Pharmacology and The Nursing Process - Linda Lane Lilley PDF

EIGHTH EDITION
Organization
New to This Edition
Additional Teaching/Learning Features
Supplemental Resources
Acknowledgments
We Welcome Your Feedback
Introduction
Overview of the Nursing Process
Assessment
Nursing Diagnoses
Planning: Outcome Identification
Implementation
Evaluation
Key Points
NCLEX® Examination Review Questions
Critical Thinking and Prioritization Questions

Overview
Pharmaceutics
Pharmacokinetics
Pharmacodynamics
Pharmacotherapeutics
Pharmacognosy
Pharmacoeconomics
Toxicology
Summary
Key Points
Overview
Drug Therapy during Pregnancy
Drug Therapy during Breastfeeding
Considerations for Neonatal and Pediatric Patients
Considerations for Older Adult Patients
Nursing Process
Key Points
Cultural Considerations
Legal Considerations
Ethical Considerations
Nursing Process
Key Points
General Impact of Errors on Patients

Medication Errors
Issues Contributing to Errors
Preventing, Responding to, Reporting, and Documenting Medication Errors: a Nursing Perspective
Other Ethical Issues
Summary
Key Points
Overview
Assessment of Learning Needs Related to Drug Therapy
Nursing Diagnoses Related to Learning Needs and Drug Therapy
Planning: Outcome Identification as Related to Learning Needs and Drug Therapy
Implementation Related to Patient Education and Drug Therapy
Evaluation of Patient Learning Related to Drug Therapy
Summary
Patient-Centered Care: Patient Teaching
Key Points
Over-the-Counter Drugs
Herbals and Dietary Supplements
Nursing Process
Key Points
Overview
Basic Principles of Genetic Inheritance
Discovery, Structure, and Function of DNA
Gene Therapy
Pharmacogenetics and Pharmacogenomics
Application of the Nursing Process as Related to Genetic Principles
Summary
Key Points
Preparing for Drug Administration
Enteral Drugs
Parenteral Drugs
Topical Drugs
Illustration Credits
Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Concept Mapping
Overview
General Anesthetics
Drugs for Moderate Sedation
Local Anesthetics
Neuromuscular Blocking Drugs
Nursing Process

Key Points
Overview
Physiology of Sleep
Benzodiazepines and Miscellaneous Hypnotic Drugs
Barbiturates
Over-the-Counter Hypnotics
Muscle Relaxants
Nursing Process
Key Points
Overview
Attention Deficit Hyperactivity Disorder
Narcolepsy
Obesity
Migraine
Analeptic-Responsive Respiratory Depression Syndromes
Drugs for Attention Deficit Hyperactivity Disorder and Narcolepsy
Anorexiants
Antimigraine Drugs
Drugs for Specific Respiratory Depression Syndromes: Analeptics
Nursing Process
Key Points
Epilepsy
Antiepileptic Drugs
Nursing Process
Key Points
Indirect-Acting Dopaminergic Drugs
Direct-Acting Dopamine Receptor Agonists
Anxiety Disorders
Affective Disorders
Psychotic Disorders
Opioids
Stimulants
Depressants
Alcohol
Nicotine
Nursing Process
Patient-Centered Care: Patient Teaching Tips
Key Points
Vocabulary
Text Notation
Enhanced Typeface
Overview
Sympathetic Nervous System
Adrenergic Drugs
Nursing Process
Key Points
Overview
Alpha Blockers
Beta Blockers
Nursing Process
Key Points
Overview
Parasympathetic Nervous System
Cholinergic Drugs
Nursing Process
Key Points
Cholinergic-Blocking Drugs
Nursing Process

Key Points
Study Time
Learning Styles
Use of Applications
Mnemonics
Flash Cards
Anatomy, Physiology, and Pathophysiology Overview
Pharmacology Overview
Review of Autonomic Neurotransmission
Adrenergic Drugs
Angiotensin-Converting Enzyme (ACE) Inhibitors
Angiotensin II Receptor Blockers
Calcium Channel Blockers
Diuretics
Vasodilators
Miscellaneous Antihypertensive Drugs
Nursing Process
Key Points
Overview
Nitrates and Nitrites
Beta Blockers
Miscellaneous Antianginal Drug

Summary of Antianginal Pharmacology
Nursing Process
Key Points
Overview
Angiotensin-Converting Enzyme Inhibitors
Beta Blockers
Aldosterone Antagonists
Miscellaneous Heart Failure Drugs
B-Type Natriuretic Peptide
Phosphodiesterase Inhibitors
Cardiac Glycosides
Nursing Process
Key Points
Dysrhythmias and Normal Cardiac Electrophysiology
Antidysrhythmic Drugs
Nursing Process
Key Points
Overview
Anticoagulants
Antiplatelet Drugs
Thrombolytic Drugs
Antifibrinolytic Drugs
Nursing Process
Key Points
Overview
Lipids and Lipid Abnormalities
Atherosclerotic Plaque Formation
Cholesterol and Coronary Heart Disease
Hyperlipidemias and Treatment Guidelines
Hydroxymethylglutaryl–Coenzyme a Reductase (HMG-CoA Reductase) Inhibitors
Bile Acid Sequestrants
Niacin
Fibric Acid Derivatives
Miscellaneous Antilipemic Drug
Nursing Process
Key Points
Overview
Carbonic Anhydrase Inhibitors
Loop Diuretics
Osmotic Diuretics
Potassium-Sparing Diuretics
Thiazides and Thiazide-Like Diuretics
Nursing Process
Key Points
Overview
Crystalloids
Colloids
Blood Products
Physiology of Electrolyte Balance
Potassium
Sodium
Nursing Process
Key Points
Study Groups
Chat Rooms and Discussion Groups
Endocrine System
Pituitary Drugs
Nursing Process
Key Points
Thyroid Function
Pathophysiology of Hypothyroidism
Pathophysiology of Hyperthyroidism
Thyroid Replacement Drugs
Antithyroid Drugs
Nursing Process
Key Points
Insulins
Oral Antidiabetic Drugs
Injectable Antidiabetic Drugs
Sodium Glucose Cotransorter Inhibitors (SGLT2 Inhibitors)
Glucose-Elevating Drugs
Adrenal System
Adrenal Drugs
Nursing Process
Key Points
Female Sex Hormones
Contraceptive Drugs
Drugs for Osteoporosis
Drugs Related to Pregnancy, Labor, Delivery, and the Postpartum Period
Male Reproductive System

Androgens and Other Drugs Pertaining to Men's Health
Nursing Process
Key Points
Time Management
Practice Questions
Overview
Antihistamines
Decongestants
Antitussives
Expectorants
Nursing Process
Key Points
Bronchodilators
Nonbronchodilating Respiratory Drugs
Active Questioning
NCLEX® Practice
Antibiotics
Beta-Lactam Antibiotics
Macrolides
Ketolides
Tetracyclines
Overview
Pathophysiology of Resistant Infections
Aminoglycosides
Quinolones
Miscellaneous Antibiotics
Nursing Process
Key Points
General Principles of Virology
Overview of Viral Illnesses and Their Treatment
Herpes Simplex Virus and Varicella-Zoster Virus Infections
Hepatitis
Antivirals (Non-HIV)
HIV Infection and Aids
Drugs Used to Treat HIV Infection
Nursing Process
Key Points
Pathophysiology of Tuberculosis
Antitubercular Drugs
Nursing Process
Key Points
Fungal Infections
Antifungal Drugs
Nursing Process
Key Points
Overview
Pathophysiology of Malaria
Antimalarial Drugs
Other Protozoal Infections
Antiprotozoal Drugs
Helminthic Infections
Anthelmintic Drugs
Nursing Process
Key Points
Overview
Nonsteroidal Antiinflammatory Drugs
Antigout Drugs
Nursing Process

Key Points
Application of Pharmacology and Making Connections
Cell Cycle–Specific Antineoplastic Drugs
Cell-Cycle–Nonspecific Antineoplastic Drugs
Miscellaneous Antineoplastics
Hormonal Antineoplastics
Immune System
Immunosuppressant Drugs
Nursing Process
Key Points
Immunity and Immunization
Immunizing Drugs
Nursing Process
Key Points
Studying for Tests
Test-Taking Strategies
Performance Evaluation
Overview
Acid-Related Pathophysiology
Antacids
H2 Receptor Antagonists
Proton Pump Inhibitors
Miscellaneous Acid-Controlling Drugs
Nursing Process
Key Points
Overview
Antidiarrheals
Laxatives
Drugs for Irritable Bowel Syndrome
Nursing Process
Key Points

Nausea and Vomiting
Antiemetic Drugs
Nursing Process
Key Points
Overview
Fat-Soluble Vitamins
Water-Soluble Vitamins
Minerals
Erythropoiesis
Types of Anemia
Erythropoiesis-Stimulating Drugs
Iron
Folic Acid
Other Anemia Drugs
Nursing Process
Key Points
Enteral Nutrition
Parenteral Nutrition

Future Application
Antimicrobials
Anesthetic, Antipruritic, and Antipsoriatic Drugs
Miscellaneous Dermatologic Drugs
Wound Care Drugs
Skin Preparation Drugs
Antiglaucoma Drugs
Antimicrobial Drugs
Antiinflammatory Drugs
Topical Anesthetics
Diagnostic Drugs
Antiallergic Drugs
Overview
Treatment of Ear Disorders
Antibacterial and Antifungal Otic Drugs
Earwax Emulsifiers
Nursing Process
Key Points

Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37
Chapter 38
Chapter 39
Chapter 40
Chapter 41
Chapter 42
Chapter 43
Chapter 44
Chapter 45
Chapter 46
Chapter 47
Chapter 48
Chapter 49
Chapter 50
Chapter 51
Chapter 52
Chapter 53
Chapter 54
Chapter 55
Chapter 56
Chapter 57
Chapter 58
Evidence-Based Practice
Patient-Centered Care: Cultural Implications
Patient-Centered Care: Lifespan Considerations for the Older Adult Patient
Patient-Centered Care: Lifespan Considerations for the Pediatric Patient
Safety: Herbal Therapies and Dietary Supplements
Safety: Laboratory Values Related to Drug Therapy

Safety and Quality Improvement: Preventing Medication Errors
Teamwork and Collaboration: Legal and Ethical Principles

Organization
New to This Edition
Additional Teaching/Learning Features
Supplemental Resources
Study Guide
Evolve Website
For students:
For instructors:
Pharmacology Online
Acknowledgments
We Welcome Your Feedback
PA R T 1
OUTLINE
Learning Strategies
1 The Nursing Process and Drug Therapy
2 Pharmacologic Principles
3 Lifespan Considerations
4 Cultural, Legal, and Ethical Considerations
5 Medication Errors: Preventing and Responding
6 Patient Education and Drug Therapy
7 Over-the-Counter Drugs and Herbal and Dietary Supplements
8 Gene Therapy and Pharmacogenomics
9 Photo Atlas of Drug Administration
Introduction
1
Objectives
When you reach the end of this chapter, you will be able to do the following:
KEY TERMS
Compliance Implementation or fulfillment of a prescriber's or caregiver's prescribed course of treatment or
therapeutic plan by a patient. Use of compliance versus adherence in this textbook is supportive of the terms
used in the current listing of NANDA-I nursing diagnoses. (p. 6)
Medication error Any preventable adverse drug event involving inappropriate medication use by a patient
or health care professional; it may or may not cause the patient harm. (p. 13)
Noncompliance An informed decision on the part of the patient not to adhere to or follow a therapeutic plan
or suggestion. Use of noncompliance versus nonadherence in this textbook is supportive of the terms used in the
current listing of NANDA-I nursing diagnoses. (p. 7)
Nursing process An organizational framework for the practice of nursing. It encompasses all steps taken
by the nurse in caring for a patient: assessment, nursing diagnoses, planning (with goals and outcome criteria),
implementation of the plan (with patient teaching), and evaluation. (p. 4)
Outcomes Descriptions of specific patient behaviors or responses that demonstrate meeting of or
achievement of behaviors related to each nursing diagnosis. These statements are specific while framed in
behavioral terms and are measurable. (p. 5)
Prescriber Any health care professional licensed by the appropriate regulatory board to prescribe
medications. (p. 7)
Overview of the Nursing Process
Box 1-1
Assessment
Analysis of Data
Nursing Diagnoses
Box 1-2
Box 1-3
Implementation
Nine Rights of Medication Administration

Right Drug
Right Dose
Right Time
TABLE 1-1
Conversion of Standard Time to Military Time
Right Route and Form

Right Patient
Right Documentation
Medication Errors
Evaluation
Key Points
2
Objectives
KEY TERMS
Additive effects Drug interactions in which the effect of a combination of two or more drugs with similar
actions is equivalent to the sum of the individual effects of the same drugs given alone. For example, 1 + 1 = 2
(compare with synergistic effects). (p. 32)
Adverse drug event Any undesirable occurrence related to administering or failing to administer a
prescribed medication. (p. 32)
Adverse drug reaction Any unexpected, unintended, undesired, or excessive response to a medication
given at therapeutic dosages (as opposed to overdose). (p. 32)
Adverse effects A general term for any undesirable effects that are a direct response to one or more drugs.
(p. 30)
Agonist A drug that binds to and stimulates the activity of one or more receptors in the body. (p. 29)
Allergic reaction An immunologic hypersensitivity reaction resulting from the unusual sensitivity of a patient
to a particular medication; a type of adverse drug event. (p. 32)
Antagonist A drug that binds to and inhibits the activity of one or more receptors in the body. Antagonists
are also called inhibitors. (p. 29)
Antagonistic effects Drug interactions in which the effect of a combination of two or more drugs is less
than the sum of the individual effects of the same drugs given alone (1 + 1 equals less than 2); it is usually
caused by an antagonizing (blocking or reducing) effect of one drug on another. (p. 32)
Bioavailability A measure of the extent of drug absorption for a given drug and route (from 0% to 100%).
(p. 21)
Biotransformation One or more biochemical reactions involving a parent drug; occurs mainly in the liver
and produces a metabolite that is either inactive or active. Also known as metabolism. (p. 25)
Blood-brain barrier The barrier system that restricts the passage of various chemicals and microscopic
entities (e.g., bacteria, viruses) between the bloodstream and the central nervous system. It still allows for the
passage of essential substances such as oxygen. (p. 25)
Chemical name The name that describes the chemical composition and molecular structure of a drug. (p.
18)
Contraindication Any condition, especially one related to a disease state or patient characteristic, including
current or recent drug therapy, which renders a particular form of treatment improper or undesirable. (p. 30)
Cytochrome P-450 The general name for a large class of enzymes that play a significant role in drug
metabolism and drug interactions. (p. 26)
Dependence A state in which there is a compulsive or chronic need, as for a drug. (p. 31)
Dissolution The process by which solid forms of drugs disintegrate in the gastrointestinal tract and become
soluble before being absorbed into the circulation. (p. 19)
Drug Any chemical that affects the physiologic processes of a living organism. (p. 18)
Drug actions The processes involved in the interaction between a drug and body cells (e.g., the action of a
drug on a receptor protein); also called mechanism of action. (p. 19)
Drug classification A method of grouping drugs; may be based on structure or therapeutic use. (p. 19)
Drug effects The physiologic reactions of the body to a drug. They can be therapeutic or toxic and describe
how the body is affected as a whole by the drug. (p. 28)
Drug-induced teratogenesis The development of congenital anomalies or defects in the developing fetus
caused by the toxic effects of drugs. (p. 33)
Drug interaction Alteration in the pharmacologic or pharmacokinetic activity of a given drug caused by the
presence of one or more additional drugs; it is usually related to effects on the enzymes required for metabolism
of the involved drugs. (p. 31)
Duration of action The length of time the concentration of a drug in the blood or tissues is sufficient to elicit
a response. (p. 28)
Enzymes Protein molecules that catalyze one or more of a variety of biochemical reactions, including those
related to the body's physiologic processes as well as those related to drug metabolism. (p. 29)
First-pass effect The initial metabolism in the liver of a drug absorbed from the gastrointestinal tract before
the drug reaches systemic circulation through the bloodstream. (p. 21)
Generic name The name given to a drug by the United States Adopted Names Council. Also called the
nonproprietary name. The generic name is much shorter and simpler than the chemical name and is not
protected by trademark. (p. 18)
Glucose-6-phosphate dehydrogenase (G6PD) deficiency A hereditary condition in which red blood cells
break down when the body is exposed to certain drugs. (p. 33)
Half-life In pharmacokinetics, the time required for half of an administered dose of drug to be eliminated by
the body, or the time it takes for the blood level of a drug to be reduced by 50% (also called elimination half-life).
(p. 27)
Idiosyncratic reaction An abnormal and unexpected response to a medication, other than an allergic
reaction, that is peculiar to an individual patient. (p. 33)
Incompatibility The characteristic that causes two parenteral drugs or solutions to undergo a reaction when
mixed or given together that results in the chemical deterioration of at least one of the drugs. (p. 32)
Intraarterial Within an artery (e.g., intraarterial injection). (p. 22)
Intraarticular Within a joint (e.g., intraarticular injection). (p. 22)
Intrathecal Within a sheath (e.g., the theca of the spinal cord, as in an intrathecal injection into the
subarachnoid space). (p. 22)
Medication error Any preventable adverse drug event (see above) involving inappropriate medication use
by a patient or health care professional; it may or may not cause patient harm. (p. 32)
Medication use process The prescribing, dispensing, and administering of medications, and the
monitoring of their effects. (p. 32)
Metabolite A chemical form of a drug that is the product of one or more biochemical (metabolic) reactions
involving the parent drug (see later). Active metabolites are those that have pharmacologic activity of their own,
even if the parent drug is inactive (see prodrug). Inactive metabolites lack pharmacologic activity and are simply
drug waste products awaiting excretion from the body (e.g., via the urinary, gastrointestinal, or respiratory tract).
(p. 32)
Onset of action The time required for a drug to elicit a therapeutic response after dosing. (p. 28)
P-glycoprotein a transporter protein that moves drugs out of cells and into the gut, urine, or bile. (p. 26)
Parent drug The chemical form of a drug that is administered before it is metabolized by the body into its
active or inactive metabolites (see metabolite). A parent drug that is not pharmacologically active itself is called a
prodrug. A prodrug is then metabolized to pharmacologically active metabolites. (p. 20)
Peak effect The time required for a drug to reach its maximum therapeutic response in the body. (p. 28)
Peak level The maximum concentration of a drug in the body after administration, usually measured in a
blood sample for therapeutic drug monitoring. (p. 28)
Pharmaceutics The science of preparing and dispensing drugs, including dosage form design. (p. 19)
Pharmacodynamics The study of the biochemical and physiologic interactions of drugs at their sites of
activity. It examines the physicochemical properties of drugs and their pharmacologic interactions with body
receptors. (p. 19)
Pharmacoeconomics The study of economic factors impacting the cost of drug therapy. (p. 19)
Pharmacogenomics The study of the influence of genetic factors on drug response that result in the
absence, overabundance, or insufficiency of drug-metabolizing enzymes (also called pharmacogenomics; see
Chapter 8). (p. 33)
Pharmacognosy The study of drugs that are obtained from natural plant and animal sources. (p. 19)
Pharmacokinetics The study of what happens to a drug from the time it is put into the body until the parent
drug and all metabolites have left the body. Pharmacokinetics represent the drug absorption into, distribution and
metabolism within, and excretion from the body. (p. 19)
Pharmacology The broadest term for the study or science of drugs. (p. 18)
Pharmacotherapeutics The treatment of pathologic conditions through the use of drugs. (p. 19)
Prodrug An inactive drug dosage form that is converted to an active metabolite by various biochemical
reactions once it is inside the body. (p. 26)
Receptor A molecular structure within or on the outer surface of a cell. Receptors bind specific substances
(e.g., drug molecules), and one or more corresponding cellular effects (drug actions) occur as a result of this
drug-receptor interaction. (p. 29)
Steady state The physiologic state in which the amount of drug removed via elimination is equal to the
amount of drug absorbed with each dose. (p. 28)
Substrates Substances (e.g., drugs or natural biochemicals in the body) on which an enzyme acts. (p. 26)
Synergistic effects Drug interactions in which the effect of a combination of two or more drugs with similar
actions is greater than the sum of the individual effects of the same drugs given alone. For example, 1 + 1 is
greater than 2 (compare with additive effects). (p. 32)
Therapeutic drug monitoring The process of measuring drug levels to identify a patient's drug exposure
and to allow adjustment of dosages with the goals of maximizing therapeutic effects and minimizing toxicity. (p.
28)
Therapeutic effect The desired or intended effect of a particular medication. (p. 28)
Therapeutic index The ratio between the toxic and therapeutic concentrations of a drug. (p. 30)
Tolerance Reduced response to a drug after prolonged use. (p. 31)
Toxic The quality of being poisonous (i.e., injurious to health or dangerous to life). (p. 19)
Toxicity The condition of producing adverse bodily effects due to poisonous qualities. (p. 28)
Toxicology The study of poisons, including toxic drug effects, and applicable treatments. (p. 19)
Trade name The commercial name given to a drug product by its manufacturer; also called the proprietary
name. (p. 18)
Trough level The lowest concentration of drug reached in the body after it falls from its peak level, usually
measured in a blood sample for therapeutic drug monitoring. (p. 28)
Overview
FIGURE 2-1 Chemical structure of the common analgesic ibuprofen and the chemical, generic, and
trade names for the drug.
FIGURE 2-2 Phases of drug activity. (From McKenry LM, Tessier E, Hogan M: Mosby's pharmacology in nursing, ed 22,
St Louis, 2006, Mosby.)
Pharmaceutics
TABLE 2-1
Drug Absorption of Various Oral Preparations
TABLE 2-2
Dosage Forms
Pharmacokinetics
Absorption
Enteral Route
Box 2-1
Sublingual and buccal routes.

Parenteral Route
TABLE 2-3
Routes of Administration and Related Nursing Considerations
NOTE: For more information on avoiding the use of abbreviations associated with dosage routes, dosage amounts, dosage frequency,
and drug names, as well as the use of symbols, please visit www.ismp.org.
Subcutaneous, intradermal, and intramuscular routes.

Topical Route
Box 2-2
Transdermal route.
Inhaled route.
Distribution
FIGURE 2-3 Drug transport in the body. GI, Gastrointestinal. (From McKenry LM, Tessier E, Hogan M: Mosby's
pharmacology in nursing, ed 22, St Louis, 2006, Mosby.)
FIGURE 2-4 Protein binding of drugs. Albumin is the most prevalent protein in plasma and the most
important of the proteins to which drugs bind. Only unbound (free) drug molecules can leave the vascular
system. Bound molecules are too large to fit through the pores in the capillary wall.
Metabolism
TABLE 2-4
Mechanisms of Biotransformation
TABLE 2-5
Common Liver Cytochrome P-450 Enzymes and Corresponding Drug Substrates
TABLE 2-6
Examples of Conditions and Drugs That Affect Drug Metabolism
Drug Metabolism
Excretion
FIGURE 2-5 Renal drug excretion. The primary processes involved in drug excretion and the
approximate location where these processes take place in the kidney are illustrated. GFR, Glomerular
filtration rate.
Half-Life
TABLE 2-7
Example of Drug Half-Life Viewed from Different Perspectives
Changing Values
Onset, Peak, and Duration

FIGURE 2-6 Characteristics of drug effect and relationship to the therapeutic window. (From McKenry LM,
Tessier E, Hogan M: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.)
Pharmacodynamics
Mechanism of Action
Receptor Interactions
FIGURE 2-7 Drugs act by forming a chemical bond with specific receptor sites, similar to a key and lock.
The better the “fit,” the better the response. Drugs with complete attachment and response are called
agonists. Drugs that attach but do not elicit a response are called antagonists.
TABLE 2-8
Drug-Receptor Interactions
Enzyme Interactions
Nonselective Interactions
Pharmacotherapeutics
Acute Therapy
Maintenance Therapy
Supplemental Therapy
Palliative Therapy
Supportive Therapy
Prophylactic Therapy and Empiric Therapy
Monitoring
Therapeutic Index
Drug Concentration
Patient's Condition
Tolerance and Dependence
Interactions
TABLE 2-9
Common Food and Drug Interactions
TABLE 2-10
Examples of Drug Interactions and Their Effects on Pharmacokinetics
Adverse Drug Events

Other Drug Effects
Box 2-3
Pharmacognosy
Pharmacoeconomics
Toxicology
TABLE 2-11
Common Poisons and Their Antidotes*
*These and other antidotes are discussed throughout this textbook where applicable.
Summary
Key Points
3
Objectives
KEY TERMS
Active transport The active (energy-requiring) movement of a substance between different tissues via
pumping mechanisms contained within cell membranes. (p. 36)
Diffusion The passive movement of a substance (e.g., a drug) between different tissues from areas of
higher concentration to areas of lower concentration. (Compare with active transport.) (p. 36)
Neonate Pertaining to a person younger than 1 month of age; newborn infant. (p. 36)
Older adult Pertaining to a person who is 65 years of age or older. (NOTE: Some sources consider “older
adult” to be 55 years of age or older.) (p. 40)
Pediatric Pertaining to a person who is 12 years of age or younger. (p. 38)
Polypharmacy The use of many different drugs concurrently in treating a patient, who often has several
health problems. (p. 40)
Overview
Drug Therapy during Pregnancy
TABLE 3-1
Pregnancy Safety Categories
Drug Therapy during Breastfeeding
Considerations for Neonatal and Pediatric Patients
TABLE 3-2
Classification of Young Patients
NOTE: The meaning of the term pediatric may vary with the individual drug and clinical situation. Often the maximum age for a pediatric
patient may be identified as 16 years of age. Consult the manufacturer's guidelines for specific dosing information.
Physiology and Pharmacokinetics
Pharmacodynamics
Dosage Calculations for Pediatric Patients
Considerations for Older Adult Patients
Issues in Clinical Drug Use in the Older Adult

Physiologic Changes
TABLE 3-3
Physiologic Changes in the Older Adult Patient
↓ ↓
↓ ↓
↑
↓
↓ ↓
↓ ↓
↓ ↓
↓ ↓
↓ ↓
Pharmacokinetics
Absorption
Distribution
Metabolism
Excretion
Problematic Medications for the Older Adult
TABLE 3-4
Medications and Conditions Requiring Special Considerations in the Older Adult Patient
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
4
Objectives
KEY TERMS
Bias Any systematic error in a measurement process. (p. 55)
Black box warning A type of warning that appears in a drug's prescribing information and is required by
the U.S. Food and Drug Administration (FDA) to alert prescribers of serious adverse events that have occurred
with the given drug. (p. 56)
Blinded investigational drug study A research design in which the subjects are purposely unaware of
whether the substance they are administered is the drug under study or a placebo. This method serves to
minimize bias on the part of research subjects in reporting their body's responses to investigational drugs. (p. 55)
Controlled substances Any drugs listed on one of the “schedules” of the Controlled Substance Act (also
called scheduled drugs). (p. 53)
Culture The customary beliefs, social forms, and material traits of a racial, religious, or social group. (p. 50)
Double-blind investigational drug study A research design in which both the investigator(s) and the
subjects are purposely unaware of whether the substance administered to a given subject is the drug under study
or a placebo. This method minimizes bias on the part of both the investigator and the subject. (p. 55)
Drug polymorphism Variation in response to a drug because of a patient's age, gender, size, and/or body
composition. (p. 51)
Ethics The rules of conduct recognized in respect to a particular class or group of human actions. (p. 58)
Ethnicity Relating to or characteristic of a human group having racial, religious, language, and other traits
in common. (p. 50)
Ethnopharmacology The study of the effect of ethnicity on drug responses, specifically drug absorption,
metabolism, distribution, and excretion as well as the study of genetic variations to drugs (i.e.,
pharmacogenetics). (p. 50)
Expedited drug approval Acceleration of the usual investigational new drug approval process by the FDA,
usually for drugs used to treat life-threatening diseases. (p. 54)
Health Insurance Portability and Accountability Act (HIPAA) An act that protects health insurance
coverage for workers and their families when they change jobs. It also protects patient information. If
confidentiality of a patient is breached, severe fines may be imposed. (p. 53)
Informed consent Written permission obtained from a patient consenting to a specific procedure. (p. 55)
Investigational new drug (IND) A drug not yet approved for marketing by the FDA but available for use in
experiments to determine its safety and efficacy. (p. 55)
Investigational new drug application An application that must be submitted to the FDA before a drug can
be studied in humans. (p. 55)
Legend drugs Another name for prescription drugs. (p. 53)
Malpractice A special type of negligence or the failure of a professional and/or individual with specialized
education and training to act in a reasonable and prudent way. (p. 57)
Narcotic A legal term established under the Harrison Narcotic Act of 1914. The term is currently used in
clinical settings to refer to any medically administered controlled substance and in legal settings to refer to any
illicit or “street” drug; also referred to as opioid. (p. 53)
Negligence The failure to act in a reasonable and prudent manner or failure of the nurse to give the care
that a reasonably prudent (cautious) nurse would render or use under similar circumstances. (p. 57)
Orphan drugs A special category of drugs that have been identified to help treat patients with rare
diseases. (p. 53)
Over-the-counter drugs Drugs available to consumers without a prescription. Also called nonprescription
drugs. (p. 52)
Pharmacogenomics The study of genetics in drug response. (p. 50)
Placebo An inactive (inert) substance (e.g., saline, distilled water, starch, sugar) that is not a drug but is
formulated to resemble a drug for research purposes. (p. 55)
Race Descendants of a common ancestor; a tribe, family, or people believed to belong to the same lineage.
(p. 50)
Cultural Considerations
Influence of Ethnicity and Genetics on Drug Response

Cultural Nursing Considerations and Drug Therapy
Legal Considerations
U.S. Drug and Related Legislation
TABLE 4-1
Summary of Major U.S. Drug and Related Legislation
AIDS, Acquired immunodeficiency syndrome; FDA, Food and Drug Administration; HIV, human immunodeficiency virus.
New Drug Development

U.S. Food and Drug Administration Drug Approval Process
Preclinical Investigational Drug Studies

Four Clinical Phases of Investigational Drug Studies
Phase I.
Phase II.
Phase III.
Phase IV.
TABLE 4-2
Controlled Substances: Schedule Categories
TABLE 4-3
Controlled Substances: Categories, Dispensing Restrictions, and Examples
*Legally permitted to be telephoned in for major emergencies only. If telephoned in, written prescription is required within 72 hours.
Legal Nursing Considerations and Drug Therapy
Box 4-1
Box 4-2
Ethical Considerations
Ethical Nursing Considerations and Drug Therapy

Nursing Process
AssessmenT
Box 4-3
Maintaining Health
Protecting Health
Restoring Health
Nursing Diagnoses
Planning and Outcome Identification
Implementation
Evaluation
Key Points
5
Preventing and Responding
Objectives
KEY TERMS
Adverse drug event Any undesirable occurrence related to administration of or failure to administer a
prescribed medication. (p. 64)
Adverse drug reactions Unexpected, unintended, or excessive responses to medications given at
therapeutic dosages (as opposed to overdose); one type of adverse drug event. (p. 64)
Allergic reaction An immunologic reaction resulting from an unusual sensitivity of a patient to a certain
medication; a type of adverse drug event and a subtype of adverse drug reactions. (p. 64)
Idiosyncratic reaction Any abnormal and unexpected response to a medication, other than an allergic
reaction, that is peculiar to an individual patient. (p. 64)
Medical errors A broad term used to refer to any errors at any point in patient care that cause or have the
potential to cause patient harm. (p. 63)
Medication errors Any preventable adverse drug events involving inappropriate medication use by a
patient or health care professional; they may or may not cause the patient harm. (p. 64)
Medication reconciliation A procedure to maintain an accurate and up-to-date list of medications for all
patients between all phases of health care delivery. (p. 70)
General Impact of Errors on Patients
Medication Errors
FIGURE 5-1 Diagram illustrating the various classes and subclasses of adverse drug events. ADRs,
Adverse drug reactions; AEs, adverse (drug) effects; ARs, allergic reactions; IRs, idiosyncratic reactions.
Box 5-1
Issues Contributing to Errors
Organizational Issues
Box 5-2
Educational System Issues and Their Potential Impact on Medication Errors
Medication Errors and Related Sociologic Factors

Preventing, Responding to, Reporting, and Documenting
Medication Errors: a Nursing Perspective
Preventing Medication Errors
Responding to, Reporting, and Documenting Medication Errors
Medication Reconciliation
Other Ethical Issues
Notification of Patients Regarding Errors
Possible Consequences of Medication Errors for Nurses

Summary
Key Points
6
Objectives
KEY TERMS
Affective domain The most intangible domain of the learning process. It involves affective behavior, which
is conduct that expresses feelings, needs, beliefs, values, and opinions; the feeling domain. (p. 75)
Cognitive domain The domain involved in the learning and storage of basic knowledge. It is the thinking
portion of the learning process and incorporates an individual's previous experiences and perceptions; the
learning/thinking domain. (p. 75)
Health literacy The degree to which individuals have the capacity to obtain and then process and
understand basic health information as well as basic health information and services needed to make appropriate
health decisions (p. 75)
Learning The acquisition of knowledge or skill. (p. 75)
Psychomotor domain The domain involved in the learning of a new procedure or skill; often called the
doing domain. (p. 75)
Teaching A system of directed and deliberate actions intended to induce learning. (p. 75)
Overview
Assessment of Learning Needs Related to Drug Therapy
Box 6-1
Box 6-2
Box 6-3
Nursing Diagnoses Related to Learning Needs and Drug
Therapy
Planning: Outcome Identification as Related to Learning Needs
and Drug Therapy
Implementation Related to Patient Education and Drug Therapy
Box 6-4
TABLE 6-1
Educational Strategies to Address Common Changes Related to Aging That May Influence Learning
Modified from Touhy T, Jett K: Ebersole and Hess gerontological nursing and healthy aging, ed 4, St Louis, 2014, Mosby.
Evaluation of Patient Learning Related to Drug Therapy
Summary
Box 6-5
Key Points
7
Objectives
KEY TERMS
Alternative medicine Herbal medicine, chiropractic, acupuncture, massage, reflexology, and any other
therapies traditionally not emphasized in Western medical schools. (p. 89)
Complementary medicine Alternative medicine when used simultaneously with, rather than instead of,
standard Western medicine. (p. 89)
Conventional medicine
The practice of medicine as taught in Western medical schools. (p. 89)
Dietary supplement A product that contains an ingredient intended to supplement the diet, including
vitamins, minerals, herbs, or other botanicals. (p. 88)
Herbal medicine The practice of using herbs to heal. (p. 89)
Herbs Plant components including bark, roots, leaves, seeds, flowers, fruit of trees, and extracts of these
plants that are valued for their savory, aromatic, or medicinal qualities. (p. 89)
Iatrogenic effects Unintentional adverse effects that are caused by the actions of a prescriber, other health
care professional, or by a specific treatment. (p. 89)
Integrative medicine Simultaneous use of both traditional and alternative medicine. (p. 89)
Legend drugs Medications that are not legally available without a prescription from a prescriber; also called
prescription drugs). (p. 89)
Over-the-counter (OTC) drugs Medications that are legally available without a prescription. (p. 86)
Phytochemicals The pharmacologically active ingredients in herbal remedies. (p. 91)
Box 7-1
Box 7-2
FIGURE 7-1 Example of an over-the-counter drug label. (From U.S. Food and Drug Administration: The new over-
the-counter medicine label: take a look, 2011. Available at
www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm133411.htm#.TnP-oVxzZyo.email. Accessed
July 7, 2014.)
TABLE 7-1
Common Over-the-Counter (OTC) Drugs
Herbals and Dietary Supplements
History
TABLE 7-2
Conventional Medicines Derived from Plants
*Includes both over-the-counter and prescription drugs.

Consumer Use of Dietary Supplements
Safety
TABLE 7-3
Selected Herbs and Dietary Supplements and Their Possible Drug Interactions
Level of Use
Nursing Process
Assessment
Herbal Products and Dietary Supplements
Nursing Diagnoses

Implementation
Evaluation
Key Points
8
Objectives
KEY TERMS
Acquired disease Any disease triggered by external factors and not directly caused by a person's genes
(e.g., an infectious disease, noncongenital cardiovascular diseases). (p. 97)
Alleles The two or more alternative forms of a gene. (p. 97)
Chromosomes Structures in the nuclei of cells that contain threads of deoxyribonucleic acid (DNA), which
transmit genetic information, and are associated with ribonucleic acid (RNA) molecules and synthesis of protein
molecules. (p. 97)
Gene The biologic unit of heredity; a segment of a DNA molecule that contains all of the molecular
information required for the synthesis of a biologic product such as an RNA molecule or an amino acid chain
(protein molecule). (p. 97)
Gene therapy New therapeutic technologies that directly target human genes in the treatment or prevention
of illness. (p. 98)
Genetic disease Any disorder caused directly by a genetic mechanism. (p. 97)
Genetic material DNA or RNA molecules or portions thereof. (p. 97)
Genetic polymorphisms (PMs) Variants that occur in the chromosomes of 1% or more of the general
population. (p. 99)
Genetic predisposition The presence of certain factors in a person's genetic makeup, or genome that
increase the individual's likelihood of developing one or more diseases. (p. 97)
Genetics The study of the structure, function, and inheritance of genes. (p. 97)
Genome The complete set of genetic material of any organism. (p. 98)
Genomics The study of the structure and function of the genome, and the way genes and their products
work in both health and disease. (p. 98)
Genotype The particular alleles present at a given site on the chromosomes that determine a specific
genetic trait for that organism (compare phenotype). (p. 97)
Heredity The characteristics and qualities that are genetically passed from one generation to the next
through reproduction. (p. 97)
Human Genome Project (HGP) A scientific project of the U.S. Department of Energy and National
Institutes of Health to describe in detail the entire genome of a human being. (p. 98)
Inherited disease Genetic disease that results from defective alleles passed from parents to offspring. (p.
97)
Nucleic acids Molecules of DNA and RNA in the nucleus of every cell. DNA makes up the chromosomes
and encodes the genes. (p. 97)
Personalized medicine The use of molecular and genetic characterizations of both the disease process
and the patient for the customization of drug therapy. (p. 99)
Pharmacogenetics A general term for the study of the genetic basis for variations in the body's response to
drugs, with a focus on variations related to a single gene. (p. 99)
Pharmacogenomics A branch of pharmacogenetics (see earlier) that involves the survey of the entire
genome to detect multigenic (multiple-gene) determinants of drug response. (p. 99)
Phenotype The expression in the body of a genetic trait that results from a person's particular genotype
(see earlier) for that trait. (p. 97)
Recombinant DNA (rDNA) DNA molecules that have been artificially synthesized or modified in a
laboratory setting. (p. 98)
Overview
Basic Principles of Genetic Inheritance
Discovery, Structure, and Function of DNA
Protein Synthesis
Human Genome Project

Gene Therapy
Background
FIGURE 8-1 Gene therapy for adenosine deaminase (ADA) deficiency attempts to correct this
immunodeficiency state. The viral vector containing the therapeutic gene is inserted into the patient's
lymphocytes. These cells can then make the ADA enzyme. (From Lewis SL, Dirksen SR, Heitkemper MM, et al:
Medical-surgical nursing: assessment and management of clinical problems, ed 8, St Louis, 2011, Elsevier.)
Current Application
Regulatory and Ethical Issues Regarding Gene Therapy

Pharmacogenetics and Pharmacogenomics
TABLE 8-1
Clinical Applications of Pharmacogenomics
CYP2D6, Cytochrome P-450 enzyme subtype 2D6; HER2/neu, human epidermal growth factor receptor 2.
Application of the Nursing Process as Related to Genetic
Principles
Summary
Key Points
9
Preparing for Drug Administration
Box 9-1
FIGURE 9-1 Using a computer-controlled drug-dispensing system to remove medication.
FIGURE 9-2 Checking the medication against the order on the electronic medication administration
record.
FIGURE 9-3 The nurse is using a bar-code scanner to identify the patient before medication
administration. Always check the patient's identification, using two patient identifiers, and allergies before
giving medications.
Box 9-2
Enteral Drugs
Administering Oral Drugs
Oral Medications
FIGURE 9-4 Some medications require special assessment before administration, such as taking an
apical pulse.
FIGURE 9-5 Using a pill-crushing device to crush a tablet.
FIGURE 9-6 Enteric-coated tablets and long-acting medications are not to be crushed, broken, or
chewed.
FIGURE 9-7 Giving oral medications.
Sublingual and Buccal Medications

FIGURE 9-8 Proper placement of a sublingual tablet.
Orally Disintegrating Medications

Liquid Medications
FIGURE 9-9 A, Liquid medication in a unit-dose package. B, Liquid measured into a medicine cup from
a multidose container. C, Liquid medication in an oral-dosing syringe.
FIGURE 9-10 Measuring liquid medication at eye level.
Oral Medications for Infants and Children

FIGURE 9-11 Administering oral liquid medication to an infant.
Administering Drugs through a Nasogastric or Gastrostomy Tube

FIGURE 9-12 Elevate the head of the bed before administering medications through a nasogastric or
other enteric tube.
FIGURE 9-13 Medications given through gastric tubes need to be administered separately. Dilute
crushed pills in 15 to 30 mL of water before administration.
FIGURE 9-14 Pour liquid medication into the syringe, then unclamp the tubing and allow it to flow in by
gravity.
Administering Rectal Drugs

FIGURE 9-15 Lubricate the suppository with a water-soluble lubricant.
FIGURE 9-16 Inserting a rectal suppository.

Parenteral Drugs
Preparing for Parenteral Drug Administration
Removing Medications from Ampules

FIGURE 9-17 NEVER RECAP A USED NEEDLE! Always dispose of uncapped needles in the
appropriate sharps container. See Box 9-1 for Standard Precautions.
FIGURE 9-18 An UNUSED needle may need to be recapped before the medication is given to the
patient, especially if the needle is fixed to the syringe, as with insulin syringes. The “scoop method” is one
way to recap an unused needle safely. Be sure not to touch the needle to the countertop or to the outside
of the needle cap.
FIGURES 9-19 AND 9-20 There are several types of needlestick prevention syringes. This example
(Figure 9-19) has a guard over the unused syringe. After the injection, the nurse pulls the guard up over
the needle until it locks into place (Figure 9-20).
FIGURE 9-21 The parts of a syringe and hypodermic needle.
FIGURE 9-22 Close-up view of the bevel of a needle.
FIGURE 9-23 Be sure to choose the correct size and type of syringe for the drug ordered.
FIGURE 9-24 Needles come in various gauges and lengths. The larger the gauge number, the smaller
the needle. Be sure to choose the correct needle—gauge and length—for the type of injection ordered.
FIGURES 9-25 AND 9-26 Some medications come in prefilled sterile medication cartridges. Figures 9-
25 and 9-26 show the Carpuject prefilled cartridge and syringe system. Follow the manufacturer's
instructions for assembling prefilled syringes. After use, dispose of the syringe in a sharps container; the
cartridge is reusable. Some prefilled syringes come with an air bubble in the syringe; do not expel the
bubble before administration.
FIGURE 9-27 Ampules containing medications come in various sizes. The neck of the ampule must be
broken carefully before the medication is withdrawn. (See Figures 9-30 and 9-31.)
FIGURE 9-28 Use a filter needle when withdrawing medication from an ampule. Filter needles help to
remove tiny glass particles that may result from the ampule breakage. DO NOT USE A FILTER NEEDLE
FOR INJECTION INTO A PATIENT! Some health care institutions may also require the use of a filter
needle to withdraw medications from a vial.
FIGURE 9-29 Tapping an ampule to move the fluid below the neck.
FIGURES 9-30 AND 9-31 Breaking an ampule. Carefully break the neck of the ampule in a direction
away from you and away from others near you.
FIGURE 9-32 Using a filter needle to withdraw medication from an ampule.

Removing Medications from Vials
FIGURE 9-33 Comparison of the sharp tip of a needle for injection (above) with the blunt tip of a fill
needle (below), which is used to remove fluid from a vial.
FIGURE 9-34 Insert air into a vial before withdrawing medication (needleless system shown).
FIGURE 9-35 Withdrawing medication from a vial (needleless system shown).

FIGURE 9-36 Using a needle and syringe to remove medication from a vial.
Injections Overview
Needle Insertion Angles for Intramuscular, Subcutaneous, and Intradermal
Injections
FIGURE 9-37 Comparison of angles of needle insertion for injections.
Box 9-3
Air-Lock Technique
FIGURE 9-38 Air-lock technique for intramuscular injections.
Intradermal Injections
FIGURES 9-39 AND 9-40 Intradermal injection.
Subcutaneous Injections
FIGURE 9-41 Potential sites for subcutaneous injections.

FIGURE 9-42 Before giving an injection, cleanse the skin with an alcohol or antiseptic swab using a
circular motion.
FIGURE 9-43 Giving a subcutaneous injection at a 90-degree angle.
FIGURE 9-44 When giving a subcutaneous injection in the abdomen, be sure to choose a site at least 2
inches away from the umbilicus.
Insulin Syringes
FIGURE 9-45 Insulin syringes are available in 100-unit (A) and 50-unit (B) calibrations.
FIGURE 9-46 Examples of prefilled insulin pens for insulin injections.

FIGURE 9-47 Mixing two types of insulin in the same syringe. NOTE: The rapid- or short-acting (clear)
insulin is always drawn up into the syringe first.
Intramuscular Injections
Z-Track Method
FIGURES 9-48 AND 9-49 Z-track method for intramuscular injections.
Ventrogluteal Site
FIGURE 9-50 Finding landmarks for a ventrogluteal injection.
FIGURES 9-51 AND 9-52 Ventrogluteal intramuscular injection.
Vastus Lateralis Site

FIGURE 9-53 Vastus lateralis intramuscular injection in a small child. The nurse stabilizes the leg before
giving the injection.
FIGURES 9-54, 9-55, AND 9-56 Vastus lateralis intramuscular injection.
Deltoid Site
FIGURES 9-57, 9-58, AND 9-59 Deltoid intramuscular injection. The deltoid site is not considered a
primary site for intramuscular injections but is used for immunizations for toddlers, older children, and
adults. This site is not used for infants.
Preparing Intravenous Medications

FIGURE 9-60 Two types of intravenous piggyback medication delivery systems. These intravenous
systems must be activated before the drug is administered to the patient.
FIGURE 9-61 Activating an intravenous piggyback infusion bag (step 1).

FIGURES 9-64, 9-65, AND 9-66 Adding a medication to an intravenous infusion bag with a needle and
syringe.
FIGURE 9-67 Note how the intravenous medication is concentrated at the bottom of the bag. Always mix
the medication thoroughly before infusing by gently turning the bag end to end. Do not shake the bag.
FIGURE 9-68 Label the intravenous infusion bag when medication has been added.
Infusions of Intravenous Piggyback Medications

FIGURE 9-69 Flush the intravenous piggyback (secondary) tubing by using the backpriming method.
Fluid is drained through the tubing into the old intravenous piggyback bag, which is then discarded. The
new dose of medication is then attached to the primed secondary tubing.
FIGURE 9-70 Infusing an intravenous piggyback medication with a primary gravity infusion. Note how
the primary bag is lower than the IVPB.
FIGURE 9-71 Infusing an intravenous piggyback medication with the primary infusion on an electronic
(smart) infusion pump.
FIGURE 9-72 Adding a medication to a volume-controlled administration set.
FIGURE 9-73 Instructing the patient on the use of a patient-controlled analgesia pump.
FIGURE 9-74 An electronic smart pump. The two components on the right side are a patient-controlled
analgesia pump.
Intravenous Push Medications

Intravenous Push Medications through an Intravenous Lock
FIGURE 9-75 Cleanse the port vigorously for 15 seconds before attaching the syringe.
FIGURE 9-76 Attaching the syringe to the intravenous lock, using a needleless system.
FIGURE 9-77 Slowly inject the intravenous push medication through the intravenous lock; use a watch
to time the injection.
Intravenous Push Medications through an Existing Infusion

FIGURE 9-78 When giving an intravenous push medication through an intravenous line, pinch the tubing
just above the injection port.
After Injection of Intravenous Push Medications

Topical Drugs
Administering Eye Medications
FIGURE 9-79 Cleanse the eye, washing from the inner to outer canthus, before giving eye medications.
Eyedrops
FIGURE 9-80 Insert the eyedrop into the lower conjunctival sac.
Eye Ointment
FIGURE 9-81 Applying eye ointment. Move from the inner to outer canthus, along the border of the
conjunctival sac.
After Instillation of Eye Medications

FIGURE 9-82 Applying gentle pressure against the nasolacrimal duct after giving eye medication.
Administering Eardrops
FIGURE 9-83 For adults, pull the pinna up and back.
FIGURE 9-84 For infants and children younger than 3 years of age, pull the pinna down and back.
Administering Inhaled Drugs
FIGURE 9-85 A, Metered-dose inhaler (MDI). B, Automated, or breath-activated, MDI. C, Dry powder
inhaler that delivers powdered medication.
Metered-Dose Inhalers
FIGURE 9-86 Using a metered-dose inhaler without a spacer.
FIGURE 9-87 Using a spacer device with a metered-dose inhaler.
Small-Volume Nebulizers
FIGURE 9-88 Adding medication to the nebulizer cup.
FIGURE 9-89 Administering a small-volume nebulizer treatment.
Administering Medications to the Skin

Lotions, Creams, Ointments, and Powders
FIGURE 9-90 Use gloves to apply topical skin preparations.

FIGURE 9-91 Spread the lotion on the skin with long, smooth, gentle strokes.
FIGURE 9-92 Measure nitroglycerin ointment carefully before application.
Transdermal Patches
FIGURE 9-93 Opening a transdermal patch medication.
FIGURE 9-94 Ensure that the edges of the transdermal patch are secure after applying.
After Administration of Topical Skin Preparations
Administering Nasal Medications

FIGURE 9-95 Nasal medications may come in various delivery forms.
Nasal Drops
FIGURE 9-96 Administering nose drops.

Nasal Spray
FIGURE 9-97 Before self-administering the nasal spray, the patient needs to occlude the other nostril.
After Administration of Nasal Medicines
Administering Vaginal Medications

FIGURE 9-98 Vaginal suppositories (right) are larger and more oval than rectal suppositories (left).
FIGURE 9-99 Vaginal cream and suppository, with applicators.
Creams, Foams, or Gels Applied with an Applicator

FIGURE 9-100 Administering vaginal cream with an applicator.
Suppositories or Vaginal Tablets

FIGURE 9-101 Administering a vaginal suppository.
Illustration Credits
PA R T 2
OUTLINE
Learning Strategies
10 Analgesic Drugs
11 General and Local Anesthetics
12 Central Nervous System Depressants and Muscle Relaxants
13 Central Nervous System Stimulants and Related Drugs
14 Antiepileptic Drugs
15 Antiparkinson Drugs
16 Psychotherapeutic Drugs
17 Substance Abuse
Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Concept Mapping
10
DRUG PROFILES
acetaminophen, p. 158
codeine sulfate, p. 155
fentanyl, p. 155
hydromorphone, p. 155
lidocaine, transdermal, p. 158
meperidine hydrochloride, p. 155
methadone hydrochloride, p. 156
morphine sulfate, p. 156

naloxone hydrochloride, p. 156
naltrexone hydrochloride, p. 157
oxycodone hydrochloride, p. 156
tramadol hydrochloride, p. 158
Objectives
KEY TERMS
Acute pain Pain that is sudden in onset, usually subsides when treated, and typically occurs over less than
a 6-week period. (p. 145)
Addiction A chronic, neurobiologic disease whose development is influenced by genetic, psychosocial, and
environmental factors (same as psychologic dependence). (p. 147)
Adjuvant analgesic drugs Drugs that are added for combined therapy with a primary drug and may have
additive or independent analgesic properties, or both. (p. 144)
Agonist A substance that binds to a receptor and causes a response. (p. 149)
Agonists-antagonists Substances that bind to a receptor and cause a partial response that is not as
strong as that caused by an agonist (also known as a partial agonist). (p. 149)
Analgesic ceiling effect Occurs when a given pain drug no longer effectively controls pain despite the
administration of the highest safe dosages. (p. 149)
Analgesics Medications that relieve pain without causing loss of consciousness (sometimes referred to as
painkillers). (p. 144)
Antagonist A drug that binds to a receptor and prevents (blocks) a response. (p. 150)
Breakthrough pain Pain that occurs between doses of pain medication. (p. 147)
Cancer pain Pain resulting from any of a variety of causes related to cancer and/or the metastasis of
cancer. (p. 146)
Central pain Pain resulting from any disorder that causes central nervous system damage. (p. 146)
Chronic pain Persistent or recurring pain that is often difficult to treat. Includes any pain lasting longer than
3 to 6 months, pain lasting longer than 1 month after healing of an acute injury, or pain that accompanies a
nonhealing tissue injury. (p. 145)
Deep pain Pain that occurs in tissues below skin level; opposite of superficial pain. (p. 146)
Gate theory The most well described theory of pain transmission and pain relief. It uses a gate model to
explain how impulses from damaged tissues are sensed in the brain. (p. 146)
Narcotics A legal term that originally applied to drugs that produce insensibility or stupor, especially the
opioids (e.g., morphine, heroin). Currently used to refer to any medically used controlled substance and to refer to
any illicit or “street” drug. (NOTE: This term is falling out of use in favor of opioid.) (p. 149)
Neuropathic pain Pain that results from a disturbance of function in a nerve. (p. 146)
Nociception Processing of pain signals in the brain that gives rise to the feeling of pain. (p. 144)
Nociceptors A subclass of sensory nerves (A and C fibers) that transmit pain signals to the central nervous
system from other body parts. (p. 144)
Nonopioid analgesics Analgesics that are not classified as opioids. (p. 146)
Nonsteroidal antiinflammatory drugs (NSAIDs) A large, chemically diverse group of drugs that are
analgesics and also possess antiinflammatory and antipyretic activity. (p. 146)
Opioid analgesics Synthetic drugs that bind to opiate receptors to relieve pain. (p. 144)
Opioid naïve Describes patients who are receiving opioid analgesics for the first time and who therefore are
not accustomed to their effects. (p. 165)
Opioid tolerance A normal physiologic condition that results from long-term opioid use, in which larger
doses of opioids are required to maintain the same level of analgesia and in which abrupt discontinuation of the
drug results in withdrawal symptoms (same as physical dependence). (p. 147)
Opioid tolerant The opposite of opioid naïve; describes patients who have been receiving opioid
analgesics (legally or otherwise) for a period of time (1 week or longer). (p. 147)
Opioid withdrawal The signs and symptoms associated with abstinence from or withdrawal of an opioid
analgesic when the body has become physically dependent on the substance. (p. 152)
Opioids A class of drugs used to treat pain. This term is often used interchangeably with the term narcotic.
(p. 149)
Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
(p. 144)
Pain threshold The level of a stimulus that results in the sensation of pain. (p. 144)
Pain tolerance The amount of pain a patient can endure without its interfering with normal function. (p. 145)
Partial agonist A drug that binds to a receptor and causes a response that is less than that caused by a full
agonist (same as agonist-antagonist). (p. 150)
Phantom pain Pain experienced in the area of a body part that has been surgically or traumatically
removed. (p. 146)
Physical dependence A condition in which a patient takes a drug over a period of time and unpleasant
physical symptoms (withdrawal symptoms) occur if the drug is stopped abruptly or smaller doses are given. The
physical adaptation of the body to the presence of an opioid or other addictive substance. (p. 145)
Psychologic dependence A pattern of compulsive use of opioids or any other addictive substance
characterized by a continuous craving for the substance and the need to use it for effects other than pain relief
(also called addiction). (p. 147)
Referred pain Pain occurring in an area away from the organ of origin. (p. 146)
Somatic pain Pain that originates from skeletal muscles, ligaments, or joints. (p. 145)
Special pain situations The general term for pain control situations that are complex and whose treatment
typically involves multiple medications, and nonpharmacologic therapeutic modalities (e.g., massage, chiropractic
care, surgery). (p. 166)
Superficial pain Pain that originates from the skin or mucous membranes; opposite of deep pain. (p. 146)
Synergistic effects Drug interactions in which the effect of a combination of two or more drugs with similar
actions is greater than the sum of the individual effects of the same drugs given alone. For example, 1 + 1 is
greater than 2. (p. 148)
Tolerance The general term for a state in which repetitive exposure to a given drug, over time, induces
changes in drug receptors that reduce the drug's effects (same as physical dependence). (p. 145)
Vascular pain Pain that results from pathology of the vascular or perivascular tissues. (p. 146)
Visceral pain Pain that originates from organs or smooth muscles. (p. 146)
World Health Organization (WHO) An international body of health care professionals that studies and
responds to health needs and trends worldwide. (p. 149)
Overview
Box 10-1
FIGURE 10-1 Illustration of the four processes of nociception. (From Jarvis C: Physical examination and health
assessment, ed 6, St Louis, 2012, Saunders.)
TABLE 10-1
Conditions That Alter Pain Tolerance
TABLE 10-2
Acute versus Chronic Pain
SNS, Sympathetic nervous system.
→
→
FIGURE 10-2 Gate theory of pain transmission. CNS, Central nervous system.
TABLE 10-3
A and C Nerve Fibers
Treatment of Pain in Special Situations

Box 10-2
Opioid Drugs
Chemical Structure
TABLE 10-4
Chemical Classification of Opioids
Mechanism of Action and Drug Effects
TABLE 10-5
Opioid Receptors and Their Characteristics
Box 10-3
EQUIANALGESIC DOSES
Indications
Contraindications
Adverse Effects
TABLE 10-6
Opioid-Induced Adverse Effects by Body System
Toxicity and Management of Overdose
TABLE 10-7
Opioid Antagonists (Reversal Drugs)
Interactions
Laboratory Test Interactions
Dosages
DOSAGES
Selected Analgesic Drugs and Related Drugs
*Actiq is not approved for use in patients younger than 16 years of age.
FDA, U.S. Food and Drug Administration; HCl, hydrochloride; IM, intramuscular; IV, intravenous; IR, immediate release; MS, morphine
sulfate; MSIR, morphine sulfate immediate-release; PCA, patient-controlled analgesia; PO, oral; PR, rectal; subcut, subcutaneous.
The maximum recommended daily dose of acetaminophen for a typical adult patient with normal liver function is 3000 mg/24 hr. For
hepatically compromised patients, this dosage may be 2000 mg or even lower. If in doubt, check with a pharmacist or prescriber
regarding a particular patient.
Drug Profiles
Opioid Agonists
codeine sulfate
Pharmacokinetics: Codeine
fentanyl
Pharmacokinetics: Fentanyl
hydromorphone (Dilaudid)
Pharmacokinetics: Hydromorphone (Dilaudid)
meperidine hydrochloride
Pharmacokinetics: Meperedine
methadone hydrochloride
Pharmacokinetics: Methadone
morphine sulfate
Pharmacokinetics: Morphine Sulfate
oxycodone hydrochloride
Pharmacokinetics (Immediate Release): Oxycodone Hydrochloride
Opioid Agonists-Antagonists
Opioid Antagonists
naloxone hydrochloride
Pharmacokinetics: Naloxone Hydrochloride
naltrexone hydrochloride
Pharmacokinetics: Naltrexone Hydrochloride
Nonopioid and Miscellaneous Analgesics
Indications
Contraindications
Adverse Effects
Interactions
Drug Profiles
acetaminophen
Pharmacokinetics: Acetaminophen
tramadol hydrochloride
Pharmacokinetics: Tramadol
lidocaine, transdermal
Nursing Process
Assessment
Nonopioids
Opioids
Opioid Antagonists
Nursing Diagnoses

Implementation
Nonopioids
Opioids
Box 10-4
TABLE 10-8
Opioid Administration Guidelines
Opioid Antagonists
General Considerations
TABLE 10-9
Drugs Not Recommended for Treatment of Cancer Pain
*DPT is the abbreviation for the trade names Demerol, Phenergan, and Thorazine.
CNS, Central nervous system.
Evaluation

Key Points
11
DRUG PROFILES
dexmedetomidine, p. 174
ketamine, p. 174
lidocaine, p. 178
nitrous oxide, p. 174
propofol, p. 174
rocuronium, p. 181
sevoflurane, p. 175
succinylcholine, p. 180
Objectives
KEY TERMS
Adjunct anesthetics Drugs used in combination with anesthetic drugs to control the adverse effects of
anesthetics or to help maintain the anesthetic state in the patient. (See balanced anesthesia.) (p. 172)
Anesthesia The loss of the ability to feel pain resulting from the administration of an anesthetic drug. (p.
172)
Anesthetics Drugs that depress the central nervous system (CNS) or peripheral nerves to produce
decreased or loss of consciousness, or muscle relaxation. (p. 172)
Anesthesia provider A health care professional who is licensed to provide anesthesia. Can be an
anesthesiologist (MD), a Certified Registered Nurse Anesthetist (CRNA), or an anesthesia assistant. (p. 172)
Balanced anesthesia The practice of using combinations of different drug classes rather than a single drug
to produce anesthesia. (p. 172)
General anesthesia A drug-induced state in which the CNS nerve impulses are altered to reduce pain and
other sensations throughout the entire body. It involves complete loss of consciousness and depression of
respiratory drive. (p. 172)
Local anesthesia A drug-induced state in which peripheral or spinal nerve impulses are altered to reduce
or eliminate pain and other sensations in tissues innervated by these nerves. (p. 172)
Malignant hyperthermia A genetically linked major adverse reaction to general anesthesia characterized
by a rapid rise in body temperature, as well as tachycardia, tachypnea, and sweating. (p. 174)
Moderate sedation A milder form of general anesthesia that causes partial or complete loss of
consciousness but does not generally reduce normal respiratory drive (also referred to as conscious sedation).
(p. 175)
Overton-Meyer theory A theory that describes the relationship between the lipid solubility of anesthetic
drugs and their potency. (p. 172)
Spinal anesthesia Local anesthesia induced by injection of an anesthetic drug near the spinal cord to
anesthetize nerves that are distal to the site of injection (p. 175)
Overview
General Anesthetics
Box 11-1
TABLE 11-1
Parenteral General Anesthetics
TABLE 11-2
Inhalational General Anesthetics
TABLE 11-3
Adjunctive Anesthetic Drugs
TABLE 11-4
Effects of Inhaled and Intravenous General Anesthetics
Indications
Contraindications
Adverse Effects
Interactions
Drug Profiles
dexmedetomidine
ketamine
nitrous oxide
propofol
sevoflurane
Drugs for Moderate Sedation
Local Anesthetics
Box 11-2
TABLE 11-5
Selected Topical Anesthetics
TABLE 11-6
Selected Parenteral Local Anesthetic Drugs*
*Othercommon parenteral anesthetic drugs include bupivacaine (Marcaine, Sensorcaine), chloroprocaine (Nesacaine), etidocaine
(Duranest), propoxycaine (Ravocaine), and ropivacaine (Naropin).

Indications
Contraindications
Adverse Effects
Box 11-3
Interactions
Drug Profiles
lidocaine
Neuromuscular Blocking Drugs

Indications
Contraindications
Adverse Effects
TABLE 11-7
Effects of Ganglionic Blockade by Neuromuscular Blocking Drugs
Box 11-4
Box 11-5
Dosages
Selected Neuromuscular Blocking Drugs
NMBD, neuromuscular blocking drug.
Interactions
Box 11-6
Dosages
Drug Profiles
Box 11-7
Depolarizing Neuromuscular Blocking Drugs
succinylcholine
Pharmacokinetics: Succinylcholine
Nondepolarizing Neuromuscular Blocking Drugs

rocuronium
Pharmacokinetics: Rocuronium
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Box 11-8
Box 11-9
Evaluation
Key Points
12
DRUG PROFILES
baclofen, p. 197
cyclobenzaprine, p. 197
diazepam, p. 193
eszopiclone, p. 193
midazolam, p. 193
pentobarbital, p. 195
phenobarbital, p. 196
ramelteon, p. 193
temazepam, p. 193
zaleplon, p. 194
zolpidem, p. 194
Objectives
KEY TERMS
Barbiturates A class of drugs used to induce sedation; chemical derivatives of barbituric acid. (p. 194)
Benzodiazepines A chemical category of drugs most frequently prescribed as anxiolytic drugs and less
frequently as sedative-hypnotic agents. (p. 190)
Gamma-aminobutyric acid (GABA) The primary inhibitory neurotransmitter found in the brain. A key
compound affected by sedative, anxiolytic, psychotropic, and muscle-relaxing medications. (p. 191)
Hypnotics Drugs that, when given at low to moderate dosages, calm or soothe the central nervous system
(CNS) without inducing sleep but when given at high dosages cause sleep. (p. 190)
Non–rapid eye movement (non-REM) sleep The largest portion of the sleep cycle. It has four stages and
precedes REM sleep. (p. 190)
Rapid eye movement (REM) sleep One of the stages of the sleep cycle. Some of the characteristics of
REM sleep are rapid movement of the eyes, vivid dreams, and irregular breathing. (p. 190)
REM interference A drug-induced reduction of REM sleep time. (p. 190)
REM rebound Excessive REM sleep following discontinuation of a sleep-altering drug. (p. 190)
Sedatives Drugs that have an inhibitory effect on the CNS to the degree that they reduce nervousness,
excitability, and irritability without causing sleep. (p. 190)
Sedative-hypnotics Drugs that can act in the body either as sedatives or as hypnotics. (p. 190)
Sleep A transient, reversible, and periodic state of rest in which there is a decrease in physical activity and
consciousness. (p. 190)
Sleep architecture The structure of the various elements involved in the sleep cycle, including normal and
abnormal patterns of sleep. (p. 190)
Therapeutic index The ratio between the toxic and therapeutic concentrations of a drug. If the index is low,
the difference between the therapeutic and toxic drug concentrations is small, and use of the drug is more
hazardous. (p. 194)
Overview
Physiology of Sleep
TABLE 12-1
Stages of Sleep
NOTE: Four to five cycles are completed during normal sleep for adults. NREM sleep constitutes about the first third of the night and
REM sleep is more prominent during the last third of the night.
REM, Rapid eye movement.
Modified from Urden LD, Stacy KM, Lough ME: Priorities in critical care nursing, ed 6, St Louis, 2012, Mosby.
Benzodiazepines and Miscellaneous Hypnotic Drugs
TABLE 12-2
Sedative-Hypnotic Benzodiazepines and Miscellaneous Drugs
*These drugs share many characteristics with the benzodiazepines but are classified as miscellaneous hypnotic drugs.
Indications
Contraindications
Adverse Effects
TABLE 12-3
Flumazenil Treatment Regimen
NOTE: Flumazenil has a relatively short half-life and a duration of effect of 1 to 4 hours; therefore, if flumazenil is used to reverse the
effects of a long-acting benzodiazepine, the dose of the reversal drug may wear off and the patient may become sedated again,
requiring more flumazenil.
Interactions
TABLE 12-4
Benzodiazepines: Drug/Food Interactions
Dosages
Drug profiles
Benzodiazepines
diazepam
DOSAGES
Selected Benzodiazepine and Other Sedative-Hypnotic Drugs
*Nonbenzodiazepine drugs.
Pharmacokinetics: Diazepam
midazolam
Pharmacokinetics: Midazolam
temazepam
Pharmacokinetics: Temazepam
Nonbenzodiazepines
eszopiclone
Pharmacokinetics: Eszopiclone
ramelteon
Pharmacokinetics: Ramelteon
zaleplon
Pharmacokinetics: Zaleplon
zolpidem
Pharmacokinetics: Zolpidem
Barbiturates
TABLE 12-5
Sedative-Hypnotic Barbiturates
Indications
Contraindications
Adverse Effects
TABLE 12-6
Barbiturates: Adverse Effects
Interactions
Dosages
DOSAGES
Selected Barbiturates
Drug profiles
TABLE 12-7
Barbiturates: Controlled Substance Schedule
pentobarbital
Pharmacokinetics: Pentobarbital
phenobarbital
Pharmacokinetics: Phenobarbital
Over-the-Counter Hypnotics
Muscle Relaxants
Indications
Contraindications
Adverse Effects
Interactions
Dosages
DOSAGES
Selected Muscle Relaxants
Drug profiles
baclofen
Pharmacokinetics: Baclofen
cyclobenzaprine
Pharmacokinetics: Cyclobenzaprine
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Box 12-1
Key Points
13
DRUG PROFILES
amphetamines, p. 206
atomoxetine, p. 206
caffeine, p. 212
doxapram, p. 212
methylphenidate, p. 207
modafinil, p. 207
orlistat, p. 208
phentermine, p. 208
sumatriptan, p. 209
Objectives
KEY TERMS
Amphetamines A class of stimulant drugs that includes amphetamine sulfate and all of its drug derivatives.
(p. 205)
Analeptics Central nervous system stimulants that have effects on the brainstem and spinal cord, which
produce an increase in responsiveness to external stimuli and stimulate respiration. (p. 211)
Anorexiants Drugs used to control or suppress appetite. (p. 207)
Attention deficit hyperactivity disorder (ADHD) A syndrome characterized by difficulty in maintaining
concentration on a given task and/or hyperactive behavior; may affect children, adolescents, and adults. The term
attention deficit disorder (ADD) has been absorbed under this broader term. (p. 204)
Cataplexy A condition characterized by abrupt attacks of muscular weakness and hypotonia triggered by an
emotional stimulus such as joy, laughter, anger, fear, or surprise. (p. 204)
Central nervous system (CNS) stimulants Drugs that stimulate specific areas of the brain or spinal cord.
(p. 204)
Ergot alkaloids Drugs that constrict blood vessels in the brain and provide relief of pain for certain migraine
headaches. (p. 209)
Migraine A common type of recurring painful headache characterized by a pulsatile or throbbing quality,
incapacitating pain, and photophobia. (p. 205)
Narcolepsy A syndrome characterized by sudden sleep attacks, cataplexy, sleep paralysis, and visual or
auditory hallucinations at the onset of sleep. (p. 204)
Serotonin receptor agonists A class of CNS stimulants used to treat migraine headaches; they are often
referred to as selective serotonin receptor agonists or triptans. (p. 209)
Sympathomimetic drugs CNS stimulants such as noradrenergic drugs whose actions resemble or mimic
those of the sympathetic nervous system. (p. 204)
Overview
TABLE 13-1
Structurally Related CNS Stimulants
TABLE 13-2
CNS Stimulants: Site of Action
TABLE 13-3
CNS Stimulants and Related Drugs: Therapeutic Categories
Attention Deficit Hyperactivity Disorder
Narcolepsy
Obesity
Migraine
Analeptic-Responsive Respiratory Depression Syndromes
Drugs for Attention Deficit Hyperactivity Disorder and
Narcolepsy
Indications
Contraindications
Adverse Effects
Interactions
TABLE 13-4
CNS Stimulants: Common Drug Interactions
CYP2D6, Cytochrome P-450 enzyme 2D6; MAOIs, monoamine oxidase inhibitors.
Dosages
Drug Profiles
Amphetamines and Related Stimulants
amphetamines
Pharmacokinetics: Dextroamphetamine
atomoxetine
Pharmacokinetics: Atomoxetine
methylphenidate
Pharmacokinetics (Immediate Release): Methylphenidate
modafinil
Pharmacokinetics: Modafinil
*Therapeutic effects.
Anorexiants
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
phentermine
orlistat
Pharmacokinetics: Orlistat
*Therapeutic effects.
Antimigraine Drugs
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
Serotonin Receptor Agonists

sumatriptan
Pharmacokinetics: Sumatriptan
DOSAGES
Selected CNS Stimulants and Related Drugs
Ergot Alkaloids
Drugs for Specific Respiratory Depression Syndromes:
Analeptics
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
caffeine
Pharmacokinetics: Caffeine
TABLE 13-5
Caffeine-Containing Beverages and Drugs
doxapram
Pharmacokinetics: Doxapram
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
General Information
Drugs Used to Treat Attention Deficit Hyperactivity Disorder
Anorexiants
Antimigraine Drugs
Key Points
14
DRUG PROFILES
carbamazepine, p. 226
ethosuximide, p. 226
gabapentin, p. 227
lamotrigine, p. 227
levetiracetam, p. 227
oxcarbazepine, p. 226
phenobarbital and primidone, p. 224
phenytoin and fosphenytoin, p. 225

pregabalin, p. 227
tiagabine, p. 227
topiramate, p. 228
valproic acid, p. 228
Objectives
KEY TERMS
Anticonvulsants Substances that prevent or reduce the severity of epileptic or other convulsive seizures.
(p. 220)
Antiepileptic drugs Prescription drugs that prevent or reduce the severity of epilepsy and different types of
epileptic seizures, not just convulsive seizures. (p. 220)
Autoinduction A metabolic process in which a drug stimulates the production of enzymes that enhance its
own metabolism, which leads to a reduction in drug concentrations. (p. 226)
Convulsion A type of seizure involving excessive stimulation of neurons in the brain and characterized by
the spasmodic contraction of voluntary muscles. (See also seizure.) (p. 219)
Electroencephalogram (EEG) A recording of the electrical activity that arises from spontaneous currents in
nerve cells in the brain. (p. 219)
Epilepsy A general term for any of a group of neurologic disorders characterized by recurrent episodes of
convulsive seizures, sensory disturbances, abnormal behavior, loss of consciousness, or any combination of
these. (p. 219)
Generalized onset seizures Seizures originating simultaneously in both cerebral hemispheres. (p. 219)
Gingival hyperplasia Overgrowth of gum tissue and often a side effect of phenytoin. (p. 225)
Partial onset seizures Seizures originating in a more localized region of the brain (also called focal
seizures). (p. 219)
Primary epilepsy Epilepsy in which there is no identifiable cause. Also known as idiopathic. (p. 219)
Seizure Excessive stimulation of neurons in the brain leading to a sudden burst of abnormal neuron activity
that results in temporary changes in brain function, primarily affecting sensory and motor activity. (p. 219)
Status epilepticus A seizure disorder characterized by generalized tonic-clonic convulsions that occur
repeatedly; considered a true medical emergency. (p. 220)
Tonic-clonic seizures Seizures involving initial muscular contraction throughout the body (tonic phase),
progressing to alternating contraction and relaxation (clonic phase). (p. 219)
Epilepsy
Box 14-1
Antiepileptic Drugs
TABLE 14-1
Currently Available Antiepileptic Drugs

Indications
TABLE 14-2
Common Seizure Indications for Antiepileptic Drugs
TABLE 14-3
Antiepileptic Drugs Used to Treat Status Epilepticus
*Off-label use (not a Food and Drug Administration–approved indication), but still used for this purpose.
Contraindications
Adverse Effects
TABLE 14-4
Adverse Effects of Selected Antiepileptic Drugs
Interactions
TABLE 14-5
Significant Drug Interactions of Antiepileptic Drugs
AED, Antiepileptic drug; CYP450, cytochrome P-450; SSRIs, selective serotonin reuptake inhibitors.
Dosages
TABLE 14-6
Therapeutic Plasma Levels of Antiepileptic Drugs with a Narrow Therapeutic Range
Drug Profiles
Barbiturates
phenobarbital and primidone

DOSAGES
Selected Antiepileptic Drugs*
†One PE = 1.5 mg fosphenytoin = 1 mg phenytoin. Therefore, 1.5 mg fosphenytoin is given for each milligram of phenytoin desired.
*See Table 14-3 for doses of drugs used for status epilepticus.
AED, Antiepileptic drug; PE, phenytoin equivalent.
Pharmacokinetics: Phenobarbital
Pharmacokinetics: Primidone
*Longer for active metabolites, including phenobarbital
Hydantoins
phenytoin and fosphenytoin

Pharmacokinetics: Phenytoin
TABLE 14-7
Comparison of Phenytoin Sodium and Fosphenytoin Sodium
*150 mg fosphenytoin sodium = 100 mg phenytoin sodium.

PE, Phenytoin sodium equivalents.
Iminostilbenes
carbamazepine
Pharmacokinetics: Carbamazepine
oxcarbazepine
Pharmacokinetics: Oxcarbazepine
Succinimide
ethosuximide
Pharmacokinetics: Ethosuximide
Miscellaneous Drugs
gabapentin
Pharmacokinetics: Gabapentin
lamotrigine
Pharmacokinetics: Lamotrigine
levetiracetam
Pharmacokinetics: Levetiracetam
pregabalin
Pharmacokinetics: Pregabalin
tiagabine
Pharmacokinetics: Tiagabine
topiramate
Pharmacokinetics: Topiramate
valproic acid
Pharmacokinetics: Valproic Acid
zonisamide
Pharmacokinetics: Zonisamide
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
15
DRUG PROFILES
amantadine, p. 240
benztropine mesylate, p. 243
bromocriptine, p. 242
carbidopa-levodopa, p. 243
entacapone, p. 241
ropinirole, p. 242
rasagiline and selegiline, p. 238
Objectives
KEY TERMS
Adjunctive drugs Drugs that are added as a second drug for combined therapy with a primary drug and
may have additive or independent properties. (p. 238)
Akinesia Classically defined as “without movement.” Absence or poverty of movement that results in a
masklike facial expression and impaired postural reflexes. (p. 237)
Bradykinesia Slowness of movement; a classic symptom of Parkinson's disease. (p. 237)
Chorea A condition characterized by involuntary, purposeless, rapid motions such as flexing and extending
the fingers, raising and lowering the shoulders, or grimacing. (p. 237)
Dyskinesia Abnormal involuntary movements; inability to control movements. (p. 237)
Dystonia Impaired or distorted voluntary movement, involving the head, neck, or feet. (p. 237)
Exogenous A term describing any substance produced outside of the body that may be taken into the body
(e.g., a medication, food, or environmental toxin). (p. 242)
On-off phenomenon A common experience of patients taking medication for Parkinson's disease in which
they experience periods of greater symptomatic control (“on” time) alternating with periods of lesser symptomatic
control (“off” time). (p. 237)
Parkinson's disease A slowly progressive, degenerative neurologic disorder characterized by resting
tremor, pill-rolling of the fingers, masklike facies, shuffling gait, forward flexion of the trunk, loss of postural
reflexes, and muscle rigidity and weakness. (p. 236)
Postural instability A decrease or change in motor and muscle movements that leads to unsteadiness and
hesitation in movement and gait when the individual starts or stops walking, or causes leaning to the left or right
when sitting; occurs in Parkinson's disease. (p. 237)
Presynaptic Drugs that exert their antiparkinson effects before the nerve synapse. (p. 240)
Rigidity Resistance of the muscles to passive movement; leads to the “cogwheel” rigidity seen in
Parkinson's disease. (p. 237)
TRAP (Tremor, Rigidity, Akinesia, Postural instability); an acronym for symptoms of Parkinson's disease. (p.
237)
Tremor In Parkinson's disease, shakiness of the extremities seen mostly at rest. (p. 237)
Wearing-off phenomenon A gradual worsening of parkinsonian symptoms as a patient's medications
begin to lose their effectiveness, despite maximal dosing with a variety of medications. (p. 237)
Pathophysiology of Parkinson's Disease

FIGURE 15-1 Basal ganglia and related structures of the brain. (From Copstead-Kirkhorn LC, Banasik JL:
Pathophysiology, ed 4, St Louis, 2010, Saunders.)
FIGURE 15-2 The neurotransmitter abnormality in Parkinson's disease.
TABLE 15-1
Classic Parkinsonian Symptoms
Treatment of Parkinson's Disease
TABLE 15-2
Review of Pharmacologic Therapy for Parkinson's Disease
*Orally disintegrating tablet (see Chapter 2).

†See Chapter 21.
‡See Chapter 36.
COMT, Catechol ortho-methyltransferase; MAO-B, monoamine oxidase type B.
Indirect-Acting Dopaminergic Drugs
Monoamine Oxidase Inhibitors
Indications
Contraindications
Adverse Effects
TABLE 15-3
Adverse Effects of Selected Antiparkinson Drugs
Interactions
Dosages
DOSAGES
Selected Antiparkinson Drugs
Drug Profiles
rasagiline and selegiline
Pharmacokinetics: Selegiline
TABLE 15-4
Selected Drug Interactions of Antiparkinson Drugs
COMT, Catechol ortho-methyltransferase; MAO-B, monoamine oxidase type B; MAOI, monoamine oxidase inhibitor.
Dopamine Modulator
Indications
Contraindications
Adverse Drug Effects
Drug Interactions
Dosage
Drug Profile
amantadine
Pharmacokinetics: Amantadine
Catechol Ortho-Methyltransferase Inhibitors
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
entacapone
Pharmacokinetics: Entacapone
Direct-Acting Dopamine Receptor Agonists
Nondopamine Dopamine Receptor Agonists

Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
bromocriptine
Pharmacokinetics Bromocriptine
ropinirole
Pharmacokinetics: Ropinirole
Dopamine Replacement Drugs

Indications
Contraindications
Adverse Effects
Interactions
Drug Profile
carbidopa-levodopa
Pharmacokinetics: Carbidopa-Levodopa
*Therapeutic effect.
Anticholinergic Drugs
Drug Profile
benztropine mesylate
Pharmacokinetics: Benztropine
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
16
DRUG PROFILES
alprazolam, p. 253
amitriptyline, p. 258
aripiprazole, p. 266
bupropion, p. 261
buspirone, p. 254
citalopram, p. 262
clozapine, p. 266
diazepam, p. 254
duloxetine, p. 262
fluoxetine, p. 262
haloperidol, p. 265
lithium, p. 255
lorazepam, p. 254
mirtazapine, p. 262
risperidone, p. 267
selegiline transdermal patch, p. 260
trazodone, p. 262
Objectives
KEY TERMS
Affective disorders Emotional disorders that are characterized by changes in mood. (p. 252)
Agoraphobia An anxiety disorder that involves an intense fear of being in unfamiliar situations or places. (p.
252)
Akathisia A movement disorder in which there is an inability to sit still; motor restlessness. It can occur as
an adverse effect of psychotropic medications. (p. 264)
Anxiety The unpleasant state of mind in which real or imagined dangers are anticipated and/or
exaggerated. (p. 252)
Biogenic amine hypothesis A theory suggesting that depression and mania are caused by alterations in
the concentrations of dopamine and norepinephrine, and of serotonin and histamine in the brain. (p. 256)
Bipolar disorder A psychological disorder characterized by episodes of mania or hypomania, cycling with
depression; formerly called manic-depressive illness. (p. 252)
Depression An abnormal emotional state characterized by exaggerated feelings of sadness, melancholy,
dejection, worthlessness, emptiness, and hopelessness. Signs include withdrawal from social contact, loss of
appetite, and insomnia. (p. 252)
Dopamine hypothesis A theory suggesting that dopamine dysregulation in certain parts of the brain is one
of the primary contributing factors to the development of psychotic disorders (psychoses). (p. 252)
Dyskinesia Term for abnormal and distressing involuntary movements; inability to control movements. (p.
264)
Dysregulation hypothesis A theory that views depression and affective disorders by failure of the brain to
regulate the levels of neurotransmitters. (p. 256)
Dystonia A syndrome of abnormal muscle contraction that produces repetitive involuntary twisting
movements and abnormal posturing of the neck, face, trunk, and extremities; often caused as an adverse
reaction to psychotropic medications. (p. 264)
Extrapyramidal symptoms The term for signs and symptoms that resemble pathologic changes to the
pyramidal portions of the brain. Such symptoms include various motion disorders similar to those seen in
Parkinson's disease, and are an adverse effect associated with use of various antipsychotic drugs. (p. 264)
Gamma-aminobutyric acid An amino acid in the brain that functions to inhibit nerve transmission in the
central nervous system. (p. 251)
Hypertensive crisis A term referring to severely elevated blood pressure; can present as hypertensive
urgency or hypertensive emergency. (p. 258)
Hypomania A less severe and less potentially hazardous form of mania. (p. 252)
Mania An acute illness characterized by an expansive emotional state, including extreme excitement,
elation, hyperactivity, agitation, talkativeness, flight of ideas, reduced attention span, increased psychomotor
activity, impulsivity, insomnia, anorexia, and sometimes violent, destructive, and self-destructive behavior. (p.
252)
Metabolic syndrome A cluster of conditions (increased glucose level, increased blood pressure, abnormal
cholesterol levels, excess body fat around the waist) occurring together that increases the risk for heart disease,
stroke, and diabetes. (p. 264)
Neuroleptic malignant syndrome An uncommon but serious adverse effect associated with the use of
antipsychotic drugs and characterized by symptoms such as fever, cardiovascular instability, and myoglobinemia
(presence in the blood of muscle breakdown proteins). (p. 264)
Neurotransmitters Endogenous chemicals in the body that serve to conduct nerve impulses between
nerve cells (neurons). (p. 251)
Permissive hypothesis A theory postulating that reduced concentrations of serotonin (5-hydroxytriptamine)
is the predisposing factor in individuals with affective disorders. (p. 256)
Psychosis (Plural: psychoses) A type of serious mental illness that is associated with being out of touch
with reality; that is, the individual is unable to distinguish imaginary from real circumstances and events. (p. 252)
Psychotherapeutics The treatment of emotional and mental disorders. (p. 252)
Psychotropic Capable of affecting mental processes; usually said of a medication. (p. 252)
Serotonin syndrome A collection of symptoms resulting from elevated levels of the neurotransmitter
serotonin; may occur with the use of any psychotropic drug (e.g., antidepressants, buspirone, tramadol) that
enhances brain serotonin activity (see Box 16-1). (p. 261)
Tardive dyskinesia A serious drug adverse effect characterized by abnormal and distressing involuntary
body movements and muscle tension that is associated with the use of antipsychotic medications. (p. 264)
Overview
Anxiety Disorders
Anxiolytic Drugs
TABLE 16-1
Currently Available Anxiolytic Drugs
Indications
Contraindications
Adverse Effects
TABLE 16-2
Adverse Effects of Selected Anxiolytic Drugs
Interactions
TABLE 16-3
Drug Interactions of Selected Anxiolytic Drugs
CNS, Central nervous system; CYP3A4, cytochrome P-450 enzyme 3A4; MAOIs, monoamine oxidase inhibitors; NSAIDs, nonsteroidal
antiinflammatory drugs; SSRIs, selective serotonin reuptake inhibitors.
Dosages
Drug Profiles
Benzodiazepines
alprazolam
DOSAGES
Selected Anxiolytic Drugs
Pharmacokinetics: Alprazolam
diazepam
Pharmacokinetics: Diazepam
lorazepam
Pharmacokinetics: Lorazepam
Miscellaneous Drug
buspirone
Pharmacokinetics: Buspirone
Affective Disorders
Mood-Stabilizing Drugs
TABLE 16-4
Currently Available Mood Stabilizers and Antidepressants
Drug Profile
lithium
Pharmacokinetics (Immediate Release): Lithium Carbonate
*Therapeutic benefit for maintenance control of mania.
Antidepressant Drugs
FIGURE 16-1 Biogenic amine hypothesis. NE, Norepinephrine.
FIGURE 16-2 Permissive hypothesis. NE, Norepinephrine; 5-HT, serotonin.
Tricyclic Antidepressants
Indications
Contraindications
Adverse Effects
TABLE 16-5
Adverse Effects of Selected Mood Stabilizers and Antidepressants
Interactions
TABLE 16-6
Drug Interactions of Selected Mood-Stabilizing and Antidepressant Drugs
CYP, Cytochrome P-450; MAOIs, monoamine oxidase inhibitors; NSAIDs, nonsteroidal antiinflammatory drugs; SNRIs, serotonin-
norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors.
Dosages
Drug Profile
amitriptyline
Pharmacokinetics: Amitriptyline
DOSAGES
Selected Mood-Stabilizing and Antidepressant Drugs
Monoamine Oxidase Inhibitors

TABLE 16-7
Food and Drink to Avoid When Taking Monoamine Oxidase Inhibitors
Drug Profile
selegiline transdermal patch
Second-Generation Antidepressants
Indications
Contraindications
Adverse Effects
Box 16-1
Interactions
Dosages
Drug Profiles
bupropion
Pharmacokinetics: Bupropion
citalopram
Pharmacokinetics: Citalopram
duloxetine
Pharmacokinetics: Duloxetine
fluoxetine
Pharmacokinetics: Fluoxetine
*Active metabolite has a half-life of 7 to 10 days.
mirtazapine
Pharmacokinetics: Mirtazapine
trazodone
Pharmacokinetics: Trazodone
Psychotic Disorders
Antipsychotic Drugs
TABLE 16-8
Currently Available Antipsychotic Drugs
MAOIs, Monoamine oxidase inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake
inhibitors.
Indications
Contraindications
Adverse Effects
TABLE 16-9
Antipsychotics: Receptor-Related Adverse Effects
TABLE 16-10
Adverse Effects of Selected Psychotropic Drugs
Interactions
TABLE 16-11
Drug Interactions of Selected Antipsychotics
CYP3A4, Cytochrome P-450 enzyme 3A4.

Dosages
Drug Profiles
Butyrophenone
haloperidol
DOSAGES
Selected Antipsychotic Drugs
Pharmacokinetics: Haloperidol
Atypical Antipsychotics
aripiprazole
Pharmacokinetics: Aripiprazole
clozapine
Pharmacokinetics: Clozapine
risperidone
Pharmacokinetics: Risperidone
Nursing Process
Assessment
Anxiolytic Drugs
Antidepressants
Antipsychotics
Nursing Diagnoses

Implementation
Anxiolytic Drugs
Antidepressants
Antipsychotics
Evaluation
Anxiolytic Drugs
Monoamine Oxidase Inhibitors and Tricyclic Antidepressants
Selective Serotonin Reuptake Inhibitors and Serotonin-Norepinephrine

Reuptake Inhibitors (Antidepressants)
Key Points
17
Objectives
KEY TERMS
Addiction Psychologic or physical dependence on a drug or psychoactive substance. (p. 278)
Amphetamine A drug that stimulates the central nervous system. (p. 280)
Detoxification A process of eliminating a toxic substance from the body; a medically supervised program
for alcohol, benzodiazepine, methamphetamine, or opioid addiction. (p. 279)
Enuresis Urinary incontinence. (p. 280)
Habituation Development of tolerance to a substance following prolonged medical use but without
psychologic or physical dependence (addiction). (p. 278)
Illicit drug use The use of a drug or substance in a way that it is not intended to be used or the use of a
drug that is not legally approved for human administration. (p. 279)
Intoxication Stimulation, excitement, or stupefaction produced by a chemical substance. (p. 278)
Korsakoff's psychosis A syndrome of amnesia with confabulation (making up of stories) associated with
chronic alcohol abuse; it often occurs together with Wernicke's encephalopathy. (p. 283)
Micturition Urination, the desire to urinate, or the frequency of urination. (p. 280)
Narcolepsy A sleep disorder characterized by sleeping during the day, disrupted nighttime sleep,
cataplexy, sleep paralysis, and hallucinations. (p. 281)
Physical dependence A condition characterized by physiologic reliance on a substance, usually indicated
by tolerance to the effects of the substance and development of withdrawal symptoms when use of the substance
is terminated. (p. 278)
Psychoactive properties Drug properties that affect mood, behavior, cognitive processes, and mental
status. (p. 280)
Psychologic dependence A condition characterized by strong desires to obtain and use a substance. (p.
278)
Raves Increasingly popular all-night parties that typically involve dancing, drinking, and the use of various
illicit drugs. (p. 280)
Roofies Pills that are classified as benzodiazepines. They have recently gained popularity as a recreational
drug; chemically known as flunitrazepam. (p. 281)
Substance abuse The use of a mood- or behavior-altering substance in a maladaptive manner that often
compromises health, safety, and social and occupational functioning, and causes legal problems. (p. 278)
Wernicke's encephalopathy A neurologic disorder characterized by apathy, drowsiness, ataxia,
nystagmus, and ophthalmoplegia; it is caused by thiamine (vitamin B1) deficiency secondary to chronic alcohol
abuse. (p. 283)
Withdrawal A substance-specific mental disorder characterized by physical symptoms, following the
cessation or reduction in use of a psychoactive substance that has been taken regularly to induce a state of
intoxication. (p. 278)
Overview
Box 17-1
Opioids
Indications
Contraindications
Adverse Effects
Management of Withdrawal, Toxicity, and Overdose
Box 17-2
Box 17-3
Stimulants
TABLE 17-1
Various Forms of Amphetamine and Cocaine with Street Names
Indications
Contraindications
Adverse Effects
Box 17-4
Depressants
Indications
Contraindications
Adverse Effects
Box 17-5
Alcohol
Indications
Adverse Effects
Interactions
Box 17-6
TABLE 17-2
Disulfiram Adverse Effects: Acetaldehyde Syndrome
Nicotine
Indications
Adverse Effects

TABLE 17-3
Nicotine Withdrawal Therapies
Nursing Process
Assessment
Box 17-7
Nursing Diagnoses
Implementation
Box 17-8
Evaluation
Patient-Centered Care: Patient Teaching Tips
Key Points
PA R T 3
OUTLINE
Learning Strategies
18 Adrenergic Drugs
19 Adrenergic-Blocking Drugs
20 Cholinergic Drugs
21 Cholinergic-Blocking Drugs
Vocabulary
Text Notation
Pain is most commonly defined as an unpleasant sensory and emotional experience associated with either actual
or potential tissue damage. It is a very personal and individual experience. Pain can be defined as whatever the
patient says it is, and it exists whenever the patient says it does. Although the mechanisms of pain are becoming
better understood, a patient's perception of pain is a complex process. Pain involves physical, psychologic, and
even cultural factors. Because pain intensity cannot be precisely quantified, health care providers must
cultivate relationships of mutual trust with their patients to provide optimal care.
There is no single approach to effective pain management. Instead, pain management is tailored to each
patient's needs. The cause of the pain, the existence of concurrent medical conditions; the characteristics of the
pain; and the psychologic and cultural characteristics of the patient need to be considered. It also requires
ongoing reassessment of the pain and the effectiveness of treatment. The patient's emotional response to pain
depends on his or her psychological experiences of pain. Pain results from the stimulation of sensory nerve fibers
known as nociceptors. These receptors transmit pain signals from various body regions to the spinal cord and
brain, which leads to the sensation of pain, or nociception. The physical impulses that signal pain activate
various nerve pathways from the periphery to the spinal cord and to the brain. The level of stimulus needed to
produce a painful sensation is referred to as the pain threshold. Because this is a measure of the physiologic
response of the nervous system, it is similar for most persons. However, variations in pain sensitivity may result
from genetic factors.
Enhanced Typeface
18
DRUG PROFILES
dobutamine, p. 301
dopamine, p. 301
epinephrine, p. 302
fenoldopam, p. 302
midodrine, p. 302
mirabegron, p. 302
norepinephrine, p. 302
phenylephrine, p. 303
Objectives
KEY TERMS
Adrenergic agonists Drugs that stimulate and mimic the actions of the sympathetic nervous system. Also
called sympathomimetics. (p. 296)
Adrenergic receptors Receptor sites for the sympathetic neurotransmitters norepinephrine and
epinephrine. (p. 296)
Alpha-adrenergic receptors A class of adrenergic receptors that are further subdivided into alpha1- and
alpha2-adrenergic receptors. (p. 296)
Autonomic functions Bodily functions that are involuntary and result from the physiologic activity of the
autonomic nervous system. The functions often occur in pairs of opposing actions between the sympathetic and
parasympathetic divisions of the autonomic nervous system. (p. 296)
Autonomic nervous system A branch of the peripheral nervous system that controls autonomic bodily
functions. It consists of the sympathetic nervous system and the parasympathetic nervous system. (p. 296)
Beta-adrenergic receptors Receptors located on postsynaptic cells that are stimulated by specific
autonomic nerve fibers. Beta1-adrenergic receptors are located primarily in the heart, whereas beta2-adrenergic
receptors are located in the smooth muscle fibers of the bronchioles, arterioles, and visceral organs. (p. 296)
Catecholamines Substances that can produce a sympathomimetic response. They are either endogenous
catecholamines (such as epinephrine, norepinephrine, and dopamine) or synthetic catecholamine drugs (such as
dobutamine). (p. 296)
Dopaminergic receptor A third type of adrenergic receptor (in addition to alpha-adrenergic and beta-
adrenergic receptors) located in various tissues and organs and activated by the binding of the neurotransmitter
dopamine, which can be either endogenous or a synthetic drug form. (p. 296)
Mydriasis Pupillary dilation, whether natural (physiologic) or drug induced. (p. 299)
Ophthalmics Drugs that are used in the eye. (p. 299)
Positive chronotropic effect An increase in heart rate. (p. 299)
Positive dromotropic effect An increase in the conduction of cardiac electrical impulses through the
atrioventricular node, which results in the transfer of nerve action potentials from the atria to the ventricles. This
ultimately leads to a systolic heartbeat (ventricular contractions). (p. 299)
Positive inotropic effect An increase in the force of contraction of the heart muscle (myocardium). (p. 299)
Sympathomimetics Drugs used therapeutically that mimic the catecholamines epinephrine,
norepinephrine, and dopamine. Also called adrenergic agonists. (p. 296)
Synaptic cleft The space either between two adjacent nerve cell membranes or between a nerve cell
membrane and an effector organ cell membrane (also called synapse). (p. 297)
Overview
FIGURE 18-1 Sympathetic nervous system in relation to the entire nervous system. ACh, Acetylcholine;
NE, norepinephrine.
Sympathetic Nervous System
TABLE 18-1
Adrenergic Receptor Responses to Stimulation
FIGURE 18-2 Mechanism by which stimulation of a nerve fiber results in a physiologic process;
adrenergic drugs mimic this same process. COMT, Catechol ortho-methyltransferase; MAO, monoamine
oxidase; NE, norepinephrine.
Adrenergic Drugs
FIGURE 18-3 Mechanism of physiologic response to direct-acting sympathomimetics. D, Drug; NE,

norepinephrine.
FIGURE 18-4 Mechanism of physiologic response to indirect-acting sympathomimetics. D, Drug; NE,

norepinephrine.
FIGURE 18-5 Mechanism of physiologic response to mixed-acting sympathomimetics. D, Drug; NE,
norepinephrine.
TABLE 18-2
Catecholamines and Their Dose-Response Relationship

Indications
Respiratory Indications
Indications for Topical Nasal Decongestants
Ophthalmic Indications
Overactive Bladder Indications
Cardiovascular Indications
Contraindications
Adverse Effects
DOSAGES
Selected Vasoactive Adrenergics

Interactions
Dosages
Drug Profiles
Vasoactive Adrenergics
dobutamine
Pharmacokinetics: Dobutamine
dopamine
Pharmacokinetics: Dopamine
epinephrine
Pharmacokinetics: Epinephrine
fenoldopam
Pharmacokinetics: Fenoldopam
midodrine
Pharmacokinetics: Midodrine
mirabegron
Pharmacokinetics: Mirabegron
norepinephrine
Pharmacokinetics: Norepinephrine
phenylephrine
Pharmacokinetics: Phenylephrine
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
19
DRUG PROFILES
atenolol, p. 314
carvedilol, p. 315
esmolol, p. 315
labetalol, p. 315
metoprolol, p. 315
phentolamine, p. 312
propranolol, p. 315
sotalol, p. 316
tamsulosin, p. 313
Objectives
KEY TERMS
Acrocyanosis Decreased amount of oxygen delivered to the extremities, causing the feet or hands to turn
blue. (p. 311)
Adrenergic receptors Specific receptor sites located throughout the body for the endogenous sympathetic
neurotransmitters norepinephrine and epinephrine. (p. 310)
Agonists Drugs with a specific receptor affinity that mimic the body's natural chemicals (e.g., hormones,
neurotransmitters). (p. 310)
Angina Paroxysmal (sudden) chest pain caused by myocardial ischemia. (p. 313)
Antagonists Drugs that bind to specific receptors and inhibit or block the response of the receptors. (p.
310)
Dysrhythmias Irregular heart rhythms; generally called arrhythmias in clinical practice. (p. 313)
Extravasation The leaking of fluid from a blood vessel into the surrounding tissues, as in the case of an
infiltrated intravenous infusion. (p. 311)
First-dose phenomenon Severe and sudden drop in blood pressure after the administration of the first
dose of an alpha-adrenergic blocker. (p. 311)
Intrinsic sympathomimetic activity The paradoxical action of some beta-blocking drugs (e.g., acebutolol)
that mimics the action of the sympathetic nervous system. (p. 313)
Lipophilicity The chemical attraction of a substance (e.g., drug molecule) to lipid or fat molecules. (p. 314)
Orthostatic hypotension A sudden drop in blood pressure when a person stands up. Also referred to as
postural hypotension or orthostasis. (p. 311)
Pheochromocytoma A vascular adrenal gland tumor that is usually benign but secretes epinephrine and
norepinephrine and thus often causes central nervous system stimulation and substantial blood pressure
elevation. (p. 311)
Raynaud's disease A narrowing of small arteries that limits the amount of blood circulation to the
extremities, causing numbness of the nose, fingers, toes, and ears in response to cold temperatures or stress. (p.
311)
Sympatholytics Drugs that inhibit the postganglionic functioning of the sympathetic nervous system. (p.
310)
Overview
Alpha Blockers
FIGURE 19-1 Mechanisms for alpha-adrenergic competitive and noncompetitive blockade by alpha
blocker drugs. A, Alpha blocker; NE, norepinephrine.
TABLE 19-1
Currently Available Adrenergic-Blocking Drugs
*Has antagonist activity at alpha1, beta1, and beta2 receptors.
Indications
Contraindications
Adverse Effects
TABLE 19-2
Alpha Blockers: Adverse Effects
Toxicity and Management of Overdosec
Interactions
TABLE 19-3
Alpha Blockers: Common Drug Interactions
Dosages
DOSAGES
Selected Alpha-Adrenergic–Blocking Drugs
*Not indicated for use in women; however, it is sometimes used for kidney stones.
Drug Profiles
phentolamine
Pharmacokinetics: Phentolamine
tamsulosin
Pharmacokinetics: Tamsulosin
Beta Blockers
Indications
Contraindications
Adverse Effects
TABLE 19-4
Beta Blockers: Common Adverse Effects
Interactions
DOSAGES
Selected Beta-Adrenergic–Blocking Drugs
TABLE 19-5
Beta Blockers: Drug Interactions
Dosages
Drug Profiles
atenolol
Pharmacokinetics: Atenolol
carvedilol
Pharmacokinetics: Carvedilol
esmolol
Pharmacokinetics: Esmolol
labetalol
Pharmacokinetics: Labetalol
metoprolol
Pharmacokinetics: Metoprolol
propranolol
Pharmacokinetics: Propranolol
sotalol
Pharmacokinetics: Sotalol
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
20
DRUG PROFILES
bethanechol, p. 324
donepezil, p. 325
memantine, p. 325
pyridostigmine, p. 325
Objectives
KEY TERMS
Acetylcholine The neurotransmitter responsible for transmission of nerve impulses to effector cells in the
parasympathetic nervous system. (p. 321)
Acetylcholinesterase The enzyme responsible for the breakdown of acetylcholine. (p. 322)
Alzheimer's disease A disease of the brain that is characterized by progressive mental deterioration
manifested by confusion, disorientation, and loss of memory, ability to calculate, and visual-spatial orientation. (p.
323)
Atony A lack of normal muscle tone. (p. 323)
Cholinergic crisis Severe muscle weakness and respiratory paralysis due to excessive acetylcholine; often
seen in patients with myasthenia gravis as an adverse effect of drugs used to treat the disorder. (p. 324)
Cholinergic receptor A nerve receptor that is stimulated by acetylcholine. (p. 321)
Miosis The contraction of the pupil. (p. 323)
Muscarinic receptors Cholinergic receptors that are located postsynaptically in the effector organs such as
smooth muscle, cardiac muscle, and glands supplied by parasympathetic fibers. (p. 321)
Nicotinic receptors Cholinergic receptors located in the ganglia (where presynaptic and postsynaptic nerve
fibers meet) of both the parasympathetic nervous system and the sympathetic nervous system; so named
because they can be stimulated by the alkaloid nicotine. (p. 321)
Parasympathomimetics Drugs that mimic the parasympathetic nervous system; also referred to as
cholinergic agonist drugs. (p. 322)
Overview
FIGURE 20-1 Parasympathetic and sympathetic nervous systems and their relationship to one another.
ACh, Acetylcholine; NE, norepinephrine.
FIGURE 20-2 Sympathetic, parasympathetic, and somatic nervous systems. Note the location of the
nicotinic and muscarinic receptors in the parasympathetic nervous system.
Cholinergic Drugs
Box 20-1

TABLE 20-1
Cholinergic Agonists: Drug Effects
RESPONSE TO STIMULATION
Indications
Direct-Acting Drugs
Indirect-Acting Drugs
Contraindications
Adverse Effects
TABLE 20-2
Cholinergic Agonists: Adverse Effects
Interactions
Dosages
Drug Profiles
bethanechol
DOSAGES
Selected Cholinergic Agonist Drugs
NMDA, N-methyl-d-aspartate.
Pharmacokinetics: Bethanechol
donepezil
Pharmacokinetics: Donepezil
memantine
Pharmacokinetics: Memantine
pyridostigmine
Pharmacokinetics: Pyridostigmine
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
21
DRUG PROFILES
atropine, p. 334
dicyclomine, p. 334
glycopyrrolate, p. 334
oxybutynin, p. 334
scopolamine, p. 335
tolterodine, p. 335
Objectives
KEY TERMS
Cholinergic-blocking drugs Drugs that block the action of acetylcholine and substances similar to
acetylcholine at receptor sites in the synapse. (p. 331)
Mydriasis Dilation of the pupil of the eye caused by contraction of the dilator muscle of the iris. (p. 332)
Parasympatholytics Drugs that reduce the activity of the parasympathetic nervous system; also called
anticholinergics. (p. 331)
Cholinergic-Blocking Drugs
Box 21-1
FIGURE 21-1 Site of action of cholinergic blockers in the parasympathetic nervous system. ACh,
Acetylcholine.
TABLE 21-1
Cholinergic Blockers: Drug Effects
Indications
Contraindications
Adverse Effects
TABLE 21-2
Cholinergic Blockers: Adverse Effects
Interactions
Dosages
Drug Profiles
atropine
Pharmacokinetics: Atropine
dicyclomine
DOSAGES
Selected Cholinergic Antagonist (Anticholinergic) Drugs
ER, Extended release.
Pharmacokinetics: Dicyclomine
glycopyrrolate
Pharmacokinetics: Glycopyrrolate
oxybutynin
Pharmacokinetics: Oxybutynin
scopolamine
Pharmacokinetics: Scopolamine
tolterodine
Pharmacokinetics: Tolterodine
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
PA R T 4
OUTLINE
Learning Strategies
22 Antihypertensive Drugs
23 Antianginal Drugs
24 Heart Failure Drugs
25 Antidysrhythmic Drugs
26 Coagulation Modifier Drugs
27 Antilipemic Drugs
28 Diuretic Drugs
29 Fluids and Electrolytes
Study Time
Learning Styles
Use of Applications
Mnemonics
Flash Cards
22
DRUG PROFILES
bosentan, p. 353
captopril, p. 349
carvedilol, p. 347
clonidine, p. 347
doxazosin, p. 347
enalapril, p. 350
eplerenone, p. 353
hydralazine, p. 353
losartan, p. 351
nebivolol, p. 348
sodium nitroprusside, p. 353

treprostinil, p. 353
Objectives
KEY TERMS
Alpha1 blockers Drugs that primarily cause arterial and venous dilation through their action on peripheral
sympathetic neurons. (p. 345)
Antihypertensive drugs Medications used to treat hypertension. (p. 344)
Cardiac output The amount of blood ejected from the left ventricle. (p. 343)
Centrally acting adrenergic drugs Drugs that modify the function of the sympathetic nervous system in
the brain by stimulating alpha2 receptors. Alpha2 receptors are inhibitory in nature and thus have a reverse
sympathetic effect and cause decreased blood pressure. (p. 345)
Essential hypertension Elevated systemic arterial pressure for which no cause can be found; also called
primary or idiopathic hypertension. (p. 343)
Hypertension A common, often asymptomatic disorder in which systolic blood pressure persistently
exceeds 150 mm Hg and/or diastolic pressure exceeds 90 mm Hg in patients over 60 years of age and 140/90 for
patients younger than 60 and those who have chronic kidney disease or diabetes. (p. 343)
Orthostatic hypotension A common adverse effect of adrenergic-blocking drugs involving a sudden drop
in blood pressure when a person changes position, especially when rising from a seated or horizontal position. (p.
346)
Prodrug A drug that is inactive in its given form and must be metabolized to its active form in the body,
generally by the liver, to be effective. (p. 348)
Secondary hypertension High blood pressure caused by another disease such as renal, pulmonary,
endocrine, or vascular disease. (p. 343)
Anatomy, Physiology, and Pathophysiology Overview
FIGURE 22-1 Normal regulation of blood pressure and corresponding medications. ACE, Angiotensin-
converting enzyme; CNS, central nervous system.
Box 22-1
Review of Autonomic Neurotransmission
FIGURE 22-2 Location of the nicotinic receptors in the parasympathetic and sympathetic nervous
systems. ACh, Acetylcholine; NE, norepinephrine.
Adrenergic Drugs

FIGURE 22-3 Site and mechanism of action of the various antihypertensive drugs. (Modified from Lewis SL,
Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 8, St Louis, 2011,
Mosby.)
Indications
Contraindications
Adverse Effects
Interactions
TABLE 22-1
Adrenergic Drugs: Drug Interactions
MAOIs, Monoamine oxidase inhibitors; TCAs, tricyclic antidepressants.
Dosages
Drug Profiles
Alpha2-Adrenergic Receptor Stimulators (Agonists)

Dosages
Selected Antihypertensive Drugs: Adrenergic Agonists and Antagonists
clonidine
Pharmacokinetics: Clonidine
Alpha1 Blockers
doxazosin
Pharmacokinetics: Doxazosin
Dual-Action Alpha1 and Beta Receptor Blockers
carvedilol
Pharmacokinetics: Carvedilol
Beta Receptor Blocker
nebivolol
Angiotensin-Converting Enzyme (ACE) Inhibitors
TABLE 22-2
ACE Inhibitors
ACE, Angiotensin-converting enzyme.

Indications
TABLE 22-3
ACE Inhibitors: Therapeutic Effects
↓ ↓ ↓
↓ ↓
↓ ↓
↓, Decreased; SVR, systemic vascular resistance.
Contraindications
Adverse Effects
Interactions
Dosages
DOSAGES
Selected Antihypertensive Drugs: ACE Inhibitors and Angiotensin II Receptor Blockers
Drug Profiles
captopril
Pharmacokinetics: Captopril
enalapril
Pharmacokinetics: Enalapril
Indications
Contraindications
Adverse Effects
Interactions
TABLE 22-4
Angiotensin II Receptor Blockers: Drug Interactions
ARB, Angiotensin II receptor blocker.
Dosages
Drug Profile
losartan
Pharmacokinetics: Losartan
Diuretics
Vasodilators
Indications
Contraindications
Adverse Effects
Interactions
Dosages
DOSAGES
Selected Antihypertensive Drugs: Vasodilators
DOSAGES
MI, Myocardial infarction.
Drug Profiles
hydralazine
Pharmacokinetics: Hydralazine
sodium nitroprusside
Pharmacokinetics: Sodium Nitroprusside
Drug Profiles
eplerenone
bosentan
treprostinil
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Antihypertensives in General
Alpha-Adrenergic Agonists
Beta Blockers
Key Points
23
DRUG PROFILES
amlodipine, p. 370
atenolol, p. 367
diltiazem, p. 369
isosorbide dinitrate, p. 365
isosorbide mononitrate, p. 365
metoprolol, p. 368
nitroglycerin, p. 365
ranolazine, p. 370
Objectives
KEY TERMS
Angina pectoris Chest pain that occurs when the heart's supply of blood carrying oxygen is insufficient to
meet the demands of the heart. (p. 363)
Atherosclerosis A common form of arteriosclerosis involving deposits of fatty, cholesterol-containing
material (plaques) within arterial walls. (p. 363)
Chronic stable angina Chest pain that is primarily caused by atherosclerosis, which results in a long-term
but relatively stable level of obstruction in one or more coronary arteries. (p. 363)
Coronary arteries Arteries that deliver oxygen to the heart muscle. (p. 363)
Coronary artery disease (CAD) Any one of the abnormal conditions that can affect the arteries of the heart
and produce various pathologic effects, especially a reduced supply of oxygen and nutrients to the myocardium.
(p. 363)
Ischemia Ischemia is damaged cells/tissue as the result of inadequate oxygen supply. (p. 363)
Ischemic heart disease Poor blood supply to the heart via the coronary arteries. (p. 363)
Myocardial infarction (MI) Necrosis of the myocardium following interruption of blood supply; it is almost
always caused by atherosclerosis of the coronary arteries and is commonly called a heart attack. (p. 363)
Reflex tachycardia A rapid heartbeat caused by a variety of autonomic nervous system effects, such as
blood pressure changes, fever, or emotional stress. (p. 364)
Unstable angina Early stage of progressive coronary artery disease. (p. 363)
Vasospastic angina Ischemia-induced myocardial chest pain caused by spasms of the coronary arteries;
also referred to as Prinzmetal or variant angina. (p. 363)
Overview
TABLE 23-1
Antianginal Drugs: Therapeutic Effects
↑↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑

↑↑↑ ↑ ↑↑↑ ↑↑
↓↓ ↑ ↓ ↓
↓ ↓ ↓↓↓ ↓↓ ↓↓
↓↓↓ ↓ ↓↓↓ ↓↓
↑ ↓↓↓ ↓ ↓↓ ↓↓
*In particular, those that are cardioselective and do not have intrinsic sympathomimetic activity.
†Preload is pressure in the heart caused by blood volume. The nitrates effectively move part of this blood out of the heart and into blood
vessels, thereby decreasing preload or filling pressure.
↑, Increase; ↓, decrease; 0, little or no effect.
FIGURE 23-1 Benefit of drug therapy for angina through increasing oxygen supply and decreasing
oxygen demand.
Nitrates and Nitrites
Indications
Contraindications
Adverse Effects
Interactions
Dosages
DOSAGES
Selected Antianginal Nitrate Coronary Vasodilators

Drug Profiles
isosorbide dinitrate
Pharmacokinetics: Isosorbide Dinitrate
isosorbide mononitrate
Pharmacokinetics: Isosorbide Mononitrate
nitroglycerin
Pharmacokinetics: Nitroglycerin
Beta Blockers

Indications
Contraindications
Adverse Effects
TABLE 23-2
Beta Blockers: Adverse Effects
Interactions
TABLE 23-3
Beta Blockers: Common Drug Interactions
Dosages
Drug Profiles
DOSAGES
Selected Beta1-Adrenergic–Blocking Drugs
atenolol
metoprolol
TABLE 23-4
Classification of Calcium Channel Blockers
Indications
Contraindications
Adverse Effects
TABLE 23-5
Calcium Channel Blockers: Adverse Effects
Interactions
TABLE 23-6
Calcium Channel Blockers: Common Drug Interactions
Dosages
DOSAGES
Selected Calcium Channel–Blocking Drugs
Drug Profiles
diltiazem
Pharmacokinetics: Diltiazem
amlodipine
Pharmacokinetics: Amlodipine
Miscellaneous Antianginal Drug
Drug Profile
ranolazine
Summary of Antianginal Pharmacology
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Nitroglycerin
Isosorbide Dinitrate or Isosorbide Mononitrate
Key Points
24
DRUG PROFILES
digoxin, p. 383
digoxin immune Fab, p. 383
dobutamine, p. 380
hydralazine/isosorbide dinitrate, p. 379
lisinopril, p. 379
milrinone, p. 381
nesiritide, p. 380
valsartan, p. 379
Objectives
KEY TERMS
Atrial fibrillation A common cardiac dysrhythmia with atrial contractions that are so rapid they prevent full
repolarization of myocardial fibers between heartbeats. (p. 381)
Automaticity A property of specialized excitable tissue in the heart that allows self-activation through the
spontaneous development of an action potential, such as in the pacemaker cells of the heart. (p. 379)
Chronotropic drugs Drugs that influence the rate of the heartbeat. (p. 377)
Dromotropic drugs Drugs that influence the conduction of electrical impulses within tissues. (p. 377)
Ejection fraction The proportion of blood that is ejected during each ventricular contraction compared with
the total ventricular filling volume. (p. 377)
Heart failure An abnormal condition in which the heart cannot pump enough blood to keep up with the
body's demand. It is often the result of myocardial infarction, ischemic heart disease, or cardiomyopathy. (p. 377)
Inotropic drugs Drugs that influence the force of muscular contractions, particularly contraction of the heart
muscle. (p. 377)
Left ventricular end-diastolic volume The total amount of blood in the ventricle immediately before it
contracts, or the preload. (p. 377)
Refractory period The period during which a pulse generator (e.g., the sinoatrial node of the heart) is
unresponsive to an electrical input signal, and during which it is impossible for the myocardium to respond. This is
the period during which the cardiac cell is readjusting its sodium and potassium levels and cannot be depolarized
again. (p. 381)
Overview
Box 24-1
Box 24-2
FIGURE 24-1 Conduction system of the heart. AV, Atrioventricular; LA, left atrium; LV, left ventricle; RA,
right atrium; RV, right ventricle; SA, sinoatrial. (Modified from Kinney MR, Packa DR: Andreoli's comprehensive cardiac
care, ed 8, St Louis, 1996, Mosby; Lewis SM, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and
management of clinical problems, ed 7, St Louis, 2007, Mosby.)
Angiotensin-Converting Enzyme Inhibitors
Drug Profile
lisinopril
Pharmacokinetics: Lisinopril
Drug Profile
valsartan
Pharmacokinetics: Valsartan
Beta Blockers
Aldosterone Antagonists
Miscellaneous Heart Failure Drugs
Drug Profiles
hydralazine/isosorbide dinitrate
dobutamine
B-Type Natriuretic Peptide
Drug Profile
nesiritide
Pharmacokinetics: Nesiritide
DOSAGES
Selected Drugs for Heart Failure

Phosphodiesterase Inhibitors
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
milrinone
Pharmacokinetics: Milrinone
Cardiac Glycosides
Indications
Contraindications
Adverse Effects
TABLE 24-1
Digoxin: Common Adverse Effects
Normal therapeutic level = 0.5 to 2 ng/mL.
TABLE 24-2
Conditions Predisposing to Digitalis Toxicity
Interactions
TABLE 24-3
Digoxin: Drug Interactions
Dosages
Drug Profiles
digoxin
Pharmacokinetics: Digoxin
digoxin immune Fab
Pharmacokinetics: Digoxin Immune Fab

Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
25
DRUG PROFILES
adenosine, p. 405
amiodarone, p. 403
atenolol, p. 402
diltiazem, p. 405
dofetilide, p. 404
esmolol, p. 402
flecainide, p. 401
ibutilide, p. 404
lidocaine, p. 401
metoprolol, p. 403
procainamide, p. 400
propafenone, p. 402
quinidine, p. 401
sotalol, p. 404
verapamil, p. 405
Objectives
KEY TERMS
Action potential Electrical activity that consists of a series of polarizations and depolarizations that travel
across the cell membrane of a nerve fiber during transmission of a nerve impulse and across the cell membranes
of a muscle cell during contraction. (p. 392)
Action potential duration The interval beginning with baseline (resting) membrane potential followed by
depolarization and ending with repolarization to baseline membrane potential. (p. 393)
Arrhythmia Technically “no rhythm,” meaning absence of heart rhythm (i.e., no heartbeat at all). More
commonly used in clinical practice to refer to any variation from the normal rhythm of the heart. A synonymous
term is dysrhythmia, which is the primary term used in this textbook. (p. 391)
Cardiac Arrhythmia Suppression Trial (CAST) A major research study conducted to investigate the
possibility of eliminating sudden cardiac death in patients with asymptomatic ectopy after a myocardial infarction.
(p. 401)
Depolarization The movement of positive and negative ions on either side of a cell membrane across the
membrane in a direction that brings the net charge to zero. (p. 392)
Dysrhythmia Any disturbance or abnormality in heart rhythm. (p. 391)
Effective refractory period The period after the firing of an impulse during which a cell may respond to a
stimulus but the response will not be passed along or continued as another impulse. (p. 393)
Internodal pathways (Bachmann bundle) Special pathways in the atria that carry electrical impulses
generated by the sinoatrial node. These impulses cause the heart to beat. (p. 393)
Relative refractory period The time after generation of an action potential during which a nerve fiber will
show a (reduced) response only to a strong stimulus. (p. 393)
Resting membrane potential (RMP) The voltage that exists when the cell membranes of heart muscle (or
other muscle or nerve cells) are at rest. (p. 391)
Sodium-potassium adenosine triphosphatase (ATPase) pump A mechanism for transporting sodium
and potassium ions across the cell membrane against an opposing concentration gradient. Energy for this
transport is obtained from the hydrolysis of adenosine triphosphate (ATP) by means of the enzyme ATPase. (p.
391)
Sudden cardiac death Unexpected, fatal cardiac arrest. (p. 402)
Threshold potential The critical state of electrical tension required for spontaneous depolarization of a cell
membrane. (p. 393)
Torsades de pointes A rare ventricular arrhythmia that is associated with long QT interval and can
degenerate into ventricular fibrillation and sudden death without medical intervention; often simply referred to as
torsades. (p. 396)
Vaughan Williams classification The system most commonly used to classify antidysrhythmic drugs. (p.
396)
Dysrhythmias and Normal Cardiac Electrophysiology
FIGURE 25-1 Phases of the action potential of a cardiac cell. In resting phase (4), the cell membrane is
polarized. The cell's interior has a net negative charge, and the membrane is more permeable to
potassium ions (K) than to sodium ions (Na). When the cell is stimulated and begins to depolarize (0),
sodium ions enter the cell, potassium leaves the cell, calcium (Ca) channels open, and sodium channels
close. In its depolarized phase (1), the cell's interior has a net positive charge. In the plateau phase (2),
calcium and other positive ions enter the cell and potassium permeability declines, which lengthens the
action potential. Then (3), calcium channels close and sodium is pulled from the cell by the sodium-
potassium pump. The cell's interior then returns to its polarized, negatively charged state (4). (From Monahan
FD: Phipps' medical-surgical nursing: health and illness perspectives, ed 8, St Louis, 2007, Mosby.)
FIGURE 25-2 Action potentials. RMP, Resting membrane potential; SA, sinoatrial; TP, threshold
potential.
FIGURE 25-3 Purkinje fiber action potential.
FIGURE 25-4 Aspects of an action potential. APD, Action potential duration; ERP, effective refractory
period; RRP, relative refractory period.
TABLE 25-1
Comparison of Action Potentials in Different Cardiac Tissue
AV, Atrioventricular; SA, sinoatrial.
Electrocardiography
FIGURE 25-5 The waves and intervals of a normal electrocardiogram. (From Goldberger AL: Clinical
electrocardiography: a simplified approach, ed 7, St Louis, 2006, Mosby.)
Common Dysrhythmias
TABLE 25-2
Common Dysrhythmias
ECG, Electrocardiogram.
Antidysrhythmic Drugs
TABLE 25-3
Vaughan Williams Classification of Antidysrhythmic Drugs
↑ ↑
↑
↑↑↑
*Sotalol also has class II properties.

↑, Increase; ±, increase or decrease.

TABLE 25-4
Antidysrhythmic Drugs: Mechanisms of Action
VAUGHAN WILLIAMS CLASS
Box 25-1
Indications
TABLE 25-5
Antidysrhythmic Drugs: Indications
Contraindications
Adverse Effects
TABLE 25-6
Antidysrhythmic Drugs: Common Adverse Effects

AV, Atroventricular; SA, sinoatrial; SLE systemic lupus erythematosus.
Interactions
TABLE 25-7
Selected Antidysrhythmic Drugs: Common Drug Interactions
*Note that enhanced activity of any antidysrhythmic drug may reach the level of drug toxicity, including potentially fatal cardiac
dysrhythmias.
†Sotalol also has class II properties.
AV, Atrioventricular; HMG-CoA, hydroxymethylglutaryl-coenzyme A; INR, international normalized ratio.
Dosages
Drug Profiles
Class Ia Drugs
procainamide
DOSAGES
Selected Antidysrhythmic Drugs
Pharmacokinetics: Procainamide
Box 25-2
quinidine
Pharmacokinetics: Quinidine
Class Ib Drugs
lidocaine
Pharmacokinetics: Lidocaine
Class Ic Drugs
flecainide
Pharmacokinetics: Flecainide
propafenone
Pharmacokinetics: Propafenone
Class II Drugs
atenolol
esmolol
Pharmacokinetics: Esmolol
metoprolol
Class III Drugs
amiodarone
Pharmacokinetics: Amiodarone
TABLE 25-8
Recommendations for Oral Dosage After Intravenous Infusion of Amiodarone
ibutilide
Pharmacokinetics: Ibutilide
dofetilide
Pharmacokinetics: Dofetilide
sotalol
Pharmacokinetics: Sotalol
Class IV Drugs
diltiazem
Pharmacokinetics: Diltiazem
verapamil
Pharmacokinetics: Verapamil
Unclassified Antidysrhythmic
adenosine
Pharmacokinetics: Adenosine
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
26
DRUG PROFILES
alteplase, p. 424
aminocaproic acid, p. 426
argatroban, p. 417
aspirin, p. 422
clopidogrel, p. 423
dabigatran, p. 417
desmopressin, p. 426
enoxaparin, p. 418
eptifibatide, p. 423
fondaparinux, p. 418
heparin, p. 419
rivaroxaban, p. 419
warfarin, p. 419
Objectives
KEY TERMS
Anticoagulants Substances that prevent or delay coagulation of the blood. (p. 414)
Antifibrinolytic drugs Drugs that prevent the lysis of fibrin and in doing so promote clot formation. (p. 414)
Antiplatelet drugs Substances that prevent platelet plugs from forming. (p. 414)
Antithrombin III A substance that inactivates (“turns off”) three major activating factors of the clotting
cascade: activated factor II (thrombin), activated factor X, and activated factor IX. (p. 414)
Clot Insoluble solid elements of blood (e.g., cells, fibrin threads) that have chemically separated from the
liquid (plasma) component of the blood. (p. 412)
Coagulation The process of blood clotting. More specifically, the sequential process by which the multiple
coagulation factors of the blood interact in the coagulation cascade, ultimately forming an insoluble fibrin clot. (p.
412)
Coagulation cascade The series of steps beginning with the intrinsic or extrinsic pathways of coagulation
and proceeding through the formation of a fibrin clot. (p. 412)
Deep vein thrombosis (DVT) The formation of a thrombus in one of the deep veins of the body. The deep
veins most commonly affected are the iliac and femoral veins. (p. 414)
Embolus A blood clot (thrombus) that has been dislodged from the wall of a blood vessel and is traveling
throughout the bloodstream. Emboli that lodge in critical blood vessels can result in ischemic injury to a vital
organ (e.g., heart, lung, brain) and result in disability or death. (p. 412)
Enzyme A protein molecule that catalyzes chemical reactions of other substances without being altered or
destroyed in the process. (p. 417)
Fibrin A stringy, insoluble protein produced by the action of thrombin on fibrinogen during the clotting
process; a major component of blood clots or thrombi (see thrombus). (p. 412)
Fibrin specificity The property of some thrombolytic drugs of activating the conversion of plasminogen to
plasmin only in the presence of established clots having fibrin threads rather than inducing systemic plasminogen
activation throughout the body. (p. 424)
Fibrinogen A plasma protein that is converted into fibrin by thrombin in the presence of calcium ions. (p.
420)
Fibrinolysis The continual process of fibrin decomposition produced by the actions of the enzymatic protein
fibrinolysin. It is the normal mechanism for removing small fibrin clots and is stimulated by anoxia, inflammatory
reactions, and other kinds of stress. (p. 412)
Fibrinolytic system An area of the circulatory system undergoing fibrinolysis. (p. 412)
Hemophilia A rare, inherited blood disorder in which the blood does not clot normally. (p. 413)
Hemorheologic drugs Drugs that alter the function of platelets without compromising their blood-clotting
properties. (p. 414)
Hemostasis The arrest of bleeding, either by the physiologic properties of vasoconstriction and coagulation
or by mechanical, surgical, or pharmacologic means. (p. 412)
Hemostatic Referring to any procedure, device, or substance that arrests the flow of blood. (p. 414)
Plasmin The enzymatic protein that breaks down fibrin into fibrin degradation products; it is derived from
plasminogen. (p. 412)
Plasminogen A plasma protein that is converted to plasmin. (p. 412)
Pulmonary embolism The blockage of a pulmonary artery by foreign matter such as fat, air, a tumor, or a
thrombus (which usually arises from a peripheral vein). (p. 414)
Stroke Occlusion of the blood vessels of the brain by an embolus, thrombus, or cerebrovascular
hemorrhage, resulting in ischemia of the brain tissue. (p. 414)
Thromboembolic events Events in which a blood vessel is blocked by an embolus carried in the
bloodstream from the site of its formation. The tissue supplied by an obstructed artery may tingle and become
cold, numb, cyanotic, and eventually necrotic (dead). (p. 414)
Thrombolytic drugs Drugs that dissolve thrombi by functioning similarly to tissue plasminogen activator.
(p. 414)
Thrombus The technical term for a blood clot (plural: thrombi); an aggregation of platelets, fibrin, clotting
factors, and the cellular elements of the blood that is attached to the interior wall of a vein or artery, sometimes
occluding the vessel lumen. (p. 412)
Tissue plasminogen activator A naturally occurring plasminogen activator secreted by vascular
endothelial cells in the walls of blood vessels. Thrombolytic drugs are based on this blood component. (p. 412)
Overview
FIGURE 26-1 Coagulation pathway and factors: extrinsic pathway. Plt, Platelets.
FIGURE 26-2 Coagulation pathway and factors: intrinsic pathway. HMW-K, High–molecular-weight
kininogen; Plt, platelets.
FIGURE 26-3 The fibrinolytic system.
TABLE 26-1
Coagulation Modifiers: Comparison of Drug Subclasses
Anticoagulants
Indications
Contraindications
Adverse Effects
TABLE 26-2
Anticoagulants: Common Adverse Effects

Interactions
TABLE 26-3
Anticoagulants: Drug Interactions
HMG-CoA, Hydroxymethylglutaryl–coenzyme A; INR, international normalized ratio; NSAIDs, nonsteroidal antiinflammatory drugs.
Dosages
Drug Profiles
argatroban
Pharmacokinetics: Argatroban
dabigatran
Pharmacokinetics: Dabigatran
enoxaparin
Pharmacokinetics: Enoxaparin
DOSAGES
Selected Anticoagulant Drugs
aPTT, Activated partial thromboplastin time; DIC, disseminated intravascular coagulation; DVT, deep vein thrombosis; HIT, heparin-
induced thrombocytopenia; INR, international normalized ratio; LMWH, low–molecular-weight heparin; MI, myocardial infarction; PCI,
percutaneous coronary intervention; PE, pulmonary embolism.
fondaparinux
Pharmacokinetics: Fondaparinux
heparin
Pharmacokinetics: Heparin
rivaroxaban
Pharmacokinetics: Rivaroxaban
warfarin
Pharmacokinetics: Warfarin
Antiplatelet Drugs
FIGURE 26-4 Relationship between platelets and the clotting cascade. ADP, Adenosine diphosphate; 5-
HT, serotonin; PF4, platelet factor IV; TXA2, thromboxane A2.

FIGURE 26-5 Cyclooxygenase pathway. PG, Prostaglandin; TX, thromboxane; TXA2, thromboxane A2.
Indications
Contraindications
Adverse Effects
TABLE 26-4
Selected Antiplatelet Drugs: Adverse Effects
Interactions
DOSAGES
Selected Antiplatelet Drugs
*See table in package insert for specific dose.

ADP, Adenosine diphosphate; GP, glycoprotein; MI, myocardial infarction; TIA, transient ischemic attack.
Dosages
Drug Profiles
aspirin
Pharmacokinetics: Aspirin
clopidogrel
Pharmacokinetics: Clopidogrel
eptifibatide
Pharmacokinetics: Eptifibatide
Thrombolytic Drugs
Indications
Contraindications
Adverse Effects
DOSAGES
Selected Thrombolytic Drugs
Interactions
Dosages
Drug Profile
alteplase
Pharmacokinetics: Alteplase
Antifibrinolytic Drugs
TABLE 26-5
Antifibrinolytics: Mechanisms of Action
Indications
Contraindications
Adverse Effects
TABLE 26-6
Antifibrinolytics: Adverse Effects
Interactions
Dosages
Drug Profiles
aminocaproic acid
DOSAGES
Selected Antifibrinolytic Drugs
Pharmacokinetics: Aminocaproic Acid
desmopressin
Pharmacokinetics: Desmopressin
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Box 26-1
Evaluation
Key Points
27
DRUG PROFILES
atorvastatin, p. 442
cholestyramine, p. 443
ezetimibe, p. 445
gemfibrozil, p. 445
niacin, p. 444
simvastatin, p. 442
Objectives
KEY TERMS
Antilipemic drugs Drugs that reduce lipid levels. (p. 437)
Apolipoproteins The protein components of lipoproteins. (p. 437)
Cholesterol A fat-soluble steroid found in animal fats, oils, and egg yolk and widely distributed in the body,
especially in the bile, blood, brain tissue, liver, kidneys, adrenal glands, and myelin sheaths of nerve fibers. (p.
437)
Chylomicrons Microscopic droplets made up of fat and protein that are produced by cells in the small
intestine and released into the bloodstream. Their main purpose is to carry fats to the tissues throughout the
body, primarily the liver. Chylomicrons consist of about 90% triglycerides and small amounts of cholesterol,
phospholipids, and proteins. (p. 437)
Exogenous lipids Lipids originating outside the body or an organ (e.g., dietary fats). (p. 437)
Foam cells The characteristic initial lesion of atherosclerosis, also known as a fatty streak. (p. 438)
Hydroxymethylglutaryl–coenzyme A (HMG-CoA) reductase inhibitors A class of cholesterol-lowering
drugs that work by inhibiting the rate-limiting step in cholesterol synthesis; also commonly referred to as statins.
(p. 440)
Hypercholesterolemia A condition in which higher than normal amounts of cholesterol are present in the
blood. High levels of cholesterol and other lipids may lead to the development of atherosclerosis and serious
illnesses such as coronary heart disease. (p. 438)
Lipoprotein A conjugated protein synthesized in the liver that contains varying amounts of triglycerides,
cholesterol, phospholipids, and protein; classified according to its composition and density. (p. 437)
Statins A class of cholesterol-lowering drugs that are more formally known as HMG-CoA reductase
inhibitors. (p. 440)
Triglycerides Compounds that consist of fatty acids and a type of alcohol known as glycerol. Triglycerides
make up most animal and vegetable fats and are the principal lipids in the blood, where they circulate bound to a
protein, forming high-density and low-density lipoproteins (HDLs and LDLs). (p. 437)
Overview
Lipids and Lipid Abnormalities
Primary Forms of Lipids
TABLE 27-1
Lipoprotein Classification
Cholesterol Homeostasis
FIGURE 27-1 Cholesterol homeostasis. CE, Cholesterol ester; HDL, high-density lipoprotein; HMG-CoA,
hydroxymethylglutaryl–coenzyme A; IDL, intermediate-density lipoprotein; LCAT, lecithin cholesterol
acetyltransferase; LDL, low-density lipoprotein; TG, triglyceride; VLDL, very–low-density lipoprotein.
Atherosclerotic Plaque Formation
Cholesterol and Coronary Heart Disease
Hyperlipidemias and Treatment Guidelines
Box 27-1
TABLE 27-2
Types of Hyperlipidemia
LIPID COMPOSITION
, Approximately equal to; IDL, intermediate-density lipoprotein; LDL, low-density lipoprotein; VLDL, very–low-density lipoprotein.
Box 27-2
Hydroxymethylglutaryl–Coenzyme a Reductase (HMG-CoA
Reductase) Inhibitors
TABLE 27-3
Intensity of Statin Therapy
Data from Stone NJ, Robinson JG, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in
Adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol 63(25 Pt B):2889-2934, 2014.
Indications
Contraindications
Adverse Effects
TABLE 27-4
HMG-CoA Reductase Inhibitors: Adverse Effects

Interactions
TABLE 27-5
HMG-CoA Reductase Inhibitors: Drug Interactions
Dosages
DOSAGES
Selected Antilipemic Drugs
Drug Profiles
atorvastatin
Pharmacokinetics: Atorvastatin
simvastatin
Pharmacokinetics: Simvastatin
Bile Acid Sequestrants
Indications
Contraindications
Adverse Effects
TABLE 27-6
Bile Acid Sequestrants: Adverse Effects
Interactions
Dosages
Drug Profile
cholestyramine
Niacin
Indications
Contraindications
Adverse Effects
TABLE 27-7
Niacin (Nicotinic Acid): Adverse Effects
Interactions
Dosages
Drug Profile
niacin
Pharmacokinetics: Niacin
Fibric Acid Derivatives
Indications
Contraindications
Adverse Effects
TABLE 27-8
Fibric Acid Derivatives: Adverse Effects
Interactions
Dosages
Drug Profiles
gemfibrozil
Pharmacokinetics: Gemfibrozil
Miscellaneous Antilipemic Drug
Cholesterol Absorption Inhibitor
ezetimibe
Pharmacokinetics: Ezetimibe
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
*The values in this table are from the National Cholesterol Education Program of the National Institutes of Health.
Key Points
28
DRUG PROFILES
acetazolamide, p. 453
furosemide, p. 455
hydrochlorothiazide, p. 458
mannitol, p. 456
metolazone, p. 459
spironolactone, p. 457
triamterene, p. 457
Objectives
KEY TERMS
Afferent arterioles The small blood vessels approaching the glomerulus (proximal part of the nephron). (p.
452)
Aldosterone A mineralocorticoid steroid hormone produced by the adrenal cortex that regulates sodium
and water balance. (p. 452)
Ascites Intraperitoneal accumulation of fluid (defined as a volume of 500 mL or more) containing large
amounts of protein and electrolytes. (p. 455)
Collecting duct The most distal part of the nephron between the distal convoluted tubule and the ureters,
which lead to the urinary bladder. (p. 452)
Distal convoluted tubule The part of the nephron immediately distal to the ascending loop of Henle and
proximal to the collecting duct. (p. 452)
Diuretics Drugs or other substances that promote the formation and excretion of urine. (p. 452)
Efferent arterioles The small blood vessels exiting the glomerulus. At this point blood has completed its
filtration in the glomerulus. (p. 452)
Filtrate The material that passes through a filter. In the kidney, the filter is the glomerulus and the filtrate is
the material extracted from the blood (normally liquid) that becomes urine. (p. 452)
Glomerular capsule The open, rounded, and most proximal part of the proximal convoluted tubule that
surrounds the glomerulus and receives the filtrate from the blood. (p. 452)
Glomerular filtration rate (GFR) An estimate of the volume of blood that passes through the glomeruli of
the kidney per minute. (p. 452)
Glomerulus The cluster of kidney capillaries that marks the beginning of the nephron and is immediately
proximal to the proximal convoluted tubule. (p. 452)
Loop of Henle The part of the nephron between the proximal and distal convoluted tubules. (p. 452)
Nephron The functional filtration unit of the kidney, consisting of (in anatomic order from proximal to distal)
the glomerulus, proximal convoluted tubule, loop of Henle, distal convoluted tubule, and collecting duct, which
empties urine into the ureters. (p. 452)
Open-angle glaucoma A condition in which pressure is elevated in the eye because of obstruction of the
outflow of aqueous humor. (p. 453)
Proximal convoluted (twisted) tubule The part of the nephron that is immediately distal to the glomerulus
and proximal to the loop of Henle. (p. 452)
Overview
FIGURE 28-1 The nephron and diuretic sites of action. ADH, Antidiuretic hormone.
TABLE 28-1
Classification of Diuretics
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
acetazolamide
Pharmacokinetics: Acetazolamide
Loop Diuretics
Summary of Major Drug Effects of Loop Diuretics
Indications
Contraindications
Adverse Effects
TABLE 28-2
Loop Diuretics: Common Adverse Effects
Interactions
TABLE 28-3
Loop Diuretics: Common Drug Interactions
Dosages
DOSAGES
Selected Loop Diuretics and Osmotic Diuretics
Drug Profile
furosemide
Pharmacokinetics: Furosemide
Osmotic Diuretics
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
mannitol
Pharmacokinetics: Mannitol
Potassium-Sparing Diuretics
Indications
Contraindications
Adverse Effects
TABLE 28-4
Potassium-Sparing Diuretics: Common Adverse Effects
Interactions
Dosages
DOSAGES
Selected Potassium-Sparing Diuretic Drugs
Drug Profiles
spironolactone
Pharmacokinetics: Spironolactone
triamterene
Pharmacokinetics: Triamterene
Thiazides and Thiazide-Like Diuretics
Indications
Contraindications
Adverse Effects
TABLE 28-5
Thiazide and Thiazide-Like Diuretics: Potential Adverse Effects
Interactions
TABLE 28-6
Thiazide and Thiazide-Like Diuretics: Common Drug Interactions
NSAIDs, Nonsteroidal antiinflammatory drugs.
Dosages
Drug Profiles
hydrochlorothiazide
DOSAGES
Selected Thiazide and Thiazide-Like Diuretic Drugs

Pharmacokinetics: Hydrochlorothiazide
metolazone
Pharmacokinetics: Metolazone
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
29
DRUG PROFILES
albumin, p. 469
conivaptan, p. 473
dextran, p. 469
fresh frozen plasma, p. 470
packed red blood cells, p. 470
potassium, p. 472
sodium chloride, p. 473
sodium polystyrene sulfonate (potassium exchange resin), p. 472
Objectives
KEY TERMS
Blood The fluid that circulates through the heart, arteries, capillaries, and veins, carrying nutriment and
oxygen to the body cells. It consists of plasma, its liquid component, plus three major solid components:
erythrocytes (red blood cells or RBCs), leukocytes (white blood cells or WBCs), and platelets. (p. 465)
Colloids Protein substances that increase the colloid oncotic pressure. (p. 468)
Colloid oncotic pressure Another name for oncotic pressure. It is a form of osmotic pressure exerted by
protein in blood plasma that tends to pull water into the circulatory system. (p. 466)
Crystalloids Substances in a solution that diffuse through a semipermeable membrane. (p. 467)
Dehydration Excessive loss of water from the body tissues. It is accompanied by an imbalance in the
concentrations of electrolytes, particularly sodium, potassium, and chloride. (p. 466)
Edema The abnormal accumulation of fluid in interstitial spaces. (p. 465)
Extracellular fluid (ECF) That portion of the body fluid comprising the interstitial fluid and intravascular
fluid. (p. 465)
Gradient A difference in the concentration of a substance on two sides of a permeable barrier. (p. 467)
Homeostasis The tendency of a cell or organism to maintain equilibrium by regulating its internal
environment and adjusting its physiologic processes. (p. 465)
Hyperkalemia An abnormally high potassium concentration in the blood, most often due to defective renal
excretion but also caused by excessive dietary potassium or certain drugs, such as potassium-sparing diuretics
or ACE inhibitors and other causes such as acidosis. (p. 471)
Hypernatremia An abnormally high sodium concentration in the blood; may be due to defective renal
excretion but is more commonly caused by excessive dietary sodium or replacement therapy or loss of water. (p.
472)
Hypokalemia A condition in which there is an inadequate amount of potassium in the bloodstream; possible
causes include diarrhea, diuretic use, and others. (p. 471)
Hyponatremia A condition in which there is an inadequate amount of sodium in the bloodstream, caused by
inadequate excretion of water or by excessive water intake. (p. 472)
Interstitial fluid (ISF) The extracellular fluid that fills in the spaces between most of the cells of the body. (p.
465)
Intracellular fluid (ICF) The fluid located within cell membranes throughout most of the body. It contains
dissolved solutes that are essential to maintaining electrolyte balance and healthy metabolism. (p. 465)
Intravascular fluid (IVF) The fluid inside blood vessels. (p. 465)
Isotonic Having the same concentration of solutes as another solution and hence exerting the same
osmotic pressure as that solution, such as an isotonic saline solution that contains an amount of salt equal to that
found in the intracellular and extracellular fluid. (p. 466)
Osmotic pressure The pressure produced by a solution necessary to prevent the osmotic passage of
solvent into it when the solution and solvent are separated by a semipermeable membrane. (p. 466)
Plasma The watery, straw-colored fluid component of lymph and blood in which the leukocytes,
erythrocytes, and platelets are suspended. (p. 465)
Serum The clear, cell-free portion of the blood from which fibrinogen has also been separated during the
clotting process, as typically carried out with a laboratory sample. (p. 467)
Solute A substance that is dissolved in another substance. (p. 465)
Transcellular fluid The fluid that is contained within specialized body compartments such as cerebrospinal,
pleural, and synovial cavities. (p. 465)
Overview
FIGURE 29-1 Distribution of total body water (TBW). ECF, Extracellular fluid; ICF, intracellular fluid; ISF,
interstitial fluid; IVF, intravascular volume.
TABLE 29-1
Types of Dehydration
TABLE 29-2
Conditions Leading to Fluid Loss or Dehydration and Associated Corresponding Symptoms*
*There may be overlap involving more than one of the symptoms depending on the patient's specific condition.
FIGURE 29-2 A depiction of what happens when red blood cells are exposed to different fluids. Isotonic
solutions cause no net fluid movement. Hypertonic solutions cause water to move out of the cells and can
cause the cells to shrink. Hypotonic solutions cause water to move into the cells, which can cause them to
burst.
Crystalloids
Indications
Adverse Effects
Interactions
Dosage
Drug Profile
sodium chloride
TABLE 29-3
Crystalloids and Colloids: Dosing Guidelines
CRYSTALLOIDS AND COLLOIDS
*Hypertonic saline is a high-risk drug and should not be given faster than 100 mL/hr for short periods. Frequent monitoring of serum
levels is required.
†Iso-oncotic solutions such as 5% albumin, dextran 70, and hetastarch.
‡Hyperoncotic solutions such as 25% albumin.
Colloids
TABLE 29-4
Commonly Used Colloids
COMPOSITION (mEq/L)
*Relative cost compared with the cost of dextran 70.

†Dextran is available in NaCl, which has 154 mEq/L of both Na and Cl. It is also available in 5% dextrose in water, which contains no Na
or Cl.
Cl, Chloride; Na, sodium.

FIGURE 29-3 Colloid osmotic pressure (oncotic pressure). As shown, the colloids inside the blood
vessel are too large to pass through the vessel wall. The resulting oncotic pressure exerted by the colloids
draws fluid from the surrounding tissues and other extravascular spaces into the blood vessels and also
keeps fluid inside the blood vessel.
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
albumin
Pharmacokinetics: Albumin
dextran
Pharmacokinetics: Dextran
Blood Products
Indications
TABLE 29-5
Blood Products: Indications
FFP, Fresh frozen plasma; PPF, plasma protein fraction; PRBCs, packed red blood cells.
Contraindications
Adverse Effects
Interactions
Dosages
TABLE 29-6
Suggested Guidelines for Blood Products: Management of Bleeding
FFP, Fresh frozen plasma; PPF, plasma protein fraction; PRBCs, packed red blood cells.
Drug Profiles
packed red blood cells
fresh frozen plasma

Physiology of Electrolyte Balance
Potassium
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
potassium
Pharmacokinetics: Potassium
sodium polystyrene sulfonate (potassium exchange resin)

Sodium
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
sodium chloride
Pharmacokinetics: Sodium Chloride
conivaptan
Pharmacokinetics: Conivaptan
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
PA R T 5
OUTLINE
Learning Strategies
30 Pituitary Drugs
31 Thyroid and Antithyroid Drugs
32 Antidiabetic Drugs
33 Adrenal Drugs
34 Women's Health Drugs
35 Men's Health Drugs
Study Groups
Chat Rooms and Discussion Groups
30
DRUG PROFILES
octreotide, p. 486
somatropin, p. 486
vasopressin, p. 487
Objectives
KEY TERMS
Hypothalamus The gland above and behind the pituitary gland and the optic chiasm. Both glands are
suspended beneath the middle area of the bottom of the brain. The hypothalamus secretes the hormones
vasopressin and oxytocin, which are stored in the posterior pituitary gland. The hypothalamus also secretes
several hormone-releasing factors that stimulate the anterior pituitary gland to secrete a variety of hormones that
control many bodily functions. (p. 483)
Negative feedback loop A system in which the production of one hormone is controlled by the levels of a
second hormone in a way that reduces the output of the first hormone. A gland produces a hormone that
stimulates a second gland to produce a second hormone. In response to the increased levels of the second
hormone, the source gland of the first hormone reduces production of that hormone until blood levels of the
second hormone fall below a certain minimum level needed; then the cycle begins again. (p. 484)
Neuroendocrine system The system that regulates the reactions to both internal and external stimuli and
involves the integrated activities of the endocrine glands and nervous system. (p. 483)
Pituitary gland An endocrine gland that is suspended beneath the brain and supplies numerous hormones
that control many vital processes. (p. 484)
Endocrine System
Box 30-1
FIGURE 30-1 Pituitary hormones. FSH, Follicle-stimulating hormone; LH, luteinizing hormone. (Adapted
from McKenry LM, Tessier E, Hogan MA: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.)
Pituitary Drugs
TABLE 30-1
Anterior and Posterior Pituitary Hormones and Drugs
T3, Triiodothyronine; T4, thyroxine.

Indications
Contraindications
Adverse Effects
TABLE 30-2
Octreotide: Common Adverse Effects
TABLE 30-3
Desmopressin and Vasopressin: Common Adverse Effects
TABLE 30-4
Growth Hormone Analogues: Common Adverse Effects
Interactions
TABLE 30-5
Pituitary Drugs: Selected Drug Interactions
Dosages
Drug Profiles
octreotide
DOSAGES
Selected Pituitary Drugs
*Normally used only in adults.

ADH, Antidiuretic hormone; GH, growth hormone; VIPoma, vasoactive intestinal peptide–producing tumor.
Pharmacokinetics: Octreotide
somatropin
Pharmacokinetics: Somatropin
vasopressin
Pharmacokinetics: Vasopressin
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
31
DRUG PROFILES
levothyroxine, p. 493
propylthiouracil, p. 495
Objectives
KEY TERMS
Euthyroid Referring to normal thyroid function. (p. 493)
Hyperthyroidism A condition characterized by excessive production of the thyroid hormones. A severe
form of this disorder is called thyrotoxicosis. (p. 492)
Hypothyroidism A condition characterized by diminished production of the thyroid hormones. (p. 492)
Thyroid-stimulating hormone (TSH) An endogenous substance secreted by the pituitary gland that
controls the release of thyroid gland hormones and is necessary for the growth and function of the thyroid gland
(also called thyrotropin). (p. 492)
Thyroxine (T4) The principle thyroid hormone that influences the metabolic rate. (p. 491)
Triiodothyronine (T3) A secondary thyroid hormone that also affects body metabolism. (p. 491)
Thyroid Function
Pathophysiology of Hypothyroidism
Pathophysiology of Hyperthyroidism
Thyroid Replacement Drugs
TABLE 31-1
Thyroid Drugs: Clinically Equivalent Doses
T3, Triiodothyronine; T4, thyroxine.
Indications
Contraindications
Adverse Effects
TABLE 31-2
Thyroid Drugs: Common Adverse Effects
Interactions
TABLE 31-3
Thyroid Drugs: Interactions
Dosages
Drug Profile
DOSAGES
Selected Thyroid Drugs
levothyroxine
Pharmacokinetics: Levothyroxine
Antithyroid Drugs
Indications
Contraindications
Adverse Effects
TABLE 31-4
Antithyroid Drugs: Common Adverse Effects
Interactions
Dosages
DOSAGES
Selected Antithyroid Drugs
*Often abbreviated PTU.
Drug Profile
propylthiouracil
Pharmacokinetics: Propylthiouracil
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
32
DRUG PROFILES
acarbose, p. 511
glipizide, p. 511
insulin glargine and insulin detemir, p. 507
insulin isophane suspension (NPH), p. 507
insulin lispro, p. 506

liraglutide, p. 513
metformin, p. 512
pioglitazone, p. 512
regular insulin, p. 507

repaglinide, p. 512
sitagliptin, p. 512
Objectives
KEY TERMS
Diabetes mellitus A complex disorder of carbohydrate, fat, and protein metabolism resulting from the lack
of insulin secretion by the beta cells of the pancreas or from defects of the insulin receptors; it is commonly
referred to simply as diabetes. There are two major types of diabetes: type 1 and type 2. (p. 501)
Diabetic ketoacidosis (DKA) A severe metabolic complication of uncontrolled diabetes that, if untreated,
leads to diabetic coma and death. (p. 503)
Gestational diabetes Diabetes that develops during pregnancy. It may resolve after pregnancy but may
also be a precursor of type 2 diabetes in later life. (p. 503)
Glucagon A hormone produced by the alpha cells in the islets of Langerhans that stimulates the conversion
of glycogen to glucose in the liver. (p. 500)
Glucose One of the simple sugars that serves as a major source of energy. It is found in foods (e.g., refined
sweets) and also is the final breakdown product of complex carbohydrate metabolism in the body; it is commonly
referred to as dextrose. (p. 500)
Glycogen A polysaccharide that is the major carbohydrate stored in animal cells. (p. 500)
Glycogenolysis The breakdown of glycogen to glucose. (p. 500)
Hemoglobin A1C (A1C) Hemoglobin molecules bound to glucose molecules; blood levels of hemoglobin
A1C are used as a diagnostic measure of average daily blood glucose levels in the monitoring and diagnosing of
diabetes; it is also called glycosylated hemoglobin and most commonly referred to as A1C. (p. 504)
Hyperglycemia A fasting blood glucose level of 126 mg/dL or higher or a nonfasting blood glucose level of
200 mg/dL or higher. (p. 500)
Hyperosmolar hyperglycemic syndrome (HHS) A metabolic complication of uncontrolled type 2 diabetes,
similar in severity to diabetic ketoacidosis but without ketosis and acidosis. (p. 503)
Hypoglycemia A blood glucose level of less than 70 mg/dL, or above 50 mg/dL with signs and symptoms of
hypoglycemia. (p. 514)
Insulin A naturally occurring hormone secreted by the beta cells of the islets of Langerhans in the pancreas
in response to increased levels of glucose in the blood. (p. 500)
Ketones Organic chemical compounds produced through the oxidation of secondary alcohols (e.g., fat
molecules), including dietary carbohydrates. (p. 500)
Polydipsia Chronic excessive intake of water; it is a common symptom of uncontrolled diabetes. (p. 500)
Polyphagia Excessive eating; it is a common symptom of uncontrolled diabetes. (p. 500)
Polyuria Increased frequency or volume of urinary output; it is a common symptom of diabetes. (p. 500)
Type 1 diabetes mellitus Diabetes mellitus that is a genetically determined autoimmune disorder
characterized by a complete or nearly complete lack of insulin production; it most commonly arises in children or
adolescents. (p. 502)
Type 2 diabetes mellitus A type of diabetes mellitus that most commonly presents in adults and is
becoming more common in children and adolescents due to inactivity and weight gain. The disease may be
controlled by lifestyle modifications, oral drug therapy, and/or insulin, but patients are not necessarily dependent
on insulin therapy. (p. 503)
Pancreas
Pathophysiology of Diabetes Mellitus
Box 32-1
TABLE 32-1
Major Long-Term Consequences of Type 1 and Type 2 Diabetes
Data from American Diabetes Association: Standards of medical care in diabetes 2015, Diabetes Care 38(Suppl 1), 2015.
TABLE 32-2
Characteristics of Type 1 and Type 2 Diabetes
Type 1 Diabetes Mellitus

FIGURE 32-1 The pancreas. A, Pancreas dissected to show main and accessory ducts. B, Exocrine
glandular cells (around small pancreatic ducts) and endocrine glandular cells of the pancreatic islets
(adjacent to blood capillaries). Exocrine pancreatic cells secrete pancreatic enzymes, alpha endocrine
cells secrete glucagon, and beta endocrine cells secrete insulin. (From Patton KT, Thibodeau GA: Anatomy and
physiology, ed 7, St Louis, 2010, Mosby.)
Acute Diabetic Complications: Diabetic Ketoacidosis and Hyperosmolar

Hyperglycemic Syndrome
TABLE 32-3
Comparison of Features of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome
Adapted from Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus
statement from the American Diabetes Association, Diabetes Care 29(12):2739-2748, 2006.
Type 2 Diabetes Mellitus
Gestational Diabetes
Nonpharmacologic Treatment Interventions

Glycemic Goal of Treatment
Insulins
TABLE 32-4
Insulin Mixing Compatibilities
Indications
Contraindications
Adverse Effects
Interactions
DOSAGES
Selected Human-Based Insulin Products

TABLE 32-5
Selected Drug Interactions with Antidiabetic Drugs
Dosages
Insulin Use in Special Populations

Drug Profiles
FIGURE 32-2 Comparison of the pharmacokinetics of various insulins. (From Messinger-Rapport BJ, Thomas
DR, Gammack JK: Clinical update on nursing home medicine: 2008, J Am Med Dir Assoc 9(7):460-475, 2008.)
Rapid-Acting Insulins
insulin lispro
Pharmacokinetics: Insulin Lispro
Short-Acting Insulin
regular insulin
Pharmacokinetics: Regular Insulin
Intermediate-Acting Insulins
insulin isophane suspension (NPH)
Pharmacokinetics: NPH insulin

Long-Acting Insulins
insulin glargine and insulin detemir
Pharmacokinetics: Insulin Glargine
Fixed-Combination Insulins
Basal-Bolus and Sliding-Scale Insulin Dosing

Oral Antidiabetic Drugs
Biguanide
Indications
Contraindications
Adverse Effects
Interactions
Dosages
DOSAGES
Selected Oral Antidiabetic Drugs
Sulfonylureas
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Glinides
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Thiazolidinediones (Glitazones)
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Alpha-Glucosidase Inhibitors
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Dipeptidyl Peptidase IV (DPP-IV) Inhibitors

Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
acarbose
Pharmacokinetics: Acarbose
glipizide
Pharmacokinetics: Glipizide
metformin
Pharmacokinetics: Metformin
pioglitazone
Pharmacokinetics: Pioglitazone
repaglinide
Pharmacokinetics: Repaglinide
sitagliptin
Pharmacokinetics: Sitagliptin
Injectable Antidiabetic Drugs
Amylin Agonists
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Incretin Mimetics
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
liraglutide
Pharmacokinetics: Liraglutide
Sodium Glucose Cotransorter Inhibitors (SGLT2 Inhibitors)
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Glucose-Elevating Drugs
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Box 32-2
Evaluation

TABLE 32-6
Diabetes Care: Correlation of Glycosylated Hemoglobin Levels with Mean Serum Glucose Levels
Data from American Diabetes Association: Standards of medical care in diabetes 2015, Diabetes Care 38(Suppl 1): 2015.
Key Points
33
DRUG PROFILES
fludrocortisone, p. 527
methylprednisolone, p. 528
prednisone, p. 527
Objectives
KEY TERMS
Addison's disease A chronic disease associated with the hyposecretion of corticosteroids. (p. 524)
Adrenal cortex The outer portion of the adrenal gland. (p. 524)
Adrenal crisis An acute, life-threatening state of profound adrenocortical insufficiency requiring immediate
medical management. It is characterized by glucocorticoid deficiency, a drop in extracellular fluid volume,
hyponatremia, and hyperkalemia. (p. 529)
Adrenal medulla The inner portion of the adrenal gland. (p. 524)
Aldosterone A mineralocorticoid hormone produced by the adrenal cortex that acts on the renal tubule to
regulate sodium and potassium balance in the blood. (p. 524)
Cortex The general anatomic term for the outer layers of a body organ or other structure. (p. 524)
Corticosteroids Any of the natural or synthetic adrenocortical hormones; those produced by the cortex of
the adrenal gland (adrenocorticosteroids). (p. 524)
Cushing's syndrome A metabolic disorder characterized by abnormally increased secretion of the
corticosteroids. (p. 524)
Epinephrine An endogenous hormone secreted into the bloodstream by the adrenal medulla; also a
synthetic drug that is an adrenergic vasoconstrictor and also increases cardiac output. (p. 524)
Glucocorticoids A major group of corticosteroid hormones that regulate carbohydrate, protein, and lipid
metabolism and inhibit the release of adrenocorticotropic hormone. (p. 524)
Hypothalamic-pituitary-adrenal (HPA) axis A negative feedback system involved in regulating the release
of corticotropin-releasing hormone by the hypothalamus, adrenocorticotropic hormone (corticotropin) by the
pituitary gland, and corticosteroids by the adrenal glands. Suppression of the HPA may lead to Addison's disease
and possible adrenal crisis or addisonian crisis. This suppression results from chronic disease or exogenous
sources, such as long-term glucocorticoid therapy. (p. 524)
Medulla An anatomic term for the most interior portions of an organ or structure. (p. 524)
Mineralocorticoids A major group of corticosteroid hormones that regulate electrolyte and water balance;
in humans the primary mineralocorticoid is aldosterone. (p. 524)
Norepinephrine An adrenergic hormone, secreted by the adrenal medulla, that increases blood pressure
by causing vasoconstriction but does not appreciably affect cardiac output; it is the immediate metabolic
precursor to epinephrine. (p. 524)
Adrenal System
TABLE 33-1
Adrenal Gland: Characteristics
Box 33-1
Adrenal Drugs
TABLE 33-2
Available Synthetic Corticosteroids
Indications
TABLE 33-3
Systemic Glucocorticoids: A Comparison
*Drugs with higher potency require smaller milligram doses than those with lower potency. This column lists the approximate dose
equivalency between different drugs that is expected to achieve a comparable therapeutic effect.
Contraindications
Adverse Effects
TABLE 33-4
Corticosteroids: Common Adverse Effects
Interactions
Dosages
Drug Profiles
Corticosteroids
DOSAGES
Selected Antiadrenal and Corticosteroid Drugs
GI, Gastrointestinal.
fludrocortisone
Pharmacokinetics: Fludrocortisone
prednisone
Pharmacokinetics: Prednisone
methylprednisolone
Pharmacokinetics: Methylprednisolone
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
34
DRUG PROFILES
alendronate, p. 542
calcitonin, p. 543
clomiphene, p. 544
contraceptive drugs, p. 540
dinoprostone, p. 545
estrogen, p. 537
medroxyprogesterone, p. 539
megestrol, p. 539
methylergonovine, p. 545
oxytocin, p. 546
raloxifene, p. 543
Objectives
KEY TERMS
Chloasma Hyperpigmentation of the skin, characterized by brownish macules on the cheeks, forehead, lips,
and/or neck; a common dermatologic adverse effect of female hormonal medications (also called melasma). (p.
537)
Corpus luteum The structure that forms on the surface of the ovary after every ovulation and acts as a
short-lived endocrine organ that secretes progesterone. (p. 534)
Endocrine glands Glands that secrete one or more hormones directly into the blood. (p. 534)
Estrogens The term for a major class of female sex steroid hormones; of the estrogens, estradiol is
responsible for most estrogenic physiologic activity. (p. 534)
Fallopian tubes The passages through which ova are carried from the ovary to the uterus. (p. 534)
Gonadotropin The hormone that stimulates the testes and ovaries. (p. 534)
Hormone replacement therapy (HRT) The term used to describe any replacement of natural body
hormones with hormonal drug dosage forms. Most commonly, HRT refers to estrogen replacement therapy for
treating symptoms associated with menopause-related estrogen deficiency. It is also referred to as simply
hormone therapy. (p. 537)
Implantation The attachment to, penetration of, and embedding of the fertilized ovum in the lining of the
uterine wall; it is one of the first stages of pregnancy. (p. 534)
Menarche The first menses in a young woman's life and the beginning of cyclic menstrual function. (p. 534)
Menopause The cessation of menses for 12 consecutive months that marks the end of a woman's
childbearing capability. (p. 534)
Menses The normal flow of blood that occurs during menstruation. (p. 534)
Menstrual cycle The recurring cycle of changes in the endometrium in which the decidual layer is shed,
regrows, proliferates, is maintained for several days, and is shed again at menstruation unless a pregnancy
begins. Also referred to as the uterine cycle. (p. 534)
Osteoporosis A condition characterized by the progressive loss of bone density and thinning of bone
tissue; it is associated with increased risk for fractures. (p. 541)
Ova Female reproductive or germ cells (singular: ovum; also called eggs). (p. 534)
Ovarian follicles The location of egg production and ovulation in the ovary; the follicle is the precursor to
the corpus luteum. (p. 534)
Ovaries The pair of female gonads located on each side of the lower abdomen beside the uterus. They
store the ova (eggs) and release ova during the ovulation phase of the menstrual cycle. (p. 534)
Ovulation The rupture of the ovarian follicle, which results in the release of an unfertilized ovum into the
peritoneal cavity, from which it normally enters the fallopian tube. (p. 534)
Progesterone A sex hormone that is produced by the corpus luteum and serves to prepare the uterus for
possible implantation. (p. 534)
Progestins Synthetic or natural substances that have properties similar to progesterone, but are not
considered to be the naturally occurring progesterone that is present in the human female body. (p. 538)
Puberty The period of life when the ability to reproduce begins. (p. 534)
Uterus The hollow, pear-shaped female organ in which the fertilized ovum is implanted (see implantation)
and the fetus develops. (p. 534)
Vagina The part of the female genitalia that forms a canal from its external orifice through its vestibule to
the uterine cervix. (p. 534)
Female Reproductive Functions

TABLE 34-1
Phases of the Menstrual Cycle
FIGURE 34-1 Hormonal activity during the monthly menstrual cycle. Gonadotropin-releasing hormone
(Gn-RH) from the hypothalamus stimulates the pituitary gland, causing it to secrete follicle-stimulating
hormone (FSH) early in the cycle (coinciding with the menses) and later luteinizing hormone (LH). FSH
stimulates the ovaries to produce estrogen (primarily estradiol). Later in the cycle, the combined surges in
the levels of estrogen, Gn-RH, FSH, and LH stimulate ovulation. The corpus luteum then secretes
estrogen and progesterone, which provide negative feedback to the hypothalamus and pituitary gland to
reduce Gn-RH, FSH, and LH secretions. If the ovum (egg) is not fertilized by a spermatozoon, levels of
estrogen and progesterone then fall to their monthly lows, Gn-RH and FSH rise again, and the onset of
menses begins a new cycle.
Female Sex Hormones
Estrogens
Box 34-1

Indications
Box 34-2
Contraindications
Adverse Effects
TABLE 34-2
Estrogens: Common Adverse Effects
Interactions
Dosages
Drug profile
estrogen
DOSAGES
Selected Estrogenic Drugs
Progestins
Indications
Contraindications
Adverse Effects
TABLE 34-3
Progestins: Common Adverse Effects
Interactions
Dosages
Drug profiles
medroxyprogesterone
DOSAGES
Selected Progestational Drugs
Pharmacokinetics: Medroxyprogesterone (Depo-Provera)
megestrol
Pharmacokinetics: Megestrol
Contraceptive Drugs
Indications
Contraindications
Adverse Effects
TABLE 34-4
Oral Contraceptives: Common Adverse Effects
Interactions
Dosages
Drug profile
Contraceptive drugs
Drugs for Osteoporosis
DOSAGES
Selected Contraceptive Drugs

Bisphosphonates
Selective Estrogen Receptor Modulators
Calcitonin
Teriparatide
Denosumab
Indications
Contraindications
Bisphosphonates
Selective Estrogen Receptor Modulators (SERMs)
Calcitonin
Teriparatide
Denosumab
Adverse Effects
Interactions
Dosages
Drug profiles
alendronate
DOSAGES
Selected Drugs Used Specifically for Osteoporosis
Pharmacokinetics: Alendronate
raloxifene
Pharmacokinetics: Raloxifene
calcitonin
Pharmacokinetics: Calcitonin
Drugs Related to Pregnancy, Labor, Delivery, and the
Postpartum Period
Fertility Drugs
Indications
Contraindications
Adverse Effects
TABLE 34-5
Fertility Drugs: Most Common Adverse Effects
Interactions
Dosages
Drug profile
clomiphene
Pharmacokinetics: Clomiphene
Uterine Stimulants

DOSAGES
Selected Fertility Drugs
Indications
Contraindications
Adverse Effects
TABLE 34-6
Oxytocic Drugs: Most Common Adverse Effects
Interactions
Dosages
Drug profiles
dinoprostone
Pharmacokinetics: Dinoprostone
methylergonovine
DOSAGES
Selected Uterine Stimulants
*Use of these medications is contraindicated in pregnancy (pregnancy category X) unless needed for the indications listed.
D5LR, Dextrose 5% in lactated Ringer's solution.
Pharmacokinetics: Methylergonovine
oxytocin
Pharmacokinetics: Oxytocin
Drugs for Preterm Labor Management

Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
35
DRUG PROFILES
finasteride, p. 558
sildenafil, p. 558
testosterone, p. 559
Objectives
KEY TERMS
Anabolic activity Any metabolic activity that promotes the building up of body tissues, such as the activity
produced by testosterone that causes the development of bone and muscle tissue; also called anabolism. (p.
554)
Androgenic activity The activity produced by testosterone that causes the development and maintenance
of the male reproductive system and male secondary sex characteristics. (p. 554)
Androgens Male sex hormones responsible for mediating the development and maintenance of male sex
characteristics. Chief among these are testosterone and its various biochemical precursors. (p. 554)
Benign prostatic hyperplasia (BPH) (also called hypertrophy) Nonmalignant (noncancerous) enlargement
of the prostate gland. (p. 555)
Catabolism The opposite of anabolic activity; any metabolic activity that results in the breakdown of body
tissues. Examples of conditions in which catabolism occurs are debilitating illnesses such as end-stage cancer
and starvation. (p. 554)
Erythropoietic effect The effect of stimulating the production of red blood cells (erythropoiesis). (p. 555)
Prostate cancer A malignant tumor within the prostate gland. (p. 556)
Testosterone The main androgenic hormone. (p. 554)
Male Reproductive System
Androgens and Other Drugs Pertaining to Men's Health

Box 35-1
Indications
TABLE 35-1
Men's Health Drugs: Indications
Contraindications
Adverse Effects
TABLE 35-2
Men's Health Drugs: Selected Adverse Effects
Interactions
Dosages
Drug Profiles
finasteride
DOSAGES
Selected Men's Health Drugs
Pharmacokinetics (finasteride)
sildenafil
Pharmacokinetics: Sildenafil
testosterone
Pharmacokinetics: Testosterone Gel
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
PA R T 6
OUTLINE
Learning Strategies
36 Antihistamines, Decongestants, Antitussives, and Expectorants
37 Respiratory Drugs
Time Management
Practice Questions
36
DRUG PROFILES
benzonatate, p. 573
codeine, p. 573
dextromethorphan, p. 573
diphenhydramine, p. 570
guaifenesin, p. 574
loratadine, p. 569
naphazoline, p. 572
Objectives
KEY TERMS
Adrenergics (sympathomimetics) Drugs that stimulate the sympathetic nerve fibers of the autonomic
nervous system that use epinephrine or epinephrine-like substances as neurotransmitters. (p. 570)
Antagonists Drugs that exert an action opposite to that of another drug or compete for the same receptor
sites. (p. 567)
Anticholinergics (parasympatholytics) Drugs that block the action of acetylcholine and similar
substances at acetylcholine receptors, which results in inhibition of the transmission of parasympathetic nerve
impulses. (p. 570)
Antigens Substances capable of inducing specific immune responses and reacting with the specific
products of those responses, such as antibodies and specifically sensitized T lymphocytes. Antigens can be
soluble (e.g., a foreign protein) or particulate or insoluble (e.g., a bacterial cell). (p. 567)
Antihistamines Substances capable of reducing the physiologic and pharmacologic effects of histamine.
(p. 567)
Antitussive A drug that reduces coughing, often by inhibiting neural activity in the cough center of the
central nervous system. (p. 572)
Corticosteroids Any of the hormones produced by the adrenal cortex, either in natural or synthetic drug
form. They control many key processes in the body, such as carbohydrate and protein metabolism, the
maintenance of serum glucose levels, electrolyte and water balance, and the functions of the cardiovascular
system, skeletal muscle, kidneys, and other organs. (p. 570)
Decongestants Drugs that reduce congestion or swelling, especially of the upper or lower respiratory tract.
(p. 570)
Empiric therapy A method of treating disease based on observations and experience, rather than a
knowledge of the precise cause for the disorder. (p. 566)
Expectorants Drugs that increase the flow of fluid in the respiratory tract, usually by reducing the viscosity
of secretions, and facilitate their removal by coughing. (p. 573)
Histamine antagonists Drugs that compete with histamine for binding sites on histamine receptors. (p.
567)
Influenza A highly contagious infection of the respiratory tract that is transmitted by airborne droplets. (p.
566)
Nonsedating antihistamines Medications that primarily work peripherally to block the actions of histamine
and therefore do not generally have the central nervous system effects of many of the older antihistamines; also
called second-generation antihistamines and peripherally acting antihistamines. (p. 569)
Reflex stimulation An irritation of the respiratory tract occurring in response to an irritation of the
gastrointestinal tract. (p. 572)
Rhinovirus Any of about 100 serologically distinct ribonucleic acid (RNA) viruses that cause about 40% of
acute respiratory illnesses. (p. 566)
Sympathomimetic drugs A class of drugs whose effects mimic those resulting from the stimulation of the
sympathetic nervous system. (p. 571)
Upper respiratory tract infection (URI) Any infectious disease of the upper respiratory tract, including the
common cold, laryngitis, pharyngitis, rhinitis, sinusitis, and tonsillitis. (p. 566)
Overview
Antihistamines
FIGURE 36-1 Comparison of the efficacy and adverse effects of selected antihistamines.
TABLE 36-1
Effects of Various Antihistamines

TABLE 36-2
Antihistamines: Drug Effects
Indications
Contraindications
Adverse Effects
TABLE 36-3
Antihistamines: Reported Adverse Effects
Interactions
TABLE 36-4
Antihistamines: Drug Interactions
Dosages
DOSAGES
Selected Antihistamines
PD, Parkinson's disease.
Drug Profiles
Nonsedating Antihistamines
loratadine
Pharmacokinetics: Loratadine
Traditional Antihistamines
diphenhydramine
Pharmacokinetics: Diphenhydramine
Decongestants
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
DOSAGES
Selected Decongestant, Expectorant, and Antitussive Drugs

naphazoline
Pharmacokinetics: Naphazoline
Antitussives
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
benzonatate
Pharmacokinetics: Benzonatate
codeine
Pharmacokinetics: Codeine
dextromethorphan
Pharmacokinetics: Dextromethorphan
Expectorants
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
guaifenesin
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
37
DRUG PROFILES
albuterol, p. 583
fluticasone propionate, p. 588
ipratropium, p. 584
methylprednisolone, p. 588
montelukast, p. 586
salmeterol, p. 583
theophylline, p. 585
Objectives
KEY TERMS
Allergen Any substance that evokes an allergic response. (p. 579)
Allergic asthma Bronchial asthma caused by hypersensitivity to an allergen or allergens. (p. 579)
Alveoli Microscopic sacs in the lungs where oxygen is exchanged for carbon dioxide; also called air sacs.
(p. 579)
Antibodies Immunoglobulins produced by lymphocytes in response to bacteria, viruses, or other antigenic
substances. (p. 579)
Antigen A substance (usually a protein) that causes the formation of an antibody and reacts specifically
with that antibody. (p. 579)
Asthma attack The onset of wheezing together with difficulty breathing. (p. 579)
Bronchial asthma The general term for recurrent and reversible shortness of breath resulting from
narrowing of the bronchi and bronchioles; it is often referred to simply as asthma. Key characteristics are
inflammation, bronchial smooth muscle spasticity, and sputum production; inflammation is the most important. (p.
579)
Bronchodilators Medications that improve airflow by relaxing bronchial smooth muscle cells (e.g.,
xanthines, adrenergic agonists). (p. 581)
Chronic bronchitis Chronic inflammation and low-grade infection of the bronchi. (p. 579)
Emphysema A condition of the lungs characterized by enlargement of the air spaces distal to the
bronchioles. (p. 579)
Immunoglobulins Proteins belonging to any of five structurally and antigenically distinct classes of
antibodies present in the serum and external secretions of the body; they play a major role in immune responses;
immunoglobulin is often abbreviated Ig. (p. 579)
Lower respiratory tract (LRT) The division of the respiratory system composed of organs located almost
entirely within the chest. (p. 579)
Status asthmaticus A prolonged asthma attack. (p. 579)
Upper respiratory tract (URT) The division of the respiratory system composed of organs located outside
the chest cavity (thorax). (p. 579)
Overview
Pathophysiology of Diseases of the Respiratory System
Asthma
Box 37-1
Box 37-2
TABLE 37-1
Stepwise Therapy for the Management of Asthma
Adapted from National Institutes of Health: Expert Panel Report 3: Guidelines for the diagnosis and management of asthma, 2007, U.S.
Department of Health and Human Services, available at www.nhlbi.nih.gov/guidelines/asthma. Accessed May 2, 2015.
Chronic Bronchitis
Emphysema
Treatment of Diseases of the Lower Respiratory Tract
TABLE 37-2
Mechanisms of Antiasthmatic Drug Action
FIGURE 37-1 Overview of the effects of various antiasthmatic medications. (From McKenry LM, Tessier E,
Hogan M: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.)
Bronchodilators
Beta-Adrenergic Agonists
FIGURE 37-2 The EpiPen Auto-Injector (epinephrine) is used for immediate treatment of anaphylaxis
(allergic emergencies). The EpiPen is given into the outer thigh, through the clothing. Anaphylactic
emergencies also require emergency medical services in addition to the EpiPen. Additional information is
available at www.epipen.com. (Copyright Mylan Specialty, L.P. Used with permission.)
DOSAGES
Bronchodilators
*Long-actingbeta agonists are no longer recommended to be used alone; they need to be combined with an asthma-controlling
medication such as an inhaled corticosteroid (e.g., Advair inhaler [fluticasone and salmeterol]).
MDI, metered-dose inhaler.
TABLE 37-3
Beta Agonist Bronchodilators
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
albuterol
Pharmacokinetics: Albuterol
salmeterol
Pharmacokinetics: Salmeterol
Anticholinergics
Indications
Contraindications
Adverse Effects
Drug Interactions
Dosages
Drug Profile
ipratropium
DOSAGES
Theophylline Salts
Pharmacokinetics: Ipratropium
Xanthine Derivatives
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
theophylline
Pharmacokinetics: Theophylline
Nonbronchodilating Respiratory Drugs
Leukotriene Receptor Antagonists
Indications
Contraindications
Adverse Effects
Interactions
TABLE 37-4
Drug Interactions: Leukotriene Receptor Antagonists
Dosages
DOSAGES
Selected Antileukotriene Drug
Drug Profile
montelukast
Pharmacokinetics: Montelukast
Corticosteroids
TABLE 37-5
White Blood Cells (Leukocytes)
*Value in parentheses is the percentage of all leukocytes represented by the given type.
Indications
Contraindications
Adverse Effects
DOSAGES
Selected Corticosteroids
COPD, Chronic obstructive pulmonary disease; MDI, metered-dose inhaler.
Interactions
Dosages
Drug Profiles
fluticasone propionate
Pharmacokinetics: Fluticasone Propionate
methylprednisolone
Pharmacokinetics: Methylprednisolone
Phosphodiesterase-4 Inhibitor
Monoclonal Antibody Antiasthmatic
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation

Beta Agonists
Box 37-3
Xanthines
Anticholinergics
Leukotriene Receptor Antagonists
Corticosteroids (Glucocorticoids)
Phosphodiesterase-4 Inhibitor
Monoclonal Antibody Antiasthmatic Drugs
Key Points
PA R T 7
OUTLINE
Learning Strategies
38 Antibiotics Part 1
39 Antibiotics Part 2
40 Antiviral Drugs
41 Antitubercular Drugs
42 Antifungal Drugs
43 Antimalarial, Antiprotozoal, and Anthelmintic Drugs
44 Antiinflammatory and Antigout Drugs
Active Questioning
NCLEX® Practice
38
DRUG PROFILES
amoxicillin, p. 608
ampicillin, p. 608
azithromycin and clarithromycin, p. 615
aztreonam, p. 613
cefazolin, p. 610
cefepime, p. 612
cefoxitin, p. 611
ceftaroline, p. 612
ceftazidime, p. 612
ceftriaxone, p. 612
cefuroxime, p. 611
cephalexin, p. 610
demeclocycline, p. 617
doxycycline, p. 617
erythromycin, p. 615
imipenem/cilastatin, p. 612
nafcillin, p. 608
penicillin G and penicillin V potassium, p. 608
sulfamethoxazole/trimethoprim (co-trimoxazole), p. 605
tigecycline, p. 617
Objectives
KEY TERMS
Antibiotic Having the ability to destroy or interfere with the development of a living organism. The term is
used most commonly to refer to antibacterial drugs. (p. 600)
Antiseptic One of two types of topical antimicrobial agents; a chemical that inhibits the growth and
reproduction of microorganisms without necessarily killing them. Antiseptics are also called static agents. (p. 601)
Bactericidal antibiotics Antibiotics that kill bacteria. (p. 606)
Bacteriostatic antibiotics Antibiotics that do not actually kill bacteria but rather inhibit their growth. (p. 604)
Beta-lactam The designation for a broad class of antibiotics that includes four subclasses: penicillins,
cephalosporins, carbapenems, and monobactams; so named because of the beta-lactam ring that is part of the
chemical structure of all drugs in this class. (p. 605)
Beta-lactamase Any of a group of enzymes produced by bacteria that catalyze the chemical opening of the
crucial beta-lactam ring structures in beta-lactam antibiotics. (p. 606)
Beta-lactamase inhibitors Medications combined with certain penicillin drugs to block the effect of beta-
lactamase enzymes. (p. 606)
Colonization The establishment and growth of microorganisms on the skin, open wounds, or mucous
membranes, or in secretions without causing an infection. (p. 601)
Community-associated infection An infection that is acquired by persons who have not been hospitalized
or had a medical procedure recently. (p. 601)
Definitive therapy The administration of antibiotics based on known results of culture and sensitivity testing
identifying the pathogen causing infection. (p. 602)
Disinfectant One of two types of topical antimicrobial agents; a chemical applied to nonliving objects to kill
microorganisms. Also called cidal agents. (p. 601)
Empiric therapy The administration of antibiotics based on the practitioner's judgment of the pathogens
most likely to be causing an apparent infection; it involves the presumptive treatment of an infection to avoid
treatment delay before specific culture information has been obtained. (p. 602)
Glucose-6-phosphate dehydrogenase (G6PD) deficiency An inherited disorder in which the red blood
cells are partially or completely deficient in glucose-6-phosphate dehydrogenase, a critical enzyme in the
metabolism of glucose. Certain medications can cause hemolytic anemia in patients with this disorder. This is an
example of a host factor related to drug therapy. (p. 603)
Health care–associated infection An infection that is acquired during the course of receiving treatment for
another condition in a health care institution. The infection is not present or incubating at the time of admission;
also known as a nosocomial infection. (p. 601)
Host factors Factors that are unique to a particular patient that affect the patient's susceptibility to infection
and response to various antibiotic drugs. Examples include a low neutrophil count or a lack of immunoglobulins in
the blood that carry antibodies. (p. 603)
Infections Invasions and multiplications of microorganisms in body tissues. (p. 600)
Microorganisms Microscopic living organisms (also called microbes). (p. 600)
Prophylactic antibiotic therapy Antibiotics taken before anticipated exposure to an infectious organism in
an effort to prevent the development of infection. (p. 602)
Pseudomembranous colitis A potentially-necrotizing inflammatory bowel condition that is often associated
with antibiotic therapy; often caused by the bacteria Clostridium difficile. A more general term that is also used is
antibiotic-associated colitis. (p. 602)
Slow acetylation A common genetic host factor in which the rate of metabolism of certain drugs is reduced.
(p. 603)
Subtherapeutic Generally refers to blood levels below therapeutic levels due to insufficient dosing. Also
refers to antibiotic treatment that is ineffective in treating a given infection. Possible causes include inappropriate
drug therapy, insufficient drug dosing, and bacterial drug resistance. (p. 602)
Superinfection (1) An infection occurring during antimicrobial treatment for another infection, resulting from
overgrowth of an organism not susceptible to the antibiotic used. (2) A secondary microbial infection that occurs
in addition to an earlier primary infection, often due to weakening of the patient's immune system function by the
first infection. (p. 602)
Teratogens Substances that can interfere with normal prenatal development and cause one or more
developmental abnormalities in the fetus. (p. 603)
Therapeutic Referring to antibiotic therapy that is given in sufficient doses so that the concentration of the
drug in the blood or other tissues renders it effective against specific bacterial pathogens. (p. 602)
Microbial Infection
FIGURE 38-1 General morphology of bacteria. (From Murray PR, Rosenthal KS, Pfaller MA: Medical microbiology, ed
6, St Louis, 2009, Mosby.)
FIGURE 38-2 Gram-positive and gram-negative bacteria. A gram-positive bacterium has a thick layer of
peptidoglycan (left). A gram-negative bacterium has a thin peptidoglycan layer and an outer membrane
(right). Structures in parentheses are not found in all bacteria. (From Murray PR, Rosenthal KS, Pfaller MA: Medical
microbiology, ed 6, St Louis, 2009, Mosby.)
Health Care–Associated Infection
TABLE 38-1
Antiseptics versus Disinfectants
Antibiotics
FIGURE 38-3 Basic sites of antibiotic activity. DNA, Deoxyribonucleic acid; mRNA, messenger
ribonucleic acid; RNA, ribonucleic acid. (From Murray PR, Rosenthal KS, Pfaller MA: Medical microbiology, ed 6, St Louis,
2009, Mosby.)
Sulfonamides
Indications
Contraindications
Adverse Effects
TABLE 38-2
Sulfonamides: Reported Adverse Effects
Interactions
Dosages
DOSAGES
Selected Sulfonamide Combination Drug Products
*Dosage ranges are typical but are not necessarily exhaustive due to space limitations. Clinical variations may occur. Check current
drug handbook for exact dosages for specific indications.
Drug Profile
sulfamethoxazole/trimethoprim (co-trimoxazole)
Pharmacokinetics: Sulfamethoxazole/Trimethoprim (Co-Trimoxazole)
Beta-Lactam Antibiotics
FIGURE 38-4 Chemical structure of penicillins showing the beta-lactam ring. R, Variable portion of drug
chemical structure.
Penicillins
TABLE 38-3
Classification of Penicillins
Indications
Contraindications
Adverse Effects
TABLE 38-4
Penicillins: Reported Adverse Effects
Interactions
TABLE 38-5
Penicillins: Drug Interactions
Dosages
Drug Profiles
Natural Penicillins
penicillin G and penicillin V potassium
Pharmacokinetics: Penicillin G
Penicillinase-Resistant Penicillins
nafcillin
Pharmacokinetics: Nafcillin
Aminopenicillins
DOSAGES
Selected Penicillins
spp., Species.
amoxicillin
Pharmacokinetics: Amoxicillin
ampicillin
Pharmacokinetics: Ampicillin
Extended-Spectrum Penicillins
Cephalosporins
TABLE 38-6
Cephalosporins: Parenteral and Oral Preparations
FIRST-GENERATION SECOND-GENERATION THIRD-GENERATION

TABLE 38-7
Cephalosporins: Drug Interactions
Dosages
Drug Profiles
First-Generation Cephalosporins
cefazolin
DOSAGES
Selected Cephalosporins
*Cefuroxime axetil and cefditoren pivoxil are both prodrugs for PO use that are hydrolyzed into the active ingredient in the fluids of the
gastrointestinal tract.
spp., Species.
Pharmacokinetics: Cefazolin
cephalexin
Pharmacokinetics: Cephalexin
Second-Generation Cephalosporins
cefoxitin
Pharmacokinetics: Cefoxitin
cefuroxime
Pharmacokinetics: Cefuroxime
Third-Generation Cephalosporins
ceftriaxone
Pharmacokinetics: Ceftriaxone
ceftazidime
Pharmacokinetics: Ceftazidime
Fourth-Generation Cephalosporins
cefepime
Pharmacokinetics: Cefepime
Fifth-Generation Cephalosporins
ceftaroline
Pharmacokinetics: Ceftaroline
Carbapenems
Drug Profile
imipenem/cilastatin
Pharmacokinetics: Imipenem/Cilastatin
Monobactams
Drug Profile
aztreonam
Pharmacokinetics: Aztreonam
Macrolides
DOSAGES
Selected Carbapenems and Monobactams
Indications
Contraindications
Adverse Effects
TABLE 38-8
Macrolides: Reported Adverse Effects
Interactions
Dosages
Drug Profiles
erythromycin
azithromycin and clarithromycin
DOSAGES
Selected Macrolides
*There are many dosage forms, and dosages may vary from those listed.
GU, Genitourinary; MAC, Mycobacterium avium-intracellulare complex.
Pharmacokinetics: Azithromycin
Pharmacokinetics: Clarithromycin
Ketolides
Tetracyclines
Box 38-1
Indications
Contraindications
DOSAGES
Selected Tetracyclines*
*Use of tetracyclines is contraindicated in children younger than 8 years of age and in pregnant women because of the risk for significant
tooth discoloration in children.
MRSA, Methicillin-resistant Staphylococcus aureus.
Adverse Effects
Interactions
Dosages
Drug Profiles
demeclocycline
doxycycline
Pharmacokinetics: Doxycycline
tigecycline
Pharmacokinetics: Tigecycline
Nursing Process
Assessment
Box 38-2
Nursing Diagnoses
Implementation
Evaluation

Key Points
39
DRUG PROFILES
amikacin, p. 627
ciprofloxacin, p. 630
clindamycin, p. 630
colistimethate, p. 630
daptomycin, p. 631
gentamicin, p. 627
levofloxacin, p. 630
linezolid, p. 630
metronidazole, p. 632
neomycin, p. 628
nitrofurantoin, p. 632
telavancin, p. 633
tobramycin, p. 628
vancomycin, p. 633
Objectives
KEY TERMS
Carbapenem-resistant Enterobacteriaceae (CRE) refers to bacteria that possess an enzyme,
carbapenemase, which renders the organism resistant to all carbapenem antibiotics as well as beta-lactam
antibiotics and monobactams. Such organisms produce a very serious resistant infection. CRE used to be known
as Klebsiella pneumoniae carbapenemase (KPC). (p. 624)
Concentration-dependent killing A property of some antibiotics, especially aminoglycosides, whereby
achieving high plasma drug concentrations, even if briefly, results in the most effective bacterial kill (compare
time-dependent killing). (p. 625)
Extended-spectrum beta-lactamases (ESBLs) A group of beta-lactamase enzymes produced by some
organisms that makes the organism resistant to all beta-lactam antibiotics (penicillins and cephalosporins) and
aztreonam. Patients who are infected by such organisms must be in contact isolation; proper handwashing is key
to preventing the spread of these organisms. (p. 624)
Methicillin-resistant Staphylococcus aureus (MRSA) A strain of Staphylococcus aureus that is resistant
to the beta-lactamase penicillin known as methicillin. Originally, the abbreviation MRSA referred exclusively to
methicillin-resistant S. aureus. It is now used more commonly to refer to strains of S. aureus that are resistant to
several drug classes, and therefore, depending on the context or health care institution, it may also stand for
“multidrug-resistant S. aureus.” (p. 624)
Microgram One millionth of a gram. Be careful not to confuse it with milligram (one thousandth of a gram),
which is one thousand times greater than 1 microgram. Confusion of these two units sometimes results in drug
dosage errors. (p. 625)
Minimum inhibitory concentration (MIC) A laboratory measure of the lowest concentration of a drug
needed to kill a certain standardized amount of bacteria. (p. 625)
Multidrug-resistant organisms Bacteria that are resistant to one or more classes of antimicrobial drugs.
These include multidrug-resistant Staphylococcus aureus, extended-spectrum beta-lactamase–producing
organisms, and carbapenemase-resistant enterobacteriaceae. (p. 624)
Nephrotoxicity Toxicity to the kidneys, often drug induced and manifesting as compromised renal function;
usually reversible upon withdrawal of the offending drug. (p. 625)
Ototoxicity Toxicity to the ears, often drug induced and manifesting as varying degrees of hearing loss that
is likely to be permanent. (p. 625)
Postantibiotic effect A period of continued bacterial suppression that occurs after brief exposure to certain
antibiotic drug classes, especially aminoglycosides (discussed in this chapter) and carbapenems (see Chapter
38). The mechanism of this effect is uncertain. (p. 626)
Pseudomembranous colitis A necrotizing inflammatory bowel condition that is often associated with
antibiotic therapy. Some antibiotics (e.g., clindamycin) are more likely to produce it than others. More commonly
referred to as antibiotic-associated colitis or Clostridium difficile diarrhea or C. difficile infection. (p. 630)
Synergistic effect Drug interaction in which the bacterial killing effect of two antibiotics given together is
greater than the sum of the individual effects of the same drugs given alone. (p. 626)
Therapeutic drug monitoring Ongoing monitoring of plasma drug concentrations and dosage adjustment
based on these values as well as other laboratory indicators such as kidney and liver function test results; it is
often carried out by a pharmacist in collaboration with medical, nursing, and laboratory staff. (p. 625)
Time-dependent killing A property of most antibiotic classes whereby prolonged high plasma drug
concentrations are required for effective bacterial kill (compare concentration-dependent killing). (p. 625)
Vancomycin-resistant Enterococcus (VRE) Enterococcus species that are resistant to beta-lactam
antibiotics and vancomycin. Most commonly refers to Enterococcus faecium. (p. 624)
Overview
Pathophysiology of Resistant Infections
Box 39-1
MRSA, Methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant Enterococcus; ESBL, extended-spectrum beta-
lactamase; CRE, carbapenemase-resistant Enterobacteriaceae.
Aminoglycosides
TABLE 39-1
Aminoglycoside Antibiotics
PEAK TROUGH
*q8h or q12h.
†mcg, microgram; note that 1 microgram = 1/1000 (one thousandth) of a milligram or 1/1,000,000 (one millionth) of a gram. Also note
that microgram is abbreviated mcg, while milligram is abbreviated mg.
Indications
TABLE 39-2
Aminoglycosides: Comparative Spectra of Antimicrobial Activity
spp., Species.
Contraindications
Adverse Effects
Interactions
Dosages
DOSAGES
Selected Aminoglycosides*
*Dosing and frequency vary depending on the age of the patient.
Drug Profiles
amikacin
Pharmacokinetics: Amikacin
gentamicin
Pharmacokinetics: Gentamicin
tobramycin
Pharmacokinetics: Tobramycin
neomycin
Pharmacokinetics: Neomycin
Quinolones
Indications
Box 39-2
TABLE 39-3
Quinolones: Common Indications for Specific Drugs
CAP, Community-associated pneumonia; COPD, chronic obstructive pulmonary disease; PRSP, penicillin-resistant streptococcal
pneumonia; STI, sexually transmitted infection.
Contraindications
Adverse Effects
DOSAGES
Selected Quinolones
TABLE 39-4
Quinolones: Reported Adverse Effects
ALT, Alanine aminotransferase; AST, aspartate aminotransferase.
Interactions
Dosages
Drug Profiles
ciprofloxacin
Pharmacokinetics: Ciprofloxacin
levofloxacin
Pharmacokinetics: Levofloxacin
Miscellaneous Antibiotics
Drug Profiles
clindamycin
DOSAGES
Selected Miscellaneous Antibiotics
*Not normally used in children except to treat amebiasis.

†Oral is not absorbed and is used only for C. difficile diarrhea.
CRE, Carbapenemase-resistant Enterobacteriaceae; GU, genitourinary; MRSA, methicillin-resistant Staphylococcus aureus; PO, oral;
spp., species; UTI, urinary tract infection; VRE, vancomycin-resistant Enterococcus.
Pharmacokinetics: Clindamycin
colistimethate
Pharmacokinetics: Colistimethate
daptomycin
Pharmacokinetics: Daptomycin
linezolid
Pharmacokinetics: Linezolid
metronidazole
Pharmacokinetics: Metronidazole
nitrofurantoin
Pharmacokinetics: Nitrofurantoin
quinupristin/dalfopristin
Pharmacokinetics: Quinupristin/Dalfopristin
telavancin
Pharmacokinetics: Telavancin
vancomycin
Pharmacokinetics: Vancomycin
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Aminoglycosides
Quinolones
Clindamycin
Linezolid
Metronidazole
Nitrofurantoin
Vancomycin
Key Points
40
DRUG PROFILES
acyclovir, p. 647
amantadine and rimantadine, p. 647
enfuvirtide, p. 653
ganciclovir, p. 647
indinavir, p. 653
nevirapine, p. 654
maraviroc, p. 654
oseltamivir and zanamivir, p. 648
raltegravir, p. 654
ribavirin, p. 648
simeprevir, p. 648
sofosbuvir, p. 648
telbivudine, p. 649
tenofovir, p. 654
zidovudine, p. 654
Objectives
KEY TERMS
Acquired immunodeficiency syndrome (AIDS) Infection caused by the human immunodeficiency virus
(HIV), which weakens the host's immune system, giving rise to opportunistic infections. (p. 643)
Antibodies Immunoglobulin molecules that have an antigen-specific amino acid sequence and are
produced by the humoral immune system (antibodies produced from B lymphocytes) in response to exposure to
a specific antigen, the purpose of which is to attack and destroy molecules of this antigen. (p. 643)
Antigen A substance, usually a protein, that is foreign to a host and causes the formation of an antibody
that reacts specifically with that antibody. Examples of antigens include bacterial exotoxins, viruses, and
allergens. An allergen (e.g., dust, pollen, mold) is a specific type of antigen that causes allergic reactions (see
Chapter 36). (p. 643)
Antiretroviral drugs A specific term for antiviral drugs that work against retroviruses such as HIV. (p. 644)
Antiviral drugs A general term for drugs that destroy viruses, either directly or indirectly by suppressing
their replication. (p. 643)
Cell-mediated immunity One of two major parts of the immune system. It consists of nonspecific immune
responses mediated primarily by T lymphocytes (T cells) and other immune system cells (e.g., monocytes,
macrophages, neutrophils) but not by antibody-producing cells (B lymphocytes). (p. 643)
Deoxyribonucleic acid (DNA) A nucleic acid composed of nucleotide units that transmit genetic
information and are found primarily in the nuclei of cells. (Compare with ribonucleic acid [RNA].) (p. 642)
Fusion The process by which viruses attach themselves to, or fuse with, the cell membranes of host cells,
in preparation for infecting the cell for purposes of viral replication. (p. 642)
Genome The complete set of genetic material of any organism; it may consist of multiple chromosomes
(groups of DNA or RNA molecules) in higher organisms; a single chromosome, as in bacteria; or one or two DNA
or RNA molecules, as in viruses. (p. 642)
Herpesviruses Several different types of viruses belonging to the family Herpesviridae that cause various
forms of herpes infection. (p. 643)
Host Any organism that is infected with a microorganism, such as bacteria or viruses. (p. 642)
Human immunodeficiency virus (HIV) The retrovirus that causes AIDS. (p. 643)
Humoral immunity One of two major parts of the immune system. It consists of specific immune responses
in the form of antigen-specific antibodies produced from B lymphocytes. (p. 643)
Immunoglobulins Synonymous with immune globulins. Glycoproteins produced and used by the humoral
immune system to attack and kill any substance (antigen) that is foreign to the body. (p. 643)
Influenza viruses The viruses that cause influenza, an acute viral infection of the respiratory tract. (p. 643)
Nucleic acids A general term referring to DNA and RNA. These complex biomolecules contain the genetic
material of all living organisms, which is passed to future generations during reproduction. (p. 642)
Nucleoside A structural component of nucleic acid molecules (DNA or RNA) that consists of a purine or
pyrimidine base attached to a sugar molecule. (p. 644)
Nucleotide A nucleoside that is attached to a phosphate unit, which makes up the side chain “backbone” of
a DNA or an RNA molecule. (p. 644)
Opportunistic infections Infections caused by any type of microorganism that occur in an
immunocompromised host but normally would not occur in an immunocompetent host. (p. 643)
Protease An enzyme that breaks down the amino acid structure of protein molecules by chemically cleaving
the peptide bonds that link together the individual amino acids. (p. 650)
Replication Any process of duplication or reproduction, such as that involved in the duplication of nucleic
acid molecules (DNA or RNA). This term is used most often to describe the entire process of viral reproduction,
which occurs only inside the cells of an infected host organism. (p. 642)
Retroviruses Viruses belonging to the family Retroviridae. These viruses contain RNA (as opposed to
DNA) as their genome and replicate using the enzyme reverse transcriptase. Currently the most clinically
significant retrovirus is HIV. (p. 643)
Reverse transcriptase An RNA-directed DNA polymerase enzyme. It promotes the synthesis of a DNA
molecule from an RNA molecule, which is the reverse of the usual process. HIV replicates in this manner. (p.
650)
Ribonucleic acid (RNA) A nucleic acid composed of nucleotide units that transmit genetic information and
are found in both the nuclei and cytoplasm of cells. (Compare with deoxyribonucleic acid [DNA].) (p. 642)
Virion A mature virus particle. (p. 642)
Viruses The smallest known class of microorganisms; viruses can only replicate inside host cells. (p. 642)
General Principles of Virology
FIGURE 40-1 Virus replication. Some viruses integrate into a host chromosome and enter a period of
latency. mRNA, Messenger RNA. (Modified from Brody TM, Larner J, Minneman KP: Human pharmacology: Molecular to
clinical, ed 5, St Louis, 2010, Mosby.)
Overview of Viral Illnesses and Their Treatment
Box 40-1
Herpes Simplex Virus and Varicella-Zoster Virus Infections
Herpes Simplex Viruses
Varicella-Zoster Virus
Hepatitis
Antivirals (Non-HIV)
Indications
TABLE 40-1
Examples of Antiviral Drugs (Non-HIV)
HIV, Human immunodeficiency virus.
Contraindications
Adverse Effects
TABLE 40-2
Selected Antiviral Drugs: Adverse Effects
Interactions
TABLE 40-3
Selected Antiviral Drugs: Interactions
Dosages
Drug Profiles
amantadine and rimantadine

DOSAGES
Antiviral Drugs (Non-HIV)
*Use bronchodilator inhaler first if applicable.

HIV, Human immunodeficiency virus; HSV-1, HSV-2, herpes simplex virus types 1 and 2; RSV, respiratory syncytial virus.
Pharmacokinetics: Amantadine
acyclovir
Pharmacokinetics (Acyclovir)
ganciclovir
Pharmacokinetics: Ganciclovir
oseltamivir and zanamivir
Pharmacokinetics: Oseltamivir
Pharmacokinetics: Zanamivir
ribavirin
Pharmacokinetics: Ribavirin
simeprevir
Pharmacokinetics: Simeprevir
sofosbuvir
Pharmacokinetics: Sofosbuvir
telbivudine
Pharmacokinetics: Telbivudine
HIV Infection and Aids
Box 40-2
FIGURE 40-2 Human immunodeficiency virus. Within the core capsid, the diploid, single-stranded,
positive-sense RNA is complexed to nucleoprotein. gp, Glycoprotein. (From Dorland's illustrated medical dictionary,
ed 32, Philadelphia, 2012, Saunders.)
FIGURE 40-3 Life cycle of the human immunodeficiency virus (HIV). The extracellular envelope protein
gp120 binds to CD4 on the surface of T lymphocytes or mononuclear phagocytes, while the
transmembrane protein gp41 mediates the fusion of the viral envelope with the cell membrane. gp,
Glycoprotein; mRNA, messenger RNA. (From Dorland's illustrated medical dictionary, ed 32, Philadelphia, 2012,
Saunders.)
FIGURE 40-4 Timeline for the spectrum of untreated HIV infection. The timeline represents the course of
untreated illness from the time of infection to clinical manifestations of disease. (From Lewis SL, Dirksen SR,
Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 8, Philadelphia, 2011,
Elsevier.)
Drugs Used to Treat HIV Infection
TABLE 40-4
Examples of Antiretrovirals Used to Treat HIV

Indications
TABLE 40-5
Recommendations for Occupational HIV Exposure Chemoprophylaxis
NOTE: Recommendations vary and change often, and the reader is referred to the CDC website (www.cdc.gov) for updated guidelines.
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
enfuvirtide
DOSAGES
HIV/AIDS Drugs
AIDS, Acquired immunodeficiency syndrome; CCR5, chemokine receptor 5; HIV, human immunodeficiency virus.
Pharmacokinetics: Enfuvirtide
indinavir
Pharmacokinetics: Indinavir
maraviroc
Pharmacokinetics: Maraviroc
nevirapine
Pharmacokinetics: Nevirapine
raltegravir
Pharmacokinetics: Raltegravir
tenofovir
Pharmacokinetics: Tenofovir
zidovudine
Pharmacokinetics: Zidovudine
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
41
DRUG PROFILES
ethambutol, p. 664
isoniazid, p. 664
pyrazinamide, p. 665
rifabutin, p. 665
rifampin, p. 665
rifapentine, p. 666
streptomycin, p. 666
Objectives
KEY TERMS
Aerobic Requiring oxygen for the maintenance of life. (p. 661)
Antitubercular drugs Drugs used to treat infections caused by Mycobacterium bacterial species. (p. 662)
Bacillus A rod-shaped bacterium. (p. 661)
Granulomas Small nodular aggregations of inflammatory cells (e.g., macrophages, lymphocytes)
characterized by clearly delimited boundaries, as found in tuberculosis. (p. 660)
Isoniazid The primary and most commonly prescribed tuberculostatic drug. (p. 661)
Multidrug-resistant tuberculosis (MDR-TB) Tuberculosis that demonstrates resistance to two or more
drugs. (p. 661)
Slow acetylator An individual with a genetic defect that causes a deficiency in the enzyme needed to
metabolize isoniazid, the most widely used tuberculosis drug. (p. 664)
Tubercle The characteristic lesion of tuberculosis; a small round gray translucent granulomatous lesion,
usually with a caseated (cheesy) consistency in its interior. (See granuloma.) (p. 661)
Tubercle bacilli Another common name for rod-shaped tuberculosis bacteria; essentially synonymous with
Mycobacterium tuberculosis. (p. 661)
Tuberculosis (TB) Any infectious disease caused by species of Mycobacterium, usually Mycobacterium
tuberculosis (adjectives: tuberculous, tubercular). (p. 660)
Pathophysiology of Tuberculosis
Box 41-1
Antitubercular Drugs
Box 41-2
Box 41-3
TABLE 41-1
Antitubercular Drugs: Mechanisms of Action
NAD, Nicotinamide adenine; TB, tuberculosis.

Indications
TABLE 41-2
Antitubercular Drugs: Clinical Uses
HiB, Haemophilus influenzae type b; HIV, human immunodeficiency virus; TB, tuberculosis.
Contraindications
Adverse Effects
TABLE 41-3
Antitubercular Drugs: Common Adverse Effects
CSF, Cerebrospinal fluid.
Interactions
TABLE 41-4
Selected Antitubercular Drugs: Drug Interactions
Dosages
DOSAGES
Selected Antitubercular Drugs

Drug Profiles
ethambutol
Pharmacokinetics: Ethambutol
isoniazid
Pharmacokinetics: Isoniazid
pyrazinamide
Pharmacokinetics: Pyrazinamide
rifabutin
Pharmacokinetics: Rifabutin
rifampin
Pharmacokinetics: Rifampin
rifapentine
Pharmacokinetics: Rifapentine
streptomycin
Pharmacokinetics: Streptomycin
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
42
DRUG PROFILES
amphotericin B, p. 673
caspofungin, p. 674
fluconazole, p. 674
nystatin, p. 675
terbinafine, p. 675
voriconazole, p. 675
Objectives
KEY TERMS
Antimetabolite A drug that is a either a receptor antagonist or that resembles a normal human metabolite
and interferes with its function in the body, usually by competing for the metabolite's usual receptors or enzymes.
(p. 672)
Dermatophyte One of several fungi that are often found in soil and infect the skin, nails, or hair of humans.
(p. 670)
Ergosterol The main sterol in fungal membranes. (p. 672)
Fungi A very large, diverse group of eukaryotic microorganisms; consist of yeasts and molds. (p. 670)
Molds Multicellular fungi characterized by long, branching filaments called hyphae, which entwine to form a
complex branched structure known as a mycelium. (p. 670)
Mycosis The general term for any fungal infection. (p. 670)
Pathologic fungi Fungi that cause mycoses. (p. 670)
Sterols Substances in the cell membranes of fungi to which polyene antifungal drugs bind. (p. 672)
Yeasts Single-celled fungi that reproduce by budding. (p. 670)
Fungal Infections
TABLE 42-1
Mycotic Infections
*Malassezia spp. are a usual part of the normal human flora and appear to cause infection in only select individuals.
spp., Species.
Antifungal Drugs
Indications
Contraindications
Adverse Effects
TABLE 42-2
Selected Antifungal Drugs: Common Adverse Effects and Cautions
Sy, Systemic; T, topical.
Interactions
TABLE 42-3
Antifungal Drugs: Drug Interactions
Dosages
Drug Profiles
amphotericin B
Pharmacokinetics: Amphotericin B
caspofungin
Pharmacokinetics: Caspofungin
DOSAGES
Selected Antifungal Drugs

fluconazole
Pharmacokinetics: Fluconazole
nystatin
Pharmacokinetics: Nystatin
terbinafine
Pharmacokinetics: Terbinafine
voriconazole
Pharmacokinetics: Voriconazole
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
43
DRUG PROFILES
atovaquone, p. 686
chloroquine and hydroxychloroquine, p. 682
mefloquine, p. 683
metronidazole, p. 686
pentamidine, p. 686
praziquantel, p. 689
primaquine, p. 683
pyrantel, p. 689
pyrimethamine, p. 683
Objectives
KEY TERMS
Anthelmintic A drug that destroys or prevents the development of parasitic worm (helminthic) infections.
Also called antihelmintic or vermicide; notice that the terms for the drug categories are spelled with only one h,
which appears in the second syllable of the term, whereas the term for worm infection (helminthic) is spelled with
two hs, appearing in both the first and third syllables of the term. (p. 686)
Antimalarial drugs Drugs that destroy or prevent the development of the malaria parasite (Plasmodium
sp.) in humans. Antimalarial drugs are a subset of the broader category of antiprotozoal drugs. (p. 680)
Antiprotozoal A drug that destroys or prevents the development of protozoans in humans. (p. 684)
Helminthic infections Parasitic worm infections. (p. 687)
Malaria A widespread protozoal infectious disease caused by four species of the genus Plasmodium. (p.
680)
Parasite Any organism that feeds on another living organism (known as a host) in a way that results in
varying degrees of harm to the host organism. (p. 680)
Parasitic protozoans Harmful protozoans that live on or in humans or animals and cause disease in the
process. (p. 679)
Protozoans Single-celled organisms that are the smallest and simplest members of the animal kingdom. (p.
679)
Overview
Pathophysiology of Malaria
FIGURE 43-1 An infected Anopheles mosquito carries parasites to humans, causing malaria. These
parasites mature in the liver before entering the bloodstream and rupturing red blood cells. A pregnant
woman infected with malaria may transmit the disease to her unborn child.
Antimalarial Drugs
Indications
Contraindications
Adverse Effects
TABLE 43-1
Antimalarial Drugs: Common Adverse Effects
6PD, Glucose-6-phosphate dehydrogenase.
Interactions
TABLE 43-2
Antimalarial Drugs: Drug Interactions
Dosages
Drug Profiles
chloroquine and hydroxychloroquine

DOSAGES
Selected Antimalarial Drugs
Pharmacokinetics: Chloroquine
Pharmacokinetics: Hydroxychloroquine
mefloquine
Pharmacokinetics: Mefloquine
primaquine
Pharmacokinetics: Primaquine
pyrimethamine
Pharmacokinetics: Pyrimethamine
Other Protozoal Infections
TABLE 43-3
Types of Protozoal Infections and Common Drug Therapy
*Pneumocystis jirovecii is now classified as a fungus.

Antiprotozoal Drugs
TABLE 43-4
Selected Antiprotozoal Drugs: Mechanisms of Action
Indications
TABLE 43-5
Selected Antiprotozoal Drugs: Indications
Contraindications
Adverse Effects
TABLE 43-6
Selected Antiprotozoal Drugs: Adverse Effects
Interactions
TABLE 43-7
Antiprotozoal Drugs: Drug and Laboratory Test Interactions
Dosages
DOSAGES
Selected Antiprotozoal Drugs
*Note: A combination product containing atovaquone and the drug proguanil is also used against malaria.
†Pneumocystis jirovecii is now classified as a fungus.
Drug Profiles
atovaquone
Pharmacokinetics: Atovaquone
metronidazole
Pharmacokinetics: Metronidazole
pentamidine
Pharmacokinetics: Pentamidine
TABLE 43-8
Anthelmintic Drugs
DOSAGES
Selected Anthelmintic Drugs
PO, Oral.
TABLE 43-9
Anthelmintics: Class of Worms Killed
TABLE 43-10
Anthelmintics: Mechanisms of Action
ACh, Acetylcholine; ATP, adenosine triphosphate.

Indications
Contraindications
Adverse Effects
TABLE 43-11
Anthelmintics: Common Adverse Effects
Interactions
Dosages
Drug Profiles
praziquantel
Pharmacokinetics: Praziquantel
pyrantel
Pharmacokinetics: Pyrantel
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
44
DRUG PROFILES
allopurinol, p. 699
aspirin, p. 697
celecoxib, p. 699
colchicine, p. 701
ibuprofen, p. 698
indomethacin, p. 698
ketorolac, p. 698
probenecid, p. 701
Objectives
KEY TERMS
Chemotaxis The chemical attraction of leukocytes to the site of inflammation, which worsens an
inflammatory response. (p. 696)
Done nomogram A standard data graph, originally published in 1960 in the journal Pediatrics, for rating the
severity of aspirin toxicity following overdose. Serum salicylate levels are plotted against time elapsed since
ingestion. (p. 696)
Gout Hyperuricemia (elevated blood uric acid level); the arthritis caused by tissue buildup of uric acid
crystals. (p. 699)
Inflammation A localized protective response stimulated by injury to tissues that serves to destroy, dilute,
or wall off (sequester) both the injurious agent and the injured tissue. (p. 692)
Nonsteroidal antiinflammatory drugs (NSAIDs) A large and chemically diverse group of drugs that
possess analgesic, antiinflammatory, and antipyretic (fever-reducing) activity. (p. 693)
Salicylism The syndrome of salicylate toxicity, including symptoms such as tinnitus (ringing sound in the
ears), nausea, and vomiting. (p. 696)
Overview
FIGURE 44-1 Arachidonic acid pathway. PGI2, Prostaglandin I2; PLT, platelet; TXA2, thromboxane A2.
Box 44-1
Box 44-2
Indications
TABLE 44-1
Suggested NSAIDs for Patients with Various Medical Conditions
COX, Cyclooxygenase.
Contraindications
Adverse Effects
TABLE 44-2
NSAIDs: Adverse Effects
MI, Myocardial infarction.
Box 44-3

TABLE 44-3
Acute or Chronic Salicylate Intoxication: Signs and Symptoms
TABLE 44-4
Acute Salicylate Intoxication: Treatment
CNS, Central nervous system.

Interactions
DOSAGES
Most Commonly Used NSAIDs
*Pregnancy category C/D = C, first trimester; D, third trimester.

†PO form is recommended only when transitioning from injectable form to oral form of ketorolac.
TABLE 44-5
Salicylates and Other NSAIDs: Drug Interactions
Dosages
Drug Profiles
Salicylates
aspirin
Pharmacokinetics: Aspirin
Acetic Acid Derivatives
indomethacin
Pharmacokinetics: Indomethacin
ketorolac
Pharmacokinetics: Ketorolac
Propionic Acid Derivatives
ibuprofen
Pharmacokinetics: Ibuprofen
Cyclooxygenase-2 Inhibitors
celecoxib
Pharmacokinetics: Celecoxib
Enolic Acid Derivatives
Antigout Drugs
FIGURE 44-2 Uric acid production. XO, Xanthine oxidase.
Drug Profiles
allopurinol
Pharmacokinetics: Allopurinol
colchicine
Pharmacokinetics: Colchicine
probenecid
Pharmacokinetics: Probenecid
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
PA R T 8
OUTLINE
Learning Strategies
45 Antineoplastic Drugs Part 1: Cancer Overview and Cell Cycle–Specific Drugs
46 Antineoplastic Drugs Part 2: Cell-Cycle–Nonspecific and Miscellaneous Drugs
47 Biologic Response–Modifying and Antirheumatic Drugs
48 Immunosuppressant Drugs
49 Immunizing Drugs
Application of Pharmacology and Making Connections
45
Cancer Overview and Cell Cycle–Specific Drugs
DRUG PROFILES
asparaginase, p. 724
capecitabine, p. 721
cladribine, p. 720
cytarabine, p. 721
etoposide, p. 722
fludarabine, p. 720
fluorouracil, p. 721
gemcitabine, p. 721
irinotecan, p. 723
methotrexate, p. 719
paclitaxel, p. 722
pegaspargase, p. 724
topotecan, p. 723
vincristine, p. 722
Objectives
KEY TERMS
Analogue A chemical compound with a structure similar to that of another compound but differing from it
with respect to some component. (p. 717)
Anaplasia The absence of the cellular differentiation that is part of the normal cellular growth process (see
differentiation; adjective: anaplastic). (p. 714)
Antineoplastic drugs Drugs used to treat cancer. Also called cancer drugs, anticancer drugs, cancer
chemotherapy, and chemotherapy. (p. 714)
Benign Denoting a neoplasm that is noncancerous and therefore not an immediate threat to life. (p. 711)
Cancer A malignant neoplastic disease, the natural course of which is fatal (see neoplasm). (p. 710)
Carcinogen Any cancer-producing substance or organism. (p. 713)
Carcinomas Malignant epithelial neoplasms that tend to invade surrounding tissue and metastasize to
distant regions of the body. (p. 711)
Cell cycle–nonspecific Denoting antineoplastic drugs that are cytotoxic in any phase of the cellular growth
cycle. (p. 715)
Cell cycle–specific Denoting antineoplastic drugs that are cytotoxic during a specific phase of the cellular
growth cycle. (p. 715)
Clone A cell or group of cells that is genetically identical to a given parent cell. (p. 711)
Differentiation An important part of normal cellular growth in which immature cells mature into specialized
cells. (p. 710)
Dose-limiting adverse effects Adverse effects that prevent an antineoplastic drug from being given in
higher dosages, often restricting the effectiveness of the drug. (p. 716)
Emetic potential The potential of a drug to cause nausea and vomiting. (p. 716)
Extravasation The leakage of any intravenously or intraarterially administered medication into the tissue
space surrounding the vein or artery; can cause serious tissue injury. (p. 717)
Gene expression How a cell expresses a receptor or gene; the process in which information from a gene is
used in the synthesis of a gene product. (p. 712)
Growth fraction The percentage of cells in mitosis at any given time. (p. 713)
Intrathecal A route of drug injection through the theca of the spinal cord and into the subarachnoid space.
This route is used to deliver certain chemotherapy medications to kill cancer cells in the central nervous system.
(p. 720)
Leukemias Malignant neoplasms of blood-forming tissues characterized by the replacement of normal bone
marrow cells with leukemic blasts resulting in abnormal numbers and forms of immature white blood cells in the
circulation. (p. 712)
Lymphomas Malignant neoplasms of lymphoid tissue. (p. 712)
Malignant Tending to worsen and cause death; anaplastic, invasive, and metastatic. (p. 711)
Metastasis The process by which a cancer spreads from the original site of growth to a new and remote
part of the body (adjective metastatic). (p. 711)
Mitosis The process of cell reproduction occurring in somatic (nonsexual) cells and resulting in the
formation of two genetically identical daughter cells containing the diploid (complete) number of chromosomes
characteristic of the species. (p. 713)
Mitotic index The number of cells per unit (usually 1000 cells) undergoing mitosis during a given time. (p.
713)
Mutagen A chemical or physical agent that induces or increases genetic mutations by causing changes in
deoxyribonucleic acid (DNA). (p. 713)
Mutation A permanent change in DNA that is transmissible to future cellular generations. Mutations can
transform normal cells into cancer cells. (p. 710)
Myelosuppression Suppression of bone marrow function, which can result in dangerously reduced
numbers of red blood cells, white blood cells, and platelets. (p. 717)
Nadir Lowest point in any fluctuating value over time; for example, the lowest white blood cell count
measured after the count has been depressed by chemotherapy. (p. 717)
Neoplasm Any new and abnormal growth, specifically growth that is uncontrolled and progressive; a
synonym for tumor. A malignant neoplasm or tumor is synonymous with cancer. (p. 711)
Nucleic acids Molecules of DNA and ribonucleic acid (RNA) in the nucleus of every cell (hence the name
nucleic acid). Chromosomes are made up of DNA and encode all of the genes necessary for cellular structure
and function. (p. 713)
Oncogenic Cancer producing; often applied to tumor-inducing viruses. (p. 713)
Paraneoplastic syndromes Symptom complexes arising in patients with cancer that cannot be explained
by local or distant spread of their tumors. (p. 712)
Primary lesion The original site of growth of a tumor. (p. 711)
Sarcomas Malignant neoplasms of the connective tissues arising in bone, fibrous, fatty, muscular, synovial,
vascular, or neural tissue, often first presenting as painless swellings. (p. 711)
Tumor A new growth of tissue characterized by a progressive, uncontrolled proliferation of cells. Tumors
can be solid (e.g., brain tumor) or circulating (e.g., leukemia or lymphoma), and benign (noncancerous) or
malignant (cancerous). Circulating tumors are more precisely called hematologic tumors or hematologic
malignancies. A tumor is also called a neoplasm. (p. 711)
Tumor lysis syndrome A common metabolic complication of chemotherapy for rapidly growing tumors. It is
characterized by the presence of excessive cellular waste products and electrolytes, including uric acid,
phosphate, and potassium, and by reduced serum calcium levels. (p. 718)
Overview
FIGURE 45-1 Schematic model of multistep carcinogenesis. Genetic change refers to events such as
the activation of protooncogenes or drug resistance genes or the inactivation of tumor suppressor genes,
antimetastasis genes, or apoptosis (normal cell death). Genetic change may be relatively minimal, as with
the translocations seen in various leukemias, or it may involve multiple sequential genetic alterations, as
exemplified by the development of colon cancer. (From Haskell CM: Cancer treatment, ed 5, Philadelphia, 2001,
Saunders.)
TABLE 45-1
Tumor Characteristics: Benign and Malignant
TABLE 45-2
Tumor Classification Based on Specific Tissue of Origin
TABLE 45-3
Paraneoplastic Syndromes Associated with Some Cancers
SIADH, Syndrome of inappropriate secretion of antidiuretic hormone.
Etiology of Cancer
TABLE 45-4
Cancer: Proposed Etiologic Factors
Age- and Sex-Related Differences
Genetic and Ethnic Factors
Oncogenic Viruses
Occupational and Environmental Carcinogens
Radiation
Immunologic Factors
Cell Growth Cycle

FIGURE 45-2 Cell life cycle and metabolic activity. Generation time is the period from M phase to M
phase. Cells not in the cycle but capable of division are in the resting phase (G0). (From Lewis SL, Dirksen SR,
Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 8, St Louis, 2011, Mosby).
TABLE 45-5
Cell Cycle Phases
FIGURE 45-3 General phase of the cell cycle in which the various cell cycle–specific chemotherapeutic
drugs have their greatest proportionate kill of cancer cells.
Cancer Drug Nomenclature
*The “5” refers to the position of a fluorine atom in the cyclic ring structure of the uracil molecule.
Drug Therapy
FIGURE 45-4 Relationship between tumor cell burden and phases of cancer treatment. (From McCance KL:
Pathophysiology: The biologic basis for disease in adults and children, ed 5, St Louis, 2006, Mosby.)
Box 45-1
Cell Cycle–Specific Antineoplastic Drugs
Antimetabolites

Folic Acid Antagonism
Purine Antagonism
Pyrimidine Antagonism
Indications
Adverse Effects
TABLE 45-6
Common Manifestations of Antineoplastic Toxicity
Interactions
TABLE 45-7
Selected Antimetabolites: Common Drug Interactions
*Not all mechanisms for these drug interactions have been clearly identified.
Drug Profiles
Folate Antagonist
methotrexate
Indications: Selected Antimetabolites
†The term lymphocytic is synonymous in the literature with the term lymphoblastic.
NHL, Non-Hodgkin's lymphoma.
Purine Antagonists
cladribine
fludarabine
Pyrimidine Antagonists
capecitabine
cytarabine
fluorouracil
gemcitabine
Mitotic Inhibitors
Indications
Adverse Effects
Toxicity and Management of Extravasation

TABLE 45-8
Mitotic Inhibitor and Etoposide Extravasation: Listed Specific Antidote
*Important: Administration of corticosteroids and topical cooling appear to worsen toxicity.

subcut, Subcutaneous.
Interactions
TABLE 45-9
Selected Mitotic Inhibitors and Etoposide: Common Drug Interactions
*Not all mechanisms for these drug interactions have been clearly identified.
CYP3A4, Cytochrome P-450 liver enzyme 3A4.
Alkaloid Topoisomerase II Inhibitors
Drug Profiles
Selected Mitotic Inhibitors and Etoposide
etoposide
Indications: Selected Mitotic Inhibitors and Etoposide
ALL, Acute lymphocytic leukemia; AML, acute myelocytic leukemia; HL, Hodgkin's lymphoma; NHL, non-Hodgkin's lymphoma.
paclitaxel
vincristine
Topoisomerase I Inhibitors
Indications
Adverse Effects
Interactions
TABLE 45-10
Irinotecan: Common Drug Interactions
*Note that not all mechanisms for these drug interactions have been clearly identified.
CYP2B6, Cytochrome P-450 liver enzyme 2B6; CYP3A4, cytochrome P-450 liver enzyme 3A4.
Drug Profiles
irinotecan
topotecan
Indications: Selected Topoisomerase I Inhibitors
Antineoplastic Enzymes
Indications
Adverse Effects
Interactions
TABLE 45-11
Selected Antineoplastic Enzymes: Common Drug Interactions
*Note that not all mechanisms for these drug interactions have been clearly identified.
Drug Profiles
asparaginase
pegaspargase
Indications: Selected Antineoplastic Enzymes
Nursing Process
Assessment
F, Female; M, male.
Box 45-2
Nursing Diagnoses

Implementation
Evaluation
Key Points
46
Cell-Cycle–Nonspecific and Miscellaneous Drugs
DRUG PROFILES
bevacizumab, p. 739
cisplatin, p. 737
cyclophosphamide, p. 737
doxorubicin, p. 738
hydroxyurea, p. 739
imatinib, p. 740
mechlorethamine, p. 737
mitotane, p. 740
mitoxantrone, p. 738
octreotide, p. 740
Objectives
KEY TERMS
Alkylation A chemical reaction in which an alkyl group is transferred from one molecule to another. In
chemotherapy, alkylation leads to damage of the cancer cell deoxyribonucleic acid (DNA) and cell death. (p. 735)
Bifunctional Referring to those alkylating drugs composed of molecules that have two reactive alkyl groups
and that are therefore able to alkylate at two sites on the DNA molecule. (p. 735)
Extravasation The leakage of any intravenously or intraarterially administered medication into the tissue
space surrounding the vein or artery. Such an event can cause serious tissue injury, especially with
antineoplastic drugs. (p. 736)
Polyfunctional Referring to the action of alkylating drugs that can engage in several alkylation reactions
with cancer cell DNA molecules per single molecule of drug. (p. 735)
Overview
Cell-Cycle–Nonspecific Antineoplastic Drugs
Alkylating Drugs
FIGURE 46-1 Organization of deoxyribonucleic acid (DNA) and site of action (*) of alkylating drugs.
Indications
TABLE 46-1
Indications: Selected Alkylating Drugs
HL, Hodgkin's lymphoma; NHL, non-Hodgkin's lymphoma.
Adverse Effects
TABLE 46-2
Commonly Used Alkylating Drugs: Severe Adverse Effects
*Carboplatin has less nephrotoxicity and neurotoxicity but more bone marrow suppression than cisplatin.
Box 46-1
TABLE 46-3
Alkylating Drug Extravasation: Specific Antidotes
Interactions
Drug Profiles
cisplatin
cyclophosphamide
mechlorethamine
Cytotoxic Antibiotics

Indications
TABLE 46-4
Indications: Selected Cytotoxic Antibiotics
HL, Hodgkin's lymphoma; NHL, non-Hodgkin's lymphoma.
Adverse Effects
TABLE 46-5
Cytotoxic Antibiotics: Severe Adverse Effects
Box 46-2
Interactions
Drug Profiles
doxorubicin
mitoxantrone
Miscellaneous Antineoplastics
Drug Profiles
bevacizumab
hydroxyurea
imatinib
mitotane
octreotide
Hormonal Antineoplastics
TABLE 46-6
Hormonal Antineoplastics: Adverse Effects
Nursing Process
Assessment
Box 46-3
Nursing Diagnoses
Implementation
Box 46-4
Evaluation
Key Points
47
DRUG PROFILES
abatacept, p. 762
adalimumab, p. 757
aldesleukin, p. 760
alemtuzumab, p. 758
anakinra, p. 760
belimumab, p. 758
bevacizumab, p. 758
certolizumab, p. 758
cetuximab, p. 758
etanercept, p. 762
filgrastim, p. 752
golimumab, p. 758
ibritumomab tiuxetan, p. 758
infliximab, p. 758
interferon alfa-2a, interferon alfa-2b, interferon alfa-n3, peginterferon alfa-2a, and peginterferon alfa-
2b, p. 754
interferon beta-1a, interferon beta-1b, p. 755
interferon gamma-1b, p. 755
leflunomide, p. 763
methotrexate, p. 763
natalizumab, p. 758
oprelvekin, p. 753
rituximab, p. 759
sargramostim, p. 753
ocilizumab, p. 760
tositumomab and iodine I-131 tositumomab, p. 759
rastuzumab, p. 759
Objectives
KEY TERMS
Adjuvant A nonspecific immunostimulant that enhances overall immune function, rather than stimulating
the function of a specific immune system cell. (p. 761)
Antibodies Immunoglobulin molecules (see Chapter 49) that have the ability to bind to and inactivate
antigen molecules through formation of an antigen-antibody complex. This process serves to inactivate foreign
antigens that enter the body. (p. 750)
Antigen A biologic or chemical substance that is recognized as foreign by the body's immune system. (p.
749)
Arthritis Inflammation of one or more joints. (p. 762)
Autoimmune disorder A disorder that occurs when the body's tissues are attacked by its own immune
system. (p. 761)
B lymphocytes (B cells) Leukocytes of the humoral immune system that develop into plasma cells, and
then produce the antibodies that bind to and inactivate antigens. B cells are one of the two principal types of
lymphocytes; T lymphocytes are the other. (p. 749)
Biologic response–modifying drugs A broad class of drugs that includes hematopoietic drugs and
immunomodulating drugs. Often referred to as biologic response modifiers (BRMs), they alter the body's
response to diseases such as cancer as well as autoimmune, inflammatory, and infectious diseases. Examples
are cytokines (e.g., interleukin, interferons), monoclonal antibodies, and vaccines. They are also called
biomodulators or immunomodulating drugs. Biologic response–modifying drugs may be adjuvants,
immunostimulants, or immunosuppressants. (p. 749)
Cell-mediated immunity Collective term for all immune responses that are mediated by T lymphocytes (T
cells). Also called cellular immunity. Cell-mediated immunity acts in collaboration with humoral immunity. (p. 749)
Colony-stimulating factors Cytokines that regulate the growth, differentiation, and function of bone
marrow stem cells. (p. 751)
Complement Collective term for about 20 different proteins normally present in plasma that assist other
immune system components (e.g., B cells and T cells) in mounting an immune response. (p. 759)
Cytokines The generic term for nonantibody proteins released by specific cell populations (e.g., activated T
cells) on contact with antigens. Cytokines act as intercellular mediators of an immune response. (p. 750)
Cytotoxic T cells Differentiated T cells that can recognize and lyse (rupture) target cells that have foreign
antigens on their surfaces. These antigens are recognized by the corresponding antigen receptors that are
expressed (displayed) on the cytotoxic T-cell surface. Also called natural killer cells. (p. 750)
Differentiation The process of cellular development from a simplified into a more specialized cellular
structure. In hematopoiesis, it refers to the multistep processes involved in the maturation of blood cells. (p. 751)
Disease-modifying antirheumatic drugs (DMARDs) Medications used in the treatment of rheumatic
diseases that have the potential to arrest or slow the actual disease process instead of providing only
antiinflammatory and analgesic effects. (p. 762)
Hematopoiesis Collective term for all of the body's processes originating in the bone marrow that result in
the formation of various types of blood components (adjective: hematopoietic). It includes the three main
processes of differentiation (see earlier): erythropoiesis (formation of red blood cells, or erythrocytes),
leukopoiesis (formation of white blood cells, or leukocytes), and thrombopoiesis (formation of platelets, or
thrombocytes). (p. 749)
Humoral immunity Collective term for all immune responses that are mediated by B cells, which ultimately
work through the production of antibodies against specific antigens. Humoral immunity acts in collaboration with
cell-mediated immunity. (p. 749)
Immunoglobulins Complex immune system glycoproteins that bind to and inactivate foreign antigens. The
term is synonymous with immune globulins. (p. 750)
Immunomodulating drugs Collective term for various subclasses of biologic response–modifying drugs
that specifically or nonspecifically enhance or reduce immune responses. The three major types of
immunomodulators, based on mechanism of action, are adjuvants, immunostimulants, and immunosuppressants
(see Chapter 48). (p. 749)
Immunostimulant A drug that enhances immune response through specific chemical interactions with
particular immune system components. An example is interleukin-2. (p. 761)
Immunosuppressant A drug that reduces immune response through specific chemical interactions with
particular immune system components. An example is cyclosporine (see Chapter 48). (p. 754)
Interferons One type of cytokine that promotes resistance to viral infection in uninfected cells and can also
strengthen the body's immune response to cancer cells. (p. 753)
Leukocytes The collective term for all subtypes of white blood cells. Leukocytes include the granulocytes
(neutrophils, eosinophils, and basophils), monocytes, and lymphocytes (B cells and T cells). Some monocytes
also develop into tissue macrophages. (p. 750)
Lymphokine-activated killer (LAK) cell Cytotoxic T cells that have been activated by interkeukin-2 and
therefore have a stronger and more specific response against cancer cells. (p. 759)
Lymphokines Cytokines that are produced by sensitized T lymphocytes on contact with antigen particles.
(p. 750)
Memory cells Cells involved in the humoral immune system that remember the exact characteristics of a
particular foreign invader or antigen for the purpose of expediting immune response in the event of future
exposure to this antigen. (p. 750)
Monoclonal Denoting a group of identical cells or organisms derived from a single cell. (p. 750)
Plasma cells Cells derived from B cells that are found in the bone marrow, connective tissue, and blood.
They produce antibodies. (p. 750)
Rheumatism General term for any of several disorders characterized by inflammation, degeneration, or
metabolic derangement of connective tissue structures, especially joints and related structures. (p. 761)
T helper cells Cells that promote and direct the actions of various other cells of the immune system. (p.
750)
T lymphocytes (T cells) Leukocytes of the cell-mediated immune system. Unlike B cells, they are not
involved in the production of antibodies but instead occur in various cell subtypes (e.g., T helper cells, T
suppressor cells, and cytotoxic T cells). They act through direct cell-to-cell contact or through production of
cytokines that guide the functions of other immune system components (e.g., B cells, antibodies). (p. 749)
T suppressor cells Cells that regulate and limit the immune response, balancing the effects of T helper
cells. (p. 750)
Tumor antigens Chemical compounds expressed on the surfaces of tumor cells. They signal to the
immune system that these cells do not belong in the body, labeling the tumor cells as foreign. (p. 749)
Overview of Immunomodulators
Immune System
Humoral Immune System

FIGURE 47-1 Cells of the humoral (antibody-mediated) immune system. Ig, Immunoglobulin.
Cell-Mediated Immune System

FIGURE 47-2 Cells of the cellular immune system.
Box 47-1
Hematopoietic Drugs
Indications
Contraindications
Adverse Effects
TABLE 47-1
Hematopoietic Drugs: Common Adverse Effects
Interactions
Dosages
DOSAGES
Hematopoietic Drugs
IL, Interleukin.
Drug Profiles
filgrastim
Pharmacokinetics: Filgrastim
sargramostim
Pharmacokinetics: Sargramostim
oprelvekin
Pharmacokinetics: Oprelvekin
Interferons
Indications
Contraindications
Adverse Effects
TABLE 47-2
Interferons: Adverse Effects
BUN, Blood urea nitrogen; ECG, electrocardiogram.
Interactions
Dosages
DOSAGES
Interferons
*May also be given by intravenous infusion for melanoma. Route and dose vary depending on indication.
†Dose is 1.5 mcg/kg/wk if given with ribavirin capsules (see Chapter 40).
BSA, body surface area.
Drug Profiles
Interferon Alfa Products
interferon alfa-2a, interferon alfa-2b, interferon alfa-n3, peginterferon alfa-2a, peginterferon alfa-2b
Interferon Beta Products
interferon beta-1a, interferon beta-1b
Interferon Gamma Product
interferon gamma-1b
Monoclonal Antibodies
Mechanism of Action, Drug Effects, and Indications
Contraindications
Adverse Effects
TABLE 47-3
Selected Immunomodulating Drugs: Common Adverse Effects
Interactions
Dosages
DOSAGES
Monoclonal Antibodies
MAB, Monoclonal antibody; RA, rheumatoid arthritis; TNF, tumor necrosis factor.
Drug Profiles
adalimumab
alemtuzumab
belimumab
bevacizumab
certolizumab
cetuximab
golimumab
ibritumomab
infliximab
natalizumab
rituximab
tositumomab and iodine I-131 tositumomab
trastuzumab
Interleukins and Related Drugs

Box 47-2
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
aldesleukin
anakinra
tocilizumab
DOSAGES
Interleukins and Related Drugs
IL, Interleukin.
Miscellaneous Immunomodulating Drugs
TABLE 47-4
Miscellaneous Immunomodulating Drugs
*An inflammatory reaction in the subcutaneous fat, often following a bacterial infection, or in reaction to drugs such as oral
contraceptives or sulfonamides.
BCG, Bacille Calmette-Guerin; MS, multiple sclerosis; RA, rheumatoid arthritis; SCID, severe combined immunodeficiency disease;
TNF, tumor necrosis factor.
Rheumatoid Arthritis
FIGURE 47-3 Areas of the body affected by rheumatoid arthritis. Rheumatoid arthritis is most frequently
seen in the shoulders, elbows, wrists, knees, and ankles, and it often affects the joints on both sides of the
body equally.
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs)

Box 47-3
Mechanism of Action, Indications, and Adverse Effects
Contraindications
Drug Profiles
abatacept
etanercept
leflunomide
methotrexate
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
48
DRUG PROFILES
azathioprine, p. 773
basiliximab, p. 773
cyclosporine, p. 773
glatiramer acetate, p. 775
muromonab-CD3, p. 776
mycophenolate mofetil, p. 776
sirolimus and tacrolimus, p. 776
Objectives
KEY TERMS
Autoimmune diseases A large group of diseases characterized by the alteration of the function of the
immune system so that the immune response is directed against normal tissue(s) of the body, which results in
pathologic conditions. (p. 770)
Grafts The term used for transplanted tissues or organs. (p. 773)
Immune-mediated diseases A large group of diseases that result when the cells of the immune system
react to a variety of situations, such as transplanted organ tissue or drug-altered cells. (p. 770)
Immunosuppressants Drugs that decrease or prevent an immune response. (p. 770)
Immunosuppressive therapy A drug treatment used to suppress the immune system. (p. 770)
Immune System
FIGURE 48-1 A simplified depiction of the complicated immune system. (From Patton KT, Thibodeau GA:
Anatomy and physiology, ed 7, St Louis, 2010, Mosby.)
Immunosuppressant Drugs
TABLE 48-1
Available Immunosuppressant Drugs: Mechanisms of Action and Indications
*Non–FDA-approved but under investigation.

†Note that “ab” in any drug name usually indicates that it is a monoclonal antibody synthesized using recombinant DNA technology.
FKBP-12, FK-binding protein 12; IL-2, interleukin-2; MS, multiple sclerosis; RRMS, relapsing-remitting multiple sclerosis.
Indications
Contraindications
Adverse Effects
TABLE 48-2
Selected Immunosuppressant Drugs: Common Adverse Effects
Interactions
TABLE 48-3
Immunosuppressant Drugs: Selected Drug Interactions
Dosages
Drug Profiles
azathioprine
Pharmacokinetics: Azathioprine
*6-8 weeks for rheumatoid arthritis.
basiliximab
Pharmacokinetics: Basiliximab
cyclosporine
DOSAGES
Selected Immunosuppressant Drugs
IV, Intravenous; PO, oral; RRMS, relapsing-remitting multiple sclerosis; subcut, subcutaneous.
Pharmacokinetics: Cyclosporine
glatiramer acetate
muromonab-CD3
Pharmacokinetics: Muromonab-CD3
mycophenolate mofetil
Pharmacokinetics: Mycophenolate
sirolimus and tacrolimus

Pharmacokinetics: Sirolimus
Pharmacokinetics: Tacrolimus
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
49
DRUG PROFILES
diphtheria and tetanus toxoids and acellular pertussis vaccine tetanus (adsorbed), p. 788
Haemophilus influenzae type b conjugate vaccine, p. 788
hepatitis B immunoglobulin, p. 791
hepatitis B virus vaccine (inactivated), p. 788
herpes zoster vaccine, p. 790
human papillomavirus vaccine, p. 790
immunoglobulin, p. 791
influenza virus vaccine, p. 789
measles, mumps, and rubella virus vaccine (live), p. 789
meningococcal vaccine, p. 789
pneumococcal vaccine, polyvalent and thirteen valent, p. 789
poliovirus vaccine (inactivated), p. 790
rabies immunoglobulin, p. 792
rabies virus vaccine, p. 790
Rh0(D) immunoglobulin, p. 791
tetanus immunoglobulin, p. 792
varicella virus vaccine, p. 791
varicella-zoster immunoglobulin, p. 792
Objectives
KEY TERMS
Active immunization A type of immunization that causes development of a complete and long-lasting
immunity to a certain infection through exposure of the body to the associated disease antigen; it can be natural
active immunization (i.e., having the disease) or artificial active immunization (i.e., receiving a vaccine or toxoid).
(p. 784)
Active immunizing drugs Toxoids or vaccines that are administered to a host to stimulate host production
of antibodies. (p. 786)
Antibodies Immunoglobulin molecules that have an antigen-specific amino acid sequence and are
synthesized by the humoral immune system (B cells) in response to exposure to a specific antigen. Their purpose
is to attack and destroy molecules of this antigen. (p. 784)
Antibody titer The amount of an antibody needed to react with and neutralize a given volume or amount of
a specific antigen. (p. 786)
Antigens Substances, usually proteins and foreign to a host, that stimulate the production of antibodies and
that react specifically with those antibodies. Examples of antigens include bacterial exotoxins and viruses. An
allergen (e.g., dust, pollen, mold) is an antigen that can produce an immediate-type hypersensitivity reaction or
allergy. (p. 783)
Antiserum A serum that contains antibodies. It is usually obtained from an animal that has been immunized
against a specific antigen. (p. 786)
Antitoxin An antiserum against a toxin (or toxoid). It is most often a purified antiserum obtained from
animals (usually horses) by injection of a toxin or toxoid so that antibodies to the toxin (i.e., antitoxin) can be
collected from the animals and used to provide artificial passive immunity to humans exposed to a given toxin
(e.g., tetanus immunoglobulin). (p. 786)
Antivenin An antiserum against a venom (poison produced by an animal) used to treat humans or other
animals that have been envenomed (e.g., by snakebite, spider bite, or scorpion sting). (p. 786)
Biologic antimicrobial drugs Substances of biologic origin used to prevent, treat, or cure infectious
diseases (e.g., vaccines, toxoids, immunoglobulins). These drugs are often simply referred to as biologics.
However, biologics also refers to drugs of bioterrorism (e.g., anthrax spores, smallpox virus), depending on the
context. (p. 784)
Booster shot A repeat dose of an antigen, such as a vaccine or toxoid, which is usually administered in an
amount smaller than that used in the original immunization. It is given to maintain the immune response of a
previously immunized patient at, or return the response to, a clinically effective level. (p. 786)
Cell-mediated immune system The immune response that is mediated by T cells (as opposed to B cells,
which produce antibodies). T cells mount their immune response through activities such as the release of
cytokines (chemicals that stimulate other protective immune functions) as well as through direct cytotoxicity (e.g.,
phagocytosis of an antigen). (p. 784)
Herd immunity Resistance to a disease on the part of an entire community or population because a large
proportion of its members are immune to the disease. (p. 786)
Immune response A cascade of biochemical events that occurs in response to entry of an antigen (foreign
substance) into the body; key processes of the immune response include phagocytosis (“eating of cells”) of
foreign microorganisms and synthesis of antibodies that react with specific antigens to inactivate them. Immune
response centers on the blood but may also involve the lymphatic system and the reticuloendothelial system (see
later). (p. 783)
Immunization The induction of immunity by administration of a vaccine or toxoid (active immunization) or
antiserum (passive immunization). (p. 784)
Immunizing biologics Toxoids, vaccines, or immunoglobulins that are targeted against specific infectious
microorganisms or toxins. (p. 784)
Immunoglobulins Glycoproteins synthesized and used by the humoral immune system (B cells) to attack
and kill all substances foreign to the body. The term is synonymous with immune globulins. (p. 784)
Passive immunization A type of immunization in which immunity to infection occurs by injecting a person
with antiserum or concentrated antibodies that directly give the host the means to fight off an invading
microorganism (artificial passive immunization). The host's immune system therefore does not have to
manufacture these antibodies. This process also occurs when antibodies pass from mother to infant during
breastfeeding or through the placenta during pregnancy (natural passive immunization). (p. 784)
Passive immunizing drugs Drugs containing antibodies or antitoxins that can kill or inactivate pathogens
by binding to the associated antigens. These are directly injected into a person (host) and provide that person
with the means to fend off infection, bypassing the host's own immune system. (p. 786)
Recombinant Relating to or containing a combination of genetic material from two or more organisms.
Such genetic recombination is one of the key methods of biotechnology and is often used to manufacture
immunizing drugs and various other medications. (p. 786)
Reticuloendothelial system Specialized cells located in the liver, spleen, lymphatics, and bone marrow
that remove miscellaneous particles from the circulation, such as aging antibody molecules. (p. 786)
Toxin Any poison produced by a plant, animal, or microorganism that is highly toxic to other living
organisms. (p. 784)
Toxoids Bacterial exotoxins that are modified or inactivated (by chemicals or heat) so that they are no
longer toxic but can still bind to host B cells to stimulate the formation of antitoxin; toxoids are often used in the
same manner as vaccines to promote artificial active immunity in humans. They are one type of active
immunizing drug (e.g., tetanus toxoid). (p. 784)
Vaccines Suspensions of live, attenuated, or killed microorganisms that can promote an artificially induced
active immunity against a particular microorganism. They are another type of active immunizing drug (e.g.,
tetanus vaccine). (p. 784)
Venom A poison that is secreted by an animal (e.g., snake, insect, or spider). (p. 786)
Immunity and Immunization
TABLE 49-1
Active versus Passive Immunization
Active Immunization
Toxoids
Vaccines
Box 49-1
Passive Immunization
Immunizing Drugs
Indications
Contraindications
Adverse Effects
TABLE 49-2
Immunizing Drugs: Minor and Severe Adverse Effects
Interactions
Dosages
Drug Profiles
Active Immunizing Drugs
diphtheria and tetanus toxoids and acellular pertussis vaccine (adsorbed)
Haemophilus Influenzae type b conjugate vaccine

hepatitis B virus vaccine (inactivated)
influenza virus vaccine

measles, mumps, and rubella virus vaccine (live)
meningococcal vaccine
pneumococcal vaccine, polyvalent and thirteen-valent

poliovirus vaccine (inactivated)
rabies virus vaccine
human papillomavirus vaccine
herpes zoster vaccine

varicella virus vaccine
Passive Immunizing Drugs
hepatitis B immunoglobulin
immunoglobulin
BOX 49-2
Rh0(D) immunoglobulin
rabies immunoglobulin
tetanus immunoglobulin
varicella-zoster immunoglobulin
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
PA R T 9
OUTLINE
Learning Strategies
50 Acid-Controlling Drugs
51 Bowel Disorder Drugs
52 Antiemetic and Antinausea Drugs
53 Vitamins and Minerals
54 Anemia Drugs
55 Nutritional Supplements
Studying for Tests
Test-Taking Strategies
Performance Evaluation
50
DRUG PROFILES
antacids, general, p. 804

cimetidine, p. 806
famotidine, p. 806
lansoprazole, p. 808
misoprostol, p. 808
omeprazole, p. 807
pantoprazole, p. 808
ranitidine, p. 806
simethicone, p. 809
sucralfate, p. 808
Objectives
KEY TERMS
Antacids Basic compounds composed of different combinations of acid-neutralizing ionic salts. (p. 803)
Chief cells Cells in the stomach that secrete the gastric enzyme pepsinogen (a precursor to pepsin). (p.
801)
Gastric glands Secretory glands in the stomach containing the following cell types: parietal, chief, mucous,
endocrine, and enterochromaffin. (p. 801)
Gastric hyperacidity The overproduction of stomach acid. (p. 800)
Hydrochloric acid (HCl) An acid secreted by the parietal cells in the lining of the stomach that maintains
the environment of the stomach at a pH of 1 to 4. (p. 801)
Mucous cells Cells whose function in the stomach is to secrete mucus that serves as a protective mucous
coat against the digestive properties of HCl. Also called surface epithelial cells. (p. 801)
Parietal cells Cells in the stomach that produce and secrete HCl. These cells are the primary site of action
for many of the drugs used to treat acid-related disorders. (p. 801)
Pepsin An enzyme in the stomach that breaks down proteins. (p. 801)
Overview
Acid-Related Pathophysiology
FIGURE 50-1 The three zones of the stomach and the associated glands.
FIGURE 50-2 Parietal cell stimulation and secretion. ADP, Adenosine diphosphate; ATP, adenosine
triphosphate; ATPase, adenosine triphosphatase; cAMP, cyclic adenosine monophosphate.
Antacids
Indications
Contraindications
Adverse Effects
Box 50-1
Interactions
TABLE 50-1
Antacids: Drug Interactions
Dosages
Drug Profiles
antacids, general
DOSAGES
Selected Antacid Drugs*
*Many more antacid products are available on the market than appear in this table. Dosages given are approximate dosages of active
ingredients; there may be variations among different products and different dosage forms of the same product.
Box 50-2
H2 Receptor Antagonists
Indications
Contraindications
Adverse Effects
TABLE 50-2
H2 Receptor Antagonists: Adverse Effects
Interactions
DOSAGES
Selected H2 Receptor Antagonists
GERD, Gastroesophageal reflux disease.
Dosages
Drug Profiles
cimetidine
Pharmacokinetics: Cimetidine
ranitidine
Pharmacokinetics: Ranitidine
famotidine
Pharmacokinetics: Famotidine
Proton Pump Inhibitors
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
omeprazole
Pharmacokinetics: Omeprazole
lansoprazole
Pharmacokinetics: Lansoprazole
pantoprazole
Pharmacokinetics: Pantoprazole
DOSAGES
Selected Proton Pump Inhibitors
GERD, Gastroesophageal reflux disease.

Miscellaneous Acid-Controlling Drugs
Drug Profiles
sucralfate
misoprostol
Pharmacokinetics: Misoprostol
simethicone
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
51
DRUG PROFILES
belladonna alkaloid combinations, p. 816

bisacodyl, p. 822
bismuth subsalicylate, p. 816
diphenoxylate with atropine, p. 816
docusate salts, p. 821
glycerin, p. 821
Lactobacillus, p. 817
lactulose, p. 822
loperamide, p. 816
magnesium salts, p. 822
methylcellulose, p. 820
mineral oil, p. 821
polyethylene glycol 3350, p. 822
psyllium, p. 820
senna, p. 822
Objectives
KEY TERMS
Antidiarrheal drugs Drugs that counter or combat diarrhea. (p. 815)
Constipation A condition of abnormally infrequent and difficult passage of feces through the lower
gastrointestinal tract. (p. 818)
Diarrhea The abnormally frequent passage of loose stools. (p. 814)
Irritable bowel syndrome (IBS) A recurring condition of the intestinal tract characterized by bloating,
flatulence, and often periods of diarrhea that alternate with periods of constipation. (p. 822)
Laxatives Drugs that promote bowel evacuation, such as by increasing the bulk of the feces, softening the
stool, or lubricating the intestinal wall. (p. 818)
Overview
Antidiarrheals
TABLE 51-1
Antidiarrheals: Drug Categories and Selected Drugs
Indications
Contraindications
Adverse Effects
TABLE 51-2
Selected Antidiarrheals: Adverse Effects
Interactions
Dosages
Drug Profiles
Adsorbents
bismuth subsalicylate
Anticholinergics
belladonna alkaloid combinations
Opiates
diphenoxylate with atropine
DOSAGES
Selected Antidiarrheal Drugs
loperamide
Probiotics
Lactobacillus
Laxatives
TABLE 51-3
Causes of Constipation
FIGURE 51-1 The digestive system. (From Patton KT, Thibodeau GA: Mosby's handbook of anatomy and physiology, St
Louis, 2010, Mosby.)
TABLE 51-4
Laxatives: Drug Categories and Selected Drugs
TABLE 51-5
Laxatives: Drug Effects
Indications
TABLE 51-6
Laxatives: Indications
Contraindications
Adverse Effects
TABLE 51-7
Laxatives: Adverse Effects
Interactions
Dosages
Drug Profiles
Bulk-Forming Laxatives
methylcellulose
DOSAGES
Selected Laxatives
*Docusate sodium is available in both capsule and liquid forms. Docusate calcium is available in capsule form only.
†Rectal route is sometimes used to reverse certain types of coma.
‡Many dosage forms; consult product labeling if in doubt. Most common dosage forms are 8.6-mg sennosides in tablet form and
8.8 mg/5 mL of sennosides in liquid form.
BM, Bowel movement; PR, per rectum.
psyllium
Emollient Laxatives
docusate salts
mineral oil
Hyperosmotic Laxatives
glycerin
lactulose
polyethylene glycol 3350

Saline Laxatives
Box 51-1
magnesium salts
Stimulant Laxatives
bisacodyl
senna
Drugs for Irritable Bowel Syndrome
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
52
DRUG PROFILES
aprepitant, p. 834
dronabinol, p. 834
meclizine, p. 833
metoclopramide, p. 834
ondansetron, p. 834
phosphorated carbohydrate solution, p. 835
prochlorperazine, p. 833
promethazine, p. 833
scopolamine, p. 833
Objectives
KEY TERMS
Antiemetic drugs Drugs given to relieve nausea and vomiting. (p. 829)
Chemoreceptor trigger zone (CTZ) The area of the brain that is involved in the sensation of nausea and
the action of vomiting. (p. 828)
Emesis The forcible emptying or expulsion of gastric and, occasionally, intestinal contents through the
mouth; also called vomiting. (p. 828)
Nausea Sensation often leading to the urge to vomit. (p. 828)
Vomiting center The area of the brain that is involved in stimulating the physiologic events that lead to
nausea and vomiting. (p. 828)
Nausea and Vomiting
TABLE 52-1
Neurotransmitters Involved in Nausea and Vomiting
CTZ, Chemoreceptor trigger zone; ACh, acetylcholine receptor; D2, dopamine 2 receptor; H1, histamine 1 receptor; 5-HT3, 5-
hydroxytriptamine 3 receptor; VC, vomiting center.
FIGURE 52-1 Various pathways and areas in the body sending signals to the vomiting center.
Antiemetic Drugs
TABLE 52-2
Antiemetic Drugs: Common Drug Categories and Indications
FIGURE 52-2 Sites of action of selected antinausea drugs. THC, Tetrahydrocannabinol.

TABLE 52-3
Antiemetic Drugs: Mechanisms of Action
ACh, Acetylcholine; CTZ, chemoreceptor trigger zone; VC, vomiting center.
Anticholinergic Drugs
Antihistamines
Antidopaminergic Drugs
Neurokinin Blockers
Prokinetic Drugs
Serotonin Blockers
Tetrahydrocannabinoids
Indications
Contraindications
Adverse Effects
TABLE 52-4
Antinausea Drugs: Adverse Effects
Interactions
Dosages
Drug Profiles
DOSAGES
Selected Antiemetic and Antinausea Drugs
Anticholinergic
scopolamine
Pharmacokinetics: Scopolamine (Transderm-Scōp, Scopace)
Antihistamines
meclizine
Pharmacokinetics: Meclizine
Antidopaminergics
prochlorperazine
Pharmacokinetics: Prochlorperazine
promethazine
Pharmacokinetics: Promethazine
Neurokinin Receptor Antagonists
aprepitant
Pharmacokinetics: Aprepitant
Prokinetic
metoclopramide
Pharmacokinetics: Metoclopramide
Serotonin Blockers
ondansetron
Pharmacokinetics: Ondansetron
Tetrahydrocannabinoid
dronabinol
Pharmacokinetics: Dronabinol
Miscellaneous Antinausea Drugs
phosphorated carbohydrate solution

Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
53
DRUG PROFILES
ascorbic acid (vitamin C), p. 853

calcifediol (vitamin D3), p. 846
calcitriol (vitamin D3), p. 846
calcium, p. 853
cyanocobalamin (vitamin B12), p. 852
ergocalciferol (vitamin D2), p. 846
magnesium, p. 855
niacin (vitamin B3), p. 850
phosphorus, p. 856
pyridoxine (vitamin B6), p. 851
riboflavin (vitamin B2), p. 849
thiamine (vitamin B1), p. 848
vitamin A, p. 844
vitamin E, p. 847
vitamin K1, p. 847
Objectives
KEY TERMS
Beriberi A disease of the peripheral nerves caused by a dietary deficiency of thiamine (vitamin B1).
Symptoms include fatigue, diarrhea, weight loss, edema, heart failure, and disturbed nerve function. (p. 848)
Coenzyme A nonprotein substance that combines with a protein molecule to form an active enzyme. (p.
841)
Enzymes Specialized proteins that catalyze biochemical reactions. (p. 841)
Fat-soluble vitamins Vitamins that can be dissolved (i.e., are soluble) in fat. (p. 841)
Minerals Inorganic substances that are ingested and attach to enzymes or other organic molecules. (p.
841)
Pellagra A disease resulting from a deficiency of niacin or a metabolic defect that interferes with the
conversion of tryptophan to niacin (vitamin B3). (p. 848)
Rhodopsin The purple pigment in the rods of the retina, formed by a protein, opsin, and a derivative of
retinol (vitamin A). (p. 842)
Rickets A condition caused by a deficiency of vitamin D. (p. 845)
Scurvy A condition resulting from a deficiency of ascorbic acid (vitamin C). (p. 852)
Tocopherols Biologically active chemicals that make up vitamin E compounds. (p. 846)
Vitamins Organic compounds essential in small quantities for normal physiologic and metabolic functioning
of the body. (p. 841)
Water-soluble vitamins Vitamins that can be dissolved (i.e., are soluble) in water. (p. 841)
Overview
TABLE 53-1
Fat-Soluble and Water-Soluble Vitamins
FAT-SOLUBLE WATER-SOLUBLE
Fat-Soluble Vitamins
Vitamin A
TABLE 53-2
Food Sources for Selected Nutrients
Adapted from USDA: Dietary guidelines for Americans, 2010. Available at http://health.gov/dietaryguidelines. Accessed March 1, 2015.
Indications
Contraindications
Adverse Effects
TABLE 53-3
Vitamin A: Adverse Effects
Interactions
Dosages
DOSAGES
Selected Vitamins
*Dosages are individualized. Higher doses may be required based on response to therapy.
Drug Profile
vitamin A
Pharmacokinetics: Vitamin A
Vitamin D
Indications
Contraindications
Adverse Effects
TABLE 53-4
Vitamin D: Adverse Effects
Interactions
Dosages
Drug Profiles
calcifediol
calcitriol
Pharmacokinetics: Calcitriol
ergocalciferol
Pharmacokinetics: Ergocalciferol, Vitamin D2
Vitamin E
Indications
Contraindications
Adverse Effects
TABLE 53-5
Vitamin E: Adverse Effects
Dosages
Drug Profile
vitamin E
Vitamin K
Indications
Contraindications
Adverse Effects
TABLE 53-6
Vitamin K: Adverse Effects
Dosages
Drug Profile
vitamin K1
Pharmacokinetics: Vitamin K1
Water-Soluble Vitamins
Box 53-1
Vitamin B1

Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
thiamine
Pharmacokinetics: Thiamine
Vitamin B2
Indications
Contraindications
Adverse Effects
Dosages
Drug Profile
riboflavin
Pharmacokinetics: Riboflavin
Vitamin B3

FIGURE 53-1 Niacin, once in the body, is converted to nicotinamide adenosine dinucleotide (NAD) and
nicotinamide adenosine dinucleotide (NADP), which are coenzymes needed for many metabolic
processes.
Indications
Contraindications
Adverse Effects
TABLE 53-7
Niacin (Vitamin B3): Adverse Effects
Dosages
Drug Profile
niacin
Pharmacokinetics (Niacin, Vitamin B3)
Vitamin B6
Indications
Contraindications
Adverse Effects
TABLE 53-8
Pyridoxine (Vitamin B6): Adverse Effects
Interactions
Dosages
Drug Profile
pyridoxine
Pharmacokinetics: Pyridoxine
Vitamin B12
FIGURE 53-2 Cyanocobalamin is a required coenzyme for many body processes.

FIGURE 53-3 Oral absorption of cyanocobalamin requires the presence of intrinsic factor, which is
secreted by gastric parietal cells.
Indications
Contraindications
Adverse Effects
TABLE 53-9
Cyanocobalamin (Vitamin B12): Adverse Effects
Interactions
Dosages
Drug Profile
cyanocobalamin
Pharmacokinetics: Cyanocobalamin, Vitamin B12
Vitamin C
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
ascorbic acid
Minerals
FIGURE 53-4 When mineral compounds are dissolved in water, they separate into positively charged
metallic cations or negatively charged nonmetallic anions.
TABLE 53-10
Mineral Elements
*Mineral elements that have a current recommended daily allowance (RDA).
Calcium
TABLE 53-11
Calcium Deficiency: Causes and Disorders

Indications
TABLE 53-12
Calcium Salts: Calcium Content
*Most commonly used forms for the prevention of osteoporosis.
Contraindications
Adverse Effects
TABLE 53-13
Calcium Salts: Adverse Effects
Interactions
Dosages
Drug Profile
calcium
Magnesium
DOSAGES
Selected Minerals
Indications
Contraindications
Adverse Effects

Interactions
Drug Profile
magnesium
Phosphorus
Indications
Contraindications
Adverse Effects
Interactions
Drug Profile
phosphorus
Zinc
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
54
DRUG PROFILES
epoetin alfa, p. 863

ferric gluconate, p. 866
ferrous fumarate, p. 866
ferrous sulfate, p. 866
folic acid, p. 866
iron dextran, p. 866
iron sucrose, p. 866
Objectives
KEY TERMS
Erythrocytes Another name for red blood cells (RBCs). (p. 861)
Erythropoiesis The process of erythrocyte production. (p. 861)
Globin The protein part of the hemoglobin molecule (see later); the four different structural globin chains
most often found in adults are the alpha1, alpha2, beta1, and beta2 chains. (p. 862)
Hematopoiesis The normal formation and development of all blood cell types in the bone marrow. (p. 861)
Heme Part of the hemoglobin molecule; a nonprotein, iron-containing pigment. (p. 862)
Hemoglobin A complex protein-iron compound in the blood that carries oxygen to the cells from the lungs
and carbon dioxide away from the cells to the lungs. (p. 862)
Hemolytic anemias Anemias resulting from excessive destruction of erythrocytes. (p. 863)
Hypochromic Pertaining to less than normal color. The term usually describes an RBC with decreased
hemoglobin content and helps further characterize anemias associated with reduced synthesis of hemoglobin. (p.
862)
Microcytic Pertaining to or characterized by smaller than normal cells. (p. 862)
Pernicious anemia A type of megaloblastic anemia usually seen in older adults and caused by impaired
intestinal absorption of vitamin B12 (cyanocobalamin) due to lack of availability of intrinsic factor. (p. 863)
Reticulocytes An immature erythrocyte characterized by a meshlike pattern of threads and particles at the
former site of the nucleus. (p. 862)
Spherocytes Small, globular, completely hemoglobinated erythrocytes without the usual central concavity
or pallor. (p. 863)
Erythropoiesis
FIGURE 54-1 Schematic structure of a hemoglobin molecule.

Types of Anemia
FIGURE 54-2 Underlying causes of anemia are red blood cell (RBC) maturation defects and factors
secondary to excessive RBC destruction.
FIGURE 54-3 Schematic showing common causes and results of red blood cell (RBC) cytoplasmic
maturation defects. ↓, Decreased.
FIGURE 54-4 Schematic showing common causes and results of red blood cell (RBC) nuclear
maturation defects.
FIGURE 54-5 Increased red blood cell (RBC) destruction occurs as a result of intrinsic and extrinsic
factors. ↑, Increased; DIC, disseminated intravascular coagulation; G6PD, glucose-6-phosphate
dehydrogenase.
Erythropoiesis-Stimulating Drugs
Drug Profiles
epoetin alfa
Pharmacokinetics: Epoetin Alfa

Iron
TABLE 54-1
Ferrous Salts: Iron Content
*Some patients may tolerate different formulations better; however, the number of tablets that must be consumed may decrease patient
adherence.
Indications
Contraindications
Adverse Effects
TABLE 54-2
Iron Preparations: Adverse Effects
Interactions
DOSAGES
Selected Anemia Drugs
*Doses are expressed in terms of elemental iron, not the salt itself.
†Expressed in milligrams of elemental iron. Dosages are calculated for each patient's weight according to manufacturer's label. Doses
are approximate.
Dosages
Drug Profiles
ferrous fumarate
Pharmacokinetics: Ferrous Fumarate
ferrous sulfate
Pharmacokinetics: Ferrous Sulfate
iron dextran
Pharmacokinetics: Iron Dextran
ferric gluconate
Pharmacokinetics: Ferric Gluconate

iron sucrose
Pharmacokinetics: Iron Sucrose

Folic Acid
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
folic acid
Pharmacokinetics: Folic Acid
Other Anemia Drugs
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
55
DRUG PROFILES
amino acids, p. 876

carbohydrate formulation, p. 874
carbohydrates, p. 877
fat formulation, p. 874
lipid emulsions, p. 877
protein formulation, p. 874
Objectives
KEY TERMS
Anabolism Metabolism characterized by the conversion of simple substances into the more complex
compounds; tissue building. (p. 872)
Casein The principal protein of milk and the basis for curd and cheese. (p. 874)
Catabolism A complex metabolic process in which energy is liberated for use in work, energy storage, or
heat production by the destruction of complex substances to form simple compounds. (p. 876)
Dumping syndrome A complex reaction to the rapid entry of concentrated nutrients into the jejunum of the
small intestine. The patient may experience nausea, weakness, sweating, palpitations, syncope, sensations of
warmth, and diarrhea. Most commonly occurs with eating following partial gastrectomy or with enteral feedings
that are administered too rapidly into the stomach or jejunum via a feeding tube. (p. 873)
Enteral nutrition The provision of food or nutrients via the gastrointestinal tract, either naturally by eating or
through a feeding tube in patients who are unable to eat. (p. 872)
Essential amino acids Those amino acids that cannot be manufactured by the body. (p. 876)
Essential fatty acid deficiency A condition that develops if fatty acids that the body cannot produce are
not present in dietary or nutritional supplements. (p. 877)
Hyperalimentation An older term for parenteral nutrition; its use is now discouraged because it may be
misinterpreted to mean overfeeding; now referred to as total parenteral nutrition (TPN). (p. 875)
Malnutrition Any disorder of undernutrition. (p. 872)
Multivitamin infusion (MVI) A concentrated solution that contains several water- and fat-soluble vitamins
and is used as part of an intravenous (parenteral) nutrition source. (p. 877)
Nonessential amino acids Those amino acids that the body can produce without extracting them from
dietary intake. (p. 876)
Nutrients Substances that provide nourishment and affect the nutritive and metabolic processes of the
body. (p. 872)
Nutritional supplements Oral, enteral, or intravenous nutritional preparations used to provide optimal
nutrients to meet the body's nutritional needs. (p. 872)
Nutritional support The provision of nutrients orally, enterally, or parenterally for therapeutic reasons. (p.
872)
Parenteral nutrition The administration of nutrients by a route other than through the alimentary canal,
such as intravenously. (p. 872)
Semiessential amino acids Those amino acids that can be produced by the body but not in sufficient
amounts in infants and children. (p. 876)
Total parenteral nutrition (TPN) The intravenous administration of the total nutrient requirements of the
patient with gastrointestinal dysfunction, accomplished via peripheral or central venous catheter. (p. 875)
Whey The thin serum of milk remaining after the casein and fat have been removed. It contains proteins,
lactose, water-soluble vitamins, and minerals. (p. 874)
Overview
Enteral Nutrition
FIGURE 55-1 Tube feeding routes. (From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing:
assessment and management of clinical problems, ed 9, St Louis, 2014, Mosby.)
TABLE 55-1
Routes of Enteral Nutrition Delivery
Box 55-1
Indications
Box 55-2
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
Elemental Formulations
Polymeric Formulations
Modular Formulations
carbohydrate formulation
fat formulation
protein formulation
Altered Amino Acid Formulations

Parenteral Nutrition
TABLE 55-2
Peripheral and Central Parenteral Nutrition: Characteristics
*Many institutions use a maximum of 12.5% dextrose.
Peripheral Total Parenteral Nutrition
Indications
Contraindications
Adverse Effects
Central Total Parenteral Nutrition
Indications
Contraindications
Adverse Effects
Dosages
TABLE 55-3
Amino Acids: Recommended Adult Daily Dosage Guidelines
Drug Profiles
Amino Acids
Box 55-3
amino acids
Carbohydrates
FIGURE 55-2 One gram of dextrose, fat, or protein will provide varying amounts of energy as calories.
Fat
FIGURE 55-3 Lipid emulsions supply essential fatty acids and energy.
lipid emulsions
Trace Elements
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation

Key Points
PA R T 1 0
OUTLINE
Learning Strategies
56 Dermatologic Drugs
57 Ophthalmic Drugs
58 Otic Drugs
Future Application
56
DRUG PROFILES
anthralin, p. 892
bacitracin, p. 887
benzoyl peroxide, p. 888
calcipotriene, p. 892
clindamycin, p. 888
clotrimazole, p. 889
fluorouracil, p. 894
imiquimod, p. 894
isotretinoin, p. 888
lindane, p. 893
miconazole, p. 890
minoxidil, p. 893
mupirocin, p. 887
neomycin and polymyxin B, p. 887
pimecrolimus, p. 894
silver sulfadiazine, p. 888
tar-containing products, p. 892
tazarotene, p. 892
tretinoin, p. 889
Objectives
KEY TERMS
Acne vulgaris A chronic inflammatory disease of the pilosebaceous glands of the skin, involving lesions
such as papules and pustules (“pimples” or “comedones”); referred to in this chapter as acne. (p. 888)
Actinic keratosis A slowly developing, localized thickening of the outer layers of the skin resulting from
long-term, prolonged exposure to the sun; also called solar keratosis. (p. 894)
Atopic dermatitis A chronic skin inflammation seen in patients with hereditary susceptibility. (p. 886)
Basal cell carcinoma The most common form of skin cancer; it arises from epidermal cells known as basal
cells and is rarely metastatic. (p. 886)
Carbuncles Necrotizing infections of skin and subcutaneous tissue caused by multiple furuncles (boils).
They are usually caused by the bacterium Staphylococcus aureus. (p. 887)
Cellulitis An acute, diffuse, spreading infection involving the skin, subcutaneous tissue, and sometimes
muscle as well. It is usually caused by infection of a wound with Streptococcus or Staphylococcus species. (p.
887)
Dermatitis Any inflammation of the skin. (p. 886)
Dermatophytes Any of the common groups of fungi that infect skin, hair, and nails. These fungi are most
commonly from the genera Microsporum, Epidermophyton, and Trichophyton. (p. 889)
Dermatosis The general term for any abnormal skin condition. (p. 886)
Dermis The layer of the skin just below the epidermis, consisting of papillary and reticular layers and
containing blood and lymphatic vessels, nerves and nerve endings, glands, and hair follicles. (p. 885)
Eczema A pruritic, papulovesicular dermatitis occurring as a reaction to many endogenous and exogenous
agents, and characterized by erythema, edema, and an inflammatory infiltrate of the dermis accompanied by
oozing, crusting, and scaling. (p. 886)
Epidermis The superficial, avascular layers of the skin, made up of an outer dead, cornified portion and a
deeper living, cellular portion. (p. 885)
Folliculitis Inflammation of a follicle, usually a hair follicle. A follicle is defined as any sac or pouchlike
cavity. (p. 887)
Furuncles Painful skin nodules caused by Staphylococcus organisms that enter the skin through the hair
follicles; also called a boil. (p. 887)
Impetigo A pus-generating, contagious superficial skin infection, usually caused by Staphylococci or
Streptococci. It generally occurs on the face and is most commonly seen in children; may be recognized by
honey-colored crusts. (p. 887)
Papules Small, circumscribed, superficial, solid elevations of the skin that are usually pink and less than 0.5
to 1 cm in diameter. (p. 887)
Pediculosis An infestation with lice of the family Pediculidae. (p. 892)
Pruritus An unpleasant cutaneous sensation that provokes the desire to rub or scratch the skin to obtain
relief. (p. 889)
Psoriasis A common, chronic squamous cell dermatosis with polygenic (multigene) inheritance and a
fluctuating pattern of recurrence and remission. (p. 886)
Pustules Visible collections of pus within or beneath the epidermis. (p. 887)
Scabies A contagious disease caused by Sarcoptes scabiei, the itch mite, characterized by intense itching
of the skin and injury to the skin (excoriation) resulting from scratching. (p. 893)
Tinea A fungal skin disease caused by a dermatophyte and characterized by itching, scaling, and,
sometimes, painful lesions. Tinea is a general term for an infection with any of various dermatophytes that occur
at several sites; also called ringworm. (p. 889)
Topical antimicrobials Substances applied to any surface that either kill microorganisms or inhibit their
growth or replication. (p. 887)
Vesicles Small sacs containing liquid; also called cysts. (p. 887)
Overview
FIGURE 56-1 Microscopic view of the skin. The epidermis, shown in longitudinal section, is raised at one
corner to reveal the ridges in the dermis. (Modified from Thibodeau GA, Patton KT: Anatomy and physiology, ed 5, St
Louis, 2003, Mosby.)
TABLE 56-1
Epidermal Layers
TABLE 56-2
Exocrine Glands of the Skin
TABLE 56-3
Dermatologic Formulations: Characteristics and Examples
Antimicrobials
General Antibacterial Drugs
Drug Profiles
bacitracin
neomycin and polymyxin B
mupirocin
silver sulfadiazine
Antiacne Drugs
Drug Profiles
benzoyl peroxide
clindamycin
isotretinoin
tretinoin
Antifungal Drugs
TABLE 56-4
Topical Antifungal Drugs
OTC, Available over the counter without prescription; Rx, currently available by prescription only.
Drug Profiles
clotrimazole
miconazole
Antiviral Drugs
Anesthetic, Antipruritic, and Antipsoriatic Drugs
Topical Anesthetics
Topical Antipruritics and Antiinflammatories
TABLE 56-5
Commonly Used Topical Corticosteroids (in Order of Decreasing Potency)
*Skin penetration and thus potency is enhanced by the vehicle (dosage form) containing the steroid. In decreasing order of effectiveness
are ointments, gels, creams, and lotions.
Antipsoriatic Drugs
Drug Profiles
tazarotene
tar-containing products
anthralin
calcipotriene
Miscellaneous Dermatologic Drugs
Drug Profiles
Ectoparasiticidal Drugs
lindane
Hair Growth Drugs
minoxidil
Sunscreens
Antineoplastic Drugs
fluorouracil
Immunomodulators
pimecrolimus
imiquimod
Wound Care Drugs
TABLE 56-6
Selected Wound Care Products
Skin Preparation Drugs
TABLE 56-7
Skin Preparation Drugs (Antiseptics)
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation

Key Points
57
DRUG PROFILES
acetylcholine, p. 907
apraclonidine, p. 908
artificial tears, p. 917
atropine sulfate, p. 916
bacitracin, p. 914
betaxolol, p. 909
ciprofloxacin, p. 914
cromolyn, p. 917
cyclopentolate, p. 916
dexamethasone, p. 915
dipivefrin, p. 908
dorzolamide, p. 910
echothiophate, p. 907
erythromycin, p. 913
fluorescein, p. 916
flurbiprofen, p. 915
gentamicin, p. 913
glycerin, p. 911
ketorolac, p. 915
latanoprost, p. 912
mannitol, p. 911
natamycin, p. 914
olopatadine, p. 917
pilocarpine, p. 907
sulfacetamide, p. 914
tetracaine, p. 916
tetrahydrozoline, p. 917
timolol, p. 909
trifluridine, p. 914
Objectives
KEY TERMS
Accommodation The adjustment of the lens of the eye for variations in distance. (p. 903)
Angle-closure glaucoma Glaucoma that occurs as a result of a narrowed anatomic angle between the lens
and cornea. Also called closed-angle glaucoma, narrow-angle glaucoma, congestive glaucoma, and pupillary
closure glaucoma. (p. 904)
Anterior chamber The bubble-like portion of the front of the eye between the iris and the cornea. (p. 903)
Aqueous humor The clear, watery fluid circulating in the anterior and posterior chambers of the eye. (p.
903)
Canal of Schlemm A tiny circular vein at the angle of the anterior chamber of the eye through which the
aqueous humor is drained and ultimately funneled into the bloodstream. Also called Schlemm canal. (p. 903)
Cataract An abnormal progressive condition of the lens of the eye, characterized by loss of transparency
with resultant blurred vision. (p. 903)
Ciliary muscle The circular muscle between the anterior and posterior chambers of the eye behind the iris.
It is connected to the suspensory ligaments that control the curvature of the lens. (p. 903)
Cones Photoreceptive (light-receiving) cells in the retina of the eye that enable a person to perceive colors
and play a large role in central (straight-ahead) vision. (p. 903)
Cornea The convex, transparent anterior part of the eye. (p. 902)
Cycloplegia Paralysis of the ciliary muscles, which prevents the accommodation of the lens for variations in
distance. (p. 903)
Cycloplegics Drugs that paralyze the ciliary muscles of the eye. (p. 903)
Dilator muscle A muscle that constricts the iris of the eye but dilates the pupil. Also called dilator pupillae.
(p. 903)
Glaucoma An abnormal condition of elevated pressure within an eye because of obstruction of the outflow
of aqueous humor. (p. 903)
Intraocular pressure The pressure of the fluids of the eye against the tunics (retina, choroid, and sclera).
(p. 903)
Iris The round, muscular portion of the eye that gives the eye its color and serves as an aperture controlling
the amount of light passing through the pupil. (p. 903)
Lacrimal ducts Small tubes that drain tears from the lacrimal glands into the nasal cavity. (p. 902)
Lacrimal glands Glands located at the medial corners of the eyelids that produce tears. (p. 902)
Lens The transparent, curved structure of the eye that is located directly behind the iris and the pupil and is
attached to the ciliary body by ligaments. (p. 903)
Lysozyme An enzyme with antiseptic actions that destroys some foreign organisms. It is normally present
in tears, saliva, sweat, and breast milk. (p. 902)
Miotics Drugs that constrict the pupil. (p. 903)
Mydriatics Drugs that dilate the pupil. (p. 903)
Open-angle glaucoma A type of glaucoma that is often bilateral, develops slowly, is genetically
determined, and does not involve a narrowing of the angle between the iris and the cornea. (Also called chronic
glaucoma, wide-angle glaucoma, and simple glaucoma.) (p. 904)
Optic nerve A major nerve that connects the posterior end of each eye to the brain, to which it transmits
visual signals. (p. 903)
Pupil A circular opening in the iris of the eye, located slightly to the nasal side of the center of the iris. The
pupil lies behind the anterior chamber of the eye and the cornea and in front of the lens. (p. 903)
Retina The innermost layer of the eye, containing both rods and cones that receive visual stimuli and
transmit them to the optic nerve. (p. 903)
Rods The photoreceptive elements arranged perpendicularly to the surface of the retina. Rods are
especially sensitive to low-intensity light and are responsible for black-and-white and peripheral (“off-to-the-side”)
vision. (p. 903)
Sphincter pupillae A muscle that expands the iris while constricting or narrowing the diameter of the pupil.
(p. 903)
Tears Watery saline or alkaline fluid secreted by the lacrimal glands to moisten the conjunctiva (see Figure
57-1). (p. 902)
Uvea The fibrous tunic beneath the sclera that includes the iris, the ciliary body, and the choroid of the eye
(see Figure 57-1). Also called tunica vasculosa bulbi or uveal tract. (p. 903)
Vitreous body A transparent, semigelatinous substance contained in a thin membrane filling the cavity
behind the lens. Also called the corpus vitreum. (p. 903)
Vitreous humor The fluid component of the vitreous body. (p. 903)
Overview
FIGURE 57-1 Horizontal section through the left eyeball, looking from the top down. (Modified from Patton
KT, Thibodeau GA: Anatomy and physiology, ed 7, St Louis, 2010, Mosby.)
FIGURE 57-2 Extrinsic muscles of the right eye, lateral view. The medial rectus muscle is hidden from
view in this figure but is directly across from the lateral rectus muscle. (Modified from Patton KT, Thibodeau GA:
Anatomy and physiology, ed 7, St Louis, 2010, Mosby.)
Lacrimal Glands
Layers of the Eye

FIGURE 57-3 Different nervous systems control pupil size.
FIGURE 57-4 Drug classes and their effects on pupil size.

FIGURE 57-5 Function of rods and cones in relation to color vision.
Pathophysiology of Glaucoma
FIGURE 57-6 How increased aqueous humor can result in impaired vision. IOP, Intraocular pressure.
FIGURE 57-7 Main structures of the eye and an enlargement of the canal of Schlemm showing the flow
of aqueous humor. A, Flow in a normal eye. B, In angle-closure glaucoma, the closure of the anterior angle
due to contact between the iris and the trabecular meshwork prevents aqueous humor from exiting through
the canal of Schlemm, which leads to increased intraocular pressure. C, In open-angle glaucoma, the
anterior angle remains open, but the canal of Schlemm is obstructed by tissue abnormalities. (Modified from
McKenry LM, Tessier E, Hogan MA: Mosby's pharmacology in nursing, ed 22, St Louis, 2006, Mosby.)
TABLE 57-1
Glaucoma: Types and Characteristics
Antiglaucoma Drugs
TABLE 57-2
Antiglaucoma Drugs: Effects on Aqueous Humor
0, No effect; +, minor effect; ++, moderate effect; +++, pronounced effect.
Cholinergic Drugs (Miotics)

FIGURE 57-8 Cholinergic response of miosis to parasympathomimetic drugs. ACh, Acetylcholine;

PSNS, parasympathetic nervous system.
FIGURE 57-9 Therapeutic effects of direct- and indirect-acting miotics on glaucoma. IOP, Intraocular
pressure.
Indications
TABLE 57-3
Miotics: Indications
Contraindications
Adverse Effects
Interactions
DOSAGES
Selected Miotics
Dosages
Drug Profiles
Direct-Acting Miotics
acetylcholine
Pharmacokinetics: Acetylcholine
pilocarpine
Pharmacokinetics Pilocarpine
Indirect-Acting Miotic
echothiophate
Pharmacokinetics: Echothiophate
Sympathomimetics (Mydriatics)

DOSAGES
Selected Ocular Sympathomimetics
FIGURE 57-10 Mechanism of mydriasis.
FIGURE 57-11 Ocular effects of alpha (α) and beta (β) stimulation. IOP, Intraocular pressure.
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
apraclonidine
Pharmacokinetics: Apraclonidine
dipivefrin
Pharmacokinetics: Dipivefrin
Beta-Adrenergic Blockers
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
betaxolol
DOSAGES
Selected Ocular Beta Blockers
Pharmacokinetics: Betaxolol
timolol
Pharmacokinetics: Timolol
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
dorzolamide
Pharmacokinetics: Dorzolamide
DOSAGES
Ocular Carbonic Anhydrase Inhibitor
Osmotic Diuretics
FIGURE 57-12 Mechanism and ocular effects of osmotic diuretics. IOP, Intraocular pressure.
Indications
Contraindications
Adverse Effects
TABLE 57-4
Osmotic Diuretics: Adverse Effects
Interactions
Dosages
Drug Profiles
glycerin
Pharmacokinetics: Glycerin
mannitol
Pharmacokinetics: Mannitol
Prostaglandin Agonists
DOSAGES
Osmotic Diuretics
DOSAGES
Ocular Prostaglandin Agonist
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profile
latanoprost
Pharmacokinetics: Latanoprost
Antimicrobial Drugs
TABLE 57-5
Common Ocular Infections
Indications
Contraindications
Adverse Effects
Interactions
Dosages
Drug Profiles
Aminoglycosides
gentamicin
Pharmacokinetics: Gentamicin
Macrolide Antibiotics
erythromycin
Pharmacokinetics: Erythromycin
DOSAGES
Selected Ocular Antimicrobials

Polypeptide Antibiotics
bacitracin
Pharmacokinetics: Bacitracin
Quinolone Antibiotics
ciprofloxacin
Pharmacokinetics: Ciprofloxacin
Sulfonamides
sulfacetamide
Pharmacokinetics: Sulfacetamide
Antifungal Drug
natamycin
Pharmacokinetics: Natamycin
Antiviral Drugs
trifluridine
Antiinflammatory Drugs
Box 57-1
Indications
Contraindications
Adverse Effects
Drug Profiles
Corticosteroid
dexamethasone
Pharmacokinetics: Dexamethasone
flurbiprofen
Pharmacokinetics: Flurbiprofen
ketorolac
Pharmacokinetics: Ketorolac
Topical Anesthetics
Indications
Contraindications
Adverse Effects
Interactions
Drug Profile
tetracaine
Pharmacokinetics: Tetracaine
Diagnostic Drugs
Drug Profiles
Cycloplegic Mydriatics
atropine sulfate
cyclopentolate
Ophthalmic Dye
fluorescein
Antiallergic Drugs
Drug Profiles
Antihistamines
olopatadine
Mast Cell Stabilizers
cromolyn
Decongestants
tetrahydrozoline
Lubricants and Moisturizers
artificial tears
DOSAGES
Ocular Antiallergics
Nursing Process
Assessment
Nursing Diagnoses

Implementation
Evaluation
Key Points
58
DRUG PROFILES
carbamide peroxide, p. 923
Objectives
KEY TERMS
Cerumen A yellowish or brownish waxy excretion produced by modified sweat glands in the external ear
canal. Also called earwax. (p. 923)
Otitis externa Inflammation or infection of the external auditory canal. (p. 922)
Otitis media (OM) Inflammation or infection of the middle ear. (p. 922)
Overview
FIGURE 58-1 Structure of the ear.

Treatment of Ear Disorders
Antibacterial and Antifungal Otic Drugs
TABLE 58-1
Common Antibacterial Otic Products
TABLE 58-2
Common Antifungal Otic Products
Neomycin, polymixin B, and hydrocortisone otic preparations are contraindicated in patients with a perforated eardrum.
Drug Profiles
Antibacterial Products
Antifungal Products
Earwax Emulsifiers
Drug Profile
carbamide peroxide
Nursing Process
Assessment
Nursing Diagnoses
Implementation
Evaluation
Key Points
APPENDIX
*Note: As part of its 2004 National Patient Safety Goals, the Joint Commission announced that all accredited organizations must
discontinue using the following abbreviations, acronyms, and symbols: U, IU, qd, qod, MS, MSO4, and MgSO4. Trailing zeros and lack
of leading zeros were also discontinued. In other words, a zero should never appear by itself after a decimal point (1 mg instead of
1.0 mg), and a zero should always be used before a decimal point (0.1 mg instead of .1 mg). In addition, abbreviations for drug names
should not be used because they can be misinterpreted. Other items are being considered for future inclusion on the official “do not use”
list, such as the @ sign (write out the word at) and the symbols > and < (write out as greater than and less than). The abbreviations “cc”
and “µg” should also be avoided and are being considered for inclusion on future lists. This National Patient Safety Goal was
incorporated into the Information Management standards in 2010.
†These abbreviations are on the List of Error Prone Abbreviations, Symbols, and Dose Designations of the Institute for Safe Medication
Practices (ISMP). These abbreviations have been reported to the ISMP as being frequently involved in medication errors. The ISMP
recommends not ever using these abbreviations when communicating medical information, including medication orders and medication
administration records.
Data from Institute for Safe Medication Practices (ISMP): ISMP's list of error-prone abbreviations, symbols, and dose designations,
2012. Available at http://www.ismp.org/tools/errorproneabbreviations.pdf. Accessed September 24, 2015.
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37
Chapter 38
Chapter 39
Chapter 40
Chapter 41
Chapter 42
Chapter 43
Chapter 44
Chapter 45
Chapter 46
Chapter 47
Chapter 48
Chapter 49
Chapter 50
Chapter 51
Chapter 52
Chapter 53
Chapter 54
Chapter 55
Chapter 56
Chapter 57
Chapter 58
General
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37
Chapter 38
Chapter 39
Chapter 40
Chapter 41
Chapter 42
Chapter 43
Chapter 44
Chapter 45
Chapter 46
Chapter 47
Chapter 48
Chapter 49
Chapter 50
Chapter 51
Chapter 52
Chapter 53
Chapter 54
Chapter 55
Chapter 56
Chapter 57
Chapter 58
Evidence-Based Practice
Patient-Centered Care: Cultural Implications
Patient-Centered Care: Lifespan Considerations for the Older
Adult Patient
Patient-Centered Care: Lifespan Considerations for the
Pediatric Patient
Safety: Herbal Therapies and Dietary Supplements
Safety: Laboratory Values Related to Drug Therapy
Safety and Quality Improvement: Preventing Medication Errors
Teamwork and Collaboration: Legal and Ethical Principles
Abbreviations for Diagnostic and Laboratory Tests

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EIGHTH EDITION

New to This Edition

Additional Teaching/Learning Features

We Welcome Your Feedback

Overview of the Nursing Process

Planning: Outcome Identification

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Drug Therapy during Pregnancy

Drug Therapy during Breastfeeding

Considerations for Neonatal and Pediatric Patients

Considerations for Older Adult Patients

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

General Impact of Errors on Patients

Issues Contributing to Errors

Other Ethical Issues

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Assessment of Learning Needs Related to Drug Therapy

Nursing Diagnoses Related to Learning Needs and Drug Therapy

Planning: Outcome Identification as Related to Learning Needs and Drug Therapy

Implementation Related to Patient Education and Drug Therapy

Evaluation of Patient Learning Related to Drug Therapy

Patient-Centered Care: Patient Teaching

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Herbals and Dietary Supplements

Patient-Centered Care: Patient Teaching

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Basic Principles of Genetic Inheritance

Discovery, Structure, and Function of DNA

Application of the Nursing Process as Related to Genetic Principles

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Preparing for Drug Administration

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Drugs for Moderate Sedation

Neuromuscular Blocking Drugs

Patient-Centered Care: Patient Teaching

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Benzodiazepines and Miscellaneous Hypnotic Drugs

Patient-Centered Care: Patient Teaching

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Attention Deficit Hyperactivity Disorder

Analeptic-Responsive Respiratory Depression Syndromes

Drugs for Attention Deficit Hyperactivity Disorder and Narcolepsy

Drugs for Specific Respiratory Depression Syndromes: Analeptics

Patient-Centered Care: Patient Teaching

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Patient-Centered Care: Patient Teaching

NCLEX® Examination Review Questions

Critical Thinking and Prioritization Questions

Indirect-Acting Dopaminergic Drugs