgs/Cdu.riileeR.snittortsse,whstffo.hmeepieeii.eAv.hd(cceolgaasw(R2,/iio.yr2p/ssnUttg0Nbne//fw0eeedafhh1ontoc1aNr.n.rCCyyi5v,,bicmg4aitppc)tHe/eWood)aeg.yee.auvdsnndsdCnrr.aA.hraertaattiSotdca,OeossrrdcctdhfestooP/poettlfa.tiouiio.efell,rax.svv,trigdlfaeS.aadnRiio…thdstti,ennohehmcyye.tiHrxddoammtdRisSddnr,lo./h/eeiPPii,leCDdessptnltdLsrroobvtr.ree.iapsarriiceyseMvvemrddetgsoo,dcvaeelee:nJmr.foo/rr.nne,.-dfhalsr/drC((Vtt/neetieoAAiiwmn.poocprhpfmDDys(r,nnsarwol2o.yFean..HHr0hmR.g/wn((t,,1t22DDeneddKD1t.00dhctpa)))er.11duS.tn:tidsA/t66Aatebccyparba./viuy.motgDl:,))a/e_/c.k.opHd,/aevtCno.D/md., s UH.SoAPfccAfa.rroar2tiSdm2GsrooldDnnahryc60vpemmdrmtnecoie71oeyfrinhidgphi3zo2ryoiohtciglntie–eoa,.ahvulic7tsb2entritlPWteaansr5:dt6opkahtesytm4gP28i.or:ndsco,y,o/00a3uhukeada7,Wpn00/t.bgny/ln5iN40seadsRwoots,odi–trrgolan.ie1aoraw2kcynrim(aln.8fc0a:aii2,1dn(1wcnstJ0lti201e0iuk–gdes5.va0rs1.9d1desod1ia1c4iNa,8stbetn0tln6i)nCk22yaeioc0.a,)dvd.0-edo.o1otCSdadi5,iLn/iArkft.ogvihD–eo,yid.jssnegsDpae2iiPoertild:uaarm2dts1udrHrrsilln0i0edfoaagoiraoEDdo..stefdne.4u:eEsp2dnnrsu0dcSésm0.ni.o.8hlud,cs1cPctfJi8ehai1sCsheoo:ahl/1ded.yu.emrrd.1yd0mJJcid,orr8cCAsut.ienJjie1hioia3.lomocPMacgin0tl0eanavl.ooio81elolAgoawbdgsv30nnfE.sei,ala//ticcCsR0drc3trsu1:,8htnulSe0cRi7ilR7tu6nocdhaa4r3ean,.irreeit0,c6stevstdseai8u&,eveotlvu9lneynte8ldsteno9aisont.n/snd-
Selected Bibliography meta-analysis and meta-regression in over 9000 ◀ Detailed References and a Selected
patients. Psychopharmacology, 233, 187–197. doi:10.1007/ Bibliography provide the foundation for
Akutagava-Martins, G. C., Rohde, L. A., & Hutz, M. H. s00213-015-4099-3 evidence-based nursing practice and sup-
(2016). Genetics of attention-deficit/hyperactivity Nallu, S. (2017). Narcolepsy. Retrieved from http:// port the currency and accuracy of the
disorder: An update. Expert Review of Neurotherapeutics, emedicine.medscape.com/article/1188433-overview textbook content.
16, 145–156. doi:10.1586/14737175.2016.1130626 National Institute of Mental Health. (2016). Attention deficit
hyperactivity disorder. Retrieved from http://www.
Buoli, M., Serati, M., & Cahn, W. (2016). Alternative nimh.nih.gov/health/topics/attention-deficit-
pharmacological strategies for adult ADHD treatment: hyperactivity-disorder-adhd/index.shtml
A systematic review. Expert Review of Neurotherapeutics, Pickett, J. (2015). ADHD drugs in preschool children.
16, 131–144. doi:10.1586/14737175.2016.1135735 Prescriber, 26(7), 5. doi:10.1002/psb.1329
Preda, A. (2015). Stimulants. Retrieved from http://
Connolly, J. J., Glessner, J. T., Kao, C., Elia, J., & emedicine.medscape.com/article/289007-overview
Hakonarson, H. (2015). Attention-deficit hyperactivity Torgersen, T., Gjervan, B., Lensing, M. B., & Rasmussen, K.
disorder & pharmacotherapy—Past, present, and (2016). Optimal management of ADHD in older adults.
future: A review of the changing landscape of drug Neuropsychiatric Disease and Treatment, 12, 79–87.
therapy. Therapeutic Innovation & Regulatory Science, 49, doi:10.2147/NDT.S59271
632–642. doi:10.1177/2168479015599811
Cunill, R., Castells, X., Tobias, A., & Capellà, D. (2016).
Efficacy, safety and variability in pharmacotherapy for
adults with attention deficit hyperactivity disorder: A
New to the Fourth Edition • More than 30 new drugs have been added to update
medications approved by the FDA since the previous
• Updated Connections features cover current topics edition.
that nurses will face in practice.
• Revised art program: More than 10 figures have been
• New Connections: Preparing for Advanced Practice added or revised in this edition to enhance the clarity
features help students develop critical thinking and of difficult pharmacologic concepts.
clinical decision-making skills.
• New Connections: Using Research in Practice features
illustrate connections to nursing or pharmacology
research.
MyLab Nursing
MyLab Nursing is an online learning and practice environment that works with the text to help students master key con-
cepts, prepare for the NCLEX-RN exam, and develop clinical reasoning skills. Through a new mobile experience, students
can study Pharmacology: Connections to Nursing Practice anytime, anywhere. New adaptive technology with remediation
personalizes learning, moving students beyond memorization to true understanding and application of the content.
MyLab Nursing contains the following features:
Dynamic Study Modules
New adaptive learning modules with remediation that personalize the learning experience by allowing students to increase
both their confidence and their performance while being assessed in real time.
NCLEX-Style Questions
Practice tests with more than 1000 NCLEX-style questions of various types build student confidence and prepare them for
success on the NCLEX-RN exam. Questions are organized by Chapter.
xvi
MyLab Nursing xvii
Decision Making Cases
Clinical case studies that provide opportunities for students to practice analyzing information and making important
decisions at key moments in patient care scenarios. These 10 unfolding case studies are designed to help prepare students
for clinical practice.
Pearson eText
Enhances student learning both in and outside the classroom. Students can take notes, highlight, and bookmark important
content, or engage with interactive and rich media to achieve greater conceptual understanding of the text content. Interac-
tive features include audio clips, pop-up definitions, figures, questions and answers, the nursing process, hotspots, and
video animations.
Contents
Unit 1 Fundamental Principles of 5 Adverse Drug Effects and Drug
Pharmacology Interactions 55
1 Introduction to Pharmacology: Concepts Adverse Drug Effects 56
and Connections 2 Drug Interactions 62
Brief History of Pharmacology 3 6 Medication Errors
Pharmacology: The Study of Medicines 4 and Risk Reduction 70
Characteristics of an Ideal Drug 5
Classification of Drugs 6 Medication Errors and Their Impact on Healthcare 71
Prototype Drugs 6 Factors Contributing to Medication Errors 73
Naming Drugs 7 Drug Names and Medication Errors 74
Connecting Pharmacology to Clinical Nursing Reporting Medication Errors 75
Practice 9 Strategies for Reducing Medication Errors 76
2 Drug Regulations 13 7 The Role of Complementary
and Alternative Therapies in
Patent Medicines 14 Pharmacotherapy 84
Brief History of Drug Legislation 15
Drug Standards 17 Types of Complementary and Alternative
The U.S. Food and Drug Administration 17 Therapies 85
Drug Approval 18 History of Herbal Therapies 86
Changes to the Drug Approval Process 20 Standardization of Herbal Products 86
Prescription and Over-the-Counter Drugs 21 Dietary Supplement Regulation 88
Drug Schedules 22 Herb–Drug Interactions 90
Prescriptive Authority for Nurses 22 Specialty Supplements 92
3 Pharmacokinetics 26 Unit 2 Pharmacology and the Nurse–Patient
Relationship
Introduction to Pharmacokinetics 27
Primary Processes of Pharmacokinetics 28 8 Pharmacotherapy During Pregnancy
and Lactation 98
Route of Administration 29
Drug Concentration and Dose 33 Rationale for Drug Use During Pregnancy and
GI Tract Environment 33 Lactation 99
Blood Flow to the Absorption Site 33 Pharmacotherapy During Pregnancy 99
Drug Ionization 34 Pharmacotherapy During Lactation 104
Drug Interactions 34
Surface Area 34 9 Pharmacotherapy of the Pediatric
Time–Response Relationships 40 Patient 110
4 Pharmacodynamics 45 Testing and Labeling of Pediatric Drugs 111
Pharmacokinetic Variables in Pediatric Patients 113
Interpatient Variability 46 Pharmacologic Implications Associated with Growth
Therapeutic Index 47 and Development 114
Dose–Response Relationship 48 Medication Safety for Pediatric Patients 117
Potency and Efficacy 48 Determining Pediatric Drug Dosages 117
Receptor Theory 50 Adverse Drug Reactions in Children and Promoting
Agonists and Antagonists 51 Adherence 118
Pharmacogenetics 51
xviii
10 Pharmacotherapy of the Geriatric Contents xix
Patient 123
Nicotinic Antagonists: Neuromuscular
Polypharmacy 124 Blockers 177
Physiologic Changes Related to Aging 125
Pharmacokinetic and Pharmacodynamic Changes PROTOTYPE DRUGS: Succinylcholine (Anectine,
in Older Adults 125 Quelicin) 178
Adherence and Drug Misuse Among Older CONNECTIONS: Nursing Practice Application
Adults 127 Patients Receiving Pharmacotherapy with
Adverse Drug Reactions in Older Adults 128 Cholinergic (Muscarinic) Antagonists 181
11 Individual Variations in Drug 15 Adrenergic Agonists 185
Responses 133
Actions of Adrenergic Agonists 186
Psychosocial Influences 134 Mechanisms of Action of Adrenergic Agonists 186
Cultural and Ethnic Variables 134 Classification of Adrenergic Agonists 187
Genetic Influences 136 Nonselective Adrenergic Agonists 188
Gender Influences 137
PROTOTYPE DRUG: Epinephrine (Adrenalin) 190
Unit 3 Pharmacology of the Autonomic Alpha-Adrenergic Agonists 192
Nervous System
PROTOTYPE DRUG: Phenylephrine
12 Review of Neurotransmitters and the (Neo-Synephrine) 193
Autonomic Nervous System 142 Beta-Adrenergic Agonists 194
PROTOTYPE DRUG: Isoproterenol (Isuprel) 195
Overview of the Nervous System 143 CONNECTIONS: Nursing Practice Application
Structure and Function of the Autonomic Nervous Patients Receiving Pharmacotherapy with
System 144 Adrenergic Agonists 197
Synaptic Transmission 146
Cholinergic Transmission 148 16 Adrenergic Antagonists 201
Cholinergic Receptors and Neurotransmitters 149 Actions of Adrenergic Antagonists 202
Termination of Acetylcholine Action 150 Alpha-Adrenergic Antagonists 202
Adrenergic Transmission 150
Alpha-Adrenergic Receptors 151 PROTOTYPE DRUG: Prazosin (Minipress) 205
Beta-Adrenergic Receptors 151 Beta-Adrenergic Antagonists 206
Termination of Norepinephrine Action 151
Regulation of Autonomic Functions 152 PROTOTYPE DRUG: Propranolol (Inderal,
Classifying Autonomic Drugs 152 InnoPran XL) 208
PROTOTYPE DRUG: Metoprolol (Lopressor,
13 Cholinergic Agonists 155 Toprol XL) 211
CONNECTIONS: Nursing Practice Application
Cholinergic Receptors 156 Patients Receiving Pharmacotherapy with
Muscarinic Agonists 158 Adrenergic Antagonists 213
PROTOTYPE DRUGS: Bethanechol (Urecholine) Unit 4 Pharmacology of the Central
159 Nervous System
Cholinergic Crisis 161
Pharmacotherapy of Myasthenia Gravis 161 17 Review of the Central Nervous
PROTOTYPE DRUGS: Pyridostigmine (Mestinon, System 218
Regonol) 163
Scope of Central Nervous System Pharmacology 219
CONNECTIONS: Nursing Practice Application Neurons and Neurotransmission 220
Patients Receiving Pharmacotherapy with Structural Divisions of the Central Nervous
Cholinergic Agonists 164 System 222
Nicotinic Agonists 166 Functional Systems of the Central Nervous
System 224
14 Cholinergic Antagonists 170
18 Pharmacotherapy of Anxiety and Sleep
Classification of Cholinergic Antagonists 171 Disorders 227
Muscarinic Antagonists 172
Anxiety Disorders 228
PROTOTYPE DRUGS: Atropine (Atropen) 174 Sleep Disorders 231
Nicotinic Antagonists: Ganglionic Blockers 176 Management of Anxiety and Sleep Disorders 234
Pharmacotherapy of Anxiety and Insomnia 237
PROTOTYPE DRUG: Lorazepam (Ativan) 238
xx Contents Pharmacotherapy of Parkinson’s Disease 307
PROTOTYPE DRUG: Levodopa and Carbidopa
PROTOTYPE DRUG: Zolpidem (Ambien, Edluar, (Sinemet, Parcopa) 308
Others) 241 PROTOTYPE DRUG: Pramipexole (Mirapex) 311
PROTOTYPE DRUG: Phenobarbital PROTOTYPE DRUG: Benztropine (Cogentin) 314
(Luminal) 246
Alzheimer’s Disease 315
CONNECTIONS: Nursing Practice Application Pharmacotherapy of Alzheimer’s Disease 317
Patients Receiving Pharmacotherapy for Anxiety
or Sleep Disorders 248 PROTOTYPE DRUG: Donepezil (Aricept) 319
Multiple Sclerosis 320
19 Pharmacotherapy of Mood
Disorders 253 PROTOTYPE DRUG: Interferon Beta-1b (Betaseron,
Extavia) 322
Categories of Mood Disorders 254 Amyotrophic Lateral Sclerosis 325
Major Depressive Disorder 254
Pathophysiology of Depression 255 CONNECTIONS: Nursing Practice Application
Assessment of Depression 256 Patients Receiving Pharmacotherapy for
Nonpharmacologic Therapies for Depression 257 Neurodegenerative Disorders 325
Pharmacotherapy of Depression 258
22 Pharmacotherapy of Seizures 330
Selective Serotonin Reuptake Inhibitors 259
PROTOTYPE DRUG: Fluoxetine (Prozac) 261 Characteristics of Seizure Disorders 331
Atypical Antidepressants 263 Classification of Seizure Disorders 334
PROTOTYPE DRUG: Venlafaxine (Effexor) 264
Tricyclic Antidepressants 267 Generalized Seizures 334
PROTOTYPE DRUG: Imipramine (Tofranil) 268 Partial Seizures 335
Monoamine Oxidase Inhibitors 269 Antiepileptic Drugs 339
PROTOTYPE DRUG: Phenelzine (Nardil) 270 PROTOTYPE DRUG: Diazepam (Valium) 342
PROTOTYPE DRUG: Phenytoin (Dilantin,
CONNECTIONS: Nursing Practice Application Phenytek) 344
Patients Receiving Pharmacotherapy with PROTOTYPE DRUG: Carbamazepine (Carbatrol,
Antidepressants 272 Tegretol, Others) 346
Bipolar Disorder 273 PROTOTYPE DRUG: Ethosuximide
Drugs for Bipolar Disorder 274 (Zarontin) 347
PROTOTYPE DRUG: Lithium Carbonate (Eskalith, PROTOTYPE DRUG: Gabapentin
Lithobid) 274 (Neurontin) 348
PROTOTYPE DRUG: Valproic Acid (Depacon,
20 Pharmacotherapy of Psychoses 281 Depakene, Depakote) 349
Other Miscellaneous Drugs 350
Characteristics of Psychoses 282
Symptoms of Schizophrenia 283 CONNECTIONS: Nursing Practice Application
Etiology of Schizophrenia 284 Patients Receiving Pharmacotherapy for
Management of Psychoses 284 Seizures 353
Antipsychotic Drugs 286
23 Pharmacotherapy of Muscle Spasms and
First-Generation Antipsychotics 288 Spasticity 358
PROTOTYPE DRUG: Chlorpromazine 290
PROTOTYPE DRUG: Haloperidol (Haldol) 291 Etiology and Pathophysiology of Muscle Spasms and
Second-Generation (Atypical) Antipsychotics 293 Spasticity 359
PROTOTYPE DRUG: Risperidone (Risperdal) 293 Nonpharmacologic Therapies for Muscle Spasms and
PROTOTYPE DRUG: Aripiprazole (Abilify) 297 Spasticity 360
Pharmacotherapy of Muscle Spasms 361
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with PROTOTYPE DRUG: Cyclobenzaprine
Antipsychotics 299 (Amrix) 363
Pharmacotherapy of Muscle Spasticity 366
21 Pharmacotherapy of Degenerative PROTOTYPE DRUG: Dantrolene (Dantrium,
Diseases of the Central Nervous Revonto) 366
System 304 Skeletal Muscle Relaxants as Surgical Adjuncts 370
Degenerative Diseases of the Central Nervous CONNECTIONS: Nursing Practice Application
System 305 Patients Receiving Pharmacotherapy for Muscle
Parkinson’s Disease 306 Spasms and Spasticity 370
Contents xxi
24 Central Nervous System Stimulants PROTOTYPE DRUG: Lidocaine (Anestacon,
and Drugs for Attention-Deficit/ Xylocaine, Zingo, Others) 439
Hyperactivity Disorder 375 Adjuncts to Anesthesia 441
Characteristics of Central Nervous System CONNECTIONS: Nursing Practice Application
Stimulants 376 Patients Receiving Local Anesthesia 442
Etiology and Pathophysiology of Attention-Deficit/
Hyperactivity Disorder 377 27 Pharmacology of Substance Abuse 447
Pharmacotherapy of Attention-Deficit/Hyperactivity
Disorder 378 Fundamental Concepts of Substance Abuse 448
Legislation of Controlled Substances 449
PROTOTYPE DRUG: Amphetamine and Addiction and Dependence 449
Dextroamphetamine (Adderall, Adderall XR) 380 Tolerance 451
PROTOTYPE DRUG: Atomoxetine (Strattera) 382
Pharmacotherapy of Narcolepsy 384 Central Nervous System Depressants 452
PROTOTYPE DRUG: Modafinil (Provigil) 384 Sedatives and Antianxiety Drugs 452
Methylxanthines 386 Opioids 453
PROTOTYPE DRUG: Caffeine 386 PROTOTYPE DRUG: Buprenorphine with Naloxone
(Suboxone, Zubsolv, Others) 454
CONNECTIONS: Nursing Practice Application Alcohol (Ethanol) 455
Patients Receiving Pharmacotherapy with Central PROTOTYPE DRUG: Disulfiram (Antabuse) 457
Nervous System Stimulants 387
Marijuana and Related Substances 458
25 Pharmacotherapy of Severe Pain and Hallucinogens 459
Migraines 392
LSD and Similar Hallucinogens 459
General Principles of Pain Management 393 Club Drugs and Miscellaneous Hallucinogens 460
Pain Management with Opioids 398 Central Nervous System Stimulants 461
Amphetamines and Methylphenidate 461
PROTOTYPE DRUG: Morphine Sulfate (Astramorph Cocaine 462
PF, Duramorph RF, Roxanol, Others) 402 Caffeine 463
Pain Management with Nonopioids 406 Nicotine 463
PROTOTYPE DRUG: Tramadol (Ultram, Others) 406 PROTOTYPE DRUG: Varenicline (Chantix) 464
Inhalants 465
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy for Pain 408 CONNECTIONS: Nursing Practice Application
Pharmacotherapy with Opioid Antagonists 412 Patients Receiving Pharmacotherapy for Substance
Pharmacotherapy of Migraines 413 Abuse Disorders 466
PROTOTYPE DRUG: Sumatriptan (Imitrex, Anabolic Steroids 467
Onzetra) 415
Unit 5 Pharmacology of the Cardiovascular
CONNECTIONS: Nursing Practice Application System
Patients Receiving Pharmacotherapy for
Migraines 417 28 Review of the Cardiovascular
System 474
26 Anesthetics and Anesthesia
Adjuncts 422 Structure and Function of the Cardiovascular
System 475
Types of Anesthesia 423 Functions and Properties of Blood 475
Principles of General Anesthesia 423 Cardiac Structure and Function 478
Intravenous Anesthetics 424 Hemodynamics and Blood Pressure 483
PROTOTYPE DRUG: Fentanyl (Sublimaze) 425 29 Pharmacotherapy of Hyperlipidemia 488
PROTOTYPE DRUG: Midazolam (Versed) 427
PROTOTYPE DRUG: Propofol (Diprivan) 428 Types of Lipids and Lipoproteins 489
Inhalation Anesthetics 430 Measurement and Control of Serum Lipids 492
PROTOTYPE DRUG: Nitrous Oxide 430 Drugs for Dyslipidemias 494
PROTOTYPE DRUG: Isoflurane (Forane) 432
Local Anesthetics 433 PROTOTYPE DRUG: Atorvastatin (Lipitor) 496
PROTOTYPE DRUG: Cholestyramine
CONNECTIONS: Nursing Practice Application (Questran) 500
Patients Receiving General Anesthesia 434 PROTOTYPE DRUG: Gemfibrozil (Lopid) 502
PROTOTYPE DRUG: Procaine (Novocaine) 438 Miscellaneous Drugs for Dyslipidemias 503
xxii Contents
CONNECTIONS: Nursing Practice Application CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy for Patients Receiving Pharmacotherapy with
Hyperlipidemia 505 Diuretics 555
30 Pharmacotherapy with Calcium Channel 33 Pharmacotherapy of Fluid Imbalance,
Blockers 510 Electrolyte, and Acid–Base Disorders 561
Physiologic Role of Calcium Channels in Muscle Principles of Fluid Balance 562
Contraction 511 Fluid Replacement Agents 563
Types of Calcium Channels 512
Consequences of Calcium Channel Blockade 513 PROTOTYPE DRUG: Normal Serum Albumin
Classification of Calcium Channel Blockers 513 (Albuminar, Plasbumin, Others) 565
PROTOTYPE DRUG: 5% Dextrose in Water
PROTOTYPE DRUG: Nifedipine (Adalat CC, (D5W) 566
Procardia XL) 515 PROTOTYPE DRUG: Dextran 40 (Gentran 40,
PROTOTYPE DRUG: Verapamil (Calan, Isoptin, Others) 567
Verelan) 517 Physiology of Electrolytes 568
Pharmacotherapy of Electrolyte Imbalances 569
CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Sodium Chloride (NaCl) 571
Patients Receiving Pharmacotherapy with Calcium PROTOTYPE DRUG: Potassium Chloride (KCl) 572
Channel Blockers 519 PROTOTYPE DRUG: Magnesium Sulfate
(MgSO4) 574
31 Drugs Affecting the Renin-Angiotensin- Pharmacotherapy of Acid–Base Imbalances 575
Aldosterone System 523 PROTOTYPE DRUG: Sodium Bicarbonate 576
PROTOTYPE DRUG: Ammonium Chloride 577
Components of the Renin-Angiotensin-Aldosterone
System 524 CONNECTIONS: Nursing Practice Application
Physiologic Actions of the Renin-Angiotensin- Patients Receiving Pharmacotherapy for Fluid and
Aldosterone System 526 Electrolyte Imbalances 578
Drugs Affecting the Renin-Angiotensin-Aldosterone
System 527 34 Pharmacotherapy of Hypertension 582
PROTOTYPE DRUG: Lisinopril (Prinivil, Etiology and Pathogenesis of Hypertension 583
Zestril) 529 Nonpharmacologic Management of Hypertension 584
PROTOTYPE DRUG: Losartan (Cozaar) 532 Guidelines for the Management of Hypertension 584
Pharmacotherapy of Hypertension 585
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with Drugs for Initial Hypertension Therapy 586
Angiotensin-Converting Enzyme Inhibitors and Adding Drugs to the Antihypertensive Regimen 587
Angiotensin Receptor Blockers 534 Enhancing Patient Adherence 587
Antihypertensives in African Americans 588
32 Diuretic Therapy and the Drug Classes for Hypertension 588
Pharmacotherapy of Chronic Kidney PROTOTYPE DRUG: Hydralazine 593
Disease 539 Management of Hypertensive Emergency 594
PROTOTYPE DRUG: Nitroprusside Sodium
Review of Renal Physiology 540 (Nitropress) 595
Pharmacotherapy for Patients with Chronic Kidney
Disease 541 CONNECTIONS: Nursing Practice Application
Diuretic Therapy 543 Patients Receiving Pharmacotherapy with Direct
Vasodilators 596
Loop (High-Ceiling) Diuretics 545
PROTOTYPE DRUG: Furosemide (Lasix) 546 35 Pharmacotherapy of Angina Pectoris
Thiazide and Thiazide-Like Diuretics 548 and Myocardial Infarction 602
PROTOTYPE DRUG: Hydrochlorothiazide
(Microzide) 549 Pathophysiology of Myocardial Ischemia 603
Potassium-Sparing Diuretics 550 Myocardial Oxygen Supply 603
PROTOTYPE DRUG: Spironolactone Myocardial Oxygen Demand 603
(Aldactone) 551
Osmotic Diuretics 552 Etiology of Coronary Artery Disease 604
PROTOTYPE DRUG: Mannitol (Osmitrol) 553 Pathophysiology of Angina Pectoris 604
Carbonic Anhydrase Inhibitors 554 Nonpharmacologic Therapy of Coronary Artery
PROTOTYPE DRUG: Acetazolamide (Diamox) 554 Disease 605
Pharmacologic Management of Angina Pectoris 606
Contents xxiii
Drug Classes for Angina Pectoris 607 Anticoagulants 665
PROTOTYPE DRUG: Nitroglycerin (Nitrostat, PROTOTYPE DRUG: Heparin 666
Nitro-Bid, Nitro-Dur, Others) 609 PROTOTYPE DRUG: Warfarin (Coumadin) 669
PROTOTYPE DRUG: Atenolol (Tenormin) 611 PROTOTYPE DRUG: Dabigatran (Pradaxa) 671
Pathophysiology of Myocardial Infarction 612 CONNECTIONS: Nursing Practice Application
Pharmacologic Management of Myocardial Patients Receiving Pharmacotherapy with
Infarction 613 Anticoagulants 672
Antiplatelet Drugs 674
Aspirin 614 PROTOTYPE DRUG: Clopidogrel
Anticoagulants and Antiplatelet Drugs 614 (Plavix) 675
Nitrates 616 PROTOTYPE DRUG: Abciximab (ReoPro) 677
Beta-Adrenergic Antagonists 616 Drugs for Intermittent Claudication 679
Angiotensin-Converting Enzyme Inhibitors 616 Thrombolytics 680
Pain Management 617 PROTOTYPE DRUG: Alteplase (Activase) 681
CONNECTIONS: Nursing Practice Application CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with Organic Patients Receiving Pharmacotherapy with
Nitrates for Angina and Myocardial Infarction 617 Thrombolytics 682
Hemostatics 684
36 Pharmacotherapy of Heart Failure 622 PROTOTYPE DRUG: Aminocaproic Acid
(Amicar) 684
Etiology of Heart Failure 623 Drugs for Hemophilia 686
Pathophysiology of Heart Failure 623
39 Pharmacotherapy of Hematopoietic
Ventricular Hypertrophy 624 Disorders 691
Activation of the Sympathetic Nervous System 625
Increased Plasma Volume and Preload 625 Physiology of Hematopoiesis 692
Natriuretic Peptides and Neurohumoral Factors 625 Hematopoietic Growth Factors 692
Pharmacologic Management of Heart Failure 626
Drugs for Heart Failure 627 PROTOTYPE DRUG: Epoetin Alfa (Epogen,
PROTOTYPE DRUG: Digoxin (Lanoxin, Procrit) 693
Lanoxicaps) 632
PROTOTYPE DRUG: Milrinone (Primacor) 635 CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with
CONNECTIONS: Nursing Practice Application Erythropoietin 696
Patients Receiving Pharmacotherapy for Heart PROTOTYPE DRUG: Filgrastim (Granix, Neupogen,
Failure 635 Zarxio) 697
37 Pharmacotherapy of Dysrhythmias 641 CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with Colony-
Etiology of Dysrhythmias 642 Stimulating Factors 699
Phases and Measurement of the Cardiac Action PROTOTYPE DRUG: Oprelvekin
Potential 642 (Neumega) 700
Classification of Dysrhythmias 645 Classification of Anemias 702
General Principles of Dysrhythmia Management 646 Antianemic Drugs 703
Drugs for Dysrhythmias 646 PROTOTYPE DRUG: Ferrous Sulfate (Feosol,
Feostat, Others) 705
Sodium Channel Blockers: Class I 647 PROTOTYPE DRUG: Cyanocobalamin
PROTOTYPE DRUG: Procainamide 649 (Nascobal) 708
Beta-Adrenergic Antagonists: Class II 652
Potassium Channel Blockers: Class III 653 Unit 6 Pharmacology of Body Defenses
PROTOTYPE DRUG: Amiodarone (Pacerone) 653
Calcium Channel Blockers: Class IV 655 40 Review of Body Defenses and the
Immune System 714
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy for Organization of the Lymphatic System 715
Dysrhythmias 656 Innate (Nonspecific) Body Defenses 715
Miscellaneous Antidysrhythmics 656
Inflammation 718
38 Pharmacotherapy of Coagulation Specific (Adaptive) Body Defenses 719
Disorders 661
Humoral Immune Response 720
Disorders of Hemostasis 662 Cell-Mediated Immune Response 720
Overview of Coagulation Modifiers 664
xxiv Contents
41 Pharmacotherapy of Inflammation Varicella Zoster 774
and Fever 723 Human Papillomavirus 775
Rotavirus 776
Pathophysiology of Inflammation and Fever 724 Passive Immunity 776
Pharmacotherapy of Inflammation 724 PROTOTYPE DRUG: Rho(D) Immune Globulin
Nonsteroidal Anti-Inflammatory Drugs 725 (RhoGAM) 776
Salicylates 725 CONNECTIONS: Nursing Practice Application
PROTOTYPE DRUG: Aspirin (Acetylsalicylic Patients Receiving Immunizations 779
Acid) 728
Ibuprofen-Like Drugs 730 Unit 7 Pharmacology of the Respiratory
PROTOTYPE DRUG: Ibuprofen (Advil, Motrin, System and Allergy
Others) 731
Cyclooxygenase-2 Inhibitors 733 44 Pharmacotherapy of Asthma and Other
PROTOTYPE DRUG: Celecoxib (Celebrex) 734 Pulmonary Disorders 786
Antipyretic and Analgesic Drugs 735
PROTOTYPE DRUG: Acetaminophen (Tylenol) 735 Physiology of the Lower Respiratory Tract 787
Pathophysiology of Asthma 788
CONNECTIONS: Nursing Practice Application Administration of Pulmonary Drugs via
Patients Receiving Pharmacotherapy for Inhalation 788
Inflammation and Fever 737 Principles of Asthma Pharmacotherapy 790
42 Immunostimulants and PROTOTYPE DRUG: Albuterol (Proventil HFA,
Immunosuppressants 741 Ventolin HFA, VoSpire ER) 792
PROTOTYPE DRUG: Ipratropium (Atrovent) 796
Immunostimulants 743 PROTOTYPE DRUG: Beclomethasone (Beconase
PROTOTYPE DRUG: Interferon Alfa-2b (Intron A) 743 AQ, Qvar) 797
PROTOTYPE DRUG: Aldesleukin (Proleukin) 746 PROTOTYPE DRUG: Cromolyn 799
PROTOTYPE DRUG: Montelukast (Singulair) 800
Immunosuppressants 747 PROTOTYPE DRUG: Theophylline 802
PROTOTYPE DRUG: Cyclosporine (Gengraf, Chronic Obstructive Pulmonary Disease 803
Neoral, Sandimmune) 751
PROTOTYPE DRUG: Azathioprine (Azasan, CONNECTIONS: Nursing Practice Application
Imuran) 753 Patients Receiving Pharmacotherapy for Asthma
PROTOTYPE DRUG: Basiliximab (Simulect) 755 and COPD 804
CONNECTIONS: Nursing Practice Application 45 Pharmacotherapy of Allergic Rhinitis
Patients Receiving Pharmacotherapy with and the Common Cold 810
Immunomodulators 757
Physiology of the Upper Respiratory Tract 811
43 Immunizing Agents 762 Pathophysiology of Allergic Rhinitis 812
Pharmacotherapy of Allergic Rhinitis 813
Discovery of Vaccines 763
Vaccines and the Immune System 763 PROTOTYPE DRUG: Fexofenadine
Types of Vaccines 764 (Allegra) 816
General Principles of Vaccine Administration 765 PROTOTYPE DRUG: Fluticasone (Flonase,
Active Immunity: Bacterial Immunizations 766 Veramyst) 818
Diphtheria 766 CONNECTIONS: Nursing Practice Application
Pertussis (Whooping Cough) 766 Patients Receiving Pharmacotherapy with
Tetanus 768 Antihistamines 819
Pneumococcus 768 Decongestants 822
Meningococcus 769 PROTOTYPE DRUG: Pseudoephedrine (Sudafed)
Active Immunity: Viral Immunizations 769 823
Hepatitis B 769 Drugs for the Common Cold 824
PROTOTYPE DRUG: Hepatitis B Vaccine Antitussives 825
(Engerix-B, Recombivax HB) 770 PROTOTYPE DRUG: Dextromethorphan (Delsym,
Hepatitis A 771 Robitussin DM, Others) 826
Influenza 771 Expectorants and Mucolytics 826
Rabies 772
Measles, Mumps, and Rubella 772 CONNECTIONS: Nursing Practice Application
Polio 773 Patients Receiving Pharmacotherapy for
Symptomatic Cough and Cold Relief 827
Unit 8 Pharmacology of Infectious and Contents xxv
Neoplastic Diseases
48 Antibiotics Affecting Bacterial Protein
46 Basic Principles of Anti-Infective Synthesis 868
Pharmacotherapy 834
Mechanisms of Antibiotic Inhibition of Bacterial
Pathogenicity and Virulence 835 Protein Synthesis 869
Describing and Classifying Bacteria 836 Tetracyclines 870
Classification of Anti-Infectives 836
Mechanisms of Action of Anti-Infectives 838 PROTOTYPE DRUG: Tetracycline (Sumycin,
Others) 872
Inhibition of Cell Wall Synthesis 838 Macrolides 874
Inhibition of Protein Synthesis 838 PROTOTYPE DRUG: Erythromycin (EryC,
Disruption of the Plasma Cell Membrane 839 Erythrocin, Others) 875
Inhibition of Nucleic Acid Synthesis 839 Aminoglycosides 876
Inhibition of Metabolic Pathways PROTOTYPE DRUG: Gentamicin (Garamycin,
(Antimetabolites) 839 Others) 878
Other Mechanisms of Action 839 Miscellaneous Inhibitors of Bacterial Protein
Acquired Resistance 839 Synthesis 880
Mechanisms of Resistance 839
Promotion of Resistance 840 CONNECTIONS: Nursing Practice Application
Prevention of Resistant Strains 841 Patients Receiving Pharmacotherapy with a
Indications and Selection of Specific Tetracycline, Macrolide, or Aminoglycoside
Anti-Infectives 844 Antibiotic 882
Host Factors Affecting Anti-Infective Selection 844
Host Defenses 845 49 Fluoroquinolones and Miscellaneous
Local Tissue Conditions 845 Antibacterials 887
Allergy History 845
Other Host Factors 845 Bacterial DNA Replication 888
Superinfections 845 Inhibition of DNA Replication 888
Fluoroquinolones 889
47 Antibiotics Affecting the Bacterial
Cell Wall 848 Adverse Effects 890
PROTOTYPE DRUG: Ciprofloxacin (Cipro) 891
Structure of Bacterial Cell Walls 849 Miscellaneous Antibacterials 893
Penicillins 850
CONNECTIONS: Nursing Practice Application
Natural Penicillins 852 Patients Receiving Pharmacotherapy with
PROTOTYPE DRUG: Penicillin G 852 Fluoroquinolones 895
Broad-Spectrum Penicillins
(Aminopenicillins) 854 50 Sulfonamides and the
PROTOTYPE DRUG: Ampicillin 854 Pharmacotherapy of Urinary Tract
Extended-Spectrum (Antipseudomonal) Infections 900
Penicillins 855
Penicillinase-Resistant (Antistaphylococcal) Pathophysiology of Urinary Tract Infections 901
Penicillins 855 Pharmacotherapy of Urinary Tract Infections 901
Cephalosporins 856
PROTOTYPE DRUG: Cefazolin Acute Uncomplicated Cystitis 902
(Ancef, Kefzol) 858 Complicated Urinary Tract Infection 902
Carbapenems 859 Infants and Children 903
PROTOTYPE DRUG: Imipenem-Cilastatin Pregnancy 903
(Primaxin) 860 Older Adults 903
Miscellaneous Cell Wall Inhibitors 862 Patients with Recurring Urinary Tract
PROTOTYPE DRUG: Vancomycin (Vancocin) 862 Infections 904
Sulfonamides 904
CONNECTIONS: Nursing Practice Application Adverse Effects 906
Patients Receiving Pharmacotherapy with PROTOTYPE DRUG: Trimethoprim-
a Penicillin, Cephalosporin, or Vancomycin Sulfamethoxazole (Bactrim, Septra) 907
Antibiotic 863 Urinary Antiseptics 908
PROTOTYPE DRUG: Nitrofurantoin (Furadantin)
and Nitrofurantoin Macrocrystals (Macrobid,
Macrodantin) 908
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy for Urinary
Tract Infection 910
xxvi Contents
51 Pharmacotherapy of Mycobacterial Drugs for Herpesviruses 979
Infections 915 PROTOTYPE DRUG: Acyclovir (Zovirax) 980
Types of Mycobacterial Infections 916 Drugs for Influenza Viruses 982
Pathogenesis and Diagnosis of Tuberculosis 916 PROTOTYPE DRUG: Amantadine (Symmetrel) 984
Pharmacotherapy of Tuberculosis 918
Drugs for Hepatitis Viruses 985
Standard Regimen 919 PROTOTYPE DRUG: Tenofovir (Vemlidy, Viread) 989
Patients Who Are HIV Positive 921
Pregnant Patients 921 CONNECTIONS: Nursing Practice Application
Chemoprophylaxis Patients 921 Patients Receiving Pharmacotherapy with
PROTOTYPE DRUG: Isoniazid (INH) 922 Antivirals for Non-HIV Viral Infections 992
CONNECTIONS: Nursing Practice Application 55 Pharmacotherapy of HIV Infection and
Patients Receiving Pharmacotherapy for AIDS 996
Tuberculosis 927
Drugs for Leprosy 928 Pathogenesis of HIV Infection 997
PROTOTYPE DRUG: Dapsone (DDS) 929 General Principles of HIV Pharmacotherapy 999
Drugs for Mycobacterium avium Complex Classification of Antiretroviral Drugs 1001
Infections 930 Antiretroviral Drugs 1003
52 Pharmacotherapy of Fungal PROTOTYPE DRUG: Zidovudine (AZT,
Infections 934 Retrovir) 1004
PROTOTYPE DRUG: Efavirenz (Sustiva) 1006
Characteristics of Fungi and Fungal Infections 935 PROTOTYPE DRUG: Lopinavir with Ritonavir
Drugs for Systemic Fungal Infections 938 (Kaletra) 1008
Prophylaxis of HIV Infections 1010
PROTOTYPE DRUG: Amphotericin B Deoxycholate
(Fungizone) 939 CONNECTIONS: Nursing Practice Application
Drugs for Both Systemic and Superficial Fungal Patients Receiving Pharmacotherapy with
Infections 941 Antiretrovirals 1011
PROTOTYPE DRUG: Fluconazole (Diflucan) 941 Pharmacotherapy of Opportunistic Infections
Drugs for Superficial Fungal Infections 943 Associated with HIV and AIDS 1015
PROTOTYPE DRUG: Nystatin (Nystop) 947
56 Basic Principles of Antineoplastic
CONNECTIONS: Nursing Practice Application Therapy 1020
Patients Receiving Pharmacotherapy with
Antifungals 948 Characteristics of Cancer 1021
Etiology of Cancer 1022
53 Pharmacotherapy of Protozoan and Detection and Prevention of Cancer 1023
Helminthic Infections 952 Goals of Chemotherapy 1023
Staging and Grading of Cancer 1024
Classification and Pathogenesis of Protozoan The Cell Cycle and Growth Fraction 1025
Infections 953 Cell Kill Hypothesis 1027
Drugs for Malaria 954 Improving the Success of Chemotherapy 1028
PROTOTYPE DRUG: Chloroquine (Aralen) 956 Combination Chemotherapy 1028
Drugs for Nonmalarial Protozoan Infections 958 Dosing Schedules 1028
Route of Administration 1028
PROTOTYPE DRUG: Metronidazole (Flagyl) 960 Toxicity of Antineoplastic Drugs 1029
PROTOTYPE DRUG: Pyrimethamine (Daraprim) 964 Hematologic System 1029
Classification and Pathogenesis of Helminthic Gastrointestinal Tract 1030
Infections 965 Cardiopulmonary System 1031
Drugs for Helminthic Infections 968 Urinary System 1031
PROTOTYPE DRUG: Mebendazole (Vermox) 968 Reproductive System 1031
Nervous System 1031
CONNECTIONS: Nursing Practice Application Skin and Soft Tissue 1032
Patients Receiving Pharmacotherapy for Protozoan Other Effects 1032
and Helminthic Infections 970
57 Pharmacotherapy of Neoplasia 1036
54 Pharmacotherapy of Non-HIV Viral
Infections 975 Classification of Antineoplastic Drugs 1037
Antineoplastic Medications 1037
Characteristics of Viruses 976
Pharmacotherapy of Non-HIV Viral Infections 978 Alkylating Agents 1037
Contents xxvii
PROTOTYPE DRUG: Cyclophosphamide Miscellaneous Drugs Used for Peptic Ulcer Disease
(Cytoxan) 1038 and Gastroesophageal Reflux Disease 1097
Antimetabolites 1043 CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy for Peptic
PROTOTYPE DRUG: Methotrexate (MTX, Ulcer Disease 1098
Rheumatrex, Trexall) 1044
60 Pharmacotherapy of Bowel
Antitumor Antibiotics 1048 Disorders and Other Gastrointestinal
Conditions 1103
PROTOTYPE DRUG: Doxorubicin
(Adriamycin) 1048 Pathophysiology of Constipation 1104
Pharmacotherapy with Laxatives 1105
Hormones and Hormone Antagonists 1051
PROTOTYPE DRUG: Psyllium Mucilloid
PROTOTYPE DRUG: Tamoxifen 1053 (Metamucil, Naturacil, Others) 1107
Pathophysiology of Diarrhea 1108
Natural Products 1056 Pharmacotherapy of Diarrhea 1109
PROTOTYPE DRUG: Vincristine (Marqibo, PROTOTYPE DRUG: Diphenoxylate with Atropine
Oncovin) 1057 (Lomotil) 1110
CONNECTIONS: Nursing Practice Application CONNECTIONS: Nursing Practice Application
Patients Receiving Cancer Chemotherapy 1060 Patients Receiving Pharmacotherapy with
Laxatives or Antidiarrheals 1111
Biologic Response Modifiers and Targeted Pharmacotherapy of Inflammatory Bowel
Therapies 1063 Disease 1112
Miscellaneous Antineoplastics 1066 PROTOTYPE DRUG: Sulfasalazine (Azulfidine) 1115
Drugs for Reducing Adverse Effects 1069 Pharmacotherapy of Irritable Bowel Syndrome 1117
Preparing and Administering Antineoplastics 1069 Pathophysiology of Nausea and Vomiting 1118
Pharmacotherapy of Nausea and Vomiting 1119
Unit 9 Pharmacology of the Gastrointestinal
System PROTOTYPE DRUG: Ondansetron (Zofran,
Zuplenz) 1123
58 Review of the Gastrointestinal Pharmacotherapy of Pancreatitis 1123
System 1074
CONNECTIONS: Nursing Practice Application
Overview of the Digestive System 1075 Patients Receiving Pharmacotherapy with
Physiology of the Upper Gastrointestinal Antiemetics 1124
Tract 1075
Physiology of the Lower Gastrointestinal PROTOTYPE DRUG: Pancrelipase (Creon,
Tract 1077 Pancreaze, Zenpep) 1126
Physiology of the Accessory Organs of
Digestion 1077 61 Vitamins and Minerals 1130
Regulation of Digestive Processes 1079
Nutrient Categories and Metabolism 1080 Role of Vitamins in Health and Disease 1131
Regulation of Vitamins 1132
59 Pharmacotherapy of Peptic Ulcer Recommended Dietary Allowance 1133
Disease 1082 Fat-Soluble Vitamins 1134
Physiology of the Upper Gastrointestinal Tract 1083 Vitamin A (Aquasol A) 1134
Etiology and Pathogenesis of Peptic Ulcer Disease Vitamin D (Calcijex, Rocaltrol) 1135
1084 Vitamin E (Aquasol E, Vita-Plus E, Others) 1136
Etiology and Pathogenesis of Gastroesophageal Reflux Vitamin K (AquaMEPHYTON) 1136
Disease 1086 Water-Soluble Vitamins 1137
Pharmacotherapy of Peptic Ulcer Disease and Thiamine: Vitamin B1 1137
Gastroesophageal Reflux Disease 1088 Riboflavin: Vitamin B2 1138
Niacin: Vitamin B3 1138
Pharmacotherapy with Proton Pump Pyridoxine: Vitamin B6 1138
Inhibitors 1088 Folic Acid (Folate): Vitamin B9 1139
Cyanocobalamin: Vitamin B12 1140
PROTOTYPE DRUG: Omeprazole (Prilosec) 1090 Vitamin C: Ascorbic Acid 1140
Minerals 1141
Pharmacotherapy with H2-Receptor Antagonists
1092 CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with Vitamin
PROTOTYPE DRUG: Ranitidine (Zantac) 1093 or Mineral Supplements 1143
Pharmacotherapy with Antacids 1094
PROTOTYPE DRUG: Aluminum Hydroxide
(AlternaGEL, Others) 1095
Pharmacotherapy of Helicobacter pylori
Infection 1096
xxviii Contents 66 Pharmacotherapy of Diabetes
Mellitus 1200
62 Enteral and Parenteral Nutrition 1147
Physiology of Serum Glucose Control 1201
Enteral Nutrition 1149 Pathophysiology of Diabetes Mellitus: Types of
Enteral Formulations 1149 Diabetes 1202
Elements of Enteral Nutrition 1149 Symptoms and Diagnosis of Diabetes 1203
Complications of Enteral Therapy 1150 Complications of Diabetes Mellitus 1204
Drug and Food Interactions 1152
PROTOTYPE DRUG: Glucagon (GlucaGen) 1205
Parenteral Nutrition 1152 Insulin Therapy 1207
Components of Total Parenteral Nutrition
Solutions 1153 Insulin Adjunct 1209
Complications of Parenteral Therapy 1154
Drug and Food Interactions 1155 PROTOTYPE DRUG: Human Regular Insulin
(Humulin R, Novolin R) 1209
CONNECTIONS: Nursing Practice Application Antidiabetic Drugs for Type 2 Diabetes 1211
Patients Receiving Pharmacotherapy with Enteral
and Parenteral Nutrition 1156 CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with
63 Weight Reduction Strategies and the Insulin 1211
Pharmacotherapy of Obesity 1162 Sulfonylureas 1215
Etiology of Obesity 1163 PROTOTYPE DRUG: Glyburide (DiaBeta,
Pathogenesis of Obesity 1164 Glynase) 1215
Measurement of Obesity 1164 Biguanides 1217
Nonpharmacologic Therapies for Obesity 1165
Pharmacotherapy of Obesity 1166 PROTOTYPE DRUG: Metformin (Glucophage,
Glumetza, Others) 1217
PROTOTYPE DRUG: Orlistat (Alli, Xenical) 1168 Meglitinides 1218
Adjuncts to Obesity Therapy 1171
PROTOTYPE DRUG: Repaglinide (Prandin) 1218
Unit 10 Pharmacology of the Endocrine Thiazolidinediones 1219
System
PROTOTYPE DRUG: Rosiglitazone
64 Review of the Endocrine System 1176 (Avandia) 1219
Alpha-Glucosidase Inhibitors 1220
Overview of the Endocrine System 1177
Hormone Receptors 1177 PROTOTYPE DRUG: Acarbose (Precose) 1220
Negative Feedback Mechanisms 1178 Incretin Therapies 1221
Hormone Pharmacotherapy 1180
PROTOTYPE DRUG: Sitagliptin (Januvia) 1221
65 Hypothalamic and Pituitary Miscellaneous Antidiabetic Drugs 1223
Drugs 1183
CONNECTIONS: Nursing Practice Application
Functions of the Hypothalamus 1184 Patients Receiving Pharmacotherapy for Type 2
Functions of the Pituitary Gland 1185 Diabetes 1223
Pharmacotherapy of Growth Hormone
Disorders 1186 67 Pharmacotherapy of Thyroid
Disorders 1229
PROTOTYPE DRUG: Somatropin (Genotropin,
Humatrope, Norditropin, Nutropin, Saizen, Physiology of the Thyroid Gland 1230
Serostim, Zorbtive) 1188 Diagnosis of Thyroid Disorders 1231
PROTOTYPE DRUG: Octreotide Pathophysiology of Hypothyroid Disorders 1232
(Sandostatin) 1190 Pharmacotherapy of Hypothyroid Disorders 1233
CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Levothyroxine (Levothroid,
Patients Receiving Pharmacotherapy with Growth Levoxyl, Synthroid, Unithroid) 1233
Hormone 1192
Pharmacotherapy of Antidiuretic Hormone CONNECTIONS: Nursing Practice Application
Disorders 1193 Patients Receiving Pharmacotherapy with Thyroid
PROTOTYPE DRUG: Desmopressin (DDAVP, Hormone Replacements 1235
Noctiva, Stimate) 1194 Pathophysiology of Hyperthyroid
Disorders 1237
CONNECTIONS: Nursing Practice Application Pharmacotherapy of Hyperthyroid
Patients Receiving Pharmacotherapy with Disorders 1237
Antidiuretic Hormone 1196
PROTOTYPE DRUG: Propylthiouracil
(PTU) 1238
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with
Antithyroid Drugs 1240
Contents xxix
68 Corticosteroids and Drugs Affecting the Emergency Contraception 1300
Adrenal Cortex 1245 Drugs for Pharmacologic Abortion 1301
Physiology of the Adrenal Gland 1246 PROTOTYPE DRUG: Mifepristone (Mifeprex) 1302
Overview of Corticosteroid Pharmacotherapy 1247
Adverse Effects of Corticosteroids 1248 71 Drugs for Disorders and Conditions of
Replacement Therapy with Corticosteroids 1250 the Male Reproductive System 1307
PROTOTYPE DRUG: Hydrocortisone (Cortef, Regulation of Male Reproductive Function 1308
Solu-Cortef, Others) 1252 Pharmacotherapy with Androgens 1308
Corticosteroids for Nonendocrine Conditions 1253
PROTOTYPE DRUG: Testosterone 1311
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with Systemic CONNECTIONS: Nursing Practice Application
Corticosteroids 1255 Patients Receiving Pharmacotherapy with
Mineralocorticoids 1257 Androgens 1312
Anabolic Steroids 1313
PROTOTYPE DRUG: Fludrocortisone 1257 Etiology of Male Sexual Dysfunction 1314
Antiadrenal Drugs 1258 Pharmacotherapy of Male Infertility 1315
Pharmacotherapy of Erectile Dysfunction 1316
69 Estrogens, Progestins, and Drugs PROTOTYPE DRUG: Sildenafil (Viagra) 1317
Modifying Uterine Function 1262 Pathophysiology of Benign Prostatic Hyperplasia 1319
Pharmacotherapy of Benign Prostatic
Hormonal Regulation of Female Reproductive Hyperplasia 1321
Function 1263 PROTOTYPE DRUG: Finasteride (Proscar) 1322
Estrogens 1263
CONNECTIONS: Nursing Practice Application
PROTOTYPE DRUG: Conjugated Estrogens Patients Receiving Pharmacotherapy for Benign
(Cenestin, Enjuvia, Premarin) 1265 Prostatic Hyperplasia 1323
CONNECTIONS: Nursing Practice Application Unit 11 Additional Drug Classes
Patients Receiving Pharmacotherapy with
Estrogen 1267 72 Pharmacotherapy of Bone and Joint
Progestins 1267 Disorders 1328
PROTOTYPE DRUG: Medroxyprogesterone Role of Calcium in Body Homeostasis 1329
(Depo-Provera, Depo-SubQ-Provera, Provera) 1269 Regulation of Calcium Balance 1330
Pharmacotherapy of Calcium Imbalances 1332
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy with Treatment of Hypocalcemia 1332
Progestin 1270 PROTOTYPE DRUG: Calcium Salts 1333
Hormone Replacement Therapy 1271 Treatment of Hypercalcemia 1334
Uterine Stimulants: Oxytocics 1273
CONNECTIONS: Nursing Practice Application
PROTOTYPE DRUG: Oxytocin (Pitocin) 1274 Patients Receiving Pharmacotherapy for
Osteoporosis 1335
CONNECTIONS: Nursing Practice Application Pathophysiology of Metabolic Bone Disease 1336
Patients Receiving Pharmacotherapy with Oxytocin Pharmacotherapy of Metabolic Bone Disease 1338
(Pitocin) 1276 PROTOTYPE DRUG: Calcitriol (Calcijex,
Uterine Relaxants: Tocolytics 1277 Rocaltrol) 1338
Pharmacotherapy of Female Infertility and Female PROTOTYPE DRUG: Alendronate (Fosamax) 1340
Sexual Desire Disorder 1278 PROTOTYPE DRUG: Raloxifene (Evista) 1343
Pathophysiology and Pharmacotherapy of Joint
PROTOTYPE DRUG: Clomiphene (Clomid, Disorders 1345
Serophene) 1281 PROTOTYPE DRUG: Adalimumab (Humira) 1350
Other DMARDS for Rheumatoid Arthritis 1351
70 Drugs for Modifying Conception 1287
CONNECTIONS: Nursing Practice Application
Options and Choices for Birth Control 1288 Patients Receiving Pharmacotherapy for
Combination Oral Contraceptives 1288 Rheumatoid Arthritis and Osteoarthritis 1353
Pharmacotherapy of Gout and Hyperuricemia 1355
PROTOTYPE DRUG: Estradiol and Norethindrone PROTOTYPE DRUG: Colchicine (Colcrys) 1356
(Ortho-Novum, Others) 1292 PROTOTYPE DRUG: Allopurinol (Lopurin,
Adverse Effects of Combination Oral Contraceptives 1293 Zyloprim) 1357
Progestin-Only Oral Contraceptives 1295
Long-Acting Reversible Contraceptives 1295
Spermicides 1298
PROTOTYPE DRUG: Nonoxynol-9 1298
CONNECTIONS: Nursing Practice Application
Patients Receiving Hormonal Contraceptives 1299
xxx Contents
CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Timolol (Betimol, Timoptic,
Patients Receiving Pharmacotherapy for Gout 1359 Others) 1396
Miscellaneous Drugs for Treating Glaucoma 1398
73 Pharmacotherapy of Dermatologic
Disorders 1364 CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy for
Anatomy of the Integumentary System 1365 Glaucoma 1398
Classification of Skin Disorders 1367 Pharmacotherapy for Eye Examinations 1399
Pharmacotherapy of Skin Infections 1367 Pharmacotherapy for Other Eye Conditions 1401
Anatomy of the Ear 1402
Scabicides and Pediculicides 1368 Pharmacotherapy with Otic Preparations 1402
PROTOTYPE DRUG: Permethrin (Acticin, Elimite, CONNECTIONS: Nursing Practice Application
Nix) 1369 Patients Receiving Pharmacotherapy for Otitis 1405
Pharmacotherapy of Acne and Rosacea 1370
Acne Vulgaris 1370 75 Emergency Preparedness: Bioterrorism
and Management of Poisoning 1409
CONNECTIONS: Nursing Practice Application
Patients Receiving Pharmacotherapy for Lice or Emergency Preparedness, Bioterrorism, and
Mite Infestation 1371 Nursing 1410
Rosacea 1373 Biologic Agents 1412
Chemical and Physical Agents 1414
PROTOTYPE DRUG: Tretinoin (Avita, Retin-A, Management of Poisoning 1416
Others) 1373
PROTOTYPE DRUG: Activated Charcoal
CONNECTIONS: Nursing Practice Application (CharcoAid) 1418
Patients Receiving Pharmacotherapy for Acne and PROTOTYPE DRUG: Edetate Calcium Disodium
Related Skin Conditions 1375 (Calcium EDTA) 1419
Pharmacotherapy of Dermatitis 1376 PROTOTYPE DRUG: Dimercaprol (BAL in Oil) 1419
Pharmacotherapy of Psoriasis 1378
Topical Drugs 1381 CONNECTIONS: Nursing Practice Application
Systemic Drugs 1381 Patients Receiving Pharmacotherapy for Poisoning
Pharmacotherapy of Minor Skin Burns 1383 or Overdose 1420
PROTOTYPE DRUG: Benzocaine (Americaine, Appendices
Anbesol, Others) 1384 A Answers to Chapter Review 1425
Pharmacotherapy of Alopecia 1385 B ISMP List of High-Alert Medications in Acute Care
74 Pharmacotherapy of Eye and Ear Settings 1457
Disorders 1389
Glossary 1458
Anatomy of the Eye 1390
Pathophysiology of Glaucoma 1392 Credits 1477
Pharmacotherapy of Glaucoma 1393
Index 1478
PROTOTYPE DRUG: Latanoprost (Xalatan) 1393
Unit 1
Fundamental Principles
of Pharmacology
CHAPTER 1 Introduction to Pharmacology: Concepts and Connections / 2
CHAPTER 2 Drug Regulations / 13
CHAPTER 3 Pharmacokinetics / 26
CHAPTER 4 Pharmacodynamics / 45
CHAPTER 5 Adverse Drug Effects and Drug Interactions / 55
CHAPTER 6 Medication Errors and Risk Reduction / 70
CHAPTER 7 The Role of Complementary and Alternative Therapies
in Pharmacotherapy / 84
1
“Wow, I just left my first
pharmacology class and my
head is swirling. How will I ever
remember all this?”
Student “Josh Remming”
Chapter 1
Introduction to Pharmacology:
Concepts and Connections
Chapter Outline Learning Outcomes
cc Brief History of Pharmacology After reading this chapter, the student should be able to:
cc Pharmacology: The Study of Medicines
cc Characteristics of an Ideal Drug 1. Identify key events in the history of pharmacology.
cc Classification of Drugs
cc Prototype Drugs 2. Compare and contrast the terms drug, pharmacology,
cc Naming Drugs and pharmacotherapy.
cc Connecting Pharmacology to Clinical Nursing
3. Explain the importance of pharmacotherapy to
Practice clinical nursing practice.
4. Using specific examples, explain the difference
between the pharmacologic and therapeutic
methods of classifying drugs.
5. Identify the advantages of using prototype drugs to
study pharmacology.
6. Classify drugs by their chemical, generic, and trade
names.
7. Discuss the rationale for a pharmaceutical company
receiving exclusivity for the marketing of a new
drug.
8. Analyze possible differences between generic drugs
and their trade-name equivalents.
9. Explain how a biosimilar drug differs from its
reference product.
10. Identify the responsibilities of the nurse in drug
administration as part of an interprofessional team.
2
Chapter 1 Introduction to Pharmacology: Concepts and Connections 3
Key Terms exclusivity, 7 pharmacotherapy, 4
generic name, 7 prototype drug, 7
bioavailability, 8 indications, 5 therapeutic classification, 6
biosimilar drug, 9 pharmacologic classification, 6 trade name, 7
chemical names, 7 pharmacology, 4
combination drugs, 8
drug, 4
More drugs are being administered to consumers than ever Little is known about pharmacology during the
before. Over 3.6 billion prescriptions are dispensed each Dark Ages. Although it is likely that herbal medicine
year in the United States, and the number is rapidly continued to be practiced, especially in monasteries and
approaching 4 billion. Sales of prescription medications at in centers of Arabic culture, few historical events related
retail pharmacies in the United States exceeded $286 billion to drug therapy were recorded. Pharmacology, and
in 2015 (Kaiser Family Foundation, 2016). The applications indeed medicine, could not advance until the discipline
of pharmacology to medicine have expanded over the cen- of science was eventually viewed differently than magic
turies and the nurse serves a key role in ensuring the suc- and superstition.
cess of pharmacotherapy. The purpose of this chapter is to
introduce fundamental concepts of pharmacology and to The first recorded reference to the word pharmacology
emphasize the connections between drug therapy and clin- was found in a text titled “Pharmacologia sen Manuductio
ical nursing practice. and Materiam Medicum” by Samuel Dale in 1693. Before
this date, the study of herbal remedies was called “Materia
PharmFACT Medica.” The term Materia Medica likely originated from a
Latin term meaning “medical matters,” although use of
From 1999 to 2014, deaths from prescription opioids such as this term continued into the early 20th century.
methadone and oxycodone quadrupled. More than 165,000
Americans died from overdoses from these prescription Although the exact starting date is obscure, modern
drugs during this period (Centers for Disease Control and pharmacology is thought to have begun in the early
Prevention, 2016). 1800s. At that time, chemists were making remarkable
progress in separating specific substances from complex
Brief History of Pharmacology mixtures. This enabled chemists to isolate the active
agents morphine, colchicine, curare, cocaine, and other
1.1 The practice of applying products to relieve early drugs from their natural plant products. Pharma-
suffering has been recorded throughout history cologists could then study their effects in animals more
by virtually every culture. precisely, using standardized amounts. Some of the early
researchers even used themselves as test subjects. Fried-
The story of pharmacology is rich and exciting, filled rich Sertürner, who first isolated morphine from opium
with accidental discoveries and landmark events. Its his- in 1805, injected himself and three of his friends with a
tory likely began when a human first used a plant to huge dose of 100 mg of his new product. He and his
relieve symptoms of disease. One of the oldest forms of cohorts experienced acute morphine intoxication for sev-
healthcare, herbal medicine has been practiced in virtu- eral days afterward.
ally every culture dating to antiquity. The Babylonians
recorded the earliest surviving “prescriptions” on clay Pharmacology as a distinct discipline was officially
tablets in 3000 BC, although magic and the art of reading recognized when the first Department of Pharmacology
omens were probably considered just as legitimate to was established in Estonia in 1847. John Jacob Abel, who is
healing as the use of herbal remedies. At about the same considered the father of American pharmacology due to
time, the Chinese recorded the Pen Tsao (Great Herbal), a his many contributions to the field, founded the first phar-
40-volume compendium of plant remedies dating to macology department in the United States at the Univer-
2700 BC. The Egyptians followed in 1500 BC by archiving sity of Michigan in 1890.
their remedies on a document known as the Eber’s papy-
rus, which contains over 700 magical formulas and reme- In the 20th century, the pace of change in all areas of
dies. Galen, the famous Greek physician, described over medicine became exponential. Pharmacologists no longer
1000 healing preparations using plant products before his needed to rely on the slow, laborious process of isolating
death in AD 201. active agents from scarce natural products. They could syn-
thesize drugs “from scratch” in the laboratory. Hundreds
of new drugs could be synthesized and tested in a rela-
tively short time span. More importantly, it became
4 Unit 1 Fundamental Principles of Pharmacology
possible to understand how drugs produced their effects, • Substances normally found in the body are not consid-
right down to their molecular mechanism of action. ered drugs unless they are administered to treat a con-
dition. For example, the hormone estrogen circulating
The current practice of pharmacology is extremely com- in the blood is not a drug. However, when it is taken
plex and has progressed far beyond its early, primitive his- as an oral contraceptive to prevent a condition (preg-
tory. The nurses and other health professionals who nancy), estrogen is considered a drug.
administer medications, however, must never forget the
early roots of pharmacology: the application of products to Once the meaning of the term drug is understood, the
relieve or prevent human suffering. Whether a substance is next essential term is pharmacology. The word pharmacology
extracted from the Pacific yew tree, isolated from a fungus, or is derived from two Greek words, pharmakon, which means
created in a laboratory, the central purpose of pharmacology “medicine” or “drug,” and logos, which means “study.”
is focused on the patient and improving the quality of life. Thus, pharmacology is most simply defined as the study of
medicines. Pharmacology is an expansive subject, ranging
CONNECTION Checkpoint 1.1 from understanding how drugs are administered, to where
they travel in the body, to the actual responses they pro-
Some modern drugs used in the treatment of diabetes, cardiovas- duce. Pharmacotherapy, or pharmacotherapeutics, is the
cular disorders, and other conditions have unique sources. Using an application of drugs for the purpose of disease prevention
online dictionary or search engine, what are the natural sources for and treatment of suffering.
exenatide (Byetta), captopril (Capoten), and hyaluronic acid? What
conditions are they used to treat? Answers to Connection Checkpoint Drugs are a form of medical intervention given to
questions are available on the faculty resources site. Please consult with improve a patient’s condition or to prevent harm. Pharmaco-
your instructor. therapy often begins when the patient experiences signs or
symptoms that cause dissatisfaction with current or future
Pharmacology: The Study health status. A major role of the nurse is to design interven-
of Medicines tions that meet the desired health goals of the patient. Phar-
macotherapy is a critical intervention for many conditions.
1.2 Pharmacology is the study of medicines. The rationale for pharmacotherapy is illustrated in Figure 1.1.
The word drug has already been used numerous times in Over 11,000 trade-name and generic drugs and combi-
this text. What exactly is a drug? Is everything a drug, nation agents are currently available for pharmacotherapy.
including water, vitamin C, or perhaps a can of cola? What Each has its own characteristic set of therapeutic applica-
about substances naturally found in the body, such as estro- tions, interactions, adverse effects, and mechanism of
gen or testosterone? Is it even possible to define a drug? action. Many drugs are prescribed for more than one dis-
ease and most produce multiple effects on the body. Fur-
The definition of a drug is indeed difficult but is never- ther complicating the study of pharmacology is the fact
theless important to the healthcare profession. There are that drugs may elicit different responses depending on
many definitions, but perhaps the clearest is that a drug is individual patient factors such as age, gender, race, body
any substance that is taken to prevent, cure, or reduce mass, health status, and genetics. Indeed, learning the
symptoms of a medical condition. Considering the sub- applications of existing medications and staying current
stances listed earlier, which, then, are drugs? Although it with new drugs introduced every year can be an enormous
may seem vague, the correct answer is “it depends.” challenge for the nurse. The task, however, is a critical one
for both the patient and the healthcare provider. When
• The caffeine consumed in a cup of coffee is not consid- applied properly, drugs can dramatically improve patients’
ered a drug. Yet caffeine is included in several thera- quality of life. If applied improperly, the consequences of
pies for headache pain, including Excedrin and drug action can cause permanent disability and even death.
Fioricet. For the patient trying to get pain relief, caf-
feine is a drug. There are important exceptions to the drug definition
mentioned earlier. What about crack cocaine, ecstasy, LSD,
• Vitamin C, if ingested as part of an orange or tomato, or the fumes in glues and paint thinners? These are cer-
is food. Food is not a drug. However, someone with a tainly drugs, but they are not taken “to prevent, cure, or
vitamin C deficiency may be administered vitamin C reduce symptoms of a medical condition.” In fact, they are
to cure scurvy. For this patient, vitamin C is then con- taken to produce a biologic effect viewed as desirable or
sidered a drug. pleasurable by the user (see Chapter 27). Other exceptions
to this definition of the term drug will become apparent as
• A can of cola is certainly not listed in any drug guide. the student studies pharmacology.
However, if a patient with diabetes is experiencing a
hypoglycemic reaction, the glucose in a can of soda
may raise the patient’s blood sugar and prevent a
coma; thus, the glucose in the cola may be considered
a drug in this example.
Chapter 1 Introduction to Pharmacology: Concepts and Connections 5
Patient’s Current Condition drug. Some drugs meet most of the
criteria, whereas others meet very few.
• Signs and symptoms • Assessment of patient At the very least, all prescription
of disease • Nursing diagnosis drugs are expected to have some
• Development of care degree of effectiveness at treating or
• Dissatisfaction with preventing a health condition. The
current health status plan, goals, and outcomes conditions for which a drug is
• Patient teaching approved are its indications. Every
• Risk of chronic health
condition
I medication has at least one indication,
n and most have multiple indications.
t Some drugs are used for conditions
e for which they have not been
r approved; these are called unlabeled
v Pharmacotherapy or off-label indications.
e
n As a general rule, the more a
t medicine strays from the perfect
i
o
n
Revised Condition drug profile, the less commonly it is
used. This is because whenever pos-
• Decreased signs • Reassessment of patient sible, healthcare providers strive to
and symptoms • Evaluation of goals and prescribe the most effective, safest,
and most convenient medication for
• Satisfaction with outcomes the patient. In the home care setting,
health status • Revision of plan of care, drugs that cause annoying adverse
effects, have inconvenient dosing
• Prevention of as needed
disease
Figure 1.1 Rationale for pharmacotherapy: a partnership between the patient and the schedules, or are expensive are often
healthcare provider. not taken by patients, potentially
worsening their condition and caus-
ing failure of treatment outcomes. Of course, some
Characteristics of an Ideal Drug essential drugs do produce serious adverse effects or
must be given by invasive routes, such as intravenously.
1.3 The perfect drug is safe and effective. In these cases, the drug is either administered in a clini-
cal setting by a nurse, or the patient receives careful
As they begin their journey in mastering pharmacology, instructions and regular monitoring on an outpatient
nursing students should start with a notion of the ideal or basis.
“perfect drug.” Learning the characteristics of an ideal
drug gives a basis for comparison to “real drugs.” It is
always the goal of pharmacotherapy to select the perfect or
ideal drug for the patient. Just what is a perfect drug? It is CONNECTIONS: Patient Safety
one that:
Preventing Interactions
• Effectively treats, prevents, or cures the patient’s
condition. A patient has tried to manage symptoms of depression natu-
rally with St. John’s wort, an herbal over-the-counter product.
• Produces a rapid, predictable response at relatively This has not been successful and the patient has decided to
low doses. visit the healthcare provider. After a thorough assessment, the
provider gives the patient a prescription for the antidepressant
• Produces no adverse effects. paroxetine (Paxil). Before teaching this patient about the new
• Can be taken conveniently, usually by mouth. prescription, the nurse consults a drug reference guide. Based
• Can be taken infrequently, usually once a day, and for on that content, what will this patient need to know about St.
John’s wort and paroxetine to ensure safe and effective medi-
a short length of time.
• Is inexpensive and easily accessible.
• Is quickly eliminated by the body after it produces its cation therapy? (Refer to this textbook or a drug reference
beneficial effect. guide for information about paroxetine [Paxil] and potential
• Does not interact with other medications or food. interactions.)
After reading this description, it should appear clear to Answers to Patient Safety questions are available on the faculty
the student that there is really no such thing as a perfect resources site. Please consult with your instructor.
6 Unit 1 Fundamental Principles of Pharmacology
Classification of Drugs Table 1.2 Organizing Drug Information by Pharmacologic
1.4 Drugs may be organized by their therapeutic Classification
classification or pharmacologic classification.
FOCUS ON HOW A DRUG WORKS: PHARMACOTHERAPY
The U.S. Food and Drug Administration (FDA, 2016) doc- OF HYPERTENSION
ument Approved Drug Products with Therapeutic Equivalence
Evaluations, informally called the “Orange Book,” lists over Mechanism of Action Pharmacologic Classification
11,000 approved drugs. With the vast number of drugs
available, it is essential that methods be used to group sim- Lowers plasma volume Diuretic
ilar agents to aid in their study and understanding. The Calcium channel blocker
two basic classifications of drugs are therapeutic and phar- Blocks heart calcium channels Angiotensin-converting enzyme inhibitor
macologic. Both categories are widely used in classifying
prescription and nonprescription drugs. The key differ- Blocks hormonal activity Adrenergic antagonist (or blocker)
ence is that the therapeutic classification describes what is
being treated by the drug, whereas the pharmacologic Blocks physiologic reactions to Vasodilator
classification describes how the drug acts. stress
Drugs are placed into therapeutic classes based on Dilates peripheral blood vessels
their usefulness in treating a specific disease. Table 1.1
shows the method of therapeutic classification, using car- the renin-angiotensin system. Notice that each example
diovascular drugs as an example. Many different types of describes how hypertension might be controlled. A drug’s
drugs affect cardiovascular function. Some drugs influence pharmacologic classification is more specific than its thera-
blood coagulation, whereas others lower cholesterol levels peutic classification and requires an understanding of bio-
or prevent the onset of stroke. Drugs may be used to treat chemistry and physiology. Pharmacologic classifications
hypertension, heart failure, abnormal cardiac rhythm, chest may use a drug’s chemical name.
pain, myocardial infarction (MI), or circulatory shock.
Thus, drugs that treat cardiovascular disorders may be Although classifications help to organize drugs, the pro-
placed in several therapeutic classes, for example, antico- cess is by no means easy or standardized. Most drugs have
agulants, antihyperlipidemics, and antihypertensives. The multiple classifications. For example, the drug epinephrine
key to therapeutic classification is to simply state what con- is classified as a vasoconstrictor, an autonomic nervous sys-
dition is being treated by the particular drug. Other exam- tem agent, an adrenergic agonist, a sympathomimetic, a
ples of therapeutic classifications include antidepressants, bronchodilator, an agent for anaphylaxis, an ocular mydri-
antipsychotics, drugs for erectile dysfunction, and antineo- atic, an antiglaucoma agent, a catecholamine, and a topical
plastics. Notice how the prefix anti- often refers to a thera- hemostatic. This is clearly a mix of therapeutic (e.g., anti-
peutic classification. glaucoma) and pharmacologic (e.g., catecholamine) classifi-
cations. Which one(s) should the student remember?
The pharmacologic classification addresses a drug’s Unfortunately for nursing students, the answer is all of
mechanism of action or how a drug produces its effect in them. The classification chosen primarily depends on the
the body. Table 1.2 illustrates the use of pharmacologic clas- specific clinical use of the drug (What condition is being
sification, using hypertension as an example. A diuretic treated?). Sometimes the classification of choice is simply a
treats hypertension by lowering plasma volume. Calcium preference of the healthcare provider. Although challenging,
channel blockers treat this disorder by decreasing the force remembering the different classifications will pay dividends
of cardiac contractions. Other drugs block components of as the student’s pharmacology course progresses.
Table 1.1 Organizing Drug Information by Therapeutic CONNECTION Checkpoint 1.2
Classification State whether each of the following classifications for aspirin is thera-
peutic or pharmacologic: anticoagulant, salicylate, central nervous sys-
THERAPEUTIC FOCUS: DRUGS AFFECTING tem agent, analgesic, antipyretic. Use a drug guide, if needed. Answers
CARDIOVASCULAR DISEASE to Connection Checkpoint questions are available on the faculty resources
site. Please consult with your instructor.
Therapeutic Usefulness Therapeutic Classification
Prototype Drugs
Influence blood clotting Anticoagulants
Lower blood cholesterol Antihyperlipidemics 1.5 A prototype drug is the agent to which all
Lower blood pressure Antihypertensives other medications in a class are compared.
Restore normal cardiac rhythm Antidysrhythmics
Treat angina Antianginals As discussed in Section 1.4 learning thousands of drugs is
simplified, at least somewhat, by grouping similar drugs
together into broad classifications. Just knowing its thera-
peutic or pharmacologic classification can reveal important
information about a drug. An additional strategy is helpful
when learning pharmacology. One common and useful
Chapter 1 Introduction to Pharmacology: Concepts and Connections 7
Figure 1.2 Obtained from the deadly nightshade plant Atropa Chemical names are assigned using standard nomencla-
belladonna, atropine remains a traditional prototype drug. ture established by the International Union of Pure and
Applied Chemistry (IUPAC). A drug has only one chemical
Courtesy of Heike Falkenberg/Fotolia. name. This chemical name is sometimes helpful in predicting
a drug’s physical and chemical properties. Although chemi-
practice is to select a single drug from a class and compare cal names convey a clear and concise meaning about the
all other medications in the class to this representative nature of a drug to the chemist, these names are often compli-
medication. This is called a prototype drug. By learning cated and difficult to remember or pronounce. For example,
about the prototype drug in depth, the actions and adverse it is unlikely that the nurse would remember that the chemi-
effects of other drugs in the same class can be predicted. cal name for alprazolam (Xanax) is 8-chloro-1-methyl-6-
For example, by learning the actions and effects of penicil- phenyl-4H-s-triazolo[4,3-α][1,4]-benzodiazepine. In only a
lin V, students can extend this knowledge to all other drugs few cases, usually when the name is brief and easily remem-
in the penicillin class of antibiotics. In this textbook, the bered, will nurses use chemical names. Examples of easy to
drug prototypes are clearly identified, and detailed infor- remember chemical names of common drugs include lithium
mation regarding their therapeutic effects, mechanism of carbonate, calcium gluconate, and sodium chloride.
action, adverse effects, contraindications, precautions, and
nursing responsibilities, including patient and family edu- Drugs are sometimes named and classified by a por-
cation, is presented. tion of their chemical structure, known as the chemical
group name. In the Xanax example, a portion of the chemi-
Selecting a drug to serve as the prototype for a class is cal name, benzodiazepine, is used as a drug class. Other
not always a simple matter; healthcare providers and text- examples include the fluoroquinolones, aminoglycosides,
books sometimes disagree. The traditional prototype phenothiazines, and thiazides. Although these names may
approach uses the oldest and best understood drug in the seem complicated when first encountered, knowledge of
class. For example, atropine has been used for thousands of chemical group names will become invaluable as the nurs-
years and still remains a prototype drug for certain indica- ing student begins to learn and understand the actions of
tions (see Figure 1.2). Sometimes, however, newer drugs the drugs in the major drug classes.
are developed in the same class that are more effective or
have a more favorable safety profile. Over time, an older The generic name of a drug is assigned by the United
prototype drug may be infrequently prescribed and a dif- States Adopted Names Council. With few exceptions,
ferent, more clinically useful prototype may be chosen for generic names are less complicated and easier to remember
the class. This textbook uses a practical approach to proto- than chemical names. Many organizations, including the
type drugs, selecting a combination of traditional drugs FDA, the United States Pharmacopeial Convention, and
and those most widely used. Regardless of the approach, the World Health Organization, routinely describe a medi-
the student must remember that the prototype is the drug cation by its generic name. Because each drug has only one
to which all others in a class are compared. generic name, healthcare providers often use this name,
and students must memorize it. Fortunately, sometimes
Naming Drugs components of a generic name can help a student recognize
other drugs in that same class. For example, the ending -lol
1.6 Drugs have chemical, generic, is used in the generic name of beta-adrenergic blockers,
and trade names. and the ending -statin denotes a lipid-lowering drug.
Despite the utility of using drug classes and prototypes A drug’s trade name, sometimes called the proprietary,
when studying pharmacology, learning thousands of drug product, or brand name, is assigned by the pharmaceutical
names remains a challenge. Adding to this difficulty is that company marketing the drug. The trade name is intentionally
most drugs have multiple names. The three basic types of selected to be short and easy to remember so that patients will
drug names are chemical, generic, and trade names. remember it (and ask for it by name). The term proprietary sug-
gests ownership. In the United States, the FDA grants the
pharmaceutical company exclusive rights to name and mar-
ket a drug for a certain number of years after it approves a
new drug application. During the period of exclusivity, com-
peting companies are not allowed to market generic versions
of the product. The rationale for exclusivity is that the devel-
oping pharmaceutical company needs sufficient time to
recoup the millions of dollars in research and development
costs involved in designing and testing a new drug. Without
the guarantee of exclusivity, pharmaceutical companies have
little incentive to develop new and unique drugs. When
8 Unit 1 Fundamental Principles of Pharmacology
exclusivity expires, competing companies may sell a generic 1.7 Generic drugs are less expensive than
equivalent drug, sometimes using a different name, which the trade-name drugs, but they may differ in
FDA must approve. The typical length of exclusivity for a new bioavailability.
drug is 5 years; however, this may be extended by 3 addi-
tional years if the drug is determined to have a new indica- During the years of exclusivity for a new drug, the phar-
tion, can be delivered by a different route, or is made available maceutical company determines the price of the medica-
in a different dosage form. If, for example, a pharmaceutical tion. Because there is no competition, the price is relatively
company completes pediatric studies and determines the dos- high. Once the exclusive rights end, competing companies
age and safety of a drug in this population, the FDA adds market the generic equivalent drug for less money, and
6 months of exclusivity. Orphan drugs (see C hapter 2) have consumer savings may be considerable. In many states,
7 years of exclusivity. Pharmaceutical companies can make pharmacists may routinely substitute a generic drug when
millions of dollars in sales from exclusivity; thus, they usually the prescription calls for a trade name. In other states, the
make great efforts to receive extensions from the FDA. Expira- pharmacist must dispense drugs directly as written by a
tion dates for the exclusivity of specific drugs are listed by the healthcare provider or obtain approval before providing a
FDA in its Approved Drug Products with Therapeutic Equivalence generic substitute.
Evaluations publication.
PharmFACT
Trade names are a challenge for students to learn
because there may be dozens of products that contain the Nine out of every 10 prescriptions dispensed in the United
same drug. In addition, many products contain more than States are for generic drugs. The greatest cost savings are for
one active ingredient. Drugs with more than one active generic drugs prescribed for mental health indications and
generic ingredient are called combination drugs. This for hypertension (Generic Pharmaceutical Association, 2015).
poses a problem when trying to match one generic name
with one product name. As an example, refer to Table 1.3 Pharmaceutical companies marketing trade-name
and consider the drug diphenhydramine (generic name), drugs often lobby aggressively against laws that might
also called Benadryl (one of many trade names). Low doses restrict the routine use of certain trade-name drugs. The
of diphenhydramine may be purchased over the counter lobbyists claim that there are significant differences
(OTC). Higher doses require a prescription. If the nurse is between a trade-name drug and its generic equivalent and
looking for diphenhydramine, it may be listed under many that switching to the generic drug may be harmful to the
trade names such as Benadryl, Nytol QuickCaps, Sominex, patient. Consumer advocates on the other hand argue that
and Unisom, formulated alone or in combination with generic substitutions should always be permitted because
other active ingredients. Acetaminophen and aspirin are of the cost savings to patients.
additional examples of agents that appear in many combi-
nation drugs with dozens of different trade names. To Are there really significant differences between a trade-
avoid this confusion, generic names should be used when name drug and its generic equivalent? The answer is
naming the active ingredients in a combination drug. When unclear. Despite the fact that the dosages may be identical,
referring to a drug, it is conventional to write the generic drug formulations are not always the same. The two drugs
name in lowercase first, followed by the trade name in may have different inert ingredients. If in tablet form, the
parentheses with the first letter capitalized. Examples active ingredients may be more tightly compressed in one
include alprazolam (Xanax) and acetaminophen (Tylenol). of the preparations. Liquid drugs may use different sol-
vents such as water or alcohol.
Table 1.3 Examples of Generic Drugs Contained
The key to comparing trade-name drugs and their
in Trade-Name Products generic equivalents lies in measuring the bioavailability of
the two agents. Bioavailability is defined by the Federal
Generic Drugs Trade Names Food, Drug, and Cosmetic Act (see Chapter 2) as the rate
Aspirin and extent to which the active ingredient is absorbed from
Acetylsalicylic Acid, Acuprin, Anacin, Aspergum, a drug product and becomes available at the site of drug
Diphenhydramine Bayer, Bufferin, Ecotrin, Empirin, Excedrin, Maprin, action to produce its effect. Bioavailability may be affected
Ibuprofen Norgesic, Salatin, Salocol, Salsprin, Supac, Talwin, by many factors, including inert ingredients and tablet
Traphen-10, Vanquish, Verin, ZORprin compression. Anything that affects the absorption of a drug
or its travel to the target cells can certainly affect drug
Allerdryl, Benadryl, Benahist, Bendylate, Caladryl, action. Measuring how long a drug takes to exert its effect
Compoz, Diahist, Diphenadril, Eldadryl, Fenylhist, (onset time) gives pharmacologists a crude measure of bio-
Fynex, Hydramine, Hydril, Insomnal, Noradryl, availability. If the trade and generic products have the same
Nordryl, Nytol, Tusstat, Wehdryl rate of absorption and have the same onset of therapeutic
action, they are said to be bioequivalent.
Advil, Amersol, Apsifen, Brufen, Haltran, Medipren,
Midol 200, Motrin, Nuprin, Pamprin-IB, Rufen,
Trendar
Chapter 1 Introduction to Pharmacology: Concepts and Connections 9
The importance of bioavailability differences between as their reference products; therefore, they are less expen-
a trade-name drug and its generic equivalent depends on sive. To be approved as a biosimilar, the manufacturer must
the specific circumstances of pharmacotherapy. For exam- demonstrate to the FDA that the drug differs very little
ple, if a patient is in circulatory shock and the generic from the approved reference product. This includes having
equivalent drug takes 5 minutes longer to produce its the same route of administration, dosage forms, and mech-
effect, that may indeed be significant. However, if a generic anism of action. The first biosimilar, Zarxio, was approved
medication for arthritis pain relief takes 45 minutes to act, by the FDA with the same indications as filgrastim
compared to the trade-name drug, which takes 40 minutes, (N eupogen), the original biologic product (FDA, 2015).
it probably does not matter which drug is used, and the Inflectra was approved in 2016 as a biosimilar to infliximab
inexpensive product should be prescribed to provide cost (Remicade). Many other biosimilars are expected to reach
savings to the consumer. As a general rule, bioavailability the market in the coming years.
is of most concern when using critical care drugs and those
with a narrow safety margin. In these cases, the patient Connecting Pharmacology
should continue taking the trade-name drug and not switch to Clinical Nursing Practice
to a generic equivalent, unless approved by the healthcare
provider. For most other drugs, the generic equivalent may 1.9 Effective pharmacotherapy depends on a
be safely substituted for the trade-name drug. nurse’s understanding of pharmacology as well
as interprofessional practice with other members
In the age of internet pharmacies, the issue of exclusive of the healthcare team.
marketing rights has drastically changed. Other countries
are not bound by U.S. drug laws, and it is easy for patients to Pharmacotherapy has become a mainstay of modern medi-
obtain medications through the mail at a fraction of the cost cal treatment, and a thorough understanding of expected
in the United States. For example, a pharmaceutical com- drug effects, the associated monitoring required, and the
pany may have exclusivity for selling Cialis in the United care and teaching associated with drugs that are prescribed
States, but companies in India and China can sell the identi- in patient care is crucial to effective nursing practice. As a
cal drug through internet pharmacies and ship it to custom- member of an interprofessional team, nurses, physicians,
ers in the United States. In some cases, they may sell the advanced practice nurses, pharmacists, and, most impor-
drug to consumers without a prescription. Some countries tantly, the patient work together to achieve optimal thera-
do not have the same high quality control standards as the peutic outcomes from drug therapy. The importance of
United States, and the patient may be purchasing a useless pharmacology to clinical nursing practice cannot be over-
or even harmful product. Furthermore, although some inter- stated, and the connection between pharmacology and nurs-
net sites may appear to be based in the United States, they ing practice is emphasized throughout this entire textbook.
may instead be obtaining their medications from sources
outside the United States. Nurses must urge their patients A major goal of this textbook is to provide a solid foun-
not to purchase drugs from overseas pharmacies because dation in the knowledge of pharmacology and pharmaco-
there is no assurance that the drugs are safe or effective. therapeutics. Chapters 2 through 4 provide the legal and
scientific bases for pharmacotherapeutics. As a member of
1.8 Biosimilar drugs are very closely related an interprofessional healthcare team, it is most often the
to biologic medications that have already nurse who serves as the connection between a prescription
received FDA approval. and the patient’s safe use of the prescribed drug. Monitor-
ing the patient’s condition before and during drug use,
Biologic drugs are medicines made by living cells, such as evaluating drug effects, teaching the patient about self-
bacteria or yeast. Because of their natural origin, biologics administration, and conducting a medication reconcilia-
are often complex molecules that require many years of tion are key nursing responsibilities. A medication
research to develop and gain status as FDA-approved reconciliation is the process of keeping track of the patient’s
drugs. In recent years, biologics have become important medications as the patient’s care proceeds from one health-
treatments for rheumatoid arthritis, multiple sclerosis, and care provider to another. For the advanced practice nurse,
cancer. They are effective medications, but are usually very an understanding of the pathophysiology underlying the
expensive. For example, some of the newer biologics for patient’s current condition, excellent assessment skills, and
hepatitis C cost thousands of dollars per dose. clinical decision-making skills aimed at choosing the best
treatment options are required.
Biosimilar drugs have comparable effectiveness and
safety to FDA-approved biologic products. Because a bio- A major goal in studying pharmacology is to eliminate
similar is not an exact, duplicate copy of the original medi- medication errors and to limit the number and severity of
cation (known as the reference product), it should not be adverse drug events. Many adverse effects are preventable.
called a generic medication. Biosimilars are not required to Nurses can routinely avoid many serious adverse drug
undergo the same rigorous preclinical and clinical testing
10 Unit 1 Fundamental Principles of Pharmacology
effects in their patients by applying their experience and always looking up unknown or new drugs will help build
knowledge of pharmacotherapeutics to clinical practice. this knowledge base. As the nurse’s experience grows,
Some adverse effects, however, are not preventable. It is anticipating drug effects and care and teaching needs
vital that the nurse be prepared to recognize and respond becomes integrated into nursing practice. For an advanced
to potential adverse effects of medications. The nursing practice nurse working as a nurse practitioner, this clinical
management of adverse effects and medication errors are experience helps to enhance the new information acquired
discussed in Chapters 5 and 6, respectively. to prepare for prescriptive authority. Chapters 12 through
75 present the foundational knowledge needed for effec-
Before any drug is administered, the nurse must obtain tive pharmacotherapy. Each unit begins with a review of
and process pertinent information regarding the patient’s the anatomy and physiology underlying the mechanism of
medical history, physical assessment, disease processes, action of drugs discussed in the unit, followed by detailed
and learning needs and capabilities. Growth and develop- information about specific classifications of drugs and
mental factors must always be considered. It is important nursing responsibilities for those classifications.
to remember that a large number of variables influence a
patient’s response to drugs throughout the lifespan. Hav- Despite its essential nature, the study of pharmacology
ing a firm understanding of these variables can increase should be viewed in the proper perspective. Drugs are just
treatment success. Chapters 8 through 11 of this textbook one of many tools available to the nurse for preventing or
address these aspects of pharmacotherapy. treating human suffering. Although pharmacology is a key
intervention in many cases, nurses must use all the healing
For a nurse, knowledge of pharmacology is an ongo- sciences in treating their patients. The effectiveness of a drug
ing, lifelong process that builds as a nurse is in practice and in treating disease can never substitute for skilled, compas-
chooses specific clinical areas. Early in practice, learning sionate nursing care. Too much reliance on drug therapy can
prototype drugs that represent a specific classification of diminish the importance of the nurse–patient relationship.
drugs, recognizing key similarities in generic names, and
Understanding Chapter 1
Key Concepts Summary 1.6 Drugs have chemical, generic, and trade names.
1.1 The practice of applying products to relieve 1.7 Generic drugs are less expensive than trade-name
suffering has been recorded throughout history drugs, but they may differ in bioavailability.
by virtually every culture.
1.8 Biosimilar drugs are very closely related to biologic
1.2 Pharmacology is the study of medicines. medications that have already received FDA
approval.
1.3 The perfect drug is safe and effective.
1.9 Effective pharmacotherapy depends on a nurse’s
1.4 Drugs may be organized by their therapeutic understanding of pharmacology as well as
classification or pharmacologic classification. interprofessional practice with other members
of the healthcare team.
1.5 A prototype drug is the agent to which all other
medications in a class are compared.
CASE STUDY: Making the Patient Connection
Remember the student Josh Remming, a 23-year-old student, is in his first semes-
“Josh Remming” at the ter of nursing school. He thought that nursing would pro-
beginning of the chapter? vide him with a great career and lots of opportunity. He
Now read the remainder of enjoys helping people and has always been fascinated with
the case study. Based on the healthcare. However, after the first pharmacology class,
information presented Josh is worried because there seems to be an overwhelming
within this chapter, respond amount of content to learn in just one semester.
to the critical thinking ques-
tions that follow. At the end of the class, Josh talks with other students
who are concerned and a bit anxious. Much of the
Chapter 1 Introduction to Pharmacology: Concepts and Connections 11
conversation centers around lecture content provided by 3. What is a prototype drug, and what advantages
the professor. Following are some of the questions from does a prototype approach to studying pharmacol-
Josh’s classmates. How would you respond? ogy offer?
Critical Thinking Questions 4. Why do nurses need to know all this pharmacology?
1. What is the difference between therapeutic classifica- Answers to Critical Thinking Questions are available on the
tion and pharmacologic classification? faculty resources site. Please consult with your instructor.
2. What classification is a barbiturate? Macrolide? Birth
control pills? Laxatives? Folic acid antagonist? Anti-
anginal agent?
Additional Case Study 1. How do generic equivalent drugs differ from a propri-
etary (trade-name) drug?
Sarah Hawkins, an older woman who lives on a fixed
income, is on multiple medications. She says that all her 2. What would you recommend that Sarah do about
friends are taking the generic form of their medications. accepting generic drugs?
While you are visiting her, she asks, “What do you think of
generic medicines? Are they safe? Are they as good? Are Answers to Additional Case Study questions are available on
they worth it?” the faculty resources site. Please consult with your instructor.
Chapter Review 2. Teaching the patient about self-administration and
any required monitoring of drug effects
1. The nurse is using a drug handbook to determine the
indications for the drug furosemide (Lasix). The term 3. Ensuring that all drug and treatment options have
indications is defined as the: been considered before beginning
pharmacotherapy
1. Way a drug works on the target organs.
4. Frequently conducting a medication reconciliation
2. Amount of the drug to be administered. to verify current medications in use
3. Conditions for which a drug is approved. 5. Determining the ideal drug to be prescribed to the
patient to treat the current condition
4. Reason that the drug should not be given.
4. Which patient characteristics, if noted in the patient’s
2. The nurse is reviewing the patient’s medication medical record, would the nurse consider important
record and does not recognize the medication, filgras- information that may affect the physiologic response
tim-sndz (Zarxio). Consulting a drug guide, the nurse to various types of drug therapy? (Select all that
finds it is listed as a “biosimilar” to filgrastim (Neupo- apply.)
gen). Which of the following best describes the defini-
tion of a biosimilar drug? 1. 82-year-old and female
2. Asian and obese
1. It is another term for a “generic” drug when the 3. Past medical history of kidney disease
two drugs exert similar biologic effects. 4. Mother and sister with diabetes
5. Has no medical insurance
2. It is a drug that has similar effects on the body, but
belongs in a different chemical and therapeutic 5. The nurse is looking up a drug that has been pre-
classification. scribed and wants to know the therapeutic classifica-
tion for the drug. Which of the following would
3. It is a drug that is derived from living cells, such as indicate a therapeutic classification?
yeast, and has comparable effectiveness and safety
to the reference product drug. 1. Beta-adrenergic antagonist
2. Antihypertensive
4. It is a drug that is identical to the reference product 3. Diuretic
drug and thus, does not require FDA approval. 4. Calcium channel blocker
3. As a member of an interprofessional team, what key
responsibilities does the nurse have to ensure effective
pharmacotherapy? (Select all that apply.)
1. Monitoring the patient’s condition before and
during pharmacotherapy
12 Unit 1 Fundamental Principles of Pharmacology 3. Not all healthcare agencies buy the same generic
drugs and that may account for the difference.
6. The nurse is asked by a family member: “They’re giv-
ing mom Motrin and she takes Advil. Hasn’t the 4. Motrin and Advil are trade names for the same
wrong drug been ordered?” The nurse will respond, generic drug, ibuprofen.
knowing that:
See Answers to Chapter Review in Appendix A.
1. There has been an error in the order and the nurse
will contact the healthcare provider.
2. There may be a reason for the healthcare provider
to order a different drug.
References http://kff.org/other/state-indicator/total-sales-for-
retail-rx-drugs
Centers for Disease Control and Prevention. (2016). U.S. Food and Drug Administration. (2015). FDA approves
Prescription opioid overdose data. Retrieved from http:// first biosimilar product Zarxio. Retrieved from http://
www.cdc.gov/drugoverdose/data/overdose.html www.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/ucm436648.htm
Generic Pharmaceutical Association. (2015). Generic drug U.S. Food and Drug Administration. (2016). Approved drug
savings in the U.S.: Seventh annual edition. Retrieved products with therapeutic equivalence evaluations (Orange
from http://www.gphaonline.org/media/wysiwyg/ book). Retrieved from http://www.fda.gov/Drugs/
PDF/GPhA_Savings_Report_2015.pdf InformationOnDrugs/ucm129662.htm
Kaiser Family Foundation. (2015). Total retail sales for
prescription drugs filled at pharmacies. Retrieved from
Selected Bibliography Practitioner, 39(7), 43–47. doi:10.1097/01
NPR.0000450739.27061.e2
Joseph, E. (2016). The challenging future of the biosimilars U.S. Food and Drug Administration. (2014). Frequently
market. Journal of Pharmacy Practice, 29, 266–267. asked questions on patents and exclusivity. Retrieved from
doi:10.1177/0897190016648304 http://www.fda.gov/Drugs/
DevelopmentApprovalProcess/ucm079031.htm
Kadam, V., Bagde, S., Karpe, M., & Kadam, V. (2016). A U.S. Food and Drug Administration. (2016). Facts about
comprehensive overview on biosimilars. Current Protein generic drugs. Retrieved from http://www.fda.gov/
& Peptide Science, 17, 756–761. doi:10.2174/13892037176 drugs/resourcesforyou/consumers/
66160226144618 buyingusingmedicinesafely/
understandinggenericdrugs/ucm167991.htm
Kinch, M. S. (2015). An overview of FDA-approved U.S. Government Accountability Office. (2012). Drug
biologics medicines. Drug Discovery Today, 20, 393–398. pricing: Research on savings from generic drug use (GAO-
doi:10.1016/j.drudis.2014.09.003 12-371R). Retrieved from http://www.gao.gov/
products/GAO-12-371R
Newman, D. J., & Cragg, G. M. (2012). Natural products as
sources of new drugs over the 30 years from 1981 to
2010. Journal of Natural Products, 75, 311–335.
doi:10.1021/np200906s
Shaw, C. R. (2014). Reducing the burden of medication
costs to improve medication adherence. The Nurse
“This headache medicine
I bought at the grocery store
must be safe because I didn’t
need a prescription.”
Patient “Gertrude Stone”
Chapter 2
Drug Regulations
Chapter Outline Learning Outcomes
cc Patent Medicines After reading this chapter, the student should be able to:
cc Brief History of Drug Legislation
cc Drug Standards 1. Explain the role of patent medicines in the history of
cc The U.S. Food and Drug Administration pharmacology and the legislation of drugs.
cc Drug Approval
cc Changes to the Drug Approval Process 2. Outline the key U.S. drug regulations and explain
cc Prescription and Over-the-Counter Drugs how each has contributed to the safety and
cc Drug Schedules effectiveness of medications.
cc Prescriptive Authority for Nurses
3. Describe how the United States Pharmacopeia-National
Formulary (USP-NF) controls drug purity and
standards.
4. Evaluate the role of the U.S. Food and Drug
Administration in the drug approval process.
5. Categorize the four stages of new drug approval.
6. Explain the role of a placebo in new drug testing.
7. Discuss how changes to the approval process have
increased the speed at which new drugs reach
consumers.
8. Compare and contrast prescription and over-the-
counter drugs.
9. Explain how scheduled drugs are classified and
regulated.
10. Discuss the requirements and regulations needed for
nurses to have the ability to prescribe drugs.
13
14 Unit 1 Fundamental Principles of Pharmacology
Key Terms New Drug Application placebo, 19
(NDA), 19 postmarketing surveillance, 20
clinical phase trials, 19 preclinical research, 19
controlled substances, 22 new molecular entities, 19 scheduled drugs, 22
dependence, 22 orphan product, 16 U.S. Food and Drug
formulary, 17 patent medicines, 14
Investigational New Drug pharmacopeia, 17 Administration (FDA), 17
(IND), 19
Laws govern all aspects of the drug approval, labeling,
marketing, manufacturing, and distribution process. The
primary purpose of this legislation is to protect the public
from unsafe and ineffective products. This chapter exam-
ines standards and legislation regulating drugs in the
United States.
Patent Medicines Figure 2.1 Patent medicines contained a trade name that clearly
identified the product and claimed to cure just about any symptom
2.1 Early American history saw the rise or disease.
of patent medicines and the lack of adequate
drug regulations. Courtesy of Library of Congress/Corbis/VCG/Getty Images.
People have an expectation that the medication they are Patent medicines were often harmless (and ineffective),
taking is effective at treating their condition, whether it is containing coloring, flavoring, and an aromatic substance
asthma, diabetes, or a headache. They expect the label to that “smelled like medicine.” At their worst, some con-
contain clear and accurate instructions on how the prod- tained hazardous levels of dangerous or addictive sub-
uct should be taken. They expect that the drug will be stances. In fact, cocaine, heroin, and morphine were freely
safe when the instructions are correctly followed. Are distributed in patent medicines; some elixirs contained up
these reasonable assumptions? In the United States and to 50% morphine, which indeed caused many painful disor-
Canada, the answer is yes. But Americans have not ders to “disappear.” Addictive ingredients were purposely
always had this reassurance. Although drugs have been added to guarantee repeat customers for their products.
used for thousands of years, it was not until the 20th cen- (Note the similarity with nicotine added to tobacco and caf-
tury that extensive standards and regulations were devel- feine added to soft drinks.) In the late 1800s, the familiar
oped to protect the public from unsafe and ineffective Coca-Cola soft drink was a patented beverage that con-
products. tained an estimated 9 mg of cocaine per serving and was
claimed to cure headache, dyspepsia, hysteria, morphine
In early America, there were few attempts to regulate addiction, and impotence. The need for stricter regulation
drugs. This period saw the rise of patent medicines. became more apparent in the 1860s as cocaine was synthe-
Although the term patent implies a legal right to manufac- sized, and the use of opiates as painkillers during the Civil
ture or sell a drug, this was not the case. Patent medicines War caused thousands of soldiers to become addicted.
contained a trade name that clearly identified the product,
such as William Radam’s Microbe Killer, Stanley’s Snake Although the marketing and use of patent medicines
Oil, Dr. Kilmer’s Swamp Root, or Dr. Moore’s Indian Root may seem humorous and even unbelievable to modern
Pills. Because there were no laws to the contrary, these consumers, a few of these products are still available over
products went untested and could claim to cure nearly the counter (OTC). Examples of patent medicines that sur-
any symptom or disease. Dr. William’s Pink Pills for Pale vived the drug regulations of the 1900s include Smith
People, which contained iron oxide and magnesium sul- Brothers Throat Drops, Fletcher’s Castoria, Doan’s Pills,
fate, claimed to cure rheumatism, nervous headache, pal- Vick’s VapoRub, and Phillip’s Milk of Magnesia. Of course,
pitations, grippe, neuralgia, locomotor ataxia, partial
paralysis, sallow complexion, and all forms of weakness
in men or women. A typical advertisement from this era is
shown in Figure 2.1.
Chapter 2 Drug Regulations 15
the ingredients of these products have changed over time Bringing the issue to the forefront was an incident in 1937
so that they conform to modern regulations regarding in which an elixir of sulfanilamide containing a poisonous
labeling, safety, and effectiveness. chemical (diethylene glycol) killed 107 people, mostly
children.
Brief History of Drug Legislation
In 1938, Congress passed the landmark Food, Drug,
2.2 In the 1900s, drug legislation was enacted and Cosmetic Act (FDCA), which corrected certain loop-
to make drugs safer and more effective. holes in previous laws. This was the first law preventing
the sale of newly developed drugs that had not been thor-
Although individual states attempted to regulate drugs, oughly tested for safety. Drug labels were required to con-
the first national law was the Drug Importation Act, tain instructions for safe use. The FDCA was also the first
passed in 1848, which attempted to stop the entry of attempt at regulating cosmetics and medical devices.
unsafe drugs into the United States. In the early 1900s, the Unfortunately, the FDCA did not clearly define “prescrip-
United States began to develop and enforce tougher drug tion” or specify which drugs required a prescription. Most
legislation to protect the public. This was spurred, in part, drugs, including many addictive and harmful substances,
by the tragic deaths of 13 children in St. Louis in 1901 who were sold by the corner druggist, sometimes legally, other
were given diphtheria antitoxin that was contaminated times illegally. In 1951, the Durham-Humphrey Amend-
with tetanus. In 1902, the Biologics Control Act was ment to the FDCA delineated the difference between safer
passed to standardize the quality of sera, antitoxins, and drugs, which were allowed to be sold OTC, and more dan-
other blood-related products. Passed shortly thereafter, gerous drugs, which required prescriptions.
the Pure Food and Drug Act (PFDA) of 1906 was a signifi-
cant and powerful piece of drug legislation that gave the In the late 1950s, the drug thalidomide was found to
government authority to regulate the labeling of medi- produce severe birth defects in the children of women tak-
cines. Essentially, this law required that drug labels accu- ing the drug as a sleeping pill and to treat morning sickness
rately reflect the contents. Prior to this date, many labels during pregnancy. Although the drug was not approved in
did not contain any indication of the active ingredient the United States, it is estimated that over 20,000 Ameri-
within the bottle or its amount. Although the ingredients cans received the drug, because it was widely distributed
had to be accurately labeled, a drug could still be mar- to healthcare providers without U.S. Food and Drug
keted for any disease. Administration (FDA) approval. As with other drug legis-
lation, it took a tragedy to convince Congress to pass
In 1912, the Sherley Amendment to the PFDA prohib- tougher regulations. Passage of the Kefauver-Harris
ited the sale of drugs labeled with false therapeutic claims Amendment to the FDCA in 1962 mandated that manufac-
that were intended to defraud the consumer. A major weak- turers prove their drugs were effective for specific pur-
ness, as borne out in subsequent legal battles, was the dif- poses, as well as safe, through the conduct of “adequate
ficulty of proving that the false claim made by the seller and well-controlled” studies. This law was applied retroac-
was intentional. tively to all drugs introduced since the passage of the
FDCA. This amendment also required that all significant
It is surprising that up to this point in American history adverse reactions be reported to the FDA and that complete
no attempt had been made to legislate the use of addictive information about adverse effects be included in literature
drugs. The Harrison Narcotic Act of 1914 was passed to distributed to healthcare providers. For the first time,
require prescriptions for high doses of narcotic drugs and to informed consent was required from patients participating
mandate that pharmacists and healthcare providers keep in experimental drug research.
narcotic records. Since 1914, hundreds of additional state and
federal laws have been passed to regulate drugs with abuse The emphasis on effectiveness continued as the FDA
potential, including the landmark Comprehensive Drug contracted with the National Academy of Sciences and the
Abuse Prevention and Control Act (see Section 2.8). Addi- National Research Council in 1966 to evaluate the effective-
tional details on the history of the regulation of controlled ness of 4000 drugs that were approved between 1938 and
substances are included in Chapter 27. 1962 based only on their safety. Approximately 40% of all
drugs introduced between 1938 and 1962 were found to be
Unfortunately, two essential components were still ineffective and were subsequently removed from the mar-
missing from the regulation of drugs in the early 20th cen- ket. In 1972, a review of OTC drugs began to examine the
tury. Although the PFDA and other legislation required safety and effectiveness of these products.
that ingredients be listed on the label and prohibited inten-
tional false claims, manufacturers did not have to prove In the 1980s, the public placed considerable political
that the drug was effective. Furthermore, product safety pressure on the FDA to find drugs to treat rare or unusual
did not have to be tested before the drug was marketed. disorders. Pharmaceutical companies were reluctant to
develop drugs for these disorders because there would not
16 Unit 1 Fundamental Principles of Pharmacology
be enough sales to recoup their research and development employees examining new drug applications at the FDA
costs. To encourage development of such drugs, the Orphan increased from 1277 to 2337. The PDUFA was reauthorized
Drug Act became law in 1983. An orphan product is a drug in 1997 with the passage of the Food and Drug Administra-
or biologic for treating rare diseases that affect fewer than tion Modernization Act, which also included provisions to
200,000 people in the United States. Drug manufacturers accelerate the review of medical devices, regulate the
are now offered development grants, tax credits for clinical advertising of unapproved uses of drugs, and regulate
investigation expenses, and 7 years of exclusivity to market health claims for foods. The PDUFA has been reauthorized
an orphan drug. Over 400 medications have been approved with the added goal of improving communication between
as orphan drugs since the passage of this act. the FDA and new drug sponsors. PDUFA fees collected in
2015 amounted to over $855 million, which supported 4133
A major focus in the 1990s was to speed the drug full-time positions to support the drug application process
approval process, which was often prolonged for many at the FDA (FDA, 2016a).
years. The Prescription Drug User Fee Act (PDUFA) of 1992
assessed fees from drug manufacturers to be used specifi- In reaction to the rising popularity of dietary supple-
cally for reducing the review time for new drug applica- ments, Congress passed the Dietary Supplement Health
tions. From 1992 to 2002, the number of full-time equivalent and Education Act of 1994 to control misleading industry
Table 2.1 Historical Timeline of Regulatory Acts, Standards, and Organizations
Year Regulatory Acts, Standards, and Organizations
1820 Physicians establish the first comprehensive publication of drug standards, the United States Pharmacopeia (USP).
1848
The Drug Importation Act requires that all drugs (as defined by the newly established pharmacopeia) entering the United States be inspected
1852 and analyzed for “quality, purity, and fitness for medical purposes.”
1862 Pharmacists found the American Pharmaceutical Association (APhA). The APhA establishes the National Formulary (NF), a standardized
publication focusing on pharmaceutical ingredients. The USP continues to catalog all drug-related substances and products.
1902
1906 The Federal Bureau of Chemistry, established under the administration of President Lincoln, eventually becomes the Food and Drug
1912 Administration (FDA).
1914
The Biologics Control Act controls the quality of sera and other blood-related products.
1938
1944 The Pure Food and Drug Act prohibits the manufacture and sale of adulterated or misbranded foods, drugs, and medications.
1970
The Sherley Amendment makes medicines safer by prohibiting the sale of drugs labeled with false therapeutic claims.
1975
1986 The Harrison Narcotics Act requires those who dispense opium, cocaine, and related substances to keep records of the drugs they dispense
and makes it illegal to possess narcotics without a prescription. This act allows physicians to prescribe narcotics only for treatment, not to
1986 addicts.
1988 The Food, Drug, and Cosmetic Act is the first law preventing the marketing of drugs not thoroughly tested.
1992
The Public Health Service Act is enacted and covers many health issues, including biologic products and the control of communicable diseases.
1994
The Comprehensive Drug Abuse Prevention and Control Act (also known as the Controlled Substances Act) organizes regulated drugs
1997 (including opiates, cocaine, cannabis, stimulants, depressants, and hallucinogens) into five schedules and imposes restrictions and penalties.
2002 The United States Pharmacopeia and National Formulary become a single standardized publication, the USP-NF.
2003 The Anti-Drug Abuse Act increases sentences and imposes mandatory minimum sentences for those convicted of illegal drug activity based on
the type and quantity of drug involved.
2007
The Childhood Vaccine Act authorizes the FDA to acquire information about patients taking vaccines, to recall biologics, and to recommend civil
2012 penalties if guidelines regarding biologic use were not followed.
The FDA is officially established as an agency of the U.S. Department of Health and Human Services.
The Prescription Drug User Fee Act requires that nongeneric drug and biologic manufacturers pay fees to be used for improvements in the drug
review process.
The Dietary Supplement Health and Education Act requires clear labeling of dietary supplements and gives the FDA the power to remove
supplements that cause a significant public risk.
The FDA Modernization Act reauthorizes the Prescription Drug User Fee Act, representing the largest reform effort of the drug review process
since 1938.
The Best Pharmaceuticals for Children Act improves the safety and efficacy of medicines for children and continues the exclusivity provisions for
pediatric drugs as mandated under the Food and Drug Administration Modernization Act of 1997.
The Medicare Prescription Drug, Improvement, and Modernization Act provides older adults and those with disabilities a prescription drug
benefit and better benefits under Medicare.
The FDA Amendments Act (FDAAA) of 2007 reauthorizes and expands the Prescription Drug User Fee Act, the Modernization Act, the Best
Pharmaceuticals for Children Act, and the Pediatric Research Equity Act.
The FDA Safety and Innovation Act (FDASIA) of 2012 reauthorizes the Prescription Drug User Fee Act. This requires the FDA to implement a
structured benefit-risk framework in the new drug approval process.
Chapter 2 Drug Regulations 17
claims. Due in part to intense lobbying from the dietary Among the first standards used by pharmacists was
supplement industry, the regulation of these products the formulary, or list of pharmaceutical products and drug
remains less stringent than that for prescription or OTC recipes. In the United States, the first comprehensive publi-
drugs. The regulation of herbal products and dietary sup- cation of drug standards, the United States Pharmacopeia
plements is discussed in detail in Chapter 7. (USP), was established in 1820. A pharmacopeia is a medi-
cal reference summarizing standards of drug purity,
In early 2000, the focus of drug regulation turned to strength, and directions for synthesis. From 1852 until 1975,
access. Advocacy groups claimed that the high cost of two major compendia maintained drug standards in the
drugs caused unequal access to adequate healthcare for the United States, the USP and the National Formulary (NF),
poor, the uninsured, the underinsured, and older adults. In which were established by the American Pharmaceutical
2003, the Medicare Prescription Drug, Improvement, and Association (APhA). All drug products were covered in the
Modernization Act was passed. The benefits are adjusted USP, whereas the NF focused on nondrug ingredients. In
periodically. In 2016, the act provided a benefit that pays 1975, the two were merged into a single publication named
75% of prescription drug spending up to the first $3310 the United States Pharmacopeia-National Formulary (USP-
(after a $360 deductible). Those qualifying for the low- NF). The current document consists of more than 300 chap-
income criteria may have their premiums and cost subsi- ters and 4900 drug monographs. The USP-NF is published
dized by the government. Participants pay a maximum annually, with two supplements being issued throughout
out-of-pocket threshold of $7062.50 per year, after which the year. Today, the USP label can be found on many medi-
Medicare will pay 95% of the prescription costs. A brief cations verifying the purity and exact amounts of ingredi-
timeline of major events in U.S. drug regulation is shown in ents found within the container. Drugs marketed in the
Table 2.1. United States must conform to USP-NF standards to avoid
possible charges of adulteration and misbranding. Sample
Drug Standards labels are illustrated in Figure 2.2. The USP also provides a
voluntary program for verifying the label accuracy of
2.3 The standardization of drug purity dietary supplements (see Chapter 7).
and strength is specified by the United States
Pharmacopeia-National Formulary. The U.S. Food and Drug
Administration
Until the 1800s, drugs were prepared from plants that were
available in the natural environment. The strength and 2.4 The regulatory agency responsible for
purity of the products varied considerably because they ensuring that drugs and medical devices are
were entirely dependent on the experience (and integrity) safe and effective is the U.S. Food and Drug
of the druggist preparing the product and the quality of Administration.
the local ingredients. Potency and safety varied from
region to region and, indeed, from batch to batch. Con- The establishment of a regulatory agency for food and
sider the simple analogy of baking. If 100 people across the drugs in the United States began with a single chemist
world were asked to bake a loaf of bread, the final prod- appointed by President Lincoln in 1862. The U.S. Food and
ucts would vary considerably in size, taste, and nutritional Drug Administration (FDA) was established by the PFDA
value. It is likely that no two loaves would be the same. It of 1906 and later expanded to carry out the provisions of
is obvious that a standard recipe must be followed. Simi- the FDCA of 1938. It is one of the oldest drug regulatory
larly, to obtain consistency in the preparation and potency
of drugs, standards (recipes) are needed.
LOT Each mL contains atropine sulfate 400 mcg (0.4 indomethacin® Inactive ingredients: antifoam AF
EXP mg), sodium chloride 9 mg and benzyl alcohol 0.015 emulsion, flavors, purified water,
mL in Water for Injection. pH 3.0-6.5; Sulfuric acid 237 mL sodium hydroxide or hydrochloric
sulfate added, if needed, for pH adjustment. ORAL SUSPENSION acid to adjust pH, sorbitol solution,
Injection, USP and tragacanth. Sorbic acid 0.1%
POISON 25 mg per 5 mL added as preservative.
10 X 20 ,mL Multiple Dose Vials
FOR SC, IM OR IV USE Usual Dose: See package insert. Alcohol 1% USUAL DOSAGE: See accompanying
circular. Keep container tightly
400 mcg/mL Store at controlled room temperature 15°-30°C Rx only closed. Protect from freezing.
SHAKE WELL BEFORE USING
(0.4 mg/mL) (59°-86° F). 237 mL | No. 3376 Store below 30°C (86°F).
Avoid temperatures above
PL PL 50°C (122°F).
Pharmaceuticals Pharmaceuticals 9108705
Practice Label
Practice Label
Caution: Federal law prohibits dispensing without
prescription.
Product Code
2210-43 B-32210 N 00063 37666 2
3
For educational purposes only Lot Exp.
Figure 2.2 Medication with the USP label (left) and without USP label (right). Practice labels “for educational purposes only.”
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