Basic Pharmacology for Nurses [12th ed.] 032300976X, 9780323009768

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k Basic

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Numbers Dosage Recommendations Dosage Forms That Should Not be Crushed

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Cost of Therapy Top-Selling Drugs .

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and much more

M Mosby An

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of Elsevier Science

1

Drug ACE

Classifications

2/

inhibitors:

Prevent the synthesis of angiotensin a potent vasoconstrictor; used to treat hypertension and

II,

Acetylcholinesterase inhibitors:

Antilipemics:

Used

to reduce

serum cholesterol and/or

triglycerides

heart failure

Promote the accumula-

tion of acetylcholine, resulting in prolonged cholinergic

Antimicrobials: Chemicals that eliminate living microorganisms pathogenic to the patient; also called antibiotics or antiinfectives

effects

Antineoplastics:

Adrenergic:

Produce effects similar to the neurotransmitter norepinephrine; see Chapter Adrenergic blocking agents: Inhibit the adrenergic sys-

alone or in combination with other treatment modalities

tem, preventing stimulation of the adrenergic receptors

Antiparkinson's: Used in the treatment of Parkinson's syndrome and other dyskinesias Antiplatelets: Prevent platelet clumping (aggregation)

1

Aminoglycosides:

Gentamicin, tobramycin, and related antibiotics; noted for potentially dangerous toxicity Analgesics: Narcotic and non-narcotic; relieve pain without producing loss of consciousness or reflex activity

Androgens:

These steroid hormones produce masculin-

izing effects

For example, local anesthesia, general anescause a loss of sensation with or without a loss of consciousness Anesthetics:

thesia;

such as radiation, surgery, or biologic response modifiers for the treatment of a variety of types of cancer

and thereby prevent an essential step in formation of a blood clot Antipsychotics: Used in the treatment of severe mental illnesses; also known as major tranquilizers or neuroleptics, although the term tranquilizer is avoided today to prevent the misperception that the patient is being tranquilized riety

pectoris

Antithyroid:

Used to treat anxiety symptoms or disorknown as minor tranquilizers or anxiolytics, al-

ders; also

though the term tranquilizer

avoided today to prevent the misperception that the patient is being tranquilized is

Antiarrhythmics: Used to correct cardiac arrhythmias (any heart rate or rhythm other than normal sinus rhythm) Antibiotics: Used to treat infections caused by pathogenic microbes; the term is often used interchangeably with antimicrobial agents

Antispasmodics:

parasympathetic nervous system; also

known

in the

Actually anticholinergic agents

Used

known

symptoms of hyperthyhormone antagonists treat or prevent symptoms

to treat the

as thyroid

Antitussive: Used to suppress a cough by acting on the cough center of the brain Antiulcer agents: These drugs, such as histamine-2 antagonists, decrease the volume and increase the pH of gastric

secretion

Used

to treat infections

caused by pathogenic

viruses

Bronchodilators:

as choliner-

reduce fevers associated with a va-

Antituberculins: Used to caused by Mycobacterium tuberculosis

Antivirals:

Block the action of acetylcholine

Anticholinergic:

to

of conditions

roidism; also

Antianxiety:

Used

Antipyretics:

Reduce the acidity of the gastric contents Antianginals: Used to prevent or treat attacks of angina Antacids:

Also called chemotherapy agents; used

Stimulate receptors within the tracheo-

gic blocking agents, antispasmodics, and parasympa-

bronchial tree to relax and dilate the airway passages,

tholytic agents

lowing a greater volume of proving oxygenation

Anticoagulants:

Do NOT

dissolve existing blood clots.

Beta-blockers:

but do prevent enlargement or extension of blood clots

Suppress abnormal neuronal activity

Anticonvulsants: the

CNS,

in

preventing seizures

Relieve depression

Antidepressants:

Also known as hypoglycemics; include insulin (used to treat type 1 diabetes mellitus) and oral hypoglycemic agents (used in the treatment of non-insulin dependent diabetes mellitus) Antidiabetics:

Antidiarrheals:

Relieve or control the symptoms of

acute or chronic diarrhea

Used to prevent or treat nausea and vomiting Used to treat fungal infections Antifungals: Antiglaucoma: Used to reduce intraocular pressure Antigout: Used in the treatment of active gout attacks or Antiemetics:

Antihistamines:

Used

to treat allergy

symptoms; may

of sympathetic transand epinephrine; used to treat angina, arrhythmias, hypertension, and glaucoma Calcium channel blockers: Also called calcium ion antagonists, slow channel blockers or calcium ion influx inhibitors; inhibit the movement of calcium ions across the cell membrane; used to decrease arrhythmias, slow rate of contraction of the heart, and cause vasodilation of blood Inhibit the activity

vessels

Carbonic anhydra.se inhibitors: Interfere with the production of aqueous humor, thereb) reducing intraocular pressure associated with glaucoma Cell-stimulating agents:

Improve immune function by

stimulating the activity of various

immune

cells

Also known as parasympathomimetics;

produce effects similar

to those

of acetylcholine These enzymes destroy

also be used to treat motion sickness, insomnia, and other

Cholmcstcraac

non-allergic reactions

acetylcholine, the cholinergic neurotransmitter

Antihypertensives: (hypertension)

Used

to treat elevated

blood pressure

al-

be exchanged and im-

mitters, norepinephrine,

Cholinergic:

to prevent future attacks

air to

(dating agent:

inhibitors:

This drug, sucralfate, forms a complex adheres to the crater of an ulcer, protecting it from aggravation from gastric secretions thai

Colony-stimulating factors: Stimulate progenitor cells in bone marrow to increase numbers of leukocytes, thereby improving immune function

These hormones are secreted by the

Corticosteroids:

Neuromuscular blockers:

Skeletal muscle relaxants used to produce muscle relaxation during anesthesia; reduce the use and side effects of general anesthetics; used to ease endotracheal intubation and prevent laryngospasm

adrenal cortex of the adrenal gland

Nitrates:

Cycloplegics:

used to

Anticholinergic agents that paralyze ac-

commodation of

the

iris

of the eye

Agents that cause direct cell death; often used for cancer chemotherapy Decongestants: Act by reducing swelling in the nasal passages caused by a common cold or allergic rhinitis Digestants: Combination products used to treat various digestive disorders and to supplement deficiencies of natCytotoxics:

enzymes

ural digestive

Digitalis glycosides:

Increase the force of contraction

and slow the heart

thereby improving cardiac

rate,

Degrade

treat

Nonsteroidal antiinflammatory drugs (NSAIDs): These "aspirin-like" drugs are chemically unrelated

to the

salicylates but are prostaglandin inhibitors

Opioids:

Centrally acting analgesic agents related to

morphine Oral contraceptives: Used for birth control Oral hypoglycemics: Used in type 2 diabetes mellitus to improve glucose metabolism and lower blood glucose levels Progestins:trial

output

to nitric oxide, a potent vasodilator

angina

Steroids regulating endometrial and

myome-

function; used alone or in combination with estrogen

for oral contraception

Act

Diuretics:

Used

Emetics: Estrogens:

Protease inhibitors: Saquinavir, ritonavir, indinavir, and related drugs; block the maturation of human immunodeficiency virus; used for HIV infections

to increase the flow of urine to induce

vomiting

Steroids that cause feminizing effects

Liquify mucus by stimulating the natural from the bronchial glands Fluoroquinolones: Ciprofloxacin and related agents; widely used broad-spectrum antibiotics Gastric stimulants: Used to increase stomach contractions, relax the pyloric valve, and increase peristalsis in the

Expectorants:

Salicylates:

lubricant fluids

tiinflammatory agents

Effective as analgesics, antipyretics, and an-

Given to an individual to produce relaxation do not necessarily produce sleep Selective serotonin reuptake inhibitors (SSRIs): Antidepressants that act by specifically blocking the reupSedatives:

and

rest;

gastrointestinal tract; result in an increase in gastric transit

take of serotonin

time and emptying of the intestinal tract

Serotonin antagonists: Used to block serotonin; prevent emesis induced by chemotherapy, radiation therapy, and

Also known as adrenocorticosteroids; Are used to regulate carbohydrate, fat, and protein metabolism Gonadal hormones: Hormones produced by the testes in the male and ovaries in the female

Statins

Herbals:

stool, thereby softening

Glucocorticoids:

ments;

Plant products usually sold as food supple-

may have pharmacologic

ated or regulated by the

Histamine crease the

H

pH

2

effects that are not evalu-

FDA

antagonists:

Decrease the volume and

in-

of gastric secretions both during the day and

Used

to decrease the

production or in-

Used

to

Hormone

Sympatholytics:

required for glucose transport to the

Interfere with the storage

Sympothomimet ics:

Used

to prevent physiologic

Mimic

A

and release of

the action of dopamine, nor-

group of drugs (alteplase, and urokinase) given to dissolve

specific

anistreplase, stretokinase,

Act by a variety of mechanisms

to treat

Used

to counteract or

block the action of excessive formation of thyroid hormones

Used when thyroid hormones

are

not being produced or are not produced in sufficient quantities to

lactation

meet the body's physiologic needs

Tricyclic antidepressants:

Inhibit the reuptake of norep-

inephrine and serotonin (include doxepin, amitriptyline,

constipation

molecular weight heparins:

Anticoagulants for the

prophylactic treatment of pulmonary thromboembolism

and deep vein thrombosis Macrolides: Erythromycin, azithromycin, and related antibiotics

MAO inhibitors:

into the

epinephrine, and epinephrine

Thyroid hormones:

cells

Laxatives:

Draw water

it

Thyroid hormone antagonists:

produce sleep

Lactation suppressants:

Block the

existing blood clots

crease the excretion of uric acid

Hypnotics:

reductase inhibitors):

Stool softeners or fecal softeners:

Thrombolytics:

Hyperuricemics:

Low

(HMG-CoA

synthesis of cholesterol

norepinephrine

the night

Insulins:

surgery

Agents

that

block monoamine oxidase,

and imipramine) Uricosuric agents: Act on the tubules of the kidneys to enhance the excretion of uric acid

Urinary analgesics: Produce a local anesthetic effect on the mucosa of the ureters and bladder to relieve burning, pain, urgency, and frequency associated with urinary tract

thereby preventing the degradation of norepinephrine and

infections (UTIs)

serotonin

Urinary antimicrobials:

Mineralocorticoids:

Steroids that cause the kidneys to

sodium and water Cause constriction of the iris Mucolytics: Reduce the thickness and stickiness of pulmonary secretions by acting directly on the mucus plugs to dissolve them Muscle relaxants: Relieve muscle spasms Mydriatics: Cause dilation of the iris

Substances excreted and con-

centrated in the urine in sufficient amounts to have an anti-

on the urine and the urinary

retain

septic effect

Miotics:

Uterine relaxants:

Used

tract

to primarily prevent

preterm

la-

bor and delivery

Uterine stimulants:

Increase the frequency or strength

of uterine contractions Vaccines:

Suspensions of either

live,

attenuated, or killed

bacteria or viruses

Vasodilators:

Relax the arteriolar smooth muscle

Basic

Pharmacology for Nurses

Basic

Pharmacology for Nurses Bruce D. Clayton, Pharm D, RPh, BS Professor of Pharmacy Practice

College of Pharmacy

&

Health Sciences

Butler University Indianapolis, Indiana

Yvonne

N. Stock,

MS, BSN, RN

Professor of Nursing

Health Occupations Department

Iowa Western Community College Council Bluffs, Iowa

twelfth edition

with

236

illustrations

M Mosby An

Affiliate of Elsevier

St.

Louis

London

Science

Philadelphia

Sydney

Toronto

_-

Digitized by the Internet Archive in

2011

http://www.archive.org/details/basicpharmacologOOclay

CONSULTANTS Marcia G. Bower, MSN,

CRNP

Netha O'Meara, MSN, CNS, RN, BS,

Course Coordinator and Instructor

Director, Associate

Abington Memorial Hospital

Wharton County

School of Nursing

Wharton, Texas

Degree Nursing Program

Junior College

Willow Grove, Pennsylvania

Susan Lori Mooberry,

LPN

BSN,

MT

Central College

Peoria,

Illinois

Anita Norton,

MSN, BSN, RN

Associate Dean, Division of Health Sciences Instructor

in

Quatre, BSN, RN, RN/C

Gavilan College

Instructor

Illinois

Nursing

Jefferson State

S.

Professor of Nursing

Community College

Birmingham, Alabama

Gilroy, California

Preface

By

side effects to drug therapy are to be anticipated.

giving

bothersome side effects, the possibility of increased adherence to the prescribed regimen is enhanced. Information on adverse drug effects needs to be taught to the patient in a manner that does not unduly upset the patient but emphasizes the need for prompt reporting of the adverse effects to the physician should they occur so the needed modifications in the regimen can be made. When individuals do not master their self-care, it must be validated in the chart and reported to the physician so necessary referrals can be made. the patient concrete suggestions to alleviate the

understanding the monitoring parameters that the nurse needs to perform and should include information on the signs and

symptoms

that

need to be reported

to the physician.

ANCILLARIES Manual The Instructor's Resource Manual has been completely updated to include information on the newly added drugs and the new chapters added to this Instructor's Resource

edition.

It

consists of four parts: drug classification review,

syllabi, test bank,

and answer section. The drug classification

section contains a quick review of the drug classification in

easy-to-understand language. This

FEATURES

is

a tool instructors can use

to help students grasp important information

New

on drug

classes.

Nutrition Chapter (Chapter 44) This new chapter provides an overview of the principles of nutrition, including

The

macronutrients, metabolic requirements, vitamins, minerals,

from the book, and new collaborative activities and projects. The test bank has added math review questions. The answers to the math review questions and test bank questions are included in the answer section. Also included are reproducible forms of patient education and monitoring forms, illustrated shaded syringes, and a blank medication administration

and malnutrition. Dietary reference intakes, recommended

di-

etary allowances, the use of enteral food supplements, and

drug/food interactions are discussed in

New Herbal

detail.

Medicines Chapter (Chapter 45) This new

chapter discusses the role of herbal medicines in rational drug

therapy and legal issues associated with their use. lists

10 factors to consider

cines.

when recommending

Box

45-1

herbal medi-

Twelve herbal medicines, representing over

90%

of the

most commonly used herbals, are discussed in detail, including actions, uses, side effects, and drug interactions. New Drugs 160 new drugs, herbal medicines, and nutritional products have been added to this edition. Drugs Used to Treat Diabetes Mellitus (Chapter 33) This chapter has been significantly rewritten to include new treatment recommendations of the American Diabetes Association and monographs on the new medicines available to treat type

include chapter objectives and outlines, key

words, math review questions and

critical

thinking questions

record.

Student Learning Guide The Student Learning Guide is available separately or packaged with the book. The study guide includes a drug classification review, chapter assign-

ments from the syllabi in the instructor's manual, content review questions, math review worksheets, collaborative activities and projects, critical thinking questions, and practice quizzes for each chapter. Also included are an answer section and reproducible patient education and monitoring forms.

Mosby's Electronic Image Collection for Pharmacology This innovative

CD-ROM

contains 150 full-color images de-

picting key concepts of nursing pharmacology.

2 diabetes.

Drugs Used

syllabi

Men's and Women's Health (Chapter

The

collection

38)

allows instructors to create custom slide shows (works well

This chapter has been substantially expanded to include dis-

with PowerPoint), export images to use in word processing programs, and create tests and quizzes.

in

cussion and treatment of benign prostatic hyperplasia and

Pharmacology Newsletter: Mosby's Pharmacology Update

erectile dysfunction.

Drug

Classification

Card

(inside front cover). This

new two-

This quarterly electronic publication includes new drugs, drug

To

color, perforated card helps students learn the functions of

news, and feature

different drug classes.

mail, please contact your sales representative.

Mosby's GenRx Receive free, 6-month online access to this comprehensive database of generic and brand name drugs. Color Color is used throughout the book for both functionality and visual enhancement. Color has been used in headings to make content easier to locate, in tables and boxes to draw attention to special topics, in figures to add clarity, and in pedagogy to add emphasis. Pedagogy Learning objectives, key word lists, and math review questions for each chapter reinforce key content. Critical Thinking Questions Critical thinking questions are included for each drug chapter to promote the development of clinical decision-making skills. Life Span Issues Boxes These boxes are interspersed throughout the book, providing important information about drug administration to various age groups, specifically the pediatric and geriatric patient populations. Patient Education and Monitoring Forms These forms are included throughout Part Two as examples for the student to adapt to the individual needs of the patient patient education.

They may be copied from

dent use. These written records

may

articles.

receive this publication via e-

This revised twelfth edition reflects the nurse's responsibilities

during the preparation, administration, and monitoring

of medication therapy in present health care settings. Each chapter in the edition has been thoroughly reviewed and updated.

We

have

tried to clarify content

and reinforce learning

We

have also placed emphasis on assisting the patient to improve his or her health by educating nursing students on the importance of their role in providing apthroughout the

text.

propriate physical care, emotional and social support, and

information necessary for self-care.

It is

our hope that

concern for

safety, precision,

and attention

to

important phys-

iologic factors and will teach and assist nurses in providing the best possible nursing care to their patients.

when providing the

book

this re-

vision will motivate the learner to administer medication with

for stu-

assist the individual in

//MAP

r

2

3

1

1

CONTENTS PART ONE

Sources of Drug Information (Canada), 7

Compendium of Pharmaceuticals and

PRINCIPLES OF BASIC

PHARMACOLOGY,

Professionals, 8

Compendium of Nonprescription

I

Specialties, 1

Nonprescription Drug Reference for Health Products, 8

Electronic Databases, 8

SBSBSSS

Unit Foundations of Pharmacology, 2 I

Sources of Patient Information, 8 United States Pharmacopeia Dispensing Information, 8 Tyler's

1

Names, Standards, and Information Sources, 2 Definitions,

Definitions, 2

Drug

Honest Herbal, 9

Legislation (United States), 9

Federal Food, Drug, and Cosmetic Act, June 25,

1938 (Amended 1952, 1962), 9 Controlled Substances Act, 1970, 9

Pharmacology, 2

Possession of Controlled Substances, 10

Drug

Therapeutic Methods, 2

Legislation (Canada), 10

Food and Drugs Act 1927;

Drugs, 2

Drug Names (United

the

Food and Drug

Regulations 1953 and 1954, Revised 1979 and

States), 3

Chemical Name, 3

Periodic

Generic

Name

(Nonproprietary Name), 3

Official

Name,

3

Amendments, 10

Narcotic Control Act (1960-1961) and the Narcotic

Control Regulations

Trademark (Brand Name), 3 Drug Classifications, 3 Drug Names (Canada), 3

(Amended

Nonprescription Drugs, Effectiveness of

Drug

1978), 11

1

Legislation, 11

New Drug

Official Drug, 3

Proper Name, 4

Development, 11 Preclinical Research and Development Stage, Clinical Research and Development Stage, New Drug Application Review, 1 1

Sources of Drug Standards (United States), 4

The United States Pharmacopeia (USP), 24th Revision, and the National Formulary (NF), 19th

Postmarketing Surveillance, 13

Rare Diseases and Orphan Drugs, 13

Revision, 4

USP Dictionary

of

USAN and International Drug

Principles of

Drug Action and Drug

Interactions, 14

Names, 4 Sources of Drug Standards (Canada), 4 Sources of Drug Information (United States), 4 American Drug Index, 4

American Hospital Formulary

Service, 5

Drug Interaction Facts, 5 Drug Facts and Comparisons, 5 Handbook on Injectable Drugs, 5 Handbook of Nonprescription Drugs, 5 Martindale-The Complete Drug Reference, 6 Medical

Letter,

Package

Inserts,

6 6

Basic Principles, 14 Absorption, 14 Distribution, 15

Metabolism, 16 Excretion, 16 Half-life, 16

Drug

Action, 17

Variable Factors Influencing

Age, 17

Body Weight,

18

Metabolic Rate, 18

Physicians Desk Reference (PDR), 6

Illness, 18

Mosby 's GenRx, 6

Psychologic Aspects, 18

'

Nursing Journals, 7

Drug Action, 17

1

1

1

Contents

Unit 2

Tolerance, 18

Dependence, 18 Cumulative Effect, 18

Drug

Interactions, 18

3 Drug Action Across the Life Span, 20 Changing Drug Action Across the Life Span, 20 Drug Absorption, 21 Drug Distribution, 21 Drug Metabolism, 22 Drug Excretion, 22 Nursing Implications When Monitoring Drug Therapy, 23

4 The Nursing Process and Pharmacology, 23 The Nursing

Process, 23

Illustrated Atlas of Medication Administration and Math Review, 49 6

A

Review of Arithmetic, 49

Roman

Numerals, 49

Fractions, 50

Common

50

Fractions,

Common

Types of

Working with Fractions, 5 Decimal Fractions, 54 Multiplying Decimals, 54

Dividing Decimals, 55

Changing Decimals

Assessment, 25

Common

Changing

Nursing Diagnosis, 27

50

Fractions,

to

Common

Fractions, 55

Fractions to Decimal Fractions, 55

Percents, 55

Planning, 28

Determining Percent One Number

Nursing Intervention or Implementation, 3

Changing Percents

to Fractions,

Evaluating and Recording Therapeutic and Expected

Changing Percents

to

Outcomes, 32

Changing

Relating the Nursing Process to Pharmacology, 32 Assessment, 32

of Another, 55

Decimal Fractions, 55

Fractions to Percents, 56

Changing Decimal Fractions Points to

Nursing Diagnoses, 33

Common

Is

55

Remember

in

to Percents,

56

Reading Decimals, 56

Ratios, 56

Planning, 33

Changing Ratios

Nursing Intervention or Implementation, 34

Changing Percents

Evaluating Therapeutic Outcomes, 41

Simplifying Ratios, 57

to Percents,

56

to Ratios,

57

Proportions, 57

5 Patient Education

and Health

Systems of Weights and Measures, 57 Household Measurements, 57 Apothecary Measurements, 58

Promotion, 41 The Three Domains of Learning, 42 Cognitive Domain, 42

Metric System, 58

Affective Domain, 42

Conversion of Metric and Apothecary Units, 59 Calculation of Intravenous Fluid and Medication

Psychomotor Domain, 42

Administration Rates, 63

Principles of Learning, 42

Focus the Learning, 42

Intravenous Fluid Orders, Drip Rates, and Pumps. 63

Learning Styles, 42

Rounding, 63

Organization Fosters Learning, 42

Volumetric and Nonvolumetric Pumps, 64

Motivating the Individual to Learn, 43

Calculation of Flow Rates, 64

Fahrenheit and Centigrade (Celcius) Temperatures, 65

Readiness to Learn, 43

Formula

Spacing the Content, 44

for Converting Fahrenheit

Temperature

to

Temperature

to

Centigrade Temperature, 66

Repetition Enhancing Learning, 44

Formula

Education Level, 44

for Converting Centigrade

Fahrenheit Temperature, 66

Culture and Ethnic Diversity, 44

Compliance, 45 Patient Education Associated with Medication

Patient Charts, 68

Health Teaching, 46

Communication and

Responsibility,

48

Expectations of Therapy, 48

Changes Changes

in

Expectations, 48

in

Therapy Through Cooperative Goal

Setting,

48

At Discharge, 48

7 Principles of Medication Administration, 67 Legal and Ethical Considerations, 67

Therapy, 46

Contents of Patient Charts, 68

Kardex Records, 73

Drug

Distribution Systems, 76

Narcotic Control Systems. 79

The Drug Order, 80 Typos

o\'

Medication Orders. 80

1

Contents

Nurse's Responsibilities, 81

The

Drug Administration,

Six Rights of

Adding 81

Set,

Right Drug, 82

a Medication with a

Piggyback or Secondary

134

Changing

Right Time, 82

xiii

to the

Next Container of Intravenous

Solution, 134

Right Dose, 82

Administering Medication by a Venous Access

Right Patient, 83

Device, 134

Right Route, 83

Central Venous Catheter Care,

Right Documentation, the Sixth Right, 84

Discontinuing an Intravenous Infusion, 135

1

35

Documentation, the Sixth Right, 136

8 Enteral Administration, 85

Monitoring Intravenous Therapy, 136

Administration of Oral Medications, 85 Administration of Solid-Form Oral Medications, 88 General Principles of Solid-Form Medication

Documentation, the Sixth Right, 138

10 Percutaneous Administration, 139

Administration, 90

Administration of Topical Medications to the

Administration of Liquid-Form Oral

Skin, 139

Administration of Creams, Lotions, and

Medications, 90 General Principles of Liquid-Form Oral Medication

Ointments, 139

Administration, 92

Patch Testing for Allergens, 141 Administration of Nitroglycerin Ointment, 143

Administration of Medications by the Nasogastric

Administration of Transdermal Drug Delivery

Tube, 92 Administration of Enteral Feedings, 94

Systems, 144

Administration of Topical Powders, 146

Tube Feedings, 94 Continuous Tube Feedings, 95 Administration of Rectal Suppositories, 96 Administration of a Disposable Enema, 97 Intermittent

Administration of Medications to

Mucous

Membranes, 146 Administration of Sublingual and Buccal Tablets, 146

9 Parenteral Administration, 99 Equipment Used

Administration of Eye Drops and Ointment, 147

in Parenteral Administration,

Administration of Ear Drops, 149

99

Administration of Nose Drops, 150

Syringes, 99

Administration of Nasal Spray,

Parenteral Dose Forms, 106

Vials,

1

5

Administration of Medications by Inhalation, 152

Ampules, 106

Administration of Medications by Metered Dose

106

Inhalers, 153

Mix-O- Vials, 107 Large- Volume Solution Containers, 107

Administration of Vaginal Medications, 154 Administration of a Vaginal Douche. 155

Small-Volume Solution Containers, 107 Preparation of Parenteral Medication, 108 Administration of Medication by the Intradermal Route, 115 Administration of Medication by the Subcutaneous

PART TWO

Route, 118

Administration of Medication by the Intramuscular Route, 119

Administration of Medication by the Intravenous

PHARMACOLOGY,

Route, 126 Sites,

APPLICATION OF THE NURSING PROCESS TO 1

57

126

General Principles of Intravenous Medication

Unit 3

Administration, 128

Drugs Affecting the Autonomic and Central Nervous Systems, 58

Preparing an Intravenous Solution for Infusion, 129 Intravenous Medication Administration, 130

1

Administration of Medication into an Established Intravenous Line (IV Bolus). 133 Administration of Medication by a Heparin (Saline

1 1 i

Lock, 133

Adding a Medication to an Intravenous Bag, or Volume Control, 134

Bottle.

Drugs Affecting the Autonomic Nervous System, 158 The Central and Autonomic Nervous Systems, 159 Autonomic Nervous System, 159 Drug

Class: Adrenergic Agents, 159

1

1

Contents

Drug

Class: Cholinergic Agents, 165

Drug Drug Drug

Class: Anticholinergic Agents, 166

Miscellaneous Anticonvulsants, 234

Class: Alpha- and Beta-Adrenergic Blocking

Agents, 163

Drug Drug

Class: Hydantoins, 233 Class: Succinimides,

234

tS 'Drugs Used for Pain Management, 240

12 Sedative-Hypnotics, 168 Sleep and Sleep Pattern Disturbance, 168

Pain, 240

Sedative-Hypnotic Therapy, 169

Treatment of Pain, 241

Drug Therapy

Drug Therapy

Drug Drug Drug

230

Class: Benzodiazepines,

for Sleep Disturbance, 170

for Pain

Management, 248

Class: Barbiturates, 170

Drug

Class: Benzodiazepines, 173

Drug^Class: Opiate Partial Agonists, 25

Class: Miscellaneous Sedative-Hypnotic

Drug Drug Drug

Agents, 175

13 Drugs Used for Parkinson's Disease, 177 for

248

Class: Opiate Antagonists,

252

Class: Salicylates, 255 Class: Nonsteriodal Antiinflammatory

Agents, 256

Miscellaneous Analgesics, 261

Parkinson's Disease, 178

Drug Therapy

Class: Opiate Agonists,

Treatment of Parkinson's

Disease, 179

Drug Drug Drug

Class:

Dopamine Agonists, 182

Unit 4

Class:

COMT Inhibitor,

Drugs Affecting the Cardiovascular System, 264

188

Class: Anticholinergic Agents, 189

Miscellaneous Anti-Parkinson Agents, 190

14 Drugs Used for Anxiety Disorders, 192

19 Drugs Used to Treat Hyperlipidemias, 264 Atherosclerosis, 264

Anxiety Disorders, 192

Drug Therapy Drug Drug Drug

for Anxiety Disorders, 193

Class: Benzodiazepines, 195 Class: Azaspirones, 198 Class: Selective Serotonin Reuptake Inhibitors

(SSRIs), 198

Treatment of Hyperlipidemias, 265 Drug Therapy for Hyperlipidemias, 265 Drug Class: Bile Acid-Binding Resins, 266 Drug Class: Niacin, 267 Drug Class: HMG-CoA Reductase Inhibitors, 268 Drug Class: Fibric Acids, 269

Miscellaneous Antianxiety Agents, 198

15 Drugs Used for

Mood

Disorders, 201

Mood Disorders, 201 Treatment of Mood Disorders, 203 Drug Therapy for Mood Disorders, 203 Drug Therapy for Depression, 205 Drug Class: Monoamine Oxidase Inhibitors, 205 Drug Class: Selective Serotonin Reuptake Inhibitors (SSRIs), 209 Drug Class: Tricyclic Antidepressants, 210 Drug Class: Miscellaneous Agents, 21 Drug Class: Antimanic Agents, 215 16 Drugs Used for Psychosis, 217 Psychosis, 218

20 Drugs Used to Treat Hypertension, 271 Hypertension, 271

Treatment of Hypertension, 273 Drug Therapy for Hypertension, 273 Drug Class: Diuretics, 277 Drug Class: Beta-Adrenergic Blocking Agents, 278 Drug Class: Angiotensin-Converting Enzyme Inhibitors, 279 Drug Class: Angiotensin II Receptor Antagonists, 281 Drug Class: Calcium Ion Antagonists, 282 Drug Class: Alpha- Adrenergic Blocking Agents, 284 Drug Class: Central-Acting Alpha-2 Agonists, 285 Drug Class: Peripheral-Acting Adrenergic Antagonists, 287 Drug Class: Direct Vasodilators, 289 1

Treatment of Psychosis, 218

Drug Therapy Drug

for Psychosis, 219

Class: Antipsychotic Agents,

21 Drugs Used to Treat Heart Failure, 291 224

17 t)rugs Used for Seizure Disorders, 226 Seizure Disorders, 226 Descriptions of Seizures, 227

Anticonvulsant Therapy, 227

Drug Therapy

for Seizure Disorders, 230

Drug Class: Barbiturates, 230

Heart Failure, 292 Treatment of Heart Failure, 292 Drug Therapy for Heart Failure, 292

Drug Class: Digitalis Glycosides, 295 Drug Class: Phosphodiesterase Inhibitors, 298 Drug Class: Angiotensin-Converting Enzyme Inhibitors, 300

Contents

22 Drugs Used to Treat Arrhythmias, 301

23 Drugs Used

to Treat

Angina

316

Pectoris,

24 Drugs Used to Treat Peripheral Vascular Disease, 323 Peripheral Vascular Disease, 324

Treatment of Peripheral Vascular Disease, 324 Drug Therapy for Peripheral Vascular Disease, 327 Drug Class: Hemorrheologic Agents, 327 Drug Class: Vasodilators, 328 Drug Class: Platelet Aggregation Inhibitors, 330

Diuretic Therapy, 332

Anhydrase

Inhibitors,

Physiology, 369

Common Lower

Respiratory Diseases, 370 Treatment of Lower Respiratory Diseases, 372

Drug Therapy Drug Drug Drug Drug

Loop

Diuretics,

335

Drug

Diseases, 378

378

Class: Antitussive Agents,

380

Class: Mucolytic Agents, 381 Class: Beta- Adrenergic Bronchodilating

Class: Anticholinergic Bronchodilating

Agents, 384

Drug

Class: Xanthine-Derivative Bronchodilating

Agents, 385

Respiratory Antiinflammatory Agents, 385

Unit 6

Class: Thiazide Diuretics, 341 Class: Potassium-Sparing Diuretics, 343 Class:

Lower Respiratory

Agents, 382

Class: Methylxanthines, 335 Class:

for

Class: Expectorants,

for Obstructive

Class: Antileukotriene Agents,

386

335

Combination Diuretic Products, 345

Thromboembolic Diseases, 346 Treatment of Thromboembolic Diseases, 347 Drug Therapy for Thromboembolic Diseases, 349

Unit 5

Lower Respiratory Tract Anatomy and

Miscellaneous Antiinflammatory Agents, 388

26 Drugs Used to Treat Thromboembolic Disorders, 346

Drug Drug Drug

28 Drugs Used to Treat Lower Respiratory Disease, 368

Drug

Diuretics, 335

Class: Carbonic

Class: Respiratory Antiinflammatory

Drug Class: Corticosteroids Used Airway Disease, 385

25 Drugs Used for Diuresis, 332

Drug Drug Drug Drug Drug Drug

Class:

Agents, 366

Angina Pectoris, 316 Treatment of Angina Pectoris, 316 Drug Therapy for Angina Pectoris, 317 Drug Class: Nitrates, 318 Drug Class: Beta- Adrenergic Blocking Agents, 321 Drug Class: Calcium Ion Antagonists, 321

Drug Therapy with

for Upper Airway Disorders, 363 Sympathomimetic Decongestants, 363 Class: Antihistamines, 364

Drug Therapy Drug Drug Drug

Arrhythmias, 301 Treatment for Arrhythmias, 302 Drug Therapy for Arrhythmias, 302 Antiarrhythmic Agents, 304

^VA"ggS

Drugs Affecting the Digestive System, 391 29 Drugs Used to Treat Oral Disorders, 391 Mouth Disorders, 391 Drug Therapy for Mouth Drug Drug

Disorders, 395

Class: Dentifrices, 395 Class:

Mouthwashes, 395

Class: Platelet Inhibitors, 349 Class: Anticoagulants, 352 Class: Fibrinolytic Agents,

357

.VAVAVA'a Used

to Treat Disorders of Drugs the Respiratory System, 359 27 Drugs Used to Treat Upper Respiratory Disease, 359 Upper Respiratory Tract Anatomy and Physiology, 359

Common Upper Respiratory

Diseases, 360 Treatment of Upper Respiratory Diseases, 362

30 Drugs Used to Treat Gastroesophageal Reflux and Peptic Ulcer Disease, 396 Physiology of the Stomach, 397

Common Stomach Disorders, 397 Treatment of Gastroesophageal Reflux and Peptic Ulcer Disease, 398 Drug Therapy for Gastroesophageal Reflux and Peptic Ulcer Disease, 398 Drug Class: Antacids, 399 Drug Class: Histamine (H 2 )-Receptor Antagonists, 402 Drug Class: Gastrointestinal Prostaglandin, 404 Drug Class: Gastric Acid Pump Inhibitors, 404 Drug Class: Coating Agent, 406 Drug Class: Prokinetic Agents, 406 Drug Class: Antispasmodic Agents, 408

1

Contents

31 Drugs Used to Treat Nausea and

36 Gonadal Hormones, 466

Vomiting, 410 Nausea and Vomiting, 410 Common Causes of Nausea and Vomiting, 411 Drug Therapy for Selected Causes of Nausea and Vomiting, 412 Drug Class: Dopamine Antagonists, 415 Drug Class: Serotonin Antagonists, 415 Drug Class: Anticholinergic Agents, 420 Drug Class: Corticosteroids, 420 Drug Class: Benzodiazepines, 421 Drug Class: Cannabinoids, 421

Class: Laxatives,

and Diarrhea, 425

425

Class: Antidiarrheal Agents,

467

Class: Progestins,

468

Class: Androgens,

468

Unit 8

Drugs Affecting the Reproductive System, 473

Drug Therapy With Pregnancy, 481

Constipation, 423

Drug Drug

Class: Estrogens,

Obstetrics, 474

Diarrhea, 423 for Constipation

Drug Drug Drug

37 Drugs Used in Obstetrics, 473

32 Drugs Used to Treat Constipation and Diarrhea, 422

Drug Therapy

The Gonads and Gonadal Hormones, 466 Drug Therapy With Gonadal Hormones, 467

Drug Drug Drug

Class: Uterine Stimulants, 481 Class: Uterine Relaxants, Class: Other Agents,

486

488

Neonatal Ophthalmic Solutions, 491

426

38 Drugs Used in Men's and Women's Health, 492

Unit 7

Vaginitis,

Drugs Affecting the Endocrine System, 430

493

Drug Therapy

for

Infections,

Leukorrhea and Genital

493

Drug Therapy

33tDrugs Used

to Treat Diabetes Mellitus,

430

Diabetes Mellitus, 430

Treatment of Diabetes Mellitus, 432 Drug Therapy for Diabetes Mellitus, 437 Drug Class: Insulins, 437 Drug Class: Biguanide Oral Hypoglycemic Agents, 442 Drug Class: Sulfonylurea Oral Hypoglycemic Agents, 442 Drug Class: Meglitinide Oral Hypoglycemic Agents, 444 Drug Class: Thiazolidinedione Oral Hypoglycemic Agents, 445 Drug Class: Antihyperglycemic Agents, 447 Drug Class: Antihypoglycemic Agents, 448

for Contraception, 497 Drug Class: Oral Contraceptives, 497 Drug Therapy for Benign Prostatic Hyperplasia, 502 Drug Class: Alpha- 1 Adrenergic Blocking Agents, 503 Drug Class: Antiandrogen Agents, 503 Drug Therapy for Erectile Dysfunction, 504 Drug Class: Phosphodiesterase Inhibitors, 504

Unit 9

^^^^^--v^^-ag

Drugs Affecting Other Body Systems, 507 39 Drugs Used to Treat Disorders of the Urinary System, 507 Urinary Tract Infections, 507

34 Drugs Used to Treat Thyroid Disease, 450 Thyroid Gland, 450 Thyroid Diseases, 450 Treatment of Thyroid Disease, 451 Drug Therapy for Thyroid Disease, 453 Drug Class: Thyroid Replacement Hormones, 453 Drug Class: Antithyroid Medicines, 454

35 Corticosteroids, 458 Corticosteroids, 458

Drug Therapy With

Corticosteroids, 461

Drug Class: Mineralocorticoids, 461 Drug Class: Glucocorticoids, 463

Drug Therapy

for Urinary Tract Infections, 510

Urinary Antimicrobial Agents, 510

Drug Drug

Class:

Fosfomycin Antibiotics, 510

Class: Quinolone Antibiotics. 51

Bladder- Active Drugs, 514

40 Drugs Used to Treat Glaucoma and Other Eye Disorders, 517 Anatomy and Physiology of the Eye, 517 Glaucoma, 518 Drug Therapy for Glaucoma, 519 Drugs Used to Lower Intraocular Pressure, 521 Drug Class: Osmotic Agents. 521

1

Contents

Drug Class: Carbonic Anhydrase Inhibitors, 524 Drug Class: Cholinergic Agents, 525 Drug Class: Cholinesterase Inhibitors, 525 Drug Class: Adrenergic Agents, 527 Drug Class: Beta-Adrenergic Blocking Agents, 528 Drug Class: Prostaglandin Agonist, 529 Other Ophthalmic Agents, 530 Drug Class: Anticholinergic Agents, 530 Drug Class: Antifungal Agents, 530 Drug Class: Antiviral Agents, 531 Drug Class: Antibacterial Agents, 532 Drug Class: Corticosteroids, 532 Ophthalmic Antiinflammatory Agents, 532 Antihistamines, 533 Antiallergic Agents, 533

Sodium

Fluorescein, 533

534 534

44 Nutrition, 599 Principles of Nutrition, 599

Malnutrition, 604

Therapy

for Malnutrition, 605

45 Herbal Therapy, 613 Herbal Medicine and Rational Therapy, 613

Herbal Therapy, 615

46 Miscellaneous Agents, 620 Miscellaneous Agents, 620

APPENDIXES, 625 A

Prescription Abbreviations, 625

B

Medical Abbreviations, 626

Artifical Tear Solutions,

Ophthalmic

Irrigants,

41 Drugs Affecting Neoplasms, 534 Cancer and the Use of Antineoplastic Agents, 535 Drug Therapy for Cancer, 535 Drug Drug Drug Drug Drug

Class: Alkylating Agents,

546

for Calculating the

Body

Surface Area of Adults and Children, 629

D Commonly

546 Class: Natural Products, 546 Class: Antimetabolites,

Used Laboratory Test and Drug

Values, 630

Class: Antineoplastic Antibiotics, Class:

C Nomogram

546

E Recommended Childhood Immunization

Hormones, 548

Schedule United States, January-December 2000, 633

42 Drugs Used to Treat the Muscular System, 549 Muscle Relaxants and Neuromuscular Blocking Agents, 550 Drug Therapy of the Muscular System, 553 Drug Class: Centrally Acting Skeletal Muscle

F

MedWatch,634

G

Dyskinesia Identification System:

Condensed User Scale (DISCUS), 636

Relaxants, 553

Drug

Class: Direct-Acting Skeletal

Muscle

H A

Simple Method to Determine Tardive AIMS Examination Procedure, 638

Relaxant, 554

Drug

Class:

Dyskinesia Symptoms:

Neuromuscular Blocking Agents, 555

43 Antimicrobial Agents, 557 Antimicrobial Agents, 558

Drug Therapy

for Infectious Disease, 561

Drug Class: Aminoglycosides, 561 Drug Class: Cephalosporins, 564 Drug Class: Macrolides, 566 Drug Class: Penicillins, 567 Drug Class: Quinolones, 568 Drug Class: Streptogramins, 571 Drug Class: Sulfonamides, 572 Drug Class: Tetracyclines, 573 Drug Class: Antitubercular Agents, 574 Drug Class: Miscellaneous Antibiotics, 576 Drug Class: Topical Antifungal Agents. 582 Drug Class: Systemic Antifungal Agents. 582 Drug Class: Antiviral Agents, 589 Drug Therapy for Urinary Tract Infections, 598

I

Template for Developing a Written Record for Patients to Monitor Their Own Therapy, 639

BIBLIOGRAPHY, 64 INDEX, 643

PRINCIPLES

OF

BASIC

PHARMACOLOGY

Chapter

Proper

Definitions,

I

Names, Standards, and Information Sources

Name

The proper name

is

gate

the nonproprietary (generic)

name used

to

describe an official drug in Canada.

SOURCES OF DRUG STANDARDS (UNITED STATES)

its

human

name, applies a

beings.

The Council

series of

SOURCES OF DRUG STANDARDS

Objectives List official

use in

studies the cheminomenclature guidelines, and then selects the USAN (generic name). It is now customary .for the FDA to accept the adopted generic name as the FDA official name for a chemical compound. cal

(CANADA) Objectives

sources of drug standards.

List official

I.

sources of drug standards.

Key Words The United

Key Words

States Pharmacopeia (USP)/National

Formulary (NF) British

Standardization

by

is

needed

to ensure that

Pharmacopee Francaise

Pharmacopoeia

drug products made

different manufacturers, or in different batches

by the same

manufacturer, will be uniformly pure and potent. Before 1 820, many drugs were manufactured in different parts of the United States with varying degrees of purity. This problem was solved by the establishment of an authoritative book, Pharmacopeia/National Formulary of the United States of America, which set forth required standards of purity for drugs, as well as methods to determine purity.

The Food and Drugs Act recognizes

the standards described

by seven international authoritative books to be acceptable as official drugs in Canada. The acceptable publications are the British Pharmacopoeia, the Pharmacopeia of the United States ofAmerica, the Pharmacopoeia International,

Pharmacopee Francaise, the British Pharmaceutical Codex, the U.S. Pharmacopeia National Formulary, and the Canadian Formulary.

the

The United States Pharmacopeia (USP), 24th Revision, and the National Formulary (NF),

SOURCES OF DRUG INFORMATION (UNITED STATES)

19th Revision

Objectives

The

USP and NF are now published as a single volume by the

United States Pharmacopeial Convention, a nonprofit, nongovernmental corporation. The latest edition, published in 2000, represents the

fifth

1.

2.

books have been combined into one volume. This book is revised every 5 years. Supplements are published more often to keep it up to date. The latest edition contains 3777 monographs and 164 general chapters. The most notable of the new

for identity, quality, strength,

and purity of substances used

The standards

USP/NF

FDA

by the

in

set forth in the

tional

supplements produced

in the

Handbook of Nonprescription Drugs

American Hospital Formulary

Martindale

Service

Drug

Interaction Facts

Drug

Facts

Medical Letter

United States.

USP Dictionary of USAN and International Drug Names is a compilation of more than 8274 drug names. Each drug monograph contains its USAN, a pronunciation guide, the molecular and graphic formula, chemical and brand name, manufacturer, and therapeutic category. It also contains the Chemical Abstracts Service registry numbers for drugs. Manufacturers submit to the USAN Council a proposal for a name, in which they announce that a certain chemical compound has therapeutic potential and that they plan to investi-

This dictionary

and describe literature resources for researching drug

American Drug Index

as "official" standards for

the manufacture and quality control of medicines and nutri-

List

Key Words

is the new section, Nutritional Supplements. The primary purpose of this volume is to provide standards

the practice of health care.

and describe literature resources for researching pre-

interactions and drug incompatibilities.

contents

are enforced

List

scription and nonprescription medications.

time these two established reference

and Comparisons

Handbook on

Injectable

Physicians'

Desk Reference

(PDR)

Drugs

American Drug Index The American Drug Index Billups, Ph.D, is

an index of

Drugs

in

and all

is

is

edited annually by

drugs available

in the

is

generic

recognized

by generic

name monographs

in the

It

United States.

the Index are listed alphabetically

name and brand name. The cate that the drug

Norman F

published by Facts and Comparisons.

U.

S.

indi-

Pharmacopeia

Definitions,

National Formulary or USAN Council listing and provide the chemical name, use, and cross-references to brand names.

Each brand name monograph

lists

the manufacturer,

compo-

sition, strength, pharmaceutical forms available, package size, dosage, and use. Other features of this reference book include a list of common medical abbreviations; tables of weights, measures, and conversion factors; normal laboratory values; a

of drug names that look and sound alike; oral dosage forms that should not be crushed or chewed; a glossary to aid

Names, Standards, and Information Sources

nationally

renowned group of physicians and pharmacists

who have

the clinical experience, scientific background,

li-

and computer resources to collect, collate, review, and evaluate the scientific accuracy of descriptions of drug interactions from world literature. Thus the book is an extremely reliable source of information. Subscribers receive an update brary,

supplement four times a

year.

list

in interpretation of the

Drug Facts and Comparisons

identify drug products;

Drug

monographs; a labeler code index to and a list of manufacturers' addresses. The book is useful for quickly comparing brand names and generic names, and also for checking the availability of strengths and dosage forms.

Facts and Comparisons is a large, loose-leaf compendium of more than 2000 pages published by Facts and Comparisons. The book is divided into 15 chapters by organ system. At the beginning of each chapter

is

a detailed table of

contents. All drugs within each chapter are subdivided by ther-

apeutic classes. For each therapeutic class of drug, a

American Hospital Formulary Service The American Hospital Formulary

Service, Drug Informacomprehensive reference book published annually by the American Society of Health-System Pharmacists in Bethesda, Md. Updated with four supplements yearly, this volume contains monographs on virtually every single-drug entity available in the United States. The monographs emphasize rational therapeutic use of drugs. Each monograph is subdivided into sections on chemistry and stability, pharmacology, pharmacokinetics, uses, cautions, toxicity, drug inter-

tion, is a

actions, laboratory test interferences, dosage, administration,

and available products. The index is cross-referenced by both generic and brand names. The American Hospital Formulary Service, Drug Information, has been adopted as an official reference by the U.S. Public Health Service and the Department of Veterans Affairs. It has also been approved for use by the American Health Care Association, the American Hospital Association, the Catholic Health Care Association of the United States, the National Association of Boards of Pharmacy, and the American Pharmaceutical Association. It is recognized by the U.S. Congress, Health Care Financing Administration, and various third-party health-care insurance providers, and is included as a required or recommended standard reference

pharmacies

in

many

in

states.

and administration. The database monographs is the most current FDA-approved package insert and publications from official groups such as the Centers for Disease Control and Prevention (CDC) and the National Academy of Sciences. The editors have reformatted the information and added additional information from the medical literature on investigational uses of the drugs. At the beginning of each monograph are tables of all drugs in that therapeutic class. The tables are particularly valuable because they are designed to allow comparison of similar products, brand names, manufacturers, cost indexes, and patient information in brief, for the

available dosage forms.

The is

index, located in the front of the

quite comprehensive and

is

is

quarterly. Within each chapter, there

is

referencing system as well, making

quite easy to gain in-

formation on drugs that

may

published in 1983 and

sive

book

is

800-page binder was

currently the most comprehen-

available on the subject of drug interactions.

The

from that of most other books: the index is in the front, and the book is not subdivided into chapters, but subdivided every 100 pages by a plastic tab sheet. format

is

somewhat

different

Each page is a single monograph describing a drug interaction. Each monograph is subdivided into a table that lists the onset and severity of the drug interaction, expected outcomes, a statement on the expected effects, the proposed mechanism, and how to manage the interaction. A short discussion (with references) on the relevance of the interaction follows. One of the most meaningful, although not obvious, benefits is the source of information used to develop Drug Interaction Facts. All of the information

it

an excellent cross-

be categorized by more than one

book

therapeutic class. Updated supplements for the entire are published monthly.

available on

CD-ROM

Handbook on

Drug Facts and Comparisons and

is

is

also

updated monthly.

Injectable Drugs the

most comprehensive

is written by Lawrence A. Trissel and published by the American Society of Health System Pharmacists of Bethesda, Md. It is a collection of monographs on almost 300 injectable drugs. Each monograph is subdivided into sections on avail-

drugs,

published by Facts and Compar-

isons. This three-ring, loose-leaf, nearly first

for easy access,

reference available on the topic of compatibility of injectable

Drug Interaction Facts Interaction Facts

book

updated both monthly and

The Handbook on Injectable Drugs,

Drug

mono-

graph provides a brief description of drug action, pharmacokinetics, metabolism, uses, contraindications, warnings, precautions, adverse effects reported, treatment of overdosage,

is

reviewed by an

inter-

ability of concentrations, stability.

pH. dosage and

rate

of ad-

ministration, compatibility information, and other useful in-

formation about the drug.

Handbook of Nonprescription Drugs The Handbook of Nonprescription Drugs is prepared and published by the American Pharmaceutical Association in Washington. D.C. It is the most comprehensive text available on OTC medications that can be purchased in the United States.

Chapters

are

divided

by therapeutic

activity,

such

as

antacid products, cold and allergy products, nutritional sup-

Chapter

Definitions,

I

Names, Standards, and Information Sources

plements, mineral and vitamin products, and feminine hy-

Section

giene products. Each chapter provides a brief review of

An

anatomy and physiology, evaluation of

the

symptoms being

treated, suggested treatments with appropriate dosages,

and a

(White), Manufacturers' index

I

alphabetic listing of each manufacturer,

emergency phone numbers, and a .

partial

its

addresses,

of available

list

products.

of medications with their ingredients.

list

This book has three particular advantages for the health professional: (1) a

list

of questions to ask the patient to deter-

mine whether treatment should be recommended, (2) product most appropriate products, and (3) counseling to be conveyed to the patient on selection guidelines for determining the

Sect/on 2 (Pink), Brand and Generic

A

comprehensive alphabetic

name products discussed

in

Name

Index

of the generic and brand the Product Information section listing

of the book.

Section 3 (Blue), Product Category Index

proper use of the recommended product.

Products are subdivided by therapeutic classes, such as anal-

and

Martindale-The Complete Drug Reference

gesics, laxatives, oxytocics,

Martindale-The Complete Drug Reference is a 2700-page volume published by the Pharmaceutical Press in London. It is one of the most comprehensive texts available for information on drugs in current use throughout the world. Part 1 contains extensive referenced monographs on the pharmacologic activity and side effects of about 4336 medicinal agents. Part 2 contains short monographs on another 827 agents that

Manufacturers have provided actual-size color pictures of their tablets and capsules. These are invaluable aids in prod-

are considered either obsolete or too

new

Section 4 (Gray), Product Identification Guide

for inclusion in Part

and manufacturers of almost 50,000 preparations or groups of preparations from 17 countries, including the United Kingdom, United States, North America, Australia, South Africa, and Japan. The index contains more than 131,500 entries. Medicinal agents are indexed by official names, chemical names, synonyms, and proprietary names. 1

.

Part 3 gives the composition

uct identification.

Sect/on 5 (White), Product Information Section This contains reprints of the package inserts for the major products of manufacturers, with information on action, uses, administration, dosages, contraindications, composition, and

how each drug

is

diagnostic tests used in hospital and office practice are

listed alphabetically

The

last section

poison control centers. The

is

Letter, Inc.,

a bi-weekly periodical newsletter.

comments on newly

lated topics ties.

Appendix by Medical

Letter, published

Rochelle, N.Y.,

by manufacturer.

of the book contains a listing of certified last

page of the book

MedWatch program,

is

a tear-

a voluntary reporting

of adverse effects of drugs by health professionals (see

Medical Letter

tains brief

supplied.

Section 6 (White), Diagnostic Product Information

Many

out form for the

The Medical

antibiotics.

It

F).

Other

lists in

FDA

tion centers, the

con-

trolled substances categories,

released drug products and re-

by an independent board of competent authorirelies on the knowledge of specialists in

The board

Pregnancy

Mosby's GenRx Mosby's GenRx

The prinew data on drug action and comparative clinical efficacy. The Medical Letter presents timely and critical summaries of data on new drugs to report

and definitions of

FDA

Use-in-

ratings.

mary purpose of

is

book include drug informa-

telephone directory, definitions of con-

various fields for their experience with certain drugs. the newsletter

the

New

is

tion pharmaceuticals

a drug information source on prescrip-

and

their suppliers.

Key components

in-

clude the following:

during their early period of promotion. Such appraisals must,

Keyword Index

necessarily, be tentative.

cross-references more than 30.000 generic and brand-name drugs by looking up words that might relate to the name. Cross-index terms are generic names, brand names, indications, FDA classes, FDA approval years, and pregnancy categories. Drugs are also listed under various categories such as orphan drugs, the top 200 selling drugs, and the Drug Enforcement Agency (DEA) schedules of controlled

The keyword index

Package Inserts Before a new drug is marketed, the manufacturer develops a comprehensive but concise description of the drug, indications

recommendations for dosage, and other pharmacologic information relating to the drug. Federal law requires that this material be approved by the FDA before the product is released for marketing and that it be presented on an insert that accompanies each package of the product. and precautions

known adverse

in clinical use,

reactions, contraindications,

Physicians 9 Desk Reference (PDR) PDR is published annually by Medical Economics,

The

of Montvale. N.J. apeutic agents

in

is

page color for easy access.

Drug

Identification

Guide

This section contains more than 1300 full-color images of brand name and generic drugs.

Drug Information Inc.,

comprised of approximately 2500 therseven sections. Each section uses a different It

substances.

The

largest section of the reference

section.

More

is

the drug

monograph

than 1700 monographs are arranged alpha-

name, and include extensive prescribfrom the FDA-approved pharmaceutical

betically by generic

ing information

Chapter

manufacturer package

inserts.

The monographs

also con-

tain product information

by dosage forms and strengths and are sorted by the price within package size, giving the product name used by the supplier, the supplier's FDA name, and the product's official National Drug Code number.

by the nationally recognized Average Wholesale Price (AWP). Prices

are

listed

Supplier Profiles

The supplier

Compendium and

of Pharmaceuticals

Specialties

The Compendium of Pharmaceuticals and Specialties (CPS) is published annually by the Canadian Pharmaceutical Association.

provides a comprehensive

It

ceutical products distributed in

on pharmaceutical suppliers. All suppliby their FDA short names, followed by the full company name, and complete address with phone numbers. Also included are estimations of medical product sales volume, whether publicly or privately owned, total numbers of employees, and names of key executives in general management, marketing, production, and research. Other information provided in the reference includes listings of withdrawn drugs; U.S. and Canadian Poison Control Centers; the latest CDC dosage recommendations; U.S. Directory of AIDS Drug Assistance Programs; and

coded

for patients written

in lay language.

list

of the pharma-

as well as other in-

The book

is

divided into six color-

sections.

tional information

GenRX, an information source

Canada

formation of practical value to health care professionals. Manufacturers voluntarily submit information concerning their products for this text.

profiles section can be used to obtain addi-

ers are listed alphabetically

Patient

and Information Sources

Definitions, S'ames, Standards,

I

—

Green Section Drug Listing of Brand and Nonproprietary Names is an alphabetic cross-reference that lists drugs by both generic and brand names, also indicate whether the product was available in Canada at the time of publication. Brand names that are in boldface type have a product monograph in the CPS White Section.

This section

Pink Section

— Therapeutic Guide

The Therapeutic Guide

is

a clinical guide for the use of sin-

CPS. Most products listed are some combination products (e.g.. antacids). The guide uses the Canadian

gle entity drugs listed in the single entity, but there are oral contraceptives,

Nursing Journals

version of the World Health Organization's Anatomical Therapeutic Chemical Classification. Drugs are classifed under 16 anatomical groups (e.g., gastrointestinal tract) and

Many

then subdivided into therapeutic categories

on drug therapy relating Heart and Lung). Nursing journals such as RN, AJN, and others have drug update information, as well as articles on nursing considerations relating to the drug therapy and drugs. The nurse must keep in mind the purpose of using resources and must be mindful of the accuracy of the information contained. Nurses should check the dates on articles to specialty journals have articles

to a specific field (e.g., Geriatric Nursing,

validate the currentness of the information. Reliable sources

drug information are

to validate

listed in the section,

Sources

further subclassified under specific therapeutic,

—

antacids aluminum containing, calcium conMedicines may be classified under more than one section if used for more than one indication. Once a generic name has been identified, the corresponding brand name can be found in the Brand/Nonproprietary Name Index (Green Section).

gory

(e.g.,

taining).

Photograph Section

arranged according to the size and color shadings of individual

dosage forms

(tablets,

capsules, liquids). Products are

cross-referenced in the white pages

Objective

section

Describe the organization of the Compendium of Pharmaand Specialties and the information contained in

ceuticals

3.

— Product Recognition Section

This section contains color photographs of drug products

SOURCES OF DRUG INFORMATION (CANADA)

2.

pharmaco-

logic or chemical subheadings within the therapeutic cate-

of Drug Information (United States).

1.

(e.g., antacids,

antiemetics, digestive enzymes, laxatives). Drugs are then

is

monograph

section. This

also printed in French.

Yellow Section

—Manufacturers' Index

This section contains names, addresses, and telephone num-

each colored section.

bers of the manufacturers and distributors o( pharmaceutical

Describe the organization of the Nonprescription Drug

products in Canada, as well as product listings for

Reference for Health Professionals.

manufacturers.

Describe

the

organization

of

the

Compendium

of

Lilac Section

many of the

— Clin-lnfo

Nonprescription Products.

This section contains tables and charts describing a wide range of information of interest to health care professionals

Compendium of Pharmaceuticals

and

Specialties (CPS)

Nonprescription Drug Refer-

ence

for

Health Professionals

would otherwise

rarely be easil) accessible, particularly

in a single reference

book. Topics include the nonmedicinal

thai

Key Words Compendium of Nonprescription Products

(CNP)

Electronic databases

ingredients of selected pharmaceuticals (e.g.. sulfite, gluten, alcohol, tartrazine content).

Systeme International

unit con-

version factors, drugs and sports competition, clinical monitoring (e.g.. anticoagulant drug monitoring, bod) surface area

nomograms, serum drug concentration monitoring),

clinical

Chapter

8

I

Definitions,

Names, Standards, and Information Sources

information on cardiac arrest, travel

(e.g.,

drinking water pu-

immunization schedules, malaria prevention and treatment), drug interactions, dietary recommendations, poison control centers in Canada and a summary of Canadian regulations for narcotics and controlled drugs, and the procedure to obtain on an emergency basis a drug not approved for use in Canada. rification,

Blue Section This section tients

—Patient Information

lists

the information to be

conveyed

to pa-

on almost 200 individual products. The information

is

allow photocopying of the patient information.

White Section

and

—Monographs of Pharmaceuticals

is

drug interactions, adverse

effects, dose,

and

Between the two major sections are approximately 40 blue pages entitled "Therapy Summaries and Patient Information." The information is abbreviated from the corresponding chapters

Drug Reference for Health ProfesThese summaries provide brief overviews of the illness

the Nonprescription

in

and the patient information that should be provided in counseling patients on the treatment of the illness. The patient information pages may be reprinted to send copies home with patients. The compendium concludes with a manufacturers' index on yellow pages with names, addresses, phone and fax numbers, and products listed. The book index, printed on green paper, provides a cross-listing of

Specialties

This unit

ings, precautions,

dose forms available on the market.

sionals.

arranged alphabetically by brand name. Margins are wider in this section to

format of pharmacology, indications, contraindications, warn-

all

generic and brand

names alpha-

betically.

an alphabetic arrangement of manufacturer's brand

information and numerous general monographs for

common

multi-source drugs; a few medical devices are described.

Nonprescription Drug Reference for Health Professionals Nonprescription Drug Reference for Health Professionals, formerly known as Self-Medication Reference for Health Professionals, is published approximately every 4 years by the Canadian Pharmaceutical Association. The text provides comprehensive information for health professionals and consumers about the nonprescription drug products available in Canada. The chapters are organized by therapeutic category,

Electronic Databases There is an ever-growing increase in the use of electronic databases as a resource for drug information. The National Library of Medicine (NLM) began providing Medline and other searchable databases (http://www.nlm.nih.gov/) on the World Wide Web at no cost in June, 1997. Most of the drug information sources listed above are available through elec-

Many college libraries subscribe CINHAL, a cumulative index of nursliterature. By using these sources, nurses

tronic retrieval at libraries.

CD-ROM

via

disks to

ing and allied health

have access to a wealth of information from sources published in the United States and other countries.

such as acne, gastrointestinal products, nutrition products, oral health care products, and smoking cessation products.

SOURCES OF PATIENT INFORMATION

Each chapter provides a review of anatomy and physiol-ogy and the conditions suitable for self-medication. Treatment measures include both nonpharmacologic and pharmacologic management suggestions and a review of the nonprescription drug alternatives available. Figures illustrating treatment

Objectives

al-

gorithms are excellent. Most chapters conclude with bullet points on counseling tips and advice for the patient.

I.

Cite a literature resource for reviewing information to be given to the patient concerning prescribed medication.

Compendium of Nonprescription Key Words

Products The Compendium of Nonprescription Products (CNP) is a nonprescription companion of CPS. CNP is comprised of two

USPDI

Tyler's

Honest Herbal

major sections, the Product Table Section and the Product Information Section. The product tables represent a comprehensive

listing

of nonprescription products available

Canada. The product tables are designed

to

in

be used for quick

Over

the past

two decades,

The following

list the brand name, ingredients, and dose forms available. Those products highlighted in bold and identified by an asterisk are cross-referenced with additional

teaching patients

information

in the

product information section.

The product information

monographs that are alphabetically listed by product brand names. The monographs are developed by the staff of the Canadian Pharmacists Association editorial staff, and are reviewed by the manufacturers. Users are informed that monographs may contain information somewhat different from the Health Canada approved product monographs. The monographs follow a standard section contains

has

become

evident that health

they must do to assume responsibility for their

reference in the practice setting. Tables are arranged by therapeutic class and alphabetically

it

care providers must do a better job of informing patients of what

material

how

is

own

health care.

an excellent source of information for

to use their medications properly.

United States Pharmacopeia Dispensing Information United States Pharmacopeia Dispensing Information (USP Dl) is an annual publication of the United States Pharmacopeia] Convention.

USP Dl updates.

Inc. is

The

a three-volume set supplemented with bimonthly

first

volume. Drug Informationfor the Health

(

'am

Professional, includes dispensing information for health care

Chapter

I

Definitions,

Names, Standards, and Information Sources

providers arranged in alphabetically ordered monographs Bach monograph is subdivided into sections on the drug's use, mech-

Drug

anism of

tising agents

action, precautions, side effects, patient consultation information, general dosing information, and dosage forms

legislation protects the

for such protection

is

consumer and

patient.

The need

great because manufacturers and adver-

may make unfounded

claims about the benefits

of their products.

available.

The second volume, Advice for the Patient, provides the layman's language for the patient consultation guidelines found in the first volume. The second volume is designed to be used

at the discretion

of the health care provider as an aid

to counseling the patient if written information

is

to

be given

Federal Food, Drug, and Cosmetic Act, June 25, 1938

(Amended 1952, 1962) The Federal Food, Drug, and Cosmetic Act of 1938 au-

tioners to reproduce the pages of advice for their patients re-

FDA of the Department of Health and Human Services to determine the safety of drugs before marketing

ceiving the prescribed drug. Generic and brand names are cross-referenced in the index of Advice for the Patient.

dards

The publisher permits

to the patient.

The

third

quirements,

health care practi-

all

volume, Approved Drug Products and Legal Rea reference source that provides a

is

drugs approved by the

FDA

list

of

all

proven to be safe and effective. It also lists which products are considered therapeutically equivalent when a drug is made from more than one manufacturer. This allows the prescriber and pharmacist to sethat are

when it is therapeutically Most insurance companies

expensive product,

lect the least

equivalent to the original product.

and

of health care only reimburse

state offices

at the

cost for therapeutically equivalent medicines, so

it

lowest is

ex-

tremely important to have a resource for easy access to check therapeutic equivalence of medicines.

thorizes the

and

in

turers are required to submit

FDA

new drug

applications to the

for review of safety studies before products

can be

re-

leased for sale.

The Durham-Humphrey Amendment

in

1952 tightened

control by restricting the refilling of prescriptions.

The Kefauver-Harris Drug Amendment in 1962 was brought about by the thalidomide tragedy. Thalidomide was an incompletely tested drug approved for use as a sedativehypnotic during pregnancy. Infants exposed to thalidomide were born with serious birth defects. This amendment provides greater control and surveillance of the distribution clinical testing of investigational

that a

Honest Herbal

and stan-

advertising are met in the marketing of products. Manufac-

and

Tyler's

to assure that certain labeling specifications

drugs and requires

product be proven both safe and effective before re-

lease for sale.

Honest Herbal is written by Varro E. Tyler, a worldrenowned pharmacognosist affiliated with Purdue University. It is the first book about herbal medicines that provides the lay perTyler's

Controlled Substances Act,

1

970

intended to bring scientific under-

The Comprehensive Drug Abuse Prevention and Control Act was passed by Congress in 1970. This statute, commonly referred to as the Controlled Substances Act, re-

commonly sold to consumers. The book is a compilation of more than 120 individual drug monographs

pealed almost 50 other laws written since 1914 that related to the control of drugs. The new composite law is designed

arranged alphabetically by herbal name. Each monograph pro-

improve the administration and regulation of manufacand dispensing of drugs found necessary to be controlled. The Drug Enforcement Administration (DEA) was organized to enforce the Controlled Substances Act, gather intelligence, and train and conduct research in the area of dangerous drugs and drug abuse. The DEA is a bureau of the Department of Justice. The director of the DEA reports to the Attorney General of the United States. The basic structure of the Controlled Substances Act consists of five classifications or schedules of controlled

son with accurate, medicines.

on the use of herbs as spanning approximately 20

scientific statements

Now in its fourth edition,

years, this paperback

book

is

standing of herbs

vides a brief description of the drug and as

its

plant origin.

The

its

proper name, as well

herb's alleged uses are described with a

nontechnical discussion of the chemistry and pharmacology of the active ingredients of the drug. Concluding paragraphs offer the author's judgment about the rational clinical uses of the herb.

References are

listed at the

end of each monograph.

DRUG LEGISLATION (UNITED STATES) Objective

to

turing, distributing,

ulations List legislative acts controlling

1.

2.

Differentiate

among Schedule

and describe nursing

The degree of

substances.

drug use and abuse. I,

II, III,

IV,

and V medications,

responsibilities associated with the

administration of each type.

depend on these classifications, flic five schedules. and examples of drugs in each schedule are

their criteria, listed

below:

Schedule

I

2. 3.

A lack of accepted EXAMPLES:

Cosmetic Act

Controlled Substances Act scheduled drugs

C Drugs

A high potential for abuse No currently accepted medical

1.

Key Words Federal Food, Drug, and

control, the conditions of record

keeping, the particular order forms required, and other reg-

h scrgic

heroin, hashish

use in the United States

safety tor use

acid dieth} lamkfc

under medical supervision

1

1

si)

i.

marijuana, peyote, SIP.

Chapter

10

Schedule 1.

2. 3.

A A

G

II

I

Definitions,

Names, Standards, and Information Sources

Possession of Controlled Substances

Drugs

make

high potential for abuse

Federal and state laws

currently accepted medical use in the United States

substances a crime, except in specifically exempted cases. The law makes no distinction between professional and

An

may

abuse potential that

lead to severe psychologic or

physical dependence

EXAMPLES:

practical nurses in regard to possession of controlled drugs.

amphetamines, meperidine, methadone. Percodan. methylphenidate secobarbital,

the possession of controlled

morphine,

pentobarbital,

Nurses may give controlled substances only under the diwho has been licensed to prescribe or dispense these agents. Nurses may not have rection of a physician or dentist

controlled substances in their possession unless they are

Schedule 1

A

III

1

reporting

PHASE 2

>

PHASE 4

Animal testing

PHASE

SHORT-TERM

TREATMENT-USE

>

S

LONG-TERM

Range: 1-3 years Average:

1

>

>

Range: 2-10 years

8 months

>

3

Surveys/sampling testing

Inspections

Range: 2 months-7 years

Average: 5 years

Average: 24 months

FDA

O

time: 30-day

safety review

NDA

NDA

submitted

approved

Industry time

Figure

I

-1 New

drug review process.

which a larger population of several hundred

experimental drug has therapeutic value and whether the drug

2, in

appears to be safe in animals. Enough data must be gained to

used. Studies are conducted to determine the success rate of

drug

justify testing the experimental

in

humans. The preclin-

phase of data collection may require 1 to 3 years, although the average length of time is 18 months. Near the end of this phase, the investigator (often a pharmaceutical manuical

New Drug Application (IND) to the FDA, which describes all studies completed to date and the safety and testing planned for human subjects. The FDA must make a decision based on safety considerations within 30 days on whether to allow the study to proceed. Only about 20% of the chemicals tested in the preclinical phase advance to the clinical testing phase. facturer) submits an Investigational

Research and Development Stage

Clinical The is

"testing in

humans"

stage, clinical stage, or

IND

stage

usually subdivided into three phases, generally described

studies determine an experi1, 2, and 3. Phase mental drug's pharmacologic properties, such as its pharmacokinetics, metabolism, and potential for toxicity at a certain as phases

1

dosage. The study population

either

is

normal volunteers or

the intended treatment population such as those patients

with certain cancers or arrhythmias. Phase require 20 to 100 subjects [f

phase

1

trials are

who

I

studies usually

are treated for 4 to 6 weeks.

successful, the drug

is

moved

to

phase

patients

is

a drug for

its intended use. If successful, the drug is advanced to phase 3 trails, in which larger patient populations are used to assure statistical significance of the results. Phase 3 studies also provide additional information on proper dosing and safety. The entire clinical research phase

may require 2 to 10 years, with the average experimental drug requiring 5 years. Each study completed is reviewed by the FDA to help assure patient safety and efficacy. Only one out of five drugs that enters the clinical trials makes it to the market place. The others fall out of the running because of efficacy or safety problems, or lack of commercial interest. In an effort to expedite drug development and approval for life-threatening illnesses such as acquired immunodeficiency syndrome (AIDS), the FDA has drafted rules that allow certain INDs to receive highest priority for review within the agency. This procedure is sometimes known as fast tracking. Additional rules allow the use of INDs to be used for treatment of a life-threatening disease in a particular patient, even though the patient does not fit the study protocol for the drug, when there is no alternative therapy. These cases are known as treatment INDs. A potentially life-saving drug may be allowed for treatment IND status late in phase II studies, during phase III studies, or alter all clinical studies have been completed but before marketing approval.

Chapter

Another mechanism

to

make INDs

I

Definitions,

available to patients

with life-threatening illnesses is known as parallel tracking. Under this procedure, an IND may be used for patients who cannot participate in controlled clinical trials and

where there

no satisfactory standard therapeutic alternatrack studies are conducted in parallel with the principal controlled clinical trials, but unlike controlled is

tive. Parallel

studies, the parallel track does not involve concurrent con-

groups. Investigators and patients must realize that may be greater uncertainty regarding the risks and benefits of therapy with agents that are in relatively early trol

Names, Standards, and Information Sources

13

facilities and products. Other studies completed during the fourth phase include identifying other patient populations where the drug may be useful, refining dosing recommendations or exploring potential drug interac-

of the manufacturing

tions.

Health care practitioners

make

a significant contribu-

knowledge of drug safety by reporting adverse effects of drugs to the FDA by using the MEDWATCH program for voluntary reporting of adverse event and product problems (see Appendix F). tion to the

there

stages of testing and development. "Parallel tracking" is similar to the "treatment IND" process, but it allows access

when

to investigational agents

accumulated evidence of efficacy than is required for a treatment IND. A drug may be released through the parallel track mechanism when phase II trials have been given approval to proceed, but have not necessarily been started. there

is less

New Drug Application Review When

sufficient data have

that the experimental

drug

is

been collected to demonstrate both safe and effective, the in-

new drug application (NDA) to the FDA, formally requesting approval to market a new drug for human use. Thousands of pages of NDA data are revestigator submits a

viewed

by

a

team

of

pharmacologists,

toxicologists,

chemists, physicians and others, as appropriate,

make

a

recommendation

to the

FDA

who

then

on whether the drug

should be approved for use. The average NDA review takes 24 months. Once a drug is approved by the FDA, it is the manufacturer's decision as to when to bring a product to the

market place.

manufacturer decides to market the medicine, the post-

marketing surveillance phase, or fourth phase of drug product development starts.

verse effects of the

for Rare Disorders

It

new

consists of an ongoing review of ad-

drug, as well as periodic inspections

(NORD),

a

coalition of 140 voluntary rare-disease groups, estimates that

more than 5000 rare health conditions exist in about 20 Examples of the rare diseases are cystic

million Americans.

fibrosis, Hansen's disease (leprosy), sickle cell anemia, blepharospasm, infant botulism and Pneumocystis carinii pneumonia. Historically, pharmaceutical manufacturers have been reluctant to develop products that could be used to treat these illnesses because they have been unable to recover the costs of the research due to a very limited use of the final product. Because no companies would "adopt" the disease to complete extensive research to develop products for treatment, the diseases became known as health orphans. In 1983, the U.S. Congress passed the Orphan Drug Act to stimulate development and market availability of products used for the treatment of rare diseases. The act defines "rare disease" as conditions affecting fewer than 200,000 persons in the United States. The law provides research grants, protocol development assistance by the FDA, special tax credits for the cost of clinical trials, and 7 years of exclusive marketing rights after the product has been approved. The Act has been quite successful more than 100 new drugs have been approved by the FDA for the treatment of rare diseases, benefiting several million people. Recent examples are the use of pentamidine and atovaquone for PCP thalidomide for Hansen's disease, zidovudine for HIV, DNase (Pulmozyme) for cystic fibrosis, and cladribine (Leustatin)

—

Postmarketing Surveillance If the

Rare Diseases and Orphan Drugs The National Organization

for hairy cell leukemia.

Principles of Drug Action

and

Drug Interactions

CHAPTER CONTENT Basic Principles

agent

(p. 14)

what the physiologic

Drug Action

(p. 17)

Interactions

was before

activity

successful

is

if

the blood pressure

is

therapy than before therapy). Therefore to

Variable Factors Influencing

Drug

in relation to

the response to drug therapy (e.g., an antihypertensive

Drug Action

it

lower during is important

perform a thorough nursing assessment to identify

the baseline data. Thereafter, regular assessments are

(p. 17)

performed by the nurse and compared with the baseline

(p. 18)

data by the physician, nurse, and pharmacist to evaluate the effectiveness of the drug therapy. 2.

BASIC PRINCIPLES

Drugs interact with the body in several The most common way in which drugs

different ways. act

is

by form-

ing chemical bonds with specific sites called receptors

Objectives

within the body. Bonding occurs only

Identify five basic principles of

1.

a drug and a receptor

drug action. 3.

problems associated with the absorption of medications.

is like that

between a key and a

The

absorption. List

4.

three categories of drug administration, and state the

Differentiate

between general and

Name term

half-life

selective types of drug

4.

when used

Drugs

5.

known

distribution

partial agonists

drug blood

ADME

metabolism

pharmacokinetics

biotransformation

absorption

excretion

enteral

half-life

(

1

drug has

The study of

metabolism, its

and excretion

own unique

ADME

char-

the

level

Absorption Absorption

is

the process by

which

a

drug

tion, the

ministered, and the solubility oi the drug.

drugs act in the body? The following are a few key remember: Drugs do not create new responses, but alter existing physiologic activity. Thus drug response must be stated

is

transferred from

of entry into the bod} to the circulating Quids of the body, the blood, and lymphatic system for distribution. The rate at which this occurs depends on the route of administraits site

facts to

14

.

drugs go through four stages:

How do 1.

in the re-

occupied.

mathematical relationships between the absorption, distribution, metabolism, and excretion of individual medicines is known as pharmacokinetics. acteristics.

percutaneous

all

distribution,

(ADME). Each

antagonists

as agonists

Once administered, absorption,

agonists

fits

sites

with a receptor to stimulate a response, but inhibit other responses are called partial agonists (Figure 2-1. D).

Key Words parenteral

number of receptor

Figure 2B). Drugs that do not stimulate a response are called antagonists (Figure 2-1. O. Drugs that interact

relation to drug therapy.

receptors

intensity of a drug response is re-

well the drug molecule

attach to a receptor but

significance to the nurse of the

in

The

how

that interact with a receptor to stimulate a re-

sponse are

meaning and

atoms within the mole-

between the receptor and the drug, the

fit

ceptor but also to the

the process that inactivates drugs.

Identify the

7.

better the

lated not only to

distribution mechanisms. 6.

several different

better the response.

routes of administration for each category. 5.

Most drugs have

cule that interlock into several locations on the receptor.

Describe nursing interventions that can enhance drug

3.

its

relationship between

lock (Figure 2-1. A).

Explain nursing assessments necessary to evaluate potential

2.

the drug and

if

The

receptor have similar shapes.

blood How through the tissue where the drug

portant to

of

fluid,

(

I

)

It

is

is

ad-

therefore im-

administer oral drugs with an adequate amount

usualK

a large (S oz) glass of water. (2) give par-

Chapter 2

and Drug

Principles of Drug Action

Interactions

p^eynonz^ thoroughly educated regarding the responsibilities and techniques associated with administering IV medications. Once it cannot be retrieved.) Regardless of the route of administration, a drug must be dissolved in body fluids before it can be absorbed into body tissues. For example, before a solid drug taken orally can be

the drug enters the bloodstream,

absorbed into the bloodstream for transport to the site of action, it must disintegrate and dissolve in the gastrointestinal fluids

Figure 2- 1 A, ceptor

Drugs act by forming a chemical bond with

sites, similar to

a key and

lock.

B, The better the

the response. Those with complete attachment agonists.

C, Drugs

that attach but do not

tagonists. D, Drugs that attach,

elicit

elicit

specific re-

"fit,"

the better

and response are

called

a response are called an-

a small response, but also block

other responses are called partial agonists.

and be transported across the stomach or

The process of converting

ing into the blood.

intestinal lin-

the drug into a

soluble form can be partially controlled by the pharmaceutical

dose form used

suspension, capsule, and and can be influenced by the relation to the presence or absence

(e.g., solution,

tablets with various coatings)

time of administration in of food in the stomach.

Distribution forms properly so that they are deposited in the correct tissue for enhanced absorption; and (3) reconstitute and dilute drugs only with the diluent recommended by the manufacturer in the package literature so that drug solubility is not impaired. Equally important are nursing assessments that imply enteral

administered subcuta-

poor absorption (e.g., neously and a lump remains at the site of injection 2 to 3 hours later, absorption from that site may be impaired). The three categories of drug administration are enteral, if

insulin

is

and percutaneous routes. The enteral route

is

ad-

ministration directly into the gastrointestinal (GI) tract

by

parenteral,

oral, rectal, or nasogastric routes.

Parenteral routes of ad-

ministration bypass the gastrointestinal tract by subcutaneous

(SC),

intramuscular (IM),

or

intravenous

Methods of percutaneous administration

(IV)

injection.

are inhalation, or

The term distribution

refers to the

ways

in

which drugs are

transported by the circulating body fluids to the sites of action (receptors), metabolism, and excretion. Drug distribution is both transport throughout the entire body by the blood and

lymphatic systems and transport from the circulating fluids into and out of the fluids that bathe the receptor sites. Organs having the most extensive blood supplies, such as the heart, liver, kidneys, and brain, receive the distributing drug most

Areas with

rapidly.

muscle, skin, and

Once

less extensive

fat,

its

distribution is determined

properties of the drug and it

more

slowly.

a drug has been dissolved and absorbed into the cir-

culating blood,

tissues

blood supplies, such as the

receive the drug

contacts.

Two

how

it is

by the chemical

affected by the blood and

of the factors that influence drug dis-

tribution are protein binding

and

lipid (fat) solubility.

Most

sublingual or topical administration. Absorption of topical

drugs are transported in combination with plasma proteins,

drugs applied to the skin can be influenced by the drug concentration, length of contact time, size of affected area, thick-

especially albumin,

ness of skin surface, hydration of tissue, and degree of skin disruption. Percutaneous absorption

newborns and young

infants,

is

who have

greatly increased in thin,

well-hydrated

can be influenced by depth of respirations, fineness of the droplet particles, available surface area of mucous membranes, contact time, hydration state, blood supply to the area, and concentration of the drug itself. The rate of absorption by parenteral routes is partially dependent on the rate of blood flow through the tissues. Circulatory insufficiency and respiratory distress may lead to hypoxia and further complicate this situation by resulting in vasoconstriction. (The nurse should therefore not give an injection where circulation is known to be impaired. Another skin. Inhalation of drugs

and

their absorption

on the rotation schedule should be used.) SC injections have the slowest absorption rate, especially if peripheral circulation is impaired. IM injections are more rapidly absorbed because of greater blood flow per unit weight of muscle compared with subcutaneous tissue. (Depositing the medication into the muscle belly is important. Nurses must carefully assess the individual patient for the correct length of needle to ensure that this occurs.) Cooling an area of injection slows the site

rate

of absorption, whereas heat or massage hasten the rate of When administered by IV injection, the drug is

which act as carriers for relatively insoluDrugs bound to plasma proteins are pharmacologically inactive because the large size of the complex keeps them in the bloodstream and prevents them from reaching the sites of action, metabolism, and excretion. Only the free or unbound portion of a drug is able to diffuse into tissues, interact with receptors, and produce physiologic effects (or be metabolized and excreted). The same proportion of bound and free drug is maintained in the blood at all times. Thus as the free drug acts on receptor sites or is metabolized, the decrease in serum drug levels causes some of the bound drug to be released from protein to maintain the ratio between bound and ble drugs.

free drug.

When

a drug

is

circulating in the blood, a blood sample

may be drawn and assayed to determine the amount of drug present. This is known as a drug blood level. It is important for certain drugs (e.g., anticonvulsants

and aminoglycoside an-

be measured to ensure that the drug is in the therapeutic range. If the drug blood level is low, the dosage must be either increased or the medicine must be administered more tibiotics) to

frequently. If the drug blood level

develop

toxicities; either the

medicine administered

less

is

too high, the patient

may

dosage must be reduced or the frequently. See Appendix D for

therapeutic blood levels for selected medicines.

Once

a drug leaves the bloodstream,

it

may become bound The more

absorption.

to tissues other than those

dispersed throughout the body most rapidly. (Nurses must be

lipid-soluble drugs have a high affinity for adipose tissue,

with active receptor

sites.

Principles of Drug Action an*

Chapter 2

16

rug Interactions

which serves as a repository site for these agents. Because is relatively low blood circulation to fat tissues, the more lipid-soluble drugs tend to stay in the body much longer. An equilibrium is established between the repository site (lipid tissue) and circulation so that as the amount of drug in the there

blood drops as a result of binding at the sites of physiologic activity, metabolism, or excretion, more drug is released from the lipid tissue.

librium

is

By

contrast, if

more drug

is

given, a

new

equi-

established between the blood, receptor sites, lipid

and metabolic and excretory

tissue repository sites,

Distribution

may be

general or selective.

Some

drugs can-

nervous system (blood-brain barrier) or the placenta (placenwhile other types of drugs readily pass into these tissues. The distribution process is very important, because tal barrier),

amount of drug

genetic variations of

enzyme systems, concurrent use of other

drugs, exposure to environmental pollutants, concurrent

sites.

not pass certain types of cell membranes, such as the central

the

Metabolism Metabolism, also called biotransformation, is the process by which the body inactivates drugs. The enzyme systems of the liver are the primary site of metabolism of drugs, but other -tissues and organs (e.g., white blood cells, GI tract, and lungs) metabolize certain drugs to a minor extent. Genetic, environmental, and physiologic factors are involved in the regulation of drug metabolism reactions. The most important factors are

that actually gets to the receptor sites de-

termines the extent of pharmacologic activity. If little of the drug actually reaches and binds to the receptor sites, the response will be only minimal.

and age (see the section fluencing Drug Action, p. 17).

nesses,

ill-

entitled, Variable Factors In-

Excretion Elimination of metabolites of drugs and, in some cases, the active drug itself

mary

from the body

routes are through the

GI

is

called excretion.

tract to the feces

The

pri-

and through

the renal tubules into the urine. Other routes of excretion in-

clude evaporation through the skin, exhalation from the lungs,

and secretion into the saliva and mother's milk. Because the kidneys are a major organ of drug excretion, |

Total drug in

dosage

oral

forrr (

1

ration of a drug if the dosage

and

S~~\ ) ~~~^

CI fluids

The

patient with re-

and frequency of administration

are not adjusted to the patient's renal function.

T disintegration

Drug dissolved

tests.

nal failure often experiences an increase in the action and duDissolution

1

in

it

appropriate for the nurse to review the chart for the results

of the urinalysis and renal function

Drug not dissolved

J

is

Stomach f emptying time

Figure 2-2

Drug lost by degradation

*"

(

is

a schematic review of the

an oral medication.

in gastric

medium

Drug

by

It is

important to note

ADME process of

how

little

of the ac-

tive ingredient actually reaches the receptor sites for action.

1

Drug

in

solution

—

f~\

in intestine

>

'

\

^^

W Drug that

in

is

lost

^

dearadation

"""

intestinal

Half-life

in

medium,

Elimination of drugs occurs by metabolism and excretion.

or by binding to food

Drug not or other absorbed

contents

o

solution

absorbed

Drug

lost

by

^^~-W secretion into bile Drug

in liver

\_)

^~-

%

-Drug

lost

Time (hours)

bound

/

w Drug reaching

to tissue

W \P f-^

general circulation

_

Drug

"""

biotransformation

lost

by

^ bound to 1

f

w

Drug distributed to body

^ O

plasma protein

^ Drug distributed to

/•

Vs.

** tissues

l-^V-Vv^..

V

*"^

^ Drug " "

bound

to tissue

Drug

Figure 2-2

and organs

other than

^

N.

site

of action

Drug

lost

by

biotransformation and excretion

at site of action

Factors modifying the quantity of drug reaching a site of

action after a single oral dose. (From Levine RR: Pharmacology, reactions. Boston IW, Little, Brown.)

duty, actions,

Half-life

—

by

biotransformation

Drua

A

measure of the time required for elimination is the half-life. The half-life is defined as the amount of time required for 50% of the drug to be eliminated from the body. For example, if a patient was given 100 mg of a drug that had a half-life of 12 hours, the following would be observed:

intestinal

and

Drug remaining 100

in

body

mg (100%)

mg (50%) mg (25%) 12.5 mg (12.5%)

12

1

50

24

2

25

36

3

48

4

6.25

mg

(6.25%)

60

5

3.12

mg

(3.12%)

Note that as each 12-hour period (one half-life) passes, the amount remaining is 50% of what was there 12 hours earlier. After six half-lives, more than 98% of the drug is eliminated from the body. The half-life is determined by an individual's ability to metabolize and excrete a particular drug. Because most patients metabolize and excrete the same drug at approximately the same rate, the approximate half-lives of most drugs are now known. When the half-life of a drug is known, dosages and frequency of administration can be calculated. Drugs with a long half-life, such as digoxii) at 36 hours, need to be administered only once daily, whereas drugs with a short half-life, such as aspirin at 5 hours, need to be administered every 4 to

Principles of Drug Action

Chapter 2

6 hours to maintain therapeutic activity. In patients who have impaired hepatic or renal function, the half-life may become considerably longer because of the inability to metabolize or excrete the drug. An example is digoxin, with a half-life of about 36 hours in a patient with normal renal function, but a half-life of about 105 hours in a patient in complete renal failure.

Monitoring diagnostic

patic function

is

important.

tests that

Whenever

measure renal or he-

laboratory data reflect

impairment of either function, the nurse should, notify the physician.

and Drug

Interactions

hives. Occasionally, a patient has a severe, life-threatening re-

action that causes respirator) distress and cardiovascular collapse, known as an anaphylactic reaction. This condition is a medical emergency and must be treated immediately. Fortunately, anaphylactic reactions

more mild it

urticarial reactions.

occur It

much

less often than the

a patient has a mild reaction,

should be taken as a warning not to take the medication again.

The

much more

likely to have an anaphylactic reacexposure to the drug. Patients should receive information regarding the drug name and be told to tell health

patient

is

tion at the next

care professionals such as nurses, physicians, pharmacists, and dentists that they have

DRUG ACTION

drug again.

had a reaction and must not receive the should wear an identification

In addition, patients

bracelet or necklace explaining the allergy.

Objective

Carcinogenicity is the ability of a drug to induce living mutate and become cancerous. Many drugs have this potential, so all drugs are tested in several animal species be-

cells to

Compare and

I.

contrast the following terms used

in rela-

tionship to medications: desired action, side effects, ad-

verse effects, allergic reactions, and idiosyncratic reactions.

human

fore

investigation to help eliminate this potential.

A

drug that induces birth defects is known as a teratogen. Organs of the body are particularly susceptible to malformation if exposed to a drug while being formed in the fetus. Because most organ systems are formed during the

Key Words

first

trimester

of pregnancy, the greatest potential for birth defects caused by drugs occurs during this period. desired action

allergic reactions

side effects

urticaria

adverse effects

hives

toxicity

carcinogenicity

idiosyncratic reaction

teratogen

VARIABLE FACTORS INFLUENCING DRUG ACTION Objectives

No

drug has a single action. When a drug enters a patient and absorbed and distributed, desired action (i.e., expected response) usually occurs. All drugs, however, have the potential is

to affect

I.

List factors that

tion,

adverse effects. When is sometimes referred to as a toxicity. Most of these side effects are predictable, and patients should be monitored so that dosages can be adjusted

known

as side effects or

adverse effects are severe, the reaction

to allow the

maximum

of side effects.

therapeutic benefits with a

As described

has a series of parameters

in Part

(e.g.,

2 of this

text,

minimum

absorption, distribu-

drug interactions)

that

Key Words placebo

drug dependence

tolerance

drug accumulation

each drug

therapeutic actions to expect,

side effects to expect, adverse effects to report, and probable

should be monitored by the nurse,

Many

drugs are unexpectedly potent patients

apy while reducing the possibility of serious adverse effects. Two other types of drug action are much more unpredictable. These are idiosyncratic reactions and allergic reactions. An idiosyncratic reaction occurs when something un-

some

when

usual or abnormal happens

a drug

is

first

administered.

shows an overresponse to the action of the drug. This type of reaction is usually due to a patient's inability

knocked me The effects of

times, patients state, "That drug really

out!" or "That drug didn't touch the pain!"

physician, pharmacist, and patient in order to optimize ther-

show

little

in

some

patients,

whereas other

response to the same dose. In addition,

same dose of a drug adBecause of individual patient variation, exact responses to drug therapy are difficult to predict. The following factors have been identified as contribupatients react differently to the

ministered

at different

tors to a variable

times.

response to drugs.

patient usually

to metabolize a drug because of a genetic deficiency of certain enzymes. Fortunately, this type of reaction is fairly rare.

Allergic reactions, also tions,

occur

in

about

known

exposed

to a

immune

as hypersensitivity reac-

6% to 10% of patients taking

Allergic reactions occur in patients

their

in

more than one body system simultaneously, produc-

ing responses

The

cause variations

metabolism, and excretion of drugs.

who have

medications.

previouslj been

drug and have developed antibodies systems.

On

to

it

from

reexposure. the antibodies cause a

most commonly seen as raised, irregular-shaped patches on the skin with severe itching, known as urticaria or reaction,

Age Infants and the very elderly tend to be the most sensitive to the response of drugs. There are important differences in the ab-

sorption, distribution, metabolism, and excretion of drugs in

premature neonates, lull-term newborns, and older children. in bod\ composition and organ function that can affect the elderl\ patient's response to drug therapy. See Chapter 3 for a more complete

The aging process brings about changes

discussion of age-related variables influencing drug action.

Chapter 2

>rug Interactions

Principles oj

Body Weight

Dependence

Considerably overweight patients usually require an increase in dosage to attain the same therapeutic response. Conversely, patients who are underweight (compared with the general

Drug dependence, also known as addiction or habituation, occurs when a person is unable to control the ingestion of drugs. The dependence may be physical, in which the person

population) tend to require lower doses for the same thera-

develops withdrawal symptoms

peutic response.

Most

pediatric doses are calculated

by mil-

ligrams of drug per kilogram of body weight to adjust for

growth

rate.

the drug is withdrawn for a which the patient is emotionally attached to the drug. Drug dependence occurs most commonly with the use of the scheduled, or controlled, medications listed in Chapter 1 such as opiates and benzodiazepines. if

certain period; or psychologic, in

Metabolic Rate Patients with a higher metabolic rate tend to metabolize drugs

Cumulative Effect

more

A

rapidly, thus requiring either larger doses or

more

fre-

drug

may accumulate

in the

body

if

the next doses are ad-

quent administration. The converse is true for those with lower metabolic rates. Chronic smoking enhances the metabolism of some drugs (e.g., theophylline), thus requiring

result in

higher doses to be administered more often for a therapeu-

the excessive ingestion of alcoholic beverages.

A

tic effect.

comes "drunk" or "inebriated" when

consumption

ministered before previously administered doses have been

metabolized or excreted. Excessive drug accumulation may drug toxicity. An example of drug accumulation is the rate of

person be-

exceeds the rate of metabolism and excretion of the alcohol.

Illness Pathologic conditions

may

DRUG INTERACTIONS

alter the rate of absorption, distri-

bution, metabolism, and excretion. For example, patients in

shock have reduced peripheral vascular circulation and will absorb IM- or SC-injected drugs slowly; patients who are vomiting may not be able to retain a medication in the stomach long enough for dissolution and absorption; patients with diseases such as nephrotic syndrome or malnutrition may have reduced amounts of serum proteins in the blood necessary for adequate distribution of drugs; patients with kidney failure must have significant reductions in the dosages of those medications that are excreted by the kidneys.

Object! State the

1

mechanisms by which drug interactions may occur.

Differentiate

2.

among

the following terms used

in

rela-

tionship to medications: additive effect, synergistic effect, antagonistic effect,

displacement, interference, and

incompatibility.

Key Words

Psychological Aspects Attitudes and expectations play a major role in a patient's re-

drug interaction

sponse to therapy and the willingness to take the medication as prescribed. Patients with diseases that have relatively rapid consequences if therapy is ignored, such as insulin-dependent diabetes, usually have a good rate of compliance. Patients with "silent" illnesses, such as hypertension, tend to be much less compliant with the treatment regimen. Another psychologic consideration is the "placebo effect." A placebo is a drug dosage form such as a tablet or capsule that has no pharmacologic activity because the dosage form has no active ingredients. When taken, the patient may report a therapeutic response. This response can be beneficial in patients being treated for such illnesses as anxiety, because the patient tends to take fewer potentially habit-forming

antagonistic effect

interference

unbound drug

synergistic effect

displacement

incompatibility

drug

drugs.

fects of the caffeine counteract the drowsiness

A drug

additive effect

is said to occur when the action of one by the action of another drug. Drug interactions are elicited in two ways: (1) agents that when combined increase the actions of one or both drugs; and (2) agents that when combined, decrease the effectiveness of one or both of the drugs. Some drug interactions are beneficial, such as the use of caffeine, a central nervous system (CNS) stimulant,

is

interaction

altered

with an antihistamine, a

CNS

depressant.

The stimulatory

ef-

caused by the

antihistamine without eliminating the antihistaminic effects.

Tolerance Tolerance occurs when a person begins to require higher doses to produce the same effects that lower doses once provided. An example is the person who is addicted to heroin. Alter a few weeks of use, larger doses are required to provide the same "high." Tolerance can be caused by psychologic dependence, or the body may metabolize a particular drug more rapidly than before, causing the effects of the drug to diminish

more

rapidly.

The mechanisms of drug

interactions can be categorized as

altering the absorption, distribution,

metabolism and/or ex-

cretion of a drug; or by enhancing the

pharmacology of a Most drug interactions that alter absorption take place in GI tract, usually the stomach. Examples of this type o\' in-

drug. the

teraction include the following: •

Antacids inhibit the dissolution of ketocona/ole tablets by increasing the gastric pH. The interaction is managed by giving antacids at least 2 hours after ketoconazole administration.

Chapter 2

•

Aluminum-containing antacids inhibit the absorption of Aluminum salts form an insoluble chemical complex with tetracycline. The interaction is managed by tetracycline.

separating the administration of tetracycline and antacids to 4 hours.

by 3

Drug

Principles of Drug Action

Drugs

that interact

and Drug

Interactions

by altering excretion usually act in the pH to enhance or inhibit excre-

kidney tubules by altering the tion.

The

classic

example of

pH

altered urine

is

with acetazo-

lamide, a drug that elevates urine pH, and quinidine.

The

al-

kaline urine produced by acetazolamide causes quinidine to

interactions that cause an alteration in distribution

be reabsorbed in the renal tubules, potentially increasing the

usually affect the binding of a drug to an inactive site, such as circulating plasma albumin or muscle protein. Once a drug is

ing of quinidine serum levels and quinidine toxicity are used

absorbed into the blood,

as guides for reducing quinidine dosages.

the

body bound

such as those

teins

it

is

usually transported throughout

plasma proteins.

to

in the

muscle.

It

A

often binds to other pro-

drug that

is

highly bound

( i.e., >90% bound) to a protein-binding site may be displaced by another drug that has a higher affinity for the binding site. Very significant interactions can take place this way because very little displacement is required to have a significant impact. Remember that only unbound drug is pharma-

cologically active. If a drug

10%

of the drug

drug

is

binding

is

90% bound

to a protein, then

providing the physiologic effect. If another administered with a stronger affinity for the proteinsite

is

and displaces just

now 15% unbound alent of a

50%

5%

of the bound drug, there

for physiologic activity. This

increase in dose, from

10%

to

15%

is

is

inducers

are

phenobarbital,

carba-

mazepine, rifampin and phenytoin. Examples of drugs whose metabolism is stimulated are disopyramide, doxycycline, griseofulvin, warfarin, metronidazole, mexiletine, quinidine.

theophylline, and verapamil.

zyme

When

inducers, the dosage of the

administered with en-

more

rapidly metabolized

drug must usually be increased to provide therapeutic activity. The patient must be monitored closely for adverse effects, especially if the enzyme inducer is discontinued. The metabolism of the induced drug decelerates, leading to accumulation and toxicity if the dosage is not reduced. An example of this type of interaction is that of a woman receiving oral contraceptives (e.g.,

last major mechanisms of drug interactions are those enhance the physiologic effect of a drug. Examples of enhanced physiologic effects are those that both cause CNS depression, such as a sedative-hypnotic and alcohol, or potentiation of neuromuscular blockade between an aminoglycoside antibiotic and a neuromuscular blocking agent such as

The

that

tubocurarine.

The following terminology

Ortho-Novum, Lo/Ovral) who requires

a

course of rifampin antimicrobial therapy. Rifampin induces enzymes that metabolize both the progestational and estrogenic components of the contraceptives, causing an increased

is

used

in

describing drug

interactions:

—

Additive effect Two drugs with similar actions are taken for a doubled effect

the equiv-

active drug.

For example, the anticoagulant action of warfarin is increased by administration with furosemide. This loop diuretic displaces warfarin from albumin-binding sites, increasing the free fraction of anticoagulant. This interaction is managed by lowering the warfarin dose. The most common ways in which drug interactions result from an alteration in metabolism is by either inhibition or induction (stimulation) of enzymes responsible for metabolism of a drug. Medicines known to bind to enzymes and slow the metabolism of other drugs are verapamil, chloramphenicol, ketoconazole, amiodarone, cimetidine, and erythromycin. Serum levels usually increase as a result of inhibited metabolism, and doses usually must be reduced to prevent toxicity. An example is that of erythromycin inhibiting the metabolism of theophylline. The dose of theophylline must be reduced based on theophylline serum levels and signs of toxicity. Because erythromycin (an antibiotic) is usually administered only in short courses, the theophylline dose most likely has to be increased again after erythromycin is discontinued.

Common enzyme

physiologic and toxic effects of quinidine. Frequent monitor-

propoxyphene + aspirin = added analgesic

EXAMPLE:

Synergistic effect

—The

greater than the

EXAMPLE:

aspirin

sum of

— One drug

tetracycline

+

effect of

effect

two drugs

is

the effect of each drug given alone

+ codeine = much

Antagonistic effect another EXAMPLE,

combined

antacid

greater analgesic effect

interferes with the action of

=

decreased

absorption

of

the

tetracycline

Displacement

—The displacement of a drug by a second drug

increases the activity of the

EXAMPLE:

warfarin

+

valproic acid

—One drug

Interference

first

=

drug increased anticoagulant effect

inhibits the

metabolism or excretion

of a second drug, causing increased activity of the second drug probenecid + spectinomycin = prolonged antibacterial acfrom spectinomycin due to blocking renal excretion by probenecid

EXAMPLE: tivity

Incompatibility

—One drug

is

chemically incompatible with

when the two drugs are same syringe or solution; incompatible drugs should not be mixed together or administered together at the same site; signs of incompatibility are haziness, a preanother drug, causing deterioration

mixed

in the

cipitate, or a

change

in color

of the solution

when drugs

are

mixed EXAMPLE:

The

ampicillin + gentamicin - ampicillm inactivates gentamicin

side effects of medicines are perhaps better tolerated

by younger persons than elderly individuals. Dizziness in the may cause a decrease in activity lor fear of falling; a dry mouth can initiate poor tolerance of dentures, along with alterations in taste and chewing, thus reducing nutritional in-

elderly

take.

Even a minor, subtle

alteration in mental or behavioral

functioning deserves to be investigated for the possibility of a

vising the patient to use an additional form of contraception

drug-induced change before any additional medicines are prescribed for the symptomatology. Drug-induced side effects are commonly mistaken for disease symptoms. Many medi-

while receiving rifampin therapy.

cines (e.g., reserpine. beta-blockers. anti-Parkinsonian drugs.

incidence of menstrual abnormalities and reduced effectiveness of conception control. This interaction is managed by ad-

Drug Action Across

Chapter 3

20

the Life

Span

and corticosteroids) cause depression. Confusion may be the first and only symptom of a drug accumulation. Because confusion and delirium are often observed in the elderly population group, such as residents of a nursing home, what actually may be a drug-induced symptom is often treated with another

Because it is impossible to memorize all of the possible drug interactions, it is the nurse's responsibility to check for drug interactions when suspected. This requires actually taking the time to consult drug resource books and pharmacists to ensure that patients receiving multiple medications do not

agent.

suffer

Drug Action Across

CHAPTER CONTENT Changing Drug Action Across the

Drug Absorption

(p.

2

from unplanned drug

the Life Span

CHANGING DRUG ACTION

| Life

Span

(p.

ACROSS THE

20)

The age of 1

therapy.

Drug

Distribution

Drug Metabolism Drug Excretion

(p. (p.

(p.

is

1

22)

2.

When

discussing the effect of age on drug therapy,

it

gories:

When

Monitoring Drug Therapy

23)

Age

Title

85

The very old

years

Within the past decade, differences in how men and respond to medications have been notably recognized.

Key Wo

women

Unfortunately,

little

scientific data exists that

documents

dif-

men and

passive diffusion

drug metabolism

ferences in the pharmacokinetics of most drugs

hydrolysis

metabolites

women. Thus in 1993, the Food and Drug Administration (FDA) issued guidelines stating that drug development must

intestinal transit

polypharmacy

protein binding

in

include evaluation in both genders. Furthermore, testing

necessary to assess differences

in

is

pharmacokinetic parame-

8

Drug Action Across

lapter 3

between men and women. The women's drug studies must differentiate between pre- and postmenopausal women and women in different phases of the menstrual cycle.

ters

the Life

Span

21

factors: absorption, distribution,

phenobarbital, aspirin) are more poorly absorbed and have lower serum concentrations than those in patients with normal gastric acidity. Premature infants and geriatric patients also have a slower gastric emptying time, partly due to the lack of acid secretion. A slower gastric emptying time may al-

(ADME). Each

low the drug

As described

in

Chapter

2,

drug action depends on four metabolism, and excretion

of these factors varies depending on age.

(e.g.,

to

longer, allowing

Drug Absorption

centration. There

Before a medicine can be absorbed, it must first be administered. Both pediatric and geriatric patients require special considerations for medication administration. Medicines administered by the intramuscular (IM) route are usually erratically absorbed in both neonatal and geriatric populations.

drugs

stay in contact with the absorptive tissue

more absorption with is

more contact time

Differences in muscle mass, blood flow to muscles, and muscular inactivity in patients who are bedridden make absorp-

(e.g.,

a higher

serum conby

also the potential for toxicity, caused

in the

stomach

for potentially ulcerogenic

nonsteroidal antiinflammatory agents).

Another factor affecting drug absorption in the newborn is enzymes needed for hydrolysis. Infants do not have the ability to hydrolyze palmitic acid from chloram-

the absence of

phenicol palmitate, thus preventing absorption of the chlo-

ramphenicol. Oral phenytoin doses are also greater than expected in infants under 6 months of age, caused by poor

tion unpredictable.

absorption (neonates 15 to 20 mg/kg/24 hr vs infants and chil-

Topical administration with percutaneous absorption is usually effective in infants because the outer layer of skin (stratum corneum) is not fully developed, and the skin is more

dren 4 to 7 mg/kg/24

fully hydrated at this age, causing water-soluble drugs to be

causing some medicines to be poorly absorbed. Sustained-re-

absorbed more readily. Infants wearing plastic-coated diapers are also more susceptible to skin absorption because the plastic forms the equivalent of an occlusive dressing that increases hydration of the skin. Inflammation (e.g., diaper rash) also increases the amount of drug absorbed. Transdermal administration

in

geriatric

patients

is

often

difficult

to

predict.

Although dermal thickness decreases with aging and may enhance absorption, conversely, drying and wrinkling occurs, as well as a decrease in hair follicles that tion.

In

diminish absorp-

With aging, decreased cardiac output and diminishing

may

hr).

As

intestinal transit rate also varies with age.

the

neonate matures into infancy, the GI transit rate increases, lease capsules

(TheoDur Sprinkles®) move through

testines so rapidly that only about

50%

compared with children more than develop decreased GI motility and

5 years of age.

of a dose

intestinal

is

the in-

absorbed

The

elderly

blood flow. This

has the potential for altered absorption of medicines, as well as either constipation or diarrhea, In general,

solids

it

is

depending on the medicine.

thought that women's stomachs empty

more slowly than men and may have greater

acidity, thus

gastric

slowing the absorption of certain types of medi-

cines, such as aspirin.

Women

also have lower gastric levels

also affect transdermal drug absorption.

of an enzyme, alcohol dehydrogenase, needed to metabolize

most cases, medicines are administered orally. However, and capsule forms are often too large for either pediatric

ingested alcohol. Thus larger amounts of ingested alcohol

tissue perfusion

tablet

may

The

or geriatric populations to swallow.

It

is

often necessary to

may be absorbed

instead of metabolized in the stomach, lead-

ing to a higher blood alcohol level in

women

than in

men

for

crush a tablet for administration with food or use a liquid for-

equal amounts of ingested alcohol. Other factors such as body

mulation for easier administration. Taste also becomes a factor when administering oral liquids, because the liquid comes

weight and drug distribution (see below) may aggravate the higher blood alcohol level in women when compared to men.

in contact with the taste buds. Sustained-release tablets (p.

85), enteric-coated tablets (p. 86)

and sublingual

tablets (p.

146) should not be crushed because of changes in the absorption rate and the potential for toxicity. Infants and older adults

chewable medicines. Geriatric patients often have a reduced salivary flow, making chewing and swallowing more difficult. Two major factors affecting drug absorption from the gastrointestinal (GI) tract are passive diffusion and gastric emptying time. Both are dependent on the pH of the environment. Newborn infants and geriatric patients have altered gastric acidity and transit time when compared with adults. Premature infants have a high gastric pH (6 to 8) because of immature acid-secreting cells in the stomach. In a full-term newborn, the gastric pH is also 6 to 8, but within 24 hours, it often do not have sufficient

amount of

teeth for

decreases to 2 to 4 because of gastric acid secretion. Infants are approximately 1 year of age before the stomach pH approximates that of adults ( to 3). Geriatric patients often have 1

a higher gastric

pH due

to loss of acid-secreting cells.

ways in which drugs are transported by the circulating body fluids to the sites of action (receptors), metabolism, and excretion. Distribution is dependent on pH, body water concentrations (intracellular, extracellular, and total body water), presence and quantity of fat tissue, protein binding, cardiac output and regional blood flow. Most medicines are transported either dissolved in the circulating water (in blood) of the body or bound to plasma proteins within the blood. Body water composition as a percentage of weight changes substantially with age (Table 3-1). Note that the total body water content of a preterm infant is 83%, whereas that of an adult male is 609f The significance of this is that infants have a larger volume of distribution for water-soluble drugs and require a higher dose on a mg/kg ba.

than an older child or adult.

sis

As we

Drugs

by gastric acid (e.g., ampicillin, penicillin) are more readily absorbed and have higher serum concentrations because of the lack of acid destruction. In contrast, drugs that depend on an acidic environment for absorption that are destroyed

Drug Distribution Distribution refers to the

age. lean

body mass and

total

body water decrease.

may have bod) weight composed of 19! to 2', tat. while a full-term newborn ma> have I59f fat Adults increase from 18% up to

foi males and 3391 n>4N', tor females between ages

while

total fat

content increases. Preterm infants

r

;

.

1

Drug Action Across

Chapter 3

22

the Life

Span

albumin levels. Disease states such as cirand malnutrition can lower albumin levels. Initial doses of highly protein-bound drugs (e.g., warfarin, phenytoin, tolbutamide, propranolol, digitoxin, or diazepam) 'should be reduced and increased slowly if there is evidence of decreased serum albumin. result of decreased

rhosis, renal failure,

Percentages of Body Water-

Total Extracellular

Intracellular

Water

(Weight)

Water (%)

(%)

Body Water (%)

Premature

60

40

83

Drug Metabolism Drug metabolism is the vates medicines. Enzyme

Age

(1.5 kg)

Full-term

56

44

74

50

50

60

40

60

59

40

60

60

(3-5 kg)

(7 kg)

year

1

systems, primarily in the

are

liver,

major pathway of drug metabolism. All enzyme systems are present at birth but mature at different rates, taking several weeks to a year to fully develop. Monitoring of serum conthe

months

5

process by which the body inacti-

centrations to ensure therapeutic levels

(10 kg)

Adult male

is

more common

aminoglycosides, phenytoin, theophylline) in the

weeks

(e.g.,

first

few

because medicines are more rapidly metabolized as the enzyme systems mature. Dose and frequency of after birth

percentage of

Developmental changes from birth to adulthood. Total body water is expressed as a total body weight. (Data from Friis-Hansen B: Body composition during

administration or both must often be increased to help main-

growth. Pediatrics 47:264, 1971.)

tain therapeutic

serum concentrations.

It is

just being recog-

nized that males and females also differ in the concentrations

and 35. Drugs

that are highly fat-soluble (e.g., antidepressants,

of some of these enzyme systems throughout

life. The full imenzyme systems guidelines on new

phenothiazines, benzodiazepines, calcium channel blockers)

pact on metabolism by these differences in

require a longer onset of action and accumulate in fat tissues,

prolonging their action and potential toxicity. For other drugs,

will hopefully be identified by the drug development.

greater proportion of

such as ethanol and aminoglycoside antibiotics, women's body fat produces higher blood levels

hepatic blood flow decrease with increasing age. This results

compared with men when given an equal dose per kilogram of body weight. With ethanol, this tends to cause higher lev-

riously aggravated

producing greater intoxication. Highly fat-soluble medicines (e.g., diazepam) must be given in smaller mg/kg doses for infants with low birth weight, since there is less fat tissue to bind the drug, leaving more drug to be active at receptor sites.

els of ethanol in brain cells,

Drugs

that are relatively insoluble are transported in the

bound

plasma proteins (albumin and binding is reduced in preterm infants because of decreased plasma protein concentrations, lower binding capacity of protein, and decreased affinity of proteins for drug binding. Drugs known to have lower protein binding in neonates compared with an adult are

circulation by being

to

globulins), especially albumin. Protein

phenytoin,

phenobarbital,

caine, penicillin, tein

binding

is

theophylline,

propranolol,

lido-

and chloramphenicol. Because serum pro-

diminished, the drugs are distributed over a

wider area of the body, and a larger loading dose

is

required

than that in older children to achieve therapeutic serum concentrations. Competition

from several drugs used azole

is

binding

well sites,

known

may

take place for binding sites

to treat neonatal conditions. Sulfisox-

for displacing bilirubin

from protein-

thus allowing the bilirubin to accumulate and

Little

difference exists between albumins

women, although

there are

some

Liver weight, the number of functioning hepatic in a

slower metabolism of drugs

in

men and

differences between the

Drug Excretion Metabolites of drugs and,

about

50%

at

filtration

tion at 9 to 12 months.

crease.

As albumin

(e.g., the

levels diminish, the

globulins) in-

unbound, active drug

increases, increased levels of naproxen, didunisal, salicylate,

and valproate have been found

in

the elderly,

presumably as

a

is

it-

equivalent to adult func-

As discussed with maturation of

ministered

unaffected, albumin concentrations

cases, the active drug

capacity of an infant increases to

4 weeks of age and

kidneys

is

some

from the body. The primary routes are through the renal tubules into the urine and the GI tract to the feces. Other generally minor routes of excretion include evaporation through the skin, exhalation from the lungs, and secretion into the saliva and mother's milk. At birth, a preterm infant has up to 15% of the renal capacity of an adult, while a full-term newborn has approxi-

binding globulins). In adults 40 years of age, the composition protein concentration

in

are eventually excreted

self,

of body proteins begins to change. Although the gradually decrease, and other proteins

This can be se-

liver disease or heart

Drugs that are extensively metabolized by the liver morphine, lidocaine, propranolol) can have substantially prolonged duration of action if hepatic blood flow is reduced. Dosage amounts usually must be reduced or the time interval between doses extended to prevent accumulation of active medicine and potential toxicity. Drug metabolism can also be affected at all ages by genetics, smoking, diet, gender, other medicines and disease. Unfortunately no specific laboratory tests like renal function tests are available to directly measure liver function to adjust dosage amounts of medicines.

zyme systems above, drugs

body

and

(e.g.,

globulin proteins (corticosteroid-binding and sex-hormone-

total

in the elderly.

by the presence of

cells,

failure.

mately 35%. The

pass into the brain, causing kernicterus.

FDA

that are excreted primarily

en-

by the

gentamicin. tobramycin) must be addoses or more often to maintain adequate

(e.g., penicillin,

in larger

therapeutic serum concentrations as renal function matures.

As

previously stated, serum drug concentrations must be

monitored regularly. With the passage of time, important physiologic changes thai lake place in the kidneys include decreased renal blood

flow caused by atherosclerosis and reduced cardiac output, a loss of glomeruli, and decreased tubular function and concen-

There is, however, a great degree of individual variation in changes in renal function, and no prediction of re-

trating ability.

nal function can be made only on the basis of Renal function of elderly patients should be,

a person's age.

a

minimum,

estimated using mathematic equations that factor

in the pa-

tient's age.

More

optimally,

at

should be measured by collecting urine creatinine specimens over time. Serum" creatinine can give a general estimate of renal function, but in elderly it

methods tend to overestimate actual functional happens because the production of creatinine dependent upon muscle mass that is diminished in the el-

patients these

capability. This is

occur only when there has been major deterioration of renal function. Blood urea nitrogen (BUN) concentration is also a poor predictor of renal function because it is significantly altered by diet, status of hydration, and blood loss, either externally or into the GI tract. derly. Significant elevations

these monitoring parameters and laboratory tests take into

account the age of the patient being monitored. For example, neonates have a greater respiratory and heart rate and lower normal blood pressure than adults. It is also important that

measuring devices be appropriate for the individual patient appropriately sized blood pressure cuff). Infants are not smaller versions of adults and we cannot extrapolate the principles of drug therapy to infants only on (e.g..

Dosages must be adjusted to age. weight, and kidney function. Measuring serum concentrations of medicines is particularly important in those drugs with potential 1\ serious adverse effects. Usually, if a pediatric dosage is not readily available in reference texts, it may not be appro-

the basis of size. liver

priate for pediatric use.

Geriatric patients represent an ever-increasing portion of the population.

is

important that health care professionals

velop with advancing age and adjust drug therapy for the

in-

Factors that place the elderly patient

patient.

renal and hepatic function, chronic illnesses that require multiple

same monitoring parameters

(e.g., vital

drug therapy (polypharmacy), and a greater likelihood

of malnourishment. All of these factors lead to accumulation

signs, urine output, renal function tests) are used to plan

of active drugs with the potential for serious adverse effects

dosages and monitor the effects of drug therapy

these patients.

patients,

it

is

at

greater risk for drug interactions or drug toxicity are reduced

Nursing Implications When Monitoring Drug Therapy the

It

understand the physiologic and pathologic changes that dedividual

Whereas many of

23

The Nursing Process and Pharmacology

Chapter 4

in all

ages of

in

absolutely crucial that the normal values for

The Nursing Process and Pharmacology

CHAPTER CONTENT The Nursing Process

(p.

Key Words

23)

nursing process

Relating the Nursing Process to Pharmacology

(p.

32)

The

THE NURSING PROCESS

practice of nursing

human

the

purpose

for

using

the

nursing

process

methodology. 2.

these steps

in

in

terms of

nursing practice.

the nursing process and describe a problem-solving

and science

that uses a sys-

method used

in

as they

strive to

maintain basie

nursing care

The

help individuals maximize their potential for maintaining the highest possible level of all

independence

State the five steps

art

function along the wellness-illness continuum.

Focus of

Identify

an

ma) experience

individuals

Objectives 1.

is

tematic approach to identity and solve the potential problems

is

to

meeting self-care needs. Conceptual frameHenderson's Complementary-Supplement Model (1980). Roger's lite Theory "s 979. Process Adaptation Model 1976). 1980), Ro)

works of

in

the basis of nursing practice, such as

(

1

(

24

The Nursing Process and Pharmacology

Chapter 4

and the Canadian Nurses' Association Testing Service (1980), are examples of models used today. The nursing process is the foundation for the clinical practice of nursing. It provides the framework for consistent nursing actions, using a problem-solving approach rather than provides a systematic method of

easier.

Accountability for nursing care and for developing

new methodologies

will also

be enhanced by the use of

this

technology.

Many ties

nursing education programs and health-care

facili-

use a five-step model that includes assessment, nursing

outcomes of the therapy delivered. In

planning, implementation, and evaluation. The model (Table 4-1) is used here for purposes of discussion. These five steps are actually an overlapping process (Figure 4-1). Information from each step is used to formulate and develop the next step in the process. Table 4-1 illustrates the process used to assemble data and organize information

addition to quality of care, the nursing process provides a sci-

into categories that help the learner identify the patient's

an intuitional approach.

working with patients tient

It

and possible padrug therapy, and

to identify actual, risk

problems, particularly those related to

helps determine what actions must be taken to correct the

When implemented

problems.

method

to evaluate the

method

properly,

it

also provides a

diagnosis, five-step

for health-care planners to assign

strengths and problem areas. Thereafter, nursing diagnosis

nursing staff to patients and to determine and justify the cost

statement(s) can be developed and focused nursing assess-

of providing nursing care in this age of soaring health-care ex-

ments can be initiated. Planning can be individualized, and measurable goals and anticipated therapeutic outcomes can be

entific, transferable

pense.

As computerization of

patient care records increases,

the ability to retrieve data based

ments and

on nursing diagnosis

to analyze the nursing care delivered will

state-

become

identified. Concurrently, individualized nursing interventions

can be developed to coincide with the individual's

abilities,

Table 4Principles of the Nursing Process

Planning

Assessment Collect

all

Intervention

problems idenfrom the assessment

Prioritize the

relevant data asso-

ciated with the individual

tified

patient's diagnosis to detect

data, with the

or possible problems needing interven-

or life-threatening first. Other problems are arranged in descending order of importance.

actual, high-risk,

tion.

Primary data sources Secondary data sources Tertiary data sources

referred to as an "ac-

when

statements to describe the behavior to be observed.

the defining characteristics

there

is

Identify the

when

a likelihood of the

diagnosis developing or being prevented;

or a "possi-

ble" nursing diagnosis

more

when

a one-part diag-

Perform ongoing assessments on a continuum.

Document

Unrealistic goals revision

may

additional findings

Follow a systematic approach to recording progress, depending on the setting and

on

charting

tect possible complications

Document

methods used. goal attainment,

of the disease process or

partial attainment,

treatments being used.

to achieve goals.

or

failure

Continue the nursing process, initiate referral

long-term goal. More

to a

community-based health agency, or execute discharge

to actually

lead to the broader,

require

or discontinuation.

care given and

monitoring pa-

may be required

persons desiring and capable

who

est level of functioning) are

safety.

than one short-term goal

nosis statement used for

of attaining a higher level of

ing the patient to the high-

ing pathophysiology.

Provide for patient

rameters to be used to de-

fied

problem. A wellness nursing

wellness

modify the care plan so that goals of care (usually, return-

correlate with each identi-

substantiate or refute the

is

Review and analyze the data regarding the patient and

Plan nursing approaches to

data are required to

diagnosis

to review and analyze data.

goals.

the chart.

are present; as a "high-risk"

nursing diagnosis*

process. Establish target data

term

attained.

Develop short- and long-term patient goals in measurable

of concern and the cause. tual" nursing diagnosis

phase of the nursing

ized short- and/or long-

valid.)

the behaviors or problems

is

achieve the individual-

cations related to exist-

other approaches may be equally

an ongoing

process that occurs at every

fre-

prioritizing;

is

vention planned to

quently used as a basis for

is

Evaluation

inter-

Monitor the patient's response to treatments, and monitor for compli-

(Maslow's hierarchy

Based on the data collected, formulate a statement of

This

most severe

Evaluation

Perform the nursing

procedures as ordered by

more

the physician

encompassing long-term goals.

currently have

an effective status. (Check hospital policy for the level

of nursing required to per-

form

this function.)

*Nursing Diagnosis: Because not complication arc placed pable of attaining

a

hi a

all

categor)

patient

problems arc amenable

to resolution

by nursing actions, those complications associated

\

known as collaborative problems thai the nurse monitors A wellness diagnosis is a one pan diag who currentl) have an effective status Check hospital policies foi the level ol nursing requii

high level of wellness

atmenl related esirins and ca

M

The Nursing Process and Pharmacology

Chapter 4

resources, and the disease processes being treated. During the

tribute data regarding the patient's care

implementation process the individual's physical, psychosocial, and cultural needs must be considered. The assessment process should continue to focus not only on the evolving changes in the presenting symptoms and problems, but also

the prescribed treatment regimen.

on the detection of the past,

all

potential complications that

potential nursing

may

occur. In

problems began the nursing

di-

to

maintain homeostasis

at-risk populations. If a nurse suspects that a

(see Figure 4-1).

is

pres-

and external en-

is

and cooperatively establish and execute

nursing functions to meet the holistic care needs of patients

can be formulated

using the term possible before the diagnostic label. See Fig. 4-2 for differentiating among actual, risk, and possible nursing diagnoses.

in

in the internal

an ongoing, cyclic process that must respond to the changing requirements of the patient. The nurse must continually interact with people in a variety of vironment, the nursing process

settings to creatively

problem

needs and response to

Just as bodily functions are constantly undergoing adjust-

ments

agnosis with the phrase Potential for; these statements are now stated as Risk for. The term High Risk for is used for the ent, a possible nursing diagnosis statement

25

Nurses should examine the nurses' practice act in the state which they practice to identify the educational and experi-

perform physical assessment and develop nursing diagnoses. Formulation of nursing diagnoses requires a broad knowledge base to make the discriminating judgments needed to identify the individual patient's care needs. All members of the health-care team need to con-

Assessment Objectives

ential qualifications necessary to

Figure 4-1

1

.

2.

Describe the components of the assessment process.

Compare

current methods used to collect, organize, and

analyze information about the health-care needs of patients

The nursing process and the

and their

holistic

significant others.

needs of the patient

The Nursing Process and Pharmacology

Chapter 4

26

Focus Assessment (pattern identification, possible explanations)

Validation of major signs

and symptoms

Yes

Validations of

Actual

risk

factors

nursing diagnosis

r

1 No

Yes

Can the nurse

identify

\

contributing factors?

I

Do you

Risk nursing diagnosis

problem

J Yes

may be

suspect a situation

present?

Record "Risk for" before the diagnostic label related to

the

Record the diagnostic

label

risk factors.

Example: Risk for Impaired

related to the specific contributing

Skin Integrity related to

factors.

immobility

and

fatigue

Example: Activity intolerance related to insufficient cardiac

output

for

1

energy expenditure, as evidenced by

dyspnea and

failure of pulse to

return to resting pulse

3

78

to

84

No after

min

No Possible nursing

No problem

diagnosis

Record the diagnostic related to

unknown

at this

label

etiology.

more

Example: Self-Concept

Collection of

Disturbance related to

data

unknown

confirm or rule out

etiology as

evidenced by

"I

present

time

is

Monitor

indicated to

have not

valued myself for several

months"

Record "Possible" before the diagnostic label. Example: Possible Feeding

Care

and IV in

Figure 4-2

Decision tree for differentiating

Nursing diagnosis application

among

velopment of certain problems

an ongoing process that starts with the admisis

completed

at the

time of dismissal.

the problem-identifying phase of the nursing process.

The

assessment must be performed by registered nurses who have the necessary assessment skills to perform the physical examination and the knowledge base to analyze the data assembled and identify patient problems based on defining initial

characteristics (signs, tion, the nurse

in

response to a disease

process or to the prescribed therapeutic interventions

sion of the patient and It is

hand

the actual, risk, and possible nursing diagnoses. (From Caipenito U: JB Lippincott.)

assessment

is

right

to clinical practice, eel 7, Philadelphia, 1997,

Key Wor

Assessment

Self-

Deficit related to fatigue

symptoms,

should identify

clinical evidence). In addi-

risk factors that

vidual or group of persons to be

cause an indi-

more vulnerable

to the de-

when

used (e.g., side effects to drugs that may require modification of the regimen). During the assessment phase, the nurse collects a comprehensive information base about the patient from the physical examination, nursing history, medication history, and professional observation. Formats commonly used for data collection, organization,

and analysis are the head-to-toe assessment,

body systems assessment, or Gordon's Functional Health Patterns Model. Both the head-to-toe and both systems approaches focus on physiology and thereby limit the nurse's knowledge of sociocultural, psychological, spiritual, and developmental factors affecting the individual's needs. The box on p. 27 shows Gordon's Functional Health Patterns Model.

i 27

The Nursing Process and Pharmacology

Chapter 4

Nursing Diagnosis Situation identified

(health status, problem)

1.

Define nursing diagnosis and discuss the wording used

in

Can the nurse

formulating nursing diagnosis statements. 2. 3.

legally order the

between

Differentiate

primary interventions

to achieve a goal?

Define a collaborative problem. a nursing diagnosis

and a medical

diagnosis. 4.

Differentiate

between problems that require formulation

of a nursing diagnosis and those categorized as collaborative

Are medical and nursing

problems, which may not require nursing diagnosis

Nursing diagnosis

interventions

needed

to achieve the patient goal?

statements.

Prescribe

Key Words

No

and execute the

interventions that are definitive for prevention, treatment, or

nursing diagnosis

defining characteristics

actual nursing diagnosis

medical diagnosis

risk nursing diagnosis

collaborative problem

wellness nursing diagnosis

focused assessment

promotion

Discharged from nursing care

Collaborative problems

Nursing diagnosis is the second phase of the five-step nursing process. The North American Nursing Diagnosis Association (NANDA) approved the following official definitions relating to nursing diagnoses:

7 and implement

Prescribe

Monitor and

Implement the

evaluate

interventions that are in

the domain of nursing

prescriptive

condition

orders of

Nursing diagnosis: A clinical judgment about individual, family, or community response to actual or potential health problems and life processes. The nursing diagnosis provides the basis for selection of nursing intervention to

achieve outcomes for which the nurse

is

accountable.*

dentistry

Figure 4-3

Differentiation of nursing diagnosis from collaborative

problems. (From Carpcniio I.J: Nursing diagnosis application 7. Philadelphia. 1997. JB Lippincott.)

t

clinical practice,

ed

(See Figure 4-2.)

Actual nursing diagnosis: Human responses to health conditions and life processes that exist in an individual, family, or community. It is supported by defining characteristics (manifestations or signs and symptoms) that cluster in patterns of related cues or inferences.

phrasing used in some instances

when an

likely to develop a particular

problem

is

Nutrition-Metabolic Pattern

3.

Elimination Pattern

4.

Activity-Exercise Pattern

5.

Sleep-Rest Pattern

6.

Cognitive-Perceptual Pattern

also high

7.

Self-Perception-Self-Concept Pattern

who

Possible nursing diagnosis: Suspected patient problems requiring additional data for confirmation.

Human

Health Perception-Health Management Pattern

2.

is

individual

risk for.

Wellness nursing diagnosis:

Gordon's Functional Health Patterns Model 1.

Risk nursing diagnosis: Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability. An added

more

medicine and

responses to levels of

8.

Role-Relationship Patterns

9.

Sexuality-Reproductive Patterns

10.

Coping-Stress-Tolerance Pattern

II.

Value-Belief Pattern

wellness in an individual, family, or community that have a potential for enhancement to a higher state.

Using

knowledge

nutrition, psychology,

and skill in anatomy, physiology, pharmacology, microbiology, nursing

It

should be noted that not

all

patient

problems identified

communication techniques, the nurse analyzes the data collected to identify whether certain major and minor defining characteristics (manifestations or signs and symptoms) that may be present relate to a particular patient

during an assessment arc treated h\ the nurse alone.

If so, the nurse may conclude that certain actual problems are present. These patient-related problems are re-

rative

ferred to as nursing diagnosis.

process

practice skills, and

problem.

Many

of

the identified problems require a multidisciplinar) approach.

When

the nurse cannot legally order the definitive interven-

tions required under the presenting circumstances, a collabo-

problem

As nursing

exists (Figure 4-3).

care has gained recognition as a cognitive

planning patient care, several national conferences have been held to identih the diagnostic terms that describe ill

areas of potential health problems nurses should anticipate "Approved

at

the 9th conference, 1990

and may

treat.

As of 1999,

the

NANDA

has recognized the

28

The Nursing Process and Pharmacology

Chapter 4

approved

listing

of nursing diagnoses for 1999-2000 (see the

box on p. 29-30). A medical diagnosis

Collaborative Problems Not

is

a statement of the patient's alter-

and results in a diagnosis of impairs normal physiologic func-

all

patient problems identified by the nurse can be re-

solved by nursing actions. The nurse

is,

however, responsible

monitoring the patient on a continuum

ations in structure and function

for

a disease or disorder that

plications that are associated with the medical diagnosis,

A nursing diagnosis usually refers to the patient's ability

tion.

to function in activities of daily living

it

diagnostic procedures, or treatments prescribed.

A

the definitive interventions can be ordered to prevent or treat

ate

medical diagnosis also tends to remain unchanged throughout the illness, whereas nursing diagnoses may vary depending

the

Concepts that help distinguish a nursing diagnosis from a medical diagnosis include

lustration of this decision-making process.

patient's state of recovery.

Conditions described by nursing diagnoses can be accurately identified by nursing assessment methods.

Nursing treatments, or methods of risk factor reduction, can resolve the condition described by a nursing diagnosis. 3. Because the necessary treatment to resolve nursing diagnoses is within the scope of nursing practice, nurses assume accountability for outcomes. 4. Nursing assumes responsibility for the research required to clearly identify the defining characteristics and etiologic factors and to improve methods of treatment and treatment outcomes for conditions described by nursing diagnoses (Gordon, 1987). The wording of an actual nursing diagnosis takes the form of a three-part statement. These statements consist of ( 1 ) a diagnostic label from the NANDA-approved list, (2) the con2.

tributing factors, or cause, if

known

il-

A

focused assessment

include

NANDA-approved vidual or group

list

more

the

diagnostic

data collected would be used to confirm or rule out the defining characteristics associated with a specific nursing diagnosis

and the risk factors

would contribute

statement.

Planning

Objectives Identify the steps included in the planning of nursing care.

1.

Explain the process of prioritizing individual patient needs

2.

using Maslow's hierarchy of needs.

Formulate measurable goal statements for

3.

whom

label that

from

make

is

you are

actively

caring

in

the

a patient for

clinical

practice

setting.

State the behavioral responses around which goal state-

ments revolve when the discharge of

the

5.

the indi-

6.

Identify the

tic

a patient

purposes and uses of a patient care

Differentiate

susceptible to the development of the

problem. Validation of a risk diagnosis risk factors that

the process of collecting additional

gested problem or nursing diagnosis. The questions asked or

risk nursing diagnosis statement consists of two-part that

is

data specific to a patient or family that would validate a sug-

4.

nursing diagnoses. statements

maintain the health status of the patient

to

or stated as etiology un-

known, and (3) the defining characteristics (manifestations or signs and symptoms). As of January 1992, problems previously referred to as potential problems are referred to as risk

The

problem

(Carpenito, 1985, 1987, 1990, 1995). See Figure 4-3 for an

Focused Assessment

the following: 1.

differenti-

iden-

the individual's or group's response to the illness.

on the

To

com-

between a problem requiring a nursing diagnosis and a collaborative problem, the nurse must decide whether

in relation

impairment induced by the medical diagnosis;

to the tifies

(ADLs)

for potential

is

planned.

plan.

between nursing interventions and therapeu-

outcomes.

the presence of the

to the individual or

group

developing the stated problem. Possible nursing diagnosis identifies a problem that

Key Words

may priority setting

nursing orders

Possible nursing diagnoses are worded as two-part state-

measurable goal statements

anticipated therapeutic

ments that include the diagnostic label and suspected, unconfirmed etiology or unconfirmed defining characteristics

nursing actions

(see Figure 4-2).

nursing interventions

occur, but the assembled data are insufficient to confirm

it.

outcomes

A wellness nursing diagnosis statement has only a one-part Once

the nursing diagnosis being applied to the situation or group.

the patient has been assessed and problems have been diagnosed, plans should be formulated to meet the patient's

The

needs. Planning usually encompasses four phases: (1) priority

label.

It

is

initiated

by Potential for Enhanced, followed by

individual or group must understand that the higher level

can be applied only to individuals or groups when the capability for attainment of a higher level of wellness is realistic. Further discussion of the philosophy and clinical use of nursing diagnoses; the specifics regarding the wording of actual, risk, and possible nursing diagnoses; and the. new categories of wellness and syndrome nursing diagnoses can be found in other primary texts and reference works, especially those developed solely for the purpose of explaining nursing

of functioning

diagnosis.

is

feasible. This

setting, (2)

development of measurable goal statements,

(3)

formulation of nursing interventions, and (4) formulation of anticipated therapeutic outcomes that can be used to evaluate the patient's status.

ment

that evolves

ing care plan.

The

from

When

all

it

is

called the nurs-

placed

in the patient's

planning process

completed,

Kardex, or chart, where for

written or computer-generated docu-

this

it

is

serves as a communication system

health-care providers. Because care needs are constantly

changing, the care plan and priorities also must be evaluated

and modified

Oil

a continuing basis to

meet the patient's needs.

miHHHi

Chapter 4

The Nursing Process and Pharmacology

Activity intolerance

Hypothermia

Activity intolerance, risk for

Incontinence, bowel

Adaptive capacity: intracranial, decreased Adjustment, impaired

Incontinence, functional

Airway clearance, Anxiety

Incontinence, stress

29

Incontinence, reflex

ineffective

Incontinence, total

Anxiety, death

Incontinence, urge

Aspiration, risk for

Incontinence, risk for urge

Body image disturbance Body temperature, risk for

Individual coping, ineffective

altered

Infant behavior, disorganized

Breastfeeding, effective

Infant behavior, potential for

Breastfeeding, ineffective

Infant behavior, risk for disorganized

Breastfeeding, interrupted

Infant feeding pattern, ineffective

Breathing pattern, ineffective

Infection, risk for

Cardiac output, decreased Caregiver role strain

Injury,

Caregiver role

Knowledge

enhanced organized

perioperative positioning

Injury, risk for

strain, risk for

deficit (specify)

Communication, impaired verbal

Latex allergy response

Community Community

coping, ineffective

Latex allergy response, risk for

coping, potential for enhanced

Loneliness, risk for

Confusion, acute

Constipation, colonic

Management of therapeutic regimen: community Management of therapeutic regimen: families, ineffective Management of therapeutic regimen: individuals, ineffective Memory, impaired

Constipation, perceived

Mobility, impaired

Decisional conflict (specify)

Mobility, impaired,

Decreased cardiac output

Mobility, impaired, physical

Defensive coping

Mobility, impaired, wheelchair

Denial, ineffective

Nausea Noncompliance

Confusion, chronic Constipation

Diarrhea Disorganized infant behavior Disorganized infant behavior,

bed

Nutrition, altered Nutrition, altered, less than

risk for

body requirements

more than body requirements

Disuse syndrome, risk for

Nutrition, altered, risk for

Diversional activity deficit

Oral mucous membrane, altered

Dysreflexia

Pain

Dysreflexia, risk for

autonomic

Pain, chronic

Energy field disturbance Environmental interpretation syndrome, impaired

Parent/infant/child attachment, risk for altered

Family coping, compromised, ineffective

Parenting, altered

Family coping, disabling, ineffective

Parenting, risk for altered

Family coping, potential for growth

Peripheral neurovascular dysfunction, risk for

Family processes, alcoholism, altered

Personal identity disturbance

Family processes, altered

Poisoning, risk for

Parental role conflict

Fatigue

Post-trauma syndrome

Fear

Post-trauma syndrome, Powerlessness

Fluid Fluid Fluid

volume deficit volume deficit, volume excess

Protection, altered

risk for

volume, imbalance, Gas exchange, impaired Fluid

risk for

Rape-trauma syndrome Rape-trauma syndrome, compound reaction Rape-trauma syndrome, silent reaction

risk for

Grieving, anticipatory

Relocation stress syndrome

Grieving, dysfunctional

Role performance, altered

Growth,

Self-care deficit, bathing/hygiene

risk for altered

Growth and development,

Self-care deficit, dressing/grooming

altered

Self-care deficit, feeding

Health maintenance, altered Health-seeking behaviors (specify)

Self-care deficit, toileting

Home

Self-esteem, chronic low

maintenance management, impaired Hopelessness Hyperthermia From North American Nursing Diagnosis

Association: Nursing

Self-esteem, situational low

Self-esteem disturbance l)iu>\i\ Definition

and Classification 1999-3000,

Philadelphia. 1994,

NANDA Continued

.

30

Chapter 4

NANDA

The Nursing Process and Pharmacology

Diagnoses,

1

999-2000— cont'd

Self-esteem disturbance

Surgical recovery, delayed *

Self-mutilation, risk for

Sensory/perceptual alterations (specify)

(visual, auditory,

Swallowing, impaired

Thermoregulation, ineffective

Thought processes, altered

kinesthetic, gustatory, tactile olfactory)

Sexual dysfunction

Tissue integrity, impaired

Sexuality patterns, altered

Tissue perfusion, altered (specify type) (renal, cerebral,

Skin integrity, impaired Skin integrity, risk for impaired

cardiopulmonary, gastrointestinal, peripheral) Trauma, risk for

Sleep pattern disturbance

Unilateral neglect

Social interaction, impaired

Social isolation

Urinary elimination, altered Urinary retention

Spiritual distress

Ventilation, inability to sustain

Spiritual distress, risk for

Ventilatory weaning response, dysfunctional

enhanced

Spiritual well-being, potential for

Violence, risk for self-directed or directed at others

Walking, impaired

Suffocation, risk for

the patient

Maslow's Hierarchy of Needs

is

essential to

promote cooperation and compliance

with the therapeutic regimen and a sense of control over the dis-

High

Self- Actualization

Needs

Esteem Needs

ease process and course of treatment. The goals established

should be patient goals, not nursing goals for the patient.

With the advent of shorter hospital

Needs Safety Needs Physiologic Needs Social

Low

spontaneous

statements will be short-term goals.

stays,

most of the goal

The nurse must keep

in

mind the usual length of hospitalization and be realistic about the number and types of goals being established. Short-term goals should serve as a bridge to meet the long term goals established in a care plan. Long-term goals can be established

Priority Setting

with assistance from referral agencies as appropriate to the

After the nursing diagnoses and collaborative problems have

dividual's needs

been identified, they must be prioritized. Maslow's hierarchy of needs (see the box above) is a model often used to establish priorities. Using Maslow's hierarchy to perform priority setting of an individual's needs focuses on organizing the needs in relation to their direct effects on the maintenance of homeostasis. Usually, physiologic needs such as oxygenation, temperature maintenance, or nutritional and fluid requirements take precedence over psychologic needs. The box on p. 3 1 lists the priority ranking of Maslow's subcategories of human needs.

health-care delivery settings.

The planning process may be scheduled with at one or more meetings. Today,

persons present

ager plays an important role in this process.

convey a willingness final plan.

After priorities of needs have been

set,

goals must be estab-

lished and statements written. Goals are usually divided into

short-term and long-term plans.

ments

start

The measurable goal

time allocated for attainment.

3.

All goal statements must be individualized and based on the patient's abilities. Statements

must also take

eration the degree of rehabilitation that son.

It is

sometimes

difficult to

is

sist

realistic in setting a

measurable goal, and

4.

5.

goals are being established,

it

is

Understand reasonable expectations of the therapy, including signs and symptoms of improvement versus complicaIdentify monitoring parameters that should be maintained

because the patient and his or her support persons will be

responsible lor the accomplishment of the goals. Involvement of

that reflects the

response to the pre-

scribed therapy

important to include

the patient and appropriate significant others in decision-making,

Understand the disease process and its effect on lifestyle and ADLs Gain knowledge and skills associated with the treatment

on a written record

tent with personal capabilities.

When

realistically

tions requiring physician consultation

strive to as-

the individual to an optimal degree of functioning consis-

each person's input into the

strengths and weaknesses of each participant in

physical therapy)

realistic for the per-

return to their pre-illness health status; therefore the nurse

must be

man-

important to

procedures so as to attain the highest level of function possible (nutrition, comfort measures, medication regimen,

into consid-

accept that not everyone can

It is

ical attention 2.

havior(s) to be performed by the patient or family, with a specific

to consider

significant

must be analyzed, and the goal statements achievable for the group. Most goal statements are based on the patient's need to do the following: 1 Reduce or resolve the symptoms (usually the chief complaint) of the disease that caused the person to seek med-

state-

with an action word (verb), followed by the be-

The

all

the case

the final care plan

must be

Measurable Goal Statements

in-

and circumstances. The long-term goals are then implemented in long-term care settings, rehabilitation centers, mental health facilities, and community-based home

6.

Establish a schedule for follow-up evaluation

The beginning

practitioner should consult a text on nursing

diagnosis lor further information on the correct wording of

apter 4

measurable goal statements associated with nursing diagnosis and collaborative problems.

Nursing Action or Intervention Statements

Priority

of

The Nursing Process and Pharmacology

Ranking of Maslow's Subcategories

Human Needs

Physiologic

Needs

Nursing action or intervention statements list in a concise form exactly what the nurse will do to achieve each goal developed for each nursing diagnosis. A nursing action is a

Water-salt balance

statement that describes nursing interventions applicable

Acid-base balance

to

any patient (e.g., promote adequate respiratory ventilation). Nursing orders describe how specific actions will be implemented for an individual patient.

Oxygen,

circulation

Food balance

Waste elimination Normal temperature Sleep, rest, relaxation Activity, exercise

EXAMPLE: (date):

(date):

Energy

Cough, turn, deep breath: 08(H). KKM). 12(M). 16(H). 18(H). 2000. 2200 Educate patient re: abdominal breathing, splinting the abdomen and purse-lip breathing, assuming correct position to facilitate

Comfort Stimulation

Cleanliness Sexuality

breathing, (date): Auscultate breath (date):

(date):

sounds 0800, 1200, 1600. 20(H) Increase fluid intake to at least 2000 ml/24 hr: 0700-1500: 1000 ml 1500-2300: 800 ml 2300-0700: 200 ml

Safety Needs Protection from physical harm Protection from psychologic threat Freedom from pain

Assess respiratory depth and rate

Stability

at

0800, 1200, 1600, 2000.

2400

Dependence world

Predictable, orderly

Anticipated Therapeutic and Expected

Outcome Statements Measurable anticipated therapeutic and expected outcome statements are also developed to document the effectiveness of the care delivered. In the previous example, the patient will do the following: • Improve in the ability to perform coughing technique • Maintain an adequate fluid intake as evidenced by achieving a mutually set goal of 2000 ml within 24 hours • Attain a respiratory rate between 18 to 24 per minute • Perform ADLs without feeling fatigued Therapeutic and expected outcomes have been developed throughout this book for each drug classification. These can be used by the student to identify the outcomes anticipated from the use of the drugs listed in a particular classification.

Belonging Needs Love and affection Acceptance Warm, communicating relationship Approval from others Unity with loved ones Group companionship Self-Esteem Needs Recognition Dignity

Appreciation from others

Importance, influence Reputation of good character Attention Status

EXAMPLE:

The primary

therapeutic

diazepine antianxiety agents

ageable level

(e.g.,

coping

is

is

outcome expected from

the benzo-

a decrease in the level of anxiety to a

Dominance over others

man-

improved, physical signs of anxieu such as

look of anxiety, tremor, and pacing are reduced).

Needs

Self-Actualization

Personal growth and maturity

Awareness of potential Increased learning

Nursing Intervention or Implementation

Objectives

development of potential Improved values Full

Religious, philosophic satisfaction

Increased creativity Increased reality perception and problem-solving

I.

Compare

the types of nursing functions classified as de-

pendent, interdependent, and independent and give examples of each.

nursing actions

in

of the novel

beauty

Increased pleasantness

Key Words implementation

more

Less of the familiar,

Greater satisfaction Less of the simple,

nursing interventions and

abilities

Less rigid conventionality

more

From Campbell C: Nursing diagn

of the complex nihl intervention in nursing /"

York. 1978, John Wil

dependent actions interdependent actions

independent actions

\

The Nursing Process and Pharmacology

Chapter 4

32

Nursing intervention or implementation

is

the actual process

of carrying out the established plan of care. Nursing care

is di-

rected at meeting the physical and emotional needs of the patient,

responsiveness that may require additional nursing diagnoses or collaboration with the physician or other professiontic

on the health-care team

als

plications,

and performing ongoing assessments as a part of the

RELATING THE NURSING PROCESS TO PHARMACOLOGY

continual process of data collection and evaluation to identify

changes

in the patient's care needs.

Nursing actions

are sug-

gested by the etiologies of the problems identified in the nursing diagnoses and are used to implement plans.

They may

in-

Assessment Object!

clude activities such as counseling, teaching, providing comfort

measures, coordinating, referring, using communication skills, and performing a physician's orders. Documentation of all care given, including patient education and the patient's apparent response, should be done regularly, both to assist in evaluation and reassessment and to make other health-care professionals aware of the patient's changing needs.

Nursing Actions Within the nursing process, there are three types of nursing actions: (1) dependent, (2) interdependent, and (3) independent. Dependent actions are those performed by the nurse based on the physician's orders, such as the administration of prescribed medications and/or treatments. It is important to note that, even though this is a dependent function, the nurse is

as plans for therapy are revised.

providing for patient safety, monitoring for potential com-

still

State the information that should be obtained as a part of

1.

a medication history. Identify primary, secondary,

2.

and tertiary sources of

infor-

mation used to build a patient information base.

Key Wor drug history

secondary sources

primary sources

tertiary sources

subjective data

objective data

responsible for exercising professional judgment in

performing the orders. Interdependent actions are those nursing actions the nurse implements cooperatively with other members of the health team for restoration or promotion of health maintenance. This allows nurses to coordinate the interventions with those of other health professionals to maximize knowledge and skills from various disciplines for the well-being of the patient. Independent actions are those nursing actions not prescribed by a physician that a nurse can provide by virtue of the education and licensure attained. These actions are usually written in the nursing care plan and originate

from the nursing diagnosis.

Assessment

is

an ongoing process that

of the patient and

is

completed

at the

starts

with the admission

time of discharge. In re-

lating the nursing process to the nursing functions associated

with medications, assessment includes taking a drug history for three reasons: (1) to evaluate the patient's need for medication; (2) to obtain his or her current

(OTC) medication, and

street drugs;

and past use of over-the-counter

prescription medication, herbal products,

and

(3) to identify

therapy. Nurses will also

want

problems related

to

drug

to identify risk factors such as al-

lergy to certain medications (e.g., penicillins) or the presence of

other diseases such as hypertension that tain types

may

limit the use

of cer-

of drugs as with sympathomimetic agents.

The nurse draws upon

three sources to build the medica-

Whenever

Evaluating and Recording

tion-related information base.

Therapeutic and Expected Outcomes

provide reliable information, the patient should be used as the

Objectives

the patient

primary source of information. Subjective and

is

able to

objective data

serve as the baseline for the formulation of drug-related nurs-

ing diagnoses. Subjective data are information provided by I.

Describe

the

evaluation

process

used

to

establish

whether patient behaviors are consistent with the fied

identi-

the patient (e.g.,

my

pale, cold,

The

final step

of the nursing process

is

evaluation of the ex-

pected outcomes of the patient's behavior. All care

is

evalu-

ated against the established nursing diagnoses (goal state-

ments), planned nursing actions, and anticipated therapeutic

I

take this medicine

I

feel sick to

makes using physiologic parameters

Skin Other required objective information is the patient's height and weight, which may be needed to select drug regimens and a that the nurse

short-term or long-term goals.

"Whenever

stomach"). Objective data are gained from observations

and moist; temperature 99.2° F

(e.g.,

orally).

monitoring parameter for drug therapy later. In some cases it is necessary to obtain information from secondary sources (relatives, significant others, medical

outcomes. In order for the evaluation process to be successful, the participants (patient, family, and nurse) must be willing to

records, laboratory reports, nursing notes, or other health pro-

receive the feedback. Therefore plans for evaluation must in-

interpretation by

volve the patient and family from the beginning.

Secondary sources of information are subject to someone other than the patient. Data collected from secondary sources should be analyzed using other

fessionals).

Although the evaluation phase is the last step in the nursing it is not an end in itself. Evaluation recognizes successful completion of previously established goals, but it also

portions of the data base to validate the conclusions reached.

provides a means for input of new, significant data indicating

a disease, nursing interventions, diagnostic tests used, phar-

the development of additional problems or a lack of therapeu-

macologic treatment prescribed,

process,

Tertiary sources of information, such as a literature search, provide an accurate depiction of the characteristics of

diets, physical therapy,

and

.

other factors pertinent to the patient's care requirements. (NOTE: When using these sources, the student should be aware that the patient has individual needs and that the plan

case process for which the medications arc being prescribed. Evaluation of the therapeutic and expected outcomes from the prescribed medications

symptoms

edness). Nursing diagnoses of this type are labeled as side effects in the

nursing diagnosis subsection of the nursing process related to drug ther-

apy sections throughout the book In this

toms of

expect, side effects to report, and potential drug interactions. In preparation for the patient's eventual discharge and need

new

in the

A second nursing diagnosis would be Injury, risk for: related to amantadine side effects {confusion, disorientation, dizziness, light-head-

going assessment activities include visiting with the patient; the need for as needed (prn) medication; monitoring vital signs; and observation for therapeutic effects, side "effects to

example, the drug amantadine, prescribed to treat the sympis also the basis of the first nursing diagnosis. The

the disease,

second nursing diagnosis

is

a collaborative

problem

that requires the

nurse to monitor the development of these side effects. In other words, a patient

health-related responsibilities, the as-

sessment process should include collection of data related to the patient's health beliefs, existing health problems, prior compliance with prescribed regimens, readiness for learning both emotionally and experientially, and ability to learn and execute the skills required for self-care.

based on the degree of improvement noted

is

present

of care must be adapted to the patient's identified needs.) Assessment related to drug therapy continues on an ongoing basis through the hospitalization period. Examples of on-

for education about

33

The Nursing Process and Pharmacology

Chapter A

w

ith

acteristics

Parkinson's disease

needed

to

have

is at

this occur.

risk

need

to intervene to

Two

of developing the defining char-

When

observed, notification of the physician

is

the defining characteristics

required, and the nurse

arc-

would

provide for the patients safety.

nursing diagnoses that apply to

all

types of medica-

tions prescribed are as follows: •

Knowledge

deficit (actual, risk, or possible), related to: the

medication regimen (patient education).

Nursing Diagnoses Objectiv

•

Noncompliance tient's value

(actual, risk, or possible) related to: the pa-

system, cognitive

ability, cultural factors,

or

economic resources.

Define problem.

1

Describe the process that

2.

could result

in

is

used to identify factors that

patient problems

when medications

Planning

are

Objectives

prescribed.

Review the content of several drug monographs to identify information that may result in patient problems from

3.

Identify steps

used to plan nursing care

in

relation to a

medication regimen prescribed for a patient.

the medication therapy.

Describe an acceptable method of organizing, implementing,

Key Words

and evaluating the patient education delivered.

Practice developing short- and long-term patient education objectives and have

drug monographs side effects

To

them

critiqued by the instructor.

pathophysiology (indications)

Key Words

deal effectively with identified problems (diagnoses), the

nurse must recognize the etiologic and contributing factors.

side effects to report

therapeutic intent

and contributing factors are those clinical and personal situations that can cause the problem or influence its Situations can be pathophysiological, treatdevelopment.

side effects to expect

ment

include the following steps:

The

etiologic

.

.

.

related, situational, or maturational. (Carpenito, 1997)

When

identifying problems related to medication therapy,

the nurse should review the

drug monographs given

Planning, with reference to the prescribed medications, must

1.

each prescribed drug. Several nursing diagnoses can be formulated based on the patient's drug therapy. Although the most commonly observed are those associated with drug treatment of a disease or the side effects from drug therapy, nursing diagnoses can also originate from pathothis text for

physiology caused by drug interactions.

2.

3.

Drugs prescribed for Parkinson's Disease are administered provide relief of symptoms (muscle tremors, slowness of movement, muscle weakness with rigidity, and alterations in posture and equilib-

EXAMPLE:

An actual nursing diagnosis of Mobility, impaired physical: related neuromuscular impairment (Parkinson's Disease) would be formulated based on the defining characteristics established for this nursing diagnosis. These nursing diagnoses are labeled as indications in the nurs-

(Why was the drug prescribed? What symptoms should be relieved?) Review of the drug monograph in this text to identify the side effects to expect (symptoms that can be alleviated or immediate planning for patient education). Review of the drug monograph in this text to identify the side effects to report (a collaborative problem in which the nurse has a responsibility to monitor the patient for adverse effects of drug therapy and report suspected adverse effects to the physician).

rium).

ing diagnosis subsection of the nursing process related to drug therapy sections throughout the textbook, meaning thai the diagnosis is associated with the medical diagnosis or signs and symptoms oi the dis

of the therapeutic intent for each pre-

prevented by actions of the nurse or patient will require

to

to

Identification

scribed medication.

later in

4.

Identification of the

recommended dosage and route of adrecommended dosage with the

ministration (compare the

dosage ordered; confirm thai the route of administration is correct and that the dosage form ordered can be tolerated by the patient).

.

Chapter 4

34

5.

6.

7.

The Nursing Process and Pharmacology

Scheduling of the administration of the medication based on the physician's orders and the policies of the healthcare facility (medications prescribed must be reviewed for drug-drug interactions and drug-food interactions; laboratory tests may also need to be scheduled if serum levels of the drug have been ordered). Teaching the patient to keep written records of his or her responses to the prescribed medications (see Appendix I). Additional education as needed on techniques of self-administration, such as injection, topical patches, instillation of drops.

8.

Information as needed on proper storage, medication, or

how

to

fill

how

to refill a

out an insurance claim for reim-

bursement.

may

Priority ranking in preparation for health education

encompass

several factors: (1) the patient's concerns

and

pri-

urgency or time available for the learning to take place; (3) a sequence that allows the patient to move from the simple to the more complex concepts; and (4) a review of the overall needs of the individual. The content taught to the patient should be well planned in advance and delivered in increments that the patient is capable of mastering. The complete teaching plan should be in the Kardex or on the patient's orities; (2) the

nance or modification of the medication orders

is

cian's responsibility; however, the data collected

and recorded

the physi-

by the nurse on the patient's chart are essential for evaluation of the effectiveness of the medications prescribed.

Interdependent Nursing Actions The nurse performs baseline and subsequent assessments

that

are valuable in establishing therapeutic goals, duration of ther-

apy, detection of drug toxicity,

and frequency of reevaluation.

The nurse should approach any problems

related to the

medication prescribed collaboratively with appropriate members of the health-care team. Whenever the nurse is in doubt about medication calculations, monitoring for therapeutic efficacy and side effects, or the establishment of nursing interventions or patient education, another qualified professional

should be consulted.

The pharmacist reviews

all

aspects of the drug order, then

prepares the medications and sends them to the unit for stor-

age in a medication room or a unit dose medication cart. If any portion of the drug order or the rationale for therapy is unclear, the

nurse and pharmacist

may

consult with each other

or the physician for clarification.

The frequency of medication administration is defined by The nurse and pharmacist

the physician in the original order.

chart.

establish the schedule of the medication based on the stan-

EXAMPLE:

Mr. Jones will be able to state the following for each pre-

scribed medication by (date) and will

by repeating

it

on

show

retention of this information

(dare):

dardized administration times used

at

the practice setting.

The

nurse, and occasionally the pharmacist, also coordinates the

schedule of the medication administration and the collection

2.

Drug name Dosage

of blood samples with the laboratory phlebotomist to monitor

drug serum

1

3.

Route and administration times

4.

Anticipated therapeutic response

5.

Side effects to expect

levels.

The nurse completes laboratory

would need to be checked at the initial time of exposure and on subsequent meetings to validate retention. Once

test requisitions based on the physician's orders to monitor drug therapy, establish dosages, and identify the most effective medication for pathogenic microorganisms. As soon as laboratory and diagnostic test results are available, the nurse and pharmacist review them to identify values that could have an influence on drug therapy. The results of the tests are conveyed to the physician. The nurse should also have

the goals have been formulated, they should not be considered

current assessment data available for collaborative discussion

6.

Side effects to report

7.

What to do if a dose is missed When, how, or if to refill the medication

8.

To

attain this goal, the patient's ability to

name

all

these

factors

final

but should be reevaluated as needed throughout the

of signs and symptoms that

may

relate to the

medications pre-

scribed, dosage, therapeutic efficacy, or adverse effects.

course of treatment.

Patient education,

including discharge medications, re-

quires that an established plan be developed, written in the pa-

Nursing Intervention or Implementation

tient's

medical record, implemented, documented, and rein-

forced by

all

persons delivering care to the patient (see the

sample teaching plan,

p. 47).

Independent Nursing Actions I

.

Differentiate

among dependent,

interdependent, and inde-

pendent nursing actions and give an example of each.

Nursing actions applied to pharmacology

may be

categorized

as dependent, interdependent, or independent.

Dependent Nursing Actions The physician admits

the patient, states the admitting diagnoand orders diagnostic procedures and medications for the immediate well-being of the patient. The physician reviews data on a continuing basis to determine the risks and benefits of maintaining or modifying the medication orders. Maintesis,

The nurse visits with the patient and obtains the nursing which includes a medication history. The history of

history,

current

and past medications, including prescription, OTC, and street drugs, is reviewed to identify treatment-related problems. The nurse verifies the drug order and assumes responsibility for correct transcription of the drug order to the nurse's Kardex, medication administration record (MAR), or comAs part of this process, the nurse makes professional judgments concerning the class of drug, therapeutic intent, usual dosage, and the patient's ability to tolerate the drug dosage form ordered. If all aspects of the verification and puter.

transcription procedure arc considered to be correct, the car-

bon copy of the original order

is

sent to the pharmacy. Text

continued on p. 41.

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8.

Insert the

(

Insert the needle

through the rubber diaphragm;

measured volume of diluent required to reconstitute the powdered drug (Figure 9-20, D and / Remove the needle from the diaphragm of the diluenl Withdraw

into the

the

I

9

the type

and volume

against the type and

ol

diluenl to be injected

amounl required.

needle

diaphragm and powder (Figure 9-20, //>.

Remove

the

in the

inject the diluent

and needle from the rubber

syringe

di-

aphragm in

container.

Recheck

l

injeel air

(Figure 9-20,C).

MIX THOROl GH1 tire!}

dissolved

ure 9 20,

f)

HI

>

I

to

OKI

ensure that the powder is enwithdrawing the dose (Fig-

1

.

Chapter 9

Parenteral Administration

1

Figure 9-20 Removal of a volume of liquid from a vial. A, Cleanse rubber diaphragm of the vial. B, Pull back on plunger of syringe to fill with an amount of air equal to the volume of solution to be withdrawn. C, Insert the needle through the rubber diaphragm; inject air with vial sitting in downward position. D, Withdraw the volume of diluent required to reconstitute the Move needle downward to facilitate removal of diluent. Change the needle as illustrated in Figure 9-19, H, I, and J. Tap the container with the powdered drug to break up the "caked" powder. G, Wipe the rubber diaphragm of the vial of powdered drug with a new antiseptic swab. H, Insert the needle in the rubber diaphragm and inject the diluent into the powdrug. E, F,

dered drug.

1

1

I,

Mix thoroughly

to ensure the

powdered drug

Label the reconstituted medication including date and time of reconstitution, volume and type of diluent added, name of reconstituted drug, concentration of reconstituted drug, expiration date and time, and

name of person

reconstitut-

ing drug. Store according to manufacturer's instructions. 12.

Change

the needle as described earlier (use principles

lustrated in Figure 9-19,

the correct

//,

gauge and length

to the patient.

/,

and

J).

il-

Attach a needle of

to administer the

medication

is

dissolved before withdrawing the prescribed dose.

Reconstitution of a Powder in a Preassembled "Piggyback*' Several routinely used medicines that have short expiration dates after being reconstituted (e.g., ampicillin) have been

preassembled by the manufacturer for ease of reconstitution. this apparatus are to maintain sterility, minimize the use of needles, and allow mixing just prior to use to minimize waste if the order for the medicine is

The primary purposes of

cancelled.

12

Parenteral Administration

Chapter 9

Removal of a 9-20, A-E )

Volume

of Liquid

From a Vial

(Figure

1.

Calculate the volume of medication required for the pre-

2.

scribed dose of medication to be administered. Cleanse the rubber diaphragm of the vial of diluent with an antiseptic pledget.

3.

back on the plunger of the syringe to fill with an amount equal to the volume of solution to be withdrawn. Insert the needle through the rubber diaphragm; inject air. Withdraw the volume of drug required to administer the Pull

of 4. 5.

air

prescribed dose. 6.

7.

Recheck all aspects of the drug order. Change the needle as described earlier lustrated in Figure 9-19, H,

I,

and

J).

(use principles

il-

Attach a needle of the

correct gauge and length to administer the medication to the patient.

Preparing a Drug From a Mix-O-Vial 1

Check

the drug order against the medication

you have

for

administration. 2.

To mix: Tap the container

•

in the

hand a few times

to break

up the

caked powder. •

Remove

•

Push firmly on the diaphragm-plunger. The downward pressure dislodges the divider between the two chambers (Figure 9-22, B and C).

•

Mix thoroughly

the plastic lid protector (Figure 9-22, A).

to ensure

PLETELY DISSOLVED

powder

that the

is

COM-

before drawing up the medica-

tion for administration. •

Figure 9-2

1

Cleanse the rubber diaphragm and remove the drug in the same manner as described for removal of a volume of liquid from a vial (see Figure 9-20, A-E).

The ADD-Vantage Needleless Drug Delivery System.

Preparing Two Medications Occasionally two medications

in

may

An example

is the ADD-Vantage System made by Abbott The ADD-Vantage System (Figure 9-21) is a needleless drug delivery system that is composed of two distinctly separate components, an ADD-Vantage diluent container (a plastic bag containing 0.9% normal saline, 5 % dextrose or 0.45% sodium chloride) and an ADD-Vantage drug

Laboratories.

medicine such as ampicillin powder). These components can be securely attached without physically mixing the drug and diluent until required. Right before the scheduled time of administration, the nurse checks all aspects of the drug order against the vial of medicine and the diluent container, holds the assembled ADD-Vantage vial and container in an uprighl (vertical) position by the bottom of the attacbed drug

vial,

reaches "through'' the flexible container of

ring that surrounds

it,

by the

plastic

and pulls Straight down. The stopper

disconnects and falls into the diluent solution. The drug powder also falls out and. with a lew squeezes ol the diluent bag, mixes with the diluent to reconstitute the drug. An ail ministration set

apparatus

is

is

then attached to the diluent bag, and the

hung on an IV pole by

the top ol the medicine vial.

administration.

the ring lab hanger

The drug

is

now ready

on

lor IV

a routine procedure, so

is

it

will be

used to

il-

lustrate the technique (Figure 9-23). 1.

Check

the compatibility of the

two drugs

to

be mixed be-

fore starting to prepare the medications. 2.

vial (containing

diluent, grasps the inner stopper in the vial

insulin

is

a preoperative medication or

of insulin are ordered to

Mixing

Syringe

be drawn into the same

most commonly done when two types be administered at the same time.

syringe for a single injection. This

when preparing

One

Check

the labels of the medications against the medication

order. 3.

Check Type:

the following:

NPH,

Regular, Lente, Humulin, other

Concentration:

U-I00(U-100 = 100

Expiration Date:

4.

Do NOT

use

if

units/ml)

outdated

Appearance: Clear, cloudy, precipitate present? Temperature: Should be at room temperature Philosophies: There are two philosophies concerning how insulin should be mixed. In one procedure, the volume of the Shorter-acting insulin is drawn into the syringe lirst, followed by the longer-acting insulin. The rationale for this approach is that a small amount of short-acting insulin is accidentally it

displaced into the second (longer-acting insulin) bottle, the onset,

peak, and duration of the longer-acting insulin will not be

appreciably affected. insulin

It

would have

done

in

reverse order, the shorter-act-

onset, peak,

and duration affected because ol the contamination by the longer-acting preparation. iii!.'

its

.

Figure 9-22 C, Push

firmly

Mix-O-Vial.

A, Remove

B, Powdered drug

is

in

lower

half; diluent

is

upper

in

13

half.

on the diaphragm-plunger. Downward pressure dislodges the divider between the two chambers.

In the second procedure, the opposite

rationale for this approach

is

The

advocated.

second and withdraw the volume of shorter-acting insulin ordered (Figure 9-23, F). Note: Check for bubbles in the insulin

• Insert the needle through the rubber seal of the

because the longeracting insulin is cloudy, a change in clarity would be immediately visible if the longer-acting insulin contaminated

bottle; inject air (Figure 9-23, E). Invert the bottle

the normally clear second (shorter-acting) insulin during

in the syringe; flick the side of the syringe with the fin-

preparation.

gers to displace the bubbles, then recheck the

The

first

institution's

for details.

procedure

is

is

that

strongly

recommended, but

•

teaching a patient to mix insulin for self-

method of preparing

amount

in

the syringe.

the

procedure manual should always be checked

When

administration, using a consistent

5.

plastic lid protector.

Parenteral Administration

9

ter

•

the

Check

the medication order against the label of the con-

tainer

and the amount

Wipe

the lid of the longer-acting insulin container again

in the syringe.

habit. This

mixture should be stressed so that the patient forms a can help prevent the patient from inadvertently

container; insert the needle of the syringe containing

reversing the dose of short- and long-acting insulin in the

the shorter-acting insulin and

mixture.

amount of longer-acting

Procedure:

careful

• Roll the bottle

between the palms of the hands

(Figure 9-23, G); recheck the drug order against this

•

•

acting insulin bottle; inject air (Figure 9-23, C).

bubble

air

through the insulin solution because

(Do it

not

may

Remove

the needle and syringe.

(Do not withdraw

in-

sulin at this time.) •

Pull to

back the plunger on the syringe

the

volume of

(Figure 9-23, D).

the

to

shorter- acting

an amount equal insulin

ordered

type of insulin

Be al-

vial.

the needle and syringe; recheck the drug order

syringe (Figure 9-23,

amount

1).

Withdraw a small amount of air into the syringe and mix the two medications. Remove air carefully so that part of

•

Change needles and proceed

the medication

is

not displaced. to

administer subcuta-

neously.

Preparing Medications for Use in the Sterile Field During an Operative Procedure The following principles apply to the operating room: 1

break up insulin particles.) •

first

•

vials with separate antiseptic

Insert the needle through the rubber seal of the longer-

Remove in the

swabs (Figure 9-23, A). Pull back the plunger on the syringe to an amount equal to the volume of the longer-acting insulin ordered (Figure 9-23, B).

•

any of the

against the label on the insulin container and the

hospital policy.

BOTH

to inject

ready in the syringe into the

to thor-

oughly mix the contents. DO NOT SHAKE (as per manufacturer's recommendation). • Check the insulin order and calculations of the preparation with another qualified nurse, in accordance with • Cleanse the top of

NOT

withdraw the specified

insulin (Figure 9-23, H).

2.

All medications used during an operative procedure must remain sterile. All medication containers (ampules, vials, piggybacks, and blood bags) used during the operative procedure should remain in the operating room until the entire procedure is completed. (In case a question arises, the container

is

available.)

Chapter 9

Administration Parenteral Adminis'

fT

Total = 25 units

Figure 9-23 dle

and

syringe;

in one syringe. A, Check insulin order; cleanse top of both vials with an antiseptic swab. B, Pull back on plunger to volume of longer-acting insulin. C, Insert needle through the rubber diaphragm of the longer-acting insulin; inject air. Remove neeinsulin. D, Pull back the plunger on the syringe to a point equal to the volume of the shorter-acting insulin ordered.

Preparing two drugs

an amount equal

to the

do not remove

E, Insert needle through the rubber diaphragm; inject

withdrawn against amount ordered. G, Rewipe the I,

Remove the needle and syringe; recheck and proceed to mix two insulins (tilt

slightly

lid

air.

F, Invert the bottle

of the longer-acting

and withdraw the volume of shorter-acting insulin ordered. Check amount H, Insert needle; withdraw the specified amount of longer-acting insulin.

insulin.

the drug order against the labels on the insulin containers syringe

back and

forth gently);

change needle.

and the amount

in

the syringe. Pull plunger back

5

.

Chapter 9

3.

Do

Parenteral Administration

1

1

not save an unused portion of medication for use in an-

other operative procedure. Discard at the end of the operative

procedure or send the patient's medication to the patient

care unit with the patient,

4.

5.

appropriate

if

(e.g.,

antibiotic

ointment for a patient having ophthalmic surgery). Adhere to hospital policies concerning handling and stor-

age of medications in the operating room. ALWAYS tell the surgeon the name and dose or concentration of the medication or solution being handed to him or her.

6.

ALWAYS repeat the entire medication order back to the surgeon

at the

time the request

made

is

to verify all aspects of

the order. If in doubt, repeat again until accuracy

The following technique

is

use in the sterile operative 1

2.

is

certain.

used to prepare medications for

field:

Prepare the drug prescribed according to the directions.

Always check

the accuracy of the drug order against the

medication being prepared storage area, (2) for use

on the

at least three

when

times during the

removed from the drug immediately before removing the solution

preparation phase: (1)

first

sterile field, (3)

immediately after complet-

ing the transfer of the medication/solution to the sterile field.

ALWAYS

tell

the surgeon the

name and dose or conwhen passing it to

centration of the medication/solution

3.

him or her for use. The circulating (nonsterile) nurse retrieves from storage, reconstitutes as needed, and

Figure A,

the medication

turns the

9-24

Preparing

a

medication

the

in

operating

room.

Circulating (nonsterile) nurse holds vial to facilitate the "scrubbed"

(sterile)

tainer.

nurse to insert the

B, The needle

is

sterile

needle

tip

into the

medication con-

disconnected from the syringe and

left in

the

vial.

med-

ication container so the scrubbed (sterile) nurse can read

the label.

It is

best to read the label aloud to ensure that

both individuals are verifying the contents against the verbal order

from the surgeon.

The following two methods may be

Method 1.

The

Regardless of the method used to transfer the medication

used:

to the sterile field, both the sterile

1

scrubbed person and the

circulating (nonsterile) nurse cleanses the top of the

nonsterile circulating nurse should

know

ampule, as described

act disposition of each medication

on the

vial or breaks off the top of the

the location and exsterile field.

earlier. 2.

The scrubbed (sterile) person chooses a syringe of the correct volume for the medication to be withdrawn and at-

ADMINISTRATION OF MEDICATION BY THE INTRADERMAL ROUTE

taches a large-bore needle to facilitate removal of the solution 3.

from the container.

The

circulating (nonsterile) nurse holds the ampule or vial such a way that the scrubbed (sterile) person can easily insert the sterile needle tip into the medication container (Figure 9-24 A). in

4.

The scrubbed person

back the plunger on the syringe until all the medication prescribed has been withdrawn from the container and from the needle used to withdraw

Objectives

pulls

I

.

Identify the

equipment needed and describe the technique

used to administer a medication

via the intradermal route.

the medication. 5.

6.

The needle is disconnected from the syringe and left in the vial or ampule (Figure 9-24, B). The medication container is again shown to the scrubbed person and read aloud to verify

all

components of

Method 2 The

circulating (nonsterile) nurse

removes the

wheal

papules

anergic

vesicles

entire lid of

the vial with a bottle opener, cleanses the rim of the vial,

2.

erythema

intradermal

the drug

prepared against the medication/solution requested.

1.

Key Words

Intradermal injections are made into the dermal layer of skin below the epidermis (Figure 9-25). Small volumes, usually 0.1 ml, are injected to produce a wheal. The absorption from intradermal sites is slow, making it the route of choice

and pours the medication directly into a sterile medicine cup held by the scrubbed nurse. The scrubbed person continues drug preparation on the sterile field in accordance with the intended use (such as ir-

just

rigation or injection).

anesthetics,

for allergy sensitivity tests, desensitization injections, local

and vaccinations.

6

Chapter 9

1 1

Parenteral Administratic

3.

Two methods

can be used to administer allergy testing.

One method

requires the injection of the allergens as

follows: • Prepare

designated solutions for injection using

the

volumes to be injected range between 0.01 and 0.05 ml. A control injection of normal aseptic technique. Usual

Epidermis

Dermis

saline or diluent

Use

also administered.

is

gloves.

• Insert the needle at a 15-degree angle with the needle

bevel upward.

The

solution being injected

the space immediately

dle quickly.

A

small bleb will

is

deposited in

remove the neeappear on the surface of

below the

skin;

the skin as the solution enters the intradermal area (see

Figure 9-25).

Be

careful not to inject into the subcuta-

neous space and do not wipe the

site

with alcohol after

injection. •

Muscle

recap any needles that have been used. Dispose of used needles and syringes into a punctureresistant container according to the policy of the em-

ploying institution.

Subcutaneous

Figure 9-25

Do NOT

A

second method of allergy testing requires the following:

• Cleanse the skin as previously described.

Intradermal injection technique.

• •

Administer a cluster of needle pricks in a specific location. Administer a drop of the allergen to the needle-pierced area.

4.

Remove

gloves and dispose of them according to agency Thoroughly wash hands. Chart the times, agents, concentrations, and amounts injected (Figure 9-26, Bottom). Make a diagram in the patient's chart numbering each location. Record what agent and concentration was injected at each site. (Subsequent "readings" of each area are then performed and charted on policy.

Equipment

5.

Medication to be injected Tuberculin syringe with 26 gauge, A-, V»-, or '/2-inch needle, OR a special needle and syringe for allergens Metric ruler, if skin-testing procedure l

Gloves

this record.)

Antiseptic pledget

6.

Follow directions for the time of the "reading" of the skin testing being performed. Inspection of the injection sites

should be performed

Sites Intradermal injections

may

be

made on any

the site should be hairless and receive clothing.

The upper

A and

suspected

skin surface, but

little

chest, scapular areas of the

inner aspect of the forearms are most ure 9-26,

good

in

light.

from back, and the

Measure

friction

commonly used

allergen

is

considered clinically

pate and measure the size of any induration.

known

the allergens

noted

Technique

is

Caution: Do not gency equipment

start is

to follow

Check with

il

to

as an anergic reaction.

No

reaction should be

the control site. easily be modified for desensitization

injections and vaccinations.

any type of allergy testing unless emer-

available in the immediate area in case of

an anaphylactic response. Staff should be familiar with the

procedure

at

The technique can allergy sensitivity testing.

and pal-

No reaction

Anergy is associated with immunodeficiency disorders. Record this

(Fig-

B).

The example of technique uses

significant.

the diameter in millimeters of erythema,

information in the patient's chart.

1.

Generally, a positive

reaction (development of a wheal) to a dilute strength of

an emergency does arise.

Patient Teaching Tell the patient the time, date,

the patient before starting the testing to be

test sites read. Tell the patient

sure that he or she has not taken any antihistamines or

until the injections

antiinflammatory agents (e.g.. aspirin, ibuprofen, corticosteroids) for 24 to 48 hours preceding the tests or is re-

he

immunosuppressant therapy.

patient has

II

or

and place not to

to return to

have the

wash or scrub

the area

have been read.

the patient develops an area of severe burning or itching,

she should

tr\

not to scratch. Tell the patient to report

doxylamine or diphenhydramine), or antiinflammatory

immediately the development of any breathing difficulty, severe hives, or rashes He or she should go to the nearest emergency room it unable to reach the physician who prescribed

agents, check with the physician before proceeding with

the skin tests.

ceiving

taken

antihistamines,

certain

sleep

If the

medications

(e.g..

the testing. 2.

Cleanse the selected area thoroughly with an antiseptic se circular motions starting at the planned site of pledget l

outward in ever widening circular the periphery Allow the area to aii drj

Documentation, the Sixth Right RIGHT DOCUMENTATION

injection, continuing

Provide the

motions

administration and responses to drug therapy.

to

of the medication

^

117

Reading Chart for Intradermal Testing Patient

Name:

Identification

Physician

1

slumber:

Nam e: Reading Time

DATE

AGENT

TIME

CONCENTRATION

DOSAGE

•

B above. Follow directions for the "reading" of the skin testing performed

•

Inspect sites

•

Record reaction

SITE

NUMBER*

in

Hours or Minutes,

e.g.,

^^ ^^ ^^

30 min. or 24, 48, or 72 hours

'Refer to diagrams A,

+ ++ +++ ++++ •

in

a good light in upper half

(1+) (2+) (3+)

box using the following guidelines,

(4+) Generalized fusing of blisters

Record measurement

of induration (process of hardening) in

Figure 9-26

1.

of

Redness of skin present (erythema) Redness (erythema) and solid elevated lesion (papule) up to 5 mm in diameter Erythema, papules, and vesicles (blisterlike areas 5 mm or less in diameter)

Intradermal

sites

A,

2.

in

lower half of box, e.g.

Posterior view. B, Anterior view.

Chart the date, time, drug name (agent, concentraamount), dose, and site of administration (Figure 9-26, Bottom). Perform a reading of each site after the application, as dition,

rected by the physician or the policy of the health-care

Bottom,

is

a

list

of

testing.

commonly used

readings of reac-

and appropriate symbols:

+ (1+) + +(2 + )

Redness (erythema) of skin present Redness (erythema) and up

Chart and report any signs and symptoms of adverse drug

/$m m

Reading chart for intradermal

The following tions

agency. 3.

—

.

mm

+ + +(3 + )

to 5

mm

in

solid elevated lesions (papules)

diameter

Erythema, papules, and vesicles

(blisterlike areas 5

mm

or less in diameter)

effects. 4.

Perform and validate essential patient education about the drug therapy and other essential aspects of intervention for the disease process affecting the individual.

+ + + +(4+)

Generalized fusing of blistered areas

Generally, a positive reaction to delayed hypersensitivity skin testing (to evaluate in vivo cell-mediated immunity) re-

quires an induration of at least 5

mm

in diameter.

.

Chapter?

lit

Parenteral Administration

ADMINISTRATION OF MEDICATION BY THE SUBCUTANEOUS ROUTE Objectives Identify the

equipment needed and describe the technique

used to administer

a

medication

via

the subcutaneous

route.

Needle Length Assess each patient so that the needle length selected will deposit the medication into the subcutaneous tissue, not muscle tissue. Needle lengths of %-, '/:-, and Vs-inch are routinely used. It is prudent to leave an extra Va inch of needle extending above the skin surface in case the needle breaks.

Needle Gauge Commonly used gauges 2 l)

Key Words

for subcutaneous injections are

25 to

gauge.

Sites

Common

sites used for the subcutaneous administration of medications include upper arms, anterior thighs, and abdomen (Figure 9-28). Less common areas are the buttocks

subcutaneous

and upper back or scapular region.

Subcutaneous

injections are

made

A

into the loose connective

between the dermis and muscle layer (Figure 9-27). Absorption is slower and drug action is generally longer with subcutaneous injections than with intramuscular or IV injections. If the circulation is adequate, the drug is completely absorbed from the tissue. Many drugs cannot be administered by this route because no more than 2 ml can ordinarily be deposited at a subcutaneous site. The drugs must be quite soluble and potent enough to be effective in small volume, without causing significant tissue irritation. Drugs commcnly injected into the subcutaneous tissue are heparin and insulin. tissue

all

The ily

who

require repeated injections (see Figure 9-28).

anterior view (see Figure 9-28, B) illustrates areas eas-

used for self-administration. The posterior view (see Figcommonly used areas that may be

ure 9-28, A) illustrates less

used by other persons injecting the medication. When administering insulin subcutaneously, it is important to rotate injection sites to prevent lipohypertrophy or

which slows the absorption rate of insulin. The American Diabetes Association Clinical Practice Recommendation of 2000 recommends that insulin injection sites be rotated systematically within one area before progressing to lipoatrophy,

new

a

site for injection (see

Figure 9-28).

known

that this

It is felt

will decrease variations in insulin absorption.

Equipment

Absorption

is

be fastest in the abdomen followed by the arms, thighs, and buttocks. Because exercise is also known to affect

Syringe Size volume of drug to be one site. The usual amount injected subcutaneously at one site is 0.5 to 2 ml. Correlate syringe size with the size of the patient and the tissue mass.

Choose

plan for rotating injection sites should be developed for

patients

a syringe that corresponds to the

injected at

to

the rate of insulin absorption, site selection should take this into consideration.

Technique 1

2.

Prepare the medication as described

Check

earlier.

the accuracy of the drug order against the medica-

tion being prepared at least three times during the prepa-

ration phase: (1)

when

first

removing the drug from the

storage area. (2) immediately after preparation, and (3) immediately before administration. 3.

Check your

hospital policy regarding whether 1 to 2 minims of air are added to the syringe AFTER accurately measuring the prescribed volume of drug for administration (NOTE: The rationale for adding the air is that it will result in the needle being completely cleared of all medication at the time of injection. Conversely, if the

Epidermis

Dermis

is

administered as long as the same size needle

drawing up ami \\l\\\ lo

Subcutaneous

injection.

4.

5.

Subcutaneous

injection technique.

used for

he completely cleared of medication by air dur-

ing administration. This issue can he critical

Muscle

is

Thus the needle should not

volumes of potent drugs are administered

Figure 9-27

volume

completely drawn into the syringe before changing the needle, the drug volume ordered will still be of medication

when

small

to infants.)

Consult the master rotation schedule lor (he patient so that the drug is administered at the correct site. Identify the patient before administration of the tion In

checking the bracelet.

medica-

..

Parenteral Administration

Chapter 9

I

If

6.

Explain what you are going to do.

especially in the thigh area. Routine aspiration (drawing back

7.

Position the patient appropriately.

8.

Expose the selected

on the injected syringe to check for blood) is not necessary." 12. As the needle is withdrawn, apply gentle pressure to the

9.

Cleanse the skin surface with an antiseptic pledget starting at the injection site and working outward in a circular motion toward the periphery.

10.

Let the area air-dry. Consult the institution's policy regarding which of the

site

and locate the landmarks. Put on

gloves.

11.

site

13.

14.

following methods to use.

Method

15.

1

Grasp the skin area of the roll

site

(DO NOT ASPIRATE FOR HEPARIN OR INSULIN),

and slowly inject the medication. If the aspiration draws blood, withdraw the needle and prepare an entirely new medication for administration (new syringe, needle, and drug). Method 2 Grasp the skin area of the site selected, spread, hold firmly, and insert the needle quickly at a 45-degree angle; aspirate (DO NOT ASPIRATE FOR HEPARIN OR INSULIN) and

Documentation, the Sixth Right Provide the

inject at a

may need

to

of the medication

Chart the date, time, drug name, dose, and route of ad-

1

ministration.

Perform and record regular patient assessments for the (e.g., blood pressure, pulse, output, improvement or quality of cough and productivity, degree and duration of pain relief). Chart and report any signs and symptoms of adverse drug

2.

evaluation of the therapeutic effectiveness

3.

pinch the skin and

45-degree angle to avoid intramuscular injection,

RIGHT DOCUMENTATION

administration and response to drug therapy:

slowly inject the medication. The 2000 American Diabetes Association Clinical Practice Recommendations state that "thin individuals or children

recap any needles that have been used. Dispose of used needles and syringes into a punctureresistant container according to the policy of the employing institution. Remove gloves and dispose of them according to agency policy. Thoroughly wash hands. Provide emotional support for the patient.

selected and create a small

or "bunch." Insert the needle quickly at a 90-degree angle,

aspirate

with an antiseptic pledget.

Do NOT

effects.

Perform and validate essential patient education about the drug therapy and other essential aspects of intervention for

4.

the disease process affecting the individual.

ADMINISTRATION OF MEDICATION BY THE INTRAMUSCULAR ROUTE Objectives 1

Identify the

equipment needed and describe the technique

used to administer medications cle,

area, 2.

in

the vastus

lateralis

mus-

rectus femoris muscle, ventrogluteal area, dorsogluteal

or the deltoid muscle.

For each anatomic

site studied,

utilized to identify the site

describe the landmarks

before administration of the

medication. 3.

Identify

of

good

sites

medication

in

an

for

intramuscular

infant,

child,

administration

adult,

and

elderly

person.

Key Words intramuscular

dorsogluteal area

vastus lateralis

deltoid muscle

rectus femoris

Z-track method

ventrogluteal area

Figure A, tion

9-28

Subcutaneous

sites and rotation plan. commonly used subcuand provides an example of a rota-

injection

Posterior view. B, Anterior view. This illustrates

taneous

sites for self-

administration

schedule for insulin injection using one

ceeding to the next

site

of administration.

site

systematically before pro-

Intramuscular (IM) injections are made by penetrating

a

needle through the dermis and subcutaneous tissue into the

muscle

layer.

The

injection deposits the medication

within the muscle mass (Figure 9-29). Absorption

is

deep

more

20

Parenteral Administration

Chapter 9

lengths appropriate for an obese patient, an infant, or an ema-

commonly used may be re-

ciated or debilitated patient. Needle lengths are

to

1

1

inches long, although longer lengths

Vi

When estimating needle length, it A inch of needle extending above

quired for an obese person. is

prudent to leave an extra

l

the skin surface in case the needle breaks.

Needle Gauge Commonly used gauges Epidermis

for

IM

injections are

used for the

IM

administration of medication

20

to

22 gauge.

Sites

Common

Dermis

sites

include the following:

Vastus Lateralis Muscle

away from one handbreadth below the greater trochanter and one handbreadth above the knee (Figure 9-30). It is generally the preferred site for IM injections in infants because it has the largest muscle mass for that age group. The vastus lateralis muscle is also a good choice for an injection site in healthy, ambulatory adults (Figure 9-30, B). It accommodates a large volume of medication and permits good drug absorption. In the older, debilitated, or nonambulatory adult, the muscle should be carefully assessed before injection because significantly less muscle mass may be present. If muscle mass is insufficient, an alternative site should be selected.

Subcutaneous

This muscle

located on the anterior lateral thigh

is

nerves and blood vessels. The midportion

Muscle

Figure 9-29

LIFE

Intramuscular injection technique.

SPAN ISSUES INJECTION SITES

The

vastus lateralis injection site

is

preferred

in infants. In

the older, debilitated, or nonambulatory adult, carefully as-

Rectus Femoris Muscle

mass before using this site for injection. The gluteal site must not be used in children under 3 years of age because the muscle is not welldeveloped yet.

The rectus femoris muscle

sess the sufficiency of the muscle

the vastus lateralis

anterior thigh.

lies just medial (Figure 9-31) to muscle but does not cross the midline of the

The

injection site

as the vastus lateralis muscle.

and adults when other tage to rapid than from subcutaneous injections because muscle

sue has a greater blood supply. Site selection

is

tis-

especially im-

portant with intramuscular injections because incorrect place-

ment of vessels.

the needle

A

may

large, healthy

cause damage to nerves or blood

Choose a syringe

that

site.

corresponds to the volume of drug to be usual amount injected intramuscu-

The

site is 0.5 to

amount should not exceed

2 ml. In infants and children, the 0.5 to

1

ml. Correlate syringe size

with the size of the patient and the tissue mass. In adults, di-

vided doses are generally 1

recommended

ml may be injected

for

amounts

m

ex

Other medica-

in the deltoid area.

factors that influence syringe size include the type tion, site of administration, thickness

tissue,

it

be used

sites are unavailable.

may be used more

A disadvantage

is

in

A

primary advan-

easily

that the

both children

by patients for

medial border

is

quite close to the sciatic nerve and major blood vessels (see

Figure 9-31). this site

may

If

the muscle

is

not well developed, injections in

also cause considerable discomfort.

is a commonly used site of injection because major nerves and blood vessels. It must not be used in children under 3 years of age because the muscle is not yet well-developed from walking. The area may be divided into two distinct injection sites: (1) the ventrogluteal area and it

Syringe Size

.ess of 3 ml;

that

is

self-administration.

The

one

use

same manner

located in the

may

Gluteal Area

Equipment

larly at

its

is

It

muscle free of infection or wounds

should be used.

injected at one

is

o\'

of subcutaneous fatty

and the aye of the individual.

Needle Length

gluteal area free of

(2) the dorsogluteal area. •

Ventrogluteal area: This patient

is

site is easily

accessible

when

prone, supine, or side-lying position.

in a

It is

the lo-

cated by placing the palm of the hand on the lateral portion of the greater trochanter, the index finger on the anterior

superior

spine,

iliac

the iliac crest.

The

and the middle finger extended

injection

is

made

to

into the center of the

V formed between

the index and middle lingers, with the needle directed slightly upward toward the crest of the il-

ium (Figure 9-32). Pain on injection can be minimized if muscle is relaxed. The patient can aid in relaxation by pointing the toes inward while lying in a prone position the

Assess each patient so that the needle length selected will the medication into the muscular tissue (see Fig-

deposit

ure 9-13). There

is

is

a

significant

difference

among needle

or In flexing the upper leg

if

lying on the side

Chapter 9

Figure 9-30

•

Vastus lateralis muscle.

Dorsogluteal area: To use this injection site (Figure 9-35), the patient must be placed in a prone position on a flat table surface. The site is identified by drawing an imaginary line from the posterior superior iliac spine to the greater trochanter of the femur. The injection should be given at any point between the imaginary straight line and below the curve of the iliac crest (hipbone). The syringe should be held perpendicular to the flat table surface with the needle directed on a straight back-to-front course. Pain on injection can be minimized if the muscle is relaxed. The patient can aid in relaxation by pointing the toes inward while lying in a prone position (see Figure 9-33).

is

Site

when

However,

it

master plan for site rotation should be developed and used for all patients requiring repeated injections (Figure

9-37).

Technique 1.

Prepare the medication as described

2.

Check

earlier.

the accuracy of the drug order against the medica-

when first removing the drug from the storage area; immediately after preparation; and immediately ration phase:

should be

volume to be injected is quite and the dose will be quickly absorbed. In adults, the volume should be limited to 2 cc or less and the substance must not cause irritation. Caution must only is

Rotation

A

often used because of ease of access in

the standing, sitting, or prone positions. in infants

of

lateral aspect

the arm.

tion being prepared at least three times during the prepa-

The deltoid muscle

small, the drug

Child/infant B, Adult

and two-thirds of the way around the outer

Deltoid Muscle

used

A,

121

Parenteral Administration

before administration.

the

nonirritating,

also be exercised to avoid the clavicle, humerus, acromion, the brachial vein and artery, and the radial nerve.

The

injec-

muscle is located by drawing an imaginary line across the armpit at the level of the axilla and the lower edge of the acromion. The lateral borders tion site (Figure 9-36) of the deltoid

of the rectangle are vertical lines parallel to the area one-third

3.

Check your

hospital policy regarding whether 0.1

or

AFTER

ac-

0.2 cc of air should be added to the syringe curately measuring the prescribed ministration. (Note:

The

volume of drug

for ad-

rationale for adding the air

is

completely cleared of all medication at the time of injection. Conversely, if the volume is completely drawn into the syringe before changing the needle, the drug volume ordered will still be administered as long as the same size needle is used for that

it

will result in the needle being

122

Chapter 9

Parenteral Administration

Femoral artery

Femoral vein

Greater trochanter

Sciatic

nerve

Rectus femoris muscle

Rectus femoris

Femoral artery

Femoral vein

Patella

Figure 9-3

I

Rectus femoris muscle.

Figure 9-32

Vfentrogfcited Site

A,

A,

Child/infant B, Adult.

Child/infant B, Adult

Chapter 9

Figure 9-33

Figure 9-34

Parenteral Administration

23

Prone position.Toes pointed to promote muscle relaxation.

Patient lying on side. Flexing the

upper

leg

promotes muscle

relaxation.

Posterior superior illiac

spine

Gluteus medious

muscle Gluteus maximus

muscle Greater

Sciatic

Figure 9-35

nerve

Dorsal gluteal

drawing up and injection. Thus the needle should not need be completely cleared of medication by air during administration. This issue can be critical when small volumes of potent drugs are administered repeatedly to infants.) Consult the master rotation schedule for the patient so that the drug is administered at the correct site (see Fig-

site.

A,

5.

to

ure 9-37).

Child/infant.

Identify the patient before administration of the medication

6. 7.

B, Adult.

by checking the

bracelet.

Explain what you are going to do. Position the patient appropriately (see Figures 9-33 and

9-34 for relaxation techniques). 8.

Expose the selected gloves.

site

and locate the landmarks. Use

L

124

Chapter 9

Parenteral Administration

A

B

Figure 9-36

Figure 9-37

Deltoid muscle

Intramuscular master rotation plan.

A,

site.

and the

and

Child/infant B, Adult

Note that the deltoid site may also be used in an infant and the drug nonirritating. B, Adult. In an adult, avoid the use

Infant/child.

or child; however, the volume of medication must be quite small

of the rectus femoris (numbers 7

A,

8} unless other sites are not available,

location of the sciatic nerve, femoral artery,

and

vein. If used,

due

be certain

to the pain to insert the

produced when

this site

is

used

needle lateral to the midline.

Chapter 9

Subcutaneous

Parenteral Administration

125

fat

Skin

Muscle

#+i= ^Wwf^ Figure 9-38 to

normal

method of intramuscular injection. A, Before starting Z-tracking. B, Stretch skin slightly to one side, C, Inject the medication; wait approximately 10 seconds. D, Remove needle and allow skin to return

Z-track

approximately one inch. position.

Do

not massage injection

site.

10.

Cleanse the skin surface with an antiseptic pledget starting at the injection site and working outward in a circular motion toward the periphery. Let the area air-dry.

1 1

Insert the needle at the correct angle

9.

and depth for the

site

being used. 1

2.

The Z-track Method The use of a Z-track method (Figure 9-38) may be appropriate for medications that are particularly irritating or that stain the tissue.

personnel 1.

Aspirate. If no blood returns, slowly inject the medication

using gentle, steady pressure on the plunger.

If blood does return, place an antiseptic pledget over the injection site as the needle is withdrawn. Start the procedure over with a new syringe, needle, and medication.

13.

Massage can increase the pain if stressed by the amount of medication 14.

the muscle

mass

is

gloves and dispose of them according Thoroughly wash hands. Apply a small bandage to the site.

17.

into the

arm or other exposed

Stretch the skin approximately

1

site.

Don gloves.

inch to one side (Fig-

Insert the needle.

Choose a needle of

sufficient length to

ensure deep muscle penetration. 4.

to

agency

Aspirate and follow previous guidelines for use of the dorsogluteal

5.

6.

policy. 16.

which

ure 9-38, B). 3.

given.

Do NOT recap any needles that have been used. Dispose of used needles and syringes into a puncture-resistant container according to the policy of the employing Remove

the hospital policy concerning

Expose the dorsogluteal site (Figure 9-38, A). Calculate and prepare the medication, then add 0.5 cc of air to ensure that the drug will clear the needle. Position the patient and Never inject

2.

institution. 15.

Check

administer by this method.

cleanse the area for injection as previously described.

After removing the needle, apply gentle pressure to the site.

may

site.

Gently inject the medication and wait approximately 10 seconds (Figure 9-38, Q. Remove the needle and allow the skin to return to the normal position (Figure 9-38, D).

7.

DO NOT massage the

Provide emotional support to the patient. Children should be given comfort during and after the injection. Some-

8.

If further injections are to

times letting a child hold your hand or say "ouch" helps.

9.

Praise the patient for assistance and cooperation.

dorsogluteal

Do NOT

injection site.

be made, alternate between

sites.

recap any needles that have been used. Dispose

of used needles and syringes into a puncture-resistant

26

Chapter 9

Parenteral Administration

container according to the policy of the employing institution.

LIFE

Remove

10.

SPAN ISSUES

gloves and dispose of them according to agency Thoroughly wash hands. Walking will help absorption. Vigorous exercise or pressure on the injection site (such as a tight girdle) should be

The most commonly used

temporarily avoided.

infants

policy.

1

1.

INTRAVENOUS SITES

scalp,

ADMINISTRATION OF MEDICATION BY THE INTRAVENOUS ROUTE dose forms

Identify the

and skill to establish and maintain an IV site, the patient tends be less mobile, and there is an increased possibility of infection and severe adverse reactions from the drug.

available, sites of administration,

and general principles of administering medications

via

Medications for IV administration are available

Describe the precautions needed to prevent the transmission of

human immunodeficiency

be implemented for 3.

all

virus (HIV) that should

patients requiring venipuncture.

vials,

and

Be

prefilled syringes.

cally states that the medication

in

ampules,

certain that the label specifiis

IV physiologic solutions come

"for

IV

use."

in a variety

of volumes and

concentrations in glass or plastic containers (see Table 9-2).

Describe the correct techniques for administering medications by

IV

line, a

a bottle

back 4.

Dose Forms

the

IV route. 2.

in

to

Objectives 1.

veins for IV administration

and children are in the temporal region of the back of the hand, and dorsum of the foot.

means of an

established peripheral or central

vascular access device, a heparin lock, an IV bag,

or volume-control device, or a secondary piggy-

set.

Describe the recommended guidelines and procedures for IV catheter care (including proper maintenance of pa-

tency of IV

lines

and implanted access device), IV

Equipment Gloves Tourniquet Administration

set

with appropriate needle, drip chamber, and

filter

Medication line

dressing changes, and peripheral and central venous IV

Physiologic solution ordered Sterile dressing materials

needle or catheter changes. 5.

to evaluate the IV therapy in

6.

Antiseptic solution

Discuss the proper baseline patient assessments needed (e.g., phlebitis,

extravasation, air

tubing).

Review the

Syringe and needle

(if

by bolus)

Arm board Tape

policies

and procedures used at the practice

setting to ensure that persons performing venipunctures

Standard IV pole or rod Heparin (saline) lock, "piggyback." and additional solutions, as appropriate

and IV therapy have the required proficiency.

Additional supplies

may

be required to access, flush, or

change IV administration sets, in-line filters, or dressings, depending on the type of peripheral, central, or implantable

Key Words

device being used. intravenous

infiltration

venipuncture

pulmonary edema

Sites

phlebitis

pulmonary embolism

Peripheral Access

When

selecting an IV site consider the length of time the IV

Intravenous (IV) administration of medication places the

will be required; condition

drug directly into the bloodstream, bypassing all barriers to drug absorption. Large volumes of medications can he ad-

infusion,

ministered into the vein, there onset of action

is

the

is

usually less irritation, and the

most rapid of

may

lie

but.

more commonly, drugs

all

parenteral routes.

Drugs

given by direct injection with a needle and syringe intermittently or by

are given

continuous infusion through an established peripheral or ^.x-n tral venous line, or via an implantable venous access device, also referred to as an implantable subcutaneous port.

IV drug administration patient, especially

administered daily.

when

is

usually

more comfortable

several doses

>i

and location of veins; purpose of example, rehydration, delivery of nutritional

parenteral nutrition |TPN|), chemotherapy, and and patient status, cooperation, and patient prefand amount of self-care of the injection site (if

(total

antibiotics;

erence lor

appropriate).

Peripheral IV devices include winged-tip needle, over-thenecille catheter (see Figure 9-12, A),

catheter (see Figure 9-12,

lor the

and inside-the-needle

The over-lhc-necdle

/>').

catheters

most commonly used venous access system used to enter both superficial and deep veins. It a prolonged course of treatment is anticipated, start the firsl l\ m the hand (Figure >>. The metacarpal veins, dorare the

medication musl be However, use of the IV route requires time (

needs

for

l

>

^

(

Chapter 9

Parenteral Administration

1

27

Cephalic vein Basilic vein

Basilic vein

Dorsal venous

network

vein

Basilic

Digital veins

Figure 9-39

IV sites on the hand.

network, cephalic, and basilic vein are

sal vein

commonly

and leakage from a previous puncture site, the subsequent venipuncture sites should be made above the earlier site. See Figure 9-40 for the veins of the forearm area that could be used for additional venipuncture sites. • Avoid the use of vessels over bony prominences or joints

used.

To avoid

irritation

• In the elderly, the use of the veins in the

hand area may

be a poor choice because of the fragility of the skin and veins in this area.

commonly used

in infants

and children for IV ad-

ministration are on the back of the hand,

dorsum of

the

temporal region of the scalp (Figure 9-41). • If possible, do not use the veins of the lower extremities because of the danger of developing thrombi and foot, or the

emboli. •

Do

not use veins with varicosities or an extremity with (e.g., the

mastectomy and lymph node

Whenever

affected side following a

dissection).

possible, initiate the

IV

in the

nondominant

arm. •

Do

central

venous

sites

most commonly used

for insertion

When

upper body veins are not acaccessed for short-term or emergency use. A physician can also elect to perform a venisection or "cutdown" to insert this type of catheter into the clavian and jugular veins.

ceptable, the femoral veins

may be

basilic or cephalic veins in the antecubital fossa.

Central sites (e.g., the

commonly used

for long-term silastic catheters

Hickman, Broviac, or Groshong catheters

in Fig-

ure 9-42) are the jugular, subclavian, or cephalic veins.

The

end of the silastic catheter is positioned in the superior vena cava to allow maximal dilution of the IV fluid with blood. The proximal end of the catheter is tunneled in subcutaneous tissue that acts as a barrier to pathogens that may later attach to the catheter line and migrate to the vein causing an distal

impaired blood flow •

The

Veins in the forearm used as IV sites.

of inside-the-needle catheters (see Figure 9-12) are the sub-

unless absolutely necessary.

• Veins

Figure 9-40

infection. After initial placement, the radiopaque catheter's

not initiate an IV in an

arm with compromised lym-

position

is

often verified by x-ray examination.

phatic or venous flow.

Note: Never

start

an IV

in

Implantable Vascular Access Devices Vascular access devices, also known as implantable

an artery!

Central Access Central IV devices are used

when

the purpose of therapy dic-

volume, high concentration, or hypertonic solutions are to be infused); when peripheral sites have been exhausted because of repeated use or condition of veins for access tates (e.g., large

is

poor;

when long-term

infusion

ports (e.g., Infus-A-Port, Port-A-Cath, Mediport. Chemoport).

or

home

therapy

is

required; and

emergency condition mandates adequate vascular access.

when

are used

when long-term therapy

cessing of the vein

is

is

required and repeated ac-

required. Vascular access devices/ports

(Figure 9-43) are implanted into a subcutaneous pocket in the chest area and arc sutured in place.

cone catheter

is

The

distal

end of the

sili-

threaded via the jugular, subclavian, or

cephalic vein to the superior vena cava.

The proximal end of

-

1

28

Chapter 9

Parentera I Administration

Scalp veins

Basilic (little

vein

Cephalic vein

finger side)

(thumb

side)

Dorsalis pedis

veins

Figure 9-4 1

the catheter

is

Veins in infants

and

children used as IV sites.

attached to the implanted port.

The

port itself

contains a self-sealing silicone rubber septum specifically de-

signed for repeated injections over an extended period.

A spe-

noncoring Huber needle is used to penetrate the skin and the septum of the implanted device to minimize damage to the self-sealing septum. Only the smallest gauge noncoring needles should be used to prolong the life of the septum.

Figure 9-42 A, Hickman

catheter.B, Brovia catheter;

C, Groshong

catheter. (Courtesy Chuck Dresner.)

cial

General Principles of Intravenous Medication Administration •

•

Use appropriate barrier precautions (universal blood and body fluid precautions) to prevent the transmission of any infectious diseases, including HIV. as recommended by the Centers for Disease Control and Prevention (CDC). Gloves should be worn throughout the venipuncture procedure. Care should be taken to wash the skin surface it the area

•

When

is

contaminated with blood.

completed, remove the gloves and dispose of them in accordance with the policies o\ the practice setting. WASH hands thoroughly as soon as the procedure

is

removed, (are should he taken not to contaminate the IV tubing and rate regulator. An\ used needles, syringes, venipuncture catheters, or vascular access devices should he placed m a puncture the gloves are

•

Figure 9-43

Silicone

Potter

Never recap, bend, or break used needles because of the danger of inadvertently puncturing the skin. Whenever possible, use needle protector systems such as blunt needles/injection ports, needle sheaths, or needle-

o\'

systems to present inadvertent needle sticks and risk introducing pathogens into oneself.

Me

certain medications lo he administered intravenously

less

are thoroughly dissolved in the correct

icsisiani container in the

oi

according to

mendations.

immediate \ icinits lor disposal the policies of the practice setting

venous catheters with infusion ports. (From and practice, ed 3. St Louis. 1995, Mosby)

PA. Perry AG: Bash nursing: theory

solution

Always follow

volume and type recom-

the manufacturer's

?ral

•

Most

clinical practice sites

ings over the IV insertion

•

now

changed

in accor-

dance with hospital policies, generally every 48 hours. Some clinical practice sites still use gauze dressings. When gauze is used, the four edges of the dressing should be sealed using tape. To prevent skin irritation, place tincture of benzoin on the skin directly under the edge of the gauze and allow it to dry before applying the dressing tape. Always check the specific policies of the employing institution, as well as the physician's orders for frequency of dressing changes. At the time of the dressing change on any type of IV site, the area should be thoroughly inspected for any drainage, redness, tenderness, irritation, or swelling.

The

this

nal, or circulatory

Preparing an Intravenous Solution for Infusion

Dose Form Check

same time.) recommended by the manufacturer

Use

in-line filters as

is

hazy

•

DO NOT administer a drug in an IV solution if the com-

ucts (e.g., albumin).

known. Drugs must be entirely infused through the IV line before adding a second medication to the IV line. Drugs given by IV push or bolus generally are given following the bolded

Saline flush

SASH

moving

Check

TKO

primary solution.

Equipment Administration set with appropriate drip chamber (microdrop or macrodrop), needle, IV catheter, and in-line

Whenever

a patient

used).

filter (if

line administration set is usually la-

start set/kit (antiseptic

pads, nonsterile gloves, site labels,

Medications for IV delivery and label Physiologic solution ordered

IV pole

Technique 1.

2.

Check tion

4.

the physician's order against the physiologic solu-

chosen for administration.

Inspect the IV container for cloudiness, discoloration, or the presence of any precipitate. Verify the expiration date

on the IV 5.

Remove

fluid container.

the plastic cover

spect the plastic

IV bag

from the IV container and

to be certain

it

is intact;

in-

squeeze

gently to detect any punctures. Inspect a glass container

of IV solution for any cracks. 6.

Choose

the administration set appropriate for the type of

solution ordered, the rate of delivery requested (micro-

receiving IV fluids, monitor intake

and output accurately. Report declining hourly outputs and those of less than 30 to 40 ml/hour.

Assemble equipment and thoroughly wash hands. Check the size and type of needle or catheter needed to access the vein selected for the IV or to access an implanted access device for the delivery of the IV solution or medication.

3.

7. is

The primary

beled universal or continue flow.

IV

(to

keep open). It is usually interpreted as an infusion rate of 10 ml/hr and should infuse less than 500 ml/24 hr. Shade IV solutions that contain drugs that should be protected from light (e.g., hyperalimentation solutions, nitrofurantoin, amphotericin B, nitroprusside). All IV solution bag/bottles should be changed every 24 hours (check hospital policy) to minimize the development of new infections. Label all IV solutions with the date and time initiated and the nurse's initials. DO NOT use marking pens directly on plastic IV containers, the ink may permeate through the plastic into the IV solution. IV administration sets used to deliver blood or blood products should be changed after the unit is administered. Sets used to infuse lipids or TPN should be changed every 24 hours. Administration sets used only for physiologic IV fluids (e.g., dextrose 5% NS 0.2%) may be changed every 72 hours (CDC, 1995)(check hospital policy). The sets/tubing must be labeled with the date and time initiated, the date to change the set, and the nurse's initials.

•

first re-

the drug/solution

tape, tranparent dressing materials, tourniquet)

first

the hospital policy for the definition of

when

from the storage area, (2) immediately after preparation, and (3) immediately before administration. Check the expiration date on any additives and the

guideline:

Administer the prescribed drug Saline flush following the drug Heparin flush line, depending on type of line, such as a Hickman catheter (check institution policy) • Once mixed, know the length of time an agent remains stable; all unused IV solutions should be returned to the pharmacy if not used within 24 hours.

•

or-

already pre-

pared by the pharmacy, check the accuracy of the drug order

patibility is not

•

IV solution

If not

it.

DO NOT mix any other drugs with blood or blood prod-

•

the physician's order for the specific

dered and for any medication to be added.

against the medication and/or solution being prepared at least

•

•

impairment.

three times during the preparation phase: (1)

or cloudy, or has foreign particles or a precipitate in

•

could be dangerous. The physician should be conwho have cardiac, re-

sulted, particularly with patients

the physician immediately. (Also take the patient's vital

of the drug to be delivered. • DO NOT administer any drug or IV solution that

•

Never "speed up" an IV flow rate to "catch up" when the volume to be infused has fallen behind. In certain cases,

presence of any of these symptoms should be reported to signs and report these at the •

•

use transparent dress-

site that are

129

Administration

8.

drop or macrodrop), and for the type of IV container being used. Plastic bag IV containers DO NOT require an air vent in the administration set. Glass containers for IV delivery must be vented or have an administration set with a vent in it. Remove the administration set from its container and inspect to ensure its sterility. Move the roller or slide clamp to the upper portion of the IV line 6 to 8 inches from the drip chamber; close the clamp. Plastic IV bags: Remove the tab from the spike receiver port; remove the tab from the administration set spike; in-

30

Parenteral Administration Admit

Chapter 9

SPAN ISSUES

LIFE

LIFE

BENZYL ALCOHOL PRESERVATIVE

INTRAVENOUS FLUID MONITORING The

Do

not use bacteriostatic water or saline containing the benzyl alcohol preservative to reconstitute or dilute med-

infusion of IV fluids necessitates careful monitoring

ages.THe microdrip chamber, which deis used whenever a small volume of intravenous solution is ordered to be infused over a specific time. Many clinical sites interpret a small volume as

for patients of

less

all

60 drops

livers

pump

ications or to flush IV catheters of

(gtts)/ml,

than 100 ml/hr.

chamber

In pediatric units

preservative

newborns because the

toxic to these patients.

controlled-volume

commonly used

infusers are is

amount

to control the

ication ordered. Purge air

infused.

the 10. sert the spike firmly into the

bag

port.

Maintain

of port and spike throughout the process. Glass IV bottle: Peel back the metal tab and

the latex

the noise

is

is

not be sterile and should be discarded. Remove the tab from the administration set spike: insert the spike firmly

may

into the port in the rubber stopper. Maintain sterility of the

When

now be

taken to the bedside for

after a venipuncture

is

at-

performed or for addi-

Intravenous Medication Administration Research the medication ordered as an IV additive (procedure also applies for direct push or bolus administration):

and spike throughout the process.

Note:

solution can

released.

IV container

not heard, the contents of the

The IV

IV system. For safety, all aspects of the IV order should be checked again immediately before attaching the IV for infusion. Note: Always identify the patient by checking the bracelet before initiating any IV procedure.

the pro-

present)

heard as the vacuum within the glass container

line before attaching

tion to an existing

lift

from the container; remove the latex-type from the top of the rubber stopper. As diaphragm is removed, a sudden noise should be

(if

from the

filter.

tachment

sterility

tective metal disk

covering

port

is

devices, such as Buretrol or Solu-set, and syringe

of fluid that

If

SPAN ISSUES

additive medications are ordered, they

Name

2.

of drug. Usual dose (take into consideration patient's age, weight,

is

3.

Compatibility of drug with existing IVs and drugs infusing.

added to an existing IV solution, clamp the line before adding the medication to the container and make sure adequate mixing takes place before the infusion is started again. (See technique used for adding a medication to an

4.

For IV push or bolus, does drug need to be diluted or can it be given undiluted (i.e., IV push)? If diluted, what types

IV solution,

5.

should be added to the large volume container before tubing is attached to help ensure a uniform mixing of the

medication and the physiologic solution.

p.

If

medication

134.)

on an IV pole; squeeze the drip chamber and fill halfway; prime the IV line by removing the protective tab from the distal end of the IV line; invert the back-check valve, open the roller or slide clamp, and allow the solution to run until all the air is removed from the line. Cover the end of the IV tubing with a sterile cap.

Hang

1

and hydration

state).

and amounts of solution can be used? If being added to an IV, what type(s) of solution is the drug compatible with?

Recommended

Premedication Assessments 1

Know

basic patient data, diagnosis,

Obtain baseline

3.

moved from line. Place an IV measuring device/tape strip on the plastic bag or glass IV container. Label the contamer with the patient's name, along with the date and time of preparation. If medication has been added, all details of the medication must be marked on label of the container: drug name. dose, rate of administration requested in physician's order, and the nurse's name who prepared IV The IV tubing is labeled with the date and he time it is opened and the date and tune to be changed CDC recommends that IV tubing should be changed every 72 hours. Administration sets used to deliver blood or blood products may be changed after each unit is in-

4.

Check Check

fused. Lipid solutions have special tubing that should be 2

\

hours

if

fusion or alter ever) unit

administered b> continuous init administered mlei miltcnll}.

Follow institutional policies where practicing. NOTl It ma\ be necessais to add in line filters to the :

it

recommended

lor the administration ol the

med

ordered, and

vital signs.

any drug allergies or prior drug reactions. the accuracy of the drug order against the medication or solution being prepared at least three times durfor

ing the preparation phase:

when

first

removing the drug/

solution from the storage area, immediately after preparation,

and immediately before administration. Check the

expiration date on the solution. 5.

Review tory

monograph to identify laborarecommended before or intermittently during

the individual drug

studies

therapy, calculation of dose, side effects to expect and side

I

changed ever)

is

the desired action of the drug for this specific individual. 2.

all

symptoms of disorder

or disease process for which the medication

air is re-

Inspect entire length of tubing to be certain

setup

rate of infusion.

the solution

effects to report, monitoring parameters the specific drug prescribed,

recommended

for

and so on.

Venipuncture follow these steps I

2.

Wash hands

m

performing venipuncture.

thoroughly.

Position the patienl appropriately. Immobilize an infant or child for patienl safety,

if

necessary.

Chapter 9

Figure 9-44 A, Apply C,

of entry, working outward

in

and

direction.

3.

D, Cleanse the skin surface with an

F,

Decrease the angle

Cut tape for stabilizing the IV needle or catheter before starting the procedure. Turn the ends of the tape back on itself to form a tab that will not adhere to a glove when the tape is to be applied or removed. The nurse must consider his or her gloves to be contaminated when they come in contact with blood. If the gloves then contact the tape and dressing materials used at the venipuncture site, the outside of the dressings and tape are then potentially contaminated. Therefore during the procedure the nurse must focus on allowing contamination only of the dominant gloved hand; the nondominant hand must be maintained as noncontaminated to handle the taping and stabilization of the needle or IV catheter. Once the needle or catheter is stabilized, the gloves can be removed; wash hands thoroughly and apply the gauze or occlusive type of dressing

Apply

the tourniquet using a slipknot 2 to 6 inches

the site chosen (shaded area in Figure 9-44,

area to identify a vein of sufficient size to the needle

slightly less

15 degrees and slowly advance the needle along the

to

vein.

,4).

vein to feel the depth and direction (Figure 9-44,

To

dilate the vein,

above

Inspect the

accommodate

and provide adequate anchorage. Palpate the

it

may be

B

and C).

necessary to place the ex-

tremity in a dependent position; massage the vein against

open and close hand repeatedly, lightly thump the vein with your fingertips; or remove the tourniquet and apply a heating pad or warm, wet towels to the extremity for 15 to 20 minutes and then start the process again. the direction of blood flow; have the patient the

5.

Cleanse the skin surface with the antiseptic starting at the site of entry and working outward in a circular motion to-

ward

the periphery (Figure 9-44, D).

6.

Let the area air-dry.

7.

Put on gloves.

8.

Provide tension on the skin surface to stretch the skin and stabilize the vein.

When

materials according to the practice-setting policies. 4.

antiseptic, starting at the anticipated

a circular motion to the periphery. E, Hold the needle (bevel up) at an angle

than 45 degrees to penetrate the skin surface. course of the

131

tourniquet using a slipknot 2 to 6 inches above the chosen (shaded) area. B, Allow veins to dilate.

Palpate the vein to feel the depth

site

Parenteral Administration

Hold

using an administration set or a needle and syringe:

(

1

45 degrees (Figure 9-44, E) and penetrate the skin surface approximately one-half inch below the intended entry site into the vein; decrease the angle to 15 degrees (Figure 9-44, F) and the needle (bevel up) at an angle slightly less than

Chapter?

132

Parenteral Administration

slowly advance the needle along the course of the vein. (2) When blood flow is established, connect the tubing to the nee-

any blood that may have contacted the skin or IV tubing, remove gloves, and anchor the needle and tubing to the arm or hand with tape figure 9-45 and dressing as prescribed in the practice setting policy. (Because it is difficult to handle tape with dle, release the tourniquet, cleanse the area to eliminate

1

|

gloves on,

it

helpful to have a second person anchor the

is

needle and tubing and adjust the flow

rate.

The

individual per-

forming the venipuncture can then remove gloves and wash hands thoroughly.) (3) Adjust the rate of flow of the solution: ml of solution x number of drops/ml hrs of administration

(4)

X 60 min/ml

drops/min

Regulate the flow by counting the drops for 15 seconds,

multiply by 4, and adjust clamp on tubing for the appropriate rate.

When

using an over-the-catheter needle (Figure 9-46): (1) until blood flow is established (Figure 9-46,

Proceed as above A). (2)

Remove

the inner needle (Figure 9-46, B), connect the

tubing to the plastic needle (Figure 9-46, C), release the tourniquet, cleanse the area to eliminate any blood that

may

have contacted the skin or IV tubing, remove gloves, and anchor the needle and tubing to the arm or hand with tape (see Figure 9-45) and dressing as prescribed in the practice setting policy. is

(Because

it is

difficult to

handle tape with gloves on,

it

helpful to have a second person anchor the needle and tub-

Figure 9-46 A, scribed

in

Figure 9-4 S

up. B, Cross adhesive tapes

is

side up.

A,

Place two small

(It will

adhere

to larger

is

to secure the plastic catheter

placed under the hub with adhesive

tape to be applied

later.)

C, A

larger piece

of tape completes the stabilization of the plastic needle or catheter. Mark the date and time of insertion and the nurse's initials or signature. Note: There are several other methods for taping IV catheters or needles. Consult the procedure manual of the practice setting for the preferred

method.

2, A).

When

established. B, After the catheter has

C, Connect

one at a time

or needle.The larger piece of tape

"Over-the

norepinephrine are called adrenergic fibers.

secrete

Most organs

by both adrenergic and cholinerExamples of these opposing actions are in the heart, where adrenergic agents increase the heart rate and cholinergic agents slow the heart rate, and in the eyes, where adrenergic agents cause pupillary dilation and cholinergic agents cause pupillary conare innervated

gic fibers, but they produce opposite responses.

striction (Table 11-1).

Drugs that cause effects in the body similar to those produced by acetylcholine are called cholinergic or parasympathomimetic drugs because they mimic the action produced by stimulation of the parasympathetic division of the autonomic nervous system. Drugs that cause effects similar to those produced by the adrenergic neurotransmitter are called adrenergic, or sympathomimetic, drugs. Agents that block or inhibit cholinergic activity are called anticholinergic agents, and agents that inhibit the adrenergic system are referred to as adrenergic-blocking agents. See Figure 11-1 for a diagram of the autonomic system and representative stimulants and inhibitors.

curs because of the activity of chemical substances called

neurotransmitters (transmitters of nerve impulses). A neurois released into the synapse at the end of one neuron, activating receptors on the next neuron in the chain or at the end of the nerve chain, stimulating the end organ (the heart, smooth muscle, or gland). Neurotransmitters can be eitransmitter

Drug

Class: Adrenergic

Agents

Actions

The adrenergic nervous system may be stimulated by two broad classes of drugs: catecholamines and noncatecholamines. ther excitatory, stimulating the next neuron, or inhibitory, inThe naturally-occurring catecholamines that are neurotranshibiting the neuron. Because a single neuron releases only one mitters in the human body are norepinephrine, epinephrine, type of neurotransmitter, the CNS is composed of systems of and dopamine. Norepinephrine is secreted primarily from different types of neurons that secrete separate neurotransmitnerve terminals, epinephrine primarily from the adrenal ters. Research indicates that there are more than 30 different medulla, and dopamine at selected sites within the brain, kidtypes of neurotransmitters. The more common neurotransmitneys, and GI tract. All three agents are also synthetically ters throughout the CNS are acetylcholine, norepinephrine, manufactured and may be administered to produce the sam« epinephrine, dopamine, glycine, gamma-aminobutyric acid effects as naturally secreted neurotransmitters The noncate (GABA), and glutamic acid. Substance P and the enkephalins cholamines have actions that are somewhat similar to those ol and endorphins regulate the sensation of pain, and serotonin S\

Chapter

Table

I

I

Drugs Affecting the Autonomic Nervous System

1 1

65

-4

Cholinergic Agents

Brand Name

Availability

Ambenonium

Mytelase

Tablets:

Bethanechol

Urecholine

Edrophonium

Tensilon, Enlon

Name

Generic

1

Clinical Use

mg

/0

Treatment of myasthenia gravis See Chapter 39

Inj:

10

mg/ml

in

1,

10, 15

ml

Diagnosis of myasthenia gravis

vials

Reverse nondepolarizing muscle relaxants such as tubocurarine

25

Guanidine

Guanidine

Tablets:

Neostigmine

Prostigmin

Tablets: 15 Inj:

1

mg

Treatment of myasthenia

mg

0.25, 0.5,

1

gravis

Treatment of myasthenia gravis Reverse nondepolarizing muscle relaxants such as

mg/ml

tubocurarine Physostigmine

Antilirium

Pilocarpine

Isopto Carpine,

Inj:

1

mg/ml

in

2 ml

amp

Reverse toxicity of overdoses of anticholinergic agents (such as pesticides, insecticides)

See Chapter 40

Pilocar,

Adsorbocarpine Pyridostigmine

Mestinon, Regonol

Tablets:

60

mg

Treatment of myasthenia gravis Reverse nondepolarizing muscle relaxants such as

Syrup: 60 mg/5 ml

Sustained release tablets: Inj:

5 mg/ml

in 2,

1

80

mg

5 ml ampules

tubocurarine Reverse toxicity of overdoses of anticholinergic agents (such as pesticides, insecticides)

Enzyme-Inducing Agents. Enzyme-inducing agents such as

smooth muscle; sweating; miosis of the eye, which reduces

cimetidine, phenobarbital, nembutal, and phenytoin enhance

intraocular pressure; increased force of contraction of skeletal

the metabolism of propranolol, metoprolol, pindolol, and tim-

muscle; and sometimes a decrease in blood pressure.

olol.

This reaction probably does not occur with nadolol or

atenolol because they are not metabolized but are excreted un-

changed. The dose of the beta-blocker

may have

creased to provide therapeutic activity. If ing agent

is

be inthe enzyme-inducto

Uses See Table 11-4.

discontinued, the dosage of the beta-blocking

agent will also require reduction.

Indomethacin and Salicylates. Indomethacin and possibly other prostaglandin inhibitors inhibit the antihypertensive activity

of propranolol and pindolol. This results in loss of hy-

The dose of the beta-blocker may have to be increased to compensate for the antihypertensive inhibitory pertensive control.

effect

of indomethacin and perhaps other prostaglandin

lursing Process for Cholinergic

Agents

See also nursing process for patients with disorders of the eyes (see Chapter 40), for patients with glaucoma (see Chapter 40), for patients with urinary system disease (see Chapter 39), and for patients with respiratory tract disease (see Chapters 27 and 28).

inhibitors.

Premedication Assessment

Drug

Class: Cholinergic

Agents

Actions Cholinergic agents, also

known

as

parasympathomimetic

agents, produce effects that are similar to those of acetyl-

choline.

Some

cholinergic agents act by directly stimulating

1.

2.

Take baseline vital signs of heart rate and blood pressure. See also premedication assessment for patients with disorders of the eyes (see Chapter 40), for patients with glaucoma (see Chapter 40), for patients with urinary system disease (see Chapter 39), and for patients with respiratory tract disease (see Chapters 27 and 28).

the parasympathetic nervous system, whereas other agents act

by inhibiting acetylcholinesterase, the enzyme that metabolizes acetylcholine once it is released by the nerve ending. These latter agents are known as indirect-acting cholinergic agents.

Some

of the cholinergic actions observed are slowing

of the heart; increased GI motility and secretions; increased contractions of the urinary bladder, with relaxation of muscle sphincter; increased secretions

and

contractility of bronchial

Planning Availability:

See Table 11-4.

Evaluation Because cholinergic fibers innervate the entire body, effects in most systems of the body can be expected. Fortunately, because all receptors do not respond to the same dosage, all adverse

.

Drugs Affecting the A utonomic Verrous System

Chapter

166

The higher the dosages used, however, the greater the likelihood for more adverse effects. Side effects to expect Nausi \. Vomiting, Diarrhea, Abdominal Cramping. These effects are not seen at all times.

symptoms

are extensions of the pharmacologic effects of the medication and are dose related. Reducing the dose may be

3.

4.

Take baseline vital signs of heart rate and blood pressure. See also premedication assessment for patients with Parkinson's disease (see Chapter 13), for patients with disorders of the eyes (see Chapter 40), and for antihistamines (see Chapter 27).

effective in controlling adverse effects without eliminating the

Planning

desired pharmacologic effect.

Availability:

Di/ziM

ss.

See Table 11-5.

Hypotension. Monitor blood pressure and pulse.

To minimize hypotensive episodes

instruct the patient to rise

slowly from a supine or sitting position and perform exercises

Evaluation Because cholinergic

fibers innervate the entire body,

we can

to prevent

expect to see effects from blocking this system throughout

sition

most systems in the body. Fortunately, because all receptors do not respond to the same dose, all adverse effects are not seen to the same degree with all cholinergic blocking agents.

down

blood pooling while standing or sitting in one pofor prolonged periods. Teach the patient to sit or lie

if

feeling faint.

Side effects to report

Bronchospasm, Wheezing, Bradycardia. Withhold the next

dose

until the patient is

evaluated by a physician.

Drug interactions

the greater the likelihood

Side effects to expect

Atropine, Antihistamines. Atropine, other anticholinergic agents, and

The higher the dosages, however, for more adverse effects.

most antihistamines antagonize the

effects of the

Blurred Vision; Constipation; Urinary Retention; Dryness of the Mucosa of the Mouth, Nose, and Throat. These symp-

toms are the anticholinergic

cholinergic agents.

effects

produced by these agents.

Patients taking these medications should be monitored for the

nerve endings, which prevents the action of acetylcholine.

development of these side effects. Dryness of the mucosa may be alleviated by sucking hard candy or ice chips or by chewing gum. If patients develop urinary hesitancy, assess for distention of the bladder. Report to the physician for further evaluation. Give stool softeners as prescribed. Encourage adequate fluid intake and foods that provide sufficient bulk. Caution the patient that blurred vision may occur, and make

The parasympathetic response is reduced, depending on the amount of anticholinergic drug blocking the receptors. Inhibi-

Side effects to report

Drug

Class: Anticholinergic

Agents

Actions Anticholinergic agents, also

known

agents or parasympatholytic

as cholinergic-blocking

agents,

block the action of

acetylcholine in the parasympathetic nervous system. These

drugs act by occupying receptor

sites

at

parasympathetic

appropriate suggestions for personal safety of the individual.

tion of cholinergic activity (anticholinergic effects) includes

Confusion, Depression, Nightmares, Hallucinations. Per-

mydriasis of the pupil with increased intraocular pressure

form a baseline assessment of the patient's degree of alertness and orientation to name, place, and time before initiating ther-

with glaucoma; dry, tenacious secretions of the mouth, nose, throat, and bronchi; decreased secretions and motility of the gastrointestinal tract; increased heart rate; and decreased sweating. in patients

Make regularly scheduled subsequent evaluations of mental status and compare findings. Report development of apy.

alterations.

Provide for patient safety during these episodes. Reduction

Use**

in the daily

The anticholinergic agents are used clinically in the treatment of Gl and ophthalmic disorders, bradycardia, Parkinson's disand genitourinary disorders; as a preoperative drying agent; and to prevent vagal stimulation from skeletal muscle relaxants or placement of an endotracheal tube (Table 1 1-5). ' ease,

dosage may control these adverse effects. Hypotension. Although this occurs

Orthostatic quently and

is

generally mild,

all

infre-

anticholinergic agents

may

cause some degree of orthostatic hypotension manifested by dizziness and weakness, particularly when therapy is being initiated.

Monitor the blood pressure daily in both the supine and standing positions. Anticipate the development of postural hypotension, and take measures to prevent an occurrence. Teach

Nursin ursing Process for Anticholinergic Agents Sec also nursing process for patients with Parkinson's disease (see Chapter 13). for patients with disorders of the eyes (see

Chapter 40), and for antihistamines (see Chapter

27).

Premedication Assessment 1

2.

Patients with open-angle

All patients should be screened for the presence

angle glaucoma. Anticholinergic agents

from a supine or sitting position, and encourage the patient to sit or lie down if feeling faint. Palpitations, Arrhythmias. Report for further evaluation. Glaucoma. All patients should be screened for the presence o\' angle-closure glaucoma before initiating therapy. the patient to rise slowly

may

of closedprecipitate

ergic agents. Monitoring

performed on

glaucoma can

safely use anticholin-

intraocular pressures should be

o\'

a regular basis.

an acute attack of angle-closure glaucoma. Patients with

Drug interactions

open-angle glaucoma can safely use anticholinergic agents in conjunction With miotic therapy.

Amantadine, Tricyclk Antidepressants, Phenothiazines. These agents maj potentiate anticholinergic side effects. Development of confusion and hallucinations are characteristic

Check

tin

history

cholinergic agents

l

enlarged prostate.

maj cause temporary

It

present, anti-

inability to void.

of excessive anticholinergic

activity.

.

Chapter

Table

I

I

1

Drugs Affecting the Autonomic Nervous System

1

167

-5

Anticholinergic Agents

Generic

Name

Atropine

Brand Name

Availability

Atropine Sulfate

Inj:

Clinical Use Presurgery

0.05, 0.1, 0.3, 0.4, 0.5, 0.8, 1

.0

mg/ml

mg

Tablets: 0.4

— reduce

salivation

and bronchial se-

cretions; minimize bradycardia during intubation

Treatment of pylorospasm and spastic conditions of the Gl tract

Treatment of urethral and Belladonna

mg/100 ml

Tincture: 30

Belladonna

biliary colic

Indigestion, peptic ulcer

Nocturnal enuresis

Tincture

Parkinsonism

mg

Clidinium bromide

Quarzan

Capsules: 2.5, 5

Dicyclomine

Bentyl.Antispas,

Tablets:

Dibent, *Bentylol

Capsules: 10,20

20

Peptic ulcer diseases

mg

Irritable

mg

bowel syndrome

Infant colic

Syrup: 10 mg/5 ml Inj:

Glycopyrrolate

Robinul

10

mg/ml

Tablets: Inj:

0.2

1

,

2

mg

Peptic ulcer disease

— reduce

mg/ml

Presurgery

salivation

and bronchial se-

cretions; minimize bradycardia during intubation

mg

Mepenzolate

Cantil

Tablets: 25

Propantheline

Pro-Banthine

Tablets: 7.5,

Available

in

1

Peptic ulcer disease

5

mg

Peptic ulcer disease

Canada.

CHAPTER REVIEW The nervous system

CRITICAL THINKING QUESTIONS

one of two primary regulators of body homeostasis and defense. The central nervous system is

is composed of the brain and spinal cord. The efferent nervous system is subdivided into the motor nervous system, which controls skeletal muscle, and the autonomic nervous system, which regulates smooth muscle and heart muscle and controls secretions from certain glands. Nerve impulses are passed between neurons and from neurons to end organs by neurotransmitters. Control of neurotransmitters is a primary way to alleviate symptoms associated with many

1

(adrenergic, adrenergic-blocking agents, cholinergic, antilist of premedication assessments that should be made before use of these

cholinergic agents), develop a

drugs. 2.

Summarize the actions of the cholinergic and anticholinergic agents. Arrange the summaries in columns to compare cholinergic and anticholinergic actions.

3.

diseases.

Based on a review of this chapter related to the actions, uses, and side effects of the primary drug classifications

Examine the drug actions listed for adrenergic-blocking mechanisms by which these drugs are beneficial for the treatment of angina pectoris, cardiac arrhythmias, and hypertension. agents. Explain the

MATH REVIEW 1.

Order: Benadryl 40 Give

mg PO

tid.

Benadryl 12.5 mg/5 ml

is

4.

2.

Order: Propranolol 60 mg Give

PO

tid.

Propranolol 40

mg

tablets are available. 3.

Explain the effect of vasoconstriction and vasodilation of

blood vessels on blood pressure.

available.

Order: Dilantin suspension 150 mg q8h. Dilantin suspension 125 mg/5 ml is available. Give

5.

What used

type of autonomic system drugs should not be

in

persons with pulmonary disorders?

.

Sedative-Hypnotics

CHAPTER CONTENT

Adequate sleep

|

Sleep and Sleep Pattern Disturbance

Sedative-Hypnotic Therapy

(p.

of sleep (p.

is

immune system

strengthening the

168)

sleep

169)

is

that progresses

for Sleep Disturbance

Drug

Class: Barbiturates (p. 170)

Drug

Class: Benzodiazepines (p.

1

(p.

170)

to

ward off disease. Natural

a rhythmic progression through four stages that pro-

vide physical and mental

Drug Therapy

through the normal stages

important to maintain body function such as

a specific set of brain

rest.

wave

Each stage

activities.

is

characterized by

Stage

I

is

a transition

phase between wakefulness and sleep. Some people experience it as wakefulness and others as drowsiness. Approximately 2% to 5% of sleep is stage I. Stage II comprises about

73)

Miscellaneous Sedative-Hypnotic Agents

(p.

1

75)

50%

of normal sleep time. People often experience a drifting

or floating sensation, and

if

awakened during this stage, will was just resting my

often deny being asleep, responding "I eyes." Stages

Objectives 1

Differentiate

I

and

arousal. Stage III

between the terms

sedative

and

ini-

re-

a transition from the lighter to deeper

IV. Stage IV is also referred to as "delta" and makes up 10% to 15% of sleep time in young, healthy adults. Stage IV sleep is dreamless, very restful, and associated with a 1 0% to 30% decrease in blood pressure, respiratory rate, and basal metabolic rate. In a normal night of sleep, a person will rhythmically cycle through the four stages of sleep. About every 90 minutes or so, a patient will develop a sleep pattern called paradoxical sleep, or rapid eye movement (REM) sleep. The early episodes of REM sleep only last a few minutes, but as sleep

state

hypnotic;

and terminal insomnia; and between

are light sleep periods that allow easy

II

is

of sleep, stage

sleep,

tial,

intermittent,

bound sleep and paradoxical excitement 2.

Identify alterations

found

in

the sleep pattern

when

hyp-

notics are discontinued. 3.

Cite nursing interventions that can be implemented as an alternative to administering a sedative-hypnotic.

4.

Compare

5.

on the central nervous system. Explain the major benefits of administering benzodi-

the effects of barbiturates and benzodiazepines

6.

Identify laboratory tests that should

be monitored when

benzodiazepines or barbiturates are administered over an

extended period of time. 7.

Develop

progresses, the duration of

REM

sleep increases,

longer and more intense around 5 a.m.

azepines rather than barbiturates.

imposed on stages

I

and

II

ing a hypnotic.

Key Words

lar activity.

REM

is

REM

sedative

sleep

stomach acids, and some muscu-

an increased frequency and duration of awakenings.

Insomnia

AND

SLEEP PATTERN

five

DISTURBANCE

Sleep is a suite of unconsciousness from which a patient can be aroused by appropriate stimulus. It is a naturally occurring

occupies about one third

ol

an adult's

life.

It is a different state of unconsciousness from that produced by deep anesthesia or coma.

168

more

It is

not

sleep. In fact,

they often sleep less but take naps more often during the day. Consequently, the geriatric patient may have difficulty sleeping through the night.

rebound sleep

insomnia

that

super-

sleep appears to be an important time for

necessarily true that older adults require

hypnotic

phenomenon

is

of sleep. This type of sleep repre-

our subconscious minds to release anxiety and tension and reestablish a psychic equilibrium. Older adults take longer to move through the relaxation stages of non-REM sleep. There

paradoxical sleep

SLEEP

becoming

sleep

sents 20% to 25% of sleep time and is characterized by rapid eye movements (REM), dreaming, increased heart rate, irregular breathing, secretion of

a plan for patient education for a patient receiv-

REM

is

the

most

percent ol

all

common

sleep disorder known,

adults experience insomnia at least

once during their lives, and up to 35% of adults will have insomnia in a given year. Insomnia is defined as the inability to sleep. Insomnia is not a disease but a symptom of physical or mental stress.

OigbtS

Common

It is usually mild and lasts for only a few causes are changes in lifestyle or environ-

ment ie g hospitalization), pain, illness, excess consumption of products containing caffeine, eating large or "rich" meak ..

,

vnapicr

shortly before bedtime, or anxiety. Initial insomnia ability to fall asleep

when

is

the in-

desired, intermittent insomnia

is

the

169

^dative-Hypnotics

l.

Obtain current blood pressure, pulse, and respira-

Vital signs:

tions prior to initiation of drug therapy.

inability to stay asleep,

Sleep pattern: Assess the patient's usual pattern of sleep and

ized

obtain information on the pattern of sleep disruption

and terminal insomnia is characterby early awakening with the inability to fall asleep again.

(e.g., dif-

ficulty in falling asleep, inability to sleep the entire night, or

awakening

Sedative-Hypnotic Therapy Drugs used

known

in

A

hypnotic

is

a drug that pro-

duces sleep. A sedative quiets the patient and gives a feeling of relaxation and rest, not necessarily accompanied by sleep. A good hypnotic should provide the following action within a short period: a restful natural sleep, a duration of action that

allows a patient to awaken

at the

usual time, a natural awaken-

ing with no "hangover" effects, and no danger of habit formation. Unfortunately, the ideal

hypnotic

is

not available, although

for short-term use, the benzodiazepines are the closest of

those medicines available.

The most commonly used

sedative-

hypnotics do increase total sleeping time, especially in stages II (light

and IV (deep sleep); however, they also denumber of REM periods and the total time in REM

sleep)

crease the

REM

needed to help an individual maintain a mental balance during daytime activities. When REM sleep is decreased, there is a strong physiologic tendency to "make it up." Compensatory REM sleep, or rebound sleep, seems to occur even when hypnotics are used for only 3 or 4 days. sleep.

Ask

conjunction with altered patterns of sleep are

as sedative-hypnotics.

sleep

morning hours unable

in the early

to return to a

restful sleep).

is

amount of sleep (hours) he or she is managed at home. have a regular time to go to bed and to wake

the patient about the

considers normal and

Does up?

the patient

how insomnia

If the patient is taking

medications, determine the drug,

dose, and frequency of administration, and whether this

may

be contributing to sleeplessness. Patients with persistent insomnia should be carefully mon-

number of "naps" taken during

itored for the

the daytime.

Investigate the type of activities performed immediately prior to retiring for sleep.

Anxiety Is

it

level:

Assess the patient's exhibited degree of anxiety.

really a sedative-hypnotic the patient needs as a thera-

peutic intervention, or

is it

someone

to listen?

Ask what

stres-

sors the patient has been experiencing in both personal

and

work environments. Environmental control: Obtain data relating to the possible disturbance present in the individual's sleeping environment that

could potentially interfere with sleeping lights, noise, traffic, restlessness

(e.g.,

room temperature,

or snoring of sleeping partner).

After chronic administration of sedative-hypnotic agents,

Nutritional needs: Take a dietary history to identify sources

REM

of caffeinated products that

rebound may be severe, accompanied by restlessness and vivid nightmares. Depending on the frequency of hypnotic administration, normal sleep patterns may not be restored for weeks. It is suspected that the effects of REM rebound may enhance chronic use of and dependence on these agents to avoid the unpleasant consequences of rebound. Because of this, a vicious cycle occurs as the normal physiologic need for sleep is not met and the body attempts to compensate for it.

may

act as stimulants.

Exercise: Obtain data relating to the patient's usual degree of

physical activity and at what times during the day.

Respiratory status: People those

who

snore heavily

with respiratory disorders and

may have low

respiratory reserve and

should not receive hypnotics because of the potential for causing respiratory depression.

Nursing Diagnosis Sedatives, used to produce relaxation and rest, and hypnotics,

• Sleep pattern disturbances (indications)

used to produce sleep, are not always different drugs. Their effects may depend on the dose and the condition of the patient. A small dose of a drug may act as a sedative, whereas a larger dose of the same drug may act as a hypnotic and produce sleep.

• Injury, risk for (side effects)

The sedative-hypnotics may be

•

Knowledge

deficit related to

medication regimen

Planning

classified into three groups:

Planning for patient care should be based on the assessment

and the miscellaneous

data and interventions should be individualized to meet pa-

the barbiturates, the benzodiazepines,

agents.

tient needs.

Uses*

and monitoring of

Central nervous system function: Schedule

The primary uses

for sedative-hypnotics are to

improve sleep

patterns for the temporary treatment of insomnia, and to de-

crease the level of anxiety and increase relaxation and/or sleep prior to diagnostic or operative procedures.

vital signs at least

CNS

assessments

every 8 hours.

Sleep pattern

Routine Orders.

Many

physicians order a sedative-hyp-

on an as-needed (PRN) basis. Do not offer it unless the patient is having difficulty sleeping and other measures to meet comfort and psychological needs have failed to produce notic

the desired effect.

lursing Process for Sedative-Hypnotic

Therapy

Premedication Assessment

tify the patient's level

to

(CNS)

function, iden-

of alertness and orientation and ability

perform motor functions.

at the

bedside "in case"

Reassess the underlying cause of sleeplessness.

Central nervous system function: Because sedative-hypnotics

depress overall central nervous system

Never leave a medication needed later.

Is

it

it

is

really

needed? If so, repeating the order for a hypnotic will not meet the patient's needs because these medicines have no analgesic value and will often not work if the patient is suffering from pain. pain control that

is

170

Chapter 12

Anxiety

sponse

level:

Sedative-Hypnotics

Be aware of

the possibility of a paradoxic re-

sedative-hypnotic medicine, particularly in the

to

derly. If the patient

is

el-

showing increasing signs of excitement. it would be harmful to

Provide for adequate ventilation, subdued lighting, correct room temperature, and control of traffic in and out of the patient's

ing a night light on and not

repeat the medication.

Environmental control: Plan for the safety needs of the patient and protect from potential injury. Make sure that the call light is within reach and place the bed in the low position with side rails up. Leave a night light on. Organize nursing activities so that the patient is disturbed as infrequently as possible while maintaining safe patient care.

Nutritional needs: Offer protein foods and dairy products at a specific time before sleep.

Encourage adequate exercise during the day so the

Exercise:

individual will be tired before trying to sleep.

Implementation Vital signs:

Obtain

vital signs periodically as the situation in-

Preoperative medication: Give preoperative medications

at

the specified time.

Monitoring

and adverse

When

effects.

a medication

is

administered,

giving

If

ing so. This

PRN

is at

if

It

is

some-

an order permits do-

the nurse's discretion based

on the evaluation

Patient Education/Health Promotion Bedtime: Encourage a standard time to go to bed to help the

rhythm and routine. Teach appropriate nutrition information concerning the food pyramid, adequate intake of fluids, and use of viestablish a bedtime

Nutrition:

Communicate

the information at the educational level

of the patient.

Avoid heavy meals

late in the

evening.

Caffeine consumption should be reduced or discontinued, especially within several hours of bedtime. Introduce the patient to decaffeinated or herbal

products that can be substi-

tuted for previously used foods containing caffeine.

Help the patient avoid products containing caffeine, such as coffee, tea, soft drinks, and chocolate. Limit the total daily intake of these items and give warm milk and crackers as a bedtime snack. Protein foods and dairy products contain an

amino acid found

that synthesizes serotonin, a neurotransmitter that

to increase sleep time

exercise: Suggest the inclusion of exercise in

and

is

tired

enough

to sleep.

For some individuals, plan a

quiet "unwinding" time prior to retiring for the night. For is pleasant and soothing, not one that will cause anxiety or fear. Stress management: Explore personal and work stressors that may have a bearing on the insomnia. Some stressors that create insomnia may be within the work environment: therefore involvement of the industrial nurse, along with a thorough exploration of work factors, may be appropriate. Stress produced within the dynamics of the family may require profes-

children, try a bedtime story that

Teach the patient relaxation techniques and personal commeasures, such as a warm bath, to relieve stress. Playing soft music may also promote relaxation.

Make

referrals for

mastery of biofeedback, meditation, or

Encourage the patient

For insomnia, suggest

warm

milk about 30 minutes before

the patient goes to bed.

Personal comfort: Position the patient for

maximum

comfort.

provide a back rub. encourage the patient to empty his or her bladder, and be certain that heckling is clean and dry. Take

meet patient's individual needs and calm

fears, luster

a trusting relationship.

Environmental control:

I

to express feelings

openly with

re-

gard to stress and insomnia. The adjustment to this situation involves working through great personal fears, frustrations, hostilities,

and resentments.

Explore coping mechanisms the person uses in response to stress and identify methods of channeling these toward positive realistic goals and alternatives to the use of medication. Fostering health maintenance: Throughout the course of treatment, discuss medication information and

how

benefit the patient. Stress the importance of the

nonpharma-

it

will

cologic interventions and the long-term effects that compli-

ance with the treatment regimen can provide. Provide the patient and/or significant others with important information contained in the specific drug monograph for the

medicines prescribed. Additional health teaching and nursing interventions for the side effects to expect and report are described in the flowing drug monographs. Written record: Enlist the patient's aid in developing and maintaining a written record of monitoring parameters (e.g., extent of insomnia, frequency; see Patient Education and

Monitoring Form on

p.

171) and response to prescribed ther-

apies for discussion with the physician.

encouraged

to bring this record

The

patient should be

on follow-up

visits.

and decrease the time required

to fall asleep.

I"

and

daily activities so that the patient obtains sufficient exercise

medications, assess the record for the ef-

of a particular patient's needs.

time

by leav-

after taking

other techniques to reduce stress levels.

effects.

times necessary to repeat a medication

is

bed

fort

fectiveness of previously administered therapy.

tamins.

in

medication. Activity

carefully assess the patient at regular intervals for therapeutic

body

smoking

sional counseling.

dicates.

PRN:

room.

Instruct the patient to provide for personal safety

restlessness, euphoria, or confusion,

iicouragc the patient to provide for

insomnia relief bj attempting u> sleep ment such as a qmet. darkened mom

in the

free

proper environ

from distractions.

Avoid using the bedroom for watching television, preparing work for the following day, eating snacks, and paying bills.

Drug Therapy for

Sleep

Disturbance

Drug

Class: Barbiturates

was placed on the market as a sedativebecame so successful that chemists idenulicd some 2500 barbiturate compounds, of which more than 50 were distributed commercially. Barbiturates became such The

first

hypnotic

barbiturate

m

1903.

It

mainstay of therapj thai fewer than a do/en other sedativehypnotic agents were SUCCessrull} marketed through I960.

a

he release of the

I

l l

>M

firsl

benzodiazepine (chlordiazepoxide)

started the decline in the use

in

of barbiturates. However,

Chapter 12

& MONITORING FORM

PATIENT EDUCATION

Sleeping Medication

TO BE TAKEN

COLOR

MEDICATIONS

Sedative-Hypnotics

Physician. Physician's

phone.

Next appt.*

Day of Discharge

Parameters Time

Arising

Bedtime Last cup of coffee

Sleep pattern

Took

hr.

or

min. to get to sleep

Awaken during

night;

hr or min.

takes

to get back to sleep

Slept

all

night

Couldn't sleep

Went Dreams

right to sleep

Dreamed

all

night

No. of dreams Did not dream Feelings the

Very tired when

next morning?

1

wake up

Awoke Exercise

No

refreshed

desire to exercise

Usual routine including

work

Unable to work Stress level

No

Time

time

to relax

1

10

Medication

to relax

1

1

5

1

Took

sleeping

medication

Please bring this record with you to your next appointment. Use the back of this sheet for additional information.

Comments

171

.

Chapter 12

172

barbiturate

several

Sedative- Hypnotics

compounds

are

stil

today

prescribed

(Table 12-1).

Nursing Process for Barbiturate Therapy Actions

Premedication Assessment

Barbiturates can reversibly depress the activity of tissues.

The

CNS

is

all

excitable

Seek information regarding prior use of sedative-hypnotic

1

particularly sensitive, but the degrees of

depression (ranging from mild sedation to deep

coma and

death) depend on the dose, route of administration, tolerance

from previous use, degree of excitability of the CNS time of administration, and condition of the patient.

medications. 2.

Obtain information relating to baseline neurological func-

H^

tion (e.g., degree of alertness)

at the

Planning See Table 12-1.

Availability:

Uses Barbiturates are used primarily for their sedative and hypnotic effects.

The long-acting

also used as an anticonvulsant. (

methohexital, thiopental)

may

barbiturate, phenobarbital, is

The

ultra-short-acting agents

be administered intravenously

implementation Dosage and administration: See Table 12-1. Rapidly discontinuing barbiturates after long-term use of high dosages

may

result

symptoms

in

similar to alcohol withdrawal.

These may vary from weakness and anxiety

as general anesthetics.

to delirium

Table 12-1

Name

Generic

Amobarbital

Brand Name

Availability

Amytal

In;:

250, 500

Adult Oral Dose

mg

vials

Sedation: 30-50

mg

IM

1

Intermediate acting; Schedule

Used

2-3 times daily

Hypnosis:

Comments

mg

00-200

II

primarily as a sedative be-

fore anesthesia or during labor

IM 30 min before bedtime Butabarbital

Butisol

Sedation: 15-30

Tablets: 15,30,50,

100 Elixir:

mg

Mebaral

Tablets: 32, 50, 100

mg

Elixir

bedtime 1

mg

3-4 times daily

Anticonvulsant

Pentobarbital

Nembutal

Capsules: 50, 100

mg

20 mg/5 ml Supp:30.60, 100, 200 mg Inj: 50 mg/ml Elixir:

mg

Sedation: 30

Used

III

primarily as a daytime

sedative and bedtime hypnotic

Sedation: 32- 00

400-600

contains 7.5% alcohol;

Intermediate acting; Schedule

mg

1

at

Mephobarbital

mg

3-4 times daily Hypnosis: 50- 00

30 mg/5 ml

acting;

primarily as an anticon-

vulsant; daily

mg mg

Schedule IV

may

also be used as a

daytime sedative

Short acting; Schedule

Used

3-4 times daily

Hypnosis: 100

Long

Used

at

sedative and bedtime hypnotic;

may

bedtime

II

primarily as a daytime

also be used as a preanes-

thetic sedative Elixir

contains 18% alcohol

Also available for IM and IV use Phenobarbital

Luminal, Solfoton,

Tablets: 15, 16,30.

100

Barbilixir

mg

Inj: 1

Secobarbital

Seconal

mg

Hypnosis: 100-320

20 mg/5 ml

30 mg/ml

2-3 times daily

50 mg/ml

1

mg in

2 ml

mg

Hypnosis: 100-200 at

bedtime

Used most commonly now as an anticonvulsant; may also be used as a daytime sedative, pre-

mg

50- 00

Tubex

Long-acting; Schedule IV

Anticonvulsant:

30, 60, 65,

Capsules: 100 Inj:

mg

2-3 times daily

Capsules: 16 Elixir: 15,

Sedation: 8-30

anesthetic, or hypnotic agent

Also available for IM and IV use Elixir contains 13.5% alcohol

mg

Short acting; Schedule

Used

II

primarily as a daytime

sedative or bedtime hypnotic

Therapy

is

not recommended

4 days Also available for IM and IV use for longer than

^Available

in


ter

and grand mal seizures. Treatment consists of cautious and gradual withdrawal over a 2- to 4-week period.

Evaluation

•

I

l

Scuat

Barbiturates reduce the effects of the following medicines: Warfarin: Monitor the prothrombin time and increase the

dose of warfarin if necessary. Monitor the digitoxin serum levels for signs of increased heart failure (e.g., dyspnea, orthopnea, edema). The dose of digitoxin may need to be increased. • Estrogens: This drug interaction may be critical in patients • Digitoxin:

General adverse effects of barbiturates include drowsiness, lethargy, headache, muscle or joint pain, and mental depression. Side effects to expect

receiving oral contraceptives containing estrogen. If pa-

Hangover, Sedation, Lethargy. Patients may complain of "morning hangover," blurred vision, and transient hypotension on arising. Hangover commonly occurs after administration of hypnotic doses of long-acting barbiturates. Patients may display a dulled affect, subtle distortion of mood, and im-^ paired coordination. Explain to the patient the need to first rise to a sitting position, equilibrate, and then stand. Assistance with ambulation may be required. If hangover becomes troublesome, there should be a reduction in the dose, a change in the medication, or both. People working around machinery, driving a car, pouring and giving medicines, or performing other duties in which they must remain mentally alert should not take these medications while working.

tients develop spotting and breakthrough bleeding, a change in oral contraceptives and the use of alternative forms of contraception should be considered.

Side effects to report

Excessive Use or Abuse. Habitual use of barbiturates result in

may

physical dependence. Discuss the case with the

physician and

make

plans to cooperatively approach gradual

withdrawal of the medications being abused. Assist the patient to

recognize the abuse problem. Identify underlying

needs and plan for more appropriate management of those needs. Provide for emotional support of the individual; dis-

play an accepting attitude and be kind but firm.

Paradoxic Response. Elderly patients and those in severe pain

may respond

paradoxically to barbiturates with excite-

ment, euphoria, restlessness, and confusion. Provide supportive physical care

During periods of excitement, protect the patient from harm and provide for physical channeling of energy (e.g., walking). Seek change in the medication order. Hypersensitivity. Reactions to barbiturates are infrequent,

may be

doxycycline,

antidepressants,

quinidine,

and chlorpro-

mazine: The patient should be monitored for signs of increased activity of the illness for which the medication was prescribed.

Dose increases may be necessary or

turate

may have

Drug

Class:

to

the barbi-

be discontinued.

Benzodiazepines

Benzodiazepines have been extremely successful products from a therapeutic and safety standpoint. A major advantage over the barbiturate and nonbarbiturate sedative-hypnotics is the wide safety margin between therapeutic and lethal doses. Intentional and unintentional overdoses of several hundred times the normal therapeutic doses are well-tolerated and are not fat al.

More than 2000 benzodiazepine derivatives have been and more than 100 have been tested for sedativehypnotic or other activity. While there are many similarities among the benzodiazepines, they are difficult to characterize identified,

as a class. This is because certain benzodiazepines are effective anticonvulsants, others serve as antianxiety agents, still

while

others are used as sedative-hypnotics.

and safety during these responses. Assess

the level of excitement and deal calmly with the individual.

but

• Corticosteroids, beta-adrenergic blockers, metronidazole,

serious.

Report symptoms of hives, pruritus, rash,

Actions is thought that the benzodiazepines have similar mechanisms of action as CNS depressants but that individual drugs within the benzodiazepine family act more selectively at specific sites, allowing for a variety of uses (e.g., sedativehypnotic, muscle relaxant, antianxiety, and anticonvulsant).

It

high fever, or inflammation of mucous membranes for evalu-

Uses

by the physician. Withhold further barbiturate adminisbeen granted. Blood Dyscrasias. Blood dyscrasias are rare, however, routine laboratory studies (RBC, WBC, and differential counts) should be scheduled when symptoms indicate the need. Stress the importance of the patient to return for this laboratory work. Monitor for the development of sore throat, fever, purpura, jaundice, or excessive and progressive weakness. Drug interactions Drugs That Increase Toxic Effects. Antihistamines, alco-

erance. During the rebound period, the

hol, analgesics, anesthetics, tranquilizers, valproic acid, chlo-

stays about the same, but

ation

tration until physician's approval has

ramphenicol,

monoamine oxidase

inhibitors,

and other seda-

tive-hypnotics: Monitor the patient for excessive sedation and

reduce the dosage of the barbiturate

if

necessary.

The effects of barbiturates on phenytoin are Serum levels may be ordered, and a change in

Phenytoin.

Benzodiazepines are the most commonly used sedative-hypnotics. When benzodiazepine therapy is started, patients feel a sense of deep or refreshing sleep. Benzodiazepine-induced sleep varies, however, from normal sleep in that there is less REM sleep. With chronic administration, the amount of REM sleep gradually increases as tolerance develops to the

suppressant effects.

When

a rebound increase in

REM

benzodiazepines are discontinued,

REM sleep may occur in spite of the tol-

number of dreams dreams are reported to be bizarre in nature. After long-term use of most benzodiazepines, there is also a rebound in insomnia. Consequently it

is

many of

the

important to use these agents only for short courses of

therapy.

phenytoin dosage may be required. Observe patients for increased seizure activity and for signs of phenytoin toxicity:

The short-acting benzodiazepines (e.g., midazolam) are used intramuscularly as a preoperative sedative and intravenously for conscious sedation before short diagnostic pro-

nystagmus, sedation, and lethargy.

cedures or for induction of general anesthesia.

variable.

It

has a more

—

— Chapter 12

174

Sedative-Hypnotics

rapid onset of action then diazepam and a tion.

also produces a greater degree

It

azepam, again making

it

much

oi'

shorter dura-

amnesia than

di-

lursmg Process for benzodiazepines

beneficial for short diagnostic and

operative procedures.

Premedication Assessment I

Therapeutic Outcomes The primary

therapeutic

outcomes sought from benzodi-

azepine therapy are as follows: •

To produce mild sedation

•

For short-term use

•

Preoperative sedation with amnesia

to

produce sleep

2.

^^^^^

Record baseline vital signs, particularly blood pressure, in sitting and lying position*. Check lor history of blood dyscrasias or hepatic disease or whether patient is in first trimester of pregnancy.

Planning Availability:

See Table 12-2.

M- w

Table 12-2

[woe

Benzodiazepines Used for Sedation-Hypnosis

Name

Generic

Estrazolam

Brand Name

Availability

ProSom

Tablets:

1

,

2

Adult Oral Dose

mg

Hypnosis: 1-2

mg

Comments Intermediate acting; Schedule IV

at

Used

bedtime

for insomnia

Tapering therapy

recommended

to reduce rebound insomnia Minimal morning hangover

Flurazepam

Dalmane,

Capsules:

15,

mg

30

Hypnosis: 15-30

^Novoflupam

mg

at

bedtime

Long

acting;

Used

for short-term treatment

Schedule IV

of insomnia, up to 4 wk Morning hangover may be significant

Rebound insomnia and REM occur

Lorazepam

Ativan, IN

Novolorazepam

Tablets: 0.5,

1

,

2

mg

Hypnosis: 2-4

Oral solution: 2 mg/ml Inj: 2 mg and 4 mg/ml in

1,

10 ml

mg

Used

at

sleep

less frequently

primarily for insomnia

but may also be used for pre-

bedtime

operative anxiety IM, IV administration also available

vials,

4 mg/ml prefilled syringes

Midazolam

Versed

Inj: 1,

5

10 ml

mg/ml vials;

1,2, 5,

in

10

mg/2 ml

Preop:

IM—0.07-0.08

mg/kg

1

hr before

surgery

prefilled syringes

0.2-0.3

mg/kg

Endoscopy: IV 0.

1

-0.

1

5

—

3-5 min

Induction of anesthesia: IV:

Short acting; Schedule IV Onset: IM 15 minutes IV

— 30-60 min

Duration: IM IV— 2-6 hr

Causes amnesia

Lower doses

mg/kg

in

in

most

patients*-

patients over

age 55

Quazepam

Doral

Tablets: 7.5, 15

mg

Hypnosis: 7.5-15 at

mg

Long acting; Schedule IV Used for insomnia

bedtime

Tapering therapy

recommended

to reduce rebound insomnia

Morning hangover may be significant

Temazepam

Restoril

Capsules: 7.5,

15,

30

mg

Hypnosis: 15-30

mg

at

bedtime

Intermediate acting; Schedule IV

Used

for insomnia

Minimal

if

any morning hangover

Rebound insomnia may occur Triazolam

Halcion

*Novo-Triolam

Tablets: 0.1 25, 0.25

mg

Hypnosis: 0.25-0.5 at

bedtime

mg

Short acting; Schedule IV Used for insomnia but tends to lose effectiveness within 2

Tapering therapy

is

wk

recommended

to reduce rebound insomnia

Rapid onset of action

No 'Available

m


dose el carbidopa-levodopa.

(

A

I

n gamma

liver function tests [elevated bilirubin,

glutamyltransferase (GGT), alkaline phos-

phatase, prothrombin time].

»ier

in

89

Dist Disease >arki Drugs Used for Parkinson's

j

i

Orthostatic hypotension. Monitor the blood pressure daily

ergic agents have

both the supine and standing positions.

tural abnormalities.

little

effect

on

rigidity, bradykinesia,

or pos-

Anticipate the development of postural hypotension and

Therapeutic Outcomes

take measures to prevent an occurrence. Teach the patient to rise

The primary

slowly from a supine or sitting position; encourage the

patient to

sit

or

lie

down

if

therapeutic

outcome sought from anticholinergic

agents in treating parkinsonism

feeling faint.

is

reduction in the severity of

the sweating, drooling, depression, and tremor that are caused

Drug interactions Levodopa. Tolcapone and levodopa have additive neurologic effects. This interaction

may be

beneficial because

it

by a

relative excess of acetylcholine in the basal ganglia.

of-

ten allows a reduction in the dose of the levodopa.

Antihpertensive agents. Dose adjustment of the antihypertensive agent static

is

)olinergic

often necessary because of excessive ortho-

Drug

Class: Anticholinergic

Agents

1.

Obtain baseline data relating to patterns of urinary and

2.

bowel elimination. Perform a baseline assessment of the patient's degree of alertness and orientation to name, place, and time before

Actions induced by the imbalance of neurotransmitThe primary imbalance appears to be a deficiency of dopamine, leaving a relative excess of the cholinergic neurotransmitter acetylcholine. Anticholinergic agents are thus used to reduce hyperstimulation

Parkinsonism

initiating therapy.

is

ters in the basal

Agent Therapy

Premedication Assessment

hypotension.

ganglia of the brain.

3.

Take blood pressure in both the supine and standing positions. Record pulse rate, rhythm, and regularity.

4.

All patients should be screened for the presence of angle-

closure glaucoma before initiation of therapy. Anticholin-

caused by excessive acetylcholine.

ergic agents •

Uses The anticholinergic agents reduce ing, drooling, depression,

the severity of the sweat-

and tremor

sonism. Anticholinergic agents

/

may

precipitate an acute attack of angle-

closure glaucoma. Patients with open-angle glaucoma can

^Xr

safely use anticholinergic agents. Monitoring of intraocu-

r^3

lar pressure

should be performed on a regular basis.

that characterize parkin-

may be

useful for patientsCt:

-Planning

with minimal symptoms, for those unable to tolerate the side

Availability: See Table 13-1 and for those who have not benefited ^Implementation from levodopa therapy. Combination therapy with levodopa and anticholinergic agents is also successful in controlling Dosage and administration: Adult: PO: See Table 13-1. symptoms of the disease more completely in about half thef^ \j Administer medication with food or milk to reduce gastric patients already stabilized on levodopa therapy. Anticholin-^ irritation.

effects of levodopa,

^^

Table 13-1 Anticholinergic Agents

Name

Generic

Benztropine

Brand Name

Availability

Cogentin

Tablets: 0.5,

mesylate Biperiden

Inj:

Akineton

hydrochloride

Diphenhydramine hydrochloride

1

mg/ml

Tablets: 2 Inj:

1

,

in

Initial 2 mg 2 ml amps

mg

5 mg/ml

0.5-

2

in

50

1

Tablets: 25,

*Allerdryl

Capsules: 25, 50

Maximum

Daily Dose (mg)

mg

at

bedtime

6

1-3

times daily

10

mg

ml amps

mg mg

Benadryl,

1

Dose (PO)

mg

25-50

3-4 times daily

300

mg/5 ml Syrup: 12.5 mg/5 ml Elixir: 12.5

Orphenadrine

Banflex,

Sustained-release tablets:

Norflex

citrate

Inj:

50

mg

3 times daily

150-250

mg

100

30 mg/ml

in 2,

10 ml

vials

Procyclidine

hydrochloride Trihexyphenidyl

hydrochloride

Kemadrin,

in

Canada.

mg

Artane,

Tablets: 2, 5

Trihexy-5

Elixir:

Aparkane

Available

Tablets: 5

2.5

mg

3 times daily

15-20

Procyclid

mg

2 mg/5ml

1

mg

daily

12-15

.

190

Drugs Used for Parkinson's Disc ase

Chapter 13

Evaluation Most side effects observed with rect extensions of their

lose effectiveness (on-off

anticholinergic agents are di-

pharmacologic properties.

Side effects to expect Bt crred Vision: Constipation;

Urinary Retention: Dryness

of Mucosa of the Mouth, Throat, and Nose. These symptoms are

anticholinergic effects

the

produced by these agents.

Patients taking these medications should be monitored for the

often necessary to

It is

add other dopamine receptor agonists such as bromocriptine or pergolide to improve the patient response and tolerance. Selegiline has been found to have similar adjunctive activity to carbidopa-levodopa in the treatment of Parkinson's disease. The combination of selegiline and carbidopa-levodopa improves memory and motor speed and may increase life

development of these side effects. Dryness of the mucosa may be relieved by sucking hard candy or ice chips, or by chewing gum. If patients develop urinary hesitancy, assess for distension of the bladder. Report to the physician for further evaluation. Give stool softeners as prescribed. Encourage adequate fluid intake and foods to provide sufficient bulk. Caution the patient that blurred vision may occur and

expectancy.

make

The primary

appropriate suggestions for personal safety of the

phenomenon) and develop more ad-

verse effects (dyskinesias) over time.

may

Selegiline

also have a "neuroprotective" effect by in-

terfering with the degeneration of striated

now

rons." It is

dopaminergic neu-

also being used early in the treatment of

Parkinson's disease to slow the progression of

symptoms and

delay the initiation of levodopa therapy.

Therapeutic Outcomes therapeutic outcomes sought from selegiline in

treating parkinsonism are as follows:

individual.

Side effects to report

1

Make

Nightmares, Depression, Confusion, Hallucinations.

regularly scheduled subsequent evaluations of mental status

and compare findings. Report development of

2.

the daily dose

in

may

the

development of symptoms and progression of the

Establish a balance of

ganglia of the

basal

alterations.

dopamine

Provide for patient safety during these episodes.

Reduction

Slow

disease.

dopamine and acetylcholine in the brain by enhancing delivery of

to brain cells.

control these adverse

effects.

Orthostatic Hypotension. Although the instance

quent and generally mild,

some degree of

anticholinergic agents

all

is infre-

may

ness and weakness, particularly

when

Monitor the blood pressure daily

therapy in

being

igiline

cause

orthostatic hypotension manifested by dizziinitiated.

1.

both the supine and

2.

is

standing positions.

rise

sit

or

lie

down

if

3.

feeling faint.

Check

any antihypertensive therapy currently preMonitor the blood pressure daily in both the supine and standing positions. If antihypertensive medica-

sible

Antidepressants,

phenothiazines.

for

4.

dose adjustment.

Check other medications prescribed and do not administer

These agents may enhance the anticholinergic side effects. Developing confusion and hallucinations are characteristic of excessive anticholinergic activity. Dose reduction may be

Planning

required.

Availability:

may slow levodopa. An in-

name, place, and time before

tions are being taken, report this to the physician for pos-

Drug interactions Tricyclic

to

scribed.

Palpitations, Arrhythmias. Report for further evaluation.

Amantadine,

and orientation

initiating therapy.

slowly from a supine or sitting position; encourage the

patient to

Obtain a history of GI symptoms. Perform a baseline assessment of the patient's degree of alertness

Anticipate the development of postural hypotension and take measures to prevent an occurrence. Teach the patient to

Therapy

Premedication Assessment

selegiline with meperidine.

PO:

5

mg

tablets

and capsules

Levodopa. Large doses of anticholinergic agents gastric

emptying and

inhibit absorption of

crease in the dose of levodopa

may

Miscellaneous Anti-Parkinson

3 days of treatment, the dose of carbidopa-levodopa should

Agents 1

start being titrated downward. Carbidopa-levodopa doses be able to be reduced by 1095 to 30%.

selegil ine (sel-edg'il-ene)

^

Implementation Dosage and administration: Dosage must be adjusted according to the patient's response and tolerance. Adult: PO: 5 mg at breakfast and lunch. Do not exceed 10 mg daily. After 2 to

be required.

Eldepr Eldepryl (el-deh-pril')

Evaluation Selegiline causes relatively few adverse effects.

Actions Selegiline that

is

a

potent

monoamine oxidase-type B

reduces the destruction of dopamine

ing greater

dopaminergic

may

inhibitor

in the brain,

allow-

It

ma\

trolled bj reducing the

dose

o\'

levodopa.

Side effects to expect

activity.

Ci\sii«>i\ii siiwi in, is Most o\' these effects may be minimized by temporary reduction in close, administration I

Uses Carbidopa-levodopa are the current drugs of choice

in-

crease the adverse dopaminergic effects of levodopa such as chorea, confusion, or hallucinations, but these can be con-

for the

treatment of Parkinson's disease. Unfortunately, these agents

with food, and use

ol stool

softeners for constipation.

«lapter Side effects to report

Neurologic. Selegiline

may

increase the adverse dopamin-

ergic effects of levodopa, such as chorea, confusion, lucinations.

Make

and hal-

regularly scheduled subsequent evaluations

of mental status and compare findings. Report development of alterations.

Drugs Used for Parkinson 's Disease

13

or entacapone may be added to levodopa therapy to reduce the metabolism of levodopa, prolonging its action. Anticholinergic agents may be added at any time to reduce the effects of the "excessive" acetylcholine. Non-pharmacologic treatment (e.g., diet, exercise, physical therapy) of Parkinson's disease

Provide for patient safety, be emotionally supportive, and

is

equally important

in

maintaining the

long-term well-being of the patient.

assure the patient that these adverse effects usually dissipate

few

as tolerance to the adverse effects develops over the next

MATH REVIEW

weeks. Orthostatic Hypotension. Monitor the blood pressure daily in

1.

both the supine and standing positions.

I

Anticipate the development of postural hypotension and take measures to prevent an occurrence. Teach the patient to rise

slowly from a supine or sitting position; encourage the

patient to

sit

or

lie

down

if

feeling faint.

Drug interactions

2.

Levodopa. Selegiline and levodopa have additive neurologic effects. This interaction

may be

beneficial because

it

of-

reported

between monoamine oxidase inhibitors and meperidine. Although this interaction has not been reported with selegiline, it is recommended that the two agents not be given concurrently. Food. Patients should be instructed to avoid food and bev-

excess of

1

mg

if

(e.g., chianti

gm

four times

how many

used and

Meperidine. Fatal drug interactions have been

beans, cheeses), particularly

wrote orders to start Mr. James on levodopa daily. Levodopa is available in 100, 250, and 500 mg strengths. Which strength should be Dr. Jones

0.25

ten allows a reduction in dose of the levodopa.

erages with a high tyramine content

wrote orders to start Mr. Lienemann on Sinemet 25/100 at an initial dose of tablet 3 times daily. Sinemet is available in ratios of 10/100,25/100, 25/250, and 50/200 mg strengths. Which strength should be used and how many tablets should be administered for each individual dose? Dr. Jones

tablets should be administered at

one time? 3.

wine, fava

Dr. Jones wrote orders to start Mrs. Smith on bromocriptine at an initial dose of 1.25 mg 2 times daily with meals. Bromocriptine is available in 2.5 mg tablets and 5 mg capsules. What should be administered to Mrs.

Smith?

receiving selegiline in doses in

per day. Rare cases of hypertensive reactions

CRITICAL THINKING QUESTIONS

have been reported. Antihypertensive Agents. Dose adjustment of the antihypertensive agent

is

often necessary because of excessive or-

1.

2.

is

physiologic effect does stimulation of

dopamine

a balance exists

choline, an excitatory neurotransmitter. The

symptoms

sociated with Parkinson's Disease develop because of a

3.

is

and the basic imbalances found with Parkinson's

Discuss the normal course of progression of Parkinson's disease and include the rationale for drug therapy to leviate the

4. as-

dopamine neuro-

Develop

al-

symptoms.

a teaching plan to

be used with the patient and

family of an individual being started

rel-

on Sinemet

for the

treatment of Parkinson's disease.

ative excess of acetylcholine in the brain. The goal of

to restore

causing the

disease.

between

dopamine, an inhibitory neurotransmitter, and acetyl-

is

their mother. Give a simple expla-

in

person. Include an explanation of what a neurotransmit-

caused by deterioration of dopamine-producing cells in the portion of the brain responsible for maintenance of posture and muscle tone and the regulation of voluntary

treatment of parkinsonism

symptoms of

is

Parkinson's disease

ter

a progressive neurologic disorder

smooth muscles. Normally,

Mrs. Hanegan's family asks you to explain the basic underlying problem that

nation of the symptoms, appropriate for use with a lay

CHAPTER REVIEW Parkinson's disease

What

receptors have?

thostatic hypotension.

5.

Explain

why

baseline assessments of an individual's

status and physical

symptoms

men-

are important before

transmitter function as close to normal as possible and re-

tal

lieve symptoms caused by "excessive" acetylcholine. Therapy must be individualized, but selegiline therapy is often started first to slow the development of symptoms. As selegiline becomes less effective, levodopa is started, with or without selegiline. Later, dopamine agonists (amantadine, bromocriptine, pergolide, ropinirole, pramipexole) may be added to directly stimulate dopamine receptors. Tolcapone

and periodically throughout the course of treatment of Parkinson's disease. 6. Mr.Janna

is

being started on an anticholinergic drug as

part of the treatment plan for Parkinson's disease. What

symptoms can be expected to improve, and conversely, what problems could also arise from starting this medication?

Drugs Used for Anxiety Disorders

CHAPTER CONTENT Anxiety Disorders

Drug Therapy

(p.

1

as a motivator for the individual to take action in a reasonable

|

and adaptive manner.

for Anxiety Disorders

(p.

when

193)

Class: Benzodiazepines (p.

Drug

Class: Azaspirones (p. 198)

Drug

Class: Selective Serotonin (p.

sometimes said

that people "rise to

their responses to stressful situations are

abnormal or irand impair normal daily functioning. The National of Mental Health identifies anxiety disorders as the

rational

Drug

(SSRIs)

It is

the occasion." Patients are said to have anxiety disorders

92)

1

95)

Institute

most commonly encountered mental disorder

in clinical prac-

Sixteen percent of the general population will experience

tice.

Reuptake Inhibitors

an anxiety disorder during their lifetimes. Anxiety disorders

198)

Miscellaneous Antianxiety Agents

more common in The most common types of anxiety disor-

usually begin before the age of 30 and are (p.

1

98)

women

than men.

ders are generalized anxiety disorder, panic disorder, social

phobia, simple phobias, and obsessive-compulsive disorder.

Generalized anxiety disorder is described as excessive and worry about two or more life circumstances (e.g.,

Objectives

unrealistic

finances, illness, misfortune)Tor 6

months or more. Symp-

Define terminology (key words) associated with anxiety

toms

states.

trating,

Describe the essential components of a baseline assess-

tremor, sweating, and gastrointestinal (GI) upset].

ment of

a patient's

mental status.

Cite the side effects of hydroxyzine therapy and identify

those effects requiring close monitoring

when used

pre-

operative^.

Develop

apprehension) and physical [tachycardia, palpitations,

The disease has a gradual onset, usually in the 20- to 30-year age group and

is

equally

common

people

Describe signs and symptoms the patient a positive therapeutic

outcome

is

will display

when

being seen for the treat-

of a high anxiety state.

Discuss psychologic and physiologic drug dependence.

in

men and women.

This illness usu-

ally follows a chronic fluctuating course of exacerbations

remissions triggered by stressful events in the person's

Panic disorder

a teaching plan for patient education of

taking antianxiety medications.

ment

are both psychologic (tension, fear, difficulty concen-

is

recognized as a separate disease and not

more severe form of chronic generalized anxiety disorder. The average age of onset is in the late 20s: the disorder is ofa

may require lifetime treatment. Genetic facappear to play a significant role in the disease because 15% to 20% of patients will have a close relative with a sim-

ten relapsing and tors

ilar illness.

Panic disorder begins as a series of acute or un-

provoked anxiety (panic) attacks involving an intense, ing fear. The attacks do not occur on exposure

terrify-

to an anxiety-causing situation as phobias do. Initially the panic attacks are spontaneous, but later in the course of the illness, it

Key Words compulsion

anxiety

and

life.

may

be associated with certain actions

ing in a crowded place). panic disorder

anxiolytics

phobias

tranquilizers

obsession

(e.g.,

driving a car, be-

include dyspnea, dizzi-

numbness, and chest pain. There are usually feelings of impending doom or a fear of losing coiurol. ness, palpitations, trembling, choking, sweating,

Phobias are

ANXIETY DISORDERS

Symptoms

irrational fears ol a specific object, activity, 6T

situation. Unlike other anxiety disorders, the object or activity

that creates the feeling

who

of fear

is

recognized by the patient,

normal human emotion, similar to fear. It is an unpleasant feeling of apprehension or nervousness caused by the perception of potential or actual danger that threatens the securit) ol the person. Mild anxiety is a state o\ heightened awareness of the surroundings and is seen in response to da$

unreasonable. The fear persists, however, and the patient seeks to avoid the situation. Social phobia is described as a fear of certain social situations

lo-day circumstances. This type of anxiety can be beneficial

speaking

Anxiety

192

is

a

also realizes that the tear

is

where the person is exposed to scrutiny by others and fears doing something embarassing A social phobia tow aid public is

fairly

common

and

is

usually avoided by the indi-

93

Drugs Used for Anxiety Disorders

Chapter 14

in-

of ethanol, bromides, chloral hydrate, and barbiturates to

tense anxiety. Social phobias are rarely incapacitating, but do

drugs with more specific antianxiety and less sedative activity, such as benzodiazepines, buspirone. meprobamate, and

vidual. If the speaking

unavoidable,

is

it is

done but with

cause some interference with social or occupational functioning. Simple phobia is an irrational fear of a specific object or situation such as heights (acrophobia), closed spaces (claus-

hydroxyzine.

More

recently, tricyclic antidepressants (e.g.,

imipramine), propranolol, (a beta-adrenergic antagonist), and

trophobia), air travel, or driving. Phobias to animals such as

serotonin agonists (SSRIs) have been successful in treating

and mice are particularly common. If the person is exposed to the object, there is an immediate feeling of panic, sweating, and tachycardia. People are quite aware of the phobia and simply avoid the feared object. Obsessive-compulsive disorder is the most disabling of the

anxiety disorders. See the individual monographs later in this

spiders, snakes,

anxiety disorders, although

is

it

responsive to treatment. The

primary features of the illness are recurrent obsessions or compulsions that cause significant distress and interfere with normal occupational responsibilities, social activities, and relationships. The average age of onset for symptoms of obsessive compulsive disorder is late adolescence to early 20s. It occurs with equal frequency in men and women. There also appears to be a genetic component to the disease. An obsession is an unwanted thought, idea, image, or urge that the patient recognizes as time-consuming and senseless but repeatedly intrudes into the consciousness, despite attempts to it. Examples of obsessions are germ contamination, fear of los-

ignore, prevent, or counteract

recurrent thoughts of dirt or

ing things, need to know or remember, need to count or check, blasphemous thoughts, or concerns about something happening to self or others. An obsession produces a tremendous sense of anxiety in the person. A compulsion is a repetitive, intentional, purposeful behavior performed to decrease the anxiety associated with an obsession. The act is done to prevent a vague, dreaded event, but the person does not derive pleasure from the act. Common compulsions deal with cleanliness, grooming, and counting. When patients are prevented from performing a compulsion, there is a sense of mounting anxiety. In some individuals, the compulsion can become the

person's lifetime activity. Obsessive-compulsive disorder

complex condition

is

a

that requires a highly individualized, inte-

grated approach to treatment with pharmacologic, behavioral,

and psychosocial components.

chapter for mechanisms of action.

Uses is treated with psychotherapy and the short-term use of antianxiety agents. The benzodiazepines, buspirone, and to some extent, the beta-adrenergicblocking agents (see Chapter 11) are used. Barbiturates, meprobamate, and antihistamines such as hydroxyzine are in-

Generalized anxiety disorder

frequently prescribed. Panic disorders

may be

treated with a

variety of agents in addition to behavioral therapy. Alpra-

zolam

(a benzodiazepine)

is

approved by the Food and Drug

Administration for treatment of panic disorder. Other agents that

show

benefit are the tricyclic antidepressants imipramine,

desipramine, and clomipramine, the serotonin agonist

flu-

and the monoamine oxidase inhibitor (MAOI) phenelzine (see Chapter 15). Phobias are treated with behavior therapy and beta-adrenergic blockers such as propranolol or atenolol or the MAOI phenelzine. Obsessive-compulsive disorder is treated with behavioral and psychosocial therapy in addition to clomipramine, fluoxetine, or fluvoxamine. oxetine,

lursing Process for Antianxiety

Therapy

Assessment

I

History of behavior: Obtain a history of the precipitating factors that may have triggered or contributed to the individual's current anxiety.

Has

the individual been using alcohol or

drugs? Has the client had a recent loss such as job, relationship, death of loved one, or divorce? Has the individual witnessed or survived a traumatic event? Does the individual have any medical problems such as hyperthyroidism that could be attributed to these symptoms? Are there symptoms present that could be attributed to a panic attack, such as a

Drug Therapy for Anxiety Disorders Anxiety

component of many medical

feeling of choking; palpitations; sweating; chest pain or dis-

illnesses involving

comfort; nausea; abdominal distress; or fear of losing control,

the cardiovascular, pulmonary, digestive, or endocrine sys-

going crazy, or fear of dying? Does the individual have symptoms of obsessions or compulsions? Does the individual have

tems.

is

It is

a

also a primary

symptom of many

psychiatric disor-

where he or she

ders such as schizophrenia, mania, depression, dementia, and

a history of agoraphobia

substance abuse. Therefore evaluation of the anxious patient

trapped or unable to escape)? Did the attack occur in response

requires a thorough history, as well as physical and psychi-

to a social or

atric

examination to determine whether the anxiety

mary condition or secondary

is

a

pri-

to another illness. Persistent

ir-

rational anxiety or episodic anxiety usually requires medical

and psychiatric treatment. Treatment of anxiety disorders usually requires a combination of pharmacologic and nonpharmacologic therapies. When it is decided to treat the anxiety in addition to the other medical or psychiatric diagnoses, anitanxiety medications, also

known

as anxiolytics or tranquil-

Actions

A

great

many medications have been used over

to treat anxiety.

They range from

the decades

the purely sedative effects

situations

feels

performance situation? Is the client also despecific fears does the individual have? Take a detailed history of all medications the individual is taking. Is there any use of central nervous system (CNS) stimulants such as cocaine, amphetamines, or CNS depressants pressed?

What

such as alcohol or barbiturates?

Ask

details regarding the length of time the individual has

been exhibiting anxiety. Has the person been treated for anxiety

previously?

When

did the

symptoms

start

—during

intox-

from a substance? Basic mental status: Note general appearance and appropriateness of attire. Is the individual clean and neat'.' Is the posture stooped, erect, or slumped? Is the person oriented to date, time, place, and person? ication or withdrawal

izers, are prescribed.

(i.e.,

194

Drugs Used for Anxiety Disorders

Chapter 14

What coping mechanisms deal with the situation?

has the individual been using to

Are they adaptive or maladaptive?

Assess the relationships that provide the individual with Is

the

individual tearful, excessively excited,

angry, hostile, or apathetic? tearful, sad. angry, or

her feelings.

Is

Is

the facial expression tense,

blank? Ask the person to describe his or

there worry over real-life problems?

Are the

*

Basic mental status:

ment of

support. Identify support groups.

Moodlaffect:

ing taken to specifically identify any that are

CNS

stimulants

or depressants.

Plan to perform a baseline assess-

the individual's mental status at specific intervals

throughout the course of treatment to identify the level of anxiety present

and response

to therapeutic interventions (includ-

ing medication therapy). Identify events that trigger anxiety. *

Review coping mechanisms being used and plan

to discuss

person's responses displayed as an intense fear, detachment,

those that are maladaptive. Initiate changes by guiding the in-

or an absence of emotions?

dividual in the use of

If the patient is

a child, are there

Patients experiencing altered thinking, behavior, or feel-

ings need careful evaluation of both verbal and nonverbal actions.

Many

more

effective coping strategies to deal * Schedule specific times to

with the threatening stimuli.

episodes of tantrums or clinging?

times, the thoughts, feelings, and behaviors dis-

discuss the patient's behavior and thoughts and foster under-

standing of

it

with family members. Involve family or signif-

icant others in the discussion of the anxiety-producing events

ways

played are inconsistent with the so-called "normal" responses of individuals in similar circumstances. Assess whether the mood being described is consistent

or circumstances and

with the circumstances being described. For example,

Moodlaffect: Review assessment data to plan strategies that

is

the

person speaking of death yet smiling? Clarity of thought: Evaluate the coherency, relevancy, and or-

Ask specific questions regarding the make judgments and decisions. Is there

ganization of thoughts. individual's ability to

any memory impairment? Psychomotor functions: Ask specific questions regarding the activity level the patient has maintained. Is the person able to work or go to school? Is the person able to fulfill responsibilities at work, socially, or within the family? How have the person's normal responses to daily activities been altered? Is the individual irritable, angry, easily startled, or hypervigilant?

Observe for gestures,

gait,

hand tremors, voice

tient in

that they

can be helpful

to the pa-

reducing the anxiety or coping more adaptively with

stressors.

will assist the individual in decreasing the level of anxiety

and identifying management techniques to handle anxietyproducing situations effectively. * Identify areas where the patient is caClarity of thought: pable of having input into setting goals and making decisions. (This will aid the individual in overcoming a sense of powerlessness over

life situations.)

for self-care.

When

plan to

Provide an opportunity to plan

the patient

make them and

is

unable to make decisions,

set goals to involve the patient to the

degree of his or her capability as abilities change with ment.

*

treat-

Identify signs of escalating anxiety; plan interven-

tions to decrease escalation of anxiety. *

Review

quivering, and type of activity such as pacing or inability to

Psychomotor function:

sit still.

the clinical setting and plan for the individual to participate in

Obsessions or compulsions: Does the individual have persistent thoughts, images, or ideas that are inappropriate

and

cause increased anxiety? Are there repetitive physical or mental

behaviors such as hand washing, need to arrange things in

words? If obsessions or compulsions are present, how often do these occur? Do the obsessions or compulsions impair the person's perfect symmetrical order, praying, silently repeating

social and/or occupational functioning?

Sleep pattern:

how has

it

What

is

the person's

normal sleep pattern, and

varied since the onset of the

symptoms? Ask

whether insomnia is present. Ask the individual to describe the amount and quality of the sleep. What is the degree of fatigue present? Is the individual having recurrent, stressful dreams (after a traumatic event)? Is there difficulty specifically

falling or staying asleep?

activities offered within

those that will provide distraction and relaxation, as well as

decrease the level of anxiety being exhibited.

*

Provide a

structured, safe environment for the individual to function. *

During severe or panic anxiety, provide a safe place for the

release of energy.

Sleep pattern: Plan for providing a nonstimulating environ-

ment (dim and sleep.

lighting, quiet area) that will

encourage drowsiness

Dietary needs: Provide an opportunity for the individual to be involved in selecting foods appropriate to needs (to lose or gain weight).

*

Deal with problems as they present themselves; practice

re-

ality orientation.

Dietary history: Ask questions relating to appetite and note

Provide a safe, structured environment; set limits on ag-

weight gains or losses not associated with intentional dieting.

gressive or destructive behaviors. Establish a trusting relationship with the patient by provid-

ing support and reassurance.

cute, chronic, panic (indication) ....

coping, ineffective (indication)

Posttraumatic response (indication) h risk tor (side effects)

Reduce stimulation by having calm environment.

Provide an opportunity tor the individual to express feelings.

Use

active listening and therapeutic

techniques. the patient

Planning History of behavior:

interactions with the patient

in a quiet,

communication Be especially aware of cues that would indicate ma\ be considering self-harm. (If suspecting

suicidal ideas, ask the patient directly *

Review data collected to identify the individual's ability to understand new information, follow di* Review medications herections, and provide self-care.

considered and intervene

Allow patients ble,

make

to

decisions

to

if

suicide

is

being

provide for safety).

make decisions of which they are capawhen the client is not capable, and pro-

.

Chapter 14

when

vide a reward for progress

decisions are initiated appro-

priately. Involve the patient in self-care activities.

During pe-

riods of severe anxiety or during escalating anxiety the indi-

may

vidual

be unable to have insight and

make

decisions

95

Drugs Used for Anxiety Disorders

written annually for anxiety.

More

than 2000 benzodiazepine

derivatives have been identified, and

more than 100 have been

tested tor sedative-hypnotic or other activity. Eight benzodi-

azepine derivatives are used as antianxiety agents (Table 14-1

).

appropriately.

Encourage the individual

to

develop coping

skills

through

the use of various techniques, for example, rehearsing or role-

playing responses to threatening stressors. Have the individual practice

problem solving; discuss possible consequences

of the solutions offered by the patient.

Actions is thought that the benzodiazepines have similar mechanisms of action as CNS depressants but individual drugs within the benzodiazepine family act more selectively at speIt

cific sites,

which allows for a variety of uses

(e.g., sedative-

hypnotic, muscle relaxant, antianxiety, and anticonvulsant).

Patient Education and Health Promotion • Orient the individual to the unit, explaining rules

how

process of "privileges" and

and the

they are obtained or

lost.

(The extent of the orientation and explanations given will depend on the individual's orientation to date, time, place, and abilities.) • Explain the activity groups available and how and when the individual will participate in these. A variety of group process activities

(e.g.,

social

skills

group, self-esteem

groups, work-related groups, and physical exercise groups) exist

within particular therapeutic

biofeedback, and relaxation therapy

settings.

may

Meditation,

also be beneficial.

and family in goal setting and integrate into the available group processes to develop positive experiences for the individual to enhance coping skills. Patient education should be individualized and based on assessment data to provide the individual with a structured environment in which to grow and enhance self-esteem.

• Involve the patient

•

In patients with

reduced hepatic function or in older adults, may be most appropriate, because they have a relatively short duration of action and have no active metabolites. Oxazepam has been the most thoroughly investigated. The other benzodiazepines all have acalprazolam, lorazepam, or oxazepam

tive metabolites that significantly

tion

and may accumulate

prolong the duration of ac-

to the point of excessive side effects

with chronic administration. The primary active ingredient of

both prazepam and clorazepate

is

desmethyldiazepam; there-

fore similar activity and patient response should be expected.

Halazepam and diazepam

are therapeutically active, but their

should be based on the patient's capabilities. Explore coping mechanisms the person uses in response to stressors, and identify methods of channeling these to-

major metabolite is also desmethyldiazepam; therefore a similar response should be expected with long-term administration. Oxazepam, lorazepam, chlordiazepoxide, diazepam, and clorazepate are all approved for use in treating the anxiety associated with alcohol withdrawal. Oxazepam is the drug of choice because it has no active metabolites. However, its use is somewhat limited in patients who cannot tolerate oral administration because it causes nausea and vomiting. Chlordiazepoxide, diazepam, or lorazepam may be administered in-

ward

tramuscularly in this case.

Initially, the

may

individual

not be capable of understand-

ing lengthy explanations; therefore the approaches used •

The benzodiazepines reduce anxiety by stimulating the action of an inhibitory neurotransmitter called gamma-aminobutyric acid (GABA).

positive realistic goals as an alternative to the use of

medications. Fostering health maintenance:

Throughout the course of treat-

ment, discuss medication information and

how

it

will benefit

nonpharmacologic inthat compliance with the

Uses Patients with anxiety reactions to recent events

and those with most

the patient. Stress the importance of the

a treatable medical illness that induces anxiety respond

terventions and the long-term effects

readily to benzodiazepine therapy.

treatment regimen can provide. Provide the patient and/or significant others with important information contained in the

specific drug

monograph

for the medicines prescribed. Addi-

and nursing interventions for the side and report are described in the drug monographs that follow. Seek cooperation and understanding of the following points so that medication compliance is increased: name of medication, dosage, route and times of administration, side effects to expect, and side effects to report. Written record: Enlist the patient's aid in developing and maintaining a written record of monitoring parameters (see the box on p. 196). Instruct the patient to bring the written tional health teaching

effects to expect

record to follow-up

Because

all

the benzodi-

azepines have similar mechanisms of action, selection of the appropriate derivative

azepine

is

is

dependent on

how

the

benzodi-

metabolized. See Actions above. Oxazepam, lo-

razepam, chlordiazepoxide, diazepam, and clorazepate are all approved for use in treating the anxiety associated with alcohol withdrawal.

Therapeutic Outcomes The primary

therapeutic

outcome expected from

azepine antianxiety agents to a

manageable

is

the benzodi-

a decrease in the level of anxiety

level (e.g.,

coping

is

improved; physical

signs of anxiety such as look of anxiety, tremor, and pacing are reduced).

visits.

g Class: Benzodiazepines Benzodiazepines are most commonly used because they are more consistently effective, less likely to interact with other drugs, less likely to cause overdose, and have less potential for abuse than barbiturates and other antianxiety agents. They

now account

for perhaps

75%

of the 100 million prescriptions

Nursing Process for Benzodiazepines

Premedication Assessment 1

2.

Record baseline data on level of anxiety present. Record baseline vital signs, particularly blood pressure, sitting and supine positions.

in

96

Chapter 14

Drugs

PATIENT EDUCATION

Use< ?d for Anxiety Disorders

i-

MONITORING FORM

COLOR

MEDICATIONS

Antianxiety Medication

TO BETAKEN Physician. Physician's

phone.

Next appt.*

Day of Discharge

Parameters Weight

AM _^-— ^*--^

Blood Pressure

—

"""

PM

Comments

AM/^" AM/' AM^^ AM/'" AM^/" /^PM /^PM ^/PM ^/>M /"PM /^PM

Resting pulse rate

1

would

like

to be alone

Some

All the

time

of

the time

1

Not really

1

10

How

1

5

1

my

about

feel

1

children?

Too much work

Fun to be with

1

1

1

10

How

5

1

1

today?

feel

Poor

Okay

Fair

1

1

10

1

S

1

B L

Appetite? Poor

Good

Fair

1

1

10

1

S

1

s

A C K

Has

family noted any problems:

Judgment? Socialization?

Does

patient dress daily (Yes/No)?

Does

patient take pride

in

appearance (Yes/No)?

Use of alcohol (Yes/No)?

Amount

(e.g.,

one

drink)?

General Mood:Tearful, excessively excited, angry,

happy or apathetic.

hostile,

Sleep pattern: Amount of sleep per night:

Degree of

slightly fatigued,

Insomnia: Yes or

'Please tun. I

si-

the bai

i

hrs.

fatigue: rested,

"i thi

exhausted.

No

//

mmmtm

Generic

Name

Alprazolam

Brand Name

Availability

Xanax

Tablets: 0.25, 0.5, 1,2

mg/5

Solution: 0.5 1

Chlordiazepoxide

Capsules:

100

Inj:

Tranxene

Clorazepate

15,

mg mg

mg

5-10

Daily Dose (mg) 4

3 times daily

300

3-4 times daily

mg

10

60

1-3 times daily

mg

22.5

mg

mg

2-10

Tablets: 2, 5, 10

*Meval

Caps, Extended Release: 15

mg

mg

Valium

mg

2-4 times daily

mg

Liquid: 5 Inj:

0.25-0.5

Maximum

25

5, 10,

Capsules: 3.75, 7.5, 15

Diazepam

Dose (PO)

ml,

Tablets: 3.75, 7.5, 11.25,

Novo-Clopate

Initial

mg/ml

Tablets: 5, 10,25

Librium, Mitran

mg

197

Drugs Used for Anxiety Disorders

Chapter 14

mg/5

5 mg/ml

ml, 5

mg/ml

1,2, 10

in

ml

vials

Paxipam

Halazepam

40 mg

Tablets: 20,

Lorazepam

Inj:

Nu-Loraz

2,4 mg/ml

Liquid: 2

Available

3.

4.

in

20

1,

10 ml

2-3

mg mg

160

-2 times daily

1

2-3 times daily

10

vials;

mg/ml

Tablets: 0.5,

Oxazepam

in

Serax

Tablets: 15

Oxpam

Capsules:

1

2

,

mg

mg 10,

10-15

15,30

mg

3-4 times daily

120

mg

Canada.

Check

on

for history of blood dyscrasias or hepatic disease. Determine whether the individual is pregnant or breast-

transient hypotension

feeding.

then standing. Assistance with ambulation

Planning See Table 14-1. Pregnancy and lactation: It is generally recommended that benzodiazepines not be administered during at least the first trimester of pregnancy. There may be an increased incidence of birth defects because these agents readily cross the placenta and enter fetal circulation. Mothers who are breastfeeding should not receive benzodiazepines regularly. The benzodiazepines readily cross into breast milk and exert a pharmacologic effect on the infant.

Availability:

Implementation Dosage and administration: See Table

14-1.

The

habitual use

may result in physical and psychologic dependence. Rapid discontinuance of benzodiazepines after long-term use may result in symptoms similar to alcohol of benzodiazepines

withdrawal. These

may

vary from weakness and anxiety to

delirium and tonic-clonic seizures.

The symptoms may

not

appear for several days after discontinuation. Treatment consists of gradual withdrawal of benzodiazepines over a 2- to

4-week period.

need for rising

first

arising.

Explain to the patient the

to a sitting position, equilibrating,

may

and

be required.

If hangover becomes troublesome, the dosage should be reduced or the medication changed, or both. People who are working around machinery, driving a car,

administering

medication,

or performing

which they must remain mentally

alert

other duties

in

should not take these

medications while working. Side effects to report

Excessive Use or Abuse. Habitual use of benzodiozepines

may

result in physical

physician and

make

dependence. Discuss the case with the

plans to cooperatively approach gradual

withdrawal of the medications being abused. Assist the patient in recognizing the abuse problem. Identify underlying

needs and plan for more appropriate management of those needs. Provide for emotional support of the individual, display an accepting attitude, and be kind but firm.

Blood Dyscrasias. Routine laboratory studies (e.g., red cell [RBC], white blood cell [WBC] counts, and differential counts) should be scheduled. Stress the patient's need to return for these tests. Monitor for the development of a sore throat, fever, purpura, jaundice, or excessive and progressive blood

weakness. Hepatotoxicity. orexia,

The symptoms of hepatotoxicity

are an-

nausea, vomiting, jaundice, hepatomegaly, spleno-

Evaluation

megaly, and abnormal liver function

Side effects to expect

aspartate aminotransferase (AST), alanine aminotransferase

Drowsiness, Hangover, Sedation, and Lethargy. Patients

may complain

of "morning hangover," blurred vision, and

(ALT),

gamma

tests [elevated bilirubin,

glutamyltransferase [GGT], alkaline phos-

phatase, prothrombin time].

98

Drugs Used for Anxiety Disorders

Chapter 14

Drug interactions Drugs Thai Increase Toxic Effects. Antihistamines, alco-

include dizziness, insomnia, nervousness, drowsiness, and lightheadedness.

People

hol, analgesics, anesthetics, tranquilizers, narcotics, cimeti-

and other sedative-hypnotics increase toxic effects. Smoking. Smoking enhances the metabolism of the benzodiazepines. Larger doses may be necessary to maintain sedative effects in patients who smoke. dine,

who

are

working around machinery or performing

other duties in which they must remain mentally alert should not take this medication while working. Side effects to report

Slurred Speech, Dizziness. These are signs of excessive dosing. Report to the physician for further evaluation. Provide

Drug

for patient safety during these episodes.

Class: Azaspirones

Drug interactions Alcohol. Buspirone and alcohol generally do not have ad-

buspirone (boos-peer'ohn)

BuSpar

ical class

is

an antianxiety agent that comes from the chem-

known

as the azaspirones.

They

are chemically un-

related to the barbiturates, benzodiazepines, or other anxiolytic agents.

The mechanism of action of buspirone

understood.

full)

in several

It

is

is

not

a partial serotonin agonist and interacts

ways with nerve systems

in the

is

properties.

signs of

It

requires 7 to 10 days of treatment before initial

improvement

| fluvoxamine (fluuv-ox'ah-meen) JF Luvox (loo-vox)

are evident, as well as 3 to 4

Actions Fluvoxamine

inhibits the reuptake of serotonin at nerve end-

ings, thus prolonging serotonin activity.

weeks of

Uses

Uses

disorder

Fluvoxamine is

approved for use

in the treatment

may be

caution.

Drug Class: Selective Serotonin Reuptake Inhibitors (SSRIs)

therapy for optimal effects.

It

Use with extreme

midbrain; therefore

sometimes called a midbrain modulator. Its advantage over other antianxiety agents is that it has lower sedative it

depressant effects, but individual patients

susceptible to impairment.

Actions Buspirone

CNS

ditive

(bue-sphar)

of anxiety disorders

and for the short-term relief of the symptoms of anxiety. Buspirone has no antipsychotic activity and should not be used in place of appropriate psychiatric treatment. Because there is minimal potential for abuse with buspirone,^flWW^»

tress, are

cial or

is

used

in the

when obsessions

treatment of obsessive-compulsive or compulsions cause

marked

dis-

time-consuming, or interfere substantially with so-

occupational responsibilities. Fluvoxamine reduces

symptoms of

the.

does not prevent obsessions

this disorder but

and compulsions. However, patients indicate that the obsessions are less intrusive and they have more control over them.

Therapeutic Outcomes Therapeutic Outcomes

The primary

The primary

is

a decrease in the level

coping

outcome expected from buspirone is of anxiety to a manageable level (e.g.,

therapeutic

improved, physical signs of anxiety such as look of anxiety, tremor, and pacing are reduced). is

therapeutic

outcome expected from fluvoxamine

a decrease in the level of anxiety to a manageable level

(e.g.,

coping with obsession

pulsive activity

is

is

improved, frequency of com-

reduced).

Nursing Process for Fluvoxamine Therapy

Nursing Process for Buspirone Therapy

See Chapter

15, Selective

Serotonin Reuptake Inhibitors,

p.

209.

Premedication Assessment Record baseline data on the

level of anxiety present.

Miscellaneous Antianxiety

Agents

Planning Availability:

PO:

5, 10.

and 15

mg

tablets.

Schedule assessments

throughout therapy for development of slurred speech or dizziness, which are signs of excessive dosing. periodically

| hydroxyzine 4?

Vistaril

(hi-drox'ee-zeen)

(vis-tar'il),

Atarax

(ata-raks)

Actions

Implementation Dosage and administration: Adult: PO: Initially. 5 mg 3 times daily. Doses may be increased by 5 mg every 2 to 3 days. Maintenance therapy often requires 20 to 30 mg clails in divided doses Do not exceed 60 mg daily.

Defined

strictly

tihistamine.

It

by chemical structure, hydroxyzine is an anwithin the CNS to produce sedation.

acts

antiemetic, anticholinergic, antihistamine, antianxiety, and

antispasmodic

activity.

somewhat multipurpose

Tins

variety

of actions makes

a

it

agent.

Evaluation

Uses

Side effects to expect

Sedation, Lethargy.

The most

of buspirone therapj are

CNS

common

disturbances

adverse effects i

J.49S

>,

which

Hydroxyzine

is

used as a mild tranquilizer

in

psychiatric con

ditions characterized In anxiety, tension, and agitation.

It

is

.

Drugs Used for Anxiety Disorders

Chapter 14

99

also routinely used as a preoperative or postoperative sedative

Side effects to report

and reduce the amount of narcotics needed for analgesia. Hydroxyzine may also be used as an antipruritic agent to relieve the itching associated

dosing. Report to the physician for further evaluation. Provide

Slurred Speech, Dizziness. These are signs of excessive

to control vomiting, diminish anxiety,

for patient safety during these episodes.

Drug interactions Drugs That Increase Toxic Effects. Antihistamines, alco-

with allergic reactions.

Therapeutic Outcomes

hol, analgesics, anesthetics, tranquilizers, barbiturates, nar-

The primary

cotics,

therapeutic outcomes expected from hydrox-

1.

A

decrease in the level of anxiety to a manageable level

(e.g.,

coping

is

if

necessary.

improved; physical signs of anxiety such as

look of anxiety, tremor, and pacing are reduced). 2.

and other sedative-hypnotics. Monitor the patient for

excessive sedation and reduce the dosage of hydroxyzine

yzine are as follows:

Sedation, relaxation, and reduced requirements for analgesics before and after surgery.

3.

Absence of vomiting when used

4.

Itching controlled in allergic reactions.

| meprobamate (mep-roe-ba'mate) 4? Equanil (ek'wah-nil), Miltown (mil'-towhn)

as an antiemetic.

Actions Meprobamate acts on multiple sites within the CNS to produce mild sedation, antianxiety, and muscle relaxation. The mechanism of

Nursing Process for Hydroxyzine Therapy

2.

3.

4.

Perform baseline assessment of anxiety symptoms. Determine level of anxiety present before and after surgical intervention; record and intervene appropriately. For nausea and vomiting, administer when nausea first starts and determine effectiveness of control of nausea before giving subsequent doses. For allergic reactions, perform baseline assessment of physical

5.

is

unknown.

Uses

Premedication Assessment 1.

action

symptoms before administering dose;

repeat be-

Meprobamate

is used as an antianxiety agent and mild skelemuscle relaxant for the short-term relief (less than 4 months) of anxiety and tension. It is of little use in the treat-

tal

ment of psychoses.

Therapeutic Outcomes The primary mate

is

therapeutic

improved; physical signs of anxiety such and pacing are reduced).

fore administration of subsequent doses to determine ef-

level (e.g.,

fectiveness.

as look of anxiety, tremor,

Monitor for

outcome expected from meproba-

a decrease in the level of anxiety to a manageable

coping

is

level of sedation present, slurred speech, or

dizziness; report to physician if excessive before administering repeat doses.

Nuursing

Availability:

sules; 10

Process for

Meprobamate Therapy

Premedication Assessment

Planning

PO:

10, 25, 50,

and 100

mg

tablets

and cap-

Record baseline data on the

level of anxiety present.

mg/5 ml syrup; 25 mg/5 ml suspension. IM: 25 and

Planning

50 mg/ml.

Availability:

Implementation

PO:

200, 400, and 600

mg tablets; 200 and 400 mg

extended-release capsules. Schedule assessments periodically

Dosage and administration Adult. Antianxiety: PO: 25 to 100 mg 3 to 4 times daily; IM: 50 to 100 mg every 4 to 6 hours. Pre- and postoperative: IM: 25 to 100 mg. Antiemetic: IM: 25 to 100 mg.

Evaluation

throughout therapy for development of slurred speech or which are signs of excessive dosing, use, or abuse.

dizziness,

Implementation Dosage and administration: Adult: PO: 400 mg 3 to 4 times Smaller doses may work well in older adults and debilitated patients. Maximum daily doses should not exceed 2400 mg. daily.

Side effects to expect

Blurred Vision; Constipation; Dryness of Mucosa of the Mouth, Throat, and Nose. These symptoms are the anticholinergic effects produced by hydroxyzine. Patients taking these medications should be monitored for the development of these side effects.

Dryness of the mucosa may be relieved by sucking hard candy or ice chips, or by chewing gum. The use of stool softeners such as docusate may be required for constipation. Caution the patient that blurred vision may occur and make appropriate suggestions for personal safety.

who

Evaluation Side effects to expect Sedation. People who are working around machinery, driving a car, administering medication, or performing other duties in

which they must remain mentally

alert

should not take

these medications while working.

Side effects to report

Slurred Speech, Dizziness. These are signs of excessive

working around machinery, driving a car, administering medication, or performing other duties in which they must remain mentally alert should not take

dosing. Report to the physician for further evaluation. Provide

these medications while working.

pendence may occur

Sedation. People

are

for patient safety during these episodes.

Excessive Use or

\bi

si

Psychological and physiologic de-

in patients

taking doses of 3.3 to 6.4 g

200

Drugs Used for Anxiety Disorders

Chapter 14

Symptoms of chronic use and abuse of high doses include ataxia, slurred speech, and dizziness. Withdrawal reactions such as vomiting, tremors, confu-

per day for 40 or more days.

and tonic-clonic seizures

sion, hallucinations,

within

1

2 to

48 hours

may develop Symptoms

after abrupt discontinuation.

usually decline within the next 12 to 48 hours. Withdrawal

from high and prolonged doses should be completed graduover 1 to 2 weeks. Discuss the case with the physician and make plans to cooperatively approach gradual withdrawal of the medications being abused. Assist the patient in recognizing the abuse problem. Identify underlying needs and plan for more appropriate management of those needs. Provide for emotional support of the individual, display an accepting attitude, and be

pharmaco-

ety disorders usually requires a combination of

and nonpharmacologic therapies. It is the responsibility of the nurse to educate patients about their therapy, monitoring for therapeutic benefit, side effects to expect, and side effects to report, intervening whenever possible to optimize therapeutic outcomes. logic

ally

MATH REVIEW Ordered: hydroxyzine

1.

On

Give: 2.

kind but firm.

(Vistaril)

20 mg, IM, stat mg per ml

hand: hydroxyzine (Vistaril) 25 ml.

Ordered: meprobamate (Equanil) 1600 mg PO daily 4 divided doses How many mg per dose should be administered?

Orthostatic Hypotension (Dizziness, Weakness, Faintness).

Although

this

effect

is

infrequent

and

meprobamate may cause some degree of

generally

sion manifested by dizziness and weakness, particularly

therapy

is

being

mild,

Ordered: lorazepam (Ativan) 2.5 mg, IM, stat hand: lorazepam (Ativan) 4 mg per ml

3.

On

orthostatic hypoten-

CRITICAL THINKING QUESTIONS

Anticipate the development of postural hypotension and take measures to prevent an occurrence. Teach the patient to rise

slowly from a supine or sitting position; encourage the

patient to

sit

or

ml

Give:

when

initiated.

lie

down

if

Mrs. Higginbaum

and report for further evaluation. Hives, Pruritus, Rash. Report symptoms for further evaluation by the physician. Pruritus may be relieved by adding baking soda in the bath water. Drug interactions Drugs That Increase Toxic Effects. Antihistamines, alcohol, analgesics, tranquilizers, narcotics, and other sedativehypnotics. Monitor the patient for excessive sedation and reduce the dosage of the meprobamate if necessary.

admitted to the unit with symptoms of

view the following information was obtained:

pressure daily in both the supine and standing positions.

Paradoxic Excitement, Arrhythmias. Withhold further doses

is

generalized anxiety disorder. During the admission inter-

feeling faint. Monitor the blood

She

is

so fearful of losing her job that she discusses

sev-

it

been an increasing concern to her over the past 8 months. Her work performance was regarded as above average; however, over the past 2 months, she has had increasing difficulty concentrating and completing her responsibilities. Finally, last week her employer suggested she take a brief vacaeral times a day as a possibility. This has

tion to "get

it

together." Since then, the

symptoms have

escalated significantly.

She

is

having difficulty

asleep and frequently awakens

falling

with palpitations and clammy hands. When asked to describe her feelings she says, "I'm out of control; I'm going

to lose

CHAPTER REVIEW

1.

Anxiety

is an unpleasant feeling of apprehension or nervousness caused by the perception of danger threatening the security of the person. In most cases, it is a normal human emotion. When a person's response to anxiety is irra-

tional

and impairs

daily functioning, patients are said to

an anxiety disorder. will

Some 16%

most common types

my

job.

What am

I

ever going to do?"

need to be made? Research a typical data intake assessment sheet used with anxiety disorders. additional nursing assessments

Her admission orders

include giving alprazolam 0.25

3 times daily. What schedule

mg

would be used to adminis-

ter these doses?

have

of the general population

experience an anxiety disorder during their

2.

What

3.

and obsessive-compulsive disorder. Anxiety is a component of many medical illnesses involving the cardiovascular, pulmonary, digestive, and/or endocrine systems. It is also a primary symptom of many psychiatric disorders. Therefore evaluation of the anxious patient requires a thorough history, as well as a physical and psychiatric examination to determine whether the anxiety is a primary condition or is secondary to another illness. Persistent irrational anxiety or episodic anxiety usually requires medical and psychiatric treatment.Treatment of anxi-

additional assessments should be

made

after initia-

tion of drug therapy using benzodiazepines.

of anxiety disorders are generalized

anxiety disorder, panic disorder, social phobia, simple phobia,

Describe premedication assessment data needed and

what

lifetime. The

4.

How

soon

after initiation of

drug therapy

able to expect a therapeutic response

is

it

reason-

from the

antianxi-

ety medication? 5.

Describe the behavior monitoring system and intervention flow records used

in

the

clinical setting

where

as-

signed to detect the side effects of anxiolytic drugs. 6.

What

assessments and nursing interventions, including

health teaching, need to be performed to deal with the

possible physical dependence or tolerance cur with benzodiazepine therapy?

known

to oc-

)

.

Drugs Used for Mood Disorders

CHAPTER CONTENT Mood

Disorders

20

(p.

Key Words mood mood

1

Mood Disorders (p. 203) Drug Therapy for Mood Disorders (p. 203)

Treatment of

Drug Therapy

for Depression

(p.

205)

Monoamine Oxidase

Drug

Class:

Drug

Class: Selective Serotonin

(p.

Inhibitors

(p.

205)

mania

labile

grandiose delusions

symptoms

Class: Tricyclic Antidepressants (p. 210)

Drug

Class: Miscellaneous

Drug

Class: Antimanic

Agents

Agents

(p.

(p.

21

MOOD DISORDERS

1)

215)

Mood is a sustained, emotional

feeling perceived along a nor-

mal continuum of sad

Mood is our perception of our

ment

present.

of a patient with depression or bipolar disorder.

mood

swings associated with bipolar disorder.

3.

Compare drug therapy used

4.

Cite monitoring parameters used for persons taking

during the treatment of the

manic phase and depressive phase of bipolar disorder.

monamine oxidase

inhibitors

(MAOIs), selective serotonin

reuptake inhibitors (SSRIs), or tricyclic antidepressants.

Prepare a teaching plan for an individual receiving

tri-

cyclic antidepressants.

Differentiate

between the physiologic and psychologic

therapeutic responses seen with antidepressant therapy. Identify the

premedication assessments necessary before

administration of

MAOIs,

SSRIs, tricyclic antidepressants,

and antimanic agents. 8.

Compare

the mechanism of action of SSRIs to that of

other antidepressant agents. 9.

Cite the advantages of SSRIs over other antidepressant agents.

10.

from negative

ences. In severe cases, other psychotic features

Discuss the

7.

brief emotional upset

Describe the essential components of a baseline assess-

2.

6.

to happy.

surroundings. A mood disorder (affective disorder) is said to be present when certain symptoms impair the person's ability to function for a duration of time. Mood disorders are characterized by abnormal feelings of depression or euphoria. They involve prolonged, inappropriate expression of emotion that

go beyond

5.

antidepressants

bipolar disorder

Drug

Objectives 1

suicide

psychomotor symptoms

209)

mood

neurotransmitters

depression cognitive

Reuptake Inhibitors

euphoria

disorder

Examine the drug monograph for SSRIs to icant drug interactions.

identify signif-

At

agnosable

least

mood

10%

life

experi-

may

also be

of the United States population has a di-

disorder in their lifetime.

Mood disorders

are

divided into depressive (unipolar) and bipolar disorders.

The underlying causes of mood disorders are still unknown. The disorders are too complex to be completely explained by a single social, developmental, or biologic theory. factors appear to

work together

to

A variety

of

cause depressive disorders.

known

that patients with depression have changes in the neurotransmitters norepinephrine, serotonin, and dopamine, but other unexpected negative life events (e.g.. sudden death of a loved one, unemployment, medical illness, other stressful events) also play a major role. Endocrine abnormalities such as excessive secretion of Cortisol and abnormal thyroid-stimulating hormone (TSH) have been found to be present in 45% to 60% of patients with depression. Genetic factors also predispose patients to the development of depression. Depressive disorders and suicide tend to cluster in families, and relatives of patients with depression are two to three times more likely to develop depression. The onset of depression tends to be in the late 20s. The lifetime frequency of depressive symptoms appears to be as high as 26% for women and 2% for men. Risk factors for deIt is

brain

1

pression include a personal or family history of depression; prior suicide attempts: female gender: lack of social support: stressful life events: substance abuse, especially alcohol

and

201

202

Chapter

ibuse;

Drugs Used for Mood Disorders

5

1

and medical

The American Psychi-

illnesses.

Association classihes episodes of depression into mild,

atric

moderate, and severe. Mild depression causes only minor functional impairment. Patients v\ ith severe depression have several s>

mptoms

that

exceed the minimum diagnostic

crite-

Bipolar disorder occurs equally between men and women and has a prevalence rate of 0.6% to 0.9% of the adult population in the United States. The onset of bipolar disorder is usually in late adolescence or early 20s.

lescence and

80%

may occur as

late as

It is rare in preadoage 50. Approximately 60%

ria

and daily functioning is greatly impaired. Hospitalization be required. Moderate depression is intermediate between mild and severe conditions for both symptomatology and functional impairment. Patients experiencing depression display varying degrees of emotional, physical, cognitive, and psychomotor symptoms. Emotionally, the depression is characterized by a persistent, reduced ability to experience pleasure in life's usual activities such as hobbies, family, and work. Patients frequently appear sad. and a change in personality is common.

to

may

manic episode. Without treatment, episodes last 6 months year for depression and 4 months for mania.

They may describe

psychiatric admission, and feelings of hopelessness. The presence of a detailed plan with intention and ability to carry it out indicates strong intent and a high risk of suicide. Other hints of potential suicidal intent include changes in personality, a sudden decision to make a will or give away possessions, and a recent purchase of a gun or hoarding a large supply of med-

their

mood

as sad. hopeless, or blue.

Patients often feel that they have

down, although

others

let

these feelings of guilt are unrealistic. Anxiety

chapter 14) are present in almost

90%

symptoms

(see

of depressed patients.

Physical symptoms often motivate the person to seek medical attention.

Chronic fatigue, sleep disturbances such as frequent

morning awakening (terminal insomnia), appetite disturbances (weight loss or gain), and other symptoms, such as stomach complaints or heart palpitations are common. Cognitive symptoms such as the inability to concentrate, slowed thinking, confusion, and poor memory of recent events are early

particularly

common

in older patients with depression. Psy-

chomotor symptoms of depression include slowed

or re-

tarded movements, thought processes, and speech, or conversely, agitation manifesting as purposeless, restless (e.g.,

motion

pacing, wringing of hands, and outbursts of shouting).

of patients with bipolar disease will begin with a

Patients with

mood

disorders have a high incidence of at-

tempting suicide. The frequency of successful suicide

30 times higher than

to a

is

15%,

that in the general population. All pa-

with depressive symptoms should be assessed for the

tients

presence of suicidal thoughts. Factors that increase the risk of

widowed, being unmar-

suicide include increasing age, being

unemployment,

ried,

living alone, substance abuse, previous

ication, including antidepressants, tranquilizers, or other toxic

substances.

The prognosis

for

mood

disorders

patients with major depression,

20%

to

is

highly variable.

30%

do not experience another bout of depression. Another

50%

have recurring episodes, often with a year or more separating the events. The remaining 20% of patients have a chronic course with persistent symptoms and social impairment. Most treated episodes of depression last approximately 3

and untreated ones

Bipolar disorder (formerly known as manic depression) is mood disorders. It is characterized by distinct episodes of mania (elation, euphoria) and depression, separated by intervals without mood disturbances. The patient displays extreme changes in mood, cognition, behavior, perception, and sensory experiences. At any one time, a patient

last

months

6 to 12 months. Patients with bipolar

another of several

with bipolar disorder

may

be manic or depressed,

may

LIFE

SPAN ISSUES DEPRESSION

exhibit

symptoms of both mania and depression (mixed), or may be

The

between episodes.

tance of continuing to take the prescribed antidepressant

The depressive state has been previously described. Symptoms of acute mania usually begin abruptly and escalate over the next several days. These symptoms are a heightened mood (euphoria), quicker thoughts (flight of ideas), more and faster

initial response. The lag time weeks between initiation of therapy and therapeutic response must be emphasized. In most cases the symptoms of depression may improve within a few days (e.g., improved appetite, sleep, and psychomotor activity). The depression, however, still exists, and monitoring

speech


therapeutic outcome expected from antidepressants

is

standing positions. Anticipate the development o\' postural hypotension ami lake measures to prevent an occurrence. Teach the patient to rise slowly from a supine or sitting position; encourage the patient to

Therapeutic Outcomes

when therapy

initiated.

the tricyclic

reduction ol

symptoms

Sedattvi Iiik ciall)

is

Tell the patient

during the onset

mav diminish or

ol

of sedative

effects, espe-

therapy. Single doses

relieve the sedative effects.

at

bedtime

.

vnapier

S/'de effects

«,»-

j

"or

Mood Disorders

211

Actions

to report

Tremor. Approximately 10% of patients develop this adverse effect. The tremor can be controlled with small doses of

lated to phenylethylamine antidepressants. Its

propranolol.

action

Numbness, Tingling. Report for further evaluation. Parkinsonian Symptoms. If these symptoms develop, the tricyclic antidepressant dosage must be reduced or discontinued. Antiparkinsonian medications will not control symptoms

sants,

induced by tricyclic antidepressants. Arrhythmias, Tachycardia, Heart Failure. Report for

Bupropion

is

a monocyclic antidepressant chemically re-

unknown. Compared with

is

it is a weak inhibitor of the reuptake and inactivation of the neurotransmitters serotonin, norephinephrine, and

dopamine.

Uses fur-

It is

approved for use

in patients

antidepressants and in patients

ther evaluation.

Seizure Activity. High doses of antidepressants lower the seizure threshold. Adjustment of anticonvulsant therapy

be required, especially

in

may

seizure-prone patients.

Suicidal Actions. Monitor the

patient

thoughts, feelings, and behaviors during the

for

changes

in

stages of

unresponsive to the tricyclic

who

cannot tolerate the ad-

verse effects of the tricyclic antidepressants. Disadvantages

include seizure activity and the requirement of multiple doses

must not be used in patients with psychotic disorits dopamine agonist activity causes increased pyschotic symptoms.

daily.

initial

mechanism of

the tricyclic antidepres-

It

ders because

therapy.

Therapeutic Outcomes

Drug interactions Enhanced Anticholinergic Activity. The following drugs enhance the anticholinergic activity associated with tricyclic

The primary

antidepressant therapy: antihistamines, phenothiazines,

depression.

tri-

therapy

is

therapeutic

elevated

outcome expected from bupropion reduction of symptoms of

mood and

hexyphenidyl, benztropine, and meperidine. The side effects are usually not severe

enough

therapy, but stool softeners

Enhanced Sedative

to cause discontinuation of

may be

Activity.

required.

The following drugs enhance

the sedative activity associated with tricyclic antidepressant

therapy: ethanol, barbiturates, narcotics, tranquilizers, antihis-

tamines, anesthetics, and sedative-hypnotics. Concurrent ther-

apy

is

not

Nursing Process for Bupropion Therapy

Premedication 1

2.

recommended.

Barbiturates. Barbiturates

may

stimulate the metabolism

Obtain baseline weight. Perform DISCUS or AIMS (see Appendixes G and H) at specified intervals to detect and/or check on EPS; record/report according to policy.

of tricyclic antidepressants. Dosage adjustments of the antidepressant

may

Planning

be necessary.

Methylphenidate, Thyroid Hormones. These agents

may

increase serum levels of the tricyclic antidepressants. This re-

Availability:

PO: 75 and 100 mg

tablets;

100 and 150

mg

100

mg

sustained-release tablets.

action has been advantageous in attempts to gain a faster onset

of antidepressant

activity, but

an increased incidence of ar-

Guanethidine, Clonidine. Tricyclic antidepressants inhibit the antihypertensive effects of these agents. Concurrent ther-

recommended. Monoamine Oxidase Inhibitors. Severe reactions, including convulsions, hyperpyrexia, and death, have been reported with concurrent use. It is recommended that 2 weeks lapse between discontinuance of an MAOI and starting tricyclic apy

is

not

antidepressants.

Phenothiazines. Concurrent therapy

may

increase serum

levels of both drugs, causing an increase in anticholinergic

Dosages of both agents may be reduced. Selective Serotonin Reuptake Inhibitors. The interaction between SSRIs and tricyclic antidepressants is complex. The net result is that there is an increased toxicity from the tricyclic antidepressants. Observe patients for signs of toxicity, such as arrhythmias, seizure activity, and CNS stimuand sedative

Implementation Dosage and administration. Adult: PO:

rhythmias also has been reported.

may

twice daily. This

be increased to 100

Initially,

mg

3 times daily (at

least every 6 hours) after several days of therapy. No single dose of bupropion should exceed 150 mg; do not exceed 450 mg daily. Avoid a dose shortly before bedtime.

Observation.

few days

Symptoms improved

of depression

may improve

within

and psychomotor activity). The depression still exists, however, and it usually takes several weeks of the therapeutic doses before improvement is noted. Suicide precautions should be maintained dura

(e.g.,

appetite, sleep,

ing this time.

activity.

Evaluation Side effects to expect

Gastrointestinal Effects. Most of these effects may be minimized by temporary reduction in dosage, administration with food, and use of stool softeners for constipation.

lation.

Restlessness, Agitation, Anxiety. Insomnia. This usually oc-

Drug

Class: Miscellaneous

Agents

curs early in therapy and

may

require short-term treatment

with sedative-hypnotic agents. Avoiding bedtime doses

may

also help decrease the incidence of insomnia.

| bupropion hydrochloride (byoo-pro ijt

Wellbutrin (wel-byoo

trihn)

pee-on)

Side effects to report Seizures. See

Seizure Disorders

Nursing (p.

228).

Assessments

for

Patients

with

Chapter

212

1

Drugs Used for

5

Actions. Monitor

Suicidal

the

Mood Disorders

patient

thoughts, feelings, and behaviors during the

for

changes

initial

in

stages of

Planning

PO:

Availability:

25, 50, and 75

mg

tablets.

therapy.

Implementation

Drug interactions CARBAMAZEPINE,

PHENOBARBITAL,

CIMETID1NE,

PHENYTOIN.

Bupropion may be an inducer of hepatic enzymes that may metabolize these agents more quickly. The dosage of these medications may need to be increased if taken concurrently with bupropion.

Carbamazepine. Carbamazepine

serum

levels, leading to

Ritonavir. Ritonavir

may

decrease bupropion

made

the evening because

in

is

often

present.

may

Observation. Symptoms of depression may improve (e.g., improved appetite, sleep, and psychomotor activity) within a few days. The depression still exists, however, and it usually takes several weeks of therapeutic doses before improvement

cause large increases

in

serum

headaches, dizziness, agitation, nausea and vomiting, and

dry mouth.

some mild dopaminergic activand may cause an increase in adverse effects from levodopa. If bupropion is to be added to levodopa therapy, it

in the depression is noted.

should be initiated in small doses with small increases dosage of bupropion.

Evaluation

Levodopa. Bupropion has

ity

4

increased sedation

decreased pharmacologic effect.

concentrations of bupropion. Monitor patients for tachycardia,

Dosage and administration: Adult: PO: Initially, 75 mg increments of 25 to 50 mg daily as needed and tolerated. The usual maintenance dose is 150 mg daily. The maximum dose is 225 mg daily. Therapeutic blood levels are 50 to 200 ng per ml. An increase in the dose should be daily. Increase in

in the

maintained during

Suicide precautions should be

this time.

See Tricyclic Antidepressants

maprotiline hydrochloride (ma-proe'ti-leen)

4

Ludiomil (loo-dee'-oh-mil)

(p.

210).

mirtazapine (mer-taz'ah-peen)

Remeron

(rem-er' on)

Actions

Actions Maprotiline was the

first

of the tetracyclic antidepressants to

be released for clinical use. The mechanism of action

known, but pharmacologic response tricyclic antidepressants.

is

is

un-

similar to that with

The frequency and

severity of anti-

cholinergic effects, cardiac arrhythmias, and orthostatic hy-

potension are reported to be lower with maprotiline

compared with

the tricyclic antidepressants. There

is

is a tetracyclic antidepressant. The mechanism of unknown, but pharmacologic response is similar to

Mirtazapine action

is

that with tricyclic antidepressants.

There

is

a threefold higher

incidence of seizure activity and delirium associated with maprotiline therapy.

when

a three-

fold higher incidence of seizure activity and delirium associ-

Uses Mirtazapine

is

used

in the

treatment of depression.

ated with maprotiline therapy.

Therapeutic Outcomes

Uses

The primary

used in the treatment of depression and the depressive phase of bipolar disorder and for the relief of anxiety associated with depression. Maprotiline

is

therapy

is

outcome expected from mirtazapine

therapeutic

elevated

mood and

reduction of

symptoms of

depression.

Therapeutic Outcomes The primary therapy

therapeutic

elevated

is

outcome expected from maprotiline reduction of symptoms of

mood and

depression.

Nursing Process for Mirtazapine Therapy

Premedication Assessment 1.

Obtain baseline blood pressures

in

supine, sitting, and

standing positions; record and report significant hypotension to the physician before administering drug.

Nursing Process for Maprotiline Therapy

2.

Obtain baseline weight; schedule weekly weights.

3.

Check

Premedication Assessment I

Obtain baseline blood pressures

in

supine, sitting, and

4.

standing positions; record and report significant hypoten-

2.

v

sion to the physician before administering drug. Obtain baseline weight: schedule weekly weights.

(heck

for history

of seizures.

II

Check hepatic

o\'

seizures. If present, notify the physi-

5.

studies before initiation and periodically

Perform

DISCUS

or

AIMS

(see

Appendixes

specified intervals to delect and/or check on

6.

studies before initiation and periodically

Check hepatic

throughout course of administration.

present, notify physician

before starting therapy. 4

for history

cian before starting therapy.

and report according to policy. Obtain a baseline and periodic white blood cause agranulocytosis has been reported.

throughout course of administration. 5.

Perform

DISCUS

or

AIMS

(see

Appendixes

specified intervals to detect and/or check on

and report according

to policy.

G

and ID at EPS; record

Planning Availability:

PO:

15. M).

and 45

mg

tabids.

G and H) at EPS; record cell

count be-

.

Mood Disorders Implementation

timization of therapy.

Dosage and administration: Adult: PO: Initially, 15 mg daily. Every 1 to 2 weeks, the dosage may be increased up to a maximum of 45 mg daily. Increases in dose should be made

600

in the

evening because increased sedation is often present. Symptoms of depression may improve (e.g.,

Observation.

improved appetite, sleep, and psychomotor activity) within a few days. The depression still exists, however, and it usually takes several weeks of therapeutic doses before improvement in the depression is noted.

maintained during

Suicide precautions should be

mg

The normal dosage range

213

300

is

to

daily.

Observation: petite, sleep,

Symptoms of depression (e.g., improved apactivity) may improve within a

and psychomotor

few days. The depression takes several is

still exists, however, and it usually weeks of therapeutic doses before improvement

noted. Suicide precautions should be maintained during

this time.

Evaluation Side effects to expect

this time.

Drowsiness, Sedation. Nefazodone has mild to moderate

Evaluation

symptoms tend

sedating effects. These

See Tricyclic Antidepressants

(p.

to disappear with con-

tinued therapy and possible readjustment of the dose.

210).

Inform the patient of possible sedative

4

Serzone

effects.

The

patient

should use caution while driving or performing other tasks that require alertness. Consult with the physician to consider

nefazodone (nehf-as'oh-doan) (sur'zone)

moving

the daily dose to bedtime if sedation continues to be

a problem.

Actions Nefazodone

an antidepressant similar in chemical structure to trazodone. It inhibits serotonin reuptake from the neuronal cleft prolonging its action. It also blocks serotonin-2 receptors. Its mechanism of action as an antidepressant is is

unknown.

Uses

The use of

Nefazodone have

Blurred Vision; Constipation; Urinary Retention; Dryness Mucosa of the Mouth, Throat, and Nose. These symptoms are the anticholinergic effects produced by these agents. Patients taking these medications should be monitored for the development of these side effects. Dryness of the mucosa may be relieved by sucking hard candy or ice chips, or by chewing gum. of the

is

used to

treat depression.

less anticholinergic, hypotensive,

stool softeners such as docusate or the occa-

This agent appears to

sional use of a potent laxative such as bisacodyl

and sedative

quired for constipation.

activity

Caution the patient that blurred vision

relative to the tricyclic antidepressants.

may

be

re-

may occur and make

appropriate suggestions for personal safety of the individual.

Therapeutic Outcomes The primary therapy

is

Orthostatic Hypotension. Nefazodone

outcome expected from nefazodone elevated mood and reduction of symptoms of therapeutic

depression.

may cause some de-

gree of orthostatic hypotension manifested by dizziness and

weakness, particularly when therapy tor the

blood pressure daily

in

is

being

initiated.

Moni-

both the supine and standing

positions.

Anticipate the development of postural hypotension and take measures to prevent an occurrence. Teach the patient to

icess for

Nefazodone Therapy

rise

Premedication Assessment 1

2.

Obtain blood pressures

3.

in the supine, sitting,

and standing

sit

or

lie

down

if

feeling faint.

Sedative Effects. Tell the patient of sedative effects, espe-

positions; report significant lowering to the physician be-

cially during the onset of therapy. Single doses at

fore administering the medicine.

may

Obtain heart rate before and

at regular intervals

following

An ECG may

bedtime

diminish or relieve the sedative effects.

Side effects to report

Bradycardia. Monitor heart rate as therapy

and

be required for baseline information before starting therapy. Report significant lowering in blood pressure to the physician before admin-

dosing

istering the medicine.

ported. Notify the physician immediately. Withhold the next

Note any GI symptoms present before start of therapy. Monitor CNS symptoms present (e.g., insomnia or

dose

nervousness).

thoughts, feelings, and behaviors during the

initiation

4.

slowly from a supine or sitting position; encourage the

patient to

of therapy.

is

is

initiated

adjusted. Bradycardias with a drop in 15 beats per

minute and rates below 50 beats per minute have been until specifically

re-

approved.

Suicidal Actions. Monitor

the

patient

for

changes

initial

in

stages of

therapy.

Planning Availability:

PO:

50, 100, 150, 200,

250

mg

tablets.

Drug interactions Monoamine Oxidase

Inhibitors. Severe reactions including

excitement, diaphoresis, rigidity, convulsions, hyperpyrexia,

Implementation Dosage and administration: Adult: PO: Initially, 100 mg 2 times daily. At no less than weekly intervals, increase the dosage by 100 to 200 mg, again on a twice-daily schedule as tolerated. Several weeks of adjustment may be required to op-

and death have been reported with concurrent use of MAOIs and nefazodone. It is recommended that at least 14 days lapse between discontinuing an MAOI and starting nefazodone. It is further recommended that there be a 1-week stop interval between discontinuing nefazodone and starting MAOI therapy.

4

2

Chapter

1

1

5

Drugs Used for Mood Disorders

Haloperidol. Nefazodone

the

inhibits

metabolism

of

Planning

PO:

does not apparently increase the serum levels but does prolong the action of haloperidol. Doses may have to be given less often to prevent potential toxicity. Carbamazepine. Nefazodone inhibits the metabolism of carbamazepine. Monitor for signs of toxicity: disorientation, ataxia, lethargy, headache, drowsiness, nausea, and vomiting. Alprazolam, triazolam. Nefazodone significantly increases serum levels of these benzodiazepines. Monitor closely for excessive sedation and impaired motor skills.

Availability:

Nefazodone significantly increases serum levels of digoxin. Monitor serum levels and signs of toxicity (e.g.,

gradually,

arrhythmias, bradycardia).

creased sedation

haloperidol.

It

Digoxin.

John's Wort. Increased sedative-hypnotic effects

St.

may

occur.

50, 100. 150,

mg

and 300

tablets.

Implementation 150 mg mg daily every 3 to 4 days while monitoring clinical response. Do not exceed 400 mg daily in outpatients or 600 mg daily in hospi-

Dosage and administration: Adult: PO:

Initially.

divided doses. Increase in increments of 50

in three

talized patients.

Dosage should be

initiated at a

particularly

elderly

in

Dose increases should be made

low

level

and increased

or debilitated patients.

evening because

in the

in-

often present. Administer medication

is

shortly after a meal or with a light snack to reduce adverse effects.

Sibutramine, trazodone.

When

sibutramine or trazodone

are used in conjunction with nefazodone, a "serotonin syn-

drome" may develop, with symptoms of

irritability,

increased

muscle tone, shivering, myoclonus, and reduced consciousness. Cisapride. Nefazodone may significantly increase the serum concentrations of cisapride, causing potentially fatal cardiac

Observation. Symptoms of depression may improve (e.g., improved appetite, sleep, and psychomotor activity) within a few days. The depression still exists, however, and it usually requires several weeks of therapeutic doses before improvement is noted. Suicide precautions should be maintained during this time.

toxicities.

Evaluation

A trazodone hydrocholoride

^^

Desyrel

Side effects to expect

(trah 'zoh-doan')

and report

Confusion. Perform a baseline assessment of the patient's (dez-er'el)

degree of alertness and orientation to name, place, and time before starting therapy.

Make

regularly scheduled subsequent

Actions

evaluations of mental status and compare findings. Report de-

Trazodone was the first of the triazolopyridine antidepressants to be released for clinical use. The triazolopyridines are

velopment of

chemically unrelated to the other classes of antidepressants.

ing episodes of dizziness; report for further evaluation.

The exact mechanisms of action of trazodone are unknown. The actions are complex and in some ways resemble those of

ving a car, administering medicines, or performing other du-

the tricyclic antidepressants, benzodiazepines,

and phenoth-

however, the overall activity of trazodone from that of each of these classes of drugs. iazines;

is

different

alterations.

Dizziness, Light- headedness. Provide for patient safety dur-

Drowsiness. People

who

are

working with machinery,

which they must remain mentally

ties in

Orthostatic Hypotension. Although

episodes

may

are

infre-

cause some de-

gree of orthostatic hypotension manifested by dizziness and

Trazodone has been shown

be as effective in treating depression; depression associated with schizophrenia; and depression, tremor, and anxiety associated with alcohol dependence.

Compared with

to

other antidepressants,

it

zodone particularly useful

in patients

weakness, particularly when therapy itor

tra-

whose antidepressant

doses are limited by anticholinergic side effects and

in

pa-

blood pressure daily

is

being

initiated.

Mon-

both the supine and standing

Anticipate the development of postural hypotension and take measures to prevent an occurrence. Teach the patient to rise

slowly from a supine or sitting position; encourage the

patient to

sit

or

lie

down

if

feeling faint.

Arrhythmias, Tachycardia. Report for further evaluation.

with severe angle-closure glaucoma, prostatic hypertro-

Drug interactions Enhanced Sedative

phy, organic mental disorders, and cardiac arrhythmias.

in

positions.

has a low

incidence of anticholinergic side effects, which makes

tients

should not take

these medications while working.

quent and generally mild, trazodone

Uses

alert

dri-

Activity.

The following drugs enhance

Therapeutic Outcomes

the

The primary therapeutic outcome expected from trazodone

ethanol. barbiturates, narcotics, tranquilizers, antihistamines,

therapy

is

elevated

mood and

reduction of

symptoms

o\'

sedative

associated

with

trazodone

therapy:

anesthetics, phenothia/ines. and sedative-hypnotics.

recommended. wi imniM. (ionidine. Trazodone

rent therapy

depression.

effects

c.i

Concur-

not

is

inhibits

the

antihy-

pertensive effects of these agents. Concurrent therapy

is

not

recommended. lurslng Process for Trazodone

Therapy

Premedication Assessment I.

Nefazodone,

When SSRIs.

trazodone

Serotonin

Selecttv] is

used

in

of

sion to physician before administering drug.

and reduced consciousness.

a "serotonin

Inhibitors.

syndrome" may develop, with symptoms

Obtain baseline blood pressures in supine, sitting, and standing positions; record and report significant hypoten-

irritability,

Rium\m

conjunction with nefazodone or

increased muscle tone, shivering, myoclonus,

5

.

Chapter

Mood Disorders

Drugs Used for

5

2

by temporary reduction

Effexor (eef ex-ohr)

food.

Restlessness, Agitation, Anxiety, Insomnia. This

may

occurs early in therapy, and the patient

Actions is

a phenethylamine derivative antidepressant

structurally related to bupropion. is

usually

require short-term

treatment with sedative-hypnotic agents. Avoiding bedtime

Venlafaxine action

1

Nausea, Anorexia. Most of these effects may be minimized in dosage and administration with

venlafaxine (vehn-lah-fax'een)

•;

1

unknown,

is

it

Although

its

antidepressant

reuptake in the neuronal

weak

inhibitor of

dopamine

help decrease the incidence of insomnia.

Side effects to report

Suicidal Actions. Monitor

a potent inhibitor of reuptake of sero-

tonin and norepinephrine and a

may

doses

for

patient

changes

initial

in

stages of

therapy.

cleft.

Drug interactions Monoamine Oxidase

Uses approved for use in patients for the treatment of depression and generalized anxiety disorder. A disadvantage is the requirement of multiple doses daily. Venlafaxine

the

thoughts, feelings, and behaviors during the

Inhibitors. Severe reactions including

is

excitement, diaphoresis, rigidity, convulsions, hyperpyrexia,

Therapeutic Outcomes

and death have been reported with concurrent use of MAOIs and venlafaxine. It is recommended that at least 14 days lapse between discontinuing an MAOI and starting venlafaxine therapy, and vice versa. Cimetidine. Cimetidine inhibits the metabolism of venlafaxine. Patients should be closely monitored for excessive effects of venlafaxine when cimetidine is added to the thera-

The primary therapy

is

therapeutic

elevated

outcome expected from venlafaxine reduction of symptoms of de-

mood and

pression and anxiety.

peutic regimen.

John's Wort. Increased sedative-hypnotic effects

St.

may

occur.

lursing

1

2. 3.

When

Trazodone.

Premedication Assessment

trazodone

is

used

in

conjunction with

syndrome" may develop, with sympincreased muscle tone, shivering, my-

venlafaxine, a "serotonin

Obtain baseline weight.

toms of

Note any GI symptoms present before starting therapy. Monitor CNS symptoms present, such as insomnia or

oclonus, and reduced consciousness.

nervousness.

increases the frequency of EPS. If used concurrently, the dose

irritability,

Haloperidol. Venlafaxine increases haloperidol levels and

of haloperidol

may need

to

be decreased.

Planning

PO:

Availability:

75, and 150

mg

25, 37.5, 50, 75, and 100

mg

tablets; 37.5,

sustained-release capsules.

Implementation Dosage and administration: Adult: PO: 75 mg daily, taken with food in two or three doses. Doses may be increased by 75 mg daily at intervals greater than every 4 days. The maximum recommended dosage is 375 mg daily, generally in three divided doses. Discontinuation of therapy. If the patient has taken the

Drug

4

Class:

Antimanic Agents

lithium carbonate (lith-ee'um) Eskalith (esk-ah'lith), Lithane (lith'ane)

Actions Lithium is a monovalent cation that competes with other monovalent and divalent cations (potassium, sodium, calcium,

magnesium)

at

cellular binding

sites

that

are sensitive to

medicine for more than 1 week, the dosage should be tapered over the next few days. If venlafaxine has been taken for longer than 6 weeks, the dosage should gradually be tapered over the next 2 weeks. Observation. Symptoms of depression may improve within a few days (e.g., improved appetite, sleep, and psychomotor activity). The depression still exists, however, and it usually requires several weeks of the therapeutic doses before improvement is noted. Suicide precautions should be maintained

changes in cation concentration. Lithium replaces intracellular and intraneuronal sodium, stabilizing the neuronal membrane. It also reduces the release of norepinephrine and increases the

during this time.

entiating

Evaluation

Uses

uptake of tryptophan, the precursor to serotonin.

of action of lithium It

should be warned not to

also inter-

in treating

mood

disorders are

unknown.

has no sedative, depressant, or euphoric properties, differ-

Lithium

Side effects to expect

It

second-messenger cellular processes to inhibit intracellular concentrations of cyclic adenosine monophosphate. Because of the complexity of the CNS, the exact mechanisms acts with

it

is

from

all

used to

other psychotropic agents.

treat acute

mania and

for the prophylaxis

work with machinery,

drive a car, administer medication, or

of recurrent manic and depressive episodes in bipolar disorder. In patients with bipolar disorder, it is more effective in

perform other duties

which mental alertness

preventing signs and

Dizziness, Drowsiness. People

til

in

is

required, un-

they are sure that these side effects are not impairing ac-

tions

and judgment.

1

pression.

It

is

symptoms of mania than those of desome patients in reducing the

also effective in

recurrence of depressive episodes in unipolar disorder.

6

2

Chapter

1

1

5

Drugs Used for Mood Disordcr

Therapeutic Outcomes The primary apy

is

therapeutic

Hand Tremor. These and tend to resolve within a week with continued therapy. Encourage the patient not to disconExcessive Thirst and Urination, Fine

outcome expected from lithium

maintaining the individual

at

ther-

an optimal level of func-

tioning with minimal exacerbations of

mood

swings.

side effects are usually mild

tinue therapy without

symptoms

persist or

first

consulting the physician. If these

become

severe, the patient should con-

sult the physician.

Side effects to report

Vocess for Lithium Therapy

Persistent

Premedication Assessment 1.

Before the initiation of lithium therapy, the following labtests should be completed for baseline infor-

oratory

mation: electrolytes, fasting blood glucose, blood urea nitrogen

(BUN), serum

urinalysis, 2.

creatinine, creatinine clearance,

and thyroid function

in

supine, sitting, and

standing positions; record and report significant hypoten-

4.

all

Hyperreflexia,

signs of impending se-

do not administer

the

next dose until reconfirmed by the physician.

Progressive Fatigue, Weight GAiN.These

may

be early signs

of hypothyroidism. Report for further evaluation.

These are

all

Ankle Edema, Metallic Taste, Hyperglycemia. rare side effects from lithium therapy. Report for

further evaluation.

Nephrotoxicity. Monitor urinalysis and kidney function

Weigh daily; check hydration of patient (e.g., moistness of mucous membranes, skin turgor, firmness of eyeball); monitor urine specific gravity. Lithium may enhance sodium depletion, which enhances lithium toxicity. Assess for early signs of lithium toxicity before giving medication, including nausea, vomiting, ab-

dominal pain, diarrhea, lethargy, speech dizziness, muscle twitching, and tremor.

Diarrhea,

rious toxicity. Report immediately, and

Pruritus,

tests.

Obtain baseline blood pressures

sion to the physician before administering drug. 3.

Profuse

Vomiting,

Lethargy, and Weakness. These are

difficulty,

mild

tests for

abnormal

results.

Report an increasing

BUN and cre-

atinine, increasing or decreasing urine output or decreasing

specific gravity (despite

amount of

and casts or

fluid intake),

protein in the urine.

Drug interactions Reduced Serum Sodium Levels. Therapeutic activity and toxicity of lithium are highly dependent on sodium concentrations. Decreased sodium levels significantly enhance the toxicity of lithium.

Planning

who

Patients

Availability:

PO:

300 and 450

mg

150, 300, and

600

mg

capsules and tablets;

slow-release tablets; and 300

mg

per 5 ml

diet,

low-sodium

are to begin diuretic therapy, a

or activities that produce excessive and prolonged sweat-

ing should be observed particularly closely.

Methyldopa. Monitor patients on concurrent, long-term

syrup.

Serum Lithium Levels. Levels are monitored once or twice weekly during initiation of therapy and monthly while on a maintenance dose. Blood should be drawn approximately 12 hours after the last dose was administered. The normal serum level is 0.4 to 1.5 mEq/L. Report serum levels above

therapy for signs (nausea, vomiting, abdominal pain, diarrhea,

these values to the physician promptly.

to potentially toxic levels

lethargy, speech difficulty, mild dizziness, and tremor) of the development of lithium toxicity.

Nsaids.

Good Nutrition. Lithium may enhance sodium depletion, which enhances lithium toxicity. It is important that patients maintain a normal dietary intake of sodium with adequate maintenance fluids (10 to 12 8-oz glasses of water daily), es-

Mood when

Dosage and administration: Adult: PO: 300 to 600 mg 3 to 4 times daily. Administer with food or milk. Adequate diet is important to maintain normal serum sodium levels and prevent the development of toxicity. Onset of the acute antimanic effect of lithium usually occurs within 5 to 7 days; full thera-

peutic effect often requires 10 to 21 days.

Evaluation Side effects to expect .

Vomiting, Anorexia, Abdominal Cramps. These side

effects are usually mild

therapy.

and tend to resolve with continued Encourage the patient not to discontinue therapy

without lust consulting the physician. II

gastric

food or milk.

irritation If

occurs,

symptoms

administer medication

with

persist or increase in severity, re-

port lor physician evaluation. These ma) also be early signs of toxicity.

(e.g.,

ibuprofen, naproxen, piroxicam) reit

to

accumulate

CHAPTER REVIEW

pecially during the initiation of therapy, to prevent toxicity.

Implementation

NSAIDs

duce the renal excretion of lithium, allowing

disorders (affective disorders) are said to be present certain

symptoms impair the person's ability to funcAt least 10% of people in the United

tion for a period.

States suffer from a diagnosable time.

Mood

mood

disorder

in

their

life-

disorders are divided into depressive (unipolar)

and bipolar disorders. Treatment of mood disorders requires both nonpharmacologic and pharmacologic therapy. Simultaneous psychotherapy and pharmacologic treatments have been shown to be more successful than either treatment alone. Antidepressant medications act on a variety of receptors both in the CNS and in the peripheral tissues and are associated with many side effects and drug interactions. It is a responsibility of the nurse to educate patients about therapy, monitoring for therapeutic benefit and side effects to expect and report, as well as intervening whenever possible to optimize therapeutic outcomes.

.

.

hand: Lithium carbonate

mg PO, twice mg tablets

50

1

daily

When

4.

it

Ordered: maprotiline 100

mg

this

am

On hand: None found in medication container; consult drug monograph for dose availability. What strength tablets

would most

likely

be dispensed, and

how would

CRITICAL THINKING QUESTIONS

tion

2.

would you

What

elicit?

interventions to alleviate

ticipated

occurred.

if it

clinical settings

where

opment

How

of EPS.

fied of

changes

5

ft

6

in tall,

weighs

1

20

lb,

"cloud has been

additional data

and has been

lifted

how

in

the

when

is

the physician noti-

is

being treated for

mg PO 4

in

the

clinic.

in this

level

What symptoms The

8.

collect during

situation,

how would you proceed?

reviewing Martha's history, the nurse reads that

her lithium

He reports that he from my mind." What

would be appropriate to

is,

ication for the past "4 days."

receiving the medication for 6 weeks. feels like a

this

times daily. She During the intake interview she tells the nurse that her medicine "never works." Further exploration reveals that she has not taken the medbeing seen today

is

When

is

what

the patients behavior?

in

bipolar disorder with lithium 300

As the nurse

He

therapy,

often are the assessments made,

Clinical Case: Martha Halleran, age 34,

7.

(Prozac).

MAOI

practicing to assess for the devel-

are they recorded, and

The next

taking fluoxetine

for

and the interventions that should be an-

it,

6.

is

monograph

potential complication of this

a hypertensive crisis. Discuss

these symptoms could be suggested? patient at the clinic

one major

to recognize

how

During her clinic visit, Mrs. Smalley complains to the nurse that since she started taking amitriptyline (Elavil) for depression, she has had a "terrible dry mouth," and she feels "sleepy all the time." What additional informa-

is

MAOI, what

Discuss the behavioral monitoring sheets used

5.

you administer the dose?

1

starting therapy with an

is

would be important?

looking at the drug

states that

therapy

tablets

Give:

a patient

health teaching

Ordered: Lithium carbonate 300

On

When

3.

MATH REVIEW

217

Drugs Used for Psychosis

Chapter 16

month before was 2.0 mEq/L. might be seen with this lithium level?

taken the

history also notes that the importance of adequate

water and sodium was discussed with Martha. does the sodium level within the body influence the metabolism of lithium? intake of

this visit?

How

Drugs Used for Psychosis

CHAPTER CONTENT Psychosis

(p.

4.

Drug Therapy

(p.

for Psychosis

2.

Identify signs

adverse effects observed with antipsy-

Develop

a teaching plan for a patient taking haloperidol

1

(p.

219)

Agents

(p.

224)

Objective 1

common

and one receiving clozapine.

2 8)

Class: Antipsychotic

Identify

chotic medications.

218)

Treatment of Psychosis

Drug

3.

|

and symptoms of psychotic behavior.

Key Words psychosis

changes

delusion

target

symptoms

hallucinations

typical

and atypical antipsy-

disorganized thinking

in affect

chotic agents

Describe major indications for the use of antipsychotic

loosening of associations

equipotent doses

agents.

disorganized behavior

extrapyramidal symptoms

218

Drugs

Chapter 16

Fn^H.

sea jor rsycnosis

obliquely related or completely unrelated (tangentiality). At

Key Words

its

dyskinesia identification sys-

dystonia

tems: condensed user scale

pseudoparkinsonian

symptoms

neuroleptic malignant

syndrome

akathisia

abnormal involuntary move-

ment

this

incoherence of thought extends into pro-

and the speaker's words become garbled or unrecognizable. Speech may also be overly concrete (loss of ability to think in abstract terms) and inexpressive; it may be repetitive, or although vociferous, it may convey little or no itself,

real information.

Disorganized behavior

depot antipsychotic

tardive dyskinesia

most serious,

nunciation

of psychoses. Problems

is

common

another

may be noted

characteristic

any form of goaldirected behavior, leading to difficulties in performing activities of daily living (ADLs) such as organizing meals or maintaining hygiene. The patient may appear markedly disheveled, may dress in an unusual manner (e.g., wearing several layers of clothing, scarves, and gloves on a hot day), or may display clearly inappropriate sexual behavior (e.g., public masturba-

medicine

scale

PSYCHOSIS Psychosis does not have a single definition but

in

a clinical

tion) or unpredictable, nontriggered agitation (e.g.. shouting

means being out of touch with reality. Psychotic symptoms can be associated with many illnesses,

or swearing). Disorganized behavior must be distinguished

descriptor

including dementias and delirium that

may have

infectious, or endocrine causes. Psychotic

common

is

that

in

mood

symptoms

are also

disorders such as major depression and

many drugs

bipolar disorder. Psychosis can also be caused by (e.g.,

metabolic,

phencyclidine, opiates, amphetamines, cocaine, hallu-

cinogens, anticholinergic agents, and alcohol). Psychotic disorders are characterized by loss of reality, perceptual deficits

such as hallucinations and delusions, and deterioration in soOf the several psychotic disorders defined by

cial functioning.

American Psychiatric Association in the Diagnostic and Manual of Mental Disorders, 4th edition, schizophrenia is the most common. Psychotic disorders are extremely complex illnesses that are influenced by biologic, psychosocial, and environmental circumstances. Some of the disorders require several months the

from behavior that is merely aimless or generally not purposeful and from organized behavior that is motivated by delusional beliefs.

Changes in affect may also be a symptom of psychosis. Emotional expressiveness is diminished; there is poor eye contact and reduced spontaneous movement. Patients appear to be withdrawn from others; the face appears immobile and unresponsive. Speech is often minimal with only brief, slow, monotone replies to questions. There is a withdrawal from areas of functioning in interpersonal relationships, work, education, and self-care.

Statistical

of observation and testing before a termined.

It

is

beyond

final

diagnosis can be de-

the scope of this text to discuss psy-

chotic disorders in detail, but general types of

symptoms

as-

A

delusion

is

a false or irrational belief that

is

firmly held

may

be

persecutory, grandiose, religious, sexual, or hypochondriac.

Delusions of reference,

in

which the

patient attributes a spe-

and usually negative significance to other peosuch as song lyrics or newspaper articles in relation to self are common. Delusions may be defined as "bizarre" if they are clearly irrational and do not derive from ordinary life experiences. A common bizarre delusion is cial, irrational,

ple, objects, or events

the patient's belief that the thinking process, parts of the body,

by some ex-

or actions or impulses are controlled or dictated ternal force.

Hallucinations are false sensory perceptions

that are

ert

perienced without an external stimulus but that nevertheless

seem as

real to the patient.

Auditory hallucinations, experienced

'voices" characteristically heard that are

commenting neg-

atively about the patient in the third person, are

prominent

in

schizophrenia. Hallucinations oi touch, sight, taste, smell, and bodil) sensation also occur.

Disorganized thinking is commonly associated with ps\ choses The thought disorders may consist of a loosening of associations so thai the speaker jumps from one idea or topic to another unrelated

one f derailment)

pnate. or disorganized way.

in

Answers

an illogical, inappro to

initial

cannot be underestimated

assessment for accurate diagnosis with acute psychosis.

in a patient

A

thorough physical and neurologic examination, mental status examination, complete family and social history, and laboratory

workup must be performed

to

exclude other causes of

psychoses, such as substance abuse. Both drug and nondrug

sociated with psychotic disorders are described as follows. despite obvious evidence to the contrary. Delusions

Treatment of Psychosis The importance of

questions may* be

therapies are critical to the treatment of most psychoses.

term outcome

is

improved

in patients

Long-

with an integrated drug

and nondrug treatment regimen. Nonpharmacologic intervenimprove insight into the illness and assist the patient in coping with stress, group therapy to enhance socialization skills, behavioral or cognitive therapy, and vocational training are beneficial to patients. Before initiation of therapy, the treatment goals and baseline level of functioning must be established and documented. Target symptoms must also be identified and documented. Target symptoms are critical monitoring parameters that are used to assess change in clinical status and response to medications. Examples of target symptoms include frequency and type of agitation, degree of suspiciousness, delusions, hallucitions such as individual psychotherapy to

nations,

loose associations,

grooming habits and hygiene,

sleep patterns, speech patterns, social skills, and judgment.

The ultimate goal

is

to restore behavioral, cognitive,

and psy-

chosocial processes and skills to as close to baseline levels as possible so that the patient is reintegrated into the community. Realistically, unless the psychosis is part of another medical diagnosis such as substance abuse, most patients will have re-

curring

symptoms of the menial disorder mosl of

Treatment target

is

their lives.

therefore focused on decreasing the severity

symptoms

thai

mosl interfere with functioning.

o\'

9

\.napier id

2

Drugs Used for Psychosis

1

Drug Therapy for Psychosis Pharmacologic treatment of psychosis is accomplished with several classes of drugs. The most specific are the antipsychotic agents, but benzodiazepines (see p. 195) are often used for control of acute psychotic symptoms. The beta-adrenergicblocking agents (see

p. 163),

antiparkinson agents (see

p.

1

79),

and anticholinergic agents (see p. 189) occasionally play a role in controlling adverse effects of antipsychotic therapy. Antipsychotic agents can be classified in several ways. Traditionally, they have been divided into the phenothiazines and the nonphenothiazines (Table 16-1 ). Antipsychotic agents can also be classified as low-potency or high-potency drugs. Low and high potency refers only to the milligram doses used for these medicines and does not suggest any difference in effectiveness (e.g., 100 mg of chlorpromazine, a lowpotency agent, is equivalent in antipsychotic activity to 2 mg of haloperidol, a high-potency agent). Chlorpromazine and thioridazine are considered low-potency agents, while triflu-

Antipsychotic Medicines Patients starting to take antipsychotic medicine can ex-

pect

therapeutic effect such as reduced psychomo-

some

tor agitation and insomnia within

reduction

in

I

week

hallucinations, delusions,

ders often requires 6 to 8 weeks for

of therapy, but

and thought disorfull

therapeutic re-

dosages of antipsychotic medication will not reduce the antipsychotic response time but will increase the frequency of adverse effects. Antipsychotic medicines may produce extrapyramidal sponse. Rapid increases

in

effects. Tardive dyskinesia

stages, but

it

becomes

may be

reversible

in

the early

irreversible with continued use of

the antipsychotic medication. Regular assessment for tar-

completed for all patients reOlder patients should be observed for hypotension and tardive dyskinesia. dive dyskinesia should be

ceiving antipsychotic agents.

operazine, fluphenazine, thiothixene, haloperidol, loxapine,

and molindone are considered high-potency agents. Since 1990, antipsychotic agents have also been classified as typical or atypical antipsychotic agents, based on mechanism of action.

The

atypical antipsychotic agents are clozapine, olan-

zapine, quetiapine, and risperidone. All of the remaining an-

The

initial

goal of antipsychotic therapy

is

both to calm the

who may

be a physical threat to self or others and to begin treatment of the psychosis and thought disorder. Combined therapy with benzodiazepines (often lorazepam) agitated patient

tipsychotic agents in Table 16-1 are considered to be typical

and antipsychotic agents allows lower doses of the antipsy-

antipsychotic agents.

chotic agent to be used, reducing the risk of serious adverse effects

Actions All

antipsychotic

more commonly seen with higher-dose

therapy.

Some

therapeutic effect such as reduced psychomotor agitation and

agents

antagonize

the

neurotransmitter

dopamine in the central nervous system (CNS). However, the exact mechanisms by which this prohibits psychotic symptoms is unknown. There is substantially more to the development of psychotic symptoms than elevated dopamine levels. There are at least five known types of dopamine receptors in various areas of the CNS. The typical antipsychotic agents specifically block Dl and D2 receptors. It is thought that an-

insomnia are observed within

1

week of

therapy, but reduc-

tagonism of the D2 receptors in the mesolimbic area of the brain reduces psychotic symptoms. Antipsychotic agents also block cholinergic, histaminic, serotonergic, and adrenergic neurotransmitter receptors to varying degrees, accounting for

and thought disorder often require 6 to 8 weeks for full therapeutic effect. Rapid increases in the dosing of antipsychotic medicines will not reduce the antipsychotic response time. Patients, families, and the health-care team must be educated to give antipsychotic agents an adequate chance to work before unnecessarily escalating the dosing and increasing the risk of adverse effects. After an acute psychotic episode has resolved and the patient is free from overt psychotic symptoms, a decision must be made as to whether maintenance therapy is necessary. This will depend on the diagnosed psychotic disorder and the pa-

many of the adverse

tient's

effects of therapy. Clozapine, quetiapine,

and risperidone are atypical in their action in that clozapine activity appears to be more specific for blocking Dl and D4 receptors, whereas quetiapine and risperidone, in addition to D2-blocking activity, also blocks serotonin receptors.

Uses All antipsychotic agents are equal in efficacy

when used

in

equipotent doses. There is some unpredictable variation between patients, however, and individual patients do sometimes show a better response to particular drugs. In general, selection of medication should be based

on the need

to avoid

tions in hallucinations, delusions,

tolerance of the adverse effects of the

disorder.

Adverse Effects of Antipsychotic Therapy Many

of the serious adverse effects of the antipsychotic

agents can be attributed to the pharmacologic effect of blocking dopaminergic, cholinergic, histaminic, serotonergic, and

adrenergic neurotransmitter receptors. Whereas these agents

D2

receptors in the mesolimbic area of the brain to stop

certain side effects in concurrent medical or psychiatric dis-

block

no proof exists that agitation responds best to sedating drugs or that withdrawn patients respond best to nonsedating drugs. Medication history should be a major factor in drug selection. The final important factors

psychotic symptoms, blockade of the

orders. Despite practice trends,

drug selection are the clinically important differences in frequency of adverse effects. No single drug is least likely to cause all adverse effects; thus individual response should be in

the best determinant of

which drug

is

to

be used.

medicine.

However, most psychotic disorders are treated with lower maintenance doses to minimize the risk of recurrence of the

D2

receptors in other ar-

eas of the brain explains the occurrence of extrapyramidal effects.

Extrapyramidal effects are the most troublesome side efand the most common cause of noncompliance associ-

fects

ated with antipsychotic therapy. There are four categories

symptoms (EPS): dystonic reactions, pseudoparkinsonism. akathisias. and tardive dyskinesia. Neu-

of extrapyramidal

220

•j

Chapter

Drugs Used for Psychosis

6

1

Antipsychotic Agents

fVC )T

Brand Name

Availability

Range (MG) Sedation

Thorazine,

Tablets: 10,25,50, 100,

30-1000

Name

Ge neric

Major

Adult

C* ^Miy

EPS*

Side Effects

Hypotension

Ace|

Phenothiaiines Chlorpromazine

200 mg

^Largactil

Sustained release capsules:

I50mg

30,75,

Syrup: 10 mg/5 ml; 30, 1

00 mg/ml

mg/ml

Injection: 25, 100

Fluphenazine

Mesoridazine

Prolixin,

Tablets: 1,2.5,5, 10

Permitil,

Elixir: 2.5

Moditen

Injection:

Serentil

Tablets:

1

mg

0.5-20

mg/5 ml; 5 mg/ml 2.5, 25 mg/ml 0, 25, 50,

mg

00

1

30-400

Concentrate: 25 mg/ml

25 mg/ml

Injection:

Perphenazine

Tablets: 2, 4, 8,

Trilafon

Concentrate: Prochlorperazine

1

6

1

mg

mg

Compazine,

Tablets: 5, 10,25

Stemetil

Sustained release capsules: 10,

2-64

+++

15-150

+++

1

6 mg/5 ml

I5,30mg

Syrup: 5 mg/5 ml Injection: 5

mg/ml

Suppository: 2.5,

Promazine

Sparine

Injection:

Thioridazine

5,

mg

25

50 mg 25, 50 mg/ml

40-1000

Tablets: 25,

Tablets:

Mellaril

1

50,

1

0,

1

5,

25, 50,

1

00,

1

50-800

200 mg

Suspension: 25, 100 mg/5 ml

Concentrate: 30, 100 mg/ml Trifluoperazine

Tablets: 1,2,5, 10

Stelazine

mg

2-40

Concentrate: 10 mg/ml Injection: 2

Triflupromazine

mg/ml 60- 50

10,20 mg/ml

Vesprin

Injection:

Navane

Capsules: 1,2,5. 10,20

1

Thioxanthenes Thiothixene

mg

6-60

Nonphenothiaz/nes

mg

Clozapine

Clozaril

Tablets: 25, 100

Haloperidol

Haldol,

Tablets: 0.5, 1,2,5,

Loxapac

5, 10,25,50 mg Concentrate: 25 mg/ml Injection: 50 mg/ml

Moban

Tablets: 5, 10,25,50, 100

Loxitane,

Molindone

1-15

+++ +

Concentrate: 2 mg/ml Injection: 5, 50, 100 mg/ml

Peridol

Loxapine

300-900

I0,20mg

20-250

Capsules:

mg

++

+++

15-225

Concentrate: 20 mg/ml

Olanzepine

Zyprexa

Tablets: 2.5. 5, 7.5, 10

Quetiapine

Seroquel

Tablets: 25, 100,

200

Risperidone

Risperdal

Tablets:

4

mg

1

Solution:

I

I

low;

loderate;

I

mpiom.
mouth, drowsiness, confusion, muscular weakness, and nau-

'

may add

symp-

tients

(K

then

Hives, Pruritus, Rash. Report

Electrolyte

sea.

who

allopurinol to the patient's medication regimen.

gas-

If

evaluation.

may

port to the physician,

tus

Gastric Irritation, Nausea, Vomiting, Constipation.

receiving thiazide therapy. Monitor the

Many symptoms

is

is

most

often pre-

associated with altered fluid and elec-

Digitai

is

Glycosides. Thiazide diuretics

may cause

exces-

sive excretion of potassium, resulting in hypokalemia. patient

is

If

the

also receiving a digitalis glycoside, monitor closely

tor digitalis toxicity (anorexia, nausea, fatigue, blurred or col-

ored vision, bradycardia, arrhythmias). Corticosteroids. Corticosteroids

(e.g..

prednisone)

may

enhance the loss of potassium. Check potassium levels and monitor more closel) for hypokalemia when these two agents arc used concurrently.

343

Drugs Used for Diuresis

Chapter 25

Thiazide-Related Products Diuretic

Brand Name

Chlorthalidone

Hygroton.Thalitone

Indapamide

Lozol

2.5-5

Metolazone

Zaroxolyn, Mykrox

2.5-10

Quinethazone

Hydromox

may

Lithium. Thiazide diuretics

Monitor patients for lithium

Dosage Forms Available

Dosage Range (MG) 50-200

Tablets: 15,25,50, 100 Tablets:

induce lithium toxicity.

by nausea,

.25, 2.5

Tablets:

50

mg

mg

Tablets: 0.5, 2.5, 5, 10

50

toxicity manifested

1

mg

mg

Planning PC-

Availability:

'S

mg

tablets.

anorexia, fine tremors, persistent vomiting, profuse diarrhea,

Implementation

hyperrefiexia, lethargy, and weakness.

Nonsteroidal Antiinflammatory Drugs.

NSAIDs

(e.g., in-

domethacin, ibuprofen, naproxen) inhibit the diuretic activity of this agent. The dose of thiazide may have to be increased or the NSAID discontinued. Maintain accurate I&O records, and monitor for a decrease in diuretic activity.

Oral Hypoglycemic Agents,

Because of the hyperglycemic effects of the thiazide diuretics, dosage adjustments of insulin and oral hypoglycemic agents are often required. Insulin.

Dosage and administration Adult.

—

PO mg

Initially

5

mg

daily.

Dosages may be

in-

increments up to 20 mg daily with close monitoring of electrolytes. Administer with food or milk to reduce

creased in 5

gastric irritation.

DO NOT

administer after midafternoon to

prevent nocturia.

Evaluation Side effects to expect

Drug

Anorexia, Nausea, Vomiting, Flatulence. These side ef-

Class: Potassium-Sparing

fects should

Diuretics

for other causes, as well as for the

i amiloride (am-ihl-or'eyd)