Pharmacology and the Nursing Process - Linda Lane Lilley 1 2

EIGHTH EDITION Organization New to This Edition Additional Teaching/Learning Features Supplemental Resources Acknowledgments We Welcome Your Feedback Introduction Overview of the Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Pharmaceutics Pharmacokinetics Pharmacodynamics Pharmacotherapeutics Pharmacognosy Pharmacoeconomics Toxicology Summary Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Drug Therapy during Pregnancy Drug Therapy during Breastfeeding Considerations for Neonatal and Pediatric Patients Considerations for Older Adult Patients Nursing Process Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Cultural Considerations Legal Considerations Ethical Considerations Nursing Process Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions General Impact of Errors on Patients Medication Errors Issues Contributing to Errors Preventing, Responding to, Reporting, and Documenting Medication Errors: a Nursing Perspective Other Ethical Issues Summary Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Assessment of Learning Needs Related to Drug Therapy Nursing Diagnoses Related to Learning Needs and Drug Therapy Planning: Outcome Identification as Related to Learning Needs and Drug Therapy Implementation Related to Patient Education and Drug Therapy Evaluation of Patient Learning Related to Drug Therapy Summary Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Over-the-Counter Drugs Herbals and Dietary Supplements Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Basic Principles of Genetic Inheritance Discovery, Structure, and Function of DNA Gene Therapy Pharmacogenetics and Pharmacogenomics Application of the Nursing Process as Related to Genetic Principles Summary Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Preparing for Drug Administration Enteral Drugs Parenteral Drugs Topical Drugs Illustration Credits Nursing Process Assessment Nursing Diagnosis Planning Implementation Evaluation Concept Mapping NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview General Anesthetics Drugs for Moderate Sedation Local Anesthetics Neuromuscular Blocking Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Physiology of Sleep Benzodiazepines and Miscellaneous Hypnotic Drugs Barbiturates Over-the-Counter Hypnotics Muscle Relaxants Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Attention Deficit Hyperactivity Disorder Narcolepsy Obesity Migraine Analeptic-Responsive Respiratory Depression Syndromes Drugs for Attention Deficit Hyperactivity Disorder and Narcolepsy Anorexiants Antimigraine Drugs Drugs for Specific Respiratory Depression Syndromes: Analeptics Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Epilepsy Antiepileptic Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Indirect-Acting Dopaminergic Drugs Direct-Acting Dopamine Receptor Agonists NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Anxiety Disorders Affective Disorders Psychotic Disorders NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Opioids Stimulants Depressants Alcohol Nicotine Nursing Process Patient-Centered Care: Patient Teaching Tips Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Vocabulary Text Notation Enhanced Typeface Overview Sympathetic Nervous System Adrenergic Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Alpha Blockers Beta Blockers Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Parasympathetic Nervous System Cholinergic Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Parasympathetic Nervous System Cholinergic-Blocking Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Study Time Learning Styles Use of Applications Mnemonics Flash Cards Anatomy, Physiology, and Pathophysiology Overview Pharmacology Overview Review of Autonomic Neurotransmission Adrenergic Drugs Angiotensin-Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blockers Calcium Channel Blockers Diuretics Vasodilators Miscellaneous Antihypertensive Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Pharmacology Overview Nitrates and Nitrites Beta Blockers Calcium Channel Blockers Miscellaneous Antianginal Drug Summary of Antianginal Pharmacology Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Pharmacology Overview Angiotensin-Converting Enzyme Inhibitors Angiotensin II Receptor Blockers Beta Blockers Aldosterone Antagonists Miscellaneous Heart Failure Drugs B-Type Natriuretic Peptide Phosphodiesterase Inhibitors Cardiac Glycosides Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Dysrhythmias and Normal Cardiac Electrophysiology Antidysrhythmic Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Pharmacology Overview Anticoagulants Antiplatelet Drugs Thrombolytic Drugs Antifibrinolytic Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Lipids and Lipid Abnormalities Atherosclerotic Plaque Formation Cholesterol and Coronary Heart Disease Hyperlipidemias and Treatment Guidelines Hydroxymethylglutaryl–Coenzyme a Reductase (HMG-CoA Reductase) Inhibitors Bile Acid Sequestrants Niacin Fibric Acid Derivatives Miscellaneous Antilipemic Drug Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Pharmacology Overview Carbonic Anhydrase Inhibitors Loop Diuretics Osmotic Diuretics Potassium-Sparing Diuretics Thiazides and Thiazide-Like Diuretics Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Crystalloids Colloids Blood Products Physiology of Electrolyte Balance Potassium Sodium Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Study Groups Chat Rooms and Discussion Groups Endocrine System Pituitary Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Thyroid Function Pathophysiology of Hypothyroidism Pathophysiology of Hyperthyroidism Thyroid Replacement Drugs Antithyroid Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Insulins Oral Antidiabetic Drugs Injectable Antidiabetic Drugs Sodium Glucose Cotransorter Inhibitors (SGLT2 Inhibitors) Glucose-Elevating Drugs NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Adrenal System Adrenal Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Female Sex Hormones Contraceptive Drugs Drugs for Osteoporosis Drugs Related to Pregnancy, Labor, Delivery, and the Postpartum Period NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Male Reproductive System Androgens and Other Drugs Pertaining to Men's Health Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Time Management Practice Questions Overview Antihistamines Decongestants Antitussives Expectorants Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Bronchodilators Nonbronchodilating Respiratory Drugs NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Active Questioning NCLEX® Practice Antibiotics Beta-Lactam Antibiotics Macrolides Ketolides Tetracyclines NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Pathophysiology of Resistant Infections Aminoglycosides Quinolones Miscellaneous Antibiotics Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions General Principles of Virology Overview of Viral Illnesses and Their Treatment Herpes Simplex Virus and Varicella-Zoster Virus Infections Hepatitis Antivirals (Non-HIV) HIV Infection and Aids Drugs Used to Treat HIV Infection Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Pathophysiology of Tuberculosis Antitubercular Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Fungal Infections Antifungal Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Pathophysiology of Malaria Antimalarial Drugs Other Protozoal Infections Antiprotozoal Drugs Helminthic Infections Anthelmintic Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Nonsteroidal Antiinflammatory Drugs Antigout Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Application of Pharmacology and Making Connections Cell Cycle–Specific Antineoplastic Drugs NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Cell-Cycle–Nonspecific Antineoplastic Drugs Miscellaneous Antineoplastics Hormonal Antineoplastics NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Pharmacology Overview NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Immune System Immunosuppressant Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Immunity and Immunization Immunizing Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Studying for Tests Test-Taking Strategies Performance Evaluation Overview Acid-Related Pathophysiology Antacids H2 Receptor Antagonists Proton Pump Inhibitors Miscellaneous Acid-Controlling Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Antidiarrheals Laxatives Drugs for Irritable Bowel Syndrome Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Nausea and Vomiting Antiemetic Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Pharmacology Overview Fat-Soluble Vitamins Water-Soluble Vitamins Minerals NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Erythropoiesis Types of Anemia Erythropoiesis-Stimulating Drugs Iron Folic Acid Other Anemia Drugs Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Enteral Nutrition Parenteral Nutrition NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Future Application Antimicrobials Anesthetic, Antipruritic, and Antipsoriatic Drugs Miscellaneous Dermatologic Drugs Wound Care Drugs Skin Preparation Drugs NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Pharmacology Overview Antiglaucoma Drugs Antimicrobial Drugs Antiinflammatory Drugs Topical Anesthetics Diagnostic Drugs Antiallergic Drugs NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Overview Treatment of Ear Disorders Antibacterial and Antifungal Otic Drugs Earwax Emulsifiers Nursing Process Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 Chapter 21 Chapter 22 Chapter 23 Chapter 24 Chapter 25 Chapter 26 Chapter 27 Chapter 28 Chapter 29 Chapter 30 Chapter 31 Chapter 32 Chapter 33 Chapter 34 Chapter 35 Chapter 36 Chapter 37 Chapter 38 Chapter 39 Chapter 40 Chapter 41 Chapter 42 Chapter 43 Chapter 44 Chapter 45 Chapter 46 Chapter 47 Chapter 48 Chapter 49 Chapter 50 Chapter 51 Chapter 52 Chapter 53 Chapter 54 Chapter 55 Chapter 56 Chapter 57 Chapter 58 Evidence-Based Practice Patient-Centered Care: Cultural Implications Patient-Centered Care: Lifespan Considerations for the Older Adult Patient Patient-Centered Care: Lifespan Considerations for the Pediatric Patient Safety: Herbal Therapies and Dietary Supplements Safety: Laboratory Values Related to Drug Therapy Safety and Quality Improvement: Preventing Medication Errors Teamwork and Collaboration: Legal and Ethical Principles Organization New to This Edition Additional Teaching/Learning Features Supplemental Resources Study Guide Evolve Website For students: For instructors: Pharmacology Online Acknowledgments We Welcome Your Feedback PA R T 1 OUTLINE Learning Strategies 1 The Nursing Process and Drug Therapy 2 Pharmacologic Principles 3 Lifespan Considerations 4 Cultural, Legal, and Ethical Considerations 5 Medication Errors: Preventing and Responding 6 Patient Education and Drug Therapy 7 Over-the-Counter Drugs and Herbal and Dietary Supplements 8 Gene Therapy and Pharmacogenomics 9 Photo Atlas of Drug Administration Introduction 1 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Compliance Implementation or fulfillment of a prescriber's or caregiver's prescribed course of treatment or therapeutic plan by a patient. Use of compliance versus adherence in this textbook is supportive of the terms used in the current listing of NANDA-I nursing diagnoses. (p. 6) Medication error Any preventable adverse drug event involving inappropriate medication use by a patient or health care professional; it may or may not cause the patient harm. (p. 13) Noncompliance An informed decision on the part of the patient not to adhere to or follow a therapeutic plan or suggestion. Use of noncompliance versus nonadherence in this textbook is supportive of the terms used in the current listing of NANDA-I nursing diagnoses. (p. 7) Nursing process An organizational framework for the practice of nursing. It encompasses all steps taken by the nurse in caring for a patient: assessment, nursing diagnoses, planning (with goals and outcome criteria), implementation of the plan (with patient teaching), and evaluation. (p. 4) Outcomes Descriptions of specific patient behaviors or responses that demonstrate meeting of or achievement of behaviors related to each nursing diagnosis. These statements are specific while framed in behavioral terms and are measurable. (p. 5) Prescriber Any health care professional licensed by the appropriate regulatory board to prescribe medications. (p. 7) Overview of the Nursing Process Box 1-1 Assessment Analysis of Data Nursing Diagnoses Box 1-2 Box 1-3 Planning: Outcome Identification Implementation Nine Rights of Medication Administration Right Drug Right Dose Right Time TABLE 1-1 Conversion of Standard Time to Military Time Right Route and Form Right Patient Right Documentation Medication Errors Evaluation Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 2 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Additive effects Drug interactions in which the effect of a combination of two or more drugs with similar actions is equivalent to the sum of the individual effects of the same drugs given alone. For example, 1 + 1 = 2 (compare with synergistic effects). (p. 32) Adverse drug event Any undesirable occurrence related to administering or failing to administer a prescribed medication. (p. 32) Adverse drug reaction Any unexpected, unintended, undesired, or excessive response to a medication given at therapeutic dosages (as opposed to overdose). (p. 32) Adverse effects A general term for any undesirable effects that are a direct response to one or more drugs. (p. 30) Agonist A drug that binds to and stimulates the activity of one or more receptors in the body. (p. 29) Allergic reaction An immunologic hypersensitivity reaction resulting from the unusual sensitivity of a patient to a particular medication; a type of adverse drug event. (p. 32) Antagonist A drug that binds to and inhibits the activity of one or more receptors in the body. Antagonists are also called inhibitors. (p. 29) Antagonistic effects Drug interactions in which the effect of a combination of two or more drugs is less than the sum of the individual effects of the same drugs given alone (1 + 1 equals less than 2); it is usually caused by an antagonizing (blocking or reducing) effect of one drug on another. (p. 32) Bioavailability A measure of the extent of drug absorption for a given drug and route (from 0% to 100%). (p. 21) Biotransformation One or more biochemical reactions involving a parent drug; occurs mainly in the liver and produces a metabolite that is either inactive or active. Also known as metabolism. (p. 25) Blood-brain barrier The barrier system that restricts the passage of various chemicals and microscopic entities (e.g., bacteria, viruses) between the bloodstream and the central nervous system. It still allows for the passage of essential substances such as oxygen. (p. 25) Chemical name The name that describes the chemical composition and molecular structure of a drug. (p. 18) Contraindication Any condition, especially one related to a disease state or patient characteristic, including current or recent drug therapy, which renders a particular form of treatment improper or undesirable. (p. 30) Cytochrome P-450 The general name for a large class of enzymes that play a significant role in drug metabolism and drug interactions. (p. 26) Dependence A state in which there is a compulsive or chronic need, as for a drug. (p. 31) Dissolution The process by which solid forms of drugs disintegrate in the gastrointestinal tract and become soluble before being absorbed into the circulation. (p. 19) Drug Any chemical that affects the physiologic processes of a living organism. (p. 18) Drug actions The processes involved in the interaction between a drug and body cells (e.g., the action of a drug on a receptor protein); also called mechanism of action. (p. 19) Drug classification A method of grouping drugs; may be based on structure or therapeutic use. (p. 19) Drug effects The physiologic reactions of the body to a drug. They can be therapeutic or toxic and describe how the body is affected as a whole by the drug. (p. 28) Drug-induced teratogenesis The development of congenital anomalies or defects in the developing fetus caused by the toxic effects of drugs. (p. 33) Drug interaction Alteration in the pharmacologic or pharmacokinetic activity of a given drug caused by the presence of one or more additional drugs; it is usually related to effects on the enzymes required for metabolism of the involved drugs. (p. 31) Duration of action The length of time the concentration of a drug in the blood or tissues is sufficient to elicit a response. (p. 28) Enzymes Protein molecules that catalyze one or more of a variety of biochemical reactions, including those related to the body's physiologic processes as well as those related to drug metabolism. (p. 29) First-pass effect The initial metabolism in the liver of a drug absorbed from the gastrointestinal tract before the drug reaches systemic circulation through the bloodstream. (p. 21) Generic name The name given to a drug by the United States Adopted Names Council. Also called the nonproprietary name. The generic name is much shorter and simpler than the chemical name and is not protected by trademark. (p. 18) Glucose-6-phosphate dehydrogenase (G6PD) deficiency A hereditary condition in which red blood cells break down when the body is exposed to certain drugs. (p. 33) Half-life In pharmacokinetics, the time required for half of an administered dose of drug to be eliminated by the body, or the time it takes for the blood level of a drug to be reduced by 50% (also called elimination half-life). (p. 27) Idiosyncratic reaction An abnormal and unexpected response to a medication, other than an allergic reaction, that is peculiar to an individual patient. (p. 33) Incompatibility The characteristic that causes two parenteral drugs or solutions to undergo a reaction when mixed or given together that results in the chemical deterioration of at least one of the drugs. (p. 32) Intraarterial Within an artery (e.g., intraarterial injection). (p. 22) Intraarticular Within a joint (e.g., intraarticular injection). (p. 22) Intrathecal Within a sheath (e.g., the theca of the spinal cord, as in an intrathecal injection into the subarachnoid space). (p. 22) Medication error Any preventable adverse drug event (see above) involving inappropriate medication use by a patient or health care professional; it may or may not cause patient harm. (p. 32) Medication use process The prescribing, dispensing, and administering of medications, and the monitoring of their effects. (p. 32) Metabolite A chemical form of a drug that is the product of one or more biochemical (metabolic) reactions involving the parent drug (see later). Active metabolites are those that have pharmacologic activity of their own, even if the parent drug is inactive (see prodrug). Inactive metabolites lack pharmacologic activity and are simply drug waste products awaiting excretion from the body (e.g., via the urinary, gastrointestinal, or respiratory tract). (p. 32) Onset of action The time required for a drug to elicit a therapeutic response after dosing. (p. 28) P-glycoprotein a transporter protein that moves drugs out of cells and into the gut, urine, or bile. (p. 26) Parent drug The chemical form of a drug that is administered before it is metabolized by the body into its active or inactive metabolites (see metabolite). A parent drug that is not pharmacologically active itself is called a prodrug. A prodrug is then metabolized to pharmacologically active metabolites. (p. 20) Peak effect The time required for a drug to reach its maximum therapeutic response in the body. (p. 28) Peak level The maximum concentration of a drug in the body after administration, usually measured in a blood sample for therapeutic drug monitoring. (p. 28) Pharmaceutics The science of preparing and dispensing drugs, including dosage form design. (p. 19) Pharmacodynamics The study of the biochemical and physiologic interactions of drugs at their sites of activity. It examines the physicochemical properties of drugs and their pharmacologic interactions with body receptors. (p. 19) Pharmacoeconomics The study of economic factors impacting the cost of drug therapy. (p. 19) Pharmacogenomics The study of the influence of genetic factors on drug response that result in the absence, overabundance, or insufficiency of drug-metabolizing enzymes (also called pharmacogenomics; see Chapter 8). (p. 33) Pharmacognosy The study of drugs that are obtained from natural plant and animal sources. (p. 19) Pharmacokinetics The study of what happens to a drug from the time it is put into the body until the parent drug and all metabolites have left the body. Pharmacokinetics represent the drug absorption into, distribution and metabolism within, and excretion from the body. (p. 19) Pharmacology The broadest term for the study or science of drugs. (p. 18) Pharmacotherapeutics The treatment of pathologic conditions through the use of drugs. (p. 19) Prodrug An inactive drug dosage form that is converted to an active metabolite by various biochemical reactions once it is inside the body. (p. 26) Receptor A molecular structure within or on the outer surface of a cell. Receptors bind specific substances (e.g., drug molecules), and one or more corresponding cellular effects (drug actions) occur as a result of this drug-receptor interaction. (p. 29) Steady state The physiologic state in which the amount of drug removed via elimination is equal to the amount of drug absorbed with each dose. (p. 28) Substrates Substances (e.g., drugs or natural biochemicals in the body) on which an enzyme acts. (p. 26) Synergistic effects Drug interactions in which the effect of a combination of two or more drugs with similar actions is greater than the sum of the individual effects of the same drugs given alone. For example, 1 + 1 is greater than 2 (compare with additive effects). (p. 32) Therapeutic drug monitoring The process of measuring drug levels to identify a patient's drug exposure and to allow adjustment of dosages with the goals of maximizing therapeutic effects and minimizing toxicity. (p. 28) Therapeutic effect The desired or intended effect of a particular medication. (p. 28) Therapeutic index The ratio between the toxic and therapeutic concentrations of a drug. (p. 30) Tolerance Reduced response to a drug after prolonged use. (p. 31) Toxic The quality of being poisonous (i.e., injurious to health or dangerous to life). (p. 19) Toxicity The condition of producing adverse bodily effects due to poisonous qualities. (p. 28) Toxicology The study of poisons, including toxic drug effects, and applicable treatments. (p. 19) Trade name The commercial name given to a drug product by its manufacturer; also called the proprietary name. (p. 18) Trough level The lowest concentration of drug reached in the body after it falls from its peak level, usually measured in a blood sample for therapeutic drug monitoring. (p. 28) Overview FIGURE 2-1 Chemical structure of the common analgesic ibuprofen and the chemical, generic, and trade names for the drug. FIGURE 2-2 Phases of drug activity. (From McKenry LM, Tessier E, Hogan M: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.) Pharmaceutics TABLE 2-1 Drug Absorption of Various Oral Preparations TABLE 2-2 Dosage Forms Pharmacokinetics Absorption Enteral Route Box 2-1 Sublingual and buccal routes. Parenteral Route TABLE 2-3 Routes of Administration and Related Nursing Considerations NOTE: For more information on avoiding the use of abbreviations associated with dosage routes, dosage amounts, dosage frequency, and drug names, as well as the use of symbols, please visit www.ismp.org. Subcutaneous, intradermal, and intramuscular routes. Topical Route Box 2-2 Transdermal route. Inhaled route. Distribution FIGURE 2-3 Drug transport in the body. GI, Gastrointestinal. (From McKenry LM, Tessier E, Hogan M: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.) FIGURE 2-4 Protein binding of drugs. Albumin is the most prevalent protein in plasma and the most important of the proteins to which drugs bind. Only unbound (free) drug molecules can leave the vascular system. Bound molecules are too large to fit through the pores in the capillary wall. Metabolism TABLE 2-4 Mechanisms of Biotransformation TABLE 2-5 Common Liver Cytochrome P-450 Enzymes and Corresponding Drug Substrates TABLE 2-6 Examples of Conditions and Drugs That Affect Drug Metabolism Drug Metabolism Excretion FIGURE 2-5 Renal drug excretion. The primary processes involved in drug excretion and the approximate location where these processes take place in the kidney are illustrated. GFR, Glomerular filtration rate. Half-Life TABLE 2-7 Example of Drug Half-Life Viewed from Different Perspectives Changing Values Onset, Peak, and Duration FIGURE 2-6 Characteristics of drug effect and relationship to the therapeutic window. (From McKenry LM, Tessier E, Hogan M: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.) Pharmacodynamics Mechanism of Action Receptor Interactions FIGURE 2-7 Drugs act by forming a chemical bond with specific receptor sites, similar to a key and lock. The better the “fit,” the better the response. Drugs with complete attachment and response are called agonists. Drugs that attach but do not elicit a response are called antagonists. TABLE 2-8 Drug-Receptor Interactions Enzyme Interactions Nonselective Interactions Pharmacotherapeutics Acute Therapy Maintenance Therapy Supplemental Therapy Palliative Therapy Supportive Therapy Prophylactic Therapy and Empiric Therapy Monitoring Therapeutic Index Drug Concentration Patient's Condition Tolerance and Dependence Interactions TABLE 2-9 Common Food and Drug Interactions TABLE 2-10 Examples of Drug Interactions and Their Effects on Pharmacokinetics Adverse Drug Events Other Drug Effects Box 2-3 Pharmacognosy Pharmacoeconomics Toxicology TABLE 2-11 Common Poisons and Their Antidotes* *These and other antidotes are discussed throughout this textbook where applicable. Summary Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 3 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Active transport The active (energy-requiring) movement of a substance between different tissues via pumping mechanisms contained within cell membranes. (p. 36) Diffusion The passive movement of a substance (e.g., a drug) between different tissues from areas of higher concentration to areas of lower concentration. (Compare with active transport.) (p. 36) Neonate Pertaining to a person younger than 1 month of age; newborn infant. (p. 36) Older adult Pertaining to a person who is 65 years of age or older. (NOTE: Some sources consider “older adult” to be 55 years of age or older.) (p. 40) Pediatric Pertaining to a person who is 12 years of age or younger. (p. 38) Polypharmacy The use of many different drugs concurrently in treating a patient, who often has several health problems. (p. 40) Overview Drug Therapy during Pregnancy TABLE 3-1 Pregnancy Safety Categories Drug Therapy during Breastfeeding Considerations for Neonatal and Pediatric Patients TABLE 3-2 Classification of Young Patients NOTE: The meaning of the term pediatric may vary with the individual drug and clinical situation. Often the maximum age for a pediatric patient may be identified as 16 years of age. Consult the manufacturer's guidelines for specific dosing information. Physiology and Pharmacokinetics Pharmacodynamics Dosage Calculations for Pediatric Patients Considerations for Older Adult Patients Issues in Clinical Drug Use in the Older Adult Physiologic Changes TABLE 3-3 Physiologic Changes in the Older Adult Patient ↓ ↓ ↑ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ Pharmacokinetics Absorption Distribution Metabolism Excretion Problematic Medications for the Older Adult TABLE 3-4 Medications and Conditions Requiring Special Considerations in the Older Adult Patient Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 4 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Bias Any systematic error in a measurement process. (p. 55) Black box warning A type of warning that appears in a drug's prescribing information and is required by the U.S. Food and Drug Administration (FDA) to alert prescribers of serious adverse events that have occurred with the given drug. (p. 56) Blinded investigational drug study A research design in which the subjects are purposely unaware of whether the substance they are administered is the drug under study or a placebo. This method serves to minimize bias on the part of research subjects in reporting their body's responses to investigational drugs. (p. 55) Controlled substances Any drugs listed on one of the “schedules” of the Controlled Substance Act (also called scheduled drugs). (p. 53) Culture The customary beliefs, social forms, and material traits of a racial, religious, or social group. (p. 50) Double-blind investigational drug study A research design in which both the investigator(s) and the subjects are purposely unaware of whether the substance administered to a given subject is the drug under study or a placebo. This method minimizes bias on the part of both the investigator and the subject. (p. 55) Drug polymorphism Variation in response to a drug because of a patient's age, gender, size, and/or body composition. (p. 51) Ethics The rules of conduct recognized in respect to a particular class or group of human actions. (p. 58) Ethnicity Relating to or characteristic of a human group having racial, religious, language, and other traits in common. (p. 50) Ethnopharmacology The study of the effect of ethnicity on drug responses, specifically drug absorption, metabolism, distribution, and excretion as well as the study of genetic variations to drugs (i.e., pharmacogenetics). (p. 50) Expedited drug approval Acceleration of the usual investigational new drug approval process by the FDA, usually for drugs used to treat life-threatening diseases. (p. 54) Health Insurance Portability and Accountability Act (HIPAA) An act that protects health insurance coverage for workers and their families when they change jobs. It also protects patient information. If confidentiality of a patient is breached, severe fines may be imposed. (p. 53) Informed consent Written permission obtained from a patient consenting to a specific procedure. (p. 55) Investigational new drug (IND) A drug not yet approved for marketing by the FDA but available for use in experiments to determine its safety and efficacy. (p. 55) Investigational new drug application An application that must be submitted to the FDA before a drug can be studied in humans. (p. 55) Legend drugs Another name for prescription drugs. (p. 53) Malpractice A special type of negligence or the failure of a professional and/or individual with specialized education and training to act in a reasonable and prudent way. (p. 57) Narcotic A legal term established under the Harrison Narcotic Act of 1914. The term is currently used in clinical settings to refer to any medically administered controlled substance and in legal settings to refer to any illicit or “street” drug; also referred to as opioid. (p. 53) Negligence The failure to act in a reasonable and prudent manner or failure of the nurse to give the care that a reasonably prudent (cautious) nurse would render or use under similar circumstances. (p. 57) Orphan drugs A special category of drugs that have been identified to help treat patients with rare diseases. (p. 53) Over-the-counter drugs Drugs available to consumers without a prescription. Also called nonprescription drugs. (p. 52) Pharmacogenomics The study of genetics in drug response. (p. 50) Placebo An inactive (inert) substance (e.g., saline, distilled water, starch, sugar) that is not a drug but is formulated to resemble a drug for research purposes. (p. 55) Race Descendants of a common ancestor; a tribe, family, or people believed to belong to the same lineage. (p. 50) Cultural Considerations Influence of Ethnicity and Genetics on Drug Response Cultural Nursing Considerations and Drug Therapy Legal Considerations U.S. Drug and Related Legislation TABLE 4-1 Summary of Major U.S. Drug and Related Legislation AIDS, Acquired immunodeficiency syndrome; FDA, Food and Drug Administration; HIV, human immunodeficiency virus. New Drug Development U.S. Food and Drug Administration Drug Approval Process Preclinical Investigational Drug Studies Four Clinical Phases of Investigational Drug Studies Phase I. Phase II. Phase III. Phase IV. TABLE 4-2 Controlled Substances: Schedule Categories TABLE 4-3 Controlled Substances: Categories, Dispensing Restrictions, and Examples *Legally permitted to be telephoned in for major emergencies only. If telephoned in, written prescription is required within 72 hours. Legal Nursing Considerations and Drug Therapy Box 4-1 Box 4-2 Ethical Considerations Ethical Nursing Considerations and Drug Therapy Nursing Process AssessmenT Box 4-3 Maintaining Health Protecting Health Restoring Health Nursing Diagnoses Planning and Outcome Identification Implementation Evaluation Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 5 Preventing and Responding Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Adverse drug event Any undesirable occurrence related to administration of or failure to administer a prescribed medication. (p. 64) Adverse drug reactions Unexpected, unintended, or excessive responses to medications given at therapeutic dosages (as opposed to overdose); one type of adverse drug event. (p. 64) Allergic reaction An immunologic reaction resulting from an unusual sensitivity of a patient to a certain medication; a type of adverse drug event and a subtype of adverse drug reactions. (p. 64) Idiosyncratic reaction Any abnormal and unexpected response to a medication, other than an allergic reaction, that is peculiar to an individual patient. (p. 64) Medical errors A broad term used to refer to any errors at any point in patient care that cause or have the potential to cause patient harm. (p. 63) Medication errors Any preventable adverse drug events involving inappropriate medication use by a patient or health care professional; they may or may not cause the patient harm. (p. 64) Medication reconciliation A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery. (p. 70) General Impact of Errors on Patients Medication Errors FIGURE 5-1 Diagram illustrating the various classes and subclasses of adverse drug events. ADRs, Adverse drug reactions; AEs, adverse (drug) effects; ARs, allergic reactions; IRs, idiosyncratic reactions. Box 5-1 Issues Contributing to Errors Organizational Issues Box 5-2 Educational System Issues and Their Potential Impact on Medication Errors Medication Errors and Related Sociologic Factors Preventing, Responding to, Reporting, and Documenting Medication Errors: a Nursing Perspective Preventing Medication Errors Responding to, Reporting, and Documenting Medication Errors Medication Reconciliation Other Ethical Issues Notification of Patients Regarding Errors Possible Consequences of Medication Errors for Nurses Summary Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 6 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Affective domain The most intangible domain of the learning process. It involves affective behavior, which is conduct that expresses feelings, needs, beliefs, values, and opinions; the feeling domain. (p. 75) Cognitive domain The domain involved in the learning and storage of basic knowledge. It is the thinking portion of the learning process and incorporates an individual's previous experiences and perceptions; the learning/thinking domain. (p. 75) Health literacy The degree to which individuals have the capacity to obtain and then process and understand basic health information as well as basic health information and services needed to make appropriate health decisions (p. 75) Learning The acquisition of knowledge or skill. (p. 75) Psychomotor domain The domain involved in the learning of a new procedure or skill; often called the doing domain. (p. 75) Teaching A system of directed and deliberate actions intended to induce learning. (p. 75) Overview Assessment of Learning Needs Related to Drug Therapy Box 6-1 Box 6-2 Box 6-3 Nursing Diagnoses Related to Learning Needs and Drug Therapy Planning: Outcome Identification as Related to Learning Needs and Drug Therapy Implementation Related to Patient Education and Drug Therapy Box 6-4 TABLE 6-1 Educational Strategies to Address Common Changes Related to Aging That May Influence Learning Modified from Touhy T, Jett K: Ebersole and Hess gerontological nursing and healthy aging, ed 4, St Louis, 2014, Mosby. Evaluation of Patient Learning Related to Drug Therapy Summary Box 6-5 Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 7 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Alternative medicine Herbal medicine, chiropractic, acupuncture, massage, reflexology, and any other therapies traditionally not emphasized in Western medical schools. (p. 89) Complementary medicine Alternative medicine when used simultaneously with, rather than instead of, standard Western medicine. (p. 89) Conventional medicine The practice of medicine as taught in Western medical schools. (p. 89) Dietary supplement A product that contains an ingredient intended to supplement the diet, including vitamins, minerals, herbs, or other botanicals. (p. 88) Herbal medicine The practice of using herbs to heal. (p. 89) Herbs Plant components including bark, roots, leaves, seeds, flowers, fruit of trees, and extracts of these plants that are valued for their savory, aromatic, or medicinal qualities. (p. 89) Iatrogenic effects Unintentional adverse effects that are caused by the actions of a prescriber, other health care professional, or by a specific treatment. (p. 89) Integrative medicine Simultaneous use of both traditional and alternative medicine. (p. 89) Legend drugs Medications that are not legally available without a prescription from a prescriber; also called prescription drugs). (p. 89) Over-the-counter (OTC) drugs Medications that are legally available without a prescription. (p. 86) Phytochemicals The pharmacologically active ingredients in herbal remedies. (p. 91) Over-the-Counter Drugs Box 7-1 Box 7-2 FIGURE 7-1 Example of an over-the-counter drug label. (From U.S. Food and Drug Administration: The new over- the-counter medicine label: take a look, 2011. Available at www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm133411.htm#.TnP-oVxzZyo.email. Accessed July 7, 2014.) TABLE 7-1 Common Over-the-Counter (OTC) Drugs Herbals and Dietary Supplements History TABLE 7-2 Conventional Medicines Derived from Plants *Includes both over-the-counter and prescription drugs. Consumer Use of Dietary Supplements Safety TABLE 7-3 Selected Herbs and Dietary Supplements and Their Possible Drug Interactions Level of Use Nursing Process Assessment Over-the-Counter Drugs Herbal Products and Dietary Supplements Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 8 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Acquired disease Any disease triggered by external factors and not directly caused by a person's genes (e.g., an infectious disease, noncongenital cardiovascular diseases). (p. 97) Alleles The two or more alternative forms of a gene. (p. 97) Chromosomes Structures in the nuclei of cells that contain threads of deoxyribonucleic acid (DNA), which transmit genetic information, and are associated with ribonucleic acid (RNA) molecules and synthesis of protein molecules. (p. 97) Gene The biologic unit of heredity; a segment of a DNA molecule that contains all of the molecular information required for the synthesis of a biologic product such as an RNA molecule or an amino acid chain (protein molecule). (p. 97) Gene therapy New therapeutic technologies that directly target human genes in the treatment or prevention of illness. (p. 98) Genetic disease Any disorder caused directly by a genetic mechanism. (p. 97) Genetic material DNA or RNA molecules or portions thereof. (p. 97) Genetic polymorphisms (PMs) Variants that occur in the chromosomes of 1% or more of the general population. (p. 99) Genetic predisposition The presence of certain factors in a person's genetic makeup, or genome that increase the individual's likelihood of developing one or more diseases. (p. 97) Genetics The study of the structure, function, and inheritance of genes. (p. 97) Genome The complete set of genetic material of any organism. (p. 98) Genomics The study of the structure and function of the genome, and the way genes and their products work in both health and disease. (p. 98) Genotype The particular alleles present at a given site on the chromosomes that determine a specific genetic trait for that organism (compare phenotype). (p. 97) Heredity The characteristics and qualities that are genetically passed from one generation to the next through reproduction. (p. 97) Human Genome Project (HGP) A scientific project of the U.S. Department of Energy and National Institutes of Health to describe in detail the entire genome of a human being. (p. 98) Inherited disease Genetic disease that results from defective alleles passed from parents to offspring. (p. 97) Nucleic acids Molecules of DNA and RNA in the nucleus of every cell. DNA makes up the chromosomes and encodes the genes. (p. 97) Personalized medicine The use of molecular and genetic characterizations of both the disease process and the patient for the customization of drug therapy. (p. 99) Pharmacogenetics A general term for the study of the genetic basis for variations in the body's response to drugs, with a focus on variations related to a single gene. (p. 99) Pharmacogenomics A branch of pharmacogenetics (see earlier) that involves the survey of the entire genome to detect multigenic (multiple-gene) determinants of drug response. (p. 99) Phenotype The expression in the body of a genetic trait that results from a person's particular genotype (see earlier) for that trait. (p. 97) Recombinant DNA (rDNA) DNA molecules that have been artificially synthesized or modified in a laboratory setting. (p. 98) Overview Basic Principles of Genetic Inheritance Discovery, Structure, and Function of DNA Protein Synthesis Human Genome Project Gene Therapy Background FIGURE 8-1 Gene therapy for adenosine deaminase (ADA) deficiency attempts to correct this immunodeficiency state. The viral vector containing the therapeutic gene is inserted into the patient's lymphocytes. These cells can then make the ADA enzyme. (From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 8, St Louis, 2011, Elsevier.) Current Application Regulatory and Ethical Issues Regarding Gene Therapy Pharmacogenetics and Pharmacogenomics TABLE 8-1 Clinical Applications of Pharmacogenomics CYP2D6, Cytochrome P-450 enzyme subtype 2D6; HER2/neu, human epidermal growth factor receptor 2. Application of the Nursing Process as Related to Genetic Principles Summary Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 9 Preparing for Drug Administration Box 9-1 FIGURE 9-1 Using a computer-controlled drug-dispensing system to remove medication. FIGURE 9-2 Checking the medication against the order on the electronic medication administration record. FIGURE 9-3 The nurse is using a bar-code scanner to identify the patient before medication administration. Always check the patient's identification, using two patient identifiers, and allergies before giving medications. Box 9-2 Enteral Drugs Administering Oral Drugs Oral Medications FIGURE 9-4 Some medications require special assessment before administration, such as taking an apical pulse. FIGURE 9-5 Using a pill-crushing device to crush a tablet. FIGURE 9-6 Enteric-coated tablets and long-acting medications are not to be crushed, broken, or chewed. FIGURE 9-7 Sublingual and Buccal Medications Giving oral medications. FIGURE 9-8 Proper placement of a sublingual tablet. Orally Disintegrating Medications Liquid Medications FIGURE 9-9 A, Liquid medication in a unit-dose package. B, Liquid measured into a medicine cup from a multidose container. C, Liquid medication in an oral-dosing syringe. FIGURE 9-10 Measuring liquid medication at eye level. Oral Medications for Infants and Children FIGURE 9-11 Administering oral liquid medication to an infant. Administering Drugs through a Nasogastric or Gastrostomy Tube FIGURE 9-12 Elevate the head of the bed before administering medications through a nasogastric or other enteric tube. FIGURE 9-13 Medications given through gastric tubes need to be administered separately. Dilute crushed pills in 15 to 30 mL of water before administration. FIGURE 9-14 Pour liquid medication into the syringe, then unclamp the tubing and allow it to flow in by gravity. Administering Rectal Drugs FIGURE 9-15 Lubricate the suppository with a water-soluble lubricant. FIGURE 9-16 Inserting a rectal suppository. Parenteral Drugs Preparing for Parenteral Drug Administration Removing Medications from Ampules FIGURE 9-17 NEVER RECAP A USED NEEDLE! Always dispose of uncapped needles in the appropriate sharps container. See Box 9-1 for Standard Precautions. FIGURE 9-18 An UNUSED needle may need to be recapped before the medication is given to the patient, especially if the needle is fixed to the syringe, as with insulin syringes. The “scoop method” is one way to recap an unused needle safely. Be sure not to touch the needle to the countertop or to the outside of the needle cap. FIGURES 9-19 AND 9-20 There are several types of needlestick prevention syringes. This example (Figure 9-19) has a guard over the unused syringe. After the injection, the nurse pulls the guard up over the needle until it locks into place (Figure 9-20). FIGURE 9-21 The parts of a syringe and hypodermic needle. FIGURE 9-22 Close-up view of the bevel of a needle. FIGURE 9-23 Be sure to choose the correct size and type of syringe for the drug ordered. FIGURE 9-24 Needles come in various gauges and lengths. The larger the gauge number, the smaller the needle. Be sure to choose the correct needle—gauge and length—for the type of injection ordered. FIGURES 9-25 AND 9-26 Some medications come in prefilled sterile medication cartridges. Figures 925 and 9-26 show the Carpuject prefilled cartridge and syringe system. Follow the manufacturer's instructions for assembling prefilled syringes. After use, dispose of the syringe in a sharps container; the cartridge is reusable. Some prefilled syringes come with an air bubble in the syringe; do not expel the bubble before administration. FIGURE 9-27 Ampules containing medications come in various sizes. The neck of the ampule must be broken carefully before the medication is withdrawn. (See Figures 9-30 and 9-31.) FIGURE 9-28 Use a filter needle when withdrawing medication from an ampule. Filter needles help to remove tiny glass particles that may result from the ampule breakage. DO NOT USE A FILTER NEEDLE FOR INJECTION INTO A PATIENT! Some health care institutions may also require the use of a filter needle to withdraw medications from a vial. FIGURE 9-29 Tapping an ampule to move the fluid below the neck. FIGURES 9-30 AND 9-31 FIGURE 9-32 Breaking an ampule. Carefully break the neck of the ampule in a direction away from you and away from others near you. Using a filter needle to withdraw medication from an ampule. Removing Medications from Vials FIGURE 9-33 Comparison of the sharp tip of a needle for injection (above) with the blunt tip of a fill needle (below), which is used to remove fluid from a vial. FIGURE 9-34 Insert air into a vial before withdrawing medication (needleless system shown). FIGURE 9-35 Withdrawing medication from a vial (needleless system shown). FIGURE 9-36 Using a needle and syringe to remove medication from a vial. Injections Overview Needle Insertion Angles for Intramuscular, Subcutaneous, and Intradermal Injections FIGURE 9-37 Box 9-3 Comparison of angles of needle insertion for injections. Air-Lock Technique FIGURE 9-38 Intradermal Injections Air-lock technique for intramuscular injections. FIGURES 9-39 AND 9-40 Intradermal injection. Subcutaneous Injections FIGURE 9-41 Potential sites for subcutaneous injections. FIGURE 9-42 Before giving an injection, cleanse the skin with an alcohol or antiseptic swab using a circular motion. FIGURE 9-43 Giving a subcutaneous injection at a 90-degree angle. FIGURE 9-44 Insulin Syringes When giving a subcutaneous injection in the abdomen, be sure to choose a site at least 2 inches away from the umbilicus. FIGURE 9-45 Insulin syringes are available in 100-unit (A) and 50-unit (B) calibrations. FIGURE 9-46 Examples of prefilled insulin pens for insulin injections. FIGURE 9-47 Mixing two types of insulin in the same syringe. NOTE: The rapid- or short-acting (clear) insulin is always drawn up into the syringe first. Intramuscular Injections Z-Track Method FIGURES 9-48 AND 9-49 Ventrogluteal Site Z-track method for intramuscular injections. FIGURE 9-50 Finding landmarks for a ventrogluteal injection. FIGURES 9-51 AND 9-52 Vastus Lateralis Site Ventrogluteal intramuscular injection. FIGURE 9-53 Vastus lateralis intramuscular injection in a small child. The nurse stabilizes the leg before giving the injection. FIGURES 9-54, 9-55, AND 9-56 Deltoid Site Vastus lateralis intramuscular injection. FIGURES 9-57, 9-58, AND 9-59 Deltoid intramuscular injection. The deltoid site is not considered a primary site for intramuscular injections but is used for immunizations for toddlers, older children, and adults. This site is not used for infants. Preparing Intravenous Medications FIGURE 9-60 Two types of intravenous piggyback medication delivery systems. These intravenous systems must be activated before the drug is administered to the patient. FIGURE 9-61 Activating an intravenous piggyback infusion bag (step 1). FIGURE 9-62 Activating an intravenous piggyback infusion bag (step 2). FIGURE 9-63 Activating an intravenous piggyback infusion bag (step 3). FIGURES 9-64, 9-65, AND 9-66 Adding a medication to an intravenous infusion bag with a needle and syringe. FIGURE 9-67 Note how the intravenous medication is concentrated at the bottom of the bag. Always mix the medication thoroughly before infusing by gently turning the bag end to end. Do not shake the bag. FIGURE 9-68 Label the intravenous infusion bag when medication has been added. Infusions of Intravenous Piggyback Medications FIGURE 9-69 Flush the intravenous piggyback (secondary) tubing by using the backpriming method. Fluid is drained through the tubing into the old intravenous piggyback bag, which is then discarded. The new dose of medication is then attached to the primed secondary tubing. FIGURE 9-70 Infusing an intravenous piggyback medication with a primary gravity infusion. Note how the primary bag is lower than the IVPB. FIGURE 9-71 Infusing an intravenous piggyback medication with the primary infusion on an electronic (smart) infusion pump. FIGURE 9-72 Adding a medication to a volume-controlled administration set. FIGURE 9-73 Instructing the patient on the use of a patient-controlled analgesia pump. FIGURE 9-74 An electronic smart pump. The two components on the right side are a patient-controlled analgesia pump. Intravenous Push Medications Intravenous Push Medications through an Intravenous Lock FIGURE 9-75 Cleanse the port vigorously for 15 seconds before attaching the syringe. FIGURE 9-76 Attaching the syringe to the intravenous lock, using a needleless system. FIGURE 9-77 Slowly inject the intravenous push medication through the intravenous lock; use a watch to time the injection. Intravenous Push Medications through an Existing Infusion FIGURE 9-78 When giving an intravenous push medication through an intravenous line, pinch the tubing just above the injection port. After Injection of Intravenous Push Medications Topical Drugs Administering Eye Medications FIGURE 9-79 Eyedrops Cleanse the eye, washing from the inner to outer canthus, before giving eye medications. FIGURE 9-80 Eye Ointment Insert the eyedrop into the lower conjunctival sac. FIGURE 9-81 Applying eye ointment. Move from the inner to outer canthus, along the border of the conjunctival sac. After Instillation of Eye Medications FIGURE 9-82 Applying gentle pressure against the nasolacrimal duct after giving eye medication. Administering Eardrops FIGURE 9-83 FIGURE 9-84 For adults, pull the pinna up and back. For infants and children younger than 3 years of age, pull the pinna down and back. Administering Inhaled Drugs FIGURE 9-85 A, Metered-dose inhaler (MDI). B, Automated, or breath-activated, MDI. C, Dry powder inhaler that delivers powdered medication. Metered-Dose Inhalers FIGURE 9-86 Using a metered-dose inhaler without a spacer. FIGURE 9-87 Small-Volume Nebulizers Using a spacer device with a metered-dose inhaler. FIGURE 9-88 Adding medication to the nebulizer cup. FIGURE 9-89 Administering a small-volume nebulizer treatment. Administering Medications to the Skin Lotions, Creams, Ointments, and Powders FIGURE 9-90 Use gloves to apply topical skin preparations. FIGURE 9-91 Spread the lotion on the skin with long, smooth, gentle strokes. FIGURE 9-92 Transdermal Patches Measure nitroglycerin ointment carefully before application. FIGURE 9-93 Opening a transdermal patch medication. FIGURE 9-94 Ensure that the edges of the transdermal patch are secure after applying. After Administration of Topical Skin Preparations Administering Nasal Medications FIGURE 9-95 Nasal medications may come in various delivery forms. Nasal Drops FIGURE 9-96 Administering nose drops. Nasal Spray FIGURE 9-97 Before self-administering the nasal spray, the patient needs to occlude the other nostril. After Administration of Nasal Medicines Administering Vaginal Medications FIGURE 9-98 Vaginal suppositories (right) are larger and more oval than rectal suppositories (left). FIGURE 9-99 Vaginal cream and suppository, with applicators. Creams, Foams, or Gels Applied with an Applicator FIGURE 9-100 Administering vaginal cream with an applicator. Suppositories or Vaginal Tablets FIGURE 9-101 Administering a vaginal suppository. Illustration Credits PA R T 2 OUTLINE Learning Strategies 10 Analgesic Drugs 11 General and Local Anesthetics 12 Central Nervous System Depressants and Muscle Relaxants 13 Central Nervous System Stimulants and Related Drugs 14 Antiepileptic Drugs 15 Antiparkinson Drugs 16 Psychotherapeutic Drugs 17 Substance Abuse Nursing Process Assessment Nursing Diagnosis Planning Implementation Evaluation Concept Mapping 10 DRUG PROFILES acetaminophen, p. 158 codeine sulfate, p. 155 fentanyl, p. 155 hydromorphone, p. 155 lidocaine, transdermal, p. 158 meperidine hydrochloride, p. 155 methadone hydrochloride, p. 156 morphine sulfate, p. 156 naloxone hydrochloride, p. 156 naltrexone hydrochloride, p. 157 oxycodone hydrochloride, p. 156 tramadol hydrochloride, p. 158 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Acute pain Pain that is sudden in onset, usually subsides when treated, and typically occurs over less than a 6-week period. (p. 145) Addiction A chronic, neurobiologic disease whose development is influenced by genetic, psychosocial, and environmental factors (same as psychologic dependence). (p. 147) Adjuvant analgesic drugs Drugs that are added for combined therapy with a primary drug and may have additive or independent analgesic properties, or both. (p. 144) Agonist A substance that binds to a receptor and causes a response. (p. 149) Agonists-antagonists Substances that bind to a receptor and cause a partial response that is not as strong as that caused by an agonist (also known as a partial agonist). (p. 149) Analgesic ceiling effect Occurs when a given pain drug no longer effectively controls pain despite the administration of the highest safe dosages. (p. 149) Analgesics Medications that relieve pain without causing loss of consciousness (sometimes referred to as painkillers). (p. 144) Antagonist A drug that binds to a receptor and prevents (blocks) a response. (p. 150) Breakthrough pain Pain that occurs between doses of pain medication. (p. 147) Cancer pain Pain resulting from any of a variety of causes related to cancer and/or the metastasis of cancer. (p. 146) Central pain Pain resulting from any disorder that causes central nervous system damage. (p. 146) Chronic pain Persistent or recurring pain that is often difficult to treat. Includes any pain lasting longer than 3 to 6 months, pain lasting longer than 1 month after healing of an acute injury, or pain that accompanies a nonhealing tissue injury. (p. 145) Deep pain Pain that occurs in tissues below skin level; opposite of superficial pain. (p. 146) Gate theory The most well described theory of pain transmission and pain relief. It uses a gate model to explain how impulses from damaged tissues are sensed in the brain. (p. 146) Narcotics A legal term that originally applied to drugs that produce insensibility or stupor, especially the opioids (e.g., morphine, heroin). Currently used to refer to any medically used controlled substance and to refer to any illicit or “street” drug. (NOTE: This term is falling out of use in favor of opioid.) (p. 149) Neuropathic pain Pain that results from a disturbance of function in a nerve. (p. 146) Nociception Processing of pain signals in the brain that gives rise to the feeling of pain. (p. 144) Nociceptors A subclass of sensory nerves (A and C fibers) that transmit pain signals to the central nervous system from other body parts. (p. 144) Nonopioid analgesics Analgesics that are not classified as opioids. (p. 146) Nonsteroidal antiinflammatory drugs (NSAIDs) A large, chemically diverse group of drugs that are analgesics and also possess antiinflammatory and antipyretic activity. (p. 146) Opioid analgesics Synthetic drugs that bind to opiate receptors to relieve pain. (p. 144) Opioid naïve Describes patients who are receiving opioid analgesics for the first time and who therefore are not accustomed to their effects. (p. 165) Opioid tolerance A normal physiologic condition that results from long-term opioid use, in which larger doses of opioids are required to maintain the same level of analgesia and in which abrupt discontinuation of the drug results in withdrawal symptoms (same as physical dependence). (p. 147) Opioid tolerant The opposite of opioid naïve; describes patients who have been receiving opioid analgesics (legally or otherwise) for a period of time (1 week or longer). (p. 147) Opioid withdrawal The signs and symptoms associated with abstinence from or withdrawal of an opioid analgesic when the body has become physically dependent on the substance. (p. 152) Opioids A class of drugs used to treat pain. This term is often used interchangeably with the term narcotic. (p. 149) Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage. (p. 144) Pain threshold The level of a stimulus that results in the sensation of pain. (p. 144) Pain tolerance The amount of pain a patient can endure without its interfering with normal function. (p. 145) Partial agonist A drug that binds to a receptor and causes a response that is less than that caused by a full agonist (same as agonist-antagonist). (p. 150) Phantom pain Pain experienced in the area of a body part that has been surgically or traumatically removed. (p. 146) Physical dependence A condition in which a patient takes a drug over a period of time and unpleasant physical symptoms (withdrawal symptoms) occur if the drug is stopped abruptly or smaller doses are given. The physical adaptation of the body to the presence of an opioid or other addictive substance. (p. 145) Psychologic dependence A pattern of compulsive use of opioids or any other addictive substance characterized by a continuous craving for the substance and the need to use it for effects other than pain relief (also called addiction). (p. 147) Referred pain Pain occurring in an area away from the organ of origin. (p. 146) Somatic pain Pain that originates from skeletal muscles, ligaments, or joints. (p. 145) Special pain situations The general term for pain control situations that are complex and whose treatment typically involves multiple medications, and nonpharmacologic therapeutic modalities (e.g., massage, chiropractic care, surgery). (p. 166) Superficial pain Pain that originates from the skin or mucous membranes; opposite of deep pain. (p. 146) Synergistic effects Drug interactions in which the effect of a combination of two or more drugs with similar actions is greater than the sum of the individual effects of the same drugs given alone. For example, 1 + 1 is greater than 2. (p. 148) Tolerance The general term for a state in which repetitive exposure to a given drug, over time, induces changes in drug receptors that reduce the drug's effects (same as physical dependence). (p. 145) Vascular pain Pain that results from pathology of the vascular or perivascular tissues. (p. 146) Visceral pain Pain that originates from organs or smooth muscles. (p. 146) World Health Organization (WHO) An international body of health care professionals that studies and responds to health needs and trends worldwide. (p. 149) Overview Box 10-1 FIGURE 10-1 Illustration of the four processes of nociception. (From Jarvis C: Physical examination and health assessment, ed 6, St Louis, 2012, Saunders.) TABLE 10-1 Conditions That Alter Pain Tolerance TABLE 10-2 Acute versus Chronic Pain SNS, Sympathetic nervous system. → → FIGURE 10-2 Gate theory of pain transmission. CNS, Central nervous system. TABLE 10-3 A and C Nerve Fibers Treatment of Pain in Special Situations Box 10-2 Pharmacology Overview Opioid Drugs Chemical Structure TABLE 10-4 Chemical Classification of Opioids Mechanism of Action and Drug Effects TABLE 10-5 Opioid Receptors and Their Characteristics Box 10-3 EQUIANALGESIC DOSES Indications Contraindications Adverse Effects TABLE 10-6 Opioid-Induced Adverse Effects by Body System Toxicity and Management of Overdose TABLE 10-7 Opioid Antagonists (Reversal Drugs) Interactions Laboratory Test Interactions Dosages DOSAGES Selected Analgesic Drugs and Related Drugs *Actiq is not approved for use in patients younger than 16 years of age. FDA, U.S. Food and Drug Administration; HCl, hydrochloride; IM, intramuscular; IV, intravenous; IR, immediate release; MS, morphine sulfate; MSIR, morphine sulfate immediate-release; PCA, patient-controlled analgesia; PO, oral; PR, rectal; subcut, subcutaneous. The maximum recommended daily dose of acetaminophen for a typical adult patient with normal liver function is 3000 mg/24 hr. For hepatically compromised patients, this dosage may be 2000 mg or even lower. If in doubt, check with a pharmacist or prescriber regarding a particular patient. Drug Profiles Opioid Agonists codeine sulfate Pharmacokinetics: Codeine fentanyl Pharmacokinetics: Fentanyl hydromorphone (Dilaudid) Pharmacokinetics: Hydromorphone (Dilaudid) meperidine hydrochloride Pharmacokinetics: Meperedine methadone hydrochloride Pharmacokinetics: Methadone morphine sulfate Pharmacokinetics: Morphine Sulfate oxycodone hydrochloride Pharmacokinetics (Immediate Release): Oxycodone Hydrochloride Opioid Agonists-Antagonists Opioid Antagonists naloxone hydrochloride Pharmacokinetics: Naloxone Hydrochloride naltrexone hydrochloride Pharmacokinetics: Naltrexone Hydrochloride Nonopioid and Miscellaneous Analgesics Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions Drug Profiles acetaminophen Pharmacokinetics: Acetaminophen tramadol hydrochloride Pharmacokinetics: Tramadol lidocaine, transdermal Nursing Process Assessment Nonopioids Opioids Opioid Agonists-Antagonists Opioid Antagonists Nursing Diagnoses Planning: Outcome Identification Implementation Nonopioids Opioids Box 10-4 TABLE 10-8 Opioid Administration Guidelines Opioid Agonists-Antagonists Opioid Antagonists General Considerations TABLE 10-9 Drugs Not Recommended for Treatment of Cancer Pain *DPT is the abbreviation for the trade names Demerol, Phenergan, and Thorazine. CNS, Central nervous system. Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 11 DRUG PROFILES dexmedetomidine, p. 174 ketamine, p. 174 lidocaine, p. 178 nitrous oxide, p. 174 propofol, p. 174 rocuronium, p. 181 sevoflurane, p. 175 succinylcholine, p. 180 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Adjunct anesthetics Drugs used in combination with anesthetic drugs to control the adverse effects of anesthetics or to help maintain the anesthetic state in the patient. (See balanced anesthesia.) (p. 172) Anesthesia The loss of the ability to feel pain resulting from the administration of an anesthetic drug. (p. 172) Anesthetics Drugs that depress the central nervous system (CNS) or peripheral nerves to produce decreased or loss of consciousness, or muscle relaxation. (p. 172) Anesthesia provider A health care professional who is licensed to provide anesthesia. Can be an anesthesiologist (MD), a Certified Registered Nurse Anesthetist (CRNA), or an anesthesia assistant. (p. 172) Balanced anesthesia The practice of using combinations of different drug classes rather than a single drug to produce anesthesia. (p. 172) General anesthesia A drug-induced state in which the CNS nerve impulses are altered to reduce pain and other sensations throughout the entire body. It involves complete loss of consciousness and depression of respiratory drive. (p. 172) Local anesthesia A drug-induced state in which peripheral or spinal nerve impulses are altered to reduce or eliminate pain and other sensations in tissues innervated by these nerves. (p. 172) Malignant hyperthermia A genetically linked major adverse reaction to general anesthesia characterized by a rapid rise in body temperature, as well as tachycardia, tachypnea, and sweating. (p. 174) Moderate sedation A milder form of general anesthesia that causes partial or complete loss of consciousness but does not generally reduce normal respiratory drive (also referred to as conscious sedation). (p. 175) Overton-Meyer theory A theory that describes the relationship between the lipid solubility of anesthetic drugs and their potency. (p. 172) Spinal anesthesia Local anesthesia induced by injection of an anesthetic drug near the spinal cord to anesthetize nerves that are distal to the site of injection (p. 175) Overview General Anesthetics Box 11-1 TABLE 11-1 Parenteral General Anesthetics TABLE 11-2 Inhalational General Anesthetics TABLE 11-3 Adjunctive Anesthetic Drugs Mechanism of Action and Drug Effects TABLE 11-4 Effects of Inhaled and Intravenous General Anesthetics Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions Drug Profiles dexmedetomidine ketamine nitrous oxide propofol sevoflurane Drugs for Moderate Sedation Local Anesthetics Box 11-2 TABLE 11-5 Selected Topical Anesthetics TABLE 11-6 Selected Parenteral Local Anesthetic Drugs* *Other common parenteral anesthetic drugs include bupivacaine (Marcaine, Sensorcaine), chloroprocaine (Nesacaine), etidocaine (Duranest), propoxycaine (Ravocaine), and ropivacaine (Naropin). Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Box 11-3 Toxicity and Management of Overdose Interactions Drug Profiles lidocaine Neuromuscular Blocking Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 11-7 Effects of Ganglionic Blockade by Neuromuscular Blocking Drugs Toxicity and Management of Overdose Box 11-4 Box 11-5 Dosages Selected Neuromuscular Blocking Drugs NMBD, neuromuscular blocking drug. Interactions Box 11-6 Dosages Drug Profiles Box 11-7 Depolarizing Neuromuscular Blocking Drugs succinylcholine Pharmacokinetics: Succinylcholine Nondepolarizing Neuromuscular Blocking Drugs rocuronium Pharmacokinetics: Rocuronium Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Box 11-8 Box 11-9 Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 12 DRUG PROFILES baclofen, p. 197 cyclobenzaprine, p. 197 diazepam, p. 193 eszopiclone, p. 193 midazolam, p. 193 pentobarbital, p. 195 phenobarbital, p. 196 ramelteon, p. 193 temazepam, p. 193 zaleplon, p. 194 zolpidem, p. 194 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Barbiturates A class of drugs used to induce sedation; chemical derivatives of barbituric acid. (p. 194) Benzodiazepines A chemical category of drugs most frequently prescribed as anxiolytic drugs and less frequently as sedative-hypnotic agents. (p. 190) Gamma-aminobutyric acid (GABA) The primary inhibitory neurotransmitter found in the brain. A key compound affected by sedative, anxiolytic, psychotropic, and muscle-relaxing medications. (p. 191) Hypnotics Drugs that, when given at low to moderate dosages, calm or soothe the central nervous system (CNS) without inducing sleep but when given at high dosages cause sleep. (p. 190) Non–rapid eye movement (non-REM) sleep The largest portion of the sleep cycle. It has four stages and precedes REM sleep. (p. 190) Rapid eye movement (REM) sleep One of the stages of the sleep cycle. Some of the characteristics of REM sleep are rapid movement of the eyes, vivid dreams, and irregular breathing. (p. 190) REM interference A drug-induced reduction of REM sleep time. (p. 190) REM rebound Excessive REM sleep following discontinuation of a sleep-altering drug. (p. 190) Sedatives Drugs that have an inhibitory effect on the CNS to the degree that they reduce nervousness, excitability, and irritability without causing sleep. (p. 190) Sedative-hypnotics Drugs that can act in the body either as sedatives or as hypnotics. (p. 190) Sleep A transient, reversible, and periodic state of rest in which there is a decrease in physical activity and consciousness. (p. 190) Sleep architecture The structure of the various elements involved in the sleep cycle, including normal and abnormal patterns of sleep. (p. 190) Therapeutic index The ratio between the toxic and therapeutic concentrations of a drug. If the index is low, the difference between the therapeutic and toxic drug concentrations is small, and use of the drug is more hazardous. (p. 194) Overview Physiology of Sleep TABLE 12-1 Stages of Sleep NOTE: Four to five cycles are completed during normal sleep for adults. NREM sleep constitutes about the first third of the night and REM sleep is more prominent during the last third of the night. REM, Rapid eye movement. Modified from Urden LD, Stacy KM, Lough ME: Priorities in critical care nursing, ed 6, St Louis, 2012, Mosby. Benzodiazepines and Miscellaneous Hypnotic Drugs TABLE 12-2 Sedative-Hypnotic Benzodiazepines and Miscellaneous Drugs *These drugs share many characteristics with the benzodiazepines but are classified as miscellaneous hypnotic drugs. Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose TABLE 12-3 Flumazenil Treatment Regimen NOTE: Flumazenil has a relatively short half-life and a duration of effect of 1 to 4 hours; therefore, if flumazenil is used to reverse the effects of a long-acting benzodiazepine, the dose of the reversal drug may wear off and the patient may become sedated again, requiring more flumazenil. Interactions TABLE 12-4 Benzodiazepines: Drug/Food Interactions Dosages Drug profiles Benzodiazepines diazepam DOSAGES Selected Benzodiazepine and Other Sedative-Hypnotic Drugs *Nonbenzodiazepine drugs. Pharmacokinetics: Diazepam midazolam Pharmacokinetics: Midazolam temazepam Pharmacokinetics: Temazepam Nonbenzodiazepines eszopiclone Pharmacokinetics: Eszopiclone ramelteon Pharmacokinetics: Ramelteon zaleplon Pharmacokinetics: Zaleplon zolpidem Pharmacokinetics: Zolpidem Barbiturates TABLE 12-5 Sedative-Hypnotic Barbiturates Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 12-6 Barbiturates: Adverse Effects Toxicity and Management of Overdose Interactions Dosages DOSAGES Selected Barbiturates Drug profiles TABLE 12-7 Barbiturates: Controlled Substance Schedule pentobarbital Pharmacokinetics: Pentobarbital phenobarbital Pharmacokinetics: Phenobarbital Over-the-Counter Hypnotics Muscle Relaxants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions Dosages DOSAGES Selected Muscle Relaxants Drug profiles baclofen Pharmacokinetics: Baclofen cyclobenzaprine Pharmacokinetics: Cyclobenzaprine Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Box 12-1 Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 13 DRUG PROFILES amphetamines, p. 206 atomoxetine, p. 206 caffeine, p. 212 doxapram, p. 212 methylphenidate, p. 207 modafinil, p. 207 orlistat, p. 208 phentermine, p. 208 sumatriptan, p. 209 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Amphetamines A class of stimulant drugs that includes amphetamine sulfate and all of its drug derivatives. (p. 205) Analeptics Central nervous system stimulants that have effects on the brainstem and spinal cord, which produce an increase in responsiveness to external stimuli and stimulate respiration. (p. 211) Anorexiants Drugs used to control or suppress appetite. (p. 207) Attention deficit hyperactivity disorder (ADHD) A syndrome characterized by difficulty in maintaining concentration on a given task and/or hyperactive behavior; may affect children, adolescents, and adults. The term attention deficit disorder (ADD) has been absorbed under this broader term. (p. 204) Cataplexy A condition characterized by abrupt attacks of muscular weakness and hypotonia triggered by an emotional stimulus such as joy, laughter, anger, fear, or surprise. (p. 204) Central nervous system (CNS) stimulants Drugs that stimulate specific areas of the brain or spinal cord. (p. 204) Ergot alkaloids Drugs that constrict blood vessels in the brain and provide relief of pain for certain migraine headaches. (p. 209) Migraine A common type of recurring painful headache characterized by a pulsatile or throbbing quality, incapacitating pain, and photophobia. (p. 205) Narcolepsy A syndrome characterized by sudden sleep attacks, cataplexy, sleep paralysis, and visual or auditory hallucinations at the onset of sleep. (p. 204) Serotonin receptor agonists A class of CNS stimulants used to treat migraine headaches; they are often referred to as selective serotonin receptor agonists or triptans. (p. 209) Sympathomimetic drugs CNS stimulants such as noradrenergic drugs whose actions resemble or mimic those of the sympathetic nervous system. (p. 204) Overview TABLE 13-1 Structurally Related CNS Stimulants TABLE 13-2 CNS Stimulants: Site of Action TABLE 13-3 CNS Stimulants and Related Drugs: Therapeutic Categories Attention Deficit Hyperactivity Disorder Narcolepsy Obesity Migraine Analeptic-Responsive Respiratory Depression Syndromes Drugs for Attention Deficit Hyperactivity Disorder and Narcolepsy Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions TABLE 13-4 CNS Stimulants: Common Drug Interactions CYP2D6, Cytochrome P-450 enzyme 2D6; MAOIs, monoamine oxidase inhibitors. Dosages Drug Profiles Amphetamines and Related Stimulants amphetamines Pharmacokinetics: Dextroamphetamine atomoxetine Pharmacokinetics: Atomoxetine methylphenidate Pharmacokinetics (Immediate Release): Methylphenidate modafinil Pharmacokinetics: Modafinil *Therapeutic effects. Anorexiants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles phentermine orlistat Pharmacokinetics: Orlistat *Therapeutic effects. Antimigraine Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles Serotonin Receptor Agonists sumatriptan Pharmacokinetics: Sumatriptan DOSAGES Selected CNS Stimulants and Related Drugs Ergot Alkaloids Drugs for Specific Respiratory Depression Syndromes: Analeptics Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles caffeine Pharmacokinetics: Caffeine TABLE 13-5 Caffeine-Containing Beverages and Drugs doxapram Pharmacokinetics: Doxapram Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching General Information Drugs Used to Treat Attention Deficit Hyperactivity Disorder Anorexiants Antimigraine Drugs Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 14 DRUG PROFILES carbamazepine, p. 226 ethosuximide, p. 226 gabapentin, p. 227 lamotrigine, p. 227 levetiracetam, p. 227 oxcarbazepine, p. 226 phenobarbital and phenytoin and pregabalin, p. 227 tiagabine, p. 227 topiramate, p. 228 primidone, p. 224 fosphenytoin, p. 225 valproic acid, p. 228 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Anticonvulsants Substances that prevent or reduce the severity of epileptic or other convulsive seizures. (p. 220) Antiepileptic drugs Prescription drugs that prevent or reduce the severity of epilepsy and different types of epileptic seizures, not just convulsive seizures. (p. 220) Autoinduction A metabolic process in which a drug stimulates the production of enzymes that enhance its own metabolism, which leads to a reduction in drug concentrations. (p. 226) Convulsion A type of seizure involving excessive stimulation of neurons in the brain and characterized by the spasmodic contraction of voluntary muscles. (See also seizure.) (p. 219) Electroencephalogram (EEG) A recording of the electrical activity that arises from spontaneous currents in nerve cells in the brain. (p. 219) Epilepsy A general term for any of a group of neurologic disorders characterized by recurrent episodes of convulsive seizures, sensory disturbances, abnormal behavior, loss of consciousness, or any combination of these. (p. 219) Generalized onset seizures Seizures originating simultaneously in both cerebral hemispheres. (p. 219) Gingival hyperplasia Overgrowth of gum tissue and often a side effect of phenytoin. (p. 225) Partial onset seizures Seizures originating in a more localized region of the brain (also called focal seizures). (p. 219) Primary epilepsy Epilepsy in which there is no identifiable cause. Also known as idiopathic. (p. 219) Seizure Excessive stimulation of neurons in the brain leading to a sudden burst of abnormal neuron activity that results in temporary changes in brain function, primarily affecting sensory and motor activity. (p. 219) Status epilepticus A seizure disorder characterized by generalized tonic-clonic convulsions that occur repeatedly; considered a true medical emergency. (p. 220) Tonic-clonic seizures Seizures involving initial muscular contraction throughout the body (tonic phase), progressing to alternating contraction and relaxation (clonic phase). (p. 219) Epilepsy Box 14-1 Antiepileptic Drugs TABLE 14-1 Currently Available Antiepileptic Drugs Mechanism of Action and Drug Effects Indications TABLE 14-2 Common Seizure Indications for Antiepileptic Drugs TABLE 14-3 Antiepileptic Drugs Used to Treat Status Epilepticus *Off-label use (not a Food and Drug Administration–approved indication), but still used for this purpose. Contraindications Adverse Effects TABLE 14-4 Adverse Effects of Selected Antiepileptic Drugs Interactions TABLE 14-5 Significant Drug Interactions of Antiepileptic Drugs AED, Antiepileptic drug; CYP450, cytochrome P-450; SSRIs, selective serotonin reuptake inhibitors. Dosages TABLE 14-6 Therapeutic Plasma Levels of Antiepileptic Drugs with a Narrow Therapeutic Range Drug Profiles Barbiturates phenobarbital and primidone DOSAGES Selected Antiepileptic Drugs* †One *See PE = 1.5 mg fosphenytoin = 1 mg phenytoin. Therefore, 1.5 mg fosphenytoin is given for each milligram of phenytoin desired. Table 14-3 for doses of drugs used for status epilepticus. AED, Antiepileptic drug; PE, phenytoin equivalent. Pharmacokinetics: Phenobarbital Pharmacokinetics: Primidone *Longer for active metabolites, including phenobarbital Hydantoins phenytoin and fosphenytoin Pharmacokinetics: Phenytoin TABLE 14-7 Comparison of Phenytoin Sodium and Fosphenytoin Sodium *150 mg fosphenytoin sodium = 100 mg phenytoin sodium. PE, Phenytoin sodium equivalents. Iminostilbenes carbamazepine Pharmacokinetics: Carbamazepine oxcarbazepine Pharmacokinetics: Oxcarbazepine Succinimide ethosuximide Pharmacokinetics: Ethosuximide Miscellaneous Drugs gabapentin Pharmacokinetics: Gabapentin lamotrigine Pharmacokinetics: Lamotrigine levetiracetam Pharmacokinetics: Levetiracetam pregabalin Pharmacokinetics: Pregabalin tiagabine Pharmacokinetics: Tiagabine topiramate Pharmacokinetics: Topiramate valproic acid Pharmacokinetics: Valproic Acid zonisamide Pharmacokinetics: Zonisamide Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 15 DRUG PROFILES amantadine, p. 240 benztropine mesylate, p. 243 bromocriptine, p. 242 carbidopa-levodopa, p. 243 entacapone, p. 241 ropinirole, p. 242 rasagiline and selegiline, p. 238 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Adjunctive drugs Drugs that are added as a second drug for combined therapy with a primary drug and may have additive or independent properties. (p. 238) Akinesia Classically defined as “without movement.” Absence or poverty of movement that results in a masklike facial expression and impaired postural reflexes. (p. 237) Bradykinesia Slowness of movement; a classic symptom of Parkinson's disease. (p. 237) Chorea A condition characterized by involuntary, purposeless, rapid motions such as flexing and extending the fingers, raising and lowering the shoulders, or grimacing. (p. 237) Dyskinesia Abnormal involuntary movements; inability to control movements. (p. 237) Dystonia Impaired or distorted voluntary movement, involving the head, neck, or feet. (p. 237) Exogenous A term describing any substance produced outside of the body that may be taken into the body (e.g., a medication, food, or environmental toxin). (p. 242) On-off phenomenon A common experience of patients taking medication for Parkinson's disease in which they experience periods of greater symptomatic control (“on” time) alternating with periods of lesser symptomatic control (“off” time). (p. 237) Parkinson's disease A slowly progressive, degenerative neurologic disorder characterized by resting tremor, pill-rolling of the fingers, masklike facies, shuffling gait, forward flexion of the trunk, loss of postural reflexes, and muscle rigidity and weakness. (p. 236) Postural instability A decrease or change in motor and muscle movements that leads to unsteadiness and hesitation in movement and gait when the individual starts or stops walking, or causes leaning to the left or right when sitting; occurs in Parkinson's disease. (p. 237) Presynaptic Drugs that exert their antiparkinson effects before the nerve synapse. (p. 240) Rigidity Resistance of the muscles to passive movement; leads to the “cogwheel” rigidity seen in Parkinson's disease. (p. 237) TRAP (Tremor, Rigidity, Akinesia, Postural instability); an acronym for symptoms of Parkinson's disease. (p. 237) Tremor In Parkinson's disease, shakiness of the extremities seen mostly at rest. (p. 237) Wearing-off phenomenon A gradual worsening of parkinsonian symptoms as a patient's medications begin to lose their effectiveness, despite maximal dosing with a variety of medications. (p. 237) Pathophysiology of Parkinson's Disease FIGURE 15-1 Basal ganglia and related structures of the brain. (From Copstead-Kirkhorn LC, Banasik JL: Pathophysiology, ed 4, St Louis, 2010, Saunders.) FIGURE 15-2 The neurotransmitter abnormality in Parkinson's disease. TABLE 15-1 Classic Parkinsonian Symptoms Treatment of Parkinson's Disease Pharmacology Overview TABLE 15-2 Review of Pharmacologic Therapy for Parkinson's Disease *Orally disintegrating tablet (see Chapter 2). †See Chapter 21. ‡See Chapter 36. COMT, Catechol ortho-methyltransferase; MAO-B, monoamine oxidase type B. Indirect-Acting Dopaminergic Drugs Monoamine Oxidase Inhibitors Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 15-3 Adverse Effects of Selected Antiparkinson Drugs Interactions Dosages DOSAGES Selected Antiparkinson Drugs Drug Profiles rasagiline and selegiline Pharmacokinetics: Selegiline TABLE 15-4 Selected Drug Interactions of Antiparkinson Drugs COMT, Catechol ortho-methyltransferase; MAO-B, monoamine oxidase type B; MAOI, monoamine oxidase inhibitor. Dopamine Modulator Mechanism of Action and Drug Effects Indications Contraindications Adverse Drug Effects Drug Interactions Dosage Drug Profile amantadine Pharmacokinetics: Amantadine Catechol Ortho-Methyltransferase Inhibitors Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile entacapone Pharmacokinetics: Entacapone Direct-Acting Dopamine Receptor Agonists Nondopamine Dopamine Receptor Agonists Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles bromocriptine Pharmacokinetics Bromocriptine ropinirole Pharmacokinetics: Ropinirole Dopamine Replacement Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Drug Profile carbidopa-levodopa Pharmacokinetics: Carbidopa-Levodopa *Therapeutic effect. Anticholinergic Drugs Drug Profile benztropine mesylate Pharmacokinetics: Benztropine Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 16 DRUG PROFILES alprazolam, p. 253 amitriptyline, p. 258 aripiprazole, p. 266 bupropion, p. 261 buspirone, p. 254 citalopram, p. 262 clozapine, p. 266 diazepam, p. 254 duloxetine, p. 262 fluoxetine, p. 262 haloperidol, p. 265 lithium, p. 255 lorazepam, p. 254 mirtazapine, p. 262 risperidone, p. 267 selegiline transdermal patch, p. 260 trazodone, p. 262 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Affective disorders Emotional disorders that are characterized by changes in mood. (p. 252) Agoraphobia An anxiety disorder that involves an intense fear of being in unfamiliar situations or places. (p. 252) Akathisia A movement disorder in which there is an inability to sit still; motor restlessness. It can occur as an adverse effect of psychotropic medications. (p. 264) Anxiety The unpleasant state of mind in which real or imagined dangers are anticipated and/or exaggerated. (p. 252) Biogenic amine hypothesis A theory suggesting that depression and mania are caused by alterations in the concentrations of dopamine and norepinephrine, and of serotonin and histamine in the brain. (p. 256) Bipolar disorder A psychological disorder characterized by episodes of mania or hypomania, cycling with depression; formerly called manic-depressive illness. (p. 252) Depression An abnormal emotional state characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness. Signs include withdrawal from social contact, loss of appetite, and insomnia. (p. 252) Dopamine hypothesis A theory suggesting that dopamine dysregulation in certain parts of the brain is one of the primary contributing factors to the development of psychotic disorders (psychoses). (p. 252) Dyskinesia Term for abnormal and distressing involuntary movements; inability to control movements. (p. 264) Dysregulation hypothesis A theory that views depression and affective disorders by failure of the brain to regulate the levels of neurotransmitters. (p. 256) Dystonia A syndrome of abnormal muscle contraction that produces repetitive involuntary twisting movements and abnormal posturing of the neck, face, trunk, and extremities; often caused as an adverse reaction to psychotropic medications. (p. 264) Extrapyramidal symptoms The term for signs and symptoms that resemble pathologic changes to the pyramidal portions of the brain. Such symptoms include various motion disorders similar to those seen in Parkinson's disease, and are an adverse effect associated with use of various antipsychotic drugs. (p. 264) Gamma-aminobutyric acid An amino acid in the brain that functions to inhibit nerve transmission in the central nervous system. (p. 251) Hypertensive crisis A term referring to severely elevated blood pressure; can present as hypertensive urgency or hypertensive emergency. (p. 258) Hypomania A less severe and less potentially hazardous form of mania. (p. 252) Mania An acute illness characterized by an expansive emotional state, including extreme excitement, elation, hyperactivity, agitation, talkativeness, flight of ideas, reduced attention span, increased psychomotor activity, impulsivity, insomnia, anorexia, and sometimes violent, destructive, and self-destructive behavior. (p. 252) Metabolic syndrome A cluster of conditions (increased glucose level, increased blood pressure, abnormal cholesterol levels, excess body fat around the waist) occurring together that increases the risk for heart disease, stroke, and diabetes. (p. 264) Neuroleptic malignant syndrome An uncommon but serious adverse effect associated with the use of antipsychotic drugs and characterized by symptoms such as fever, cardiovascular instability, and myoglobinemia (presence in the blood of muscle breakdown proteins). (p. 264) Neurotransmitters Endogenous chemicals in the body that serve to conduct nerve impulses between nerve cells (neurons). (p. 251) Permissive hypothesis A theory postulating that reduced concentrations of serotonin (5-hydroxytriptamine) is the predisposing factor in individuals with affective disorders. (p. 256) Psychosis (Plural: psychoses) A type of serious mental illness that is associated with being out of touch with reality; that is, the individual is unable to distinguish imaginary from real circumstances and events. (p. 252) Psychotherapeutics The treatment of emotional and mental disorders. (p. 252) Psychotropic Capable of affecting mental processes; usually said of a medication. (p. 252) Serotonin syndrome A collection of symptoms resulting from elevated levels of the neurotransmitter serotonin; may occur with the use of any psychotropic drug (e.g., antidepressants, buspirone, tramadol) that enhances brain serotonin activity (see Box 16-1). (p. 261) Tardive dyskinesia A serious drug adverse effect characterized by abnormal and distressing involuntary body movements and muscle tension that is associated with the use of antipsychotic medications. (p. 264) Overview Pharmacology Overview Anxiety Disorders Anxiolytic Drugs TABLE 16-1 Currently Available Anxiolytic Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 16-2 Adverse Effects of Selected Anxiolytic Drugs Toxicity and Management of Overdose Interactions TABLE 16-3 Drug Interactions of Selected Anxiolytic Drugs CNS, Central nervous system; CYP3A4, cytochrome P-450 enzyme 3A4; MAOIs, monoamine oxidase inhibitors; NSAIDs, nonsteroidal antiinflammatory drugs; SSRIs, selective serotonin reuptake inhibitors. Dosages Drug Profiles Benzodiazepines alprazolam DOSAGES Selected Anxiolytic Drugs Pharmacokinetics: Alprazolam diazepam Pharmacokinetics: Diazepam lorazepam Pharmacokinetics: Lorazepam Miscellaneous Drug buspirone Pharmacokinetics: Buspirone Affective Disorders Mood-Stabilizing Drugs TABLE 16-4 Currently Available Mood Stabilizers and Antidepressants Drug Profile lithium Pharmacokinetics (Immediate Release): Lithium Carbonate *Therapeutic benefit for maintenance control of mania. Antidepressant Drugs FIGURE 16-1 Biogenic amine hypothesis. NE, Norepinephrine. FIGURE 16-2 Permissive hypothesis. NE, Norepinephrine; 5-HT, serotonin. Tricyclic Antidepressants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 16-5 Adverse Effects of Selected Mood Stabilizers and Antidepressants Toxicity and Management of Overdose Interactions TABLE 16-6 Drug Interactions of Selected Mood-Stabilizing and Antidepressant Drugs CYP, Cytochrome P-450; MAOIs, monoamine oxidase inhibitors; NSAIDs, nonsteroidal antiinflammatory drugs; SNRIs, serotoninnorepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors. Dosages Drug Profile amitriptyline Pharmacokinetics: Amitriptyline DOSAGES Selected Mood-Stabilizing and Antidepressant Drugs Monoamine Oxidase Inhibitors TABLE 16-7 Food and Drink to Avoid When Taking Monoamine Oxidase Inhibitors Drug Profile selegiline transdermal patch Second-Generation Antidepressants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Box 16-1 Interactions Dosages Drug Profiles bupropion Pharmacokinetics: Bupropion citalopram Pharmacokinetics: Citalopram duloxetine Pharmacokinetics: Duloxetine fluoxetine Pharmacokinetics: Fluoxetine *Active metabolite has a half-life of 7 to 10 days. mirtazapine Pharmacokinetics: Mirtazapine trazodone Pharmacokinetics: Trazodone Psychotic Disorders Antipsychotic Drugs TABLE 16-8 Currently Available Antipsychotic Drugs MAOIs, Monoamine oxidase inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors. Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 16-9 Antipsychotics: Receptor-Related Adverse Effects TABLE 16-10 Adverse Effects of Selected Psychotropic Drugs Interactions TABLE 16-11 Drug Interactions of Selected Antipsychotics CYP3A4, Cytochrome P-450 enzyme 3A4. Dosages Drug Profiles Butyrophenone haloperidol DOSAGES Selected Antipsychotic Drugs Pharmacokinetics: Haloperidol Atypical Antipsychotics aripiprazole Pharmacokinetics: Aripiprazole clozapine Pharmacokinetics: Clozapine risperidone Pharmacokinetics: Risperidone Nursing Process Assessment Anxiolytic Drugs Mood-Stabilizing Drugs Antidepressants Antipsychotics Nursing Diagnoses Planning: Outcome Identification Implementation Anxiolytic Drugs Mood-Stabilizing Drugs Antidepressants Antipsychotics Evaluation Patient-Centered Care: Patient Teaching Anxiolytic Drugs Mood-Stabilizing Drugs Monoamine Oxidase Inhibitors and Tricyclic Antidepressants Selective Serotonin Reuptake Inhibitors and Serotonin-Norepinephrine Reuptake Inhibitors (Antidepressants) Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 17 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Addiction Psychologic or physical dependence on a drug or psychoactive substance. (p. 278) Amphetamine A drug that stimulates the central nervous system. (p. 280) Detoxification A process of eliminating a toxic substance from the body; a medically supervised program for alcohol, benzodiazepine, methamphetamine, or opioid addiction. (p. 279) Enuresis Urinary incontinence. (p. 280) Habituation Development of tolerance to a substance following prolonged medical use but without psychologic or physical dependence (addiction). (p. 278) Illicit drug use The use of a drug or substance in a way that it is not intended to be used or the use of a drug that is not legally approved for human administration. (p. 279) Intoxication Stimulation, excitement, or stupefaction produced by a chemical substance. (p. 278) Korsakoff's psychosis A syndrome of amnesia with confabulation (making up of stories) associated with chronic alcohol abuse; it often occurs together with Wernicke's encephalopathy. (p. 283) Micturition Urination, the desire to urinate, or the frequency of urination. (p. 280) Narcolepsy A sleep disorder characterized by sleeping during the day, disrupted nighttime sleep, cataplexy, sleep paralysis, and hallucinations. (p. 281) Physical dependence A condition characterized by physiologic reliance on a substance, usually indicated by tolerance to the effects of the substance and development of withdrawal symptoms when use of the substance is terminated. (p. 278) Psychoactive properties Drug properties that affect mood, behavior, cognitive processes, and mental status. (p. 280) Psychologic dependence A condition characterized by strong desires to obtain and use a substance. (p. 278) Raves Increasingly popular all-night parties that typically involve dancing, drinking, and the use of various illicit drugs. (p. 280) Roofies Pills that are classified as benzodiazepines. They have recently gained popularity as a recreational drug; chemically known as flunitrazepam. (p. 281) Substance abuse The use of a mood- or behavior-altering substance in a maladaptive manner that often compromises health, safety, and social and occupational functioning, and causes legal problems. (p. 278) Wernicke's encephalopathy A neurologic disorder characterized by apathy, drowsiness, ataxia, nystagmus, and ophthalmoplegia; it is caused by thiamine (vitamin B1) deficiency secondary to chronic alcohol abuse. (p. 283) Withdrawal A substance-specific mental disorder characterized by physical symptoms, following the cessation or reduction in use of a psychoactive substance that has been taken regularly to induce a state of intoxication. (p. 278) Overview Box 17-1 Opioids Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Management of Withdrawal, Toxicity, and Overdose Box 17-2 Box 17-3 Stimulants TABLE 17-1 Various Forms of Amphetamine and Cocaine with Street Names Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Management of Withdrawal, Toxicity, and Overdose Box 17-4 Depressants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Management of Withdrawal, Toxicity, and Overdose Box 17-5 Alcohol Mechanism of Action and Drug Effects Indications Adverse Effects Interactions Management of Withdrawal, Toxicity, and Overdose Box 17-6 TABLE 17-2 Disulfiram Adverse Effects: Acetaldehyde Syndrome Nicotine Mechanism of Action and Drug Effects Indications Adverse Effects Management of Withdrawal, Toxicity, and Overdose TABLE 17-3 Nicotine Withdrawal Therapies Nursing Process Assessment Box 17-7 Nursing Diagnoses Planning: Outcome Identification Implementation Box 17-8 Evaluation Patient-Centered Care: Patient Teaching Tips Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions PA R T 3 OUTLINE Learning Strategies 18 Adrenergic Drugs 19 Adrenergic-Blocking Drugs 20 Cholinergic Drugs 21 Cholinergic-Blocking Drugs Vocabulary Text Notation Pain is most commonly defined as an unpleasant sensory and emotional experience associated with either actual or potential tissue damage. It is a very personal and individual experience. Pain can be defined as whatever the patient says it is, and it exists whenever the patient says it does. Although the mechanisms of pain are becoming better understood, a patient's perception of pain is a complex process. Pain involves physical, psychologic, and even cultural factors. Because pain intensity cannot be precisely quantified, health care providers must cultivate relationships of mutual trust with their patients to provide optimal care. There is no single approach to effective pain management. Instead, pain management is tailored to each patient's needs. The cause of the pain, the existence of concurrent medical conditions; the characteristics of the pain; and the psychologic and cultural characteristics of the patient need to be considered. It also requires ongoing reassessment of the pain and the effectiveness of treatment. The patient's emotional response to pain depends on his or her psychological experiences of pain. Pain results from the stimulation of sensory nerve fibers known as nociceptors. These receptors transmit pain signals from various body regions to the spinal cord and brain, which leads to the sensation of pain, or nociception. The physical impulses that signal pain activate various nerve pathways from the periphery to the spinal cord and to the brain. The level of stimulus needed to produce a painful sensation is referred to as the pain threshold. Because this is a measure of the physiologic response of the nervous system, it is similar for most persons. However, variations in pain sensitivity may result from genetic factors. Enhanced Typeface 18 DRUG PROFILES dobutamine, p. 301 dopamine, p. 301 epinephrine, p. 302 fenoldopam, p. 302 midodrine, p. 302 mirabegron, p. 302 norepinephrine, p. 302 phenylephrine, p. 303 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Adrenergic agonists Drugs that stimulate and mimic the actions of the sympathetic nervous system. Also called sympathomimetics. (p. 296) Adrenergic receptors Receptor sites for the sympathetic neurotransmitters norepinephrine and epinephrine. (p. 296) Alpha-adrenergic receptors A class of adrenergic receptors that are further subdivided into alpha1- and alpha2-adrenergic receptors. (p. 296) Autonomic functions Bodily functions that are involuntary and result from the physiologic activity of the autonomic nervous system. The functions often occur in pairs of opposing actions between the sympathetic and parasympathetic divisions of the autonomic nervous system. (p. 296) Autonomic nervous system A branch of the peripheral nervous system that controls autonomic bodily functions. It consists of the sympathetic nervous system and the parasympathetic nervous system. (p. 296) Beta-adrenergic receptors Receptors located on postsynaptic cells that are stimulated by specific autonomic nerve fibers. Beta1-adrenergic receptors are located primarily in the heart, whereas beta2-adrenergic receptors are located in the smooth muscle fibers of the bronchioles, arterioles, and visceral organs. (p. 296) Catecholamines Substances that can produce a sympathomimetic response. They are either endogenous catecholamines (such as epinephrine, norepinephrine, and dopamine) or synthetic catecholamine drugs (such as dobutamine). (p. 296) Dopaminergic receptor A third type of adrenergic receptor (in addition to alpha-adrenergic and betaadrenergic receptors) located in various tissues and organs and activated by the binding of the neurotransmitter dopamine, which can be either endogenous or a synthetic drug form. (p. 296) Mydriasis Pupillary dilation, whether natural (physiologic) or drug induced. (p. 299) Ophthalmics Drugs that are used in the eye. (p. 299) Positive chronotropic effect An increase in heart rate. (p. 299) Positive dromotropic effect An increase in the conduction of cardiac electrical impulses through the atrioventricular node, which results in the transfer of nerve action potentials from the atria to the ventricles. This ultimately leads to a systolic heartbeat (ventricular contractions). (p. 299) Positive inotropic effect An increase in the force of contraction of the heart muscle (myocardium). (p. 299) Sympathomimetics Drugs used therapeutically that mimic the catecholamines epinephrine, norepinephrine, and dopamine. Also called adrenergic agonists. (p. 296) Synaptic cleft The space either between two adjacent nerve cell membranes or between a nerve cell membrane and an effector organ cell membrane (also called synapse). (p. 297) Overview FIGURE 18-1 Sympathetic nervous system in relation to the entire nervous system. ACh, Acetylcholine; NE, norepinephrine. Sympathetic Nervous System TABLE 18-1 Adrenergic Receptor Responses to Stimulation FIGURE 18-2 Mechanism by which stimulation of a nerve fiber results in a physiologic process; adrenergic drugs mimic this same process. COMT, Catechol ortho-methyltransferase; MAO, monoamine oxidase; NE, norepinephrine. Adrenergic Drugs FIGURE 18-3 FIGURE 18-4 Mechanism of physiologic response to direct-acting sympathomimetics. D, Drug; NE, norepinephrine. Mechanism of physiologic response to indirect-acting sympathomimetics. D, Drug; NE, norepinephrine. FIGURE 18-5 Mechanism of physiologic response to mixed-acting sympathomimetics. D, Drug; NE, norepinephrine. TABLE 18-2 Catecholamines and Their Dose-Response Relationship Mechanism of Action and Drug Effects Indications Respiratory Indications Indications for Topical Nasal Decongestants Ophthalmic Indications Overactive Bladder Indications Cardiovascular Indications Contraindications Adverse Effects Toxicity and Management of Overdose DOSAGES Selected Vasoactive Adrenergics Interactions Laboratory Test Interactions Dosages Drug Profiles Vasoactive Adrenergics dobutamine Pharmacokinetics: Dobutamine dopamine Pharmacokinetics: Dopamine epinephrine Pharmacokinetics: Epinephrine fenoldopam Pharmacokinetics: Fenoldopam midodrine Pharmacokinetics: Midodrine mirabegron Pharmacokinetics: Mirabegron norepinephrine Pharmacokinetics: Norepinephrine phenylephrine Pharmacokinetics: Phenylephrine Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 19 DRUG PROFILES atenolol, p. 314 carvedilol, p. 315 esmolol, p. 315 labetalol, p. 315 metoprolol, p. 315 phentolamine, p. 312 propranolol, p. 315 sotalol, p. 316 tamsulosin, p. 313 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Acrocyanosis Decreased amount of oxygen delivered to the extremities, causing the feet or hands to turn blue. (p. 311) Adrenergic receptors Specific receptor sites located throughout the body for the endogenous sympathetic neurotransmitters norepinephrine and epinephrine. (p. 310) Agonists Drugs with a specific receptor affinity that mimic the body's natural chemicals (e.g., hormones, neurotransmitters). (p. 310) Angina Paroxysmal (sudden) chest pain caused by myocardial ischemia. (p. 313) Antagonists Drugs that bind to specific receptors and inhibit or block the response of the receptors. (p. 310) Dysrhythmias Irregular heart rhythms; generally called arrhythmias in clinical practice. (p. 313) Extravasation The leaking of fluid from a blood vessel into the surrounding tissues, as in the case of an infiltrated intravenous infusion. (p. 311) First-dose phenomenon Severe and sudden drop in blood pressure after the administration of the first dose of an alpha-adrenergic blocker. (p. 311) Intrinsic sympathomimetic activity The paradoxical action of some beta-blocking drugs (e.g., acebutolol) that mimics the action of the sympathetic nervous system. (p. 313) Lipophilicity The chemical attraction of a substance (e.g., drug molecule) to lipid or fat molecules. (p. 314) Orthostatic hypotension A sudden drop in blood pressure when a person stands up. Also referred to as postural hypotension or orthostasis. (p. 311) Pheochromocytoma A vascular adrenal gland tumor that is usually benign but secretes epinephrine and norepinephrine and thus often causes central nervous system stimulation and substantial blood pressure elevation. (p. 311) Raynaud's disease A narrowing of small arteries that limits the amount of blood circulation to the extremities, causing numbness of the nose, fingers, toes, and ears in response to cold temperatures or stress. (p. 311) Sympatholytics Drugs that inhibit the postganglionic functioning of the sympathetic nervous system. (p. 310) Overview Alpha Blockers Mechanism of Action and Drug Effects FIGURE 19-1 Mechanisms for alpha-adrenergic competitive and noncompetitive blockade by alpha blocker drugs. A, Alpha blocker; NE, norepinephrine. TABLE 19-1 Currently Available Adrenergic-Blocking Drugs *Has antagonist activity at alpha1, beta1, and beta2 receptors. Indications Contraindications Adverse Effects TABLE 19-2 Alpha Blockers: Adverse Effects Toxicity and Management of Overdosec Interactions TABLE 19-3 Alpha Blockers: Common Drug Interactions Dosages DOSAGES Selected Alpha-Adrenergic–Blocking Drugs *Not indicated for use in women; however, it is sometimes used for kidney stones. Drug Profiles phentolamine Pharmacokinetics: Phentolamine tamsulosin Pharmacokinetics: Tamsulosin Beta Blockers Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 19-4 Beta Blockers: Common Adverse Effects Toxicity and Management of Overdose Interactions DOSAGES Selected Beta-Adrenergic–Blocking Drugs TABLE 19-5 Beta Blockers: Drug Interactions Dosages Drug Profiles atenolol Pharmacokinetics: Atenolol carvedilol Pharmacokinetics: Carvedilol esmolol Pharmacokinetics: Esmolol labetalol Pharmacokinetics: Labetalol metoprolol Pharmacokinetics: Metoprolol propranolol Pharmacokinetics: Propranolol sotalol Pharmacokinetics: Sotalol Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 20 DRUG PROFILES bethanechol, p. 324 donepezil, p. 325 memantine, p. 325 pyridostigmine, p. 325 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Acetylcholine The neurotransmitter responsible for transmission of nerve impulses to effector cells in the parasympathetic nervous system. (p. 321) Acetylcholinesterase The enzyme responsible for the breakdown of acetylcholine. (p. 322) Alzheimer's disease A disease of the brain that is characterized by progressive mental deterioration manifested by confusion, disorientation, and loss of memory, ability to calculate, and visual-spatial orientation. (p. 323) Atony A lack of normal muscle tone. (p. 323) Cholinergic crisis Severe muscle weakness and respiratory paralysis due to excessive acetylcholine; often seen in patients with myasthenia gravis as an adverse effect of drugs used to treat the disorder. (p. 324) Cholinergic receptor A nerve receptor that is stimulated by acetylcholine. (p. 321) Miosis The contraction of the pupil. (p. 323) Muscarinic receptors Cholinergic receptors that are located postsynaptically in the effector organs such as smooth muscle, cardiac muscle, and glands supplied by parasympathetic fibers. (p. 321) Nicotinic receptors Cholinergic receptors located in the ganglia (where presynaptic and postsynaptic nerve fibers meet) of both the parasympathetic nervous system and the sympathetic nervous system; so named because they can be stimulated by the alkaloid nicotine. (p. 321) Parasympathomimetics Drugs that mimic the parasympathetic nervous system; also referred to as cholinergic agonist drugs. (p. 322) Overview Parasympathetic Nervous System FIGURE 20-1 Parasympathetic and sympathetic nervous systems and their relationship to one another. ACh, Acetylcholine; NE, norepinephrine. FIGURE 20-2 Sympathetic, parasympathetic, and somatic nervous systems. Note the location of the nicotinic and muscarinic receptors in the parasympathetic nervous system. Cholinergic Drugs Box 20-1 Mechanism of Action and Drug Effects TABLE 20-1 Cholinergic Agonists: Drug Effects RESPONSE TO STIMULATION Indications Direct-Acting Drugs Indirect-Acting Drugs Contraindications Adverse Effects TABLE 20-2 Cholinergic Agonists: Adverse Effects Toxicity and Management of Overdose Interactions Dosages Drug Profiles bethanechol DOSAGES Selected Cholinergic Agonist Drugs NMDA, N-methyl-d-aspartate. Pharmacokinetics: Bethanechol donepezil Pharmacokinetics: Donepezil memantine Pharmacokinetics: Memantine pyridostigmine Pharmacokinetics: Pyridostigmine Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 21 DRUG PROFILES atropine, p. 334 dicyclomine, p. 334 glycopyrrolate, p. 334 oxybutynin, p. 334 scopolamine, p. 335 tolterodine, p. 335 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Cholinergic-blocking drugs Drugs that block the action of acetylcholine and substances similar to acetylcholine at receptor sites in the synapse. (p. 331) Mydriasis Dilation of the pupil of the eye caused by contraction of the dilator muscle of the iris. (p. 332) Parasympatholytics Drugs that reduce the activity of the parasympathetic nervous system; also called anticholinergics. (p. 331) Parasympathetic Nervous System Cholinergic-Blocking Drugs Box 21-1 Mechanism of Action and Drug Effects FIGURE 21-1 Site of action of cholinergic blockers in the parasympathetic nervous system. ACh, Acetylcholine. TABLE 21-1 Cholinergic Blockers: Drug Effects Indications Contraindications Adverse Effects TABLE 21-2 Cholinergic Blockers: Adverse Effects Toxicity and Management of Overdose Interactions Dosages Drug Profiles atropine Pharmacokinetics: Atropine dicyclomine DOSAGES Selected Cholinergic Antagonist (Anticholinergic) Drugs ER, Extended release. Pharmacokinetics: Dicyclomine glycopyrrolate Pharmacokinetics: Glycopyrrolate oxybutynin Pharmacokinetics: Oxybutynin scopolamine Pharmacokinetics: Scopolamine tolterodine Pharmacokinetics: Tolterodine Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions PA R T 4 OUTLINE Learning Strategies 22 Antihypertensive Drugs 23 Antianginal Drugs 24 Heart Failure Drugs 25 Antidysrhythmic Drugs 26 Coagulation Modifier Drugs 27 Antilipemic Drugs 28 Diuretic Drugs 29 Fluids and Electrolytes Study Time Learning Styles Use of Applications Mnemonics Flash Cards 22 DRUG PROFILES bosentan, p. 353 captopril, p. 349 carvedilol, p. 347 clonidine, p. 347 doxazosin, p. 347 enalapril, p. 350 eplerenone, p. 353 hydralazine, p. 353 losartan, p. 351 nebivolol, p. 348 sodium nitroprusside, p. 353 treprostinil, p. 353 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Alpha1 blockers Drugs that primarily cause arterial and venous dilation through their action on peripheral sympathetic neurons. (p. 345) Antihypertensive drugs Medications used to treat hypertension. (p. 344) Cardiac output The amount of blood ejected from the left ventricle. (p. 343) Centrally acting adrenergic drugs Drugs that modify the function of the sympathetic nervous system in the brain by stimulating alpha2 receptors. Alpha2 receptors are inhibitory in nature and thus have a reverse sympathetic effect and cause decreased blood pressure. (p. 345) Essential hypertension Elevated systemic arterial pressure for which no cause can be found; also called primary or idiopathic hypertension. (p. 343) Hypertension A common, often asymptomatic disorder in which systolic blood pressure persistently exceeds 150 mm Hg and/or diastolic pressure exceeds 90 mm Hg in patients over 60 years of age and 140/90 for patients younger than 60 and those who have chronic kidney disease or diabetes. (p. 343) Orthostatic hypotension A common adverse effect of adrenergic-blocking drugs involving a sudden drop in blood pressure when a person changes position, especially when rising from a seated or horizontal position. (p. 346) Prodrug A drug that is inactive in its given form and must be metabolized to its active form in the body, generally by the liver, to be effective. (p. 348) Secondary hypertension High blood pressure caused by another disease such as renal, pulmonary, endocrine, or vascular disease. (p. 343) Anatomy, Physiology, and Pathophysiology Overview FIGURE 22-1 Normal regulation of blood pressure and corresponding medications. ACE, Angiotensinconverting enzyme; CNS, central nervous system. Pharmacology Overview Box 22-1 Review of Autonomic Neurotransmission FIGURE 22-2 Location of the nicotinic receptors in the parasympathetic and sympathetic nervous systems. ACh, Acetylcholine; NE, norepinephrine. Adrenergic Drugs Mechanism of Action and Drug Effects FIGURE 22-3 Site and mechanism of action of the various antihypertensive drugs. (Modified from Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 8, St Louis, 2011, Mosby.) Indications Contraindications Adverse Effects Interactions TABLE 22-1 Adrenergic Drugs: Drug Interactions MAOIs, Monoamine oxidase inhibitors; TCAs, tricyclic antidepressants. Dosages Drug Profiles Alpha2-Adrenergic Receptor Stimulators (Agonists) Dosages Selected Antihypertensive Drugs: Adrenergic Agonists and Antagonists clonidine Pharmacokinetics: Clonidine Alpha1 Blockers doxazosin Pharmacokinetics: Doxazosin Dual-Action Alpha1 and Beta Receptor Blockers carvedilol Pharmacokinetics: Carvedilol Beta Receptor Blocker nebivolol Angiotensin-Converting Enzyme (ACE) Inhibitors TABLE 22-2 ACE Inhibitors ACE, Angiotensin-converting enzyme. Mechanism of Action and Drug Effects Indications TABLE 22-3 ACE Inhibitors: Therapeutic Effects ↓ ↓ ↓ ↓, Decreased; SVR, systemic vascular resistance. Contraindications Adverse Effects ↓ ↓ ↓ ↓ Toxicity and Management of Overdose Interactions Dosages DOSAGES Selected Antihypertensive Drugs: ACE Inhibitors and Angiotensin II Receptor Blockers ACE, Angiotensin-converting enzyme. Drug Profiles captopril Pharmacokinetics: Captopril enalapril Pharmacokinetics: Enalapril Angiotensin II Receptor Blockers Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions TABLE 22-4 Angiotensin II Receptor Blockers: Drug Interactions ARB, Angiotensin II receptor blocker. Dosages Drug Profile losartan Pharmacokinetics: Losartan Calcium Channel Blockers Diuretics Vasodilators Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions Dosages DOSAGES Selected Antihypertensive Drugs: Vasodilators DOSAGES Miscellaneous Antihypertensive Drugs MI, Myocardial infarction. Drug Profiles hydralazine Pharmacokinetics: Hydralazine sodium nitroprusside Pharmacokinetics: Sodium Nitroprusside Miscellaneous Antihypertensive Drugs Drug Profiles eplerenone bosentan treprostinil Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Antihypertensives in General Alpha-Adrenergic Agonists Beta Blockers Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 23 DRUG PROFILES amlodipine, p. 370 atenolol, p. 367 diltiazem, p. 369 isosorbide dinitrate, p. 365 isosorbide mononitrate, p. 365 metoprolol, p. 368 nitroglycerin, p. 365 ranolazine, p. 370 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Angina pectoris Chest pain that occurs when the heart's supply of blood carrying oxygen is insufficient to meet the demands of the heart. (p. 363) Atherosclerosis A common form of arteriosclerosis involving deposits of fatty, cholesterol-containing material (plaques) within arterial walls. (p. 363) Chronic stable angina Chest pain that is primarily caused by atherosclerosis, which results in a long-term but relatively stable level of obstruction in one or more coronary arteries. (p. 363) Coronary arteries Arteries that deliver oxygen to the heart muscle. (p. 363) Coronary artery disease (CAD) Any one of the abnormal conditions that can affect the arteries of the heart and produce various pathologic effects, especially a reduced supply of oxygen and nutrients to the myocardium. (p. 363) Ischemia Ischemia is damaged cells/tissue as the result of inadequate oxygen supply. (p. 363) Ischemic heart disease Poor blood supply to the heart via the coronary arteries. (p. 363) Myocardial infarction (MI) Necrosis of the myocardium following interruption of blood supply; it is almost always caused by atherosclerosis of the coronary arteries and is commonly called a heart attack. (p. 363) Reflex tachycardia A rapid heartbeat caused by a variety of autonomic nervous system effects, such as blood pressure changes, fever, or emotional stress. (p. 364) Unstable angina Early stage of progressive coronary artery disease. (p. 363) Vasospastic angina Ischemia-induced myocardial chest pain caused by spasms of the coronary arteries; also referred to as Prinzmetal or variant angina. (p. 363) Overview Pharmacology Overview TABLE 23-1 Antianginal Drugs: Therapeutic Effects ↑↑ ↑ ↑↑↑ ↑↑↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↓↓ ↓ ↑ ↓ ↓↓↓ ↓ ↓ ↓↓ ↓↓↓ ↓↓ ↓ ↓↓ ↓↓ ↓↓ ↑ *In ↓ ↓↓↓ ↓↓↓ particular, those that are cardioselective and do not have intrinsic sympathomimetic activity. †Preload is pressure in the heart caused by blood volume. The nitrates effectively move part of this blood out of the heart and into blood vessels, thereby decreasing preload or filling pressure. ↑, Increase; ↓, decrease; 0, little or no effect. FIGURE 23-1 Benefit of drug therapy for angina through increasing oxygen supply and decreasing oxygen demand. Nitrates and Nitrites Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages DOSAGES Selected Antianginal Nitrate Coronary Vasodilators Drug Profiles isosorbide dinitrate Pharmacokinetics: Isosorbide Dinitrate isosorbide mononitrate Pharmacokinetics: Isosorbide Mononitrate nitroglycerin Pharmacokinetics: Nitroglycerin Beta Blockers Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 23-2 Beta Blockers: Adverse Effects Interactions TABLE 23-3 Beta Blockers: Common Drug Interactions Dosages Drug Profiles DOSAGES Selected Beta1-Adrenergic–Blocking Drugs atenolol Pharmacokinetics: Atenolol metoprolol Pharmacokinetics: Metoprolol Calcium Channel Blockers TABLE 23-4 Classification of Calcium Channel Blockers Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 23-5 Calcium Channel Blockers: Adverse Effects Interactions TABLE 23-6 Calcium Channel Blockers: Common Drug Interactions Dosages DOSAGES Selected Calcium Channel–Blocking Drugs Drug Profiles diltiazem Pharmacokinetics: Diltiazem amlodipine Pharmacokinetics: Amlodipine Miscellaneous Antianginal Drug Drug Profile ranolazine Summary of Antianginal Pharmacology Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Nitroglycerin Isosorbide Dinitrate or Isosorbide Mononitrate Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 24 DRUG PROFILES digoxin, p. 383 digoxin immune Fab, p. 383 dobutamine, p. 380 hydralazine/isosorbide dinitrate, p. 379 lisinopril, p. 379 milrinone, p. 381 nesiritide, p. 380 valsartan, p. 379 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Atrial fibrillation A common cardiac dysrhythmia with atrial contractions that are so rapid they prevent full repolarization of myocardial fibers between heartbeats. (p. 381) Automaticity A property of specialized excitable tissue in the heart that allows self-activation through the spontaneous development of an action potential, such as in the pacemaker cells of the heart. (p. 379) Chronotropic drugs Drugs that influence the rate of the heartbeat. (p. 377) Dromotropic drugs Drugs that influence the conduction of electrical impulses within tissues. (p. 377) Ejection fraction The proportion of blood that is ejected during each ventricular contraction compared with the total ventricular filling volume. (p. 377) Heart failure An abnormal condition in which the heart cannot pump enough blood to keep up with the body's demand. It is often the result of myocardial infarction, ischemic heart disease, or cardiomyopathy. (p. 377) Inotropic drugs Drugs that influence the force of muscular contractions, particularly contraction of the heart muscle. (p. 377) Left ventricular end-diastolic volume The total amount of blood in the ventricle immediately before it contracts, or the preload. (p. 377) Refractory period The period during which a pulse generator (e.g., the sinoatrial node of the heart) is unresponsive to an electrical input signal, and during which it is impossible for the myocardium to respond. This is the period during which the cardiac cell is readjusting its sodium and potassium levels and cannot be depolarized again. (p. 381) Overview Box 24-1 Box 24-2 Pharmacology Overview FIGURE 24-1 Conduction system of the heart. AV, Atrioventricular; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SA, sinoatrial. (Modified from Kinney MR, Packa DR: Andreoli's comprehensive cardiac care, ed 8, St Louis, 1996, Mosby; Lewis SM, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St Louis, 2007, Mosby.) Angiotensin-Converting Enzyme Inhibitors Drug Profile lisinopril Pharmacokinetics: Lisinopril Angiotensin II Receptor Blockers Drug Profile valsartan Pharmacokinetics: Valsartan Beta Blockers Aldosterone Antagonists Miscellaneous Heart Failure Drugs Drug Profiles hydralazine/isosorbide dinitrate dobutamine B-Type Natriuretic Peptide Drug Profile nesiritide Pharmacokinetics: Nesiritide DOSAGES Selected Drugs for Heart Failure Phosphodiesterase Inhibitors Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions Dosages Drug Profile milrinone Pharmacokinetics: Milrinone Cardiac Glycosides Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 24-1 Digoxin: Common Adverse Effects Normal therapeutic level = 0.5 to 2 ng/mL. Toxicity and Management of Overdose TABLE 24-2 Conditions Predisposing to Digitalis Toxicity Interactions TABLE 24-3 Digoxin: Drug Interactions Dosages Drug Profiles digoxin Pharmacokinetics: Digoxin digoxin immune Fab Pharmacokinetics: Digoxin Immune Fab Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 25 DRUG PROFILES adenosine, p. 405 amiodarone, p. 403 atenolol, p. 402 diltiazem, p. 405 dofetilide, p. 404 esmolol, p. 402 flecainide, p. 401 ibutilide, p. 404 lidocaine, p. 401 metoprolol, p. 403 procainamide, p. 400 propafenone, p. 402 quinidine, p. 401 sotalol, p. 404 verapamil, p. 405 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Action potential Electrical activity that consists of a series of polarizations and depolarizations that travel across the cell membrane of a nerve fiber during transmission of a nerve impulse and across the cell membranes of a muscle cell during contraction. (p. 392) Action potential duration The interval beginning with baseline (resting) membrane potential followed by depolarization and ending with repolarization to baseline membrane potential. (p. 393) Arrhythmia Technically “no rhythm,” meaning absence of heart rhythm (i.e., no heartbeat at all). More commonly used in clinical practice to refer to any variation from the normal rhythm of the heart. A synonymous term is dysrhythmia, which is the primary term used in this textbook. (p. 391) Cardiac Arrhythmia Suppression Trial (CAST) A major research study conducted to investigate the possibility of eliminating sudden cardiac death in patients with asymptomatic ectopy after a myocardial infarction. (p. 401) Depolarization The movement of positive and negative ions on either side of a cell membrane across the membrane in a direction that brings the net charge to zero. (p. 392) Dysrhythmia Any disturbance or abnormality in heart rhythm. (p. 391) Effective refractory period The period after the firing of an impulse during which a cell may respond to a stimulus but the response will not be passed along or continued as another impulse. (p. 393) Internodal pathways (Bachmann bundle) Special pathways in the atria that carry electrical impulses generated by the sinoatrial node. These impulses cause the heart to beat. (p. 393) Relative refractory period The time after generation of an action potential during which a nerve fiber will show a (reduced) response only to a strong stimulus. (p. 393) Resting membrane potential (RMP) The voltage that exists when the cell membranes of heart muscle (or other muscle or nerve cells) are at rest. (p. 391) Sodium-potassium adenosine triphosphatase (ATPase) pump A mechanism for transporting sodium and potassium ions across the cell membrane against an opposing concentration gradient. Energy for this transport is obtained from the hydrolysis of adenosine triphosphate (ATP) by means of the enzyme ATPase. (p. 391) Sudden cardiac death Unexpected, fatal cardiac arrest. (p. 402) Threshold potential The critical state of electrical tension required for spontaneous depolarization of a cell membrane. (p. 393) Torsades de pointes A rare ventricular arrhythmia that is associated with long QT interval and can degenerate into ventricular fibrillation and sudden death without medical intervention; often simply referred to as torsades. (p. 396) Vaughan Williams classification The system most commonly used to classify antidysrhythmic drugs. (p. 396) Dysrhythmias and Normal Cardiac Electrophysiology FIGURE 25-1 Phases of the action potential of a cardiac cell. In resting phase (4), the cell membrane is polarized. The cell's interior has a net negative charge, and the membrane is more permeable to potassium ions (K) than to sodium ions (Na). When the cell is stimulated and begins to depolarize (0), sodium ions enter the cell, potassium leaves the cell, calcium (Ca) channels open, and sodium channels close. In its depolarized phase (1), the cell's interior has a net positive charge. In the plateau phase (2), calcium and other positive ions enter the cell and potassium permeability declines, which lengthens the action potential. Then (3), calcium channels close and sodium is pulled from the cell by the sodiumpotassium pump. The cell's interior then returns to its polarized, negatively charged state (4). (From Monahan FD: Phipps' medical-surgical nursing: health and illness perspectives, ed 8, St Louis, 2007, Mosby.) FIGURE 25-2 Action potentials. RMP, Resting membrane potential; SA, sinoatrial; TP, threshold potential. FIGURE 25-3 Purkinje fiber action potential. FIGURE 25-4 Aspects of an action potential. APD, Action potential duration; ERP, effective refractory period; RRP, relative refractory period. TABLE 25-1 Comparison of Action Potentials in Different Cardiac Tissue AV, Atrioventricular; SA, sinoatrial. Electrocardiography FIGURE 25-5 The waves and intervals of a normal electrocardiogram. (From Goldberger AL: Clinical electrocardiography: a simplified approach, ed 7, St Louis, 2006, Mosby.) Common Dysrhythmias TABLE 25-2 Common Dysrhythmias ECG, Electrocardiogram. Antidysrhythmic Drugs TABLE 25-3 Vaughan Williams Classification of Antidysrhythmic Drugs ↑ ↑ ↑↑↑ ↑ ↑ *Sotalol also has class II properties. ↑, Increase; ±, increase or decrease. Mechanism of Action and Drug Effects TABLE 25-4 Antidysrhythmic Drugs: Mechanisms of Action VAUGHAN WILLIAMS CLASS Box 25-1 Indications TABLE 25-5 Antidysrhythmic Drugs: Indications *Sotalol also has class II properties. Contraindications Adverse Effects TABLE 25-6 Antidysrhythmic Drugs: Common Adverse Effects *Sotalol also has class II properties. AV, Atroventricular; SA, sinoatrial; SLE systemic lupus erythematosus. Toxicity and Management of Overdose Interactions TABLE 25-7 Selected Antidysrhythmic Drugs: Common Drug Interactions *Note that enhanced activity of any antidysrhythmic drug may reach the level of drug toxicity, including potentially fatal cardiac dysrhythmias. †Sotalol also has class II properties. AV, Atrioventricular; HMG-CoA, hydroxymethylglutaryl-coenzyme A; INR, international normalized ratio. Dosages Drug Profiles Class Ia Drugs procainamide DOSAGES Selected Antidysrhythmic Drugs *Sotalol also has class II properties. Pharmacokinetics: Procainamide Box 25-2 quinidine Pharmacokinetics: Quinidine Class Ib Drugs lidocaine Pharmacokinetics: Lidocaine Class Ic Drugs flecainide Pharmacokinetics: Flecainide propafenone Pharmacokinetics: Propafenone Class II Drugs atenolol Pharmacokinetics: Atenolol esmolol Pharmacokinetics: Esmolol metoprolol Pharmacokinetics: Metoprolol Class III Drugs amiodarone Pharmacokinetics: Amiodarone TABLE 25-8 Recommendations for Oral Dosage After Intravenous Infusion of Amiodarone ibutilide Pharmacokinetics: Ibutilide dofetilide Pharmacokinetics: Dofetilide sotalol Pharmacokinetics: Sotalol Class IV Drugs diltiazem Pharmacokinetics: Diltiazem verapamil Pharmacokinetics: Verapamil Unclassified Antidysrhythmic adenosine Pharmacokinetics: Adenosine Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 26 DRUG PROFILES alteplase, p. 424 aminocaproic acid, p. 426 argatroban, p. 417 aspirin, p. 422 clopidogrel, p. 423 dabigatran, p. 417 desmopressin, p. 426 enoxaparin, p. 418 eptifibatide, p. 423 fondaparinux, p. 418 heparin, p. 419 rivaroxaban, p. 419 warfarin, p. 419 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Anticoagulants Substances that prevent or delay coagulation of the blood. (p. 414) Antifibrinolytic drugs Drugs that prevent the lysis of fibrin and in doing so promote clot formation. (p. 414) Antiplatelet drugs Substances that prevent platelet plugs from forming. (p. 414) Antithrombin III A substance that inactivates (“turns off”) three major activating factors of the clotting cascade: activated factor II (thrombin), activated factor X, and activated factor IX. (p. 414) Clot Insoluble solid elements of blood (e.g., cells, fibrin threads) that have chemically separated from the liquid (plasma) component of the blood. (p. 412) Coagulation The process of blood clotting. More specifically, the sequential process by which the multiple coagulation factors of the blood interact in the coagulation cascade, ultimately forming an insoluble fibrin clot. (p. 412) Coagulation cascade The series of steps beginning with the intrinsic or extrinsic pathways of coagulation and proceeding through the formation of a fibrin clot. (p. 412) Deep vein thrombosis (DVT) The formation of a thrombus in one of the deep veins of the body. The deep veins most commonly affected are the iliac and femoral veins. (p. 414) Embolus A blood clot (thrombus) that has been dislodged from the wall of a blood vessel and is traveling throughout the bloodstream. Emboli that lodge in critical blood vessels can result in ischemic injury to a vital organ (e.g., heart, lung, brain) and result in disability or death. (p. 412) Enzyme A protein molecule that catalyzes chemical reactions of other substances without being altered or destroyed in the process. (p. 417) Fibrin A stringy, insoluble protein produced by the action of thrombin on fibrinogen during the clotting process; a major component of blood clots or thrombi (see thrombus). (p. 412) Fibrin specificity The property of some thrombolytic drugs of activating the conversion of plasminogen to plasmin only in the presence of established clots having fibrin threads rather than inducing systemic plasminogen activation throughout the body. (p. 424) Fibrinogen A plasma protein that is converted into fibrin by thrombin in the presence of calcium ions. (p. 420) Fibrinolysis The continual process of fibrin decomposition produced by the actions of the enzymatic protein fibrinolysin. It is the normal mechanism for removing small fibrin clots and is stimulated by anoxia, inflammatory reactions, and other kinds of stress. (p. 412) Fibrinolytic system An area of the circulatory system undergoing fibrinolysis. (p. 412) Hemophilia A rare, inherited blood disorder in which the blood does not clot normally. (p. 413) Hemorheologic drugs Drugs that alter the function of platelets without compromising their blood-clotting properties. (p. 414) Hemostasis The arrest of bleeding, either by the physiologic properties of vasoconstriction and coagulation or by mechanical, surgical, or pharmacologic means. (p. 412) Hemostatic Referring to any procedure, device, or substance that arrests the flow of blood. (p. 414) Plasmin The enzymatic protein that breaks down fibrin into fibrin degradation products; it is derived from plasminogen. (p. 412) Plasminogen A plasma protein that is converted to plasmin. (p. 412) Pulmonary embolism The blockage of a pulmonary artery by foreign matter such as fat, air, a tumor, or a thrombus (which usually arises from a peripheral vein). (p. 414) Stroke Occlusion of the blood vessels of the brain by an embolus, thrombus, or cerebrovascular hemorrhage, resulting in ischemia of the brain tissue. (p. 414) Thromboembolic events Events in which a blood vessel is blocked by an embolus carried in the bloodstream from the site of its formation. The tissue supplied by an obstructed artery may tingle and become cold, numb, cyanotic, and eventually necrotic (dead). (p. 414) Thrombolytic drugs Drugs that dissolve thrombi by functioning similarly to tissue plasminogen activator. (p. 414) Thrombus The technical term for a blood clot (plural: thrombi); an aggregation of platelets, fibrin, clotting factors, and the cellular elements of the blood that is attached to the interior wall of a vein or artery, sometimes occluding the vessel lumen. (p. 412) Tissue plasminogen activator A naturally occurring plasminogen activator secreted by vascular endothelial cells in the walls of blood vessels. Thrombolytic drugs are based on this blood component. (p. 412) Overview FIGURE 26-1 Coagulation pathway and factors: extrinsic pathway. Plt, Platelets. FIGURE 26-2 Coagulation pathway and factors: intrinsic pathway. HMW-K, High–molecular-weight kininogen; Plt, platelets. FIGURE 26-3 The fibrinolytic system. Pharmacology Overview TABLE 26-1 Coagulation Modifiers: Comparison of Drug Subclasses Anticoagulants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 26-2 Anticoagulants: Common Adverse Effects Toxicity and Management of Overdose Interactions TABLE 26-3 Anticoagulants: Drug Interactions HMG-CoA, Hydroxymethylglutaryl–coenzyme A; INR, international normalized ratio; NSAIDs, nonsteroidal antiinflammatory drugs. Dosages Drug Profiles argatroban Pharmacokinetics: Argatroban dabigatran Pharmacokinetics: Dabigatran enoxaparin Pharmacokinetics: Enoxaparin DOSAGES Selected Anticoagulant Drugs aPTT, Activated partial thromboplastin time; DIC, disseminated intravascular coagulation; DVT, deep vein thrombosis; HIT, heparininduced thrombocytopenia; INR, international normalized ratio; LMWH, low–molecular-weight heparin; MI, myocardial infarction; PCI, percutaneous coronary intervention; PE, pulmonary embolism. fondaparinux Pharmacokinetics: Fondaparinux heparin Pharmacokinetics: Heparin rivaroxaban Pharmacokinetics: Rivaroxaban warfarin Pharmacokinetics: Warfarin Antiplatelet Drugs FIGURE 26-4 Relationship between platelets and the clotting cascade. ADP, Adenosine diphosphate; 5HT, serotonin; PF4, platelet factor IV; TXA2, thromboxane A2. Mechanism of Action and Drug Effects FIGURE 26-5 Cyclooxygenase pathway. PG, Prostaglandin; TX, thromboxane; TXA2, thromboxane A2. Indications Contraindications Adverse Effects TABLE 26-4 Selected Antiplatelet Drugs: Adverse Effects Interactions DOSAGES Selected Antiplatelet Drugs *See table in package insert for specific dose. ADP, Adenosine diphosphate; GP, glycoprotein; MI, myocardial infarction; TIA, transient ischemic attack. Dosages Drug Profiles aspirin Pharmacokinetics: Aspirin clopidogrel Pharmacokinetics: Clopidogrel eptifibatide Pharmacokinetics: Eptifibatide Thrombolytic Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose DOSAGES Selected Thrombolytic Drugs Interactions Dosages Drug Profile alteplase Pharmacokinetics: Alteplase Antifibrinolytic Drugs Mechanism of Action and Drug Effects TABLE 26-5 Antifibrinolytics: Mechanisms of Action Indications Contraindications Adverse Effects TABLE 26-6 Antifibrinolytics: Adverse Effects Interactions Dosages Drug Profiles aminocaproic acid DOSAGES Selected Antifibrinolytic Drugs Pharmacokinetics: Aminocaproic Acid desmopressin Pharmacokinetics: Desmopressin Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Box 26-1 Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 27 DRUG PROFILES atorvastatin, p. 442 cholestyramine, p. 443 ezetimibe, p. 445 gemfibrozil, p. 445 niacin, p. 444 simvastatin, p. 442 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Antilipemic drugs Drugs that reduce lipid levels. (p. 437) Apolipoproteins The protein components of lipoproteins. (p. 437) Cholesterol A fat-soluble steroid found in animal fats, oils, and egg yolk and widely distributed in the body, especially in the bile, blood, brain tissue, liver, kidneys, adrenal glands, and myelin sheaths of nerve fibers. (p. 437) Chylomicrons Microscopic droplets made up of fat and protein that are produced by cells in the small intestine and released into the bloodstream. Their main purpose is to carry fats to the tissues throughout the body, primarily the liver. Chylomicrons consist of about 90% triglycerides and small amounts of cholesterol, phospholipids, and proteins. (p. 437) Exogenous lipids Lipids originating outside the body or an organ (e.g., dietary fats). (p. 437) Foam cells The characteristic initial lesion of atherosclerosis, also known as a fatty streak. (p. 438) Hydroxymethylglutaryl–coenzyme A (HMG-CoA) reductase inhibitors A class of cholesterol-lowering drugs that work by inhibiting the rate-limiting step in cholesterol synthesis; also commonly referred to as statins. (p. 440) Hypercholesterolemia A condition in which higher than normal amounts of cholesterol are present in the blood. High levels of cholesterol and other lipids may lead to the development of atherosclerosis and serious illnesses such as coronary heart disease. (p. 438) Lipoprotein A conjugated protein synthesized in the liver that contains varying amounts of triglycerides, cholesterol, phospholipids, and protein; classified according to its composition and density. (p. 437) Statins A class of cholesterol-lowering drugs that are more formally known as HMG-CoA reductase inhibitors. (p. 440) Triglycerides Compounds that consist of fatty acids and a type of alcohol known as glycerol. Triglycerides make up most animal and vegetable fats and are the principal lipids in the blood, where they circulate bound to a protein, forming high-density and low-density lipoproteins (HDLs and LDLs). (p. 437) Overview Lipids and Lipid Abnormalities Primary Forms of Lipids TABLE 27-1 Lipoprotein Classification Cholesterol Homeostasis FIGURE 27-1 Cholesterol homeostasis. CE, Cholesterol ester; HDL, high-density lipoprotein; HMG-CoA, hydroxymethylglutaryl–coenzyme A; IDL, intermediate-density lipoprotein; LCAT, lecithin cholesterol acetyltransferase; LDL, low-density lipoprotein; TG, triglyceride; VLDL, very–low-density lipoprotein. Atherosclerotic Plaque Formation Cholesterol and Coronary Heart Disease Hyperlipidemias and Treatment Guidelines Box 27-1 TABLE 27-2 Types of Hyperlipidemia LIPID COMPOSITION , Approximately equal to; IDL, intermediate-density lipoprotein; LDL, low-density lipoprotein; VLDL, very–low-density lipoprotein. Box 27-2 Hydroxymethylglutaryl–Coenzyme a Reductase (HMG-CoA Reductase) Inhibitors TABLE 27-3 Intensity of Statin Therapy Data from Stone NJ, Robinson JG, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 63(25 Pt B):2889-2934, 2014. Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 27-4 HMG-CoA Reductase Inhibitors: Adverse Effects Toxicity and Management of Overdose Interactions TABLE 27-5 HMG-CoA Reductase Inhibitors: Drug Interactions Laboratory Test Interactions Dosages DOSAGES Selected Antilipemic Drugs Drug Profiles atorvastatin Pharmacokinetics: Atorvastatin simvastatin Pharmacokinetics: Simvastatin Bile Acid Sequestrants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 27-6 Bile Acid Sequestrants: Adverse Effects Toxicity and Management of Overdose Interactions Dosages Drug Profile cholestyramine Niacin Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 27-7 Niacin (Nicotinic Acid): Adverse Effects Interactions Dosages Drug Profile niacin Pharmacokinetics: Niacin Fibric Acid Derivatives Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 27-8 Fibric Acid Derivatives: Adverse Effects Toxicity and Management of Overdose Interactions Dosages Drug Profiles gemfibrozil Pharmacokinetics: Gemfibrozil Miscellaneous Antilipemic Drug Cholesterol Absorption Inhibitor ezetimibe Pharmacokinetics: Ezetimibe Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation *The values in this table are from the National Cholesterol Education Program of the National Institutes of Health. Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 28 DRUG PROFILES acetazolamide, p. 453 furosemide, p. 455 hydrochlorothiazide, p. 458 mannitol, p. 456 metolazone, p. 459 spironolactone, p. 457 triamterene, p. 457 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Afferent arterioles The small blood vessels approaching the glomerulus (proximal part of the nephron). (p. 452) Aldosterone A mineralocorticoid steroid hormone produced by the adrenal cortex that regulates sodium and water balance. (p. 452) Ascites Intraperitoneal accumulation of fluid (defined as a volume of 500 mL or more) containing large amounts of protein and electrolytes. (p. 455) Collecting duct The most distal part of the nephron between the distal convoluted tubule and the ureters, which lead to the urinary bladder. (p. 452) Distal convoluted tubule The part of the nephron immediately distal to the ascending loop of Henle and proximal to the collecting duct. (p. 452) Diuretics Drugs or other substances that promote the formation and excretion of urine. (p. 452) Efferent arterioles The small blood vessels exiting the glomerulus. At this point blood has completed its filtration in the glomerulus. (p. 452) Filtrate The material that passes through a filter. In the kidney, the filter is the glomerulus and the filtrate is the material extracted from the blood (normally liquid) that becomes urine. (p. 452) Glomerular capsule The open, rounded, and most proximal part of the proximal convoluted tubule that surrounds the glomerulus and receives the filtrate from the blood. (p. 452) Glomerular filtration rate (GFR) An estimate of the volume of blood that passes through the glomeruli of the kidney per minute. (p. 452) Glomerulus The cluster of kidney capillaries that marks the beginning of the nephron and is immediately proximal to the proximal convoluted tubule. (p. 452) Loop of Henle The part of the nephron between the proximal and distal convoluted tubules. (p. 452) Nephron The functional filtration unit of the kidney, consisting of (in anatomic order from proximal to distal) the glomerulus, proximal convoluted tubule, loop of Henle, distal convoluted tubule, and collecting duct, which empties urine into the ureters. (p. 452) Open-angle glaucoma A condition in which pressure is elevated in the eye because of obstruction of the outflow of aqueous humor. (p. 453) Proximal convoluted (twisted) tubule The part of the nephron that is immediately distal to the glomerulus and proximal to the loop of Henle. (p. 452) Overview FIGURE 28-1 The nephron and diuretic sites of action. ADH, Antidiuretic hormone. Pharmacology Overview TABLE 28-1 Classification of Diuretics Carbonic Anhydrase Inhibitors Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile acetazolamide Pharmacokinetics: Acetazolamide Loop Diuretics Mechanism of Action and Drug Effects Summary of Major Drug Effects of Loop Diuretics Indications Contraindications Adverse Effects TABLE 28-2 Loop Diuretics: Common Adverse Effects Toxicity and Management of Overdose Interactions TABLE 28-3 Loop Diuretics: Common Drug Interactions Dosages DOSAGES Selected Loop Diuretics and Osmotic Diuretics Drug Profile furosemide Pharmacokinetics: Furosemide Osmotic Diuretics Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile mannitol Pharmacokinetics: Mannitol Potassium-Sparing Diuretics Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 28-4 Potassium-Sparing Diuretics: Common Adverse Effects Interactions Dosages DOSAGES Selected Potassium-Sparing Diuretic Drugs Drug Profiles spironolactone Pharmacokinetics: Spironolactone triamterene Pharmacokinetics: Triamterene Thiazides and Thiazide-Like Diuretics Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 28-5 Thiazide and Thiazide-Like Diuretics: Potential Adverse Effects Toxicity and Management of Overdose Interactions TABLE 28-6 Thiazide and Thiazide-Like Diuretics: Common Drug Interactions NSAIDs, Nonsteroidal antiinflammatory drugs. Dosages Drug Profiles hydrochlorothiazide DOSAGES Selected Thiazide and Thiazide-Like Diuretic Drugs Pharmacokinetics: Hydrochlorothiazide metolazone Pharmacokinetics: Metolazone Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 29 DRUG PROFILES albumin, p. 469 conivaptan, p. 473 dextran, p. 469 fresh frozen plasma, p. 470 packed red blood cells, p. 470 potassium, p. 472 sodium chloride, p. 473 sodium polystyrene sulfonate (potassium exchange resin), p. 472 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Blood The fluid that circulates through the heart, arteries, capillaries, and veins, carrying nutriment and oxygen to the body cells. It consists of plasma, its liquid component, plus three major solid components: erythrocytes (red blood cells or RBCs), leukocytes (white blood cells or WBCs), and platelets. (p. 465) Colloids Protein substances that increase the colloid oncotic pressure. (p. 468) Colloid oncotic pressure Another name for oncotic pressure. It is a form of osmotic pressure exerted by protein in blood plasma that tends to pull water into the circulatory system. (p. 466) Crystalloids Substances in a solution that diffuse through a semipermeable membrane. (p. 467) Dehydration Excessive loss of water from the body tissues. It is accompanied by an imbalance in the concentrations of electrolytes, particularly sodium, potassium, and chloride. (p. 466) Edema The abnormal accumulation of fluid in interstitial spaces. (p. 465) Extracellular fluid (ECF) That portion of the body fluid comprising the interstitial fluid and intravascular fluid. (p. 465) Gradient A difference in the concentration of a substance on two sides of a permeable barrier. (p. 467) Homeostasis The tendency of a cell or organism to maintain equilibrium by regulating its internal environment and adjusting its physiologic processes. (p. 465) Hyperkalemia An abnormally high potassium concentration in the blood, most often due to defective renal excretion but also caused by excessive dietary potassium or certain drugs, such as potassium-sparing diuretics or ACE inhibitors and other causes such as acidosis. (p. 471) Hypernatremia An abnormally high sodium concentration in the blood; may be due to defective renal excretion but is more commonly caused by excessive dietary sodium or replacement therapy or loss of water. (p. 472) Hypokalemia A condition in which there is an inadequate amount of potassium in the bloodstream; possible causes include diarrhea, diuretic use, and others. (p. 471) Hyponatremia A condition in which there is an inadequate amount of sodium in the bloodstream, caused by inadequate excretion of water or by excessive water intake. (p. 472) Interstitial fluid (ISF) The extracellular fluid that fills in the spaces between most of the cells of the body. (p. 465) Intracellular fluid (ICF) The fluid located within cell membranes throughout most of the body. It contains dissolved solutes that are essential to maintaining electrolyte balance and healthy metabolism. (p. 465) Intravascular fluid (IVF) The fluid inside blood vessels. (p. 465) Isotonic Having the same concentration of solutes as another solution and hence exerting the same osmotic pressure as that solution, such as an isotonic saline solution that contains an amount of salt equal to that found in the intracellular and extracellular fluid. (p. 466) Osmotic pressure The pressure produced by a solution necessary to prevent the osmotic passage of solvent into it when the solution and solvent are separated by a semipermeable membrane. (p. 466) Plasma The watery, straw-colored fluid component of lymph and blood in which the leukocytes, erythrocytes, and platelets are suspended. (p. 465) Serum The clear, cell-free portion of the blood from which fibrinogen has also been separated during the clotting process, as typically carried out with a laboratory sample. (p. 467) Solute A substance that is dissolved in another substance. (p. 465) Transcellular fluid The fluid that is contained within specialized body compartments such as cerebrospinal, pleural, and synovial cavities. (p. 465) Overview FIGURE 29-1 Distribution of total body water (TBW). ECF, Extracellular fluid; ICF, intracellular fluid; ISF, interstitial fluid; IVF, intravascular volume. TABLE 29-1 Types of Dehydration TABLE 29-2 Conditions Leading to Fluid Loss or Dehydration and Associated Corresponding Symptoms* *There may be overlap involving more than one of the symptoms depending on the patient's specific condition. FIGURE 29-2 A depiction of what happens when red blood cells are exposed to different fluids. Isotonic solutions cause no net fluid movement. Hypertonic solutions cause water to move out of the cells and can cause the cells to shrink. Hypotonic solutions cause water to move into the cells, which can cause them to burst. Crystalloids Mechanism of Action and Drug Effects Indications Adverse Effects Interactions Dosage Drug Profile sodium chloride TABLE 29-3 Crystalloids and Colloids: Dosing Guidelines CRYSTALLOIDS AND COLLOIDS *Hypertonic saline is a high-risk drug and should not be given faster than 100 mL/hr for short periods. Frequent monitoring of serum levels is required. †Iso-oncotic solutions such as 5% albumin, dextran 70, and hetastarch. ‡Hyperoncotic solutions such as 25% albumin. Colloids TABLE 29-4 Commonly Used Colloids COMPOSITION (mEq/L) *Relative cost compared with the cost of dextran 70. †Dextran is available in NaCl, which has 154 mEq/L of both Na and Cl. It is also available in 5% dextrose in water, which contains no Na or Cl. Cl, Chloride; Na, sodium. Mechanism of Action and Drug Effects FIGURE 29-3 Colloid osmotic pressure (oncotic pressure). As shown, the colloids inside the blood vessel are too large to pass through the vessel wall. The resulting oncotic pressure exerted by the colloids draws fluid from the surrounding tissues and other extravascular spaces into the blood vessels and also keeps fluid inside the blood vessel. Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles albumin Pharmacokinetics: Albumin dextran Pharmacokinetics: Dextran Blood Products Mechanism of Action and Drug Effects Indications TABLE 29-5 Blood Products: Indications FFP, Fresh frozen plasma; PPF, plasma protein fraction; PRBCs, packed red blood cells. Contraindications Adverse Effects Interactions Dosages TABLE 29-6 Suggested Guidelines for Blood Products: Management of Bleeding FFP, Fresh frozen plasma; PPF, plasma protein fraction; PRBCs, packed red blood cells. Drug Profiles packed red blood cells fresh frozen plasma Physiology of Electrolyte Balance Potassium Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions Dosages Drug Profiles potassium Pharmacokinetics: Potassium sodium polystyrene sulfonate (potassium exchange resin) Sodium Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles sodium chloride Pharmacokinetics: Sodium Chloride conivaptan Pharmacokinetics: Conivaptan Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions PA R T 5 OUTLINE Learning Strategies 30 Pituitary Drugs 31 Thyroid and Antithyroid Drugs 32 Antidiabetic Drugs 33 Adrenal Drugs 34 Women's Health Drugs 35 Men's Health Drugs Study Groups Chat Rooms and Discussion Groups 30 DRUG PROFILES octreotide, p. 486 somatropin, p. 486 vasopressin, p. 487 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Hypothalamus The gland above and behind the pituitary gland and the optic chiasm. Both glands are suspended beneath the middle area of the bottom of the brain. The hypothalamus secretes the hormones vasopressin and oxytocin, which are stored in the posterior pituitary gland. The hypothalamus also secretes several hormone-releasing factors that stimulate the anterior pituitary gland to secrete a variety of hormones that control many bodily functions. (p. 483) Negative feedback loop A system in which the production of one hormone is controlled by the levels of a second hormone in a way that reduces the output of the first hormone. A gland produces a hormone that stimulates a second gland to produce a second hormone. In response to the increased levels of the second hormone, the source gland of the first hormone reduces production of that hormone until blood levels of the second hormone fall below a certain minimum level needed; then the cycle begins again. (p. 484) Neuroendocrine system The system that regulates the reactions to both internal and external stimuli and involves the integrated activities of the endocrine glands and nervous system. (p. 483) Pituitary gland An endocrine gland that is suspended beneath the brain and supplies numerous hormones that control many vital processes. (p. 484) Endocrine System Box 30-1 FIGURE 30-1 Pituitary hormones. FSH, Follicle-stimulating hormone; LH, luteinizing hormone. (Adapted from McKenry LM, Tessier E, Hogan MA: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.) Pituitary Drugs TABLE 30-1 Anterior and Posterior Pituitary Hormones and Drugs T3, Triiodothyronine; T4, thyroxine. Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 30-2 Octreotide: Common Adverse Effects TABLE 30-3 Desmopressin and Vasopressin: Common Adverse Effects TABLE 30-4 Growth Hormone Analogues: Common Adverse Effects Interactions TABLE 30-5 Pituitary Drugs: Selected Drug Interactions Dosages Drug Profiles octreotide DOSAGES Selected Pituitary Drugs *Normally used only in adults. ADH, Antidiuretic hormone; GH, growth hormone; VIPoma, vasoactive intestinal peptide–producing tumor. Pharmacokinetics: Octreotide somatropin Pharmacokinetics: Somatropin vasopressin Pharmacokinetics: Vasopressin Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 31 DRUG PROFILES levothyroxine, p. 493 propylthiouracil, p. 495 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Euthyroid Referring to normal thyroid function. (p. 493) Hyperthyroidism A condition characterized by excessive production of the thyroid hormones. A severe form of this disorder is called thyrotoxicosis. (p. 492) Hypothyroidism A condition characterized by diminished production of the thyroid hormones. (p. 492) Thyroid-stimulating hormone (TSH) An endogenous substance secreted by the pituitary gland that controls the release of thyroid gland hormones and is necessary for the growth and function of the thyroid gland (also called thyrotropin). (p. 492) Thyroxine (T4) The principle thyroid hormone that influences the metabolic rate. (p. 491) Triiodothyronine (T3) A secondary thyroid hormone that also affects body metabolism. (p. 491) Thyroid Function Pathophysiology of Hypothyroidism Pathophysiology of Hyperthyroidism Thyroid Replacement Drugs TABLE 31-1 Thyroid Drugs: Clinically Equivalent Doses T3, Triiodothyronine; T4, thyroxine. Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 31-2 Thyroid Drugs: Common Adverse Effects Interactions TABLE 31-3 Thyroid Drugs: Interactions Dosages Drug Profile DOSAGES Selected Thyroid Drugs levothyroxine Pharmacokinetics: Levothyroxine Antithyroid Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 31-4 Antithyroid Drugs: Common Adverse Effects Interactions Dosages DOSAGES Selected Antithyroid Drugs *Often abbreviated PTU. Drug Profile propylthiouracil Pharmacokinetics: Propylthiouracil Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 32 DRUG PROFILES acarbose, p. 511 glipizide, p. 511 insulin glargine and insulin detemir, p. 507 insulin isophane suspension (NPH), p. 507 insulin lispro, p. 506 liraglutide, p. 513 metformin, p. 512 pioglitazone, p. 512 regular insulin, p. 507 repaglinide, p. 512 sitagliptin, p. 512 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Diabetes mellitus A complex disorder of carbohydrate, fat, and protein metabolism resulting from the lack of insulin secretion by the beta cells of the pancreas or from defects of the insulin receptors; it is commonly referred to simply as diabetes. There are two major types of diabetes: type 1 and type 2. (p. 501) Diabetic ketoacidosis (DKA) A severe metabolic complication of uncontrolled diabetes that, if untreated, leads to diabetic coma and death. (p. 503) Gestational diabetes Diabetes that develops during pregnancy. It may resolve after pregnancy but may also be a precursor of type 2 diabetes in later life. (p. 503) Glucagon A hormone produced by the alpha cells in the islets of Langerhans that stimulates the conversion of glycogen to glucose in the liver. (p. 500) Glucose One of the simple sugars that serves as a major source of energy. It is found in foods (e.g., refined sweets) and also is the final breakdown product of complex carbohydrate metabolism in the body; it is commonly referred to as dextrose. (p. 500) Glycogen A polysaccharide that is the major carbohydrate stored in animal cells. (p. 500) Glycogenolysis The breakdown of glycogen to glucose. (p. 500) Hemoglobin A1C (A1C) Hemoglobin molecules bound to glucose molecules; blood levels of hemoglobin A1C are used as a diagnostic measure of average daily blood glucose levels in the monitoring and diagnosing of diabetes; it is also called glycosylated hemoglobin and most commonly referred to as A1C. (p. 504) Hyperglycemia A fasting blood glucose level of 126 mg/dL or higher or a nonfasting blood glucose level of 200 mg/dL or higher. (p. 500) Hyperosmolar hyperglycemic syndrome (HHS) A metabolic complication of uncontrolled type 2 diabetes, similar in severity to diabetic ketoacidosis but without ketosis and acidosis. (p. 503) Hypoglycemia A blood glucose level of less than 70 mg/dL, or above 50 mg/dL with signs and symptoms of hypoglycemia. (p. 514) Insulin A naturally occurring hormone secreted by the beta cells of the islets of Langerhans in the pancreas in response to increased levels of glucose in the blood. (p. 500) Ketones Organic chemical compounds produced through the oxidation of secondary alcohols (e.g., fat molecules), including dietary carbohydrates. (p. 500) Polydipsia Chronic excessive intake of water; it is a common symptom of uncontrolled diabetes. (p. 500) Polyphagia Excessive eating; it is a common symptom of uncontrolled diabetes. (p. 500) Polyuria Increased frequency or volume of urinary output; it is a common symptom of diabetes. (p. 500) Type 1 diabetes mellitus Diabetes mellitus that is a genetically determined autoimmune disorder characterized by a complete or nearly complete lack of insulin production; it most commonly arises in children or adolescents. (p. 502) Type 2 diabetes mellitus A type of diabetes mellitus that most commonly presents in adults and is becoming more common in children and adolescents due to inactivity and weight gain. The disease may be controlled by lifestyle modifications, oral drug therapy, and/or insulin, but patients are not necessarily dependent on insulin therapy. (p. 503) Pancreas Pathophysiology of Diabetes Mellitus Box 32-1 TABLE 32-1 Major Long-Term Consequences of Type 1 and Type 2 Diabetes Data from American Diabetes Association: Standards of medical care in diabetes 2015, Diabetes Care 38(Suppl 1), 2015. TABLE 32-2 Characteristics of Type 1 and Type 2 Diabetes Type 1 Diabetes Mellitus FIGURE 32-1 The pancreas. A, Pancreas dissected to show main and accessory ducts. B, Exocrine glandular cells (around small pancreatic ducts) and endocrine glandular cells of the pancreatic islets (adjacent to blood capillaries). Exocrine pancreatic cells secrete pancreatic enzymes, alpha endocrine cells secrete glucagon, and beta endocrine cells secrete insulin. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 7, St Louis, 2010, Mosby.) Acute Diabetic Complications: Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome TABLE 32-3 Comparison of Features of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome Adapted from Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association, Diabetes Care 29(12):2739-2748, 2006. Type 2 Diabetes Mellitus Gestational Diabetes Nonpharmacologic Treatment Interventions Glycemic Goal of Treatment Pharmacology Overview Insulins TABLE 32-4 Insulin Mixing Compatibilities Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions DOSAGES Selected Human-Based Insulin Products TABLE 32-5 Selected Drug Interactions with Antidiabetic Drugs Dosages Insulin Use in Special Populations Drug Profiles FIGURE 32-2 Comparison of the pharmacokinetics of various insulins. (From Messinger-Rapport BJ, Thomas DR, Gammack JK: Clinical update on nursing home medicine: 2008, J Am Med Dir Assoc 9(7):460-475, 2008.) Rapid-Acting Insulins insulin lispro Pharmacokinetics: Insulin Lispro Short-Acting Insulin regular insulin Pharmacokinetics: Regular Insulin Intermediate-Acting Insulins insulin isophane suspension (NPH) Pharmacokinetics: NPH insulin Long-Acting Insulins insulin glargine and insulin detemir Pharmacokinetics: Insulin Glargine Fixed-Combination Insulins Basal-Bolus and Sliding-Scale Insulin Dosing Oral Antidiabetic Drugs Biguanide Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages DOSAGES Selected Oral Antidiabetic Drugs Sulfonylureas Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Glinides Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Thiazolidinediones (Glitazones) Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Alpha-Glucosidase Inhibitors Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Dipeptidyl Peptidase IV (DPP-IV) Inhibitors Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles acarbose Pharmacokinetics: Acarbose glipizide Pharmacokinetics: Glipizide metformin Pharmacokinetics: Metformin pioglitazone Pharmacokinetics: Pioglitazone repaglinide Pharmacokinetics: Repaglinide sitagliptin Pharmacokinetics: Sitagliptin Injectable Antidiabetic Drugs Amylin Agonists Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Incretin Mimetics Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile liraglutide Pharmacokinetics: Liraglutide Sodium Glucose Cotransorter Inhibitors (SGLT2 Inhibitors) Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Glucose-Elevating Drugs Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Box 32-2 Evaluation Patient-Centered Care: Patient Teaching TABLE 32-6 Diabetes Care: Correlation of Glycosylated Hemoglobin Levels with Mean Serum Glucose Levels Data from American Diabetes Association: Standards of medical care in diabetes 2015, Diabetes Care 38(Suppl 1): 2015. Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 33 DRUG PROFILES fludrocortisone, p. 527 methylprednisolone, p. 528 prednisone, p. 527 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Addison's disease A chronic disease associated with the hyposecretion of corticosteroids. (p. 524) Adrenal cortex The outer portion of the adrenal gland. (p. 524) Adrenal crisis An acute, life-threatening state of profound adrenocortical insufficiency requiring immediate medical management. It is characterized by glucocorticoid deficiency, a drop in extracellular fluid volume, hyponatremia, and hyperkalemia. (p. 529) Adrenal medulla The inner portion of the adrenal gland. (p. 524) Aldosterone A mineralocorticoid hormone produced by the adrenal cortex that acts on the renal tubule to regulate sodium and potassium balance in the blood. (p. 524) Cortex The general anatomic term for the outer layers of a body organ or other structure. (p. 524) Corticosteroids Any of the natural or synthetic adrenocortical hormones; those produced by the cortex of the adrenal gland (adrenocorticosteroids). (p. 524) Cushing's syndrome A metabolic disorder characterized by abnormally increased secretion of the corticosteroids. (p. 524) Epinephrine An endogenous hormone secreted into the bloodstream by the adrenal medulla; also a synthetic drug that is an adrenergic vasoconstrictor and also increases cardiac output. (p. 524) Glucocorticoids A major group of corticosteroid hormones that regulate carbohydrate, protein, and lipid metabolism and inhibit the release of adrenocorticotropic hormone. (p. 524) Hypothalamic-pituitary-adrenal (HPA) axis A negative feedback system involved in regulating the release of corticotropin-releasing hormone by the hypothalamus, adrenocorticotropic hormone (corticotropin) by the pituitary gland, and corticosteroids by the adrenal glands. Suppression of the HPA may lead to Addison's disease and possible adrenal crisis or addisonian crisis. This suppression results from chronic disease or exogenous sources, such as long-term glucocorticoid therapy. (p. 524) Medulla An anatomic term for the most interior portions of an organ or structure. (p. 524) Mineralocorticoids A major group of corticosteroid hormones that regulate electrolyte and water balance; in humans the primary mineralocorticoid is aldosterone. (p. 524) Norepinephrine An adrenergic hormone, secreted by the adrenal medulla, that increases blood pressure by causing vasoconstriction but does not appreciably affect cardiac output; it is the immediate metabolic precursor to epinephrine. (p. 524) Adrenal System TABLE 33-1 Adrenal Gland: Characteristics Box 33-1 Adrenal Drugs TABLE 33-2 Available Synthetic Corticosteroids Mechanism of Action and Drug Effects Indications TABLE 33-3 Systemic Glucocorticoids: A Comparison *Drugs with higher potency require smaller milligram doses than those with lower potency. This column lists the approximate dose equivalency between different drugs that is expected to achieve a comparable therapeutic effect. Contraindications Adverse Effects TABLE 33-4 Corticosteroids: Common Adverse Effects Interactions Dosages Drug Profiles Corticosteroids DOSAGES Selected Antiadrenal and Corticosteroid Drugs GI, Gastrointestinal. fludrocortisone Pharmacokinetics: Fludrocortisone prednisone Pharmacokinetics: Prednisone methylprednisolone Pharmacokinetics: Methylprednisolone Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 34 DRUG PROFILES alendronate, p. 542 calcitonin, p. 543 clomiphene, p. 544 contraceptive drugs, p. 540 dinoprostone, p. 545 estrogen, p. 537 medroxyprogesterone, p. 539 megestrol, p. 539 methylergonovine, p. 545 oxytocin, p. 546 raloxifene, p. 543 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Chloasma Hyperpigmentation of the skin, characterized by brownish macules on the cheeks, forehead, lips, and/or neck; a common dermatologic adverse effect of female hormonal medications (also called melasma). (p. 537) Corpus luteum The structure that forms on the surface of the ovary after every ovulation and acts as a short-lived endocrine organ that secretes progesterone. (p. 534) Endocrine glands Glands that secrete one or more hormones directly into the blood. (p. 534) Estrogens The term for a major class of female sex steroid hormones; of the estrogens, estradiol is responsible for most estrogenic physiologic activity. (p. 534) Fallopian tubes The passages through which ova are carried from the ovary to the uterus. (p. 534) Gonadotropin The hormone that stimulates the testes and ovaries. (p. 534) Hormone replacement therapy (HRT) The term used to describe any replacement of natural body hormones with hormonal drug dosage forms. Most commonly, HRT refers to estrogen replacement therapy for treating symptoms associated with menopause-related estrogen deficiency. It is also referred to as simply hormone therapy. (p. 537) Implantation The attachment to, penetration of, and embedding of the fertilized ovum in the lining of the uterine wall; it is one of the first stages of pregnancy. (p. 534) Menarche The first menses in a young woman's life and the beginning of cyclic menstrual function. (p. 534) Menopause The cessation of menses for 12 consecutive months that marks the end of a woman's childbearing capability. (p. 534) Menses The normal flow of blood that occurs during menstruation. (p. 534) Menstrual cycle The recurring cycle of changes in the endometrium in which the decidual layer is shed, regrows, proliferates, is maintained for several days, and is shed again at menstruation unless a pregnancy begins. Also referred to as the uterine cycle. (p. 534) Osteoporosis A condition characterized by the progressive loss of bone density and thinning of bone tissue; it is associated with increased risk for fractures. (p. 541) Ova Female reproductive or germ cells (singular: ovum; also called eggs). (p. 534) Ovarian follicles The location of egg production and ovulation in the ovary; the follicle is the precursor to the corpus luteum. (p. 534) Ovaries The pair of female gonads located on each side of the lower abdomen beside the uterus. They store the ova (eggs) and release ova during the ovulation phase of the menstrual cycle. (p. 534) Ovulation The rupture of the ovarian follicle, which results in the release of an unfertilized ovum into the peritoneal cavity, from which it normally enters the fallopian tube. (p. 534) Progesterone A sex hormone that is produced by the corpus luteum and serves to prepare the uterus for possible implantation. (p. 534) Progestins Synthetic or natural substances that have properties similar to progesterone, but are not considered to be the naturally occurring progesterone that is present in the human female body. (p. 538) Puberty The period of life when the ability to reproduce begins. (p. 534) Uterus The hollow, pear-shaped female organ in which the fertilized ovum is implanted (see implantation) and the fetus develops. (p. 534) Vagina The part of the female genitalia that forms a canal from its external orifice through its vestibule to the uterine cervix. (p. 534) Female Reproductive Functions TABLE 34-1 Phases of the Menstrual Cycle FIGURE 34-1 Hormonal activity during the monthly menstrual cycle. Gonadotropin-releasing hormone (Gn-RH) from the hypothalamus stimulates the pituitary gland, causing it to secrete follicle-stimulating hormone (FSH) early in the cycle (coinciding with the menses) and later luteinizing hormone (LH). FSH stimulates the ovaries to produce estrogen (primarily estradiol). Later in the cycle, the combined surges in the levels of estrogen, Gn-RH, FSH, and LH stimulate ovulation. The corpus luteum then secretes estrogen and progesterone, which provide negative feedback to the hypothalamus and pituitary gland to reduce Gn-RH, FSH, and LH secretions. If the ovum (egg) is not fertilized by a spermatozoon, levels of estrogen and progesterone then fall to their monthly lows, Gn-RH and FSH rise again, and the onset of menses begins a new cycle. Female Sex Hormones Estrogens Box 34-1 Mechanism of Action and Drug Effects Indications Box 34-2 Contraindications Adverse Effects TABLE 34-2 Estrogens: Common Adverse Effects Interactions Dosages Drug profile estrogen DOSAGES Selected Estrogenic Drugs Progestins Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 34-3 Progestins: Common Adverse Effects Interactions Dosages Drug profiles medroxyprogesterone DOSAGES Selected Progestational Drugs Pharmacokinetics: Medroxyprogesterone (Depo-Provera) megestrol Pharmacokinetics: Megestrol Contraceptive Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 34-4 Oral Contraceptives: Common Adverse Effects Interactions Dosages Drug profile Contraceptive drugs Drugs for Osteoporosis DOSAGES Selected Contraceptive Drugs Mechanism of Action and Drug Effects Bisphosphonates Selective Estrogen Receptor Modulators Calcitonin Teriparatide Denosumab Indications Contraindications Bisphosphonates Selective Estrogen Receptor Modulators (SERMs) Calcitonin Teriparatide Denosumab Adverse Effects Interactions Dosages Drug profiles alendronate DOSAGES Selected Drugs Used Specifically for Osteoporosis Pharmacokinetics: Alendronate raloxifene Pharmacokinetics: Raloxifene calcitonin Pharmacokinetics: Calcitonin Drugs Related to Pregnancy, Labor, Delivery, and the Postpartum Period Fertility Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 34-5 Fertility Drugs: Most Common Adverse Effects Interactions Dosages Drug profile clomiphene Pharmacokinetics: Clomiphene Uterine Stimulants Mechanism of Action and Drug Effects DOSAGES Selected Fertility Drugs Indications Contraindications Adverse Effects TABLE 34-6 Oxytocic Drugs: Most Common Adverse Effects Interactions Dosages Drug profiles dinoprostone Pharmacokinetics: Dinoprostone methylergonovine DOSAGES Selected Uterine Stimulants *Use of these medications is contraindicated in pregnancy (pregnancy category X) unless needed for the indications listed. D5LR, Dextrose 5% in lactated Ringer's solution. Pharmacokinetics: Methylergonovine oxytocin Pharmacokinetics: Oxytocin Drugs for Preterm Labor Management Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 35 DRUG PROFILES finasteride, p. 558 sildenafil, p. 558 testosterone, p. 559 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Anabolic activity Any metabolic activity that promotes the building up of body tissues, such as the activity produced by testosterone that causes the development of bone and muscle tissue; also called anabolism. (p. 554) Androgenic activity The activity produced by testosterone that causes the development and maintenance of the male reproductive system and male secondary sex characteristics. (p. 554) Androgens Male sex hormones responsible for mediating the development and maintenance of male sex characteristics. Chief among these are testosterone and its various biochemical precursors. (p. 554) Benign prostatic hyperplasia (BPH) (also called hypertrophy) Nonmalignant (noncancerous) enlargement of the prostate gland. (p. 555) Catabolism The opposite of anabolic activity; any metabolic activity that results in the breakdown of body tissues. Examples of conditions in which catabolism occurs are debilitating illnesses such as end-stage cancer and starvation. (p. 554) Erythropoietic effect The effect of stimulating the production of red blood cells (erythropoiesis). (p. 555) Prostate cancer A malignant tumor within the prostate gland. (p. 556) Testosterone The main androgenic hormone. (p. 554) Male Reproductive System Androgens and Other Drugs Pertaining to Men's Health Mechanism of Action and Drug Effects Box 35-1 Indications TABLE 35-1 Men's Health Drugs: Indications Contraindications Adverse Effects TABLE 35-2 Men's Health Drugs: Selected Adverse Effects Interactions Dosages Drug Profiles finasteride DOSAGES Selected Men's Health Drugs Pharmacokinetics (finasteride) sildenafil Pharmacokinetics: Sildenafil testosterone Pharmacokinetics: Testosterone Gel Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions PA R T 6 OUTLINE Learning Strategies 36 Antihistamines, Decongestants, Antitussives, and Expectorants 37 Respiratory Drugs Time Management Practice Questions 36 DRUG PROFILES benzonatate, p. 573 codeine, p. 573 dextromethorphan, p. 573 diphenhydramine, p. 570 guaifenesin, p. 574 loratadine, p. 569 naphazoline, p. 572 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Adrenergics (sympathomimetics) Drugs that stimulate the sympathetic nerve fibers of the autonomic nervous system that use epinephrine or epinephrine-like substances as neurotransmitters. (p. 570) Antagonists Drugs that exert an action opposite to that of another drug or compete for the same receptor sites. (p. 567) Anticholinergics (parasympatholytics) Drugs that block the action of acetylcholine and similar substances at acetylcholine receptors, which results in inhibition of the transmission of parasympathetic nerve impulses. (p. 570) Antigens Substances capable of inducing specific immune responses and reacting with the specific products of those responses, such as antibodies and specifically sensitized T lymphocytes. Antigens can be soluble (e.g., a foreign protein) or particulate or insoluble (e.g., a bacterial cell). (p. 567) Antihistamines Substances capable of reducing the physiologic and pharmacologic effects of histamine. (p. 567) Antitussive A drug that reduces coughing, often by inhibiting neural activity in the cough center of the central nervous system. (p. 572) Corticosteroids Any of the hormones produced by the adrenal cortex, either in natural or synthetic drug form. They control many key processes in the body, such as carbohydrate and protein metabolism, the maintenance of serum glucose levels, electrolyte and water balance, and the functions of the cardiovascular system, skeletal muscle, kidneys, and other organs. (p. 570) Decongestants Drugs that reduce congestion or swelling, especially of the upper or lower respiratory tract. (p. 570) Empiric therapy A method of treating disease based on observations and experience, rather than a knowledge of the precise cause for the disorder. (p. 566) Expectorants Drugs that increase the flow of fluid in the respiratory tract, usually by reducing the viscosity of secretions, and facilitate their removal by coughing. (p. 573) Histamine antagonists Drugs that compete with histamine for binding sites on histamine receptors. (p. 567) Influenza A highly contagious infection of the respiratory tract that is transmitted by airborne droplets. (p. 566) Nonsedating antihistamines Medications that primarily work peripherally to block the actions of histamine and therefore do not generally have the central nervous system effects of many of the older antihistamines; also called second-generation antihistamines and peripherally acting antihistamines. (p. 569) Reflex stimulation An irritation of the respiratory tract occurring in response to an irritation of the gastrointestinal tract. (p. 572) Rhinovirus Any of about 100 serologically distinct ribonucleic acid (RNA) viruses that cause about 40% of acute respiratory illnesses. (p. 566) Sympathomimetic drugs A class of drugs whose effects mimic those resulting from the stimulation of the sympathetic nervous system. (p. 571) Upper respiratory tract infection (URI) Any infectious disease of the upper respiratory tract, including the common cold, laryngitis, pharyngitis, rhinitis, sinusitis, and tonsillitis. (p. 566) Overview Antihistamines FIGURE 36-1 Comparison of the efficacy and adverse effects of selected antihistamines. TABLE 36-1 Effects of Various Antihistamines Mechanism of Action and Drug Effects TABLE 36-2 Antihistamines: Drug Effects Indications Contraindications Adverse Effects TABLE 36-3 Antihistamines: Reported Adverse Effects Interactions TABLE 36-4 Antihistamines: Drug Interactions Dosages DOSAGES Selected Antihistamines PD, Parkinson's disease. Drug Profiles Nonsedating Antihistamines loratadine Pharmacokinetics: Loratadine Traditional Antihistamines diphenhydramine Pharmacokinetics: Diphenhydramine Decongestants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile DOSAGES Selected Decongestant, Expectorant, and Antitussive Drugs naphazoline Pharmacokinetics: Naphazoline Antitussives Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles benzonatate Pharmacokinetics: Benzonatate codeine Pharmacokinetics: Codeine dextromethorphan Pharmacokinetics: Dextromethorphan Expectorants Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile guaifenesin Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 37 DRUG PROFILES albuterol, p. 583 fluticasone propionate, p. 588 ipratropium, p. 584 methylprednisolone, p. 588 montelukast, p. 586 salmeterol, p. 583 theophylline, p. 585 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Allergen Any substance that evokes an allergic response. (p. 579) Allergic asthma Bronchial asthma caused by hypersensitivity to an allergen or allergens. (p. 579) Alveoli Microscopic sacs in the lungs where oxygen is exchanged for carbon dioxide; also called air sacs. (p. 579) Antibodies Immunoglobulins produced by lymphocytes in response to bacteria, viruses, or other antigenic substances. (p. 579) Antigen A substance (usually a protein) that causes the formation of an antibody and reacts specifically with that antibody. (p. 579) Asthma attack The onset of wheezing together with difficulty breathing. (p. 579) Bronchial asthma The general term for recurrent and reversible shortness of breath resulting from narrowing of the bronchi and bronchioles; it is often referred to simply as asthma. Key characteristics are inflammation, bronchial smooth muscle spasticity, and sputum production; inflammation is the most important. (p. 579) Bronchodilators Medications that improve airflow by relaxing bronchial smooth muscle cells (e.g., xanthines, adrenergic agonists). (p. 581) Chronic bronchitis Chronic inflammation and low-grade infection of the bronchi. (p. 579) Emphysema A condition of the lungs characterized by enlargement of the air spaces distal to the bronchioles. (p. 579) Immunoglobulins Proteins belonging to any of five structurally and antigenically distinct classes of antibodies present in the serum and external secretions of the body; they play a major role in immune responses; immunoglobulin is often abbreviated Ig. (p. 579) Lower respiratory tract (LRT) The division of the respiratory system composed of organs located almost entirely within the chest. (p. 579) Status asthmaticus A prolonged asthma attack. (p. 579) Upper respiratory tract (URT) The division of the respiratory system composed of organs located outside the chest cavity (thorax). (p. 579) Overview Pathophysiology of Diseases of the Respiratory System Asthma Box 37-1 Box 37-2 TABLE 37-1 Stepwise Therapy for the Management of Asthma Adapted from National Institutes of Health: Expert Panel Report 3: Guidelines for the diagnosis and management of asthma, 2007, U.S. Department of Health and Human Services, available at www.nhlbi.nih.gov/guidelines/asthma. Accessed May 2, 2015. Chronic Bronchitis Emphysema Treatment of Diseases of the Lower Respiratory Tract TABLE 37-2 Mechanisms of Antiasthmatic Drug Action FIGURE 37-1 Overview of the effects of various antiasthmatic medications. (From McKenry LM, Tessier E, Hogan M: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.) Bronchodilators Beta-Adrenergic Agonists Mechanism of Action and Drug Effects FIGURE 37-2 The EpiPen Auto-Injector (epinephrine) is used for immediate treatment of anaphylaxis (allergic emergencies). The EpiPen is given into the outer thigh, through the clothing. Anaphylactic emergencies also require emergency medical services in addition to the EpiPen. Additional information is available at www.epipen.com. (Copyright Mylan Specialty, L.P. Used with permission.) DOSAGES Bronchodilators *Long-acting beta agonists are no longer recommended to be used alone; they need to be combined with an asthma-controlling medication such as an inhaled corticosteroid (e.g., Advair inhaler [fluticasone and salmeterol]). MDI, metered-dose inhaler. TABLE 37-3 Beta Agonist Bronchodilators Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles albuterol Pharmacokinetics: Albuterol salmeterol Pharmacokinetics: Salmeterol Anticholinergics Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Drug Interactions Dosages Drug Profile ipratropium DOSAGES Theophylline Salts Pharmacokinetics: Ipratropium Xanthine Derivatives Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile theophylline Pharmacokinetics: Theophylline Nonbronchodilating Respiratory Drugs Leukotriene Receptor Antagonists Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions TABLE 37-4 Drug Interactions: Leukotriene Receptor Antagonists Dosages DOSAGES Selected Antileukotriene Drug Drug Profile montelukast Pharmacokinetics: Montelukast Corticosteroids Mechanism of Action and Drug Effects TABLE 37-5 White Blood Cells (Leukocytes) *Value in parentheses is the percentage of all leukocytes represented by the given type. Indications Contraindications Adverse Effects DOSAGES Selected Corticosteroids COPD, Chronic obstructive pulmonary disease; MDI, metered-dose inhaler. Interactions Dosages Drug Profiles fluticasone propionate Pharmacokinetics: Fluticasone Propionate methylprednisolone Pharmacokinetics: Methylprednisolone Phosphodiesterase-4 Inhibitor Monoclonal Antibody Antiasthmatic Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Beta Agonists Box 37-3 Xanthines Anticholinergics Leukotriene Receptor Antagonists Corticosteroids (Glucocorticoids) Phosphodiesterase-4 Inhibitor Monoclonal Antibody Antiasthmatic Drugs Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions PA R T 7 OUTLINE Learning Strategies 38 Antibiotics Part 1 39 Antibiotics Part 2 40 Antiviral Drugs 41 Antitubercular Drugs 42 Antifungal Drugs 43 Antimalarial, Antiprotozoal, and Anthelmintic Drugs 44 Antiinflammatory and Antigout Drugs Active Questioning NCLEX® Practice 38 DRUG PROFILES amoxicillin, p. 608 ampicillin, p. 608 azithromycin and aztreonam, p. 613 clarithromycin, p. 615 cefazolin, p. 610 cefepime, p. 612 cefoxitin, p. 611 ceftaroline, p. 612 ceftazidime, p. 612 ceftriaxone, p. 612 cefuroxime, p. 611 cephalexin, p. 610 demeclocycline, p. 617 doxycycline, p. 617 erythromycin, p. 615 imipenem/cilastatin, p. 612 nafcillin, p. 608 penicillin G and penicillin V potassium, p. 608 sulfamethoxazole/trimethoprim (co-trimoxazole), p. 605 tigecycline, p. 617 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Antibiotic Having the ability to destroy or interfere with the development of a living organism. The term is used most commonly to refer to antibacterial drugs. (p. 600) Antiseptic One of two types of topical antimicrobial agents; a chemical that inhibits the growth and reproduction of microorganisms without necessarily killing them. Antiseptics are also called static agents. (p. 601) Bactericidal antibiotics Antibiotics that kill bacteria. (p. 606) Bacteriostatic antibiotics Antibiotics that do not actually kill bacteria but rather inhibit their growth. (p. 604) Beta-lactam The designation for a broad class of antibiotics that includes four subclasses: penicillins, cephalosporins, carbapenems, and monobactams; so named because of the beta-lactam ring that is part of the chemical structure of all drugs in this class. (p. 605) Beta-lactamase Any of a group of enzymes produced by bacteria that catalyze the chemical opening of the crucial beta-lactam ring structures in beta-lactam antibiotics. (p. 606) Beta-lactamase inhibitors Medications combined with certain penicillin drugs to block the effect of betalactamase enzymes. (p. 606) Colonization The establishment and growth of microorganisms on the skin, open wounds, or mucous membranes, or in secretions without causing an infection. (p. 601) Community-associated infection An infection that is acquired by persons who have not been hospitalized or had a medical procedure recently. (p. 601) Definitive therapy The administration of antibiotics based on known results of culture and sensitivity testing identifying the pathogen causing infection. (p. 602) Disinfectant One of two types of topical antimicrobial agents; a chemical applied to nonliving objects to kill microorganisms. Also called cidal agents. (p. 601) Empiric therapy The administration of antibiotics based on the practitioner's judgment of the pathogens most likely to be causing an apparent infection; it involves the presumptive treatment of an infection to avoid treatment delay before specific culture information has been obtained. (p. 602) Glucose-6-phosphate dehydrogenase (G6PD) deficiency An inherited disorder in which the red blood cells are partially or completely deficient in glucose-6-phosphate dehydrogenase, a critical enzyme in the metabolism of glucose. Certain medications can cause hemolytic anemia in patients with this disorder. This is an example of a host factor related to drug therapy. (p. 603) Health care–associated infection An infection that is acquired during the course of receiving treatment for another condition in a health care institution. The infection is not present or incubating at the time of admission; also known as a nosocomial infection. (p. 601) Host factors Factors that are unique to a particular patient that affect the patient's susceptibility to infection and response to various antibiotic drugs. Examples include a low neutrophil count or a lack of immunoglobulins in the blood that carry antibodies. (p. 603) Infections Invasions and multiplications of microorganisms in body tissues. (p. 600) Microorganisms Microscopic living organisms (also called microbes). (p. 600) Prophylactic antibiotic therapy Antibiotics taken before anticipated exposure to an infectious organism in an effort to prevent the development of infection. (p. 602) Pseudomembranous colitis A potentially-necrotizing inflammatory bowel condition that is often associated with antibiotic therapy; often caused by the bacteria Clostridium difficile. A more general term that is also used is antibiotic-associated colitis. (p. 602) Slow acetylation A common genetic host factor in which the rate of metabolism of certain drugs is reduced. (p. 603) Subtherapeutic Generally refers to blood levels below therapeutic levels due to insufficient dosing. Also refers to antibiotic treatment that is ineffective in treating a given infection. Possible causes include inappropriate drug therapy, insufficient drug dosing, and bacterial drug resistance. (p. 602) Superinfection (1) An infection occurring during antimicrobial treatment for another infection, resulting from overgrowth of an organism not susceptible to the antibiotic used. (2) A secondary microbial infection that occurs in addition to an earlier primary infection, often due to weakening of the patient's immune system function by the first infection. (p. 602) Teratogens Substances that can interfere with normal prenatal development and cause one or more developmental abnormalities in the fetus. (p. 603) Therapeutic Referring to antibiotic therapy that is given in sufficient doses so that the concentration of the drug in the blood or other tissues renders it effective against specific bacterial pathogens. (p. 602) Microbial Infection FIGURE 38-1 General morphology of bacteria. (From Murray PR, Rosenthal KS, Pfaller MA: Medical microbiology, ed 6, St Louis, 2009, Mosby.) FIGURE 38-2 Gram-positive and gram-negative bacteria. A gram-positive bacterium has a thick layer of peptidoglycan (left). A gram-negative bacterium has a thin peptidoglycan layer and an outer membrane (right). Structures in parentheses are not found in all bacteria. (From Murray PR, Rosenthal KS, Pfaller MA: Medical microbiology, ed 6, St Louis, 2009, Mosby.) Health Care–Associated Infection TABLE 38-1 Antiseptics versus Disinfectants Pharmacology Overview Antibiotics FIGURE 38-3 Basic sites of antibiotic activity. DNA, Deoxyribonucleic acid; mRNA, messenger ribonucleic acid; RNA, ribonucleic acid. (From Murray PR, Rosenthal KS, Pfaller MA: Medical microbiology, ed 6, St Louis, 2009, Mosby.) Sulfonamides Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 38-2 Sulfonamides: Reported Adverse Effects Interactions Dosages DOSAGES Selected Sulfonamide Combination Drug Products *Dosage ranges are typical but are not necessarily exhaustive due to space limitations. Clinical variations may occur. Check current drug handbook for exact dosages for specific indications. Drug Profile sulfamethoxazole/trimethoprim (co-trimoxazole) Pharmacokinetics: Sulfamethoxazole/Trimethoprim (Co-Trimoxazole) Beta-Lactam Antibiotics FIGURE 38-4 Chemical structure of penicillins showing the beta-lactam ring. R, Variable portion of drug chemical structure. Penicillins TABLE 38-3 Classification of Penicillins Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 38-4 Penicillins: Reported Adverse Effects Interactions TABLE 38-5 Penicillins: Drug Interactions Dosages Drug Profiles Natural Penicillins penicillin G and penicillin V potassium Pharmacokinetics: Penicillin G Penicillinase-Resistant Penicillins nafcillin Pharmacokinetics: Nafcillin Aminopenicillins DOSAGES Selected Penicillins spp., Species. amoxicillin Pharmacokinetics: Amoxicillin ampicillin Pharmacokinetics: Ampicillin Extended-Spectrum Penicillins Cephalosporins TABLE 38-6 Cephalosporins: Parenteral and Oral Preparations FIRST-GENERATION SECOND-GENERATION THIRD-GENERATION TABLE 38-7 Cephalosporins: Drug Interactions Dosages Drug Profiles First-Generation Cephalosporins cefazolin DOSAGES Selected Cephalosporins *Cefuroxime axetil and cefditoren pivoxil are both prodrugs for PO use that are hydrolyzed into the active ingredient in the fluids of the gastrointestinal tract. spp., Species. Pharmacokinetics: Cefazolin cephalexin Pharmacokinetics: Cephalexin Second-Generation Cephalosporins cefoxitin Pharmacokinetics: Cefoxitin cefuroxime Pharmacokinetics: Cefuroxime Third-Generation Cephalosporins ceftriaxone Pharmacokinetics: Ceftriaxone ceftazidime Pharmacokinetics: Ceftazidime Fourth-Generation Cephalosporins cefepime Pharmacokinetics: Cefepime Fifth-Generation Cephalosporins ceftaroline Pharmacokinetics: Ceftaroline Carbapenems Drug Profile imipenem/cilastatin Pharmacokinetics: Imipenem/Cilastatin Monobactams Drug Profile aztreonam Pharmacokinetics: Aztreonam Macrolides DOSAGES Selected Carbapenems and Monobactams Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 38-8 Macrolides: Reported Adverse Effects Interactions Dosages Drug Profiles erythromycin azithromycin and clarithromycin DOSAGES Selected Macrolides *There are many dosage forms, and dosages may vary from those listed. GU, Genitourinary; MAC, Mycobacterium avium-intracellulare complex. Pharmacokinetics: Azithromycin Pharmacokinetics: Clarithromycin Ketolides Tetracyclines Box 38-1 Mechanism of Action and Drug Effects Indications Contraindications DOSAGES Selected Tetracyclines* *Use of tetracyclines is contraindicated in children younger than 8 years of age and in pregnant women because of the risk for significant tooth discoloration in children. MRSA, Methicillin-resistant Staphylococcus aureus. Adverse Effects Interactions Dosages Drug Profiles demeclocycline doxycycline Pharmacokinetics: Doxycycline tigecycline Pharmacokinetics: Tigecycline Nursing Process Assessment Box 38-2 Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 39 DRUG PROFILES amikacin, p. 627 ciprofloxacin, p. 630 clindamycin, p. 630 colistimethate, p. 630 daptomycin, p. 631 gentamicin, p. 627 levofloxacin, p. 630 linezolid, p. 630 metronidazole, p. 632 neomycin, p. 628 nitrofurantoin, p. 632 telavancin, p. 633 tobramycin, p. 628 vancomycin, p. 633 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Carbapenem-resistant Enterobacteriaceae (CRE) refers to bacteria that possess an enzyme, carbapenemase, which renders the organism resistant to all carbapenem antibiotics as well as beta-lactam antibiotics and monobactams. Such organisms produce a very serious resistant infection. CRE used to be known as Klebsiella pneumoniae carbapenemase (KPC). (p. 624) Concentration-dependent killing A property of some antibiotics, especially aminoglycosides, whereby achieving high plasma drug concentrations, even if briefly, results in the most effective bacterial kill (compare time-dependent killing). (p. 625) Extended-spectrum beta-lactamases (ESBLs) A group of beta-lactamase enzymes produced by some organisms that makes the organism resistant to all beta-lactam antibiotics (penicillins and cephalosporins) and aztreonam. Patients who are infected by such organisms must be in contact isolation; proper handwashing is key to preventing the spread of these organisms. (p. 624) Methicillin-resistant Staphylococcus aureus (MRSA) A strain of Staphylococcus aureus that is resistant to the beta-lactamase penicillin known as methicillin. Originally, the abbreviation MRSA referred exclusively to methicillin-resistant S. aureus. It is now used more commonly to refer to strains of S. aureus that are resistant to several drug classes, and therefore, depending on the context or health care institution, it may also stand for “multidrug-resistant S. aureus.” (p. 624) Microgram One millionth of a gram. Be careful not to confuse it with milligram (one thousandth of a gram), which is one thousand times greater than 1 microgram. Confusion of these two units sometimes results in drug dosage errors. (p. 625) Minimum inhibitory concentration (MIC) A laboratory measure of the lowest concentration of a drug needed to kill a certain standardized amount of bacteria. (p. 625) Multidrug-resistant organisms Bacteria that are resistant to one or more classes of antimicrobial drugs. These include multidrug-resistant Staphylococcus aureus, extended-spectrum beta-lactamase–producing organisms, and carbapenemase-resistant enterobacteriaceae. (p. 624) Nephrotoxicity Toxicity to the kidneys, often drug induced and manifesting as compromised renal function; usually reversible upon withdrawal of the offending drug. (p. 625) Ototoxicity Toxicity to the ears, often drug induced and manifesting as varying degrees of hearing loss that is likely to be permanent. (p. 625) Postantibiotic effect A period of continued bacterial suppression that occurs after brief exposure to certain antibiotic drug classes, especially aminoglycosides (discussed in this chapter) and carbapenems (see Chapter 38). The mechanism of this effect is uncertain. (p. 626) Pseudomembranous colitis A necrotizing inflammatory bowel condition that is often associated with antibiotic therapy. Some antibiotics (e.g., clindamycin) are more likely to produce it than others. More commonly referred to as antibiotic-associated colitis or Clostridium difficile diarrhea or C. difficile infection. (p. 630) Synergistic effect Drug interaction in which the bacterial killing effect of two antibiotics given together is greater than the sum of the individual effects of the same drugs given alone. (p. 626) Therapeutic drug monitoring Ongoing monitoring of plasma drug concentrations and dosage adjustment based on these values as well as other laboratory indicators such as kidney and liver function test results; it is often carried out by a pharmacist in collaboration with medical, nursing, and laboratory staff. (p. 625) Time-dependent killing A property of most antibiotic classes whereby prolonged high plasma drug concentrations are required for effective bacterial kill (compare concentration-dependent killing). (p. 625) Vancomycin-resistant Enterococcus (VRE) Enterococcus species that are resistant to beta-lactam antibiotics and vancomycin. Most commonly refers to Enterococcus faecium. (p. 624) Overview Pathophysiology of Resistant Infections Box 39-1 MRSA, Methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant Enterococcus; ESBL, extended-spectrum betalactamase; CRE, carbapenemase-resistant Enterobacteriaceae. Aminoglycosides TABLE 39-1 Aminoglycoside Antibiotics PEAK *q8h TROUGH or q12h. †mcg, microgram; note that 1 microgram = 1/1000 (one thousandth) of a milligram or 1/1,000,000 (one millionth) of a gram. Also note that microgram is abbreviated mcg, while milligram is abbreviated mg. Mechanism of Action and Drug Effects Indications TABLE 39-2 Aminoglycosides: Comparative Spectra of Antimicrobial Activity spp., Species. Contraindications Adverse Effects Interactions Dosages DOSAGES Selected Aminoglycosides* *Dosing and frequency vary depending on the age of the patient. Drug Profiles amikacin Pharmacokinetics: Amikacin gentamicin Pharmacokinetics: Gentamicin tobramycin Pharmacokinetics: Tobramycin neomycin Pharmacokinetics: Neomycin Quinolones Mechanism of Action and Drug Effects Indications Box 39-2 TABLE 39-3 Quinolones: Common Indications for Specific Drugs CAP, Community-associated pneumonia; COPD, chronic obstructive pulmonary disease; PRSP, penicillin-resistant streptococcal pneumonia; STI, sexually transmitted infection. Contraindications Adverse Effects DOSAGES Selected Quinolones TABLE 39-4 Quinolones: Reported Adverse Effects ALT, Alanine aminotransferase; AST, aspartate aminotransferase. Interactions Dosages Drug Profiles ciprofloxacin Pharmacokinetics: Ciprofloxacin levofloxacin Pharmacokinetics: Levofloxacin Miscellaneous Antibiotics Drug Profiles clindamycin DOSAGES Selected Miscellaneous Antibiotics *Not normally used in children except to treat amebiasis. †Oral is not absorbed and is used only for C. difficile diarrhea. CRE, Carbapenemase-resistant Enterobacteriaceae; GU, genitourinary; MRSA, methicillin-resistant Staphylococcus aureus; PO, oral; spp., species; UTI, urinary tract infection; VRE, vancomycin-resistant Enterococcus. Pharmacokinetics: Clindamycin colistimethate Pharmacokinetics: Colistimethate daptomycin Pharmacokinetics: Daptomycin linezolid Pharmacokinetics: Linezolid metronidazole Pharmacokinetics: Metronidazole nitrofurantoin Pharmacokinetics: Nitrofurantoin quinupristin/dalfopristin Pharmacokinetics: Quinupristin/Dalfopristin telavancin Pharmacokinetics: Telavancin vancomycin Pharmacokinetics: Vancomycin Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Aminoglycosides Quinolones Clindamycin Linezolid Metronidazole Nitrofurantoin Vancomycin Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 40 DRUG PROFILES acyclovir, p. 647 amantadine and rimantadine, p. 647 enfuvirtide, p. 653 ganciclovir, p. 647 indinavir, p. 653 nevirapine, p. 654 maraviroc, p. 654 oseltamivir and zanamivir, p. 648 raltegravir, p. 654 ribavirin, p. 648 simeprevir, p. 648 sofosbuvir, p. 648 telbivudine, p. 649 tenofovir, p. 654 zidovudine, p. 654 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Acquired immunodeficiency syndrome (AIDS) Infection caused by the human immunodeficiency virus (HIV), which weakens the host's immune system, giving rise to opportunistic infections. (p. 643) Antibodies Immunoglobulin molecules that have an antigen-specific amino acid sequence and are produced by the humoral immune system (antibodies produced from B lymphocytes) in response to exposure to a specific antigen, the purpose of which is to attack and destroy molecules of this antigen. (p. 643) Antigen A substance, usually a protein, that is foreign to a host and causes the formation of an antibody that reacts specifically with that antibody. Examples of antigens include bacterial exotoxins, viruses, and allergens. An allergen (e.g., dust, pollen, mold) is a specific type of antigen that causes allergic reactions (see Chapter 36). (p. 643) Antiretroviral drugs A specific term for antiviral drugs that work against retroviruses such as HIV. (p. 644) Antiviral drugs A general term for drugs that destroy viruses, either directly or indirectly by suppressing their replication. (p. 643) Cell-mediated immunity One of two major parts of the immune system. It consists of nonspecific immune responses mediated primarily by T lymphocytes (T cells) and other immune system cells (e.g., monocytes, macrophages, neutrophils) but not by antibody-producing cells (B lymphocytes). (p. 643) Deoxyribonucleic acid (DNA) A nucleic acid composed of nucleotide units that transmit genetic information and are found primarily in the nuclei of cells. (Compare with ribonucleic acid [RNA].) (p. 642) Fusion The process by which viruses attach themselves to, or fuse with, the cell membranes of host cells, in preparation for infecting the cell for purposes of viral replication. (p. 642) Genome The complete set of genetic material of any organism; it may consist of multiple chromosomes (groups of DNA or RNA molecules) in higher organisms; a single chromosome, as in bacteria; or one or two DNA or RNA molecules, as in viruses. (p. 642) Herpesviruses Several different types of viruses belonging to the family Herpesviridae that cause various forms of herpes infection. (p. 643) Host Any organism that is infected with a microorganism, such as bacteria or viruses. (p. 642) Human immunodeficiency virus (HIV) The retrovirus that causes AIDS. (p. 643) Humoral immunity One of two major parts of the immune system. It consists of specific immune responses in the form of antigen-specific antibodies produced from B lymphocytes. (p. 643) Immunoglobulins Synonymous with immune globulins. Glycoproteins produced and used by the humoral immune system to attack and kill any substance (antigen) that is foreign to the body. (p. 643) Influenza viruses The viruses that cause influenza, an acute viral infection of the respiratory tract. (p. 643) Nucleic acids A general term referring to DNA and RNA. These complex biomolecules contain the genetic material of all living organisms, which is passed to future generations during reproduction. (p. 642) Nucleoside A structural component of nucleic acid molecules (DNA or RNA) that consists of a purine or pyrimidine base attached to a sugar molecule. (p. 644) Nucleotide A nucleoside that is attached to a phosphate unit, which makes up the side chain “backbone” of a DNA or an RNA molecule. (p. 644) Opportunistic infections Infections caused by any type of microorganism that occur in an immunocompromised host but normally would not occur in an immunocompetent host. (p. 643) Protease An enzyme that breaks down the amino acid structure of protein molecules by chemically cleaving the peptide bonds that link together the individual amino acids. (p. 650) Replication Any process of duplication or reproduction, such as that involved in the duplication of nucleic acid molecules (DNA or RNA). This term is used most often to describe the entire process of viral reproduction, which occurs only inside the cells of an infected host organism. (p. 642) Retroviruses Viruses belonging to the family Retroviridae. These viruses contain RNA (as opposed to DNA) as their genome and replicate using the enzyme reverse transcriptase. Currently the most clinically significant retrovirus is HIV. (p. 643) Reverse transcriptase An RNA-directed DNA polymerase enzyme. It promotes the synthesis of a DNA molecule from an RNA molecule, which is the reverse of the usual process. HIV replicates in this manner. (p. 650) Ribonucleic acid (RNA) A nucleic acid composed of nucleotide units that transmit genetic information and are found in both the nuclei and cytoplasm of cells. (Compare with deoxyribonucleic acid [DNA].) (p. 642) Virion A mature virus particle. (p. 642) Viruses The smallest known class of microorganisms; viruses can only replicate inside host cells. (p. 642) General Principles of Virology FIGURE 40-1 Virus replication. Some viruses integrate into a host chromosome and enter a period of latency. mRNA, Messenger RNA. (Modified from Brody TM, Larner J, Minneman KP: Human pharmacology: Molecular to clinical, ed 5, St Louis, 2010, Mosby.) Overview of Viral Illnesses and Their Treatment Box 40-1 Herpes Simplex Virus and Varicella-Zoster Virus Infections Herpes Simplex Viruses Varicella-Zoster Virus Hepatitis Antivirals (Non-HIV) Mechanism of Action and Drug Effects Indications TABLE 40-1 Examples of Antiviral Drugs (Non-HIV) HIV, Human immunodeficiency virus. Contraindications Adverse Effects TABLE 40-2 Selected Antiviral Drugs: Adverse Effects Interactions TABLE 40-3 Selected Antiviral Drugs: Interactions Dosages Drug Profiles amantadine and rimantadine DOSAGES Antiviral Drugs (Non-HIV) *Use bronchodilator inhaler first if applicable. HIV, Human immunodeficiency virus; HSV-1, HSV-2, herpes simplex virus types 1 and 2; RSV, respiratory syncytial virus. Pharmacokinetics: Amantadine acyclovir Pharmacokinetics (Acyclovir) ganciclovir Pharmacokinetics: Ganciclovir oseltamivir and zanamivir Pharmacokinetics: Oseltamivir Pharmacokinetics: Zanamivir ribavirin Pharmacokinetics: Ribavirin simeprevir Pharmacokinetics: Simeprevir sofosbuvir Pharmacokinetics: Sofosbuvir telbivudine Pharmacokinetics: Telbivudine HIV Infection and Aids Box 40-2 FIGURE 40-2 Human immunodeficiency virus. Within the core capsid, the diploid, single-stranded, positive-sense RNA is complexed to nucleoprotein. gp, Glycoprotein. (From Dorland's illustrated medical dictionary, ed 32, Philadelphia, 2012, Saunders.) FIGURE 40-3 Life cycle of the human immunodeficiency virus (HIV). The extracellular envelope protein gp120 binds to CD4 on the surface of T lymphocytes or mononuclear phagocytes, while the transmembrane protein gp41 mediates the fusion of the viral envelope with the cell membrane. gp, Glycoprotein; mRNA, messenger RNA. (From Dorland's illustrated medical dictionary, ed 32, Philadelphia, 2012, Saunders.) FIGURE 40-4 Timeline for the spectrum of untreated HIV infection. The timeline represents the course of untreated illness from the time of infection to clinical manifestations of disease. (From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 8, Philadelphia, 2011, Elsevier.) Drugs Used to Treat HIV Infection TABLE 40-4 Examples of Antiretrovirals Used to Treat HIV Mechanism of Action and Drug Effects Indications TABLE 40-5 Recommendations for Occupational HIV Exposure Chemoprophylaxis NOTE: Recommendations vary and change often, and the reader is referred to the CDC website (www.cdc.gov) for updated guidelines. Contraindications Adverse Effects Interactions Dosages Drug Profiles enfuvirtide DOSAGES HIV/AIDS Drugs AIDS, Acquired immunodeficiency syndrome; CCR5, chemokine receptor 5; HIV, human immunodeficiency virus. Pharmacokinetics: Enfuvirtide indinavir Pharmacokinetics: Indinavir maraviroc Pharmacokinetics: Maraviroc nevirapine Pharmacokinetics: Nevirapine raltegravir Pharmacokinetics: Raltegravir tenofovir Pharmacokinetics: Tenofovir zidovudine Pharmacokinetics: Zidovudine Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 41 DRUG PROFILES ethambutol, p. 664 isoniazid, p. 664 pyrazinamide, p. 665 rifabutin, p. 665 rifampin, p. 665 rifapentine, p. 666 streptomycin, p. 666 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Aerobic Requiring oxygen for the maintenance of life. (p. 661) Antitubercular drugs Drugs used to treat infections caused by Mycobacterium bacterial species. (p. 662) Bacillus A rod-shaped bacterium. (p. 661) Granulomas Small nodular aggregations of inflammatory cells (e.g., macrophages, lymphocytes) characterized by clearly delimited boundaries, as found in tuberculosis. (p. 660) Isoniazid The primary and most commonly prescribed tuberculostatic drug. (p. 661) Multidrug-resistant tuberculosis (MDR-TB) Tuberculosis that demonstrates resistance to two or more drugs. (p. 661) Slow acetylator An individual with a genetic defect that causes a deficiency in the enzyme needed to metabolize isoniazid, the most widely used tuberculosis drug. (p. 664) Tubercle The characteristic lesion of tuberculosis; a small round gray translucent granulomatous lesion, usually with a caseated (cheesy) consistency in its interior. (See granuloma.) (p. 661) Tubercle bacilli Another common name for rod-shaped tuberculosis bacteria; essentially synonymous with Mycobacterium tuberculosis. (p. 661) Tuberculosis (TB) Any infectious disease caused by species of Mycobacterium, usually Mycobacterium tuberculosis (adjectives: tuberculous, tubercular). (p. 660) Pathophysiology of Tuberculosis Box 41-1 Antitubercular Drugs Box 41-2 Box 41-3 Mechanism of Action and Drug Effects TABLE 41-1 Antitubercular Drugs: Mechanisms of Action NAD, Nicotinamide adenine; TB, tuberculosis. Indications TABLE 41-2 Antitubercular Drugs: Clinical Uses HiB, Haemophilus influenzae type b; HIV, human immunodeficiency virus; TB, tuberculosis. Contraindications Adverse Effects TABLE 41-3 Antitubercular Drugs: Common Adverse Effects CSF, Cerebrospinal fluid. Interactions TABLE 41-4 Selected Antitubercular Drugs: Drug Interactions Dosages DOSAGES Selected Antitubercular Drugs Drug Profiles ethambutol Pharmacokinetics: Ethambutol isoniazid Pharmacokinetics: Isoniazid pyrazinamide Pharmacokinetics: Pyrazinamide rifabutin Pharmacokinetics: Rifabutin rifampin Pharmacokinetics: Rifampin rifapentine Pharmacokinetics: Rifapentine streptomycin Pharmacokinetics: Streptomycin Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 42 DRUG PROFILES amphotericin B, p. 673 caspofungin, p. 674 fluconazole, p. 674 nystatin, p. 675 terbinafine, p. 675 voriconazole, p. 675 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Antimetabolite A drug that is a either a receptor antagonist or that resembles a normal human metabolite and interferes with its function in the body, usually by competing for the metabolite's usual receptors or enzymes. (p. 672) Dermatophyte One of several fungi that are often found in soil and infect the skin, nails, or hair of humans. (p. 670) Ergosterol The main sterol in fungal membranes. (p. 672) Fungi A very large, diverse group of eukaryotic microorganisms; consist of yeasts and molds. (p. 670) Molds Multicellular fungi characterized by long, branching filaments called hyphae, which entwine to form a complex branched structure known as a mycelium. (p. 670) Mycosis The general term for any fungal infection. (p. 670) Pathologic fungi Fungi that cause mycoses. (p. 670) Sterols Substances in the cell membranes of fungi to which polyene antifungal drugs bind. (p. 672) Yeasts Single-celled fungi that reproduce by budding. (p. 670) Fungal Infections TABLE 42-1 Mycotic Infections *Malassezia spp. are a usual part of the normal human flora and appear to cause infection in only select individuals. spp., Species. Antifungal Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 42-2 Selected Antifungal Drugs: Common Adverse Effects and Cautions Sy, Systemic; T, topical. Interactions TABLE 42-3 Antifungal Drugs: Drug Interactions Dosages Drug Profiles amphotericin B Pharmacokinetics: Amphotericin B caspofungin Pharmacokinetics: Caspofungin DOSAGES Selected Antifungal Drugs fluconazole Pharmacokinetics: Fluconazole nystatin Pharmacokinetics: Nystatin terbinafine Pharmacokinetics: Terbinafine voriconazole Pharmacokinetics: Voriconazole Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 43 DRUG PROFILES atovaquone, p. 686 chloroquine and hydroxychloroquine, p. 682 mefloquine, p. 683 metronidazole, p. 686 pentamidine, p. 686 praziquantel, p. 689 primaquine, p. 683 pyrantel, p. 689 pyrimethamine, p. 683 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Anthelmintic A drug that destroys or prevents the development of parasitic worm (helminthic) infections. Also called antihelmintic or vermicide; notice that the terms for the drug categories are spelled with only one h, which appears in the second syllable of the term, whereas the term for worm infection (helminthic) is spelled with two hs, appearing in both the first and third syllables of the term. (p. 686) Antimalarial drugs Drugs that destroy or prevent the development of the malaria parasite (Plasmodium sp.) in humans. Antimalarial drugs are a subset of the broader category of antiprotozoal drugs. (p. 680) Antiprotozoal A drug that destroys or prevents the development of protozoans in humans. (p. 684) Helminthic infections Parasitic worm infections. (p. 687) Malaria A widespread protozoal infectious disease caused by four species of the genus Plasmodium. (p. 680) Parasite Any organism that feeds on another living organism (known as a host) in a way that results in varying degrees of harm to the host organism. (p. 680) Parasitic protozoans Harmful protozoans that live on or in humans or animals and cause disease in the process. (p. 679) Protozoans Single-celled organisms that are the smallest and simplest members of the animal kingdom. (p. 679) Overview Pathophysiology of Malaria FIGURE 43-1 An infected Anopheles mosquito carries parasites to humans, causing malaria. These parasites mature in the liver before entering the bloodstream and rupturing red blood cells. A pregnant woman infected with malaria may transmit the disease to her unborn child. Antimalarial Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 43-1 Antimalarial Drugs: Common Adverse Effects 6PD, Glucose-6-phosphate dehydrogenase. Interactions TABLE 43-2 Antimalarial Drugs: Drug Interactions Dosages Drug Profiles chloroquine and hydroxychloroquine DOSAGES Selected Antimalarial Drugs Pharmacokinetics: Chloroquine Pharmacokinetics: Hydroxychloroquine mefloquine Pharmacokinetics: Mefloquine primaquine Pharmacokinetics: Primaquine pyrimethamine Pharmacokinetics: Pyrimethamine Other Protozoal Infections TABLE 43-3 Types of Protozoal Infections and Common Drug Therapy *Pneumocystis jirovecii is now classified as a fungus. Antiprotozoal Drugs Mechanism of Action and Drug Effects TABLE 43-4 Selected Antiprotozoal Drugs: Mechanisms of Action *Pneumocystis jirovecii is now classified as a fungus. Indications TABLE 43-5 Selected Antiprotozoal Drugs: Indications *Pneumocystis jirovecii is now classified as a fungus. Contraindications Adverse Effects TABLE 43-6 Selected Antiprotozoal Drugs: Adverse Effects Interactions TABLE 43-7 Antiprotozoal Drugs: Drug and Laboratory Test Interactions Dosages DOSAGES Selected Antiprotozoal Drugs *Note: A combination product containing atovaquone and the drug proguanil is also used against malaria. †Pneumocystis jirovecii is now classified as a fungus. Drug Profiles atovaquone Pharmacokinetics: Atovaquone metronidazole Pharmacokinetics: Metronidazole pentamidine Pharmacokinetics: Pentamidine Helminthic Infections TABLE 43-8 Helminthic Infections Anthelmintic Drugs DOSAGES Selected Anthelmintic Drugs PO, Oral. TABLE 43-9 Anthelmintics: Class of Worms Killed Mechanism of Action and Drug Effects TABLE 43-10 Anthelmintics: Mechanisms of Action ACh, Acetylcholine; ATP, adenosine triphosphate. Indications Contraindications Adverse Effects TABLE 43-11 Anthelmintics: Common Adverse Effects Interactions Dosages Drug Profiles praziquantel Pharmacokinetics: Praziquantel pyrantel Pharmacokinetics: Pyrantel Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 44 DRUG PROFILES allopurinol, p. 699 aspirin, p. 697 celecoxib, p. 699 colchicine, p. 701 ibuprofen, p. 698 indomethacin, p. 698 ketorolac, p. 698 probenecid, p. 701 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Chemotaxis The chemical attraction of leukocytes to the site of inflammation, which worsens an inflammatory response. (p. 696) Done nomogram A standard data graph, originally published in 1960 in the journal Pediatrics, for rating the severity of aspirin toxicity following overdose. Serum salicylate levels are plotted against time elapsed since ingestion. (p. 696) Gout Hyperuricemia (elevated blood uric acid level); the arthritis caused by tissue buildup of uric acid crystals. (p. 699) Inflammation A localized protective response stimulated by injury to tissues that serves to destroy, dilute, or wall off (sequester) both the injurious agent and the injured tissue. (p. 692) Nonsteroidal antiinflammatory drugs (NSAIDs) A large and chemically diverse group of drugs that possess analgesic, antiinflammatory, and antipyretic (fever-reducing) activity. (p. 693) Salicylism The syndrome of salicylate toxicity, including symptoms such as tinnitus (ringing sound in the ears), nausea, and vomiting. (p. 696) Overview FIGURE 44-1 Arachidonic acid pathway. PGI2, Prostaglandin I2; PLT, platelet; TXA2, thromboxane A2. Nonsteroidal Antiinflammatory Drugs Box 44-1 Box 44-2 Mechanism of Action and Drug Effects Indications TABLE 44-1 Suggested NSAIDs for Patients with Various Medical Conditions COX, Cyclooxygenase. Contraindications Adverse Effects TABLE 44-2 NSAIDs: Adverse Effects MI, Myocardial infarction. Box 44-3 Toxicity and Management of Overdose TABLE 44-3 Acute or Chronic Salicylate Intoxication: Signs and Symptoms TABLE 44-4 Acute Salicylate Intoxication: Treatment CNS, Central nervous system. Interactions DOSAGES Most Commonly Used NSAIDs *Pregnancy †PO category C/D = C, first trimester; D, third trimester. form is recommended only when transitioning from injectable form to oral form of ketorolac. TABLE 44-5 Salicylates and Other NSAIDs: Drug Interactions ACE, Angiotensin-converting enzyme. Dosages Drug Profiles Salicylates aspirin Pharmacokinetics: Aspirin Acetic Acid Derivatives indomethacin Pharmacokinetics: Indomethacin ketorolac Pharmacokinetics: Ketorolac Propionic Acid Derivatives ibuprofen Pharmacokinetics: Ibuprofen Cyclooxygenase-2 Inhibitors celecoxib Pharmacokinetics: Celecoxib Enolic Acid Derivatives Antigout Drugs FIGURE 44-2 Drug Profiles allopurinol Uric acid production. XO, Xanthine oxidase. Pharmacokinetics: Allopurinol colchicine Pharmacokinetics: Colchicine probenecid Pharmacokinetics: Probenecid Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions PA R T 8 OUTLINE Learning Strategies 45 Antineoplastic Drugs Part 1: Cancer Overview and Cell Cycle–Specific Drugs 46 Antineoplastic Drugs Part 2: Cell-Cycle–Nonspecific and Miscellaneous Drugs 47 Biologic Response–Modifying and Antirheumatic Drugs 48 Immunosuppressant Drugs 49 Immunizing Drugs Application of Pharmacology and Making Connections 45 Cancer Overview and Cell Cycle–Specific Drugs DRUG PROFILES asparaginase, p. 724 capecitabine, p. 721 cladribine, p. 720 cytarabine, p. 721 etoposide, p. 722 fludarabine, p. 720 fluorouracil, p. 721 gemcitabine, p. 721 irinotecan, p. 723 methotrexate, p. 719 paclitaxel, p. 722 pegaspargase, p. 724 topotecan, p. 723 vincristine, p. 722 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Analogue A chemical compound with a structure similar to that of another compound but differing from it with respect to some component. (p. 717) Anaplasia The absence of the cellular differentiation that is part of the normal cellular growth process (see differentiation; adjective: anaplastic). (p. 714) Antineoplastic drugs Drugs used to treat cancer. Also called cancer drugs, anticancer drugs, cancer chemotherapy, and chemotherapy. (p. 714) Benign Denoting a neoplasm that is noncancerous and therefore not an immediate threat to life. (p. 711) Cancer A malignant neoplastic disease, the natural course of which is fatal (see neoplasm). (p. 710) Carcinogen Any cancer-producing substance or organism. (p. 713) Carcinomas Malignant epithelial neoplasms that tend to invade surrounding tissue and metastasize to distant regions of the body. (p. 711) Cell cycle–nonspecific Denoting antineoplastic drugs that are cytotoxic in any phase of the cellular growth cycle. (p. 715) Cell cycle–specific Denoting antineoplastic drugs that are cytotoxic during a specific phase of the cellular growth cycle. (p. 715) Clone A cell or group of cells that is genetically identical to a given parent cell. (p. 711) Differentiation An important part of normal cellular growth in which immature cells mature into specialized cells. (p. 710) Dose-limiting adverse effects Adverse effects that prevent an antineoplastic drug from being given in higher dosages, often restricting the effectiveness of the drug. (p. 716) Emetic potential The potential of a drug to cause nausea and vomiting. (p. 716) Extravasation The leakage of any intravenously or intraarterially administered medication into the tissue space surrounding the vein or artery; can cause serious tissue injury. (p. 717) Gene expression How a cell expresses a receptor or gene; the process in which information from a gene is used in the synthesis of a gene product. (p. 712) Growth fraction The percentage of cells in mitosis at any given time. (p. 713) Intrathecal A route of drug injection through the theca of the spinal cord and into the subarachnoid space. This route is used to deliver certain chemotherapy medications to kill cancer cells in the central nervous system. (p. 720) Leukemias Malignant neoplasms of blood-forming tissues characterized by the replacement of normal bone marrow cells with leukemic blasts resulting in abnormal numbers and forms of immature white blood cells in the circulation. (p. 712) Lymphomas Malignant neoplasms of lymphoid tissue. (p. 712) Malignant Tending to worsen and cause death; anaplastic, invasive, and metastatic. (p. 711) Metastasis The process by which a cancer spreads from the original site of growth to a new and remote part of the body (adjective metastatic). (p. 711) Mitosis The process of cell reproduction occurring in somatic (nonsexual) cells and resulting in the formation of two genetically identical daughter cells containing the diploid (complete) number of chromosomes characteristic of the species. (p. 713) Mitotic index The number of cells per unit (usually 1000 cells) undergoing mitosis during a given time. (p. 713) Mutagen A chemical or physical agent that induces or increases genetic mutations by causing changes in deoxyribonucleic acid (DNA). (p. 713) Mutation A permanent change in DNA that is transmissible to future cellular generations. Mutations can transform normal cells into cancer cells. (p. 710) Myelosuppression Suppression of bone marrow function, which can result in dangerously reduced numbers of red blood cells, white blood cells, and platelets. (p. 717) Nadir Lowest point in any fluctuating value over time; for example, the lowest white blood cell count measured after the count has been depressed by chemotherapy. (p. 717) Neoplasm Any new and abnormal growth, specifically growth that is uncontrolled and progressive; a synonym for tumor. A malignant neoplasm or tumor is synonymous with cancer. (p. 711) Nucleic acids Molecules of DNA and ribonucleic acid (RNA) in the nucleus of every cell (hence the name nucleic acid). Chromosomes are made up of DNA and encode all of the genes necessary for cellular structure and function. (p. 713) Oncogenic Cancer producing; often applied to tumor-inducing viruses. (p. 713) Paraneoplastic syndromes Symptom complexes arising in patients with cancer that cannot be explained by local or distant spread of their tumors. (p. 712) Primary lesion The original site of growth of a tumor. (p. 711) Sarcomas Malignant neoplasms of the connective tissues arising in bone, fibrous, fatty, muscular, synovial, vascular, or neural tissue, often first presenting as painless swellings. (p. 711) Tumor A new growth of tissue characterized by a progressive, uncontrolled proliferation of cells. Tumors can be solid (e.g., brain tumor) or circulating (e.g., leukemia or lymphoma), and benign (noncancerous) or malignant (cancerous). Circulating tumors are more precisely called hematologic tumors or hematologic malignancies. A tumor is also called a neoplasm. (p. 711) Tumor lysis syndrome A common metabolic complication of chemotherapy for rapidly growing tumors. It is characterized by the presence of excessive cellular waste products and electrolytes, including uric acid, phosphate, and potassium, and by reduced serum calcium levels. (p. 718) Overview FIGURE 45-1 Schematic model of multistep carcinogenesis. Genetic change refers to events such as the activation of protooncogenes or drug resistance genes or the inactivation of tumor suppressor genes, antimetastasis genes, or apoptosis (normal cell death). Genetic change may be relatively minimal, as with the translocations seen in various leukemias, or it may involve multiple sequential genetic alterations, as exemplified by the development of colon cancer. (From Haskell CM: Cancer treatment, ed 5, Philadelphia, 2001, Saunders.) TABLE 45-1 Tumor Characteristics: Benign and Malignant TABLE 45-2 Tumor Classification Based on Specific Tissue of Origin TABLE 45-3 Paraneoplastic Syndromes Associated with Some Cancers SIADH, Syndrome of inappropriate secretion of antidiuretic hormone. Etiology of Cancer TABLE 45-4 Cancer: Proposed Etiologic Factors Age- and Sex-Related Differences Genetic and Ethnic Factors Oncogenic Viruses Occupational and Environmental Carcinogens Radiation Immunologic Factors Cell Growth Cycle FIGURE 45-2 Cell life cycle and metabolic activity. Generation time is the period from M phase to M phase. Cells not in the cycle but capable of division are in the resting phase (G0). (From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 8, St Louis, 2011, Mosby). TABLE 45-5 Cell Cycle Phases FIGURE 45-3 General phase of the cell cycle in which the various cell cycle–specific chemotherapeutic drugs have their greatest proportionate kill of cancer cells. Cancer Drug Nomenclature *The “5” refers to the position of a fluorine atom in the cyclic ring structure of the uracil molecule. Drug Therapy FIGURE 45-4 Relationship between tumor cell burden and phases of cancer treatment. (From McCance KL: Pathophysiology: The biologic basis for disease in adults and children, ed 5, St Louis, 2006, Mosby.) Box 45-1 Cell Cycle–Specific Antineoplastic Drugs Antimetabolites Mechanism of Action and Drug Effects Folic Acid Antagonism Purine Antagonism Pyrimidine Antagonism Indications Adverse Effects TABLE 45-6 Common Manifestations of Antineoplastic Toxicity Interactions TABLE 45-7 Selected Antimetabolites: Common Drug Interactions *Not all mechanisms for these drug interactions have been clearly identified. NSAIDs, Nonsteroidal antiinflammatory drugs. Drug Profiles Folate Antagonist methotrexate Indications: Selected Antimetabolites †The term lymphocytic is synonymous in the literature with the term lymphoblastic. NHL, Non-Hodgkin's lymphoma. Purine Antagonists cladribine fludarabine Pyrimidine Antagonists capecitabine cytarabine fluorouracil gemcitabine Mitotic Inhibitors Mechanism of Action and Drug Effects Indications Adverse Effects Toxicity and Management of Extravasation TABLE 45-8 Mitotic Inhibitor and Etoposide Extravasation: Listed Specific Antidote *Important: Administration of corticosteroids and topical cooling appear to worsen toxicity. subcut, Subcutaneous. Interactions TABLE 45-9 Selected Mitotic Inhibitors and Etoposide: Common Drug Interactions *Not all mechanisms for these drug interactions have been clearly identified. CYP3A4, Cytochrome P-450 liver enzyme 3A4. Alkaloid Topoisomerase II Inhibitors Drug Profiles Selected Mitotic Inhibitors and Etoposide etoposide Indications: Selected Mitotic Inhibitors and Etoposide ALL, Acute lymphocytic leukemia; AML, acute myelocytic leukemia; HL, Hodgkin's lymphoma; NHL, non-Hodgkin's lymphoma. paclitaxel vincristine Topoisomerase I Inhibitors Mechanism of Action and Drug Effects Indications Adverse Effects Interactions TABLE 45-10 Irinotecan: Common Drug Interactions *Note that not all mechanisms for these drug interactions have been clearly identified. CYP2B6, Cytochrome P-450 liver enzyme 2B6; CYP3A4, cytochrome P-450 liver enzyme 3A4. Drug Profiles irinotecan topotecan Indications: Selected Topoisomerase I Inhibitors Antineoplastic Enzymes Indications Adverse Effects Interactions TABLE 45-11 Selected Antineoplastic Enzymes: Common Drug Interactions *Note that not all mechanisms for these drug interactions have been clearly identified. NSAIDs, Nonsteroidal antiinflammatory drugs. Drug Profiles asparaginase pegaspargase Indications: Selected Antineoplastic Enzymes Nursing Process Assessment F, Female; M, male. Box 45-2 Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 46 Cell-Cycle–Nonspecific and Miscellaneous Drugs DRUG PROFILES bevacizumab, p. 739 cisplatin, p. 737 cyclophosphamide, p. 737 doxorubicin, p. 738 hydroxyurea, p. 739 imatinib, p. 740 mechlorethamine, p. 737 mitotane, p. 740 mitoxantrone, p. 738 octreotide, p. 740 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Alkylation A chemical reaction in which an alkyl group is transferred from one molecule to another. In chemotherapy, alkylation leads to damage of the cancer cell deoxyribonucleic acid (DNA) and cell death. (p. 735) Bifunctional Referring to those alkylating drugs composed of molecules that have two reactive alkyl groups and that are therefore able to alkylate at two sites on the DNA molecule. (p. 735) Extravasation The leakage of any intravenously or intraarterially administered medication into the tissue space surrounding the vein or artery. Such an event can cause serious tissue injury, especially with antineoplastic drugs. (p. 736) Polyfunctional Referring to the action of alkylating drugs that can engage in several alkylation reactions with cancer cell DNA molecules per single molecule of drug. (p. 735) Overview Cell-Cycle–Nonspecific Antineoplastic Drugs Alkylating Drugs Mechanism of Action and Drug Effects FIGURE 46-1 Indications Organization of deoxyribonucleic acid (DNA) and site of action (*) of alkylating drugs. TABLE 46-1 Indications: Selected Alkylating Drugs HL, Hodgkin's lymphoma; NHL, non-Hodgkin's lymphoma. Adverse Effects TABLE 46-2 Commonly Used Alkylating Drugs: Severe Adverse Effects *Carboplatin Box 46-1 has less nephrotoxicity and neurotoxicity but more bone marrow suppression than cisplatin. TABLE 46-3 Alkylating Drug Extravasation: Specific Antidotes Interactions Drug Profiles cisplatin cyclophosphamide mechlorethamine Cytotoxic Antibiotics Mechanism of Action and Drug Effects Indications TABLE 46-4 Indications: Selected Cytotoxic Antibiotics HL, Hodgkin's lymphoma; NHL, non-Hodgkin's lymphoma. Adverse Effects TABLE 46-5 Cytotoxic Antibiotics: Severe Adverse Effects Toxicity and Management of Overdose Box 46-2 Interactions Drug Profiles doxorubicin mitoxantrone Miscellaneous Antineoplastics Drug Profiles bevacizumab hydroxyurea imatinib mitotane octreotide Hormonal Antineoplastics TABLE 46-6 Hormonal Antineoplastics: Adverse Effects Nursing Process Assessment Box 46-3 Nursing Diagnoses Planning: Outcome Identification Implementation Box 46-4 Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 47 DRUG PROFILES abatacept, p. 762 adalimumab, p. 757 aldesleukin, p. 760 alemtuzumab, p. 758 anakinra, p. 760 belimumab, p. 758 bevacizumab, p. 758 certolizumab, p. 758 cetuximab, p. 758 etanercept, p. 762 filgrastim, p. 752 golimumab, p. 758 ibritumomab tiuxetan, p. 758 infliximab, p. 758 interferon alfa-2a, interferon alfa-2b, interferon alfa-n3, peginterferon alfa-2a, and peginterferon alfa2b, p. 754 interferon beta-1a, interferon beta-1b, p. 755 interferon gamma-1b, p. 755 leflunomide, p. 763 methotrexate, p. 763 natalizumab, p. 758 oprelvekin, p. 753 rituximab, p. 759 sargramostim, p. 753 ocilizumab, p. 760 tositumomab and iodine I-131 tositumomab, p. 759 rastuzumab, p. 759 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Adjuvant A nonspecific immunostimulant that enhances overall immune function, rather than stimulating the function of a specific immune system cell. (p. 761) Antibodies Immunoglobulin molecules (see Chapter 49) that have the ability to bind to and inactivate antigen molecules through formation of an antigen-antibody complex. This process serves to inactivate foreign antigens that enter the body. (p. 750) Antigen A biologic or chemical substance that is recognized as foreign by the body's immune system. (p. 749) Arthritis Inflammation of one or more joints. (p. 762) Autoimmune disorder A disorder that occurs when the body's tissues are attacked by its own immune system. (p. 761) B lymphocytes (B cells) Leukocytes of the humoral immune system that develop into plasma cells, and then produce the antibodies that bind to and inactivate antigens. B cells are one of the two principal types of lymphocytes; T lymphocytes are the other. (p. 749) Biologic response–modifying drugs A broad class of drugs that includes hematopoietic drugs and immunomodulating drugs. Often referred to as biologic response modifiers (BRMs), they alter the body's response to diseases such as cancer as well as autoimmune, inflammatory, and infectious diseases. Examples are cytokines (e.g., interleukin, interferons), monoclonal antibodies, and vaccines. They are also called biomodulators or immunomodulating drugs. Biologic response–modifying drugs may be adjuvants, immunostimulants, or immunosuppressants. (p. 749) Cell-mediated immunity Collective term for all immune responses that are mediated by T lymphocytes (T cells). Also called cellular immunity. Cell-mediated immunity acts in collaboration with humoral immunity. (p. 749) Colony-stimulating factors Cytokines that regulate the growth, differentiation, and function of bone marrow stem cells. (p. 751) Complement Collective term for about 20 different proteins normally present in plasma that assist other immune system components (e.g., B cells and T cells) in mounting an immune response. (p. 759) Cytokines The generic term for nonantibody proteins released by specific cell populations (e.g., activated T cells) on contact with antigens. Cytokines act as intercellular mediators of an immune response. (p. 750) Cytotoxic T cells Differentiated T cells that can recognize and lyse (rupture) target cells that have foreign antigens on their surfaces. These antigens are recognized by the corresponding antigen receptors that are expressed (displayed) on the cytotoxic T-cell surface. Also called natural killer cells. (p. 750) Differentiation The process of cellular development from a simplified into a more specialized cellular structure. In hematopoiesis, it refers to the multistep processes involved in the maturation of blood cells. (p. 751) Disease-modifying antirheumatic drugs (DMARDs) Medications used in the treatment of rheumatic diseases that have the potential to arrest or slow the actual disease process instead of providing only antiinflammatory and analgesic effects. (p. 762) Hematopoiesis Collective term for all of the body's processes originating in the bone marrow that result in the formation of various types of blood components (adjective: hematopoietic). It includes the three main processes of differentiation (see earlier): erythropoiesis (formation of red blood cells, or erythrocytes), leukopoiesis (formation of white blood cells, or leukocytes), and thrombopoiesis (formation of platelets, or thrombocytes). (p. 749) Humoral immunity Collective term for all immune responses that are mediated by B cells, which ultimately work through the production of antibodies against specific antigens. Humoral immunity acts in collaboration with cell-mediated immunity. (p. 749) Immunoglobulins Complex immune system glycoproteins that bind to and inactivate foreign antigens. The term is synonymous with immune globulins. (p. 750) Immunomodulating drugs Collective term for various subclasses of biologic response–modifying drugs that specifically or nonspecifically enhance or reduce immune responses. The three major types of immunomodulators, based on mechanism of action, are adjuvants, immunostimulants, and immunosuppressants (see Chapter 48). (p. 749) Immunostimulant A drug that enhances immune response through specific chemical interactions with particular immune system components. An example is interleukin-2. (p. 761) Immunosuppressant A drug that reduces immune response through specific chemical interactions with particular immune system components. An example is cyclosporine (see Chapter 48). (p. 754) Interferons One type of cytokine that promotes resistance to viral infection in uninfected cells and can also strengthen the body's immune response to cancer cells. (p. 753) Leukocytes The collective term for all subtypes of white blood cells. Leukocytes include the granulocytes (neutrophils, eosinophils, and basophils), monocytes, and lymphocytes (B cells and T cells). Some monocytes also develop into tissue macrophages. (p. 750) Lymphokine-activated killer (LAK) cell Cytotoxic T cells that have been activated by interkeukin-2 and therefore have a stronger and more specific response against cancer cells. (p. 759) Lymphokines Cytokines that are produced by sensitized T lymphocytes on contact with antigen particles. (p. 750) Memory cells Cells involved in the humoral immune system that remember the exact characteristics of a particular foreign invader or antigen for the purpose of expediting immune response in the event of future exposure to this antigen. (p. 750) Monoclonal Denoting a group of identical cells or organisms derived from a single cell. (p. 750) Plasma cells Cells derived from B cells that are found in the bone marrow, connective tissue, and blood. They produce antibodies. (p. 750) Rheumatism General term for any of several disorders characterized by inflammation, degeneration, or metabolic derangement of connective tissue structures, especially joints and related structures. (p. 761) T helper cells Cells that promote and direct the actions of various other cells of the immune system. (p. 750) T lymphocytes (T cells) Leukocytes of the cell-mediated immune system. Unlike B cells, they are not involved in the production of antibodies but instead occur in various cell subtypes (e.g., T helper cells, T suppressor cells, and cytotoxic T cells). They act through direct cell-to-cell contact or through production of cytokines that guide the functions of other immune system components (e.g., B cells, antibodies). (p. 749) T suppressor cells Cells that regulate and limit the immune response, balancing the effects of T helper cells. (p. 750) Tumor antigens Chemical compounds expressed on the surfaces of tumor cells. They signal to the immune system that these cells do not belong in the body, labeling the tumor cells as foreign. (p. 749) Overview of Immunomodulators Immune System Humoral Immune System FIGURE 47-1 Cells of the humoral (antibody-mediated) immune system. Ig, Immunoglobulin. Cell-Mediated Immune System FIGURE 47-2 Cells of the cellular immune system. Pharmacology Overview Box 47-1 Hematopoietic Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 47-1 Hematopoietic Drugs: Common Adverse Effects Interactions Dosages DOSAGES Hematopoietic Drugs IL, Interleukin. Drug Profiles filgrastim Pharmacokinetics: Filgrastim sargramostim Pharmacokinetics: Sargramostim oprelvekin Pharmacokinetics: Oprelvekin Interferons Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 47-2 Interferons: Adverse Effects BUN, Blood urea nitrogen; ECG, electrocardiogram. Interactions Dosages DOSAGES Interferons *May also be given by intravenous infusion for melanoma. Route and dose vary depending on indication. †Dose is 1.5 mcg/kg/wk if given with ribavirin capsules (see Chapter 40). BSA, body surface area. Drug Profiles Interferon Alfa Products interferon alfa-2a, interferon alfa-2b, interferon alfa-n3, peginterferon alfa-2a, peginterferon alfa-2b Interferon Beta Products interferon beta-1a, interferon beta-1b Interferon Gamma Product interferon gamma-1b Monoclonal Antibodies Mechanism of Action, Drug Effects, and Indications Contraindications Adverse Effects TABLE 47-3 Selected Immunomodulating Drugs: Common Adverse Effects Interactions Dosages DOSAGES Monoclonal Antibodies MAB, Monoclonal antibody; RA, rheumatoid arthritis; TNF, tumor necrosis factor. Drug Profiles adalimumab alemtuzumab belimumab bevacizumab certolizumab cetuximab golimumab ibritumomab infliximab natalizumab rituximab tositumomab and iodine I-131 tositumomab trastuzumab Interleukins and Related Drugs Mechanism of Action and Drug Effects Box 47-2 Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles aldesleukin anakinra tocilizumab DOSAGES Interleukins and Related Drugs IL, Interleukin. Miscellaneous Immunomodulating Drugs TABLE 47-4 Miscellaneous Immunomodulating Drugs *An inflammatory reaction in the subcutaneous fat, often following a bacterial infection, or in reaction to drugs such as oral contraceptives or sulfonamides. BCG, Bacille Calmette-Guerin; MS, multiple sclerosis; RA, rheumatoid arthritis; SCID, severe combined immunodeficiency disease; TNF, tumor necrosis factor. Rheumatoid Arthritis FIGURE 47-3 Areas of the body affected by rheumatoid arthritis. Rheumatoid arthritis is most frequently seen in the shoulders, elbows, wrists, knees, and ankles, and it often affects the joints on both sides of the body equally. Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs) Box 47-3 Mechanism of Action, Indications, and Adverse Effects Contraindications Drug Profiles abatacept etanercept leflunomide methotrexate Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 48 DRUG PROFILES azathioprine, p. 773 basiliximab, p. 773 cyclosporine, p. 773 glatiramer acetate, p. 775 muromonab-CD3, p. 776 mycophenolate mofetil, p. 776 sirolimus and tacrolimus, p. 776 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Autoimmune diseases A large group of diseases characterized by the alteration of the function of the immune system so that the immune response is directed against normal tissue(s) of the body, which results in pathologic conditions. (p. 770) Grafts The term used for transplanted tissues or organs. (p. 773) Immune-mediated diseases A large group of diseases that result when the cells of the immune system react to a variety of situations, such as transplanted organ tissue or drug-altered cells. (p. 770) Immunosuppressants Drugs that decrease or prevent an immune response. (p. 770) Immunosuppressive therapy A drug treatment used to suppress the immune system. (p. 770) Immune System FIGURE 48-1 A simplified depiction of the complicated immune system. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 7, St Louis, 2010, Mosby.) Immunosuppressant Drugs Mechanism of Action and Drug Effects TABLE 48-1 Available Immunosuppressant Drugs: Mechanisms of Action and Indications *Non–FDA-approved †Note but under investigation. that “ab” in any drug name usually indicates that it is a monoclonal antibody synthesized using recombinant DNA technology. FKBP-12, FK-binding protein 12; IL-2, interleukin-2; MS, multiple sclerosis; RRMS, relapsing-remitting multiple sclerosis. Indications Contraindications Adverse Effects TABLE 48-2 Selected Immunosuppressant Drugs: Common Adverse Effects Interactions TABLE 48-3 Immunosuppressant Drugs: Selected Drug Interactions Dosages Drug Profiles azathioprine Pharmacokinetics: Azathioprine *6-8 weeks for rheumatoid arthritis. basiliximab Pharmacokinetics: Basiliximab cyclosporine DOSAGES Selected Immunosuppressant Drugs IV, Intravenous; PO, oral; RRMS, relapsing-remitting multiple sclerosis; subcut, subcutaneous. Pharmacokinetics: Cyclosporine glatiramer acetate muromonab-CD3 Pharmacokinetics: Muromonab-CD3 mycophenolate mofetil Pharmacokinetics: Mycophenolate sirolimus and tacrolimus Pharmacokinetics: Sirolimus Pharmacokinetics: Tacrolimus Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 49 DRUG PROFILES diphtheria and tetanus toxoids and acellular pertussis vaccine tetanus (adsorbed), p. 788 Haemophilus influenzae type b conjugate vaccine, p. 788 hepatitis B immunoglobulin, p. 791 hepatitis B virus vaccine (inactivated), p. 788 herpes zoster vaccine, p. 790 human papillomavirus vaccine, p. 790 immunoglobulin, p. 791 influenza virus vaccine, p. 789 measles, mumps, and rubella virus vaccine (live), p. 789 meningococcal vaccine, p. 789 pneumococcal vaccine, polyvalent and thirteen valent, p. 789 poliovirus vaccine (inactivated), p. 790 rabies immunoglobulin, p. 792 rabies virus vaccine, p. 790 Rh0(D) immunoglobulin, p. 791 tetanus immunoglobulin, p. 792 varicella virus vaccine, p. 791 varicella-zoster immunoglobulin, p. 792 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Active immunization A type of immunization that causes development of a complete and long-lasting immunity to a certain infection through exposure of the body to the associated disease antigen; it can be natural active immunization (i.e., having the disease) or artificial active immunization (i.e., receiving a vaccine or toxoid). (p. 784) Active immunizing drugs Toxoids or vaccines that are administered to a host to stimulate host production of antibodies. (p. 786) Antibodies Immunoglobulin molecules that have an antigen-specific amino acid sequence and are synthesized by the humoral immune system (B cells) in response to exposure to a specific antigen. Their purpose is to attack and destroy molecules of this antigen. (p. 784) Antibody titer The amount of an antibody needed to react with and neutralize a given volume or amount of a specific antigen. (p. 786) Antigens Substances, usually proteins and foreign to a host, that stimulate the production of antibodies and that react specifically with those antibodies. Examples of antigens include bacterial exotoxins and viruses. An allergen (e.g., dust, pollen, mold) is an antigen that can produce an immediate-type hypersensitivity reaction or allergy. (p. 783) Antiserum A serum that contains antibodies. It is usually obtained from an animal that has been immunized against a specific antigen. (p. 786) Antitoxin An antiserum against a toxin (or toxoid). It is most often a purified antiserum obtained from animals (usually horses) by injection of a toxin or toxoid so that antibodies to the toxin (i.e., antitoxin) can be collected from the animals and used to provide artificial passive immunity to humans exposed to a given toxin (e.g., tetanus immunoglobulin). (p. 786) Antivenin An antiserum against a venom (poison produced by an animal) used to treat humans or other animals that have been envenomed (e.g., by snakebite, spider bite, or scorpion sting). (p. 786) Biologic antimicrobial drugs Substances of biologic origin used to prevent, treat, or cure infectious diseases (e.g., vaccines, toxoids, immunoglobulins). These drugs are often simply referred to as biologics. However, biologics also refers to drugs of bioterrorism (e.g., anthrax spores, smallpox virus), depending on the context. (p. 784) Booster shot A repeat dose of an antigen, such as a vaccine or toxoid, which is usually administered in an amount smaller than that used in the original immunization. It is given to maintain the immune response of a previously immunized patient at, or return the response to, a clinically effective level. (p. 786) Cell-mediated immune system The immune response that is mediated by T cells (as opposed to B cells, which produce antibodies). T cells mount their immune response through activities such as the release of cytokines (chemicals that stimulate other protective immune functions) as well as through direct cytotoxicity (e.g., phagocytosis of an antigen). (p. 784) Herd immunity Resistance to a disease on the part of an entire community or population because a large proportion of its members are immune to the disease. (p. 786) Immune response A cascade of biochemical events that occurs in response to entry of an antigen (foreign substance) into the body; key processes of the immune response include phagocytosis (“eating of cells”) of foreign microorganisms and synthesis of antibodies that react with specific antigens to inactivate them. Immune response centers on the blood but may also involve the lymphatic system and the reticuloendothelial system (see later). (p. 783) Immunization The induction of immunity by administration of a vaccine or toxoid (active immunization) or antiserum (passive immunization). (p. 784) Immunizing biologics Toxoids, vaccines, or immunoglobulins that are targeted against specific infectious microorganisms or toxins. (p. 784) Immunoglobulins Glycoproteins synthesized and used by the humoral immune system (B cells) to attack and kill all substances foreign to the body. The term is synonymous with immune globulins. (p. 784) Passive immunization A type of immunization in which immunity to infection occurs by injecting a person with antiserum or concentrated antibodies that directly give the host the means to fight off an invading microorganism (artificial passive immunization). The host's immune system therefore does not have to manufacture these antibodies. This process also occurs when antibodies pass from mother to infant during breastfeeding or through the placenta during pregnancy (natural passive immunization). (p. 784) Passive immunizing drugs Drugs containing antibodies or antitoxins that can kill or inactivate pathogens by binding to the associated antigens. These are directly injected into a person (host) and provide that person with the means to fend off infection, bypassing the host's own immune system. (p. 786) Recombinant Relating to or containing a combination of genetic material from two or more organisms. Such genetic recombination is one of the key methods of biotechnology and is often used to manufacture immunizing drugs and various other medications. (p. 786) Reticuloendothelial system Specialized cells located in the liver, spleen, lymphatics, and bone marrow that remove miscellaneous particles from the circulation, such as aging antibody molecules. (p. 786) Toxin Any poison produced by a plant, animal, or microorganism that is highly toxic to other living organisms. (p. 784) Toxoids Bacterial exotoxins that are modified or inactivated (by chemicals or heat) so that they are no longer toxic but can still bind to host B cells to stimulate the formation of antitoxin; toxoids are often used in the same manner as vaccines to promote artificial active immunity in humans. They are one type of active immunizing drug (e.g., tetanus toxoid). (p. 784) Vaccines Suspensions of live, attenuated, or killed microorganisms that can promote an artificially induced active immunity against a particular microorganism. They are another type of active immunizing drug (e.g., tetanus vaccine). (p. 784) Venom A poison that is secreted by an animal (e.g., snake, insect, or spider). (p. 786) Immunity and Immunization TABLE 49-1 Active versus Passive Immunization Active Immunization Toxoids Vaccines Box 49-1 Passive Immunization Immunizing Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 49-2 Immunizing Drugs: Minor and Severe Adverse Effects Interactions Dosages Drug Profiles Active Immunizing Drugs diphtheria and tetanus toxoids and acellular pertussis vaccine (adsorbed) Haemophilus Influenzae type b conjugate vaccine hepatitis B virus vaccine (inactivated) influenza virus vaccine measles, mumps, and rubella virus vaccine (live) meningococcal vaccine pneumococcal vaccine, polyvalent and thirteen-valent poliovirus vaccine (inactivated) rabies virus vaccine human papillomavirus vaccine herpes zoster vaccine varicella virus vaccine Passive Immunizing Drugs hepatitis B immunoglobulin immunoglobulin BOX 49-2 Rh0(D) immunoglobulin rabies immunoglobulin tetanus immunoglobulin varicella-zoster immunoglobulin Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions PA R T 9 OUTLINE Learning Strategies 50 Acid-Controlling Drugs 51 Bowel Disorder Drugs 52 Antiemetic and Antinausea Drugs 53 Vitamins and Minerals 54 Anemia Drugs 55 Nutritional Supplements Studying for Tests Test-Taking Strategies Performance Evaluation 50 DRUG PROFILES antacids, general, p. 804 cimetidine, p. 806 famotidine, p. 806 lansoprazole, p. 808 misoprostol, p. 808 omeprazole, p. 807 pantoprazole, p. 808 ranitidine, p. 806 simethicone, p. 809 sucralfate, p. 808 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Antacids Basic compounds composed of different combinations of acid-neutralizing ionic salts. (p. 803) Chief cells Cells in the stomach that secrete the gastric enzyme pepsinogen (a precursor to pepsin). (p. 801) Gastric glands Secretory glands in the stomach containing the following cell types: parietal, chief, mucous, endocrine, and enterochromaffin. (p. 801) Gastric hyperacidity The overproduction of stomach acid. (p. 800) Hydrochloric acid (HCl) An acid secreted by the parietal cells in the lining of the stomach that maintains the environment of the stomach at a pH of 1 to 4. (p. 801) Mucous cells Cells whose function in the stomach is to secrete mucus that serves as a protective mucous coat against the digestive properties of HCl. Also called surface epithelial cells. (p. 801) Parietal cells Cells in the stomach that produce and secrete HCl. These cells are the primary site of action for many of the drugs used to treat acid-related disorders. (p. 801) Pepsin An enzyme in the stomach that breaks down proteins. (p. 801) Overview Acid-Related Pathophysiology FIGURE 50-1 The three zones of the stomach and the associated glands. FIGURE 50-2 Parietal cell stimulation and secretion. ADP, Adenosine diphosphate; ATP, adenosine triphosphate; ATPase, adenosine triphosphatase; cAMP, cyclic adenosine monophosphate. Antacids Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Box 50-1 Interactions TABLE 50-1 Antacids: Drug Interactions Dosages Drug Profiles antacids, general DOSAGES Selected Antacid Drugs* *Many more antacid products are available on the market than appear in this table. Dosages given are approximate dosages of active ingredients; there may be variations among different products and different dosage forms of the same product. Box 50-2 H2 Receptor Antagonists Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 50-2 H2 Receptor Antagonists: Adverse Effects Interactions DOSAGES Selected H2 Receptor Antagonists GERD, Gastroesophageal reflux disease. Dosages Drug Profiles cimetidine Pharmacokinetics: Cimetidine ranitidine Pharmacokinetics: Ranitidine famotidine Pharmacokinetics: Famotidine Proton Pump Inhibitors Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles omeprazole Pharmacokinetics: Omeprazole lansoprazole Pharmacokinetics: Lansoprazole pantoprazole Pharmacokinetics: Pantoprazole DOSAGES Selected Proton Pump Inhibitors GERD, Gastroesophageal reflux disease. Miscellaneous Acid-Controlling Drugs Drug Profiles sucralfate misoprostol Pharmacokinetics: Misoprostol simethicone Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 51 DRUG PROFILES belladonna alkaloid combinations, p. 816 bisacodyl, p. 822 bismuth subsalicylate, p. 816 diphenoxylate with atropine, p. 816 docusate salts, p. 821 glycerin, p. 821 Lactobacillus, p. 817 lactulose, p. 822 loperamide, p. 816 magnesium salts, p. 822 methylcellulose, p. 820 mineral oil, p. 821 polyethylene glycol 3350, p. 822 psyllium, p. 820 senna, p. 822 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Antidiarrheal drugs Drugs that counter or combat diarrhea. (p. 815) Constipation A condition of abnormally infrequent and difficult passage of feces through the lower gastrointestinal tract. (p. 818) Diarrhea The abnormally frequent passage of loose stools. (p. 814) Irritable bowel syndrome (IBS) A recurring condition of the intestinal tract characterized by bloating, flatulence, and often periods of diarrhea that alternate with periods of constipation. (p. 822) Laxatives Drugs that promote bowel evacuation, such as by increasing the bulk of the feces, softening the stool, or lubricating the intestinal wall. (p. 818) Overview Antidiarrheals TABLE 51-1 Antidiarrheals: Drug Categories and Selected Drugs Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 51-2 Selected Antidiarrheals: Adverse Effects Interactions Dosages Drug Profiles Adsorbents bismuth subsalicylate Anticholinergics belladonna alkaloid combinations Opiates diphenoxylate with atropine DOSAGES Selected Antidiarrheal Drugs loperamide Probiotics Lactobacillus Laxatives TABLE 51-3 Causes of Constipation FIGURE 51-1 The digestive system. (From Patton KT, Thibodeau GA: Mosby's handbook of anatomy and physiology, St Louis, 2010, Mosby.) TABLE 51-4 Laxatives: Drug Categories and Selected Drugs Mechanism of Action and Drug Effects TABLE 51-5 Laxatives: Drug Effects Indications TABLE 51-6 Laxatives: Indications Contraindications Adverse Effects TABLE 51-7 Laxatives: Adverse Effects Interactions Dosages Drug Profiles Bulk-Forming Laxatives methylcellulose DOSAGES Selected Laxatives *Docusate †Rectal sodium is available in both capsule and liquid forms. Docusate calcium is available in capsule form only. route is sometimes used to reverse certain types of coma. ‡Many dosage forms; consult product labeling if in doubt. Most common dosage forms are 8.6-mg sennosides in tablet form and 8.8 mg/5 mL of sennosides in liquid form. BM, Bowel movement; PR, per rectum. psyllium Emollient Laxatives docusate salts mineral oil Hyperosmotic Laxatives glycerin lactulose polyethylene glycol 3350 Saline Laxatives Box 51-1 magnesium salts Stimulant Laxatives bisacodyl senna Drugs for Irritable Bowel Syndrome Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 52 DRUG PROFILES aprepitant, p. 834 dronabinol, p. 834 meclizine, p. 833 metoclopramide, p. 834 ondansetron, p. 834 phosphorated carbohydrate solution, p. 835 prochlorperazine, p. 833 promethazine, p. 833 scopolamine, p. 833 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Antiemetic drugs Drugs given to relieve nausea and vomiting. (p. 829) Chemoreceptor trigger zone (CTZ) The area of the brain that is involved in the sensation of nausea and the action of vomiting. (p. 828) Emesis The forcible emptying or expulsion of gastric and, occasionally, intestinal contents through the mouth; also called vomiting. (p. 828) Nausea Sensation often leading to the urge to vomit. (p. 828) Vomiting center The area of the brain that is involved in stimulating the physiologic events that lead to nausea and vomiting. (p. 828) Nausea and Vomiting TABLE 52-1 Neurotransmitters Involved in Nausea and Vomiting CTZ, Chemoreceptor trigger zone; ACh, acetylcholine receptor; D2, dopamine 2 receptor; H1, histamine 1 receptor; 5-HT3, 5hydroxytriptamine 3 receptor; VC, vomiting center. FIGURE 52-1 Various pathways and areas in the body sending signals to the vomiting center. Antiemetic Drugs TABLE 52-2 Antiemetic Drugs: Common Drug Categories and Indications FIGURE 52-2 Sites of action of selected antinausea drugs. THC, Tetrahydrocannabinol. Mechanism of Action and Drug Effects TABLE 52-3 Antiemetic Drugs: Mechanisms of Action ACh, Acetylcholine; CTZ, chemoreceptor trigger zone; VC, vomiting center. Anticholinergic Drugs Antihistamines Antidopaminergic Drugs Neurokinin Blockers Prokinetic Drugs Serotonin Blockers Tetrahydrocannabinoids Indications Contraindications Adverse Effects TABLE 52-4 Antinausea Drugs: Adverse Effects Interactions Dosages Drug Profiles DOSAGES Selected Antiemetic and Antinausea Drugs Anticholinergic scopolamine Pharmacokinetics: Scopolamine (Transderm-Scōp, Scopace) Antihistamines meclizine Pharmacokinetics: Meclizine Antidopaminergics prochlorperazine Pharmacokinetics: Prochlorperazine promethazine Pharmacokinetics: Promethazine Neurokinin Receptor Antagonists aprepitant Pharmacokinetics: Aprepitant Prokinetic metoclopramide Pharmacokinetics: Metoclopramide Serotonin Blockers ondansetron Pharmacokinetics: Ondansetron Tetrahydrocannabinoid dronabinol Pharmacokinetics: Dronabinol Miscellaneous Antinausea Drugs phosphorated carbohydrate solution Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 53 DRUG PROFILES ascorbic acid (vitamin C), p. 853 calcifediol (vitamin D3), p. 846 calcitriol (vitamin D3), p. 846 calcium, p. 853 cyanocobalamin (vitamin B12), p. 852 ergocalciferol (vitamin D2), p. 846 magnesium, p. 855 niacin (vitamin B3), p. 850 phosphorus, p. 856 pyridoxine (vitamin B6), p. 851 riboflavin (vitamin B2), p. 849 thiamine (vitamin B1), p. 848 vitamin A, p. 844 vitamin E, p. 847 vitamin K1, p. 847 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Beriberi A disease of the peripheral nerves caused by a dietary deficiency of thiamine (vitamin B1). Symptoms include fatigue, diarrhea, weight loss, edema, heart failure, and disturbed nerve function. (p. 848) Coenzyme A nonprotein substance that combines with a protein molecule to form an active enzyme. (p. 841) Enzymes Specialized proteins that catalyze biochemical reactions. (p. 841) Fat-soluble vitamins Vitamins that can be dissolved (i.e., are soluble) in fat. (p. 841) Minerals Inorganic substances that are ingested and attach to enzymes or other organic molecules. (p. 841) Pellagra A disease resulting from a deficiency of niacin or a metabolic defect that interferes with the conversion of tryptophan to niacin (vitamin B3). (p. 848) Rhodopsin The purple pigment in the rods of the retina, formed by a protein, opsin, and a derivative of retinol (vitamin A). (p. 842) Rickets A condition caused by a deficiency of vitamin D. (p. 845) Scurvy A condition resulting from a deficiency of ascorbic acid (vitamin C). (p. 852) Tocopherols Biologically active chemicals that make up vitamin E compounds. (p. 846) Vitamins Organic compounds essential in small quantities for normal physiologic and metabolic functioning of the body. (p. 841) Water-soluble vitamins Vitamins that can be dissolved (i.e., are soluble) in water. (p. 841) Overview Pharmacology Overview TABLE 53-1 Fat-Soluble and Water-Soluble Vitamins FAT-SOLUBLE WATER-SOLUBLE Fat-Soluble Vitamins Vitamin A TABLE 53-2 Food Sources for Selected Nutrients Adapted from USDA: Dietary guidelines for Americans, 2010. Available at http://health.gov/dietaryguidelines. Accessed March 1, 2015. Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 53-3 Vitamin A: Adverse Effects Toxicity and Management of Overdose Interactions Dosages DOSAGES Selected Vitamins *Dosages are individualized. Higher doses may be required based on response to therapy. Drug Profile vitamin A Pharmacokinetics: Vitamin A Vitamin D Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 53-4 Vitamin D: Adverse Effects Toxicity and Management of Overdose Interactions Dosages Drug Profiles calcifediol calcitriol Pharmacokinetics: Calcitriol ergocalciferol Pharmacokinetics: Ergocalciferol, Vitamin D2 Vitamin E Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 53-5 Vitamin E: Adverse Effects Dosages Drug Profile vitamin E Vitamin K Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 53-6 Vitamin K: Adverse Effects Toxicity and Management of Overdose Dosages Drug Profile vitamin K1 Pharmacokinetics: Vitamin K1 Water-Soluble Vitamins Box 53-1 Vitamin B1 Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile thiamine Pharmacokinetics: Thiamine Vitamin B2 Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Dosages Drug Profile riboflavin Pharmacokinetics: Riboflavin Vitamin B3 Mechanism of Action and Drug Effects FIGURE 53-1 Niacin, once in the body, is converted to nicotinamide adenosine dinucleotide (NAD) and nicotinamide adenosine dinucleotide (NADP), which are coenzymes needed for many metabolic processes. Indications Contraindications Adverse Effects TABLE 53-7 Niacin (Vitamin B3): Adverse Effects Dosages Drug Profile niacin Pharmacokinetics (Niacin, Vitamin B3) Vitamin B6 Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 53-8 Pyridoxine (Vitamin B6): Adverse Effects Interactions Dosages Drug Profile pyridoxine Pharmacokinetics: Pyridoxine Vitamin B12 FIGURE 53-2 Cyanocobalamin is a required coenzyme for many body processes. Mechanism of Action and Drug Effects FIGURE 53-3 Indications Contraindications Adverse Effects Oral absorption of cyanocobalamin requires the presence of intrinsic factor, which is secreted by gastric parietal cells. TABLE 53-9 Cyanocobalamin (Vitamin B12): Adverse Effects Interactions Dosages Drug Profile cyanocobalamin Pharmacokinetics: Cyanocobalamin, Vitamin B12 Vitamin C Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile ascorbic acid Minerals FIGURE 53-4 When mineral compounds are dissolved in water, they separate into positively charged metallic cations or negatively charged nonmetallic anions. TABLE 53-10 Mineral Elements *Mineral elements that have a current recommended daily allowance (RDA). Calcium TABLE 53-11 Calcium Deficiency: Causes and Disorders Mechanism of Action and Drug Effects Indications TABLE 53-12 Calcium Salts: Calcium Content *Most commonly used forms for the prevention of osteoporosis. Contraindications Adverse Effects TABLE 53-13 Calcium Salts: Adverse Effects Toxicity and Management of Overdose Interactions Dosages Drug Profile calcium Magnesium DOSAGES Selected Minerals Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions Drug Profile magnesium Phosphorus Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Toxicity and Management of Overdose Interactions Drug Profile phosphorus Zinc Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 54 DRUG PROFILES epoetin alfa, p. 863 ferric gluconate, p. 866 ferrous fumarate, p. 866 ferrous sulfate, p. 866 folic acid, p. 866 iron dextran, p. 866 iron sucrose, p. 866 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Erythrocytes Another name for red blood cells (RBCs). (p. 861) Erythropoiesis The process of erythrocyte production. (p. 861) Globin The protein part of the hemoglobin molecule (see later); the four different structural globin chains most often found in adults are the alpha1, alpha2, beta1, and beta2 chains. (p. 862) Hematopoiesis The normal formation and development of all blood cell types in the bone marrow. (p. 861) Heme Part of the hemoglobin molecule; a nonprotein, iron-containing pigment. (p. 862) Hemoglobin A complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs. (p. 862) Hemolytic anemias Anemias resulting from excessive destruction of erythrocytes. (p. 863) Hypochromic Pertaining to less than normal color. The term usually describes an RBC with decreased hemoglobin content and helps further characterize anemias associated with reduced synthesis of hemoglobin. (p. 862) Microcytic Pertaining to or characterized by smaller than normal cells. (p. 862) Pernicious anemia A type of megaloblastic anemia usually seen in older adults and caused by impaired intestinal absorption of vitamin B12 (cyanocobalamin) due to lack of availability of intrinsic factor. (p. 863) Reticulocytes An immature erythrocyte characterized by a meshlike pattern of threads and particles at the former site of the nucleus. (p. 862) Spherocytes Small, globular, completely hemoglobinated erythrocytes without the usual central concavity or pallor. (p. 863) Erythropoiesis FIGURE 54-1 Schematic structure of a hemoglobin molecule. Types of Anemia FIGURE 54-2 Underlying causes of anemia are red blood cell (RBC) maturation defects and factors secondary to excessive RBC destruction. FIGURE 54-3 Schematic showing common causes and results of red blood cell (RBC) cytoplasmic maturation defects. ↓, Decreased. FIGURE 54-4 Schematic showing common causes and results of red blood cell (RBC) nuclear maturation defects. FIGURE 54-5 Increased red blood cell (RBC) destruction occurs as a result of intrinsic and extrinsic factors. ↑, Increased; DIC, disseminated intravascular coagulation; G6PD, glucose-6-phosphate dehydrogenase. Erythropoiesis-Stimulating Drugs Drug Profiles epoetin alfa Pharmacokinetics: Epoetin Alfa Iron TABLE 54-1 Ferrous Salts: Iron Content *Some patients may tolerate different formulations better; however, the number of tablets that must be consumed may decrease patient adherence. Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects TABLE 54-2 Iron Preparations: Adverse Effects Toxicity and Management of Overdose Interactions DOSAGES Selected Anemia Drugs *Doses are expressed in terms of elemental iron, not the salt itself. †Expressed in milligrams of elemental iron. Dosages are calculated for each patient's weight according to manufacturer's label. Doses are approximate. Dosages Drug Profiles ferrous fumarate Pharmacokinetics: Ferrous Fumarate ferrous sulfate Pharmacokinetics: Ferrous Sulfate iron dextran Pharmacokinetics: Iron Dextran ferric gluconate Pharmacokinetics: Ferric Gluconate iron sucrose Pharmacokinetics: Iron Sucrose Folic Acid Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile folic acid Pharmacokinetics: Folic Acid Other Anemia Drugs Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 55 DRUG PROFILES amino acids, p. 876 carbohydrate formulation, p. 874 carbohydrates, p. 877 fat formulation, p. 874 lipid emulsions, p. 877 protein formulation, p. 874 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Anabolism Metabolism characterized by the conversion of simple substances into the more complex compounds; tissue building. (p. 872) Casein The principal protein of milk and the basis for curd and cheese. (p. 874) Catabolism A complex metabolic process in which energy is liberated for use in work, energy storage, or heat production by the destruction of complex substances to form simple compounds. (p. 876) Dumping syndrome A complex reaction to the rapid entry of concentrated nutrients into the jejunum of the small intestine. The patient may experience nausea, weakness, sweating, palpitations, syncope, sensations of warmth, and diarrhea. Most commonly occurs with eating following partial gastrectomy or with enteral feedings that are administered too rapidly into the stomach or jejunum via a feeding tube. (p. 873) Enteral nutrition The provision of food or nutrients via the gastrointestinal tract, either naturally by eating or through a feeding tube in patients who are unable to eat. (p. 872) Essential amino acids Those amino acids that cannot be manufactured by the body. (p. 876) Essential fatty acid deficiency A condition that develops if fatty acids that the body cannot produce are not present in dietary or nutritional supplements. (p. 877) Hyperalimentation An older term for parenteral nutrition; its use is now discouraged because it may be misinterpreted to mean overfeeding; now referred to as total parenteral nutrition (TPN). (p. 875) Malnutrition Any disorder of undernutrition. (p. 872) Multivitamin infusion (MVI) A concentrated solution that contains several water- and fat-soluble vitamins and is used as part of an intravenous (parenteral) nutrition source. (p. 877) Nonessential amino acids Those amino acids that the body can produce without extracting them from dietary intake. (p. 876) Nutrients Substances that provide nourishment and affect the nutritive and metabolic processes of the body. (p. 872) Nutritional supplements Oral, enteral, or intravenous nutritional preparations used to provide optimal nutrients to meet the body's nutritional needs. (p. 872) Nutritional support The provision of nutrients orally, enterally, or parenterally for therapeutic reasons. (p. 872) Parenteral nutrition The administration of nutrients by a route other than through the alimentary canal, such as intravenously. (p. 872) Semiessential amino acids Those amino acids that can be produced by the body but not in sufficient amounts in infants and children. (p. 876) Total parenteral nutrition (TPN) The intravenous administration of the total nutrient requirements of the patient with gastrointestinal dysfunction, accomplished via peripheral or central venous catheter. (p. 875) Whey The thin serum of milk remaining after the casein and fat have been removed. It contains proteins, lactose, water-soluble vitamins, and minerals. (p. 874) Overview Enteral Nutrition FIGURE 55-1 Tube feeding routes. (From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 9, St Louis, 2014, Mosby.) TABLE 55-1 Routes of Enteral Nutrition Delivery Box 55-1 Mechanism of Action and Drug Effects Indications Box 55-2 Contraindications Adverse Effects Interactions Dosages Drug Profiles Elemental Formulations Polymeric Formulations Modular Formulations carbohydrate formulation fat formulation protein formulation Altered Amino Acid Formulations Parenteral Nutrition TABLE 55-2 Peripheral and Central Parenteral Nutrition: Characteristics *Many institutions use a maximum of 12.5% dextrose. Peripheral Total Parenteral Nutrition Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Central Total Parenteral Nutrition Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Dosages TABLE 55-3 Amino Acids: Recommended Adult Daily Dosage Guidelines Drug Profiles Amino Acids Box 55-3 amino acids Carbohydrates FIGURE 55-2 One gram of dextrose, fat, or protein will provide varying amounts of energy as calories. Fat FIGURE 55-3 lipid emulsions Trace Elements Lipid emulsions supply essential fatty acids and energy. Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions PA R T 1 0 OUTLINE Learning Strategies 56 Dermatologic Drugs 57 Ophthalmic Drugs 58 Otic Drugs Future Application 56 DRUG PROFILES anthralin, p. 892 bacitracin, p. 887 benzoyl peroxide, p. 888 calcipotriene, p. 892 clindamycin, p. 888 clotrimazole, p. 889 fluorouracil, p. 894 imiquimod, p. 894 isotretinoin, p. 888 lindane, p. 893 miconazole, p. 890 minoxidil, p. 893 mupirocin, p. 887 neomycin and polymyxin B, p. 887 pimecrolimus, p. 894 silver sulfadiazine, p. 888 tar-containing products, p. 892 tazarotene, p. 892 tretinoin, p. 889 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Acne vulgaris A chronic inflammatory disease of the pilosebaceous glands of the skin, involving lesions such as papules and pustules (“pimples” or “comedones”); referred to in this chapter as acne. (p. 888) Actinic keratosis A slowly developing, localized thickening of the outer layers of the skin resulting from long-term, prolonged exposure to the sun; also called solar keratosis. (p. 894) Atopic dermatitis A chronic skin inflammation seen in patients with hereditary susceptibility. (p. 886) Basal cell carcinoma The most common form of skin cancer; it arises from epidermal cells known as basal cells and is rarely metastatic. (p. 886) Carbuncles Necrotizing infections of skin and subcutaneous tissue caused by multiple furuncles (boils). They are usually caused by the bacterium Staphylococcus aureus. (p. 887) Cellulitis An acute, diffuse, spreading infection involving the skin, subcutaneous tissue, and sometimes muscle as well. It is usually caused by infection of a wound with Streptococcus or Staphylococcus species. (p. 887) Dermatitis Any inflammation of the skin. (p. 886) Dermatophytes Any of the common groups of fungi that infect skin, hair, and nails. These fungi are most commonly from the genera Microsporum, Epidermophyton, and Trichophyton. (p. 889) Dermatosis The general term for any abnormal skin condition. (p. 886) Dermis The layer of the skin just below the epidermis, consisting of papillary and reticular layers and containing blood and lymphatic vessels, nerves and nerve endings, glands, and hair follicles. (p. 885) Eczema A pruritic, papulovesicular dermatitis occurring as a reaction to many endogenous and exogenous agents, and characterized by erythema, edema, and an inflammatory infiltrate of the dermis accompanied by oozing, crusting, and scaling. (p. 886) Epidermis The superficial, avascular layers of the skin, made up of an outer dead, cornified portion and a deeper living, cellular portion. (p. 885) Folliculitis Inflammation of a follicle, usually a hair follicle. A follicle is defined as any sac or pouchlike cavity. (p. 887) Furuncles Painful skin nodules caused by Staphylococcus organisms that enter the skin through the hair follicles; also called a boil. (p. 887) Impetigo A pus-generating, contagious superficial skin infection, usually caused by Staphylococci or Streptococci. It generally occurs on the face and is most commonly seen in children; may be recognized by honey-colored crusts. (p. 887) Papules Small, circumscribed, superficial, solid elevations of the skin that are usually pink and less than 0.5 to 1 cm in diameter. (p. 887) Pediculosis An infestation with lice of the family Pediculidae. (p. 892) Pruritus An unpleasant cutaneous sensation that provokes the desire to rub or scratch the skin to obtain relief. (p. 889) Psoriasis A common, chronic squamous cell dermatosis with polygenic (multigene) inheritance and a fluctuating pattern of recurrence and remission. (p. 886) Pustules Visible collections of pus within or beneath the epidermis. (p. 887) Scabies A contagious disease caused by Sarcoptes scabiei, the itch mite, characterized by intense itching of the skin and injury to the skin (excoriation) resulting from scratching. (p. 893) Tinea A fungal skin disease caused by a dermatophyte and characterized by itching, scaling, and, sometimes, painful lesions. Tinea is a general term for an infection with any of various dermatophytes that occur at several sites; also called ringworm. (p. 889) Topical antimicrobials Substances applied to any surface that either kill microorganisms or inhibit their growth or replication. (p. 887) Vesicles Small sacs containing liquid; also called cysts. (p. 887) Overview FIGURE 56-1 Microscopic view of the skin. The epidermis, shown in longitudinal section, is raised at one corner to reveal the ridges in the dermis. (Modified from Thibodeau GA, Patton KT: Anatomy and physiology, ed 5, St Louis, 2003, Mosby.) TABLE 56-1 Epidermal Layers TABLE 56-2 Exocrine Glands of the Skin Pharmacology Overview TABLE 56-3 Dermatologic Formulations: Characteristics and Examples Antimicrobials General Antibacterial Drugs Drug Profiles bacitracin neomycin and polymyxin B mupirocin silver sulfadiazine Antiacne Drugs Drug Profiles benzoyl peroxide clindamycin isotretinoin tretinoin Antifungal Drugs TABLE 56-4 Topical Antifungal Drugs OTC, Available over the counter without prescription; Rx, currently available by prescription only. Drug Profiles clotrimazole miconazole Antiviral Drugs Anesthetic, Antipruritic, and Antipsoriatic Drugs Topical Anesthetics Topical Antipruritics and Antiinflammatories TABLE 56-5 Commonly Used Topical Corticosteroids (in Order of Decreasing Potency) *Skin penetration and thus potency is enhanced by the vehicle (dosage form) containing the steroid. In decreasing order of effectiveness are ointments, gels, creams, and lotions. Antipsoriatic Drugs Drug Profiles tazarotene tar-containing products anthralin calcipotriene Miscellaneous Dermatologic Drugs Drug Profiles Ectoparasiticidal Drugs lindane Hair Growth Drugs minoxidil Sunscreens Antineoplastic Drugs fluorouracil Immunomodulators pimecrolimus imiquimod Wound Care Drugs TABLE 56-6 Selected Wound Care Products Skin Preparation Drugs TABLE 56-7 Skin Preparation Drugs (Antiseptics) Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 57 DRUG PROFILES acetylcholine, p. 907 apraclonidine, p. 908 artificial tears, p. 917 atropine sulfate, p. 916 bacitracin, p. 914 betaxolol, p. 909 ciprofloxacin, p. 914 cromolyn, p. 917 cyclopentolate, p. 916 dexamethasone, p. 915 dipivefrin, p. 908 dorzolamide, p. 910 echothiophate, p. 907 erythromycin, p. 913 fluorescein, p. 916 flurbiprofen, p. 915 gentamicin, p. 913 glycerin, p. 911 ketorolac, p. 915 latanoprost, p. 912 mannitol, p. 911 natamycin, p. 914 olopatadine, p. 917 pilocarpine, p. 907 sulfacetamide, p. 914 tetracaine, p. 916 tetrahydrozoline, p. 917 timolol, p. 909 trifluridine, p. 914 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Accommodation The adjustment of the lens of the eye for variations in distance. (p. 903) Angle-closure glaucoma Glaucoma that occurs as a result of a narrowed anatomic angle between the lens and cornea. Also called closed-angle glaucoma, narrow-angle glaucoma, congestive glaucoma, and pupillary closure glaucoma. (p. 904) Anterior chamber The bubble-like portion of the front of the eye between the iris and the cornea. (p. 903) Aqueous humor The clear, watery fluid circulating in the anterior and posterior chambers of the eye. (p. 903) Canal of Schlemm A tiny circular vein at the angle of the anterior chamber of the eye through which the aqueous humor is drained and ultimately funneled into the bloodstream. Also called Schlemm canal. (p. 903) Cataract An abnormal progressive condition of the lens of the eye, characterized by loss of transparency with resultant blurred vision. (p. 903) Ciliary muscle The circular muscle between the anterior and posterior chambers of the eye behind the iris. It is connected to the suspensory ligaments that control the curvature of the lens. (p. 903) Cones Photoreceptive (light-receiving) cells in the retina of the eye that enable a person to perceive colors and play a large role in central (straight-ahead) vision. (p. 903) Cornea The convex, transparent anterior part of the eye. (p. 902) Cycloplegia Paralysis of the ciliary muscles, which prevents the accommodation of the lens for variations in distance. (p. 903) Cycloplegics Drugs that paralyze the ciliary muscles of the eye. (p. 903) Dilator muscle A muscle that constricts the iris of the eye but dilates the pupil. Also called dilator pupillae. (p. 903) Glaucoma An abnormal condition of elevated pressure within an eye because of obstruction of the outflow of aqueous humor. (p. 903) Intraocular pressure The pressure of the fluids of the eye against the tunics (retina, choroid, and sclera). (p. 903) Iris The round, muscular portion of the eye that gives the eye its color and serves as an aperture controlling the amount of light passing through the pupil. (p. 903) Lacrimal ducts Small tubes that drain tears from the lacrimal glands into the nasal cavity. (p. 902) Lacrimal glands Glands located at the medial corners of the eyelids that produce tears. (p. 902) Lens The transparent, curved structure of the eye that is located directly behind the iris and the pupil and is attached to the ciliary body by ligaments. (p. 903) Lysozyme An enzyme with antiseptic actions that destroys some foreign organisms. It is normally present in tears, saliva, sweat, and breast milk. (p. 902) Miotics Drugs that constrict the pupil. (p. 903) Mydriatics Drugs that dilate the pupil. (p. 903) Open-angle glaucoma A type of glaucoma that is often bilateral, develops slowly, is genetically determined, and does not involve a narrowing of the angle between the iris and the cornea. (Also called chronic glaucoma, wide-angle glaucoma, and simple glaucoma.) (p. 904) Optic nerve A major nerve that connects the posterior end of each eye to the brain, to which it transmits visual signals. (p. 903) Pupil A circular opening in the iris of the eye, located slightly to the nasal side of the center of the iris. The pupil lies behind the anterior chamber of the eye and the cornea and in front of the lens. (p. 903) Retina The innermost layer of the eye, containing both rods and cones that receive visual stimuli and transmit them to the optic nerve. (p. 903) Rods The photoreceptive elements arranged perpendicularly to the surface of the retina. Rods are especially sensitive to low-intensity light and are responsible for black-and-white and peripheral (“off-to-the-side”) vision. (p. 903) Sphincter pupillae A muscle that expands the iris while constricting or narrowing the diameter of the pupil. (p. 903) Tears Watery saline or alkaline fluid secreted by the lacrimal glands to moisten the conjunctiva (see Figure 57-1). (p. 902) Uvea The fibrous tunic beneath the sclera that includes the iris, the ciliary body, and the choroid of the eye (see Figure 57-1). Also called tunica vasculosa bulbi or uveal tract. (p. 903) Vitreous body A transparent, semigelatinous substance contained in a thin membrane filling the cavity behind the lens. Also called the corpus vitreum. (p. 903) Vitreous humor The fluid component of the vitreous body. (p. 903) Overview FIGURE 57-1 Horizontal section through the left eyeball, looking from the top down. (Modified from Patton KT, Thibodeau GA: Anatomy and physiology, ed 7, St Louis, 2010, Mosby.) FIGURE 57-2 Extrinsic muscles of the right eye, lateral view. The medial rectus muscle is hidden from view in this figure but is directly across from the lateral rectus muscle. (Modified from Patton KT, Thibodeau GA: Anatomy and physiology, ed 7, St Louis, 2010, Mosby.) Lacrimal Glands Layers of the Eye FIGURE 57-3 Different nervous systems control pupil size. FIGURE 57-4 Drug classes and their effects on pupil size. FIGURE 57-5 Function of rods and cones in relation to color vision. Pathophysiology of Glaucoma FIGURE 57-6 How increased aqueous humor can result in impaired vision. IOP, Intraocular pressure. FIGURE 57-7 Main structures of the eye and an enlargement of the canal of Schlemm showing the flow of aqueous humor. A, Flow in a normal eye. B, In angle-closure glaucoma, the closure of the anterior angle due to contact between the iris and the trabecular meshwork prevents aqueous humor from exiting through the canal of Schlemm, which leads to increased intraocular pressure. C, In open-angle glaucoma, the anterior angle remains open, but the canal of Schlemm is obstructed by tissue abnormalities. (Modified from McKenry LM, Tessier E, Hogan MA: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.) TABLE 57-1 Glaucoma: Types and Characteristics Pharmacology Overview Antiglaucoma Drugs TABLE 57-2 Antiglaucoma Drugs: Effects on Aqueous Humor 0, No effect; +, minor effect; ++, moderate effect; +++, pronounced effect. Cholinergic Drugs (Miotics) Mechanism of Action and Drug Effects FIGURE 57-8 FIGURE 57-9 Indications Cholinergic response of miosis to parasympathomimetic drugs. ACh, Acetylcholine; PSNS, parasympathetic nervous system. Therapeutic effects of direct- and indirect-acting miotics on glaucoma. IOP, Intraocular pressure. TABLE 57-3 Miotics: Indications Contraindications Adverse Effects Interactions DOSAGES Selected Miotics Dosages Drug Profiles Direct-Acting Miotics acetylcholine Pharmacokinetics: Acetylcholine pilocarpine Pharmacokinetics Pilocarpine Indirect-Acting Miotic echothiophate Pharmacokinetics: Echothiophate Sympathomimetics (Mydriatics) Mechanism of Action and Drug Effects DOSAGES Selected Ocular Sympathomimetics FIGURE 57-10 FIGURE 57-11 Indications Contraindications Adverse Effects Interactions Mechanism of mydriasis. Ocular effects of alpha (α) and beta (β) stimulation. IOP, Intraocular pressure. Dosages Drug Profiles apraclonidine Pharmacokinetics: Apraclonidine dipivefrin Pharmacokinetics: Dipivefrin Beta-Adrenergic Blockers Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles betaxolol DOSAGES Selected Ocular Beta Blockers Pharmacokinetics: Betaxolol timolol Pharmacokinetics: Timolol Carbonic Anhydrase Inhibitors Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile dorzolamide Pharmacokinetics: Dorzolamide DOSAGES Ocular Carbonic Anhydrase Inhibitor Osmotic Diuretics Mechanism of Action and Drug Effects FIGURE 57-12 Indications Contraindications Adverse Effects Mechanism and ocular effects of osmotic diuretics. IOP, Intraocular pressure. TABLE 57-4 Osmotic Diuretics: Adverse Effects Interactions Dosages Drug Profiles glycerin Pharmacokinetics: Glycerin mannitol Pharmacokinetics: Mannitol Prostaglandin Agonists DOSAGES Osmotic Diuretics DOSAGES Ocular Prostaglandin Agonist Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profile latanoprost Pharmacokinetics: Latanoprost Antimicrobial Drugs TABLE 57-5 Common Ocular Infections Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Dosages Drug Profiles Aminoglycosides gentamicin Pharmacokinetics: Gentamicin Macrolide Antibiotics erythromycin Pharmacokinetics: Erythromycin DOSAGES Selected Ocular Antimicrobials Polypeptide Antibiotics bacitracin Pharmacokinetics: Bacitracin Quinolone Antibiotics ciprofloxacin Pharmacokinetics: Ciprofloxacin Sulfonamides sulfacetamide Pharmacokinetics: Sulfacetamide Antifungal Drug natamycin Pharmacokinetics: Natamycin Antiviral Drugs trifluridine Antiinflammatory Drugs Box 57-1 Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Drug Profiles Corticosteroid dexamethasone Pharmacokinetics: Dexamethasone Nonsteroidal Antiinflammatory Drugs flurbiprofen Pharmacokinetics: Flurbiprofen ketorolac Pharmacokinetics: Ketorolac Topical Anesthetics Mechanism of Action and Drug Effects Indications Contraindications Adverse Effects Interactions Drug Profile tetracaine Pharmacokinetics: Tetracaine Diagnostic Drugs Drug Profiles Cycloplegic Mydriatics atropine sulfate cyclopentolate Ophthalmic Dye fluorescein Antiallergic Drugs Drug Profiles Antihistamines olopatadine Mast Cell Stabilizers cromolyn Decongestants tetrahydrozoline Lubricants and Moisturizers artificial tears DOSAGES Ocular Antiallergics Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions 58 DRUG PROFILES carbamide peroxide, p. 923 Objectives When you reach the end of this chapter, you will be able to do the following: KEY TERMS Cerumen A yellowish or brownish waxy excretion produced by modified sweat glands in the external ear canal. Also called earwax. (p. 923) Otitis externa Inflammation or infection of the external auditory canal. (p. 922) Otitis media (OM) Inflammation or infection of the middle ear. (p. 922) Overview FIGURE 58-1 Structure of the ear. Treatment of Ear Disorders Antibacterial and Antifungal Otic Drugs TABLE 58-1 Common Antibacterial Otic Products TABLE 58-2 Common Antifungal Otic Products Neomycin, polymixin B, and hydrocortisone otic preparations are contraindicated in patients with a perforated eardrum. Drug Profiles Antibacterial Products Antifungal Products Earwax Emulsifiers Drug Profile carbamide peroxide Nursing Process Assessment Nursing Diagnoses Planning: Outcome Identification Implementation Evaluation Patient-Centered Care: Patient Teaching Key Points NCLEX® Examination Review Questions Critical Thinking and Prioritization Questions APPENDIX *Note: As part of its 2004 National Patient Safety Goals, the Joint Commission announced that all accredited organizations must discontinue using the following abbreviations, acronyms, and symbols: U, IU, qd, qod, MS, MSO4, and MgSO4. Trailing zeros and lack of leading zeros were also discontinued. In other words, a zero should never appear by itself after a decimal point (1 mg instead of 1.0 mg), and a zero should always be used before a decimal point (0.1 mg instead of .1 mg). In addition, abbreviations for drug names should not be used because they can be misinterpreted. Other items are being considered for future inclusion on the official “do not use” list, such as the @ sign (write out the word at) and the symbols > and < (write out as greater than and less than). The abbreviations “cc” and “µg” should also be avoided and are being considered for inclusion on future lists. This National Patient Safety Goal was incorporated into the Information Management standards in 2010. †These abbreviations are on the List of Error Prone Abbreviations, Symbols, and Dose Designations of the Institute for Safe Medication Practices (ISMP). These abbreviations have been reported to the ISMP as being frequently involved in medication errors. The ISMP recommends not ever using these abbreviations when communicating medical information, including medication orders and medication administration records. Data from Institute for Safe Medication Practices (ISMP): ISMP's list of error-prone abbreviations, symbols, and dose designations, 2012. Available at http://www.ismp.org/tools/errorproneabbreviations.pdf. Accessed September 24, 2015. Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 Chapter 21 Chapter 22 Chapter 23 Chapter 24 Chapter 25 Chapter 26 Chapter 27 Chapter 28 Chapter 29 Chapter 30 Chapter 31 Chapter 32 Chapter 33 Chapter 34 Chapter 35 Chapter 36 Chapter 37 Chapter 38 Chapter 39 Chapter 40 Chapter 41 Chapter 42 Chapter 43 Chapter 44 Chapter 45 Chapter 46 Chapter 47 Chapter 48 Chapter 49 Chapter 50 Chapter 51 Chapter 52 Chapter 53 Chapter 54 Chapter 55 Chapter 56 Chapter 57 Chapter 58 General Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 Chapter 21 Chapter 22 Chapter 23 Chapter 24 Chapter 25 Chapter 26 Chapter 27 Chapter 28 Chapter 29 Chapter 30 Chapter 31 Chapter 32 Chapter 33 Chapter 34 Chapter 35 Chapter 36 Chapter 37 Chapter 38 Chapter 39 Chapter 40 Chapter 41 Chapter 42 Chapter 43 Chapter 44 Chapter 45 Chapter 46 Chapter 47 Chapter 48 Chapter 49 Chapter 50 Chapter 51 Chapter 52 Chapter 53 Chapter 54 Chapter 55 Chapter 56 Chapter 57 Chapter 58 Evidence-Based Practice Patient-Centered Care: Cultural Implications Patient-Centered Care: Lifespan Considerations for the Older Adult Patient Patient-Centered Care: Lifespan Considerations for the Pediatric Patient Safety: Herbal Therapies and Dietary Supplements Safety: Laboratory Values Related to Drug Therapy Safety and Quality Improvement: Preventing Medication Errors Teamwork and Collaboration: Legal and Ethical Principles Abbreviations for Diagnostic and Laboratory Tests

Pharmacology and the Nursing Process - Linda Lane Lilley 1 2

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