Introduction to Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 Introduction to Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
A Message to Students 2 Overview 2 Sources of Drugs 3 Drug Classifications and Prototypes 3 Drug Names 3 Drug Marketing 3 Pharmacoeconomics 4 Prescription and Nonprescription Drugs 4 Drug Approval Processes 4 Sources of Drug Information 7 Strategies for Studying Pharmacology 7


Basic Concepts and Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Overview 9 Cellular Physiology 9 Drug Transport Through Cell Membranes 10 Pharmacokinetics 10 Pharmacodynamics 15 Variables That Affect Drug Actions 17 Tolerance and Cross-Tolerance 20 Adverse Effects of Drugs 20


Administering Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Overview 29 General Principles of Accurate Drug Administration Legal Responsibilities 30 Medication Errors 30 Medication Systems 31 Medication Orders 31 Drug Preparations and Dosage Forms 32 Calculating Drug Dosages 34 Routes of Administration 35 29


Nursing Process in Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Overview 47 Nursing Process in Drug Therapy 48 Integrating Nursing Process, Critical Paths and Drug Therapy General Principles of Drug Therapy 59 51





Drugs Affecting the Central Nervous System
Characteristics and Functions of the Central Nervous System Drugs Affecting the Central Nervous System 77 72

. . . . . . . . . . . 71

Physiology of the Central Nervous System . . . . . . . . . . . . . . . . . . . . . . 72


Opioid Analgesics and Opioid Antagonists . . . . . . . . . . . . . . . . . . . . . 79
Overview 79 Pain 79 Endogenous Analgesia System Opioid Analgesics 80 Individual Drugs 82 Principles of Therapy 89 80


Analgesic–Antipyretic–Anti-inflammatory and Related Drugs . . . . . 99
Overview 99 Pain, Fever, and Inflammation 100 Mechanism of Action 100 Indications for Use 102 Contraindications to Use 103 Subgroups and Individual Drugs 104 Principles of Therapy 114


Antianxiety and Sedative-Hypnotic Drugs . . . . . . . . . . . . . . . . . . . . . 124
Overview 124 Anxiety 125 Sleep and Insomnia 125 Drugs Used to Treat Anxiety and Insomnia Principles of Therapy 134



Antipsychotic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Psychosis 144 Schizophrenia 145 Antipsychotic Drugs 145 Principles of Therapy 152


Drugs for Mood Disorders: Antidepressants and Mood Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . 163
Mood Disorders 163 Antidepressant Drugs 165 Types of Antidepressants and Individual Drugs Principles of Therapy 171 166


Antiseizure Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Seizure Disorders 182 Antiseizure Drugs 183 Individual Antiseizure Drugs Principles of Therapy 193 184




Antiparkinson Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Parkinson’s Disease 202 Antiparkinson Drugs 202 Individual Antiparkinson Drugs Principles of Therapy 207 203


Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Skeletal Muscle Relaxants 213 Individual Drugs 214 Principles of Therapy 217


Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
General Anesthesia 220 Regional Anesthesia 221 Adjuncts to Anesthesia 221 Individual Anesthetic Agents 222 Principles of Therapy 222


Substance Abuse Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Substance Abuse 236 Dependence 236 Central Nervous System Depressants 237 Central Nervous System Stimulants 243 Principles of Therapy 249


Central Nervous System Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Uses 251 Types of Stimulants 252 Individual Central Nervous System Stimulants Principles of Therapy 255 252


Drugs Affecting the Autonomic Nervous System
Autonomic Nervous System 261 Characteristics of Autonomic Drugs

. . . . . . 260

Physiology of the Autonomic Nervous System . . . . . . . . . . . . . . . . . . 261


Adrenergic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Description 268 Individual Adrenergic Drugs 272 Principles of Therapy 275


Antiadrenergic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Description 283 Individual Antiadrenergic Drugs Principles of Therapy 290 285




Cholinergic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Description 298 Individual Cholinergic Drugs Principles of Therapy 303 299


Anticholinergic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Description 308 Individual Anticholinergic Drugs Principles of Therapy 314 310


Drugs Affecting the Endocrine System
Overview 321 Endocrine System–Nervous System Interactions 321 General Characteristics of Hormones 322 General Characteristics of Hormonal Drugs 324

. . . . . . . . . . . . . . . . . 320

Physiology of the Endocrine System . . . . . . . . . . . . . . . . . . . . . . . . . . 321


Hypothalamic and Pituitary Hormones . . . . . . . . . . . . . . . . . . . . . . . 325
Overview 325 Therapeutic Limitations 327 Individual Hormonal Agents 328 Principles of Therapy 331


Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Overview 334 Endogenous Corticosteroids 334 Exogenous Corticosteroids (Glucocorticoid Drugs) Principles of Therapy 343 337


Thyroid and Antithyroid Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Overview 353 Thyroid Disorders 354 Individual Drugs 356 Principles of Therapy 360


Hormones That Regulate Calcium and Bone Metabolism . . . . . . . . 366
Overview 366 Drugs Used for Calcium and Bone Disorders Principles of Therapy 375 368


Antidiabetic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Overview 382 Endogenous Insulin 382 Diabetes Mellitus 384 Hypoglycemic Drugs 385 Principles of Therapy 394




Estrogens, Progestins, and Hormonal Contraceptives . . . . . . . . . . . 409
Overview 409 Estrogens 410 Progesterone 410 Estrogens and Progestins Used as Drugs 411 Individual Estrogens, Progestins, and Combination Products Principles of Therapy 418



Androgens and Anabolic Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Overview 425 Testosterone 425 Anabolic Steroids 426 Abuse of Androgenic and Anabolic Steroid Drugs 426 Androgens and Anabolic Steroids Used As Drugs 427 Principles of Therapy 429


Nutrients, Fluids, and Electrolytes . . . . . . . . . . . . . . . . . . . . . . 433
30 Nutritional Support Products and Drugs for Obesity . . . . . . . . . . . . 434
Overview 434 Nutritional Deficiency States Nutritional Products 435 Pancreatic Enzymes 435 Obesity 436 Principles of Therapy 442 434


Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Overview 453 Description and Uses 454 Vitamin Supplements 454 Principles of Therapy 460


Minerals and Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Overview 469 Minerals as Nutrients 470 Individual Agents Used In Mineral–Electrolyte Imbalances Principles of Therapy 483 470


Drugs Used to Treat Infections
Overview 494 Microorganisms and Infections 494 Host Defense Mechanisms 499 Characteristics of Anti-Infective Drugs Principles of Therapy 502

. . . . . . . . . . . . . . . . . . . . . . . . . . 493

General Characteristics of Antimicrobial Drugs . . . . . . . . . . . . . . . . 494





Beta-Lactam Antibacterials: Penicillins, Cephalosporins, and Others . . . . . . . . . . . . . . . . . . . . . . 510
Overview 510 Penicillins 511 Cephalosporins 517 Carbapenems 518 Monobactam 519 Principles of Therapy 519


Aminoglycosides and Fluoroquinolones . . . . . . . . . . . . . . . . . . . . . . 527
Overview 527 Aminoglycosides 527 Fluoroquinolones 530 Principles of Therapy 531


Tetracyclines, Sulfonamides, and Urinary Agents . . . . . . . . . . . . . . 537
Overview 537 Principles of Therapy 543


Macrolides and Miscellaneous Antibacterials . . . . . . . . . . . . . . . . . . 548
Overview 548 Macrolides 548 Miscellaneous Antibacterial Drugs Principles of Therapy 552 550


Drugs for Tuberculosis and Mycobacterium avium Complex (MAC) Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
Overview 559 Epidemiology of Tuberculosis 560 Drug-Resistant Tuberculosis 561 Preventing the Development and Spread of Tuberculosis Antitubercular Drugs 561 Treatment of Active Tuberculosis 567 Mycobacterium avium Complex Disease 567 Principles of Therapy 568



Antiviral Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576
Overview 576 Principles of Therapy 585


Antifungal Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
Overview 595 Fungal Infections 596 Principles of Therapy 606


Antiparasitics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
Overview 614 Protozoal Infections 614 Helminthiasis 616 Scabies and Pediculosis 616 Antiparasitic Drugs 617 Principles of Therapy 623




Drugs Affecting Hematopoiesis and the Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
42 Physiology of the Hematopoietic and Immune Systems . . . . . . . . . . 628
Overview 628 Hematopoietic Cytokines 628 Overview of Body Defense Mechanisms 630 Immunity 631 Immune Cells 632 Patient-Related Factors That Influence Immune Function 637 Immune Disorders 638 Drugs That Alter Hematopoietic and Immune Responses 638


Immunizing Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
Overview 640 Immunization 641 Agents for Active Immunity 641 Agents for Passive Immunity 641 Individual Immunizing Agents 642 Principles of Therapy 648


Hematopoietic and Immunostimulant Drugs . . . . . . . . . . . . . . . . . . . 657
Overview 657 General Characteristics of Hematopoietic and Immunostimulant Drugs Principles of Therapy 663 657


Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Overview 671 Autoimmune Disorders 672 Tissue and Organ Transplantation Immunosuppressant Drugs 675 Principles of Therapy 682 674


Drugs Affecting the Respiratory System
Overview 694 Summary 696 Disorders of the Respiratory System Drug Therapy 696

. . . . . . . . . . . . . . . 693

Physiology of the Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . 694


Drugs for Asthma and Other Bronchoconstrictive Disorders . . . . . 697
Overview 697 Drug Therapy 700 Principles of Therapy 706




Antihistamines and Allergic Disorders . . . . . . . . . . . . . . . . . . . . . . . . 715
Overview 715 Histamine and Its Receptors 715 Hypersensitivity (Allergic) Reactions Antihistamines 718 Principles of Therapy 723 716


Nasal Decongestants, Antitussives, and Cold Remedies . . . . . . . . . . 728
Overview 728 The Common Cold 728 Sinusitis 729 Common Signs and Symptoms of Respiratory Disorders Drugs for Respiratory Disorders 729 Individual Drugs 730 Principles of Therapy 733



Drugs Affecting the Cardiovascular System
Overview 739 Heart 739 Blood Vessels 740 Blood 741 Cardiovascular Disorders 742 Drug Therapy in Cardiovascular Disorders

. . . . . . . . . . . 738

Physiology of the Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . 739



Drug Therapy of Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
Overview 743 Drug Therapy 744 Principles of Therapy 750


Antidysrhythmic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 758
Overview 758 Cardiac Electrophysiology 758 Cardiac Dysrhythmias 759 Antidysrhythmic Drugs 760 Classifications and Individual Drugs Principles of Therapy 767



Antianginal Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774
Overview 774 Antianginal Drugs 777 Principles of Therapy 782


Drugs Used in Hypotension and Shock . . . . . . . . . . . . . . . . . . . . . . . 788
Overview 788 Antishock Drugs 789 Individual Drugs 789 Principles of Therapy 792




Antihypertensive Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 797
Overview 797 Regulation of Arterial Blood Pressure Hypertension 798 Antihypertensive Drugs 801 Individual Drugs 803 Principles of Therapy 804 797


Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818
Overview 818 Renal Physiology 818 Alterations in Renal Function Diuretic Drugs 821 Principles of Therapy 824 821


Drugs That Affect Blood Coagulation . . . . . . . . . . . . . . . . . . . . . . . . 832
Overview 832 Hemostasis 833 Clot Lysis 833 Thrombotic and Thromboembolic Disorders 833 Drugs Used in Thrombotic and Thromboembolic Disorders Principles of Therapy 843



Drugs for Dyslipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851
Overview 851 Atherosclerosis 851 Blood Lipids 852 Dyslipidemia 853 Initial Management of Dyslipidemia 853 Drug Therapy of Dyslipidemia 854 Principles of Therapy 857


Drugs Affecting the Digestive System . . . . . . . . . . . . . . . . . . . 863
59 Physiology of the Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . 864
Overview 864 Organs of the Digestive System 864 Secretions of the Digestive System 866 Effects of Drugs on the Digestive System 866


Drugs Used for Peptic Ulcer and Acid Reflux Disorders . . . . . . . . . 867
Overview 867 Peptic Ulcer Disease 867 Types of Drugs 869 Principles of Therapy 875




Laxatives and Cathartics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 883
Overview 883 Defecation 883 Laxatives and Cathartics 884 Principles of Therapy 887


Antidiarrheals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 892
Overview 892 Antidiarrheal Drugs 893 Principles of Therapy 897


Antiemetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902
Overview 902 Antiemetic Drugs 903 Principles of Therapy 907


Drugs Used in Special Conditions . . . . . . . . . . . . . . . . . . . . . . . 912
64 Drugs Used in Oncologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 913
Overview 913 Normal and Malignant Cells Cancer 914 Antineoplastic Drugs 916 Individual Drugs 919 Cytoprotectant Drugs 919 Principles of Therapy 920 913


Drugs Used in Ophthalmic Conditions . . . . . . . . . . . . . . . . . . . . . . . . 935
Overview 935 Disorders of the Eye 936 Types of Ophthalmic Drugs 937 Ophthalmic Drug Therapy 937 Individual Drugs 937 Principles of Therapy 938


Drugs Used in Dermatologic Conditions . . . . . . . . . . . . . . . . . . . . . . 949
Overview 949 Disorders of the Skin 950 Types of Dermatologic Drugs Individual Drugs 953 Principles of Therapy 957 952




Drug Use During Pregnancy and Lactation . . . . . . . . . . . . . . . . . . . 965
Overview 965 Pregnancy and Lactation 965 Maternal–Placental–Fetal Circulation 966 Drug Effects on the Fetus 966 Fetal Therapeutics 970 Maternal Therapeutics 970 Abortifacients 973 Tocolytics 973 Drugs Used During Labor and Delivery at Term 974 Neonatal Therapeutics 975 Principles of Therapy 976


Recently Approved and Miscellaneous Drugs . . . . . . . . . . . . . . . . . . 981

The International System of Units . . . . . . . . . . . . . . . . . . . . . . . . . . . 983

Therapeutic Serum Drug Concentrations for Selected Drugs . . . . . 984

Canadian Drug Laws and Standards . . . . . . . . . . . . . . . . . . . . . . . . . 985

Canadian Drug Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986 INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995

The basic precepts underlying previous editions of Clinical Drug Therapy continue to guide the writing of this seventh edition. The overall purpose is to promote safe, effective, and rational drug therapy by: • Providing information that accurately reflects current practices in drug therapy. • Facilitating the acquisition, comprehension, and application of knowledge related to drug therapy. Application requires knowledge about the drug and the client receiving it. • Identifying knowledge and skills the nurse can use to smooth the interface between a drug and the client receiving it.

• Preventing the need for drug therapy, when possible, by promoting health and preventing
conditions that require drug therapy.

• Using appropriate and effective nonpharmacologic interventions instead of, or in conjunction with, drug therapy when indicated. When used with drug therapy, such interventions may promote lower drug dosage, less frequent administration, and fewer adverse effects. • Enhancing therapeutic effects by administering drugs accurately and considering clients’ individual characteristics that influence responses to drug therapy. • Preventing or minimizing adverse drug effects by knowing the major adverse effects associated with particular drugs, identifying clients with characteristics that may increase risks of experiencing adverse effects, and actively monitoring for the occurrence of adverse effects. When adverse effects occur, early recognition allows interventions to minimize their severity. Because all drugs may cause adverse effects, nurses must maintain a high index of suspicion that symptoms, especially new ones, may be drug-induced. • Teaching clients and caregivers about accurate administration of medications, nonpharmacologic treatments to use with or instead of pharmacologic treatments, and when to contact a health care provider.

The content of Clinical Drug Therapy is organized in 11 sections, primarily by therapeutic drug groups and their effects on particular body systems. This approach helps the student make logical connections between major drug groups and the conditions for which they are used. It also provides a foundation for learning about new drugs, most of which fit into known groups. The first section contains the basic information required to learn, understand, and apply drug knowledge. The chapters in this section include drug names, classifications, prototypes, costs, laws and standards, schedules of controlled substances, drug approval processes, and learning strategies (Chapter 1); cellular physiology, drug transport, pharmacokinetic processes, the receptor theory of drug action, types of drug interactions, and factors that influence drug effects on body tissues (Chapter 2); dosage forms and routes and methods of accurate drug administration (Chapter 3); and guidelines for using the nursing process in drug therapy and general principles of drug therapy (Chapter 4). Most drug sections include an initial chapter that reviews the physiology of a body system followed by several chapters that discuss drug groups used to treat disorders of that body system. The seven physiology review chapters are designed to facilitate understanding of drug effects on a



body system. These include the central nervous system; the autonomic nervous system; and the endocrine, hematopoietic, immune, respiratory, cardiovascular, and digestive systems. Other chapters within each section emphasize therapeutic classes of drugs and prototypical or commonly used individual drugs, those used to treat common disorders, and those likely to be encountered in clinical nursing practice. Drug chapter content is presented in a consistent format and includes a description of a condition for which a drug group is used; a general description of a drug group, including mechanism(s) of action, indications for use, and contraindications; and descriptions and tables of individual drugs, with recommended dosages and routes of administration. Additional clinically relevant information is presented under the headings of Nursing Process, Principles of Therapy, and Nursing Actions. The Nursing Process section emphasizes the importance of the nursing process in drug therapy, including assessment of the client’s condition in relation to the drug group, nursing diagnoses, expected outcomes, needed interventions, and evaluation of the client’s progress toward expected outcomes. Client teaching guidelines are displayed separately from other interventions to emphasize their importance. The Principles of Therapy section presents guidelines for individualizing drug therapy in specific populations (eg, children, older adults, clients with renal or hepatic impairments). General principles are included in Chapter 4; specific principles related to drug groups are included in the chapters where those drug groups are discussed. This approach, rather than separate chapters on pediatric and geriatric pharmacology, for example, was chosen because knowledge about a drug is required before that knowledge can be applied to a specific population with distinctive characteristics and needs in relation to drug therapy. Each drug chapter includes a Nursing Actions display that provides specific nursing responsibilities related to drug administration and client observation. Other drug sections include products used to treat nutritional, infectious, oncologic, ophthalmic, and dermatologic disorders.

• Updated Drug Information. More than 100 new drugs have been added. Some are additions to well-known drug groups, such as the angiotensin II receptor antagonists (Chapter 55); antidiabetic drugs (Chapter 27); antiretroviral drugs (Chapter 39); and drugs that affect blood coagulation (Chapter 57). Others represent advances in the drug therapy of some disease processes, such as newer anti-cancer agents (Chapter 64). In addition, continuing trends in drug dosage formulations are reflected in the increased numbers of fixed-dose combination drug products, long-acting preparations, and nasal or oral inhalation products. Major Revision of Many Chapters. Chapter revisions reflect current practices in drug therapy, integrate new drugs, explain the major characteristics of new drug groups, provide increased information about pharmacokinetics and toxicology, and add content related to herbal and dietary supplements when relevant to chapter content. Herbal and Dietary Supplements. Commonly used products are introduced in Chapter 4 and included in selected later chapters. Safety aspects are emphasized. New Tables. These include the conversion of all remaining drug monographs to a tabular format for drug dosages, tables of pharmacokinetic data for selected drug groups, a table of commonly overdosed drugs and their antidotes, and a table of commonly used herbal supplements. New Illustrations. Several new illustrations have been developed, primarily to enhance understanding of drug actions. New Boxed Displays. These include information to promote understanding of drug therapy for selected conditions.

• • • •

• Readability. Since the first edition of Clinical Drug Therapy was published in 1983, many
students and faculty have commented about the book’s clear presentation style.



• Organizational Framework. The book’s organizational framework allows it to be used
effectively as both a textbook and as a reference. As a textbook, students can read chapters in their entirety to learn the characteristics of major drug classes, their prototypical drugs or commonly used representatives, their uses and effects in prevention or treatment of disease processes, and their implications for nursing practice. As a reference book, students can readily review selected topics for classroom use or clinical application. Facilitating such uses are a consistent format and frequent headings that allow the reader to identify topics at a glance. Four-Color Design. The striking design enhances liveliness of the text and promotes student interest and interactivity. Interactive Displays. Presented in consistent formats and colors throughout the text, these displays heighten student attention and emphasize critical thinking and clinical decisionmaking skills. Drug-related chapters contain two or more of the following displays: an opening critical thinking scenario, a knowledge application situation, a medication error prevention exercise, and an ethical/legal dilemma. The solutions to the knowledge application situations and the medication error prevention exercises appear at the ends of chapters. Chapter Objectives. Learning objectives at the beginning of each chapter focus the student’s attention on important chapter content. Client Teaching Guidelines. This feature is designed to meet several goals. One is to highlight the importance of teaching clients and caregivers how to manage drug therapy at home, where most medications are taken. This is done by separating teaching from other nursing interventions. Another goal is to promote active and knowledgeable client participation in drug therapy regimens, which helps to maximize therapeutic effects and minimize adverse effects. In addition, written guidelines allow clients and caregivers to have a source of reference when questions arise in the home setting. A third goal is to make client teaching easier and less time consuming. Using the guidelines as a foundation, the nurse can simply add or delete information according to a client’s individual needs. To assist both the nurse and client further, the guidelines contain minimal medical jargon. Principles of Therapy. This unique section describes important drug-related and client-related characteristics that need to be considered in drug therapy regimens. Such considerations can greatly increase safety and therapeutic effects, and all health care providers associated with drug therapy should be aware of them. Most chapters contain principles with the headings of Use in Children, Use in Older Adults, Use in Renal Impairment, Use in Hepatic Impairment, and Home Care to denote differences related to age, developmental level, pathophysiology, and the home care setting. Some chapters include principles related to Genetic and Ethnic Considerations, Use in Critical Illness, and Management of Drug Toxicity or Drug Withdrawal. Nursing Actions Displays. These displays emphasize nursing interventions during drug therapy within the following categories: Administer accurately, Observe for therapeutic effects, Observe for adverse effects, and Observe for drug interactions. The inclusion of rationales for interventions provides a strong knowledge base and scientific foundation for clinical practice and critical thinking. Review and Application Exercises. Located at the end of each chapter, these questions encourage students to rehearse clinical application strategies in a nonclinical, nonstressful, nondistracting environment. They also promote self-testing in chapter content and can be used to promote classroom discussion. Answers to these exercises can be found on the connection companion Website Appendices. These include recently approved and miscellaneous drugs, the International System of Units, therapeutic serum drug concentrations for selected drugs, Canadian drug laws and standards, and Canadian drug names. Extensive Index. Listings of generic and trade names of drugs, nursing process, and other topics provide rapid access to desired information.

• •

• •

• •

Nursing students must develop skills in critical thinking, information processing, decision making, collaboration, and problem solving. How can a teacher assist students to develop these skills in relation to drug therapy? The goal of the ancillary package is to assist both student and teacher in this development.



The Study Guide engages the student’s interest and active participation by providing a variety of learning exercises and opportunities to practice cognitive skills. Worksheets promote the learning of concepts, principles, and characteristics and uses of major drug groups. The worksheets can be completed independently, by a small group as an in-class learning activity, or by the instructor, with answers elicited from the class as a whole. Clinical challenge scenarios promote appropriate data collection, critical analysis of both drug-related and client-related data, and application of the data in patient care. The connection companion Website provides online updates for faculty and students, links to newly-approved drugs, answers to the chapter questions for review and application, and more. The free Back of Book CD-ROM is an invaluable learning tool that provides 3-D animated depictions of pharmacology concepts, video on preventing medication errors, NCLEX-style review questions, and monographs of the 100 most commonly prescribed drugs. The Instructor’s Resource CD-ROM facilitates use of the text in designing and implementing courses of study. To fulfill this purpose, the CD-ROM contains an Instructor’s Manual, an Electronic Testbank, and PowerPoint Slides. The Instructor’s Manual includes the following: • General observations and comments about teaching and learning pharmacology in relation to nursing • A sample syllabus for a separate three-credit hour, one-semester pharmacology course that may be taught in a traditional classroom or a nontraditional online setting • General teaching strategies for classroom or online teaching, with a listing of additional requirements for an online course (eg, a computer network and software such as WebCT or Blackboard; student computer skills and access to a computer; interactivity between students and faculty and among students; student preparation and participation; an online mechanism for submitting assignments, taking tests, and receiving grades; and modified teaching strategies) • Specific teaching strategies for classroom, online, small group, and clinical teaching of content in each chapter • A list of major topics; text locations of objectives, displays, and selected elements; terms and concepts; and selected individual drugs for each drug-related chapter of the text • Suggestions for designing an independent study course for RNs seeking a BSN • Suggestions for including pharmacology content in the nursing courses of an integrated curriculum. • Discussion/solutions of Clinical Challenges from the Study Guide • Drug Jeopardy Game, with a description and sample questions and answers The Brownstone® Testbank includes approximately 1,000 multiple-choice test items in NCLEX format, a Test Generator, and Grade Book. These materials can assist the instructor in evaluating students’ knowledge of drug information and their ability to apply that information in client care. PowerPoint slides include text and art from Clinical Drug Therapy to provide significant classroom or online teaching support. These varied materials allow each instructor to choose or adapt those relevant to his or her circumstances. The author and publisher hope the materials are truly helpful in easing the day-to-day rigors of teaching pharmacology, and invite comments from instructors regarding the materials. Anne Collins Abrams, RN, MSN

Sondra G. Ferguson, RN, MSN, CS, ANP, APRN, BC
Assistant Professor of Nursing Berea College Berea, Kentucky Chapters 50, 51, 55, 57, 58

Carol Ann Barnett Lammon, RN, PhD
Assistant Professor of Nursing Capstone College of Nursing University of Alabama Tuscaloosa, Alabama Chapter 17–21

Tracey Goldsmith, PharmD
Independent Legal and Healthcare Consultant Magnolia, Texas Chapters 33–37
Note: These chapters were reviewed by John Mohr, PharmD, Clinical Specialist, Infectious Diseases, Memorial Hermann Hospital, Houston, Texas

Sandra Smith Pennington, RN, PhD
Associate Professor of Nursing Berea College Berea, Kentucky Chapters 50, 52, 53, 54, 56

Constance J. Hirnle, RN, MN
Nursing Development Specialist Virginia Mason Medical Center Seattle, Washington and Lecturer, Biobehavioral Nursing and Health Systems University of Washington Seattle, Washington Chapter Opening Critical Thinking Scenarios, Nursing Notes: Apply Your Knowledge, How Can You Avoid This Medication Error?, and Ethical/Legal Dilemma

Frank Romanelli, PharmD, BCSP
Assistant Professor College of Pharmacy and College of Health Sciences University of Kentucky Lexington, Kentucky Chapters 39 and 41



NEW* Drugs at a Glance tables give students characteristics, and routes and dosage ranges in an easy-to-read format.





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t or kfas g or bjm brea O ecti er s ftve se 2 y. A with do il ST g AFTE aily, aR ce d startin once d e inUDYING THIS n o CHAPTE mg ximum 4 mg e1. dos k interR, THE 2 – – a s STUDEN eescus lly 1 eal. M dose 1 increa 2-wDi us s char T WILL um BE ABLE m initia ellit e to mac d, xim rolide an acteristics an TO: PO, t main tenanc reache s at 1- ls. Ma es M d spec tibacte e is firs Main bet les e lev2. ific uses g . r ria y ia y o m s . ls. il Co il h s da of stic less e of 2 f 2 mg gluco nce da nm or D re and epa 2–3 ri F c , te k s s o d o co o c 4. Disc common ntrast m pea rug mg a do ments n bloo 8 mg ; uss hara D ly h 8 ac C in us l o , rolides O ed antib a ut 1 for usin characteristic incre based d dose ulin, P 3. Ap e, 30 m wi : Or acteria abo pl s e , sy prin l drugs. th other o nce zolid, m g chloramphen s and clinical tion ciples of vals mend with in eal. le d Gla f ac indicatio etronida icol, cl using m sing client situat com ation ain m ta et o an a a re s d n ac io s va in in m ns. O rolides ncomyc zole, quinup indamycin, lin ns g on rst ame aily omb in select ristin/d in. eDru 5. Disc rati h In c h the fi mg d de N alfopris ed ene uss ily , wit y. wit ially 5 fast. /Tra tin, ose nd G dail g da vancom the roles of m eric eco init break 40 mg 2.5 m ingle d S , yc et Gen , in O ro in the tre nidazole P membr as ithitica Cr reas aryl) fore dose, rt w in e lu an at an l y b y t. m Th ou d il ent of ps oral inking s colitis on um ay sta Yo da (Am h; kfas g e a im Sc Sulf . .5 eu x m id u en m re 1 do a ar ario e an in y, M –5 1– epir ith b wio 2.5 lderl resistd Glim ately aily. dafe ilyct n contro an In e itially xim St g ap mg tm l nurse in ppro 20 ca.5 3 es y. hylococcus de who wi PO, akfast. se, de –, n, a h il ci pe aure ll y 1re g da bre m do dr ctio ug (MRSA) be providing mstan ally in long-te us u si itiall of a 10–16 2 t ; in e im . lo e 1 h x Becaus ce and rm it re Ma se PO dose, Ons ration 2–4 approp e MRS ng-term care nu rst b ca a als facilities, h firia A has be du rses wi ately tter ab tervm your Glyn ximum Reflect on: y wit k inte easure be roxim dail s to prev goal is to in en a significa th an update Ma ee aily app ase is about Factors crea nt mes - to 8-w mes d ary, ent spre on n t in tion th attipr 4 ree ad of th se knowledg problem over methicilline ti ecess t f ac 4 h. Gly r (onse given f om th a o re v W ot , l) t e abou hy e resi g nc ase is orga o e n is 2 o mva g th if st se le t the de the last m ) om ni 5 re cotr an Ons ration ts faste ), and forms o sm. g c 2 ce c yc 0 lu k in may velopm ; in Wha 60be th ially of 5 du e (G lsris an antib d glu thto , ac n 24 h other r t it a io e o id ent of d e e tic in s ks e s iz d lo e s. o m e re dr lb eun volve ugeof PO, main Glip sorb duratio s than tim m d har mo Wha choice ing inra se, ndiad h tuin e im ing wh ig io of max fe for MRS thre ect tp rona w 1 h; er dos n eig en s os co w mgvancomyc A. ll ro , Mic l pr1 to a atients n 1-h p lient 00 food t nts t in is us ac sma ride. tic rs te p Beta ) fi es to o C n ed r ra ia e . are e ce consiste u e up (fo nding hyd res e (D s Tab ifssary glyb ith th ned ranc ntly to e ses re p arbo urid re to limit treat M dep nd tole eed do dose). daily w crease of c food a at the Glyb nase P the spre RSA. a s d tion ct ad of M els g may n ximum e time ually in Gly iges ose an (GI) tra d a RSA an k ys d l rb 60 (the m mg thre al, gra d other y il a Dela en aca testina e d y resistan es OVERV dail itially 25 main m wh stroin m t organi ti rs o e a IEW sms. in ch d thre in g time hibit PO, e of ea . g an e mg e In 00 bit ssary ornin nts of sam idas 1 s m , e he o drugs de nece dose luc with creme p to a se) in th , o -G s y c a sc m il u te ribe th in ary, re duin this Alph e da se in xim t ydra eir antimic e (P s a n ic h s s e o o M su o tw ch mgte es and robial rb arb uses. So e d if nece on pati y r ar spectra, 500 ap fluids an as Aca of c rl e m d teroge eks incre wehe sene y char d may tion elde . dependin ;ac circumst e are used ofin In s 3 sticaily, ba itiall meals .ou te iges be bact g on dr –ri te in 2 ose ar an d vels m ys d ug eriostat some PO, en; g d s, san e effect very d u e le ning drugs ar ces. The m Dela tract cl ic or ba e0us 0m in im ive agai concentration ic ac co max /d e ar ev ed al g ro 0 e desc lu lid on ctericid 3 g GI m A in nst gram ly f d streptoc ribed in 500 es od toin spec an and dosa r develal, e loo m se s b u -positive infected tissu le oc a th if ct ic ci e d ed re mis ge ra fo , pneum xim are also an es. ut es allo inc w bng sk fo co eg ce m in t ri c oc atha lla r o re r of n se oc ef ne e e Glaa individu ctions; ci, and m cci, includin They ra fective ll ra ous le do n ma , nc e hig sis , po na to ta s g group ag al t os bl m ne ts , ai dr a n es, rout es. t staphy n m nst spec t) da, Neiss are c acido n. Thus functio atie ugs are listeaily es e lo lyse ie p s , co id s er lt cc of (G an iv ro u o l ti i. They dae e d d in the Dru bic orga ia, and Mycop Corynebacte acti r ad litol f lac rena two onc gs Mig Olde ment o fatal re ring of rium, Tr nisms su la e or Azithro mg 30 dos ech as Ba sma and agai mycin an op ntially ito M 15– one mon ed. ACROLID ns cteroide atypical d cl PO , in pote s and ES s and C t some mycobac arithromycin end aily e d s m d o re ) e lo m comb also are d e stridia. teria th efo pl use onc ex reco The macro hag e e g ac at (M p b in tiv id m o re cause M Ad e agains m a lides C) dise ay a luc in 0 uan 4–8 w (Zithro yc t th as ase hich , or n; ,m Big 1–3 fection c in (G reat include PO oses mfax suli tformin in th occurs m e. MAC diseas obacterium av e orm aily, al. mun d cl o in ), m eal; (Dyn um e is an ium es d a me im Metf ainly in ed erythr tsac omycin , e arithromyc c ab im h m od ef ic lin opportu ), l;ncy ie e usin (B people e tim if skip , az effe in eac E . Max m have si ay b su ea ith ssm iaxin), virus in nistic ni thre ro with ad ry ryth e ycin se h m m fore ssa g m a s a it ila s e ro ; o of m w an fe b r re ip va m n d ct antib . d diri e action. ycin, th nced hu it sk Inc ne or suli mth 120 if of min if neccas us ro e protot ion. man ee m ey are w acterial PO ec 30 yc alo54nylurea ts of in Th microbi ls. O 15– ls in do ype, is ea c idely di sp rmin o8 al resist meatra g d m it ath now us man re mha sulf es effe metfo stribut Om l. e developm h an ,1 ed le 1–2 g befo ec ily. a as en ith y wit r ce, numerou eak t il PO ed4in of to bo m g da d a me tabolized s drug in ss often beo Incre ne or w in; p w mdy e da ridne ) e er s m ic s tis to 6 in m e d te 1 ac twth lyliv ra ro alo 20 bu er .5 if a zon e, mately (Acto , e or ith e hin and excr lides. Erythrom ctions, and dos dose 20 Glita eak one onc %w g lly, PO 2 , wit a eted mai ycin is in; p h mg litaz ted is excr tion etted add menly 250 ly trea in: Initia n Piog f ac , 3–4h in 30 m ly 3–4 ) o to in urine. D n mg/ et o h us ndia ls, rm epending in bile; approx Ons duratio on, wit ximate (Ava 1.25 previo metfo h mea gs. ie on O ro n ti ; P it th ts s p c h e specifi dru plu daily w lly, Patien tazo of a tion ap te li ia a t c salt it ra ig e re . a In Ros Ons ; dura eals ulfonylu g twice of sep m h 1 g er s 500 m doses s ) m e th ix o / id 5 s rl mg 1.2 ; 2.5 iou litin (Sta or 5 ed prev in with Meg linide ons etform rmin; g in) exce m arati tfo tNate rand prep 0 mg g me e e (P le in and 25 500 m 0 mg m linid b g a a il Rep Ava buride de and and 50 gly lyburi uride g ce) mg mg glyb van rug* (Gluco or 5 in nD o in ti form bina metform m o C e/ urid Glyb R s oute and Dos R age



Macrol i Antibac des and Misc ellaneo terials us


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Chapter Objectives let students know what they’re going to learn in each and every chapter. Critical Thinking Scenarios at the beginning of each chapter help students prepare for using their knowledge in the real world. Prototype drugs are highlighted in the text for the first time.




Nursing Process material helps students think about Drug Therapy in terms of the nursing process.

How Can You Avoid This Medication Error? gives students examples of common mistakes, and helps them avoid them in the future.

There ar CHAPTE R 7 AN cosamin e no known ALGESIC cont –ANTIP e, YRETIC tation an but it should be raindications –ANTI-IN FLAMMA to the us d in child avoided TORY AN effects D RELA include ren, because ef during pregnanc e of gluTED DR GI upse fects are UGS y and la sea, cons • t cunknow Activity (eg, epig 113 tipation, n. In as rash. N A di to tri dv arrhea), lerance c pain, erse • Risk fo o intera he re dr la ar ow r te tb ctions w si been re • Risk fo Poisoning: Ace d to pain ith OTC ness, headache urn, nauported. r Injury taminop or prescr , and sk Glucosa re he lated to in renal in iption dr mine an adverse n overdose ugs have but are d chon drug effe • Defici sufficiency) m ent K cts (GI bl dosages ore often take droitin can ea eeding, common nowledge: Th n in co ch be us as listed erapeutic mbinatio ly used ed alon creased above. • drugs e, Deficien Use of and adve af this com n, with the sa t rse effe K J. Theo ter it was high no wledge: me bination cts of fever, an dosakis. ly praise C or grea d inflam rect use d in The As with mation of OTC Arthritis tly indrugs fo studies in studies of the Cure by Plannin r pain, in volving g/Goals glucosam dividual compo Americ The clie an ne ine and nt will: chondroi nts, many of th tion do College of Rhe no um e tin are fl • Experie aw they do t recommend th atology and th nc e Arthrit ed. The e use of not belie drug effe e relief of disc is th demonst Fo es ve undae supple reported omfort cts 193 rate • m GS si with m en Ex DRU gni research ts becaus perienc ANTISEIZURE disease inimal studies process. ficant relief of CHAPTER 11 e adverse • Inform e increased m sym ad These or with larg obility an health ca ganizatio ptoms or slow equately er grou re d re activity pr gu ure ps in ns ov cl seiz la g of peop in ientatta say long iders if ta rly of the s, so tole n and ime le reg m er ar ki • e bed cl e ng Se ph in needed. prescri aspirin or rance lf-admin ysicians 3 month When qu ical trials comply with the is suggest an s (gluco le te r the drug NSAID • Avoid estio ta 3 times samine y. A sing ov rap control. a da 500 mg king the supple ned by ation the • Use m eruse of the dr s safely y) ane. If d de versus combin toms ment fo and dication Error? sibl ugs easures n pos impr whe r Avoid This Me 3. Monotherapy y) is recommended ove (eg,ad-cide for themse chondroitin to prev dose, es How Can You whether 400 mg the less pa lves whe ent acci has notherap rgery in the pe (mo rapy rosu g ci othe neu dru th al for in mon , dental in ey wantdrug th ly in ch , • Experie icato your unit trolling seizures ildre g– to contin improved abili er their sympgestion e holds all med ly is admitted nce few effective in con effects, fewer dru ue. Ms. Hammer ty to w or over n night. The nurs er and le n er adverse drug alk) and h is usually take client is NPO after mid ss severe morning. She vantages of few medication, whic usually greater Interven attacks ly’s surgery is her antiseizure age, lower costs, and dos ti s, , Ms. Hammer of migra te on ion ning tions, including qua ract mor wers ade inte the sho in le 6 AM. In ine Implem first drug, her shower. Whi the adwith If le at midnight and . her ptab nce en t measu unacce complia ses decide to help N cau ed seizure. u or an s raliz rs re ure d gene delayed so you s as in a seiz inflamm to prev ces gP be rotrie merly experien fails to control ent or m ation: nt should ced ss ing, Ms. Ham • Treat inimize then another age sequen the di verse effects, pain, fe Aers recommend before ver, Most practition ssessm cumstan sease processe enher t apy monotherapy. as monot ce s nts (e s age e g, infect (e • thre g, Assess impaire activity ls of two to ion, arth tria fo Y tial . d , AP r apy po bl si ER ood supp ritis) or or positio s an OF TH bination therseverity, thergn ond be sec com d ci the sy , ring ca ly rni m side , us PRINCIPLES ng ptoms of la con duration, D for ano one AE • Treat ing pain, fever, or body alignm ck of physical pain, su (s ape ee Cha d utic theran factors th reac When substituting pain or inflam ch as lo top. ent) thou wed 6).h at cause cation, ed and•allo al mation ght to Assess dua vent seve as soon as po decreased lly or g should be add re dru gra fo ss is Therapeutic Go lie g ib re r dru ve the pa fever (try when le pain an ore the first[3 analgesi clients of all hermom 7.3 in d anxiet ; early treatm necessa C] not blood levels bef is c sϒ ent may nt of epilepsy for are Thi usua ontinued. vice eter readings other no drugs. Use dist y and allow th flus the main treatme llyor minimal adine hed fa co ama in dosage and disc nsidered e use of preabove 99 np Drug therapy is raction, ure activity with ce; zep e for carb reduced milder fever). relaxa apy, whe harmacologic .6ϒ ur is to control seiz oxcarbazepin t be individine m F ting mus apy stitu . ur sub H ther te l, ay ages. The goal ilar n in ot ch e output , dry sk niques al tion techniqu are sim accompa some• With ac appropriate. meet this goa D is drugsdr To AE the e le cts. in es, aus and ; at effe sing on ny g ; bec nd, an a ed g with dr d concen fever if . ive, a seco versa, ute mus verse dru tment with fect inef ug therth culoskel rapy•isA plicatio however, st clients, trea ssess fo bination therapy e person also trated etal inju When monothe ns com 30% of clients, ualized. In mo If to ca ed. r 20% n add in In be l. decrease ries (eg, flamm is dehy the Apply fo t this goa sess d, drug may edema, an nee bination ther at reas thir com a sp , to io pa es d eral ra n. tim in r sufficient to mee gen ins), co approx Log–l si , swel . In n may d pain or icia • Assist the clin druca Ds are required gns are fe interactions or ver, elical tend clients w imately 20 min ling, and inflam ld apditions is ineffective, two or more AE erness adverse effects, , med evatcon ith migra ure m ed whitediso ut ; system redness, heat, of seizan with more severe rder or ts. d weakn Assist cl ine to id es, then remov ation. seizure bloo client for type apy is associated the , and higher cos te es d nce entify an e. cell coun ic signs includ aggrava s. • W poor compliance an NSA ients to drink ions that plia Ds, ract com d ith AE e inte av and g t een ar dru oi Ds, (le betw 2 to 3 L ID regu thrit AE d “trigger ukocytos ss of is or othe ene ctiv la of effe he s.” rly fo fl is the lp r pain an uid daily ), . This s to m decrease regimen. r musculosk d lim therapy when ed • drugab ita of aspirin aintain good ki decreases gast client coneletal diso tio trol ns , con with the prescrib Ask ease dney fu ric irrita taking in ouseiz , fluids activd rders, as t usure incr nction. e of Ole, ity retion and n may cr he s tio an nde in se ys lp lec form exte fla d ss ta Se TC age to W m ls g m mp obility. ith pr in Dru m. 4. Dos analgesi re at For ory exa nce drugs an accurate • plia to preven the urinary tra event precipita long-term use com c, antip ntain mo abou venience, and Askdos ct. With tion s can mai d he or. Therefore, an yretic, t precip form CHA t al rb of PTER age al or 9 ANTIPSYCHOT lergic salic ofet or antian ted. In ure is a major fact urate ki •cting cy di uen ylate re IC DRUGS freq eCL actio ary supp reas g therapy is star 1. Type of seiz dney ston itation of urate tigout drugs, fl lease or long-a Asses dec forls nsIEN 153 hiand to Tpi leve gs ntial before dru TEA story le l CH ui onset crystals as dru es ora m tia ialm in en ING . part le lly seru ki rin Fl of ilab ent ts GU dn both ui w diagnosis is esse sist ava . pe IDE or d intake ey hen seru and form ds help con LINES NSAID Ds are ptAn dithe ic ul AE sord activity against of ce with m is st leve tip er ids at s. r of Ds Mo e, es ur . • sy di s. io liqu AE gin l ion , pecially uric acid ic acid le ch se n of oti ase, general le as ora c administrat With mig Dr ilab G include lamotri ug ava s im ve I s ar are ra ure bl po ls e in few seiz ee a being ex are high e, assess rtant inis; ding, or , and zonisamide. and generalized creted. and larg severity tablets or capsule ate, valproic acid Evaluat e amount s. ude an or da N solu maj pa be tte sition may ion tiracetam, topiram t useful for partial seizures incl s ipsy ng Dia or injectable ur cho e this Ant s ofsoc ticrn drug bec red are mos gn curr give gs conside osaus nobarbi• with n to ence be er dru es chro Intesch new • A nic men Drugs considered s. clients rvie gh the arbazepine, phe Cost should cu tal 5. hou oxc , illne izop w te Alt . ntin ss. hren an Pa nce ape Bec s, ia, gab d ob in ause of the•natu complia older a nt resp  These drug sea Inte than clie ence seizure d • ons in rv abs carbamazepine, or rate ible C re e rv For fact of tole hr adu re ie the s er ne. should be tape onic garding w an dise ase, and bett ein Pa , and tiagabi d ob ctiv about de- lt caregiver is needed red in dosage pam and chpart relief of ued grad leve whi to ls ng rv pro tal, phenytoin Costs, taki and discontinicul are generally effe quite expensive. of y;sy choice; clonaze . mpt a cliese they sho mpt nt e regarding uall - ar doses and to • is the drug of omuld the drug also rma man s. not be stopped abruptly pha Inte age mobili ther othe apy regimen, ed seizures, a com ethosuximide rvie r aspects agents, they are . w an lesale prices and as follows. effective. For mix d observ Medication Adm ty and activity s and ufacturers’ who th unt man e amo on e ry. valproate are also dr d inis dos e essa Gen pen trat ug regardin ion eral Considerati s. l as prescribed arch gs is usually nec wel • nge dru rese g as ons Ass s of cha as Se n g sa ist kup and atio lvin or prom lect drug fe,pt bin cies’ mar efthe gs are evo pharma fe  cies dru ng clie ct er Ask nt s amo iv y new to: abo ap use r var e for ut per propria  Take medicat us of of coststhe planned drug therap Guidelines erience with thei tely. other factors, may r, the following list ions in the e the desired resu y regi correct doses e and clinical exp approved for comeve times, to mai and at the corr and may be lts, when results can men, including Ds tent studies are don are ntain blood leve AEthe over time. How ect be expected, ative leng of these agents ls and beneficial  Avoid taking parisons among e- th of drug whose and gs are carb dru these medicat increases. Most therapy. effects.  r month allow com tice. Costs of olde AEDs in clients Mai er nta oth in h ions with anta an wit le ade is needed (eg, for cids. If an anta to $158), quate supply of med 05 adm in clinical prac led with a sing ($1 bination therapy ful trol regu de hea use con cid imi rtbu lar icat sux tely rn), ion to ensure it should be take inis adequa tration. Consist fore or 2 hours apy of and to $81), etho ), her 4 not ($5 $35 e n to mo 1 6 ent hou afte ess epin seizures are not for ($2 r bloo r the antipsycho ary to control sym ed maz bed leve nytoin crease absorpt pine is approv tic drug. Antacids thought ($2 to $5), phe gs are ptoms and prevent recu ls are necion of these drug er acu drug. Oxcarbaze new der drugs are also tedru phenobarbital illness and hos rring episodes ts of of  Lie down for s from the inte ; some of the othe pitalization. to $280). Cos  Do $289), stine. approximately to ($196 partial seizures allo valproate ($80 gine not w the client to y. an hour after ication, if dizz drive a car, ope or in as monotherap to to $354), lamotri perf receiving med 7 fact 39 g ines ($9 ($1 e idin orm s ntin pin and rate dec acti to be effective aze ape faintness occ machinery, or vities that requ arb gab be the  Take the med ur. ire alertness whe s can 05 to $315), oxcmedicat g effects may 4), ication at bed $35 8 toDro ion. ($8 n drowsy from types of seizure 2. Adverse dru time, if able, levetiracetam ($1 to $190), topiramate wsines ness aids slee so that drowsiD because most muscle p and is minimiz pre- s, slowed thinking, and imp e,atio abine ($99 coo gs. The use of sibl tiag rdin dru pos choosing an AE 8), of en  $35 ety ed aire n Wh Pra are duri vari 1). d ctice good ora especially like ng waking hou ely by a 2 weeks of begs ($100 to $20 l hygiene, incl ly during the fi rs. g dru drug ther be treated effectiv increased largely by choosin apy but tend to uding dental and zonisamide thorough and rst nce  Rep checkups, decrease with ort unusua and valproic acid frequent toothb chofor ourage complia l side time carbamazepine effects and all ce plans or, rushing, drin cognitive and psy and frequent scribers can enc ran cau nts’ insu king fluids, physical illnesse . se changesgin mouth rinsing. less sedation and dru ther covered by clie and phenytoin, drug s, Mou ive betal are cause they cause mon ther ens th arbi that apy dryn exp side nob  may be indicate ess is a com effect of the ent than phe choosing lessTry to prevent the client ous addrugs. Althoug d. serious, dry from taki motor impairm h it is usually uninsured clients, er potentially seri ications, includin mouth can lead not may cause oth and e availab ng unprescribed medly cause g s thos to mouth infe dental cavities ent girl although they AEDs reported le without pres apy regimens. thos ado ctions and e lesc prescribed for D . active st of the newer cription or AE another person, d than the  Minimize exp risk. Sexually an rate ncy uire tole verse effects. Mo req gna er able Pre bett who to prevent und 6. osure to sunligh al drug interactions e effects and are esirentially . Alcohol and t, wear protecti dbearing potentibe avoy clos and use sunscre ely becaus fewer adverse sleeping pills also cause pot ve clot women of chil ver ided bec en lotions. Sen ause they may should ough they may erse ed and monitored sitivity to sunligh hing, with some of cause excess ness and dec older drugs alth and milder adv the drugs and must be evaluat t occurs ive drowsireased awarene effects. Fewer may produce ness to of skin reaction ss of safety haz ling env wil iron a sunburn-typ s ’ nt serious adverse men clie . t. ards in the e increase a  atly Avo  gre id Kee exp can p osure to excess all physicians effects
informed abo being taken by ut all the med the client, to ications decrease risk able drug inte s of undesirractions. ive heat. Som ications may e of these med cause fever and heat prostration environmental with high temperatures. In hot weather keep the client or climates, indoors and use during the hou air conditioning rs of highest hea or fans t levels.

Client Teaching Guidelines gives students specific information they may need to educate patients. Nursing Notes: Apply Your Knowledge asks students a specific question about information from the chapter.

undergo extensiv e first-pass met abolism in the significant por liver so that a tion of a dose doe s not reach the culation and low systemic cirserum drug leve ls are produced. intramuscular In contrast, (IM) doses avo id first-pass met produce serum abolism and drug levels app roximately dou oral doses. Thu ble those of s, usual IM dos es are approxima oral doses. tely half the Initial drug ther apy for acute psy quire IM adminis chotic episode s may retration and hos pitalization; sym usually control led within 48 ptoms are to 72 hours, afte drugs can be giv r which oral en. When trea tment is initiate d with oral

drugs, divided daily doses are recommended. nance therapy, For mainteonce daily dos ing is usually pre gle bedtime dos ferred. A sine is effective for most clients. Thi increases com pliance with pre s scribed drug ther schedule better nighttime apy, allows sleep, and dec reases hypoten sion and day-

Nursing Notes:



Nursing Notes:

Apply Your Kn


You are assigne d to care for John Chou, hospitali and started on fl zed 2 weeks ago uphenazine hyd rochloride (Pro psychotic symptom lixin) to treat acut s. During your e assessment, John less, unable to sit appears reststill, and uncoord inated. He also tremor. How wou has a fine hand ld you interpre t these data?

Mr. Seager, 37 years of age and homeless, has been treated for schi diagnosed and zophrenia and alcohol abuse for He is admitted the last 15 year to the hospital for s. pneumonia. Wh room to adminis en you enter his ter his prescrib ed antipsychoti his antibiotic, c medication and he swears at you and tells you to because he has leave the room no plans to take that poison. Reflect on:

• Does Mr. Seager hav • Does his psychiat e the right to refuse to take his med ric history alte ication? r his rights? • Role play how you
the nurse in this would respond to Mr. Seager if you were situation.









ent and hepatic impairm ciated nts may develop ed antibiotic-asso t of critically ill clie s colitis (also call men nou elop bra dev mem pseudo at high risk for are agnts ive clie n rece colitis). These ause they ofte spectrum nous colitis bec ltiple or broadpseudomembra nrga therapy with mu roo tic mic bio el anti e gressiv normal bow gs that destroy ill clients d in critically antibacterial dru ole is often use for drug toxrisk at are isms. Metronidaz nts comycin ctions. These clie with mixed infe metabolites. Van ulation of active and achieves icity from accum ically ill clients ues well in crit ibitory coninh m imu penetrates tiss min ls well above the occi. Plasma therapeutic leve cci and enteroc Although most staphyloco centration for uld be monitored. renal function sho en orally to and giv ls is leve ycin g dru sion, vancom infu pristin IV alfo by en in/d Quinuprist usually giv branous colitis. treat pseudomem

because ically ill clients often used in crit occur in this and linezolid are ns commonly resistant pathoge infections with population.

NEW* Herbal and Dietary Supplement Content is highlighted so students are aware of how these alternative therapies can affect traditional medications.

gs may be Drugs at a Gla cellaneous dru nce: Drugs for nurse is rolides and mis Migraine of the home care Most of the mac Generic/Trade Name e setting. The role ; that is, the hom apy the Routes and Dos ther in ic n take age Ranges other antibiot adwith g as dru e Sero ut sam tonin agonist caregivers abo generally the s (Triptans) or nts l clie h ora ng Almotriptan (Axe d to teac For clients taki rt) nurse may nee PO 6.25 mg, s coliexpected effects. nou and repe bra n at after 2 h if mem atio istr min necesfor pseudo sary. Maximu the triptan (Amerge) m, 12.5 mg/24h or vancomycin tested inNara PO 1–2.5 mg metronidazole be collected and as a single dose ens may need to ; repeat in ins. 4 tox Riza h or if tript tis, stool specim nece ms an ssary. Maximum (Maxalt) ficile organis dif , 5 mg/d C. PO for 5 – ry 10 mg as a single laborato dos
Sumatriptan (Imitrex) e; repeat after 2 h if nece ssary. Maximu m dose, 30 mg/ d PO 25–100 mg as a single dos e. Maximum dose, 300 mg/d SC 6 mg as a single dose. Max imum, 12 mg/d Nasal spray 5, 10 or 20 mg by unit-dose spray device. Maximum, 40 mg/d PO 1.25–2.5 mg as a single dose; may repeat after 2 h if necessary. Maximum dose, 10 mg/d

Home Care




Macrolides an

d Miscellaneo

us Antibacter

Zolmitriptan (Zomig)


TIONS NURSING AC accurately g to manu1. Administer arations accordin ed hromycin prep er, at evenly spac a. Give oral eryt 6 to 8 oz of wat with , ions ruct inst facturers’ the clock. intervals, around

PO, sublingually, 1–2 mg at ons et of migraine, then 2 mg q30 min, if necessary, to a max imum of 6 mg/ 24 h or 10 mg/wk ty Inha emp lation, 0.36 mg on an (one inhalatio oral suspension n) at onset of migr ycin, give the ets without aine, repeat in b. With azithrom or 2 h after a meal. Give tabl Herbal and Die 5 min, if necessary, to re a maximum of with aluminum tary Supplem stomach, 1 h befo 6 inhalations/24 h Ergotamine tart oral azithromycin ents give not Do ns. ls. rate atio Adults: PO 2 tabl regard to mea In addition to the r’s recommend cids. and ly. ture anta caff rate ufac ing eine accu ets tain Man (Cafergot) con at onset of midrugs described well to measure the oral susgraine, then 1 ed or magnesiumand mix above, many her cine ets be ld s tabl are tablet q30 min used to relieve give regular bal medisuspensions shou lease cin, , if necAll d-re essa omy pain nde ithr ry, and exte up clar /or inflammatio to 6 tablets per of these (eg, com c. With . Give the attack or n. For most frey, marigold, 10 tablets/wk or without food on well before peppermint, prim usage is anecdo pension with Shake the suspensi Rectal suppos rose), such tal and unsupp XL) with food. itory 0.5–1 sup orte tablets (Biaxin d few by pos rucclin sup itory onset of migr ical studies. For plements, ther at tion, and inst dose. aine, repeat in e is some evid a stability in solu h after a meal. measuring the 1 h, if with few adverse necessary, up ence of effectiv ion has limited food or within 1 apeutic effects. to two suppos effects; these are eness ycin, give with The IV formulat to achieve ther itories per attack or rucdescribed belo Chondroitin sulf d. With dirithrom followed carefully tent and continuous infusions. five suppositori ufacturer’s inst w. tions must be es/wk ate (CS), a sup Children: PO 0.5 rmit , consult the man inte . Indiss ycin for ’ drug er aire hrom anim the diff – g plem ionn 1 eryt tablet initially, al cartilage or ent extracted ice for Leg e. For IV administerin Also, instructions then 0.5 tablet q30 manufactured ). treatment of cho ng, diluting, and 408 min, if necessar is the r 30–60 min SECTION 4 ycin treat arthritis, is synthetically and from DRUGS AFFECTING THE ENDOCRINE SYSTEM tions for dissolvi y, to a ly (eg, q6h ove maximum of thre Dihydroergotami IV erythrom . thought to dela used to y or intermittent e tablets ne it is rarely used y the breakdown tilage (by inhibit IM 1 mg at ons fuse continuousl mesylate (DH ease. Otherwise, of joint caring elastase, a et of migraine E 45) , may pro syn teol be repe ovial membranes ytic enzyme fou ated hourly, if d levels necessary, to bloo ), nd in tic to stim apeu ulate synthesis total of 3 mg a (by stimulating maintain ther Nursing Notes: Apply 12. For a diabetic n and of new cartilag rptio Your who reports using dietary and Knowle chondrocytes to dge IV 1 mg, client e herbal To increase abso phenicol: repeated, if nece produce teog lycan), and to pro supplem ls, q6h around f. With chloram ents, ssar analyze y, afterents in relation specific supplem 1 h; max mote the “shock- collagen and proor 2 h after mea re imu to m befo h dos with 1 e cart 2 mg. Do not ilage (by retainin absorbing” qua their potential exceed impact on blood (1) Give oral drug testinal (GI) upset occurs, give sugar control. 6 mg/wk. lity of g water). Answer: NPH gastroin

ty Ergot Preparat taken on an emp ions Some should be Ergotam n tartrate to meals. ntaiine without regard s help to mai regular interval (Ergomar) n; rptio abso aids Adequate water d levels. therapeutic bloo antacids decrease the suspension; s absorption of Food decrease ension ets and the susp absorption of tabl

can be taken stomach; some

metabolism of rizatriptan and zolmitriptan pro metabolites. Sub duces active cutaneous sum atriptan produc verse effects than es more adthe oral drugs, whi effects (eg, pain , paresthesias, nau ch have similar adverse sea ness). These dru gs are considered , dizziness, and drowsisafer than ergot Ergotamine tar alkaloids. trate (Ergomar) only in the trea is an ergot alka tment of migrain loid used e. Ergot prepar migraine by con ations relieve stricting blood vessels. Ergotam effective when ine is most given sublinguall y or by inhalat onset of headac ion at the he. When given orally, ergotam cally absorbed, ine is erratiand therapeutic effects may be to 30 minutes. delayed for 20 Ergotamine is contraindicated nancy and in the during pregpresence of sev ere hypertensio vascular disease, n, peripheral coronary artery disease, renal or ease, and severe hepatic disinfections. Ergotamine tar trate and caffein monly used anti e (Cafergot) is migraine prepar a comation. Caffeine increases the abs reportedly orption and vas oconstrictive effe gotamine. Dih ydroergotamine cts of ermesylate (DH semisynthetic derivative of erg E 45) is a otamine that is less effective than less toxic and the parent drug.

is an intermediate-acting insulin that Chondroitin is the clock. If usually a normal com peaks 8 to 12 hours after administration. ponent of join which contains Hypoglycemia is most food. 5% dextrose t cartilage, water (65 to 80% 50–100 mL of likely to occur before meals. The morning ), collagen, pro and chondrocy ramphenicol in NPH is most likely to SELECTED REFERENCES teoglycans, tes that produc . (2) Mix IV chlo min cause 30 hypoglyce – mia before dinner and the evening NPH e new collagen se over 15 cans. CS was fi spe is ci likely fi call and proteoglyy rst in water and infu for use n the to cause hypoglycemia after d as a dietary sup trea American tme Diabetes eal irritatio midnight, Associatio nt the hag so of n. diabetics (2002). ies mod ken Insulin esop need plem sug to administra id The thic eat erat an : tion. avo ges y e ent may Diabetes are or severe migrain To ted that it wou ycin because studed sele evening snack. Care, 25 (Suppl. 1, Clinical Practice drug stability and callrate g. With clindam ld promote hea es. 2002, sero Recommendations toni ly. ctive dam n 5-HT1 receptor s of water. January), cau pou aged by inflamm not required for r accu ling of cartilag they act on aS112 with a full glas –S115. agonists beRefrigeration is sure and se ation or injury. speci e fic sub . (1) Give capsules on the client’s it difficult to mea The daily dose crease sero of sero J. B. (1999).type tonin rece tuted oral solution Overview toninBuse, weight: under solution, making of current is based therapeutic ptor to (5-hydr formation options igerate reconsti in- in type 2 diabetes. oxy abscess 120 tryp and 200 n, tam lbs, Diabetes The ratio lbs, ine 800 (2) Do not refr Care, y indu or C65 1200 mg CS; ove 22(Suppl. 3), relieve migrain mg CS; 120 to 5-H –T) C69. in the brain. decrease pain, To e ) r by 200 ed . con tinu lbs, DerMarder sites stric ally taken with te Can You Avoid This Medication How (con osian, A. (Ed.) 1600 mg CS. CS ting(2001). of their vasoco bloodThe review of natural products. St. ves Error? deeply, and rota food, in two to sels. Bec Louis: is usunstrictive Compariso ause cular injections properties four divided dos ns. ction. Proponents of CS indicated in clie Facts and , the drugs are (3) Give intramus es. in a single inje Answer: Metformin nts wit cite clinical trial Drug contrafacts comparison h and e than 600 mg a hist (Glucophage) should be discontinued s. (Updated monthly). effeand ory of ang s that indicate ben St Louis: Facts cts.Comcard a few For example, ialdays Do not give mor ina pectori infarction, parisons. before any efi
diagnostic procedure involving a contrast s, myocial one study cited or uncontrolled compared CS with medium toons vary in dehypertension. The Fetrow, C. W. & Avila, crease the chance of lactic acidosis, diclofenac sodium by Fetrow and Avila R. (1999). Professional dru a potentially lethal side effect. et of action, with ’s handbook gs of complemen subcutaJ. with , an NSAID, in the most rapidly tary & alternative osteoart neous sum The incidence of lactic acidosis increases hritis of the kne 146 clients atriptan Springhous e, PA: when renal insufficiency and starting to medicines. Springhous acti e Corporation. ng e. The NSA auth is present. Urinary tract infections can Fleming, reli with ors ID D. R. eve migg (1999). Challengin concluded that relieved pain fast in 10 minutes. Mo traditional contribute to renal damage. rain insulin e headac the er but the effects st clie he injection Documenting in Mrs. Watson’s chart nts get American up topractices. Journal ofreli with Nursing, 3 months after of CS lasted long 99 (2),1 that she has taken ef wit 72 all –74. of the ora hin her mettreatment. Propon to 2 hours l drugs. er, formin is good but this is not enough Guven, S., Kuenzi, The dru J. gs A., are & Mat of CS In fin, G. (2002). Diabetes because the physician ents also tout the liver bymay inC. com met monoaminPorth M. parison with abolized in the mellitus. overlook reading it in the chart. The physician safety e oxi(Ed.), the dase Pathophysi adv ology: Concepts erse or cytochr should be notified bemai of altered effe health n states, adv cts of NSAIDs. 6therse ed., effects ome P450 enzym cause it would be prudent to reschedule pp. 930–952. Philadelphia: are reportedly The Lippincott Williamses; Mrs. Watson’s IVP. & Wilkins. addition, there minor stomach Guyton, A. C. & Hall, J. E. (2000). Textbook is ups a theo et. retical risk of blee In of medical physiology, 10th ed. ding because of Philadelphia: W. B. Saunders. the Halter, J. B. (2000). Approach to the elderly patient with diabetes. In H. D. Humes (Ed.), Kelley’s Textbook Review and Application Exercises of internal medicine, 4th ed., pp. 3032–3037. Philadelphia: Lippincott Williams & Wilkins. Hoffman, R. P. (2001). Eating disorders in adolescents with type 1 diabetes. 1. What is the function of insulin in normal Postgraduate Medicine, 109(4), 67–69, 73–74. cellular metabHu, F. B., Manson, J. E., Stampfer, M. olism? J., et al. (2001). Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. New England Journal of 2. What are the effects of insulin, cortisol, Medicine, 345(11), 790–797. epinephrine, glucagon, and growth hormone on blood Inzucchi, S. E. (2002). Oral antihyperg glucose levels? lycemic therapy for type 2 diabetes. Journal of the American Medical Association 3. What are the major differences between , 287(3), 360–372. type 1 and type Kudolo, GB. (2001). The effect of 3-month 2 diabetes? ingestion of ginkgo biloba extract (EGb761) on pancreatic beta-cell function in response to glucose 4. What is the rationale for maintaining loading in individuals with non-insulin-dependent diabetes mellitus. near-normal blood Journal of Clinical Pharmacology, 41(6), glucose levels? What is the major risk? 600–611. Ludwig, D. S. & Ebbeling, C. B. (2001). Type 2 diabetes mellitus in chil5. At what blood glucose range is brain dren. Journal of the American Medical damage most likely Association, 286(12), 1427–1430. to occur? Massey, P. B. (2002). Dietary supplement s. Medical Clinics of North America, 86(1), 127–147. 6. Compare regular, NPH, and Lente insulins in terms of Mautz, H. (2001). Undiagnosed diabetes common among Mexican-Americans. onset, peak, and duration of action. Diabetes Care, 24(7), 1204–1209. 7. Describe major characteristics and Rocchini, A. P. (2002). Childhood obesity and a diabetes uses of insulin epidemic (Editorial). New England Journal of Medicine, 346 analogs. (11), 854–855. Setter, S. M., White, J. R., Jr., & Campbell, R. K. (2000). Diabetes. In E. T. 8. In a diabetic client with typical signs and symptoms, disHerfindal & D. R. Gourley (Eds.), Textbook of therapeutic s: Drug and tinguish between manifestations of hypergly disease management, 7th ed., pp. 377– cemia and 406. hypoglycemia. Silverstein, J. H. & Rosenbloom, A. L. (2000). New developments in type 1 (insulin-dependent) diabetes. Clinical 9. Contrast the five types of oral hypoglyc Pediatrics, 39, 257–266. emic agents in Sinha, R., Fisch, G., Teague, B., et al. (2002). Prevalence of impaired gluterms of mechanisms of action, indicatio cose tolerance among children and adolescents ns for use, conwith marked obesity. New traindications to use, and adverse effects. England Journal of Medicine, 346(11), 802–810. Skyler, J. S. (2000). Approach to hyperglyce 10. For an adult client newly diagnose mia in the patient with diad with type 2 diabetes mellitus. In H. D. Humes (Ed.), Kelley betes, outline interventions to assist the ’s Textbook of internal medclient in learnicine, 4th ed., pp. 2635–2648. Philadelph ia: Lippincott Williams & ing self-care. Wilkins. Thompson, W. G. (2001). Early recognition and treatment of glucose abnormalities to prevent type 2 diabetes mellitus and coronary heart disease. Mayo Clinic Proceedings, 76, 1137–1143.

Home Care content is highlighted in the text. Nursing Actions give students specific instructions on administration of drugs, with rationales for each step.

11. Prepare a teaching plan for a client starting insulin therapy and for a client starting an oral hypoglyc emic drug.

Nursing Notes and How Can You Avoid This Medication Error? answers are provided at the end of the chapter so students can think on their own, and compare their answers to the ones within the text. Review and Application Exercises gives students the opportunity to review what they just learned.

Associate of Science in Nursing Mississippi University for Women Columbus. Delaware. Truttmann. MS. MS Associate Professor of Nursing Onondaga Community College Syracuse. RN. BScN. New York Deanna L. RN. MSN Nursing Instructor Northeast Wisconsin Technical College Green Bay. Indiana Judy M.Reviewers Sarah P. Wisconsin Christine Hobbs. Reising. MSN Associate Professor of Nursing Pennsylvania College of Technology Williamsport. MEd. RN. CS. Virginia Denise R. RN. BSN. CNS Associate Professor Columbus State Community College Columbus. BSN Nursing Instructor Southwest Virginia Community College Grundy. PhD Mary Elliott. MSN Assistant Professor of Nursing Truman State University Nursing Program Kirksville. RN. BSN. RNC. Mississippi Dorothy Mathers. RN. Pennsylvania viii . Ontario Canada Assistant Professor Indiana University School of Nursing Bloomington. Missouri Peggy Przybycien. Ohio Mary Jo Kirkpatrick. RNC. RN. MSN Director. MEd Professor Humber College of Applied Arts and Technology Etobicoke. York.

1 Introduction to Drug Therapy .

chapter 1 Introduction to Pharmacology Objectives AFTER STUDYING THIS CHAPTER. Develop personal techniques for learning about drugs and using drug knowledge in client care. Select authoritative sources of drug information. Define a prototypical drug. ᮣ Review your course syllabus and pharmacology text. Drug therapy. is the use of drugs to prevent. you want to develop a strong foundation in pharmacology. You anticipate that pharmacology will be challenging. To increase your clinical knowledge and ensure that you will be a safe practitioner. Have you ever wondered why it’s usually okay to give children Tylenol but not aspirin? Why a lot of middle-aged and older people take an aspirin a day? Why people with high blood pressure. grandparents. Perhaps you’ve given medicines to your children. and where they are used in daily life. Develop a learning plan (eg. 2. . Differentiate the main categories of controlled substances in relation to therapeutic use and potential for abuse. and pharmacology. student study groups) and develop a plan to use them. This quarter you will be taking a basic nursing theory course. 7. Discuss the role of the Food and Drug Administration. peer tutors. readings. The purpose of 2 Y this book is to help you learn about medicines and the why. study times for major tests) and enter this plan into your calendar. Bon voyage!! OVERVIEW Pharmacology is the study of drugs (chemicals) that alter functions of living organisms. or others. how. symptoms. 8. also called pharmacotherapy. Differentiate between pharmacology and drug therapy. ᮣ Assess support for your learning at your school (eg. Critical Thinking Scenario This is your first semester of clinical nursing. learning center. Discuss nursing responsibilities in handling controlled substances correctly. Reflect on which strategies might be helpful this semester. a skills laboratory. parents. 3. relief of symptoms can greatly improve quality of life and ability to function in activities of daily living. 9. when. and disease processes. 4. Drugs given for therapeutic purposes are usually called medications. assignments. Differentiate between generic and trade names of drugs. 10. what. or diabetes take ACE inhibitors and what ACE inhibitors are? When an antibiotic should NOT be prescribed for an infection? You are embarking on an exciting journey of discovery as you begin or continue your study of pharmacology. When prevention or cure is not a reasonable goal. Discuss major drug laws and standards. THE STUDENT WILL BE ABLE TO: 1. A MESSAGE TO STUDENTS ou’ve probably been taking medicines and seeing other people take medicines most of your life. diagnose. 6. Reflect on: ᮣ List successful strategies you have used in the past to learn difficult material. Analyze the potential impact of drug costs on drug therapy regimens. heart failure. Much of what you learn will apply to your personal and family life as well as your professional life as a nurse. 5. or treat signs.

antidepressants. For example. Other pharmaceutical companies cannot manufacture and market the drug. trade names are capitalized and generic names are lowercase unless in a list or at the beginning of a sentence. Trimox) and several of which use only the generic name. In many instances. to relieve signs and symptoms of chronic disorders). some of which assign a specific trade name (eg. DRUG MARKETING A new drug is protected by patent for 14 years. benzodiazepines). fluvoxamine (Luvox). act mainly at the site of application. deleting. can often create a useful new drug by altering the chemical structure of an existing drug (eg. which are often the first drug of a particular group to be developed. For example. However. morphine can be classified as a central nervous system depressant. Many drugs are given for their long-term effects. animals (eg. However. called a clone. Drugs may be prescribed and dispensed by generic or trade name. Most drugs are given for their systemic effects. and sertraline (Zoloft). The names of therapeutic classifications usually reflect the conditions for which the drugs are used (eg. Drug classifications and prototypes are quite stable. Each hybrid molecule produces a genetically identical molecule. their therapeutic uses. drugs may be given for local or systemic effects. groups reflect their chemical characteristics rather than therapeutic uses (eg. and their chemical characteristics. similar drugs are compared.CHAPTER 1 INTRODUCTION TO PHARMACOLOGY 3 Medications may be given for various reasons. Such techniques and other technologic advances have enabled the production of new drugs as well as synthetic versions of many drugs originally derived from plants and animals. with different generic and trade names. but the two most commonly used are the generic name and the trade name (also called the brand or proprietary name). amoxicillin) is related to the chemical or official name and is independent of the manufacturer. However. other companies often produce similar drugs. DRUG NAMES Individual drugs may have several different names. and as an opiate (derived from opium). during which it can be marketed only by the pharmaceutical manufacturer that developed it. Those with systemic effects are taken into the body. drugs were mainly derived from plants (eg. iron). most drugs are synthetic chemical compounds manufactured in laboratories. antiadrenergics. DRUG CLASSIFICATIONS AND PROTOTYPES Drugs are classified according to their effects on particular body systems. Drugs may also be given for relatively immediate effects (eg. more commonly used drugs. and an incentive for developing other drugs. and most new drugs can be assigned to a group and compared with an established prototype. Cloning also allows production of adequate amounts of the drug for therapeutic or research purposes. adding. for new drugs that are popular and widely used. Prototypes. The trade name is designated and patented by the manufacturer. paroxetine (Paxil). and minerals (eg. This process involves manipulating deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) and recombining genes into hybrid molecules that can be inserted into living organisms (Escherichia coli bacteria are often used) and repeatedly reproduced. for example. insulin). Synthetic drugs are more standardized in their chemical characteristics. amoxicillin is manufactured by several pharmaceutical companies. the goal of drug therapy is to lessen disease processes rather than cure them. which may require years of work and millions of dollars. Cloning makes it possible to identify the DNA sequence in a gene and produce the protein product encoded by a gene. in acute problems such as pain or infection) or long-term effects (eg. Generic drugs are required to be therapeutically equivalent and are much less expensive than trade name drugs. Prozac was approved in 1987 and went off patent in 2001. SOURCES OF DRUGS Where do medications come from? Historically. drugs with generic names ending in “cillin” are penicillins). such as sunscreen lotions and local anesthetics. The generic name often indicates the drug group (eg. such as citalopram (Celexa). Chemists. For example. or altering a side-chain). and less likely to produce allergic reactions. antidiabetic drugs). Semisynthetic drugs (eg. penicillin is the prototype of antibacterial drugs. For example. adrenergics. To meet this goal. Amoxil. Now. more consistent in their effects. morphine). Drugs with local effects. Biotechnology is also an important source of drugs. many antibiotics) are naturally occurring substances that have been chemically modified. the marketing of fluoxetine (Prozac) led to the introduction of similar drugs from different companies. Individual drugs that represent groups of drugs are called prototypes. This is seen as a return on the company’s investment in developing a drug. a narcotic or opioid analgesic. including insulin and several other body proteins. In drug literature. Many commonly used drugs fit into multiple groups because they have wide-ranging effects on the human body. some groups lack a universally accepted prototype and some prototypes are replaced over time by newer. the names of many drug . and eventually eliminated from the body. morphine is the prototype of opioid analgesics. antihypertensives. The generic name (eg. are usually the standards with which newer. meaning that any pharmaceutical company could then manufacture and market the generic formulation of fluoxetine. circulated through the bloodstream to their sites of action in various body tissues.

called the Controlled Substances Act. or the Physicians’ Desk Reference (PDR). the organization does not test the drugs. the stricter laws usually apply. the Comprehensive Drug Abuse Prevention and Control Act. Nurses are responsible for storing controlled substances in locked containers. and research projects that compare costs have greatly increased in recent years. administration (eg. is illegal. Title II of this law. pharmacy technicians). many drugs were marketed without confirmation of safety or . Before passage of the Food. storage. salaries of pharmacists. Costs are increasingly being considered a major factor in choosing medications. In addition. and provide for secure storage. the Public Health Service regulates vaccines and other biologic products.4 SECTION 1 INTRODUCTION TO DRUG THERAPY PHARMACOECONOMICS Pharmacoeconomics involves the costs of drug therapy. Canadian Drug Laws and Standards Canada and its provinces have laws and standards that parallel those of the United States. It also confers official status on drugs listed in The United States Pharmacopeia. morphine. is labeled C–II). The names of these drugs may be fol- lowed by the letters USP. The DurhamHumphrey Amendment designated drugs that must be prescribed by a physician and dispensed by a pharmacist. and reporting discrepancies to the proper authorities. are safe and effective. particularly those related to controlled substances (see Appendix D). The Food and Drug Administration (FDA) is charged with enforcing the law. whether prescription or OTC. from managed care organizations) to prescribe less costly drugs. Both of these routes are regulated by various drug laws. Another important law. How did the resources you used differ in the organization and depth of information provided about drugs? DRUG APPROVAL PROCESSES The FDA is responsible for assuring that new drugs are safe and effective before approving the drugs and allowing them to be marketed. distribution. These drugs are categorized according to therapeutic usefulness and potential for abuse (Box 1–1) and labeled as controlled substances (eg. such as a physician. The Drug Enforcement Administration (DEA) is charged with enforcing the Controlled Substances Act. Official drugs must meet standards of purity and strength as determined by chemical analysis or animal response to specified doses (bioassay). hallucinogens. The FDA reviews research studies (usually conducted or sponsored by a pharmaceutical company) about proposed new drugs. and losses from expiration. These laws may be more stringent than federal laws. costs of supplies). The goal of most studies is to define drug therapy regimens that provide the desired benefits at the least cost. Their main goal is to protect the public by ensuring that drugs marketed for therapeutic purposes. Nursing Notes: Apply Your Knowledge Using this text and a drug handbook. The other route is by over-the-counter (OTC) purchase of drugs that do not require a prescription. and labeling of drugs. dispensing (eg. American consumers have two routes of access to therapeutic drugs. PRESCRIPTION AND NONPRESCRIPTION DRUGS Legally. The Food. regulates the manufacture and distribution of narcotics. look up the following drugs: meperidine and diazepam. and Cosmetic Act. dentist. Their main provisions are summarized in Table 1–1. Indicate the controlled substance category for each drug. there is considerable pressure on prescribers (eg. keep accurate records of all transactions. was passed in 1970. if so. Drug. state laws also regulate the sale and distribution of controlled drugs. American Drug Laws and Standards Current drug laws and standards have evolved over many years. or nurse practitioner. laboratory and other tests used to monitor client responses. Physicians are assigned a number by the DEA and must include the number on all prescriptions they write for a controlled substance. Acquiring and using prescription drugs for nontherapeutic purposes. recording each dose given on agency narcotic sheets and on the client’s medication administration record. by persons who are not authorized to have the drugs or for whom they are not prescribed. and anabolic steroids. From the information you obtained in researching the drug. advertising. For drugs or regimens of similar efficacy and toxicity. maintaining an accurate inventory. Individuals and companies legally empowered to handle controlled substances must be registered with the DEA. including those of purchasing. In addition to federal laws. a new prescription is required. Prescriptions for Schedule II drugs cannot be refilled. salaries of nurses. administering them only to people for whom they are prescribed. depressants. Length of illness or hospitalization is also considered. stimulants. reflect on why each drug was placed in the assigned category. Drug. and Cosmetic Act of 1938 was especially important because this law and its amendments regulate the manufacture. One route is by prescription or order from a licensed health care provider. and the Federal Trade Commission can suppress misleading advertisements of nonprescription drugs. a Schedule II drug.

and drugs limited to prescription use under a manufacturer’s new drug application) • Required a manufacturer to provide evidence (from well-controlled research studies) that a drug was effective for claims and conditions identified in the product’s labeling • Gave the federal government the authority to standardize drug names • Regulated distribution of narcotics and other drugs of abuse • Categorized these drugs according to therapeutic usefulness and potential for abuse Pure Food and Drug Act Sherley Amendment Harrison Narcotic Act Food. Drug. and other safeguards. Schedule IV Drugs with some potential for abuse: benzodiazepines (eg. by hiring more staff) • Specified a review time of 12 months for standard drugs and 6 months for priority drugs • Updated regulation of biologic products • Increased client access to experimental drugs and medical devices • Accelerated review of important new drugs • Allowed drug companies to disseminate information about off-label (non–FDA-approved) uses and costs of drugs • Extended user fees FDA. drugs considered unsafe for use except under supervision by a health care provider. methadone. and use of opium. meperidine. and mixtures containing small amounts of controlled substances (eg. barbiturates not listed in other schedules). mescaline. but abuse may lead to psychological or physical dependence: an- . BOX 1–1 CATEGORIES OF CONTROLLED SUBSTANCES drogens and anabolic steroids. oxycodone. phentermine). marijuana. such as diphenoxylate and atropine (Lomotil). record keeping. controlled substances. marijuana. benzphetamine). tetrahydrocannabinol. hydromorphone. manufacture. lorazepam. Schedule V Products containing moderate amounts of controlled substances. Food and Drug Administration. Schedule III Drugs with less potential for abuse than those in Schedules I and II. lysergic acid diethylamide (LSD). with each new drug application. and some prescription appetite suppressants (eg. codeine. other sedative-hypnotics (eg. Title II. methamphetamine. sale. to shorten the review time (eg. and Cosmetic Act 1945 1952 Amendment Durham-Humphrey Amendment 1962 Kefauver-Harris Amendment 1970 1978 1983 1987 1992 Comprehensive Drug Abuse Prevention and Control Act. chloral hydrate). phenobarbital. methylphenidate). Included are antidiarrheal drugs. pentobarbital. some CNS stimulants (eg. such as insulin and antibiotics Designated drugs that must be prescribed by a physician and dispensed by a pharmacist (eg. peyote. temazepam). Schedule II Drugs that are used medically and have high abuse potentials: opioid analgesics (eg. and barbiturate sedative-hypnotics (amobarbital. morphine. codeine. and other drugs that the act defined as narcotics • Required proof of safety from the manufacturer before a new drug could be marketed • Authorized factory inspections • Established penalties for fraudulent claims and misleading labels Required governmental certification of biologic products. oxymorphone). central nervous system (CNS) stimulants (eg. diazepam. cocaine. Schedule I Drugs that are not approved for medical use and have high abuse potentials: heroin. Controlled Substances Act Drug Regulation Reform Act Orphan Drug Act Prescription Drug User Fee Act 1997 FDA Modernization Act • Established guidelines for research studies and data to be submitted to the FDA by manufacturers • Shortened the time required to develop and market new drugs • Decreased taxes and competition for manufacturers who would produce drugs to treat selected serious disorders affecting relatively few people • Established new regulations designed to speed up the approval process for high-priority medications • Allowed the FDA to collect user fees from pharmaceutical companies. mazindol.CHAPTER 1 INTRODUCTION TO PHARMACOLOGY 5 TABLE 1–1 Year 1906 1912 1914 1938 Name American Drug Laws and Amendments Main Provision(s) Established official standards and requirements for accurate labeling of drug products Prohibited fraudulent claims of drug effectiveness Restricted the importation. cocaine. They may be dispensed by the pharmacist without a physician’s prescription but with some restrictions regarding amount. secobarbital).

Other research methods include control studies. random assignment of subjects to experimental groups. FDA approval of a drug for OTC availability involves evaluation of evidence that the consumer can use the drug safely. Numerous drugs have been transferred from prescription to OTC status in recent years and the trend is likely to continue. in which some clients receive a known drug rather than a placebo. and subject matching. absorption. For drugs taken orally. partly or mainly because of the increased postmarketing surveillance. For example. 600. and recognize drugs already being taken that might interact adversely with the drug being considered? .6 SECTION 1 INTRODUCTION TO DRUG THERAPY efficacy. Questions to be answered include the following: 1. interpret warnings and contraindications and determine whether they apply. The drugs are carefully evaluated at each step. Individual patients are not identified in these databases. the recommended dose is usually 200 to 400 mg three or four times daily. In 1992. Several drugs have been withdrawn in recent years. controlled experimental design that involves selection of subjects according to established criteria. and toxicity. and shifts primary responsibility for safe and effective drug therapy from health care professionals to consumers. the client must make these decisions. The drug then undergoes clinical trials in humans. and may require additional clinical trials to determine safety and effectiveness of OTC use. With OTC drugs. Phase III studies help to determine whether the potential benefits of the drug outweigh the risks. “1S” status indicates standard review and drugs with few. metabolism. Advil) in 200-mg tablets and used for pain. and recommended doses are usually lower for the OTC formulation. One such effort involves contracts with some commercial companies that provide access to databases containing information on the actual use of prescription drugs in adults and children. verse effects. especially for their adThe FDA approves many new drugs annually. The FDA has increased efforts to monitor marketed drugs more closely in recent years. placebo-controlled designs. and requires manufacturers to continue monitoring the drug’s effects. Can consumers accurately self-diagnose the condition for which a drug is indicated? 2. With prescription ibuprofen. newly developed drugs have been extensively tested before being marketed for general use. and administration of the test drug to one group and a control substance to another group. including the transfer of drugs from prescription to OTC status. Since then. however. In crossover studies. each subject receives the experimental drug during half the study and a placebo during the other half. the drug is given to a larger and more representative group of subjects. the FDA evaluates the data from the first three phases for drug safety and effectiveness. and dysmenorrhea. fever. and the use of prescription drugs in hospitalized children. The next step involves FDA review of the data obtained in the animal studies. Motrin is the common trade name and dosage may be 400. routes of administration. Since 1962. the new drug is similar to one already available). some drugs are marketed but later withdrawn. excretion. proponents claim that the faster review process helps clients with serious diseases to gain effective treatment more quickly. With prescription drugs. especially for drugs used to treat acquired immunodeficiency syndrome. “1P” status indicates a new drug reviewed on a priority basis and with some therapeutic advantages over similar drugs already available. a few doses are given to a few subjects with the disease or symptom for which the drug is being studied. In Phase III. Testing usually proceeds if there is evidence of safety and effectiveness but may be stopped at any time for inadequate effectiveness or excessive toxicity. Food and Drug Administration Approval Testing and Clinical Trials The testing process begins with animal studies to determine potential uses and effects. in which clients are paired with others of similar characteristics. In Phase IV. half the subjects receive the new drug and half receive a placebo. Some adverse drug effects may become evident during the postmarketing phase as the drug is more widely used. Can consumers read and understand the label well enough to determine the dosage. and determines a need for the drug. Critics contend that changes enacted to streamline the approval process have allowed unsafe drugs to be marketed. In Phase I. or 800 mg three or four times daily. procedures were changed to accelerate the approval process. for OTC ibuprofen. and responses are compared with those of healthy subjects. new drugs are categorized according to their review priority and therapeutic potential. if any. In Phase II. with or without consultation with a health care provider. using information on the product label. usually because of adverse effects that become evident only when the drug is used in a large. The FDA also approves drugs for OTC availability. subjects serve as their own controls. In double-blind. diverse population. Examples of information include how long nonhospitalized patients stay on prescribed medications. allows the drug to be marketed for general use. a few doses are given to a few healthy volunteers to determine safe dosages. which combinations of medications are being prescribed to patients. indications for use may be different. Many potential drugs are discarded and never marketed. Most newly approved drugs are “1S” prescription drugs. a health care professional diagnoses the condition. Most clinical trials use a randomized. with neither subjects nor researchers knowing who receives which formulation. which is available under its generic and several trade names (eg. therapeutic advantages (ie. often with the help of laboratory and other diagnostic tests.

Different references give you different information and are organized differently.rxmed. especially for dosage ranges. published annually) and pharmacologic. Disadvantages include inaccurate self-diagnoses and potential risks of choosing a wrong or contraindicated drug. morphine is the prototype of opioid analgesics (see Chap. Numerous drug handbooks (eg. Diazepam (Valium) is an antianxiety agent that has some potential for abuse. Journal articles often present information about drug therapy for clients with specific disease processes and may thereby facilitate application of drug knowledge in clinical practice. Is the drug effective when used as recommended? 4. 6). These include the main indications for delaying treatment by a health care professional. any reported side effect is given rather than identifying the most common or most serious side effects). definitions of new terms. 3. is a compilation of manufacturers’ package inserts for selected drugs. write notes. Helpful Internet sites include the Food and Drug Administration (http:// www.fda. journal articles. and trade names of drugs encountered in clinical practice settings directly into your pharmacology textbook. Costs to consumers may increase because health insurance policies do not cover OTC drugs. For example. Also. They are arranged alphabetically and assume you have a basic understanding of pharmacology. up-to-date drug reference readily available. 5. and related nursing care needs. including pharmacology textbooks. It provides the reader with drug inserts from the manufacturer and color photographs of many medications. This is a much more reliable source of drug information than memory. faster and more convenient access to effective treatment. and possibly increased efforts by consumers to learn about their symptoms/conditions and recommended treatments.CHAPTER 1 INTRODUCTION TO PHARMACOLOGY 7 3. and nursing journals also contain information about drugs. common and potentially serious adverse effects. preferably at work and home. prevent. Compare a newly encountered drug with a prototype when possible. This allows you to predict therapeutic effects and to predict. it was estimated that Americans spent more than $19 billion on OTC drugs. Advantages include greater autonomy. pharmaceutical companies’ sales and profits increase and insurance companies’ costs decrease. published yearly. Understanding morphine makes learning about other opioid analgesics easier because they are compared with morphine. The PDR is available in many health care facilities. It is published annually. 6. Concentrate your study efforts on major characteristics. answers to review questions. fewer visits to a health care provider. medical. Lippincott’s Nursing Drug Guide. The PDR. 7. drug reference books. Concentrate on therapeutic classifications and their prototypes. Drug handbooks are helpful when you are trying to research specific information about a specific drug. A widely available but less authoritative source is the Physicians’ Desk Reference (PDR). conditions in which the drug is contraindicated or must be used cautiously. SOURCES OF DRUG INFORMATION There are many sources of drug data. For the beginning student of pharmacology. The mental processing required for these activities helps in both initial learning and later retention of knowledge. It is the best resource to use when you are first learning about drugs. and Internet sites. For the year 2000. or minimize adverse effects by early detection and treatment. Use the reference freely whenever you encounter an unfamiliar drug or when a question arises about a familiar possibly earlier resumption of usual activities of daily living. A nursing textbook of pharmacology is comprehensive and gives you enough information to understand how drugs work. Drug reference books are most helpful in relation to individual drugs. Keep an authoritative. and RxMed (http://www. “What if I have a client who is receiving this drug? What must I do to safely administer the drug? For what must I assess the client before giving the drug and for what must I observe the client after drug administration? What if my client is an elderly person or a child?” Nursing Notes: Apply Your Knowledge Answer: Meperidine (Demerol) is an opioid analgesic that is used to manage severe pain. so it is listed as a Schedule IV drug. but without prioritization (eg. Is the drug safe when used as instructed? Having drugs available OTC has potential advantages and disadvantages for consumers. When a drug is switched from prescription to OTC status. STRATEGIES FOR STUDYING PHARMACOLOGY 1. Relating the unknown to the known aids learning and retention of knowledge. and developing adverse drug reactions and interactions. Two authoritative sources are the American Hospital Formulary Service and Drug Facts and Comparisons. 2. Use your own words when taking notes or writing drug information cards. 8. which can make it difficult for a beginning student to use effectively. so it is a good resource for new drugs. Mentally rehearse applying drug knowledge in nursing care by asking yourself. a textbook is usually the best source of information because it describes groups of drugs in relation to therapeutic uses. The latter is published by the Facts and Comparisons division of Lippincott Williams & Wilkins and updated monthly (looseleaf edition) or annually (hardbound edition). Much information is provided. Try to understand how the drug acts in the body. The former is published by the American Society of Health-System Pharmacists and updated periodically. Its abuse potential is high and it is therefore given a Schedule II classification. .

Accessed 25 January 2003. United States Food and Drug Administration. pp. Philadelphia: Lippincott Williams & Wilkins. In H.. Why is it helpful for nurses to know the generic names of commonly used medications? 4. Journal of the American Board of Family Practice. . Lipsky.). J. D. (2001). 345(11).8 SECTION 1 INTRODUCTION TO DRUG THERAPY Review and Application Exercises 1. (2000). 6. B.] Available: http://www. P. 810–816. List at least three strategies for studying pharmacology. Frequently asked questions. New England Journal of Medicine. [On-line. Can a client experience systemic effects of local drugs and local effects of systemic drugs? Why or why not? 3. (2001). L. From idea to market: The drug approval process. & Sharp.fda. Kelley’s Textbook of internal medicine. List at least three authoritative sources of drug information. S. Geriatric clinical pharmacology.html. 3095–3107. Why is it helpful to study prototypes of drug groups? 5. 4th ed. Schwartz. Changing the status of drugs from prescription to overthe-counter availability. 362–367. SELECTED REFERENCES Brass. What is the difference between local and systemic effects of drugs? 2. 14(5). K. E. Humes (Ed.

9. Although cells differ from one tissue to another. They can stimulate or inhibit normal cellular functions and activities. Green.chapter 2 Basic Concepts and Processes Objectives AFTER STUDYING THIS CHAPTER. Discuss general management of drug overdose and toxicity. what factors might alter the pharmacokinetics (absorption. THE STUDENT WILL BE ABLE TO: 1. Identify signs and symptoms that may occur with adverse drug effects on major body systems. Discuss the clinical usefulness of measuring serum drug levels. lives alone and has recently started taking many heart medications. busy. These concepts and processes form the foundation of rational drug therapy and the content of this chapter. manufacture various products required to maintain cellular and bodily functions. and leave body cells? How do people respond to drug actions? The answers to these questions are derived from cellular physiology. To act on body cells. Critical Thinking Scenario Mrs. 4. and deliver those products to their appropriate destinations in the body. and other basic concepts and processes. Differentiate between agonist drugs and antagonist drugs. they must enter the body and be circulated to their sites of action (target cells). Reflect on: ᮣ Considering Mrs. Describe major characteristics of the receptor theory of drug action. Box 2–1). pathways A and mechanisms of drug transport. interact with. metabolism. 7. their common characteristics include the ability to: 9 . an 89-year-old widow. 5. you assess therapeutic and adverse effects of her medications. She prides herself on being independent and able to manage on her own despite failing memory and failing health. pharmacodynamics. drugs given for systemic effects must reach adequate concentrations in blood and other tissue fluids surrounding the cells. That is. 2–1. 8. excretion) of the drugs she takes? What data will you collect to determine her risk? ᮣ What psychosocial factors could affect the therapeutic and adverse effects of Mrs. Describe the main pathways and mechanisms by which drugs cross biologic membranes and move through the body. 11. Discuss selected drug antidotes. pharmacokinetics. After they act on cells. Green’s age. Describe each process of pharmacokinetics. Discuss cellular physiology in relation to drug therapy. Discuss mechanisms and potential effects of drug–drug interactions. Describe drug-related and client-related variables that affect drug actions. 10. Thus. distribution. they must be eliminated from the body. When you visit as a home health nurse. CELLULAR PHYSIOLOGY Cells are dynamic. “factories” (Fig. Drugs are chemicals that alter basic processes in body cells. the risk for drug interactions and toxicity increases. they take in raw materials. OVERVIEW ll body functions and disease processes and most drug actions occur at the cellular level. 3. 2. Green? ᮣ When clients are taking many medications. 6. Describe how you will develop a plan to research possible drug interactions for any client. How do systemic drugs reach. Green’s medications? What data will be important to collect before developing a plan for Mrs. they cannot add functions and activities.

structural proteins. drug half-life. systemic absorption occurs from the mucosa of the oral cavity. Dosage form is a major determinant of a drug’s bioavailability (the portion of a dose that reaches the systemic circulation and is available to act on body cells). systemic effects). Absorption is rapid from IM sites because muscle tissue has an abundant blood supply. scopolamine). Several transport pathways and mechanisms are used to move drug molecules through the body (Fig. leave the bloodstream and attach to receptors on cells. and other complex molecules • Duplicate themselves (reproduce) • Communicate with each other via various biologic chemicals. liver. However. and other important aspects of drug therapy. drug molecules must cross numerous cell membranes. peak and duration of drug actions. and be excreted in urine. therapeutic and adverse drug effects. neurotransmitters. the presence of food or other drugs. 2–3 and Box 2–2). Drugs absorbed through mucous membranes pass directly into the bloodstream. route of administration. Most drugs are given for effects on body cells that are distant from the sites of administration (ie. Systemic absorption is minimal from intact skin but may be considerable when the skin is inflamed or damaged. To move through the body and reach their sites of action. the presence of food in the stomach slows the rate of absorption and may decrease the amount of drug absorbed. GI function. Numerous factors affect the rate and extent of drug absorption. mucous membranes. PHARMACOKINETICS Pharmacokinetics involves drug movement through the body (ie. reach drug-metabolizing enzymes in liver cells. Drugs injected intravenously (IV) do not need to be absorbed because they are placed directly into the bloodstream. Also. as well as physiologic substances such as hormones and neurotransmitters. Other absorptive sites include the skin. Drugs injected into subcutaneous (SC) or intramuscular (IM) tissues are usually absorbed more rapidly than oral drugs because they move directly from the injection site to the bloodstream. enzymes. a number of drugs have been formulated in adhesive skin patches for absorption through the skin (eg. metabolism. and excretion (Fig. dissolved in gastric fluid. it also may decrease absorption because some drugs may move through the small intestine too rapidly to be absorbed. For example. Rapid movement through the stomach and small intestine may increase drug absorption by promoting contact with absorptive mucous membrane. blood flow to the site of administration. clonidine. and capillaries to reach the bloodstream.10 SECTION 1 INTRODUCTION TO DRUG THERAPY Cell membrane Cytoplasm Lysosomes Chromatin Nucleus Endoplasmic reticulum Ribosomes Golgi apparatus Mitochondria distribution. eye. Specific processes are absorption. Most oral drugs must be swallowed. nose. sunscreens). circulate to their target cells. Most drugs applied to the skin are given for local effects (eg. metabolism (biotransformation). onset. fentanyl. circulate to the liver. Figure 2–1 organelles. and rectum. Some drugs applied to mucous membranes also are given for local effects. an oral drug is virtually always less than 100% bioavailable because some is not absorbed from the GI tract and some goes to the liver and is partially metabolized before reaching the systemic circulation. . these processes largely determine serum drug levels. nitroglycerin. re-enter the bloodstream (usually as metabolites). and other variables. including dosage form. and excretion. vagina. such as neurotransmitters and hormones DRUG TRANSPORT THROUGH CELL MEMBRANES Drugs. molecules of most oral drugs must cross the membranes of cells in the gastrointestinal (GI) tract. An intravenous drug is virtually 100% bioavailable. metabolism. Onset of drug action is largely determined by the rate of absorption. and delivered to the small intestine (which has a large surface area for absorption of nutrients and drugs) before they are absorbed. Overall. and excretion. estrogen. and lungs. return to the bloodstream. intensity is determined by the extent of absorption. Absorption Absorption is the process that occurs from the time a drug enters the body to the time it enters the bloodstream to be circulated. Schematic diagram of cell highlighting cytoplasmic • Exchange materials with their immediate environment • Obtain energy from nutrients • Synthesize hormones. circulate to the kidneys. must reach and interact with or cross the cell membrane in order to stimulate or inhibit cellular function. Liquid medications are absorbed faster than tablets or capsules because they need not be dissolved. The lungs have a large surface area for absorption of anesthetic gases and a few other drugs. 2–2). “what the body does to the drug”) to reach sites of action. For many drugs. perform their action.

The cell membrane. Electrolytes provide chemicals for cellular reactions and are required for some processes (eg. enzymes. electrolytes (potassium. include integral and peripheral proteins. electrolytes. In addition. destroying surrounding cells. consists of a thin. foreign substances (eg.CHAPTER 2 BASIC CONCEPTS AND PROCESSES 11 BOX 2–1 CELL STRUCTURES AND FUNCTIONS activated by enzyme inhibitors and excessive tissue destruction is prevented. and other chemicals are dissolved or suspended in the water. located in the middle of the membrane. a storage form of glucose that can be rapidly converted when needed. cellular enzymes. a complex structure composed of phospholipids. The lipid layer is composed of phospholipid (fatty acid and phosphate) molecules. but is impermeable to water-soluble substances such as ions and glucose. and carbohydrates. When a cell becomes worn out or damaged. and the cell itself. Cell membrane carbohydrates occur mainly in combination with proteins (glycoproteins) or lipids (glycolipids). after an appropriate stimulus. the carbohydrate molecules are free to interact with extracellular substances and perform several important functions. They are usually attached to the intracellular side of the membrane and to integral proteins. proteins. Third. separates intracellular contents from the extracellular environment. which covers the entire surface of the cell. The protein portion protrudes on the intracellular side of the cell membrane. mainly phospholipids and cholesterol. the glyco portion protrudes to the outside of the cell. phosphate. The Golgi complex stores hormones and other substances produced by the ER. damaged cellular structures. cholesterol and carbohydrates. The nucleus might be called the “manager” of cellular activities because it regulates the type and amount of proteins. the “carbohydrate coat” of some cells attaches to the carbohydrate coat of other cells and thereby connects cells to each other. form the membranes that separate structures inside the cell and the cell itself from surrounding cells and body fluids. and helps regulate growth and proliferation. These proteins function as enzymes and other substances that regulate intracellular function. the membrane around the lysosome breaks and the enzymes (hydrolases) are released. Mitochondria generate energy for cellular activities and require oxygen. potassium. Still others act as enzymes to catalyze chemical reactions within the cell. and calcium ions) can diffuse between extracellular and intracellular fluids. The cytoplasm surrounds the nucleus and contains the working units of the cell. is soluble only in fat. and bicarbonate). Lysosomes are membrane-enclosed vesicles that contain enzymes capable of digesting nutrients (proteins. It is composed of water. are released from the cell through the process of exocytosis. Thus. lysosomal contents also are released into extracellular spaces. many of the carbohydrates act as receptor molecules for binding hormones (eg. proteins. The phosphate end of each phospholipid molecule. Normally. Protoplasm comprises the internal environment of body cells. Lipids. Peripheral proteins do not penetrate the cell membrane. most of which are combined with a carbohydrate as glycoproteins. As a result. sulfate. which then move out of the Golgi complex into the cytoplasm and. The receptor–hormone combination then activates the attached inner core of protein to perform its enzymatic or other functions in the cell. transmission of electrochemical impulses in nerve and muscle cells). the enzymes are in- . which synthesize enzymes and other proteins. Integral proteins penetrate through the entire membrane so that each end is available to interact with other substances. bacteria). participates in electrical events that occur in nerve and muscle cells. Glucose is present in extracellular fluid and readily available to supply the cell’s need for energy. Carbohydrates play a minor role in cell structure. 2–3). a small amount of carbohydrate is stored within the cell as glycogen. The endoplasmic reticulum (ER) contains ribosomes. double layer of lipids interspersed with proteins (see Fig. Some of these proteins provide structural channels or pores through which water and water-soluble substances (eg. and other substances to be produced. They consist of “physical” proteins that form the structure of cells and “chemical” proteins that function mainly as enzymes within the cell. is soluble in water. located on the external surface and in contact with the tissue fluids surrounding the cell. Cell membrane proteins. dangling outward from the cell surface. The cell membrane. However. These include enzymes that synthesize glycogen. sodium. magnesium. Second. Water makes up 70% to 85% of most cells. It also packages these substances into secretory granules. The fatty acid end of the phospholipid molecule. provides receptors for hormones and other biologically active substances. These enzymatic proteins come into direct contact with other substances in the cell fluid and catalyze chemical reactions within the cell. Glycoproteins composed of carbohydrate around a small. inner core of protein (called proteoglycans) often are attached to and cover the entire outside surface of the cell. Others act as carriers to transport substances that otherwise could not penetrate the lipid layer of the membrane. insulin). this portion of the membrane allows easy penetration of fat-soluble substances such as oxygen and alcohol. carbohydrates. fats). triglycerides. The ER is important in the production of hormones by glandular cells and the production of plasma proteins and drug-metabolizing enzymes by liver cells. many have a negative electrical charge which gives most cells an overall negative surface charge that repels other negatively charged substances. and steroids and those that detoxify drugs and other chemicals. First. Proteins comprise 10% to 20% of the cell mass. but a major role in cell nutrition. lipids.

Distribution Distribution involves the transport of drug molecules within the body. etc. Drug distribution during pregnancy and lactation is also unique (see Chap. However. metabolism. and excretion. expired air. Distribution depends largely on the adequacy of blood circulation. diffusing through open or gated channels. Nucleus Potassium Carrier proteins attach to drug molecules and move them across cell membranes. . During pregnancy. These storage mechanisms maintain lower. GI tract) Excretion (eg. Most drugs form a complex with plasma proteins. many drugs enter breast milk and may affect the nursing infant. liver. Most often. such as the heart. body fat) PLASMA Bound Drug Free Drug Site of Action (eg. and kidneys. As the free drug acts on cells. only drugs that are lipid soluble or have a transport system can cross the blood–brain barrier and reach therapeutic concentrations in brain tissue. 67). Protein binding allows part of a drug dose to be stored and released as needed. which act as carriers. an active drug is changed into one or more inactive metabolites. Drug distribution into the central nervous system (CNS) is limited because the blood–brain barrier. and excretion. which are Cell membrane Lipid-soluble drugs dissolve in the lipid layer of the cell membrane and diffuse into or out of the cell. metabolism. lung. Cytoplasm Sodium Gated channels regulate movement of ions. it is carried by the blood and tissue fluids to its sites of pharmacologic action. the decrease in plasma drug levels causes some of the bound drug to be released. or other body tissues and released gradually when plasma drug levels fall. fat. limits movement of drug molecules into brain tissue. cell receptor) Metabolism (eg. it also can make drug therapy of CNS disorders more difficult because drugs must pass through cells of the capillary wall rather than between cells. Only the free or unbound portion of a drug acts on body cells. Drugs that are highly bound to plasma proteins or stored extensively in other tissues have a long duration of action. feces) Figure 2–2 Entry and movement of drug molecules through the body to sites of action. and excretion. fat. Figure 2–3 Drug transport pathways. During lactation. sweat. and skin is usually slower. oral. more even blood levels and reduce the risk of toxicity. which is composed of capillaries with tight walls. This barrier usually acts as a selectively permeable membrane to protect the CNS. Metabolism Metabolism is the method by which drugs are inactivated or biotransformed by the body. An important factor in drug distribution is protein binding (Fig.12 SECTION 1 INTRODUCTION TO DRUG THERAPY Drug Administration (eg. Most drug molecules enter and leave the bloodstream at the capillary level. Drugs are distributed rapidly to organs receiving a large blood supply. through gaps between the cells that form capillary walls. Distribution to other internal organs. Drug molecules bound to plasma proteins are pharmacologically inactive because the large size of the complex prevents their leaving the bloodstream through the small openings in capillary walls and reaching their sites of action. muscle. parenteral. metabolism. As a result. or attaching to carrier proteins. Drug molecules cross cell membranes to move into and out of body cells by directly penetrating the lipid layer. Some drugs also are stored in muscle. liver. kidney.) Drug Absorption (from site of administration into plasma) Storage in Tissue (eg. Once a drug is injected or absorbed into the bloodstream. 2–4). most drugs cross the placenta and may affect the fetus. mainly albumin.

which are able to dissolve in the lipid layer of the cell membrane. Some active drugs yield metabolites that are also active and that continue to exert their effects on body cells until they are metabolized further or excreted. after oral administration. When the drug is circulated. nine of which metabolize endogenous substances and three of which metabolize drugs. facilitated diffusion. each of which metabolizes specific drugs. Passive diffusion. to carry oral drugs from the intestine to the bloodstream. kidneys. However. Hepatic drug metabolism or clearance is a major mechanism for terminating drug action and eliminating drug molecules from the body. a characteristic that aids their movement across cell membranes. The stimulus for opening and closing the gates may be voltage gating or chemical (also called ligand) gating. This process requires a carrier substance and the release of cellular energy. reduction. These transport systems are an important means of moving drug molecules through the body. In active transport. The three groups that metabolize drugs are labeled CYP1. Passive diffusion continues until a state of equilibrium is reached between the amount of drug in the tissues and the amount in the blood. They are used. Most drugs are lipid soluble. when the gates open. potassium ions (K+) move from the cell into extracellular fluid. They catalyze the chemical reactions of oxidation. the most common mechanism. involves movement of a drug from an area of higher concentration to one of lower concentration. Most drugs are metabolized by enzymes in the liver (called the cytochrome P450 [CYP] or the microsomal enzyme system). Most systemic drugs are formulated to be lipid soluble so they can move through cell membranes. This promotes movement of the drug into the bloodstream. Individual members of the groups. Mechanisms Once absorbed into the body. the electrical potential across the cell membrane determines whether the gate is open or closed. CYP2 and CYP3. then excreted. The most common pathway is direct penetration of the membrane by lipid-soluble drugs. so that the drug moves (from capillaries) into the fluids surrounding the cells or into the cells themselves. the gates are located on the inside of the cell membrane. The cytochrome P450 system consists of 12 groups or families. one function of metabolism is to convert fat-soluble drugs into water-soluble metabolites. Only a few drugs are able to use this pathway because most drug molecules are too large to pass through the small channels. and the CYP1 group about 5%. blocks the channel opening) to prevent additional ion movement. but their movement is regulated by specific channels with a gating mechanism. and to carry drug molecules from the blood into renal tubules. A second pathway involves passage through protein channels that go all the way through the cell membrane. except that drug molecules combine with a carrier substance. located within hepatocytes. red blood cells. Small ions (eg. All of the carrier proteins are selective in the substances they transport. plasma. and GI mucosa also contain drug-metabolizing enzymes. the initial concentration of a drug is higher in the gastrointestinal tract than in the blood. Bound drug (A–D) stays in bloodstream and is pharmacologically inactive. such as an enzyme or other protein. even oral tablets and capsules that must be sufficiently water soluble to dissolve in the aqueous fluids of the stomach and small intestine. The gate is a flap of protein that opens for a few milliseconds to allow ion movement across the cell membrane. With voltage gating. and active transport. Free drug (D) can leave the bloodstream and act on body cells. hydrolysis. the CYP2 group about 45%. Facilitated diffusion is a similar process. act as carriers for drug molecules (D). a drug’s structure determines which carrier will transport it. On potassium channels. for example. can excrete only water-soluble substances. which are the primary excretory organs. the CYP3 group of enzymes is thought to metabolize about 50%. Therefore. Pathways There are three main pathways of drug movement across cell membranes. Bloodstream A D A D A D D D A D D Tissue fluid around cells D Figure 2–4 Plasma proteins. lungs. or CYP3A4 enzymes. drug molecules are moved from an area of lower concentration to one of higher concentration. With chemical gating. a chemical substance (a ligand) binds with the protein forming the channel and changes the shape of the protein to open or close the gate. For example. the kidneys. sodium ions (Na+) move from extracellular fluid into the cell. are further categorized. to carry hormones to their sites of action inside body cells.CHAPTER 2 BASIC CONCEPTS AND PROCESSES 13 BOX 2–2 DRUG TRANSPORT PATHWAYS AND MECHANISMS The third pathway involves carrier proteins that transport molecules from one side of the cell membrane to the other. the concentration is higher in the blood than in body cells. These enzymes. many drugs are metabolized by CYP2D6. mainly albumin (A). Other drugs (called prodrugs) are initially inactive and exert no pharmacologic effects until they are metabolized. Chemical gating (eg. On sodium channels. then closes (ie. are complex proteins with binding sites for drug molecules (and endogenous substances). CYP2C9. For example. sodium and potassium) use this pathway. by neurotransmitters such as acetylcholine) is very important in the transmission of signals from one nerve cell to another and from nerve cells to muscle cells to cause muscle contraction. drugs are transported to and from target cells by such mechanisms as passive diffusion. the gates are located on the outside of the cell membrane. when the gates open. and conjugation with endogenous sub- . Of the many drugs metabolized by the liver.

an antituberculosis drug. then eliminated in feces. It is determined primarily by the drug’s rates of metabolism and excretion. estrogens. With chronic administration. and skin). In this case. Enzyme induction accelerates drug metabolism because larger amounts of the enzymes (and more binding sites) allow larger amounts of a drug to be metabolized during a given time. in people with impaired blood flow to the liver or severe hepatic or cardiovascular disease. 2C. reabsorbed from the small intestine. enough drug to be beneficial. It reflects dosage. The skin has minimal excretory function. The lungs mainly remove volatile substances. Toxic concentrations may stem from a single large dose. inhibits several CYP enzymes (eg. Some drugs are extensively metabolized in the liver. four or five halflives are required to achieve steady-state concentrations and develop equilibrium between tissue and serum concentra- .14 SECTION 1 INTRODUCTION TO DRUG THERAPY stances. Most drugs are excreted by the kidneys and eliminated unchanged or as metabolites in the urine. When a single dose of a drug is given. Serum Half-Life Serum half-life. is the time required for the serum concentration of a drug to decrease by 50%. A minimum effective concentration (MEC) must be present before a drug exerts its pharmacologic action on body cells. for chronic. The duration of action is the time during which serum drug levels are at or above the MEC. When a drug is given at a stable dose. Cimetidine. and the rates of metabolism and excretion. or slow metabolism that allows the drug to accumulate in the body. lungs. drug action stops when drug levels fall below the MEC. bowel. metabolized and excreted) from the body. this is largely determined by the drug dose and how well it is absorbed into the bloodstream. especially severe renal disease. others are excreted in bile. or possible adverse effects. and vitamin D). • When a drug overdose is suspected. Then. drug levels decline as the drug is eliminated (ie. such as glucuronic acid or sulfate. acetaminophen). For most drugs. A toxic concentration is an excessive level at which toxicity occurs. The rate of drug metabolism also is reduced in infants (their hepatic enzyme system is immature). • To monitor unexpected responses to a drug dose. Enzyme inhibition occurs within hours or days of starting an inhibiting agent. lithium. until it reaches its highest concentration and peak drug action occurs. This is called the first-pass effect or presystemic metabolism. a gastric acid suppressor. A drug with a short half-life requires more frequent administration than one with a long half-life. Between these low and high concentrations is the therapeutic range. and eventually excreted in urine. This could be either a lack of therapeutic effect or increased adverse effects. with only part of a drug dose reaching the systemic circulation for distribution to sites of action. measuring serum drug levels is useful in several circumstances: • When drugs with a low or narrow therapeutic index are given. Although there may still be numerous drug molecules in the body. onset of action occurs when the drug level reaches the MEC. aminoglycoside antibiotics. such as anesthetic gases. metabolized. which is the goal of drug therapy—that is. As a result. In clinical practice. serum levels indicate the onset. Some oral drugs are not absorbed and are excreted in the feces. Factors impairing excretion. Excretion Excretion refers to elimination of a drug from the body. because new enzyme proteins must be synthesized. and duration of drug action. repeated small doses. theophylline). Drugs that induce enzyme production also may increase the rate of metabolism for endogenous steroidal hormones (eg. enzyme induction does not occur for 1 to 3 weeks after an inducing agent is started. 2–5). the goal is usually to give sufficient doses often enough to maintain serum drug levels in the therapeutic range and avoid the toxic range. smaller doses of the slowly metabolized drug may be needed to avoid adverse reactions and toxicity from drug accumulation. bioavailability. Rapid metabolism may also increase the production of toxic metabolites with some drugs. therapeutic effects. • To document the serum drug levels associated with particular drug dosages. testosterone. lead to accumulation of numerous drugs and may cause severe adverse effects if dosage is not reduced. returned to the liver (called enterohepatic recirculation). larger doses of the rapidly metabolized drug may be required to produce or maintain therapeutic effects. Serum Drug Levels A serum drug level is a laboratory measurement of the amount of a drug in the blood at a particular time (Fig. is a strong inducer of CYP 1A and 3A enzymes Metabolism also can be decreased or delayed in a process called enzyme inhibition. also called elimination half-life. but not enough to be toxic. some drugs stimulate liver cells to produce larger amounts of drug-metabolizing enzymes (a process called enzyme induction). Effective excretion requires adequate functioning of the circulatory system and of the organs of excretion (kidneys. they are absorbed from the GI tract and carried to the liver through the portal circulation. peak. When multiple doses of a drug are given (eg. These are drugs with a narrow margin of safety because their therapeutic doses are close to their toxic doses (eg. 1A2. and in people who are malnourished or on low-protein diets. which most often occurs with concurrent administration of two or more drugs that compete for the same metabolizing enzymes. and 3A) and can greatly decrease drug metabolism. The drug level continues to climb as more of the drug is absorbed. (eg. digoxin. cortisol. Rifampin. half-life. However. absorption. Some drugs or metabolites are excreted in bile. long-lasting conditions). When drugs are given orally.

If concentrations above 25 units/mL are toxic and no more drug is given. Drug action starts when enough drug is absorbed to reach the minimum effective concentration (MEC). Because maximal therapeutic effects do not occur until equilibrium is established. sodium–potassium adenosine triphosphatase) or structural processes (eg. the amount of drug given must equal the amount eliminated from the body. Because almost all cellular functions are catalyzed by enzymes. wanes as drug molecules are metabolized and excreted (if no more doses are given). and nucleic acids (eg. an epinephrine–receptor complex increases the activity of the intracellular enzyme adenyl cyclase. and other metabolic activities. To maintain steady-state conditions. which then causes the formation of cyclic adenosine PHARMACODYNAMICS Pharmacodynamics involves drug actions on target cells and the resulting alterations in cellular biochemical reactions and functions (ie. DNA) involved in cellular protein synthesis. how long will it take for the blood level to reach the nontoxic range? . When drug molecules bind with receptor molecules. when a drug is discontinued. “what the drug does to the body”). Toxic concentration Serum Drug Levels Steady-state serum drug level Regularly scheduled doses Drug action starts Last dose Waning serum drug levels Figure 2–5 Serum drug levels with single and multiple oral drug doses. and stops when the serum level drops below the MEC. Specific receptors include enzymes involved in essential metabolic or regulatory processes (eg. drug-induced changes can markedly increase or decrease the rate of cellular metabolism. hormones and neurotransmitters) that normally regulate cell functions. Receptors are mainly proteins located on the surfaces of cell membranes or within cells. As previously stated. reproduction. tubulin).CHAPTER 2 BASIC CONCEPTS AND PROCESSES 15 Toxic concentration Serum Drug Levels Peak serum drug level ti o n ab Therapeutic concentration Drug action stops eli mi na tio n Dr rp ug Drug action starts Dr ug so Duration of drug action Minimum effective concentration (MEC) Administration of an oral drug Time (hours) Drug action in relation to serum drug levels and time after a single does. or other alterations of intracellular enzymes. inactivation. tions. When a drug dose is changed. Therapeutic concentration Duration of drug action Drug action stops Minimum effective concentration (MEC) First dose of drug enters body Time (days) Drug is eliminated from the body Drug action in relation to serum drug levels with repeated doses. Nursing Notes: Apply Your Knowledge A client has a drug level of 100 units/mL. One type of reaction involves activation. The goal of drug therapy is to maintain serum drug levels in the therapeutic range. the resulting drug–receptor complex initiates physiochemical reactions that stimulate or inhibit normal cellular functions. proteins involved in transport (eg. all drug actions occur at the cellular level. 2–6). Receptor Theory of Drug Action Like the physiologic substances (eg. continues as long as the serum level is above the MEC. dihydrofolate reductase. an additional four to five halflives are required to re-establish equilibrium. acetylcholinesterase). it is eliminated gradually over several half-lives. For example. The drug’s half-life is 1 hour. most drugs exert their effects by chemically binding with receptors at the cellular level (Fig. some drugs are not fully effective for days or weeks.

acetylcholine. Presumably. prolonged stimulation of body cells with an excitatory agonist usually reduces the number or sensitivity of receptors. both are agonists. can initiate any one of many different intracellular actions. Agonists are drugs that produce effects similar to those produced by naturally occurring hormones. For example. At other times. for example. serotonin) that regulate many physiologic processes. receptors may be saturated. movement of the ions into the cells may alter intracellular functions. 3. increasing the drug dosage increases the pharmacologic effects. depending on the type of receptor activated. Conversely. In muscle cells. Receptors vary in type. monophosphate (cAMP). Receptor type and location influence drug action. cAMP. number. release. Drugand client-related variables that affect drug actions are further described below. These substances stimulate or inhibit cellular function. and insulin. including growth hormone. Because all drugs are chemical substances. In this instance. and acetylcholine-like drugs act on the heart to slow the heart rate. This action inhibits neuronal excitability and function. and circulate to the liver for metabolism and the kidneys for excretion. the cell becomes less responsive to the agonist (a process called receptor desensitization . such as receptors for opiates and benzodiazepines in the brain and subgroups of receptors for epinephrine in the heart (beta1-adrenergic receptors) and lungs (beta2-adrenergic receptors). Minor changes in drug structure may produce major changes in pharmacologic effects. For example. The receptor protein is a structural component of the cell membrane. and its binding to a drug molecule may open or close ion channels. The number of receptor sites available to interact with drug molecules also affects the extent of drug action. increasing the drug dosage produces no additional pharmacologic effect. In nerve cells. even though virtually all cell receptors are exposed to any drug molecules circulating in the bloodstream. This prevents natural body substances or other drugs from occupying the receptor sites and activating cell functions. a drug’s chemical structure affects its ability to reach tissue fluids around a cell and bind with its cell receptors.16 SECTION 1 INTRODUCTION TO DRUG THERAPY Cell membrane H Cytoplasm H H Da H Receptor site Db NT Nucleus H NT NT Da Db H Receptor site Figure 2–6 Cell membrane contains receptors for physiologic substances such as hormones (H) and neurotransmitters (NT). For example. drug molecules may detach from receptor molecules (ie. and only those drugs able to bond chemically to the receptors in a particular body tissue can exert pharmacologic effects on that tissue. Additional elements and characteristics of the receptor theory include the following: 1. Thus. Another major factor is the concentration of drug molecules that reach receptor sites in body tissues. Agonists may accelerate or slow normal cellular processes. if most receptor sites are occupied. chemical characteristics determine drug actions and pharmacologic effects. Drugs vary even more widely than receptors. Drug molecules (Da and Db) also interact with receptors to stimulate or inhibit cellular function. return to the bloodstream. A second type of reaction involves changes in the permeability of cell membranes to one or more ions. norepinephrine. A third reaction may modify the synthesis. Thus. location. thyroid hormone. in turn. the chemical binding is reversible). few drug effects occur. The receptor is often described as a lock into which the drug molecule fits as a key. if many receptors are available but only a few are occupied by drug molecules. if only a few receptors are available for many drug molecules. Most types occur in most body tissues. such as receptors for epinephrine and norepinephrine (whether received from stimulation of the sympathetic nervous system or administration of drug formulations) and receptors for hormones. potassium channels may open and allow movement of potassium ions out of the cell. many different types of receptors have been identified. Receptors are dynamic cellular components that can be synthesized by body cells and altered by endogenous substances and exogenous drugs. In this instance. epinephrine-like drugs act on the heart to increase the heart rate. 2. Some occur in fewer body tissues. and other substances. sodium or calcium ion channels may open and allow movement of ions into the cell. This usually causes the cell membrane to depolarize and excite the cell. a minimal number of receptors must be occupied by drug molecules to produce pharmacologic effects. When drug molecules chemically bind with cell receptors. such as the direct effect of calcium ions in stimulating muscle contraction. For example. Antagonists are drugs that inhibit cell function by occupying receptor sites. the exact effect depending on the type of cell. all body cells do not respond to all drugs. As a result. and functional capacity. neurotransmitters. The site and extent of drug action on body cells are determined primarily by specific characteristics of receptors and drugs. or inactivation of the neurohormones (eg. Once drug action occurs. the pharmacologic effects are those due to either agonism or antagonism.

When tablets or capsules are taken with or soon after food. These dosages usually produce a mixture of therapeutic and adverse effects. Prolonged inhibition of normal cellular functions with an antagonist may increase receptor number or sensitivity. Drug–Diet Interactions Food may alter the absorption of oral drugs. For example. Route of Administration Routes of administration affect drug actions and responses largely by influencing absorption and distribution. the cell becomes excessively responsive to an agonist (a process called receptor upregulation). norepinephrine is active for only a few milliseconds before it is inactivated by MAO. dose indicates the amount to be given at one time and dosage refers to the frequency. renal. food slows absorption by slowing gastric emptying time and altering GI secretions and motility. The oral route usually produces slower drug action than parenteral routes. Because dosage includes the amount of the drug and the frequency of administration. 4. However. certain drugs or dosage forms are better absorbed with certain types of meals. older adults. Metal chelating agents. ingesting tyramine-containing foods with an MAO inhibitor may produce severe hypertension or intracranial VARIABLES THAT AFFECT DRUG ACTIONS Expected responses to drugs are largely based on those occurring when a particular drug is given to healthy adult men (18 to 65 years of age) of average weight (150 lb [70 kg]). some foods contain substances that react with certain drugs. dosage form. and function of cardiovascular. For rapid drug action and response. cause the drug does not reach an adequate concentration at target cells. Therefore. Doses that cause death are called lethal doses. Antacids. Nonreceptor Drug Actions Relatively few drugs act by mechanisms other than combination with receptor sites on cells. Drugs that are structurally similar to nutrients required by body cells (eg. These include: 1. Tyramine causes the release of norepinephrine. different ethnic or racial groups. However. pharmacokinetics. whether the drug is applied to skin or mucous membranes. both therapeutic and adverse. overdosage may occur with a single large dose or with chronic ingestion of smaller amounts. a strong vasoconstrictive agent. lead) to form a complex that can be more readily excreted. Food also may decrease absorption by combining with a drug to form an insoluble drug–food complex. In addition. Absorption and action of topical drugs vary according to the drug formulation. and others) and of the recipient (age. which combine with toxic metals (eg. such as nucleic acids. If the amount is too large or administered too often. which increase the osmolarity of plasma and pull water out of tissues into the bloodstream 3. Dosages recommended in drug literature are usually those that produce particular responses in 50% of the people tested. This interferes with normal cell functioning. current clinical trials are including more representatives of these groups. state of health. pyrimidines) and that can be incorporated into cellular constituents. Dosage is a major determinant of drug actions and responses. For some drugs. some of which are described in the following sections. In other instances. and clients with diseases or symptoms that the drugs are designed to treat) receive drugs and respond differently than healthy adult men. size. no pharmacologic action occurs be- . other groups of people (eg. the IM route also produces drug action within a few minutes because muscles have a large blood supply. however. however. and number of doses. therefore. The dosage of a particular drug depends on many characteristics of the drug (reason for use. In any client. weight. Osmotic diuretics (eg. toxicity (poisoning) may occur. which act chemically to neutralize the hydrochloric acid produced by gastric parietal cells and thereby raise the pH of gastric fluid 2. Drug-Related Variables Dosage Although the terms dose and dosage are often used interchangeably. the recommended dosages are intended only as guidelines for individualizing dosages. and hepatic systems). Interactions that alter drug absorption can be minimized by spacing food and medications.and client-related variables. One such interaction occurs between tyraminecontaining foods and monoamine oxidase (MAO) inhibitor drugs. a fatty meal increases the absorption of some sustained-release forms of theophylline. because MAO inhibitor drugs prevent inactivation of norepinephrine. women. potency. Normally.CHAPTER 2 BASIC CONCEPTS AND PROCESSES 17 or down-regulation). children. responses may be altered by both drug. These changes in receptors may explain why some drugs must be tapered in dosage and discontinued gradually if withdrawal symptoms are to be avoided. Doses that produce signs and symptoms of toxicity are called toxic doses. In many instances. route of administration. mannitol). Thus. from the adrenal medulla and sympathetic neurons. drug molecules are delivered to absorptive sites in the small intestine more slowly. they dissolve more slowly. and other factors. If the antagonist is suddenly reduced or stopped. If the amount is too small or administered infrequently. purines. the IV route is most effective because the drug is injected directly into the bloodstream. Several anticancer drugs act by this mechanism.

Displacement of one drug from plasma protein-binding sites by a second drug increases the effects of the displaced drug. MAO inhibitors include the antidepressants isocarboxazid and phenelzine and the antineoplastic procarbazine.18 SECTION 1 INTRODUCTION TO DRUG THERAPY hemorrhage. has just had a change in her antihypertension medications to felodipine 10 mg qd. A drug with a strong attraction to protein-binding sites may displace a less tightly bound drug. Her blood pressure is 148/70. Example: ethanol + sedative drug → increased sedation 2. Two days later Mrs. an antibiotic. calcium channel blockers. freed from their bound form. Example: cimetidine inhibits CYP 1A. Most interactions occur whenever the interacting drugs are present in the body. causing decreased absorption and decreased antibiotic effect of tetracycline 3. When these drugs are given concurrently with cimetidine. occur when the interacting drugs are given at or near the same time. Additive effects occur when two drugs with similar pharmacologic actions are taken. unabsorbable compound that is excreted in the feces. benzodiazepine antianxiety and hypnotic drugs. a drug that is a specific antidote is given to antagonize the toxic effects of another drug. ethanol. For example. Examples of such interactions are as follows: 1. become pharmacologically active. Example: acetaminophen (non-opioid analgesic) + codeine (opioid analgesic) → increased analgesia 3. 2. especially those affecting the absorption of oral drugs. Because vitamin K antagonizes the action of warfarin. . The drug combines with the calcium in milk products to form an insoluble. and 3A drug-metabolizing enzymes in the liver and therefore interferes with the metabolism of many drugs (eg. tricyclic antidepressants. These drugs are infrequently used nowadays. and pickled herring. Increased excretion occurs when urinary pH is changed and renal reabsorption is blocked. Example: aluminum or magnesium hydroxide (antacids) + oral tetracycline (an antibiotic) → binding of tetracycline to aluminum or magnesium. a frequently used oral anticoagulant. 4. some. Example: sodium bicarbonate + phenobarbital → increased excretion of phenobarbital. theophylline. 2C. Decreased intestinal absorption of oral drugs occurs when drugs combine to produce nonabsorbable compounds. phenytoin. The sodium bicar- How Can You Avoid This Medication Error? Mrs. drugs metabolized by the same enzymes may compete for enzyme binding sites and there may not be enough binding sites for two or more drugs. and warfarin). and foods containing vitamin K. Also. Drug–Drug Interactions The action of a drug may be increased or decreased by its interaction with another drug in the body. and dairy products. Increased Drug Effects Interactions that can increase the therapeutic or adverse effects of drugs are as follows: 1. Protein binding is also the basis for some important drug–drug interactions. chicken livers. Tyramine-rich foods to be avoided by clients taking MAO inhibitors include beer. In some situations. beta blockers and antiseizure drugs. The basic cause of many drug–drug interactions is altered drug metabolism. rifampin). Example: phenobarbital (a barbiturate) + warfarin (an anticoagulant) → decreased effects of warfarin 4. A third interaction occurs between tetracycline. a calcium channel blocker. Synergism or potentiation occurs when two drugs with different sites or mechanisms of action produce greater effects when taken together than either does when taken alone. some drugs induce or inhibit the metabolism of other drugs. An interaction may occur between warfarin. Interference by one drug with the metabolism or elimination of a second drug may result in intensified effects of the second drug. they are likely to cause adverse and toxic effects. large amounts of spinach and other green leafy vegetables may offset the anticoagulant effects and predispose the person to thromboembolic disorders. some antidysrhythmics. aged cheeses. This increase occurs because the molecules of the displaced drug. yeast products. Several drugs (eg. and cigarette smoking are known enzyme inducers. Example: naloxone (a narcotic antagonist) + morphine (a narcotic or opioid analgesic) → relief of opioidinduced respiratory depression. wine. such as milk and cheese. Beecher’s blood pressure is 96/60. and the overall effect is the same as taking a larger dose of the displaced drug. partly because of this potentially serious interaction and partly because other effective drugs are available. Activation of drug-metabolizing enzymes in the liver increases the metabolism rate of any drug metabolized primarily by that group of enzymes. You give her the tablet with a large glass of grapefruit juice and caution her to swallow the tablet whole. Beecher. a 76-year-old nursing home client. Example: aspirin (an anti-inflammatory/analgesic/ antipyretic agent) + warfarin (an anticoagulant) → increased anticoagulant effect Decreased Drug Effects Interactions in which drug effects are decreased are grouped under the term antagonism. The displaced drug then becomes pharmacologically active. Naloxone molecules displace morphine molecules from their receptor sites on nerve cells in the brain so that the morphine molecules cannot continue to exert their depressant effects.

healthy children handle drugs similarly to healthy adults. Body Weight Body weight affects drug action mainly in relation to dose. there is decreased blood flow. Other people are deficient in glucose-6-phosphate dehydrogenase. When given the same drug in the same dose. Changes in the GI tract include decreased gastric acidity. but liver function and the blood–brain barrier are still immature. rapid acetylators may need larger-than-usual doses to achieve therapeutic effects. Therefore. a chemical conjugation process in which the drug molecule combines with an acetyl group of acetyl coenzyme A. Theophylline. and older adults. Genetics A person’s genetic characteristics may influence drug action in several ways. cell membranes. In addition. including increased toxicity. Recommended doses for many drugs are listed in terms of grams or milligrams per kilogram of body weight. These people may experience prolonged paralysis and apnea if given succinylcholine. Drug distribution. decreased glomerular filtration rate. depending largely on genetically controlled differences in acetyltransferase activity. Children (1 to 12 years) experience a period of increased activity of drug-metabolizing enzymes so that some drugs are rapidly metabolized and eliminated. several genetic variations of the cytochrome P450 drugmetabolizing system have been identified. infants. some people experience inadequate therapeutic effects. and others experience unusual or exaggerated effects. The ratio between the amount of drug given and body weight influences drug distribution and concentration at sites of action. metabolism. drug action depends largely on age and developmental stage. In addition. a potent muscle relaxant used in some surgical procedures. These interindividual variations in drug response are often attributed to genetic or ethnic differences in drug pharmacokinetics or pharmacodynamics. some people lack the plasma pseudocholinesterase enzyme that normally inactivates succinylcholine. drugs cross the placenta and may harm the fetus. The ionized particles cannot pass easily through renal tubular membranes. whereas toxicity developed in other people. In the liver. and slow acetylators may need smaller-than-usual doses to avoid toxic effects. because their organ systems are not fully developed. Genetic characteristics that alter any of these proteins can alter drug pharmacokinetics or pharmacodynamics. blood flow and metabolizing enzymes are decreased. and decreased tubular secretion of drugs. or procainamide (an antidysrhythmic) showed no therapeutic effects. metabolism. however. physiologic changes may alter all pharmacokinetic processes. Changes in the cardiovascular system include decreased cardiac output and therefore slower distribution of drug molecules to their sites of action. Clinically. In general. Drugs are given to elicit certain responses that are relatively predictable for most drug recipients. have a longer action. decreased blood flow. As another example of genetic variation in drug metabolism. In older adults (65 years and older). All of these changes tend to slow excretion and promote accumulation of drugs in the body. people heavier than average need larger doses. possibilities for interactions among drugs and between drugs and diseased organs are greatly multiplied. The reaction is catalyzed by a hepatic drug-metabolizing enzyme called acetyltransferase. When most drugs enter the body. As a result. Despite these changes. Older infants (1 month to 1 year) reach approximately adult levels of protein binding and kidney function. Newborn infants (birth to 1 month) also handle drugs inefficiently. and cardiovascular functions are adequate. older adults are more likely to have acute and chronic illnesses that require multiple drugs or long-term drug therapy. It was further established that humans may acetylate the drug rapidly or slowly. less drug is reabsorbed into the blood and more is excreted by the kidneys. During pregnancy. Thus. Genetic and Ethnic Characteristics Client-Related Variables Age The effects of age on drug action are most pronounced in neonates. tissues. and decreased motility. drug-metabolizing enzymes in the liver and other organs) to be biotransformed and eliminated from the body. they interact with proteins (eg. Thus. One of the earliest genetic variations to be identified derived from the observation that some people taking usual doses of isoniazid (an antitubercular drug). and excretion. in plasma. Specific variations may influence any of the chemical processes by which drugs are metabolized. especially premature infants. an enzyme normally found in red blood cells and . there is increased awareness that genetic and ethnic characteristics are important factors and that diverse groups must be included in clinical trials. there is little difference in absorption. Although the onset and duration of this period are unclear. Fetuses have no effective mechanisms for metabolizing or eliminating drugs because their liver and kidney functions are immature. In the kidneys. and with other proteins (eg. hepatic. many drugs are metabolized more slowly.CHAPTER 2 BASIC CONCEPTS AND PROCESSES 19 bonate alkalinizes the urine. and excretion differ markedly in neonates. In children. hydralazine (an antihypertensive agent). Impaired kidney and liver function greatly increase the risks of adverse drug effects. a few studies have been done with particular drugs. however. For example. for example. Research established that these drugs are normally metabolized by acetylation. and are more likely to accumulate with chronic administration. genes determine the types and amounts of proteins produced in the body. After approximately 12 years of age. provided that their renal. and drug receptor sites) to reach their sites of action. is cleared much faster in a 7-year-old child than in a neonate or adult (18 to 65 years). raising the number of barbiturate ions in the renal filtrate.

all pharmacokinetic processes are decreased in cardiovascular disorders characterized by decreased blood flow to tissues. Women with clinical depression. gender has been considered a minor influence on drug action. They also influence compliance or the willingness to carry out the prescribed drug regimen. all drugs can produce adverse effects. the need to include women in drug studies is evident. the term adverse effects refers to any undesired responses to drug administration. the absorption of oral drugs is decreased with various GI disorders. and other CNS depressants. such as hyperthyroidism and fever. TOLERANCE AND CROSS-TOLERANCE Drug tolerance occurs when the body becomes accustomed to a particular drug over time so that larger doses must be given to produce the same effects. They also are attributed to decreased sensitivity or numbers of receptor sites. which accelerates drug metabolism and excretion. and antidepressants. an antihypertensive. antipyretics. and other drugs. as opposed to therapeutic effects. may need higher doses of antidepressant medications premenstrually. Tolerance and cross-tolerance are usually attributed to activation of drug-metabolizing enzymes in the liver.20 SECTION 1 INTRODUCTION TO DRUG THERAPY other body tissues. diabetes mellitus. propranolol. Excretion is decreased in kidney disease. an anticonvulsant. few subjects of other ethnic groups are included. epilepsy. Interethnic variations became evident when drugs and dosages developed for white people produced unexpected responses. Distribution is altered in liver or kidney disease and other conditions that alter plasma proteins. If given the higher doses required by men. Another example is that women with schizophrenia require lower dosages of antipsychotic medications than men. an antianxiety agent. Several reasons have been advanced for excluding women from clinical drug trials. altered responses have been demonstrated in some women taking clonidine. and lower doses during the rest of the menstrual cycle. A placebo is a pharmacologically inactive substance. However. alcohol. In general. Interestingly. Gender Except during pregnancy and lactation. a significant percentage of women with arthritis. when given to other ethnic groups. asthma. Ethnicity Most drug information has been derived from clinical drug trials using white men. In addition. sulfonamides. Psychological Considerations Psychological considerations influence individual responses to drug administration. a beta-adrenergic blocking drug used in the management of hypertension. inadequate protein to synthesize drugmetabolizing enzymes) and severe liver disease. if symptoms exacerbate. analgesics. For example. especially opioid analgesics. AfricanAmerican hypertensive clients respond better to diuretics or calcium channel blockers than to ACE inhibitors and beta blockers. Metabolism is decreased in malnutrition (eg. including beta blockers and several psychotropic drugs (eg. Although this area has received little attention in research studies and clinical practice. although specific mechanisms are unknown. an antipsychotic). An example is the placebo response. angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic blocking drugs are less effective as single-drug therapy. larger-than-usual doses are required to produce a pharmacologic effect—this is cross-tolerance. including the risks to a fetus if a woman becomes pregnant and the greater complexity in sample size and data analysis. In addition. a mood-stabilizing agent. alprazolam. or a placebo influence client response. a particular drug. phenytoin. ADVERSE EFFECTS OF DRUGS As used in this book. lithium. and haloperidol. Pathologic Conditions Pathologic conditions may alter pharmacokinetic processes (Table 2–1). Most research studies related to drugs have involved men. The increased symptoms may indicate a need for adjustments in their drug therapy regimens. Another interethnic variation is that Asians usually require much smaller doses of some commonly used drugs. Some documented interethnic variations are included in later chapters. Some gender-related differences in responses to drugs may stem from hormonal fluctuations in women during the menstrual cycle. a person who regularly drinks large amounts of alcohol becomes able to ingest even larger amounts before becoming intoxicated—this is tolerance to alcohol. and migraine. it may be increased in conditions that generally increase body metabolism. One common interethnic variation is that African Americans are less responsive to some antihypertensive drugs than are white people. These people may have hemolytic anemia when given antimalarial drugs. Tolerance may be acquired to the pharmacologic action of many drugs. Tolerance to pharmacologically related drugs is called cross-tolerance. angina pectoris. which are desired responses. for example. such as heart failure. Adverse effects may produce es- . In general. recipients often report both therapeutic and adverse effects from placebos. If the person is then given sedative-type drugs or a general anesthetic. For example. Attitudes and expectations related to drugs in general. women are likely to have adverse drug reactions. Placebos are used in clinical drug trials to compare the medication being tested with a “dummy” medication. depression. especially with long-term drug therapy. including toxicity. and migraine experience increased symptoms premenstrually. because differences between men and women in responses to drug therapy are being identified. and clinicians have extrapolated the findings to women. Most drugs produce a mixture of therapeutic and adverse effects.

Decreased hepatic blood flow slows metabolism. dosages of drugs that are extensively metabolized need adjustments according to the level of thyroid function. and the duration of action may be shorter because the drug is metabolized and excreted more quickly. hepatitis. In addition. Severe liver disease or cirrhosis may impair all pharmacokinetic processes. cerebral irritation may occur with head injuries and lead to stimulation of the sympathetic nervous system and increased cardiac output. Metabolism may be impaired by hepatic and nonhepatic disorders that reduce hepatic blood flow. the rate of drug metabolism also returns to normal. Metabolism and excretion are impaired because of decreased blood flow to the liver and kidneys. As a result. subcutaneous. Hypothyroidism slows metabolism. Increased blood flow may accelerate all pharmacokinetic processes. brain ischemia from inadequate cerebral blood flow. or impair blood flow to body tissues (eg. an impaired liver may not be able to synthesize adequate amounts of drug-metabolizing enzymes. as described previously. With cirrhosis. which impairs all pharmacokinetic processes. With decreased protein binding. where metabolism occurs. drugs that depress or stimulate brain function) Gastrointestinal (GI) disorders that interfere with GI function or blood flow (eg. pancreatitis) Inflammatory bowel disorders (eg. acute myocardial infarction. which can affect the unbound portion of a drug dose. Concurrent administration of foods or tube feeding solutions that decrease drug absorption. It may be decreased because hypermotility and diarrhea may move the drug through the GI tract too rapidly to be adequately absorbed. antacids. especially albumin. redistributing cardiac output (more blood flow to the heart and brain. Crushing tablets or opening capsules to give a drug through a GI tube. decrease cardiac output. abdominal infection. Pathologic Conditions Cardiovascular disorders that impair the pumping ability of the heart. proton pump inhibitors). hypotension. Most drugs are eliminated from the body by hepatic metabolism. Absorption of oral drugs may be decreased in cirrhosis because of edema in the GI tract. increased amounts of circulating catecholamines and cortisol) affects drug action by increasing cardiac output. (continued ) . The impaired liver may be unable to synthesize adequate amounts of plasma proteins. renal excretion or both.or hyperventilation and acid–base imbalances. but faster metabolism and excretion may shorten duration of action. Those who are able to take oral drugs may experience impaired absorption because of: Vomiting or diarrhea. the serum concentration of active drug is increased and the drug is distributed to sites of action and elimination more rapidly. and thereby accelerates drug metabolism. producing a shorter duration of action and a faster elimination rate. brain trauma or injury. Symptoms of impaired GI function commonly occur with both GI and non-GI disorders. CNS impairment may alter pharmacokinetics indirectly by causing hypo. and shock) Central nervous system (CNS) disorders that alter respiration or circulation (eg. Hyperthyroidism accelerates metabolism. cirrhosis) Impaired circulation may decrease all pharmacokinetic processes. Distribution may be altered by changes in plasma proteins. less to kidneys. propranolol) must be given in reduced doses to prevent high blood levels and toxicity. Distribution is impaired because of decreased blood flow to body tissues and thus to sites of drug action. trauma or surgery of the GI tract. hepatic enzyme activity. Increased hepatic blood flow increases delivery of drug molecules to hepatocytes. histamine-2 blockers.CHAPTER 2 BASIC CONCEPTS AND PROCESSES 21 TABLE 2–1 Effects of Pathologic Conditions on Drug Pharmacokinetics Pharmacokinetic Consequences Absorption of oral. Thus. and GI tract). Decreased adrenal function causes hypotension and shock. oral drugs are distributed directly into the systemic circulation rather than going through the portal circulation and the liver first. Stress also changes plasma protein levels. liver. which prolongs drug action and slows elimination from the body. Thus. Crohn’s disease. drug action may be more rapid. As a thyroid disorder is treated and thyroid function returns to normal. ulcerative colitis) Endocrine disorders that impair function or change hormonal balance Diabetes-induced cardiovascular disorders Thyroid disorders Adrenal disorders resulting from the underlying illness or the stress response that accompanies illness Hepatic disorders that impair hepatic function and blood flow (eg. peak blood levels may be higher and cause adverse effects. onset of drug action may be faster. causing fluid retention. intramuscular. Hepatic metabolism depends on hepatic blood flow. The main effect is on metabolism. serum bilirubin) that can displace drugs from protein-binding sites. With faster absorption and distribution. many patients cannot take oral medications. and increasing blood volume. Also. Concurrent administration of drugs that raise the pH of gastric fluids (eg. and topical drugs is erratic because of decreased blood flow to sites of drug administration. heart failure. paralytic ileus. and plasma protein binding. It may be increased because GI hypermotility rapidly delivers drug molecules to sites of absorption in the small intestine and the drugs tend to be absorbed more rapidly from inflamed tissue. This shunting of blood around the liver means that oral drugs that are normally extensively metabolized during their first pass through the liver (eg. liver impairment leads to inadequate metabolism and accumulation of substances (eg. Increased adrenal function (ie. Absorption of oral drugs is variable. Also.




Effects of Pathologic Conditions on Drug Pharmacokinetics (continued )
Pharmacokinetic Consequences Excretion may be increased when protein binding is impaired because larger amounts of free drug are circulating in the bloodstream and being delivered more rapidly to sites of metabolism and excretion. The result is a shorter drug half-life and duration of action. Excretion is decreased when the liver is unable to metabolize lipid-soluble drugs into water-soluble metabolites that can be excreted by the kidneys. ARF and CRF can interfere with all pharmacokinetic processes. Absorption of oral drugs may be decreased indirectly by changes that often occur with renal failure (eg, delayed gastric emptying, changes in gastric pH, GI symptoms such as vomiting and diarrhea). Also, in the presence of generalized edema, edema of the GI tract may impair absorption. In CRF, gastric pH may be increased by administration of oral alkalinizing agents (eg, sodium bicarbonate, citrate) and the use of antacids for phosphate-binding effects. This may decrease absorption of oral drugs that require an acidic environment for dissolution and absorption and increase absorption of drugs that are absorbed from a more alkaline environment. Distribution of many drugs may be altered by changes in extracellular fluid volume (ECF), plasma protein binding, and tissue binding. Water-soluble drugs are distributed throughout the ECF, including edema fluid, which is usually increased in renal impairment because the kidney’s ability to eliminate water and sodium is impaired. Drug binding with albumin, the main drug-binding plasma protein for acidic drugs, is usually decreased with renal impairment. Protein binding may be decreased because of less albumin or decreased binding capacity of albumin for a drug. Reasons for decreased albumin include hypermetabolic states (eg, stress, trauma, sepsis) in which protein breakdown exceeds protein synthesis, nephrotic states in which albumin is lost in the urine, and liver disease that decreases hepatic synthesis of albumin. Reasons for reduced binding capacity include structural changes in the albumin molecule or uremic toxins that compete with drugs for binding sites. When less drug is bound to albumin, the higher serum drug levels of unbound or active drug can result in drug toxicity. In addition, more unbound drug is available for distribution into tissues and sites of metabolism and excretion so that faster elimination can decrease drug half-life and therapeutic effects. For basic drugs (eg, clindamycin, propafenone), alpha1-acid glycoprotein (AAG) is the main binding protein. The amount of AAG increases in some patients, including those with renal transplants and those receiving hemodialysis. If these patients are given a basic drug, a larger amount is bound and a smaller amount is free to exert a pharmacologic effect. Finally, some conditions that often occur in renal impairment (eg, metabolic acidosis, respiratory alkalosis, others) may alter tissue distribution of some drugs. For example, digoxin can be displaced from tissue-binding sites by metabolic products that cannot be adequately excreted by impaired kidneys. Metabolism can be increased, decreased, or unaffected by renal impairment. One factor is alteration of drug metabolism in the liver. In uremia, reduction and hydrolysis reactions may be slower, but oxidation by cytochrome P450 enzymes and conjugation with glucuronide or sulfate usually proceed at normal rates. Another factor is the inability of impaired kidneys to eliminate drugs and pharmacologically active metabolites, which may lead to accumulation and adverse drug reactions with long-term drug therapy. Metabolites may have pharmacologic activity similar to or different from that of the parent drug. A third factor may be impaired renal metabolism of drugs. Although the role of the kidneys in excretion of drugs and drug metabolites is well known, their role in drug metabolism has received little attention. The kidney itself contains many of the same metabolizing enzymes found in the liver, including renal cytochrome P450 enzymes, which metabolize a variety of chemicals and drugs. Excretion of many drugs and metabolites is reduced by renal impairment. The kidneys normally excrete both the parent drug and metabolites produced by the liver and other tissues. Processes of renal excretion include glomerular filtration, tubular secretion, and tubular reabsorption, all of which may be affected by renal impairment. If the kidneys are unable to excrete drugs and metabolites, some of which may be pharmacologically active, these substances may accumulate and cause adverse or toxic effects. Respiratory impairment may indirectly affect drug metabolism. For example, hypoxemia leads to decreased enzyme production in the liver, decreased efficiency of the enzymes that are produced, and decreased oxygen available for drug biotransformation. Mechanical ventilation leads to decreased blood flow to the liver.

Pathologic Conditions

Renal impairment—acute renal failure (ARF) and chronic renal failure (CRF)

Respiratory impairments




Effects of Pathologic Conditions on Drug Pharmacokinetics (continued )
Pharmacokinetic Consequences Sepsis may affect all pharmacokinetic processes. Early sepsis is characterized by hyperdynamic circulation, with increased cardiac output and shunting of blood to vital organs. As a result, absorption, distribution, metabolism, and excretion may be accelerated. Late sepsis is characterized by hypodynamic circulation, with diminished cardiac output and reduced blood flow to major organs. Thus, absorption, distribution, metabolism, and excretion may be impaired. Shock may inhibit all pharmacokinetic processes. Absorption is impaired by decreased blood flow to sites of drug administration. Distribution is impaired by decreased blood flow to all body tissues. Metabolism is impaired by decreased blood flow to the liver. Excretion is impaired by decreased blood flow to the kidneys.

Pathologic Conditions Sepsis-induced alterations in cardiovascular function and hepatic blood flow

Shock-induced alterations in cardiovascular function and blood flow

sentially any sign, symptom, or disease process and may involve any body system or tissue. They may be common or rare, mild or severe, localized or widespread, depending on the drug and the recipient. Some adverse effects occur with usual therapeutic doses of drugs (often called side effects); others are more likely to occur and to be more severe with high doses. Common or serious adverse effects include the following: 1. CNS effects may result from CNS stimulation (eg, agitation, confusion, delirium, disorientation, hallucinations, psychosis, seizures) or CNS depression (dizziness, drowsiness, impaired level of consciousness, sedation, coma, impaired respiration and circulation). CNS effects may occur with many drugs, including most therapeutic groups, substances of abuse, and over-the-counter preparations. 2. Gastrointestinal effects (anorexia, nausea, vomiting, constipation, diarrhea) are among the most common adverse reactions to drugs. Nausea and vomiting occur with many drugs from local irritation of the gastrointestinal tract or stimulation of the vomiting center in the brain. Diarrhea occurs with drugs that cause local irritation or increase peristalsis. More serious effects include bleeding or ulceration (most often with aspirin and nonsteroidal anti-inflammatory agents) and severe diarrhea/colitis (most often with antibiotics). 3. Hematologic effects (blood coagulation disorders, bleeding disorders, bone marrow depression, anemias, leukopenia, agranulocytosis, thrombocytopenia) are relatively common and potentially life threatening. Excessive bleeding is most often associated with anticoagulants and thrombolytics; bone marrow depression is usually associated with antineoplastic drugs. 4. Hepatotoxicity (hepatitis, liver dysfunction or failure, biliary tract inflammation or obstruction) is potentially life threatening. Because most drugs are metabolized by the liver, the liver is especially susceptible to druginduced injury. Drugs that are hepatotoxic include acetaminophen (Tylenol), isoniazid (INH), methotrexate (Mexate), phenytoin (Dilantin), and aspirin and other salicylates. In the presence of drug- or disease-induced liver damage, the metabolism of many drugs is impaired. Consequently, drugs metabolized by the liver

tend to accumulate in the body and cause adverse effects. Besides hepatotoxicity, many drugs produce abnormal values in liver function tests without producing clinical signs of liver dysfunction. 5. Nephrotoxicity (nephritis, renal insufficiency or failure) occurs with several antimicrobial agents (eg, gentamicin and other aminoglycosides), nonsteroidal antiinflammatory agents (eg, ibuprofen and related drugs), and others. It is potentially serious because it may interfere with drug excretion, thereby causing drug accumulation and increased adverse effects. 6. Hypersensitivity or allergy may occur with almost any drug in susceptible clients. It is largely unpredictable and unrelated to dose. It occurs in those who have previously been exposed to the drug or a similar substance (antigen) and who have developed antibodies. When readministered, the drug reacts with the antibodies to cause cell damage and the release of histamine and other intracellular substances. These substances produce reactions ranging from mild skin rashes to anaphylactic shock. Anaphylactic shock is a lifethreatening hypersensitivity reaction characterized by respiratory distress and cardiovascular collapse. It occurs within a few minutes after drug administration and requires emergency treatment with epinephrine. Some allergic reactions (eg, serum sickness) occur 1 to 2 weeks after the drug is given. 7. Drug fever is a fever associated with administration of a medication. Drugs can cause fever by several mechanisms, including allergic reactions, damaging body tissues, increasing body heat or interfering with its dissipation, or acting on the temperatureregulating center in the brain. The most common mechanism is an allergic reaction. Fever may occur alone or with other allergic manifestations (eg, skin rash, hives, joint and muscle pain, enlarged lymph glands, eosinophilia) and its pattern may be low grade and continuous or spiking and intermittent. It may begin within hours after the first dose if the client has taken the drug before, or within approximately 10 days of continued administration if the drug is new to the client. If the causative drug is discontinued, fever usually subsides within 48 to 72 hours unless







drug excretion is delayed or significant tissue damage has occurred (eg, hepatitis). Many drugs have been implicated as causes of drug fever, including most antimicrobials, several cardiovascular agents (eg, beta blockers, hydralazine, methyldopa, procainamide, quinidine), drugs with anticholinergic properties (eg, atropine, some antihistamines, phenothiazine antipsychotic agents, and tricyclic antidepressants), and some anticonvulsants. Idiosyncrasy refers to an unexpected reaction to a drug that occurs the first time it is given. These reactions are usually attributed to genetic characteristics that alter the person’s drug-metabolizing enzymes. Drug dependence (see Chap. 15) may occur with mind-altering drugs, such as opioid analgesics, sedative-hypnotic agents, antianxiety agents, and CNS stimulants. Dependence may be physiologic or psychological. Physiologic dependence produces unpleasant physical symptoms when the dose is reduced or the drug is withdrawn. Psychological dependence leads to excessive preoccupation with drugs and drugseeking behavior. Carcinogenicity is the ability of a substance to cause cancer. Several drugs are carcinogens, including some hormones and anticancer drugs. Carcinogenicity apparently results from drug-induced alterations in cellular DNA. Teratogenicity is the ability of a substance to cause abnormal fetal development when taken by pregnant women. Drug groups considered teratogenic include analgesics, diuretics, antiepileptic drugs, antihistamines, antibiotics, antiemetics, and others.

must have a high index of suspicion so that toxicity can be rapidly recognized and treated.

Drug Overdose: General Management
Most poisoned or overdosed clients are treated in emergency rooms and discharged to their homes. A few are admitted to intensive care units (ICUs), often because of unconsciousness and the need for endotracheal intubation and mechanical ventilation. Unconsciousness is a major toxic effect of several commonly ingested substances such as benzodiazepine antianxiety and sedative agents, tricyclic antidepressants, ethanol, and opiates. Serious cardiovascular effects (eg, cardiac arrest, dysrhythmias, circulatory impairment) are also common and warrant admission to an ICU. The main goals of treatment for a poisoned patient are supporting and stabilizing vital functions (ie, airway, breathing, circulation), preventing further damage from the toxic agent by reducing additional absorption or increasing elimination, and administering specific antidotes when available and indicated. General aspects of care are described below; selected antidotes are listed in Table 2–2; and specific aspects of care are described in relevant chapters. 1. For patient who are seriously ill on first contact, enlist help for more rapid assessment and treatment. In general, starting treatment as soon as possible after drug ingestion leads to better patient outcomes. 2. The first priority is support of vital functions, as indicated by a rapid assessment of the patient’s condition (eg, vital signs, level of consciousness). In serious poisonings, an electrocardiogram is indicated and findings of severe toxicity (eg, dysrhythmias, ischemia) justify more aggressive and invasive care. Standard cardiopulmonary resuscitation (CPR) measures may be needed to maintain breathing and circulation. An intravenous (IV) line is usually needed to administer fluids and drugs, and invasive treatment or monitoring devices may be inserted. Endotracheal intubation and mechanical ventilation are often required to maintain breathing (in unconscious patients), correct hypoxemia, and protect the airway. Hypoxemia must be corrected quickly to avoid brain injury, myocardial ischemia, and cardiac dysrhythmias. Ventilation with positive end expiratory pressure (PEEP) should be used cautiously in hypotensive patients because it decreases venous return to the heart and worsens hypotension. Serious cardiovascular manifestations often require pharmacologic treatment. Hypotension and hypoperfusion may be treated with inotropic and vasopresssor drugs. Dysrhythmias are treated according to Advanced Cardiac Life Support (ACLS) protocols. Recurring seizures or status epilepticus require treatment with anticonvulsant drugs. 3. For unconscious patients, as soon as an IV line is established, some authorities recommend a dose of naloxone (2 mg IV) for possible narcotic overdose

Toxic Effects of Drugs
Drug toxicity (also called poisoning, overdose, or intoxication) results from excessive amounts of a drug and may cause reversible or irreversible damage to body tissues. It is a common problem in both adult and pediatric populations. It may result from a single large dose or prolonged ingestion of smaller doses. It may involve alcohol or prescription, over-the-counter, or illicit drugs. Poisoned patients may be seen in essentially any setting (e.g., inpatient hospital units, patients’ homes, long-term care facilities), but are especially likely to be encountered in hospital emergency departments. In some cases, the patient or someone accompanying the patient may know the toxic agent (eg, accidental overdose of a therapeutic drug, use of an illicit drug, a suicide attempt). Often, however, multiple drugs have been ingested, the causative drug or drugs are unknown, and the circumstances may involve traumatic injury or impaired mental status that make the patient unable to provide useful information. Clinical manifestations are often nonspecific for drug overdoses and may indicate other disease processes. Because of the variable presentation of drug intoxication, health care providers




Antidotes for Overdoses of Selected Therapeutic Drugs
Antidote Acetylcysteine (Mucomyst) Route and Dosage Ranges PO 140 mg/kg initially, then 70 mg/kg q4h for 17 doses IV, IM 2 mg. Give IV slowly, over at least 2 min. IV 0.2 mg over 30 sec; if no response, may give 0.3 mg. Additional doses of 0.5 mg may be given at 1-min intervals up to a total amount of 3 mg IV 50–150 mcg/kg (5–10 mg for adults) over 1 min initially, then 2–5 mg/h by continuous infusion as needed IV 1 g over 5 min; may be repeated Adults: IV 2 mg, repeated as needed Children: IV 0.05 mg/kg, up to 2 mg IV 40 mg (1 vial) for each 0.6 mg of digoxin ingested. Reconstitute each vial with 4 mL Water for Injection, then dilute with sterile isotonic saline to a convenient volume and give over 30 min, through a 0.22-micron filter. If cardiac arrest seems imminent, may give the dose as a bolus injection. IV 1 mg/100 units of heparin, slowly, over at least 10 min. A single dose should not exceed 50 mg. IM 1 g q8h PRN IV 15 mg/kg/h if hypotensive Comments Dilute 20% solution to a 5% solution with a cola or other soft drink for oral administration Infrequently used because of its toxicity Should not be given to patients with overdose of unknown drugs or drugs known to cause seizures in overdose (eg, cocaine, lithium) Glucagon increases myocardial contractility; not FDA-approved for this indication Increases myocardial contractility If poisoning is due to organophosphates (eg, insecticides), pralidoxime may be given with the atropine Recommended for severe toxicity; reverses cardiac and extracardiac symptoms in a few minutes Note: Serum digoxin levels increase after antidote administration, but the drug is bound and therefore inactive.

Overdosed Drug (Poison) Acetaminophen (see Chap. 7)

Anticholinergics (atropine; see Chap. 21) Benzodiazepines (see Chap. 8)

Physostigmine Flumazenil

Beta blockers (see Chap. 19)


Calcium channel blockers (see Chaps. 53, 55) Cholinergics (see Chap. 20)

Calcium gluconate 10% Atropine

Digoxin (see Chap. 51)

Digoxin immune fab (Digibind)

Heparin (see Chap. 57)

Protamine sulfate

Iron (see Chap. 32)


Isoniazid (INH)


Lead Opioid analgesics (Chap. 6) Phenothiazine antipsychotic agents (see Chap. 9) Thrombolytics (see Chap. 57)

Succimer Naloxone (Narcan) Diphenhydramine (Benadryl)

Aminocaproic acid (Amicar)

IV 1 g per gram of INH ingested, at rate of 1 g q2–3 min. If amount of INH unknown, give 5 g; may be repeated. Children: PO 10 mg/kg q8h for 5 days Adults: IV 0.4–2 mg PRN Children: IV 0.1 mg/kg per dose Adults: IV 50 mg Children: IV 1–2 mg/kg, up to a total of 50 mg PO, IV infusion, 5 g initially, then 1–1.25 g/h for 8 h or until bleeding is controlled. Maximum dose, 30 g/24h

Indicated for serum iron levels >500 mg/dL or serum levels >350 mg/dL with GI or cardiovascular symptoms Can bind and remove a portion of an ingested dose; urine becomes red as iron is excreted Indicated for management of seizures and correction of acidosis

Can also be given IM, SC, or by endotracheal tube Given to relieve extrapyramidal symptoms (movement disorders)

(continued )




Antidotes for Overdoses of Selected Therapeutic Drugs (continued)
Antidote Sodium bicarbonate Route and Dosage Ranges IV 1–2 mEq/kg initially, then continuous IV drip to maintain serum pH of 7.5 PO 5–10 mg daily IV (severe overdose) continuous infusion at rate no faster than 1 mg/min Comments To treat cardiac dysrhythmias, conduction disturbances, and hypotension

Overdosed Drug (Poison) Tricyclic antidepressants (see Chap. 10) Warfarin (see Chap. 57)

Vitamin K1

and thiamine (100 mg IV) for possible brain dysfunction due to thiamine deficiency. In addition, a fingerstick blood glucose test should be done and, if hypoglycemia is indicated, 50% dextrose (50 ml IV) should be given. 4. Once the patient is out of immediate danger, a thorough physical examination and efforts to determine the drug(s), the amounts, and the time lapse since exposure are needed. If the patient is unable to supply needed information, interview anyone else who may be able to do so. Ask about the use of prescription, over-the-counter, alcohol, and illicit substances. 5. There are no standard laboratory tests for poisoned patients. The client’s condition and the clinician’s judgment determine which laboratory tests are needed, although baseline tests of liver and kidney function are usually indicated. Specimens of blood, urine, or gastric fluids may be obtained for laboratory analysis. Screening tests for toxic substances are not very helpful because test results may be delayed, many substances are not detected, and the results rarely affect initial treatment. Initial treatment should never be delayed to obtain results of a toxicology screen. Identification of an unknown drug or poison is often based on the patient’s history and signs and symptoms, with specific tests as confirmation. Serum drug levels are needed when acetaminophen, alcohol, digoxin, lithium, aspirin, or theophylline is known to be an ingested drug, to assist with treatment. 6. For orally ingested drugs, gastrointestinal (GI) decontamination has become a controversial topic. For many years, standard techniques for removing drugs from the GI tract included ipecac syrup for alert patients, to induce emesis; gastric lavage for patients with decreased levels of consciousness; activated charcoal to adsorb the ingested drug in the GI tract; and a cathartic (usually 70% sorbitol) to accelerate elimination of the adsorbed drug. More recently, whole bowel irrigation (WBI) was introduced as an additional technique. Currently, there are differences of opinion regarding whether and when these techniques are indicated. These differences led to the convening of a consensus group of toxicologists from the American Academy of Clinical Toxicology (AACT) and the European

Association of Poison Centres and Clinical Toxicologists (EAPCCT). This group issued treatment guidelines that have also been endorsed by other toxicology organizations. Generally, the recommendations state that none of the aforementioned techniques should be used routinely and that adequate data to support or exclude their use are often lacking. Opinions expressed by the consensus group and others are described below: Ipecac. Usage in hospital settings has declined. Its use may delay administration or reduce effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. It is contraindicated in patients who are less than fully alert (because of the danger of aspiration). Ipecac may be used to treat mild poisonings in the home, especially in children. Parents should call a poison control center or a health care provider before giving ipecac. If used, it is most beneficial if administered within an hour after ingestion of a toxic drug dose. Gastric lavage. Its usefulness is being increasingly questioned. It is contraindicated in less than alert patients unless the patient has an endotracheal tube in place (to prevent aspiration). It may be beneficial in serious overdoses if performed within an hour of drug ingestion. If the ingested agent delays gastric emptying (eg, tricyclic antidepressants and other drugs with anticholinergic effects), the time limit may be extended. When used after ingestion of pills or capsules, the tube lumen should be large enough to allow removal of pill fragments. Activated charcoal. Sometimes called the universal antidote, it is useful in many poisoning situations. It is being used alone for mild or moderate overdoses and with gastric lavage in serious poisonings. It effectively adsorbs many toxins and rarely causes complications. It is most beneficial when given within an hour of ingestion of a potentially toxic amount of a drug known to bind to charcoal. Its effectiveness decreases with time and there are inadequate data to support or exclude its use later than 1 hour after ingestion. Activated charcoal is usually mixed in water (about 50 g or 10 heaping tablespoons in 8 oz. water) to make a slurry, which is gritty and unpleasant to



swallow. It is often given by GI tube. The charcoal blackens later bowel movements. Adverse effects include pulmonary aspiration and impaction of the charcoal–drug complex. If used with whole bowel irrigation, activated charcoal should be given before the WBI solution is started. If given during WBI, the binding capacity of the charcoal is decreased. Cathartic. It is not recommended alone and its use with activated charcoal has produced conflicting data. If used, it should be limited to a single dose to minimize adverse effects. Whole bowel irrigation (WBI). This technique is most useful for removing toxic ingestions of long-acting, sustained-release drugs (eg, many beta blockers, calcium channel blockers, and theophylline preparations); enteric coated drugs; and toxins that do not bind well with activated charcoal (eg, iron, lithium, lead). It may also be helpful in removing packets of illicit drugs, such as cocaine or heroin. When given, polyethylene glycol solution (eg, Colyte) 1–2 liters/ hour to a total of 10 liters is recommended. WBI is contraindicated in patients with serious bowel disorders (eg, obstruction, perforation, ileus), hemodynamic instability, or respiratory impairment (unless intubated). 7. Urinary elimination of some drugs and toxic metabolites can be accelerated by changing the pH of urine (eg, acidifying with amphetamine overdose; alkalinizing with salicylate overdose), diuresis, or hemodialysis. Hemodialysis is the treatment of choice in severe lithium and aspirin (salicylate) poisoning. 8. Administer specific antidotes when available and indicated by the client’s clinical condition. Available antidotes vary widely in effectiveness. Some are very effective and rapidly reverse toxic manifestations (eg, naloxone for opiates, flumazenil for benzodiazepines, specific Fab fragments for digoxin). Others are less effective (eg, deferoxamine for acute iron ingestion) or potentially toxic themselves (eg, physostigmine for tricyclic antidepressant overdose). When an antidote is used, its half-life relative to the toxin’s half-life must be considered. For example, the half-life of naloxone, a narcotic antagonist, is relatively short compared with the half-life of the longer-acting opiates such as methadone. Similarly, flumazenil has a

How Can You Avoid This Medication Error?
Answer: Grapefruit juice interacts with many medications, including felodipine. The drug level of felodipine increases because the grapefruit juice inhibits the isozyme of cytochrome P450, which is important in the metabolism of felodipine. As the blood level increases, serious toxic effects can occur. Other juices do not impact cytochrome P450 so it would be safe to have Mrs. Beecher take her medication with another type of juice or water. Notify the physician regarding Mrs. Beecher’s hypotension and the drug–food interaction. If Mrs. Beecher remains on felodipine, she must be cautioned to eliminate grapefruit juice from her diet.

shorter half-life than most benzodiazepines. Thus, repeated doses of these agents may be needed to prevent recurrence of the toxic state.

Review and Application Exercises
1. Why do nurses need to understand cellular physiology in relation to drug therapy? 2. What are some factors that decrease absorption of an oral drug? 3. Drug dosage is a major determinant of both therapeutic and adverse drug effects. How can you use this knowledge in monitoring a client’s response to drug therapy? 4. Does protein binding speed or slow drug distribution to sites of action? 5. Are drugs equally distributed throughout the body? Why or why not? 6. What are the implications of hepatic enzyme induction and inhibition in terms of drug metabolism and elimination from the body? 7. For a drug in which biotransformation produces active metabolites, is drug action shortened or lengthened? What difference does this make in client care? 8. Which pharmacokinetic processes are likely to be impaired with severe cardiovascular disease and with severe renal disease? 9. What are the main elements of the receptor theory of drug action? 10. When drug–drug interactions occur, are drug actions increased or decreased? 11. What are some reasons for individual differences in responses to drugs? SELECTED REFERENCES
Barone, J. A. & Hermes-DeSantis, E. R. (2000). Adverse drug reactions and drug-induced diseases. In E. T. Herfindal & D. R. Gourley (Eds.), Textbook of therapeutics: Drug and disease management, 7th ed., pp. 21–34. Philadelphia: Lippincott Williams & Wilkins.

Nursing Notes: Apply Your Knowledge
Answer: Half-life is the time required for the serum concentration of a drug to decrease by 50%. After 1 hour, the serum concentration would be 50 units/mL (100/2). After 2 hours, the serum concentration would be 25 units/mL (50/2) and reach the nontoxic range.



Brater, D. C. (2000). Principles of clinical pharmacology. In H. D. Humes (Ed.), Kelley’s Textbook of internal medicine, 4th ed., pp. 311–319. Philadelphia: Lippincott Williams & Wilkins. Drug facts and comparisons. (Updated monthly). St. Louis: Facts and Comparisons. Ensom, M. H. H. (2000). Gender-based differences and menstrual cyclerelated changes in specific diseases: Implications for pharmacotherapy. Pharmacotherapy, 20(5), 523–539. Guyton, A. C. & Hall, J. E. (2000). Textbook of medical physiology, 10th ed. Philadelphia: Saunders. Klein-Schwartz, W. & Oderda, G. M. (2000). Clinical toxicology. In E. T. Herfindal & D. R. Gourley (Eds.), Textbook of therapeutics: Drug and dis-

ease management, 7th ed., pp. 51–68. Philadelphia: Lippincott Williams & Wilkins. Krenzelok, E. P. & Vale, J. A. (1998, May). The AACT/EAPCCT position statements on gut decontamination in acute poisoning. Hospital Pharmacy, 33(5), 533–543. Matthews, H. W. & Johnson, J. (2000). Racial, ethnic, and gender differences in response to drugs. In E. T. Herfindal & D. R. Gourley (Eds.), Textbook of therapeutics: Drug and disease management, 7th ed., pp. 93–103. Philadelphia: Lippincott Williams & Wilkins. Tatro, D. S. (2000). Drug interactions. In E. T. Herfindal & D. R. Gourley (Eds.), Textbook of therapeutics: Drug and disease management, 7th ed., pp. 35–49. Philadelphia: Lippincott Williams & Wilkins.

chapter 3 Administering Medications

1. List the five rights of drug administration. 2. Discuss knowledge and skills needed to implement the five rights. 3. List requirements of a complete drug order or prescription. 4. Accurately interpret drug orders containing common abbreviations. 5. Differentiate drug dosage forms for various routes and purposes of administration.

6. Discuss advantages and disadvantages of oral, parenteral, and topical routes of drug administration. 7. Identify supplies, techniques, and observations needed for safe and accurate administration by different routes.

Critical Thinking Scenario Ms. Mabel Zack is transferred to your rehabilitation facility after a cerebral vascular accident (stroke) 2 weeks ago. When you review her chart, it indicates she has right-sided hemiparesis, memory deficits, and dysphagia (difficulty swallowing). Reflect on: ᮣ Outline appropriate assessments to determine if it is safe to give Ms. Zack oral medications. ᮣ If a swallowing evaluation indicates that Ms. Zack can take medications orally, what precautions can you take to help ensure her safety? ᮣ How might you individualize your teaching plan, considering Ms. Zack’s memory deficits?

rugs given for therapeutic purposes are called medications. Giving medications to clients is an important nursing responsibility in many health care settings, including ambulatory care, hospitals, long-term care facilities, and clients’ homes. The basic requirements for accurate drug administration are often called the “five rights”: giving the right drug, in the right dose, to the right client, by the right route, at the right time. These “rights” require knowledge of the drugs to be given and the clients who are to receive them as well as specific nursing skills and interventions. When one of these rights is violated, medication errors can occur. Nurses need to recognize circumstances in which errors are likely to occur and intervene to prevent errors and protect clients. This chapter is concerned with safe and accurate medication administration.


• Follow the “five rights” consistently. • Learn essential information about each drug to be given
(eg, indications for use, contraindications, therapeutic effects, adverse effects, and any specific instructions about administration). • Interpret the prescriber’s order accurately (ie, drug name, dose, frequency of administration). Question the prescriber if any information is unclear or if the drug seems inappropriate for the client’s condition. • Read labels of drug containers for the drug name and concentration (usually in mg per tablet, capsule, or milliliter of solution). Many medications are available in different dosage forms and concentrations; it is extremely important that the correct ones be used.




How Can You Avoid This Medication Error?
You are administering 6 AM medications to a client on a medical unit. You enter Mr. Gonzales’ room, gently shake him awake, and call him by name. He slowly awakens and appears groggy. You explain that you have his medications, which he takes and quickly falls back to sleep. On exiting the room, you look at the room number and realize that you just gave medications to Mr. Sanchez.

son is that children have limited sites for administration of IV drugs, and several may be given through the same site. In many cases, the need for small volumes of fluid limits flushing between drugs (which may produce undesirable interactions with other drugs and IV solutions). In 1998, the Food and Drug Administration published a requirement that new drugs likely to be important or frequently used in the treatment of children should be labeled with instructions for safe pediatric use.

• Minimize the use of abbreviations for drug names, doses,
routes of administration, and times of administration. This promotes safer administration and reduces errors. When abbreviations are used, by prescribers or others, interpret them accurately or question the writers about intended meanings. Calculate doses accurately. Current nursing practice requires few dosage calculations (most are done by pharmacists). However, when they are needed, accuracy is essential. For medications with a narrow safety margin or potentially serious adverse effects, ask a pharmacist or a colleague to do the calculation also and compare the results. This is especially important when calculating children’s dosages. Measure doses accurately. Ask a colleague to doublecheck measurements of insulin and heparin, unusual doses (ie, large or small), and any drugs to be given intravenously. Use the correct procedures and techniques for all routes of administration. For example, use appropriate anatomic landmarks to identify sites for intramuscular (IM) injections, follow the manufacturers’ instructions for preparation and administration of intravenous (IV) medications, and use sterile materials and techniques for injectable and eye medications. Seek information about the client’s medical diagnoses and condition in relation to drug administration (eg, ability to swallow oral medications; allergies or contraindications to ordered drugs; new signs or symptoms that may indicate adverse effects of administered drugs; heart, liver, or kidney disorders that may interfere with the client’s ability to eliminate drugs). Verify the identity of all clients before administering medications; check identification bands on clients who have them (eg, in hospitals or long-term facilities). Omit or delay doses as indicated by the client’s condition; report or record omissions appropriately. Be especially vigilant when giving medications to children because there is a high risk of medication errors. One reason is their great diversity, in age from birth to 18 years and weight from 2–3 kilograms (kg) to 100 kg or more. Another is that most drugs have not been tested in children. A third reason is that many drugs are marketed in dosage forms and concentrations suitable for adults. This often requires dilution, calculation, preparation, and administration of very small doses. A fourth rea-

Registered and licensed practical nurses are legally empowered, under state nurse practice acts, to give medications ordered by licensed physicians and dentists. In some states, nurse practitioners may prescribe medications. When giving medications, the nurse is legally responsible for safe and accurate administration. This means the nurse may be held liable for not giving a drug or for giving a wrong drug or a wrong dose. In addition, the nurse is expected to have sufficient drug knowledge to recognize and question erroneous orders. If, after questioning the prescriber and seeking information from other authoritative sources, the nurse considers that giving a drug is unsafe, the nurse must refuse to give the drug. The fact that a physician wrote an erroneous order does not excuse the nurse from legal liability if he or she carries out that order. The nurse also is legally responsible for actions delegated to people who are inadequately prepared for or legally barred from administering medications (such as nursing assistants). However, certified medical assistants (CMAs) administer medications in physicians’ offices and certified medication aides (nursing assistants with a short course of training, also called CMAs,) often administer medications in long-term care facilities. The nurse who consistently follows safe practices in giving medications does not need to be excessively concerned about legal liability. The basic techniques and guidelines described in this chapter are aimed at safe and accurate preparation and administration; most errors result when these practices are not followed. Legal responsibilities in other aspects of drug therapy are less tangible and clear-cut. However, in general, nurses are expected to monitor clients’ responses to drug therapy (eg, therapeutic and adverse effects) and to teach clients safe and effective self-administration of drugs when indicated. These aspects are described more fully in Chapter 4.

• • •

Increasing attention is being paid to the number and consequences of medication errors. In one study of 1116 hospitals, medication errors (a total of 430,586) were reported in approximately 5% of admitted patients. In 913 of those hospitals, over 17,000 errors (0.25% of admitted patients) re-



portedly caused adverse client outcomes (usually described as serious illness, conditions that prolong hospitalization or require additional treatment, or death). Other studies have reported that common errors include giving an incorrect dose, not giving an ordered drug, and giving an unordered drug. Specific drugs often associated with errors include insulin, heparin, and warfarin. There are several steps and numerous people involved in getting each dose of a medication to the intended client. Each step or person has a potential for contributing to a medication error (Box 3–1). All health care providers involved in drug therapy must be extremely vigilant in all phases of drug administration.

Each agency has a system for distributing drugs. The unitdose system, in which most drugs are dispensed in singledose containers for individual clients, is widely used. Drug orders are checked by a pharmacist or pharmacy technician, who then places the indicated number of doses in the client’s medication drawer at scheduled intervals. When a dose is due, the nurse removes the medication and takes it to the client. Unit-dose wrappings of oral drugs should be left in

place until the nurse is in the presence of the client and ready to give the medication. Each dose of a drug must be recorded on the client’s medication administration record (MAR) as soon as possible after administration. Increasingly, agencies are using automated, computerized, locked cabinets for which each nurse on a unit has a password or code for accessing the cabinet and obtaining a drug dose. These automated systems maintain an inventory and drugs are restocked as needed. Controlled drugs, such as opioid analgesics, are usually kept as a stock supply in a locked drawer or automated cabinet and replaced as needed. Each dose is signed for and recorded on the client’s MAR. Each nurse must comply with legal regulations and agency policies for dispensing and recording controlled drugs.

Medication orders should include the full name of the client; the generic or trade name of the drug; the dose, route, and frequency of administration; and the date, time, and signature of the prescriber, usually a physician. Most orders in a health care agency are handwritten on an order sheet in the client’s medical record or typed into a com-

BOX 3–1

age; fail to keep appointments for follow-up care; and fail to ask for information about prescription and nonprescription drugs when needed. Drugs Drugs may have similar names that can lead to erroneous prescribing, dispensing, or administration. For example, the antiseizure drug Lamictal (generic name, lamotrigine) has been confused with Lamisil, an antifungal drug, lamivudine, an antiviral drug, and others. As a result, the FDA-proposed labeling changes to make the differences more noticeable. The FDA is also looking at proposed trade names of new drugs prior to marketing, to see if they are likely to be confused with older drugs, and increasing surveillance of medication errors attributed to drug name confusion. In addition to similar names, many drugs, especially those produced by the same manufacturer, have similar packaging. This can lead to errors if container labels are not read carefully, especially if the products are shelved or stored next to each other. Long-acting oral dosage forms with various, sometimes unclear indicators (eg, LA, XL, XR), may be crushed, chewed, or otherwise broken so that the long-acting feature is destroyed. This can cause an overdose. Circumstances Prescribers, pharmacists, and nurses may have a heavy workload, with resultant rushing of prescribing, dispensing, or administering medications. They may also experience distractions by interruptions, noise, and other events in the work environment that make it difficult to pay needed attention to the medication-related task.

Medication errors may occur during any phase of drug therapy, including prescribing, dispensing, and administration. The main purpose of including potential sources of errors here is to increase the ability of health care providers to recognize risky situations and to prevent errors when possible. Health Care Providers Prescribers may write orders illegibly; order a drug that is not indicated by the client’s condition; fail to order a drug that is indicated; fail to consider the client’s age, size, kidney function, liver function, and disease process when selecting a drug or dosage; fail to consider other medications the client is taking, including prescription and over-the-counter drugs; lack sufficient knowledge about the drug; fail to monitor for, or instruct others to monitor for, effects of administered drugs; and fail to discontinue drugs appropriately. Pharmacists may not know the client’s condition or recognize an inappropriate or erroneous physician’s order. They may dispense incorrect medications, mislabel containers, or fail to ask outpatients about other drugs being taken. Nurses may have inadequate knowledge about a drug or about the client receiving the drug; not follow the “five rights”; fail to question the medication order when indicated. Clients/Consumers People may take drugs from several prescribers; fail to inform one physician about drugs prescribed by another; get prescriptions filled at more than one pharmacy; fail to get prescriptions filled or refilled; underuse or overuse an appropriately prescribed drug; take drugs left over from a previous illness or prescribed for someone else; fail to follow instructions for drug administration or stor-



puter. Occasionally, verbal or telephone orders are acceptable. These are written on the client’s order sheet, signed by the person taking the order, and later countersigned by the prescriber. Once the order is written, a copy is sent to the pharmacy, where the order is recorded and the drug is dispensed to the appropriate client care unit. In many agencies, pharmacy staff prepare a computer-generated MAR for each 24-hour period. For clients in ambulatory care settings, the procedure is essentially the same for drugs to be given immediately. For drugs to be taken at home, written prescriptions are given. In addition to the previous information, a prescription should include instructions for taking the drug (eg, dose and frequency) and whether the prescription can be refilled. Prescriptions for Schedule II controlled drugs cannot be refilled. To interpret medication orders accurately, the nurse must know commonly used abbreviations for routes, dosages, and times of drug administration (Table 3–1). If the nurse cannot read the physician’s order or if the order seems erroneous, he or she must question the order before giving the drug.

Drug preparations and dosage forms vary according to the drug’s chemical characteristics, reason for use, and route of administration. Some drugs are available in only one dosage form; others are available in several forms. Characteristics of various dosage forms are described below and in Table 3–2. Dosage forms of systemic drugs include liquids, tablets, capsules, suppositories, and transdermal and pump delivery systems. Systemic liquids are given orally (PO) or by injection. Those given by injection must be sterile. Tablets and capsules are given PO. Tablets contain active drug plus binders, colorants, preservatives, and other substances. Capsules contain active drug enclosed in a gelatin capsule. Most tablets and capsules dissolve in the acidic fluids of the stomach and are absorbed in the alkaline fluids of the upper small intestine. Enteric-coated tablets and capsules are coated with a substance that is insoluble in stomach acid. This delays dissolution until the medication reaches the intestine, usually to avoid gastric irritation or to keep the drug from being destroyed by gastric acid. Tablets for sublingual or buccal administration must be specifically formulated for such use. Several controlled-release dosage forms and drug delivery systems are available and more continue to be developed. These formulations maintain more consistent serum drug levels and allow less frequent administration, which is more convenient for clients. Oral tablets and capsules are called by a variety of names (eg, timed release, sustained release, extended release) and their names usually include SR, XL, or other indications that they are long-acting formulations. Most of these formulations are given once or twice daily. Some drugs (eg, alendronate for osteoporosis and fluoxetine for major depression) are available in formulations that deliver a full week’s dosage in one oral tablet. Because controlled-release tablets and capsules contain high amounts of drug intended to be absorbed slowly and act over a prolonged period of time, they should never be broken, opened, crushed, or chewed. Such an action allows the full dose to be absorbed immediately and constitutes an overdose, with potential organ damage or death. Transdermal (skin patch) formulations include systemically absorbed clonidine, estrogen, fentanyl, nitroglycerin, and scopolamine. These medications are slowly absorbed from the skin patches over varying periods of time (eg, 1 week for clonidine and estrogen). Pump delivery systems may be external or implanted under the skin and refillable or long acting without refills. Pumps are used to administer insulin, opioid analgesics, antineoplastics, and other drugs. Solutions, ointments, creams, and suppositories are applied topically to skin or mucous membranes. They are formulated for the intended route of administration. For example, several drugs are available in solutions for nasal or oral inhalation; they are usually self-administered as a spray into the nose or mouth. Many combination products containing fixed doses of two or more drugs are also available. Commonly used combinations include analgesics, antihypertensive drugs, and cold remedies. Most are oral tablets, capsules, or solutions.


Common Abbreviations

Routes of Drug Administration IM IV OD OS OU PO SC SL Drug Dosages intramuscular intravenous right eye* left eye* both eyes* by mouth, oral subcutaneous sublingual

cc cubic centimeter g gram gr grain gt drop† mg milligram mL milliliter oz ounce tbsp tablespoon tsp teaspoon Times of Drug Administration ac ad lib bid hs pc PRN qd q4h qid qod stat tid before meals as desired twice daily bedtime after meals when needed every day, daily every four hours four times daily every other day immediately three times daily

*Because of errors made with the abbreviations, some authorities recommend spelling out the site (eg, right eye). †drops = gtt.




Drug Dosage Forms
Characteristics Considerations/Precautions

Dosage Forms and Their Routes of Administration Tablets Regular: PO, GI tube (crushed and mixed with water) Chewable: PO Enteric coated: PO

Extended release (XL): PO

Sublingual: Under the tongue Buccal: Held in cheek Capsules Regular: PO

• Contain active drug plus binders, dyes, preservatives • Dissolve in gastric fluids Colorful and flavored, mainly for young children who are unable to swallow or who refuse regular tablets Dissolve in small intestine rather than stomach; mainly used for medications that cause gastric irritation • Also called sustained release (SR), long acting (LA), and others • Formulated for slow absorption and prolonged action • Effects of most last 12–24 hours • Contain relatively large doses of active drug • Dissolve quickly • Medication absorbed directly into the bloodstream and exerts rapid systemic effects

8 oz of water recommended when taken orally, to promote dissolution and absorption Colors and flavors appeal to children; keep out of reach to avoid accidental overdose. Do not crush; instruct clients not to chew or crush.

Warning: Crushing to give orally or through a GI tube administers an overdose, with potentially serious adverse effects or death!! Never crush; instruct clients not to chew or crush Few medications formulated for administration by these routes

Extended release (XL): PO

• Contain active drug, fillers, and preservatives in a gelatin capsule • Gelatin capsules dissolve in gastric fluid and release medication • Also called sustained release (SR), long acting (LA), and others • Formulated for slow absorption and prolonged action • Effects of most last 12–24 hours • Contain relatively large doses of active drug

As with oral tablets, 8 oz of fluid recommended to promote dissolution of capsule and absorption of medication Warning: Emptying a capsule to give the medication orally or through a GI tube administers an overdose, with potentially serious adverse effects or death!! Instruct clients not to bite, chew or empty these capsules.

Solutions Oral: PO, GI tube Parenteral: IV, IM SC, intradermal

• Absorbed rapidly because they do not need to be dissolved • Medications and all administration devices must be sterile • IV produces rapid effects; SC is used mainly for insulin and heparin; IM is used for only a few drugs; intradermal is used mainly to inject skin test material rather than therapeutic drugs.

Use of appropriate measuring devices and accurate measurement are extremely important. Use of appropriate equipment (eg, needles, syringes, IV administration sets) and accurate measurement are extremely important. Insulin syringes should always be used for insulin and tuberculin syringes are recommended for measuring small amounts of other drugs.

Suspensions PO, SC (NPH and Lente insulins) Dermatologic Creams, Lotions, Ointments Topically to skin

• These are particles of active drug suspended in a liquid; the liquid must be rotated or shaken before measuring a dose.

Drug particles settle to the bottom on standing. If not remixed, the liquid vehicle is given rather than the drug dose.

• Most are formulated for minimal absorption through skin and local effects at the site of application; medications in skin patch formulations are absorbed and exert systemic effects.

Formulations vary with intended uses and are not interchangeable. When removed from the client, skin patches must be disposed of properly to prevent someone else from being exposed to the active drug remaining in the patch. Several research studies indicate that patients often do not use MDIs correctly and sometimes are incorrectly taught by health care providers. Correct use is essential to obtaining therapeutic effects and avoiding adverse effects. Can be systemically absorbed and cause systemic adverse effects

Solutions and Powders for Oral or Nasal Inhalation, Including Metered Dose Inhalers (MDIs) Eye Solutions and Ointments

• Oral inhalations are used mainly for asthma; nasal sprays for nasal allergies (allergic rhinitis) • Effective with less systemic effect than oral drugs • Deliver a specified dose per inhalation • Should be sterile • Most are packaged in small amounts, to be used by a single patient • Used for cough and sore throat • Used mainly for ear infections

Throat Lozenges Ear Solutions

(continued )




Drug Dosage Forms (continued )
Characteristics • Formulated for insertion into the vagina • Commonly used to treat vaginal infections • Formulated for insertion into the rectum • Suppositories may be used to administer sedatives, analgesics, laxatives • Medicated enemas are used to treat inflammatory bowel diseases (eg, ulcerative colitis) Effects somewhat unpredictable because absorption is erratic Considerations/Precautions

Dosage Forms and Their Routes of Administration Vaginal Creams and Suppositories Rectal Suppositories and Enemas

PO, oral; GI, gastrointestinal; IV, intravenous; IM, intramuscular; SC, subcutaneous.

When calculating drug doses, the importance of accuracy cannot be overemphasized. Accuracy requires basic skills in mathematics, knowledge of common units of measurement, and methods of using data in performing calculations.

Systems of Measurement
The most commonly used system of measurement is the metric system, in which the meter is used for linear measure, the gram for weight, and the liter for volume. One milliliter (mL) equals 1 cubic centimeter (cc), and both equal 1 gram (g) of water. The apothecary system, now obsolete and rarely used, has units called grains, minims, drams, ounces, pounds, pints, and quarts. The household system, with units of drops, teaspoons, tablespoons, and cups, is infrequently used in health care agencies but may be used at home. Table 3–3 lists equivalent measurements within and among these systems. Equivalents are approximate. A few drugs are ordered and measured in terms of units or milliequivalents (mEq). Units express biologic activity in

animal tests (ie, the amount of drug required to produce a particular response). Units are unique for each drug. For example, concentrations of insulin and heparin are both expressed in units, but there is no relation between a unit of insulin and a unit of heparin. These drugs are usually ordered in the number of units per dose (eg, NPH insulin 30 units subcutaneously [SC] every morning, or heparin 5000 units SC q12h) and labeled in number of units per milliliter (U 100 insulin contains 100 units/mL; heparin may have 1000, 5000, or 10,000 units/mL). Milliequivalents express the ionic activity of a drug. Drugs such as potassium chloride are ordered and labeled in the number of milliequivalents per dose, tablet, or milliliter.

Mathematical Calculations
Most drug orders and labels are expressed in metric units of measurement. If the amount specified in the order is the same as that on the drug label, no calculations are required, and preparing the right dose is a simple matter. For example, if the order reads “ibuprofen 400 mg PO” and the drug label reads “ibuprofen 400 mg per tablet,” it is clear that one tablet is to be given. What happens if the order calls for a 400-mg dose and 200-mg tablets are available? The question is, “How many 200-mg tablets are needed to give a dose of 400 mg?” In this case, the answer can be readily calculated mentally to indicate two tablets. This is a simple example that also can be used to illustrate mathematical calculations. This problem can be solved by several acceptable methods; the following formula is presented because of its relative simplicity for students lacking a more familiar method. D X = H V D = desired dose (dose ordered, often in milligrams) H = on-hand or available dose (dose on the drug label, often in mg per tablet, capsule, or milliliter) X = unknown (number of tablets, in this example) V = unit (one tablet, here)


Apothecary = 15 or 16 minims = 1 fluid dram = 1 gr = 1/2 gr = 1 oz = 8 oz = 1 lb = 16 oz = 32 oz = 1 mg =1g = 2.2 lb = 10 gr Household = 15 or 16 drops = 1 tsp = 2 tbsp = 1 cup = 1 pint = 1 quart = 2.2 lb

1 mL = 1 cc 4 or 5 mL 60 or 65 mg 30 or 32 mg 30 g = 30 mL 250 mL 454 g 500 mL = 500 cc 1 L = 1000 mL 1000 mcg* 1000 mg 1000 g = 1 kg 0.6 g = 600 mg or 650 mg
*mcg = microgram.



400 mg X tablet = 200 mg 1 tablet Cross multiply: 200 X = 400 400 X= = 2 tablets 200 What happens if the order and the label are written in different units? For example, the order may read “amoxicillin 0.5 g” and the label may read “amoxicillin 500 mg/capsule.” To calculate the number of capsules needed for the dose, the first step is to convert 0.5 g to the equivalent number of milligrams, or convert 500 mg to the equivalent number of grams. The desired or ordered dose and the available or label dose must be in the same units of measurement. Using the equivalents (ie, 1 g = 1000 mg) listed in Table 3–2, an equation can be set up as follows: 1g 0.5 g = 1000 mg X mg X = 0.5 × 1000 = 500 mg The next step is to use the new information in the formula, which then becomes: D X = H V 500 mg X capsules = 500 mg 1 capsule 500 X = 500 500 X= = 1 capsule 500 The same procedure and formula can be used to calculate portions of tablets or dosages of liquids. These are illustrated in the following problems: 1. Order: 25 mg PO Label: 50-mg tablet 25 mg X tablet = 50 mg 1 tablet 50 X = 25 X= 2. Order: 25 mg IM Label: 50 mg in 1 cc 25 mg X cc = 50 mg 1 cc 50 X = 25 X= 25 = 0.5 cc 50 25 = 0.5 tablet 50

3. Order: 4 mg IV Label: 10 mg/mL 4 mg X mL = 10 mg 1 mL 10 X = 4 X= 4 = 0.4 mL 10

4. Order: Heparin 5000 units Label: Heparin 10,000 units/mL 5000 units X mL = 10, 000 units 1 mL 10, 000 X = 5000 X= 5000 = 0.5 mL 10, 000

5. Order: KCl 20 mEq Label: KCl 10 mEq/5 mL 20 mEq X mL = 10 mEq 5 mL 10 X = 100 X= 100 = 10 mL 10

Routes of administration depend on drug characteristics, client characteristics, and desired responses. The major routes are oral, parenteral, and topical. Each has advantages, disadvantages, indications for use, and specific techniques of administration (Table 3–4). The term parenteral refers to any route other than gastrointestinal (enteral), but is commonly used to indicate SC, IM, and IV injections. Injections require special drug preparations, equipment, and techniques. General characteristics are described below; specific considerations for the intravenous route are described in Box 3–2.

Drugs for Injection
Parenteral drugs must be prepared, packaged, and administered in ways to maintain sterility. Vials are closed glass or plastic containers with rubber stoppers through which a sterile needle can be inserted for withdrawing medication. Single-dose vials usually do not contain a preservative and must be discarded after a dose is withdrawn; multiple-dose vials contain a preservative and may be reused if aseptic technique is maintained. Ampules are sealed glass containers, the tops of which must be broken off to allow insertion of a needle and withdrawal of the medication. Broken ampules and any remaining medication are discarded; they are no longer sterile and




Routes of Drug Administration
Advantages • Simple and can be used by most people • Convenient; does not require complex equipment • Relatively inexpensive Disadvantages • Amount of drug acting on body cells is unknown because varying portions of a dose are absorbed and some drug is metabolized in the liver before reaching the bloodstream for circulation • Slow drug action • Irritation of gastrointestinal mucosa by some drugs • With nasogastric tubes, medications may be aspirated into the lungs • Small-bore tubes often become clogged • Requires special precautions to give correctly and avoid complications • Only a small amount of drug (up to 1 mL) can be given • Drug absorption is relatively slow • Only a few drugs can be given SC Comments The oral route should generally be used when possible, considering the client’s condition and ability to take or tolerate oral drugs.

Route and Description Oral

GI tubes (eg, nasogastric, gastrostomy)

• Allows use of GI tract in clients who cannot take oral drugs • Can be used over long periods of time, if necessary • May avoid or decrease injections

Subcutaneous (SC) injection—injection of drugs under the skin, into the underlying fatty tissue

• Relatively painless • Very small needles can be used • Insulin and heparin, commonly used medications that often require multiple daily injections, can be given SC • May be used for several drugs • Drug absorption is rapid because muscle tissue has an abundant blood supply • Allows medications to be given to a patient who cannot take fluids or drugs by GI tract • Bypasses barriers to drug absorption that occur with other routes • Rapid drug action • Larger amounts can be given than by SC and IM routes • Allows slow administration when indicated

Intramuscular (IM) injection—injection of drugs into selected muscles Intravenous (IV) injection—injection of a drug into the bloodstream

Topical administration— application to skin or mucous membranes. Application to mucous membranes includes drugs given by nasal or oral inhalation; by instillation into the lungs, eyes, or nose; and by insertion under the tongue (sublingual), into the cheek (buccal), and into the vagina or rectum.

• With application to intact skin, most medications act at the site of application, with little systemic absorption or systemic adverse effects. • Some drugs are given topically for systemic effects (eg, medicated skin patches). Effects may last several days and the patches are usually convenient for clients. • With application to mucous membranes, most drugs are well and rapidly absorbed

• A relatively small amount of drug (up to 3 mL) can be given • Risks of damage to blood vessels or nerves if needle is not positioned correctly • Time and skill required for venipuncture and maintaining an IV line • Once injected, drug cannot be retrieved if adverse effects or overdoses occur • High potential for adverse reactions from rapid drug action and possible complications of IV therapy (ie, bleeding, infection, fluid overload, extravasation) • Phlebitis commonly occurs and increases risks of thrombosis • Phlebitis and thrombosis cause discomfort or pain, may take days or weeks to subside, and limit the veins available for future therapy • Some drugs irritate skin or mucous membranes and cause itching, rash, or discomfort • With inflamed, abraded, or damaged skin, drug absorption is increased and systemic adverse effects may occur • Application to mucous membranes may cause systemic adverse effects (eg, beta blocker eye drops, used to treat glaucoma, can cause bradycardia just as oral beta blockers can) • Specific drug preparations must be used for the various routes (ie, dermatologics for skin; ophthalmics for eyes; sublingual, buccal, vaginal, and rectal preparations for those sites).

• Liquid preparations are preferred over crushed tablets and emptied capsules, when available • Tube should be rinsed before and after instilling medication The SC route is commonly used for only a few drugs because many drugs are irritating to SC tissues. Such drugs may cause pain, necrosis and abscess formation if injected SC. It is very important to use anatomic landmarks when selecting IM injection sites.

• The nurse should wear latex gloves to start IV infusions, for protection against exposure to bloodborne pathogens. • Phlebitis and thrombosis result from injury to the endothelial cells that form the inner lining (intima) of veins and may be caused by repeated venipunctures, the IV catheter, hypertonic IV fluid, or irritating drugs.

When available and effective, topical drugs are often preferred over oral or injected drugs, because of fewer and/or less severe systemic adverse effects.



BOX 3–2

lumen of the vein is recommended. This allows good blood flow and rapidly dilutes drug solutions as they enter the vein. This, in turn, prevents high drug concentrations and risks of toxicity. Also, once a catheter is inserted, it is very important to tape it securely so that it does not move around. Movement of the catheter increases venous irritation and risks of thrombophlebitis and infection. If signs of venous irritation and inflammation develop, the catheter should be removed and a new one inserted at another site. Additional recommendations include application of a topical antibiotic or antiseptic ointment at the IV site after catheter insertion, a sterile occlusive dressing over the site, and limiting the duration of placement to a few days. Many medications are administered through peripherally inserted central catheters (PICC lines) or central venous catheters, in which the catheter tips are inserted into the superior vena cava, next to the right atrium of the heart. Central venous catheters may have single, double, or triple lumens. Other products, which are especially useful for long-term IV drug therapy, include a variety of implanted ports, pumps, and reservoirs. If a catheter becomes clogged, do not irrigate it. Doing so may push a clot into the circulation and result in a pulmonary embolus, myocardial infarction, or stroke. It may also cause septicemia, if the clot is infected. Needleless systems are one of the most important advances in IV therapy. Most products have a blunt-tipped plastic insertion device and an injection port that opens. These systems greatly decrease needle-stick injuries and exposure to bloodborne pathogens. Electronic infusion devices allow amounts and flow rates of IV drug solutions to be set and controlled by a computer. Although the devices save nursing time, because the nurse does not need to count drops and continually adjust flow rates, probably the biggest advantage is the steady rate of drug administration. The devices are used in most settings where IV drugs and IV fluids are administered, but they are especially valuable in pediatrics, where very small amounts of medication and IV fluid are needed, and in intensive care units, where strong drugs and varying amounts of IV fluid are usually required. Several types of pumps are available, even within the same health care agency. It is extremely important that nurses become familiar with the devices used in their work setting, so they can program them accurately and determine whether or not they are functioning properly (ie, delivering medications as ordered). Site Selection IV needles are usually inserted into a vein on the hand or forearm; IV catheters may be inserted in a peripheral site or centrally (the catheter tip ends in the superior vena cava, near the right atrium of the heart, and medications and fluids are rapidly diluted and flow directly into the heart). In general, recommendations are: • Start at the most distal location. This conserves more proximal veins for later use, if needed. Veins on the back of the hand and on the forearm are often used. These sites usually provide more comfort and freedom of movement for clients than other sites. • Use veins with a large blood volume flowing through them when possible. Many drugs cause irritation and phlebitis in small veins. (continued )

Methods IV injection or IV push is the direct injection of a medication into the vein. The drug may be injected through an injection site on IV tubing or an intermittent infusion device. Most IV push medications should be injected slowly. The time depends on the particular drug, but is often 2 minutes or longer for a dose. Rapid injection should generally be avoided because the drug produces high blood levels and is quickly circulated to the heart and brain, where it may cause adverse or toxic effects. Although IV push may be useful with a few drugs or in emergency situations, slower infusion of more dilute drugs is usually preferred. Intermittent infusion is administration of intermittent doses, often diluted in 50 to 100 mL of fluid and infused over 30– 60 minutes. The drug dose is usually prepared in a pharmacy and connected to an IV administration set that controls the amount and flow rate. Intermittent infusions are often connected to an injection port on a primary IV line, through which IV fluids are infusing continuously. The purpose of the primary IV line may be to provide fluids to the client or to keep the vein open for periodic administration of medications. The IV fluids are usually stopped for the medication infusion, then restarted. Drug doses may also be infused through an intermittent infusion device (eg, a heparin lock) to conserve veins and allow freedom of motion between drug doses. The devices decrease the amount of IV fluids given to patients who do not need them (ie, who are able to ingest adequate amounts of oral fluids) and those who are at risk of fluid overload, especially children and older adults. An intermittent infusion device may be part of an initial IV line or used to adapt a continuous IV for intermittent use. The devices include a heparin lock or a resealable adapter added to a peripheral or central IV catheter. These devices must be flushed routinely to maintain patency. If the IV catheter has more than one lumen, all must be flushed, whether being used or not. Saline is probably the most commonly used flushing solution; heparin may also be used if recommended by the device’s manufacturer or required by institutional policy. For example, heparin (3 to 5 mL of 100 units/mL, after each use or monthly if not in use) is recommended for implanted catheters. Continuous infusion indicates medications mixed in a large volume of IV fluid and infused continuously, over several hours. For example, vitamins and minerals (eg, potassium chloride) are usually added to liters of IV fluids. Greater dilution of the drug and administration over a longer time decreases risks of accumulation and toxicity, as well as venous irritation and thrombophlebitis. Equipment Equipment varies considerably from one health care agency to another. Nurses must become familiar with the equipment available in their work setting, including IV catheters, types of IV tubing, needles and needleless systems, types of volume control devices, and electronic infusion devices (IV pumps). Catheters vary in size (both gauge and length), design and composition (eg, polyvinyl chloride, polyurethane, silicone). The most common design type is over the needle; the needle is used to start the IV, then it is removed. When choosing a catheter to start an IV, one that is much smaller than the



BOX 3–2


• When possible, avoid the antecubital vein on the inner surface
of the elbow, veins over or close to joints, and veins on the inner aspect of the wrists. Reasons include the difficulty of stabilizing and maintaining an IV line at these sites. In addition, the antecubital vein is often used to draw blood samples for laboratory analysis and inner wrist venipunctures are very painful. Do not perform venipuncture in foot or leg veins. The risks of serious or fatal complications are too high. Rotate sites when long-term use (more than a few days) of IV fluid or drug therapy is required. Venous irritation occurs with longer duration of site use and with the administration of irritating drugs or fluids. When it is necessary to change an IV site, use the opposite arm if possible.

• For any IV medication that is prepared or added to an IV bag,
label the medication vial or IV bag with the name of the patient, drug, dosage, date, time of mixing, expiration date, and the preparer’s signature. Drug Administration • Most IV medications are injected into a self-sealing site in any of several IV set-ups, including a scalp–vein needle and tubing, a plastic catheter connected to a heparin lock or other intermittent infusion device, or IV tubing and a plastic bag containing IV fluid. • Before injecting any IV medication, be sure the IV line is open and functioning properly (eg, catheter not clotted, IV fluid not leaking into surrounding tissues, phlebitis not present). If leakage occurs, some drugs are very irritating to subcutaneous tissues and may cause tissue necrosis. • Maintain sterility of all IV fluids, tubings, injection sites, drug solutions, and equipment coming into contact with the IV system. Because medications and fluids are injected directly into the bloodstream, breaks in sterile technique can lead to serious systemic infections (septicemia) and death. • When two or more medications are to be given one after the other, flush the IV tubing and catheter (with the infusing IV fluid or with sterile 0.9% sodium chloride injection) so that the drugs do not come into contact with each other. • If a medication is to be injected or infused through an intermittent infusion device containing heparin, the drug should be compatible with heparin or the device should be irrigated with sterile saline before and after medication administration. After irrigation, heparin then needs to be reinstilled. This is not a common event, because most heparin locks and other intermittent infusion devices are now filled with saline rather than heparin. • In general, administer slowly to allow greater dilution of the drug in the bloodstream. Most drugs given by IV push (direct injection) can be given over 2–5 minutes and most drugs diluted in 50–100 mL of IV fluid can be infused in 30–60 minutes. • When injecting or infusing medications into IV solutions that contain other additives (eg, vitamins, insulin, minerals such as potassium or magnesium), be sure the medications are compatible with the other substances. Consult compatibility charts (usually available on nursing units) or pharmacists when indicated. • IV flow rates are usually calculated in mL/hour and drops per minute. Required information includes the amount of solution or medication to be infused, the time or duration of the infusion, and the drop factor of the IV administration set to be used. The drop factor of macrodrip sets may be 10, 15, or 20 drops per milliliter, depending on the manufacturer. Most agencies use mainly one manufacturer’s product. The drop factor of all microdrip sets is 60 drops per mL. Following is a sample calculation: Order: Cefazolin 1 g IV q8h Label: Cefazolin 1 g in 100 mL of 0.9% sodium chloride injection; infuse over 60 minutes Solution: Divide 100 by 60 to determine mL/min (1.66). Multiply 1.66 by the drop factor to determine drops/min (eg, with a drop factor of 20 drops/mL, 33 drops/min would deliver the dose). Count drops and regulate the flow rate manually or program an IV pump to deliver the dose.

Drug Preparation Most IV drugs are prepared for administration in pharmacies and this is the safest practice. When a nurse must prepare a medication, considerations include the following. • Only drug formulations manufactured for IV use should be given IV. Other formulations contain various substances that are not sterile, pure enough, or soluble enough to be injected into the bloodstream. In recent years, there have been numerous reports of medication errors resulting from IV administration of drug preparations intended for oral use!! Such errors can and should be prevented. For example, when liquid medications intended for oral use are measured or dispensed in a syringe (as they often are for children, adults with difficulty in swallowing tablets and capsules, or for administration through a gastrointestinal [GI] tube), the syringe should have a blunt tip that will not connect to or penetrate IV tubing injection sites. • Use sterile technique during all phases of IV drug preparation. • Follow the manufacturer’s instructions for mixing and diluting IV medications. Some liquid IV medications need to be diluted prior to IV administration and powdered medications must be reconstituted appropriately (eg, the correct amount of the recommended diluent added). The diluent recommended by the drug’s manufacturer should be used because different drugs require different diluents. In addition, be sure any reconstituted drug is completely dissolved to avoid particles that may be injected into the systemic circulation and lead to thrombus formation or embolism. A filtered aspiration needle should be used when withdrawing medication from a vial or ampule, to remove any particles in the solution. The filter needle should then be discarded, to prevent filtered particles from being injected when the medication is added to the IV fluid. Filters added to IV tubing also help to remove particles. • Check the expiration date on all IV medications. Many drugs have a limited period of stability after they are reconstituted or diluted for IV administration. • IV medications should be compatible with the infusing IV fluids. Most are compatible with 5% dextrose in water or saline solutions. • If adding a medication to a container of IV fluid, invert the container to be sure the additive is well mixed with the solution.



Nursing Notes: Apply Your Knowledge
Your client has a nasogastric feeding tube in place. You will be administering morning medications, including 4 tablets, 1 capsule, and 10 cc of an elixir. Describe how you will safely administer medications through a feeding tube to this client.

cannot be reused. When vials or ampules contain a powder form of the drug, a sterile solution of water or 0.9% sodium chloride must be added and the drug dissolved before withdrawal. Use a filter needle to withdraw the medication from an ampule or vial because broken glass or rubber fragments may need to be removed from the drug solution. Replace the filter needle with a regular needle before injecting the client. Many injectable drugs (eg, morphine, heparin), are available in prefilled syringes with attached needles. These units are inserted into specially designed holders and used like other needle/syringe units.

In many settings, needleless systems are being used. These involve a plastic tip on the syringe that can be used to enter vials and injection sites on IV tubing. Openings created by the tip reseal themselves. Needleless systems were developed because of the risk of injury and spread of blood-borne pathogens, such as the viruses that cause acquired immunodeficiency syndrome and hepatitis B. Syringes also are available in various sizes. The 3-mL size is probably used most often. It is usually plastic and is available with or without an attached needle. Syringes are calibrated so that drug doses can be measured accurately. However, the calibrations vary according to the size and type of syringe. Insulin and tuberculin syringes are used for specific purposes. Insulin syringes are calibrated to measure up to 100 units of insulin. Safe practice requires that only insulin syringes be used to measure insulin and that they be used for no other drugs. Tuberculin syringes have a capacity of 1 mL. They should be used for small doses of any drug because measurements are more accurate than with larger syringes.

Equipment for Injections
Sterile needles and syringes are used to measure and administer parenteral medications; they may be packaged together or separately. Needles are available in various gauges and lengths. The term gauge refers to lumen size, with larger numbers indicating smaller lumen sizes. For example, a 25-gauge needle is smaller than an 18-gauge needle. Choice of needle gauge and length depends on the route of administration, the viscosity (thickness) of the solution to be given, and the size of the client. Usually, a 25-gauge, 5⁄8-inch needle is used for SC injections and a 22- or 20-gauge, 11⁄2-inch needle for IM injections. Other needle sizes are available for special uses, such as insulin or intradermal injections. When needles are used, avoid recapping them and dispose of them in appropriate containers. Such containers are designed to prevent accidental needle-stick injuries to health care and housekeeping personnel.

Sites for Injections
Common sites for subcutaneous injections are the upper arms, abdomen, back, and thighs (Fig. 3–1). Sites for intramuscular injections are the deltoid, dorsogluteal, ventrogluteal, and vastus lateralis muscles. These sites must be selected by first identifying anatomic landmarks (Fig. 3–2). Common sites for intravenous injections are the veins on the back of the hands and on the forearms (Fig. 3–3). Other sites (eg, subclavian and jugular veins) are also used, mainly in critically ill clients. Additional parenteral routes include injection into layers of the skin (intradermal), arteries (intra-arterial), joints (intraarticular), and cerebrospinal fluid (intrathecal). Nurses may administer drugs intradermally or intra-arterially (if an established arterial line is present); physicians administer intraarticular and intrathecal medications.

Figure 3–1

Subcutaneous injection sites.




Gluteus medius Gluteus maximus

Posterior superior iliac spine


Mid-deltoid area

Brachial vessels

Sciatic nerves Superior gluteal artery

Ventrogluteal area Anterior superior (in triangle) iliac spine

Greater trochanter of the femur


Greater trochanter of femur

Greater trochanter

Mid-portion vastus lateralis


Iliac crest X

Posterior edge iliac crest


Figure 3–2 IM injection sites. (A) Placement of the needle for insertion into the deltoid muscle. The area of injection is bounded by the lower edge of the acromion on the top to a point on the side of the arm opposite the axilla on the bottom. The side boundaries of the rectangular site are parallel to the arm and one third and two thirds of the way around the side of the arm. (B) Proper placement of the needle for an intramuscular injection into the dorsogluteal site. It is above and outside a diagonal line drawn from the greater trochanter of the femur to the posterior superior iliac spine. Notice how this site allows the nurse to avoid entering an area near the sciatic nerve and the superior gluteal artery. (C) Placement of the needle for insertion into the ventrogluteal area. Notice how the nurse’s palm is placed on the greater trochanter and the index finger on the anterior superior iliac spine. The middle finger is spread posteriorly as far as possible along the iliac crest. The injection is made in the middle of the triangle formed by the nurse’s fingers and the iliac crest. (D) Placement of the needle for insertion into the vastus lateralis. It is usually easier to have the client lying on his or her back. However, the client may be sitting when using this site for intramuscular injections. It is a suitable site for children when the nurse grasps the muscle in her hand to concentrate the muscle mass for injection.

c.CHAPTER 3 ADMINISTERING MEDICATIONS 41 Cephalic vein Basilic vein Brachial artery Accessory cephalic vein Cephalic vein Radial artery Median cubital vein Ulnar artery Median antebrachial vein Basilic vein Cephalic vein Basilic vein Dorsal venous arch Superficial veins of the forearm Digital veins Metacarpal veins Superficial veins of the dorsal aspect of the hand Figure 3–3 Veins of the hand and forearm that may be used to administer intravenous fluids and medications. NURSING ACTIONS NURSING ACTIONS Drug Administration RATIONALE/EXPLANATION 1. Use sterile technique in preparing and administering injections. and identifying clients To prevent infection and cross-contamination To prevent infection. while measuring the dose. as free of interruptions and distractions as possible. to prevent contamination or spilling of medications. (continued ) d. Wash hands before preparing medications and. and cleansing injection sites with an antiseptic. if needed. and before returning the container. b. e. Read the medication administration record (MAR) carefully. Follow general rules for administering medications safety and effectively. calculating dosages. a. Sterile technique involves using sterile needles and syringes. Prepare and give drugs in well-lighted areas. not touching sterile objects to any unsterile objects. dosage or concentration. For accurate drug administration. Also. . using sterile drug solutions. To prevent errors in selecting ordered drugs. and route of administration. Most nursing texts instruct the nurse to read a drug label three times: when removing the container. during administration. and compare with the MAR in terms of drug. To prevent accidental or deliberate ingestion by anyone other than the intended person. Read the label on the drug container. Do not leave medications unattended.

To decrease risks of aspirating medication into lungs. nitroglycerin. place medication in a medicine cup. if indicated. For suspensions. preferably by comparing the identification wristband to the medication sheet. For narcotics and other controlled substances. For example. omit the one dose. If it is necessary to omit a scheduled dose for some reason. k. (2) Have the client in a sitting position when not contraindicated. “I’m . Analgesics. p. Aspiration may lead to difficulty in breathing and aspiration pneumonia. For example. . With adults (1) To give tablets or capsules. Generally. antiemetics. diluent may be given rather than the active drug. and asking someone else are unreliable methods. relying on the name on a door or bed. and measure the dosage at the bottom of the meniscus. give drugs ordered once or twice daily at a later time. Food in the stomach usually delays drug absorption and action. the decision to give the dose later or omit it depends largely on the drug and frequency of administration. and give the drug at the next scheduled time. and give the cup to the client. shake or invert containers to mix the medication before measuring the dose. Do not give a drug when signs and symptoms of toxicity are present. l. although they must be used occasionally when the client lacks a name band. n. and eye medications. Calling by name. To maintain clean technique and measure doses accurately.42 SECTION 1 INTRODUCTION TO DRUG THERAPY NURSING ACTIONS f. Position the client appropriately for the intended route of administration. If the order is not clear. to decrease gastric irritation by diluting drug concentration. To promote dissolution and absorption of tablets and capsules. Common exceptions are antacids. I have your medication for you. For solutions. and record that the drug was omitted and why. call the physician for clarification before giving the drug. The same procedure applies when the client questions drug orders at the bedside. Provide water or other supplies as needed. . drugs are not omitted without a careful assessment of the client’s condition and a valid reason. any question arises regarding the drug. the dose. check the physician’s orders or MAR for the name. Also. m. sign drugs out on separate narcotic records according to agency policies. and determine the time of the most recently administered dose. A temporary change in the time of administration—usually for one dose only— may be necessary to maintain therapeutic effects. a common side effect of oral drugs. the client may state he has been receiving different drugs or different doses. . and if not mixed. i.” h. (3) Give before. To prevent complications. Suspensions settle on standing. RATIONALE/EXPLANATION This is the best way to verify identity. g. Administration of PRN medications requires nursing assessment and decision making. If. or after meals as indicated by the specific drug. Record drug administration (or omission) as soon as possible and according to agency policies. check the original physician’s order. with. Giving drugs at appropriate times in relation to food intake can increase therapeutic effects and decrease adverse effects. and antipyretics are often ordered PRN. Identify yourself. o. and frequency of administration. However. For medications ordered as needed (PRN). hold the cup at eye level. Do not leave medications at the bedside as a general rule. or whether the client is supposed to receive it. Identify the client. such as aspiration of oral drugs into the lungs To promote comfort of the client and to ensure drug administration To prevent omitting or losing the drug or hoarding of the drug by the client Additional doses of a drug increase toxicity. It also decreases gastric irritation. j. assess the client’s condition. For others. and state your reason for approaching the client. (continued ) (4) Give most oral drugs with a full glass (8 oz) of water or other fluid. dose. Notify the physician. at any time during drug preparation or administration. open the unit-dose wrapper. To meet legal requirements for dispensing controlled substances To promote safety and prevent errors. Explaining actions helps to decrease client anxiety and increase cooperation in taking prescribed medication. To maintain an accurate record of drugs received by the client Clients may be unable to take the drug at the scheduled time because of diagnostic tests or many other reasons. 2. For oral medications: a.

c. b. Water “pushes” the drug into the stomach and rinses the tube. and increase client comfort and cooperation To prevent infection Either is acceptable for most clients. Oral drugs and fluids increase vomiting. Use a clean bulb syringe or other catheter-tipped syringe. fluid and electrolyte problems may result from loss of gastric acid. If this is done. the tissue fold may keep the needle from hitting bone. no benefit results from the drug.CHAPTER 3 ADMINISTERING MEDICATIONS 43 NURSING ACTIONS b. based on client preferences. applesauce. and visual inspection of possible sites. Also. placing medication on the tongue or buccal mucosa and giving slowly. Oral drugs and fluids may interfere with diagnostic tests or be otherwise contraindicated. d. Use a liquid preparation when possible. Hold the syringe like a pencil. In long-term therapy. Use enough force to penetrate the skin and subcutaneous tissue in one smooth movement. Select an appropriate injection site. c. and do not empty sustained-release capsules. crush a tablet or empty a capsule into about 30 mL of water and mix well. Thus. To avoid aspiration of drugs into the lungs owing to impaired ability to swallow Particles of tablets or powders from capsules may obstruct the tube lumen. 5⁄8-inch needle for most SC injections. Use only sterile drug preparations labeled or commonly used for SC injections. or other vehicle. Before instilling medication. or other lesions. If necessary. Use a 25-gauge. Add fluids to avoid instilling air into the stomach unnecessarily. To increase the child’s ability and willingness to take the medication. For accurate measurement and administration. Altering sustained-release products increases risks of overdosage and adverse effects. To avoid removing the medication from the stomach (2) Vomiting (3) Excessively sedated or unconscious 3. Do not crush enteric-coated or sustained-release products. To give the drug correctly with minimal client discomfort. For medications given by nasogastric tube: a. For subcutaneous (SC) injections: a. Most drugs can be given after diagnostic tests are completed. The syringe allows aspiration and serves as a funnel for instillation of medication and fluids into the stomach. This size needle is effective for most clients and drugs. Many parenteral drugs are too irritating to subcutaneous tissue for use by this route. which occur with repeated injections in the same location. (continued ) . (2) Medications are often mixed with juice. Additional water or other fluids may be given according to fluid needs of the client. otherwise. use a small amount. Instill medication by gravity flow. With children. If the client is obese. bruises. tightening the skin may be easier. 4. Giving slowly decreases risks of aspiration. f. To be sure the tube is in the stomach Gravity flow is safer than applying pressure. liquids or chewable tablets are usually given. and insert the needle quickly at a 45-degree angle. These techniques allow the client to participate in his or her care. Cleanse the site with an alcohol sponge. rotate injection sites. b. Clamp off the tube from suction or drainage for at least 30 minutes. e. such as with insulin. preoperative drug orders are cancelled. e. aspirate gastric fluid or use another method to check tube placement. and be sure the child takes all of it. d. with possible client discomfort. (1) Measure and give liquids to infants with a dropper or syringe. Do not give oral drugs if the client is: (1) NPO (receiving nothing by mouth) RATIONALE/EXPLANATION Children under 5 years of age are often unable to swallow tablets or capsules. thereby maintaining tube patency. If the client is very thin. less than the ordered dose is given. avoid tissue damage and unpredictable absorption. and follow it with at least 50 mL of water. drug characteristics. c. Tighten the skin or pinch a fold of skin and tissue between thumb and fingers. If the client is having surgery. New orders are written postoperatively. Avoid areas with lumps. Do not allow the syringe to empty completely between additions.

hold the syringe like a pencil. Most drugs in powder form can be dissolved in sterile water or sodium chloride for injection. For intravenous (IV) injections: a. A long needle is necessary to reach muscle tissue. as a general rule. The length of time required to give the drug depends on the specific drug and the amount. Check label instructions for the type and amount of fluid to use for dissolving or diluting the drug. and aspirate a small amount of blood into the syringe to be sure that the needle is in the vein. Aspirate (see 4g. and visual inspection of possible sites. Rotate sites if frequent injections are being given. d. g. Remove the needle quickly and apply pressure for several seconds. To prevent bleeding Some parenteral drug preparations cannot be given safely by the IM route. Tighten the skin. and inject the drug slowly. b. Prepare drugs just before use. a 20-gauge may be used for viscous medications. Use only drug preparations that are labeled for IV use. bruises. Some drugs are unstable in solution. For safe and accurate drug administration with minimal risk to the client. Also. Use a 11⁄2-inch needle for most adults and a 5⁄8. remove the needle. For venipuncture and direct injection into a vein. which underlies subcutaneous fat. add drugs to IV fluids just before use. and avoid areas with lumps. over several minutes. Use enough force to penetrate the skin and subcutaneous tissue into the muscle in one smooth motion. allows immediate discontinuation if adverse effects occur. Cleanse the site with an alcohol sponge. 5. This is the preferred method because sterility can be better maintained. Remove the needle quickly and apply gentle pressure for a few seconds. Use the smallest-gauge needle that will accommodate the medication. To decrease tissue damage and client discomfort To increase client comfort and participation and to avoid tissue damage. depending on the size of the client. anatomic landmarks. or other lesions. and insert the needle quickly at a 90-degree angle. Remove the needle and apply pressure until there is no evidence of bleeding. RATIONALE/EXPLANATION To prevent accidental injection into the bloodstream. e. f. c. select a site in the arm. Release the skin so that both hands are free to manipulate the syringe. povidone-iodine or alcohol). drug characteristics.35–7. insert the needle. inject the drug. drugs are mixed and added to IV fluids in the pharmacy. Remove the tourniquet. Use only drug preparations labeled or commonly used for IM injections. based on client preferences. apply a tourniquet. and reprepare the medication. cleanse the skin with an antiseptic (eg. Select an appropriate injection site. If no blood enters the syringe.44 SECTION 1 INTRODUCTION TO DRUG THERAPY NURSING ACTIONS g. 6. If blood is aspirated into the syringe. In some agencies. Check label instructions for mixing drugs in powder form. b. To prevent infection To give the drug correctly with minimal client discomfort To prevent bleeding Others are not pure enough for safe injection into the bloodstream or are not compatible with the blood pH (7. For intramuscular (IM) injections: a. Slow administration. h. Pull back gently on the plunger (aspirate). h. Some drugs require special preparation techniques to maintain solubility or pharmacologic activity. Identification of anatomic landmarks is mandatory for safe administration of IM drugs. SC injections).to 11⁄2-inch needle for children. c. Blood return in the syringe is an uncommon occurrence. d. (continued ) . A 22-gauge is satisfactory for most drugs. Most drug solutions can be given with dextrose or dextrose and sodium chloride IV solutions.45).

open the eye to expose the conjunctival sac. usually in 1 hour or less. Careful positioning and restraint to avoid sudden movements are necessary to decrease risks of injury to the eye. not on the eyeball. down and back for children.CHAPTER 3 ADMINISTERING MEDICATIONS 45 NURSING ACTIONS e. add solution to maintain the infusion. depending on the drug. tongue blade. steady the hand holding the medication on the child’s head. To straighten the canal and promote maximal contact between medication and tissue (continued ) . Whether a volume-control or piggyback apparatus is used depends on agency policy and equipment available. instill the medication. Once the drug is infused. Inject the drug into an injection site after cleansing the site with an alcohol sponge and infuse. Open the ear canal by pulling the ear up and back for adults. place the child in a prone position. f. Give only as ordered With children. or increased toxicity. place the child in a head-lowered position. place in a supine position with the head lowered. and inject the drug slowly. add the drug to 50–100 mL of IV solution in a separate container. and instill the medication into the conjunctival sac. and clamp it so that no further fluid enters the chamber and dilutes the drug. prepare the medication. For instillation of eye drops: a. (3) To use a volume-control set. Insert the needle in an injection site on the main IV tubing after cleansing the site. When nose drops are used for rhinitis and nasal congestion accompanying the common cold. If two or more eye drops are scheduled at the same time. use sterile gloves. do not give the drug until a new IV line is begun. Infuse the drug over 15–60 minutes. For administration by an established IV line: (1) Check the infusion for patency and flow rate. and drop the medication on the side of the canal. Use drug preparations labeled for ophthalmic use. For instillation of ear medications: a. Physical and chemical interactions between the drugs may occur and cause precipitation. 8. or information may be obtained from the pharmacy. Use drug preparations labeled for dermatologic use. This method is also used for intermittent administration of antibiotics and other drugs. (2) For direct injection. and drop the medication into the sac. Then. With children. This method is used for administration of antibiotics on an intermittent schedule. and drop the medication into the nostrils. flush the line between drugs. remove any previously applied medication. cleanse an injection site on the IV tubing. gently retract the lower lid. 10. wait 1–5 minutes between instillations. Cleanse the skin. 7. or cotton-tipped applicator to apply the drug. Most tubings have injection sites to facilitate drug administration. overuse results in a rebound congestion that may be worse than the original symptom. For broken skin or open lesions. Provide a tissue for blotting any excess drug. and maintain the position for 2–3 minutes. 9. insert the needle. Have the client hold his or her head back. (4) To use a “piggyback” method. fill it with 50–100 mL of IV fluid. If infiltration or phlebitis is present. inactivation. To promote therapeutic effects and minimize adverse effects Ophthalmic preparations must be sterile to avoid infection. For instillation of nose drops and nasal sprays: a. Dilution of the drug decreases adverse effects. and apply the drug in a thin layer. For application to skin: a. Most nursing units have charts depicting drug compatibility. Do not mix drugs in syringes or in IV fluids unless the drug literature states that the drugs are compatible. RATIONALE/EXPLANATION The solution must be flowing freely for accurate drug administration. When more than one drug is to be given. Wash your hands. without touching the dropper tip to anything. Blot any excess drug from the inner canthus near the nose to decrease systemic absorption of the drug. Check the venipuncture site for signs of infiltration and phlebitis before each drug dose. Attach the IV tubing and a needle.

Also. L. D. what approaches or interventions might persuade the client to take the medication? Would the same approach be indicated if the medication were a vitamin supplement or a laxative? Nursing Notes: Apply Your Knowledge Answer: First check tube placement by aspirating gastric content or instilling air into the stomach (listen with a stethoscope for a swishing sound over the gastric area). S. Hospital Pharmacy. (2001). Be sure the client knows the correct procedure. & Hirnle. SELECTED REFERENCES Argo. Some women may be embarrassed and prefer self-administration. A. wear a glove or finger cot. F. M. Note: Do not crush enteric-coated or sustainedrelease products because this alters their rate of absorption and could be dangerous to the client. what safety precautions are needed with various routes? 7. Which dosage forms must be kept sterile during administration? 5. Accurate identification of the client is imperative. the client had been asleep and may have been responding simply to being awakened. 2. Use liquid preparations when possible.. which dosage forms are acceptable? Which are unacceptable. In this situation. language and culture may have been a factor. Plumer’s Principles and practice of intravenous therapy. S.46 SECTION 1 INTRODUCTION TO DRUG THERAPY NURSING ACTIONS 11. Craven. & Kelley. and insert into the rectum the length of the finger. provide supplies for selfadministration. If the client prefers and is able. flush the feeding tube with tap water. For rectal suppositories: a. Place the suppository next to the mucosal wall. Cox. and why? 4. especially when the client may be confused or unable to respond appropriately. American Journal of Nursing. To administer. wash thoroughly with soap and water after each use. Be sure the client knows the correct procedure. Togger. When a liquid formulation is not available. (2000). 12. When all medications are given. The ten most common lethal medication errors in hospital patients. When administering medications. W. Preferably. flush the tube with 50 mL of water unless the client is on a fluid restriction. 101(10). 26–32. then flush the tube again. 3rd ed. P. N. With a client who refuses an important medication. What are some legal factors that influence a nurse’s administration of medications? 6. Fundamentals of nursing: Human health and function. provide supplies for selfadministration.. Use gloves or an applicator for insertion. Philadelphia: Lippincott Williams & Wilkins. What safety precautions must the nurse practice consistently to avoid self-injury and exposure to blood-borne pathogens? 8. R. what are some interventions to aid absorption and hasten therapeutic effects? . J. Louis: Facts and Comparisons. give each medication separately and rinse the tube between medications. (Updated monthly). If an applicator is used. The nurse did not check the client’s name band and relied on the client to respond to her calling his name. When giving an oral medication. Metered dose inhalers. C. For a client who receives all medications through a nasogastric feeding tube. K. 7th ed. Weinstein. Lubricate the end with a water-soluble lubricant. 470–474. A. Allowing self-administration may prevent embarrassment to the client. If the client prefers and is able. RATIONALE/EXPLANATION To promote absorption. Review and Application Exercises 1. How Can You Avoid This Medication Error? Answer: This medication error occurred because the medication was given to the wrong client. Drug facts and comparisons. Philadelphia: Lippincott Williams & Wilkins. 35(5). (2001). & Brenner. St. K. crush a tablet or empty a capsule into 15 to 30 mL of warm water and mix well. (2000). For vaginal medications: a. What are the advantages and disadvantages of the oral route and the IV route of drug administration? 3. draw medication into a syringe. and slowly instill the medication into the tube. Small feeding tubes occlude very easily and must be rinsed well to prevent clogging.

When indicated. 5. For clients who use herbal and dietary supplements.chapter 4 Nursing Process in Drug Therapy Objectives AFTER STUDYING THIS CHAPTER. drug therapy is one of many responsibilities in client care. provide or assist them in obtaining reliable information. Teach clients and family members how to use prescription and OTC drugs safely and effectively. Obtain a medication history about the client’s use of prescription. pharmacists. and otherwise benefit recipients. clients. physiology (normal body functions). Discuss interventions to increase benefits and decrease hazards of drug therapy. and times of administration. this is only one aspect of the nursing process 47 . and social drugs as well as herbal and dietary supplements. Chapter 3 emphasized drug preparation and administration. and must be adept at using all steps of the nursing process. health–illness status. Are these acceptable doses for elderly clients? What criteria will you use to determine therapeutic effects for each drug? Note any side effects that are likely for each drug and what assessment data will be important to collect. To fulfill this responsibility. Observe clients for therapeutic and adverse responses to drug therapy. OVERVIEW rug therapy involves the use of drugs to prevent or treat disease processes and manifestations. 11. For the nurse. Chapter 2 described cellular physiology and concepts and processes essential to understanding drug effects in humans. dosages. but they are more likely to occur with incorrect use. 2. 4. Although the importance of safe and accurate administration cannot be overemphasized. Describe major considerations in drug therapy for clients with impaired renal or hepatic function or critical illness. Chapter 1 included general information about drugs and suggested strategies for studying pharmacology. 9. Identify nondrug interventions to prevent or decrease the need for drug therapy. THE STUDENT WILL BE ABLE TO: 1. Critical Thinking Scenario You are making the first home visit for an elderly client with arthritis and hypertension who is taking the following medications: Ibuprofen 800 mg every 4 hours Prednisone 5 mg daily Lasix 20 mg twice a day Captopril 25 mg twice a day Pepcid 20 mg at bedtime Look up each of these medications. 6. 7. and pathophysiology (alterations in mental and physical functions due to disease processes). Physicians. Discuss guidelines for rational choices of drugs. improve the quality of life. Discuss application of the nursing process in home care settings. It may save lives. teach clients about the potential effects of herbal and dietary supplements. weight. Assess clients’ conditions in relation to age. and nurses all have important roles to play in the safe and effective use of drugs. over-the-counter (OTC). and lifestyle habits likely to influence drug effects. It also may cause adverse effects. 10. Adverse effects and failure to achieve therapeutic effects may occur with correct use. Note the drug class and why you think this client is taking them. the nurse must be D knowledgeable about pharmacology (drugs and their effects on the body). 3. 8. routes.

However. Some guidelines for obtaining needed assessment data are described below. assess age. indigestion. client. As part of the initial assessment. Although listed as the important first step in the nursing process. All available sources of assessment data should be used (eg. how much and how often taken. or constipation. The nurse also must monitor responses to drug therapy. Specific data to be acquired depend on the medication and the client’s condition. arthritis). hypertension. decision-making. knowledge and informed. Laboratory tests of liver. and general nursing actions. they provide a basis for decisions about continuing or revising nursing care. and nontherapeutic (eg. because some people do not think of these preparations as drugs. ask for names. This can be done by observing and interviewing the client. To help the nurse continue to acquire knowledge and skills related to drug therapy. both prescribed and OTC. Unless the reaction is further explored. their reason for use. dietitians. assessment is actually a component of all steps and occurs with every contact with the client. reviewing medical records for pertinent laboratory and diagnostic test reports. and perceived benefits or adverse effects. Early recognition and treatment may prevent or decrease organ impairment. and interventions. cocaine. all seriously ill clients should be assessed for risk factors and manifestations of impaired function of vital organs. For example. the client may have therapy withheld inappropriately. such as those taken for chronic illnesses (eg. The effects of these client-related factors on drug therapy are discussed in Chapter 2. Specific questions and areas of assessment include: • What are current drug orders? • What does the client know about current drugs? Is teaching needed? • What drugs has the client taken before? Include any drugs taken regularly. the initial assessment needs to be especially thorough because the information gained may guide the care provided by oneself. or is likely to abuse drugs. family members. pharmacists). Other data that may . • In addition to nursing assessment data. and blood clotting tests before anticoagulant therapy. culture and susceptibility studies before antimicrobial therapy. If so. Some specific laboratory tests include serum potassium levels before diuretic therapy. nursing diagnosis. It involves both cognitive and psychomotor skills. or the information can be incorporated into any data collection tool. and other sources as available and relevant. • On initial contact with a client. this chapter includes nursing process guidelines. and ability to function in usual activities of daily living. diabetes mellitus. and teach clients about drugs. nonprescription. and evaluation. colds. before drug therapy is started. pathologic conditions. use progress notes. NURSING PROCESS IN DRUG THERAPY The nursing process is a systematic way of gathering and using information to plan and provide individualized client care and to evaluate the outcomes of care. and other methods. Assessment Assessment involves collecting data about client characteristics known to affect drug therapy. Knowledge and skill in the nursing process are required for drug therapy. One might say that assessment and interventions are the “action” phases whereas analysis of assessment data and establishing nursing diagnoses and goals are “thinking” phases. medical records). principles and actions related to specific drug groups and individual drugs are included in appropriate chapters throughout this text. laboratory reports. general principles of drug therapy. for how long. The five steps of the nursing process are assessment. weight. interviewing family members or others involved in client care. Later assessments of a client’s condition and response to treatment are ongoing. planning and establishing goals for nursing care.48 SECTION 1 INTRODUCTION TO DRUG THERAPY in drug therapy. other nurses. caffeine. A medication history (Box 4–1) is useful. if liver or kidney damage exists. echinacea. rational thinking should underlie all data collection. such as requesting medication? Can he or she swallow oral medications? • Are any other conditions present that influence drug therapy? For example. kidney. It also may be helpful to ask about nonprescription drugs for headache. can the client afford to buy medications? Is transportation available for obtaining medications or seeing a health care provider for monitoring and follow-up care? • Can the client communicate his or her needs. alcohol. • Assess for previous or current use of herbal or dietary supplements (eg. • Has the client ever had an allergic reaction to a drug? If so. • If long-term drug therapy is likely. drug metabolism or excretion may be altered. nicotine. marijuana) drugs. Guidelines. health status. obtain baseline data on measurements to be used in monitoring therapeutic or adverse effects. • What are the client’s attitudes about drugs? Try to obtain information to help assess whether the client takes drugs freely or reluctantly. interventions. Also. and other health care providers (eg. and bone marrow function are often helpful because some drugs may damage these organs. what signs and symptoms occurred? This information is necessary because many people describe minor nausea and other symptoms as allergic reactions. both therapeutic and adverse. • Assess for previous and current use of prescription. is likely to comply with a prescribed drug regimen. completing a physical assessment. gingko. as in other aspects of client care. glucosamine/ chondroitin).

ability and willing- ness to take the drugs as prescribed. the nursing diagnoses needed to adequately . ask to specify. They should be individualized according to the client’s condition and the drugs prescribed. Have you had any symptoms or problems that you think are caused by your medicines? If yes. Do you take any prescription medications on an irregular basis? If yes. Do you take any prescription medications on a regular basis? 2. Part 1: Prescription Medications 1. weight. ask the following about each medication. if needed.)? If so. and urine output. As a result. glucosamine/chondroitin. Thus. describe specific effects or symptoms. assess the client’s response in relation to therapeutic and adverse effects. vital signs. Do you need help from another person to take your medicines? 6. describe client problems or needs and are based on assessment data. • Seek information about ordered drugs.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 49 BOX 4–1 MEDICATION HISTORY Name___________________________________________________________________________ Age_________________________ Health problems. reason for use. Amount/day Yes/No Name Amount Frequency be relevant include physical assessment data. ask the following about each medication. continued assessment is needed. In general. Once assessment data are obtained. nurses must provide care based on available information while knowing that assessment data are always relatively incomplete. gingko. perceived effectiveness. kava. they need to be analyzed for their relevance to the client’s current condition and nursing care needs. how much and how often taken. as developed by the North American Nursing Diagnosis Association. Do you have any difficulty in taking your medicines? If yes. 4. ask to specify problem areas. If yes. Nursing Diagnoses These statements. any adverse effects. Name Dose Frequency Specific times How long taken Reason for use 3. ask for names. acute and chronic Are you allergic to any medications? If yes. and other aspects of safe and effective drug therapy. 5. Name Dose Frequency Reason How long taken Part 2: Nonprescription Medications Do you take over-the-counter medications? Medication Problem Pain Headache Sleep Cold Indigestion Heartburn Diarrhea Constipation Other Part 3: Social Drugs Yes/No Coffee Tea Cola drinks Alcohol Tobacco Part 4: Herbal or Dietary Supplements Do you take any herbal or dietary supplements (eg. With later contacts and after drug therapy is begun.

those related to particular drug groups are included in later chapters. Some examples include: • Promoting healthful lifestyles in terms of nutrition. and using nondrug measures to enhance therapeutic effects or to decrease adverse effects. These are presented under the heading of “Principles of Therapy. exercise. and other assessment data Evaluation This step involves evaluating the client’s status in relation to stated goals and expected outcomes. Planning/Goals This step involves stating the expected outcomes of the prescribed drug therapy. often extending from hospitalization and direct observation by the nurse to self-care at home and occasional contact with a health care provider. and Client Teaching Guidelines: Safe and effective use of over-the-counter (OTC) medications. Adequate knowledge and preparation are required to fulfill teaching responsibilities. and sleep • Handwashing and other measures to prevent infection • Positioning • Assisting to cough and deep breathe • Ambulating • Applying heat or cold • Increasing or decreasing sensory stimulation • Scheduling activities to allow periods of rest or sleep • Recording vital signs. Some outcomes can be evaluated within a few minutes of drug administration (eg. promoting compliance with the prescribed drug therapy regimen. identifying barriers to compliance. observing for drug interactions). Later drug-related chapters contain client teaching guidelines for the drugs discussed in particular chapters. Client Teaching Guidelines: Safe and effective use of prescription medications. ensuring adequate fluid intake and blood pressure and avoiding or following safety precautions with nephrotoxic drugs (eg. Because almost any nursing diagnosis may apply in specific circumstances. In addition. accurate administration. For example. goals should be stated in terms of client behavior. preventing or decreasing the need for drug therapy. solving problems related to drug therapy. aminoglycoside antibiotics) helps to prevent ARF. weighing seriously ill clients helps in calculating dosages of several drugs and in assessing changes in clients’ fluid balance or nutritional status. General interventions include promoting health. nursing interventions are integrated with background information and client characteristics to assist in individualizing care. These factors. reason for use.50 SECTION 1 INTRODUCTION TO DRUG THERAPY reflect the client’s condition vary considerably. including diagnostic tests and office visits) • Deficient Knowledge: Safe and effective selfadministration (when appropriate) • Risk for Injury related to adverse drug effects • Noncompliance: Overuse • Noncompliance: Underuse • Implementing specific interventions indicated by a particular drug or the client’s condition. ensuring that blood samples for serum drug levels are drawn at correct times in relation to drug administration helps to increase the usefulness and accuracy of these tests in monitoring the client’s condition. assessing for therapeutic and adverse effects. Areas of nursing intervention may include assessment. and others. These are presented under the heading of “Nursing Actions. As a general rule. Other nursing interventions presented in a separate section of most chapters are the actions needed once a drug is ordered (ie. in clients at risk for developing acute renal failure (ARF). and monitoring of response by health care providers. drug ordered. the client is likely to experience brief contacts with many health care providers rather than extensive contacts with a few health care providers. the client will: • Receive or take drugs as prescribed • Experience relief of signs and symptoms • Avoid preventable adverse drug effects • Avoid unnecessary drug ingestion • Self-administer drugs safely and accurately • Verbalize essential drug information • Keep appointments for monitoring and follow-up • Use any herbal and dietary supplements with caution • Report the use of herbal and dietary supplements to health care providers Interventions This step involves implementing planned activities and actually includes any task performed on a client’s behalf. not nurse behavior. Teaching about drug therapy is essential because most medications are selfadministered and clients need information and assistance to use therapeutic drugs safely and effectively. drug administration.” General principles or guidelines are included in this chapter. con- . Most. require much longer periods of time. the caregiver needs to understand about the medications. For example. With the current emphasis on outpatient treatment and short hospitalizations. however. plus a client’s usual reluctance to admit noncompliance. financial assistance for obtaining medications). expected effects. Client teaching as a nursing intervention is presented separately to emphasize its importance. urine output. rather than self-administered. fluid intake.” and rationales for the interventions are included. identifying resources (eg. and. teaching about medications. Teaching aids to assist the nurse in this endeavor include Box 4–2: Preparing to teach a client or caregiver. this text emphasizes those diagnoses that generally apply to any course of drug therapy. When medications are given by another caregiver. • Deficient Knowledge: Drug therapy regimen (eg. fluids. relief of acute pain after administration of an analgesic). rest.

These difficulties can be managed by using appropriate techniques and criteria of evaluation. For example. some are potentially serious. missed doses of glaucoma medication can lead to optic nerve damage and blindness. If the client has been taking a drug for a while. In many instances. The client should know the name. blood pressure with antihypertensive drugs). nursing responsibilities related to drug therapy are designated in critical paths (also called clinical pathways or care maps). Proceed slowly. INTEGRATING NURSING PROCESS. compliance with instructions. or other measures. or other symptoms]) and a place with minimal noise and distractions. accurate adminis- tration. emphasize the importance of taking medications as prescribed. remember dosage schedules. Many people stop taking a drug rather than report adverse reactions. a combination of verbal and written instructions is more effective than either alone. A medication history (see Box 4–1) helps to assess the client’s knowledge and attitudes about drug therapy. some are minor. This saves time for both nurse and client by avoiding repetition of known material. If reactions are reported. the drug is familiar and can be described from personal knowledge. drug reference books. Although people vary in the amount of drug information they want and need. from pain. including medication records and laboratory and other diagnostic test reports. It also promotes compliance with prescribed drug therapy.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 51 BOX 4–2 PREPARING TO TEACH A CLIENT OR CAREGIVER a safety measure. and checking appropriate medical records. Common client errors include taking incorrect doses. the goal is to provide needed information without causing unnecessary anxiety. especially if an allergic or other potentially serious adverse reaction or overdose occurs. • General criteria include progress toward stated outcomes. and so on. taking doses at the wrong times. avoidance of preventable adverse effects. Treatment failure can often be directly traced to these errors. The client should also know the purpose of prescribed drugs. interviewing the client or others about the client’s response to drug therapy. The occurrence of severe reactions indicates that the drug should be stopped and the prescribing physician should be notified. CRITICAL PATHS AND DRUG THERAPY In many agencies. With outpatients. and stopping a medication too soon. If side effects occur. Usually. and others. forgetting to take doses. when the client is mentally alert and not in acute distress [eg. Allow time for questions and try to ensure that the client understands how. when. Clients and caregivers may feel overwhelmed by complicated medication regimens and are more likely to make errors with large numbers of medications or changes in the medication regimen. Throughout the teaching session and perhaps at other contacts. and why to take the medications. Such knowledge is • • • • • • • • • • • tribute to difficulties in evaluating outcomes of drug therapy. discuss specific ways to take medications so that usual activities of daily living are minimally disrupted. teach them how to manage minor ones and which ones to report to a health care provider. of any drugs being taken. Planning with a client to develop a convenient routine. • Assess learning needs. provide specific instructions about taking the medications. Specific criteria indicate the parameters that must be measured to evaluate responses to particular drugs (eg. difficulty in breathing. describe the name. These techniques may be used at every contact with a client. may help increase compliance with the prescribed regimen. If the drug is unfamiliar. This includes finding out what the person already knows about a particular drug. verify by questions and observations that he or she already knows essential drug information and takes the drug correctly. Most drugs produce undesirable effects. Assess ability to manage a drug therapy regimen (ie. expected effects. When explaining a drug therapy regimen to a hospitalized client. When teaching a client about medications to be taken at home. Choose an appropriate time (eg. in small steps. blood sugar with antidiabetic drugs. purpose. Reassess learning needs when medication orders are changed (eg. It also decreases the risk of mistaking one drug for another and promotes a greater sense of control and responsibility regarding drug therapy. use available resources (eg. “pill counts” may be done to compare doses remaining with the number prescribed during a designated time. preferably both the generic and a trade name. especially when new drugs are added or new conditions are being treated. When teaching a client about potential adverse drug effects. and provide ample opportunities to express concerns or ask questions. within the limitations imposed by individual drugs. pharmacists) to learn about the drug and provide accurate information to the client. when medications are added because of a new illness or stopped). Minimize medical jargon and be aware that clients may have difficulty understanding and retaining the material being taught because of the stress of the illness. • Techniques include directly observing the client’s status. such as relief of symptoms. read printed instructions and drug labels. changing the time of administration. Also teach the client and caregiver to observe for beneficial and adverse effects. Try to decrease their anxiety and provide positive reinforcement for effort. Do not assume that teaching is unneeded. if appropriate. it may be possible to continue drug therapy by reducing dosage. the purpose can usually be simply stated in terms of symptoms to be relieved or other expected benefits. develop an individualized teaching plan. selfadminister medications by ordered routes). emphasize essential information. From assessment data. In addition. Critical paths are guidelines for the care of .

Do not take medications if you are not alert or cannot see clearly. alcoholic beverages and driving a car should be avoided with medications that cause drowsiness or decrease alertness. or crushing tablets or taking the medication out of capsules. should I avoid certain foods. Often. ✔ Keep all health care providers informed about all the drugs being taken. ✔ Report any drug allergies to all health care providers and wear a medical identification emblem that lists allergens. ✔ Do not take drugs left over from a previous illness or prescribed for someone else and do not share prescription drugs with anyone else. ✔ Get all prescriptions filled at the same pharmacy. A schedule that minimally disrupts usual household activities is more convenient and more likely to be followed accurately. such as: What is the medicine’s name? What is it supposed to do (ie. Therapeutic effects greatly depend on taking medications correctly. This information can help avoid new prescriptions or OTC drugs that have similar effects or cancel each other’s effects. If breast-feeding. or nurse before starting an OTC medication or herbal or dietary supplement. and for how long? Should it be taken with food or on an empty stomach? While taking this medicine. ✔ Ask questions (and write down the answers) about newly prescribed medications. at the same time and place each day). Some medications need to be tapered in dosage and gradually discontinued. ✔ Take medications in a well-lighted area and read labels of containers to ensure taking the intended drug. Inform health care providers if you have diabetes or kidney or liver disease. when possible.52 SECTION 1 INTRODUCTION TO DRUG THERAPY CLIENT TEACHING GUIDELINES Safe and Effective Use of Prescription Medications General Considerations ✔ Use drugs cautiously and only when necessary because all drugs affect body functions and may cause adverse effects. It is a good idea to carry a copy of this list at all times. If pregnant. laboratory or other diagnostic tests that monitor therapeutic or adverse effects of drugs). This is an important safety factor in helping to avoid several prescriptions of the same or similar drugs and to minimize undesirable interactions of newly prescribed drugs with those already in use. talk to a doctor. Develop a plan for renewing or refilling prescriptions so that the medication supply does not run out when the prescribing physician is unavailable or the pharmacy is closed. It may be helpful to remind the physician periodically of the medications being taken and ask if any can be discontinued or reduced in dosage. ✔ As a general rule. These conditions require special precautions with drug therapy. One way to do this is to keep a written record of all current medicines. “dilutes” the drug so that it is less likely to upset the stomach. including their names and doses and how they are taken. Some long-acting preparations are dangerous if altered so that the entire dose is absorbed at the same time. If unable to take them whole. changes in kidney function. in a sitting or standing position. ✔ Follow instructions for follow-up care (eg. and so on. report them to the prescribing physician rather than stopping the drug. an adjustment in dosage or other aspect of administration may solve the problem. Altering the dose or time may cause underdosage or overdosage. The water helps tablets and capsules dissolve in the stomach. beverages. However. ✔ Take drugs as prescribed and for the length of time prescribed. notify a health care provider if unable to obtain or take a medication. and promotes absorption of the drug into the bloodstream. office visits. including over-the-counter (OTC) products and herbal or dietary supplements. ✔ Take drugs in current use when seeing a physician for any health-related problem. The likelihood of having the right drug in the right dose is remote and the risk of adverse effects is high in such circumstances. When taking prescription medications. ✔ Use nondrug measures. to prevent accidental ingestion. pharmacist. certain activities? (For example. With long-term use of a medication. ✔ ✔ ✔ ✔ ✔ ✔ Self-Administration ✔ Develop a routine for taking medications (eg. The upright position helps the drug reach the stomach rather than getting stuck in the throat or esophagus. If problems occur with taking the drug. consult your obstetrician before taking any medications prescribed by another physician. take oral medications with 6–8 oz of water. safety requires periodic checks with essentially all medications. ask a health care provider before splitting. ✔ Most tablets and capsules should be taken whole. other medications. to prevent the need for drug therapy or to enhance beneficial effects and decrease adverse effects of drugs. This is a safety factor to avoid undesirable drug interactions.) Will this medication work safely with the others I’m already taking? What side effects are likely and what do I do if they occur? Will the medication affect my ability to sleep or work? What should I do if I miss a dose? Is there a drug information sheet I can have? Store medications out of reach of children and never refer to medications as “candy”. when possible. responses may change over time with aging. chewing. consult your obstetrician or pediatrician before taking any medications prescribed by another physician. Stopping a medication may cause a recurrence of the problem for which it was given or withdrawal symptoms. . what symptoms or problems will it relieve)? How and when do I take it. Some drugs require more frequent monitoring than others.

If the liquid medication is packaged with a measuring cup that shows teaspoons or tablespoons. and moisture may cause them to decompose. For clients. that should be used to measure doses. many clinical pathways have specific guidelines related to drug therapy. A dose cannot be measured accurately with household teaspoons or tablespoons because they are different sizes and deliver varying amounts of medication. • Development and implementation of the critical paths should be an interdisciplinary. clients having coronary artery bypass grafts. take about the same time every day. Discard outdated medications. Report problems or new symptoms to a health care provider. If a dose is omitted. if ordered once daily. Prescription medications often include instructions to take on an empty stomach or with food.” Herbal and Dietary Supplements In recent years. be sure to ask a health care provider. all health care professionals usually involved in the care of a client with a particular medical diagnosis should be represented. and skin medications is essential for therapeutic effects. For example. and neutraceuticals. Store medications safely. an antacid usually should not be taken at the same time as other oral medications because the antacid decreases absorption of many other drugs. ✔ Follow instructions about taking a medication with food or on an empty stomach. usually assess clients’ conditions daily to evaluate progress toward the desired outcomes. dry place. Depending on the medical diagnoses. light. the critical path may state. With assessment. in a cool. • Medical diagnoses for which critical paths are developed are those often encountered in an agency and those that often result in complications or prolonged lengths of stay (eg. If ordered twice daily or morning and evening. or taking with fluids other than water. Herbal medicines. phytochemicals. do not keep drugs for long periods. myocardial infarction. it is never a safe practice because it increases the likelihood of taking the wrong drug. the next dose should be taken at the next scheduled time. and hip or knee replacement). for adults or children. a mineral. The 1994 Dietary Supplement Health and Education Act (DSHEA) defined a dietary supplement as “a vitamin. are derived from plants. For example. a comprehensive pathway extending from illness onset through treatment and recovery could pro- mote continuity of care among agencies and health care providers. This is especially important for young children because most of their medications are given in liquid form. measure with a calibrated medication cup or measuring spoon. Keep medications in the container in which they were dispensed by the pharmacy. Do not store them near a dangerous substance. ✔ If a dose is missed. • In hospital settings. If not clear how a medication is to be used. also called botanicals. case managers. desired client outcomes. ask a health care provider whether they may be taken together or at different times. Thus. Additional characteristics include the following: • Major components include a medical diagnosis. an additional nursing concern has emerged in the form of herbal and dietary supplements. or cure . relieve. aspects of care related to the medical diagnosis. especially when away from home for work or travel. especially if exposed to heat and moisture. “Assess for bleeding if on anticoagulant. which could be taken by mistake. for example. • Critical paths may be used in most health care settings. who may be nonnurses. and time frames (usually days) for achieving the desired outcomes during the expected length of stay. ✔ ✔ ✔ ✔ clients with particular conditions.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 53 CLIENT TEACHING GUIDELINES Safe and Effective Use of Prescription Medications (Continued ) ✔ Take most oral drugs at evenly spaced intervals around the clock. Drugs are chemicals that may deteriorate over time. collaborative effort. If taking several medications. and clients who take them are likely to be encountered in any clinical practice setting. where the label identifies it and gives directions. ✔ If taking a liquid medication (or giving one to a child). take about 12 hours apart. but the products cannot claim to diagnose. In addition. These guidelines may affect any step of the nursing process. having many containers increases the risks of medication errors and adverse drug interactions. eye drops.” Under this law. Correct use of oral or nasal inhalers. Although this may be more convenient. Do not double the dose. prevent. These supplements are increasingly being used. Use other types of medications according to instructions. other dietary supplements may be derived from a variety of sources. an herb or other botanical used to supplement the diet. herbs can be labeled according to their possible effects on the human body. most authorities recommend taking the dose if remembered soon after the scheduled time and omitting the dose if it is not remembered for several hours. about taking with other medications. heat. Do not put several different tablets or capsules in one container. Do not store them in a bathroom.

This could lead to severe hypertension and stroke. check expiration dates periodically and discard those that have expired. are essentially unknown. Most products have not been studied sufficiently to evaluate their safety or effectiveness. With the continued caution that relatively little reliable information is known about these products. when information is available and deemed clinically relevant. pharmacist. What is the nursing role in relation to these products and safe and effective drug therapy? Two major concerns are that use of supplements may keep the client from seeking treatment from a health care provider when indicated and that the products may interact with prescription drugs to decrease therapeutic effects or increase adverse effects. nurses need to have an adequate knowledge base and to incorporate their knowledge in all steps of the nursing process (see below). Because all these drugs cause drowsiness. consult a health care provider before taking any nonprescription drugs to avoid undesirable drug interactions and adverse effects. • Client teaching guidelines. to avoid worsening the problem. teaspoons. Do not assume continued safety of an OTC medication you have taken for years. Do not take a laxative if you have stomach pain. Note tamper-resistant features and do not buy products with damaged packages. or sleeping pills. possible side effects.54 SECTION 1 INTRODUCTION TO DRUG THERAPY CLIENT TEACHING GUIDELINES Safe and Effective Use of Over-the-Counter (OTC) Medications ✔ Read product labels carefully. For example. fever. in their original containers. when to stop using the medication or when to see a doctor. nausea. ✔ ✔ ✔ ✔ ✔ ✔ ✔ specific human diseases unless approved by the FDA. hypertension. or stroke. It is not safe to use household teaspoons or tablespoons because they are different sizes and deliver varying amounts of medication. In this chapter. guidelines may emphasize avoidance or caution in using supplements (text continues on page 59) . Some specific precautions include the following: Avoid alcohol if taking antihistamines. heart attack. including: • Table 4–1 describes some commonly used herbal and dietary supplements. indications for use. sedation. ✔ Use a magnifying glass. usual dosage. or migraine. and expiration dates. are described. Claritin D). Store OTC drugs in a cool. Actifed. Avoid OTC sleeping aids if you are taking a prescription sedative-type drug (eg. selected herbal and dietary supplements with some scientific support for their use are described in more detail. potentially dangerous. and in combination with pharmaceutical drugs. Ask a health care provider before taking other products containing aspirin if you are already taking a regular dose of aspirin to prevent blood clots. Aspirin is commonly used for this purpose. Older people are more likely to have adverse drug reactions and interactions because of changes in heart. For children. ✔ Do not take OTC medications longer or in higher doses than recommended. general information is provided (see Client Teaching Guidelines: General information about herbal and dietary supplements). ✔ If you do not understand the information on labels. Sudafed). Coumadin). or vomiting. In later chapters. thyroid disorders). a multisymptom cold remedy containing pseudoephedrine (eg. If such a device is not available. Overall. Consult a health care provider before taking the product if you have one of the contraindicated conditions. for nervousness or depression). or celebrities. the effects of these products on particular consumers. or nurse. Sinutab). an antihistamine-decongestant combination (eg. in Chapter 7. consult your pediatrician or family doctor before taking any OTC medications. If breast-feeding. ✔ If taking any prescription medications. If pregnant. Do not take a nasal decongestant (eg. ✔ Note that all OTC medications are not safe for everyone. often in doses of 81 mg (a child’s dose) or 325 mg. Measure liquid OTC medications with the measuring device that comes with the product (some have a dropper or plastic cup calibrated in milliliters. The labels contain essential information about the name. or personal testimonials from family members. kidneys. to read the fine print. some products reported to be useful in relieving pain. follow any age limits on the label. Some suggestions and guidelines include the following: • Seek information from authoritative. friends. cough or cold remedies containing dextromethorphan. or the herbal medicine ephedra (Ma Huang) if you are taking a prescription medication for high blood pressure. use a measuring spoon. Such products can raise blood pressure and decrease or cancel the blood pressure–lowering effect of the prescription drug. Accurate measurement of doses is especially important for young children because most of their medications are given in liquid form. ask a physician. consult your obstetrician before taking any OTC medications. ingredients. and other organs that occur with aging and various disease processes. Many OTC medications warn against use with certain illnesses (eg. most available information involves self-reports of a few people. dry place. Ask a health care provider before taking products containing aspirin if you are taking an anticoagulant (eg. if necessary. in combination with other herbal and dietary supplements. In general. objective sources rather than product labels. inflammation. advertisements. In later chapters. combining any of them with alcohol may result in excessive. several resources are provided in this text. or tablespoons).

a peripheral neurotransmitter of pain. the substances from which warfarin. redness. itching. in people allergic to ragweed. vomiting. may relieve abdominal cramping Few studies and little data to support use and effectiveness in GI disorders Arthritis Several studies support use • Athletes take creatine supplements to gain extra energy. and headache • An amino acid produced in liver and kidneys and stored in muscles • Causes weight gain. 7) Creatine Echinacea • Usually ingested as a tea • May cause contact dermatitis • May cause severe hypersensitivity reactions. dizziness. with reports of shorter durations and possibly decreased severity of symptoms • Most often used for the common cold. and reduced pulse rate • Most clinical trials done with Remefemin. so progesterone not needed in women with an intact uterus Applied topically Capsaicin (see Chap. transport. an oral anticoagulant. and stinging Chamomile Chondroitin (see Chap.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 55 TABLE 4–1 Name Black cohosh Herbal and Dietary Supplements Characteristics • Thought to relieve menopausal symptoms by suppressing the release of luteinizing hormone (LH) from the pituitary gland and dysmenorrhea by relaxing uterine muscle • Well tolerated. anti-infective) (continued ) . a liquid. neuropathy. including anaphylaxis. vaginal dryness. and chrysanthemums • May delay absorption of oral medications • May increase risks of bleeding (contains coumarins. may cause occasional stomach upset. other trade names include Estroven and Femtrol Uses • Most often used to relieve symptoms of menopause (eg. usually within 2 weeks of starting use • Legal and available in health food stores as a powder to be mixed with water or juice. visual disturbances. but also advertised for many other uses (immune system stimulant. nausea. and improve performance • Not recommended for use by children because studies have not been done and effects in children are unknown • Nurses and parents need to actively discourage children and adolescents from using creatine supplements • Hard to interpret validity of medicinal claims because various combinations of species and preparations used in reported studies • A few studies support use in common cold. In overdose may cause nausea. • Self-defense as the active ingredient in “pepper spray” • Used mainly for antispasmodic effects in the gastrointestinal (GI) tract. asters. to train longer and harder. may include GI upset. is derived) • Derived from the trachea cartilage of cattle slaughtered for food • Usually taken with glucosamine • Adverse effects minor. flushes. • Used to treat pain associated with neuralgia. 6) • Derived from cayenne pepper • Pain with first application • Adverse effects include skin irritation. twice daily • Not recommended for use longer than 6 months because long-term effects are unknown • Apparently has no effect on endometrium. and osteoarthritis. irritability) • May also relieve premenstrual syndrome (PMS) and dysmenorrhea Remarks • No apparent advantage over traditional estrogen replacement therapy (ERT) • May be useful when ERT is contraindicated for a client or the client refuses ERT • Recommended dose is 1 tab standardized to contain 20 mg of herbal drug. purpurea most often used medicinally • Effects on immune system include stimulation of phagocytes and monocytes • Contraindicated in persons with immune system disorders because stimulation of the immune system may aggravate autoimmune disorders • Hepatotoxic with long-term use • Capsaicin is a topical analgesic that may inhibit the synthesis. as tablets and capsules • Many species but E. and release of substance P. in small numbers of women.

bleeding. clopidogrel) Uses Anorexiant for weight loss. chrysanthemums. 7) Migraines. menstrual irregularities. Ginkgo biloba . patients with intermittent claudication showed significant improvement. myocardial infarctions • May increase effects of other cardiac and CNS stimulants and cause potentially life-threatening illnesses • May decrease effects of antihypertensive medications • May increase clotting time and risk of bleeding • May cause hypersensitivity reactions in people allergic to ragweed. tremor. up to 6 or 8 weeks. nausea. may be useful in treating peripheral arterial disease Should not be used for morning sickness associated with pregnancy— may increase risk of miscarriage • Some studies indicate slight improvement in Alzheimer’s disease. Feverfew (see Chap. ephedra is considered especially hazardous for people with conditions that might be aggravated (eg. dizziness. seizures. decreased therapeutic effects or increased adverse effects). warfarin. • Although not recommended for use by anyone. seizures. or daisies • May cause withdrawal syndrome if use is stopped abruptly • Active ingredient is thought to be allicin • Has antiplatelet activity and may increase risk of bleeding. and a recommendation to use no longer than 3 months. • In European studies. allergic skin reaction • May increase risks of bleeding with any drug that has antiplatelet effects (eg. nausea. stimulant Remarks The Food and Drug Administration (FDA) has issued warnings against use of ephedra because of potentially severe adverse effects. hypertension.56 SECTION 1 INTRODUCTION TO DRUG THERAPY TABLE 4–1 Name Ephedra (Ma Huang) Herbal and Dietary Supplements (continued ) Characteristics • Acts the same as the adrenergic drugs ephedrine and pseudoephedrine. bronchodilator. vomiting • Inhibits platelet aggregation. headache. cardiac palpitations) or who take medications associated with significant drug interactions (eg. dermatitis). heparin. including motion sickness and postoperative nausea Used mainly to improve memory and cognitive function in people with Alzheimer’s disease. may increase clotting time • Gastroprotective effects in animal studies • Reportedly increases blood flow to the brain. should not be used with anticoagulants • May decrease blood sugar and cholesterol • Adverse effects include allergic reactions (asthma. A disadvantage is a delayed response. although a recent study did not support its effectiveness for this purpose • Also used for antihypertensive and antibiotic effects. which are cardiac and central nervous system (CNS) stimulants as well as decongestants and bronchodilators (see Chap. irritation of GI tract. vomiting. especially those of deodorized supplements Ginger Used mainly to treat nausea. arthritis Some studies support use in migraine Garlic • Used mainly to lower serum cholesterol levels. cardiac dysrhythmias. but there is little reliable evidence for such use Medicinal effects probably exaggerated. decongestant. improves memory and decreases dizziness and ringing in the ears (tinnitus) • Improves blood flow to legs and decreases intermittent claudication associated with peripheral arterial insufficiency • Antioxidant • Inhibits platelet aggregation • Adverse effects include GI upset. Whether this shows clinically significant benefits is still unclear. nervousness. strokes. aspirin and other nonsteroidal anti-inflammatory drugs [NSAIDs]. 18) • Commonly found in herbal weightloss products • May cause or aggravate hypertension. asters. including death. headache.

headache. strength. Caution clients to avoid ingesting excessive amounts. and tremors may occur • Usually used with chondroitin • Has beneficial effects on cartilage • Adverse effects mild. decreases blood glucose and cholesterol) • Adverse effects include hypertension. selegiline. inhibits platelet aggregation. weight loss. during pregnancy and lactation. additional claims include treatment of depression. mania. chest pain. and hepatotoxicity • May increase effects of alcohol and other CNS depressants (any herb or drug that causes drowsiness and sedation). St. antistress. diarrhea. impotence. headache. such combinations should be avoided Uses Used to increase stamina. gait. tranylcypromine). and promotion of wound healing • Use as a calming agent is supported by limited evidence from a few small clinical trials. plasma proteins. urge him or her to check blood glucose frequently until ginseng’s effects on blood sugar are known. phenelzine. John’s wort. However. thus possible mood elevating. has been reported. drowsiness • Produces mild euphoria and sedation. or hypertension to check with their primary physician before taking ginseng. skin rashes. amenorrhea. insomnia. by enhancing effects of GABA (an inhibitory neurotransmitter in the CNS) • Adverse effects include impaired coordination. Also to promote sleep and relieve depression Remarks • A few small studies in humans support benefits of ginseng in improving psychomotor and cognitive functioning and sleep. nausea. • Instruct clients with cardiovascular disease. thrombocytopenia. and in children under 12 years old (continued ) . aspirin and other NSAIDs. clopidogrel) • Increases risk of hypoglycemic reactions if taken concurrently with insulin or oral antidiabetic agents • Should not be taken concurrently with other herbs or drugs that inhibit monoamine oxidase (eg. warfarin. or neutropenia • Should be avoided by people with hepatic disease. with symptoms of insomnia. muscle spasms. more well-controlled studies are needed before the herb can be recommended for these uses. If a client insists on using. antidepression. because of its hypoglycemic effect alone and apparent ability to increase the hypoglycemic effects of insulin and oral antidiabetic drugs. and sedative effects. headache. and vomiting • May increase risks of bleeding with any drug that has antiplatelet effects (eg. depression. pruritus.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 57 TABLE 4–1 Name Ginseng Herbal and Dietary Supplements (continued ) Characteristics • Active ingredients called ginsenosides or panaxosides • Has a variety of pharmacologic effects that vary with dose and duration of use (eg. other therapeutic claims are poorly documented • Should be used cautiously by people with renal disease. may have antiseizure effects • May act similarly to benzodiazepines. emotional excitability and restlessness. hypotonia. Several studies support use Glucosamine (see Chap. nervousness. vaginal bleeding. asthma. stress. 7) Arthritis Kava (see Chap. epistaxis. endurance. and edema. heparin. insomnia. decreased platelets. may include GI upset. diabetes mellitus. bilirubin and urea). and mental acuity. • Diabetics should use ginseng very cautiously. Siberian ginseng should not be used longer than 3 weeks. if at all. pain. palpitations. may depress or stimulate central nervous system [CNS]. and judgment. • Instruct any client taking ginseng to avoid long-term use. lymphocytes. rheumatism. • A ginseng abuse syndrome. pupil dilation • Chronic heavy use may cause hematologic abnormalities (eg. 8) Most studied and used to treat anxiety.

dizziness. or neurologic disorders • Adverse effects include altered sleep patterns. insomnia. fatigue and confusion • May interact with numerous drugs to increase their effects. energy level. 10) Used mainly for treatment of depression • Should not be combined with monoamine oxidase inhibitor (MAOI) or selective serotonin reuptake inhibitor (SSRI) antidepressants. depression. Diarrhea may occur with high doses Uses Used mainly for treatment of insomnia and prevention and treatment of jet lag Remarks Patients with renal impairment should use cautiously Saint John’s wort (Chap. and organ transplant drugs (eg. fatigue. nausea. headache.58 SECTION 1 INTRODUCTION TO DRUG THERAPY TABLE 4–1 Name Melatonin (Chap. sedation. hypersensitivity reactions. unsafe when combined with ephedra • Can decrease effectiveness of birth control pills. drowsiness. adrenergics and others • Action unknown. because of slowed melatonin clearance). tachycardia • Active component thought to be hypericin. dizziness. and mood indicate some improvement.5 g • May cause additive sedation if combined with other CNS depressants. confusion. probably by inhibiting their metabolism. GI upset. adverse effects usually minor but may include GI upset. but at least 10 potentially active components have been identified • Thought to act similarly to fluoxetine (Prozac). may have antiandrogenic effects • Generally well tolerated. risk of liver damage from combination products containing valerian and from overdoses averaging 2. Also. because the herb can reduce levels of PSA and produce a false-negative result. antineoplastic drugs. cyclosponne) Saw palmetto Used mainly to relieve urinary symptoms in men with benign prostatic hyperplasia (BPH) Valerian (Chap. which increases serotonin in the brain • Studies (most lasting 6 months or less) indicate improvement in mild to moderate depression • Apparently not effective in major or serious depression • Adverse effects include photosensitivity (especially in fair-skinned persons). these combinations should be avoided Used mainly to promote sleep and allay anxiety and nervousness. itching. headache. 8) • Sedative effects may be due to increasing GABA in the brain • Adverse effects with acute overdose or chronic use include blurred vision. Also has muscle relaxant effects • Reportedly effective in doses of 320 mg/day for 1–3 months • Men should have a prostate specific antigen (PSA) test (a blood test for prostate cancer) before starting saw palmetto. excitability. compared with placebo • Contraindicated in persons with hepatic insufficiency (especially cirrhosis. • Should not be combined with sedative drugs and should not be used regularly • Many extract products contain 40–60% alcohol and may not be appropriate for all patients • Most studies flawed—experts do not believe there is sufficient evidence to support the use of valerian for treatment of insomnia . a history of cerebrovascular disease. antivirals used to treat acquired immunodeficiency syndrome (AIDS). 8) Herbal and Dietary Supplements (continued ) Characteristics • Several studies of effects on sleep. mental alertness. headache. These include antidepressants.

These products are often advertised as “natural. • Assessment guidelines. John’s wort) can interfere with or increase the effects of some drugs. ✔ The safety and effectiveness of these products are not documented or regulated by laws designed to protect consumers. For example. GENERAL PRINCIPLES OF DRUG THERAPY General Goals and Guidelines 1. ✔ ✔ ✔ ✔ ✔ ✔ thought to interact adversely with prescribed drugs or particular client conditions. most products contain several active ingredients and it is often not known which ingredient has the desired pharmacologic effect. capsule. ✔ The product label should also state specific percentages. the types and amounts of ingredients may not be standardized or even identified on the product label. Store herbal and dietary supplements out of the reach of children. affect blood pressure or heart rhythm.nccam. little research has been done to determine either their benefits or their adverse effects. depending on the soil. and strengths of active ingredients. 3. “natural” does not mean safe. some supplements are known to increase blood pressure (see Chap. Thus. amounts. With herbal medicines especially.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 59 CLIENT TEACHING GUIDELINES General Information About Herbal and Dietary Supplements ✔ Herbal and dietary products are chemicals that have druglike effects in people. different brands of the same herb vary in the amounts of active ingredients per recommended dose. their effects are largely unknown and may be dangerous for some people because there is little reliable information about them. • One of the best sources of information is the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health. In addition. This is not true. some have unknown effects when combined with anesthetics.” Many people interpret this to mean the products are safe and better than synthetic or man-made products. general information about the use or nonuse of supplements is assessed. echinacea. Most herbal and dietary supplements should be avoided during pregnancy or lactation and in young children. When taking herbal or dietary supplements. • Teach clients about these products and their possible interactions with each other and with their prescription drugs (when such information is available). Some products (eg. As a result. Many variables influence a drug’s effects on the human body. Failure to consider these variables may decrease therapeutic effects or increase risks of adverse effects to an unacceptable level. garlic. For most products. If so. In fact. In later chapters. dietary supplements. In this chapter. especially when taken concurrently with other herbals. . dose. as are pharmaceutical drugs. ✔ These products can be used more safely if they are manufactured by a reputable company that states the ingredients are standardized (meaning that the dose of medicine in each tablet or capsule is the same). 55) or risk of excessive bleeding (see Chap. the nurse can ask about the use of specific supplements that may interact with the drug group(s) discussed in that chapter. Drug therapy should be individualized. other perioperative medications. tea. and climate where the plants are grown. ginseng. frequency and duration of use. tablet. Expected benefits should outweigh potential adverse effects. 2. kava. 57). ephedra. try to determine the name. feverfew. • End-of-chapter references. Contact: NCCAM Clearinghouse PO Box 8218 Silver Spring. or increase risks of bleeding. Inform health care providers when taking any kind of herbal or dietary supplement. or drugs. Inappropriate use or taking excessive amounts may cause dangerous side effects. MD 20907-8218 Tel: 1-888-644-6226 Website: www. drugs usually should not be prescribed for trivial problems or problems for which nondrug measures are effective. follow the instructions on the product label. valerian and St. The American Society of Anesthesiologists recommends that all herbal products be discontinued 2–3 weeks before any surgical procedure. and surgical procedures. to reduce risks of severe adverse effects or drug–supplement interactions. The goal of drug therapy should be to maximize beneficial effects and minimize adverse effects. • Ask clients whether they use herbal medicines or other dietary supplements. Unfortunately. Dosing is also difficult because a particular herb may be available in several different dosage forms (eg. water. extract) with different amounts of active ingredients. components and active ingredients of plants can vary considerably.nih.

recommended dosages are listed in amounts likely to be effective for most people. Drug Therapy in Children Drug therapy in neonates (birth to 1 month). In general. mainly because clients are more likely to take them. Hydrochloride. When drug actions are not urgent. they are only guidelines to be interpreted according to the client’s condition. Dermatologic drugs are often formulated in different salts and dosage forms. and sodium salts are often used. Body surface area. these should be used. Also. different salts of the same drug rarely differ pharmacologically. and therefore dosages have not been established. 2. vagina. give the non-opioid drug if it is effective in relieving pain. However. The following methods are used for these calculations: a. Some drugs are not recommended for use in children. If it has a long half-life and optimal therapeutic effects do not usually occur for several days or weeks. Choice of drug is often restricted because many drugs commonly used in adult drug therapy have not been sufficiently investigated to ensure safety and effectiveness in children. doses for children are extrapolated from those established for adults. Nursing Notes: Apply Your Knowledge You are assigned to care for a low-birth-weight infant. neonatal therapeutics are discussed further in Chapter 67. solubility is especially important with parenteral drugs. A drug can be started rapidly or slowly. For example. and organ function. application to intact skin or the mucous membranes of the eye. Minimizing the number of drugs and the frequency of administration increases client compliance with the prescribed drug regimen and decreases risks of serious adverse effects. and drug therapy is less predictable than in adults. Additional principles and guidelines include the following: 1. and general principles. 3. manufacturers’ literature states that “safety and effectiveness for use in children have not been established. solubility.” Most drugs given to adults also are given to children. however. many of the combination products are formulated to be long acting. who has been started on digoxin to treat congenital heart problems until corrective surgery can be performed. Clark’s rule is based on weight and is used for children at least 2 years of age: Weight (in pounds) × adult dose = child’s dose 150 b. 4. however. according to their intended uses (eg. The digoxin dosage seems very low to you. therapy may be initiated with a maintenance dose. with expectations of measurable improvement as a result of drug therapy. based on General Drug Selection and Dosage Considerations Numerous factors must be considered when choosing a drug and dosage range for a particular client. For many drugs. Quality-of-life issues are also being emphasized in research studies. Pharmacists and chemists choose salts on the basis of cost. Physiologic differences alter drug pharmacokinetics (Table 4–2). sulfate. 2. Although individual drugs allow greater flexibility of dosage than fixed-dose combinations. and nursing process guidelines apply. infants (1 month to 1 year). and the amount needed for a specific dose must be calculated as a fraction of the adult dose. nose. When pediatric dosage ranges are listed in drug literature. What factors might you consider before questioning the physician regarding the dosage that was ordered? . All aspects of pediatric drug therapy must be guided by the child’s age. weight. the physician may order a limited number of relatively large (loading) doses followed by a regular schedule of smaller (maintenance) doses. they are expressed in the amount of drug to be given per kilogram of body weight or square meter of body surface area. 5. techniques of drug administration. convenience. developmental level. or rectum). In drug literature. and stability. Often. Safe therapeutic dosage ranges are less well defined for children than for adults. Drug effects on quality of life should be considered in designing a drug therapy regimen. which also promotes compliance. Neonates are especially vulnerable to adverse drug effects because of their immature liver and kidney function. For example. taste is a factor with oral drugs. 6. clients with serious illnesses may require larger doses of some drugs than clients with milder illnesses. For example. multiple drugs are commonly used to treat severe hypertension or serious infections. including hazardous drug–drug interactions. use as few drugs in as few doses as possible. and children (approximately 1 to 12 years) requires special consideration because of the child’s changing size. Most drug use in children is empiric in nature because few studies have been done in that population.60 SECTION 1 INTRODUCTION TO DRUG THERAPY 4. 3. For example. The least amount of the least potent drug that yields therapeutic benefit should be given to decrease adverse reactions. including the following: 1. For the most part. clients with severe kidney disease often need much smaller doses of renally excreted drugs. mouth. and level of growth and development. if a mild non-opioid and a strong opioid analgesic are both ordered. There are notable exceptions to this basic rule. Calculating dosage based on body surface area is considered a more accurate method than those based on other characteristics. For many drugs. fixed-dose combinations are increasingly available and commonly used.

slowed excretion of drugs eliminated by the kidneys. Although age in years is an important factor. Increased capacity for biotransformation of some drugs. compared with older children and adults. before prescribing . 4. diazepam (Valium). out of reach of children. but in this book people 65 years of age and older are so categorized. height and weight. compared with adults. This occurs because older adults are usually less able to metabolize and excrete drugs efficiently.73 square meters ( m 2 ) × adult dose = child’s dose c. Try to obtain the child’s cooperation. salicylates (eg. impaired memory and cognition. and theophylline (Theolair). others). Responses also differ in the same person over time. precisely when a person becomes an “older adult” is not clearly established. This results in slowed metabolism and elimination.” with efforts to prevent or control symptoms and maintain the client’s ability to function in usual activities of daily living. The net effect is often a need for decreased dosage. It may be difficult to separate the effects of aging from the effects of disease processes or drug therapy. Additional principles include the following: 1. For example. Any prescriber should review current medications. compared with 50% to 60% in children older than 2 years of age and adults) Altered protein binding until approximately 1 year of age. This may result in a greater proportion of unbound or pharmacologically active drug and greater risks of adverse drug effects. multiple drug therapy for acute and chronic disorders. phenobarbital. Iidocaine (Xylocaine). This results in a rapid rate of metabolism and elimination. prolonged drug half-life and decreased rate of drug clearance may offset. including nonprescription drugs. and do not refer to medications as “candy. is estimated using a nomogram (Fig. Use the estimated body surface area in the following formula to calculate the child’s dose: Body surface area (in square meters) 1. Dosages obtained from these calculations are approximate and must be individualized. and Children: Physiologic Characteristics and Pharmacokinetic Consequences Pharmacokinetic Consequences Increased absorption of topical drugs (eg. The amount and binding capacity of plasma proteins may be reduced. older adults are quite heterogeneous in their responses to drug therapy and responses differ widely within the same age group. organ function) is more important than chronologic age. pathologic changes due to disease processes. with increased risks of drug accumulation and adverse effects. and difficulty in complying with drug orders. This would seem to indicate a need for larger doses. theophylline is cleared about 30% faster in a 7-year-old child than in an adult and approximately four times faster than in a neonate. In neonates and infants. Kidney function develops progressively during the first few months of life and is fairly mature by 1 year of age. 3. In this population. In addition. general nursing process guidelines and principles of drug therapy apply. Medications—both prescription and nonprescription drugs—should be taken only when necessary. Symptoms attributed to aging or disease may be caused by medications.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 61 TABLE 4–2 Neonates. phenytoin (Dilantin). nafcillin (Unipen). However.” Drug Therapy in Older Adults Aging is a continuum. Physiologic Characteristics Increased thinness and permeability of skin in neonates and infants Immature blood–brain barrier in neonates and infants Increased percentage of body water (70% to 80% in neonates and infants. aspirin). digoxin (Lanoxin). Infants. use the thigh muscles because the deltoid muscles are quite small and the gluteal muscles do not develop until the child is walking. 2. 4. the goal of drug therapy may be “care” rather than “cure. For safety. keep all medications in childproof containers. Decreased activity of liver drug-metabolizing enzyme systems in neonates and infants Increased activity of liver drug-metabolizing enzyme systems in children Decreased capacity for biotransformation of drugs. If intramuscular injections are required in infants. Drugs with decreased protein binding in neonates. compared with older children and adults. drugs are more likely to accumulate. particularly long-term drug therapy. Dosage of these drugs may need to be decreased. never force oral medications because forcing may lead to aspiration. Dosage requirements may be decreased or modified by other factors. Overall. include ampicillin (Omnipen. 4–1). These doses can be used initially and then increased or decreased according to the child’s response. Use the oral route of drug administration when possible. 6. corticosteroids may be absorbed sufficiently to suppress adrenocortical function) Increased distribution of drugs into the central nervous system because myelinization (which creates the blood–brain barrier to the passage of drugs) is not mature until approximately 2 years of age Usually increased volume of distribution in infants and young children. adverse effects are likely because of physiologic changes associated with aging (Table 4–3). As a result. Physiologic age (ie. when it reaches adult levels Decreased glomerular filtration rate in neonates and infants. 5. depending on the infant’s age and level of growth and development.

In addition.4 20 10 15 5 0.30 1. 9. In addition.8 3' 34" 32" 30" 28" 26" 2' 22" 20" 18" 16" 14" 1' 10" 9" 8" 20 25 0.5 30 25 0. new drugs.20 1. The nurse gives Jamie 30 cc of amoxicillin for his morning dose.00 0. to be administered q8h in equally divided doses Jamie weighs 10 kg and the recommendations for infants are 20–40 mg/kg/day. The basic principle of giving the smallest effective number of drugs applies especially to older adults. The smallest number of effective doses should be prescribed.05 1. or other aspects need to be revised.45 1. This is especially important when a serious illness or significant changes in health status have occurred.25 1.35 1. A How Can You Avoid This Medication Error? Amoxicillin is prescribed for Jamie for an ear infection. The dosage can then be increased or decreased according to response. the dosage should usually be smaller than for younger adults.70 2.90 2. All drugs should be given for the shortest effective time.10 2. This allows less disruption of usual activities and promotes compliance with the prescribed regimen.62 SECTION 1 INTRODUCTION TO DRUG THERAPY Nomogram for estimating the surface area of infants and young children Height feet centimeters Nomogram for estimating the surface area of older children and adults Height feet centimeters Surface area in square meters Weight pounds 65 60 55 50 45 40 35 15 7' 10' 8' 6' 4' 2' 6' 10' 8' 6' 4' 2' 5' 10' 8' 6' 4' 2' 4' 5 10' 8' 6' Surface area in square meters Weight pounds 440 420 400 380 360 340 320 300 290 280 270 260 250 240 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 30 60 25 50 kilograms 30 25 20 kilograms 200 190 180 170 160 150 140 130 120 110 100 95 90 85 80 75 70 65 60 55 50 45 40 35 0.40 2.6 0.00 1.80 2. draw a straight line between the point representing his or her height on the left vertical scale to the point representing weight on the right vertical scale. and many drugs are continued for years. 8.60 20 Figure 4–1 Body surface nomograms.15 1.65 0. 6.00 2. When any drug is started.3 50 45 40 35 0. If an increased dosage is indicated.70 0. 7. increments should be .55 1. many older adults are unable to self-administer more than three or four drugs correctly.65 1.7 0.95 0.40 1.80 0.85 1.75 1. When drug therapy is required.10 1. the choice of drug should be based on available drug information regarding effects in older adults.80 1.75 0.95 1. Health care providers must reassess drug regimens periodically to see whether drugs. The order is for 300 mg daily. Some drugs. unnecessary drugs should be discontinued.70 1.30 2. especially with long-term use. 5.50 1. The amoxicillin is supplied in syrup containing 100 mg/10 cc.60 2.90 1. This interval is not established for most drugs.50 2. dosages. need to be tapered in dosage and discontinued gradually to avoid withdrawal symptoms. regimen of several drugs increases the incidence of adverse reactions and potentially hazardous drug interactions. To determine the surface area of the client.20 2.2 10 4 220 215 210 205 200 195 190 185 180 175 170 165 160 155 150 145 140 135 130 125 120 115 110 105 100 95 90 85 80 75 30 3 2 4 3 4' 2' 1 3' 10' 8' 6' 3.60 1.1 95 90 85 80 75 70 65 60 55 0.90 0. The point at which this line intersects the middle vertical scale represents the client’s surface area in square meters (Courtesy of Abbott Laboratories).85 0.

decreased size of the liver. c. a. decreased number of functioning nephrons. hypertension. with resultant higher plasma concentrations and higher risks of toxicity with a given dose. the client can tell at a glance whether a dose has been taken. For example. Several devices may be used to schedule drug doses and decrease risks of omitting or repeating doses. Often. the drug also may be metabolized and excreted more rapidly. In clients with nor- . When a client acquires new symptoms or becomes less capable of functioning in usual activities of daily living. avoid childproof containers for an older adult with arthritic hands. In addition. Fat-soluble drugs (eg. nonsteroidal anti-inflammatory drugs such as ibuprofen. subcutaneous or muscle tissue). Also available are drug containers with doses prepared and clearly labeled as to the day and time each dose is to be taken. acetaminophen. or administration of nephrotoxic drugs. This conservative. This may increase risks of adverse effects. and increased risks of toxicity • Age-related alterations in renal function are consistent and well described. d. and decreased tubular secretion smaller and made at longer intervals in older adults. insomnia is a common complaint among older adults. drug interactions occur with co-administration of multiple drugs that are highly protein bound. effects on extended-release formulations are unknown • Slower absorption from some sites of administration (eg. major surgery or trauma. the result is larger concentrations of free drug. and charts. and antiulcer drugs. Use nondrug measures to decrease the need for drugs and to increase their effectiveness or decrease their adverse effects. which may lead to drug accumulation and increased risks of adverse or toxic effects Water-soluble drugs (eg.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 63 TABLE 4–3 Older Adults: Physiologic Characteristics and Pharmacokinetic Consequences Pharmacokinetic Consequences Minimal effects on absorption of most oral drugs. As above. Clients with disease processes such as diabetes. Be sure the client can open drug containers. pharmacologically active drug. by avoiding caffeine-containing beverages and excessive napping) is much safer than taking sedative-hypnotic drugs. They may then be ignored or treated by prescribing a new drug. aspirin. With the latter system.” 10. effects on absorption from skin and mucous membranes are unknown • Decreased distribution to sites of action in tissues. prolonged half-life. Drug Therapy in Renal Impairment Many clients have or are at risk for impaired renal function. calendars. (Numerous drugs metabolized by the CYP enzymes are often prescribed for older adults. or heart failure may have renal insufficiency on first contact. For example. label drug containers with large lettering for easier readability. go slow. antimicrobials. accumulate in fat. If vision is impaired. Decreased availability of protein for binding and transporting drug molecules. Physiologic Characteristics Decreased gastrointestinal secretions and motility Decreased cardiac output Decreased blood flow to the liver and kidneys Decreased total body water and lean body mass per kg of weight. decreased number and activity of the cytochrome P450 (CYP) oxidative drug-metabolizing enzymes Decreased blood flow to the kidneys. safe approach is sometimes called “start low. For people receiving long-term drug therapy at home. gastrointestinal tract. 11. increased body fat Decreased serum albumin Decreased blood flow to the liver. use measures to help them take drugs safely and effectively. especially for those that are normally highly protein bound (eg. with increased risks of drug accumulation and toxic effects. calcium channel blockers. This increases serum concentration of free. • Impaired drug excretion. warfarin). when stopping or reducing the dose of an old drug is the indicated intervention. These include written schedules. ethanol. Metabolism of drugs metabolized by conjugative reactions (eg. diazepam. thereby offsetting at least some of the risks. Slowed metabolism and detoxification of many drugs. Preventing it (eg. The drugs compete for protein-binding sites and are more likely to cause adverse effects with decreased levels of serum albumin. lithium) are distributed into a smaller area. morphine. steroids) does not change significantly with aging). and have a longer duration of action in the body. However. with potential for delaying the onset and reducing the extent of therapeutic effects Delayed metabolism and excretion. Renal mass is also decreased and older adults may be more sensitive to drugs that further impair renal function (eg. new signs and symptoms are attributed to aging or disease. decreased glomerular filtration rate. A magnifying glass also may be useful. Enlist family members or friends when necessary. and this may be worsened by illness. b. the statin cholesterol-lowering drugs. When renal blood flow is decreased. less drug is delivered to the kidney for elimination. consider the possibility of adverse drug effects. diazepam) are distributed to a larger area. including beta blockers. 12. which older adults often take for pain or arthritis).

all health care providers need to be knowledgeable about risk factors for development of renal impairment.0 mg/dL). As a result. tetracyclines except doxycycline). an erroneous value will be obtained. hemodialysis or some type of filtration). specific guidelines for particular drug groups are included in appropriate chapters. there are no effective substitutes and nephrotoxic drugs must be given. an adequate fluid intake is required to excrete drugs by the kidneys. hemodynamic. Some drugs are excreted exclusively (eg. In relation to drug therapy. increased blood urea nitrogen or increased serum creatinine (>2 mg/dL or an increase of ≥0. which is then used to calculate creatinine clearance as a measure of the glomerular filtration rate (GFR). Drugs known to be nephrotoxic should be avoided when possible. including aminoglycoside antibiotics. amphotericin B. However.5 mg/dL over a baseline value of <3. others can be used if safety guidelines are followed (eg. stable serum creatinine) and average muscle mass (for their age. However. the creatinine clearance should be estimated to be less than 10 mL/minute. the serum creatinine measurement can- not be used as the sole indicator of renal function unless the client is a young. the treatment removes variable amounts of drugs that are . reducing dosage. 1. illnesses and their physiologic changes (eg. Clients with renal impairment may respond to a drug dose or serum concentration differently than clients with normal renal function because of the physiologic and biochemical changes. Chronic renal failure (CRF) usually results from disease processes that destroy renal tissue. Many commonly used drugs may adversely affect renal function. dialysis or transplantation is required. In some instances. interfere with secretion of creatinine into kidney tubules. which include cimetidine and trimethoprim. shock due to sepsis or blood loss. diuretic drugs. If a fluctuating serum creatinine is used to calculate the GFR. Renal status should be monitored in any client with renal insufficiency or risk factors for development of renal insufficiency. or diarrhea) increase the risk of worsening renal impairment in clients who already have impairment or of causing impairment in those who previously had normal function. health care providers need to know and use these recommendations to maximize the safety and effectiveness of drug therapy. Drug selection should be guided by baseline renal function and the known effects of drugs on renal function. Estimations of creatinine clearance are more accurate for clients with stable renal function (ie. and digoxin. Serum creatinine is also a relatively unreliable indicator of renal function in elderly or malnourished clients. nephrotoxic drugs. Acute renal failure (ARF) may occur in any illness in which renal blood flow or function is impaired. seriously impaired cardiovascular function. When possible. inadequate fluid intake. as often occurs in acute illness. well-nourished person with a sudden acute illness. weight. 2. In addition. regardless of the serum creatinine concentration. 4. and metabolic alterations) that affect renal function. If a client is oliguric (<400 mL urine/24 hours). lithium) and most are excreted primarily or to some extent by the kidneys. most cephalosporin antibiotics. renal. nephrologists should design drug therapy regimens. For some drugs. Estimations are less accurate for emaciated and obese clients and for those with changing renal function. Some medications can increase serum creatinine levels and create a false impression of renal failure. Advil). including nonsteroidal anti-inflammatory drugs such as prescription or OTC ibuprofen (Motrin. when possible. and medication dosages are adjusted according to the extent of renal impairment. for example. For clients receiving renal replacement therapy (eg. Because these clients usually have diminished muscle mass. fluoroquinolones. major surgery. loss of body fluids with blood loss. effective treatment can help to conserve functioning nephrons and delay progression to end-stage renal disease (ESRD). Thus. hepatic. contributing factors are eliminated or treated effectively. and the effects of various drugs on renal function. vomiting. and height). avoiding dehydration). aminoglycoside antibiotics. the most effective dosage adjustments are based on the client’s clinical responses and serum drug levels. however. or other conditions. monitoring serum drug levels and renal function tests. serum creatinine levels are increased without an associated decrease in renal function. renal failure may develop from depletion of intravascular fluid volume. Guidelines have been established for the use of many drugs. renal function may recover if the impairment is recognized promptly. 3. and cisplatin. With CRF. a smaller dose or a longer interval between doses is recommended for clients with moderate (creatinine clearance 10 to 50 mL/minute) or severe renal insufficiency (creatinine clearance < 10 mL/minute). 5. Because serum creatinine is determined by muscle mass as well as the GFR. With ARF. relatively healthy. Dosage of many drugs needs to be decreased in renal failure. Some commonly used nephrotoxic drugs include aminoglycoside antibiotics. Any factors that deplete extracellular fluid volume (eg. This is usually determined by measuring serum creatinine. they may have a normal serum level of creatinine even if their renal function and GFR are markedly reduced. Some general guidelines are listed here.64 SECTION 1 INTRODUCTION TO DRUG THERAPY mal renal function. drug therapy must be individualized according to the extent of renal impairment. Drug therapy must be especially cautious in clients with renal impairment because of the risks of drug accumulation and adverse effects. If ESRD develops. Signs and symptoms of ARF include decreased urine output (<600 mL/24 hours). Some drugs are contraindicated in renal impairment (eg. for many commonly used drugs. These drugs. the major concern with renal impairment is the high risk of drug accumulation and adverse effects because the kidneys are unable to excrete drugs and drug metabolites.

intestine. below). clindamycin. 4. so that drug pharmacokinetics and pharmacodynamics vary widely. Drug selection should be based on knowledge of drug effects on hepatic function. Dosage should be reduced for drugs that are extensively metabolized in the liver because. nurses in emergency departments often initiate and maintain treatment for several hours. dosage. jaundice. and. whereas chronic cirrhosis or severe liver impairment may affect all pharmacokinetic processes. Hepatic metabolism depends mainly on blood flow and enzyme activity in the liver and protein binding in the plasma. 2.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 65 usually excreted through the kidneys. Although critical care nursing is a specialty area of practice and much of critical care is performed in an intensive care unit (ICU). the two main sources of the liver’s blood supply. renal. Indicators of hepatic impairment include serum bilirubin levels above 4 to 5 mg/dL. Alcohol is toxic to the liver by itself and increases the risks of hepatotoxicity with other drugs. although the liver is often damaged. a serum albumin below 2. During drug therapy. cimetidine. In addition. major surgery. many other drugs can cause or aggravate liver impairment by decreasing hepatic blood flow and drug-metabolizing capacity. for the shortest effective time. ketoconazole) inhibit hepatic metabo- lism of many coadministered drugs. and duration of use are not well established. or both. and cholesterol-lowering statins. For example. renal excretion. Drug Therapy in Critical Illness The term critical illness. elimination is slower. 1. some oral drugs are normally extensively metabolized during their “first pass” through the liver. With cirrhosis. and verapamil. An additional factor is hepatotoxic drugs. In some clients. serum drug levels are higher. quinidine. morphine.5 times control. or trauma) or hepatic enzyme production. nurses in numerous other settings also care for these clients. increasingly. drug distribution is usually increased because of less protein binding and increased extracellular fluid. In addition to hepatotoxic drugs. phenytoin. denotes the care of clients who are experiencing acute. hepatitis. meperidine. 3. a supplemental dose may be needed to maintain therapeutic blood levels of drug. with severe hepatic impairment. such as many antimicrobials. and toxicity is more likely to occur in a client with hepatic disease. lidocaine is normally rapidly deactivated by hepatic metabolism. If blood flow is impaired so that lidocaine molecules in the blood are unable to reach drug-metabolizing liver cells. Several drugs (eg. Fortunately. Commonly used hepatotoxic drugs include acetaminophen. In relation to drug therapy. cirrhosis) and those with disease processes that impair blood flow to the liver (eg. cimetidine. including cardiovascular. shock. The consequence may be toxicity from the inhibited drugs if the dose is not decreased. Drug Therapy in Hepatic Impairment Most drugs are eliminated from the body by hepatic metabolism. acute liver impairment may interfere with drug metabolism and elimination. Liver function tests should be monitored in clients with or at risk for liver impairment. epinephrine and related drugs may cause vasoconstriction in the hepatic artery and portal vein. vomiting. Drug elimination is usually impaired because of decreased blood flow and decreased function of the liver and kidneys. ranitidine. the blood carrying the drug molecules is shunted around the liver so that oral drugs go directly into the systemic circulation. theophylline. Hepatotoxic drugs should be avoided when possible. Overall. more drug stays in the bloodstream longer. lorazepam. Also.0 g/dL. a prothrombin time greater than 1. kidneys. Thus. Some general guidelines for increasing drug safety and effectiveness are listed here. especially when clients are receiving potentially hepatotoxic drugs. isoniazid. nurses on other hospital units care for clients who are transferred to or from ICUs. It is difficult to predict the effects of drug therapy because of wide variations in liver function and few helpful diagnostic tests. heart failure. known guidelines for particular drug groups are included in appropriate chapters. they should be used in the smallest effective doses. If they cannot be avoided. liver enlargement) and abnormal results of laboratory tests of liver function (see 4. serious. so that a relatively small portion of an oral dose reaches the systemic circulation. and elevated serum alanine (ALT) and aspartate (AST) aminotransferases. Critically ill clients are at risk for multiple organ failure. Clients at risk for impaired liver function include those with primary liver disease (eg. fluoxetine. clients formerly cared for in . nausea. diazepam. propranolol. Although blood volume is often decreased. lungs) may become more important in eliminating drugs from the body. With some drugs. labetalol. or life-threatening illness. it has a great capacity for cell repair and may be able to function with as little as 10% of undamaged hepatic cells. Some drugs whose dosages should be decreased in hepatic failure include cefoperazone. For example. extrahepatic sites of drug metabolism (eg. and hepatic impairments that influence all aspects of drug therapy. critically ill clients exhibit varying degrees of organ dysfunction and their conditions tend to change rapidly. if doses are not reduced. as used here. abnormal liver function test results may occur without indicating severe liver damage and are often reversible. For example. guidelines for drug selection. clients with impaired liver function require close monitoring for signs and symptoms (eg. Betaadrenergic blocking agents decrease hepatic blood flow by decreasing cardiac output.

For example. rapid drug action. which are often given to prevent stress ulcers and GI bleeding. Moreover. severity of illness) and organ function. and the kidneys cannot excrete drugs effectively. Sublingual. Dosage requirements may vary considerably among clients and within the same client at different times during an illness. or by skin patch because shock impairs absorption from their sites of administration. Some general guidelines to increase safety and effectiveness of drug therapy in critical illness are listed here. especially cardiovascular. Laboratory tests are often needed before and during drug therapy of critical illnesses to assess the client’s . Drug therapy in clients who are critically ill is often more complex. Commonly used drugs include analgesics. With many drugs. Nurses need to be especially diligent in administering drugs and vigilant in observing client responses. Thus. neys. As a result. as indicated by symptoms or laboratory tests). One reason is that clients often have multiple organ impairments that alter drug effects and increase the risks of adverse drug reactions. periodic weights help to assess clients for loss of body mass or gain in body water. For clients who receive oral medications or nutritional solutions through a nasogastric. and the drugs used to treat the illnesses. subcutaneously. In many instances. or jejunostomy tube. hepatic. For clients with hypotension and shock. antiulcer drugs. Route of administration should also be guided by the client’s clinical status. and transdermal medications may be used effectively in some critically ill clients. Thus. few drugs are available in these formulations. the goal of drug therapy is to support vital functions and relieve life-threatening symptoms until healing can occur or definitive treatment can be instituted. 1. 2. and experienced nurses may transfer to an ICU. 7. and less predictable than in most other populations. gastric acid suppressants. and metabolic alterations) that can be caused by the illnesses. cardiovascular agents. hemodynamic. Once-daily drug doses should be given at approximately the same time each day. However. 4. many new graduates seek employment in critical care settings. more pronounced. Another reason is that critically ill clients often require aggressive treatment with large numbers. impaired function of the GI tract. increasing numbers of nursing students are introduced to critical care during their educational programs. gastrostomy. Overall. Drug selection should be guided by the client’s clinical status (eg. large doses. and that maintenance dosages are titrated according to client responses and changes in organ function (eg. the IV route achieves more reliable and measurable blood levels. more problematic. multiple-daily doses should be given at approximately even intervals around the clock. initially and periodically. antimicrobials. If the client is able to take oral medications. intramuscularly. it is especially important that initial dosages are individualized according to the severity of the condition being treated and client characteristics such as age and organ function. In addition. A standard dose may be effective. cardiovascular and central nervous system (CNS) effects may be faster. renal. distribution to body cells is unpredictable. However. and longer lasting than usual. renal. many factors may interfere with drug effects (eg. effects may include excessive sedation and cardiac depression. 3. In this at-risk population. or even at home. and hepatic functions. subtherapeutic. heart. the timing of administration may be important in increasing therapeutic effects and decreasing adverse effects. or liver) and drug–drug and drug–diet interactions may occur if precautions are not taken. more specific guidelines related to particular drugs are included in the appropriate chapters. this is probably the preferred route. there may be drug–food interactions that impair drug absorption. If the drug is a sedative. In addition. oral inhalation. or toxic. neuromuscular blocking agents. 8. crushing tablets or opening capsules to give a drug by a GI tube may alter the absorption and chemical stability of the drug. symptoms. both of which affect the pharmacokinetics of the drugs administered. and relatively large doses. In addition. When a drug is given IV. and skin. all nurses need to know about drug therapy in critically ill clients. it reaches the heart and brain quickly because the sympathetic nervous system and other homeostatic mechanisms attempt to maintain blood flow to the heart and brain at the expense of blood flow to other organs such as the kid- 6. therapeutic effects may be decreased and risks of adverse reactions and interactions may be increased because the client’s body may be unable to process or respond to drugs effectively. may decrease absorption of other drugs. 5. gastrointestinal (GI) tract. safe and effective drug therapy requires that all involved health care providers be knowledgeable about common critical illnesses. liver. because dosage of many drugs is based on weight. Weigh clients when possible.66 SECTION 1 INTRODUCTION TO DRUG THERAPY an ICU are on medical-surgical hospital units. 9. Drugs used in critical illness represent most drug classifications and are also discussed in other chapters. Most drugs are given intravenously (IV) because critically ill clients are often unable to take oral medications and require many drugs. and combinations of highly potent medications. and sedatives. kidneys. drugs usually should not be given orally. the liver cannot metabolize drugs effectively. the physiologic changes (eg. in long-term care facilities.

unbound molecules are metabolized and excreted more readily so that therapeutic effects may be decreased. In addition to safe and accurate administration. The nurse may wish to schedule a daily time for receiving and making nonemergency calls. Establish a method for contact in case the appointment must be canceled by either party. assess the client’s ability to obtain medications and keep appointments for followup visits to health care providers. If so. and provide nursing care. 4. elicit cooperation. the role of the nurse is to teach the client or caregiver to administer medications and monitor their effects. In addition. answer questions. identify problems. Explain that the nurse needs this information because some herbals and dietary supplements may cause various health problems or react adversely with prescription or OTC medications. these drugs are eliminated more slowly than usual. 2. state the main purpose of the visit and approximately how long the visit will be. preferably at a convenient time for the client and caregiver. but they may need information about timing in relation to food intake. Assess the environment for potential safety hazards (eg. . Clients may require short. drugs with opposing or duplicate effects. Skilled nursing care. meperidine. Clients and caregivers should be given a telephone number to call with questions about medications. Home Care Home care is an expanding area of health care. Demonstrating and having the client or caregiver do a return demonstration is a good way to teach psychomotor skills such as giving a medication through a GI tube. fluid and electrolyte balance) and response to treatment. renal and hepatic functions. Most general principles and nursing responsibilities related to drug therapy apply in home care as in other health care settings. the nurse is a guest and must work within the environment to establish rapport. The results of these tests may indicate that changes are needed in drug therapy. Between home visits. risk of infection with corticosteroids and other immunosuppressants. 3. Serum albumin. 8. 5. the nurse may initially need to demonstrate administration or coach the client or caregiver through each step. reasons for use. which binds acidic drugs such as phenytoin and diazepam. is often required during follow-up. With this information. Ask if the client takes any herbal medicines or dietary supplements. In most instances. duration of use. With other routes. In both instances. 10. The consequences of this trend include increased outpatient care and brief hospitalizations for severe illness or major surgery. propranolol. differences between instructions and client usage of medications. electronic mail may be a convenient and efficient method of communication. Serum protein levels should be monitored in critically ill clients because drug binding may be significantly altered. teach them how to manage minor ones and which ones to report to a health care provider. Other tests may include measurement of serum drug levels. including inadequate production by the liver. 6. when to omit the drug. the nurse may be able to reinforce the client’s compliance or identify potential problem areas (eg. risk of falls and other injuries with opioid analgesics and other drugs with sedating effects). the bound portion of a dose increases for some drugs (eg. Alpha1-acid glycoprotein binds basic drugs and its synthesis may increase during critical illness. and ask how and when the client takes each one. and so forth. preparing and administering an injection. or manipulating an intravenous infusion pump. continued use of medications that were supposed to be discontinued. Most people are accustomed to taking oral drugs. For clients and nurses with computers and Internet access. the home care nurse can maintain contact with clients and caregivers to monitor progress. drugs discontinued because of adverse effects). especially the costs of hospitalization. who will be the primary caregiver for medication administration and ob7.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 67 condition (eg. As a result. Provide whatever information and assistance is needed for home management of the drug therapy regimen. frequency. In addition. If there is not enough albumin to bind a drug. side effects. is usually decreased during critical illness for a variety of reasons. In a client’s home. Some additional principles and factors include the following: 1. In addition. and perceived beneficial or adverse effects. If side effects occur. Assess the client’s attitude toward the prescribed medication regimen and his or her ability to provide self-care. This trend evolved from efforts to reduce health care costs. and other aspects. imipramine. whether a tablet can be crushed.or long-term drug therapy. 9. blood levels are higher and may cause adverse effects. teach the client and caregiver to observe for beneficial and adverse effects. and one purpose is to schedule a home visit. try to determine the amount. clients of all age groups are often discharged to their homes for follow-up care and recovery. lidocaine) and therapeutic blood levels may not be achieved unless higher doses are given. and provide reassurance. Also. If the client is unable. cardiovascular. such as managing medication regimens. serving for medication effects? What are the learning needs of the client or caregiver in relation to the medication regimen? Ask to see all prescribed and OTC medications the client takes. The initial contact is usually by telephone.

Medications and supplies are usually kept on a medication cart in a hospital or long-term care facility. Some drugs require specific techniques of preparation and administration. Observe for therapeutic effects. 2. Check vital signs when indicated. ask a colleague or a pharmacist to do the calculation. Administer drugs accurately (see Chap. Commonly needed reports include serum potassium levels before giving diuretics. electrolytes. compare the client’s symptoms with your knowledge base about adverse effects associated with the drugs or consult a drug reference. No variation is allowed in the other rights. e. and right time). Is it contraindicated? Is it likely to interact with other drugs the client is taking? Does the client’s ordered dose fit within the dosage range listed in the drug reference? Can a tablet be crushed or a capsule opened without decreasing therapeutic effects or increasing adverse effects?) These rights are ensured if the techniques described in Chapter 3 are consistently followed. Practice the five rights of drug administration (right drug. administer at least 2 hours apart. Calculate doses when indicated. complete blood count [CBC]. sterile equipment and techniques are required for injection of any drug. start preparing about 30 minutes before the scheduled administration time when possible. d. For example. do not give antacids with any other oral drugs. If unsure about the results. Specific observations depend on the specific drug or drugs being given. Check temperature before giving an antipyretic. use pencil and paper to decrease the risk of errors. a. c. prothrombin time or international normalized ratio (INR) before giving Coumadin. Observe for adverse effects. d. a. right route. 3. Check laboratory reports when indicated. Except for very simple calculations. 2. laboratory or other diagnostic test reports. Accuracy is vital. and those receiving large doses of any drug. Specific adverse effects for which to observe depend on the drugs being given. This is often needed to look up new or unfamiliar drugs. In general. Use correct techniques for different routes of administration. Check laboratory (eg. Assemble appropriate supplies and equipment. Compare results. to avoid rushing and increasing the risk of errors. although the incidence and severity of adverse reactions vary among drugs and clients. or ability to function. Check blood pressure (recent recordings) before giving antihypertensive drugs. The time may vary by approximately 30 minutes. (continued ) . the nurse should know the expected effects and when they are likely to occur. 1. If noted. right dose. blood urea nitrogen and serum creatinine. People most likely to have adverse reactions are those with severe liver or kidney disease. When both are ordered. a drug ordered for 9 AM can be usually given between 8:30 AM and 9:30 AM. Look for signs and symptoms of new problems or worsening of previous disorders. other uses include assessing a drug in relation to a particular client (eg. All drugs are potentially harmful. Ask questions to determine whether the client is feeling better. b. In general. Antacids decrease absorption of many oral drugs. Follow label instructions regarding mixing or other aspects of giving specific drugs. 3). those who are very young or very old. b. culture and susceptibility reports before giving an antibiotic. Check drug references when indicated. a. those taking several drugs. b. a. c. right client. Prepare medications for administration. b.68 SECTION 1 INTRODUCTION TO DRUG THERAPY NURSING ACTIONS NURSING ACTIONS Monitoring Drug Therapy RATIONALE/EXPLANATION If giving medications to a group of patients. Look for improvement in signs and symptoms. For example. liver function tests) and other diagnostic test reports for abnormal values.

PA: Springhouse Corp. and what information should usually be included? 8. Look for signs and symptoms of new problems or worsening of previous ones. C. 4. (1999). especially with the very young and the very old. and how can they be prevented or minimized? 6. sedatives. it is helpful to build a knowledge base about important interactions with commonly used drugs (eg. the danger of potential drug toxicity is high. Anticipate the questions a client might ask about a drug and rehearse possible answers. Louis: Facts and Comparisons. what are some likely differences between the nursing care needed by a child and an adult? 10. to start drug doses low and increase if necessary. especially low-birth-weight infants. worsening congestive heart failure). excretion is reduced because the liver and kidneys are often immature in the low-birth-weight infant. go slow” and why it is a good approach to drug therapy. The review of natural products. Decreased protein binding may result in higher blood levels of digoxin. a. RATIONALE/EXPLANATION Interactions may occur whenever the client is receiving two or more drugs concurrently and the number of possible interactions is very large. . It is prudent. Ask questions to determine how the client is feeling and whether he or she is having difficulties that may be associated with drug therapy. Describe at least three important nursing considerations for clients who have renal or hepatic impairment or critical illness. How Can You Avoid This Medication Error? Answer: The nurse administered the wrong dose of medication to Jamie. For a client who reports using particular herbal or dietary supplements. what are some potential difficulties with drug administration. A. which should be administered every 8 hours. 9. d. 4. Why is client teaching about drug therapy needed. DerMarderosian. cardiovascular drugs). M. Pharmacotherapy. what information is needed about present and previous medications or herbal and dietary supplements? Boullata. Women’s Health series: Herbs of special interest to women. Although no one can be expected to know or recognize all potential or actual interactions. 234–242. (2000). Consider a possible interaction when a client does not experience expected therapeutic effects or develops adverse effects. Professional’s handbook of complementary & alternative medicines. rather than 100 mg. Journal of the Americal Pharmaceutical Association. causing toxicity. With children. Why do nurses need to know the therapeutic and adverse effects of the drugs they give? 2. what are some potential difficulties with drug administration. Fetrow. including drugs that are well known to you and those that are not. Given a newly assigned client. With older adults. Also. SELECTED REFERENCES Review and Application Exercises 1. especially if your assessment reveals that therapeutic effects have not occurred (eg. 3. L. 7. Observe for drug interactions. Thirty cc would provide the entire daily dose of amoxicillin. explain what is meant by “start low. 20(3). Carefully reread the order and recalculate the dosage ordered. If noted. I. 40(2). For the home care nurse assisting with a medication regimen. M. W. 257–269. Hardy. Springhouse. It is never wrong to discuss your concerns with the physician. (Ed. Assess for decreasing ability to function at previous levels. compare the client’s symptoms with your knowledge base about interactions associated with the drugs or consult a drug reference to validate your observations. and how can they be prevented or minimized? 5.CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 69 NURSING ACTIONS c. Safety issues with herbal medicine. & Avila. b. R. This is especially true for a drug like digoxin that has a narrow therapeutic range. Unit dosing can help double–check calculations and avoid errors. For older adults.) (2001). St. warfarin. A. & Nace. J. J. how can the nurse evaluate whether they are safe or unsafe in view of the client’s condition and drug therapy regimen? Nursing Notes: Apply Your Knowledge Answer: With infants. (2000).

4(2).. E. Kelley’s Textbook of internal medicine. [On-line]. 4th ed. Geriatric clinical pharmacology. Small.. T. A.tyle/sram0402. S. 4(2).. limitations. Creatine use among young athletes.. Murch. 101(2). J. Harris. (2001). Kelley’s Textbook of internal medicine. Waddell. W. In H.. Alternative medicine: Prevalence. L. 108(2). Phytopharmaceuticals: Problems.. Three herbs you should get to know. 48–53. S. Jackson. White paper on herbal products. D. L.). Schwartz. 421—425. In H.. 2001.n02/sram0402. Humes (Ed. Philadelphia: Lippincott Williams & Wilkins. 3095–3107. Available: http://www.02. T. and usefulness. B.. Pediatrics. 36–43.murc/sram0402. J. Multach.. D.). . (2001). Scientific Review of Alternative Medicines.medscape. Metzl. [On-line]. 4th ed. J.tyle. & Saxena. 877–891. F. & Knell. KrishnaRaj. R. 319– v04. E. (2000). D. Philadelphia: Lippincott Williams & Wilkins. A. 101(4). (2000). 17–21. K. pp.. Miller. (2000). American Journal of Nursing. Tyler.. pp.02.html. D. 20(7). A. Hummel. & Sumners. Kanmaz. S.n02/sram0402. J. (2000).. (2001). American Journal of Nursing. M. T. S. cost.01. M. V. (2000). M. 33–37. Cauffield. Pharmacotherapy. & Levine. E. M.. The proverbial prometheus/SRAM/2000/v04. Chin... I. 2001. Product definition deficiencies in clinical studies of herbal medicines. G. E. J. Hume.01. Humes (Ed. Accessed January. Available: http://www.70 SECTION 1 INTRODUCTION TO DRUG THERAPY Hatcher. P.html Accessed January. Scientific Review of Alternative Med- icines.medscape. and solutions.

2 Drugs Affecting the Central Nervous System .

3. Most neurons are composed of a cell 72 body. modify. Neurons must be able to communicate with other neurons and body tissues. An axon is a finger-like projection that carries impulses away from the cell body. the neuron is the basic functional unit. Many axons are covered by a fatty substance called myelin. More specific components of the communication network include neurotransmitters. Discuss signs and symptoms of central nervous system (CNS) depression. Discuss general types and characteristics of CNS depressant drugs. THE STUDENT WILL BE ABLE TO: 1. This communication involves a complex network of electrical and chemical signals that receive. A lack of coordination or imbalances among the components may lead to mental or physical disorders. Neurotransmitters Neurotransmitters are chemical substances that carry messages from one neuron to another. An axon together with its myelin sheath is called a nerve fiber. and components of the CNS have complex interactions with each other. memory) and with muscle function. Nerve fibers involved in the transmission of the same type of impulses (eg. interpret. reasoning. knob-like structures called vesicles. problem solving. Thus. the vasomotor and respiratory centers in the medulla oblongata). They are . or from a neuron to other body tissues. synapses. emotions can strongly influence neural control of body function. A cluster of cell bodies or nuclei with the same function is called a center (eg. The CNS has complex interactions with other parts of the body. and an axon. composed of the brain and spinal cord. both skeletal and smooth. learning. such as cardiac or skeletal muscle. the CNS constantly receives information about blood levels of oxygen and carbon dioxide. a dendrite. It is also concerned with higher intellectual functions (eg. pain signals) are found together in a common pathway or tract. These structures project into the synapse and contain the granules where neurotransmitters are stored. it is the overall coordination of the “mind/body” connections that produces mental and physical health. and receptors (described below). Afferent or sensory neurons carry messages to the CNS. which are then conducted toward the cell body. More specific characteristics are reviewed to aid understanding of drugs that act by altering CNS functions. Describe the process of neurotransmission. The central nervous system (CNS). Although various components of brain function are often studied individually. efferent or motor neurons carry messages away from the CNS. CHARACTERISTICS AND FUNCTIONS OF THE CENTRAL NERVOUS SYSTEM Neurons The CNS is composed mainly of two types of cells: the glia protect. thought. and send messages. called ganglia or nuclei. Describe major neurotransmitters and their roles in nervous system functioning. A dendrite has a branching structure with many synapses or sites for receiving stimuli or messages. and alterations in neural functions can strongly influence mood and behavior. 2. Nerve cell bodies usually occur in groups or clusters. body temperature. acts as the control center for regulating physical and mental body processes. Characteristics that allow neurons to communicate with other cells include excitability (the ability to produce an action potential or be stimulated) and conductivity (the ability to convey electrical impulses). More specifically.chapter 5 Physiology of the Central Nervous System Objectives AFTER STUDYING THIS CHAPTER. support. The end of the axon branches into presynaptic fibers that end with small. and sensory stimuli and sends messages to effector organs to adjust the environment toward homeostasis. 4. and nourish the neuron. The myelin cover or sheath protects and insulates the axon.

5–1). More specifically. which may alter neurotransmitter synthesis. For example. and peptides. release. For most receptors. in which sodium and potassium ions can rapidly conduct an electrical impulse from one neuron to another. Prolonged effects are thought to involve closure of calcium channels. A neurotransmitter– receptor complex may have an excitatory or inhibitory effect on the postsynaptic neuron. when norepinephrine binds with alpha. receptors are constantly being synthesized and degraded. and others. Neurotransmitter molecules (eg. rapidly acting neurotransmitters. Like other protein molecules in the body. and alterations in the numbers of excitatory or inhibitory postsynaptic membrane receptors. In the CNS. One factor is the availability of precursor proteins and enzymes required to synthesize particular neurotransmitters. Neurotransmitter release and removal occur in the synapses. slowly acting neurotransmitters. most receptors are on postsynaptic neurons. They decrease in number and activity (down-regulation) when there is overactivity. all of which are derived from body proteins. it is believed that receptor proteins are constantly being formed by the endoplasmic reticulum–Golgi apparatus and inserted into presynaptic and postsynaptic membranes. . When released from the synaptic vesicles. Substance P plays a role in transmitting pain signals from peripheral tissues to the CNS and the stress response to noxious stimuli. In this case. Several factors affect the availability and function of neurotransmitters. and glycine). norepinephrine and acetylcholine). diffusion into surrounding body fluids. norepinephrine is metabolized by monoamine oxidase and catecholomethyl transferase). Synapses may be electrical. Receptors increase in number and activity (up-regulation) when there is underactivity at the synapse. such as the neuropeptide hormones (eg. Some receptors act rapidly to open ion channels. changes in cellular metabolism. gamma-aminobutyric acid [GABA].or beta-adrenergic receptors. The basis for the action potential is the transient opening of ion channels. molecules of neurotransmitter cross the synapse. The entry of calcium ions is required for neurotransmitter release from storage sites in small sacs called synaptic vesicles. Most prolonged CNS responses are caused by large-molecule. bind to receptors in the cell membrane of the postsynaptic neuron (Fig. Free neurotransmitter molecules (ie.and beta-adrenergic receptors. and drugs. for which specific characteristics and functions have not yet been delineated. amino acids. Another factor is the number and binding capacity of receptors in the cell membranes of presynaptic and postsynaptic nerve endings. The chemical synapse is more commonly used to communicate with other neurons or target cells. norepinephrine. hypoxia. Other important factors include acid–base imbalances (acidosis decreases and alkalosis increases synaptic transmission). or destruction by enzymes (eg. Some peptides (eg. glutamate. A neurotransmitter must bind to receptors to exert an effect on the next neuron in the chain. Most acute CNS responses are caused by small-molecule. intracellular events include activation of the enzyme adenyl cyclase and the production of cyclic adenosine monophosphate (cAMP). and amino acids (aspartate. which causes CNS depression (coma occurs within seconds without oxygen). the cAMP is a second messenger that activates cellular functions and the physiologic responses controlled by the alpha. changes in activation or deactivation of specific genes in the cell nucleus. released by the presynaptic nerve. Storage of neurotransmitters allows them to be available quickly when needed and to avoid degradation by enzymes in the nerve terminal. and excite or inhibit postsynaptic neurons. cross the synapse and bind with receptor proteins in the cell membrane of the postsynaptic nerve. ADH) serve as chemical messengers in both the nervous system and the endocrine system. acetylcholine is degraded by cholinesterase. but some are on presynaptic nerve terminals. the amines (dopamine. Three main types of neurotransmitters are amines. adrenocorticotropic hormone [ACTH or corticotropin] and antidiuretic hormone [ADH]). Synapses Neurons in a chain are separated by a microscopic gap called a synapse or synaptic cleft. If the Presynaptic nerve terminal SYNAPSE Release site Postsynaptic nerve terminal Receptor sites Neurotransmitters Presynaptic nerve cell membrane Postsynaptic nerve cell membrane Figure 5–1 Neurotransmission in the central nervous system. degradation. or binding to receptors to cause either CNS stimulation or depression. Receptors Receptors are proteins embedded in the cell membranes of neurons. or chemical. such as acetylcholine. several subtypes have been identified. others interact with a variety of intracellular proteins to initiate a second messenger system.CHAPTER 5 PHYSIOLOGY OF THE CENTRAL NERVOUS SYSTEM 73 synthesized and stored in presynaptic nerve terminals and released in response to an electrical impulse (action potential) arriving at the end of the first neuron (presynaptic fiber). in which a neurotransmitter conducts the message to the next neuron. serotonin). those not bound to receptors) are rapidly removed from the synapse by three mechanisms: transportation back into the presynaptic nerve terminal (reuptake) for reuse. substance P.

memory. dopamine actions at the cellular level depend on the subtype of receptor to which it binds and the simultaneous effects of other neurotransmitters at the same target neurons. they are thought to inhibit activation of adenyl cyclase and subsequent production of cAMP. a disorder caused by destruction of dopamine-producing neurons in the substantia nigra. GABAB has not been delineated. synaptic fatigue and downgrading or upgrading of receptors work with other control mechanisms of the nervous system to readjust abnormally stimulated or depressed nerve function toward normal. and serotonergic networks. synapses. it is then postulated that many of the receptor proteins are inactivated and removed from the synaptic membrane. motor activity. but it is thought to function in the regulation of ion channels and biochemical pathways. Major neurotransmission systems are the cholinergic.and beta-adrenergic receptors and their subtypes. are divided into alpha. Activation of alpha2 receptors is associated with inhibition of adenyl cyclase activity and decreased production of cAMP. . and is a precursor substance in the synthesis of norepinephrine and epinephrine. beta1. regulation of arousal. suppress calcium ion currents. with high concentrations in the substantia nigra and basal ganglia. the effect is similar to that of a negative feedback system that inhibits the release of norepinephrine. In the CNS. Norepinephrine receptors in the CNS. and D4 receptors. alpha2 receptors on the presynaptic nerve ending are believed to regulate norepinephrine release. is located in many areas of the brain. Activation of alpha1. as in the sympathetic nervous system. The dopaminergic system uses dopamine as its neurotransmitter. In the CNS. Repeated stimulation of dopamine receptors decreases their numbers (down-regulation) and their sensitivity to dopamine (desensitization). when high levels of extracellular norepinephrine act on presynaptic alpha2 receptors. Although neurotransmitters. It is the major inhibitory neurotransmitter in the CNS. the noradrenergic system is associated with mood. Acetylcholine exerts excitatory effects at synapses and nerve–muscle junctions and inhibitory effects at some peripheral sites. Overall. There is evidence of multiple subtypes of GABA receptors and important functional differences among them. It is thought to play an important role in producing rapid-eyemovement (REM) sleep. in renal and mesenteric blood vessels. These effects on ion channels may increase membrane resistance to stimuli and inhibit the firing of CNS neurons. the midbrain. For example. GABA-ergic. Norepinephrine is mainly an excitatory neurotransmitter that stimulates the brain to generalized increased activity. The noradrenergic system uses norepinephrine as its neurotransmitter and extends to virtually every area of the brain. 9) and Parkinson’s disease. and receptors are discussed separately here. GABA is synthesized in the brain (cerebellum. Dopamine is derived from tyrosine. an amino acid. Acetylcholine. and beta2 receptors is thought to stimulate activity of intracellular adenyl cyclase and the production of cAMP. A and B. GABA receptors have been divided into two main types. The GABAA receptor is a chloride ion channel that opens when GABA is released from presynaptic neurons. When released. In other words. and cerebral cortex) and spinal cord in abundant amounts. numerous neurotransmitters and subtypes of receptors have been identified and characterized. it is inhibitory in a few areas because of inhibitory receptors at some nerve synapses. D2 receptors have been described most thoroughly. acetylcholine is associated with level of arousal. and reward. In addition. One group includes D1 and D5 receptors. and the hypothalamus. Much of the information about dopamine is derived from studies of antipsychotic drugs (see Chap. Neurotransmission Systems Neurons function through communication networks that may be called neurotransmission systems. D3 and D4 receptor functions have not been delineated. and speech.74 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM synapses are overused and excessive amounts of neurotransmitter combine with receptor proteins. The other group includes D2. which activate adenyl cyclase to produce cAMP. dopamine stimulates these receptors and a negative feedback system is initiated that inhibits further dopamine synthesis and release. Prolonged blockade of dopamine receptors increases their numbers and sensitivity to dopamine. The GABA-ergic system uses GABA as its neurotransmitter. norepinephrine is a catecholamine synthesized from tyrosine. Dopamine also occurs outside the brain. with a role in many neuronal circuits (estimated at nearly one third of CNS synapses). D3. the effects of norepinephrine–alpha2 receptor coupling are thought to stem mainly from activation of receptor-operated potassium ion channels and suppression of voltage-operated calcium ion channels. including the reticular formation. Overall. synapses. during which dreaming occurs. Thus. However. dopamine is thought to be inhibitory in the basal ganglia but may be excitatory in other areas. with especially high concentrations in the motor cortex and basal ganglia. and receptors. dopaminergic. It is found in relatively large amounts in the hypothalamus and the limbic system and in smaller amounts in most areas of the brain. the first substance to be designated as a neurotransmitter in the CNS. Some receptors (called autoreceptors) occur on the presynaptic nerve terminal. It is also a neurotransmitter in the autonomic nervous system and at peripheral neuromuscular junctions. a great deal of knowledge has been gained. basal ganglia. Two groups of dopamine receptors have been identified. The cholinergic system uses acetylcholine as its neurotransmitter. motor conditioning. Dopamine makes up more than half the catecholamine content in the brain and is found in the substantia nigra. it is the interaction among these elements that promotes order or disorder in the body’s physical and mental processes. and activate potassium ion currents. such as organs supplied by the vagus nerve. However. noradrenergic. Like dopamine. the major elements of which are neurotransmitters. They are differentiated by the intracellular events that follow dopamine–receptor binding. Although many details of neuronal function remain elusive.

the resulting dysregulation and imbalances lead to signs and symptoms of CNS disorders. Glycine receptors have many of the features described for GABAA receptors. A summary of their characteristics follows. glutamate has been implicated in the pathogenesis of epilepsy. stroke. norepinephrine. Glutamate is considered the most important excitatory neurotransmitter in the CNS. and spinal cord. Neurotransmission Systems in Selected Central Nervous System Disorders Abnormalities in neurotransmission systems (eg. Aspartate is an excitatory neurotransmitter found in high concentrations in the brain. including inhibition of pain pathways in the spinal cord. then. including some drugs of abuse. the sleep–wake cycle. CNS function in both health and disease is probably determined by interactions among neurotransmission systems. However. neurotransmission systems function interdependently. CNS serotonin is usually an inhibitory neurotransmitter and is associated with mood. such as severe anxiety or psychosis. Serotonin receptors are found in regions of the CNS that are associated with mood and anxiety and are also thought to be involved in temperature regulation. energy. hypothalamus. complex mechanisms regulate the amounts and binding capacities of neurotransmitters and receptors. Although some glutamate is apparently necessary for normal neurotransmission. the pathogenesis of excessive CNS stimulation may involve one or more of the following mechanisms: 1. It plays a major role in the blood coagulation process. Many psychiatric disorders. and drugs of abuse may cause varying degrees of CNS stimulation. including the cerebral cortex. altered receptor response to neurotransmitters) are implicated in many CNS disorders. Several subtypes of serotonin receptors have been identified. limbic structures. Such hyperactivity reflects a wide range of observable behaviors and nonobservable thoughts and feelings. Serotonin is also found outside the CNS. each with a unique distribution in the CNS. manifestations include unpleasant feelings of tension. habituation. glutamate) 2. It may also be involved in the vascular spasm associated with some pulmonary allergic reactions (during which it is released from mast cells) and migraine headaches. as well as the balance between excitatory and inhibitory forces. Several subtypes of glutamate receptors have been identified. beginning in the midbrain and projecting into the thalamus. where increased release and impaired reuptake of glutamate lead to excessive stimulation of glutamate receptors and subsequent cell death. cerebral cortex. Insufficient amounts of inhibitory neurotransmitters (eg. Except for mental depression. Excessive amounts of excitatory neurotransmitters (eg. psychomotor agitation. even when very tired. The functions of these receptor subtypes have not been established. Serotonin-synthesizing neurons are widely distributed in the CNS. and sensory perceptions. and hippocampus. Serotonin is thought to produce sleep by inhibiting CNS activity and arousal. for example. but research suggests that the N-methyl D-aspartate (NMDA) glutamate receptor subtype plays a role in memory. subtypes have been identified but their functions are unknown. the amount of tryptophan intake in the diet and the enzyme tryptophan hydroxylase control the rate of serotonin production. In people with psychiatric illnesses. Amino acids were recognized as neurotransmitters relatively recently. GABA abnormalities occur in anxiety. manifestations may include pleasant feelings of mild euphoria and high levels of enthusiasm. In most people. This process may be similar to the neurotoxicity as- sociated with brain injury (eg. Aspartate and glutamate are considered the major fast-acting.CHAPTER 5 PHYSIOLOGY OF THE CENTRAL NERVOUS SYSTEM 75 The serotonergic system uses serotonin (also called 5-hydroxytryptamine or 5-HT) as its neurotransmitter. most psychiatric symptoms result from CNS stimulation and usually involve physical and mental hyperactivity. GABA) 4. which are implicated in neuronal cell death associated with some neurodegenerative diseases and toxic chemicals. In health. decreased acetylcholine is a characteristic of Alzheimer’s disease. Overall. and seizure disorders. or hypoxia). Because serotonin is synthesized from the amino acid tryptophan. For example. Glycine is an inhibitory neurotransmitter found in the brain stem and spinal cord. and their roles and functions in this regard have not been completely elucidated. and decreased ability to rest and sleep. during which it is released from platelets and causes vasoconstriction. mainly in mast cells of the lungs and platelets. dysfunction or destruction of the neurons that normally produce neurotransmitters. Events leading to neuronal death are triggered by excessive activation of NMDA receptors and movement of calcium ions into the neurons. dopamine abnormalities occur in psychosis and Parkinson’s disease. Altered glutamate metabolism may also lead to the formation of free radicals. It occurs in high concentrations in virtually every area of the CNS. basal ganglia. schizophrenia. therapeutic drugs. hyperarousal states. and productivity. excitatory neurotransmitters in the brain. from ischemia. some of which are linked to inhibition of adenyl cyclase activity or to regulation of potassium or calcium ion channels. Decreased numbers or sensitivity of inhibitory receptors . In general. nervousness. one system may increase. brief exposure of neurons to high concentrations can lead to neuronal cell death. or otherwise modify the effects of another system. The amino acid system includes several amino acids that may serve as both structural components for protein synthesis and neurotransmitters. Although most research has focused on single neurotransmitters and their respective receptors. When abnormalities occur in any of these elements. decrease. peripheral serotonin cannot cross the blood–brain barrier. and serotonin abnormalities are thought to be involved in mental depression and sleep disorders. and Huntington’s disease. Activation of some receptors leads to hyperpolarization and neuronal inhibition. Increased numbers or sensitivity of excitatory receptors 3. hypoglycemia.

Hypothalamus The hypothalamus has extensive neurologic and endocrine functions. Oxytocin initiates uterine contractions to begin labor and delivery and helps to release milk from breast glands during breastfeeding. it is the center for motor control. if the respiratory center is stimulated. For example. body temperature. ACTH. It receives impulses from all parts of the body. Thalamus The thalamus receives impulses carrying sensations such as heat. including thyroid-stimulating hormone. Reticular Activating System The reticular activating system is a network of neurons that extends from the spinal cord through the medulla and pons to the thalamus and hypothalamus. In the CNS. intensity. another anterior pituitary hormone. water. and limbic system. reticular activating system. In the autonomic nervous system. It is anatomically connected to the posterior pituitary gland. verbalization. it may involve stimulation of motor centers to produce movement or speech. The vasomotor center in the medulla oblongata and pons maintains a state of partial contraction in blood vessels (vasomotor tone). and blood pressure is raised. The hypothalamic factor called prolactin-inhibiting factor inhibits secretion of prolactin. 4. such as learning. which occupy the greater portion of the cortex. the response may be to store the perception in memory. molarity is low. hormone levels. If the respiratory center is depressed. where they are interpreted regarding location. with the overall effect of relative vasodilation and lowering of arterial blood pressure. The hypothalamus. ADH helps maintain fluid balance by controlling water excretion. in others. Around the sensory and motor areas are the “association” areas. They are relayed to the cerebral cortex. spinal cord. respiratory rate and depth are decreased. 3. Regulating food and water intake by the hypothalamic thirst. and more water is excreted in the urine. The thalamus also relays motor impulses from the cortex to the spinal cord. When osmolarity is high. and it regulates the activity of the anterior pituitary.” which cause the anterior pituitary to secrete these hormones. These areas analyze the information received by the sensory areas and decide on the appropriate response. evaluates the significance of the impulses. Medulla Oblongata The medulla oblongata contains groups of neurons that form the vital cardiac. these structures form the brain stem. sweating and dilation of blood vessels in the skin lower the temperature. depending on which portions of the hypothalamus are stimulated. and satiety centers. It constantly collects information about the internal environment of the body and helps maintain homeostasis by making continuous adjustments in water balance. sweating ceases and vasoconstriction occurs. gastrointestinal motility. The medulla and pons varolii also contain groups of neurons from which originate cranial nerves 5 through 12. The hypothalamus secretes “releasing factors. arterial blood pressure. and growth hormone. This means that water is retained in the body to dilute the extracellular fluid and return it toward normal or homeostatic levels. Some parts of the cortex receive incoming nerve impulses and are called sensory areas. When the impulses from the hypothalamus inhibit the vasomotor center. and hormones in the blood. less ADH is secreted. respiratory rate and depth are increased. and voluntary body movements. In the endocrine system. Regulating body temperature. sneezing. cold. In some instances. Producing oxytocin and ADH. electrolytes. quality.76 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Cerebral Cortex The cerebral cortex is involved in all conscious processes. 2. other parts send impulses to peripheral structures and are called motor areas. medulla oblongata. ADH secretion is controlled by the osmolarity of the extracellular fluid. swallowing. and vasomotor centers. increased blood pressure and heart rate). pain. which are stored in the posterior pituitary gland and released in response to nerve impulses from the hypothalamus. and salivating. it is connected with the thalamus. hunger. When heat loss is decreased. The medulla also contains reflex centers for coughing. These sensations produce only a crude awareness at the thalamic level. When nerve impulses from the hypothalamus excite the vasomotor center. the temperature is raised. reasoning. vasomotor tone or vasoconstriction is decreased. respiratory. 6. appetite. Together with the midbrain. vomiting. Assisting in regulation of arterial blood pressure by its effects on the vasomotor center. vasomotor tone or vasoconstriction is increased. . The hypothalamus can exert excitatory or inhibitory effects on the vasomotor center. Regulating the physical changes associated with emotions (eg. Regulating anterior pituitary hormones. more ADH is secreted. and other body functions. the hypothalamus controls the secretion of all pituitary hormones. When body temperature is elevated. and muscle position sense. When body temperature is low. The hypothalamus is stimulated or inhibited by nerve impulses from different portions of the nervous system and by concentrations of nutrients. thalamus. and significance. and cerebral cortex interact to produce the feelings associated with emotions. memory. When os5. heart rate. There is a hypothalamic releasing factor for each hormone. Specific neuroendocrine functions include: 1.

weakness. purposeful movements. crying). Impulses are then carried from the spinal cord to skeletal muscle. physiologic changes in blood pressure. Limbic System The limbic system borders and interconnects with the thalamus. Reflexes are involuntary responses to certain nerve impulses received by the spinal cord (eg. glucose. along sensory and motor nerve fibers. It also helps to maintain balance and posture by receiving nerve impulses from the inner ear that produce appropriate reflex responses. sometimes called centrally active drugs. and behavior (eg. some are contracted and some are relaxed for smooth. which is characterized by rigidity and increased muscle tone. cause dopamine to be released in decreased amounts. and is a center for reflex actions. the brain must have an adequate and continuous supply of oxygen. thus. and septum. are broadly classified as depressants or stimulants. The brain requires more oxygen than any other organ. the knee-jerk and pupillary reflexes). impulses from the right side of the cerebral cortex control skeletal muscle movements of the left side of the body. This process is a factor in the development of Parkinson’s disease. and permanent damage to the cerebral cortex. Degenerative changes in one of these areas. Glucose is required as an energy source for brain cell metabolism. sedative-hypnotics) produce a general depression of the CNS when given in sufficient dosages. emotions (eg. and impulses from the left control muscle movements of the right side. coordinates muscular activity. disease processes affecting higher levels of the CNS involve both tracts. amygdala. opioid analgesics. Many nerve impulses from the limbic system are transmitted through the hypothalamus. People in whom hypoxia is relatively prolonged may survive. hippocampus. Degeneration in peripheral nerves leads to polyneuritis and muscle atrophy. and thiamine. and paralysis.CHAPTER 5 PHYSIOLOGY OF THE CENTRAL NERVOUS SYSTEM 77 and decides which impulses to transmit to the cerebral cortex. Thiamine is required for production and use of glucose. CNS depressant drugs (eg. loss of consciousness. although they may have irreversible brain damage. Cerebellum The cerebellum. Such degeneration in central neurons leads to a form of encephalopathy known as Wernicke-Korsakoff syndrome. where they end at various levels. Cerebral cortex cells are very sensitive to lack of oxygen (hypoxia). As depression progresses. It carries impulses to and from the brain. decreased . Pyramidal and Extrapyramidal Systems The pyramidal and extrapyramidal systems are pathways out of the cerebral cortex. the sleep–wake cycle. antipsychotics. respiration. sadness). go down the brain stem to the medulla. In the extrapyramidal system. Stimulation of these neurons produces wakefulness and mental alertness. where the fibers cross. depression causes sedation and loss of consciousness. anger. Hypoglycemia (low blood sugar) may cause mental confusion. Thiamine deficiency can reduce glucose use by approximately half and can cause degeneration of the myelin sheaths of nerve cells. The fibers are called extrapyramidal because they do not enter the medullary pyramids and cross over. It participates in regulation of feeding behavior. It also excites or inhibits motor nerves that control both reflex and voluntary movement. and hormone secretion occur in response to the emotions. Normal function is influenced by dopamine. dizziness. laughing. Brain stem cells are less sensitive to hypoxia. Oxygen is carried to the brain by the carotid and vertebral arteries. When several skeletal muscles are involved. there is drowsiness or sleep. fear. the substantia nigra. and continue down the spinal cord. which is connected with motor centers in the cerebral cortex and basal ganglia. pleasure. glia and brain stem. nerve fibers originate in the cerebral cortex. and interruption of blood supply causes immediate loss of consciousness. convulsions. Basal Ganglia The basal ganglia are concerned with skeletal muscle tone and orderly activity. Pyramidal and extrapyramidal systems intermingle in the spinal cord. a neurotransmitter produced in several areas of the brain. The cord is a pathway between the brain and the peripheral nervous system. Spinal Cord The spinal cord is continuous with the medulla oblongata and extends down through the vertebral column to the sacral area. heart rate. Brain Metabolism To function correctly. basal ganglia. Mild CNS depression is characterized by lack of interest in surroundings and inability to focus on a topic (short attention span). It consists of 31 segments. hypothalamus. Because the fibers cross in the medulla. each of which is the point of origin for a pair of spinal nerves. fibers originate mainly in the premotor area of the cerebral cortex and travel to the basal gan- DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs affecting the CNS. In the pyramidal or corticospinal tract. aggression.

and death. and death. norepinephrine. Severe CNS depression produces unconsciousness or coma. excessive talking. Central nervous system stimulants produce a variety of effects. mental alertness. Where are neurotransmitters synthesized and stored? 2. Excessive stimulation can cause convulsive seizures. how are the remaining molecules inactivated? 4. How would you expect a person with excessive CNS stimulation to look and behave? SELECTED REFERENCES Review and Application Exercises 1. Textbook of therapeutics: Drug and disease management. & Gourley. How would you expect a person with CNS depression to look and behave? 8. heat. Increasing stimulation produces hyperactivity. decreased ability to move. Herfindal. respiratory failure. dopamine. E. 7th ed. T. . (Eds. harmful CNS stimulation by these drugs. and cold. Once a neurotransmitter is released and acts on receptors. CNS stimulants are less useful for therapeutic purposes than are CNS depressants. J. 10th ed. Because it is difficult to avoid excessive. Textbook of medical physiology. and learning? 6. R. E. Philadelphia: Lippincott Williams & Wilkins. (2000). Saunders. loss of reflexes. and insomnia. & Hall. D. GABA. What part of the brain is concerned mainly with thoughts. B.) (2000). 3. Mild stimulation is characterized by wakefulness. C. reasoning. What events occur at the synapse between two neurons? Guyton. What part of the brain contains vital respiratory and cardiovascular centers? 7. Philadelphia: W. and decreased perception of sensations such as pain. cardiac dysrhythmias. and decreased fatigue. What are the main functions of acetylcholine.78 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM muscle tone. nervousness. A. and serotonin? 5.

ask how postoperative pain will be handled. Tylenol No. if anticipating surgery. and because analgesics may mask pain for which medical attention is needed. use the least amount of the mildest drug that is likely to be effective in a particular situation. . most opioids may be taken as needed. Percocet. and shortens the duration of action. whether taken alone or in a combination product.CLIENT TEACHING GUIDELINES Opioid (Narcotic) Analgesics General Considerations ✔ Use nonpharmacologic treatments of pain (eg. including drug dependence. alcohol abusers). Oxycontin). The maximum recommended daily dose. ✔ Stay in bed at least 30–60 minutes after receiving an opioid analgesic by injection. Vicodin. Combining drugs with similar effects may lead to excessive sedation. Self-administration ✔ Take oral narcotics with 6–8 oz of water. Lortab. unsteady gait. sleeping pills) while taking opioid analgesics. is 4000 milligrams (eg. cook. even coma. Crushing or chewing causes immediate release of the drug. Injected drugs may cause dizziness. ask a health care provider. drowsiness. If desired effects are not achieved. a narcotic may be alternated with a non-narcotic analgesic or a combination product containing a narcotic and nonnarcotic may be effective. Metamucil daily or a mild laxative every other day may be needed. and falls when walking around. with or after food to reduce nausea. These are safety measures to prevent falls or other injuries because these analgesics may cause drowsiness. around the clock. ask someone for assistance. severe nausea. over several hours. 8 tablets or capsules containing 500 mg each or 12 tablets containing 325 mg each). It is better to take adequate medication and be able to cough. heat and cold applications) instead of or along with analgesics. or operate machinery when drowsy or dizzy or when vision is blurred from medication. and being as active as tolerated. report to the physician. ✔ Most combination products (eg. excessive drowsiness. the drugs should be taken on a regular schedule. such as whole-grain cereals. and difficulty in breathing. weakness. drinking 2–3 quarts of fluid daily. The tablets are formulated to release the active drug slowly. ✔ For pain that is not relieved by nondrug treatments. It may be prevented or managed by eating highfiber foods. ✔ For pain that is not relieved by a non-narcotic analgesic. ✔ Constipation is a common adverse effect of opioid analgesics. ✔ When a choice of analgesics is available. some antihistamines. ✔ Omit one or more doses if severe adverse effects occur (eg. Lorcet. MS Contin. ✔ Take only as prescribed. 3) contain acetaminophen and there is a risk of liver failure from high doses of acetaminophen or from lower doses in people who already have liver damage (eg. sedative-type drugs for nervousness or anxiety. with a high risk of overdose and adverse effects. If unsure whether a combination product contains acetaminophen. and ambulate than to avoid or minimize pain medication and be unable to perform activities that promote recovery and healing. ✔ For acute episodes of pain. If it is necessary to get out of bed. Although these principles apply to all medications. Do not object to having bedrails up and asking for assistance to ambulate when receiving a strong narcotic analgesic. ask the physician or nurse about potential methods of pain management. exercise. and so on. Use of a narcotic analgesic for acute pain is acceptable and unlikely to lead to addiction. for chronic pain. Do not increase the dose and do not take medication more often than prescribed. deep breathe. they are especially important with opioid analgesics because of potentially serious adverse reactions. For someone unable to take these preventive measures. ✔ Do not smoke. drive a car. a nonnarcotic analgesic (eg. For example. fruits. ✔ When hospitalized. how you need to report pain and request pain medication. or constipation) and report to a health care provider. and blurred vision. vomiting. and vegetables. ✔ Do not crush or chew long-acting tablets (eg. ✔ Do not drink alcohol or take other drugs that cause drowsiness (eg. acetaminopen or ibuprofen) may be taken. when effective. difficulty in breathing.

Differentiate among antiplatelet. Prostaglandins are chemical mediators found in most body tissues. and principles of therapy. They are formed when cellular injury occurs and phospholipids in cell membranes release arachidonic acid.chapter 7 Analgesic–Antipyretic– Anti-inflammatory and Related Drugs Objectives AFTER STUDYING THIS CHAPTER. indications for use. NSAIDs. and acetaminophen in terms of indications for use and adverse effects. 6. 2. fever. Discuss the role of prostaglandins in the etiology of pain. 5. OVERVIEW The analgesic–antipyretic–anti-inflammatory drug group includes chemically and pharmacologically diverse drugs that share the ability to relieve pain. Drugs discussed in this chapter include aspirin (acetylsalicylic acid or ASA). Prostaglandins exert various and opposing effects in different body tissues (Table 7–1). and drugs used to prevent or treat gout and migraine. because they inhibit the synthesis of prostaglandins. fever. 8. His parents have recently come to this country from Mexico and speak very little English. aspirin-related drugs that are often called nonsteroidal anti-inflammatory drugs (NSAIDs. triptans. analgesic. which act briefly in the area where they are produced and are then inactivated. THE STUDENT WILL BE ABLE TO: 1. Teach clients interventions to prevent or decrease adverse effects of aspirin. nursing process. and acetaminophen can also be called antiprostaglandin drugs. Reflect on: ᮣ Why is Tylenol overdose potentially so serious for this young child? ᮣ What would emergency and follow-up treatment for Tylenol overdose be? ᮣ How has this child’s developmental stage increased the likelihood for accidental poisoning? ᮣ Develop a teaching plan for this family to prevent recurrence. eg. Differentiate between traditional NSAIDs and cyclooxygenase-2 inhibitors. Discuss recognition and management of acetaminophen toxicity. symptoms associated with many injuries and illnesses. acetaminophen. Compare and contrast aspirin. contraindications to use. and acetaminophen. and/or inflammation. and acetaminophen in special populations. Identify factors influencing the use of aspirin. Aspirin. 99 . Discuss aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) in terms of mechanism of action. they help regulate many cell functions and participate in the inflammatory response. The child does not appear acutely ill and the parents become very upset when the physician wants to admit the child. 4. and inflammation. ibuprofen). Arachidonic acid is then metabolized by cyclooxygenase enzymes to produce prostaglandins. other NSAIDs. Discuss the use of NSAIDs and antigout drugs. Critical Thinking Scenario You are working in an emergency room when parents bring in their 2-year-old son who has just ingested half a bottle of acetaminophen (Tylenol). NSAIDs. 10. 7. other NSAIDs. and anti-inflammatory doses of aspirin. 3. and ergot antimigraine drugs. 9. Discuss the use of NSAIDs. the prototype.

or diseases involving the hypothalamus. vascular smooth muscle To aid understanding of prostaglandins.100 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM TABLE 7–1 Prostaglandin D2 E2 Prostaglandins Locations Airways. It is an attempt by the body to remove the damaging agent and repair the damaged tissue. COX-1 is normally synthesized continuously and present in all tissues and cell types. 7–1). brain injury. and prostaglandins. more blood flows through the skin. Redness and heat result from vasodilation and increased blood supply. fever. vasoconstriction and vasodilation) and platelet function. and weakness. fever. especially platelets. anti-inflammatory drugs are needed when the inflammatory response is inappropriate. it is thought to occur in small amounts or to be in- . When there is excessive heat production. and pain. chemicals released by the damaged cells. pressure. brain. platelets Thromboxane A2 Kidneys. NSAIDs. Inflammation is the normal body response to tissue damage from any source and it may occur in any tissue or organ. infectious processes. fever. kidneys. along with bacterial toxins and other substances. edema. In the stomach. increase mucus secretion. inflammation may be acute or chronic. Because inflammation may be a component of virtually any illness. have been identified. bone. Normally. sweating occurs. Two forms of cyclooxygenase. their roles in pain. and for which the drugs discussed in this chapter are used. It is a common human ailment and may occur with tissue injury and inflammation. and the kidneys. Aspirin and traditional NSAIDs inhibit both COX-1 and COX-2 enzymes. Drug-induced inhibition of these prostaglandins results in the adverse effects associated with aspirin and related drugs. and the female reproductive system). and inflammation. endothelial cells. especially gastric irritation. In the kidneys. the heat-regulating center in the hypothalamus is reset so that it tolerates a higher body temperature. endothelium. hurt. Common conditions that are characterized by pain. prostaglandins act as pyrogens (fever-producing agents). Local manifestations are redness. heat. menstrual cramps) Decreased platelet aggregation Gastroprotection Vasodilation Increased platelet aggregation Vasoconstriction F2 Airways. vascular smooth muscle I2 (Prostacyclin) Brain. In the cardiovascular system. eyes. COX-2 is also normally present in several tissues (eg. macrophages. and acetaminophen inactivate cyclooxygenases. Inhibition of COX-1 activity in platelets may be more responsible for GI bleeding than inhibition in gastric mucosa. these prostaglandins help to maintain adequate blood flow and function. GI tract. Systemic manifestations include leukocytosis. and body temperature usually stays within normal range. they decrease gastric acid secretion. Both local and systemic manifestations vary according to the cause and extent of tissue damage. AND INFLAMMATION Pain is the sensation of discomfort. the gastrointestinal (GI) tract. Prostaglandin formation is stimulated by such circumstances and. PAIN. called COX-1 and COX-2. Prostaglandins sensitize pain receptors and increase the pain associated with other chemical mediators such as bradykinin and histamine (Box 7–1). mast cells Brain. Body temperature is controlled by a regulating center in the hypothalamus. blood vessels dilate. kidneys. inflammation. the enzymes required for prostaglandin formation (Fig. or distress. and regulate blood circulation. or destroys tissue. mechanisms to increase heat loss are activated. Fever may be produced by dehydration. abnormal. When fever occurs. and inflammation are described in the following section. headache. loss of appetite. increased erythrocyte sedimentation rate. ulceration. kidneys. brain. there is a balance between heat production and heat loss so that a constant body temperature is maintained. platelets Effects • • • • • • • • • • • • • • • Bronchoconstriction Bronchodilation Gastroprotection Increased activity of GI smooth muscle Increased sensitivity to pain Increased body temperature Vasodilation Bronchoconstriction Increased activity of GI smooth muscle Increased uterine contraction (eg. and pain occurs when pain receptors on nerve endings are stimulated by heat. uterus. Fever is an elevation of body temperature above the normal range. Prostaglandins produced by COX-1 are important in numerous homeostatic functions and are associated with protective effects on the stomach and kidneys. or persistent. As a result. the prostaglandins help regulate vascular tone (ie. edema results from leakage of blood plasma into the area. and bleeding. some drugs. platelets. MECHANISM OF ACTION Aspirin. However. edema. vascular smooth muscle cells. lethargy or malaise. In addition. are described in Box 7–2. FEVER.

complement destroys cell membranes of body cells (eg. Interferons are . and basophils. bronchial. Thus. release histamine into the vascular system in response to stimuli (eg. heat. Platelet-activating factor (PAF). red blood cells. viruses). H1 receptors are located mainly on smooth muscle cells in blood vessels and the respiratory and GI tracts. More specifically. such as viruses and rickettsiae. degranulation of mast cells and basophils. The system is initiated by an antigen–antibody reaction or by tissue injury. Bradykinin is a kinin in body fluids that becomes physiologically active with tissue injury. resulting events include contraction of smooth muscle. When histamine binds to these receptors. IL-1. GI tract. which are abundant in skin and connective tissue. and dilation of capillaries in the skin. The peak effects of histamine occur within 1 to 2 minutes of its release and may last as long as 10 minutes. Histamine is the first chemical mediator released in the inflammatory response and immediate hypersensitivity reactions (anaphylaxis). including fever. white blood cells (WBCs) increase in the area and ingest damaged cells to remove them from the area. thereby inducing formation of leukotrienes and other substances that increase vascular permeability and chemotaxis. and secretion of lysosomal enzymes by leukocytes. PAF effects can occur in virtually every organ and tissue. Besides causing platelet aggregation. tissue injury. and opsonization (coating a microbe or other antigen so it can be more readily phagocytized). or on distant cells if sufficient amounts reach the bloodstream. on surrounding cells. increased mucus secretion and bronchodilation in the airways. It enables the body to produce inflammation and localize an infective agent. causing vasodilation (increasing blood flow to the area and producing hypotension) and increasing permeability of capillaries and venules (producing edema). When tissue cells are damaged. C3a and C5a. especially those in which the antigen is a microbial agent. act mainly by liberating histamine from mast cells and platelets. stimulating salivary. production of nasal mucus. and degranulation of basophils (with additional release of histamine and other mediators) in the bloodstream. bradykinin may aggravate and prolong the erythema. cytokines act locally and systemically to produce inflammatory and immune responses. contraction of esophageal muscles. Activation yields products with profound inflammatory effects. Mast cells. When histamine is released from mast cells and basophils. In addition. also called anaphylatoxins. Interleukin-1 (IL-1) mediates several inflammatory responses. increases vascular permeability. H2 receptors are also located in the airways. vasodilation. stimulation of sensory nerves. causes vasodilation. Complement is a group of plasma proteins essential to normal inflammatory and immunologic processes. vascular permeability. and pain of local inflammatory reactions. bacteria. chemotaxis. antigen–antibody reaction. including increased vascular permeability and chemotaxis of macrophages. stimulating sensory nerve endings to cause pain and itching. is derived from arachidonic acid metabolism and has multiple inflammatory activities. platelets) and pathogenic microorganisms (eg. after which it is inactivated by histaminase (produced by eosinophils) or N-methyltransferase. Two major types of cytokines are interleukins (produced by leukocytes) and interferons (produced by T lymphocytes or fibroblasts). both types of receptors mediate hypotension (in anaphylaxis). The activated kinins increase and prolong the vasodilation and increased vascular permeability caused by histamine. More specific reactions include increased vascular permeability. the complement system breaks down antigen–antibody complexes. Cytokines may act on the cells that produce them. tachycardia. PAF activates neutrophils. C5a performs the same functions as C3a and also promotes movement of WBCs into the injured area (chemotaxis). there is increased secretion of gastric acid by parietal cells in the stomach mucosal lining. Histamine is formed (from the amino acid histidine) and stored in most body tissue. monocytes. Because these cells are widely distributed. and headache. It is produced by mast cells. They also cause pain by stimulating nerve endings for pain in the area. increased vascular permeability. PAF. and platelets. When the WBCs die. like prostaglandins and leukotrienes. and IL-2 (also called T-cell growth factor) is required for the growth and function of T lymphocytes. gastrointestinal (GI) tract. In allergic reactions. and intestinal secretions. and causes IL-1 and tumor necrosis factor–alpha (TNF-alpha) to be released. and other tissues. basophils. and TNF-alpha can induce each other’s release. gastric. Once released. lymphocytes. with high concentrations in mast cells. neutrophils. It also increases mucous gland secretion. In the immune response. C3a causes or increases smooth muscle contraction. When histamine binds with these receptors. and platelets. inhibition of lymphocyte function. it activates the lipoxygenase pathway of arachidonic acid metabolism in neutrophils and macrophages. and uterus. and some drugs). neutrophils. it diffuses rapidly into other tissues. Thus. and their effects are therefore similar to those of histamine.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 101 BOX 7–1 CHEMICAL MEDIATORS OF INFLAMMATION AND IMMUNITY cytokines that protect nearby cells from invasion by intracellular microorganisms. and stimulating movement of eosinophils into injured tissue. they release enzymes that activate kinins. Components of the system (called C1 through C9) are activated in a cascade type of reaction in which each component becomes a proteolytic enzyme that splits the next component in the series. histamine is highly vasoactive. Other effects include contracting smooth muscles in the bronchi (producing bronchoconstriction and respiratory distress). skin flushing. It then acts on target tissues through both histamine-1 (H1) and histamine-2 (H2) receptors. They also limit the growth of some cancer cells. pruritus. attracts eosinophils.

tissues around these joints. and disruptive of usual activities of daily living. prostaglandins produced by COX-2 are associated with pain and other signs of inflammation.” “housemaid’s knee. dental extraction. serotonin. As joint cartilage deteriorates over time. inflammatory disorder that affects hingelike joints. and friction and abrasion lead to inflammation of the synovial membrane lining of the joint. tendinitis. the fluid reduces friction between tendons and bones or ligaments). then binds irreversibly to platelet COX-1. COX-2 is also induced by trauma and Helicobacter pylori infection. aged cheeses). often in the feet. thought to be caused by prostaglandins that increase contractility of the uterine muscle. aspirin and other NSAIDs differ in their approved uses. Juvenile rheumatoid arthritis is a chronic. including alcohol (especially red wine). and progressive loss of mobility. AND ACETAMINOPHEN ARE COMMONLY USED Bursitis—inflammation of a bursa (a cavity in connective tissue that contains synovial fluid. active until stimulated by pain and inflammation. minor surgery (eg. This action prevents synthesis of thromboxane A2. a common cause of peptic ulcer disease. the acetyl portion dissociates. there is less padding and lubricating fluid. prostaglandins) in the brain. A small single dose (325 mg) irreversibly acetylates circulating platelets within a few minutes. Common forms include acute painful shoulder. they do not cure the underlying disorders that cause the symptoms. largely because of adverse effects on the gastrointestinal . painful. urate deposits may form renal calculi or cause other damage. but one theory is that certain circumstances cause an imbalance of chemicals (eg. chocolate. edema. This imbalance results in vasodilation. and thereby inhibits platelet aggregation. more susceptible to injury. Migraine—a type of headache characterized by periodic attacks of pain. minor trauma (eg. To relieve pain. a prostaglandin derivative. antihypertensives. throbbing or pulsating in nature. “tennis elbow. interfere with blood coagulation. Gout—a disorder characterized by an inability to metabolize uric acid. headache. and effects last for the lifespan of the platelets (7 to 10 days). and other acute and chronic conditions. edema. Osteoarthritis (OA)—a disease that affects the cartilage of weight-bearing joints and produces pain. OTHER NSAIDs. The joint becomes unstable. athletic injuries such as sprains). systemic disease that may cause joint or connective tissue damage and visceral lesions throughout the body. often develops from repeated joint injury or repetitive motion. aspirin has greater effects. The pain is often worse on one side of the head. release of inflammatory mediators. and less efficient in repairing itself. joint stiffness. and physical and emotional stress. When aspirin is ab- sorbed into the bloodstream. Onset may occur before 16 years of age. Rheumatoid arthritis (RA)—a chronic. Although these drugs relieve symptoms and contribute greatly to the client’s comfort and quality of life. Inhibition of COX-2 results in the therapeutic effects of analgesia and anti-inflammatory activity. oral contraceptives). Knee OA. some foods (eg. To relieve fever. Related drugs act peripherally to prevent sensitization of pain receptors to various chemical substances released by damaged cells. dysmenorrhea. The COX-2 inhibitor drugs are NSAIDs designed to selectively inhibit COX-2 and relieve pain and inflammation with fewer adverse effects. its usage has declined for most indications. For inflammation.” and bunions. and increased sensitivity to light and sound. inflammatory. and irritation of nerve endings. Migraine occurs more often in women than men and may be associated with menses. In the kidneys. In the GI tract. Thus. nausea. however. It is considered an autoimmune disorder in which the body attacks its own tissues. some medications (eg. and eventually other body organs (systemic effects). Numerous circumstances have been implicated as “triggers” for the chemical imbalance and migraine. episiotomy). underlying bone is exposed. but all the drugs except acetaminophen and the COX-2 inhibitors inhibit platelet aggregation. Despite many similarities. the drugs prevent prostaglandins from increasing the pain and edema produced by other substances released by damaged cells. a waste product of protein metabolism.102 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM BOX 7–2 SELECTED CONDITIONS FOR WHICH ASPIRIN. Dysmenorrhea—pain associated with menstruation. osteoarthritis. INDICATIONS FOR USE These drugs are widely used to prevent and treat mild to moderate pain and/or inflammation associated with musculoskeletal disorders (eg. decreased range of motion. usually aggravated by movement. COX-2 is induced by inflammatory chemical mediators such as interleukin-1 (IL-1) and tumor necrosis factor alpha (TNF alpha). and inflammation (gouty arthritis). the drugs act on the hypothalamus to decrease its response to pyrogens and reset the “thermostat” at a lower level. and deformity occur as the disease advances. gout). and increase the risk of bleeding. The resulting hyperuricemia may be asymptomatic or may lead to urate deposits in various tissues. In inflamed tissues. urate deposits produce periodic episodes of severe pain. The etiology is unknown. aspirin acts both centrally and peripherally to block the transmission of pain impulses. Pain in and around the knee occurs early in the disease process. In the musculoskeletal system. irregular patterns of eating and sleeping. Most other NSAIDs bind reversibly with platelet COX-1 so that antiplatelet effects occur only while the drug is present in the blood. Although aspirin is effective in many disorders. especially stomach damage. Overall. Aspirin and traditional NSAIDs also have antiplatelet effects that differ in mechanism and extent. moderate or severe in intensity. a common type.

asthma. vasodilation) and lungs (eg. In people who are allergic to aspirin. but it lacks anti-inflammatory and antiplatelet effects. is commonly used as an aspirin substitute for pain and fever. In addition. This indication stems from its antiplatelet activity and resultant effects on blood coagulation (ie. which can be given orally and parenterally. which differs chemically from aspirin and other NSAIDs. in which the drug reduces the number of polyps and may decrease risks of colon cancer. inflammatory) prostaglandins: Actions of antiprostaglandin drugs. At the same time. an allergic reaction to other NSAIDs. or hormonal stimuli Arachidonic acid Traditional NSAIDs block COX-1 and COX-2 enzymes COX-2 inhibitor NSAIDs block COX-2 enzyme Cyclooxygenase-1 (COX-1) Cyclooxygenase-2 (COX-2) Physiologic prostaglandins Figure 7–1 Physiologic and pathologic (ie. Most of the other NSAIDs are too toxic to use as analgesics and antipyretics. or severe renal impairment.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 103 Cell activated by physical. maintain blood flow to mucosa) Renal protection (help maintain blood flow and function) Regulate smooth muscle tone in blood vessels (eg. Selective inhibition of COX-2 produces anti-inflammatory effects while maintaining protective effects on the stomach. Prostaglandins play important roles in normal body functions as well as inflammatory processes. Some NSAIDs such as ibuprofen (Motrin) and related drugs are widely used as anti-inflammatory agents and analgesics. Inhibition of both COX-1 and COX-2 by traditional NSAIDs produces adverse effects on the stomach (eg. nonaspirin NSAIDs also are contraindicated because hypersensitivity reactions may occur with any drugs that inhibit prostaglandin synthesis. Selective COX-2 inhibitors are contraindicated for clients with a history of peptic ulcers. lowdose aspirin is increasingly prescribed for clients at risk of myocardial infarction or stroke from thrombosis. Celecoxib (Celebrex) is also used to treat familial adenomatous polyposis. They are used primarily in rheumatoid arthritis and other musculoskeletal disorders that do not respond to safer drugs. history of hypersensitivity reactions. In children and adolescents. is used only as an analgesic. ↑ mucus production. bleeding) as well as anti-inflammatory effects. celecoxib and valdecoxib are contraindicated in clients . Acetaminophen. and impaired renal function. irritation. Several NSAIDs are formulated as eye drops for use in treating eye disorders (see Chap. GI bleeding. aspirin is contraindicated in the presence of viral infections such as influenza or chickenpox because of its association with Reye’s syndrome. decreased clot formation). ketorolac (Toradol). 65). CONTRAINDICATIONS TO USE Contraindications to aspirin and nonselective NSAIDs include peptic ulcer disease. chemical. bronchodilation) Regulate blood clotting Pathologic prostaglandins Inflammation Vasodilation ↑ Capillary permeability Edema Pain Leukocytosis Activate white blood cells to release inflammatory cytokines tract and the advent of newer drugs. gastrointestinal (GI) or other bleeding disorders. GI protection (↓ gastric acid. ulceration.

Antipyretic. or to clients who are currently taking aspirin or other NSAIDs. It is reportedly equal or superior to aspirin in mild to moderate pain. liver. trade names. Compared with aspirin. muscles. Thus. especially in older adults at high risk for GI bleeding. Taking aspirin with food slows absorption. an active metabolite. Hematomas and wound bleeding have been reported with postoperative use. enteric-coated. they are much more expensive and may cause all the adverse effects associated with aspirin and other prostaglandin inhibitors. bone marrow depression. It is available by prescription and OTC. Absorption of enteric-coated aspirin and rectal suppositories is slower and less complete. Ibuprofen. This warning states that people who drink three or more alcoholic drinks daily should ask their doctors before taking the products. In addition to their use as anti-inflammatory agents. Acetic acid derivatives include indomethacin (Indocin). colds. Aspirin is a home remedy for headaches. aspirin binds to albumin (75 to 90%). its use is limited to 5 days because it increases the risk of bleeding. ibuprofen. and oxaprozin (Daypro). It can be purchased in plain. its unique characteristic is that it can be given by injection. people tend to underestimate its usefulness. peaks in 1 to 2 hours. rheumatoid arthritis. including fetal tissues. and other connective tissue. In addition to other uses. a commonly used drug. such as arthritis. Because it is a nonprescription drug and is widely available. their action starts within 15 to 30 minutes. peaks in 1 to 2 hours. and lasts 4 to 6 hours. In plasma. oral suspension. Although adverse reactions occur less often with sulindac and tolmetin.) Other drugs related to this group are etodolac (Lodine). ketoprofen (Orudis). and naproxen are available OTC. Advil). ketoprofen. before or during any major surgery. or naproxen). However. Meloxicam has a serum half-life of 15 to 20 hours (text continues on page 108) SUBGROUPS AND INDIVIDUAL DRUGS Sub-groups and selected individual drugs are described below. and lasts 4 to 6 hours. and oral drops. heart. Anti-inflammatory Drugs. it has less antipyretic effect. and has a longer duration of action. NSAIDs Propionic acid derivatives include fenoprofen (Nalfon). It is not marketed in liquid form because it is unstable in solution. with recommended doses smaller and durations of use shorter than those for prescription formulations. Diflunisal (Dolobid) is a salicylic acid derivative that differs chemically from aspirin. the other drugs were developed in an effort to find equally effective but less toxic derivatives of indomethacin. but also decreases gastric irritation. sulindac (Clinoril). and dosage ranges of individual drugs are listed in Drugs at a Glance: Analgesic. pH of 8). Ibuprofen. naproxen (Naprosyn). blood is shunted from the aorta to the pulmonary artery. and although it can be given orally. and lungs. (The ductus arteriosus joins the pulmonary artery to the aorta in the fetal circulation. It is useful in inflammatory disorders. ketoprofen. It is metabolized in the liver and excreted through the kidneys. These drugs have strong anti-inflammatory effects and more severe adverse effects than the propionic acid derivatives. ibuprofen (Motrin. and fever. Aspirin is the prototype of the analgesic–antipyretic– anti-inflammatory drugs and the most commonly used salicylate. mental confusion. Aspirin has a short half-life of 15– 20 minutes because it is rapidly converted to salicylic acid. The Food and Drug Administration (FDA) requires an alcohol warning on the labels of all OTC pain relievers and fever reducers. The highest concentrations are found in the plasma. but many people prefer drugs that cause less gastric irritation. Ketorolac is used only for pain. chewable. and the central nervous system (CNS). depression. Regular aspirin tablets are well absorbed after oral administration. and nabumetone (Relafen). ketorolac should not be administered during labor and delivery. hemolytic anemia. especially that involving the skin. The drug is highly bound (about 99%) to plasma proteins and has a half-life of about 2 hours. is well absorbed with oral administration. Parenteral ketorolac reportedly compares with morphine and other opioids in analgesic effectiveness for moderate or severe pain. breast milk. some are used as analgesics and antipyretics. It is effective in pain of low to moderate intensity. and osteoarthritis. In alkaline urine (eg. indications for use. Oxicam drugs include meloxicam (Mobic) and piroxicam (Feldene). causes less gastric irritation. and psychosis. Although these drugs are usually better tolerated than aspirin. Over-the-counter (OTC) products containing these drugs are contraindicated for chronic alcohol abusers because of possible liver damage (with acetaminophen) or stomach bleeding (with aspirin. Etodolac reportedly causes less gastric irritation. . ketorolac (Toradol). Salicylic acid has a half-life of 2 to 3 hours at low doses and 6 to 12 hours at therapeutic antiinflammatory doses. for use by adults and children. chewable tablets. causing severe cardiopulmonary problems. they are still common. with suspected or confirmed cerebrovascular bleeding. intravenous (IV) indomethacin is approved for treatment of patent ductus arteriosus in premature infants. renal excretion of salicylate is greatly increased. When it fails to close. Its action starts in about 30 minutes. joints. flurbiprofen (Ansaid). Aspirin is distributed to all body tissues and fluids. These effects are especially associated with indomethacin.104 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM who are allergic to sulfonamides and ketorolac is contraindicated in clients at risk of excessive bleeding. It undergoes oxidation and conjugation in the liver and its metabolites are excreted through the kidneys. and effervescent tablets and rectal suppositories. muscular aches. in tablets. capsules. and tolmetin (Tolectin). Potentially serious adverse effects include GI ulceration. influenza and other respiratory infections.

1–2 y.5– 26. fever Osteoarthritis (OA). for 2 wk.9– 32. 11 y. 120 mg. It may be used for all indications. Maximum recommended dose for adults is 4 g/d. or 1000 mg three or four times per day.6–15. 162 mg. 2–3 y. Celecoxib (Celebrex) Osteoarthritis Rheumatoid arthritis Familial adenomatous polyposis (FAP) Diclofenac potassium (Cataflam) Diclofenac sodium (Voltaren. 9–10 y. 60–71 lb (26. 120 mg q4–6h. Anti-inflammatory Drugs Routes and Dosage Ranges Generic/Trade Name Acetaminophen (Tylenol. 36–47 lb (16–21. usual single dose. 6–8 y. Recommended doses for weight: 24–35 lb (10. 4–11 mo. in divided doses. 80 mg. 480 mg. in divided doses TIAs. 648 mg Juvenile RA: PO 60–110 mg/kg/d in divided doses q6–8h Acute rheumatic fever.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 105 Drugs at a Glance: Analgesic.6 g in 24 h Pain. others) Indications for Use Pain Fever Adults PO 325–650 mg q4–6h.8 kg). 650 mg OA. TIA. and stroke: PO 81–325 mg/d Acute rheumatic fever: PO 5–8 g/d.4 kg). Rectal suppository: age under 3 y. three or four divided doses 200-mg doses should be taken with food Dosage not established Diclofenac potassium is available only in 50-mg. fever: PO 325– 650 mg q4h PRN. Doses may be given q4–6h to a maximum of 5 doses in 24 h.3 kg). 40 mg. 72–95 lb (32. then 75 mg/kg/d for 4–6 wk Dosage not established Comments Warning: Overdoses may cause fatal liver damage. 486 mg. immediate-release tablets. 320 mg. Rectal suppository 650 mg q4–6h. maximum.3 kg or above). PO 1300 mg/d in divided doses (650 mg twice a day or 325 mg four times a day) Therapeutic serum level of salicylate is 100–300 mcg/mL for treatment of arthritis and rheumatic fever. RA: PO 2–6 g/d in divided doses Prophylaxis of MI. consult physician. PO 100 mg/kg/d. 160 mg. 96 lb or above (43. maximum 4 g/d Children PO 10 mg/kg or according to age as follows: 0–3 mo. maximum 2.9 kg). up to 60–80 mg/kg/d. 720 mg in 24 h. age 6–12 y. 48–59 lb (21. from all sources.2 kg). 50 mg two or three times or 75 mg twice or 100 mg once daily) RA: PO 150–200 mg/d in two. 405 mg. 324 mg. Voltaren XR) Osteoarthritis Rheumatoid arthritis OA: PO 100 mg twice daily or 200 mg once daily RA: PO 100–200 mg twice daily FAP: PO 200 mg twice daily OA: PO 100–150 mg/d in divided doses (eg. Antipyretic. Parents and caregivers should ask pediatricians about the amounts of acetaminophen children may take safely. 4–5 y. (continued ) . 325 mg q4–6h. maximum of 6 in 24 h Aspirin Pain. age 3–6 y. 240 mg. 243 mg.4– 43. fever: PO 10–15 mg/kg q4h. toxicity occurs at levels above 300 mcg/mL. 400 mg. rheumatoid arthritis (RA) Prophylaxis of myocardial infarction (MI). transient ischemic attacks (TIAs) and stroke in men Rheumatic fever Pain.

dysmenorrhea: (diclofenac potassium only) PO 50 mg three times daily OA. in two divided doses.3 mg/kg q12h for a total of three doses Available in numerous dosage forms and concentrations. 50-.5°F) or less. Lodine XL) Osteoarthritis Rheumatoid arthritis Pain Dosage not established Available in immediaterelease and extendedrelease (XL) tablets of various strengths. . RA: PO 300–600 mg three or four times per day Pain: PO 200 mg q4–6h PRN Maximum. IV 0. dysmenorrhea Adults AS: PO 100–125 mg/d in four or five divided doses (eg. Motrin. Fenoprofen (Nalfon) Osteoarthritis Rheumatoid arthritis Pain Dosage not established Flurbiprofen (Ansaid) Osteoarthritis Rheumatoid arthritis Osteoarthritis Rheumatoid arthritis Pain. for infants) The sustained-release form is not recommended for acute gouty arthritis. PO 20–40 mg/kg/d.2–0. then 250– 500 mg q8–12h OA. Anti-inflammatory Drugs (continued ) Routes and Dosage Ranges Generic/Trade Name Indications for Use Ankylosing spondylitis (AS) Pain.106 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Analgesic. maximum dose. 20 mg/kg/d for <60 kg OA. or four divided doses OA. 25 mg four or five times daily) Pain. in three or four divided doses Premature infants with patent ductus arteriosus. dysmenorrhea Fever Dosage not established Ibuprofen (Advil. PO 5 mg/kg q6–8h. The immediate-release forms should be used to treat acute pain. oral suspensions (of 100 mg/5 mL). Diflunisal (Dolobid) Osteoarthritis Rheumatoid arthritis Pain Etodolac (Lodine. RA: PO 500– 1000 mg/d.2°C (102. increased to a maximum of 1500 mg/d if necessary Pain: PO 500–1000 mg initially. PediaCare) Indomethacin (Indocin. RA: PO 300–600 mg 3 or 4 times per day. chewable tablets. and 75-mg delayedrelease tablets and a 100-mg extendedrelease (XR) tablet. initial temperature above 39. increased by 25 mg/d at weekly intervals to a maximum of 150–200 mg/d.5°F). three. 75 mg/d initially. capsules. and oral drops (of 40 mg/mL. if necessary 1–12 y: Fever. rectal suppository. dysmenorrhea: PO 400 mg q4–6h PRN Maximum. maximum. PO 10 mg/kg q6–8h. RA: PO 200–300 mg/d in two. initial temperature 39. 3200 mg/d Not recommended for use in children <12 years of age Children Comments Diclofenac sodium is available in 25-. Indocin SR) Osteoarthritis Rheumatoid arthritis Ankylosing spondylitis Tendinitis Bursitis Acute painful shoulder Acute gout Closure of patent ductus arteriosus (IV only) PO. 40 mg/kg/d Juvenile arthritis. Antipyretic. including regular tablets. It is not recommended for acute pain or dysmenorrhea. RA: PO 600– 1200 mg/d in two to four divided doses Pain: PO 200–400 mg q6–8h Maximum according to weight: 1200 mg/d for 60 kg (132 lbs) or more. 3200 mg/d OA.2°C (102. 2400 mg/d Pain.

300 mg/d for regular formulation. XL) that indicate long-acting dosage forms. Anaprox. Naprelan) Osteoarthritis Rheumatoid arthritis Osteoarthritis Rheumatoid arthritis Juvenile arthritis Ankylosing spondylitis Pain Dysmenorrhea Bursitis Tendinitis Acute gout Dosage not established Juvenile arthritis (naproxen only): PO 10 mg/kg/d in two divided doses.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 107 Drugs at a Glance: Analgesic. IM 15 mg q6h to a maximum of 60 mg/d PO 7. those with renal impairment. 2. 5 mL. increased to 15 mg once daily if necessary PO 1000–2000 mg/day in one or two doses Naproxen: PO 250– 500 mg twice daily Gout: PO 750 mg initially.5 once daily. IM 30 mg q6h PRN to a maximum of 120 mg/d PO 10 mg q4–6h to a maximum of 40 mg/d Older adults (>65 y). 39 kg (84 lb). 7–14 d for painful shoulder). 200 mg/d for extended release. acute tendinitis. PO 75–150 mg/d in three or four divided doses until pain and inflammation are controlled (eg. for short term (up to 5 days) treatment Dosage not established Treatment is started with one or more injected doses. dysmenorrhea: PO 25–50 mg q6–8h PRN OA. Maximum duration of both injected and oral doses. bursitis: PO 550 mg q12h or 275 mg q6–8h Maximum. Extended-release capsules are available as generic ketoprofen and Oruvail. 5 days. Ketorolac (Toradol) Moderately severe. Meloxicam (Mobic) Osteoarthritis Dosage not established May be taken without regard to meals Available in 500-mg and 750-mg tablets Available in several dosage strength tablets. Antipyretic. in a suspension. then discontinued Pain.5 mL OTC preparation not recommended for children < 12 y (continued ) . Oruvail) Pain Dysmenorrhea Osteoarthritis Rheumatoid arthritis Do not give to children <16 years unless directed by a physician. acute pain. RA: PO 150–300 mg/d in three or four divided doses Sustained-release (Oruvail SR). 3–5 d for gout. 25 kg (55 lb).5 mL. 750– 1000 mg once daily Children Comments Ketoprofen (Orudis. Oral suspension (125 mg/ 5 mL) twice daily according to weight: 13 kg (29 lb). and in immediateand delayed-release formulations Nabumetone (Relafen) Naproxen (Naprosyn) Naproxen sodium (Aleve. RA. IV. 100–150 mg/d for clients with impaired renal function IV. acute painful shoulder. 7. 200 mg once daily Maximum. then 250 mg q8h until symptoms subside Maximum. Anti-inflammatory Drugs (continued ) Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Acute gouty arthritis. then 275 mg q8h until symptoms subside Controlled-release (Naprelan). those with weight < 50 kg (110 lbs). SR. followed by oral doses when the client is able to take them. 1250 mg/d Naproxen sodium: Pain. dysmenorrhea. 1375 mg/d OA. AS: PO 275– 550 mg twice a day Acute gout: PO 825 mg initially. Note that the names do not contain any letters (eg.

maximum. As a result. 400 mg/d Acute gout. the drugs do not raise blood pressure in normotensive clients) and some clients receiving a COX-2 inhibitor had a small increase in the incidence of myocardial infarction and stroke due to thrombosis. Diclofenac sodium (Voltaren) is chemically different from but pharmacologically similar to other NSAIDs. These concerns are being investigated.5–25 mg once daily Acute pain. A small amount is excreted unchanged in the urine. Celecoxib (Celebrex) is well absorbed with oral administration. compared with clients receiving a nonselective NSAID (naproxen) or placebo. In addition. dysmenorrhea: PO 50 mg once daily as needed Children Dosage not established Comments Lower doses recommended for patients with low body weight or milder disease Piroxicam (Feldene) Rofecoxib (Vioxx) Osteoarthritis Rheumatoid arthritis Osteoarthritis Pain Dysmenorrhea Dosage not established Dosage not established Available in tablets of 12. Piroxicam has a half-life of about 50 hours. peaks in about 20 minutes to 2 hours. Anti-inflammatory Drugs (continued ) Routes and Dosage Ranges Generic/Trade Name Oxaprozin (Daypro) Indications for Use Osteoarthritis Rheumatoid arthritis Adults PO 600–1200 mg once daily Maximum. Formulations are delayed or extended-release and onset of action is therefore delayed. increased to 1800 mg/d if necessary OA. they produce less gastric irritation than aspirin and other NSAIDs. peak plasma levels and peak action occur approximately 3 hours after an oral dose. Thus. The long half-lives allow the drugs to be given once daily. It is metabolized by the cytochrome P450 enzymes in the liver to inactive metabolites that are then excreted in the urine. in divided doses PO 20 mg/d or 10 mg twice daily OA: PO 12. Peak action occurs in about 2 hours and effects last 12 to 15 hours. RA: PO 10 mg once daily Dysmenorrhea: PO 20 mg twice daily as needed Dosage not established Juvenile RA: PO 20 mg/kg/d in three or four divided doses Dosage not established and is excreted about equally through urine and feces. then reduce dosage or discontinue PO 400 mg three times daily initially.5 mg/5 mL or 25 mg/5 mL May be taken with or without food Sulindac (Clinoril) Osteoarthritis Rheumatoid arthritis Ankylosing spondylitis Bursitis Tendinitis Acute painful shoulder Acute gout Tolmetin (Tolectin) Valdecoxib (Bextra) Osteoarthritis Rheumatoid arthritis Juvenile rheumatoid arthritis Osteoarthritis Rheumatoid arthritis Dysmenorrhea PO 150–200 mg twice a day. The formulation of diclofenac potassium (Cataflam) is immediate-release.5. whichever is lower. 7–14 d). there have been a few cases reported in which hypertension was acutely worsened by the drugs (blood pressure returned to previous levels when the drugs were discontinued. 1800 mg/d or 26 mg/kg/d. It is metabolized in the liver and excreted in urine and feces. 25 and 50 mg and a suspension containing 12. Antipyretic. and also lasts 12 to 15 hours. acute painful shoulder: PO 200 mg twice a day until pain and inflammation subside (eg. Diclofenac has a serum halflife of about 2 hours and is excreted mainly in the urine. they are not associated with increased risks of bleeding because they do not have the antiplatelet effects of aspirin and other NSAIDs. Valdecoxib (Bextra) is a newer COX-2 inhibitor. the potassium salt may be given for rapid relief of pain and primary dysmenorrhea. . Rofecoxib (Vioxx) acts within 45 minutes and peaks in 2 to 3 hours. It is 87% protein bound and has a half-life of 17 hours. Despite the rel- ative safety of these drugs.108 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Analgesic. Cyclooxygenase-2 inhibitors block production of prostaglandins associated with pain and inflammation without blocking those associated with protective effects on gastric mucosa. action starts quickly. but optimal efficacy may not occur for 1 to 2 weeks. others are being developed. It is highly protein bound (97%) and its serum half-life is about 11 hours.

then 0.5–1 mg/d PO 250 mg twice a day for 1 wk. In acute or chronic overdose situations. or GI bleeding. The probable mechanism for increased risk of hepatotoxicity in this population is that ethanol induces drug-metabolizing enzymes in the liver. which occurs with gout and with antineoplastic drug therapy. naratriptan (Amerge). most often in treating sexually transmitted diseases. The resulting rapid metabolism of acetaminophen produces enough toxic metabolite to exceed the available glutathione. PO 150 mg/d.5 mg q3–6h until response is obtained. but it lacks anti-inflammatory activity. which is normally inactivated by conjugation with glutathione and excreted in urine. gradually increased over 1 wk to a maximum of 400–800 mg/d Children Secondary hyperuricemia from anticancer drugs: <6 y. Acetaminophen is metabolized in the liver. Duration of action is 3 to 4 hours. Drugs for Migraine Individual drugs are described below. PO 100–200 mg/d Secondary hyperuricemia from anticancer drugs. Acute attacks of gout may result when urate deposits are mobilized. or oxycodone for added analgesic effects. These may be prevented by concomitant administration of colchicine until serum uric acid levels are lowered. It increases blood levels and prolongs the action of penicillin by decreasing the rate of urinary excretion. concomitant administration of colchicine prevents this effect. and it does not interfere with blood clotting. Probenecid may precipitate acute gout until serum uric acid levels are within the normal range. Colchicine decreases inflammation by decreasing the movement of leukocytes into body tissues containing urate crystals. Colchicine is usually given during initial sulfinpyrazone therapy to prevent acute gout. it is the drug of choice for relieving joint pain and edema. PO 400–600 mg/d Hyperuricemia in clients with renal insufficiency. rizatriptan (Maxalt). Almotriptan (Axert).” were developed . (Probenecid also is used with penicillin. 3-d interval between courses of therapy IV 1–2 mg initially. approximately 94% is excreted in the urine as inactive glucuronate and sulfate conjugates. PO 200– 400 mg/d Severe gout. It is not effective in acute attacks of gouty arthritis but prevents hyperuricemia and tophi associated with chronic gout. The drug promotes resorption of urate deposits and prevents their further development. however. a sufficient amount of glutathione is available in the liver to detoxify acetaminophen. This uricosuric action is used therapeutically to treat hyperuricemia and gout. It is especially useful in chronic gout characterized by tophi (deposits of uric acid crystals in the joints. then 500 mg twice a day PO 100–200 mg twice a day. It is equal to aspirin in analgesic and antipyretic effects. Allopurinol (Zyloprim) is used to prevent or treat hyperuricemia. liquid. Colchicine is an anti-inflammatory drug used to prevent or treat acute attacks of gout. an abbreviation for N-Acetyl-P-Aminophenol) is a nonprescription drug commonly used as an aspirin substitute because it does not cause nausea. frovatriptan (Frova). In people who abuse alcohol.) Sulfinpyrazone (Anturane) is a uricosuric agent similar to probenecid. PO 0. the supply of glutathione may become depleted. Approximately 4% is metabolized to a toxic metabolite. PO 0.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 109 Acetaminophen (also called APAP. and soft tissues) and impaired renal function. and rectal suppository forms and is in numerous combination products marketed as analgesics and cold remedies. the toxic metabolite combines with liver cells and causes damage or fatal liver necrosis.5 mg q1h until pain is relieved or toxicity (nausea. called “triptans. kidneys. Acetaminophen is well absorbed with oral administration and peak plasma concentrations are reached within 30 to 120 minutes. PO 300 mg/d Colchicine Dosage not established Probenecid (Benemid) Sulfinpyrazone (Anturane) >2 y. In acute attacks. vomiting. It has no analgesic or antipyretic effects. dosages are listed in Drugs at a Glance: Drugs for Gout. diarrhea) occurs. Acetaminophen is available in tablet. usual therapeutic doses may cause or increase liver damage. 6–10 y. In the absence of glutathione. vomiting. hydrocodone. maximum 800 mg/d Acute attacks. Allopurinol prevents formation of uric acid by inhibiting xanthine oxidase. Uric acid is formed by purine metabolism and an enzyme called xanthine oxidase. It is not effective in acute gout but prevents or decreases tissue changes of chronic gout. and zolmitriptan (Zomig). Drugs at a Glance: Drugs for Gout Routes and Dosage Ranges Generic/ Trade Name Allopurinol (Zyloprim) Adults Mild gout. With usual therapeutic doses. PO 40 mg/kg/d in divided doses Dosage not established Drugs Used in Gout and Hyperuricemia Individual drugs are described below. PO 100–200 mg/d. maximum total dose 4 mg Prophylaxis. sumatriptan (Imitrex). dosages are listed in Drugs at a Glance: Drugs for Migraine. It is often prescribed with codeine. Probenecid (Benemid) increases the urinary excretion of uric acid.

peppermint. The authors concluded that the NSAID relieved pain faster but the effects of CS lasted longer. may repeat after 2 h if necessary. if necessary. The main adverse effects are reportedly minor stomach upset. metabolism of rizatriptan and zolmitriptan produces active metabolites. CS is usually taken with food.5 tablet q30 min. marigold. For example. These drugs are considered safer than ergot alkaloids. may be repeated hourly. Ergotamine is most effective when given sublingually or by inhalation at the onset of headache. 800 mg CS. one study cited by Fetrow and Avila compared CS with diclofenac sodium. Maximum dose. a supplement extracted from animal cartilage or manufactured synthetically and used to treat arthritis. nausea. renal or hepatic disease. to a maximum of 6 inhalations/24 h Adults: PO 2 tablets at onset of migraine. 1–2 mg at onset of migraine. if necessary. there is some evidence of effectiveness with few adverse effects. Maximum dose.5–1 tablet initially. 0. In addition. pain. to a total of 3 mg IV 1 mg. and to promote the “shock-absorbing” quality of cartilage (by retaining water). Maximum. Because of their vasoconstrictive properties. For most of these (eg. proteoglycans. Dihydroergotamine mesylate (DHE 45) is a semisynthetic derivative of ergotamine that is less toxic and less effective than the parent drug. 300 mg/d SC 6 mg as a single dose. Herbal and Dietary Supplements In addition to the drugs described above. to a maximum of three tablets IM 1 mg at onset of migraine. The drugs vary in onset of action. Chondroitin is a normal component of joint cartilage. up to 6 tablets per attack or 10 tablets/wk Rectal suppository 0. Chondroitin sulfate (CS). up to 3 months after treatment.5–1 suppository at onset of migraine. after 1 h. 10 or 20 mg by unit-dose spray device. Ergotamine tartrate (Ergomar) is an ergot alkaloid used only in the treatment of migraine. repeat in 5 min. myocardial infarction. the drugs are contraindicated in clients with a history of angina pectoris.110 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Drugs for Migraine Generic/Trade Name Routes and Dosage Ranges Serotonin agonists (Triptans) Almotriptan (Axert) PO 6. Ergotamine is contraindicated during pregnancy and in the presence of severe hypertension. 12 mg/d Nasal spray 5. an NSAID. or uncontrolled hypertension. 12. comfrey. many herbal medicines are used to relieve pain and/or inflammation. repeated. coronary artery disease. if necessary.36 mg (one inhalation) at onset of migraine. and drowsiness). 10 mg/d Ergot Preparations Ergotamine tartrate (Ergomar) Ergotamine tartrate and caffeine (Cafergot) Dihydroergotamine mesylate (DHE 45) PO. Ergot preparations relieve migraine by constricting blood vessels. which have similar adverse effects (eg. these are described below. Maximum. They are called selective serotonin 5-HT1 receptor agonists because they act on a specific subtype of serotonin receptor to increase serotonin (5-hydroxytryptamine or 5-HT) in the brain. peripheral vascular disease. 40 mg/d Zolmitriptan (Zomig) PO 1.5 mg as a single dose. Proponents of CS cite clinical trials that indicate beneficial effects. collagen. 1200 mg CS. CS was first used as a dietary supplement because studies suggested that it would promote healing of cartilage damaged by inflammation or injury. Maximum dose. repeat in 4 h if necessary. repeat after 2 h if necessary. primrose). . Most clients get relief within 1 to 2 hours with all of the oral drugs. Proponents also tout the safety of CS in comparison with the adverse effects of NSAIDs. a proteolytic enzyme found in synovial membranes).5 mg/24h Naratriptan (Amerge) PO 1–2. They relieve migraine by constricting blood vessels. up to two suppositories per attack or five suppositories/wk Children: PO 0. The daily dose is based on the client’s weight: under 120 lbs.25 mg. which contains water (65 to 80%). then 1 tablet q30 min. if necessary. For a few supplements. 30 mg/d Sumatriptan (Imitrex) PO 25–100 mg as a single dose. then 2 mg q30 min.5 mg as a single dose. 120 to 200 lbs. then 0. if necessary. Subcutaneous sumatriptan produces more adverse effects than the oral drugs. in 146 clients with osteoarthritis of the knee. with subcutaneous sumatriptan acting the most rapidly and starting to relieve migraine headache within 10 minutes. if necessary. sublingually. is thought to delay the breakdown of joint cartilage (by inhibiting elastase. 1600 mg CS.25–2. 5 mg/d Rizatriptan (Maxalt) PO 5–10 mg as a single dose. When given orally. such usage is anecdotal and unsupported by clinical studies. in two to four divided doses. Do not exceed 6 mg/wk. paresthesias. Maximum. maximum dose 2 mg. repeat in 1 h. if necessary. and chondrocytes that produce new collagen and proteoglycans. and therapeutic effects may be delayed for 20 to 30 minutes. to a maximum of 6 mg/24 h or 10 mg/wk Inhalation. Maximum. there is a theoretical risk of bleeding because of the specifically for the treatment of moderate or severe migraines. Caffeine reportedly increases the absorption and vasoconstrictive effects of ergotamine. to stimulate synthesis of new cartilage (by stimulating chondrocytes to produce collagen and proteoglycan). Ergotamine tartrate and caffeine (Cafergot) is a commonly used antimigraine preparation. The drugs are metabolized in the liver by monoamine oxidase or cytochrome P450 enzymes. ergotamine is erratically absorbed. repeat after 2 h if necessary. dizziness. and severe infections. over 200 lbs.

Sine-Aid IB). and Other NSAIDs General Considerations ✔ Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil. ringing in ears. Ecotrin. when taken for inflammatory disorders. or similar drugs. These include diclofenac sodium (Voltaren or Voltaren XR). ulcer. Motrin) are used to relieve pain. do not take aspirin for approximately 2 weeks before the estimated delivery date. generally avoid taking additional aspirin in over-the-counter (OTC) aspirin or products containing aspirin (eg. Advil. or if new symptoms develop. if unsure whether the medicine you are taking is long-acting. ketoprofen or Oruvail extended release capsules. Note: These are prescription drugs and most are also available in short-acting products. Orudis KT). ✔ Inform any health care provider if taking aspirin. It may be taken on an empty stomach. Alka-Seltzer. contact a health care provider. naproxen delayed-release (EC-Naprosyn) or controlled-release (Naprelan) tablets. nose bleed. ✔ Do not take OTC ibuprofen more than 3 days for fever or 10 days for pain. or swelling and weight gain. store aspirin in a closed childproof container and keep out of children’s reach. Improvement of symptoms depends on the reason for use. ✔ Inform health care providers if you have ever had an allergic reaction (eg. Most preparations . etodolac (Lodine XL). ✔ With NSAIDs. The coating is applied to decrease stomach irritation by making the tablet dissolve in the intestine. dizziness. Vioxx. Also. diflunisal (Dolobid). Dristan Sinus. Arthritis Pain Formula. Bufferin. avoid OTC products containing ibuprofen (eg. ✔ Report signs of bleeding (eg. Because these drugs are so widely used and available. ask a health care provider. ✔ Acetaminophen is an effective aspirin substitute for pain or fever but not for inflammation or preventing heart attack or stroke. Aspirin. There are two exceptions if you are taking a small dose of aspirin daily (usually 81–325 mg). If pregnant. Also. ibuprofen. skin rash or hives. ibuprofen. Knowing drug names. do not chew or crush. and other NSAIDs with a full glass of liquid and food to decrease stomach irritation. ✔ Avoid aspirin for approximately 2 weeks before and after major surgery or dental work to decrease the risk of excessive bleeding. to prevent heart attack and stroke. or naproxen (Aleve). ✔ Taking a medication for fever is not usually recommended unless the fever is high or is accompanied by other symptoms. ibuprofen. Motrin IB. which can cause the tablet to dissolve in the stomach. Ascriptin. bleeding) after taking aspirin. Acetaminophen ✔ Acetaminophen is often the initial drug of choice for relieving mild-to-moderate pain and fever because it is effective and does not cause gastric irritation or bleeding. and inflammation. do not take with an antacid. another one may work because people vary in responses to the drugs. Doan’s Pills/Caplets. ✔ To avoid accidental ingestion and aspirin poisoning. Anacin. ✔ Acetaminophen is available in its generic form and with many OTC brand names (eg. there is a high risk of overdosing on different products containing the same drug or products containing similar drugs. Midol. vomiting blood. Second. Vanquish). Rofecoxib (Vioxx) and meloxicam (Mobic) may be taken without regard to food. you should continue taking the aspirin if Celebrex. If you are taking aspirin or an NSAID regularly for pain or inflammation. Aspirin is as effective as the more costly NSAIDs. blood in urine or stools). do not chew or crush. OTC ibuprofen is the same medication as prescription Motrin. The Food and Drug Administration requires an alcohol warning on the labels of OTC pain and fever relievers and urges people who drink three or more alcoholic drinks every day to ask their doctors before using the products. and using the following precautions can increase safety in using these drugs: 1. asthma. or Bextra is prescribed. Tylenol). but is more likely to cause stomach irritation and bleeding problems. Recommended doses are smaller for OTC products than for prescription drugs. Excedrin. reading product labels. the drugs usually act within 30 to 60 minutes. These drugs are available as both prescription and OTC products. Self-Administration ✔ Take aspirin. difficulty in breathing. improvement may occur within 24 to 48 hours with aspirin and 1 to 2 weeks with other NSAIDs. However. Fever is one way the body fights infection. If you are taking any prescription NSAID regularly. ✔ Avoid or minimize alcoholic beverages because alcohol increases gastric irritation and risks of bleeding. First. ✔ Swallow any long-acting pills or capsules whole. fever. This advantage of NSAIDs may be minimal if high doses are taken. OTC naproxen is the same as prescription Naprosyn. it is generally safe to take occasional doses of aspirin or an NSAID for pain or fever.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 111 CLIENT TEACHING GUIDELINES Acetaminophen. difficulty breathing. bruising. do not combine the OTC products with each other or with aspirin. 2. This decreases gastric irritation and helps to maintain good kidney function. Midol IB. such as arthritis. severe stomach upset. If these symptoms persist or worsen. When taken for pain. if one is not effective. OTC ketoprofen is the same as prescription Orudis. any combination of these drugs could constitute an overdose. ketoprofen (Actron. Ecotrin) whole. hives) or severe GI symptoms (eg. ✔ Swallow enteric-coated aspirin (eg. or any other NSAID regularly. ✔ Drink 2–3 quarts of fluid daily when taking an NSAID regularly.

almost all OTC pain relievers (often labeled “nonaspirin”) and cold. With osteoarthritis (OA). ✔ Drink 2–3 quarts of fluid daily with antigout drugs. In general. Antigout Drugs ✔ When colchicine is taken for acute gout. They also state that little is known about long-term toxicity of the compound. but there have been no reports of bleeding from the use of CS. and stopping the preparation abruptly can result in withdrawal symptoms of pain and stiffness. other studies indicate little or no benefit when glucosamine is compared with placebo. and joint cartilage deteriorates. Opponents question the quality of the studies. chrysanthemums. In addition. Fluid intake is especially important initially. asters. possibly as well as NSAIDs. For occasional pain or fever. commercial preparations are not standardized and may contain different amounts of parthenolide. A study of 212 patients with knee OA indicated that longterm use of glucosamine improves symptoms and prevents changes in joint structure. in osteoarthritis). a synthetic supplement. Dosage is based on the client’s weight: under 120 lbs. especially in reducing the incidence and severity.112 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM CLIENT TEACHING GUIDELINES Acetaminophen. ✔ Do not exceed recommended doses. aspirin) or an anticoagulant (eg. do not take more than 4000 mg (eg. This prevents or minimizes acute attacks of gout. whether CS is absorbed systemically. and the release of inflammatory mediators such as histamine. 1500 mg GS. glucosamine production is decreased. Glucosamine is available as a hydrochloride salt and as a sulfate salt. which is the preferred form. or 3 days for fever in adults and children) without consulting a physician. because of its large molecule size. but its exact mechanism in migraine prophylaxis is unknown. 10 days in adults. of too short duration. flu. and sinus remedies contain acetaminophen. vomiting. Most studies have been done with glucosamine sulfate (GS). carry the drug and start taking it as directed (usually one pill every hour for several hours until relief is obtained or nausea. but more studies are needed. 650–1000 mg may be taken three or four times daily. The rationale for taking supplementary glucosamine is to reduce cartilage breakdown and improve cartilage production and repair. synovial fluid becomes thin and less effective in lubricating the joint. ✔ When allopurinol is taken. For example. Larger doses may cause life-threatening liver damage. Feverfew is an herbal medicine with some evidence of effectiveness in migraine. with potential overdoses. Adverse effects include hypersensitivity reactions in people who are allergic to ragweed. The usual recommended dose is 25 to 50 mg daily with food. ✔ Avoid or minimize alcoholic beverages because alcohol increases risk of liver damage. Thus. For daily. ✔ Do not exceed recommended duration of use (longer than 5 days in children. The Food and Drug Administration requires an alcohol warning on the labels of OTC pain and fever relievers and urges people who drink three or more alcoholic drinks every day to ask their doctors before taking products containing acetaminophen. Some reviewers of this study said the pain relief was minor and the radiographic changes were insignificant and did not indicate improvement in disease progression. People who have hepatitis or other liver disorders and those who ingest alcoholic beverages frequently should take no more than 2000 mg daily. warfarin). It is contraindicated in pregnant and lactating women. all consumers should read product labels carefully to avoid taking the drug in several products. when uric acid levels in the blood are high and large amounts of uric acid are being excreted in the urine. No interactions with OTC or prescription drugs have been reported. 2000 mg GS. An adequate fluid intake helps prevent formation of uric acid kidney stones. The researchers concluded that significant improvement of symptoms and less joint deterioration occurred in clients receiving glucosamine. Glucosamine is an essential structural component of joint connective tissue. eight 500 mg or extrastrength tablets or capsules) daily. . 120 to 200 lbs. over 200 lbs. ✔ With colchicine for chronic gout. Most studies are criticized as being too small. but there is a potential for increasing risks of bleeding in clients taking an antiplatelet drug (eg. radiographs of the knees were taken before starting glucosamine and after 1 and 3 years of treatment. These patients took 1500 mg of glucosamine sulfate or placebo once a day for 3 years. and whether it is able to reach cartilage cells. or daisies. Feverfew is thought to inhibit platelet aggregation. drug’s structural similarity to heparin. is also taken for arthritis. Glucosamine. pain is usually relieved in 4–12 hours with IV administration and 24–48 hours with oral administration. blood levels of uric acid usually decrease to normal range within 1–3 weeks. and Other NSAIDs (Continued ) contain 500 mg of drug per tablet or capsule. clients should be encouraged to try standard methods of preventing and treating migraine before taking products with uncertain benefits and risks. long-term use (eg. and diarrhea occur) when joint pain starts. and of having flawed designs. Aspirin. prostaglandin synthesis. The total daily dosage is usually taken with food in two to four divided doses. There is controversy about glucosamine’s ability to affect cartilage structure and delay joint deterioration. 1000 mg GS. Some studies indicate that glucosamine may decrease mild to moderate OA pain in some patients. Its main active ingredient is thought to be parthenolide. Inflammation and edema may not decrease for several days.

Nursing Diagnoses • Acute Pain • Chronic Pain • Interview and observe regarding safe. antipyretic. No interactions with OTC or prescription drugs have been reported. fluids help to prevent precipitation of salicylate crystals in the urinary tract. early treatment may prevent severe pain and anxiety and allow the use of milder analgesic drugs. • Activity Intolerance related to pain • Risk for Poisoning: Acetaminophen overdose • Risk for Injury related to adverse drug effects (GI bleeding. nausea. Nursing Process Assessment • Assess for signs and symptoms of pain. • Interview and observe regarding mobility and activity levels. 6). • With acute musculoskeletal injuries (eg. reduced urine output. systemic signs include fever. with the same dosages as listed above. Theodosakis. or antiinflammatory drugs and herbal or dietary supplements. especially in children • Experience fewer and less severe attacks of migraine Interventions Implement measures to prevent or minimize pain. such as location.” Assist clients to drink 2 to 3 L of fluid daily when taking an NSAID regularly. GI bleeding. With long-term use of aspirin. poor positioning or body alignment) thought to be causing pain. assess severity and patterns of occurrences. This decreases gastric irritation and helps to maintain good kidney function. heat. Use of this combination greatly increased after it was highly praised in The Arthritis Cure by J. duration. and factors that cause or relieve the pain (see Chap. fever. and inflammation. Assess for fever (thermometer readings above 99. diarrhea). and skin rash. or kidney disorders. The American College of Rheumatology and the Arthritis Foundation do not recommend the use of these supplements because they do not believe reported research studies adequately demonstrate significant relief of symptoms or slowing of the disease process. • severity. cold applications can decrease pain. flushed face. With antigout drugs. many of the studies involving glucosamine and chondroitin are flawed. . Glucosamine and chondroitin can each be used alone. less pain. fever. renal insufficiency) • Deficient Knowledge: Therapeutic and adverse effects of commonly used drugs • Deficient Knowledge: Correct use of OTC drugs for pain. Ask about allergic reactions to aspirin or NSAIDs. and concentrated urine may accompany fever if the person also is dehydrated.3°C] are usually considered fever). • Select drugs appropriately. but it should be avoided during pregnancy and lactation and in children. or inflammation • Treat pain as soon as possible. Fluid intake is especially important initially when serum uric acid levels are high and large amounts of uric acid are being excreted. impaired blood supply. Adverse effects include GI upset (eg. Assess for history of peptic ulcer disease. Ask about use of OTC analgesic. effective use of the drugs. Assess for inflammation. and inflammation Planning/Goals The client will: • Experience relief of discomfort with minimal adverse drug effects • Experience increased mobility and activity tolerance • Inform health care providers if taking aspirin or an NSAID regularly • Self-administer the drugs safely • Avoid overuse of the drugs • Use measures to prevent accidental ingestion or overdose. elevated white blood cell count (leukocytosis). fluids help to prevent precipitation of urate crystals and formation of urate kidney stones. and weakness. epigastric pain. Hot. then remove. infection. when appropriate. With migraine. When questioned by clients. improved ability to walk) and whether they want to continue. some physicians suggest taking the supplement for 3 months (glucosamine 500 mg and chondroitin 400 mg 3 times a day) and decide for themselves whether their symptoms improve (eg.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 113 There are no known contraindications to the use of glucosamine. With arthritis or other musculoskeletal disorders. arthritis) or circumstances (eg. and pain or tenderness. These organizations say longer clinical trials with larger groups of people are needed. Apply for approximately 20 minutes. headache.6°F [37. dry skin. edema. because effects are unknown. lack of physical activity. As with studies of the individual components. heartburn. but are more often taken in combination. fever. drowsiness. Use distraction. and inflammation: • Treat the disease processes (eg. • Assist clients with migraine to identify and avoid “triggers. assess for pain and limitations in activity and mobility. other nonpharmacologic techniques along with drug therapy. • • • • • • Evaluation • Interview and observe regarding relief of symptoms. relaxation techniques. constipation. Local signs are redness. swelling. sprains).

one of these drugs should not be taken if an ergot preparation has been taken within the previous 24 hours. codeine) or given between opioid doses. These are symptoms of ergot toxicity. the high doses and frequent administration required for anti-inflammatory effects increase the risks of GI upset. However. Rectal suppositories are sometimes used when oral administration is contraindicated. If self-administering injectable sumatriptan. aspirin is contraindicated because of its association with Reye’s syndrome. aspirin is useful in both short. long-term use in arthritis. tell your prescribing physician immediately and do not take any additional doses without specific instructions to do so.5 mg of frovatriptan. the drug of first choice is probably sumatriptan (Imitrex) or a related drug. For pain. However. Aspirin dosage depends mainly on the condition being treated. For more severe pain. The medications used to relieve acute migraine can constrict blood vessels. For chronic pain. ✔ Never take an antimigraine medication prescribed for someone else or allow someone else to take yours. . aspirin must be used appropriately to maximize therapeutic benefits and minimize adverse reactions. or a second dose of naratriptan sooner than 4 hours after the first dose. take oral drugs (except for rizatriptan orally disintegrating tablets) with fluids. Although effective. If symptoms return. and bleeding. ✔ If you have frequent or severe migraine attacks. do not exceed recommended doses. The tablet should be removed from its package with dry hands and placed on the tongue immediately. face or lips. a regular schedule of administration. or hives) occur after taking a triptan drug. report signs of poor blood circulation. plain aspirin tablets are preferred. or nasal spray. a second dose may be taken. however. Self-administration ✔ Take medication at onset of pain. is more effective. Do not take more than 12. skin rash. fever. 4. Some guidelines include the following: 1. Sumatriptan can be taken by mouth. acetaminophen. a second spray may be taken 2 hours or longer after the first spray. so such use is rational. Larger doses are needed for anti-inflammatory effects than for analgesic and antipyretic effects. Rizatriptan is available in a regular tablet. ✔ ✔ ✔ ✔ PRINCIPLES OF THERAPY Guidelines for Therapy With Aspirin When pain. If symptoms of an allergic reaction (eg. swelling of eyelids. wheezing. 3. raise blood pressure. Do not take more than 40 mg of nasal spray or 200 mg orally or by injection in any 24-hour period. aspirin is taken when the pain occurs and is often effective within a few minutes. aspirin is useful alone when the discomfort is of low to moderate intensity. Aspirin and opioid analgesics act by different mechanisms. Like any other drug. For chronic pain. For acute pain or fever. or 10 mg of zolmitriptan in any 24-hour period. by heart disease or hypertension). 5. shortness of breath. serious. ✔ With triptans. do not take a second dose of sumatriptan or zolmitriptan sooner than 2 hours after the first dose. to prevent development of more severe symptoms. which can be taken with fluids. or inflammation is present. In children. consult a physician about medications to prevent or reduce the frequency of acute attacks.and long-term therapy of conditions characterized by pain and inflammation. numbness. such as tingling sensations or coldness. heart pounding. 7. 2. ✔ For moderate to severe migraine attacks. potentially fatal reactions may occur. and cause serious adverse effects. aspirin. aspirin may be combined with an oral opioid (eg. To avoid potentially serious adverse effects. aspirin is effective across a wide range of clinical conditions.114 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM CLIENT TEACHING GUIDELINES Drugs for Migraine General Considerations ✔ Try to identify and avoid situations known to precipitate acute attacks of migraine. or another nonsteroidal anti-inflammatory drug may be effective. which can be dissolved on the tongue and swallowed without fluids. injection. 5 mg of naratriptan. such as rheumatoid arthritis or osteoarthritis. For inflammation. ✔ For mild or infrequent migraine attacks. when possible. For the nasal spray. aspirin is effective if drug therapy is indicated. For acute pain.5 mg of almotriptan. With ergot preparations. be sure to give in fatty tissue under the skin. This drug must not be taken intravenously. and daily use for antiplatelet effects. or weakness of the arms and legs. Low doses are used for antiplatelet effects in preventing arterial thrombotic disorders such as myocardial infarction or stroke. enteric-coated tablets may be better tolerated. if not contraindicated (eg. Lower-than-average doses are needed for clients with low serum albumin levels because a larger proportion of each dose is free to exert pharmacologic activity. For fever. If symptoms recur. ulceration. such as every 4 to 6 hours. and in an orally disintegrating tablet. the usual dose is one spray into one nostril. Instructions should be strictly followed for the prescribed method of administration.

seizures) indicates life-threatening toxicity. decreased hearing. vomiting. NSAIDs increase effects of a variety of drugs. delirium. beta blockers. compared with aspirin. With lithium. prolonging the serum halflife. lead to gastric ulceration and bleeding. Recognition: Signs and Symptoms Manifestations of salicylism include nausea. With cyclosporine. With ACE inhibitors. Guidelines for Therapy With Acetaminophen Acetaminophen is effective and widely used for the treatment of pain and fever. With anticoagulants. electrolyte. Toxicity: Salicylate Poisoning Salicylate intoxication (salicylism) may occur with an acute overdose or chronic use of therapeutic doses. and acid–base imbalances. and hemodialysis effectively removes salicylates from the blood.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 115 6. IV fluids are indicated when high fever or dehydration is present. ibuprofen and indomethacin may increase serum levels. It is the drug of choice for children with febrile illness (because of the association of aspirin with Reye’s syndrome). With beta blockers. In severe salicylate overdose. not for the life of the platelet (approximately 1 week) as aspirin does. especially the higher doses taken for anti-inflammatory effects. coma. acetaminophen is probably not the drug of choice for people with hepatitis or other liver disorders or those who drink substantial amounts of alcoholic beverages. and pregnant women (because aspirin is associated with several maternal and fetal disorders. and naproxen are available by prescription and OTC. Guidelines for Therapy With NSAIDs Nonaspirin NSAIDs are widely used and preferred by many people because of less gastric irritation and GI upset. When the drug may still be in the GI tract. The specific content of IV fluids depends on the serum electrolyte and acid–base status. increasing urinary excretion. ketoprofen. stopping the drug or reducing the dose is usually sufficient. stupor. serum drum levels and pharmacologic effects. Ibuprofen. Prevention To decrease risks of toxicity. Thus. Therapeutic levels are 150 to 300 mcg/mL. Intravenous (IV) sodium bicarbonate produces an alkaline urine in which salicylates are more rapidly excreted. nephrotoxicity) may be increased. and correcting fluid. treatment is symptomatic and aimed at preventing further absorption from the GI tract. fluid and electrolyte deficiencies. and diuretics. With methotrexate. bone marrow suppression. Severe central nervous system dysfunction (eg. confusion. With diuretics. elderly adults with impaired renal function (because aspirin and NSAIDs may cause further impairment). Celecoxib and meloxicam apparently do not increase methotrexate toxicity. decreased effects on hypertension and edema are attributed to retention of sodium and water. severe toxic effects may occur at levels > 400 mcg/mL. nephrotoxicity associated with both drugs may be increased. may be increased. Effects of NSAIDs on Other Drugs NSAIDs decrease effects of ACE inhibitors. risks of toxicity (eg. they are not prescribed therapeutically for antiplatelet effects. With phenytoin. prothrombin time may be prolonged and risks of bleeding are increased by NSAID-induced gastric irritation and antiplatelet effects. fever. Because NSAIDs lead to renal impairment in some clients. The major drawback to acetaminophen use is potentially fatal liver damage with overdose. stomatitis. hyperventilation. several are approved for more general use as an analgesic or antipyretic. visual changes. Two major advantages over aspirin are that acetaminophen does not cause gastric irritation or increase the risk of bleeding. Treatment In mild salicylism. serum drug levels and risk of toxicity may be increased (except with sulindac. Signs of salicylate toxicity occur at serum levels > 200 mcg/mL. In general. decreased antihypertensive effects are attributed to NSAID inhibition of renal prostaglandin synthesis. there are decreased antihypertensive effects. Clients must be instructed to avoid combined use of prescription and nonprescription NSAIDs because of the high risk of adverse effects. and causing drug accumulation. which allows unopposed pressor systems to produce hypertension. thereby slowing drug elimination. The kidneys and myocardium may also be damaged. plasma salicylate levels should be measured when an acute overdose is suspected and periodically when large doses of aspirin are taken long term. and others. Despite its high degree of safety when used appropriately. probably because of sodium and water retention. However. NSAIDs inhibit platelet activity only while drug molecules are in the bloodstream. drowsiness. blood urea nitrogen and serum creatinine should be checked approximately 2 weeks after starting any of the agents. including bleeding). gastric lavage and activated charcoal help reduce absorption. Many NSAIDs are prescription drugs used primarily for analgesia and anti-inflammatory effects in arthritis and other musculoskeletal disorders. Chronic ingestion of large doses saturates a major metabolic pathway. including adverse or toxic effects. which has no effect or may decrease serum lithium levels). tinnitus. With digoxin. The COX-2 inhibitors have little effect on platelet function. NSAIDs commonly cause gastric mucosal damage. and prolonged use may . clients taking low-dose aspirin to prevent myocardial infarction or stroke should continue the aspirin if prescribed a COX-2 inhibitor NSAID.

numerous brand names of acetaminophen are available OTC and acetaminophen is an ingredient in many prescription and OTC combination products (eg. the drug may be continued. In addition. vomiting. Rest. Treatment Gastric lavage is recommended if overdose is detected within 4 hours after ingestion and activated charcoal can be given to inhibit absorption. from all sources. Glutathione combines with a toxic metabolite and decreases hepatotoxicity if acetylcysteine is given. flu. Metabolism of acetaminophen produces a toxic metabolite that is normally inactivated by combining with glutathione. anorexia. and sinus remedies). Also. the supply of glutathione is depleted and the toxic metabolite accumulates and directly damages liver cells. intra-articular injections of corticosteroids (see Chap. diaphoresis) and may not be considered serious or important enough to report or seek treatment. 10 days or less in adults.116 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Toxicity: Acetaminophen Poisoning Poisoning may occur with a single large dose (possibly as little as 6 g. It does not reverse damage that has already occurred. has severe osteoarthritis. if no benefits seem evident or toxicity occurs. Whynn. a mucolytic agent given by inhalation in respiratory disorders. Synvisc. physical therapy. headache. Additional treatments for knee OA include topical capsaicin. AST. For chronic alcohol abusers. symptoms may subside but tests of liver function (eg. rather than the larger anti-inflammatory doses given for rheumatoid arthritis. short-term ingestion of usual therapeutic doses may cause hepatotoxicity and it is recommended that they ingest no more than 2 g daily. Another recommendation is to limit duration of use (5 days or less in children. She has also experienced dizziness when getting up from bed. should not be exceeded. With blood levels >300 mcg/mL at 4 hours after ingestion. a 73-year-old widow. At 24 to 48 hours. and drugs are used to attain these goals. Lately. although available NSAIDs have comparable effectiveness. and today she fainted. a product that helps restore the “shock-absorbing” Nursing Notes: Apply Your Knowledge Mrs. Minimal hepatotoxicity is associated with plasma levels of <120 mcg/mL at 4 hours after ingestion or <30 mcg/mL at 12 hours after ingestion. 24) or hyaluronic acid (eg. Potentially fatal hepatotoxicity is the main concern and is most likely to occur with doses of 20 g or more. Recognition: Signs and Symptoms Early symptoms (12 to 24 hours after ingestion) are nonspecific (eg. A contributing factor may be that some people think the drug is so safe that they can take any amount without harm. an NSAID is usually given. If therapeutic benefits occur. In overdose situations. it is usually given orally (dosage is listed with other antidotes in Chap. Later manifestations may include jaundice. Ingestion of an overdose may be accidental or intentional. the FDA may strengthen the warning on products containing acetaminophen and emphasize that the maximum dose of 4 g daily. Plasma acetaminophen levels should be obtained when an overdose is known or suspected. Acute renal failure may also occur. a precursor substance required for the synthesis of glutathione. preferably within 4 hours after ingestion and every 24 hours for several days. She asks you if this could be related to the medications she is taking and what she should do. about 90% of clients develop liver damage. another drug may be tried. she has been feeling weak and tired. Osteoarthritis (OA) The main goal of drug therapy is relief of pain. OTC cold. recovery in nonfatal overdoses occurs in 7 to 8 days. Because of multiple reports of liver damage from acetaminophen poisoning. A COX-2 inhibitor may be preferred for clients at high risk of GI ulceration and bleeding. oral chondroitin and glucosamine. The drug provides cysteine. To control the pain. For acetaminophen poisoning. Guidelines for Treating Arthritis The primary goals of treatment are to control pain and inflammation and to minimize immobilization and disability. bilirubin. coma. If they ingest three or more alcoholic drinks daily. A drug may be given for 2 or 3 weeks on a trial basis. Few of these measures prevent or slow joint destruction. but usually 10–15 g). . Ibuprofen and other propionic acid derivatives are often used. Another may be that people take the drug in several formulations without calculating or realizing that they are taking potentially harmful amounts. or chronic ingestion of excessive doses (5 to 8 g/day for several weeks or 3 to 4 g/day for 1 year). nausea. vomiting. she takes ibuprofen 400 mg every 4 hours while awake and prednisone 5 mg daily. and CNS stimulation with excitement and delirium. exercise. ALT. prothrombin time) begin to show increased levels. NSAIDs are usually given in analgesic doses for OA. and 3 days in both adults and children when used to reduce fever) unless directed by a physician. Acetylcysteine is most beneficial if given within 8 to 10 hours of acetaminophen ingestion. the specific antidote is acetylcysteine (Mucomyst). additional amounts constitute an overdose. but may be helpful up to 36 hours. they should avoid acetaminophen or ask a physician before using even small doses. Prevention The recommended maximum daily dose is 4 g for adults. Peak hepatotoxicity occurs in 3 to 4 days. Acetaminophen is probably the initial drug of choice. followed by vascular collapse. she swims and uses moist heat to decrease stiffness and discomfort. For example. For clients whose pain is inadequately relieved by acetaminophen. Percocet. 2). and death.

CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 117 ability of joint structures). rather than the smaller. Infants’ doses are measured with a dropper. several of the drugs are used to relieve pain. maintain therapeutic salicylate blood levels. is given in smaller doses for RA. For children with juvenile rheumatoid arthritis. children’s doses are measured by teaspoon. to read the labels of all drug products very carefully. The concentrations are different and cannot be given interchangeably. or other contraindications. However. surgery. or radiation). for moderate or severe RA. An overdose can occur with large doses of one product or smaller amounts of several different products. In addition. One of these drugs may be used alone or given along with methotrexate in clients whose symptoms are inadequately controlled by methotrexate alone. and pain remedies. When an NSAID is given during late pregnancy to prevent premature labor. and leflunomide (Arava). Aspirin. Children seem less susceptible to liver toxicity than adults. Rheumatoid Arthritis (RA) Acetaminophen may relieve pain. such as dental extractions and episiotomies. Reye’s syndrome usually occurs after a viral infection. especially after relatively minor procedures. Pediatric indications for use and dosages have not been established for most of the other drugs. It is unknown whether MTX has disease-modifying effects or just improves symptoms and quality of life. ibuprofen. nabumetone and piroxicam have long half-lives and must be discontinued approximately 1 week before surgery. aspirin. fever. Aspirin is not recommended because of its association with Reye’s syndrome. aspirin or another NSAID may relieve pain and inflammation. and other serious problems. After surgery. naproxen. Second-line drugs. anti-inflammatory doses for RA. analgesic doses given for OA. flu. these drugs prevent sensitization of peripheral pain receptors by inhibiting prostaglandin formation. the fetus’s kidneys may be adversely affected. bleeding and hematomas may occur. and the drugs should not be given if there are other risk factors for bleeding. and fatigue). apparently because they form less of the toxic metabolite during metabolism of acetaminophen. the goal with immunosuppressants is to relieve symptoms and also slow tissue damage (so-called disease-modifying effects). ketorolac. About 75% of clients have a beneficial response. and Other NSAIDs in Cancer Pain Cancer often produces chronic pain from tumor invasion of tissues or complications of treatment (chemotherapy. and Other NSAIDs in Children Acetaminophen is usually the drug of choice for pain or fever in children. the only injectable NSAID. a life-threatening illness characterized by encephalopathy. or tolmetin may be given. For mild pain. pain. another NSAID may be given. toxicity has occurred when parents or caregivers have given the liquid concentration intended for children to infants. a combination of analgesics is often needed to provide optimal pain relief. Most other NSAIDs should be discontinued approximately 3 days before surgery. For those who cannot take aspirin or a nonselective NSAID because of gastric irritation. the drug has several advantages over opioid analgesics. Aspirin is contraindicated for the client receiving chemotherapy that depresses the bone marrow because of the high risk of thrombocytopenia and bleeding. a selective COX-2 inhibitor NSAID may be preferred. Nonopioid and opioid analgesics can be given together or alternated. bleeding disorders. there is a risk of overdose and hepatotoxicity because acetaminophen is a very common ingredient in OTC cold. which is also used in cancer chemotherapy. Aspirin. Caution parents and caregivers to ask pediatricians for written instructions on giving acetaminophen to their children. Both groups of drugs may cause serious adverse effects. peptic ulcer disease. the neonate’s kidneys may be adversely affected. infliximab (Remicade). less morning stiffness. with improvement usually evident within 4 to 8 weeks (ie. acetaminophen or an NSAID may be used alone. They are especially effective for pain associated with bone metastases. these drugs may be continued and a opioid analgesic added. during which aspirin was given for fever. such as influenza or chickenpox. When aspirin is used. Ibuprofen also may be given for fever. Use of Acetaminophen. The goal of treatment with corticosteroids is to relieve symptoms. dosage usually ranges between 2 and 6 g daily but should be individualized to relieve symptoms. Although . joint edema. In addition. Caution is needed because of increased risks of bleeding. and minimize adverse effects. include corticosteroids and immunosuppressants (see Chap. has been used in more extensive surgeries. Clients who continue to have severe pain and functional impairment despite medical treatment may need knee replacement surgery. When one is given shortly after birth to close a patent ductus arteriosus. 45). Use of Acetaminophen. For people who cannot take aspirin. Aspirin is effective but many people are unable to tolerate the adverse effects associated with anti-inflammatory doses. Clinical improvement usually occurs within a few weeks. NSAIDs are usually given in larger. hepatic damage. Methotrexate (MTX). As with acute pain. Three newer immunosuppressants used to treat RA are etanercept (Enbrel). including greatly increased susceptibility to infection. for moderate to severe pain. and avoid giving children acetaminophen from multiple sources. Perioperative Use of Aspirin and Other NSAIDs Aspirin should generally be avoided for 1 to 2 weeks before and after surgery because it increases the risk of bleeding.

Thus. others think that lowering serum uric acid levels may prevent joint inflammation and renal calculi. or pyuria. Use in Renal Impairment Acetaminophen. including a hypersensitivity reaction that leads to acute renal failure. When renal blood flow is normal. and the client should lie down in a quiet. reducing dosage. Other prophylactic drugs include propranolol and other beta-adrenergic blocking agents (see Chap. COX-2 inhibitor NSAIDs may be especially beneficial in older adults because they are less likely to cause gastric ulceration and bleeding. However. manifested by proteinuria. their synthesis is increased and they protect the kidneys from ischemia and hypoxia by antagonizing the vasoconstrictive effects of angiotensin II. In addition. For moderate to severe migraine attacks. When renal blood flow is decreased. Older adults also are more likely than younger adults to acquire nephrotoxicity with NSAIDs. For frequent (two or more per month) or severe migraine attacks. darkened room. these metabolites may accumulate in renal failure. Measures to prevent or minimize renal damage include avoiding nephrotoxic drugs when possible. and those with hypertension. osteoarthritis). For example. Aspirin. they should not be taken by people with coronary artery disease or hypertension. Although these drugs are usually well tolerated. They are usually well tolerated. Colchicine also should be given for several weeks to prevent acute attacks of gout while serum uric acid levels are being lowered. ketoprofen 50 to 75 mg bid or tid. When used to prevent migraine associated with menses. Aspirin is usually safe in the small doses prescribed for prevention of myocardial infarction and stroke (antiplatelet effects). norepinephrine. and Other NSAIDs in Older Adults Acetaminophen is usually safe in recommended doses unless liver damage is present or the person is a chronic alcohol abuser. acetaminophen is nephrotoxic in overdose because it forms a metabolite that attacks kidney cells and may cause necrosis. the prostaglandin-blocking effects of aspirin and NSAIDS result in constriction of renal arteries and arterioles. because they are strong vasoconstrictors. However. hematuria. decreased renal blood flow. older adults have a high incidence of musculoskeletal disorders (eg. Guidelines for Treating Migraine For infrequent or mild migraine attacks. Although it was hoped that these drugs would have protective effects on the kidneys as they do on the stomach. monitoring renal function. People at highest risk from the use of these drugs are those with pre-existing renal impairment. Some authorities do not think drug therapy is indicated. Urate crystals are more likely to precipitate in acid urine. Acetaminophen is normally metabolized in the liver to metabolites that are excreted through the kidneys. especially with high doses or long-term use. Those for whom the triptans and ergot preparations are contraindicated for acute attacks and those whose attacks are predictable (eg. aspirin. those taking diuretics. 19). studies indicate that their effects on the kidneys are similar to those of the older NSAIDs. Aspirin is nephrotoxic in high doses. and other NSAIDs can cause or aggravate renal impairment even though they are eliminated mainly by hepatic metabolism. stopping the NSAID if renal impairment occurs. and protein binding of aspirin is reduced in renal failure so that blood levels of active drug are higher. In addition. During initial administration of these drugs. naproxen 250 to 750 mg daily or 250 mg tid). or other NSAIDs may be effective. diabetes. and an NSAID is often prescribed. Small doses. however. menstrual) may also need drug therapy to reduce the incidence and severity of acute attacks. because the drugs may reduce blood flow to the kidneys. those older than 50 years of age. Biopsy reports usually indicate inflammatory reactions such as glomerulonephritis or interstitial nephritis. probenecid. Allopurinol. Aspirin and other NSAIDs are probably safe in therapeutic doses for occasional use as an analgesic or antipyretic. Long-term use increases the risk of serious GI bleeding. Numerous medications have been used for prophylaxis. these prostaglandins have limited activity. treating the disorders that increase risk of renal damage. and other substances. If an ergot preparation is used. long-term use is not recommended because of GI and renal toxicity associated with chronic inhibition of prostaglandin production. peri- . They are also expensive compared with other antimigraine drugs. and retention of salt and water. it should be given at the onset of headache. and maintaining hydration. they should be started approximately 1 week before and continued through the menstrual period. acetaminophen. sumatriptan and related drugs are effective and they cause fewer adverse effects than ergot preparations. gradual increments. including aspirin (650 mg bid) and NSAIDs (ibuprofen 300 to 600 mg tid. aspirin. Guidelines for Treating Hyperuricemia and Gout Opinions differ regarding treatment of asymptomatic hyperuricemia. a high fluid intake (to produce approximately 2000 mL of urine per day) and alkaline urine are recommended to prevent renal calculi. aspirin and other NSAIDs can decrease blood flow in the kidneys by inhibiting synthesis of prostaglandins that dilate renal blood vessels. NSAIDs can also cause kidney damage by other mechanisms. prophylactic therapy is needed. or heart failure. decreased glomerular filtration rate. or sulfinpyrazone may be given for this purpose. and taking the drug with food or a full glass of water may decrease GI effects. adverse effects are relatively minor and usually brief. NSAIDs are often effective in migraines associated with menstruation. The role of COX-2 inhibitor NSAIDs in renal impairment is not clear.118 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Use of Acetaminophen. in clients who depend on prostaglandins to maintain an adequate renal blood flow.

alcoholics are at high risk of hepatotoxicity with usual therapeutic doses. Thus. older age group. If a client presents with acute renal failure. Give aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) with a full glass of water or other fluid and with or just after food. they should be used with caution and in lower doses in people with impaired hepatic function or a history of liver disease. the drugs should be used cautiously. adverse drug effects should be reviewed with clients. cigarette smoking. naproxen and sulindac may be metabolized more slowly and aggravate hepatic impairment if dosage is not reduced. he or she may be more likely to experience impaired liver function. the home care nurse may need to assist clients in perceiving a need for additional information and provide that information. Even though food delays absorption and decreases peak plasma levels of some of the drugs. multiple OTC NSAIDs or an OTC and a prescription NSAID). For example. Many people are aware of the drugs’ beneficial effects in relieving pain. and increases risks of adverse effects and toxicity from overdose. partly because they are usually given orally and many clients are unable to take oral medications. the effects of NSAIDs on liver function and the effects of hepatic impairment on most NSAIDs are largely unknown. Rofecoxib and meloxicam may be given without regard to food. Administer accurately a. Do not crush tablets or open capsules of long-acting dosage forms and instruct patients not to crush or chew the products. If a client is known to drink alcoholic beverages and take acetaminophen. destroys the long-acting feature. IM injections. inserting urinary catheters or GI tubes) or diagnostic procedures (eg.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 119 Use in Hepatic Impairment Except for acetaminophen. If a client has been taking an NSAID regularly. overuse of the drugs) that increase the risks of adverse effects. NSAID ingestion must be considered as a possible cause. avoiding multiple sources of acetaminophen or NSAIDs (eg. but they may not be adequately informed about potential problems associated with use of the drugs. Thus. not exceeding recommended dosages without consulting a health care provider. angiography). possibly in reduced dosage. blood levels of oral sumatriptan and related antimigraine drugs may be high because less drug is metabolized on its first pass through the liver and a higher proportion of a dose reaches the systemic circulation. Ecotrin) (2) Diclofenac sodium (Voltaren or Voltaren XR). there is a risk of bleeding from common therapeutic (eg. In liver impairment. In addition. Home Care Home use of acetaminophen and NSAIDs is extremely widespread. including the low doses prescribed for antithrombotic effects. venipuncture. In cirrhotic liver disease. by rectal suppository for pain or fever in clients who are unable to take oral drugs. renal impairment. Examples include: (1) Enteric-coated aspirin (eg. Because the drugs are metabolized in the liver. (3) Diflunisal (Dolobid) (4) Etodolac (Lodine XL) (5) Indomethacin or Indocin SR (continued ) To decrease gastric irritation. . The hepatotoxic metabolite is formed more rapidly when drugmetabolizing enzymes in the liver have been stimulated by ingestion of alcohol. aspirin. Thus. and clients should be assessed for characteristics (eg. it is probably safer to give them with food. he or she may be more likely to experience renal failure if the critical illness causes dehydration or requires treatment with one or more nephrotoxic drugs. drawing blood. Use in Critical Illness Acetaminophen. Acetaminophen may be given NURSING ACTIONS NURSING ACTIONS Analgesic–Antipyretic–Anti-inflammatory and Related Drugs RATIONALE/EXPLANATION 1. b. Pain is more likely to be treated with injectable opioid analgesics in this population. These drugs may be risk factors for renal or hepatic impairment or bleeding disorders. if a client has a history of taking aspirin. Specific suggestions include reading and following instructions on labels of OTC analgesics. For example. and other NSAIDs are infrequently used during critical illness. some authorities recommend a maximum daily dose of 2 g for people with hepatitis (compared with a maximum daily dose of 4 g for people who do not have impaired liver function). Acetaminophen can cause fatal liver necrosis in overdose because it forms a metabolite that can destroy liver cells. Breaking the tablets or capsules allows faster absorption. and drugs such as anticonvulsants and others.

insomnia. b. ulceration RATIONALE/EXPLANATION To prevent development of more severe symptoms. thrombocytopenia. anemia) (3) Central nervous system effects—headache. These effects may simulate asthma in people who are allergic to aspirin and aspirin-like drugs. and valdecoxib. bronchospasm. confusion. and bone marrow depression (leukopenia. Renal damage is usually reversible when the drug is discontinued. 3. melena. indomethacin. and sulfinpyrazone and less likely with acetaminophen. When drugs are given for pain. observe for decreased or absent manifestations of pain. With analgesic–antipyretic–anti-inflammatory and antigout agents. absence of new tophi. retention of sodium and water with resultant edema . Tinnitus (ringing or roaring in the ears) is a classic sign of aspirin overdose (salicylate intoxication). dermatitis (5) Hypersensitivity reactions with dyspnea. These are common reactions. rofecoxib. asthma. and stiffness of joints. especially when fluid intake is decreased or fluid loss is increased. Pain relief is usually evident within 30–60 minutes. fainting. observe for relief of symptoms. especially with high dosages. dizziness. Observe for therapeutic effects a. diarrhea. and observe for a decrease. When triptans or ergot preparations are given in migraine headache. observe for decreased size of tophi. heat. When drugs are given for arthritis and other inflammatory disorders. bleeding. d. increased serum creatinine. tolmetin. f. observe for: (1) Gastrointestinal problems—anorexia. probenecid. Therapeutic effects occur within 4–12 hours after intravenous colchicine administration and 24–48 hours after oral administration. More likely to occur in people with preexisting renal impairment. May result in severe symptoms. or rhinitis. Therapeutic effects are usually evident within 15–30 minutes. hyperkalemia. nausea. vomiting. Serum uric acid levels usually decrease to normal range within 1–3 weeks. skin rashes These effects are relatively common with indomethacin and may occur with most of the other drugs. observe for normal serum uric acid level (approximately 2–8 mg/100 mL). observe for decreased pain. bruises. fenoprofen. especially with overdosage. (continued ) (6) Tinnitus. record temperature every 2 to 4 hours. decreased joint pain and increased joint mobility. diflunisal. including potentially fatal bronchospasm. epistaxis. piroxicam. redness. Give antimigraine preparations at the onset of headache. g. Bone marrow depression is more likely to occur with colchicine. colchicine. and normal serum uric acid levels. When allopurinol. hematuria. Edema may not decrease for several days. c. Also observe for increased joint mobility and exercise tolerance. more likely with aspirin. Older adults are at greater risk because of decreased renal blood flow and increased incidence of congestive heart failure and diuretic therapy. With aspirin. ataxia. e. improvement is usually noted within 24–48 hours. sulindac. drowsiness (4) Skin rashes. When drugs are given for fever. naproxen. blurred vision (7) Nephrotoxicity—decreased urine output. It occurs with NSAIDs as well. With most of the NSAIDs. When colchicine is given for acute gouty arthritis. 2. 1–2 weeks may be required before beneficial effects become evident. Most likely to occur in patients with a history of nasal polyps. edema.120 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS (6) Ketoprofen or Oruvail extended-release capsules (7) Naproxen delayed-release (EC-Naprosyn) or naproxen sodium controlled-release (Naprelan) c. (2) Hematologic problems—petechiae. etodolac. observe for decreased pain and inflammation in involved joints. celecoxib. or sulfinpyrazone is given for hyperuricemia. ibuprofen. Observe for adverse effects a. When the above drugs are given for chronic gout. increased blood urea nitrogen (BUN).

a prostaglandin. Additive gastric irritation and possible ulcerogenic effects Inhibits liver enzymes that normally metabolize celecoxib. numbness. dizziness. Gangrene of extremities rarely occurs with usual doses unless peripheral vascular disease or other contraindications are also present.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 121 NURSING ACTIONS (8) Cardiovascular effects—increased hypertension RATIONALE/EXPLANATION Long known to occur with older NSAIDs. The ergot alkaloids are highly toxic. Drug that decreases effects of fenoprofen: (1) Phenobarbital e. Circulatory impairments may result from vasoconstriction and vascular insufficiency. A few cases have been reported with COX-2 inhibitors. weak pulse. diarrhea (2) Symptoms of ergot poisoning (ergotism)—coolness. sodium bicarbonate) (2) Misoprostol (Cytotec) d. However. gangrene of the extremities These drugs have a direct effect on the vomiting center of the brain and stimulate contraction of gastrointestinal smooth muscle. ascorbic acid) (2) Alcohol (3) Anticoagulants. dizziness. was developed specifically to prevent aspirin and NSAID-induced gastric ulcers. Allergic reactions are relatively uncommon. With ergot antimigraine drugs. nausea. Blood pressure may rise as a result of generalized vasoconstriction induced by the ergot preparation. vomiting. Drug that increases effects of celecoxib: (1) Fluconazole (and possibly other azole antifungal drugs) c. Aspirin or an NSAID can often be used with these drugs to provide adequate pain relief without excessive doses and sedation. People taking anticoagulants should avoid aspirin and aspirin-containing products. observe for: (1) Nausea. in overdose or in people with underlying liver disease Most adverse effects are mild and transient. convulsions. Induces drug-metabolizing enzymes in the liver and decreases blood levels of rofecoxib (continued ) (5) Corticosteroids (eg. Additive analgesic effects because of different mechanisms of action. Dosage of fenoprofen may need to be increased if phenobarbital is started or decreased if phenobarbital is discontinued. because of their vasoconstrictive effects. oxycodone Acidify urine and thereby decrease the urinary excretion rate of salicylates Increases gastric irritation and occult blood loss Increase risk of bleeding substantially. Observe for drug interactions a. poisoning may be acute or chronic. drowsiness. cyanosis. Occurs mainly with acetaminophen. probably due to retention of sodium and water. observe for: (1) Chest tightness or pain. they may cause or aggravate angina pectoris and hypertension. Drug that decreases effects of rofecoxib (1) Rifampin . headache. confusion. paresthesias c. thirst. muscle weakness and pain. and tingling of the extremities. prednisone) b. angina-like chest pain. mechanism unknown. transient tachycardia or bradycardia. hydrocodone. (3) Hypertension (4) Hypersensitivity reactions—local edema and pruritus. (9) Hepatotoxicity—liver damage or failure b. anaphylactic shock 4. Large doses also damage capillary endothelium and may cause thrombosis and occlusion. Drugs that decrease effects of aspirin and other NSAIDs: (1) Alkalinizing agents (eg. increases serum celecoxib levels Increase rate of renal excretion This drug. chronic poisoning is usually a result of overdosage. Induces drug-metabolizing enzymes in the liver and decreases blood levels of fenoprofen. fatigue. Acute poisoning is rare. With triptan antimigraine drugs. oral (4) Codeine. vomiting. hypertension. Drugs that increase effects of aspirin and other NSAIDs: (1) Acidifying agents (eg.

Decrease uricosuric effects Mainly at salicylate doses of less than 2 g/day. epinephrine. sodium bicarbonate) RATIONALE/EXPLANATION Increase risk of gastrointestinal bleeding. decrease uricosuric effects of probenecid and sulfinpyrazone but do not interfere with the action of allopurinol. Blood loss is often gradual. How do aspirin and other NSAIDs produce analgesic. Drugs that increase effects of ergot preparations: (1) Vasoconstrictors (eg. For a 6-year-old child with fever. ibuprofen. make sure Mrs. Delay absorption from the gastrointestinal tract Decrease risks of renal calculi from precipitation of uric acid crystals. or acetaminophen be preferred? Why? . Nursing Notes: Apply Your Knowledge Answer: The symptoms may be related to her medications. Drugs that increase the effects of triptan antimigraine drugs: (1) Monoamine oxidase inhibitors (MAOIs) Increase serum levels of triptans and may cause serious adverse effects. Take Mrs. especially with daily ingestion? 3. anti-inflammatory. These drugs should not be used concurrently. including cardiac arrhythmias and myocardial infarction. probenecid. and sulfinpyrazone: (1) Alkalinizing agents (eg. oral (2) Corticosteroids (3) Salicylates (4) Heparin g. but you need to collect more information before you can be sure. ephedrine. Increase ulcerogenic effect Increase ulcerogenic effect Increases risk of bleeding. For a 50-year-old adult with rheumatoid arthritis. phenylephrine) j. Triptans and MAOIs must not be taken concurrently. 4. who will test her stool for blood. antipyretic. Indomethacin causes gastric irritation and is considered an ulcerogenic drug. so patients get used to the fatigue. (2) Ergot preparations Triptans and ergot preparations should not be taken concurrently or within 24 hours of each other. Recommended for concurrent use until serum uric acid levels return to normal. will do some diagnostic tests. to prevent falls and accidental injury. Refer her to her physician. Whynn seeks care promptly. What adverse effects occur with aspirin and other NSAIDs. persistent hypertension and intracranial hemorrhage (2) Colchicine (3) Diuretics (4) Salicylates i.122 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS f. Drugs that decrease effects of allopurinol. Alkalinizing agents are recommended until serum uric acid levels return to normal. because severe hypertension and stroke may occur. Decreases attacks of acute gout. would aspirin or acetaminophen be preferred? Why? 5. Additive vasoconstriction with risks of severe. Whynn’s postural blood pressure. A very common side effect of aspirin (and all nonsteroidal antiinflammatory drugs) is gastric irritation that can cause gastrointestinal ulceration and bleeding. Most important. Drugs that increase effects of indomethacin: (1) Anticoagulants. another NSAID. and antiplatelet effects? 2. and acetaminophen. Compare and contrast the uses and effects of aspirin. Salicylates are uricosuric at doses greater than 5 g/day. When patients become volume depleted secondary to the blood loss. a triptan should not be taken for at least 2 weeks after an MAOI is discontinued. would aspirin. Review and Application Exercises 1. and if blood is present. Drugs that decrease effects of indomethacin: (1) Antacids h. they can exhibit signs of dizziness and syncope.

T. J. and acetaminophen. & Patrono. For a 75-year-old adult with osteoarthritis and a long history of “stomach trouble. Journal of the American Medical Association. Graves.1903). PA: Springhouse Corporation. pp 667—678. L. Whitaker. Approach to the patient with headache. P. & Hunder. M. (2000). Worsening of hypertension by cyclooxygenase-2 inhibitors. C. T. C. Gulin. Glucosamine and chondroitin for treatment of osteoarthritis.. Journal of Clinical Hypertension. 396–398. W. Louis: Facts and Comparisons. (2000). L. J. 345(6). The arthritis cure. Philadelphia: Lippincott Williams & Wilkins. E. other NSAIDs. New England Journal of Medicine. placebocontrolled trial of glucosamine to control pain in osteoarthritis of the knee. what information do you think would be most helpful in home management of migraine? SELECTED REFERENCES Barkin. The coxibs. (2000). D. Springhouse. Pharmacologic management of acute and chronic pain. J.. McAlindon. p. (2000). October 29–November 2. Abstract No. 4th ed.CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 123 6. Gourley (Eds. W. Fetrow. (2001). T. What are some nursing interventions to decrease the adverse effects of aspirin. J. D. R. What is the rationale for combining opioid and nonopioid analgesics in the treatment of moderate pain? 11. W. (2000). E. & Barkin. Philadelphia: Lippincott Williams & Wilkins. G. 94(8). A. A. J.). what information must be included? 9. D. R.. 756–812. Osteoarthritis. Drug facts and comparisons. Humes (Ed. 2(6). Southern Medical Journal. Philadelphia. LaValley. double-blind.. (1997). St. 7th ed. & Avila. If you were a client. A. (2001). 2000. R. When teaching a client about home use of aspirin. . selective inhibitors of cyclooxygenase-2. A. In H.). In E. J. Hughes. Textbook of therapeutics: Drug and disease management. other NSAIDs. I.. (Updated monthly). Lance. 2836–2844. What is the rationale for using acetylcysteine in the treatment of acetaminophen toxicity? 10. or acetaminophen be preferred? Why? 7. Theodosakis.” would aspirin. A randomized. A. & Carr. 1469–1475. New York: St Martin’s Press. R. Fitzgerald. 168. and acetaminophen? 8. (Program and abstracts from the 64th Annual Scientific Meeting of the American College of Rheumatology. Kelley’s Textbook of internal medicine. another NSAID. P. 433–442. & Small. Herfindal & D. R. 283. (1999). & Felson. Professional’s handbook of complementary & alternative medicines. pp.

sedating herbs such as kava and valerian. Sominex. Xanax. stress management. is sometimes confused with ranitidine (Zantac). ambulating without help. For long-term relief. When being discontinued. they may be taken with food if stomach upset occurs. Also. preferably by the generic and trade names. and the dietary supplement melatonin) while taking any antianxiety or sedative-hypnotic drugs (except buspirone). Accidental or intentional ingestion may lead to serious adverse effects. Store drugs safely. ✔ Take buspirone on a daily schedule. Ativan. which may eventually cause worse problems than the original anxiety or insomnia. Stimulant drugs include asthma and cold remedies and appetite suppressants. This may prevent or decrease the severity of nervousness or insomnia so that sedative-type drugs are not needed. and cause dependence. It is not fully effective until after 3–4 weeks of regular use. or to take one drug for daytime sedation and another for sleep. ✔ Do not perform tasks that require alertness if drowsy from medication. cause drowsiness. ✔ Omit one or more doses if excessive drowsiness occurs to avoid difficulty breathing. Do not take “sleeping pills” every night. ✔ Avoid alcohol and other depressant drugs (eg. and Restoril are commonly used examples of this group. but there are several others as well. operating machinery. Do not stop taking a Valium-related drug abruptly. and thereby make routine activities potentially hazardous. Physical exercise. and other potentially serious adverse drug effects. difficulty breathing. This helps avoid multiple prescriptions of drugs with similar effects and reduces the risk of serious adverse effects from overdose. reading. ✔ Inform all health care providers when taking a sedativetype medication. ✔ Use nondrug measures to promote relaxation. . ✔ Take oral benzodiazepines with a glass of water. Tylenol PM). rest. these factors can cancel or decrease the drugs’ effects. because the drug acts quickly to cause drowsiness. These drugs lose their effectiveness in 2–4 weeks if taken nightly. These activities may lead to falls or other injuries if undertaken while alertness is impaired. Avoid smoking. at bedtime. and how long to take the drugs. With rare exceptions. driving a car. Because these drugs depress brain functioning when taken alone. Thus. ✔ Try to identify and avoid factors that cause nervousness or insomnia. and other adverse drug effects. Alprazolam (Xanax). over-thecounter [OTC] antihistamines and sleeping pills. Compoz. and relaxation techniques are safer than any drug. and zolpidem (Ambien) can cause physical dependence. ✔ Most “nerve pills” and “sleeping pills” belong to the same chemical group and have similar effects. narcotic analgesics. counseling or psychotherapy may be more beneficial because it can help you learn other ways to decrease your nervousness and difficulty in sleeping. combining them produces additive depression and may lead to excessive drowsiness.CLIENT TEACHING GUIDELINES Antianxiety and Sedative-Hypnotic Drugs General Considerations ✔ “Nerve pills” and “sleeping pills” can relieve symptoms temporarily but they do not cure or solve the underlying problems. a drug for heartburn and peptic ulcers. These drugs produce more beneficial effects and fewer adverse reactions when used in the smallest effective doses and for the shortest duration feasible in particular circumstances. falls. these drugs are recommended only for short-term use. If the drugs are used. including the ability to decrease nervousness. Nytol. and other potentially hazardous tasks. ✔ Take sleeping pills just before going to bed so that you are lying down when the expected drowsiness occurs. dosage should be gradually reduced. All of the Valium-related drugs. The drugs often impair mental and physical functioning. ✔ ✔ ✔ ✔ ✔ Self-Administration ✔ Follow instructions carefully about how much. because a person sedated by a previous dose may take additional doses. and sleep when possible. brain-depressant drugs should be taken only by those people for whom they are prescribed. zaleplon (Sonata). there is no logical reason to take a combination of the drugs for anxiety. it is ineffective for occasional use. Withdrawal symptoms can occur. how often. An antihistamine that causes drowsiness is the active ingredient in OTC sleep aids (eg. traumatic injuries. ✔ Take zolpidem on an empty stomach. such as caffeine-containing beverages and stimulant drugs. Do not share these drugs with anyone else. do not keep the drug container at the bedside. Unisom) and many pain reliever products with “PM” as part of their names (eg. as directed and with the supervision of a health care provider. especially during the first several days of use. craft work. and cause sleep disturbances when stopped. out of reach of children and adults who are confused or less than alert. Valium. These mindaltering.

thorough and frequent toothbrushing. ✔ Take the medication at bedtime. a responsible adult caregiver is needed to prompt a client about taking particular doses and to manage other aspects of the drug therapy regimen. . wear protective clothing. Although it is usually not serious. when results can be expected. General Considerations ✔ Ask about the planned drug therapy regimen. to decrease risks of undesirable drug interactions. a chronic mental illness. Antacids decrease absorption of these drugs from the intestine. If an antacid is needed (eg. operate machinery. including the desired results. ✔ Maintain an adequate supply of medication to ensure regular administration. slowed thinking.CLIENT TEACHING GUIDELINES Antipsychotic Drugs Antipsychotic drugs are given to clients with schizophrenia. Sensitivity to sunlight occurs with some of the drugs and may produce a sunburn-type of skin reaction. ✔ These drugs should be tapered in dosage and discontinued gradually. to prevent undesirable drug interactions. so that drowsiness aids sleep and is minimized during waking hours. drinking fluids. ✔ Avoid taking these medications with antacids. keep the client indoors and use air conditioning or fans during the hours of highest heat levels. and impaired muscle coordination are especially likely during the first 2 weeks of drug therapy but tend to decrease with time. including dental checkups. ✔ Do not allow the client to drive a car. ✔ Practice good oral hygiene. dry mouth can lead to mouth infections and dental cavities. Alcohol and sleeping pills should be avoided because they may cause excessive drowsiness and decreased awareness of safety hazards in the environment. Some of these medications may cause fever and heat prostration with high environmental temperatures. Medication Administration Assist or prompt the client to: ✔ Take medications in the correct doses and at the correct times. and use sunscreen lotions. and the tentative length of drug therapy. ✔ Report unusual side effects and all physical illnesses. it should be taken 1 hour before or 2 hours after the antipsychotic drug. to maintain blood levels and beneficial effects. Because of the nature of the disease. Mouth dryness is a common side effect of the drugs. ✔ Keep all physicians informed about all the medications being taken by the client. ✔ Minimize exposure to sunlight. ✔ Try to prevent the client from taking unprescribed medications. Drowsiness. for heartburn). ✔ Lie down for approximately an hour after receiving medication. Consistent blood levels are necessary to control symptoms and prevent recurring episodes of acute illness and hospitalization. In hot weather or climates. or perform activities that require alertness when drowsy from medication. they should not be stopped abruptly. including those available without prescription or those prescribed for another person. because changes in drug therapy may be indicated. if dizziness and faintness occur. as follows. ✔ Avoid exposure to excessive heat. if able. and frequent mouth rinsing.

McGrath’s risk for depression. and nursing process implications. what suggestions would you have for Mrs. Etiology Despite extensive study and identification of numerous potential contributory factors. and cyclothymia (Box 10–1).chapter 10 Drugs for Mood Disorders: Antidepressants and Mood Stabilizers Objectives AFTER STUDYING THIS CHAPTER. was recently widowed. the etiology of depression is unclear. maintain their home. The average depressive episode lasts about 5 months. Her children live out of state. recognizing. Betty’s daughter calls you because she is concerned about her mother. and sleeps much more than usual. mirtazapine. Monoamine Neurotransmitter Dysfunction Depression is thought to result from a deficiency of norepinephrine and/or serotonin. 6. It is likely that depression results from interactions among several complex factors. and venlafaxine. Describe major features of depression and bipolar disorder. She depended on her husband to handle their finances. Discuss interventions to increase safety of lithium therapy. 8. indications for use. McGrath seems to be losing weight. principles of therapy. 5. complains she feels very tired. This hypothesis stemmed from M 163 . 3. but they write and call often. nefazodone. bipolar disorder and mood stabilizing drugs are also discussed. Depression is estimated to affect 5% to 10% of adults in the United States and to be increasing in children and adolescents. THE STUDENT WILL BE ABLE TO: 1. Discuss characteristics of antidepressants in terms of mechanism of action. and treating overdoses of antidepressant drugs and lithium. ᮣ What symptoms does Mrs. Two of the major theories of depression pathogenesis are described below. and having one episode is a risk factor for developing another episode. and make major decisions. dysthymia. ᮣ List factors that might increase Mrs. stays home most of the time. bipolar disorder. Describe the nursing role in preventing. 2. 4. Compare and contrast selective serotonin reuptake inhibitors with tricyclic antidepressants. She is also reluctant to go out with friends or visit her children. Describe the use of lithium in bipolar disorder. It is associated with impaired ability to function in usual activities and relationships. Mrs. McGrath and her daughter? MOOD DISORDERS ood disorders include depression. Critical Thinking Scenario Betty McGrath. She enjoyed the role of homemaker and never worked outside the home. Depression and antidepressant drug therapy are emphasized in this chapter. 7. Analyze important factors in using antidepressant drugs and lithium in special populations. Discuss selected characteristics of bupropion. McGrath have that may indicate she is depressed? ᮣ What additional data would support a diagnosis of depression? ᮣ At this point. adverse effects. 73 years of age.

inflated self-esteem. and leisure and sexual activities Inappropriate feelings of guilt and worthlessness Loss of appetite and weight loss. they are not severe enough to meet the criteria for major depression. poor concentration. located on presynaptic nerve terminals. little need for sleep. This down-regulation of receptors. presynaptic receptors regulate the release and reuptake of neurotransmitters. constant movement. Symptoms are similar to those of acute psychosis or schizophrenia. postsynaptic receptors participate in the transmission of nerve impulses to target tissues. severe or major depression is a psychiatric illness and requires treatment. Cyclothymia Cyclothymia is a mild type of bipolar disorder which involves periods of hypomania and depression that do not meet the criteria for mania and major depression. There is evidence that alpha2 receptors are also down-regulated by antidepressant drugs. whose secretion is increased in depression. All known treatments for depression lead to the down-regulation of beta receptors and occur in the same period as the behavioral changes associated with antidepressant drug therapy. but they are less severe. A major non-monoamine is corticotropin releasing factor. anorexia. Studies demonstrated that chronic drug administration (ie. corresponds with therapeutic drug effects. insomnia. animal studies indicate that serotonin is required for optimal functioning of the neurons that produce norepinephrine. constipation. is characterized by depressed mood. Alpha2-adrenergic receptors (called autoreceptors). and possibly other neurotransmission systems (eg. Overall. CRF-secreting neurons are widespread in the CNS. or hormone (CRF or CRH). indicate less CNS stimulation and hyperactivity. and CRF apparently functions as a neuro- . Hypomania involves the same symptoms. such as mood. work. Neuroendocrine Factors In addition to monoamine neurotransmission systems. integration.164 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM BOX 10–1 TYPES OF MOOD DISORDERS Obsession with death. thus allowing in- creased norepinephrine release. With serotonin receptors. Physiologically. 4th edition (Text Revision). and cognitive and psychomotor functions. dopamine. Mania is characterized by excessive CNS stimulation with physical and mental hyperactivity (eg. appetite. low self-esteem. but relief of depression occurred only after weeks of drug therapy. such as hallucinations and delusions Dysthymia Dysthymia involves a chronically depressed mood and at least two other symptoms (eg. available antidepressants may increase the sensitivity of postsynaptic receptors and decrease the sensitivity of presynaptic receptors. fatigue Indecisiveness Difficulty thinking and concentrating Loss of interest in appearance. Serotonin helps regulate several behaviors that are disturbed in depression. It seems apparent that long-term administration of antidepressant drugs produces complex changes in the sensitivities of both presynaptic and postsynaptic receptor sites. often described as the most common mental illness. For example. Emphasis shifted toward receptors because the neurotransmitter view did not explain why the amounts of neurotransmitter increased within hours after single doses of a drug. researchers have identified non-monoamine systems that influence neurotransmission and are significantly altered in depression. and it occurs in all age groups. impulsiveness. racing thoughts. in which people of usually normal moods experience recurrent episodes of depression. may also play a role. or excessive eating and weight gain Sleep disorders (hypersomnia or insomnia) Somatic symptoms (eg. and interactions among norepinephrine. Changes in neurons may also play a major role. Major Depression The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. thoughts of suicide Psychotic symptoms. Depression Depression. Serotonin received increased attention after the selective serotonin reuptake inhibitor (SSRI) antidepressants were marketed. low energy. energy level. feelings of sadness. grandiose ideas. increased neurotransmitter in the synapse for several weeks) results in fewer receptors on the postsynaptic membrane. Researchers identified changes in norepinephrine and serotonin receptors with chronic antidepressant drug therapy. overeating. first noted with beta-adrenergic receptors. poor concentration. When these receptors are stimulated. serotonin. feelings of hopelessness) for two years. constant talking. or emotional upset. headache. there is increasing awareness that balance. Mild depression occurs in everyone as a normal response to life stresses and losses and usually does not require treatment. sleep. lists criteria for a major depressive episode as a depressed mood plus at least five of the following symptoms for at least 2 weeks: Loss of energy. they inhibit the release of norepinephrine. Major depression also is categorized as unipolar. short attention span) for at least one week. Symptoms must be present for at least two years. acetylcholine) are probably more important etiologic factors than single neurotransmitter or receptor alterations. agitation. It does not usually require drug therapy. atypical pain) studies demonstrating that antidepressant drugs increase the amounts of one or both of these neurotransmitters in the central nervous system (CNS) synapse by inhibiting their reuptake into the presynaptic neuron. Bipolar Disorder Bipolar disorder involves episodes of depression alternating with episodes of mania. Although the symptoms may cause significant social and work-related impairments. and last 3 or 4 days. hypersomnia.

the HPA axis. which apparently change brain structure and function and contribute to the development of depression in some people. • They are metabolized by the cytochrome P450 enzymes in the liver. Additional Factors Additional factors thought to play a role in the etiology of depression include the immune system. adrenocortiocotropic hormone (ACTH) by the anterior pituitary. These mechanisms thereby increase the amount of neurotransmitter available to bind to receptors. After neurotransmitters are released from presynaptic nerve endings. More specifically. gamma-aminobutyric acid [GABA]). Extrahypothalamic CRF is also increased in depression. which becomes hyperactive in depression. and the noradrenergic neurotransmission system. Older antidepressants include the tricyclic antidepressants (TCAs) and the monoamine oxidase inhibitors (MAOIs). which affect neurotransmission. SSRIs selectively inhibit the reuptake of serotonin. norepinephrine receptors. and tumor necrosis factor). . MAOIs. Changes have been identified in CRF. Possible mechanisms of cytokine-induced depression include increased CRF and activation of the HPA axis. the approximate time interval required for the drugs to improve symptoms of depression. • They are given orally. antidepressants may interact with each other and with a wide variety of drugs that are normally metabolized by the same subgroups of enzymes. receptors adapt to the presence of increased neurotransmitter by decreasing their number or sensitivity to the neurotransmitter. Environmental factors include stressful life events. immune. there is increased secretion of CRF by the hypothalamus. norepinephrine) or a relative deficiency of inhibitory neurotransmitters (eg. Mechanisms of Action Although their actions are still being studied in relation to newer information about brain function and the etiology of mood disorders. Bipolar Disorder Like depression. ANTIDEPRESSANT DRUGS Drugs used in the pharmacologic management of depressive disorders are derived from several chemical groups. The serotonin2 receptor. genetic factors. where they undergo extensive first-pass metabolism before reaching the systemic circulation. Hypothalamic CRF is part of the hypothalamic-pituitary-adrenal (HPA) axis. Thus. Most antidepressants prevent the reuptake of multiple neurotransmitters. interferons. all of which are activated as part of the stress response. Secretion of both hypothalamic and extrahypothalamic CRF apparently returns to normal with recovery from depression.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 165 transmitter and mediator of the endocrine. and cortisol (glucocorticoid) receptors may also be downregulated. With chronic drug administration. T lymphocytes and B lymphocytes) produce cytokines (eg. mania and hypomania may result from abnormal functioning of neurotransmitters or receptors. and environmental factors. autonomic. antidepressant drugs apparently normalize abnormal neurotransmission systems in the brain by altering the amounts of neurotransmitters and the number or sensitivity of receptors. This alteration of cortisol receptors takes about two weeks. Genetic factors are considered important mainly because close relatives of a depressed person are more likely to experience depression. the molecules that are not bound to receptors are normally inactivated by reuptake into the presynaptic nerve fibers that released them or metabolized by monoamine oxidase (MAO). enter the portal circulation. This view is supported by animal studies indicating that antidepressant drugs restore the ability of cortisol receptors to bind with cortisol. and behavioral responses to stress as well as a releasing factor for corticotropin. but they differ in their adverse effects. As a result. interleukins. Most studies have involved early life trauma such as physical or sexual abuse in childhood. • All must be taken for 2 to 4 weeks before depressive symptoms improve. and circulate through the liver. a postsynaptic receptor. Newer drugs include the selective serotonin reuptake inhibitors (SSRIs) and several individual drugs that differ from TCAs. such as a relative excess of excitatory neurotransmitters (eg. Drugs that stimulate the CNS can cause manic and hypomanic behaviors that are easily confused with schizophreniform psychoses. absorbed from the small bowel. and cortisol by the adrenal cortex. These changes are thought to cause a hypersensitive or exaggerated response to later stressful events. alteration of monoamine neurotransmitters in several areas of the brain. The increased cortisol (part of the normal physiologic response to stress) is thought to decrease the numbers or sensitivity of cortisol receptors (downregulation) and lead to depression. or cytokines functioning as neurotransmitters and exerting direct effects on brain function. Immune cells (eg. Other neuroendocrine factors in depression are thought to include abnormalities in the secretion and function of thyroid and growth hormones. and SSRIs. especially postsynaptic beta receptors and presynaptic alpha2 receptors. Many antidepressants and other drugs are metabolized by the 2D6 or 3A4 subgroup of the enzymes. are downregulated. the HPA axis and cortisol activity). They may also modify interactions among neurotransmission systems and affect endocrine function (eg. including mild stress or daily life events. MAOIs prevent the metabolism of neurotransmitter molecules. General characteristics of antidepressants include the following: • All are effective in relieving depression.

anxiety. TCAs are also commonly used in the treatment of neuropathic pain. Fluoxetine also forms an active metabolite with a half-life of 7 to 9 days. and drug effects decrease slowly (over 2 to 3 months) when fluoxetine is discontinued. Although some of the drugs act more selectively on one neurotransmission system than another initially. and have a half-life of 24 to 72 hours.166 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Thus. potassium. of which imipramine is the prototype. SSRIs are usually given once daily. Because SSRIs are highly bound to plasma proteins. especially in overdose. Selective Serotonin Reuptake Inhibitors (SSRIs) Selective serotonin reuptake inhibitors (SSRIs). It also stabilizes postsynaptic receptor sensitivity to neurotransmitters. urinary retention). Thus. In addition. Most also cause some degree of CNS stimulation (eg. Normally. Sertraline (Zoloft) and citalopram (Celexa) also have active metabolites. reactions have occurred from combined therapy with an SSRI and an MAOI. and fluvoxamine (Luvox) reach steady-state concentrations in 1 to 2 weeks. Sarafem) is the prototype. antidepressants are increasingly being used for treatment of anxiety disorders. names. Because of adverse effects on the heart. anticholinergic effects (eg. which is most prominent with fluoxetine. an inhibitory neurotransmitter. are similar drugs that produce a high incidence of adverse effects such as sedation. a TCA may be given after physical causes (eg. but first-pass metabolism by the liver results in blood level variations of 10. dopamine. release. excessive intake of fluids) have been ruled out. it is known to affect the synthesis. antidepressant effects are attributed to changes in receptors rather than changes in 30-fold among people given identical doses. probably by competing with calcium. produce fewer serious adverse effects than the TCAs. mixed mania and depression. largely because of their potential for serious interactions with certain foods and other drugs. these drugs are widely distributed in body tissues and metabolized by the liver to active and inactive metabolites. Serious. Paroxetine. narrow-angle glaucoma. With lithium. Foods that interact contain tyramine. baseline and follow-up electrocardiograms (ECGs) are recommended for all clients. Indications for Use Antidepressant drug therapy may be indicated if depressive symptoms persist at least 2 weeks. dry mouth. and sodium ions for binding sites. indications for use. are highly protein bound (95%). but fluoxetine and paroxetine (Paxil) are more likely to accumulate. Amitriptyline (Elavil) is a commonly used TCA. or cardiovascular disease. urethral irritation. of which fluoxetine (Prozac. Once absorbed. this selectivity seems to be lost with chronic administration. diarrhea. GABA. For example. nervousness. Contraindications to Use Antidepressant drugs are contraindicated or must be used with caution in clients with acute schizophrenia. and weight gain. cardiac dysrhythmias. magnesium. and dosage ranges of individual drugs are listed in Drugs at a Glance: Antidepressant Agents. orthostatic hypotension. a monoamine precursor of norepinephrine. delayed ejaculation in men and impaired orgasmic ability in women). which may lead to accumulation with chronic administration. Adverse effects include a high incidence of gastrointestinal symptoms (eg. they accumulate in the CNS and other adipose-rich tissue. the drugs compete with endogenous compounds and other medications for binding sites. severe renal. fluoxetine should be discontinued at least 5 weeks before starting an MAOI. and norepinephrine. mainly because they may interact with some foods and drugs to produce severe hypertension and possible heart attack or stroke. Because they are highly lipid soluble. weight loss) and sexual dysfunction (eg. and reuptake of several neurotransmitters in the brain. and seizure disorders. However. If a client on an SSRI is to be transferred to an MAOI. the drug may increase the activity of GABA. Monoamine Oxidase Inhibitors MAOIs are infrequently used. sertraline. and the drugs should not be given concurrently or within 2 weeks of each other. vision. In this setting. including acetylcholine. the exact mechanism of action is unknown. constipation. sometimes fatal. They are well absorbed after oral administration. most SSRIs should be discontinued at least 14 days before starting the MAOI. nausea. suicidal tendencies. hepatic. insomnia). They are well absorbed with oral administration. undergo extensive first-pass metabolism in the liver. TCAs may be used in children and adolescents in the management of enuresis (bedwetting or involuntary urination resulting from a physical or psychological disorder). tyramine is deactivated in the gastrointestinal tract and liver so that large amounts do not Tricyclic Antidepressants Tricyclic antidepressants (TCAs). MAOIs are considered third-line drugs. impair social relationships or work performance. and occur independently of life events. steady-state blood levels are achieved slowly. over several weeks. blurred . TYPES OF ANTIDEPRESSANTS AND INDIVIDUAL DRUGS Additional characteristics of antidepressants and lithium are described in the following sections.

Give maintenance dose once daily. increased to 100 mg daily if necessary Children >6 y: Enuresis. increased up to 62. if necessary. Maximum dose. 60 mg/d Controlled-release tablets. Maximum dose. maximum dose. Give maintenance dose in a single dose at bedtime. PO 75 mg daily in 3 divided doses. if necessary Elderly/hepatic impairment: PO 20 mg daily PO 20 mg once daily in the morning.5 mg/d if necessary Elderly or debilitated adults: PO 10 mg once daily. increased in 25-mg increments every 4–7 days if necessary. 150 mg/d Adolescents and older adults: 30–50 mg/d. increased at 1 week or longer intervals. Pamelor) Protriptyline (Vivactil) Trimipramine maleate (Surmontil) Depression Depression Depression PO 50–100 mg once daily at bedtime. PO 100–200 mg daily in divided doses or as a single daily dose. increased to 100 mg 2 or 3 times daily by end of 1 week. Paxil CR) Depression Generalized anxiety disorder Obsessive-compulsive disorder Panic disorder Social anxiety disorder PO 50 mg once daily at bedtime. gradually increased to 200 mg daily if necessary. increased to 150 mg/d if necessary. PO 25 mg once daily in the morning. Give doses larger than 20 mg once in the morning or in 2 divided doses. Maximum dose 200 mg/d PO 20 mg once daily in the morning. Maximum dose. Maximum dose. whichever is smaller. Maximum dose. Sarafem) Fluvoxamine (Luvox) Depression Obsessive-compulsive disorder Bulimia nervosa Premenstrual dysphoric disorder (Sarafem) Obsessive-compulsive disorder Paroxetine (Paxil. For daily amounts above 100 mg. Maximum dose. 250 mg daily Children and adolescents: PO 25 mg daily. Maximum dose. increased to 40 mg daily in 1 week. increased to 100 mg daily by end of 2 weeks. 200 mg/d. in divided doses or a single dose at bedtime. in divided doses or a single dose once daily PO 15–40 mg daily in 3 or 4 divided doses. 150 mg/d PO 75–150 mg daily. 300 mg/d Children 8–17 y: PO 25 mg once daily at bedtime. Maximum dose. 40 mg Severe renal or hepatic impairment: Same as for older adults (continued ) . morning and noon. IM 80–120 mg daily in 4 divided doses Adolescents and older adults: PO 10 mg 3 times daily and 20 mg at bedtime. increased if necessary. increased to 3 mg/kg or 100 mg. Give maintenance dose in a single dose at bedtime. starting 7 days after the last 20-mg dose Selective Serotonin Reuptake Inhibitors (SSRIs) Depression Citalopram (Celexa) Fluoxetine (Prozac. increased after several weeks if necessary. 300 mg/d Adolescents and older adults: PO 25–100 mg daily in divided doses or as a single daily dose. increased to 100 mg/d if necessary PO 20 mg once daily. over 2 weeks. whichever is smaller. PO 50 mg 2 or 3 times daily. increased to 50 mg 2 or 3 times daily by end of 1 week. in divided doses. Adolescents and older adults: PO 5 mg 3 times daily. 300 mg/d. gradually increased to 150 mg daily if necessary. Adolescents and older adults: PO 50 mg daily. Older adults: PO 25 mg 2 or 3 times daily. Maximum dose. Give maintenance dose in a single dose at bedtime. PO 25 mg daily. Give maintenance dose in a single dose at bedtime. PO 25–50 mg 1 hour before bedtime PO 25 mg 3 or 4 times daily or in a single dose (75–100 mg) at bedtime. 20–50 mg/d. give in 2 divided doses. 3 mg/kg or 200 mg. morning or evening. with meals. increase gradually if necessary PO 75 mg daily. PO 90 mg once each week. give in 2 divided doses. 60 mg. Maintenance dose. in divided doses or a single dose at bedtime. Maximum dose. increased in 50-mg increments every 4–7 days if necessary.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 167 Drugs at a Glance: Antidepressant Agents Generic/Trade Name Tricyclic Antidepressants Amitriptyline (Elavil) Indications for Use Routes and Dosage Ranges Depression Amoxapine (Asendin) Depression Clomipramine (Anafranil) Obsessive-compulsive disorder Desipramine (Norpramin) Depression Doxepin (Sinequan) Imipramine (Tofranil) Depression Depression Childhood enuresis Nortriptyline (Aventyl. 75–150 mg daily Adolescents and older adults: PO 30–40 mg daily in divided doses. usual range. For daily amounts above 50 mg. maximum daily dose 80 mg Prozac weekly (delayed-release capsules).

increased to a maximum dose of 600 mg daily if necessary Immediate release tablets. increased to 100 mg 3 times daily (at least 6 h apart) if necessary. increased to 90 mg/d if necessary PO 30 mg daily in divided doses. Other common adverse effects include dry mouth. Zyban) inhibits the reuptake of dopamine. 300–600 mg/d. After an oral dose. Increase by 75 mg/d (4 days or longer between increments) up to 225 mg/d if necessary. and serotonin. Lithobid) Bipolar disorder (mania) PO 600 mg 3 times daily or 900 mg twice daily (slow release forms) Maintenance dose. Increase by 15 mg/d (at least 1–2 weeks between increments) up to 45 mg/d if necessary PO 200 mg daily in 2 divided doses. excitement. Miscellaneous Antidepressants Bupropion (Wellbutrin. Acute episodes of depression usually require several months of drug therapy. the drug has CNS stimulant effects (agitation. PTSD. nausea and vomiting. 25 mg once daily. levodopa. Zyban) Smoking cessation (Zyban) Maprotiline Mirtazapine (Remeron) Nefazodone (Serzone) Depression Depression Depression PO 10 mg twice daily. at bedtime. Drugs that should be avoided include CNS stimulants (eg. PO initially 75 mg/d in 2 or 3 divided doses. where it causes a sudden release of large amounts of norepinephrine. when deactivation is blocked by MAOIs. Effexor XR) Depression Depression Generalized anxiety disorder (extended release only) Immediate release tablets. increase at 1-week intervals in increments of 100–200 mg/d. The average drug half-life is about 14 hours. Maximum single dose. and constipation. In addition to seizures. increased to 150 mg twice daily (at least 8 hours apart). 13–17 y 50 mg once daily Monoamine Oxidase Inhibitors Isocarboxazid (Marplan) Depression Phenelzine (Nardil) Depression Tranylcypromine Depression (Parnate) Miscellaneous Antidepressants Bupropion (Wellbutrin. headache. Bupropion has few adverse effects on cardiac function and does not cause orthostatic hypotension or sexual dysfunction. . 150 mg. Dosage should be reduced with impaired hepatic or renal function. increased to 60 mg/d if necessary. amphetamines. Hepatic or renal impairment: Reduce dose by 50% and increase very slowly Mood-Stabilizing Agent Lithium carbonate (Eskalith. Foods that should be avoided include aged cheeses and meats. The drug is metabolized in the liver and excreted primarily in the urine. pseudoephedrine). antidepressants (SSRIs. PO 50 mg once daily morning or evening. Extended release capsules. increased at 1-week or longer intervals to a maximum daily dose of 200 mg Panic. anxiety. sauerkraut. These effects may increase the risk of abuse. in a single dose. OCD. usual range. PO 25 mg once daily.5 or 75 mg/d in a single dose morning or evening. venlafaxine). with food. however. Sustained release tablets. Maximal single dose. Depression (Wellbutrin) Wellbutrin SR. increased motor activity. Seizures are most likely to occur with doses above 450 mg/day and in clients known to have a seizure disorder. increased to 60 mg/d if necessary Trazodone (Desyrel) Venlafaxine (Effexor. buspirone. increased after 1 week to 50 mg once daily Children: OCD. and meperidine. Maprotiline is similar to the TCAs in therapeutic and adverse effects. 150 mg PO 75 mg daily in single or divided doses. PO 150 mg once daily in the morning. PO 300 mg 3 or 4 times daily to maintain a serum lithium level of 0. increased to a maximum of 300 mg daily if necessary PO 15 mg/d. and fava beans. cocaine). PO 100 mg twice daily.168 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Antidepressant Agents (continued ) Generic/Trade Name Sertraline (Zoloft) Indications for Use Depression Obsessive-compulsive disorder (OCD) Panic disorder Post-traumatic stress disorder (PTSD) Routes and Dosage Ranges Depression. It was marketed with warnings related to seizure activity. peak plasma levels are reached in about 2 hours. concentrated yeast extracts. adrenergics (eg. insomnia. restlessness) that may require a sedative during the first few days of administration. Increase by 75 mg/d (4 days or longer between increments) up to 225 mg/d if necessary. Several metabolites are pharmacologically active. Bupropion is also used as a smoking cessation aid. PO initially 37. norepinephrine. tyramine is absorbed systemically and transported to adrenergic nerve terminals. However.2 mEq/L reach the systemic circulation. Elderly or debilitated adults: PO initially 100 mg/d in 2 divided doses PO 100–300 mg daily. in 2 to 4 divided doses PO 15 mg 3 times daily.6–1. 6–12 y.

Venlafaxine (Effexor) inhibits the reuptake of norepinephrine. increased appetite. Consequently. insomnia. diarrhea). confusion. oxcarbazepine) are being used and studied regarding their effects in bipolar disorder. mania. A deficiency of sodium causes more lithium to be reabsorbed and increases the risk of lithium toxicity. urinary frequency). electroconvulsive therapy. . dizziness. If a client on nefazodone is to be transferred to an MAOI. serotonin. Venlafaxine does not interact with drugs metabolized by the cytochrome P450 system. most of the drugs seem to have some beneficial effects but additional studies are needed. the nefazodone should be discontinued at least 7 days before starting the MAOI. alcohol or benzodiazepine antianxiety or hypnotic agents) because of additive sedation. because they modify nerve cell function. it should not be taken concurrently with an MAOI or for 14 days after stopping an MAOI. Approximately 80% of a lithium dose is reabsorbed in the proximal renal tubules. dizziness. Lithium is not metabolized by the body. insomnia. Common adverse effects include drowsiness (with accompanying cognitive and motor impairment). rash. The drug crosses the placenta and may enter breast milk. which are inhibited by nefazodone. It is excreted in breast milk. Before lithium therapy is begun. Mirtazapine should not be taken concurrently with other CNS depressants (eg. It is contraindicated during pregnancy. and peak plasma concentrations are obtained within 30 minutes to 2 hours. Adverse effects include CNS (anxiety. orthostatic hypotension. dreams. baseline studies of renal. agitation. hypovolemia. cardiac. Because of its association with liver failure. dry mouth. Nefazodone (Serzone) inhibits the neuronal reuptake of serotonin and norepinephrine. excessive sodium intake causes more lithium to be excreted (ie. sedation. dizziness. and peak plasma levels occur within 2 hours after an oral dose. aspartate and alanine aminotransferases [AST and ALT]) should be measured before starting nefazodone therapy. Mood-Stabilizing Agents Lithium carbonate (Eskalith) is a naturally occurring metallic salt that is used in bipolar disorder. thereby increasing the amount of these neurotransmitters in the brain. In addition. Other potentially serious drug interactions include increased CNS depression with general anesthetics and decreased metabolism of drugs metabolized by the cytochrome P450 3A4 enzymes. genitourinary (abnormal ejaculation. tachycardia. It is often given concurrently with a stimulating antidepressant. and thyroid status should be obtained because adverse drug effects involve these organ systems. It is metabolized in the liver and excreted in urine. debilitation. It has a long half-life (2 to 3 days) and crosses the placenta. constipation. Serum lithium concentrations should be monitored frequently because they vary widely among clients taking similar doses and because of the narrow range between therapeutic and toxic levels. if a client on an MAOI is to be transferred to venlafaxine. gabapentin. It is metabolized by the liver and excreted primarily by the kidneys. Thus far. and priapism (prolonged and painful penile erection). Baseline electrolyte studies are also necessary. so adequate renal function is a prerequisite for lithium therapy. cardiovascular (hypertension. suicidal ideation. pruritus) symptoms. dehydration. and women should use effective birth control methods while taking this drug. sertraline. It is metabolized in the liver. lamotrigine. the drug decreases anxiety. If a client on venlafaxine is to be transferred to an MAOI. but none are FDA-approved for this purpose. Newer drugs (eg. anorexia. with peak serum levels in 1 to 3 hours after a dose and steadystate concentrations in 5 to 7 days. Adverse effects include sedation. and feces. fluoxetine. diarrhea). periodically during therapy. the MAOI should be discontinued at least 14 days before starting venlafaxine. topiramate. The drug is well absorbed after oral administration. edema. or venlafaxine. the MAOI should be discontinued at least 14 days before starting nefazodone. GI (anorexia. impotence. An MAOI should not be started until at least 14 days after stopping mirtazapine. lithium diuresis) and may lower serum lithium levels to nontherapeutic ranges. serum levels of liver enzymes (eg. vasodilation). vomiting. and dopamine. vomiting. hepatic cirrhosis. Trazodone is well absorbed with oral administration. dark urine) develop. including agitation. It is contraindicated in pregnancy and liver damage and should be used with caution in people with cardiovascular or cerebrovascular disorders. headache. Nefazodone should not be taken with an MAOI because of the risk of severe toxic effects. nausea. The amount of reabsorption depends on the concentration of sodium in the proximal renal tubules. Anticonvulsants (see Chap. It is metabolized in the liver and produces two active metabolites. and histamine H1 receptors. mainly to inactive metabolites. but it should not be taken concurrently with MAOIs because of increased serum levels and risks of toxicity. cardiac dysrhythmias. urine.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 169 Mirtazapine (Remeron) blocks presynaptic alpha2adrenergic receptors (which increases the release of norepinephrine). serotonin receptors. and lactation. Trazodone (Desyrel) is used more often for sedation and sleep than for depression because high doses (>300 mg/day) are required for antidepressant effects and these amounts cause excessive sedation for many clients. Carbamazepine (Tegretol) and valproate (Depakene) are commonly used. thereby increasing the activity of these neurotransmitters in the brain. GI symptoms (nausea. mainly to treat and prevent manic episodes. Adverse effects resemble those of SSRIs and TCAs. dizziness. tremors). weight gain. vomiting. It does not cause sexual dysfunction. and immediately when symptoms of liver dysfunction (eg. nausea. 11) are also used as mood stabilizing agents in bipolar disorder. if a client on an MAOI is to be transferred to nefazodone. hypomania. it is entirely excreted by the kidneys. somnolence. the venlafaxine should be discontinued at least 7 days before starting the MAOI. and skin rash. such as bupropion. and dermatologic (sweating. It is well absorbed after oral administration. and constipation. and migraine headache as well as depression. insomnia. nervousness.

• Call the client by name. John’s wort (Hypericum perforatum) is an herb that is widely self-prescribed for depression. dizziness. A 3-year. • When a client appears depressed or has a history of depression. both consumers and health care professionals seem to underestimate the risks of taking this herbal supplement. nasal decongestants or other overthe-counter cold and flu medications. or amino acid supplements containing phenylalanine and tyrosine. Most of the previous studies were considered flawed. to avoid the herb during pregnancy. For example. Severe or prolonged illness. TCAs). and sleep disturbances. and social interactions when unable to provide self-care • Resume self-care and other usual activities • Avoid preventable adverse drug effects Nursing Process Assessment Assess the client’s condition in relation to depressive disorders. family and social relationships. Most authorities agree that there is insufficient evidence to support the use of St. Depression also occurs without an identifiable cause. assess for suicidal thoughts and behaviors. when feasible. and job dissatisfaction may precipitate depression. • Be cared for by staff in areas of nutrition. which are usually infrequent and mild. dry mouth. Statements indicating a detailed plan. John’s wort. skin rash. alcohol. although several other active components have also been identified. Areas to assess include health status. The mechanism of action is unknown. ability to perform usual tasks. For example. ability. Clinical Herbal Supplement St. photosensitivity. Helpful actions may involve relieving pain or insomnia. multicenter study by the National Institutes of Health concluded that the herb is not effective in major depression. manifestations are nonspecific and vary in severity. These symptoms are relieved by stopping the herb. try to determine their frequency. • Identify clients at risk for current or potential depression. and to use sunscreen lotions and clothing to protect themselves from sun exposure. significant other. because effects are unknown. indicate its usefulness in mild to moderate depression. John’s wort. and cold and flu medications while taking St. Specific measures include the following: • Support the client’s usual mechanisms for handling stressful situations. caretakers will implement safety measures. nausea. allow him or her to participate in setting goals and making . place the client at high risk for suicide. to avoid taking antidepressant drugs. impaired interpersonal relationships. Some herbalists refer to St. General measures include supportive psychotherapy and reduction of environmental stress. John’s wort as “natural Prozac. Coping mechanisms vary widely. whereas another may find increased contact desirable. and behavior that may be helpful to one client may not be helpful to another. Nursing Diagnoses • Dysfunctional Grieving related to loss (of health. fatigue.170 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM • Observe for signs and symptoms of depression. exercise. MAOIs. accompanied by the intent. job.” Adverse effects. John’s wort should not be combined with alcohol. possibly severe. Overall. Interventions Use measures to prevent or decrease the severity of depression. • Identify the client’s usual coping mechanisms for stressful situations. one person may prefer being alone or having decreased contact with family and friends. and increasing or decreasing socialization. teach them to purchase products from reputable sources because the amount and type of herbal content may vary among manufacturers. and severity. SSRIs. opioid analgesics. All of these interactions may result in hypertension. John’s wort for mild to moderate depression and that more studies are needed in order to confirm the herb’s safety and effectiveness. hygiene. and so forth) • Self Care Deficit related to fatigue and self-esteem dis• • • • turbance with depression or sedation with antidepressant drugs Sleep Pattern Disturbance related to mood disorder or drug therapy Risk for Injury related to adverse drug effects Risk for Violence: Self-Directed or Directed at Others Deficient Knowledge: Effects and appropriate use of antidepressant and mood stabilizing drugs Planning/Goals The client will: • Experience improvement of mood and depressive state • Receive or self-administer the drugs correctly • Be kept safe while sedated during therapy with the TCAs and related drugs • Be assessed regularly for suicidal tendencies. bronchodilators. include constipation. GI distress. Several studies. If present. inability to work. and work status. Drug interactions may be extensive. encourage self-care activities. duration. St. with fewer adverse effects than antidepressant drugs. antidepressant drugs (eg. scheduling rest periods. For clients who report use of St. but the herb is thought to act similarly to antidepressant drugs. and method for carrying out the plan. restlessness. Antidepressant effects are attributed mainly to hypericin. fatigue and insomnia may be caused by a variety of disorders and range from mild to severe. most of which used about 900 mg daily of a standardized extract. When symptoms are present.

it does not cause sexual dysfunction or clinically significant drug–drug interactions. and desipramine are less likely to cause seizures. As with most other drugs. Criteria for choosing bupropion. but the SSRIs. Bupropion does not cause orthostatic hypotension or sexual dysfunction. and removal of potential weapons from the environment. Specific guidelines for dosage include the following: 1. With SSRIs. clomipramine. the choice of an antidepressant depends on the client’s age. nefazodone. nefazodone. Lithium is the drug of choice for clients with bipolar disorder. and praise efforts to accomplish tasks. serum nefazodone levels are increased in clients with cirrhosis. These drugs are effective and usually produce fewer and milder adverse effects than other drugs. Institute suicide precautions for clients at risk. • When signs and symptoms of depression are observed. often on a one-to-one basis. Antidepressant drug therapy is usually initiated with small. nefazodone. and causes sexual dysfunction. Venlafaxine and MAOIs can increase blood pressure. If therapeutic effects do not occur within 4 weeks. For clients with seizure disorders. SSRIs. migraines. and the specific drug’s adverse effects. because some clients tolerate or respond better to one TCA than to another. and maprotiline should be avoided. if a client (or a close family member) responded well to a particular drug in the past. and insomnia. For example. Mirtazapine decreases anxiety. SSRIs may have a hypoglycemic effect and bupropion and venlafaxine have little effect on blood sugar levels. When used prophylactically. if any. but does not cause significant drug–drug interactions For clients with cardiovascular disorders. and the drug inhibits cytochrome P450 3A4 enzymes that metabolize many drugs. and agitation. PRINCIPLES OF THERAPY Drug Selection Because the available drugs seem similarly effective. smaller doses may be indicated in older adults and clients taking multiple medications. they may be more cost effective overall because TCAs are more likely to cause serious adverse effects. With TCAs. 7. Additional guidelines for choosing a drug include the following: 1. agitation. it has been associated with liver failure and probably should not be given to clients with significant liver impairment. bupropion. 6. These usually involve close observation. increases blood pressure. In addition. and venlafaxine. Venlafaxine has stimulant effects. Dosage and Administration Dosage of antidepressant drugs should be individualized according to clinical response. In addition. an optimal response may require 300 mg to 500 mg daily. the TCA probably should be discontinued or changed. 2.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 171 decisions. When used therapeutically. therapy is begun with once-daily oral administration of the manufacturer’s recommended dosage. For clients hospitalized on medical-surgical units. • Observe and interview regarding suicidal thoughts and behaviors. The newer drugs are much more expensive than the TCAs. an anticonvulsant. and venlafaxine are not clearly defined. The SSRIs are the drugs of first choice. It is often used in clients who do not respond to lithium. With nefazodone. an SSRI or another newer drug is preferred over a TCA because the TCAs are much more toxic in overdoses. transfer to a psychiatric unit may be needed. although it is not FDA approved for that purpose. MAOIs are third-line drugs for the treatment of depression because of their potential interactions with other drugs and certain foods. anxiety. The response of family members to individual drugs may be significant because there is a strong genetic component to depression and drug response. and clients are more likely to stop taking them. the drug decreases the frequency and intensity of manic cycles. . • Observe and interview regarding adverse drug effects. medical conditions. Evaluation • Observe for behaviors indicating lessened depression. These actions promote a positive self-image. 4. most antidepressants can cause hypotension. MAOIs. For a potentially suicidal client. Dosage may be increased after 3 or 4 weeks if depression is not relieved. divided doses that are gradually increased until therapeutic or adverse effects occur. 8. Nefazodone has sedating and anxiolytic properties that may be useful for clients with severe insomnia. For clients with diabetes mellitus. that is probably the drug of choice for repeated episodes of depression. 3. However. lithium is effective in controlling mania in 65% to 80% of clients. Cost also needs to be considered. and venlafaxine are rarely associated with cardiac dysrhythmias. initiate treatment before depression becomes severe. However. • Interview regarding feelings and mood. initial selection may be based on the client’s previous response or susceptibility to adverse effects. Guidelines for choosing one SSRI over another have not been established. mirtazapine. as well as depression. other antidepressant drugs or when electroconvulsive therapy is refused or contraindicated. may be as effective as lithium as a mood-stabilizing agent. An MAOI is most likely to be prescribed when the client does not respond to 5. previous history of drug response. bupropion. they require monitoring of plasma drug levels and ECGs. Carbamazepine (Tegretol).

take two or three times daily. and do not take the morning dose of lithium until the blood sample has been obtained. Increased intake may decrease therapeutic effects. the dose. the type of drug. 6. If signs of overdose occur (eg. low-salt diet) increases risk of adverse effects from lithium. lithium therapy may be lifelong. diarrhea. ✔ Avoid alcohol and other central nervous system depressants (eg. Also. There are several different types of antidepressant drugs. vomiting. fainting. An allergic reaction may require that the drug be discontinued. Celexa. ✔ With nefazodone (Serzone) and venlafaxine (Effexor). muscle weakness). Minimize activities that cause excessive perspiration. unsteady walking. as prescribed. and low blood pressure may occur. ✔ Do not take other prescription or over-the-counter drugs without consulting a health care provider. and other nonmedication treatments are recommended along with drug therapy. it is very important not to think the drug is ineffective and stop taking it prematurely. Zoloft). driving a car. Accurate measurement of serum drug levels requires that blood be drawn approximately 12 hours after the previous dose of lithium. 3. Report for measurements of lithium blood levels as instructed. report urinary retention. relaxation techniques. drowsiness. John’s wort while taking a prescription antidepressant drug. As a result. Caffeine has a diuretic effect and dehydration increases lithium toxicity. irregular heartbeat. If significant progress is not made by approximately 7 weeks. Loss of salt in sweat increases the risk of adverse effects from lithium. 4. it is considered unlikely that longer drug use will be helpful. These drugs are often taken twice daily. ✔ Do not take the herbal supplement St. Antidepressants are usually given for several months. ✔ Inform any physician. notify a health care provider if a skin rash or other allergic reaction occurs. Zyban). tremor. Overdoses may cause seizures. ✔ With lithium. In addition. ✔ Learn the name and type of a prescribed antidepressant drug to help avoid undesirable interactions with other drugs or a physician prescribing other drugs with similar effects. Self-administration ✔ With a selective serotonin reuptake inhibitor (eg. Drink 8 to 12 glasses of fluids daily. . amitriptyline). Decreased salt intake (eg. If a problem occurs. Zyban is recommended for up to 12 weeks if progress is being made. Take with food or milk or soon after a meal to decrease stomach upset. dizziness. Do not alter dietary salt intake. restlessness. Allergic reactions are uncommon but may require that the drug be discontinued. ✔ Do not stop taking any antidepressant drug without discussing it with a health care provider. stop taking lithium and contact the prescribing physician or other health care provider.172 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM CLIENT TEACHING GUIDELINES Antidepressants and Lithium General Considerations ✔ Take antidepressants as directed to maximize therapeutic benefits and minimize adverse effects. ✔ Bupropion is a unique drug prescribed for depression (brand name. Potentially serious drug interactions may occur. dentist or nurse practitioner about the antidepressant drugs being taken. When used for smoking cessation. take in the morning because the drug may interfere with sleep if taken at bedtime. including overthe-counter cold remedies. take at bedtime to aid sleep and decrease side effects. and mental confusion. as well as other adverse effects. Excessive drowsiness. or other aspects may be changed to solve the problem and allow continued use of the medication. with different characteristics and precautions for safe and effective usage. perhaps years. Serious interactions may occur. ✔ Avoid activities that require alertness and physical coordination (eg. ✔ Therapeutic effects (relief of symptoms) may not occur for 2 to 4 weeks after drug therapy is started. Prozac. ✔ With a tricyclic antidepressant (eg. operating other machinery) until reasonably sure the medication does not make you drowsy or impair your ability to perform the activities safely. Regular measurements of blood lithium levels are necessary for safe and effective lithium therapy. Do not alter doses when symptoms subside. ✔ With bupropion. Paxil. seizures. take as directed or ask for instructions. difficulty breathing. It is extremely important not to increase the dose or take the two brand names at the same time (as might happen with different physicians or filling prescriptions at different pharmacies). support groups. 2. surgeon. Wellbutrin) and for smoking cessation (brand name. These are potentially serious adverse drug effects. ✔ Counseling. any drugs that cause drowsiness). several precautions are needed for safe use: 1. Notify a health care provider if a skin rash or other allergic reaction occurs. Potentially serious adverse effects or drug interactions may occur if certain other drugs are prescribed. avoid excessive intake of caffeine-containing beverages. 5. with potentially serious consequences.

and long-term therapy after a third episode. For most clients. erythromycin. dosage may be increased to 450 mg. TCAs are often given once daily at bedtime. gradually increased to 300 mg. which metabolizes many drugs. clozapine. the therapeutic range of serum levels is 0. caffeine. . 3. If no clinical improvement occurs after several weeks of 300 mg/day. theophylline. • Fluoxetine. The maximal single dose of immediate-release tablets is 150 mg (sustained-release. tricyclic antidepressants. TCAs can be administered once or twice daily because they have long elimination half-lives. 5 years after symptoms subside for a second episode. Thus. for immediate-release tablets. cyclosporine. decreased cardiac output). With bupropion. saquinavir). b. Give the drug in equally divided doses. lithium doses should be lowered. Inhibiting the enzymes that normally metabolize or inactivate a drug produces the same effect as an excessive dose of the inhibited drug. d.5 to 1.2 mmol/L). followed by gradual tapering of the dose and drug discontinuation. Once dosage is established. Duration of Drug Therapy Guidelines for the duration of antidepressant drug therapy are not well established. ritonavir. 2. low-salt diet. midazolam. The recommended initial dose is 200 mg. long-term therapy is the usual practice because of a high recurrence rate if the drug is discontinued.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 173 Nursing Notes: Apply Your Knowledge Ms. Minimal effective doses are approximately 150 mg/day of imipramine (Tofranil) or its equivalent. most often because of adverse effects or the client’s lack of adherence to the prescribed regimen. therapy is begun with small doses. 12 hours after the last dose of lithium. warfarin. The long-term effects of SSRIs and newer agents have not been studied. As a result. Serum lithium levels should be measured at least every 3 months during long-term maintenance therapy. recent studies indicate that full therapeutic doses (if clients can tolerate the adverse effects) for up to 5 years are effective in preventing recurrent episodes. She also complains that she is having trouble sleeping. which are increased to the desired dose over 1 to 2 weeks. and there are differences of opinion. and successive episodes often are more severe and more difficult to treat. Maintenance therapy for depression requires close supervision and periodic reassessment of the client’s condition and response. and large or abrupt increases in dosage. This regimen is effective and well tolerated by most clients. indinavir. steroids. haloperidol. When lithium is discontinued.5 mEq/L because the risk of serious toxicity is increased at higher levels. triazolam). Effects of Antidepressants on Other Drugs The SSRIs are strong inhibitors of the cytochrome P450 enzyme system. One argument for long-term maintenance therapy is that depression tends to relapse or recur. 200 mg). Inhibition of 1A2 enzymes slows metabolism of acetaminophen. What teaching is appropriate for Ms. olanzapine. Jordan? Once symptoms of mania are controlled. With lithium. With the use of TCAs for acute depression. renal impairment. However. 2D6. gradually tapering the dose over 2 to 4 weeks delays recurrence of symptoms. Recommendations to avoid these risk factors are: a. 0. and zolpidem. 400 mg). Inhibition of 3A4 enzymes slows metabolism of benzodiazepines (alprazolam. When lithium therapy is being initiated. low doses have been given for several months. 4. control of symptoms. serum drug levels and risks of adverse effects are greatly increased. she states she is still depressed and requests that the dosage of Prozac be increased.2 mEq/L (SI units. Jordan started taking fluoxetine (Prozac) for depression 1 week ago. With TCAs. c. With TCAs. Lower doses are indicated for older adults and for clients with conditions that impair lithium excretion (eg. The recommended maintenance dose is the lowest amount that maintains remission. three times daily (at least 6 hours apart). and 3A4 groups of enzymes. dosage should be based on serum lithium levels. diuretic drug therapy. codeine. Serum levels are required because therapeutic doses are only slightly lower than toxic doses and because clients vary widely in rates of lithium absorption and excretion. verapamil). paroxetine. large total doses. dehydration. tacrine. nifedipine. twice daily for sustained-release tablets. With lithium. protease inhibitors (antiAIDS drugs. Elderly clients may experience fewer adverse reactions if divided doses are continued. When she returns to the clinic.5 to 1. seizures are more likely to occur with large single doses. a dose that is therapeutic in one client may be toxic in another. and occurrence of adverse effects. and sertraline inhibit 2D6 enzymes and slow metabolism of bupropion. Some authorities recommend 9 months of treatment after symptoms subside for a first episode of depression. calcium channel blockers (diltiazem. and warfarin. especially those metabolized by the 1A2. the serum drug concentration should be measured two or three times weekly in the morning. plasma levels are helpful in adjusting dosages. the maximal daily dose for immediate-release tablets (sustained-release. tamoxifen. Serum lithium levels should not exceed 1. Specific interactions include the following: • Fluvoxamine inhibits both 1A2 and 3A4 enzymes.

Most antidepressants may be tapered and discontinued over approximately 1 week without serious withdrawal symptoms. Bupropion overdose: Symptoms include agitation and other mental status changes. Hypotension and excessive sedation may occur with nefazodone. In general. impaired consciousness. As with other psychotropic drugs. hemodialysis is preferred because it removes lithium from the body. MAOI overdose: Symptoms occur 12 hours or more after drug ingestion and consist primarily of adrenergic ef- fects (eg. Symptoms . over 7 to 10 days. vomiting. dosage of the benzodiazepine should be reduced by 50% or more. confusion. acidification of urine. dextromethorphan. • Nefazodone also inhibits 3A4 enzymes and slows the metabolism of many drugs (see fluvoxamine. coma. Toxicity of Antidepressants and Lithium: Recognition and Management Some antidepressant drugs are highly toxic and potentially lethal when taken in large doses. including correction of fluid and electrolyte imbalances. Nefazodone or venlafaxine overdose: Symptoms include increased incidence or severity of adverse effects. Other SSRIs have short half-lives and may cause withdrawal reactions if stopped abruptly. lorazepam) is the drug of first choice. propranolol. the occurrence of withdrawal symptoms may indicate that the client has omitted doses or stopped taking the drug. and death. or other life-threatening conditions are present. myocardial depression). seizures. decreasing absorption (eg. nausea. may be associated with relatively severe withdrawal symptoms even when discontinued gradually. restlessness. lorazepam) if seizures occur. giving intravenous fluids and vasopressors for severe hypotension. vomiting. establishing and maintaining a patent airway. Death usually results from cardiac. mood disturbances. tremors. agitation. tremors. performing continuous ECG monitoring of comatose clients or those with respiratory insufficiency or wide QRS intervals. heart block. sweating. tremor. Fluoxetine has a long half-life and has not been associated with withdrawal symptoms. respiratory. nausea and vomiting. convulsive seizures. oliguria. With severe overdoses. nystagmus. • TCAs are metabolized by 2D6 enzymes and may inhibit the metabolism of other drugs metabolized by the 2D6 group (other antidepressants. stopping the drug. and supporting vital functions. increased rate of respiration. Specific measures include the following: SSRI overdose: Symptoms include nausea. and timolol. giving activated charcoal to conscious clients). Measures to prevent acute poisoning from drug overdose include dispensing only a few days’ supply (ie. with nausea. Prevention and Management of Withdrawal Symptoms Withdrawal symptoms have been reported with sudden discontinuation of most antidepressant drugs. and suicidal tendencies. Lithium overdose: Toxic manifestations occur with serum lithium levels above 2. and giving intravenous phenytoin (Dilantin) or fosphenytoin (Cerebyx) or a parenteral benzodiazepine (eg. an intravenous benzodiazepine (eg. Management includes symptomatic and supportive treatment. metoprolol.174 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM desipramine. and circulatory failure. hypomania. flecainide. There are no specific antidotes. hypotension. If nefazodone is given with alprazolam or triazolam (benzodiazepines). and headache and last from several days to several weeks. and seizures. and instituting treatment if indicated. Management of TCA toxicity consists of performing gastric lavage and giving activated charcoal to reduce drug absorption. Toxicity is most likely to occur in depressed clients who intentionally ingest large amounts of drug in suicide attempts and in young children who accidentally gain access to medication containers. and other signs of CNS stimulation. If seizures occur. delirium. but few studies have been done and effects are unknown. phenothiazines. these drugs should be tapered in dosage and discontinued gradually unless severe drug toxicity. Paroxetine. or hemodialysis to remove the drug from the body. seizures and diastolic hypertension with venlafaxine. Management consists of diuresis. 5 to 7 days) to clients with suicidal tendencies and storing the drugs in places inaccessible to young children. tachycardia. hypotension. anaphylactic reactions. such as maintaining an adequate airway and ventilation and administering activated charcoal. risperidone. coma). nortriptyline. dysrhythmias. More serious symptoms may include aggression. Lower-than-usual doses of both the TCA and the other drug may be needed. symptoms occur more rapidly and may be more intense with drugs having a short half-life. General measures to treat acute poisoning include early detection of signs and symptoms. • Mirtazapine and venlafaxine are not thought to have clinically significant effects on cytochrome P450 enzymes. withdrawal symptoms include dizziness. visual or tactile hallucinations.5 mEq/L and include nystagmus. propafenone). General treatment measures include hospitalization. above). With SSRIs. which has a half-life of approximately 24 hours and does not produce active metabolites. and drowsiness most often reported. agitation. For a client on maintenance drug therapy. treatment is symptomatic and supportive. Treatment involves supportive care to maintain vital functions. TCA overdose: Symptoms occur 1 to 4 hours after drug ingestion and consist primarily of CNS depression and cardiovascular effects (eg. convulsions. carbamazepine. flecainide. restlessness. choreiform movements. hypomania. The most clearly defined withdrawal syndromes are associated with SSRIs and TCAs. phenothiazines.

and metabolize TCAs more slowly than whites. experience a higher incidence of adverse effects. there are no apparent differences between effects in Asians and whites. When you approach her with her morning medications (including an antidepressant). initial doses should be approximately half the usual doses given to whites and later doses should be titrated according to clinical response and serum drug levels. 3. It is usually recommended that antidepressants be tapered in dosage and gradually discontinued. and adverse effects derived from white recipients. Lithium may prolong the effects of anesthetics and neuromuscular blocking drugs. Considerations include the following: 1. perioperatively because of the risk of serious adverse effects and adverse interactions with anesthetics and other commonly used drugs. dizziness. a 17-year-old. leave the room. Asians tend to metabolize antidepressant drugs slowly and therefore have higher plasma drug levels for a given dose than whites. African Americans report more adverse reactions than whites and may need smaller doses. Although some antidepressants are approved for other uses in children (eg. abdominal cramping. she is lying on her bed in a fetal position. This recommendation is supported by a survey from several Asian countries that reported the use of much smaller doses of TCAs than in the United States. especially on the cardiovascular system and CNS. MAOIs are contraindicated and should be discontinued at least 10 days before elective surgery. if at all. With TCAs. are approved for treatment of obsessive-compulsive disorder. and sweating). When stopped abruptly. drug therapy is largely empiric and of unproven effectiveness. The differences are mainly attributed to genetic or ethnic variations in drugmetabolizing enzymes in the liver. there are few reliable data or guidelines for the use of antidepressants in children and adolescents. 1. Most studies have been done with TCAs and a limited number of Asian subgroups. With lithium. For adolescents. initial doses may need to be lower than those given to whites and later doses should be titrated according to clinical response and serum drug levels. it is probably best to reserve drug therapy for those who do not respond to nonpharmacologic treatment and those whose depression is persistent or severe enough to impair function in usual activities of daily living. it cannot be assumed that all antidepressant drugs and all people of Asian heritage respond the same. Lithium should be stopped 1 to 2 days before surgery and resumed when full oral intake of food and fluids is allowed. Moreover. baseline and periodic ECGs are recommended to detect adverse drug effects on the heart. the longterm effects of antidepressant drugs on the developing brain are unknown. muscle aches. and insomnia. headache. Studies have not been done with newer antidepressants. Although all ethnic groups are genetically heterogeneous and individual members may respond differently. . however. whereas others report no differences between Hispanics and whites. pharmacokinetic data. porting a need for lower doses of TCAs and greater susceptibility to anticholinergic effects. two SSRIs. fluvoxamine and sertraline. SSRIs and miscellaneous antidepressants have not been studied in relation to perioperative use. hypersalivation. especially with high doses. To avoid drug toxicity. it seems reasonable to discontinue the drugs when feasible because of potential adverse effects. was admitted to your psychiatric unit after a suicide attempt. diarrhea. Thus. You do so. With lithium. the main concern is over those with strong anticholinergic effects. Overall. urinary urgency. How Can You Avoid This Medication Error? Jane. 2. In addition. Studies have not been done with newer antidepressants. baseline and periodic ECGs are recommended to detect adverse drug effects on the heart. health care providers need to consider potential differences in responses to drug therapy. several studies document differences in drug effects in nonwhite populations. Hispanics’ responses to antidepressant drugs are largely unknown. and chart the medications. TCAs should be discontinued several days before elective surgery and resumed several days after surgery. vomiting. none is approved for treatment of depression. However. with some re- Use in Children Depression commonly occurs in children and adolescents and antidepressant drugs are widely prescribed. In addition. Few studies have been done. Use in Perioperative Periods Antidepressants must be used very cautiously. and some TCAs are approved for treatment of enuresis). fatigue. African Americans tend to have higher plasma levels for a given dose. She instructs you to just leave her medications on the table so she can take them later. For most children and adolescents. it may be important to discuss sexual effects because the SSRIs and venlafaxine cause a high incidence of sexual dysfunction (eg.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 175 may include a flu-like syndrome with nausea. anorgasmia. The shortacting SSRIs should be tapered in dosage and gradually discontinued to prevent or minimize withdrawal reactions. She opens her eyes when you call her name. these drugs can cause symptoms of excessive cholinergic activity (ie. respond more rapidly. Genetic or Ethnic Considerations Antidepressant drug therapy for nonwhite populations in the United States is based primarily on dosage recommendations. However. To decrease adverse effects. A recommended rate for tapering TCAs is approximately 25 to 50 mg every 2 to 3 days. in Asians as in African Americans. 2.

MAOIs may be more likely to cause hypertensive crises in older adults because cardiovascular. Initial and maintenance doses should be small because the drugs are metabolized and excreted more slowly than in younger adults. headache) are more common in children than in adults. These drugs produce similar adverse effects in older adults as in younger adults. renal. it is often difficult to distinguish therapeutic effects (improvement of mood. as for other groups. erectile dysfunction). initial doses should be low and increased gradually. and less frequent dosing are indicated. initial doses should be relatively low and gradually increased according to regular measurements of serum drug levels. longer intervals between doses. and withdrawal symptoms (eg. ECGs. serum drug levels. nervousness. Use in Hepatic Impairment Hepatic impairment leads to reduced first-pass metabolism of most antidepressant drugs. Lithium is not approved for use in children younger than 12 years of age. according to regular measurements of serum drug levels. but increased plasma levels can occur with severe hepatic impairment. restlessness). from 7 to 9 days to 12 days. for children. hypomania. hypotension. Use in Older Adults SSRIs are the drugs of choice in older adults as in younger ones because they produce fewer sedative. increments should be small. cardiac conduction abnormalities. TCAs are not recommended for use in children younger than 12 years of age except for short-term treatment of enuresis in children older than 6 years of age. When a TCA is used for enuresis. and sedation. blood pressure. Initial dosage should be decreased by 30% to 50% to avoid serious adverse reactions. 4. and their safety and effectiveness have not been established. and hepatic functions are often diminished. malaise. A TCA probably is not a drug of first choice for adolescents because TCAs are more toxic in overdose than other antidepressants and suicide is a leading cause of death in adolescents. 6. The weight loss often associated with . and nefazodone are unlikely to cause sexual dysfunction. they are used to treat depression. Common adverse effects include sedation and activation. Because of potentially serious adverse effects. the active metabolite. SSRIs may be eliminated more slowly. In clients with cirrhosis. Use in Renal Impairment Antidepressants should be used cautiously in the presence of severe renal impairment. and venlafaxine in children younger than 18 years of age. cardiotoxic. Vital signs. with resultant higher plasma levels. If a TCA is chosen for an older adult. The drugs should be used cautiously in clients with severe liver impairment. fatigue. Common adverse effects include sedation. Bupropion. Paroxetine has a short half-life and no active metabolites. Fluoxetine and sertraline are less readily metabolized to their active metabolites with hepatic impairment. and ECGs should be monitored regularly. and that of norfluoxetine. slow increases.176 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM 3. SSRIs may be undesirable in older adults. There is evidence that children metabolize TCAs faster than adults. the average half-life of fluoxetine may increase from 2 to 3 days to more than 7 days. urinary retention. As with adults. increased GI motility. SSRIs are not approved in children (<18 years of age). nefazodone. small initial doses. Nefazodone and venlafaxine may also be used in older adults. Divided doses may be better tolerated and minimize withdrawal symptoms. but severe impairment may increase plasma levels and adverse effects of virtually all antidepressants. and smaller or less frequent doses may be prudent. and plasma drug levels should be monitored. decreased libido. the dose must be markedly reduced and plasma lithium levels must be closely monitored. 5. mirtazapine. increased energy and motivation) from the adverse effects of behavioral activation (agitation. confusion. However. and sleep disorders. any TCA should be given in small doses initially and gradually increased over several weeks. impaired compensatory mechanisms make older adults more likely to experience anticholinergic effects. TCAs may cause or aggravate conditions that are common in older adults (eg. if necessary. Cautious use means lower doses. anticholinergic. Children normally excrete lithium more rapidly than adults. these drugs are considered first-line antidepressants and safer than TCAs and MAOIs. desipramine. with smaller initial doses and increments recommended. mirtazapine. imipramine. effectiveness may decrease over time. In addition. If given to a client with renal impairment or unstable renal function. Lithium is eliminated only by the kidneys and it has a very narrow therapeutic range. Mild or moderate impairment has few effects. to achieve therapeutic effects. Although their effects in older adults are not well delineated. With lithium. However. Thus. and psychomotor adverse effects than the TCAs and related antidepressants. mainly amitriptyline. nortriptyline or desipramine is preferred. and nortriptyline. narrow-angle glaucoma). In addition. for example. and slower dose increases than usual. and no residual benefits continue once the drug is stopped. Clearance of sertraline is also decreased in clients with cirrhosis. but it has been used to treat bipolar disorder and aggressiveness. Safety and effectiveness have not been established for amoxapine and MAOIs in children younger than 16 years of age or for bupropion.

(continued ) . 2. c.6–1. Also. decreased anxiety. and interest in surroundings. improved sleep patterns. other drugs being given. Administer accurately a. ginger ale. decreased somatic complaints. the nurse needs to observe the client’s response and assess for suicidal thoughts or plans. Give most selective serotonin reuptake inhibitors (SSRIs) once daily in the morning. and other factors.5 mEq/L with acute mania.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 177 Tricyclic antidepressants are also less readily metabolized with severe hepatic impairment (eg. Give tricyclic antidepressants (TCAs) and mirtazapine at bedtime. lemon/lime soda. Observe for therapeutic effects a. its use must be NURSING ACTIONS NURSING ACTIONS Antidepressants RATIONALE/EXPLANATION 1. he or she must be vigilant for signs and symptoms of major depression. citalopram and sertraline may be given morning or evening. physical activity. Therapeutic effects do not occur until approximately 7 to 10 days after therapeutic serum drug levels (1–1. The main role of the nurse may be in recognizing depressive states and referring clients for treatment. with multiple organ dysfunctions. give immediately after mixing. In mania. severe cirrhosis). Use in Critical Illness Critically ill clients may be receiving an antidepressant drug when the critical illness develops or may need a drug to combat the depression that often develops with major illness. Home Care Whatever the primary problem for which a home care nurse is visiting a client. potential adverse drug effects. blood levels of nefazodone are higher in clients with cirrhosis. observe for statements of feeling better or less depressed.2 mEq/L for maintenance therapy) are attained. This increases the risk of adverse effects such as sedation and hypotension. increased appetite. 0. Mix sertraline oral concentrate (20 mg/mL) in 4 oz of water. In addition. b. improved appearance. Depression often accompanies any serious physical illness and may occur in many other circumstances as well. If an antidepressant medication was recently started. the nurse may need to remind the client that it usually takes 2 to 4 weeks to feel better. The decision to continue or start an antidepressant drug should be based on a thorough assessment of the client’s condition. observe for decreased symptoms of the disorders (see Chap. cautious and slow and the client’s responses carefully monitored because critically ill clients are often frail and unstable. d. nausea and vomiting) Therapeutic effects occur 2 to 4 weeks after drug therapy is started. b. Give venlafaxine and lithium with food. observe for decreases in manic behavior and mood swings. If an antidepressant is given. or orange juice only. With lithium. With antidepressants for anxiety disorders. a benzodiazepine or an antipsychotic drug is usually given to reduce agitation and control behavior until the lithium takes effect. lemonade. To prevent insomnia Manufacturer’s recommendation To aid sleep and decrease daytime sedation To decrease gastrointestinal (GI) effects (eg. 8) c. With antidepressants for depression. the nurse should encourage the client to continue taking the medication. Nefazodone has been associated with a few cases of liver failure and should not be given to clients with severe liver impairment.

blurred vision. diarrhea. increased muscle tone Anticholinergic effects are common. ataxia. Toxic symptoms occur at serum drug levels above 2. dry mouth. insomnia. diarrhea.178 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS 3. confusion. polydipsia. nausea. muscular weakness. weight gain. diarrhea.2 mEq/L). observe for dizziness. SSRIs and other newer drugs are less likely to cause significant sedation. dizziness. constipation. dry mouth. With nefazodone. constipation. observe for sedation. if any. nausea. Has CNS depressant and anticholinergic effects. and insomnia are common with venlafaxine. slurred speech. constipation (3) Cardiovascular effect—orthostatic hypotension (4) Hepatic effect—liver failure (anorexia. With lithium. With mirtazapine. Cardiovascular effects are most serious in overdose. skin rash. constipation (4) Other effects—blurred vision. and orthostatic hypotension are common with nefazodone. and weight loss. fatigue. Severe adverse effects may be managed by decreasing lithium dosage. and weight gain (2) More severe nausea and diarrhea. Symptoms listed in (1) are common. effects on cardiac conduction and does not cause orthostatic hypotension. vomiting. nausea and vomiting. diarrhea. dry mouth. nausea and vomiting. observe for: (1) CNS effects—anxiety. and usually subside during the first few weeks of drug therapy. and cardiac arrhythmias but are more likely to cause nausea. dizziness. e. 20–120 mg daily. dizziness. observe for seizure activity. and insomnia. urinary retention. observe for blurred vision. they are usually less serious than those occurring with most other antidepressants. Propranolol (Inderal). polyuria. sedation. observe for: (1) Central nervous system (CNS) effects—drowsiness.5 mEq/L. f. confusion. diarrhea. tinnitus. skin rash. hyperactivity. dizziness. hand tremors. Lithium mobilizes white blood cells (WBCs) from bone marrow to the bloodstream. headache. GI upset. dizziness. observe for: (1) Metallic taste. photosensitivity. occur at therapeutic serum drug levels (0. With TCAs. b. delusions). With monoamine oxidase inhibitors (MAOIs). dark urine.8–1. Although numerous adverse effects may occur. Compared with the TCAs. hypotension. hypotension. hypoglycemia. Common effects are drowsiness. jaundice) g. hypotension. orthostatic hypotension (3) GI effects—nausea. incoordination. (3) Leukocytosis (continued ) . nervousness. d. poor memory (2) Cardiovascular effects—cardiac arrhythmias. GI upset. Hypoglycemia results from a drug-induced reduction in blood sugar. Most adverse effects result from anticholinergic or antiadrenergic activity. omitting a few doses. With bupropion. insomnia (2) GI effects—nausea. headache. muscle twitching and tremors. edema. Nausea may be decreased by giving lithium with meals. nervousness. or discontinuing the drug temporarily.5 mEq/L). and weight gain. Maximum increase in WBCs occurs in 7 to 10 days. dry mouth. Adverse effects are most likely to occur if recommended doses are exceeded. CNS stimulation (agitation. abdominal pain.5–2. Observe for adverse effects a. With SSRIs nefazodone and venlafaxine. insomnia. may be given to control tremors. hallucinations. Symptoms listed in (2) occur at higher serum drug levels (1. sexual dysfunction. RATIONALE/EXPLANATION GI upset and diarrhea are common with SSRIs. agitation. Note that bupropion has few. urinary retention. vomiting. sexual dysfunction. urinary retention. weight gain c. headache. nausea. vomiting. dry mouth. drowsiness. tachycardia. Most clients who take lithium experience adverse effects. anorexia. dizziness. tachycardia.

dry mouth. and an MAOI should be stopped at least 14 days before starting mirtazapine. Drugs that increase effects of SSRIs: (1) Cimetidine (2) MAOIs RATIONALE/EXPLANATION Drug interactions with the SSRIs vary with individual drugs. opioid analgesics) (6) MAOIs (7) SSRIs e. urinary retention. Drugs that increase effects of TCAs: (1) Antiarrhythmics (eg. benzodiazepine antianxiety and hypnotic agents. Inhibit metabolism of TCAs These drugs induce drug-metabolizing enzymes in the liver. The reaction. This is an antihistamine with antiserotonin effects. b. rifampin. atropine. and death have occurred with concurrent use. convulsions. above. may cause hyperthermia. antipsychotic agents. Drugs that increase effects of MAOIs: (1) Anticholinergic drugs (eg. attributed to excess serotonin and called the serotonin syndrome. d. and venlafaxine: (1) MAOIs See SSRIs. rifampin (2) Cyproheptadine c. phenylephrine). levodopa. which increases the rate of TCA metabolism and elimination from the body. and other drugs with anticholinergic effects (3) Antihypertensives (4) Cimetidine (5) CNS depressants (eg. atropine. phenytoin. phenytoin. hyperpyrexia. quinidine. disopyramide. May increase serum drug levels of SSRIs by slowing their metabolism SSRIs and MAOIs should not be given concurrently or close together because serious and fatal reactions have occurred. Mirtazapine should be stopped at least 14 days and nefazodone or venlafaxine at least 7 days before starting an MAOI. an SSRI should not be started for at least 2 weeks after an MAOI is discontinued. nefazodone or venlafaxine. blurred vision. and an MAOI should not be started for at least 2 weeks after an SSRI has been discontinued (5 weeks with fluoxetine. To avoid this reaction. Drugs that increase the effects of mirtazapine. These drugs and MAOIs should not be given concurrently or close together because serious and fatal reactions have occurred. These drugs induce liver enzymes that accelerate the metabolism of the SSRIs. meperidine (continued ) . epinephrine. Drugs that decrease effects of SSRIs: (1) Carbamazepine. muscle spasm. nicotine (cigarette smoking) f. because of its long half-life). delirium. procainamide) (2) Antihistamines. Drugs that decrease effects of TCAs: (1) Carbamazepine. alcohol.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 179 NURSING ACTIONS 4. nefazodone. constipation) Additive hypotension Increases risks of toxicity by decreasing hepatic metabolism and increasing blood levels of TCAs Additive sedation and CNS depression TCAs should not be given with MAOIs or within 2 weeks after an MAOI drug. Observe for drug interactions a. alcohol (some beers and wines). agitation. TCAs) (2) Adrenergic agents (eg. increasing risk of heart block Additive anticholinergic effects (eg. Additive effects on cardiac conduction. Additive anticholinergic effects Hypertensive crisis and stroke may occur. and coma.

& Barkin. What are common adverse effects of TCAs. L. Barkin. hydrochlorothiazide) RATIONALE/EXPLANATION Decrease renal clearance of lithium and thus increase serum lithium levels and risks of toxicity. 756–812. 12. and venlafaxine. 3. 568–574. How do the newer drugs. pp. D. Increase neurotoxicity and cardiotoxicity of lithium by increasing excretion of sodium and potassium and thereby decreasing excretion of lithium. Decrease renal clearance of lithium and thus increase serum levels and risks of lithium toxicity. Washington. List the main elements of treatment for antidepressant overdoses. [On-line] Available: .. S. giving the client more energy to carry out suicidal actions. R. J. What are the major groups of antidepressant drugs? 4. (2000). Often they can be forgotten or taken away with the food tray. It is important to teach all clients beginning therapy with antidepressants that they may not see significant improvement in their depression for a number of weeks. In this situation. Consumer use of St. 20(5). Text Revision (DSM-IV-TR). Diagnostic and statistical manual of mental disorders. & Switzer. what information would you provide for preventing a hypertensive crisis? 9. 4th ed. Adverse Drug Reaction Bulletin. Baldwin. and how may they be minimized? 7. captopril) (2) Diuretics (eg. sodium chloride (in excessive amounts). compare with the SSRIs in terms of adverse effects and adverse drug–drug interactions? 11. E. Southern Medical Journal. Is antidepressant drug therapy indicated for most episodes of temporary sadness? Why or why not? American Psychiatric Association. Pharmacologic management of acute and chronic pain. What is the nurse’s role in assessing and managing depression in special populations? In the home setting? SELECTED REFERENCES Review and Application Exercises 1. Beckman. D. Missing a dose of a medication can affect therapeutic blood levels. Depressed clients could save up medication to commit suicide by overdosing. W. John’s Wort. Drugs that decrease effects of lithium: (1) Acetazolamide. During the initial assessment of any client. When a client begins antidepressant drug therapy. mirtazapine. No. it might help to take the drug in the morning. These drugs also may precipitate a manic episode and increase risks of hypothyroidism. why is it important to explain that relief of depression may not occur for a few weeks? 6. Adverse drug reactions to newer antidepressants. Jordan’s sleeping difficulty could be a symptom of her depression or a side effect of the Prozac. D. If it is a drug side effect.: American Psychiatric Association. For a client taking an MAOI. 200. Drugs that increase effects of lithium: (1) Angiotensin-converting enzyme inhibitors (eg. R. S. theophylline How Can You Avoid This Medication Error? Answer: Do not leave medications at the bedside of a client. Nursing Notes: Apply Your Knowledge Answer: Prozac has a long half-life (24 to 72 hours). How do the drugs act to relieve depression? 5. drugs with a high sodium content (eg. What is the advantage of giving a TCA at bedtime rather than in the morning? 8. (2001). The risk for this increases as the antidepressant drugs start to work. 763–766.180 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS g. Ms. so it takes longer than a week to reach steady state. (2000). Pharmacotherapy. Increase excretion of lithium (3) Nonsteroidal anti-inflammatory drugs (4) Phenothiazines (5) TCAs h. How do the SSRIs differ from TCAs? 10. ticarcillin). 94(8). what kinds of appearances or behaviors may indicate depression? 2. Increased risk of hyperglycemia May increase effects of lithium and are sometimes combined with lithium for this purpose. special care should be taken to supervise all medications. What are common adverse effects of lithium. furosemide. Sommi. and how may they be minimized? 13. (2000). Wake Jane up and firmly encourage her to take her medications as you watch. The dosage is usually not increased for 3 to 4 weeks.C. nefazodone. ISSN 0044-6394.

R. Medscape article. American Journal of Nursing. (2000). Drug facts and comparisons. . Springhouse. Hummel. Public Health Service. (Updated monthly). Department of Health and Human Services. 2: Treatment of major depression.html. A. T. (Ed.medscape. & Sumners. Rockville. Update on the neurobiology of depression. MD: U. J. St. 93-0551. & Avila. A. N.medscape. E.08. Stimmel. ginkgo. Gourley (Eds. 2001. R.beck-01. Philadelphia: Lippincott Williams & Wilkins. 7th ed. (Ed. AHCPR publication No. (2001). (2000). The review of natural products. C. R.CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS 181 http://www. (1993). In Medscape/psychiatry/Treatment Update/2000/tu03/public/toc-tu03.n05/pharm 2005. W. Mood disorders. John’s Wort. Waddell... Louis: Facts and Comparisons. B.S. 1203–1216. 101(4). (2001).). Louis: Facts and Comparisons. Accessed March 18. D. Herfindal & D. & Nemeroff. M. D. Agency for Health Care Policy and Research. Professional’s handbook of complementary & alternative medicines. Kim. Inc. L. 2001. Three herbs you should get to know: Kava. Handbook of adverse drug interactions. Fetrow. St. [On-line] Available: http://www. NY: The Medical Letter. Depression Guideline Panel. C. Accessed Nov. 48–54. St. DerMarderosian. G. L. Sadek. PA: Springhouse Corporation.) (2001). Clinical practice guideline: Depression in primary care. (1999). New Rochelle.). Textbook of therapeutics: Drug and disease management.html. pp.beck/pharm2005.

THE STUDENT WILL BE ABLE TO: 1. Reflect on: ᮣ How you would feel as a new parent if your infant were diagnosed with a seizure disorder. It is diagnosed by clinical signs and symptoms of seizure activity and by the presence of abnormal brain wave patterns on the electroencephalogram. 8.chapter 11 Antiseizure Drugs Objectives AFTER STUDYING THIS CHAPTER. He will be discharged today to his single. lidocaine. management of Jamie during a seizure to ensure safety. theophylline). overdoses of numerous drugs (eg. Differentiate characteristics and effects of commonly used antiseizure drugs. Epilepsy is characterized by abnormal and excessive electrical discharges of nerve cells. Discuss the use of antiseizure drugs in special populations. 7. stroke. SEIZURE DISORDERS ntiseizure drugs are also called antiepileptic drugs (AEDs) or anticonvulsants. Critical Thinking Scenario You are caring for 6-month-old Jamie. and drug therapy is usually required. causes include developmental defects. which could increase risk of seizures. or birth injury. A seizure involves a brief episode of abnormal electrical activity in nerve cells of the brain that may or may not be accompanied by visible changes in appearance or behavior. What would be your most significant fears? ᮣ Given 15 minutes for discharge teaching. electrolyte imbalances. who will be the primary caregiver. The incidence of epilepsy is A . methylphenidate. who was just diagnosed with tonic-clonic seizures. 5. 6. 2. Compare advantages and disadvantages between monotherapy and combination drug therapy for seizure disorders. and withdrawal of alcohol or sedative-hypnotic drugs. methods to avoid skipping doses. although they are not the same. amphetamine. the disorder is called epilepsy. He was started on valproic acid (Depakene) 30 mg qid and has only had one seizure during his 4-day hospitalization. cocaine. When epilepsy begins in adulthood. brain tumor) or alcohol and other drug effects. A convulsion is a tonic-clonic type of seizure characterized by spasmodic contractions of involuntary muscles. 3. When epilepsy begins in infancy. Differentiate between older and newer antiseizure drugs. Fever is a common cause during late infancy and early childhood. metabolic disease. The terms seizure and convulsion are often used interchangeably. The cause is unknown in 60% to 80% of children and adolescents and 50% of older adults. Apply the nursing process with clients receiving antiepileptic drugs. prioritize your teaching plan. antipsychotics. considering the following: safe administration of an anticonvulsant medication to a 6-month-old. it is often caused by an acquired neurologic disorder (eg. treatment of the underlying problem or temporary use of an AED may relieve the seizures. and inherited forms usually begin in childhood or adolescence. Seizures may occur as single events in response to hypoglycemia. recurrent pattern. 4. fever. Discuss major factors that influence choice of an antiseizure drug for a client with a seizure disorder. In these instances. Describe strategies for prevention and treatment of status epilepticus. lithium. head injury. isoniazid. 182 Epilepsy When seizures occur in a chronic. Identify types and potential causes of seizures. teenaged mother.

In addition to maintenance treatment of epilepsy. AEDs also are used to stop acute. carbamazepine. Other types of generalized seizures include the myoclonic type (contraction of a muscle or group of muscles) and the akinetic type (absence of movement). including trials of different drugs. In a person taking medications for a diagnosed seizure disorder. oxcarbazepine is approved for monotherapy and studies indicate that most of the other newer drugs may be effective as monotherapy in some types of seizures. Some people are subject to mixed seizures. Once acute seizure activity is controlled. GABA. a brief warning. dosage over a period of time. causes of status epilepticus include brain trauma or tumors. trauma. staring expression with or without blinking of the eyelids. In this chapter. such as a flash of light or a specific sound. a longer-acting drug. Mechanisms of Action Although the exact mechanism of action is unknown for most AEDs. Status epilepticus is a life-threatening emergency characterized by generalized tonic-clonic convulsions lasting for several minutes or occurring at close intervals during which the client does not regain consciousness. such as opisthotonos. Drug therapy of epilepsy is rapidly evolving as older. levetiracetam. during which the person becomes cyanotic. Hypotension. stroke. Movements are usually automatic. repetitive. Indications for Use The major clinical indication for AEDs is the prevention or treatment of seizures. cocaine. most of the newer drugs are indicated for use with one or two other AEDs to treat more severe seizure disorders that do not respond to a single drug. the drugs are thought to stabilize neuronal membranes and decrease neuronal firing in response to stimuli. tonic-clonic convulsions and status epilepticus. zonisamide) are discussed. a social stigma and adverse drug effects that often lead to poor client compliance. characterized by abrupt alterations in consciousness that last only a few seconds. the major excitatory neurotransmitter. phenytoin. tiagabine. appropriate treatment is instituted. the level of consciousness is decreased. There is a high risk of permanent brain damage and death unless prompt. systemic or central nervous system (CNS) infections. abnormal postures. oxcarbazine) and GABA enhancers (eg. in complex partial seizures. Overall. the drugs are thought to suppress seizures by decreasing movement of ions into nerve cells. consciousness is not impaired. Tonic-clonic seizures are sometimes preceded by an aura. lack of seizure control while drugs are being selected and dosages adjusted. or aversive movements. Attempts to overcome these difficulties have led to the development of several new drugs in recent years. swallowing. and cardiac dysrhythmias may also occur. the most common cause of status epilepticus is abruptly stopping AEDs. alcohol withdrawal. less excitable cell membranes. blocking these ions decreases responsiveness to stimuli and results in stabilized. The most common type is the tonic-clonic or major motor seizure. and other motor movements. and absence of respiration. or tumor. for both clinicians and clients. twitching of the head or arms. phenobarbital. hypoxia. and undesirable drug interactions among AEDs and between AEDs and other drugs. Behavior is sometimes so bizarre that the person is diagnosed as psychotic or schizophrenic. In other clients. The drug of choice for this purpose is an intravenous (IV) benzodiazepine. benzodiazepines and most of the newer AEDs) raise the amount of stimulation required to produce a seizure (called the seizure threshold). Epilepsy is broadly classified as partial and generalized seizures. and inappropriate to the situation. The tonic phase involves sustained contraction of skeletal muscles. the need to titrate . especially the chronic recurring seizures of epilepsy. usually lorazepam. The actions of both sodium channel blockers (eg. the major inhibitory neurotransmitter in the brain. and overdoses of drugs (eg. Because movement of sodium and calcium ions is required for normal conduction of nerve impulses. febrile seizures (ie. Indications for particular drugs depend on the types and severity of seizures involved. The person may have a blank. Numerous difficulties. However. Generalized seizures are bilateral and symmetric and have no discernible point of origin in the brain. consideration of monotherapy versus two or more drugs. regardless of whether they have a diagnosed seizure disorder. such as chewing. The clonic phase is characterized by rapid rhythmic and symmetric jerking movements of the body. glutamate). or a combination of these mechanisms. They produce symptoms ranging from simple motor and sensory manifestations to more complex abnormal movements and bizarre behavior. topiramate. In children.CHAPTER 11 ANTISEIZURE DRUGS 183 higher in young children and older adults than in other age groups. tonic-clonic seizures that occur in the absence of other identifiable causes) are the most common form of epilepsy. For example. Another type of generalized seizure is the absence seizure. such as ANTISEIZURE DRUGS Antiseizure drugs can usually control seizure activity but do not cure the underlying disorder. have been associated with AED therapy. Increasing the activity of gamma-aminobutyric acid (GABA). also decrease nerve cell excitability. more toxic drugs are virtually eliminated from clinical usage and the roles of newer drugs are being defined. In simple partial seizures. older drugs that are still commonly used (phenytoin. ethosuximide. lamotrigine. altering the activity of neurotransmitters (eg. Some seem able to suppress abnormal neuronal firing without suppressing normal neurotransmission. valproate) and newer drugs (gabapentin. and decreasing the activity of glutamate. theophylline). oxcarbazepine. Partial seizures begin in a specific area of the brain and often indicate a localized brain lesion such as birth injury.

Phenytoin is highly bound (90%) to plasma proteins.184 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM phenytoin or fosphenytoin. is also common. lethargy) and gastrointestinal (GI) tract (nausea. It is often the initial drug of choice. Phenytoin (Dilantin). With oral phenytoin. some people suggest they be called neuromodulators or neurostabilizers rather than AEDs or anticonvulsants. nephritis. Prompt-acting forms reach peak plasma levels in 2 to 3 hours. carbamazepine and valproate) although they are not FDA-approved for this purpose.5 hours with the liquid suspension. Phenytoin. it is sometimes used to treat cardiac dysrhythmias. Phenytoin. Carbamazepine is approved for treatment of the pain associated with trigeminal neuralgia. Most are metabolized in the liver. Serious reactions are uncommon but may include allergic reactions. For IV administration. topiramate. loss of therapeutic effectiveness. and an injectable solution. topiramate and zonisamide are contraindicated or must be used cautiously in clients with hepatic or renal impairment. If a client takes Dilantin and switches to a generic form.5–25 mg PE/mL. it can increase the metabolism of itself and many other drugs. they cannot be adequately discussed as groups. carbamazepine. an oral suspension. tiagabine. Carbamazepine is contraindicated in clients with previous bone (text continues on page 188) . In contrast to other preparations of injectable phenytoin. Intramuscular phenytoin is poorly absorbed and not recommended. The most common adverse effects of phenytoin affect the CNS (eg. and other symptoms). is given to prevent recurrence. especially in children. lamotrigine. and mental confusion. arthralgia. drowsiness. Most produce ataxia (impaired muscular coordination such as a staggering gait when trying to walk). There may also be differences in bioavailability among generic formulations manufactured by different companies. and can be given IV more rapidly. lamotrigine. carbamazepine. AEDs also are used prophylactically in clients with brain trauma from injury or surgery. Carbamazepine (Tegretol) is used. and infused at a maximal rate of 150 mg PE/minute. dizziness. It is given orally and peak blood levels are reached in about 1. In addition to treatment of seizure disorders. a few are eliminated mainly through the kidneys. oxcarbazepine. agranulocytosis). in addition to seizure disorders. levetiracetam. Gingival hyperplasia. confusion. the rate and extent of absorption vary with the drug formulation. or pancreatitis. both AEDs and non-AEDs. It is approved for treatment of status epilepticus and for short-term use in clients who cannot take oral phenytoin. some may cause serious or life-threatening adverse effects such as cardiac dysrhythmias. neuropathic pain. gabapentin. Consequently. In addition to treatment of seizure disorders. can be diluted with 5% dextrose or 0. It is metabolized in the liver to an active metabolite. and valproate are contraindicated in clients who have experienced a hypersensitivity reaction to the particular drug (usually manifested by a skin rash. there is a risk of lower serum phenytoin levels. especially in adults. Because the drugs are so diverse. vomiting). and long-acting forms in about 12 hours. Gabapentin is also being used. bone marrow depression. fosphenytoin can be diluted to a concentration of 1. and other disorders. and drowsiness as common adverse effects. Because the drugs are being used for other indications than seizure disorders. ataxia. ethosuximide. the drugs are described individually. there is a risk of higher serum phenytoin levels and toxicity. its half-life shortens with chronic administration. types of seizures for which the drugs are used and dosages are listed in Drugs at a Glance: Antiseizure Drugs. 4 to 5 hours with conventional tablets. carbamazepine with bone marrow depression (eg. Phenytoin may interact with many other drugs. The injectable solution is highly irritating to tissues and special techniques are required when the drug is given intravenously (IV). the prototype. hepatitis. INDIVIDUAL ANTISEIZURE DRUGS Most AEDs are well absorbed with oral administration and are usually given by this route. Additional contraindications include phenytoin with sinus bradycardia or heart block. Fosphenytoin is available in 2-mL and 10-mL vials with 50 mg PE/mL (fosphenytoin 50 mg PE = phenytoin 50 mg). Also. fosphenytoin causes minimal tissue irritation. Because it induces its own metabolism. is one of the oldest and most widely used AEDs. Clients should not switch between generic and trade name formulations of phenytoin because of differences in absorption and bioavailability. Some of the newer AEDs are being tested for effectiveness in relation to bipolar. All of the drugs must be used cautiously during pregnancy because they are teratogenic in animals. but it is not approved for this indication and is not considered better than carbamazepine. The manufacturer recommends that all dosages be expressed in phenytoin equivalents (PE). leukopenia. and seizures. Fosphenytoin (Cerebyx) is a prodrug formulation that is rapidly hydrolyzed to phenytoin after IV or intramuscular (IM) injection. mainly because it induces drug-metabolizing enzymes in the liver. an overgrowth of gum tissue.9% sodium chloride solution. Thus. and tiagabine and valproic acid with liver disease. If a client is stabilized on a generic formulation and switches to Dilantin. a chewable tablet. to treat trigeminal neuralgia and bipolar disorder. AEDs are used to treat bipolar disorder (eg. and 3 to 12 hours with extended-release forms (tablets and capsules). bone marrow depression. although few studies validate their effectiveness for this purpose. Contraindications to Use AEDs are contraindicated or must be used with caution in clients with CNS depression. Phenytoin is available in generic and brand name capsules. They are also used in the management of chronic neuropathic pain. many other drugs can affect phenytoin metabolism and protein binding. It is metabolized in the liver to inactive metabolites that are excreted in the urine.

maximum dose. PO initially 500 mg/d. Intervals between doses should not exceed 12 h.5 mg every week. and a suspension of 100 mg/5 mL. increased by 0. approximately 750–1000 mg/d Dosage not established Schedule IV drug Schedule IV drug Available in oral capsules and syrup Therapeutic serum drug level is 40–80 mcg/mL. • The suspension is absorbed more rapidly and produces higher peak drug levels than tablets.5 mg two times daily. with other AEDs PO 1. Much easier to give IV than phenytoin. PO 200 mg twice daily. repeat every 5–10 min if needed. if necessary. may increase to 1000 mg daily for children 12–15 years and 1200 mg for children over 15 y.01–0. maximum dose. IV 15–20 mg PE/kg. Diazepam (Valium) Acute convulsive seizures. increase to 1000 mg daily if necessary. maximum dose.5 mg over 2–3 min.2–0. with other AEDs >12 y: PO 900–1800 mg/d. Does not cause significant drug–drug interactions (continued ) . maximum dose. increased at weekly intervals until seizures are controlled or toxicity occurs. at a rate of 100–150 mg PE/min PO 900 mg daily. in 3 divided doses (same as adults). extended-release tablets and capsules.5 mg every week. 3–12 y: 10–15 mg/kg/d. maximum dose. increased by 7. 0.5 mg/d every 3–7 days if necessary. increased gradually to 1200 mg if necessary Children >12 y: PO 200 mg twice daily. increased by 250 mg weekly until seizures are controlled or toxicity occurs. every 2–5 min up to a maximum of 5 mg 5 y and older: IV 1 mg every 2–5 min up to a maximum of 10 mg. if necessary 6–12 y: PO 100 mg twice daily (tablet) or 50 mg 4 times daily (suspension). Intervals between doses should not exceed 12 h. and mixed seizures Adults Epilepsy. PO 200 mg daily. status epilepticus Ethosuximide (Zarontin) Absence seizures. in 3 divided doses. increased up to 1800 mg/d if necessary.2 mg/kg/d >12 y: PO same as adults 9–12 y: PO maximal initial dose 7. IM loading dose 1–20 mg PE/kg.5 mg/d. also may be effective in myoclonic and akinetic epilepsy Fosphenytoin (Cerebyx) Status epilepticus and short-term use in clients who cannot take oral phenytoin PO 0. 17–51 µmol/L). • Therapeutic serum drug level is 4 to 12 mcg/mL (SI units.CHAPTER 11 ANTISEIZURE DRUGS 185 Drugs at a Glance: Antiseizure Drugs Routes and Dosage Ranges Generic/Trade Name Carbamazepine (Tegretol) Types of Seizures Used to Treat Partial. maximum dose. generalized tonicclonic. if necessary. increased gradually to 600– 1200 mg daily if needed. maximum dose. possibly effective in generalized tonic-clonic and psychomotor seizures Partial seizures. 30 mg.5 mg 3 times daily. increased if necessary. 60 mg/d >30 d and <5 y: IV 0. increased by 7. 90 mg/d IV 5–10 mg no faster than 2 mg/min. IV. 100 mg/24 h. can also be given IM Gabapentin (Neurontin) Partial seizures. PO initially 250 mg/d. 20 mg/d PO maximal initial dose 7. status epilepticus.03 mg/kg/d. 1500 mg/d Nonemergent seizures. Repeat in 2–4 hours if necessary. in 3 or 4 divided doses Trigeminal neuralgia. in 3 divided doses. in 3 or 4 divided doses Remarks • Available in oral and chewable tablets. increased by 0. maximum dose. maintenance dose 4–6 mg PE/kg/d. Schedule IV drug Clonazepam (Klonopin) Clorazepate (Tranxene) Myoclonic or akinetic seizures. alone or with other AEDs.25– 0. Repeat in 2–4 hours if necessary.5 mg/d every 3–7 days if necessary.

250–500 mg End-stage renal disease. A newer drug that may have several advantages over older agents . 300 mg 2 times daily (600 mg/d). 500– 1000 mg. give 5 mg on alternate days for 2 wk. If calculated dose is 2. rounded to nearest 5 mg. dosage must be substantially reduced. Crcl 15–30 mL/min. increased by 1000 mg/d every 2 wk. 400 mg 3 times daily (1200 mg/d). PO 0. Crcl <30.5–5 mg. Crcl <15 mL/min. PO 300–500 mg daily in 1 or 2 doses Dosage not established Valproic acid slows lamotrigine’s metabolism by approximately 50%. PO 100–400 mg daily in 1 or 2 divided doses With valproic acid. with other AEDs Lennox-Gastaut syndrome. 300–500 mg/d in 2 divided doses. then 0. then 25 mg daily for 2 wk Maintenance dose.3 mg/kd/d in 1 or 2 doses. if necessary. PO 5–15 mg/kg/d in 2 divided doses >12 y: With enzymeinducing AEDs. For patients on hemodialysis. Crcl 30–60 mL/min. 300 mg every other day. then 25 mg once daily for 2 wk. Children Remarks Lamotrigine (Lamictal) Partial seizures. 100–150 mg/d in 2 divided doses. 300 mg once daily. 500–1500 mg. Usual maintenance dose. on hemodialysis. With AEDs including valproic acid: PO 25 mg every other day for 2 wk. Crcl 50–80. Crcl 30–50. then increase by 25 to 50 mg/d every 1–2 wk to a maintenance dose. Maximum dose. PO 25 mg every other day for 2 wk.186 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Antiseizure Drugs (continued ) Routes and Dosage Ranges Generic/Trade Name Types of Seizures Used to Treat Adults Renal impairment: Crcl >60 mL/min. 500–1000 mg. with other AEDs PO 500 mg twice daily initially. With AEDs other than valproic acid: PO 50 mg once daily for 2 wk. 250–750 mg. initially. 3000 mg daily Renal Impairment: Crcl >80. 200– 300 mg after each 4 h of hemodialysis. then 50 mg twice daily (100 mg/d) for 2 wk.15 mg/kg/d in 1 or 2 doses for 2 wk. for 2 wk Maintenance dose. Usual maintenance dose. If lamotrigine is combined with other AEDs plus valproic acid. PO 50 mg daily for 2 wk. with a supplemental dose of half the total daily dose (250–500 mg) 2–12 y: With enzymeinducing AEDs. then increase by 100 mg/d at weekly intervals to a maintenance dose. initially. with other AEDs Levetiracetam (Keppra) Partial seizures. then 100 mg daily in 2 divided doses for 2 wk Maintenance dose.

maximum dose 56 mg/d in 2–4 divided doses 12–18 y: PO 4 mg daily for 1 wk. or 5% dextrose in water. those receiving valproate monotherapy) may require lower doses or a slower dose titration. maximum 50 mg/min Children Dosage not established Remarks Schedule IV drug Oxcarbazepine (Trileptal) Partial seizures. with other AEDs PO 4 mg daily for 1 wk. increased to 8 mg/d in 2 divided doses for 1 wk. PO 8–10 mg/kg/d. Usual dose. as monotherapy or with other AEDs in adults. immediate-release and extended-release capsules.CHAPTER 11 ANTISEIZURE DRUGS 187 Drugs at a Glance: Antiseizure Drugs (continued ) Routes and Dosage Ranges Generic/Trade Name Lorazepam (Ativan) Types of Seizures Used to Treat Acute convulsive seizures. increase by 1–3 mg/kg/d at 1. and 600-mg scored tablets and a 60 mg/mL fruitflavored suspension Serum drug levels of 10–25 mcg/mL are in the therapeutic range • Available in chewable tablets. status epilepticus Adults IV 2–10 mg. 300-. Usual dose 5–9 mg/kg/d. 25 mg every PM. and solution for injection • Therapeutic serum level is 5–20 mcg/mL (SI units 40–80 µmol/L). with other AEDs in children 4–16 years old With other AEDs. Topiramate (Topamax) Partial seizures. Concentrations at or above the upper therapeutic level may be associated with toxicity.9% sodium chloride injection. oral suspension. increased by 4–8 mg/wk until desired effect. increased by 25–50 mg per week until response. in 2 divided doses (continued ) . Use in noninduced patients (eg. Most experience obtained in patients receiving at least one concomitant enzyme-inducing AED. diluted in an equal amount of sterile water for injection. PO 300 mg twice daily (600 mg/d) and increased slowly until response achieved PO 100–300 mg daily in 2–3 divided doses PO 100 mg three times daily initially. with other AEDs PO 25–50 mg daily. Dilantin) Tiagabine (Gabitril) Partial seizures. 400 mg daily in 2 divided doses 2–16 y: PO wk 1. not to exceed 600 mg twice daily. then increased by 4–8 mg/wk up to a maximum of 32 mg/d in 2 to 4 divided doses <12 y: not recommended A newer drug with possible advantages over older drugs Available in 150-. Titrate to reach target dose over 2 wk. and injected over 2 min PO 600 mg twice daily (1200 mg/d) Severe renal impairment (Crcl <30 mL/min). maximum dose 300 mg/d Phenytoin (prototype. 0. 300 mg (long-acting) once daily as maintenance IV 100 mg q6–8h. Phenobarbital Generalized tonic-clonic and partial seizures Generalized tonic-clonic and some partial seizures Prevention and treatment of seizures occurring during or after neurosurgery PO 5 mg/kg per day in 2–3 divided doses PO 4–7 mg/kg/d in divided doses.or 2-wk intervals until response.

abnormal vision. increase by 100 mg/d every 1–2 wk if necessary. marrow depression or hypersensitivity to carbamazepine and in clients receiving monoamine oxidase inhibitors (MAOIs). nausea. The elimination half-life is approximately 30 hours in children and 60 hours in adults. alone or with other AEDs. is not appreciably metabolized. Tolerance to antiseizure effects develops with long-term use. maximum dose. Ethosuximide (Zarontin) is the AED of choice for absence seizures. diluted in 5% dextrose or 0.9% sodium chloride injection Children PO 15–30 mg/kg/d Remarks • Therapeutic serum levels are 50–100 mcg/mL (SI units 350–700 µmol/L) • Note: Dosage ranges are the same for the different formulations. Zonisamide (Zonegran) Partial seizures. • Do not give IV >14 days. antiepileptric drug. Diazepam and lorazepam are used to terminate acute convulsive seizures. In status epilepticus. Most adverse effects subside spontaneously or with dosage reduction. 1000–1600 mg. Several formulations of valproic acid are available in the United States. Clonazepam has a long half-life and may require weeks of continued administration to achieve therapeutic serum levels. a steady-state serum concentration is reached in about 5 days. Gabapentin (Neurontin) is used with other AEDs for treatment of partial seizures. tremor. circulates largely in a free state because of minimal binding to plasma proteins.188 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Antiseizure Drugs (continued ) Routes and Dosage Ranges Generic/Trade Name Valproic acid (Depakene capsules). or the maximum dose (60 mg/kg/d) is reached. vomiting. Crcl. Clonazepam (Klonopin). Because of clonazepam’s long halflife. diazepam (Valium). adverse effects occur. phenytoin equivalent. Ethosuximide may be used with other AEDs for treatment of mixed types of seizures. creatinine clearance. in divided doses IV client’s usual dose. Gabapentin reportedly does not cause significant drug–drug interactions. fatigue. and complex partial seizures Adults PO 10–15 mg/kg/d. Abrupt withdrawal may precipitate seizure activity or status epilepticus. withdrawal symptoms may appear several days after administration is stopped. dosage must be reduced in clients with renal impairment. Divalproex sodium (Depakote enteric-coated tablets) Types of Seizures Used to Treat Absence. Sodium valproate (Depakene syrup. such as phenytoin. switch to oral product when possible. Give amounts >250 mg/d in divided doses. it is followed with a long-acting anticonvulsant. about 20% is excreted unchanged through the kidneys. Depacon injection). Because the drug is eliminated only by the kidneys. It is eliminated mainly by hepatic metabolism to inactive metabolites. gingivitis. mixed. 600 mg daily <16 y: not recommended AED. especially the life-threatening seizures of status epilepticus. until seizures controlled. or a combination of the two (divalproex sodium). Adverse effects include dizziness. as the sodium salt (sodium valproate). Usual daily dose. depending on creatinine clearance. and lorazepam (Ativan) are benzodiazepines (see Chap. Lorazepam has become the drug of choice for status epilepticus because its effects last longer than those of diazepam. doses are in valproic acid equivalents. and pruritus. PE. MAOIs should be discontinued at least 14 days before carbamazepine is started. with other AEDs PO 100–200 mg daily as a single dose or as 2–3 divided doses. It is well absorbed with oral administration and reaches peak serum levels in 3 to 7 hours. Clonazepam and clorazepate are used in long-term treatment of seizure disorders. loss of muscle coordination. clorazepate (Tranxene). It is 60% absorbed with usual doses. . Diazepam has a short duration of action and must be given in repeated doses. drowsiness. The elimination half-life is 5 to 7 hours with normal renal function and up to 50 hours with impaired renal function. 8) used in seizure disorders. As with other benzodiazepines. and is eliminated by the kidneys as unchanged drug. These products may contain valproic acid as the acid. clonazepam produces physical dependence and withdrawal symptoms. increase weekly by 5–10 mg/kg/d.

Overall. and phenobarbital induce drugmetabolizing enzymes in the liver and accelerate lamotrigine’s metabolism. It induces drug-metabolizing enzymes in the liver and thereby accelerates the metabolism of most AEDs when given with them. Thus. However.5 to 4. the equivalent dose of oxcarbazepine is 50% higher than the carbamazepine dosage. but it progresses in some clients to a more severe form. an excitatory neurotransmitter. nausea and vomiting. Lamotrigine has little effect on the metabolism of other AEDs. and serum sodium levels should be monitored periodically during maintenance therapy. Because a serious skin rash may occur. dizziness. nausea. may reduce plasma levels of the active metabolite by about one third. the recommended equivalent oxcarbazepine dosage is 20% higher than the carbamazepine dosage. The drug inhibits cytochrome P450 2C19 enzymes and induces 3A4 enzymes to influence the metabolism of other drugs metabolized by these enzymes.5 hours. who take drugs with increased potential for drug interactions. either drug may be substituted for the other without tapering the dose of one or gradually increasing the dose of the other. and rhinitis.CHAPTER 11 ANTISEIZURE DRUGS 189 Lamotrigine (Lamictal) is used with other AEDs for treatment of partial seizures. CNS depression and other adverse effects associated with barbiturates may occur. Lamotrigine is about 55% bound to plasma proteins. It is approved for both monotherapy and adjunctive (with other AEDs) therapy in adults with partial seizures and for adjunctive therapy only in children. For example. including phenytoin. in combination with other AEDs. double vision. it has a low potential for drug interactions. vomiting. ataxia. Effects on other drugs begin 1 or 2 weeks after phenobarbital therapy is started. Most effects are attributed to an active metabolite produced during first-pass metabolism in the liver. cimetidine. the metabolite is 40% protein bound. hypotension. especially in children. If lamotrigine is combined with other AEDs plus valproic acid. It inhibits abnormal neuronal firing but does not affect normal neuronal excitability or function. levetiracetam has pharmacokinetic and other characteristics that may make it especially useful in clients who require combination antiepileptic drug therapy. It may resolve if lamotrigine is discontinued. hostility. Adverse effects include dizziness. oxcarbazepine should be used with caution in clients taking other drugs that decrease serum sodium levels. . but drug dependence and barbiturate intoxication are unlikely with usual antiepileptic doses. Most of a dose (66%) is eliminated by the kidneys as unchanged drug. Several drug–drug interactions may occur with oxcarbazepine. To discontinue. but other AEDs affect lamotrigine’s metabolism. In older adults. blurred or double vision. Levetiracetam (Keppra) is a newer drug approved for treatment of partial seizures. Phenobarbital is a long-acting barbiturate that is used alone or with another AED (most often phenytoin). along with a small amount of unchanged drug. amnesia. Some studies indicate that skin reactions occur less often with oxcarbazepine than with carbamazepine. paresthesia. oxcarbazepine increases metabolism of estrogens and may decrease the effectiveness of oral contraceptives and postmenopausal estrogen replacement therapy. It is thought to reduce the release of glutamate. dosage should be tapered over at least 2 weeks. pharyngitis. Valproic acid inhibits those enzymes and thereby slows lamotrigine’s metabolism by approximately 50%. The drug is not metabolized by the liver and does not affect the hepatic metabolism of other drugs. with peak plasma levels reached in 1.5 hours. others include decreases in red and white blood cell counts. in the brain. headache. Its use has declined with the advent of other AEDs that cause less sedation and cognitive impairment. erythromycin) do not significantly affect the elimination of oxcarbazepine or its metabolite. peak plasma levels occur in about one hour. Levetiracetam is well and rapidly absorbed with oral administration. It is chemically unrelated to other AEDs and its mechanism of action is unknown. and hyponatremia. This rapid attainment of therapeutic effects is especially useful for patients with frequent or severe seizures. other drugs that induce cytochrome P450 enzymes. Oxcarbazepine (Trileptal) is a newer drug that is structurally related to carbamazepine. Dosage must be reduced in patients with severe renal impairment (ie. Common adverse effects include drowsiness. Food reduces peak plasma levels by 20% and delays them to 1. It is metabolized in the liver to an inactive metabolite and eliminated mainly in the urine. Because of the risk of hyponatremia. and fatigue. carbamazepine. adverse effects were similar in adult and pediatric patients and when oxcarbazepine was used alone or with other AEDs. creatinine clearance < 30 mL/min). with peak plasma levels in about 5 hours. Dosage must be reduced with impaired renal function. The drug is minimally bound (10%) to plasma proteins and reaches steady-state plasma concentrations after 2 days of twice daily administration. The metabolite is conjugated with glucuronic acid in the liver and excreted in the urine. The drug is well absorbed with oral administration. Skin rash is more likely to occur with concomitant valproic acid therapy. The elimination half-life is 2 hours for oxcarbazepine and 9 hours for the metabolite. It is metabolized in the liver. It is well absorbed after oral administration. Because phenobarbital has a long half-life (50 to 140 hours). and rapid titration rate. It was well tolerated in clinical trials and the incidence of adverse events was similar to that of placebo. anxiety. drugs that inhibit these enzymes (eg. dizziness. nervousness. drowsiness. Phenytoin. emotional lability. about 25% is eliminated unchanged in the urine. For patients receiving carbamazepine or oxcarbazepine. it takes 2 to 3 weeks to reach therapeutic serum levels and 3 to 4 weeks to reach a steady-state concentration. such as Stevens-Johnson syndrome. skin rash. ataxia. dosage must be substantially reduced. but does not affect the extent of drug absorption. or who have impaired liver function. In clinical trials. They included cardiac dysrhythmias. In addition. lamotrigine should not be given to children younger than 16 years of age and should be discontinued at the first sign of skin rash in an adult. high lamotrigine starting dose. drowsiness. and weakness.

which can be reduced by increasing dosage gradually. does not seem to inhibit zonisamide metabolism or increase its halflife. Although they are uncommon. which may increase GABA levels in the brain. drowsiness. Only 1% of the drug is excreted unchanged in the urine and the metabolites are excreted in urine and feces. Topiramate (Topamax). It is highly protein bound (96%) and is extensively metabolized in the liver. Clients with impaired liver function may need smaller doses because the drug is cleared more slowly. Depakote) are chemically unrelated to other AEDs. ataxia. and nausea. Zonisamide (Zonegran) is chemically a sulfonamide (and contraindicated for use in clients who are allergic to sulfonamides). phenytoin. sodium valproate is a syrup formulation. It is 40% bound to plasma proteins and also binds extensively to red blood cells. Nursing Process Assessment Assess client status in relation to seizure activity and other factors: • If the client has a known seizure disorder and is taking antiseizure drugs. The most common adverse effects are ataxia. tiagabine is well absorbed. After oral administration. carbamazepine. The average elimination half-life is about 21 hours. Valproic acid preparations (Depakene. confusion. which inhibits the cytochrome P450 enzymes. Zonisamide is well absorbed with oral administration and produces peak plasma levels in 2 to 6 hours. including the life-threatening Stevens-Johnson syndrome. over several weeks. peak plasma levels occur in about 45 minutes if taken on an empty stomach and 2. carbamazepine). It is excreted in the urine as unchanged drug (35%) and metabolites (65%). Its elimination half-life is about 63 hours in plasma and >100 hours in red blood cells.190 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Tiagabine (Gabitril). abnormal thinking. Clients with impaired renal function may require lower doses or a slower titration schedule. There is also a risk of kidney stones. administration with cimetidine. potentially serious adverse effects include hepatotoxicity and pancreatitis. It is rapidly absorbed and produces peak plasma levels in about 2 hours after oral administration. zonisamide). dizziness. They are thought to enhance the effects of GABA in the brain. which is higher in clients with an inadequate fluid intake or who also take topiramate or triamterene. what parts of the body are involved? Does he or she lose consciousness? Is he or she drowsy and tired afterward? . and steady-state concentrations are reached in about 4 days with normal renal function. Interventions to help prevent renal stones include maintaining an adequate fluid intake. helpful assessment data can be obtained by interviewing the client. dosage should be reduced by one half. triamterene. drowsiness. The drugs are contraindicated in people who have had hypersensitivity reactions to any of the preparations and people with hepatic disease or impaired hepatic function. dizziness. Drugs that induce the cytochrome P450 enzymes (eg. They are primarily metabolized in the liver and metabolites are excreted through the kidneys. Depacon is an injectable formulation of valproate.5 hours if taken with food. Adverse effects include drowsiness. Dosages of all formulations are expressed in valproic acid equivalents. heart failure) or a history of renal stones. has been observed. Valproic acid (Depakene) is available in capsules. may act by increasing the effects of GABA and other mechanisms. Valproic acid preparations are well absorbed after oral administration and produce peak plasma levels in 1 to 4 hours (15 minutes to 2 hours with the syrup). However. It is approved for adjunctive treatment of partial seizures and may also be effective for monotherapy and generalized seizures. It is not extensively metabolized and is primarily eliminated unchanged through the kidneys. confusion. Depacon. which has a broad spectrum of antiseizure activity. The elimination half-life is 4 to 7 hours in clients receiving enzymeinducing AEDs (eg. Additive CNS depression may occur with alcohol and other CNS depressant drugs. They are also used to treat manic reactions in bipolar disorder and to prevent migraine headaches. GI upset and a serious skin rash may also occur. For clients with a creatinine clearance below 70 mL/minute. It is metabolized by the cytochrome P450 3A enzymes and perhaps other pathways. It is thought to act by inhibiting the entry of sodium and calcium ions into nerve cells. is used with other AEDs in clients with partial seizures. phenytoin) increase the metabolism of zonisamide and reduce its half-life. or what is the frequency of seizures? • Does any particular situation or activity precipitate a seizure? • How does the seizure affect the client? For example. and fatigue. Divalproex sodium (Depakote) contains equal parts of valproic acid and sodium val- proate and is available as delayed-release tablets and sprinkle capsules. Skin rash. Some questions and guidelines include the following: • How long has the client had the seizure disorder? • How long has it been since seizure activity occurred. and avoiding topiramate in people with conditions requiring fluid restriction (eg. impaired concentration or speech) are the most common adverse effects. It is 20% bound to plasma proteins. Renal stones may also occur. by the cytochrome P450 3A family of enzymes. nervousness. avoiding concurrent use of topiramate with other drugs associated with renal stone formation or increased urinary pH (eg. Zonisamide apparently does not induce or inhibit the cytochrome P450 enzymes and therefore has little effect on the metabolism of other drugs. CNS effects (eg. These preparations produce less sedation and cognitive impairment than phenytoin and phenobarbital. They are highly bound (90%) to plasma proteins.

chronic alcohol ingestion. compliance or rejection of drug therapy. seizure disorders may develop with brain surgery. fever. and infection. The cyanosis. such as alcohol and barbiturates. check laboratory reports of serum drug levels for therapeutic ranges or evidence of underdosing or overdosing. Interventions Use measures to minimize seizure activity. Discuss the seizure disorder. especially those that impair safety. especially around the neck and chest. . such as flashing lights and loud noises. however. • Interview and observe for avoidance of adverse drug effects. Involve the client in decision making when possible. • Help the client identify conditions under which seizures are likely to occur. such as lidocaine). and others. duration. In people without previous seizure activity. the plan for treatment. • Turning the client to one side so that accumulated secretions can drain from the mouth and throat when convulsive movements stop. increasing exercise. improving sleep and diet) and treatment of existing disorders can reduce the frequency of seizures. Assess for risk of status epilepticus. note the location (localized or generalized). abnormal movements. • Loosening tight clothing. concomitant events. use of drugs known to cause seizures. hypoglycemia. to promote respiration. • • • • • • • • • • Nursing Diagnoses • Ineffective Coping related to denial of the disease process and need for long-term drug therapy • Deficient Knowledge: Disease process • Deficient Knowledge: Drug effects • Risk for Injury: Trauma related to ataxia. Guidelines include the following: • When available. and postseizure behavior. drug overdosage (CNS stimulants. Assist the client in planning how to get enough rest and exercise and eat a balanced diet. Check reports of serum drug levels for abnormal values. Most of these seizures. or does he or she find it difficult to do so? • What other drugs are taken? This includes both prescription and nonprescription drugs. Discuss social and economic factors that promote or prevent compliance. and withdrawal from CNS depressants. as well as those taken regularly or periodically. or has sustained an injury. • Not restraining the client’s movements. and a physician should be notified immediately. and the person starts responding and regaining normal skin color. Risk factors include recent changes in antiseizure drug therapy. Inform the client and family that seizure control is not gained immediately when drug therapy is started. These precipitating factors. head injury. try to prevent or minimize their occurrence. confusion • Risk for Injury: Seizure activity or drug toxicity • Noncompliance: Underuse of medications Planning/Goals The client will: • • • • • Take medications as prescribed Experience control of seizures Avoid serious adverse drug effects Verbalize knowledge of the disease process and treatment regimen • Avoid discontinuing antiseizure medications abruptly • Keep follow-up appointments with health care providers Evaluation • Interview and observe for decrease in or absence of seizure activity. and loss of consciousness that characterize a generalized tonic-clonic seizure can be quite alarming to witnesses. are identified. If the person has one seizure after another (status epilepticus). hypoxia. • What is the client’s attitude toward the seizure disorder? Clues to attitude may include terminology. to be avoided or decreased when possible. The goal is to avoid unrealistic expectations and excessive frustration while drugs and dosages are being changed in an effort to determine the best regimen for the client. subside within 3 or 4 minutes. may include ingestion of alcoholic beverages or stimulant drugs. reducing alcohol and caffeine intake. dizziness. if needed.CHAPTER 11 ANTISEIZURE DRUGS 191 • Which antiseizure drugs are taken? How do they affect the client? How long has the client taken the drugs? Is the currently ordered dosage the same as what the client has been taking? Does the client usually take the drugs as prescribed. Identify risk factors for seizure disorders. severe physical or emotional stress. or local anesthetics. and the importance of complying with prescribed drug therapy with the client and family members. has trouble breathing or continued cyanosis. To observe and record seizure activity accurately. specific characteristics of abnormal movements or behavior. When risk factors for seizures. further care is needed. such as amphetamines or cocaine. especially status epilepticus. willingness or reluctance to discuss the seizure disorder. such as loss of consciousness and loss of bowel or bladder control. Identification of precipitating factors is important because lifestyle changes (reducing stress. This information is necessary because many drugs interact with antiseizure drugs to decrease seizure control or increase drug toxicity. fractures may result. Protect a client experiencing a generalized tonic-clonic seizure by: • Placing a pillow or piece of clothing under the head if injury could be sustained from the ground or floor. and sensory stimuli.

operate machinery. ✔ Do not drive a car. seizures may occur if the drugs are stopped abruptly. Store the suspension at room temperature and use the bottle within 7 weeks or discard the amount remaining. This is extremely important. 3. you may need to check your blood sugar more often or take a higher dose of your antidiabetic medication. or vice versa. This is necessary for rapid and appropriate treatment in the event of a seizure. notify the physician immediately if a skin rash or decreased seizure control develops. If taking lamotrigine. If you are taking oxcarbazepine liquid suspension or giving it to a child. Ask your physician if you should take (or give a child) supplements of folic acid. Severe. decreased physical coordination. This will prevent or decrease nausea. ✔ Do not suddenly stop taking any antiseizure medication. Phenytoin may inhibit the release of insulin and increase blood sugar. When outdoors. mix it thoroughly immediately before use and measure it with a calibrated medicine cup or a measuring teaspoon. Lamotrigine may cause photosensitivity. The syrup formulation may be diluted in water or milk but should not be mixed in carbonated beverages. Taking valproic acid at bedtime may reduce dizziness and drowsiness. If you have diabetes. or other emergency situation. wear protective clothing and sunscreen. vitamin D. the regular capsule should not be opened and the tablet should not be crushed for administration. Notify your physician or another health care professional if you develop a skin rash. chewing or crushing may cause irritation of the mouth and throat. 4. The sprinkle capsule may be opened and the contents sprinkled on soft food for administration. mix it thoroughly immediately before use. even life-threatening. These supplements may help to prevent some adverse effects of phenytoin. 5. unexplained fever. seizure activity. Swallow tablets or capsules of valproic acid (Depakene or Depakote) whole. ✔ When taking generic phenytoin or the Dilantin brand of phenytoin: 1. yellowish skin or eyes. additional doses must not be taken because of increased risks of serious adverse reactions. or any indication of infection or bleeding. vomiting. Excessive drowsiness. ✔ Discuss any problems (eg. swollen or tender gums. and zonisamide (Zonegran) may be taken with or without food. With valproic acid. including over-the-counter antihistamines and sleep aids. without discussing with the prescribing physician. There are many potential drug interactions in which the effects of the antiseizure drug or other drugs may be altered when drugs are given concomitantly. These drugs must be taken regularly to maintain blood levels adequate to control seizure activity. ✔ Carry identification. or perform other activities requiring physical and mental alertness when drowsy from antiseizure medications. swollen glands. ✔ Do not take other drugs without the physician’s knowledge and inform any other physician or dentist about taking antiseizure medications. with the name and dose of the medication being taken. unusual bleeding or bruising. topiramate (Topamax). Measure it with the syringe supplied by the manufacturer and squirt the medication directly into the mouth. severe nausea and vomiting. calcium. sore throat. ✔ Notify your physician if you become pregnant or intend to become pregnant during therapy. 2. At the same time. which are adverse reactions to most of these drugs. such as a MedicAlert device. bleeding. accidental injury. ✔ Notify your physician if you are breast-feeding or intend to breast-feed during therapy. ✔ Do not take any other drugs that cause drowsiness. and decreased mental alertness increase the likelihood of injury. If you are taking phenytoin liquid suspension or giving it to a child. ✔ ✔ ✔ ✔ ✔ . Levetiracetam (Keppra). excessive drowsiness. Oxcarbazepine (Trileptal) decreases the effectiveness of oral contraceptive drugs. and if you become pregnant. persistent headache. joint pain. Self-administration ✔ Take most antiseizure medications with food or a full glass of fluid.192 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM CLIENT TEACHING GUIDELINES Antiseizure Medications General Considerations ✔ Take the medications as prescribed. other adverse effects) associated with an antiseizure medication with the prescribing physician or other health care professional. and gastric distress. Brush and floss your teeth and have regular dental care to prevent or delay a gum disorder called gingival hyperplasia. 6. Do not switch from a generic to Dilantin. Do not use regular teaspoons because they hold varying amounts of medication. oxcarbazepine (Trileptal). It is helpful to write the date opened and the expiration date on the container. or vitamin K. ✔ There are differences in formulations that may upset seizure control and cause adverse effects. Adjusting dosage or time of administration may relieve the problems.

therapy must be individualized. drug may be added. Hammerly experiences a generalized seizure. the clinician may need to reassess the client for type of seizure. 2. Ms. phenytoin ($26 to $35). treatment with a single AED is sufficient to meet this goal. and compliance. Most of the newer AEDs reportedly cause fewer adverse effects and are better tolerated than the older drugs although they may also cause potentially serious adverse effects. combination therapy is associated with more severe adverse effects. in adequate dosage. a second. tiagabine ($99 to $190). In general. levetiracetam ($105 to $315). although they may cause other potentially serious adverse effects. prescribers can encourage compliance by choosing drugs that are covered by clients’ insurance plans or. Type of seizure is a major factor. Sexually active adolescent girls and women of childbearing potential who require an AED must be evaluated and monitored very closely because . In 20% to 30% of clients. In the morning. Although the newer drugs are generally effective and better tolerated than older agents. may vary among pharmacies and change over time. lamotrigine ($196 to $289). monotherapy has the advantages of fewer adverse drug effects. While showering. oxcarbazepine ($97 to $358). If combination therapy is ineffective. Oxcarbazepine is approved for monotherapy of partial seizures. poor compliance. However. which is usually taken at midnight and 6 AM. topiramate ($88 to $354). To meet this goal. fewer drug–drug interactions. The goal is to control seizure activity with minimal adverse drug effects. a few are available as oral liquids or injectable solutions. A single drug (monotherapy) is recommended when possible. She is NPO after midnight. some of the other drugs are also thought to be effective as monotherapy. ethosuximide is the drug of choice. Cost should be considered because this may be a major factor in client compliance. and sometimes a third. oxcarbazepine. Pregnancy risk. Therefore. This is not necessary when substituting oxcarbazepine for carbamazepine or vice versa. Hammerly is admitted to your unit for neurosurgery in the morning. and zonisamide. clonazepam and valproate are also effective. levetiracetam. interactions between AEDs. a combination of drugs is usually necessary. valproic acid. and zonisamide ($100 to $201). In most clients. Dosage forms may increase seizure control. the second drug should be added and allowed to reach therapeutic blood levels before the first drug is gradually decreased in dosage and discontinued. fails to control seizures or causes unacceptable adverse effects. extended release or long-acting dosage forms can maintain more consistent serum drug levels and decrease frequency of administration. 5. If effective in controlling seizures. Monotherapy versus combination therapy. For mixed seizures. including her antiseizure medication. Costs of newer drugs are gabapentin ($139 to $354). The nurse holds all medications. PRINCIPLES OF THERAPY Therapeutic Goal Drug therapy is the main treatment of epilepsy for clients of all ages. phenobarbital ($2 to $5). and compliance with the prescribed drug therapy regimen. Most of the AEDs are available in oral tablets or capsules. For absence seizures. Costs. however. client convenience. When substituting one AED for another. choosing less expensive drug therapy regimens. If the first drug. two or more AEDs are required. then another agent should be tried as monotherapy. 6. which depend on manufacturers’ wholesale prices and pharmacies’ markups as well as prescribed dose amounts and other factors. When monotherapy is ineffective. and tiagabine. When possible. Guidelines for newer drugs are evolving as research studies are done and clinical experience with their use increases. Ms. AEDs with activity against both partial-onset and generalized seizures include lamotrigine. and valproate ($80 to $280). Fewer and milder adverse effects can greatly increase a client’s willingness to 4. Adverse drug effects may be the deciding factor in choosing an AED because most types of seizures can be treated effectively by a variety of drugs. medical conditions or drug– drug interactions that aggravate the seizure disorder or decrease the effectiveness of AEDs. In general. because the drugs are similar. Costs of older drugs are carbemazepine ($54 to $81). and higher costs. For example. for uninsured clients. and usually greater client compliance. ethosuximide ($105 to $158). they are also quite expensive. an accurate diagnosis is essential before drug therapy is started. Hammerly’s surgery is delayed so you decide to help her with her shower. phenytoin. lower costs. 3. the following list of costs per month allow comparisons among AEDs and may be useful in clinical practice. The use of carbamazepine and valproic acid increased largely because they cause less sedation and cognitive and psychomotor impairment than phenobarbital and phenytoin. Drugs considered most useful for partial seizures include carbamazepine. comply with the prescribed regimen and attain seizure control. Drug Selection 1. phenobarbital. topiramate. Most of these agents are approved for combination therapy with other AEDs in clients whose seizures are not adequately controlled with a single drug. Most practitioners recommend sequential trials of two to three agents as monotherapy before considering combination therapy.CHAPTER 11 ANTISEIZURE DRUGS 193 How Can You Avoid This Medication Error? Ms. gabapentin.

especially when multiple AEDs are being given. blood samples should generally be obtained in the morning. The first drug is usually stopped when therapeutic effects or therapeutic serum drug levels of the second drug are attained. Periodic measurements of serum drug levels are recommended. When fosphenytoin is substituted for oral phenytoin. before the first daily dose of an AED. Usually. To be useful. and in cases involving trauma. For most patients. In other words. Other causes include incorrect diagnosis of the type of seizure. Eng. How should you proceed? Drug Dosage The dosage of most drugs is determined empirically by observation of seizure control and adverse effects. Adverse effects are more likely to occur during initiation of treatment and. Several antiseizure drugs have the potential for causing blood. and to evaluate possible drug-related adverse effects. serum protein. 3. infants exposed to one AED have a significantly higher risk of birth defects than those not exposed and infants exposed to two or more AEDs have a significantly higher risk than those exposed to one AED. to assess for drug malabsorption or client noncompliance. there are several possible causes. dosage of the one being added is gradually increased while the one being discontinued is gradually decreased. either agent may be substituted for the other without gradual reduction or titration of the dose. and topiramate must be given in the presence of renal impairment. hyponatremia) or use of alcohol or recreational drugs. aspartate aminotransferase) be performed before drug therapy starts and periodically thereafter. studies indicate that medications can be stopped in approximately two thirds of clients whose epilepsy is completely controlled with drug therapy. Duration and Discontinuation of Therapy Antiseizure drug therapy may be discontinued for some clients. usually after a seizure-free period of at least 2 years. to guide dosage adjustments. seizure control. For this reason. if treatment is started too aggressively. it is usually recommended that baseline blood studies (complete blood count. 2. levetiracetam. theophylline) and severe electrolyte imbalances (eg. platelet count) and liver function tests (eg. doses may be lowered to the minimum effective level. Nursing Notes: Apply Your Knowledge You are a nurse working in a clinic. probably owing to differences in hepatic metabolism. Monitoring Antiepileptic Drug Therapy 1. . and smaller doses of lamotrigine must be given when combined with valproic acid and another AED. 4. For most drugs. 5. or kidney disorders. A common one is the client’s failure to take the antiseizure drug as prescribed. larger doses are needed for a single drug than for multiple drugs. doses should not be increased or decreased solely to maintain a certain serum drug level. initial doses are relatively low. the equivalent oxcarbazepine dosage is 50% higher than the carbamazepine dosage. use of the wrong drug for the type of seizure. For patients receiving carbamazepine or oxcarbazepine therapy. liver. His speech also seems somewhat slurred. Then. When one AED is being substituted for another. For routine monitoring. comes into the clinic complaining of problems with poor coordination and fatigue.194 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM all of the drugs are considered teratogenic. the recommended equivalent oxcarbazepine dosage is 20% higher than the carbamazepine dosage. the same total daily dosage (in PE) may be given IV or IM. clients may be unwilling to continue a particular medication even if doses are reduced in amount or frequency of administration. for people with a large body mass (assuming normal liver and kidney function). Mr. Smaller doses are usually required when liver disease is present and when multiple drugs are being given. its dosage should always be tapered gradually. usually over 1 to 3 months. or adverse drug effects. In general. serum drug levels must be interpreted in relation to clinical responses because there are wide variations among clients receiving similar doses. This helps to document blood levels associated with particular drug dosages. and too-frequent changes or premature withdrawal of drugs. and emotional stress. In addition. 1. His Dilantin level is drawn and is 19 mcg/mL. When switching between agents in older adults. surgery. 3. Although opinions differ about whether. Abruptly stopping an AED may exacerbate seizures or cause status epilepticus. Additional causes may include drug overdoses (eg. when. When drug therapy fails to control seizures. When an AED is being discontinued. inadequate drug dosage. to assess and document therapeutic failures. the timing of blood samples in relation to drug administration is important. doses are gradually increased until seizures are controlled or adverse effects occur. and how the drugs should be discontinued. an epileptic for the last 10 years. 2. His seizures have been well controlled on phenytoin (Dilantin) 300 mg hs. Smaller doses of gabapentin. to decrease adverse effects. bilirubin. The effectiveness of drug therapy is evaluated primarily by client response in terms of therapeutic or adverse effects.

but rates become more rapid than those of adults by 2 to 3 months of age. such as IV phenytoin (20 mg/kg at 50 mg/minute) or fosphenytoin (20 mg/kg phenytoin equivalents at 150 mg/ minute). Levetiracetam does not induce or inhibit hepatic metabolism of drugs and risks of interactions are minimal. Fatalities have been reported with most antiseizure drugs. periodic attempts to decrease the number or dosage of drugs are probably desirable to minimize adverse reactions. or changing dosage must be done gradually over 2 to 3 months for each drug and with close medical supervision because sudden withdrawal or dosage decreases may cause status epilepticus. Even if drugs cannot be stopped completely. digoxin. Because there is a risk of significant respiratory depression with IV benzodiazepines. the consequence of decreasing the effects of sulfonylureas may be greater difficulty in controlling blood sugar levels in diabetic clients who require both drugs. their combination with any other CNS depressant drugs may cause excessive sedation and other adverse CNS effects. personnel and supplies for emergency resuscitation must be readily available. Hemodialysis is effective in removing drugs that are poorly bound to plasma proteins and that are excreted mainly or partly by the kidneys (eg. gabapentin. methadone. If an antiseizure drug is necessary during the first 7 to 10 days of life. However. cardiovascular problems such as dysrhythmias and hypotension) and are life-threatening.CHAPTER 11 ANTISEIZURE DRUGS 195 Advantages of discontinuation include avoiding adverse drug effects and decreasing costs. oral antidiabetic agents (eg. Drug Therapy for Status Epilepticus An IV benzodiazepine (eg. phenothiazines. If toxicity is suspected. CNS and cause drowsiness. to prevent aspiration). cyclosporine. Because the drugs depress the . and theophylline. Oxcarbazepine decreases effectiveness of felodipine and oral contraceptives (a barrier type of contraception is recommended during oxcarbazepine therapy). The consequence of increasing metabolism of oral contraceptives may be unintended pregnancy. Discontinuing drugs. topiramate. amiodarone. levodopa. Few interactions have been reported with the newer drugs. female sex hormones (estrogens. This produces therapeutic serum drug levels earlier in children than in adults. mainly by inducing drug-metabolizing enzymes in the liver. Activated charcoal is not effective in adsorbing topiramate and is not recommended for topiramate overdose. electrocardiogram (ECG). oral contraceptives. doxycycline. valproate). They may also decrease the effects of numerous other drugs. phenytoin decreases therapeutic effects. larger doses of the affected drugs are needed to achieve therapeutic effects. oral anticoagulants. haloperidol). children require higher doses per kilogram of body weight than adults. disopyramide. In infants and children. AEDs must be used cautiously to avoid excessive sedation and interference with learning and social development. antipsychotic drugs (eg. mexilitene. with possible status epilepticus. In some cases. oral contraceptives. With acetaminophen. Effects of Antiepileptic Drugs on Non-Antiepileptic Drugs Antiepileptic drugs may have clinically significant interactions with many non-AEDs. changing drugs.1 mg/kg at 2 mg/ minute) is the drug of choice for rapid control of tonic-clonic seizures. Carbamazepine reduces the effects of tricyclic antidepressants. Further treatments are based on the patient’s response to these medications. gastric lavage and activated charcoal. IM phenobarbital is effective. and haloperidol. to prevent absorption of additional drug. furosemide. quinidine). disadvantages include recurrence of seizures. Consequently. seizures often recur unless the benzodiazepine is repeated or another. a serum drug level is indicated for those drugs with established therapeutic ranges. doxycycline. lorazepam 0. Topiramate decreases effects of digoxin and oral contraceptives. Severe overdoses disturb vital functions (eg. felodipine. and urine output should be monitored. Vital signs. More interactions with these drugs may be observed with longer clinical use. Enzyme induction means the affected drugs are metabolized and eliminated more quickly. if indicated. level of consciousness. pupillary reflexes. The effects on acetaminophen are the same as those of phenytoin (see above). oral drugs are rapidly absorbed and have short half-lives. sulfonylureas). but may increase the risk of hepatotoxicity by accelerating production of the metabolite that damages the liver. levonorgestrel). There are no specific antidotes and treatment is symptomatic and supportive (ie. Toxicity of Antiseizure Drugs: Recognition and Management Signs and symptoms of overdose and toxicity are usually extensions of known adverse effects. respiratory depression. The rapid rate of drug elimination persists until approximately 6 years of age. Metabolism and excretion also are delayed during the first 2 weeks of life. Only one drug should be reduced in dosage or gradually discontinued at a time. Phenytoin reduces the effects of cardiovascular drugs (eg. Zonisamide interacts with other AEDs but no interactions have been reported with non-AEDs. An endotracheal tube should be inserted prior to lavage. levetiracetam. dopamine. Use in Children Oral drugs are absorbed slowly and inefficiently in newborns. bupropion. adrenal corticosteroids. impaired consciousness and possible coma. CNS depression with confusion. longer-acting drug is given. then decreases until it stabilizes around the adult rate by age 10 to 14 years. Rates of metabolism and excretion also are increased.

tiagabine. renal failure. especially if they also take sodiumlosing diuretics (eg. In general. oxcarbazepine. topiramate. may also be helpful. older adults may develop a tremor that is difficult to diagnose because of its gradual onset and similarity to the tremor occurring with Parkinson’s disease. and dose adjustment for renal dysfunction is not necessary. to minimize peak plasma concentrations. Use in Critical Illness Phenytoin is often used to prevent or treat seizure disorders in critically ill clients. Topiramate may also be cleared more slowly even though it is eliminated mainly through the kidneys and does not undergo significant hepatic metabolism. For clients in critical care units for other disorders. there is little information about their effects in children. including those with head injuries. Elimination of tiagabine is not significantly affected by renal insufficiency. Increased plasma levels of unbound tiagabine. lamotrigine. older adults are also more likely to develop some adverse effects associated with specific drugs. Tiagabine is cleared more slowly in clients with liver impairment. oxcarbazepine. The tremor is often dose-related and reverses when the drug is reduced in dosage or discontinued. Similarly. and topiramate) are approved for use in children. or hemodialysis. phenytoin. with subsequent risks of dizziness. with carbamazepine. frequent assessment of clients for adverse effects and periodic monitoring of serum drug levels. The drugs should be used cautiously. levetiracetam. tremor) have been observed in clients with mild and moderate hepatic insufficiency. At the same time. and frequent observation for toxic effects. Zonisamide should not be given to patients with renal failure and should be discontinued in patients who develop acute renal failure or increased serum creatinine and blood urea nitrogen during therapy. impaired coordination. increased elimination half-life. a history of long-term AED therapy may be a risk factor for seizures. The use of phe- . a low total phenytoin level may still be therapeutic and a dosage increase is not indicated. take multiple drugs. Older adults with preexisting heart disease should have a thorough cardiac evaluation before starting carbamazepine therapy. or zonisamide. decreased elimination by the liver and kidneys may lead to drug accumulation. dizziness. or cardiac dysrhythmias. they may develop hyponatremia. Oxcarbazepine is metabolized faster in children younger than 8 years of age. including status epilepticus. Valproic acid is a hepatotoxic drug and contraindicated for use in hepatic impairment. No dosage adjustment is indicated with levetiracetam. With valproic acid. nobarbital in clients with severe renal impairment requires markedly reduced dosage. and increased frequency of neurologic adverse effects (eg. drowsiness. Most of the drugs (eg. and have decreases in protein binding and liver and kidney function. continuing an AED may complicate drug therapy of other conditions because of adverse Use in Renal Impairment Phenytoin is often used to prevent or treat seizure disorders in seriously ill clients. small initial doses. For example. clients with severe illnesses may metabolize the drug more slowly and therefore experience toxicity. dizziness. and zonisamide must be given in the presence of renal impairment because these drugs are eliminated primarily through the kidneys. As a result. Dosage of oxcarbazepine should be decreased by 50% in patients with creatinine clearance <30 mL/minute. reduced levels of serum albumin may increase the active portion of highly protein bound AEDs (eg. and drowsiness that may occur with most AEDs. especially if they have underlying heart disease. It should be used with caution in the presence of hepatic impairment. oxcarbazepine. but laboratories usually report the total serum drug concentration. Because phenytoin is extensively metabolized in the liver. Use in Hepatic Impairment Most AEDs are metabolized in the liver and may accumulate in the presence of liver disease or impaired function. valproic acid) and increase risks for adverse effects even when total serum drug concentrations are normal. In addition. hydrochlorothiazide). Several studies indicated that oxcarbazepine is effective in monotherapy and combination therapy. and small maintenance doses are needed. and injuries due to falls. when available. if the drug is stopped abruptly. active drug is higher than in clients with normal renal function. Use in Older Adults Seizure disorders commonly occur in older adults and require drug therapy. In some clients. For example. In addition to the ataxia. slow titration to desired doses. with relatively few and mild adverse effects. the drug should be reduced in dosage or discontinued until serum levels decrease. Older adults often have multiple medical conditions. the rate of metabolism is similar to that in adults after 8 years. protein binding is decreased and the amount of free. furosemide. Renal stones have been reported with topiramate and zonisamide. Smaller doses of gabapentin. levetiracetam and zonisamide are not approved for use in children. These effects may also occur with oxcarbazepine. close monitoring of plasma drug levels. With renal impairment. ataxia. and kidney function are indicated. confusion. The occurrence of nystagmus (abnormal movements of the eyeball) indicates phenytoin toxicity. Using controlledrelease formulations.196 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM With the newer AEDs. Most of these potential problems can be averted or minimized by using AEDs very cautiously in older adults. gabapentin. Phenytoin therapy can best be monitored by measuring free serum phenytoin concentrations. older adults are at high risk of adverse drug effects and adverse drug–drug interactions with AEDs. Doses may need to be reduced or given at less frequent intervals. liver function.

and the concentrated drug will be given later. Rapid administration must be avoided because it may produce myocardial depression. Overdosage will follow. When an AED is started. and encouraging compliance with the prescribed regimen. the primary IV solution must be normal saline or the line must be flushed with normal saline before and after administration of phenytoin. Regular household teaspoons and tablespoons used for eating and serving are not acceptable because sizes vary widely. Home Care The home care nurse must work with clients and family members to implement and monitor AED therapy. Give most oral antiseizure drugs after meals or with a full glass of water or other fluid. a few weeks may be required to titrate the dosage and determine whether the chosen drug is effective in controlling seizures. b. a drug often used to treat hypotension and shock in critical care units. NURSING ACTIONS NURSING ACTIONS Antiseizure Drugs RATIONALE/EXPLANATION 1. If “piggybacked” into a primary IV line. and characteristics of seizures can be very helpful). drug particles settle to the bottom of the container. duration. With long-term use of the drugs. On standing. underdosage will occur at first. the liquid vehicle will be given initially. (3) Give phenytoin as an undiluted (IV) bolus injection at a rate not exceeding 50 mg/min. phenytoin decreases ventricular automaticity and should not be used in critically ill clients with sinus bradycardia or heart block. (2) Do not mix parenteral phenytoin in the same syringe with any other drug. To maintain therapeutic blood levels of drugs Most antiseizure drugs cause some gastric irritation. topiramate. Using the same measuring container ensures consistent dosage. nausea. Phenytoin solution is highly alkaline (pH approximately 12) and physically incompatible with other drugs. and even cardiac arrest. ensuring that the client keeps appointments for serum drug levels and follow-up care. A precipitate occurs if mixing is attempted. That is. Taking the drugs with food or fluid helps decrease gastrointestinal side effects. especially with changes in drugs or dosages. Phenytoin cannot be diluted or given in IV fluids other than normal saline because it precipitates within minutes.CHAPTER 11 ANTISEIZURE DRUGS 197 effects and potential drug–drug interactions. To give phenytoin: (1) Shake oral suspensions of the drug vigorously before pouring and always use the same measuring equipment. particles of drug are suspended in water or other liquid. cardiac arrhythmias. hypotension. If the contents are not mixed well every time a dose is given. phenytoin decreases the effects of dopamine. and little if any therapeutic benefit will result. and the risks of serious toxicity are greatly increased. Give on a regular schedule about the same time each day. The dose is expressed in phenytoin equivalents (PE. the nurse may need to review the potential loss of seizure control and potential for status epilepticus. For example. d.9% NaCl) and administer over approximately 30–60 minutes. levetiracetam. An in-line filter is recommended. Slow administration and dilution decrease local venous irritation from the highly alkaline drug solution. then flush the IV line with normal saline or dilute in 50–100 mL of normal saline (0. c. In addition. Administer accurately a. interviewing the family about the occurrence of seizures (a log of date. or vomiting. fosphenytoin 50 mg PE = phenytoin 50 mg). To give IV fosphenytoin: (1) Check the physician’s order and the drug concentration carefully. With any evidence that the client is not taking medication as directed. In suspensions. Shaking the container is necessary to distribute drug particles in the liquid vehicle. (continued ) . oxcarbazepine. the nurse must monitor the client for therapeutic and adverse drug effects. Calibrated medication cups or measuring teaspoons or tablespoons are acceptable. The nurse can play an important role by clinical assessment of the client. time. and zonisamide may be taken with or without food.

About 25–30% of patients with allergic reactions to carbamazepine are likely to be allergic to oxcarbazepine. The other disorders indicate bone marrow depression and are potentially life threatening. Also check expiration date. Hepatic damage may occur with phenytoin. abnormal liver function test results g. Optimum therapeutic benefits of phenytoin occur approximately 7–10 days after drug therapy is started. vomiting c. Gingival hyperplasia h. These may occur with almost all the antiseizure drugs. Dilution and tube irrigation decrease such adherence. e. Some are mild. StevensJohnson syndrome (a severe reaction accompanied by headache.198 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS (2) Dilute the dose in 5% dextrose or 0. exfoliative dermatitis. double vision b. thrombocytopenia. Hypocalcemia (continued ) . agranulocytosis e. use the 10-mL oral dosing syringe provided by the manufacturer with each bottle. arthralgia. especially during the first week or two of drug therapy.9% sodium chloride and infused in approximately 10 min at the maximal recommended rate. Liver damage—hepatitis symptoms. When the drug is given on a long-term basis to prevent seizures. Occurs often with phenytoin. dizziness. 3. Observe for adverse effects a. They do not usually occur with phenytoin. some are potentially serious but rare. is given IV to control acute seizures. and fatal hepatotoxicity has been reported with valproic acid. jaundice. This is not likely to be a significant adverse reaction except when a depressant drug. possibly because of drug adherence to the NG tube. For a 100-mg PE dose. 2. this amount could be infused in about 1 min at the maximal recommended rate. Observe for therapeutic effects a. Even then. which may progress to megaloblastic anemia. Respiratory depression f. such as status epilepticus.9% sodium chloride solution to a concentration of 1. To give oxcarbazepine suspension. These common effects of oral drugs can be reduced by taking the drugs with food or a full glass of water. Hypersensitivity reactions—often manifested by skin disorders such as rash. Central nervous system (CNS) effects—ataxia. To give carbamazepine and phenytoin suspensions by nasogastric (NG) feeding tube. especially in children. urticaria. Gastrointestinal effects—anorexia. When the drug is given to stop an acute convulsive seizure. A 1-g loading dose could be added to 50 mL of 0. but may infrequently occur with most other antiseizure drugs. The suspension is stored at room temperature and must be used within 7 weeks after opening the bottle. IV lorazepam is the drug of choice for controlling an acute convulsion.5 mg PE/mL to 25 mg PE/mL and infuse no faster than 150 mg PE/min. To avoid error (3) Consult a pharmacist or the manufacturer’s literature if any aspect of the dose or instructions for administration are unclear. These effects are common. RATIONALE/EXPLANATION The drug is preferably diluted in the pharmacy and labeled with the concentration and duration of the infusion. Most antiseizure drugs decrease blood levels of folic acid. and rinse the NG tube before and after administration. May occur when antiseizure drugs are taken in high doses and over long periods b. drowsiness. nausea. Blood dyscrasias—anemia. f. such as lorazepam. dilute with an equal amount of water. seizure activity usually slows or stops within a few minutes. It may be prevented or delayed by vigorous oral hygiene. respiratory depression can be minimized by avoiding overdosage and rapid administration. These skin reactions are usually sufficient reason to discontinue the drug. Absorption is slow and decreased. leukopenia. Therapeutic effects begin later with antiseizure drugs than with most other drug groups because the antiseizure drugs have relatively long half-lives. and other symptoms in addition to skin lesions) d. observe for a decrease in or absence of seizure activity. diluting with 4 mL yields the maximum concentration of 25 mg PE/mL. For accurate measurement and a reminder that the suspension is given orally only.

Observe for drug interactions a. most often with phenytoin. whether a significant interaction will occur in a client is unpredictable. and trimethoprim increase effects. to increase therapeutic effects. and other factors. hydrochlorothiazide). This reaction has occurred with several antiseizure drugs. Dosage of antiseizure drugs may need to be increased. (continued ) d. (3) Phenobarbital has variable interactions with phenytoin. clarithromycin. . and verapamil increase effects. metronidazole. Hyponatremia RATIONALE/EXPLANATION May occur with carbamazepine and oxcarbazepine. Inadequate fluid intake or concurrent administration of triamterene may increase risk. allopurinol. the degree of liver enzyme induction already present. 2C8. isoniazid. Additive CNS depression Additive or synergistic effects. Thus. cimetidine. chlorpheniramine. Usually transient and levels return to normal with fluid restriction or dose reduction. These drugs increase phenytoin toxicity by inhibiting hepatic metabolism of phenytoin or by displacing it from plasma proteinbinding sites. sucralfate.and longterm therapy with valproic acid. miconazole. diltiazem. its interaction with phenytoin differs. Kidney stones 4. Additional drugs that alter effects of carbamazepine: (1) Cimetidine. and other enzyme inducers c. The drugs are often given in combination. route. nausea. and/or 3A4 groups) that normally metabolize carbamazepine. folic acid. or by unknown mechanisms. fluconazole. Phenytoin and phenobarbital have complex interactions with unpredictable effects. antineoplastics. isoniazid. Life-threatening pancreatitis has occurred after short. rifampin. These drugs inhibit themselves and other antiseizure drugs by activating liver enzymes and accelerating the rate of drug metabolism. Although phenobarbital induces drug metabolism in the liver and may increase the rate of metabolism of other anticonvulsant drugs. amiodarone. antacids. (2) Alcohol (chronic ingestion). Drugs that decrease effects of antiseizure drugs: (1) Tricyclic antidepressants. Drugs that increase effects of antiseizure drugs: (1) CNS depressants—alcohol. benzodiazepines. sedatives (2) Most other antiseizure drugs b. especially if taken concurrently with sodium-losing diuretics (eg. These drugs may lower the seizure threshold and precipitate seizures. Phenobarbital apparently decreases serum levels of phenytoin and perhaps its half-life. Additional drugs that alter effects of phenytoin and fosphenytoin: (1) Alcohol (acute ingestion). j. phenytoin. omeprazole. May occur with topiramate and zonisamide. sertraline. Still. benzodiazepines. The interaction apparently varies with dosage. paroxetine. the anticonvulsant effects of the two drugs together are greater than those of either drug given alone. Most of these drugs inhibit the cytochrome P450 enzymes (1A2. sedating antihistamines. Patients should be monitored for the development of acute abdominal pain. Pancreatitis l. fluoxetine. and theophylline decrease effects. Probably the most important clinical implication is that close observation of the client is necessary when either drug is being added or withdrawn. valproic acid.CHAPTER 11 ANTISEIZURE DRUGS 199 NURSING ACTIONS i. opioid analgesics. time of administration. These drugs decrease effects of phenytoin by decreasing absorption. pyridoxine. Toxicity may result even if carbamazepine blood levels are at therapeutic concentrations. Valproic acid inhibits an epoxide hydrolase enzyme and causes an active metabolite to accumulate. Lymphadenopathy resembling malignant lymphoma k. antipsychotic drugs (2) Carbemazepine. furosemide. thereby increasing blood levels of carbamazepine. and vomiting. accelerating metabolism. erythromycin.

200 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS (2) Alcohol. why is it important to verify the type of seizure by electroencephalogram before starting antiseizure drug therapy? 2. and phenobarbital decrease effects. Valproic acid inhibits the liver enzymes that metabolize lamotrigine. e. May increase plasma levels of phenobarbital as much as 40%. phenytoin. As a result. Drugs that alter the effects of gabapentin: (1) Antacids RATIONALE/EXPLANATION These drugs increase activity of hepatic drug-metabolizing enzymes. Eng’s Dilantin level falls within the high end of normal (10–20 mcg/mL). Mr. lamotrigine dosage must be substantially reduced when the drug is given in a multidrug regimen that includes valproic acid. These drugs induce drug-metabolizing enzymes in the liver and thereby increase the metabolism and hasten the elimination of oxcarbazepine. These drugs induce drug-metabolizing enzymes in the liver and thereby increase the rate of metabolism of themselves and of lamotrigine. Inhibits drug-metabolizing enzymes. thereby increasing the serum level of unbound valproic acid These drugs induce drug-metabolizing enzymes in the liver and thereby increase the metabolism and hasten the elimination of zonisamide. surgery patients are permitted to take medications with a sip of water. Even missing two doses could affect this level. phenytoin. phenobarbital k. and how can they be minimized? 4. lorazepam. and diazepam How Can You Avoid This Medication Error? Answer: Blood levels need to remain within a therapeutic range to prevent seizures. Reduce absorption of gabapentin. Gabapentin should be given at least 2 hours after a dose of an antacid to decrease interference with absorption. These drugs are benzodiazepines. Drugs that decrease effects of zonisamide (1) Carbamazepine. Eng should be referred to his physician for evaluation of Dilantin toxicity and adjustment of Dilantin dosage. phenytoin. thereby decreasing blood levels of carbamazepine. Good judgment requires a nurse to check with the physician when significant medications are withheld. Review and Application Exercises 1. g. thereby increasing blood levels and slowing metabolism of lamotrigine. and phenobarbital decrease effects. phenytoin. Frequently. Additional drugs that increase effects of valproate: (1) Cimetidine (2) Salicylates j. What are the advantages and disadvantages of treatment with a single drug and of treatment with multiple drugs? 5. Interactions with clonazepam. thereby slowing elimination from the body and increasing blood levels of valproic acid Displace valproic acid from binding sites on plasma proteins. . Drugs that decrease effects of oxcarbazepine (1) Phenobarbital. even when they are NPO. How are the newer drugs similar to or different from phenytoin? Nursing Notes: Apply Your Knowledge Answer: Although Mr. valproic acid. What are the major adverse effects of commonly used AEDs. discussed in Chapter 8. f. Drug that increase the effects of phenobarbital: (1) Valproic acid i. Which of the benzodiazepines are used as antiseizure agents? 6. For a client with a newly developed seizure disorder. Laboratory values are guides for appropriate dosing. but it is important that treatment be based on clinical data. verapamil h. his symptoms indicate phenytoin toxicity. What are the indications for use of the major AEDs? 3. Drugs that alter effects of lamotrigine: (1) Valproic acid increases effects. probably by inhibiting liver metabolizing enzymes. and phenobarbital? 7. (2) Carbamazepine. phenytoin. What are the advantages of carbamazepine and valproic acid compared with the benzodiazepines.

T. 2001. Pharmacologic management of epilepsy in the elderly. Pharmacotherapy. (2001). Why is it important when teaching clients to emphasize that none of the AEDs should be stopped abruptly? 10.n11/pp0711. Philadelphia: Lippincott Williams & Wilkins. 4th ed. B. 1375–1388. 21(11). K. Kelley’s Textbook of internal medicine. Textbook of therapeutics: Drug and disease management. What is the treatment of choice for an acute convulsion or status epilepticus? 9. Philadelphia: Lippincott Williams & Wilkins. Gidal. 1107–1137. Handbook of adverse drug interactions. pp. 01. B. R. How can a home care nurse monitor AED therapy during a home visit? SELECTED REFERENCES Alldredge. Humes (Ed.). (2001). A.buck-01. 7(11). Bourdet. Seizure disorders. Kim. NY: The Medical Letter. Gourley (Eds. Hovinga. Buck.). St. L. (2000). (Ed.). M. Levetiracetam: A novel antiepileptic drug.. Inc. E.01. [On-line]. K. 41(3). 711–716. pp. In E. (2001). C. (Updated monthly). Available: http://pediatrics. B. V. medscape. Oxcarbazepine use in children and adolescents.. Herfindal & D. A. S. R. New Rochelle. 421–436. . In H. Pediatric Pharmacotherapy. 2865–2876. Approach to the patient with seizures. Delgado-Escueta.. 7th ed. D.html. Louis: Facts and Comparisons. Accessed December. & Alldredge.. Drug facts and (2001). Journal of the American Pharmaceutical Association. (2000). V.CHAPTER 11 ANTISEIZURE DRUGS 201 8. B.buck/pp0711.

glutamate. and voluntary movement. Rod was diagnosed with Parkinson’s disease 1 week ago. 3. ANTIPARKINSON DRUGS Drugs used in Parkinson’s disease increase levels of dopamine (levodopa. joint and muscular rigidity). 5. It occurs equally in men and women. Imbalances of other neurotransmitters (eg. gamma aminobutyric acid [GABA]. resulting in a decrease in inhibitory brain dopamine and a relative increase in excitatory acetylcholine.chapter 12 Antiparkinson Drugs Objectives AFTER STUDYING THIS CHAPTER. genetics. usually between 50 and 80 years of age. Use of the newer “atypical” antipsychotic drugs may reduce the incidence of drug-induced parkinsonism. norepinephrine. Signs and symptoms of the disease also may occur with other CNS diseases. His symptoms included slow. dopamine agonists. Discuss therapeutic and adverse effects of dopaminergic and anticholinergic drugs. Classic parkinsonism probably results from destruction or degenerative changes in dopamineproducing nerve cells. carbon monoxide. brain tumors. shuffling gait. Apply the nursing process with clients experiencing parkinsonism. progressive. age-related degeneration. The cause of the nerve cell damage is unknown. His physician started him on levodopa 500 mg tid and benztropine (Cogentin) 1 mg hs. Discuss the use of antiparkinson drugs in special populations. The correct balance of dopamine and acetylcholine is important in regulating posture. fine tremor at rest. organophosphate pesticides) are possible etiologic factors. Early-onset parkinsonism (before 45 years) is thought to have a genetic component. and head injuries and with the use of typical or traditional antipsychotic drugs (eg. 4. Reflect on: ᮣ How can Parkinson’s disease affect Mr. Rod. muscle tone. monoamine oxidase [MAO] inhibitors. phenothiazines). You are a home health nurse visiting Mr. Rod’s ability to function normally? ᮣ How does each medication work to restore the balance of neurotransmitters? ᮣ What assessment data will you collect to evaluate whether the antiparkinson medications are effective? ᮣ What assessment data should be collected to detect adverse effects of antiparkinson drugs? PARKINSON’S DISEASE arkinson’s disease (also called parkinsonism) is a chronic. bradykinesia. degenerative disorder of the central nervous system (CNS) characterized by abnormalities in movement and posture (tremor. and exposure to toxins (eg. Differentiate the types of commonly used antiparkinson drugs. Thus. the drugs help adjust the balance of neurotransmitters. Critical Thinking Scenario Mr. THE STUDENT WILL BE ABLE TO: 1. 2. stooped posture. Describe major characteristics of Parkinson’s disease. . 202 P The basal ganglia in the brain normally contain substantial amounts of the neurotransmitters dopamine and acetylcholine. People with Parkinson’s disease have an imbalance in these neurotransmitters. and serotonin) also occur. catechol-O-methyltransferase [COMT] inhibitors) or inhibit the actions of acetylcholine (anticholinergic agents) in the brain. and mask-like facial expression.

Consequently. For example. The dopamine is stored in presynaptic dopaminergic neurons and functions like endogenous dopamine. levodopa. Selegiline. In addition to the primary anticholinergic drugs. entacapone. Some of the other drugs have additional uses. of antipsychotic drugs. carbidopa. Levodopa readily penetrates the CNS and is converted to dopamine by the enzyme amino acid decarboxylase (AADC). Selegiline blocks one of the enzymes (MAO-B) that normally inactivates dopamine. kidney. Anticholinergic Drugs Anticholinergic drugs are discussed in Chapter 21 and are described here only in relation to their use in the treatment of Parkinson’s disease. whose concentration is greater in peripheral tissues than in the brain. prostatic hypertrophy. Mechanisms of Action Dopaminergic drugs increase the amount of dopamine in the brain by various mechanisms. levodopa is extensively metabolized by decarboxylase. In addition. bromocriptine. transient ischemic attacks. entacapone. pergolide. most levodopa is metabolized in peripheral tissues and large amounts are required to obtain therapeutic levels of dopamine in the brain. especially bradykinesia and rigidity. and tolcapone are contraindicated in people with hypersensitivity reactions to the drugs. liver. In peripheral tissues (eg. and tolcapone are indicated for the treatment of idiopathic or acquired parkinsonism. dysrhythmias. directly or indirectly. gastrointestinal obstruction. gastrointestinal tract). The drugs must be used cautiously in clients with cardiovascular disorders (eg. selegiline. pramipexole. names. Carbidopa is used only in conjunction with levodopa. Although levodopa does not alter the underlying disease process. renal. and ropinirole are dopamine agonists that directly stimulate postsynaptic dopamine receptors. Contraindications to Use Levodopa is contraindicated in clients with narrow-angle glaucoma. Entacapone and tolcapone block another enzyme (COMT) that normally inactivates dopamine and levodopa. or endocrine disorders. ropinirole. Levodopa acts to replace dopamine in the basal ganglia of the brain. and tolcapone increase dopamine concentrations in the brain and exert dopaminergic activity. an antihistamine (diphenhydramine) is used for parkinsonism because of its strong anticholinergic effects. it may improve a client’s quality of life. pergolide. pulmonary. Bromocriptine and pergolide are ergot derivatives and therefore are contraindicated in people hypersensitive to ergot alkaloids or those with uncontrolled hypertension. Bromocriptine. and dosage ranges are listed in Drugs at a Glance: Antiparkinson Drugs. hepatic. there are fewer dopaminergic neurons and thus less storage capacity for dopamine derived from levodopa. tachycardia. Anticholinergic drugs are used in idiopathic parkinsonism to decrease salivation.CHAPTER 12 ANTIPARKINSON DRUGS 203 Dopaminergic Drugs Levodopa. Atropine and scopolamine are centrally active but are not used because of a high incidence of adverse reactions. those that penetrate the blood–brain barrier) are useful in treating parkinsonism. hypertension) and liver or kidney disease. Amantadine increases dopamine release and decreases dopamine reuptake by presynaptic nerve fibers. The other drugs are used as adjunctive agents. Levodopa is a precursor substance that is converted to dopamine. Anticholinergic drugs are contraindicated in clients with glaucoma. pramipexole. It relieves all major symptoms. In advanced stages of Parkinson’s disease. a course of therapy of approximately 3 months is recommended because symptoms usually subside by then even if the antipsychotic drug is continued. They are used primarily for people who have minimal symptoms or who cannot tolerate levodopa. urinary bladder neck obstruction. As a result. It is metabolized to a lesser extent by the enzyme COMT. pramipexole. Bromocriptine is also used in the treatment of amenorrhea and galactorrhea associated with hyperprolactinemia. Levodopa (Larodopa. Peripheral metabolism of levodopa can be reduced (and the amounts Indications for Use Entacapone. carbidopa is used only to decrease peripheral breakdown of levodopa. routes. and myasthenia gravis. amantadine is also used to prevent and treat influenza A viral infections. pergolide. and in clients taking MAO inhibitor drugs. This decreases the apparent excess of acetylcholine in relation to the amount of dopamine. ropinirole. If used for this purpose. and tremors. hemolytic anemia. or in combination with other antiparkinson drugs. levodopa has a shorter duration of action and drug effects “wear off” between doses. Anticholinergic drugs decrease the effects of acetylcholine. selegiline. INDIVIDUAL ANTIPARKINSON DRUGS Dopaminergic antiparkinson drugs are described in this section. or a history of melanoma or undiagnosed skin disorders. Only anticholinergic drugs that are centrally active (ie. Tolcapone is contraindicated in people with impaired liver function. spasticity. Anticholinergic agents also are used to relieve symptoms of parkinsonism that can occur with the use . Dopar) is the most effective drug available for the treatment of Parkinson’s disease. amantadine. usually with levodopa. levodopa must be used with caution in clients with severe cardiovascular. Levodopa is the mainstay of drug therapy for idiopathic parkinsonism. Dopamine cannot be used for replacement therapy because it does not penetrate the blood–brain barrier. severe angina pectoris.

125 mg 3 times daily initially. wk 3. juvenile Huntington’s chorea. Levodopa is well absorbed from the small intestine after oral administration.1 mg/d at bedtime. 100 mg. PO 1 tab of 25 mg carbidopa/250 mg levodopa 3 or 4 times daily for clients taking >1500 mg levodopa or 1 tab of 25 mg carbidopa/100 mg levodopa for clients taking <1500 mg levodopa PO 100 mg twice a day PO 1. wk 3. Absorption is decreased by delayed gastric emptying. 400 mg Children: Drug-induced extrapyramidal reactions. Levodopa is metabolized to 30 or more metabolites. wk 6.5–1 g/d initially in 3 or 4 divided doses. 1 mg 3 times daily PO 5 mg twice daily. increased by 0.05–0. 0. maximal daily dose. gradually increased to 50 mg 4 times daily if necessary Adults: Drug-induced extrapyramidal reactions.25 mg 3 times daily. 0. PO 2 mg 3–4 times daily Drug-induced extrapyramidal reactions. chronic manganese poisoning). 0. hyperacidity of gastric secretions.125 mg 3 times daily. 600 mg daily Diphenhydramine (Benadryl) Procyclidine (Kemadrin) Trihexyphenidyl (Trihexy) PO 0.25 mg twice a day with meals. wk 2. up to a maximum of 1. up to 8 times (1600 mg) daily PO 0. and competition with amino acids (from digestion of protein foods) for sites of absorption in the small intestine. wk 4. Levodopa relieves only parkinsonian symptoms in these conditions.25 mg 3 times daily. the COMT pathway becomes more important (see entacapone and tolcapone. usually within 24 hours. below).5 mg 2 times daily. gradually increased to 5 mg 3–4 times daily if necessary PO 1–2 mg daily initially. carbidopa.5–1 mg at bedtime initially.15 mg every 3 d to a maximum dose of 6 mg/d if necessary PO wk 1. 0. especially nausea and vomiting. wk 5. IM 5 mg/kg per day. Sinemet CR PO 1 tab twice daily at least 6 h apart initially. gradually increased to 4–6 mg daily if necessary Parkinsonism. increased by 1 tablet every day or every other day until a dosage of 8 tablets daily is reached. and has a short serum half-life (1 to 3 hours). maximal daily dose.5 mg 3 times daily. reaches peak serum levels within 30 to 90 minutes. PO 200 mg with each dose of levodopa/carbidopa.75 mg 3 times daily. Reduce dose gradually if severe adverse effects occur. increased up to 8 tablets daily and q4h intervals if necessary Clients receiving levodopa: Discontinue levodopa at least 8 h before starting Sinemet. IV 10–50 mg.05–0. The rate of dosage increase depends mainly on the client’s tolerance of adverse effects. up to a maximum of 1. 0. wk 2. 300 mg PO 5 mg twice daily initially. The two drugs are usually given together in a fixed-dose formulation called Sinemet. Dosage must be reduced when carbidopa is also given (see carbidopa. PO 2 mg 1–3 times daily. some of which are pharmacologically active and probably contribute to drug toxicity.5 mg 3 times daily Renal impairment: Creatinine clearance (Crcl) > 60 mL/min. maximal single dose. increased by 2. up to a maximum of 1. so that the levodopa dosage can be reduced by approximately 70%.5 mg 3 times daily.5 mg/d every 2–4 wk if necessary for therapeutic benefit. 0.5 mg once daily PO wk 1. wk 7. IM. gradually increased to 12–15 mg daily.75 g/d. 0. levodopa also may be useful in other CNS disorders in which symptoms of parkinsonism occur (eg. maximum dose. PO 70–100 mg/d. until therapeutic or adverse effects occur Adults: Drug-induced extrapyramidal reactions. . Crcl 15–34 mL/min.125 mg 2 times daily initially.5 mg 3 times daily. In addition to treating Parkinson’s disease. 3–6 g/d.204 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Antiparkinson Drugs Generic/Trade Name Dopaminergic Agents Levodopa (Larodopa) Routes and Dosage Ranges Carbidopa (Lodosyn) Levodopa/carbidopa (Sinemet) Amantadine (Symmetrel) Bromocriptine (Parlodel) Entacapone (Comtan) Pergolide (Permax) Pramipexole (Mirapex) Ropinirole (Requip) Selegiline (Eldepryl) Tolcapone (Tasmar) Anticholinergic Agents Benztropine (Cogentin) Biperiden (Akineton) PO 0. 8 g/d.25 mg 3 times daily. depending on dosage of levodopa. 1. wk 4. the metabolites are excreted primarily in the urine. maximum dose. levodopa is often reserved for clients with significant symptoms and functional disabilities. PO 1 mg initially. 1. 0. 0.75 mg 3 times daily. IM 2 mg repeated q30min if necessary to a maximum of 8 mg in 24 h PO 25 mg 3 times daily. Average maintenance dose. The combination of levodopa and carbidopa greatly increases the amount of available levodopa.125 mg once daily. Crcl 35–59 mL/min. below). every 3–7 d. Because of side effects and recurrence of parkinsonian symptoms after a few years of levodopa therapy. COMT inhibitors. When carbidopa inhibits the decarboxylase pathway of levodopa metabolism. 1 mg 3 times daily. increase gradually by no more than 0. maximum dose. 200 mg/d Clients not receiving levodopa: PO 1 tab of 25 mg carbidopa/100 mg levodopa 3 times daily or 1 tab of 10 mg carbidopa/100 mg levodopa 3 or 4 times daily. gradually increased to 5–15 mg daily if necessary reaching the brain can be increased) by giving the AADC inhibitor. morning and noon PO 100–200 mg 3 times daily. 0.

Although there were few instances of liver enzyme elevation or hemoglobin decreases during clinical trials. It is less than 20% bound to plasma proteins and has an elimination half-life of 8 to 12 hours. As a result. within 1 to 5 days. The drug relieves symptoms 3-week periods during initiation of drug therapy with longeracting agents (eg. It is highly protein bound (98%). 10% is excreted in the urine. Entacapone (Comtan)and tolcapone (Tasmar) are COMT inhibitors. pulmonary and peritoneal fibrosis and constriction of coronary arteries). Entacapone is well absorbed with oral administration and reaches a peak plasma level in 1 hour. then every 2 months. Pramipexole (Mirapex) and ropinirole (Requip) are newer drugs that also stimulate dopamine receptors in the brain. dark urine. They are approved for both beginning and advanced stages of Parkinson’s disease. Amantadine is often given in conjunction with levodopa. it is usually given for 2. You administer 1 tablet to Mr. renal failure may cause higher-than-usual plasma levels and possible toxicity. only 10% of the drug is metabolized. Although the main mechanism of action seems to be inhibiting the metabolism of levodopa in the bloodstream. Diarrhea was a common adverse effect during clinical trials. less levodopa is decarboxylated in peripheral tissues. Dosage must How Can You Avoid This Medication Error? Mr. and dosage of levodopa must be reduced. liver failure may decrease metabolism.5 hours. When used. It is excreted unchanged in the urine. which are excreted through the kidneys. then every 4 weeks for 6 months. . Bromocriptine (Parlodel) and pergolide (Permax) are ergot derivatives that directly stimulate dopamine receptors in the brain. These drugs are used only in conjunction with levodopa/ carbidopa. Most of the drug is excreted unchanged in the urine. and much smaller doses of levodopa can be given. It is metabolized by the cytochrome P450 enzymes in the liver to inactive metabolites. Amantadine increases the release and inhibits the reuptake of dopamine in the brain. Pramipexole is rapidly absorbed with oral administration. and vomiting. and increase adverse effects. Consequently. As a result. clay-colored stools). Dosage must be reduced with impaired renal function to avoid drug accumulation. it is most often given in a levodopa/carbidopa fixed-dose combination product called Sinemet. Although carbidopa is available alone. to prolong effectiveness and allow reduced dosage of levodopa. but hepatic disease is unlikely to alter drug effects. Amantadine (Symmetrel) is a synthetic antiviral agent initially used to prevent infection from influenza A virus. where it is decarboxylated to dopamine. Thus. a client with Parkinson’s disease. These drugs are not ergot derivatives and may not cause some adverse effects associated with bromocriptine and pergolide (eg. hallucinations. but it loses efficacy with approximately 6 to 8 weeks of continuous administration. It is 40% bound to plasma proteins and has an elimination half-life of 6 hours. and is metabolized in the liver to an inactive metabolite. In advanced stages. liver aminotransferase enzymes (serum alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) should be monitored every 2 weeks for 1 year. allow drug accumulation. Peak serum levels are reached in 1 to 3 hours after a dose and steady-state concentrations in about 2 days. nausea. Less than 10% of ropinirole is excreted unchanged in the urine. The parent drug and the metabolite are 90% excreted through the biliary tract and feces. Pergolide has a longer duration of action than bromocriptine and may be effective in some clients unresponsive to bromocriptine. drowsiness. with levodopa/carbidopa. be reduced by 50% in the presence of impaired liver function. Evans for his morning dose. entacapone and tolcapone increase levels of dopamine in the brain and relieve symptoms more effectively and consistently. one of the drugs can be used alone to improve motor performance. thereby increasing dopamine levels. Amantadine is well absorbed from the gastrointestinal tract and has a relatively long duration of action. has a half-life of about 2. Compared with other antiparkinson drugs.CHAPTER 12 ANTIPARKINSON DRUGS 205 Carbidopa (Lodosyn) inhibits the enzyme AADC. Renal failure does not appear to alter drug effects. Selegiline (Eldepryl) increases dopamine in the brain by inhibiting its metabolism by MAO. or when symptoms worsen. They are used in the treatment of idiopathic Parkinson’s disease. MAO exists in two types. COMT plays a role in brain metabolism of dopamine and metabolizes approximately 10% of peripheral levodopa. tolcapone should be used only in clients who do not respond to other drugs. In early stages. Adverse effects are similar for the two drugs. dizziness. abdominal tenderness. or if parkinsonian symptoms do not improve after 3 weeks of taking tolcapone. amantadine is considered less effective than levodopa but more effective than anticholinergic agents. to improve ability to participate in usual activities of daily living. one of the drugs can be used with levodopa and perhaps other antiparkinson drugs to provide more consistent relief of symptoms between doses of levodopa and allow reduced dosage of levodopa. By inhibiting COMT. more levodopa reaches the brain. and to delay levodopa therapy. it is recommended that liver enzymes and red blood cell counts be done periodically. These can be reduced by lowering the dose of either levodopa or entacapone. Tolcapone is also well absorbed with oral administration. levodopa). if symptoms of liver failure occur (anorexia. the drugs may also inhibit COMT in the brain and prolong the activity of dopamine at the synapse. Your pharmacy supplies you with Sinemet 25/250. Ropinirole is also well absorbed with oral administration. Carbidopa does not penetrate the blood–brain barrier. It reaches peak serum levels in 1–2 hours and steady-state concentrations within 2 days. Adverse effects include confusion. jaundice. has carbidopa/ levodopa (Sinemet) 25/100 ordered tid. Because of several reports of liver damage and deaths from liver failure. Tolcapone should be discontinued if ALT and AST are elevated. Evans. Its elimination half-life is 2 to 3 hours and it is metabolized in the liver.

his functional abilities continue to decline. rapid. Doses above 10 mg/day should be avoided in Parkinson’s disease. selectivity is lost and metabolism of both MAO-A and MAO-B is inhibited.206 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Nursing Notes: Apply Your Knowledge Mr. His physician prescribes a tricyclic antidepressant. eating. They are differentiated by their relative specificities for individual catecholamines. and self• • • • care abilities Experience improvement of self-concept and body image Increase knowledge of the disease process and drug therapy Take medications as instructed Avoid falls and other injuries from the disease process or drug therapy. there is excessive stimulation of the sympathetic nervous system and severe hypertension and stroke can occur. legs. Nursing Diagnoses • Bathing/Grooming Self Care Deficit related to tremors • • • • • and impaired motor function Impaired Physical Mobility related to alterations in balance and coordination Disturbed Body Image related to disease and disability Deficient Knowledge: Safe usage and effects of antiparkinson drugs Imbalanced Nutrition: Less Than Body Requirements related to difficulty in chewing and swallowing food Risk for Injury: Dizziness. If MAO-A is inhibited in the intestine. in the brain. MAO-A and MAO-B. other exercises. chopped or soft foods may be necessary. MAO-B metabolizes dopamine. isolated. immobile facial expression Speech problems (eg. At doses higher than 10 mg/day. and neck Mask-like. depending on the severity and stage of progression: • Slow movements (bradykinesia) and difficulty in chang• • • • • • ing positions. giving frequent. • Spend time with the client and encourage socialization with other people. both of which are found in the CNS and peripheral tissues. In advanced disease. dressing. and other self-care activities Stooped posture Accelerating gait with short steps Tremor at rest (eg. and allowing privacy during mealtime may be helpful. Velcro-type fasteners or zippers are easier to handle than buttons. monotonous tone. it is given to enhance the effects of levodopa. most MAO activity is due to type B. Victims of Parkinson’s disease tend to become withdrawn. norepinephrine. Slip-on shoes are easier to manage than laced ones. • Encourage self-care as much as possible. epinephrine. difficult to understand) . tyramine in various foods is absorbed systemically rather than deactivated. • Help with active and passive range-of-motion exercises. In early Parkinson’s disease. selegiline inhibits MAO-B selectively and is unlikely to cause severe hypertension and stroke. These include the following: • Provide physical therapy for heel-to-toe gait training. however. Nursing Process Assessment Assess for signs and symptoms of Parkinson’s disease and drug-induced extrapyramidal reactions. and tremors • Experience improved motor function. “pill rolling” movements of fingers) Rigidity of arms. Its addition aids symptom control and allows the dosage of levodopa/carbidopa to be reduced. despite treatment with Sinemet. and serotonin. assuming an upright position. spasticity. muscle rigidity. and depressed. assisted if necessary. small meals. At oral doses of 10 mg/day or less. • Encourage ambulation and frequent changes of position. which may take several months. The intellect is usually intact until the late stages of the disease process. Interventions Use measures to assist the client and family in coping with symptoms and maintaining function. MAO-A acts more specifically on tyramine. This life-threatening reaction can also occur with medications that are normally metabolized by MAO. hypotension related to adverse drug effects Planning/Goals The client will: • Experience relief of excessive salivation. These may include the following. Selegiline inhibition of MAO-B is irreversible and drug effects persist until more MAO is synthesized in the brain. mobility. If the client has difficulty chewing or swallowing. As a result. Cutting meat. Simmons has had Parkinson’s disease for 4 years and. widening stance to increase balance and base of support. It is the main subtype in gastrointestinal mucosa and the liver and is responsible for metabolizing dietary tyramine. low volume. selegiline may be effective as monotherapy. He comes to the clinic 3 weeks later complaining of constipation and difficulty voiding. Are these symptoms related to his medications? • • • • • Excessive salivation and drooling Dysphagia Excessive sweating Constipation from decreased intestinal motility Mental depression from self-consciousness and embarrassment over physical appearance and activity limitations. opening cartons.

✔ Report adverse effects. ✔ Do not take other drugs without the physician’s knowledge and consent. a combination of medications is used. do not stop taking them before they have had a chance to work. Although all four of the available dopamine agonists are similarly effective. 1. An anticholinergic agent may be given with levodopa alone or with a levodopa/carbidopa combination. Evaluation • Interview and observe for relief of symptoms. nausea. impaired speech. especially when tremor is the major symptom. Amantadine may be useful in relieving bradykinesia or tremor. and slow disease progression. • Interview and observe for increased mobility and participation in activities of daily living. if needed. a. ✔ Decrease excessive mouth dryness by maintaining an adequate fluid intake (2000–3000 mL daily if not contraindicated) and using sugarless chewing gum and hard candies. CLIENT TEACHING GUIDELINES Antiparkinson Drugs General Considerations ✔ Beneficial effects of antiparkinson drugs may not occur for a few weeks or months. Adverse effects can often be reduced by changing drugs or dosages. 3. and wear elastic stockings. It is formulated to be released slowly. Drug Selection Choices of antiparkinson drugs depend largely on the type of parkinsonism (idiopathic or drug induced) and the severity of symptoms. ✔ Take or give selegiline in the morning and at noon. rigidity. to reduce levodopa dosage. c. Amantadine may be given in combination with levodopa or other antiparkinson agents. A dopamine agonist may improve functional disability related to bradykinesia. the newer agents (pramipexole and ropinirole) may cause fewer or less severe adverse effects than bromocriptine and pergolide. A dopamine agonist is usually given with levodopa/ carbidopa. several drug therapy strategies and combinations are used to delay the start of levodopa therapy and. adverse effects. • Provide facial tissues if drooling is a problem. especially when assuming an upright position. For drug-induced parkinsonism or extrapyramidal symptoms.CHAPTER 12 ANTIPARKINSON DRUGS 207 • Schedule rest periods. several drugs may be used as monotherapy. excessive mouth dryness causes discomfort and dental caries. ✔ Change positions slowly. ✔ Avoid driving an automobile or operating other potentially hazardous machinery if vision is blurred or drowsiness occurs with levodopa. maintain functional ability in activities of daily living. In addition. when symptoms and functional disability are relatively mild. b. For early idiopathic parkinsonism. loss of effectiveness in a few years. However. However. possible acceleration of the loss of dopaminergic neurons in the brain). ✔ Do not crush or chew Sinemet CR. and tremor. This schedule decreases stimulating effects that may interfere with sleep if the drug is taken in the evening. once started. The combination provides more effective relief of symptoms and allows lower dosage of levodopa. a. Two advantages of combination therapy are better control of symptoms and reduced dosage of individual drugs. • Interview and observe regarding correct usage of medications. an anticholinergic agent is the drug of choice. b. This is usually a therapeutic effect in Parkinson’s disease. shuffling gait. For advanced idiopathic parkinsonism. to prevent dizziness from a drop in blood pressure. An anticholinergic agent may be the initial drug of choice in clients younger than 60 years of age. 2. minimize adverse drug effects. crushing or chewing destroys this feature. c. impaired physical dexterity. An anticholinergic relieves tremor in approximately 50% of clients. This is necessary to avoid adverse drug interactions. . and vomiting. Self. PRINCIPLES OF THERAPY Goals of Treatment The goals of antiparkinson drug therapy are to control symptoms. some adverse effects usually must be tolerated for control of disease symptoms. Prescription and nonprescription drugs may interact with antiparkinson drugs to increase or decrease effects. Tremor and rigidity are aggravated by fatigue and emotional stress. because of difficulties with levodopa therapy (eg. Both anticholinergics and levodopa may cause mouth dryness.or Caregiver Administration ✔ Take antiparkinson drugs with or just after food intake to prevent or reduce anorexia.

especially with cardiovascular disease. and psychosis may occur. The optimal dose is the lowest one that allows the client to function adequately. Anticholinergic drugs may cause blurred vision. When centrally active anticholinergics are given for Parkinson’s disease. because levodopa becomes less effective after approximately 5 to 7 years. When the drugs are discontinued. The levodopa/carbidopa combination is probably the most effective drug when bradykinesia and rigidity become prominent. When combinations of drugs are used. Use in Children Safety and effectiveness for use in children have not been established for most antiparkinson drugs. e. 50 mg carbidopa/ 200 mg levodopa) of sustained-release tablets (Sinemet CR). They also decrease sweating and may cause fever or heatstroke. Doses need to be adjusted as parkinsonism progresses. dosage of levodopa/carbidopa must be reduced. Inhibition of levodopa/dopamine metabolism is a valuable addition to levodopa as an exogenous source of dopamine. because of its association with liver failure. The general rule is to start with a low initial dose and gradually increase the dosage until therapeutic effects. Dosage must be individualized for levodopa and carbidopa. When carbidopa is given with levodopa. 6. However. dosage adjustments of individual components are often necessary. selegiline may have a neuroprotective effect and slow the loss of dopaminergic neurons in the brain. However. Optimal dosage may not be established for 6 to 8 weeks with levodopa. the dosage of levodopa must be reduced by approximately 75%. Amantadine for influenza A prevention or treatment is not recommended for neonates or infants younger than 1 year of age but may be given to children 9 to 12 years of age. 2.208 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM d. Tolcapone should be used only when other drugs are ineffective. Selegiline and entacapone may both be used with levodopa/carbidopa because entacapone acts peripherally and selegiline acts in the brain. These include some . one change at a time is recommended so that effects of the change are clear. Dosage of levodopa/ carbidopa may need to be reduced because of an age-related decrease in peripheral AADC. When levodopa is added to a regimen of anticholinergic drug therapy. simultaneous administration of COMT and AADC inhibitors significantly increases the plasma half-life of levodopa. even with the addition of carbidopa. 5. levodopa (<12 years). When changes are made in a drug therapy regimen. antiparkinson drugs are most likely to be used for other purposes in children. With pramipexole and ropinirole. With levodopa. lower doses are indicated in older adults and those with renal impairment. and urinary retention. dosage is started at low levels and gradually increased over several weeks. However. being transferred to Sinemet CR needs a dosage increase of approximately one third. therapeutic effects may be increased and adverse effects decreased by frequent administration of small doses. Only 5% to 10% of a dose of levodopa reaches the CNS. Sinemet CR is not as well absorbed as the short-acting form. which increase the bioavailability of levodopa without increasing its plasma half-life. and a client Use in Older Adults Dosage of amantadine may need to be reduced because the drug is excreted mainly through the kidneys and renal function is usually decreased in older adults. agitation. strenuous activity. Entacapone is used only with levodopa/carbidopa. hallucinations. many other drugs have significant anticholinergic activity. tachycardia. 4. mental confusion. Additional guidelines include the following. and 25 mg carbidopa /250 mg levodopa) of immediaterelease tablets (Sinemet) and two dosage formulations (25 mg carbidopa/100 mg levodopa. With pramipexole. they should be tapered in dosage over 1 week. with ropinirole. dry mouth. 1. anticholinergics are sometimes given to children who have drug-induced extrapyramidal reactions. A daily dose of approximately 70 to 100 mg of carbidopa is required to saturate peripheral amino acid decarboxylase. for example. dosage should be gradually increased to the desired therapeutic level. 25 mg carbidopa/100 mg levodopa. Fever may occur in any age group. many clinicians use other drugs first and reserve levodopa for use when symptoms become more severe. but heatstroke is more likely to occur in older adults. the enzyme that carbidopa inhibits. However. Drug Dosage The dosage of antiparkinson drugs is highly individualized. including the centrally acting anticholinergics (all ages). and bromocriptine (<15 years). In addition to the primary anticholinergics. adverse effects. Selegiline may be given with levodopa/carbidopa. Various preparations can be mixed to administer optimal amounts of each ingredient. Because parkinsonism is a degenerative disorder of adults. f. A levodopa /carbidopa combination is available in three dosage formulations (10 mg carbidopa /100 mg levodopa. In addition. or maximum drug dosage is achieved. Although evidence is limited and opinions differ. 4. and high environmental temperatures. the anticholinergic drug need not be discontinued or reduced in dosage. in contrast to AADC inhibitors. when a dopaminergic drug is added to a regimen containing levodopa/carbidopa. 3. lower doses may be needed with hepatic impairment.

tricyclic antidepressants. To prevent or reduce nausea and vomiting Crushing and chewing destroys the controlled-release feature of the formulation. but may not reach optimum levels for 6 months. handwriting. and mood may be elevated. drooling. teaching may be needed about preventing or managing adverse drug effects. Decreased salivation and sweating are therapeutic effects when these drugs are used in Parkinson’s disease. With tolcapone. Give selegiline in the morning and at noon. In clients with noncirrhotic liver disease. speech therapists. c. pramipexole dosage may need to be reduced in older adults with impaired renal function. Older clients are at increased risk of having hallucinations with dopamine agonist drugs.CHAPTER 12 ANTIPARKINSON DRUGS 209 antihistamines. Use in Renal Impairment Home Care Amantadine is excreted primarily by the kidneys and should be used with caution in clients with renal failure. In addition. b. Give most antiparkinson drugs with or just after food. Do not give levodopa with iron preparations or multivitaminmineral preparations containing iron. b. dosage reductions are not needed. Although liver failure has not been associated with entacapone. salivation. Use in Hepatic Impairment Ropinirole should be used cautiously in hepatic impairment and dosage may need to be reduced. When an anticholinergic is needed by an older adult. With anticholinergic agents. tolcapone metabolism is impaired and plasma drug levels are high. speech. Observe for therapeutic effects a. entacapone can be given without regard to meals. posture. gait. however. Also. observe for decreased tremor. vated liver enzymes and a few deaths from liver failure have been reported. and sweating. With pramipexole. and clients should be closely monitored for adverse drug effects. 2. Drooling and seborrhea may be abolished. the nurse can encourage clients to consult physical therapists. dosage should be minimized. liver transaminase enzymes should be monitored frequently. combinations of drugs with anticholinergic effects should be avoided. including those in over-the-counter cold remedies and sleep aids. dressing) take longer and require considerable effort by clients with parkinsonism. observe for improvement in mobility. Therapeutic effects are usually evident within 2–3 weeks. Caregivers may need to be informed that most activities (eg. ele- NURSING ACTIONS NURSING ACTIONS Antiparkinson Drugs RATIONALE/EXPLANATION 1. as levodopa dosage approaches 2–3 g/d. Do not crush Sinemet CR and instruct clients not to chew the tablet. The home care nurse can help clients and caregivers understand that the purpose of drug therapy is to control symptoms and that noticeable improvement may not occur for several weeks. periodic measurements of liver transaminase enzymes are recommended. Administer accurately a. and self-care ability. clearance is reduced in clients with moderate or severe renal impairment and lower initial and maintenance doses are recommended. To decrease central nervous system (CNS) stimulating effects that may interfere with sleep if the drug is taken in the evening (continued ) . In addition. eating. balance. With ropinirole and entacapone. In clients with hepatic cirrhosis. and dietitians to help maintain their ability to perform activities of daily living. With levodopa and dopaminergic agents. d. no dosage adjustments are needed for renal impairment. Dosage should be reduced and maintenance dosage should be less than the 600 mg daily recommended for noncirrhotic clients. In addition. and phenothiazine antipsychotic drugs. but they are adverse effects when the drugs are used in other disorders. Iron decreases absorption of levodopa.

ataxia. confusion. Compared with other antiparkinson drugs. such as: (1) Tachycardia and palpitations (2) Excessive CNS stimulation (tremor. It is related to duration of levodopa therapy rather than dosage. This effect is common during the first few weeks but usually subsides eventually. and reversible. nausea. adverse effects increase if daily dosage exceeds 200 mg. mental confusion. slurred speech. premature ventricular contractions) and increased myocardial contractility (4) Dyskinesia—involuntary movements that may involve only the tongue. delirium) (3) Sedation and drowsiness RATIONALE/EXPLANATION These effects may occur with usual therapeutic doses but are not likely to be serious except in people with underlying heart disease. propranolol) to counteract these effects.210 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS 3. The ones that occur are mild. bluish discoloration of skin on the legs (continued ) . and there is no way to prevent it except by decreasing levodopa dosage. These symptoms usually disappear after a few months of drug therapy. and vomiting (2) Orthostatic hypotension—check blood pressure in both sitting and standing positions q4h while the client is awake. gradually increasing dosage. It often occurs after long-term levodopa use. observe for: (1) CNS stimulation—insomnia. Ocular effects are due to paralysis of accommodation and relaxation of the ciliary muscle and the sphincter muscle of the iris. administering smaller doses more frequently or adding carbidopa so that dosage of levodopa can be reduced. With amantadine. Many people prefer dyskinesia to lowering drug dosage and subsequent return of the parkinsonism symptoms. impaction. delirium (6) Abrupt swings in motor function (on–off phenomenon) c. Dyskinesia eventually develops in most people who take levodopa. Levodopa and its metabolites stimulate beta-adrenergic receptors in the heart. This reaction is caused by loss of muscle tone in the bladder and is most likely to occur in elderly men who have enlarged prostate glands. This is a benign but cosmetically unappealing condition. These effects result from decreased gastrointestinal motility and muscle tone. thus. additive effects may occur. The drug has antihistaminic and anticholinergic properties. paralytic ileus (5) Urinary retention (6) Dilated pupils (mydriasis). mouth. Carbidopa may heighten this adverse effect. This effect is most likely to occur with large doses of trihexyphenidyl (Artane) or benztropine (Cogentin). However. observe for atropine-like effects. It may occur with levodopa. and sedation is attributed to the antihistamine effect. (3) Cardiac arrhythmias (tachycardia. This is more likely to occur with levodopa/carbidopa combination drug therapy. dizziness. hyperexcitability. agitation. transient. hallucinations (2) Livedo reticularis—patchy. and face or the whole body (5) CNS stimulation—restlessness. amantadine produces few adverse effects. confusion. They may be severe because decreased intestinal motility and constipation also are characteristics of Parkinson’s disease. It usually occurs with long-term use of amantadine and disappears when the drug is discontinued. photophobia b. With levodopa. These are most likely to occur with benztropine. It can be minimized by arising slowly from supine or sitting positions and by wearing elastic stockings. blurred vision. Observe for adverse effects a. This fluctuation may indicate progression of the disease process. restlessness. hallucinations. (4) Constipation. People with pre-existing coronary artery disease may need a beta-adrenergic blocking agent (eg. They may be minimized by giving levodopa with food. observe for: (1) Anorexia. With anticholinergic drugs.

These drugs counteract the inhibition of gastrointestinal motility and tone. pergolide. Drugs that decrease effects of anticholinergic drugs: (1) Cholinergic agents c. vomiting. diarrhea. Drugs that increase effects of anticholinergic drugs: (1) Antihistamines. disopyramide (Norpace). selectivity may be lost at doses higher than the recommended 10 mg/d. pramipexole. and tricyclic antidepressants b. ropinirole. an MAO-B inhibitor. Selegiline is used with levodopa. With selegiline. Heart palpitations. However. observe for: (1) CNS effects—agitation. Levodopa and MAO-A inhibitors should not be given concurrently. insomnia (2) Nausea. The combination of a catecholamine precursor (levodopa) and MAO-A inhibitors that decrease metabolism of catecholamines can result in excessive amounts of dopamine. These drugs have anticholinergic properties and produce additive anticholinergic effects. With entocapone and tolcapone. phenelzine (Nardil). These effects occurred more commonly than others during clinical trials. ataxia. tolcapone (2) Tricyclic antidepressants (3) Monoamine oxidase type A (MAO-A) inhibitors. thiothixene (Navane). they usually disappear with a decrease in dosage. bromocriptine. including isocarboxazid (Marplan). Observe for drug interactions a. bradykinesia. entacapone. Drugs that increase effects of levodopa: (1) Amantadine. dyskinesias. observe for: (1) Anorexia. With pramipexole and ropinirole. abdominal pain g. levodopa should not be started within 3 weeks after an MAO-A inhibitor is discontinued. drowsiness (4) Dyskinesias (5) Orthostatic hypotension f. constipation (2) Dizziness. (continued ) .CHAPTER 12 ANTIPARKINSON DRUGS 211 NURSING ACTIONS d. hypertensive crisis. dizziness. hallucinations. observe for: (1) Nausea (2) Confusion and hallucinations (3) Hypotension e. If adverse effects do occur. and tranylcypromine (Parnate) RATIONALE/EXPLANATION These symptoms are usually mild and can be minimized by starting with low doses and increasing the dose gradually until the desired effect is achieved. epinephrine. These drugs potentiate levodopa effects and increase the risk of cardiac arrhythmias in people with heart disease. which more selectively inhibits the metabolism of dopamine. Effects of MAO-A inhibitors persist for 1–3 weeks after their discontinuation. headache. selegiline. anticholinergic agents. Also. With bromocriptine and pergolide. hallucinations (3) Dizziness. nausea. and stroke may occur. observe for: (1) Nausea (2) Confusion. These effects are unlikely to occur with selegiline. These drugs are often used in combination for treatment of Parkinson’s disease. phenothiazines. carbidopa. These effects occurred more commonly than others during clinical trials. which is a side effect of anticholinergic drug therapy. drowsiness (3) Dyskinesias and dystonias (4) Hallucinations (5) Orthostatic hypotension 4. and norepinephrine. confusion.

When administering a combination product. Parkinson’s disease revisited. Ropinirole: A dopamine agonist for the treatment of Parkinson’s disease. Simmons to his physician to see if another antidepressant with fewer anticholinergic side effects could be used. J. Medical Clinics of North America. and how can they be minimized? SELECTED REFERENCES Nursing Notes: Apply Your Knowledge Answer: Yes. the enzyme that converts levodopa to dopamine. When these medications are given together. Pathophysiology: Concepts of altered health states.). & Dole. R. What is the rationale for various combinations of antiparkinson drugs? 6. E. 3. you give the patient 250 mg of levodopa rather than the 100 mg that was ordered. benzodiazepines (eg. St. Evans. In E. Factor.. where antiparkinson effects occur. Young.212 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS d. Dopamine agonists. Herndon. Management of early Parkinson’s disease. Philadelphia: Lippincott Williams & Wilkins. (1999)..). What are the major adverse effects of antiparkinson drugs. Humes (Ed. Which neurotransmitter is deficient in idiopathic and drug-induced parkinsonism? 2. the Sinemet provided contained 25 mg of carbidopa and 250 mg of levodopa. A. Philadelphia: Lippincott Williams & Wilkins. possibly by as much as 50%. haloperidol (Haldol). G. (2002). and less reaches the CNS. 217–224. M. they also may decrease effects of levodopa by delaying gastric emptying. S. 415–443. M. Reich. & Curtis. 83. Kelley’s Textbook of internal medicine. including urinary retention and constipation. 4th ed.. M. (1999). In this situation. more levodopa is metabolized in peripheral tissues. 6th ed. K. A. Alterations in motor function. This causes more levodopa to be metabolized in the stomach and decreases the amount available for absorption from the intestine. Call the pharmacy and request that Sinemet 25/100 be provided. Parkinsonism. (2) Alcohol. antiemetics. Philadelphia: Lippincott Williams & Wilkins. How Can You Avoid This Medication Error? Answer: This medication error occurred because the wrong dose of levodopa was given to Mr. (2000). Herndon. 2915–2918. C.. Herfindal & D. In C. Parkinson’s disease and related disorders. diazepam [Valium]). Drugs that decrease effects of dopaminergic antiparkinson drugs: (1) Antipsychotic drugs (2) Metoclopramide These drugs are dopamine antagonists and therefore inhibit the effects of dopamine agonists. 56. This interaction does not occur when carbidopa is given with levodopa. American Journal of Health-System Pharmacy. antipsychotics such as phenothiazines. it is important that the dosage be correct for each medication. (1999). J. (Updated monthly). How do the antiparkinson drugs act to alter the level of the deficient neurotransmitter? Chen. In H. 7th ed. (2000). Refer Mr. Both Sinemet and tricyclic antidepressants have anticholinergic side effects. Porth (Ed. Journal of Neuroscience Nursing. J. Drugs that decrease effects of levodopa: (1) Anticholinergics RATIONALE/EXPLANATION Although anticholinergics are often given with levodopa for increased antiparkinson effects. Tachycardia and palpitations can also occur. 216–221. When administering Sinemet 25/250. enhanced anticholinergic effects are seen. Review and Application Exercises 1. 393–414. 32(4). Textbook of therapeutics: Drug and disease management. D. Why is it desirable to delay the start of levodopa therapy and. Hauser. 83. S. and thiothixene (Navane) (3) Oral iron preparations (4) Pyridoxine (vitamin B6) e. & Shimomura. C. R. & Zesiewicz. reduce dosage as much as possible? 5. Louis: Facts and Comparisons. Gourley (Eds. A.. As a result. 1139–1155. Drug facts and comparisons. M. The mechanisms by which most of these drugs decrease effects of levodopa are not clear. T. Iron binds with levodopa and reduces levodopa absorption. D.). Porth. pp. Kuzel. Medical Clinics of North America. K. (2000). A. R. 1123–1157. Pyridoxine stimulates decarboxylase. . once started. What are the advantages and disadvantages of the various drugs used to treat parkinsonism? 4. pp.. T. S. pp. Phenothiazines block dopamine receptors in the basal ganglia. D.

It is considered an autoimmune disorder that occurs in genetically susceptible individuals. It is also encountered with acute or chronic low back pain. Each person needs to be assessed for personal precipitating factors. dressing. bursitis. acute. and the ability to perform activities of daily living (eg. spinal cord. Stimuli that precipitate spasms vary from one individual to another and may include muscle stretching. constipation and bowel distention. and 213 . awkward movements. and has a pattern of exacerbations and remissions. Spasticity Spasticity involves increased muscle tone or contraction and stiff. Myelin normally insulates the neuron from electrical activity and conducts electrical impulses rapidly along nerve fibers.chapter 13 Skeletal Muscle Relaxants Objectives AFTER STUDYING THIS CHAPTER. Although no bones were broken. 4. Spasms may involve alternating contraction and relaxation (clonic) or sustained contraction (tonic). strains. 14. painful muscle contraction that occurs with trauma or an irritant. His physician orders Tylox PRN for the pain and cyclobenzaprine (Flexeril) tid for muscle spasms. and work or recreational activities). Critical Thinking Scenario John Moore was in an automobile accident 5 days ago. self-care in hygiene. 3. THE STUDENT WILL BE ABLE TO: 1. It involves destruction of portions of the myelin sheath that covers nerves in the brain. although its cause is unknown. Describe nonpharmacologic interventions to relieve muscle spasm and spasticity. which probably results from inflammation). Discuss common symptoms/disorders for which skeletal muscle relaxants are used. involuntary. 2. In patients with spinal cord injury. sprains. subacute. (Neuromuscular blocking agents used as adjuncts to general anesthesia for surgery are discussed in Chap. arthritis).) S Muscle Spasm Muscle spasm or cramp is a sudden. dantrolene). Apply the nursing process with clients experiencing muscle spasm or spasticity. he continues to have pain and muscle spasms. Differentiate uses and effects of selected drugs. bladder infections or stones. Muscle spasm may occur with musculoskeletal trauma or inflammation (eg. sustaining trauma to his back and shoulder. a common condition that is primarily a disorder of posture. Reflect on: ᮣ Why are two different medications ordered to manage John’s discomfort? ᮣ What nonpharmacologic treatments can be used to promote comfort? ᮣ What teaching needs to be done before sending John home? SKELETAL MUSCLE RELAXANTS keletal muscle relaxants are used to decrease muscle spasm or spasticity that occurs in certain neurologic and musculoskeletal disorders. fibrotic lesions are formed and nerve conduction is slowed or blocked around the lesions. occurs more often in women than in men. Lesions in various states of development (eg. When myelin is destroyed (a process called demyelination. It occurs with neurologic disorders such as spinal cord injury and multiple sclerosis. mobility. Treatment measures include passive range-of-motion and muscle-stretching exercises and antispasmodic medications (eg. or infections. and optic nerve. Multiple sclerosis (MS) is a major cause of neurologic disability among young and middle-aged adults. baclofen. so they can be avoided when possible. eating. spasticity requires treatment when it impairs safety.

driving a car. In recent years. Muscle weakness and other symptoms vary according to the location and duration of the myelin damage. For preoperative prophylaxis in people with previous episodes of malignant hyperthermia. Spasticity may be controlled with the use of baclofen. and lasts 4 to 8 hours. The person with minimal symptoms does not require treatment. infections. peaks in 2 hours. but should be encouraged to maintain a healthy lifestyle. Baclofen (Lioresal) is used mainly to treat spasticity in MS and spinal cord injuries. tizanidine. Common . diazepam. although parenteral administration of some drugs (eg. metabolic acidosis. including antidepressants for depression and skeletal muscle relaxants for spasticity. parenteral agents are given to facilitate orthopedic procedures and examinations. skeletal muscle relaxants are indicated when spasticity causes severe pain or inability to tolerate physical therapy. Avoiding environmental heat and conditions that cause fever may also help because an elevated body temperature slows nerve conduction and often aggravates MS symptoms. Dantrolene is the only skeletal muscle relaxant that acts peripherally on the muscle it- INDIVIDUAL DRUGS Individual skeletal muscle relaxants are described below. After an occurrence during surgery. and cyanosis. exposure to cold by wearing a cooling vest or exercising in cool water temporarily increases the rate of nerve conduction and improves symptoms in some people. the drug is given orally for 1–3 days to prevent recurrence of symptoms. eating. fever. The drugs should not be given if they cause excessive muscle weakness and impair rather than facilitate mobility and function. dressing). Orphenadrine and cyclobenzaprine have high levels of anticholinergic activity and therefore should be used cautiously with glaucoma. or tachycardia. the drug is given intravenously. immunosuppressive drugs (eg. It is unclear whether relief of pain results from sedative effects. methotrexate) are used to treat progressive disease. Betaseron) or glatiramer (Copaxone) is given to prevent relapses. It is metabolized in the liver and excreted in urine. and in clients who must be alert for activities of daily living (eg. a rare but life-threatening complication of anesthesia characterized by hypercarbia. subcutaneous pump. researchers have discovered that nerve cells can be repaired (remyelinated) if the process that damaged the myelin is stopped before the oligodendrocytes (the cells that form myelin) are destroyed. an inhibitory neurotransmitter. 24). Dantrolene also is indicated for prevention and treatment of malignant hyperthermia. Check the pump manufacturer’s literature for information about pump implantation and drug infusion techniques. or a placebo effect. but may involve blockage of nerve impulses that cause increased muscle tone and contraction. For intraoperative malignant hyperthermia. Baclofen and diazepam increase the effects of gammaaminobutyric acid. The action of oral baclofen starts in 1 hour. Mechanism of Action All skeletal muscle relaxants except dantrolene are centrally active drugs. skeletal muscle rigidity. In some cases. or participate in self-care activities of daily living (eg. it is uncertain whether oral administration of usual doses exerts a beneficial effect in acute or chronic disorders.214 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM chronic) often occur at multiple sites in the CNS. or dantrolene. environmental temperature extremes. Contraindications to Use Most skeletal muscle relaxants cause CNS depression and have the same contraindications as other CNS depressants. interferon beta (Avonex. It can be given orally and intrathecally through an implanted. Drug therapy for MS may involve several types of medications for different types and stages of the disease. In cases of severe spasticity. cardiac arrhythmias. urinary retention. its half-life is 3 to 4 hours. decreasing spasticity may not be desirable because clients with severe leg weakness may require some degree of spasticity to ambulate. and excessive fatigue. Indications for Use Skeletal muscle relaxants are used primarily as adjuncts to other treatment measures such as physical therapy. Occasionally. the drug is given orally for 1 to 2 days before surgery. Those with more extensive symptoms should try to avoid emotional stress. Other researchers are trying to develop methods for enhancing nerve conduction velocity in demyelinated nerves. In addition. For example. and occupational therapy may help maintain ability to perform activities of daily living. methocarbamol) relieves pain associated with acute musculoskeletal trauma or inflammation. Pharmacologic action is usually attributed to general depression of the central nervous system (CNS). routes and dosages ranges are listed in Drugs at a Glance: Skeletal Muscle Relaxants. It inhibits the release of calcium in skeletal muscle cells and thereby decreases the strength of muscle contraction. Physical therapy may help maintain muscle tone. It is contraindicated in people with hypersensitivity reactions to it and those with muscle spasm from rheumatic disorders. muscular relaxation. baclofen may be given intrathecally through an implanted subcutaneous pump. and symptoms are treated with a variety of drugs. Dosage must be reduced in clients with impaired renal function. In spastic disorders. and tizanidine inhibits motor neurons in the brain. self. sit in a wheelchair. Acute exacerbations are treated with corticosteroids (see Chap. operating potentially hazardous machinery). They should be used cautiously in clients with impaired renal or hepatic function or respiratory depression.

It is not recommended for long-term use and. Common adverse effects are drowsiness.04–0. hypotension.5 hours. Carisoprodol (Soma) is used to relieve discomfort from acute. Oral drug acts in 1 hour. painful. a rare metabolic disorder characterized by acute abdominal pain and neurologic symptoms. half-life is 3. insomnia. gradually increased weekly (by increments of 50–100 mg/d) to a maximal dose of 400 mg daily in 4 divided doses Preoperative prophylaxis of malignant hyperthermia: PO 4–8 mg/kg per day in 3–4 divided doses for 1 or 2 days before surgery Intraoperative malignant hyperthermia: IV push 1 mg/kg initially. When discontinued. it can cause physical dependence (ie. dysrhythmias. peaks in 4 to 6 hours and lasts 12 to . constipation. symptoms of withdrawal if stopped abruptly). increased gradually if needed. PO 1 mg/kg per day initially. Common adverse effects include drowsiness. and impaired motor coordination. Intrathecal via implanted pump: Dosage varies widely. heart block) or hyperthyroidism. above. 60 mg daily PO 25 mg daily initially.2 mg/kg in a single dose. It is contraindicated in clients with cardiovascular disorders (eg. not to exceed 0. adverse effects include drowsiness. and weakness. dizziness. with the last dose at bedtime PO 800 mg 3 times daily until desired effect attained. Oral drug acts within 30 minutes. 3 weeks. musculoskeletal disorders. then 400 mg 4 times daily or less for maintenance as needed PO 10 mg 3 times daily. The drug is metabolized in the liver and excreted in urine. 10 mg 3 times daily for 3 days. not to exceed 400 mg daily Same as adult Dantrolene (Dantrium) Diazepam (Valium) Metaxalone (Skelaxin) Methocarbamol (Robaxin) Orphenadrine citrate (Norflex) Tizanidine (Zanaflex) PO 1.0 g 4 times daily for maintenance IM 500 mg q8h IV 1–3 g daily at a rate not to exceed 300 mg/min (3 mL of 10% injection). intramuscular. Chlorphenesin (Maolate) is used to relieve discomfort from acute.8 mg/kg per day in 3 or 4 divided doses IM. maximal recommended dose. see manufacturer’s recommendations. The drug is contraindicated in clients with intermittent porphyria. dizziness. confusion. dosage should be tapered and the drug withdrawn over 1 to 2 weeks. Maximal recommended duration. IV 5–10 mg repeated in 3–4 hours if necessary PO 800 mg 3 or 4 times daily Children <12 years: Safety not established Carisoprodol (Soma) Chlorphenesin (Maolate) <12 years: Not recommended Dosage not established Cyclobenzaprine (Flexeril) <15 years: Safety and effectiveness have not been established. 15 mg 3 times daily for 3 days. recent myocardial infarction. PO. PO 350 mg 3 or 4 times daily. Cyclobenzaprine (Flexeril) has the same indication for use as carisoprodol and chlorphenesin. then 20 mg 3 times daily. headache. It is metabolized in the liver and has a half-life of 8 hours. if necessary. oral. reduced to 1. painful.6 mg/kg within an 8-h period >12 years: Same as adults <12 years: Safety and effectiveness have not been established Safety and effectiveness have not been established except for treatment of tetanus (IV 15 mg/kg every 6 hours as indicated) Not recommended Safety and effectiveness have not been established IM. Do not give IV more than 3 days. nausea. dizziness. fatigue. if used long term or in high doses.12–0. Oral drug effects peak in 1 to 3 hours and last 8 to 12 hours. IV 60 mg twice daily PO 4 mg q6–8h initially.5–2 g 4 times daily for 48–72 hours. IV. musculoskeletal disorders. PO 100 mg twice daily IM. continued until symptoms are relieved or a maximum total dose of 10 mg/kg has been given Postcrisis follow-up treatment: PO 4–8 mg/kg per day in 4 divided doses for 1–3 days PO 2–10 mg 3 or 4 times daily IM. nausea. IV 0.CHAPTER 13 SKELETAL MUSCLE RELAXANTS 215 Drugs at a Glance: Skeletal Muscle Relaxants Routes and Dosage Ranges Generic/Trade Name Baclofen (Lioresal) Adults PO 5 mg 3 times daily for 3 days. confusion. gradually increased to a maximal dose of 3 mg/kg 4 times daily. peaks in 1 to 2 hours and lasts 4 to 6 hours. intravenous. Maximum of 3 doses and 36 mg in 24 h PO 0.

spinal cord injury) and to prevent or treat malignant hyperthermia. Liver function tests should be monitored periodically in all clients receiving dantrolene. Duration of use should not exceed 3 weeks. musculoskeletal disorders. coronary insufficiency. tachycardia. musculoskeletal disorders. and is excreted in urine and feces. and precipitating factors (eg. Tizanidine (Zanaflex) is an alpha2 adrenergic agonist. After an occurrence during surgery. is metabolized in the liver. fever. peaks in 2 hours and lasts 4 to 6 hours. it may also be used to treat tetanus. assess for: • Pain. that is used to treat spasticity in clients with multiple sclerosis. dry mouth. but clients should be informed about it. Dantrolene (Dantrium) acts directly on skeletal muscle to inhibit muscle contraction. Methocarbamol (Robaxin) is used to relieve discomfort from acute. or signs of inflammation (redness. duodenal obstruction. tachycardia). hepatotoxicity and hemolytic anemia may also occur. IV drug acts rapidly. nausea. constipation. The drug has a halflife of 14 hours. It may also cause psychotic symptoms. Common adverse effects include drowsiness. Metaxalone (Skelaxin) is used to relieve discomfort from acute. and urinary retention. Your stock supply has 10 mg Valium in 2-cc vial. and anticholinergic effects (eg. dizziness. is metabolized in the liver. dysrhythmias) and renal or hepatic impairment. painful. and fatigue. It is contraindicated in clients with anemias or severe renal or hepatic impairment. tenderness to touch) • With spasticity. or black. • Accompanying signs and symptoms. dizziness. painful. such as bruises (ecchymoses). incoordination. diarrhea. parenteral drug acts rapidly but peak and duration of action are unknown. The drug may also discolor urine to a green. bladder neck obstruction. dizziness. Oral drug acts slowly. edema. dressing). and nausea. metabolic acidosis. For preoperative prophylaxis in people with previous episodes of malignant hyperthermia. peaks in about 5 hours and lasts 6 to 8 hours. Oral drug acts within 30 minutes and peaks in 2 hours. heat. dry mouth. In addition. This is a prominent symptom of muscle spasm and is usually aggravated by movement. Common adverse effects are drowsiness. and myasthenia gravis. Common adverse effects include drowsiness. dizziness. brown. Nursing Diagnoses • Pain related to muscle spasm • Impaired Physical Mobility related to spasm and pain • Bathing/Hygiene Self-Care Deficit related to spasm and pain • Deficient Knowledge: Nondrug measures to relieve muscle spasm. pain. traumatic injury. duration. a rare but life-threatening complication of anesthesia characterized by hypercarbia. edema.216 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM 24 hours. It has a half life of 2 to 3 hours. severe spasticity interferes with ambulation and other movement as well as exercises to maintain joint and muscle mobility. strenuous exercise). dry mouth. the drug is contraindicated in glaucoma. and spasticity and safe usage of skeletal muscle relaxants . peaks in 2 hours and lasts 4 to 6 hours. and hypotension. half-life is 1 to 3 days. For intraoperative malignant hyperthermia. painful. constipation. or brain trauma. as well as the intensity. Common adverse effects include drowsiness. nausea. multiple sclerosis. and is excreted in urine and feces. spinal cord injury. Hypotension may be significant and occur at usual doses. urinary retention. assess for pain and impaired functional ability in self-care (eg. Parenteral drug is contraindicated in clients with renal impairment because the solution contains polyethylene glycol. It is used to relieve spasticity in neurologic disorders (eg. peaks in 1 to 2 hours. Its half-life is 3 to 4 hours. • With muscle spasm. similar to clonidine. is metabolized in the liver. Common adverse effects with oral drug include drowsiness. It is given orally and its action starts within 30 to 60 minutes. Because of its strong anticholinergic effects. heart failure. and lasts 3 to 4 hours. Common adverse effects include drowsiness. musculoskeletal disorders. It should be used cautiously with renal or hepatic impairment and hypotension. and hypotension. with jaundice and other symptoms that usually occur within 1 month of starting drug therapy. eating. the drug is given orally for 1 to 3 days to prevent recurrence of symptoms. skeletal muscle rigidity. including hallucinations. Liver function should be monitored during therapy. The most serious adverse effect is potentially fatal hepatitis. and urticaria. This is considered a harmless effect. Nursing Process Assessment Assess for muscle spasm and spasticity. the drug is given intravenously. It should be used cautiously in clients with cardiovascular disease (eg. Discuss how you will safely administer this medication. The drug has a half life of 1 to 2 hours. Orphenadrine (Norflex) is used to relieve discomfort from acute. peaks in 4 to 6 hours and lasts 8 to 10 hours. Oral drug acts within 60 minutes. constipation. The action of both oral and parenteral drug Nursing Notes: Apply Your Knowledge Sarah Johnson is experiencing severe muscle spasms. it is metabolized in the liver and excreted in urine. and is excreted in urine. the drug is given orally for 1 to 2 days before surgery. dizziness. Her physician orders Valium 50 mg to be given IV stat. These adverse effects do not occur with short-term use of IV drug for malignant hyperthermia. prostatic hypertrophy. and cyanosis. effects with injected drug also include fainting. Try to determine the location as specifically as possible. dizziness.

Cyclobenzaprine should not be used longer than 3 weeks. sedation related to CNS depression Drug Selection Choice of a skeletal muscle relaxant depends mainly on the disorder being treated: 1. Dosage should be decreased gradually. The drugs should be used only when clearly indicated. including nonprescription drugs. and muscle spasticity without impairing the ability to perform self-care activities of daily living. headache. Risks of falls. For acute muscle spasm and pain. 5. 2. The major risk occurs with concurrent use of alcohol. It is variably effective. Evaluation • Interview and observe for relief of symptoms. operating potentially dangerous machinery) if drowsy from medication. weekly or monthly) is more likely to cause acute muscle spasm. stopping the other drugs may cause fatigue. ✔ Do not stop drugs abruptly. and nausea. CLIENT TEACHING GUIDELINES Skeletal Muscle Relaxants General Considerations ✔ Use nondrug measures. including kava and valerian. Self-Administration ✔ Take the drugs with milk or food. or other drugs that cause drowsiness. Baclofen (Lioresal) is approved for treatment of spasticity in people with multiple sclerosis. and when mobility and alertness are not required.CHAPTER 13 SKELETAL MUSCLE RELAXANTS 217 • Risk for Injury: Dizziness. Parenteral agents are preferred for orthopedic procedures because they have greater sedative and painrelieving effects. and cyclobenzaprine (Flexeril). and its clinical usefulness may be limited by adverse reactions. the choice of drug should be limited to those with established pediatric dosages. Strenuous exercise performed on an occasional basis (eg. ✔ Do not take other drugs without the physician’s knowledge. mental confusion. safety and effectiveness for use in children 12 years of age and younger have not been established. to decrease muscle spasm and spasticity. when close supervision is available for monitoring drug effects (especially sedation). None of the skeletal muscle relaxants has been established as safe for use during pregnancy and lactation. • Interview and observe regarding correct usage of medications and nondrug therapeutic measures. especially with baclofen (Lioresal). For children. muscle spasm. 3. sleeping aids. antihistamines. holding heavy objects close to the body. an oral or parenteral drug may be given. 4. moist heat. and other adverse effects are higher because of impaired drug metabolism and excretion. Any CNS depressant or sedating drugs should be used cautiously in older adults. PRINCIPLES OF THERAPY Use in Older Adults Goal of Treatment The goal of treatment is to relieve pain. driving an automobile. stooping rather than bending to lift objects. to avoid nausea and stomach irritation. such as exercises and applications of heat and cold. Planning/Goals The client will: • Experience relief of pain and spasm • Experience improved motor function • Increase self-care abilities in activities of daily living • Take medications as instructed • Use nondrug measures appropriately • Be safeguarded when sedated from drug therapy Interventions Use adjunctive measures for muscle spasm and spasticity: • Physical therapy (massage. ✔ Avoid herbal preparations that cause drowsiness or sleep. ✔ Avoid activities that require mental alertness or physical coordination (eg. not lifting excessive amounts of weight) • Regular exercise and use of warm-up exercises. Use in Children For most of the drugs. exercises) • Bed rest for acute muscle spasm • Relaxation techniques • Correct posture and lifting techniques (eg. . The drugs cause sedation and other adverse effects and are recommended for short-term use. for short periods. carisoprodol (Soma). Suddenly stopping baclofen may cause hallucinations.

dantrolene. liver function should be assessed before starting either drug The home care nurse is likely to be involved with the use of baclofen.) 2. observe for: (1) Increased ability to maintain posture and balance (2) Increased ability for self-care (eg. and periodically during treatment. e. monitoring of functional abilities. b. observe for: (1) Decreased pain and tenderness (2) Increased mobility (3) Increased ability to participate in activities of daily living b. eating and dressing) (3) Increased tolerance for physical therapy and exercises Therapeutic effects usually occur within 30 minutes after IV injection of diazepam or methocarbamol. and give IM methocarbamol deeply into a gluteal muscle. hypotension. Thrombophlebitis may occur at IV injection sites. A slow rate of injection minimizes the risks of respiratory depression and apnea. To prevent or reduce tissue irritation Rapid administration may cause bradycardia. (continued ) . Administer accurately a. the drugs should be stopped. assistance in arranging blood tests of liver function. and other care. Home Care Use in Hepatic Impairment Dantrolene may cause potentially fatal hepatitis. c. Avoid contact with IV solutions as much as possible. chlorphenesin. The drugs should not be given to clients with preexisting liver disease. With IV methocarbamol. With IV methocarbamol. dosage of baclofen must be reduced. and inject intramuscular (IM) diazepam deeply into a gluteal muscle. have the client lie down during and at least 15 minutes after administration. To minimize orthostatic hypotension and other adverse drug effects Parenteral methocarbamol is a hypertonic solution that is very irritating to tissues. Observe for therapeutic effects a. (Dividing the dose and giving two injections is preferred. Do not mix parenteral diazepam in a syringe with any other drugs. g. d.218 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Use in Renal Impairment The drugs should be used cautiously in clients with renal impairment. Avoid extravasation with IV methocarbamol. Metaxalone and tizanidine can cause liver damage. with jaundice and other symptoms that usually occur within 1 month of starting drug therapy. Avoid extravasation with IV diazepam. NURSING ACTIONS NURSING ACTIONS Skeletal Muscle Relaxants RATIONALE/EXPLANATION 1. f. Give baclofen. When the drug is given for spasticity in chronic neurologic disorders. metaxalone with milk or food. and dizziness. Clients may need continued assessment of drug effects. or tizanidine in chronic spastic disorders. If liver damage occurs. Diazepam may cause a precipitate if diluted. and sloughing of tissue may occur at sites of extravasation or IM injections. Inject intravenous (IV) diazepam directly into a vein or the injection site nearest the vein (during continuous IV infusions) at a rate of approximately 2 mg/min. To decrease gastrointestinal distress Diazepam is physically incompatible with other drugs. Thus. inject or infuse slowly. When the drug is given for acute muscle spasm. Caregivers may need instruction about nonpharmacologic interventions to help prevent or relieve spasticity. Liver function tests should be monitored periodically in all clients receiving dantrolene.

Porth. respiratory depression.. observe for: (1) Drowsiness. A 50-mg dose is unsafe and should not be given. Most likely to occur with long-term use of large doses Adverse effects are usually transient. With centrally active agents. . What are the major adverse effects of these drugs..). Normal IV Valium dosage is 5–10 mg every 3–4 hours. pp. Pathophysiology: Concepts of altered health states. Drugs that increase effects of skeletal muscle relaxants: (1) Central nervous system (CNS) depressants (alcohol. vomiting (2) Headache. antihistamines. lethargy. weakness. pruritus (5) Psychological or physical dependence with diazepam and other antianxiety agents b. St. 6th ed. Louis: Facts and Comparisons. nausea. Women over age 35 years who take estrogens have the highest risk. antianxiety agents. 2912–2915. 3. These effects are most likely to occur with large oral doses. (2000). (Updated monthly). Humes (Ed. Alterations in motor function. Any time you have to administer 10 cc IV push you should question whether the dose is appropriate. How do skeletal muscle relaxants act to relieve spasm and pain? 2. J. monitoring liver enzymes (aspartate aminotransferase and alanine aminotransferase) during therapy. They are usually transient. 4. (2002). What are the indications for the use of skeletal muscle relaxants? Drug facts and comparisons. areflexia. M. antidepressants. ataxia. nervousness (3) Hepatotoxicity RATIONALE/EXPLANATION These are the most common adverse effects. observe for: (1) Drowsiness and dizziness (2) Blurred vision. Hepatotoxicity can be prevented or minimized by administering the lowest effective dose. Richert. R. & Curtis. Less common effects This potentially serious adverse effect is most likely to occur in people older than 35 years of age who have taken the drug 60 days or longer. 1123–1157. flaccid paralysis. Observe for drug interactions a. Demyelinating diseases. M. L. hypotension (4) Hypersensitivity—skin rash. anorexia. abdominal distress. Serious allergic reactions (eg. and how can they be minimized? 5. With a peripherally active agent (dantrolene). flushing (3) Nausea. R. constipation or diarrhea. What are some nonpharmacologic interventions to use instead of or along with the drugs? SELECTED REFERENCES Review and Application Exercises 1. tachycardia. especially with tizanidine Nursing Notes: Apply Your Knowledge Answer: Check this order with the physician. anaphylaxis) are rare. What are the contraindications to the use of these drugs? 4.CHAPTER 13 SKELETAL MUSCLE RELAXANTS 219 NURSING ACTIONS 3. Porth. pp. D. These effects occur more often with IV administration of drugs. fatigue. The drug should be discontinued if hypersensitivity reactions occur. In C. sedative-hypnotics) (2) Monoamine oxidase inhibitors (3) Antihypertensive agents Additive CNS depression with increased risks of excessive sedation and respiratory depression or apnea May potentiate effects by inhibiting metabolism of muscle relaxants Increased hypotension. antipsychotic drugs. Philadelphia: Lippincott Williams & Wilkins. C. Observe for adverse effects a. vomiting. lethargy. Kelley’s Textbook of internal medicine. Philadelphia: Lippincott Williams & Wilkins. and discontinuing the drug if no beneficial effects occur within 45 days. These effects are the most common. In H. 4th ed.

drowsiness. client safety. during which there is complete loss of sensation. Several different drugs are usually combined to produce desired levels of these components without excessive CNS depression. An anesthetic barbiturate or propofol may be used alone for anesthesia during brief diagnostic tests or surgical procedures. Patients are usually discharged on the same day. Reflect on: ᮣ What effects would you expect to see as the general anesthesia wears off? ᮣ Compare and contrast how these effects might be the same or different for the patient receiving local anesthesia. and cardiopulmonary depression persist into the postoperative period. pain perception. . Compare general and local anesthetics in terms of administration. a rare hereditary disorder characterized by recurrent attacks of physical and mental disturbances. They interrupt the conduction of painful nerve impulses from a site of injury to the brain. This so-called balanced anesthesia also allows lower dosages of potent general anesthetics. and memory. propofol or thiopental) given intravenously and is 220 maintained with a gas mixture of an anesthetic agent and oxygen given by inhalation. 5. 4. liver. and muscle relaxation. and then to fatty tissues. Patients may be given general or local anesthetics for minor surgical procedures. and nursing care. kidneys) and muscles. The intravenous (IV) agent produces rapid loss of consciousness and provides a pleasant induction and recovery. General anesthesia is usually induced with a fast-acting drug (eg. THE STUDENT WILL BE ABLE TO: 1. Discuss the use of anesthetics and neuromuscular blocking agents in special populations. some diagnostic tests. Anesthetic drugs are given to prevent pain and promote relaxation during surgery. Duration of action can be prolonged and accumulation is more likely to occur with repeated doses or continuous IV infusion. Discuss factors considered when choosing an anesthetic agent. Describe the nurse’s role in relation to anesthetics and adjunctive drugs. Because they are slowly released from fatty tissues back into the bloodstream. The two basic types of anesthesia are general and regional. and some treatments. ᮣ Identify priorities of nursing care to maintain patient safety during this period. The drugs are short acting because they are quickly redistributed from the brain to highly perfused organs (eg. GENERAL ANESTHESIA General anesthesia is a state of profound central nervous system (CNS) depression. Anesthesia means loss of sensation with or without loss of consciousness. Its rapid onset of action is attributed to rapid circulation to the brain and accumulation in the neuronal tissue of the cerebral cortex. childbirth. Discuss the rationale for using adjunctive drugs before and during surgical procedures. Barbiturates are contraindicated in patients with acute intermittent porphyria. anesthesia. Describe characteristics of general and regional/local anesthetic agents. It has three components: hypnosis. analgesia. Critical Thinking Scenario You are a nurse working in the postanesthesia recovery unit of an outpatient surgery center. 2. consciousness.chapter 14 Anesthetics Objectives AFTER STUDYING THIS CHAPTER. heart. Your responsibilities include monitoring during the immediate recovery period as the effects of the anesthesia wear off. 3. 6.

and the specific gravity. or injections into highly vascular areas (eg. Field block anesthesia involves injecting the anesthetic solution around the area to be anesthetized.CHAPTER 14 ANESTHETICS 221 Inhalation anesthetics vary in the degree of CNS depression produced and thereby vary in the rate of induction. redistributed by the blood to other body tissues. 2. Spinal anesthesia involves injecting the anesthetic agent into the cerebrospinal fluid. oral mucosa. Local anesthetics for topical use are usually ingredients of various ointments. such as epinephrine. in turn. which involves injecting the anesthetic into the epidural space. When a vasoconstrictor drug. a vasoconstrictor. such as anesthesiologists and nurse anesthetists. has been added. itching. have a lower specific gravity than cerebrospinal fluid. CNS stimulation or depression. 21). is used most often in obstetrics during labor and delivery. Solutions of local anesthetics used for spinal anesthesia are either hyperbaric or hypobaric. Some local anesthetic is absorbed into the bloodstream and circulated through the body. The drugs are then transported to the liver for metabolism. REGIONAL ANESTHESIA Regional anesthesia involves loss of sensation and motor activity in localized areas of the body. The area anesthetized may be the site of application. In general. and skin. or it may be distal to the point of injection. depends on the rate at which the drug is transported from the alveoli to the blood. 4. especially sodium. Goals of preanesthetic medication include decreased anxiety without excessive drowsiness. 8). 6. For example. hemorrhoids. and eliminated by the lungs. Hyperbaric or heavy solutions are diluted with dextrose. Peripheral nerve block involves injecting the anesthetic solution into the area of a larger nerve trunk or a nerve plexus at some access point along the course of a nerve distant from the area to be anesthetized. in turn. lungs). nerve impulses cannot be initiated or conducted by the anesthetized nerves. Anesthetic effects dwindle and end as drug molecules diffuse out of neurons into the bloodstream. degree of muscle relaxation. is determined by the site of injection. or lotions designed for use at particular sites. The neuromuscular blocking agents are described in this chapter. and other stimuli. The rate and amount of absorption depend mainly on the drug dose and blood flow to the site of administration. the position of the client. This action stabilizes and reduces excitability of cell membranes. General inhalation anesthetics should be given only by specially trained people. usually in the lumbar spine. ADJUNCTS TO ANESTHESIA Several nonanesthetic drugs are used as adjuncts or supplements to anesthetic drugs. prolong anesthetic effects. transported past the blood–brain barrier to reach the CNS. ears. client amnesia for the peri- . Epinephrine. 5. Drug groups include antianxiety agents and sedative-hypnotics (see Chap. Spinal anesthesia is especially useful for surgery involving the lower abdomen and legs. hypotension) of local anesthetics. The drugs act to decrease the permeability of nerve cell membranes to ions. The extent and duration of anesthesia produced by injection of local anesthetics depend on several factors. and control bleeding. especially when injected or applied to mucous membrane. large amounts. Infiltration involves injecting the local anesthetic solution directly into or very close to the area to be anesthetized. and only with appropriate equipment. The body area anesthetized is determined by the level to which the drug solution rises in the spinal canal. The anesthetic blocks sensory impulses at the root of peripheral nerves as they enter the spinal cord. decreased myocardial conduction and contractility. heart. Topical or surface anesthesia involves applying local anesthetics to skin or mucous membrane. and concentration of the injected solution. onset and duration of anesthesia are prolonged because of slow absorption and elimination of the anesthetic agent. This route is also used to provide analgesia (often with a combination of a local anesthetic and an opioid) for clients with postoperative or other pain. It is induced by application or injection of local anesthetic drugs. anticholinergics (see Chap. Most are discussed elsewhere and are described here only in relation to anesthesia. The highest concentrations are found in organs with a large blood supply (eg. mainly to inactive metabolites. have a higher specific gravity than cerebrospinal fluid. anesthetic potency. and gravitate toward the lower (caudal) end of the spinal canal when the client is tilted in a headdown position. Regional anesthesia is usually categorized according to the site of application. amount. head and neck. Epinephrine also controls bleeding in the affected area. CNS depression is determined by the concentration of the drug in the CNS. bradycardia. Duration depends on the chemical characteristics of the drug used and the rate at which it leaves nerve tissue. As a result. Systemic absorption accounts for most of the potentially serious adverse effects (eg. Specific types of anesthesia attained with local anesthetic drugs include the following: 1. Epidural anesthesia. This. brain. preparations are available for use on eyes. high concentrations. liver. Such application makes sensory receptors unresponsive to pain. 6). and opioid analgesics (see Chap. and analgesic potency. When excitability falls low enough. intercostal and paracervical sites) produce peak plasma levels rapidly. perineum. Drug concentration. Depth of anesthesia can be regulated readily by varying the concentration of the inhaled anesthetic gas. is often added to a local anesthetic to slow systemic absorption. solutions. 3. the drugs prevent the cells from responding to pain impulses and other sensory stimuli. nose. The metabolites are excreted in the urine. along with a small amount of unchanged drug. Hypobaric or light solutions are diluted with distilled water. and gravitate toward the head when the client is tilted in a head-down position.

synthetic nondepolarizing agents are available and are preferred over succinylcholine in most instances. a muscle relaxant. the muscle fibers are not stimulated. Succinylcholine is normally deactivated by plasma pseudocholinesterase. which may damage muscles. 20). Artificial ventilation is necessary because these drugs paralyze muscles of respiration as well as other skeletal muscles. Antianxiety Agents and Sedative-Hypnotics Antianxiety agents and sedative-hypnotics are given to decrease anxiety. bradycardia. stomach. Injury to muscle cells may cause postoperative muscle pain and release potassium into the circulation. they can see and hear environmental activities and conversations. Various regimens. and less anesthetic agent is required. administration of a reversal agent may be unnecessary. These drugs may be given the night before to aid sleep and 1 or 2 hours before the scheduled procedure. It is often used in ambulatory surgical or invasive diagnostic procedures and regional anesthesia. and allow the use of smaller amounts of anesthetic agent. rocuronium) that allow spontaneous recovery of neuromuscular function when an IV infusion is discontinued. Anticholinergics Anticholinergic drugs are given to prevent vagal effects associated with general anesthesia and surgery (eg. Several newer. INDIVIDUAL ANESTHETIC AGENTS General anesthetics are listed in Table 14–1. They are ordered by an anesthesiologist and the choice of a particular drug depends on several factors. therefore. In clients with renal or hepatic impairment. see Chap. the parent drug or its metabolites may accumulate and cause prolonged paralysis. There are two types of neuromuscular blocking agents: depolarizing and nondepolarizing. are antidotes and can be used to reverse muscle paralysis. A benzodiazepine such as diazepam (Valium) or midazolam (Versed) is often used. Like acetylcholine. usually of two or three drugs. such as neostigmine (Prostigmin. Hypnotic doses are usually given for greater sedative effects. The drugs do not cause sedation. Morphine and fentanyl may be given in anesthetic doses in certain circumstances. There is no antidote except reconstituted fresh-frozen plasma that contains pseudocholinesterase. Midazolam has a rapid onset and short duration of action. reduced requirement for inhalation anesthetic. These drugs potentiate the CNS depression produced by other drugs. trachea. a naturally occurring plant alkaloid that causes skeletal muscle relaxation or paralysis. postanesthetic vomiting). reduced adverse effects associated with some inhalation anesthetics (eg. Some have short elimination half-lives (eg. and reduces the dose of opioid analgesics required during surgery. Anticholinesterase drugs. unless the recipients are unconscious. the nerve cell membrane is not depolarized. anticholinergics. and skeletal muscle contraction does not occur. The drugs also vary in routes of elimination. As a result. salivation. Repolarization and further muscle contraction are then inhibited as long as an adequate concentration of drug remains at the receptor site. Succinylcholine is the Preanesthetic Medications Principles for using preanesthetic drugs (antianxiety agents. peritoneum. With these agents. coughing. produces minimal cardiovascular side effects. causes amnesia. neuromuscular blocking agents should be used very cautiously in clients with renal or hepatic impairment. Neuromuscular Blocking Agents PRINCIPLES OF THERAPY Neuromuscular blocking agents cause muscle relaxation. and local anesthetics in Table 14–3. Vagal stimulation occurs with some inhalation anesthetics. hypotension). opioid analgesics) are the same when these drugs are given before surgery as at other times. with succinylcholine. are used. If hyperkalemia develops. The prototype drug is tubocurarine. Consequently. the specific procedure to be performed and its . and reduced perioperative stress. and increase client safety by allowing easier induction of anesthesia and smaller doses of anesthetic agents. Nondepolarizing neuromuscular blocking agents prevent acetylcholine from acting at neuromuscular junctions. Some client-related factors include age. Opioid Analgesics Opioid analgesics induce relaxation and pain relief in the preanesthetic period. neuromuscular blocking agents in Table 14–2. it is usually mild and insignificant but may cause cardiac dysrhythmias or even cardiac arrest in some situations. Muscle paralysis is preceded by muscle spasms. or other viscera and procedures in which pressure is exerted on the eyeball. the active ingredient of curare. The drugs vary in onset and duration of action. mivacurium. with most involving both hepatic and renal mechanisms. Useful drugs are atropine and glycopyrrolate (Robinul). the third component of general anesthesia. promote rest.222 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM operative period. and with surgical procedures in which there is manipulation of the pharynx. the drug combines with cholinergic receptors at the motor endplate to produce depolarization and muscle contraction initially. only commonly used depolarizing drug. bradycardia. intestine.

it may not produce adequate analgesia and muscle relaxation at a dosage that is not likely to produce significant adverse effects. Isoflurane (Forane) Used for induction and maintenance of general anesthesia Nitrous oxide Used in balanced anesthesia with IV barbiturates. Depresses functions of the kidneys. opioid analgesics. 3. sensitizes heart to catecholamines—increases risk of cardiac dysrhythmias. or both. rapid induction and recovery. Similar to isoflurane Used for induction and maintenance of general anesthesia A frequently used agent Halothane (Fluothane) Halothane has largely been replaced by newer agents with increased efficacy. Bradycardia is common. It may be used in balanced anesthesia with other agents. renal or hepatic toxicity not reported Nonexplosive. Note: Nitrous oxide is an incomplete anesthetic. hypotension. Depresses contractility of the heart and vascular smooth muscle. A nonanalgesic hypnotic used for induction and Etomidate (Amidate) maintenance of general anesthesia May be used as a primary anesthetic or an analgesic adjunct in balanced anesthesia May be used with nitrous oxide and oxygen in maintenance of general anesthesia for short operative procedures such as uterine dilation and curettage (continued ) .CHAPTER 14 ANESTHETICS 223 TABLE 14–1 Generic/Trade Name General Anesthetics Characteristics Remarks General Inhalation Anesthetics Desflurane (Suprane) Similar to isoflurane Enflurane (Ethrane) Nonexplosive. good analgesic. that is. and brief surgical procedures. causes no appreciable damage to vital organs unless hypoxia is allowed to develop and persist. It is safer for prolonged surgical procedures (see “Characteristics”). Produces rapid induction with little or no excitement. rapid recovery with little excitement or nausea and vomiting 2. Depresses pharyngeal and laryngeal reflexes. liver. one of oldest and safest anesthetics. nitrous oxide is given to increase analgesic effects. Although quite potent. Nonexplosive gas. May cause jaundice and hepatitis 8. Used for induction and maintenance of general anesthesia Sevoflurane (Ultane) General Intravenous Anesthetics Opioid analgesic–anesthetic related to fentanyl and Alfentanil (Alfenta) sufentanil. Rapid acting. and an IV barbiturate is used to produce rapid. it cannot produce surgical anesthesia. It is used alone for analgesia in dentistry. by itself. nonflammable volatile liquid. Causes cardiac dysrhythmias. May cause malignant hyperthermia Similar to halothane but less likely to cause cardiovascular depression and ventricular dysrhythmias. ventricular dysrhythmias are uncommon unless ventilation is inadequate. Sensitizes heart to catecholamines. 4. Does not irritate respiratory tract mucosa. which causes decreased cardiac output. and immune system 7. after which halothane is given to maintain anesthesia. and more potent inhalation anesthetics. and bradycardia 2. weak anesthetic. obstetrics. therefore does not increase saliva and tracheobronchial secretions 3. neuromuscular blocking agents. nonflammable volatile liquid Advantages: 1. Isoflurane may cause malignant hyperthermia but apparently does not cause hepatotoxicity. which decreases risk of laryngospasm and bronchospasm Disadvantages: 1. a neuromuscular blocking agent is given to increase muscle relaxation. decreased adverse effects. Depresses respiration and may produce hypoxemia and respiratory acidosis (hypercarbia) 6. Circulatory failure may occur with high doses. similar to halothane but may produce better analgesia and muscle relaxation. smooth induction. administered with oxygen to prevent hypoxia. Therefore. increases risk of cardiac dysrhythmias 5.

awakening may require several hours. given IV by intermittent injection or by continuous infusion of a dilute solution. It is generally contraindicated in clients with increased intracranial pressure. but respiratory depression may last 3–4 hours into the postoperative recovery period. general anesthetics) are given concurrently. Remarks Either drug may be used alone. vomiting. and other signs of CNS depression. hypersalivation. diagnostic. presence of chronic diseases. general anesthetics and neuromuscular blocking agents should be given only by people with special training in correct usage and only in locations where staff. It is used alone only for brief procedures. If used for major surgery. unpleasant psychic symptoms may occur. it is usually supplemented by inhalation anesthetics and muscle relaxants. anticipated duration. may be a contraindication to regional anesthesia. including severity of illness.224 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM TABLE 14–1 Generic/Trade Name General Anesthetics (continued ) Characteristics Droperidol (Inapsine) is related to the antipsychotic agent haloperidol. severe coronary artery disease. An opioid analgesic–anesthetic with a rapid onset and short duration of action A synthetic opioid analgesic-anesthetic related to fentanyl. it should be corrected before anesthesia. the client’s physical condition. immobility. and the client’s mental status. Severe anxiety. If a medical disorder of a vital organ system (cardiovascular. may be given IV or IM. Recovery is rapid. including dreams and hallucinations. Given IM for preoperative sedation. General Anesthesia General anesthesia can be used for almost any surgical. and maintenance of general anesthesia with nitrous oxide and oxygen for short surgical procedures Given by IV bolus or infusion for induction or maintenance of general anesthesia or sedation in intensive care Fentanyl and droperidol combination (Innovar) Ketamine (Ketalar) Methohexital sodium (Brevital) Midazolam (Versed) Propofol (Diprivan) Remifentanil (Ultiva) Sufentanil (Sufenta) Used for induction and maintenance of general anesthesia May be used as a primary anesthetic or an analgesic adjunct in balanced anesthesia Thiopental sodium (Pentothal) Thiopental is commonly used. anesthesia and major surgical procedures have profound effects on normal body functioning. General Regional and Local Anesthesia Regional or local anesthesia is usually safer than general anesthesia because it produces fewer systemic effects. Rapid-acting nonbarbiturate anesthetic. and a lack of awareness of surroundings (called dissociative anesthesia). occurring within minutes after the drug is stopped. and the client may require larger doses of preanesthetic sedative-type medication. death with IV administration. produces marked analgesia. or psychiatric disorders. sedation. for example. Consciousness returns rapidly. Innovar is a fixed-dose combination of the two drugs. whereas droperidol’s effects last 3–6 hours. when possible. Compared with fentanyl. Usually given to induce anesthesia. When alterations due to other disorders are also involved. Because of the risks. May cause respiratory depression. See thiopental. during recovery. Given IV for conscious sedation during short endoscopic or other diagnostic procedures. induction of general anesthesia. For . Additional doses of fentanyl are often needed because its analgesic effect lasts approximately 30 minutes. Fentanyl citrate (Sublimaze) is a very potent opioid analgesic whose actions are similar to those of morphine but of shorter duration. or therapeutic procedures.opioid analgesics. and drugs are available for emergency use or cardiopulmonary resuscitation. respiratory. Neuroleptanesthesia can be used for major surgical procedures. but they are often used together for neuroleptanalgesia and combined with nitrous oxide for neuroleptanesthesia. including torsades de pointes. apnea. Used most often for brief surgical. used almost exclusively in general anesthesia. diagnostic. it is more potent and faster acting and may allow a more rapid recovery. Smaller doses are needed if other CNS depressants (eg. and any other drugs being given. below. For major surgery. associated with the use of droperidol. Ultrashort-acting barbiturate. such as bronchoscopy and burn dressings. and transient skin rashes also may occur during recovery. the risks of anesthesia and surgery are greatly increased. apnea. hypertension. A single dose produces unconsciousness in less than 30 seconds and lasts 20–30 minutes. The Food and Drug Administration recently issued a warning about serious cardiac dysrhythmias. It produces sedative and antiemetic effects. amnesia. Neuroleptanalgesia is a state of reduced awareness and reduced sensory perception during which a variety of diagnostic tests or minor surgical procedures can be done. it must be supplemented by other general anesthetics. equipment. excellent hypnotic but does not produce significant analgesia or muscle relaxation. May cause hypotension. A rapid-acting hypnotic used with other agents in balanced anesthesia. or therapeutic procedure. renal) is present. Hyperactivity and unpleasant dreams occur less often with children than adults. It also may be used to induce anesthesia. An ultrashort-acting barbiturate similar to thiopental Short-acting benzodiazepine.

Malignant hyperthermia may occur. formulated with epinephrine Effects occur in 1–6 min and last 1 hour Poorly water soluble Minimal systemic absorption Available in numerous preparations. It is not used for spinal anesthesia. and throat Dibucaine (Nupercainal) Topical anesthesia of skin and mucous membranes (continued ) . effects of the drugs can be reversed by neostigmine (Prostigmin). earache. Butamben (Butesin) Chloroprocaine (Nesacaine) Used mainly in minor burns and skin irritations Regional anesthesia by infiltration. nerve block. but its potency is greater and duration of action is shorter Rapidly metabolized and less likely to cause systemic toxicity than other local anesthetics Given by injection Effects occur in 6–12 min and last 30 min A naturally occurring plant alkaloid Readily absorbed through mucous membranes A Schedule II controlled substance with high potential for abuse. produces psychic dependence and tolerance with prolonged use Too toxic for systemic use Effects occur in 1–5 min and last 30–60 min May cause local allergic reactions Effects occur in <15 min and last 3–4 hours Clinical Uses Local infiltration and nerve block for dental and periodontal procedures or oral surgery Topical anesthesia of skin and mucous membrane to relieve pain and itching of sunburn. and ointments May cause allergic reactions Effects occur in 5 min or less and last 15–45 min Given by injection May cause systemic toxicity Effects occur in 5 min and last 2–4 hours with injection. such as endoscopy and endotracheal intubation Nondepolarizing Type Atracurium (Tracrium) Cisatracurium (Nimbex) Doxacurium (Nuromax) Metocurine (Metubine) Mivacurium (Mivacron) Pancuronium (Pavulon) Intermediate acting* Intermediate acting* Long acting* Long acting. occasionally to facilitate mechanical ventilation Adjunct to general anesthesia. sore throat. lotions. nose. nerve block. occasionally to aid endotracheal intubation or mechanical ventilation Adjunct to general anesthesia. Septodont) Benzocaine (Americaine) Bupivacaine (Marcaine) Regional anesthesia by infiltration. other minor burns and wounds.CHAPTER 14 ANESTHETICS 225 TABLE 14–2 Generic/Trade Name Neuromuscular Blocking Agents (Skeletal Muscle Relaxants) Characteristics Uses Depolarizing Type Succinylcholine (Anectine) Short acting after single dose. hemorrhoids. recommended only for procedures expected to last 90 minutes or longer Adjunct to general anesthesia to aid endotracheal intubation and provide muscle relaxation during surgery or mechanical ventilation Adjunct to general anesthesia. skin abrasions. to facilitate endotracheal intubation and mechanical ventilation *All the nondepolarizing agents may cause hypotension. and epidural anesthesia during childbirth. action can be prolonged by repeated injections or continuous intravenous infusion. rectal suppositories. All types of surgery and brief procedures. and epidural anesthesia Cocaine Topical anesthesia of ear. throat lozenges. the prototype of nondepolarizing drugs* Intermediate acting* Adjunct to general anesthesia Same as rocuronium. largely because of euphoria and other central nervous system (CNS) stimulatory effects. 10–20 min and 3–5 hours with epidural administration Applied topically to skin only Related to procaine. below Adjunct to general anesthesia Same as vecuronium. including aerosol sprays. below Adjunct to general anesthesia Mainly during surgery after general anesthesia has been induced. TABLE 14–3 Generic/Trade Name Local Anesthetics Characteristics Newer drug. and other conditions Articaine (Septocaine. more potent than tubocurarine* Short acting* Long acting* Pipecuronium (Arduan) Rocuronium (Zemuron) Long acting* Intermediate acting* Tubocurarine Vecuronium (Norcuron) Long acting.

nerve block.) Lidocaine 2. is available in topical and injectable forms. effects occur in 2–5 min and last 15–60 min Causes minimal irritation of the eye but may cause allergic contact dermatitis of the fingers Given by injection or epidural infusion With epidural infusion. spinal anesthesia is often the anesthesia of choice for surgery involving the lower abdomen and lower extremities. To prevent accidental injection into a blood vessel. A major advantage of spinal anesthesia is that it causes less CNS and respiratory depression. nerve block. the patches are to be applied for 12 hours daily only. effects occur in 5–15 min and last 1–3 hours Not injected or applied to nasal mucosa because it irritates tissues Effects occur in 3–5 min Similar to lidocaine in effectiveness but has a slower onset. Local anesthetics should be injected only by people with special training in correct usage and only in locations where staff. effects occur in 5–15 min and last 1–3 hours With topical use. especially in people who are elderly or have chronic lung disease. 2. effects occur within 10 min and last about 8 hours Given topically and by injection One of the most widely used local anesthetic drugs Topical patches are available for the relief of painful conditions such as postherpetic neuralgia. and spinal anesthesia. equipment. longer duration. effects occur in 10–30 min and last up to 6 hours Applied topically Formerly injected for regional anesthesia but now rarely injected because of possible allergic reactions Clinical Uses Topical anesthesia in otolaryngology Local or regional anesthesia for surgery and obstetrics and for postoperative pain management Lidocaine (Xylocaine) Topical anesthesia and regional anesthesia by local infiltration. and less toxicity because it is more rapidly metabolized and excreted With injection. hemorrhoids. and epidural anesthesia Intravenously to prevent or treat cardiac dysrhythmias (see Chap. one of the most widely used. Guidelines for injections of local anesthetic agents include the following: 1. 52). Proparacaine (Alcaine) Ropivacaine (Naropin) Topical anesthesia of the eye for tonometry and for removal of sutures.5 hours Epidurally. nerve block. Lidocaine. local anesthetic solutions must not be injected into blood vessels because of the high risk of serious adverse reactions involving the cardiovascular system and CNS. action slower in onset and longer in duration than lidocaine With injection. endotracheal intubation. dermatoses.5% and prilocaine 2. effects occur in <2 min and last 30–60 min With epidural use. contraindicated for use on mucous membranes or abraded skin Must be applied at least 1 hour before the planned procedure Effects occur in 1–2 hours and last 1–2 hours Related to lidocaine. Not used topically. 3. spinal. effects occur in 3–5 min and last 0. Acts as an antidysrhythmic drug by decreasing myocardial irritability With injection. Choice of a local anesthetic depends mainly on the reason for use or the type of regional anesthesia desired. needle placement must be verified by aspirat- . (Warning: Do not use preparations containing epinephrine for dysrhythmias. foreign bodies.226 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM TABLE 14–3 Generic/Trade Name Dyclonine (Dyclone) Levobupivacaine (Chirocaine) Local Anesthetics (continued ) Characteristics Absorbed through skin and mucous membranes Effects occur in <10 min and last <60 min Newer drug May be given by local infiltration and epidurally When given epidurally. effects occur in <2 min and last 60 min Epidurally. and epidural infusion Prilocaine (Citanest) Procaine (Novocain) Regional anesthesia by infiltration. and epidural anesthesia Pramoxine (Tronothane) Topical anesthesia for skin wounds. effects occur in 5–15 min and last 1–3 hours Rarely used Rapidly metabolized With injection.5% (EMLA) Topical anesthesia for vaccinations or venipunctures in children Mepivacaine (Carbocaine) Infiltration. and cataracts Obstetric or postoperative analgesia and local or regional surgical anesthesia Topical anesthesia Tetracaine (Pontocaine) example.75–1. nerve block. sigmoidoscopy Regional anesthesia by infiltration. effects occur in 2–5 min and last 15–45 min Formulated to be absorbed through intact skin. and drugs are available for emergency use or cardiopulmonary resuscitation. Except with IV lidocaine for cardiac dysrhythmias.

you realize that you administered it to the wrong patient. maintaining fluid balance and urine output). or other disease processes). respiratory problems. attitude toward anesthesia and surgery. Ask about drug allergies. and stroke. and electrolytes to promote healing). This helps promote respiratory and cardiovascular function and decreases anxiety. myocardial infarction. respiratory. • Ask about the use of herbal drugs during the previous week. This is often a major source of anxiety. obesity. • Continue to assess vital signs. • Explain how postoperative pain will be managed. ask if the client has ever had an allergic reaction to a local anesthetic. assist the client to achieve optimal conditions for surgery. cough. limited exercise or activity. hypovolemia or hypervolemia). assess vital signs and respiratory and cardiovascular function every 5 to 15 minutes until reactive and stabilizing. Assess the client’s understanding of the intended procedure. • Assess use of prescription and nonprescription drugs. After you finally administer the drug. deep breathe. Some guidelines include the following: • Provide foods and fluids to improve or maintain nutritional status (eg. Assess for risk factors for complications of anesthesia and surgery (cigarette smoking. If use of local or regional anesthesia is anticipated. those high in protein. • Give pain medication appropriately as indicated by the client’s condition. • Assess for signs of complications (eg. thrombophlebitis. and perform other self-care activities until he or she can perform them independently. and surgery • Risk for Ineffective Breathing Patterns related to respiratory depression • Anxiety or Fear related to anticipated surgery and possible outcomes Planning/Goals Nursing Process Preoperative Assessment • Assess nutritional status. laboratory data. If potential problems are identified (eg. Assess ability and willingness to participate in postoperative activities to promote recovery. Postoperatively. You have been asked to extend your shift because someone has called in sick. The client will: • Receive sufficient emotional support and instruction to facilitate a smooth preoperative and postoperative course • Be protected from injury and complications while selfcare ability is impaired • Have emergency supplies and personnel available if needed • Have postoperative discomfort managed appropriately Interventions Preoperatively. close observation and monitoring during postanesthesia recovery. Effects of anesthetics and adjunctive medications persist into postanesthesia recovery. Assess vital signs. wound infection). kava and valerian can increase effects of sedatives. when feasible. especially those that are likely to cause perioperative complications. and ginseng can increase risks of bleeding. • Help the client maintain exercise and activity. and laboratory and other data. intervene to prevent them from becoming actual problems. level of consciousness. renal. ephedra increases risks of cardiac dysrhythmias. Nursing Diagnoses • Risk for Injury: Trauma related to impaired sensory perception and impaired physical mobility from anesthetic or sedative drugs . wound status. and other data as indicated to establish baseline measurements for monitoring changes. leg exercises and early ambulation. you are interrupted twice. hypertension. other medications. • Initiate discharge planning for a smooth transition to home care. • Risk for Injury: CNS depression with premedications and general anesthetics • Pain related to operative procedure • Decreased Cardiac Output related to effects of anesthetics. • Maintain IV infusions. amount. • Help the client to turn. the major focus is on maintaining a safe environment and vital functions. and degree of anxiety and fear. especially those taken within the past 3 days. feverfew. and elimination frequently until sensory and motor functions return. • Use sterile technique in wound care. ambulate. vitamin C and other vitamins. • • • • • Postoperative Assessment • During the immediate postoperative period. fluid and electrolyte imbalance. chronic cardiovascular. fluid balance. approximate length of stay). then periodically until discharge. You are preparing some intravenous morphine to administer to one patient. coughing and deep-breathing exercises. • Assist clients with measures to facilitate recovery postoperatively (eg. exercise legs. • Explain the expected course of events of the perioperative period (eg. Specific interventions include: • Observe and record vital signs. respiratory and cardiovascular status.CHAPTER 14 ANESTHETICS 227 How Can You Avoid This Medication Error? You are working in a busy postanesthesia recovery unit (PACU). garlic. caring for two patients recovering from general anesthesia. but before you administer the morphine. and type of fluids. For example. specific preparations for surgery. Monitor the site. ginkgo.

during. For spinal or epidural anesthesia. or drink hot liquids until the anesthetic has completely worn off. ✔ With preanesthetic. gers. or after surgery. and other exercises to promote recovery. the concentration of epinephrine should be no greater than 1:200. This combination of drugs should not be used for nerve blocks in areas supplied by end arteries (fin- b. Because few studies and little testing have been done. chew. You may fall or otherwise injure yourself if you get out of bed without assistance. Such activities can lead to injuries. oral. movement. ✔ Follow instructions and try to cooperate with health care personnel in activities to prevent postoperative complications. 4. Severe ventricular dysrhythmias may result. Multiple-dose containers are not used because of the risk of injecting contaminated solutions. If blood is aspirated into the syringe. another injection site must be selected. sedation. John’s wort) can interfere with or increase the effects of some drugs. Such solutions require special safety precautions. kava. ✔ After a local anesthetic is injected for dental or other oral surgery procedures. ✔ Do not try to perform activities requiring mental alertness and physical coordination while drowsy or less than alert from general anesthesia. ears. • Observe for improved ability in self-care activities. ✔ After surgery. penis) because it may produce ischemia and gangrene. CLIENT TEACHING GUIDELINES Perioperative Medications ✔ When anticipating a surgical procedure and a general anesthetic. and expulsion of meconium before birth and marked depression after birth. take enough pain medication to allow ambulation. Epinephrine is often added to local anesthetic solutions to prolong anesthetic effects. Local anesthetics given during labor cross the placenta and may depress muscle strength. ask how pain will be managed after surgery and what you will need to do to promote recovery. increased movement. nose. Most of the commonly used herbal products (eg. echinacea. tracheal.228 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Evaluation • Observe for absence of injury and complications (eg. or pain medication. The American Society of Anesthesiologists recommends that all herbal products be stopped two or three weeks before any surgical procedure. affect blood pressure or heart rhythm. Dosage used for spinal anesthesia during labor is too small to depress the fetus or the newborn. c. This combination should not be given IV or in excessive dosage because the local anesthetic and epinephrine can cause serious systemic toxicity. or increase risks of bleeding. gingko. laryngeal. Instructions about postoperative activities vary with the type of surgery. These drugs should not be used in clients with severe cardiovascular disease or hyperthyroidism. use only local anesthetic solutions that have been specifically prepared for spinal anesthesia and are in single-dose containers. If used in obstetrics. others recommend stopping most products two or three days before surgery. no fever or other signs of infection). do not eat. The drugs are well absorbed through mucous membranes and may cause systemic adverse reactions. ✔ If having surgery. you will receive pain medication by injection (often intravenously) for 2 or 3 days. muscle tone.000 because of the danger of producing vasoconstriction in uterine blood vessels. and St. • The client states that pain has been managed satisfactorily. ephedra. such as the following: a. local anesthetics should be given in the lowest effective dosage. e. If excessive amounts are used (eg. d. stay in bed with the siderails up and use the call light if help is needed. . valerian. some products have unknown effects when combined with anesthetics. including respiratory and wound infections. in paracervical block). and rooting behavior in the newborn. This combination should not be used with inhalation anesthetic agents that increase myocardial sensitivity to catecholamines. coughing and deep breathing. Apgar scores are usually normal. 5. including cardiac dysrhythmias. Topical Anesthesia of Mucous Membranes When used to anesthetize nasal. garlic. sedative-type medications. toes. In most instances. or urethral mucosa. ginseng. Such vasoconstriction may cause decreased placental circulation. ing before injecting the local anesthetic solution. other medications given before. pharyngeal. and the surgical procedures themselves. then by mouth. 6. and prolonged labor. decreased intensity of uterine contractions. bronchial. local anesthetics may cause fetal bradycardia. feverfew. be sure to inform health care providers about any herbal or other dietary supplements you take.

report the condition to the physician. does not stimulate the sympathetic nervous system or potentiate cardiac dysrhythmias. and the preference of the anesthesiologist. aspiration) and death from anesthesia. It also decreases cerebral blood flow and intracranial pressure. or other bronchospastic disorders. Most preparations are specifically made to apply on certain areas. the formulation now contains an antimicrobial agent. whoever administers anesthetics to children should be knowledgeable about anesthetics and their effects in children. ✔ Use local anesthetic preparations for only a short period. Use in Children Compared with adults. Local irritation. a local anesthetic prescribed to relieve itching may aggravate an open wound. However. the nurse who cares for a child before. and tetracaine have not been established in children younger than 12 years of age. it is much more expensive than halothane. precautions. than healthy adults. ✔ With spray preparations. 7. Thus. atracurium. full stomach) and for intramuscular administration when a suitable vein is unavailable. Slow titration of dosage. they must have direct contact with the affected area. although children are less likely than adults to have ventricular dysrhythmias. and they cannot be used effectively and safely on other body parts. and produces a minimal increase in intracranial pressure. For example. features that make it especially useful for children with asthma. is now contraindicated for routine. children are at greater risk of complications (eg. a newer agent. spray near food. cystic fibrosis. sedation. a rapid metabolism rate. In general. In addition. relative to size and weight. However. 2. intermediate-acting nondepolarizing agents (eg. Propofol may be given by injection for induction and an IV infusion pump for maintenance of anesthesia or sedation. For short surgical procedures. ✔ Do not apply more often than directed. Safety and efficacy of bupivacaine. laryngospasm. 3. or nausea. 1. ✔ Inform dentists or other physicians if allergic to any local anesthetic drug. and pain with injection. ✔ Use the drug only for the condition for which it was prescribed. the choice depends on the type of surgery and anesthesia. Some agencies allow parents to be present during induction of general anesthesia. do not inhale vapors. bronchospasm. a large-bore IV catheter. propofol is widely used for sedation with diagnostic tests or special procedures that require children to be sedated and immobile. and slow drug injection into a rapidly flowing IV can minimize these effects. ✔ Apply local anesthetics to clean areas. Succinylcholine. Benzocaine should not be used in infants younger than 1 year of age. In addition. and adverse effects in children as in adults. or store near any heat source. so it may not be indicated in clients who already have increased intracranial pressure or mass lesions. may have some advantages over halothane in pediatric anesthesia. formerly a commonly used agent. Local anesthetics usually have the same uses.CHAPTER 14 ANESTHETICS 229 CLIENT TEACHING GUIDELINES Topical Anesthetics ✔ Use the drug preparation only on the part of the body for which it was prescribed. With muscle relaxants. laryngospasm. Dosages in children . another type of local anesthetic can usually be substituted safely. Halothane may also sensitize the myocardium to epinephrine. 6. succinylcholine is still indicated in children who require emergency intubation or rapid securing of the airway (eg. skin rash. Halothane has been commonly used. infants and children have a higher anesthetic requirement. It allows a faster induction and emergence. and after surgical or other procedures that require anesthesia or sedation must be skilled in using the nursing process with children. hypotension. and hives can develop. Sevoflurane. making it useful in neurosurgery. during. adding lidocaine. 5. It has a rapid onset. dyclonine. and a smooth emergence with little mental confusion. This precaution stems from reports of several deaths associated with the use of succinylcholine in children with previously undiagnosed skeletal muscle myopathy. the drug dilates blood vessels in the brain and increases intracranial pressure. Adverse effects include respiratory depression. which should reduce risks of infection. It causes bronchodilation and does not irritate respiratory mucosa. 4. In addition. Children are more likely to have postoperative nausea and vomiting than adults. If the condition for which it is being used persists. contraindications to a particular agent. mivacurium) are commonly used. Allergic reactions are rare. This seems to reduce anxiety for both parents and children. but if they have occurred. For the drugs to be effective. 8. the presence of client conditions that affect or preclude use of a particular drug. Propofol is approved for use in children 3 years of age and older. elective surgery in children and adolescents. However.

With local anesthetics. delayed excretion and a longer halflife lead to higher peak plasma levels. clients receiving other CNS depressant drugs (eg. injections of the amide type (eg. Thus. Propofol is metabolized mainly in the liver to inactive metabolites. renal impairment may lead to accumulation of neuromuscular blocking agents or their metabolites. clients with severe hepatic impairment are more likely to acquire toxic plasma concentrations of lidocaine and prilocaine from topical use of EMLA because of impaired ability to metabolize the drug. Doses can be increased in small amounts every 5 to 10 minutes to achieve sedation and decreased in small amounts every 5 to 10 minutes to allow awakening. airway obstruction. A mixture of lidocaine and prilocaine (Eutectic Mixture of Local Anesthetics [EMLA]) was formulated to penetrate intact skin. repeated doses may cause accumulation of the drug or its metabolites and increased risks of adverse effects. and several may accumulate in the presence of renal impairment because of delayed elimination. and cardiac arrest. Propofol Use in Renal Impairment Most inhalation general anesthetic agents can be used in clients with renal impairment because they are eliminated mainly by exhalation from the lungs. heart block. For example. liver metabolism produces active metabolites. Long-term infusion may result in accumulation in body fat and prolonged elimination. Succinylcholine is also metabolized in the liver and should be used very cautiously in clients with hepatic impairment. These drugs should be administered and monitored only by health care personnel who are skilled in the management of critically ill clients. older adults may be at risk for decreased cardiac output. and adjunctive medications. These metabolites can accumulate and cause hyperkalemia in clients with renal impairment. provide local anesthesia. They may accumulate with hepatic impairment because of delayed elimination. there is greater systemic absorption and risk of toxicity in infants. Use in Older Adults Older adults often have physiologic changes and pathologic conditions that make them more susceptible to adverse effects of anesthetics. body weight. apnea. hypotension. renal effects vary among the drugs. Use in Hepatic Impairment Most inhalation general anesthetics are minimally metabolized in the liver and therefore are unlikely to accumulate with short-term usage. the level of sedation may be adjusted to the client’s condition and needs. Thus. including cardiopulmonary resuscitation and airway management. in minimally effective doses. all general anesthetics reduce blood flow to the liver. With long-term infusion. Neuromuscular blocking agents vary in the extent to which they are metabolized in the liver. Because cardiovascular homeostatic mechanisms are often impaired. rocuronium. It is given by continuous IV infusion in doses of 5 to 50 mcg/kg/min. and critically ill clients. . Propofol is an anesthetic used in subanesthetic doses for short-term sedation of clients who are intubated and mechanically ventilated. glomerular filtration. the rate should be slower in older adults. The drugs should be used very cautiously in clients with renal impairment. It has a rapid onset of action. and decrease pain of vaccinations and venipuncture. however. Most neuromuscular blocking agents are metabolized or excreted in urine to varying extents. and clients awaken within a few minutes of stopping drug administration. Critical care nurses must often care for clients receiving IV infusions of the drugs and titrate dosage and flow rate to achieve desired effects and minimize adverse effects. such as a lighter level during visiting hours or a deeper level during painful procedures. which are metabolized primarily in the liver. For topical application to mucous membranes. neuromuscular blocking agents. which is mainly metabolized by the liver with a small amount excreted unchanged in urine. low concentrations of local anesthetics should be used. and physical condition. Thus. and vecuronium are eliminated mainly by the liver. The cream is applied at the injection site with an occlusive dressing at least 60 minutes before vaccination or venipuncture. With atracurium. With propofol. lidocaine). The drugs should be used cautiously. Use in Critical Illness Propofol. and the liver’s ability to metabolize other drugs may be impaired. in such clients. In addition. These drugs are readily absorbed through mucous membranes and may cause systemic toxicity. and urine volume. some of which are excreted through the kidneys. Higher plasma levels can cause hypotension. The rate of infusion should be individualized and titrated to clinical response. As a general rule. they reduce renal blood flow. Propofol clearance may be slower because of decreased hepatic blood flow. With succinylcholine. and local anesthetics are commonly used in intensive care units. With topical applications to intact skin. as do IV general anesthetics. metabolism of atracurium produces a metabolite (laudanosine) that accumulates in renal failure and may cause neurotoxicity. are more likely to reach high plasma levels and cause systemic toxicity in clients with hepatic disease. However. With injections of a local anesthetic. opioids or benzodiazepines). In addition. EMLA cream should not be used on mucous membranes (or abraded skin). atracurium.230 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM should be reduced according to age. which are then excreted by the kidneys. However. short-term use of bolus doses does not impair renal function. neuromuscular blocking agents. and oxygen desaturation if dosage is not reduced. lower doses of these agents are usually needed.

lidocaine is often given in coronary care units to decrease myocardial irritability and prevent or treat ventricular tachydysrhythmias (see Chap. the client may be sedated longer than necessary. b. oxygen saturation. With propofol intravenous (IV) infusion: (1) Administer through a central or large peripheral IV catheter. pulmonary capillary wedge pressures. Approximately 1. Reduced doses are indicated to decrease adverse effects. For example. muscle wasting. dosage is decreased every 12 or 24 hours to maintain light sedation. if possible. fentanyl). During propofol infusion. and treat status epilepticus. Preanesthetic medications are often ordered “on call” rather than for a specific time. and resistance to mechanical ventilation. Schedule the administration of preanesthetic medications so that their peak effects are reached at the optimal time. If compatibility is unknown. some clinicians recommend that its use be limited to 24 to 48 hours. Clients requiring prolonged use of neuromuscular blocking agents usually have life-threatening illnesses such as adult respiratory distress syndrome. If a combination of injectable preanesthetic medications is ordered. electrocardiograms. or shock.25 mL (20 minims) is the upper limit for subcutaneous injections. Administer accurately a. The drug can irritate peripheral veins. medication effects may wear off before induction of anesthesia. the client may suffer needless anxiety and not be relaxed and drowsy when anesthesia is being initiated. and nurse anesthetists administer anesthetic drugs. For neurologic assessment. In addition to usual uses of local anesthetics. arterial blood gas levels. prolong muscle weakness. probably no more than 2 to 3 mL should be given intramuscularly (IM) for both drug absorption and client comfort. In addition. or one of the drugs may be inactivated or altered when combined. do not mix in the same syringe and give as one injection unless the drugs are known to be compatible and the total volume is approximately 2 mL. Accumulation results mainly from delayed elimination. In addition. Also. pneumonia. and the risk of postanesthetic respiratory and circulatory complications is increased. When the drugs are used for extended periods. and the client may or may not become sedated before being transported to the surgery suite. if a local anesthetic (eg. give two or more injections if necessary. vecuronium). control increased intracranial pressure. and malnutrition. hypotension. with an infusion pump. or multiple organ dysfunction syndrome. bupivacaine) is infused epidurally with an opioid analgesic (eg. atracurium. dosage of both agents must be reduced to decrease risks of respiratory arrest. Neuromuscular blocking agents are used to facilitate mechanical ventilation. Local anesthetics should be used with caution in critically ill clients. The most commonly used are the nondepolarizing agents (eg. Timing is important. 1. After assessment. heart block. the drugs may accumulate. the dose is increased until the desired level of sedation occurs. and other measurements are needed. If they are given too early. 52). vital functions need to be assessed and monitored at regular intervals.CHAPTER 14 ANESTHETICS 231 lacks analgesic effects. vital signs. It is better if these medications are administered so that peak sedative effects occur before administration of anesthetics to avoid excessive central nervous system (CNS) depression. especially those with impaired cardiovascular function such as dysrhythmias. Because propofol is expensive. agitation. Although larger amounts are sometimes given. and make weaning from a ventilator more difficult. Repeated doses may cause accumulation of the drug or its metabolites or slow its metabolism. An infusion pump is required for accurate administration and dosage titration. clients are at risk for development of complications of immobility such as atelectasis. c. If they are given too late. (continued ) . It also has antiemetic properties. dentists. critical care nurses may administer propofol or a neuromuscular blocking agent to patients being mechanically ventilated. Do not mix the drugs. The drug should not be stopped because rapid awakening may be accompanied by anxiety. NURSING ACTIONS NURSING ACTIONS Anesthetic Drugs RATIONALE/EXPLANATION Drug administration in relation to anesthesia refers primarily to preanesthetic or postanesthetic drugs because physicians. which are given by intermittent bolus or continuous infusion. systemic inflammatory response syndrome. atropine and glycopyrrolate (Robinul) are compatible with morphine. so analgesia must be provided for patients in pain or those having painful procedures. For hemodynamic and respiratory assessment. A precipitate may develop.

f. observe for excessive sedation. d. lactated Ringer’s. If assisting a physician in injecting a local anesthetic solution. (4) Propofol is compatible with 5% dextrose. observe for relief of the symptom for which the drug was ordered. adverse reactions to epinephrine may occur. observe for relaxation. observe for tolerance of mechanical ventilation. Manufacturer’s recommendation Strict aseptic administration and maintenance techniques are needed because of the potential for microbial contamination. b. 3. detect. Depending on dose and client condition. the nurse often assists by obtaining and perhaps holding the drug vial while the physician aspirates drug solution into a syringe. The incidence of adverse reactions increases with the amount and concentration of local anesthetic solution injected. and other problems. b. hypotension. For example. Have drugs and equipment for resuscitation readily available in any location where propofol.2% sodium chloride IV solutions (5) Change IV tubing and propofol solution every 6 hours if manufactured IV solution is not used. observe for: (1) Excessive sedation—delayed awakening. When adjunctive drugs are given for preanesthetic medication. and movement. During general anesthesia. When propofol is used for sedation in an intensive care unit. Relief is usually obtained within a few minutes. drowsiness. 2. The early recovery period is normally marked by a progressive increase in alertness. change IV tubing every 12 hours. When local anesthetic drugs are applied for surface anesthesia. The nurse observes for adverse effects in the preanesthetic and postanesthetic periods. the anesthesiologist monitors the client’s condition constantly to prevent. Other preparations are used only on the skin. lidocaine viscous is used only as an oral preparation for anesthesia of the mouth and throat. Most preparations are used in particular conditions or bodily locations. responsiveness. such as sore mouth or throat. If manufactured solution is used and the nurse only has to access the bag of fluid.232 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS (2) Do not mix with other drugs before administration. After general anesthesia and during propofol administration in intensive care units. When a neuromuscular blocking agent is used in an intensive care unit. these effects are usually evident within 20 to 30 minutes after the drugs are given. Observe for adverse effects Serious adverse effects are most likely to occur during and within a few hours after general anesthesia and major surgery. Observe for therapeutic effects a. cardiac dysrhythmias. or treat hypoxia. failure to respond to verbal or tactile stimuli . show the drug container to the physician and verbally verify the name of the drug. and 5% dextrose and 0. e. lactated Ringer’s and 5% dextrose. Although the physician is responsible for drugs he or she administers. hypotension. c. These drugs can cause cardiovascular collapse. The often-used combination of an opioid analgesic and a sedativetype drug produces additive CNS depression. RATIONALE/EXPLANATION Propofol is an emulsion that is incompatible with other drugs.45% sodium chloride. the percentage concentration. (continued ) a. and arousability for neurologic assessment when drug dosage is reduced by slowing the IV infusion rate. and respiratory failure. d. be certain to use the appropriate preparation of the prescribed drug. Accuracy of administration is essential so that adverse reactions can be avoided or treated appropriately if they do occur. and relief of pain. Therapeutic effects depend on the type of drug and the reason for use. or local anesthetics are being used. and itching of hemorrhoids. and whether the solution is plain or contains epinephrine. When applying local anesthetics for topical or surface anesthesia. and if not. pain in skin or mucous membrane. neuromuscular blocking agents. (3) Dilute with 5% dextrose injection and do not dilute to a concentration of <2 mg/mL. assess the situation to determine whether further action is needed. Also. tolerance of mechanical ventilation. With preanesthetic drugs. Ask the client if the symptom has been relieved. 5% dextrose and 0. observe for lack of agitation and movement.

opioid analgesics. observe for: (1) CNS stimulation at first (hyperactivity. 8). after surgery. sedative-hypnotics (5) Corticosteroids . high concentrations. Additive hypotension may occur during and after surgery because of adrenocortical atrophy and reduced ability to respond to stress. hypoxia. Vital signs are often unstable during the early recovery period and therefore need to be checked frequently. injections into highly vascular areas. administration of analgesics would aggravate hypoxia. ventricular tachycardia or ventricular fibrillation may occur. Extreme changes must be reported to the surgeon or the anesthesiologist. or accidental injection into a blood vessel. With ketamine. or hypoxia and should be assessed carefully before action is taken. Any combination of these drugs with each other or with general anesthetic agents produces additive CNS depression. excitement. in decreasing doses. unpleasant dreams or hallucinations also may occur. Headache is more likely to occur if the person does not lie flat for 8 to 12 hours after spinal anesthesia is given. and vomiting. antidepressants. When they are combined with general anesthetics. For clients who have been receiving corticosteroids. For interactions involving preanesthetic medications.CHAPTER 14 ANESTHETICS 233 NURSING ACTIONS (2) Respiratory problems—laryngospasm. 6). Anticholinergic Drugs (Chap. Restlessness may be caused by the anesthetic. Hypoxia and hypercarbia indicate inadequate ventilation and may result from depression of the respiratory center in the medulla oblongata. Halothane and a few rarely used general anesthetics sensitize the myocardium to the effects of catecholamines. Local anesthetics depress myocardial contractility and the cardiac conduction system. shock. or retention of respiratory tract secretions due to a depressed cough reflex. pain. antihistamines. These antibiotics inhibit neuromuscular transmission. tachycardia and other cardiac arrhythmias. see Antianxiety and Sedative-Hypnotics Drugs (Chap. and CNS depression is a side effect. prolonged paralysis of respiratory muscles with muscle relaxant drugs. antianxiety agents. Increased likelihood of cardiac arrhythmias. c. Urinary retention may occur in anyone but is more likely in older men with enlarged prostate glands. seizure activity) followed by CNS depression (2) Cardiovascular depression—hypotension. Doses used for spinal or epidural anesthesia usually have little effect on cardiovascular function. Some are used therapeutically for their CNS depressant effects. hypercarbia RATIONALE/EXPLANATION Laryngospasm may occur after removal of the endotracheal tube used to administer general anesthesia. arrhythmias (3) Headache and urinary retention with spinal anesthesia 4. additive muscle relaxation occurs with increased likelihood of respiratory paralysis and apnea. epinephrine. For example. fluid and electrolyte imbalances (4) Other problems—restlessness. After regional anesthesia. If they are combined. and circulatory failure may occur. Observe for drug interactions a. 21). These effects are most likely to occur with high doses. and. anticonvulsants. isoproterenol. Such a combination is contraindicated. during. These problems are most likely to occur while general anesthesia is being administered and progressively less likely as the patient recovers or awakens. others are used mainly for other purposes. These symptoms are more likely to occur with large doses. Extreme caution must be used to prevent excessive CNS depression. antipsychotics. norepinephrine (4) CNS depressants—alcohol. barbiturates. (continued ) (3) Cardiovascular problems—hypotension. and Opioid Analgesics and Opioid Antagonists (Chap. if caused by hypoxia but interpreted as being caused by pain. Additive hypotension. Drugs that increase effects of general anesthetic agents: (1) Antibiotics—aminoglycosides (gentamicin and related drugs) (2) Antihypertensives (3) Catecholamines—dopamine. most physicians recommend administration of hydrocortisone before. nausea. CNS depressants include many different drug groups and hundreds of individual drugs.

lithium. Additive muscle relaxation Drugs that produce hypokalemia potentiate skeletal muscle relaxants Additive muscle relaxation (2) General anesthetics (3) Thiazide diuretics (eg. verapamil) (continued ) . With chronic ingestion. Atropine is often given as preanesthetic medication to prevent reflex bradycardia. tolerance to the effects of alcohol and general anesthetics develops. Few drugs actually decrease effects of general anesthetics. They should not be given local anesthetic solutions to which epinephrine has been added. which may occur with general inhalation anesthetics. in clients with hyperthyroidism or severe heart disease or those receiving adrenergic blocking agents for hypertension. Effects of general inhalation anesthetics decrease rapidly once administration is discontinued. clients taking MAO inhibitors should not be given general anesthesia. there is increased risk of hypotension. quinidine. and acute ingestion has an additive CNS depressant effect with general anesthetic agents. It is contraindicated for this use. that is. (4) Succinylcholine (Anectine) d.234 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS (6) Monoamine oxidase (MAO) inhibitors—isocarboxazid. however. respiratory depression. These drugs should be discontinued at least 10 days to 3 weeks before elective surgery. These are seldom necessary or desirable. If given with other blocking agents. propranolol (Inderal) (2) CNS depressants (3) Epinephrine Additive depression and increased risk of hypotension and arrhythmias Additive CNS depression with high doses Epinephrine is often used in dental anesthesia to prolong anesthetic effects by delaying systemic absorption of the local anesthetic drug. and other problems develop. If emergency surgery is required. When clients are excessively depressed and hypotension. Although they may be given spinal anesthesia. Effects of IV anesthetics decrease more slowly. Drugs that increase effects of local anesthetics: (1) Cardiovascular depressants—general anesthetics. Drugs that decrease effects of general anesthetics: (1) Alcohol (2) Atropine c. others RATIONALE/EXPLANATION Additive CNS depression. Drugs that decrease effects of local anesthetics: (1) Succinylcholine (Anectine) e. Additive relaxation of skeletal muscles. additive blockade and increased risk of respiratory depression and apnea occur. If overdosage of local anesthetics occurs. These drugs are given for this therapeutic effect so that smaller amounts of general anesthetics may be given. procarbazine. (7) Neuromuscular blocking agents b. Alcohol is a CNS depressant. isoniazid. magnesium sulfate. larger amounts of general anesthetic agents are required in clients who have acquired tolerance to alcohol. This drug may be given to treat acute convulsions resulting from toxicity of local anesthetic drugs. cardiac dysrhythmias. treatment is mainly symptomatic and supportive. however. gentamicin) These drugs can cause neuromuscular blockade on their own. procainamide. hydrochlorothiazide) (4) Others (clindamycin. the main treatment is stopping the anesthetic and supporting vital functions rather than giving additional drugs. Apnea may be prolonged by the combination of a local anesthetic agent and succinylcholine. Drugs that increase effects of neuromuscular blocking agents (muscle relaxants): (1) Aminoglycoside antibiotics (eg. tranylcypromine.

Journal of the American Medical Association.). Guyton. Springhouse. M. S. Drug facts and comparisons. during. & Hall. 208–216. Review and Application Exercises 1. Other factors that could have contributed to the error include the length of time the nurse had worked (fatigue) and the interruptions that distracted her concentration. or after general anesthesia. B. neostigmine) RATIONALE/EXPLANATION These drugs often are used to reverse the effects of the nondepolarizing agents. D. Kowalski. S. 8(1). P. J. (2000). & Yuan. Textbook of critical care. phenytoin) How Can You Avoid This Medication Error? Answer: The risk of administering a drug to the wrong patient is increased in the PACU because patients are unconscious and patient turnover is frequent. Professional’s handbook of complementary & alternative medicines. These drugs may increase metabolism of neuromuscular blocking agents so that drug onset of action is delayed and duration of action is shorter. C. it is essential that the patient is properly identified using the name band and the orders verified on the patient’s chart.CHAPTER 14 ANESTHETICS 235 NURSING ACTIONS f. R. pp.. C. 961–971.. 4th ed. (1999). what are important factors to consider? . In A. 5. Ayres. A post hoc descriptive study of patients receiving propofol. M. They do not reverse the effects of succinylcholine and may potentiate them instead. carbamazepine. J. W. A. When assessing a client before. or after local or regional anesthesia. Shoemaker (Eds. Saunders. W. Philadelphia: W. E. Sedatives and analgesics in critical care. during. Herbal medicines and perioperative care. & Rayfield. J. what are important factors to consider? 2. C. What interventions are needed to ensure client safety during recovery from general anesthesia? 4. (2) Enzyme inducers (eg. B. (2000). Saunders. Textbook of medical physiology. C. Holbrook & W. 507–513. J. (Updated monthly). S. (2001). 10th ed. K. When assessing a client before. In these situations. PA: Springhouse Corporation. St. C. Fetrow. R. Grenvik. M. What are the main elements of drug administration and client assessment when propofol or a neuromuscular blocking agent is used in critical care settings? SELECTED REFERENCES Ang-Lee. (1999). & Hoyt. & Avila. Hadbavny. What are major adverse effects of local anesthetic agents? 6. Philadelphia: W. A. What are major adverse effects of general anesthetics and neuromuscular blocking agents? 3. American Journal of Critical Care. Louis: Facts and Comparisons. What interventions are needed to ensure client safety during recovery from local or regional anesthesia? 7. A.. 286(2). Drugs that decrease effects of neuromuscular blocking agents: (1) Anticholinesterase drugs (eg. Moss.

often with unsuccessful attempts to decrease its use. 5. 2. Commonly abused drugs include CNS depressants (eg. Psychological dependence involves feelings of satisfaction and pleasure from taking the drug.chapter 15 Substance Abuse Disorders Objectives AFTER STUDYING THIS CHAPTER. substance abuse is defined as selfadministration of a drug for prolonged periods or in excessive amounts to the point of producing physical or psychological dependence and reduced ability to function as a productive member of society. and nicotine on selected body organs. and compulsive self-administration. SUBSTANCE ABUSE buse of alcohol and other drugs is a significant health. nicotine). traumatic injury. ᮣ Discuss important follow-up with this adolescent and his family after the incident. cocaine. Identify risk factors for development of drug dependence. crime. Describe specific antidotes for overdoses of central nervous system (CNS) depressant drugs and the circumstances indicating their use. economic. per- . THE STUDENT WILL BE ABLE TO: 1. and legal problem. an 8th grader approaches you saying he is very worried about his friend. benzodiazepines. Critical Thinking Scenario You are a school nurse working in a middle school. and opiates. mental or legal problems. Outline major elements of treatment for overdoses of commonly abused drugs that do not have antidotes. ethanol. DEPENDENCE Characteristics of drug dependence include craving a drug. ᮣ List factors. and continuing to take a drug despite adverse consequences (eg. Although these drugs produce 236 A different effects. CNS stimulants (eg. cocaine. These feelings. child and spouse abuse. social. Substance abuse is often associated with substantial damage to the abuser and society (eg. These include prescription and nonprescription and legal and illegal drugs. compulsive drug-seeking behavior. Most drugs of abuse are those that affect the CNS and alter the state of consciousness. positive reinforcement. opioid analgesics). After lunch. especially during the adolescent period. 4. benzodiazepines. Just after lunch. As used in this chapter. on a dare. they are associated with feelings of pleasure. “ecstasy”). cocaine and other CNS stimulants. 3. Reflect on: ᮣ Prioritize your assessment when you reach the intoxicated youth. Compare and contrast characteristics of dependence associated with alcohol. This means that the body adjusts to the drugs so that higher doses are needed to achieve feelings of pleasure or stave off withdrawal symptoms. his friend drank over half a bottle of vodka and no one has been able to wake him up. cocaine. Describe interventions to prevent or manage withdrawal reactions associated with barbiturates. and opiates. amphetamines. antianxiety/ sedative-hypnotic agents. physical dependence (withdrawal symptoms if drug use is stopped). that increase the likelihood a person will experiment with or abuse alcohol. marijuana. Describe the effects of alcohol. death). job loss or decreased ability to function in an occupation. impaired family relationships). and other mind-altering drugs (eg. Most are also associated with tolerance if used repeatedly. alcohol. drug-related illnesses. marijuana. 6.

adolescents and young adults may be more likely to use illicit drugs and older adults are more likely to abuse alcohol and prescription drugs. In addition. Alcohol. frequency. at least partly because of easy access. marijuana. family. those who use illegal street drugs may not know what they have taken because of varying purity. or serious medical problems resulting from chronic drug overuse. acute intoxication. and nicotine because the drugs are rapidly absorbed from the large surface area of the lungs. • Substance abusers who inject drugs intravenously are prey to serious problems because they use impure drugs of unknown potency. and return to drug-taking behavior after periods of abstinence. and Central Nervous System Stimulants (see Chap. • Drug effects vary according to the type of substance being abused. phlebitis. development and maintenance of drug abuse patterns. 16). • Multiple drugs are often abused concurrently. A person may be dependent on more than one drug. and route of administration are also important. for example. endocarditis. 6). nurses) are also considered at high risk for development of substance abuse disorders. pharmacists. marijuana. Attempts to avoid withdrawal symptoms reinforce psychological dependence and promote continuing drug use and relapses to drugtaking behavior. acute intoxication often produces profound behavioral changes and chronic abuse often leads to serious organ damage and impaired ability to function in work. • A person who abuses one drug is likely to abuse others. and hyperactivity. and drugs used to treat substance-related disorders (see Drugs at a Glance: Drugs Used to Treat Substance Abuse Disorders). Most abusers understate the amount and frequency of substance use. human immunodeficiency virus infection. Thus. It is legal and readily available. The specific drug and the amount. or abuse. Physical dependence involves physiologic adaptation to chronic use of a drug so that unpleasant symptoms occur when the drug is stopped or its action is antagonized by another drug. probably because it is legal and readily available. withdrawal symptoms of alco- hol and sedative-type drugs are mainly agitation. There is no clear dividing line between use and abuse. They include alcohol. For example. potency. In addition. Most of these have clinical usefulness and are discussed elsewhere: Antianxiety and Sedative-Hypnotic Drugs (see Chap. alcohol. • Substance abusers rarely seek health care unless circumstances force the issue. physicians. poor hygiene. characteristics and treatment of substance-related disorders. CENTRAL NERVOUS SYSTEM DEPRESSANTS CNS depressants are drugs that slow down or “depress” brain activity. and medical illness). Drug dependence is a complex phenomenon of unknown cause. For example. and phase of substance abuse (eg. Tolerance is often an element of drug dependence. withdrawal syndromes. Patterns of abuse may vary in age groups. opioids. Peer pressure is often an important factor in initial and continuing drug ingestion. the amount. and opiates. The withdrawal or abstinence syndrome produces specific manifestations according to the type of drug and does not occur as long as adequate dosage is maintained. organ damage. Many drugs are abused for their mind-altering properties. A genetic factor seems evident in alcohol abuse: Studies indicate that children of abusers are at risk of becoming abusers themselves. but . Then. In addition to drug effects. Specific problems include overdoses. contribute to acute intoxication. and sedatives are often used to combat the anxiety and nervousness induced by cocaine and other CNS stimulants. One view is that drugs stimulate or inhibit neurotransmitters in the brain to produce pleasure and euphoria or to decrease unpleasant feelings such as anxiety. names. Withdrawal symptoms are characteristic for particular types of drugs and are usually opposite the effects originally produced. other influencing factors include a person’s psychological and physiologic characteristics and environmental or circumstantial characteristics. Additional general characteristics of substance abuse and dependence include the following: • Substance abuse involves all socioeconomic levels and almost all age groups. route of administration. and cellulitis at injection sites). • Alcohol and other drug abusers are not reliable sources of information about the types or amounts of drugs used. even if reared away from the abusing parent. duration of use. they rapidly circulate to the heart and brain without dilution by the systemic circulation or metabolism by enzymes. or social settings. most substance abuse comes to the attention of health care professionals when the abuser experiences a complication such as acute intoxication. contaminated needles. and other dangerous practices. is often used with other drugs of abuse. and its use is accepted in most societies. additives. from school-aged children to elderly adults. death. misuse. inhaling vapors from the heated drug produces blood levels comparable to those obtained with intravenous (IV) administration. withdrawal. • Smoking or inhaling drug vapors is a preferred route of administration for cocaine. and substitutions of one drug for another. Thus. Alcohol (Ethanol) Alcohol is the most abused drug in the world.CHAPTER 15 SUBSTANCE ABUSE DISORDERS 237 ceived as extremely desirable by the drug-dependent person. and numerous infections (eg. nervousness. Health care professionals (eg. and increasing doses are therefore required to obtain psychological effects or avoid physical withdrawal symptoms. With crack cocaine. This chapter describes commonly abused substances. 8). antianxiety and sedativehypnotic agents. hepatitis. heroin addicts may overstate the amount used in attempts to obtain higher doses of methadone. Opioid Analgesics and Opioid Antagonists (see Chap.

PO 2 mg q6–8h initially. Habitrol. 14 mg/d for 2 wk. should not be started until patient is opioid-free for at least 7 d Should not be used while continuing to smoke because of high risk of serious adverse effects Used patches contain enough nicotine to be toxic to children and pets. Nicoderm CQ. Maintenance doses of 60–80 mg daily more effective than 20–30 mg daily in decreasing heroin use May precipitate acute withdrawal symptoms With opiate dependence. 1 piece every 2–4 h for wks 7–9. Nicotrol NS) Transdermal patches. then increase to 150 mg twice daily. to a maximum of 80 sprays (40 mg) per day for heavy smokers. Taper by using less often or spraying 1 nostril per dose. every 1–2 h. opiate withdrawal Unlabeled uses May cause hypotension Disulfiram (Antabuse) Chronic alcohol abuse.2 mg/min up to 1 mg Limited effectiveness because many alcoholics will not take the drug. then discontinue Nicotrol nasal spray. 1 piece every 4–8 h for wks 10–12 Nicotrol inhaler. then tapered over 1–2 wk Withdrawal. 7 mg/d for 2 wk Nicotrol patch: 15 mg/16 hours for 6 wk Nicotrol chewing gum: 1 piece every 1–2 h for wks 1–6. morphine. they should be discarded in a safe manner . others) Opiate dependence. Nicotrol. benzodiazepine withdrawal Alcohol withdrawal. marijuana. Nicorette. inhalants. alcohol withdrawal hallucinations or seizures. 1 spray to each nostril. IM q30 min–6 h PRN. and phencyclidine. maintenance therapy of heroin addiction IV 0. Nicoderm: 21 mg/d for 6 wk. then gradually taper dosage over 6–12 wk. alcohol withdrawal Opiate withdrawal. to prevent continued alcohol ingestion Flumazenil (Romazicon) Haloperidol (Haldol) Levomethadyl (LAAM) (Orlaam) Lorazepam (Ativan) Acute intoxication or overdose of benzodiazepine antianxiety or sedative-hypnotic drugs Psychotic symptoms associated with acute intoxication with cocaine and other central nervous system (CNS) stimulants Maintenance therapy of heroin addiction Excessive CNS stimulation associated with acute intoxication with cocaine and other CNS stimulants. Nicotrol Inhaler. IM 2 mg. reduced by 5–10 mg daily over 7–10 days.1–0. should not be given until at least 12 h after alcohol ingestion May precipitate acute withdrawal symptoms Other antipsychotic agents may also be used IM 2–5 mg every 30 min to 6 h PRN for psychotic behavior PO 60–100 mg 3 times weekly Methadone Naloxone (Narcan) Naltrexone (ReVia) Acute intoxication or overdose of opiates (heroin. alcohol dependence Aid smoking cessation by relieving nicotine withdrawal symptoms Agitation. 2 wk needed for long-acting benzodiazepines Nicotine (Habitrol. benzodiazepine withdrawal. repeated if necessary. 300 mg/d PO 50 mg q6–8h initially. PO 20–80 mg daily initially.3–0. Maximum dose. maintenance PO 20–80 mg daily IV 0.6 mg q6h Opiate withdrawal PO 2 mcg/kg 3 times daily for 7–10 days PO 125–500 mg daily Comments Chlordiazepoxide (Librium) Clonidine (Catapres) Alcohol detoxification. 6–12 cartridges/d for 3 mo.238 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Drugs Used to Treat Substance Abuse Disorders Generic/Trade Name Bupropion (Zyban) Indications for Use Smoking cessation Routes and Dosage Ranges PO 150 mg once daily for 3 days. hallucinogens. at least 8 hours apart.4–2 mg q3min PO 50 mg daily Reportedly as effective and well accepted by heroin addicts as methadone 1 wk of tapering usually adequate for withdrawal from short-acting benzodiazepines. then tapered over 1–2 wk Alcohol withdrawal PO 0.

anxiety. which is most apparent in children born to alcoholic mothers. and hypoactivity or hyperactivity. which leads to bone resorption and decreased skeletal mass. Once absorbed. and liver disease. hypophosphatemia. and thinking processes. hypogonadism. hypomagnesemia. edema. infection. Fetal alcohol syndrome is characterized by low birth weight and length and by birth defects. abnormal heart sounds. and hyperkalemia. edema. iron deficiency anemia usually from gastrointestinal bleeding. osteoporosis. and feminization in men with cirrhosis due to decreased secretion of male sex hormones. episodes of acute myopathy associated with a drinking spree. which lead to decreased resistance to infection. pancreatic disease. Other effects include decreased bone density. leading to accumulation and toxic effects. such as malnutrition. degenerative changes in the anterior pituitary gland. damage to the epithelial cells of the intestinal mucosa. decreases use and increases production of lipids. how rapidly it was ingested. hypoglycemia due to impaired glucose synthesis or hyperglycemia due to glycogenolysis. impaired motor coordination. impaired memory. possible impairment of coronary blood flow and myocardial contractility. leading to hyperlipidemia and fatty liver. Alcohol exerts profound metabolic and physiologic effects on all organ systems (Box 15–1). probably from inadequate dietary intake of phosphorus. and conduction disturbances. nitrogen. a portion is inactivated in the stomach (by the enzyme alcohol dehydrogenase) and not absorbed systemically. hemolytic anemia from abnormalities in the structure of red blood cells. increased intestinal motility. Cardiovascular Effects Damage to myocardial cells. atrophy. brain damage. such as thiamine. When alcohol is ingested orally. leading to hepatomegaly. decreased renal excretion of uric acid. alcohol is absorbed partly from the stomach but mostly from the upper small intestine. chronic infection. Fatty liver causes accumulation of fat and protein. and electrocardiographic changes indicating left ventricular hypertrophy. abnormal T waves. hypersplenism. Skeletal Effects Impaired growth and development. multiple nutritional deficiencies. an excitatory neurotransmitter. and mental retardation becomes apparent. and CNS effects usually occur within a few minutes. It is rapidly absorbed when the stomach and small intestine are empty. eventually produces severe liver injury characterized by necrosis and inflammation (alcoholic hepatitis) or by fibrous bands of scar tissue that irreversibly alter structure and function (cirrhosis). and increased susceptibility to fractures. women are especially vulnerable to adverse effects of alcohol. sideroblastic anemia (sideroblasts are precursors of red blood cells) probably from nutritional deficiency. which probably contributes to the diarrhea that often occurs with alcoholism. an inhibitory neurotransmitter. decreased numbers and impaired function of white blood cells. alcohol is quickly distributed to all body tissues. whereas others become evident with chronic intake of substantial amounts. poor task performance. Women have less enzyme activity than men and therefore absorb approximately 30% more alcohol than men when comparable amounts are ingested according to weight and size. learning. eventually damages the liver enough to impair drug metabolism. cardiomyopathy manifested by cardiomegaly. and fatty liver and bone marrow failure associated with cirrhosis. and elevated creatine phosphokinase. insomnia. In men and women. impaired interpersonal relationships. polyneuritis and Wernicke-Korsakoff syndrome. The alcohol concentration in the brain rapidly approaches that in the blood. and other factors. which contributes to malabsorption of fat. decreased secretion of antidiuretic hormone from the posterior pituitary. including more rapid intoxication from smaller amounts of alcohol and earlier development of hepatic cirrhosis and other complications of alcohol abuse. Food delays absorption by diluting the alcohol and delaying gastric emptying. including protein and water-soluble vitamins. Alcohol is thought to exert its effects on the CNS by enhancing the activity of gamma-aminobutyric acid. mental depression. and vitamin B12. osteonecrosis due to obstructed blood supply. and anemias from hemodilution. several types of anemia including megaloblastic anemia from folic acid deficiency. Central and Peripheral Nervous System Effects Sedation ranging from drowsiness to coma. The incidence of liver disease correlates with the amount of alcohol consumed and the progression of liver damage is attributed directly to ethanol or indirectly to the metabolic changes produced by ethanol. altered speech patterns. hypocalcemia. thrombocytopenia and decreased platelet aggregation from folic acid deficiency. with ataxia or staggering gait. BOX 15–1 EFFECTS OF ALCOHOL ABUSE Hematologic Effects Bone marrow depression due to alcohol or associated conditions. These effects depend on the amount ingested. . and vitamin B12. Gastrointestinal Effects Slowed gastric emptying time. such as cleft palate and cardiac septal defects. tenderness. which may further stimulate bone resorption. folic acid. Impairment of growth and motor development persists in the postnatal period. dyspnea. Some of these effects are evident with acute alcohol intake. or by inhibiting the activity of glutamate. Endocrine Effects Increased release of cortisol and catecholamines and decreased release of aldosterone from the adrenal glands. which may be manifested by acute pain. Muscular Effects Acute myopathy. decreases use and increases production of lactate. partly because it is lipid soluble and crosses cell membranes easily. and secondary hyperuricemia. which may involve muscle weakness. gynecomastia. Hepatic Effects Induces drug-metabolizing enzymes that accelerate metabolism of alcohol and many other drugs and produces tolerance and cross-tolerance. As a result. leading to lactic acidosis. and other factors. chronic myopathy.CHAPTER 15 SUBSTANCE ABUSE DISORDERS 239 rather a continuum of progression over several years. whether the stomach was empty.

Chronic ingestion induces metabolizing enzymes. and tricyclic antidepressants). alcohol produces significant distress (flushing. Conscious control of behavior is lost. This is the amount of alcohol contained in approximately 2/3 oz of whiskey. cefoperazone. and. oral anticoagulants. tachycardia. These impairments lead to poor work performance. talkative. which can be used for energy or converted to fat and stored. Although the rate of metabolism differs with acute ingestion or chronic intake and some other factors. and psychomotor coordination. Acute ingestion increases anticoagulant effects and the risk of bleeding. respiratory depression. alcohol no longer exerts depressant effects on the CNS. Acute intoxication impairs thinking. The alcohol-dependent person is unlikely to seek treatment for alcohol abuse unless an acute situation forces the issue. and metronidazole (Flagyl). However. In older adults. including several cephalosporin antibiotics (cefamandole. general anesthetics. Chronic ingestion decreases anticoagulant effects by inducing drugmetabolizing enzymes in the liver and increasing the rate of warfarin metabolism. chlorpropamide (Diabinese). delusions. and to the extent that physical health and social relationships are impaired. equivalent amounts of alcohol produce higher blood levels in older adults because of changes in body composition (eg. If the first step of treatment is recognition of alcohol abuse. This reaction may be used to treat alcohol dependence. it is approximately 120 mg/kg of body weight or 10 mL/hour. visual hallucinations. nausea. tachycardia. impaired mental and physical functioning. and assaultiveness often result. ceforanide. • With antihypertensive agents. and gastroenteritis. a greater proportion of fatty tissue). Unless . Treatment of Alcohol Dependence Alcohol dependence is a progressive illness. Withdrawal symptoms start within a few hours after a person’s last drink and last for several days. hyperreflexia. disorientation. cefonicid. judgment. and exhibitionism. These interactions often differ between acute and chronic ingestion. aggressiveness. sweating. insomnia. antipsychotic agents. • With disulfiram (Antabuse). depression. and outgoing or more impulsive and aggressive because inhibitions have been lessened. alcohol potentiates vasodilation and hypotensive effects. Psychological dependence. bronchospasm. is characterized by confusion. • With oral antidiabetic drugs. alcohol potentiates hypoglycemic effects. and disulfiram. opioid analgesics. fever. thereby increasing their effects and the likelihood of toxicity. antidiabetic agents. convulsions and delirium. Thus. Because so many variables influence alcohol’s interactions with other drugs. which normally controls behavior. the most serious form of alcohol withdrawal. When metabolized to acetaldehyde. sweating. Most alcohol is oxidized in the liver to acetaldehyde. Long-term ingestion of large amounts of alcohol. and disturbed relationships with other people. nausea and vomiting). if chronic ingestion has caused liver damage. Alcohol Interactions With Other Drugs Alcohol may cause several potentially significant interactions when used with other drugs. or 8 to 12 oz of beer. tremors. • A disulfiram-like reaction also may occur with other drugs. This increases the rate of metabolism and decreases drug effects. Acute ingestion inhibits drug-metabolizing enzymes. to seek treatment for other disorders. Combining alcohol with these drugs may be lethal and should be avoided. These are summarized as follows: • With other CNS depressants (eg. cefotetan). physical dependence. However. metabolism of warfarin may be slowed. Alcohol Dependence Alcohol dependence involves acute or chronic consumption of alcohol in excess of the limits accepted by the person’s culture. The rate of alcohol metabolism largely determines the duration of CNS effects. Signs and symptoms of alcohol withdrawal include agitation. the second step is probably confronting the client with evidence of alcohol abuse and trying to elicit cooperation. and other effects. accidents. antianxiety agents. However. such as nervousness. some important interactions include those with other CNS depressants. • With oral anticoagulants (eg. Chronic ingestion affects essentially all body systems and may cause severe organ damage and mental problems. if severe. alcohol interactions vary. tolbutamide (Orinase). and other signs of acute psychosis. however. and early recognition and treatment are desirable. Effects are summarized in Box 15–1. alcohol potentiates CNS depression and increases risks of excessive sedation. however.240 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Effects with acute intoxication usually progress from a feeling of relaxation to impaired mental and motor functions to stupor and sleep. health professionals may recognize alcohol abuse in its early stages if they are aware of indicative assessment data. postural hypotension. Alcohol is metabolized at the same rate regardless of the amount present in body tissues. causes liver damage and impaired ability to metabolize drugs. This slows the metabolism of some drugs. The intensity of the alcohol withdrawal syndrome varies with the duration and amount of alcohol ingestion. anxiety. at times considered inappropriate by that culture. This increases the risk of excessive anticoagulant effect and bleeding. tolerance. antihypertensive agents. anxiety. He or she is likely. warfarin). The person may seem more relaxed. Excited behavior may occur because of depression of the cerebral cortex. 3 to 4 oz of wine. Delirium tremens. the pharmacokinetics of alcohol are essentially the same as for younger adults. it is difficult to predict effects of interactions in particular people. sedative-hypnotics. and cross-tolerance (with other CNS depressants) are prominent characteristics.

nervousness. Clonidine may be given to reduce symptoms (eg. myocardial infarction. Disulfiram alone may produce adverse reactions of drowsiness. cardiac arrhythmias. Withdrawal is similar to alcohol withdrawal and may be more severe. cooperation. Midazolam or propofol may be useful for treating delirium tremens because their doses can be easily titrated to manage the symptoms. unconsciousness. Alcoholic patients usually require high doses of benzodiazepines because of the drugs’ cross-tolerance with alcohol. Unfortunately. even in overdose. and vomiting. If alcohol is ingested during disulfiram therapy. abusers often combine drugs in their quest for a greater “high” or to relieve the unpleasant effects of CNS stimulants and other street drugs. insomnia. tolerance. dizziness. Antiseizure drugs need not be given for more than a few days unless the person has a preexisting seizure disorder. as long as alcohol is present in the blood. These are more likely to occur during the first 2 weeks of treatment. psychological dependence. Barbiturate and Benzodiazepine Dependence This type of dependence resembles alcohol dependence in symptoms of intoxication and withdrawal. Lorazepam and oxazepam are less likely to accumulate and may be best for older adults or patients with hepatic disease. respiratory depression may require insertion of an artificial airway and mechanical ventilation. With long-acting drugs such as diazepam (Valium) and chlordiazepoxide (Librium). such as depression. poor motor coordination. Naltrexone is an opiate antagonist that reduces craving for alcohol and increases abstinence rates when combined with psychosocial treatment. however. 8) and are also widely abused. Overdoses may cause respiratory depression. The duration of the reaction varies from a few minutes to several hours. memory impairment. If the client agrees to treatment. Severe reactions include respiratory depression. Because of these reactions. the three primary approaches are psychological counseling. after which they usually subside. Other characteristics include physical dependence. Barbiturates and Benzodiazepines Barbiturates are old drugs that are rarely used therapeutically but remain drugs of abuse. The client may fail to make return visits or may seek treatment elsewhere. success is unlikely. Drug therapy for maintenance of sobriety is limited. and confusion. The two drugs approved for this purpose are disulfiram (Antabuse) and naltrexone (ReVia). The client must be closely observed because sedatives potentiate alcohol. blurred vision. hyperactivity. They provide adequate sedation and have a significant anticonvulsant effect. hypotension. Antidepressant drugs seem to decrease alcohol intake as well as relieve depression. others include anxiety. acetaldehyde causes nausea and vomiting. Symptoms begin 12 to 24 hours after the last dose of a short-acting drug such as alprazolam (Xanax). Withdrawal reactions can be extremely uncomfortable. Combining any of these drugs with each other or with alcohol can cause serious depression of vital functions and death. and knowledge. Benzodiazepine antianxiety agents are the drugs of choice for treating alcohol withdrawal syndromes. and cross-tolerance. and confusion. congestive heart failure. fatigue. tremors) associated with excessive stimulation of the sympathetic nervous system. Naltrexone is hepatotoxic in high doses and contraindicated in patients with acute hepatitis or liver failure.CHAPTER 15 SUBSTANCE ABUSE DISORDERS 241 the client admits that alcohol abuse is a problem and agrees to participate in a treatment program. and drug therapy. Signs and symptoms of withdrawal include anxiety. Benzodiazepines are widely used for antianxiety and sedative-hypnotic effects (see Chap. mainly by people who also abuse alcohol or other drugs. and peak at 24 to 72 hours. In addition to drug therapy to treat withdrawal and maintain sobriety. cardiovascular collapse. and excessive CNS depression may occur. withdrawal symptoms begin 12 to 24 hours after the last dose and peak at 24 to 72 hours. If the client is comatose. which may increase blood levels of the drugs and increase their toxicity. lorazepam or oxazepam). headache. Ingestion of prescription and over-the-counter medications that contain alcohol may cause a reaction in the disulfiram-treated alcoholic. and death. syncope. cause oversedation. For example. unless taken with alcohol or other drugs. dyspnea. tachycardia. which is thought to reinforce alcohol craving and consumption. Some physicians prefer a benzodiazepine with a long halflife (eg. The severity of reactions varies but is usually proportional to the amounts of alcohol and disulfiram taken. If the client is hyperactive and combative. tremors and muscle twitch- . supportive measures are indicated. alcohol abusers often need treatment of coexisting psychiatric disorders. headache. diazepam or chlordiazepoxide) whereas others prefer one with a short half-life (eg. a sedativetype drug may be given. They may. and dermatitis. mainly because of poor compliance. If the client is already sedated and stuporous. Disulfiram also interferes with the metabolism of phenytoin and warfarin. The most common adverse effect is nausea. impotence. Seizures and death can occur. With short-acting barbiturates such as pentobarbital (Nembutal) and secobarbital (Seconal). Acute intoxication with alcohol does not usually require treatment. disulfiram must be given only with the client’s full consent. coma. Disulfiram interferes with hepatic metabolism of alcohol and allows accumulation of acetaldehyde. headache. With phenobarbital. A possible mechanism is blockade of the endogenous opioid system. drowsiness. referral to a self-help group such as Alcoholics Anonymous. convulsions. he or she can be allowed to sleep off the alcohol effects. They can help the client participate in rehabilitation programs and can be gradually reduced in dosage and discontinued. Benzodiazepines rarely cause respiratory depression or death. symptoms begin 24 to 48 hours after the last dose and peak within 5 to 8 days. Seizures require treatment if they are repeated or continuous. and death. symptoms begin 24 to 48 hours after the last dose and peak in 5 to 8 days.

and physical and mental characteristics of the user. smoking. Thus. dizziness. weight loss. Signs and symptoms of withdrawal are less severe with the benzodiazepines than with the barbiturates. which occurs within seconds. Treatment of Opiate Dependence Treatment may be needed for overdose or withdrawal syndromes. and other infections often accompany opiate overdose and require specific treatment measures. Overdose may produce severe respiratory depression and coma. Opiates Opiates are potent analgesics and extensively used in pain management (see Chap. each situation requires specific drug therapy and supportive measures. Treatment is unnecessary for mild overdose if vital functions are adequate. respiratory depression. nightmares. There may be a period of excitement and emotional lability followed by progressively increasing signs of CNS depression (eg. Overdose produces intoxication similar to that produced by alcohol. pulmonary edema. route of administration. Convulsions are more likely to occur during the first 48 hours of withdrawal and delirium after 48 to 72 hours. and is followed by a period of sedation. weakness. The person may experience cardiovascular collapse. They may produce euphoria. Giving an opioid antagonist can precipitate withdrawal symptoms. Treatment of Barbiturate or Benzodiazepine Abuse Treatment may involve overdose and withdrawal syndromes. The rate of recovery depends primarily on the amount of drug ingested and its rate of metabolism. If they do occur. “addiction” should not be an issue when the drugs are needed for pain management in patients with cancer or other severe illnesses. Effects diminish over approximately 4 hours. IV injection produces intense euphoria. hypoglycemia. and sedation). or nasal application (snorting). the symptoms may be caused by depressant drugs other than opiates. In addition to profound respiratory depression. Like other opiates. and delirium that resembles the delirium tremens of alcoholism or a major psychotic episode. then tapering the dose until the drug can be discontinued. There is no antidote for barbiturate overdose. and acute psychotic episodes. sedation. Insertion of an artificial airway and mechanical ventilation often are necessary. cycling between desired effects and symptoms of withdrawal. generalized tonic-clonic seizures. confusion. heroin causes severe respiratory depression with overdose and produces a characteristic abstinence syndrome. Barbiturate and benzodiazepine withdrawal syndromes can be life threatening. but morphine-like drugs produce dependence with repeated administration of small doses. depending on the dose. pneumonia. . These treatments were formerly used for benzodiazepine overdoses and may still be needed in some cases (eg. insomnia. Hypotension and shock are usually treated with IV fluids. analgesia. The goals of treatment are to maintain vital functions until the drug is metabolized and eliminated from the body. distorted visual perceptions. Medical usage of these drugs produces physical dependence and tolerance but rarely leads to use or abuse for mind-altering effects. leading to dosage escalation and continued use to avoid withdrawal. Insertion of an endotracheal tube and mechanical ventilation may be required. These can be prevented by gradually withdrawing the offending drug. such as health care professionals or staff at detoxification centers. Heroin. cellulitis. coma. If the person is comatose. They are also commonly abused. It is a Schedule I drug in the United States and is not used therapeutically. Addicts may inject several times daily. impaired mental function. vasodilation. a specific antidote is now available to reverse sedation. Treatment of withdrawal may involve administration of a benzodiazepine or phenobarbital to relieve acute signs and symptoms. The drug has a short duration of action. More severe overdoses cause respiratory depression and coma. treatment is symptomatic and supportive. overdoses involving multiple drugs). Tolerance to euphoric effects develops rapidly. postural hypotension. Drug therapy consists of an opioid antagonist to reverse opioid effects. Diuresis helps to eliminate the drugs and can be induced by IV fluids or diuretic drugs. generalized tonic-clonic seizures. Acute effects of opiate administration vary according to dosage. Opiate Dependence Opiates produce tolerance and high degrees of psychological and physical dependence. the focus here is heroin. Because therapeutic opiates are discussed elsewhere. Hemodialysis also removes most of these drugs and may be used with high serum drug levels or failure to respond to other treatment measures. and constipation.242 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM ing. and respiratory depression. 6). Flumazenil (Romazicon) competes with benzodiazepines for benzodiazepine receptors. postural hypotension. tachycardia. Heroin may be taken by IV injection. muscular incoordination. Recipients must be closely observed because symptoms of overdose may recur when the effects of a dose of flumazenil subside and because the drug may precipitate acute withdrawal symptoms (eg. agitation. a semisynthetic derivative of morphine. and repeated IV injections are usually needed. Gastric lavage may help if started within approximately 3 hours of drug ingestion. If there is no response to the opioid antagonist. pupil constriction. The client usually sleeps off the effects of the drug. Withdrawal reactions should be supervised and managed by experienced people. seizures) in benzodiazepine abusers. is a common drug of abuse. nausea and vomiting. a cuffed endotracheal tube should be inserted and the cuff inflated before lavage to prevent aspiration. lasts a few minutes. However. Most other drugs that produce dependence do so with prolonged usage of large doses.

the goal of treatment for opiate abuse is abstinence from further opiate usage. If the patient has severe pain and requires an opioid. Schedule II opioid indicated only for the treatment of opiate dependence. and administration of an antipsychotic drug. Except for the use of methylphenidate in treating ADHD. It is metabolized to longacting. Small amounts produce mental alertness. dopamine. Proponents say that methadone blocks euphoria produced by heroin. Because this goal is rarely met. If the patient taking naltrexone has mild or moderate pain. Symptomatic treatment includes sedation. Because amphetamines delay gastric emptying. Also. In addition. gastric lavage may be helpful even if several hours have passed since drug ingestion. norepinephrine. it should be given in a setting staffed and equipped for cardiopulmonary resuscitation because respiratory depression may be deeper and more prolonged than usual. and recovering from a drug. usually a single. Also. an opioid antagonist that prevents opiates from occupying receptor sites and thereby prevents their physiologic effects. the Friday dose may need to be larger to prevent withdrawal symptoms until the Monday dose can be given. can be managed by gradually reducing dosage over several days. Used to maintain opiate-free states in the opiate addict. however. peak in about 4 hours. Patients must be informed about the delayed effects of the drug and the risks of overdosage if they take other opiates. withdrawal allows these conditions to emerge in an exaggerated form. fever. CENTRAL NERVOUS SYSTEM STIMULANTS Amphetamines and Related Drugs Amphetamines and related drugs (see Chap. including cocaine. However. Acute ingestion of these drugs masks underlying fatigue or depression. Ideally. and reduces preoccupation with drug use. an antihypertensive drug. opiates. because methadone is free. which increases . Large amounts may cause psychosis (eg. also called LAAM. LAAM has proarrhythmic effects and an electrocardiogram should be done prior to starting the drug and periodically during therapy. acts longer. methylphenidate) produce stimulation and euphoria. LAAM (Orlaam) is a synthetic. Methadone has long been used for this purpose. agitated. Another drug approved for maintenance therapy is levomethadyl acetate hydrochloride. such as amphetamines (“uppers”). it is recommended for use in conjunction with psychological counseling to promote client motivation and compliance. Sedative-type drugs must be used with great caution. Psychological effects of amphetamines are similar to those produced by cocaine and are largely dose related. oral dose given in a methadone clinic. In addition. which are then heated and the vapors smoked or inhaled. the drugs are more important as drugs of abuse than therapeutic agents. if given on a Monday/Wednesday/Friday schedule. After oral administration. and hallucinating (toxic psychosis) and may have tachycardia. Therapeutic withdrawal. One of the drugs. such as alcohol or sedative-type drugs (“downers”). however. A third treatment option is naltrexone (ReVia). Cocaine Cocaine is a popular drug of abuse. It produces powerful CNS stimulation by preventing reuptake of neurotransmitters (eg. effects often sought by drug users. hallucinations and paranoid delusions). using.CHAPTER 15 SUBSTANCE ABUSE DISORDERS 243 Signs and symptoms of withdrawal can be reversed immediately by giving the drug producing the dependence. wakefulness. is sometimes used to relieve withdrawal symptoms associated with sympathetic nervous system overactivity. initial dosage needs careful titration to prevent withdrawal symptoms but avoid overdosage when peak effects occur. Amphetamine-Type Dependence Amphetamines and related drugs (eg. a substantial percentage of those receiving methadone maintenance therapy abuse other drugs. and increased energy. serotonin). One method uses opioid substitutes to prevent withdrawal symptoms and improve a lifestyle that revolves around obtaining. Clonidine. The user may increase the amount and frequency of administration to reach or continue the state of stimulation. This allows a more normal lifestyle for the client and reduces morbidity and mortality associated with the use of illegal and injected drugs. Tolerance develops to amphetamines. and last about 72 hours. effects occur within 90 minutes. and sedativehypnotic drugs do. which is more comfortable and safer. lowering of body temperature. Users may take them alone or to counteract the effects of other drugs. and other symptoms. In the latter case. nonopioid analgesics (eg. long-term drug therapy may be used to treat heroin dependence. Treatment of Amphetamine-Type Abuse Treatment of amphetamine-type abuse is mainly concerned with overdosage because these drugs do not produce physical dependence and withdrawal as alcohol. the heroin addict does not commit crimes to obtain drugs. because depression and sleep usually follow amphetamine use. potent metabolites. and these after-effects can be aggravated by sedative administration. patients needing elective surgery and opioid analgesics should be instructed to stop taking naltrexone at least 72 hours before the scheduled procedure. acetaminophen or a nonsteroidal anti-inflammatory drug) should be given. The resulting exhaustion and depression reinforce the compulsion to continue using the drugs. daily. these drugs may be part of a pattern of polydrug use in which CNS depressants. are alternated with CNS stimulants. 16) are used therapeutically for narcolepsy and attention deficit-hyperactivity disorder (ADHD). may be chemically treated to produce potent crystals (called “ice”). The client is likely to be hyperactive. Its main advantage over methadone is that it can be given three times weekly rather than daily. methamphetamine. Opponents say that methadone maintenance only substitutes one type of drug dependence for another.

Cocaine Dependence Cocaine-induced euphoria is intense but brief and often leads to drug ingestion every few minutes as long as the drug is available. and intense craving occur as drug effects dissipate. weight loss. difficulty in maintaining erection. nicotine is implicated in the vascular disease and sudden cardiac death associated with smoking. Respiratory Effects With snorting of cocaine. inexpensive. although fatigue. respiratory failure. rhinitis. hyperactivity. cellulitis. convulsions. It reportedly can cause psychological dependence with one use. “crack” is heated and the vapors inhaled. and widely used form of cocaine. endocarditis. It is prepared by altering cocaine hydrochloride with chemicals and heat to form rock-like formations of cocaine base. excessive central nervous system stimulation. and dependence. fatigue. insomnia. With inhalation of crack cocaine vapors. intestinal ischemia. respiratory arrest. subarachnoid and other hemorrhages. skin. cardiac dysrhythmias may be treated with usual antidysrhythmic drugs. It is also excreted in breast milk of nursing mothers. cancer and pulmonary BOX 15–2 PHYSIOLOGIC AND BEHAVIORAL EFFECTS OF COCAINE ABUSE striction and ischemia. Nicotine is readily absorbed through the lungs. crack acts within a few seconds. human immunodeficiency virus infection. and damage (ulceration. Nicotine poisoning can occur in infants and children from ingestion of tobacco products. Central Nervous System Effects Cerebral infarct. perforation. myocardial infarction. myocardial ischemia and acute myocardial infarction. behavioral therapy. convulsions. depression. Acute use of cocaine or crack produces intense euphoria. psychosis with paranoid delusions and hallucinations that may be indistinguishable from schizophrenia. and drowsiness as drug effects wear off. delirium. agitation and hyperactivity may be treated with a benzodiazepine antianxiety agent. The process removes impurities and results in a very potent drug. and fatal lung hemorrhage. sexual arousal. myocardial infarction may be treated by standard methods. Adverse effects include nausea in new smokers at low blood levels and in experienced smokers at blood levels higher than their accustomed levels. drowsiness. manifested by anxiety. Inhaling smoke from a cigarette produces CNS stimulation in a few seconds. stroke. anorexia and weight loss. rhinorrhea. and so forth. abuse. possible necrosis. and paralysis of skeletal muscle. stroke. psychosis may be treated with haloperidol or other antipsychotic agent. Gastrointestinal Effects Nausea. which limits the amount of nicotine absorbed. including tachycardia. coma. Both acute and chronic use produce numerous physiologic effects (Box 15–2). agitation. and restlessness followed by depression. healthy adults and even with initial exposure. one of many active ingredients in tobacco products. Treatment of Cocaine Abuse Drug therapy is largely symptomatic. Nicotine Nicotine. Crack is a strong. The average cigarette contains approximately 6 to 8 mg of nicotine and delivers approximately 1 mg of nicotine systemically to the smoker (most is burned or dissipated as “sidestream” smoke). ventricular tachycardia and fibrillation. tachycardia. Initial detoxification and long-term treatment are best accomplished in centers or units that specialize in substance abuse disorders. cough. Oral ingestion usually causes vomiting. rupture of the aorta. Cocaine is not thought to produce physical dependence. Nicotine obtained from chewing tobacco produces longer-lasting effects because it is more slowly absorbed than inhaled nicotine. pulmonary edema. Cardiovascular Effects Dysrhythmias. extremely addicting. the role of nicotine in the etiology of other disorders (eg. bronchospasm. Thus. and mucous membranes. respiratory symptoms occur in up to 25% of users and may include bronchitis. cardiopathy. dyspnea. seizures. It is extensively metabolized. and death. increased energy and alertness. Toxic effects of a large dose may include hypertension. skin contact with used nicotine transdermal patches. pneumonia. constriction of coronary and peripheral arteries. or chewing nicotine gum. Nicotine produces its effects by increasing levels of dopamine and other substances in the brain. and its metabolites are eliminated by the kidneys. irritability. necrosis) of the nasal septum from vasocon- . With chronic tobacco use. and 12-step programs. When the drug is heated and the vapors inhaled. many patients need treatment for coexisting psychiatric disorders. mainly in the liver. even in young. However. Effects of Intravenous Use Hepatitis. is the ingredient that promotes compulsive use. hypertension. premature ventricular contractions. cardiac dysrhythmias. Poisoning may also occur with accidental ingestion of insecticide sprays containing nicotine. dysphoria. and asystole. abscesses. Long-term treatment of cocaine abuse usually involves psychotherapy. Cocaine is commonly inhaled (snorted) through the nose. In addition. Genitourinary Effects Delayed orgasm for men and women. Overdosage can cause cardiac dysrhythmias.244 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM and prolongs neurotransmitter effects. increased blood pressure.

Some people call them depressants. hypertension. possibly feelings of enjoyment. or recent myocardial infarction). weight gain. is 5 to 10 times as potent as commonly available marijuana. headache. and a nasal spray. The products are contraindicated in people with significant cardiovascular disease (angina pectoris. dizziness. subjective BOX 15–3 EFFECTS OF NICOTINE Gastrointestinal Effects Increases secretion of gastric acid. convulsions at high doses. and the environment in which the drug is taken. treatment regimens that combine counseling and behavioral therapy with drug therapy are more successful than those using drug therapy alone. and skin irritation at sites of transdermal patch application. Treatment of Nicotine Dependence Most tobacco users who quit do so on their own. many resume smoking. Overall. an oral inhaler. some call them stimulants. and increased cardiac workload. . These products prevent or reduce withdrawal symptoms. increased appetite. hashish. These cannabis preparations contain several related compounds called cannabinoids. It is also difficult to predict the effects of these drugs. which grows in most parts of the world. Transdermal patches produce a steady blood level of nicotine and patients seem to use them more consistently than they use the other products. vomiting. there are two main methods of treatment. Cigarette smokers may smoke to obtain the perceived pleasure of nicotine’s effects. It is more potent and more rapid in its actions when inhaled. although specific cannabinoid receptors have been identified in several regions of the brain. For those who are strongly dependent and unable or unwilling to quit on their own. In addition. restlessness. The gum. the smoking-cessation formulation is Zyban. psychotomimetic. Effects are summarized in Box 15–3. and spray are used intermittently during the day. decreased appetite. sleep disturbances). the inhaler and nasal spray require a prescription. nausea. route of administration. or unique in terms of fitting into drug categories. increased blood pressure. personality variables. hallucinogenic. Mental depression is also associated with nicotine dependence. but metabolites and other constituents also may exert pharmacologic activity. tremors. Nicotine products are intended to be used for limited periods of 3 to 6 months. irritability. Marijuana Marijuana and other cannabis preparations are obtained from Cannabis sativa. or both. with tapering of dosage and discontinuation. Nicotine Dependence Like alcohol and opiate dependence. dysrhythmias. The other method is nicotine replacement therapy with drug formulations of nicotine. Central Nervous System Effects Central nervous system stimulation with increased alertness. avoid the discomfort of nicotine withdrawal. aggravates gastroesophageal and peptic ulcer disease. Other factors include dose. increased force of myocardial contraction. Although they are effective in helping smokers achieve abstinence. Marijuana can be taken orally but is more often smoked and inhaled through the lungs. Nicotine is available in transdermal patches. a combination of Zyban and nicotine transdermal patches is sometimes used and may be more effective than either drug alone. Evidence indicates a compulsion to smoke when blood levels of nicotine become low. Abstinence from smoking leads to signs and symptoms of withdrawal (eg. anxiety. difficulty concentrating. inhaler. a sustained-release tablet. the hemp plant. confusion. an antidepressant (see Chap. Cardiovascular Effects Cardiac stimulation with tachycardia. Adverse effects include soreness of mouth and throat (with gum). which usually begin within 24 hours of the last exposure to nicotine. Many factors apparently influence a person’s response. One factor is the amount of active ingredients. dysrhythmias. nicotine dependence is characterized by compulsive use and the development of tolerance and physical dependence. The antidepressant formulation is marketed as Wellbutrin. The patches and gum are available over the counter. nausea and vomiting. It is unknown whether depression leads to smoking or develops concomitantly with nicotine dependence. the transdermal patch is applied once daily. chewing gum. Cannabis preparations are difficult to classify. Marijuana and hashish are the two cannabis preparations used in the United States. and others label them as mind-altering.CHAPTER 15 SUBSTANCE ABUSE DISORDERS 245 disease) associated with chronic use of tobacco is unknown. which varies with the climate and soil where the plants are grown and with the method of preparation. After smoking. The mechanism of action is unknown. vasoconstriction. 10). One method is the use of bupropion. prepared from plant resin. The endogenous substances that react with these receptors have not been determined. but they do not produce the subjective effects or peak blood levels seen with cigarettes. Delta-9-tetrahydrocannabinol (∆-9-THC) is the main psychoactive ingredient. including the entire United States. increases muscle tone and motility. Marijuana is obtained from leaves and stems.

Musculoskeletal Effects Ataxia. and death.” is an illegal. or months after the drug is taken). distorts perception of time and space. possibly increased risk of mouth. “flashbacks” (a phenomenon characterized by psychological effects and hallucinations that may recur days. throat. commonly called “ecstasy. weeks. and psychomotor tasks. These effects occur within an hour after oral ingestion and last 6 to 8 hours. orthostatic hypotension and tachycardia at high doses. disturbances in time perception. impaired gas exchange. tablet. which is important in emotion. MDMA (3. Cardiovascular Effects Hypertension. and feelings of closeness to others. decreased intraocular pressure. and effects cannot be predicted accurately. elevated body temperature. delirium. and lung cancer (some known carcinogens are much higher in marijuana smoke than in tobacco smoke). and last 2 to 3 hours. There is no specific treatment other than abstinence. Many physiologic effects (Box 15–4) and adverse reactions have been reported with marijuana use. sadness. and produces sympathomimetic reactions. aspergillosis in immunocompromised . panic reactions. Marijuana Dependence Tolerance and psychological dependence do not usually develop with occasional use but may occur with chronic use. Adverse effects include cardiac dysrhythmias. It is usually taken by adolescents and young adults. and teeth grinding. drug use is usually followed by several days of depression. Users report increased energy and perception. marijuana and other cannabis preparations are illegal and not used therapeutically in most of the United States. pupil dilation. seizures. Miscellaneous Effects Constipation. LSD (lysergic acid diethylamide) is a synthetic derivative of lysergic acid. such as memory and problem-solving ability. LSD is usually distributed as a soluble powder and ingested in capsule. repeated use of MDMA may lead BOX 15–4 EFFECTS OF MARIJUANA people. The exact mechanism of action is unknown. Large doses can produce panic reactions and hallucinations similar to acute psychosis. Low doses are mildly intoxicating and similar to small amounts of alcohol. peak in approximately 30 minutes. Another major concern is the drug’s neurotoxicity. Except for dronabinol (Marinol). low energy. depersonalization. including impaired ability to drive an automobile and perform other common tasks of everyday life. rhabdomyolysis. restlessness. Although users apparently think this is a safe drug. However. and the drug may cause physical and psychological dependence. decreased libido. hyponatremia. bronchospasm.4 methylenedioxymethamphetamine). as well as pupil dilation. perceptual and sensory distortions. impairs most intellectual functions. dehydration. thirst. or liquid form. clinicians state that such usage is no more effective than available legal treatments with less abuse potential. Long-term or permanent changes may result from damage to the nerve cells in the brain that transmit serotonin. and body temperature. euphoria. Dronabinol. including increased blood pressure. MDMA floods the brain with high amounts of serotonin. bradycardia. Cannabinoids can also decrease intraocular pressure and may be useful in treating glaucoma. drowsiness with high doses.” and its use is reportedly increasing.246 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM effects begin in minutes. Central Nervous System Effects Impaired memory. These effects have occurred with a single use. impaired performance on cognitive. and elevated blood pressure. Respiratory Effects Irritation and cellular changes in bronchial mucosa. is used to treat nausea and vomiting associated with anticancer drugs and to stimulate appetite in patients with acquired immunodeficiency syndrome (AIDS). often at dance parties called “raves. As a result. and a decreased ability to feel emotions or pleasure. coma. evidence indicates it is extremely dangerous. Some people promote legalization of marijuana for medical uses. Schedule I derivative of amphetamine that produces hallucinogenic and stimulant effects when taken orally. mood alteration. heart rate. increased reaction time. tachycardia. The risks of abuse are high. Adverse reactions include self-injury and possibly suicide. peripheral vasoconstriction. perceptual. delusions. and memory. anxiety. Effects wear off as THC is metabolized to inactive products. psychotic episodes. a formulation of ∆-9-THC. and small doses can alter normal brain functioning. physical dependence rarely occurs. a compound in ergot and some varieties of morning glory seeds. depersonalization. distorted sensory perceptions. and possible chromosomal damage resulting in birth defects. It is very potent. LSD alters sensory perceptions and thought processes. impaired coordination. mood. paranoid ideation. involuntary jaw clenching. violent behavior. Early effects include spasmodic jerking. It is a Schedule III controlled drug. Even without these life-threatening adverse effects. hyperthermia. hallucinations. Hallucinogens Hallucinogenic drugs include a variety of substances that cause mood changes. hypertension.

Some . Mescaline is an alkaloid of the peyote cactus. Hallucinogen Dependence Tolerance develops. memory impairment. especially in high doses. cocaine. including abuse of prescription drugs. Emergency treatment of MDMA abuse usually involves decreasing the high body temperature. PCP is often sold as LSD. Some general screening-type questions are appropriate for any initial nursing assessment. Phencyclidine is usually distributed in liquid or crystal form and can be ingested. You overhear a coworker stating. If it does occur. which can lead to panic reactions in which users may try to injure themselves (eg.” Reflect on: • What are your feelings about caring for someone who abuses drugs or alcohol? • How would you feel if you heard the coworker speaking judgmentally? • Role play what you might say to the coworker. including initial mild euphoria followed by ataxia. “This is the third time she has been admitted for her drinking. Phencyclidine (PCP) produces excitement. and death. There is some question about whether physical dependence occurs. altered sensory perceptions. These substances produce symptoms comparable with those of acute alcohol intoxication. or carbon tetrachloride are especially likely to cause serious damage to the liver. It is the least active of the commonly used psychotomimetic agents but produces effects similar to those of LSD. and death. and sedative-hypnotics. or THC (the active ingredient in marijuana). Volatile Solvents (Inhalants) These drugs include acetone. by running into traffic). and it is the taxpayers that end up paying her bill. and other products. but there is no apparent physical dependence or abstinence syndrome. including death. methamphetamine. Suffocation sometimes occurs when the sniffer loses consciousness while the bag covers the face. Treatment of Hallucinogen Abuse There is no specific treatment for hallucinogen dependence. aerosol sprays. mescaline. nystagmus and diplopia. Users may prefer one of these drugs. and low energy or passivity. MDMA is not thought to cause dependence or withdrawal syndromes. These substances produce psychological dependence. There have been numerous reports of other drugs (eg. such as nitrous oxide. Bizarre murders. sedation and analgesia. It is usually sprayed or sprinkled on marijuana or herbs and smoked. replacing fluids and electrolytes. in a very judgmental tone. and monitoring for cardiovascular complications. the drug user may experience severe and unexpected reactions. including a state of intoxication similar to that produced by alcohol. Large doses may cause convulsions. supportive environment until drug effects wear off or may be given a sedative-type drug. and some produce tolerance. Some substances in gasoline and toluene also may produce symptoms similar to those produced by the hallucinogens. it is considered less intense than the physical dependence associated with alcohol. inhaled. convulsions. and pressor effects that can cause hypertensive crisis. LSD. Collins is admitted for cirrhosis after an acute drinking episode. ketamine. or injected. Substances containing gasoline. psychotic reactions. easily synthesized. These solvents may be constituents of some types of glue. such as antianxiety agents. and opiates. hallucinations. and other profound psychological and physiologic effects. users also need to be concerned about the actual product they are taking. confusion. It is usually ingested in the form of a soluble powder or capsule.CHAPTER 15 SUBSTANCE ABUSE DISORDERS 247 to depression. All of these drugs may have serious adverse effects as well. Those who experience severe panic reactions may be kept in a safe. It is very hard for me even to go in the room and take care of her. hallucinations. coma. Volatile solvents are most often abused by preadolescents and adolescents who squeeze glue into a plastic bag. coma. but they apparently do without or substitute another drug if the one they favor is unavailable. have also been abused to the point of dependence. and loss of selfcontrol. Nursing Notes: Ethical/Legal Dilemma You are working on a medical unit when Mrs. and bone marrow. Psychological dependence probably occurs but is usually not intense. insomnia. Some general inhalation anesthetics. It is also added to low-potency marijuana without the user’s knowledge. cerebral hemorrhage. and disorientation. impaired thought processes. or phencyclidine [PCP]) being sold as ecstasy. Nursing Process Assessment Assess clients for signs of alcohol and other drug abuse. toluene. including euphoria. and gasoline. Consequently. for example. A major danger with these drugs is their ability to impair judgment and insight. benzene. and readily available. opioids. and sniff the fumes. impaired motor skills. recklessness. kidneys. In addition to adverse effects of MDMA. The drug also produces flashbacks. Probably because it is cheap. The overall purpose of these questions is to determine whether a current or potential problem exists and whether additional information is needed. Death from overdose also has occurred as a result of respiratory depression. delirium. barbiturates. plastic cements. and self-mutilations have been attributed to the schizophrenic reaction induced by PCP. suicides.

or Self-Directed Violence related to disturbed thought processes. • Risk for Injury: Adverse effects of abused drug(s) • Disturbed Thought Processes related to use of psychoactive drugs • Risk for Other.” most of which have numerous. Request patient referrals to psychiatric/mental health physicians. or self-help programs when indicated. liver disease. • Decrease environmental stimuli for the person undergoing drug withdrawal. Teach nondrug techniques for coping with stress and anxiety. These and other factors aid effective planning of nursing care. Interventions • Administer prescribed drugs correctly during acute intoxication or withdrawal. Provide positive reinforcement for efforts toward quitting substance abuse. • Record vital signs. of course. Useful information includes each specific drug. and other signs of excessive central nervous system (CNS) depression or stimulation. and discuss ways to control weight without smoking. and acidosis are common in alcoholics). • Assess for disorders that may be caused by substance abuse. altered speech patterns. People who abuse one drug are likely to abuse others. such as long-term use of alcohol or psychotropic drugs. Denial of excessive drinking and of problems resulting from alcohol use is a prominent characteristic of alcoholism. For smokers who are concerned about weight gain if they quit smoking. information may be obtained that would indicate the likelihood of a withdrawal reaction. when available. • Interview the client regarding alcohol and other drug use to help determine immediate and long-term nursing care needs. and alcohol and drug levels in the blood. health-related benefits of stopping substance use or abuse. underreporting the extent of drug use is common in other types of drug abuse as well. Use therapeutic communication skills to discuss alcohol or other drug-related health problems. respiratory. for abnormal liver function test results. more specific questions can be formulated to assess the scope and depth of the problem. Observe for appropriate use of drugs to decrease abuse of other drugs. • Assess behavior that may indicate drug abuse. impaired judgment. frequently changed names. and abuse of multiple drugs is a more common pattern than abuse of a single drug. Impairments in work performance and in interpersonal relationships also may be behavioral clues. and the duration of administration. Inform smokers with young children in the home that cigarette smoke can precipitate or aggravate asthma and upper respiratory disorders in children. AIDS related to use of contaminated needles and syringes for IV drugs Planning/Goals • Safety will be maintained for clients impaired by alcohol and drug abuse. abnormal electrolytes (hypocalcemia. efforts to keep up with drug names and terminology may be helpful. and psychiatric problems of anxiety or depression. commits no injury to self or others). less impulsiveness. Observe for use or avoidance of nonprescribed drugs while hospitalized. hyperactivity or hypoactivity. hypomagnesemia. and are nonspecific. • Information will be provided regarding drug effects and treatment resources. and available services or treatment options. and behavior at regular intervals. abnormal white blood cell counts. Support use of resources for stopping drug abuse (psychotherapy. emphasize that the health benefits of quitting far outweigh the disadvantages of gaining a few pounds. For nurses who often encounter substance abusers. the frequency of administration. cardiovascular. the risk of increased or decreased effects of a variety of drugs. staggering gait. and neu• • • rologic functions. Inform smokers with nonsmoking spouses or other members of the household that “second-hand” smoke can increase the risks of cancer and lung disease in the nonsmokers as well as the smoker. accidental injuries. These disorders may be caused by other factors. • • • • • Nursing Diagnoses • Ineffective Coping related to reliance on alcohol or other drugs Evaluation • Observe for improved behavior (eg. • Dysfunctional Family Processes: Alcoholism • Risk for Injury: Infection. • Check laboratory reports. and impulsive behavior • Imbalanced Nutrition: Less Than Body Requirements related to drug effects and drug-seeking behavior . and the client’s susceptibility to drug abuse. • • • • improved judgment and thought processes. treatment programs). If answers to general questions reveal problem areas. such as alcohol on the breath. nurse clinical specialists. Interview to determine the client’s insight into personal problems stemming from drug abuse.248 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM clients may refuse to answer or give answers that contradict other assessment data. the amount. mental status. For example. hepatitis. It may be especially difficult to obtain needed information about illegal “street drugs. • The client’s efforts toward stopping drug usage will be recognized and reinforced. These disorders may include infections. Verify enrollment in a treatment program. indications of anemia.

Consequently. as early as possible. and clients certainly should not be denied their benefits. Initially. Decrease the supply or availability of commonly abused drugs. c. Each person must take personal responsibility for drinking alcoholic beverages and taking mind-altering drugs. but drug dependence develops in most instances only after prolonged use.nih. The belief that a drug is available for every mental and physical discomfort and should be taken in preference to tolerating even minor discomfort. The widespread acceptance and use of alcohol. This period varies somewhat. educating clients about the drugs prescribed for them. Since you are an RN. Also. the client must use them in prescribed doses and preferably for a short www. prescribing mind-altering drugs in limited amounts and for limited periods. using nondrug measures when they are likely to be effective. and participating in drug education programs. b. and recognizing. 5. nicotine. and this attitude is probably perpetuated by physicians who are quick to prescribe drugs and nurses who are quick to administer them. MD 20857 Phone: (301) 443-0365 E-Mail: nnadal@samhsa. it is very difficult but more effective in the long run. d. and other drugs of abuse because of potentially harmful effects on the fetus.nida. there are many appropriate uses of drugs. conscious. The apparently prevalent view that drug abuse refers only to the use of illegal drugs and that using alcohol or prescription drugs.CHAPTER 15 SUBSTANCE ABUSE DISORDERS 249 Nursing Notes: Apply Your Knowledge Your daughter brings her college roommate home for a weekend visit. clients who are abusing or are likely to abuse drugs. Treatment Measures for Substance Abuse Treatment measures for alcohol and other drug abuse are not very successful. Pregnant women should avoid alcohol. such as opioid analgesics and barbiturates. Most efforts at prevention have tried to reduce the supply of drugs. The acceptance and use of illegal drugs in certain subgroups of the population. She went to her physician for a prescription for “the patch” and she even bought some nicotine gum at the drug store in case the cravings get really bad. and if either parent is a heavy cigarette smoker. Physicians can help prevent drug abuse by prescribing drugs appropriately. She tells you she has tried to quit smoking many times before but this time she is determined. Efforts to change attitudes and decrease demand for drugs can be made through education and counseling about such topics as drug effects and nondrug ways to handle the stresses and problems of daily life. The difficulties emerge when there is excessive reliance on drugs as chemical solutions to problems that are not amenable to chemical solutions. Many current attitudes seem to promote drug use. may be used. misuse. In some groups. This is especially prevalent in high school and college students. PRINCIPLES OF THERAPY Prevention of Alcohol and Other Drug Abuse Use measures to prevent substance abuse. For example. to take a drug or not to take it. MD 20892-9561 Phone: (301) 443-1124 www. voluntary choices are made to drink or not to drink. When mind-altering drugs are prescribed for a legitimate reason. 6. teaching clients about drugs prescribed for them. every social occasion is accompanied by alcoholic beverages of some kind. and abuse. Decrease the demand for drugs. some of the following community-wide and individual measures may be helpful: 1. what advice can you give her regarding smoking cessation? 3. Other laws regulate circumstances in which legal drugs. Children are more likely to use illegal drugs if their parents have a generally permissive attitude about drug taking. laws designate certain drugs as illegal and provide penalties for possession or use of these drugs. Because this involves changing attitudes. 4. Some resources for information and educational materials include the following: National Institute on Drug Abuse 6001 Executive Blvd Bethesda. Of course. as well as the mother of a friend. participating in drug education programs. laws regulate the sale of alcoholic beverages. including: a. Although there are difficulties in trying to prevent conditions for which causes are not known. You notice a patch on her right upper arm and her left upper arm. Nurses can help prevent drug abuse by administering drugs 7. Even people who have been institutionalized . Parents can help prevent drug abuse in their children by minimizing their own use of drugs and by avoiding heavy cigarette smoking. if either parent takes mind-altering drugs National Clearinghouse for Alcohol and Drug Abuse Information (NCADI) Center for Substance Abuse Prevention 5600 Fishers Lane Rockwall II Rockville. society has a permissive attitude toward taking drugs. using nondrug measures when possible. does not constitute drug abuse. however inappropriately.

B. & Hillis. J. It is also important to tell her she must apply only one patch at a time and avoid concurrent use of nicotine gum to prevent nicotine toxicity. such as respiration and circulation. 109(2). and duration of drug-taking behavior and the particular situation for which treatment is needed. T. In E. What are the advantages of treating substance abuse disorders in centers established for that purpose? SELECTED REFERENCES Cooke.. American Journal of Nursing. until the drug is metabolized and eliminated from the body. Humes (Ed. Kelley’s Textbook of internal medicine. have been more successful than health professionals in dealing with drug abuse. Nursing Notes: Apply Your Knowledge Answer: Although you are not in a formal professional relationship with this young woman.) (2001). G. Alcoholism. A. D.. C. cocaine. First. Fourth. and opiates? 3.. or various medical-surgical conditions. 391–393. Why is it important to assess each client in relation to alcohol and other substance abuse? 2. benzodiazepine antianxiety or hypnotic agents. Lange. 26–32. Herfindal & D. still a crude drug with underappreciated toxicity.. Phipps. pp. T. III (2000). S. (2000). N.). DerMarderosian. Kelley’s Textbook of internal medicine. St. S. including psychotherapy.. Henderson-Martin. Cardiovascular complications of cocaine use. D. D. 7th ed. 100(9). 3. for example. 65(3). Emergency: Delirium tremens. What are general interventions for treatment of drug overdoses? 4. there are some clinical indications for drug therapy. T. Philadelphia: Lippincott Williams & Wilkins. Psychological rehabilitation efforts should be part of any treatment program for a drug-dependent person. pp.. No more surprises: Screening patients for alcohol abuse. minimized. treatment depends on the type. In H. Hashimoto. L.). it is important to support her efforts in smoking cessation. American Journal of Nursing. 4. 41–42. Philadelphia: Lippincott Williams & Wilkins. & Paty. including treatment of overdose or withdrawal syndromes. and other types of emotional support and counseling. (Ed. D. respiratory depression from an overdose of a CNS depressant drug may be treated by inserting an artificial airway and me- chanical ventilation. 2. there are few guidelines for optimal use. Philadelphia: Lippincott Williams & Wilkins. such as Alcoholics Anonymous and Narcotics Anonymous. R. & Tong. New England Journal of Medicine. Which commonly abused drugs may produce lifethreatening withdrawal reactions if stopped abruptly? 6. What are signs and symptoms of overdose with alcohol. Sachse.. Louis: Facts and Comparisons. The aim of treatment is usually to support vital functions. Drug therapy is limited in treating drug dependence for several reasons. For example. 284–289. Marijuana: A decade and a half later. however. Refer her back to her health care provider if she has additional questions or concerns. C. and vice versa. Humes (Ed. A. Gourley (Eds. 7th ed. voluntary self-help groups. extent. (2000). As a general rule. Pediatrics. Textbook of therapeutics: Drug and disease management. there is a high risk of substituting one abused drug for another. (2000). In E. 5. 1289–1312. Enoch. Several approaches may be useful. What are specific antidotes for opiate and benzodiazepine overdoses. withdrawal syndromes. In H. Despite these drawbacks. R. How can severe withdrawal syndromes be prevented. Approach to the problem of substance abuse. H. M. Removal of some drugs can be hastened by hemodialysis. S. there are significant drawbacks to giving CNS stimulants to reverse effects of CNS depressants. 229–233. So far. . (2001). or safely managed? 7. R. there is often inadequate information about the types and amounts of drugs taken. 2933–2936. pp. American Family Physician. Philadelphia: Lippincott Williams & Wilkins. 4th ed. depression is common and may require antidepressant drug therapy. (2000). Review and Application Exercises 1. pp. J. In The review of natural products. R. must often be estimated initially and then titrated according to response. B. 4th ed. D. Substance abuse. Some general management principles include the following: 1. C. General care of clients with drug overdose is primarily symptomatic and supportive. Lobo. (2000). J. O’Brien. R. D. specific antidotes are available only for benzodiazepines (flumazenil) and opioid narcotics (naloxone). Even when drug therapy is indicated. such as intoxication or overdose.). P. 351–358.250 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM and achieved a drug-free state for prolonged periods are apt to resume their drug-taking behavior when released from the institution. pp. Treatment of substance abuse may be complicated by the presence of other disorders. A. (2002).. Marijuana. Gourley (Eds. Second. and how are they administered? 5. & Goldman. Jr. The neurologic complications and consequences of ethanol use and abuse. Problem drinking and alcoholism: Diagnosis and treatment. L. 100(5). Schwartz. 345(5). Third.. W. A. & Eoff. Baldwin.). 441–450. Tell her how proud you are that she is trying to quit and that research shows that it usually takes many attempts before success is obtained. Health professionals are more likely to be involved in acute situations. Herfindal & D. voluntary groups. For example. Doses. (2002). 1313–1341. Textbook of therapeutics: Drug and disease management.

Identify nursing interventions to prevent. because her son may have attention deficit-hyperactivity disorder (ADHD).chapter 16 Central Nervous System Stimulants Objectives AFTER STUDYING THIS CHAPTER. and their indications for use are limited. ADHD is now thought to continue into adolescence and adulthood in one third to two thirds of clients. prevention of sleep deprivation. In addition to drug therapy. She was talking to a neighbor. Identify effects and sources of caffeine. peer groups. M known. and short naps may be helpful in reducing daytime sleepiness. restlessness. classrooms). Discuss the rationale for treating attention deficit-hyperactivity disorder with CNS stimulant drugs. Williams comes to your office with her 6-year-old son. ᮣ Possible negative effects if the boy does not have ADHD. who encouraged her to talk with a physician about prescribing Ritalin. USES any drugs stimulate the CNS. It occurs before 7 years of age and is characterized by persistent hyperactivity. Formerly thought to disappear with adolescence. 4. She likes a clean. Williams. but only a few are used therapeutically. and disturbances of nighttime sleep patterns. Discuss reasons for decreased use of amphetamines for therapeutic purposes. 2. recognize. Its cause is un- . Narcolepsy affects men and women equally and usually starts during teenage or young adult years. Critical Thinking Scenario Mrs. She complains that he is a very active child who always seems to be getting into mischief. sleep studies are required for an accurate diagnosis. family members. and impulsiveness. THE STUDENT WILL BE ABLE TO: 1. 5. Such behaviors make it difficult for the child to get along with others (eg. Attention Deficit-Hyperactivity Disorder ADHD is reportedly the most common psychiatric or neurobehavioral disorder in children. ᮣ Possible therapeutic effects if the boy has ADHD. The hazards of drowsiness during normal waking hours and suddenly going to sleep in unsafe environments restrict activities of daily living. Describe general characteristics of central nervous system (CNS) stimulant drugs. although she would like to see his grades improve. difficulty completing assigned tasks or schoolwork. Reflect on: ᮣ What advice you would have for Mrs. He seems to be doing OK in school. orderly house and he likes to make messes. In adolescents and adults. and treat stimulant overdose. Signs and symptoms also include excessive daytime drowsiness. teachers) and to function in situations requiring more controlled behavior (eg. avoiding shift work. Two disorders treated with CNS stimulants are narcolepsy and attention deficit-hyperactivity disorder (ADHD). impulsiveness and inattention continue but hyperactivity is 251 Narcolepsy Narcolepsy is a sleep disorder characterized by daytime “sleep attacks” in which the victim goes to sleep at any place or any time. muscle weakness and hallucinations at onset of sleep. fatigue. regular sleeping and waking times. a short attention span. 3.

Halflife is 1 to 3 hours. Contraindications to Use Central nervous system stimulants cause cardiac stimulation and thus are contraindicated in clients with cardiovascular disorders (eg. Amphetamines and Related Drugs Amphetamine. Analeptics Doxapram (Dopram) is occasionally used by anesthesiologists and pulmonary specialists as a respiratory stimulant. Endotracheal intubation and mechanical ventilation are safer and more effective in relieving respiratory depression from depressant drugs or other causes. A major criterion for diagnosing later ADHD is a previous diagnosis of childhood ADHD. Dexmethylphenidate is indicated only for ADHD. Large doses can impair mental and physical functions by producing restlessness. In children. and confusion. The drugs are somewhat selective in their actions at lower doses but tend to involve the entire CNS at higher doses. Some studies indicate that children with ADHD are more likely to have learning disabilities. dopamine. A combination of caffeine and . TYPES OF STIMULANTS Most CNS stimulants act by facilitating initiation and transmission of nerve impulses that excite other cells. No-Doz). resulting in increased heart rate and blood pressure. glaucoma. but pharmacologic effects last 4 to 6 hours. Analeptics are infrequently used (see doxapram and modafinil. and possibly serotonin in the brain. These drugs are widely sold on the street and commonly abused (see Chap. slowed gastrointestinal motility. Xanthines stimulate the cerebral cortex. agitation. produce signs of excessive CNS stimulation. and gastritis. and methamphetamine (Desoxyn) are closely related drugs that share characteristics of the amphetamines as a group. Other effects include myocardial stimulation with increased cardiac output and heart rate. Amphetamine-related drugs (methylphenidate and dexmethylphenidate) have essentially the same effects as the amphetamines and are also Schedule II drugs. It is well absorbed with oral administration. and substance abuse disorders as adolescents and adults as well as continuing difficulties in structured settings such as school or work. hyperactivity. such as restlessness.252 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM not a prominent feature. diuresis. nervousness. 15). mood disorders. The major groups are amphetamines and related drugs. the other one is approved only for treatment of narcolepsy. Dexmethylphenidate (Focalin) is very similar to methylphenidate and the amphetamines. Amphetamines also stimulate the sympathetic nervous system. and xanthines. They also are contraindicated in clients with anxiety or agitation. Caffeine (a xanthine) is an ingredient in nonprescription analgesics and stimulants that promote wakefulness (eg. anxiety. cardiac dysrhythmias. agitation. Prescriptions for them are nonrefillable. pupil dilation (mydriasis). increasing mental alertness and capacity for work. Overdoses can produce convulsions and psychotic behavior. it also has Indications for Use Amphetamines and methylphenidate are used in the treatment of narcolepsy and ADHD. They are more important as drugs of abuse than as therapeutic agents. dysrhythmias. but its mechanism of action is unknown. Modafinil (Provigil) is a newer drug for treatment of narcolepsy. nervousness. sodium benzoate is occasionally used as a respiratory stimulant in neonates. the drugs reduce behavioral symptoms and may improve cognitive performance. difficulty concentrating on a task. Limitations include a short duration of action (5 to 10 minutes after a single intravenous [IV] dose) and therapeutic dosages near or overlapping those that produce convulsions. insomnia. hypertension) that are likely to be aggravated by the drugs. Methylphenidate (Ritalin) is chemically related to amphetamines and produces similar actions and adverse effects. increasing mental alertness and decreasing drowsiness and fatigue. dextroamphetamine (Dexedrine). They are usually contraindicated in clients with a history of drug abuse. It is well absorbed with oral administration and reaches peak plasma levels in 1 to 1. below). One analeptic is used occasionally to treat respiratory depression. and other symptoms.5 hours. Like other CNS stimulants. Amphetamines increase the amounts of norepinephrine. It is metabolized in the liver and excreted in urine. dosages are listed in Drugs at a Glance: Central Nervous System Stimulants. or hyperthyroidism. decreasing fatigue and drowsiness. and increased secretion of pepsin and hydrochloric acid. Its ability to promote wakefulness is similar to that of amphetamines and methylphenidate. INDIVIDUAL CENTRAL NERVOUS SYSTEM STIMULANTS Individual drugs are described below. it also increases oxygen consumption and carbon dioxide production. Amphetamines are Schedule II drugs under the Controlled Substances Act and have a high potential for drug abuse and dependence. In ADHD. angina. however. Most of a dose is metabolized in the liver and excreted in urine. Larger doses. analeptics. Although it increases tidal volume and respiratory rate. peak plasma levels occur in about 2 hours with immediate-release tablets and about 5 hours with extended-release tablets. thereby producing mood elevation or euphoria. and prolonging wakefulness.

Adverse effects include anxiety.5 mg/kg in single or divided doses. Steady-state concentrations are reached in 2 to 4 days and half-life with chronic use is about 15 hours. perception. Modafinil is not recommended for patients with a history of left ventricular hypertrophy or ischemic changes on electrocardiograms. >6 y: PO 5 mg once or twice daily initially. dyspnea. increase by 5 mg/d at weekly intervals until optimal response (usually no more than 40 mg/d) PO 5–10 mg daily initially. cardiac stimulation. Metadate) ADHD in children ADHD Narcolepsy Narcolepsy: PO 10 mg daily initially. increased if necessary ADHD ADHD Narcolepsy Narcolepsy: PO 10–60 mg/d in 2 or 3 divided doses PO 2. irritability. headache. in 2 divided doses >6y: ADHD. increase if necessary Narcolepsy: >6 y: PO 5 mg/d initially. skeletal muscle stimulation. reaches peak plasma levels in 2 to 4 hours. Dosage should be reduced by 50% with se- vere hepatic impairment. caffeine increases alertness and capacity for work and decreases fatigue. Dose by infusion should not exceed 3 g. It is a Schedule IV drug. Dosage should be reduced by 50% with severe hepatic impairment. >6 y: PO 5 mg once or twice daily initially. Concerta. diarrhea. increase by 2.5–1. . including CNS stimulation. PO 5 mg twice a day initially.5 mg/min or more. increase by 2. In low to moderate amounts. dizziness. Interactions with other drugs include decreased effects of cyclosporine and oral contraceptives and increased effects of phenytoin. nervousness. and warfarin. increase by 5 mg/wk to effective dose ADHD: 3–5 y: PO 2. hyperglycemia. effects of severe renal impairment are unknown. and palpitations. and is 90% metabolized by the liver to metabolites that are then excreted in urine. dysrhythmias.CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 253 Drugs at a Glance: Central Nervous System Stimulants Routes and Dosage Ranges Generic/Trade Name Amphetamines Amphetamine Indications for Use Adults Children Narcolepsy ADHD Narcolepsy: PO 5–60 mg/d in divided doses Dextroamphetamine (Dexedrine) Narcolepsy ADHD Narcolepsy: PO 5–60 mg in divided doses Methamphetamine (Desoxyn) Amphetamine mixture (Adderall) Amphetamine-Related Drugs Dexmethylphenidate (Focalin) Methylphenidate (Ritalin. diuresis. Xanthines Caffeine has numerous pharmacologic actions. increased secretion of gastric acid and pepsin. Usual dose. nausea. 15–25 mg daily. nausea. in the morning. chest pain.5 mg/d initially.5 mg/d at weekly intervals until optimal response. increase by 5–10 mg at weekly intervals to a maximum of 60 mg/d if necessary Analeptics Doxapram (Dopram) Modafinil (Provigil) Narcolepsy IV 0.5–10 mg twice daily ≥6 y: ADHD. IV continuous infusion 5 mg/min initially. Ritalin SR. coronary and peripheral vasodilation. Dosage not established for children <16 years of age psychoactive and euphoric effects that alter mood.5 mg/d initially.5 mg/d at weekly intervals until response. PO 200 mg once daily. and thinking. Large amounts cause excessive CNS stimulation with anxiety. agitation. and bronchodilation from relaxation of smooth muscle. PO 5 mg 1–2 times daily. increase by 5 mg/d at weekly intervals until optimal response (usually no more than 40 mg/d) Narcolepsy: >6 y: PO 5 mg/d initially. tricyclic antidepressants. cerebrovascular vasconstriction. insomnia. increase by 5 mg/wk to effective dose ADHD: 3–5 y: PO 2. It is rapidly absorbed (food may delay absorption). nervousness. decreased to 2. is 60% bound to plasma proteins.

healthy. coffee. reproductive disorders. a barbiturate. toxicity may result from concomitant consumption of caffeine from several sources.254 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM premature ventricular contractions. nonpregnant adults consume no more than 250 mg of caffeine daily. Some authorities recommend that normal. Because of the widespread ingestion of caffeine-containing beverages and the wide availability of over-the-counter products that contain caffeine. A combination of caffeine and sodium benzoate is used as a respiratory stimulant in neonatal apnea unresponsive to other therapies. Pibb. energy drinks. Caffeine is usually prescribed as caffeine citrate for oral use and caffeine and sodium benzoate for parenteral use because these forms are more soluble than caffeine itself. Excedrin. and cola drinks). Diet Coke Pepsi. up to 6/d (240 mg/d) Also contains butalbital. hyperactivity and restlessness. With large amounts or chronic use. dysrhythmias). up to 6 tabs (600 mg/attack) Recommended dose 1–2 cap every 4 hours. Theophylline preparations are xanthines used in the treatment of respiratory disorders. usually in combination with ephedra (ma huang). which is present in greater amounts than in coffee beans or dried tea leaves. Pharmaceutical preparations include an oral preparation and a solution for injection. Guarana is widely used as a source of caffeine by soft drink manufacturers. Sources and amounts of caffeine are summarized in Table 16–1. then 1 tab every hour if needed. tachycardia. CNS stimulation is then an adverse effect (see Chap. caplet or geltab 32–33 60–65 1 tablet or capsule 200 1 tablet 100 Recommended dose 2 tablets 3 times daily (600 mg/d) 1 tablet 1 capsule 100 40 Recommended dose 2 tabs at onset of migraine. Vanquish APAP-Plus. caffeine has been implicated as a causative or aggravating factor in cardiovascular disease (hypertension. leaf or bag Instant Iced Soft Drinks Coke. and is a Schedule III controlled drug . Diet Sources of Caffeine Amount (oz) Caffeine (mg) Remarks 5–8 5–8 2 40–180 30–120 120 Caffeine content varies with product and preparation 8 8 12 80 50 70 Caffeine content varies with product and preparation 12 12 12 12 45 38 54 57 Most other cola drinks contain 35–45 mg/12 oz OTC Analgesics Anacin. gastrointestinal disorders (esophageal reflux. Caffeine produces tolerance to its stimulating effects. carcinogenicity. and most is consumed from dietary sources (eg. NoDoz. It is combined with an ergot alkaloid to treat migraine headaches (eg. Midol OTC Antisleep Products Caffedrine. such as asthma and bronchitis. tremors. In these conditions. vit- TABLE 16–1 Source Coffee Brewed. Toxic amounts may cause delirium and seizures. peptic ulcers). It is also used as a flavoring agent and an ingredient in herbal stimulant and weight-loss products. tea. the desired effect is bronchodilation and improvement of breathing. and vomiting. Cafergot) and is the active ingredient in nonprescription stimulant (antisleep) preparations. osteoporosis (may increase loss of calcium in urine). Diet Pepsi Mountain Dew Mr. and drug abuse liability. Herbal and Dietary Supplements Guarana is made from the seeds of a South American shrub. regular Instant Espresso Tea Brewed. and psychological dependence or habituation occurs. Caffeine is a frequently consumed CNS stimulant worldwide. psychiatric disturbances. It is an ingredient in some nonprescription analgesic preparations and may increase analgesia. 47). The main active ingredient is caffeine. Vivarin OTC Diuretic Aqua-Ban Prescription Drugs Cafergot Fiorinal 1 tablet or caplet 1 tablet. The caffeine content of coffee and tea beverages is determined by the particular coffee bean or tea leaf and the method of preparation.

PRINCIPLES OF THERAPY Appropriate Use Stimulant drugs are often misused and abused by people who want to combat fatigue and delay sleep. nervousness. IV fluids. • • • • • over-the-counter. hyperactivity. urinary acidification. and IV diuretics (eg. is also available in teas. For any client receiving amphetamines or methylphenidate. elixirs. and they have no legitimate use in athletics. Overall. high body temperature. confusion. After emptying the stomach. or social environments for adolescents and adults with ADHD • Reports of decreased inappropriate sleep episodes with narcolepsy Nursing Process Assessment • Assess use of stimulant and depressant drugs (prescribed. alone or in combination with other central nervous system (CNS) stimulants. In general. haloperidol may be given for symptoms of psychosis. hallucinations. Assess caffeine intake as a possible cause of nervousness. summers) to increase beneficial effects and help prevent drug dependence and stunted growth. consumers may not know how much caffeine they are ingesting in products containing guarana. irritability. For a child with possible attention deficit hyperactivity disorder (ADHD). or tachycardia. Gastric lavage may be helpful if done within 4 hours of ingestion of the stimulant. • Provide information about the condition for which a stimulant drug is being given and the potential consequences of overusing the drug. or concurrent ingestion of a stimulant and another drug that slows the metabolism of the stimulant. • Record weight at least weekly. Evaluation • Reports of improved behavior and academic performance from parents and teachers of children with ADHD • Self. In general. furosemide or mannitol) hasten drug excretion. capsules. Nursing Diagnoses • Sleep Pattern Disturbance related to hyperactivity. hyperactivity. guarana may cause excessive nervousness and insomnia. the use of guarana as a CNS stimulant and weight-loss aid is not recommended and should be discouraged. such as long-distance drivers. in people who are sensitive to the effects of caffeine or who have cardiovascular disease. • Promote nutrition to avoid excessive weight loss. . delirium. When a CNS stimulant is prescribed.CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 255 amin supplements. If cardiovascular collapse occurs. nervousness. insomia. the caffeine content of a guarana product is unknown and guarana may not be listed as an ingredient. panic states. drug dependence) • Deficient Knowledge: Drug effects on children and adults • Noncompliance: Overuse of drug Planning/Goals The client will: • Take drugs safely and accurately • Improve attention span and task performance (children and adults with ADHD) and decrease hyperactivity (children with ADHD) • Have fewer sleep episodes during normal waking hours (for clients with narcolepsy) Interventions • For a child receiving CNS stimulants. tremors. insomnia Toxicity of CNS Stimulants: Recognition and Management Overdoses may occur with acute or chronic ingestion of large amounts of a single stimulant. Assess for conditions that are aggravated by CNS stimulants. students. weekends. or street drugs). school. The product. assess behavior as specifically and thoroughly as possible. Treatment is largely symptomatic and supportive. if at all. which may also contain theophylline and theobromine. cardiac dysrhythmias. and minimize external stimulation. giving the smallest effective dose and limiting the number of doses obtained with one prescription decrease the likelihood of drug dependence or diversion (drug use by people for whom the drug is not prescribed). monitor cardiac function and temperature. and tablets of various strengths. extracts. hypertension. Signs of toxicity may include severe agitation.or family reports of improved ability to function in work. It is contraindicated during pregnancy and lactation and should be used cautiously. and death. restlessness. As a result. Use of amphetamines or other stimulants for this purpose is not justified. assist parents in scheduling drug administration and drug holidays (eg. Try to identify potentially significant sources of caffeine. circulatory collapse. assess behavior for signs of tolerance and abuse. insomnia. and chewing gums. IV diazepam or lorazepam can be given to calm agitation. These drugs are dangerous for drivers and those involved in similar activities. combinations of stimulants. coma. As with caffeine from other sources. combativeness. candies. activated charcoal (1 g/kg) may be given. and athletes. or seizures. fluid replacement and vasopressors may • Risk for Injury: Adverse drug effects (excessive cardiac and CNS stimulation. seizures. place the client in a cool room. With amphetamines.

It may increase effects of aspirin by increasing aspirin absorption. ✔ Record weight at least weekly. Modafinil may increase effects of clomipramine. Self-Administration and Administration to Children ✔ Take regular tablets approximately 30 to 45 minutes before meals. ✔ Prevent nervousness. with gastric lavage and activated charcoal if indicated. tricyclic antidepressants. and metabolic acidosis. fever. Dexmethylphenidate and meth- . ✔ Avoid other central nervous system stimulants. and insomnia. and by interviewing the child. muscle hypertonicity. ylphenidate may increase effects of phenytoin and antidepressants (selective serotinin reuptake inhibitors and tricyclics). Concerta. parental counseling or family therapy) are recommended along with drug therapy for effective treatment and realistic expectations of outcomes. necessary resting mechanisms for the body. decerebrate posturing. When used. They should be swallowed whole. In ADHD. Sprite and 7-Up have no caffeine. to avoid interference with sleep. muscle tremors or spasms. and Medadate ER are long-acting forms of methylphenidate. be used. tremors. Treatment is symptomatic and supportive. CNS stimulants may exacerbate symptoms. and warfarin. These are adverse drug effects and dosage may need to be reduced. ✔ If excessive weight loss. Use in Children Central nervous system stimulants are not recommended for ADHD in children younger than 6 years of age. Guidelines for treatment of ADHD include the following: 1. and they may decrease effects of antihypertensive drugs. Hemodialysis is indicated if the serum caffeine concentration is >100 mcg/mL or if life-threatening seizures or cardiac dysrhythmias occur. and cause dizziness or drowsiness. or insomnia develops. rhabdomyolysis with subsequent renal failure. ask the prescribing physician if the dose can be reduced or taken on a different schedule to relieve these adverse effects.256 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM CLIENT TEACHING GUIDELINES Methylphenidate and Dexmethylphenidate General Considerations ✔ These drugs may mask symptoms of fatigue. Some authorities believe that this condition is overdiagnosed and that stimulant drugs are prescribed unnecessarily. hyperglycemia. With caffeine. ✔ Notify a health care provider of nervousness. insomnia. phenytoin. Signs of toxicity are correlated with serum levels of caffeine. and insomnia from excessive caffeine intake by decreasing consumption of coffee and other caffeine-containing beverages or by drinking decaffeinated coffee. Cardiac dysrhythmias and seizures occur at higher levels. anxiety. these are normal. Counseling and psychotherapy (eg. It may decrease effects of lithium by increasing lithium clearance. and cola. hypokalemia. Use caution while driving or performing other tasks requiring alertness. The risks of drug dependence are lessened if they are taken correctly. ketosis. Oral doses of 5 g or more may cause death. impair physical coordination. anorexia. It may decrease effects of cyclosporine and oral contraceptives. heart palpitations. especially in children. Medadate CD. nervousness. This can be done by videotapes of behavior. Several cups of coffee may produce levels of 5 to 10 mcg/mL and symptoms of agitation and tremors. tea. or skin rash. vomiting. ingestion of 15 to 30 mg/kg (1 to 2 g for a person of 70 kg or 150 lbs) may cause myocardial irritability. Additional manifestations of caffeine toxicity include opisthotonus. dosage should be carefully titrated and monitored to avoid excessive CNS stimulation. leukocytosis. In children with psychosis or Tourette syndrome. caloric intake (of nutritional foods) may need to be increased. If a long-acting form of the stimulant drug has been ingested. parents. Effects of CNS Stimulants on Other Drugs Caffeine may increase adverse effects of clozapine and theophylline by decreasing their metabolism and increasing their blood levels. pulmonary edema. or caretakers. Do not take stimulant drugs to delay fatigue and sleep. ✔ Ritalin SR. and growth should be monitored at regular intervals during drug therapy. including caffeine. saline cathartics may be useful to remove undissolved drug granules. Suppression of weight and height have been reported. before 6 PM. observations and ratings by clinicians familiar with ADHD. ✔ Take these drugs only as prescribed by a physician. ✔ The drugs may cause weight loss. ✔ Get adequate rest and sleep. ✔ Take the last dose of the day in the afternoon. careful documentation of baseline symptoms over approximately 1 month is necessary to establish the diagnosis and evaluate outcomes of treatment. without crushing or chewing. IV diazepam or lorazepam may be used to control seizures. and vomiting. These drugs have a high potential for abuse. report excessive losses.

4. Drug therapy is indicated when symptoms are moderate to severe. Do not crush or open and instruct clients not to bite or chew long-acting forms of methylphenidate (Concerta. hypertension) that may be aggravated by the cardiac-stimulating effects of the drugs. other dysrhythmias. Metadate ER. the drug-free periods decrease weight loss and growth suppression. Adverse effects include appetite suppression and weight loss. An overdose may result. Older adults are likely to experience anxiety. These reactions are more likely to occur with large doses. Gastrointestinal effects—anorexia. Dosage adjustments are often needed at least annually as the child grows and hepatic metabolism slows. Give amphetamines and methylphenidate early in the day. c. and interfere in social. Then. academic. 5. diarrhea. insomnia. Desirable effects may include improvement in behavior. When possible. or behavioral functioning. Fewer “sleep attacks” with narcolepsy b. To minimize the drugs’ appetite-suppressing effects and risks of interference with nutrition and growth. psychotic behavior b. slowed metabolism and excretion increase the risks of accumulation and toxicity. give the last dose of the day at an earlier time or decrease the dose. nervousness. Use in Older Adults CNS stimulants should be used cautiously in older adults. at least 6 hours before bedtime. nervousness. including dietary caffeine. facilitate learning. and mental confusion from excessive CNS stimulation. and promote social development. b. In addition. Improved behavior and performance of cognitive and psychomotor tasks with ADHD c. gastritis. and better relationships with other children and family members. In addition. Administer accurately a. which may be worse during the first 6 months of therapy. Observe for therapeutic effects a. Cardiovascular effects—tachycardia. 2. Therapeutic effects depend on the reason for use. insomnia. angina. NURSING ACTIONS NURSING ACTIONS Central Nervous System Stimulants RATIONALE/EXPLANATION 1. are present for several months. 3. It is usually given daily. As with most other drugs. convulsions. weight loss. Ritalin SR). nausea. reduced doses are safer in older adults. (continued ) . drug therapy should be omitted or reduced in dosage when children are not in school. Metadate CD. including weekends. constipation Adverse effects may occur with acute or chronic ingestion of any CNS stimulant drugs. Methylphenidate is the most commonly used drug. To avoid interference with sleep. Drug holidays (stopping drug administration) are controversial. Excessive central nervous system (CNS) stimulation— hyperactivity. and quality and quantity of school work. Observe for adverse effects a. older adults often have cardiovascular disorders (eg. attention span. For children with attention deficit-hyperactivity disorder (ADHD).CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 257 2. These reactions are caused by the sympathomimetic effects of the drugs. tremors. Breaking the tablets or capsules destroys the extended-release feature and allows the drug to be absorbed faster. Young children may not require treatment until starting school. dysrhythmias. Other clinicians believe they are desirable when children are not in school (eg. the goal of drug therapy is to control symptoms. summer) and necessary periodically to re-evaluate the child’s condition. hypertension c. for the first 3 to 4 weeks to allow caregivers to assess beneficial and adverse effects. anxiety. Increased mental alertness and decreased fatigue 3. Some clinicians say they are indicated only if no significant problems occur during the drug-free pe- riod and are not recommended for most children. If insomnia occurs. In general. give amphetamines and methylphenidate about 30 minutes before meals.

258 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM NURSING ACTIONS 4. Decrease or antagonize the excessive CNS stimulation produced by amphetamines. fluvoxamine. rifampin g. These drugs induce drug-metabolizing enzymes. oral contraceptives h. Observe for drug interactions a. Drugs that decrease effects of CNS stimulants: (1) CNS depressants c. IV diazepam or lorazepam may be used to decrease agitation. Potentiate amphetamines by slowing drug metabolism. Drugs that decrease effects of amphetamines: (1) Acidifying agents (2) Antipsychotic agents e. rifampin . phenytoin. theophylline (2) Cimetidine. ammonium chloride) increase urinary excretion and lower blood levels of amphetamines. thereby decreasing blood levels and increasing clearance of caffeine. subarachnoid hemorrhage. Decreased absorption and increased excretion serve to decrease drug effects. phenytoin. The combination may cause death and should be avoided. These drugs induce cytochrome P450 3A4 enzymes that partly metabolize modafinil. (2) Monoamine oxidase (MAO) inhibitors d. mexilitene. These drugs cause CNS and cardiac stimulating effects. Urinary acidifying agents (eg. These drugs inhibit the cytochrome P450 1A2 enzymes that participate in the metabolism of caffeine. Drugs that decrease effects of modafinil: (1) Carbamazepine. and other signs of a hypertensive crisis. These drugs thereby increase the risks of headache. pseudoephedrine b. antacids) RATIONALE/EXPLANATION Such combinations are potentially dangerous and should be avoided or minimized. Chlorpromazine (Thorazine) or haloperidol (Haldol) is sometimes used in treating amphetamine overdose. ketoconazole f. and urinary alkalinizers decrease urinary excretion. Drugs that increase effects of caffeine: (1) Enoxacin. Decreased metabolism may increase adverse effects. Drugs that increase the effects of CNS stimulants: (1) Other CNS stimulant drugs (2) Albuterol and related antiasthmatic drugs. and seizures occurring with stimulant overdose. Drugs that increase effects of amphetamines: (1) Alkalinizing agents (eg. Increased absorption and decreased excretion serve to potentiate drug effects. May impair caffeine metabolism. Drugs that increase the alkalinity of the gastrointestinal tract increase intestinal absorption of amphetamines. These drugs inhibit cytochrome P450 3A4 enzymes that partly metabolize modafinil. Drugs that decrease effects of caffeine: (1) Carbamazepine. hyperactivity. Drugs that increase effects of modafinil: (1) Itraconazole.

T. T. SELECTED REFERENCES Carillo. C. 1130–1134. R. Kim. B. and how may they be minimized? 5. Attention-deficit/hyperactivity disorder (ADHD). 127–153. Archives of General Psychiatry.. What are the major adverse effects of CNS stimulants. 35(9).. NY: The Medical Letter. R. 1247–1270. 58(8). J. (1999). Clinical Pharmacokinetics. 775–782.. Efficacy of a mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. . Philadelphia: Lippincott Williams & Wilkins. J. A.. Louis: Facts and Comparisons. et al. St. J.CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 259 Review and Application Exercises 1. (2001). W. A. Gourley (Eds. Clinically significant pharmacokinetic interactions between dietary caffeine and medications. (2000). 39(2). & Phelps. Treatment of attention deficit hyperactivity disorder in children. Spencer. W.). Hovinga. What is the rationale for treating narcolepsy and ADHD with CNS stimulants? 4. & Avila. (2001). New Rochelle. The medical letter handbook of adverse drug interactions.) (2001). T. The Annals of Pharmacotherapy. Drug facts and comparisons. Fetrow. J. & Benitez. Textbook of therapeutics: Drug and disease management. C. Biederman. (Updated monthly). Inc. (Ed. Professional’s handbook of complementary & alternative medicines. R. S. Herfindal & D. Wilens. A. (2000). In E. What kinds of behaviors may indicate narcolepsy? 2. Springhouse. J. What kinds of behaviors may indicate ADHD? 3. Do you think children taking CNS stimulants for ADHD should have drug-free periods? Justify your answer. 7th ed. PA: Springhouse Corporation. Kehoe. pp.

3 Drugs Affecting the Autonomic Nervous System .

The ANS. Preganglionic impulses travel from the CNS along the preganglionic nerves to ganglia. Describe signal transduction and the intracellular events that occur when receptors of the autonomic nervous system are stimulated. Autonomic nerve impulses are carried through preganglionic fibers. Acetylcholine is synthesized from acetylcoenzyme A and choline and released at preganglionic fibers of both the SNS and PNS and at postganglionic fibers of the PNS. 3. Norepinephrine is the end product. 6. THE STUDENT WILL BE ABLE TO: 1. without conscious thought or effort. State names and general characteristics of drugs affecting the autonomic nervous system. Norepinephrine is released at most postganglionic fibers of the 261 . The central nervous system includes the brain and spinal cord. the central nervous system (CNS) and the peripheral nervous system (Fig. controls involuntary activities in the visceral organs of the body such as the heart. Differentiate subtypes and functions of sympathetic nervous system receptors. smooth muscle. These functions can be broadly described as activities designed to maintain a constant internal environment (homeostasis). A neurotransmitter is released from the terminal end of the preganglionic nerve allowing the nervous impulse to bridge the synapse between the preganglionic and postganglionic nerve. brain stem. and postganglionic fibers. and secretory glands. The autonomic nervous system is subdivided into the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The efferent neurons carry motor signals from the CNS to the peripheral areas of the body. where most of the norepinephrine is converted to epinephrine.chapter 17 Physiology of the Autonomic Nervous System Objectives AFTER STUDYING THIS CHAPTER. The peripheral nervous system includes all the neurons and ganglia found outside the CNS. blood vessels. Ganglia are composed of the terminal end of the preganglionic nerve and clusters of postganglionic cell bodies. 5). The postganglionic impulses travel from ganglia to effector tissues of the heart. Identify physiologic effects of the sympathetic nervous system. tyrosine → dopamine → norepinephrine → epinephrine). ganglia. including the hypothalamus. 2. Identify physiologic effects of the parasympathetic nervous system. Norepinephrine is synthesized from the amino acid tyrosine by a series of enzymatic conversions that also produce dopamine and epinephrine (ie. The peripheral nervous system is subdivided into the afferent neurons and efferent neurons. 5). Nerve impulses are generated and transmitted to body tissues in the sympathetic and parasympathetic nervous systems as they are in the CNS (see Chap. to respond to stress or emergencies. 4. Afferent neurons carry sensory input from the periphery to the CNS and modify motor output through the action of reflex arcs. Acetylcholine is also released from postganglionic sympathetic neurons that innervate the sweat glands and from motor neurons of the somatic nervous system that innervate the skeletal muscles. The somatic nervous system innervates skeletal muscles and controls voluntary movement. 5. AUTONOMIC NERVOUS SYSTEM The nervous system is composed of two main divisions. Differentiate subtypes and functions of parasympathetic nervous system receptors. 17–2). 17–1). and spinal cord. and smooth muscle (Fig. and to repair body tissues. glands. other visceral organs. The ANS is regulated by centers in the CNS. The efferent portion of the peripheral nervous system is further subdivided into the somatic and autonomic nervous system (ANS). except in the adrenal medulla. The nerve fibers that secrete acetylcholine are called cholinergic fibers. The main neurotransmitters of the ANS are acetylcholine and norepinephrine (see Chap.

262 SECTION 3 DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM The Human Nervous System Central Nervous System (CNS) (brain and spinal cord) Peripheral Nervous System (neurons and ganglia outside the brain and spinal cord) Afferent (sensory) Neurons Efferent (motor) Neurons Somatic Nervous System (voluntary) Autonomic Nervous System (ANS) (involuntary) Sympathetic Nervous System (SNS) (adrenergic) Figure 17–1 Divisions of the human nervous system. Parasympathetic Nervous System (PNS) (cholinergic) Muscarinic receptors Parasympathetic ganglion Acetylcholine Parasympathetic nervous system (PNS) Presynaptic neuron Acetylcholine Heart Blood vessels Glands Visceral organs Smooth muscle Muscarinic receptors Sweat glands Dopamine Postsynaptic neuron Sympathetic nervous system with sympathoadrenal branch Nicotinic receptors Norepinephrine Acetylcholine Alpha. Beta receptors Heart Blood vessels Glands Visceral organs Smooth muscle Adrenal medulla (nicotinic receptors) Epinephrine and norepinephrine Nicotinic receptors Skeletal muscle Acetylcholine Figure 17–2 Organization of the autonomic and somatic nervous systems. Nicotinic receptors Postsynaptic neuron Acetylcholine Presynaptic neuron Sympathetic ganglion Dopamine receptors Renal vascular smooth muscle Somatic nervous system .

beta1. When receptors located on target tissues are stimulated by a ligand. Increased mental activity and ability to think clearly 7. (Note that acetylcholine is the neurotransmitter for this sympathetic response.CHAPTER 17 PHYSIOLOGY OF THE AUTONOMIC NERVOUS SYSTEM 263 SNS. When dopamine acts on body cells that respond to adrenergic stimulation. This is a deviation from the normal postganglionic neurotransmitter. The remainder of the norepinephrine. and increasing intracellular calcium levels. 5). and temperature extremes. alpha and beta. When the sympathetic system excites a particular organ. such as strenuous exercise or work. However. Exceptions to this antagonistic action include sweating and regulation of arteriolar blood vessel diameter. The two divisions of the ANS are usually antagonistic in their actions on a particular organ. Increased breakdown of muscle glycogen for energy 5. Several compounds are being tested to treat obesity. These receptors have been further subdivided into alpha1. Increased rate of blood coagulation 9. Only dopamine can activate . decreased blood flow to viscera. a cascade of intracellular events known as signal transduction is initiated. Stimulation of both systems causes excitatory effects in some organs but inhibitory effects in others. In the brain. This reuptake can be inhibited by cocaine and tricyclic antidepressant medications and is responsible for the activation of the sympathetic nervous system seen with these drugs. Increased capacity for vigorous muscle activity in response to a perceived threat. is often called the fight-or-flight reaction. Increased muscle strength 8. the parasympathetic system often inhibits it. epinephrine acts on both alpha and beta receptors. this ligand–receptor interaction activates a cell membrane-bound G protein and an effector enzyme that then activate a molecule inside the cell called a second messenger. These hormones are metabolized mainly in the liver by the enzymes MAO and COMT. and animal studies suggest that drugs targeted to this receptor may augment heat production. thereby resting the heart. A beta3 receptor has been identified. Norepinephrine is synthesized in adrenergic nerve endings and released into the synapse when adrenergic nerve endings are stimulated. Figure 17–3 illustrates the intracellular events of signal transduction that occur when an adrenergic beta receptor is stimulated by epinephrine. dopamine is essential for normal function (see Chap. stimulating other enzymes. along with epinephrine. Increased blood sugar 6. Norepinephrine acts mainly on alpha receptors. The larger proportion of the circulating hormones (approximately 80%) is epinephrine. In response to adrenergic nerve stimulation. they interact with two distinct adrenergic receptors. Specific body responses include: 1. The ligand that binds the receptor is the so-called first messenger. and skeletal muscles. such as opening ion channels. Increased sweating. it can activate alpha1 and beta1 receptors as well as dopaminergic receptors. There are no beta3 agonist compounds approved by the Food and Drug Administration for human use. alpha2. Pupil dilation to aid vision 11. medications. the effects last longer because the hormones are removed from the blood more slowly. This second messenger is the link between events that are occurring outside the cell (ie. parasympathetic stimulation decreases rate and force of contraction. whether real or imaginary. respectively. For example. and beta2 receptors. and the problem of insulin resistance in diabetes. or hormones that bind to receptors are collectively called ligands.) These responses are protective mechanisms designed to help the person cope with the stress or get away from it. which is controlled by the SNS. Most of the norepinephrine is taken up again by the nerve endings and reused as a neurotransmitter. It exerts intense but brief effects on presynaptic and postsynaptic adrenergic receptors. which is norepinephrine. sympathetic stimulation of the heart causes an increased rate and force of myocardial contraction. which was not taken back into the nerve endings. diffuses into surrounding tissue fluids and blood. Neurotransmitters. The intensity and duration of responses depend on the amounts of norepinephrine and epinephrine present. produce lipolysis (thermogenesis). in peripheral tissues. Norepinephrine also functions as a hormone. norepinephrine and epinephrine are secreted into the bloodstream by the adrenal medullae and transported to all body tissues. Nerve fibers secreting norepinephrine are called adrenergic fibers. Increased rate and depth of respiration 10. most organs are predominantly controlled by one system. skin. These catecholamines exert the same effects as those caused by direct stimulation of the SNS. intense emotions. They are continually present in arterial blood in amounts that vary according to the degree of stress present and the ability of the adrenal medullae to respond to stimuli. Adrenergic Receptors When norepinephrine and epinephrine act on body cells that respond to sympathetic nerve or catecholamine stimulation. Increased blood flow to the brain. Dopamine is also an adrenergic neurotransmitter and catecholamine. Increased rate of cellular metabolism—increased oxygen consumption and carbon dioxide production 4. and other organs not needed for fight-or-flight 3. hyperglycemia. pain. hemorrhage. Increased arterial blood pressure and cardiac output 2. Acetylcholine and norepinephrine act on receptors in body organs and tissues to cause parasympathetic or sympathetic effects. and increase energy expenditure. In most cases. These intracellular events ultimately produce the physiologic responses to neurotransmitter and hormone release or drug administration. its main effects are on the heart and blood vessels of the renal system and viscera. Sympathetic Nervous System The SNS is stimulated by physical or emotional stress. or it is metabolized by monoamine oxidase (MAO) or catechol-O-methyltransferase (COMT). However. heart. receptor activation by the ligand) and resulting events that will occur inside the cell.

the “second messenger. Table 17–1 describes the location of adrenergic receptors in the body and the response that occurs when each receptor is stimulated. which bring about the biologic responses to epinephrine (6). Like alpha and beta receptors.” interacts with a beta receptor (2). The result is decreased sympathetic outflow and an antiadrenergic effect. which (4) catalyzes the conversion of adenosine triphosphate (ATP) to cyclic adenosine monophosphate (cAMP). Epinephrine (1). The intracellular events (of signal transduction) after stimulation of adrenergic receptors are thought to include the following mechanisms: • Alpha1 receptors: The binding of adrenergic substances to receptor proteins in the cell membrane of smooth muscle cells is thought to open ion channels. and specific effects depend on which subtype of receptor is activated. The . Dopamine receptors are located in the brain. some of the norepinephrine released into the synaptic cleft between neurons returns to the nerve endings from which it was released and stimulates presynaptic alpha2 receptors. This hormone-receptor complex activates a G protein. dopaminergic receptors. • Alpha2 receptors: In the brain. gastrointestinal and bladder sphincter contraction).264 SECTION 3 DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM (1) Epinephrine ("first messenger") Outside cell (2) Plasma membrane of cell Beta receptor (3) G protein Adenyl cyclase ATP Inside cell GTP (4) cAMP "second messenger" (5) Phosphorylates (activates) enzymes in target tissue (6) Produces physiologic responses to epinephrine Liver Heart Smooth muscle Increased heart rate Increased force of contraction Increased automaticity Increased AV conduction Glycogenolysis Gluconeogenesis Fatty tissue Relaxation Lipolysis Figure 17–3 Signal transduction mechanism for an adrenergic beta receptor. the “first messenger. vasoconstriction. The activated G protein then activates the enzyme adenyl cyclase. and produce muscle contraction (eg. in blood vessels of the kidneys and other viscera. dopamine receptors are divided into several subtypes (D1 to D5). which reacts with a guanosine triphosphate (GTP) (3).” (5) cAMP activates enzymes. and probably in presynaptic sympathetic nerve terminals. allow calcium ions to move into the cell. This negative feedback causes