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Pharmacology Connections to Nursing Practice

FOURTH EDITION

Michael Patrick Adams Adjunct Professor of Anatomy and Physiology Hillsborough Community College Formerly Dean of Health Professions Pasco-Hernando State College

Carol Quam Urban Director, School of Nursing Associate Dean, College of Health and Human Services Associate Professor George Mason University

Rebecca E. Sutter Assistant Professor, College of Health and Human Services, School of Nursing George Mason University

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The authors and publisher have exerted every effort to ensure that drug selections and dosages set forth in this text are in accord with current recommendations and practice at time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package inserts of all drugs for any change in indications of dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.

Library of Congress Cataloging-in-Publication Data Names: Adams, Michael, author. | Urban, Carol Q. (Carol Quam), author. Title: Pharmacology: connections to nursing practice / Michael Patrick Adams, Carol Quam Urban. Description: Fourth edition. | Boston : Pearson, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017026174| ISBN 9780134867366 | ISBN 013486736X Subjects: | MESH: Drug Therapy—nursing | Drug Administration Schedule | Medication Errors—prevention & control | Nursing Records | Pharmacology—methods Classification: LCC RM300 | NLM WY 100.1 | DDC 615.1—dc23 LC record available at https://lccn.loc.gov/2017026174

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About the Authors

Michael Patrick Adams, PhD, is an accomplished and has worked with Dr. Rebecca Sutter to open three educator, author, and national speaker. The National Insti- nurse-managed health clinics, academic–community part- tute for Staff and Organizational Development in Austin, nerships that care for uninsured patients and provide edu- Texas, named Dr. Adams a Master Teacher. He has pub- cational opportunities for Mason nursing students. She has lished two other textbooks with Pearson Education: Core published the Pearson textbook Pharmacology for Nurses: A Concepts in Pharmacology and Pharmacology for Nurses: A Pathophysiologic Approach with Dr. Adams and Dr. Holland. Pathophysiologic Approach. To my daughter, Joy, an extraordinary and resilient Dr. Adams obtained his master’s degree in pharmacol- woman who continues to change the world for the better, ogy from Michigan State University and his doctorate in and in memory of my son, Keith, and my husband, Mike. education from the University of South Florida. Dr. Adams —CQU was on the faculty of Lansing Community College and St. Rebecca E Sutter, DNP, BC-FNP, is Assistant Profes- Petersburg College, and was Dean of Health Professions at sor in the School of Nursing and one of the directors of an Pasco-Hernando State College for over 19 years. He is cur- academic nurse-managed clinic within the College of rently Adjunct Professor of Anatomy and Physiology at Health and Human Services at George Mason University Hillsborough Community College. in Fairfax, Virginia. She has been on the nursing faculty for I dedicate this book to nursing educators, who contribute over 15 years at community colleges and universities, and every day to making the world a better and more caring has practiced for over 20 years as a pediatric ICU nurse place. and a board-certified family nurse practitioner. —MPA To my husband, Lee, and my parents, Jane and Ellis, who Carol Quam Urban, PhD, RN, Associate Professor, is have given me the foundation to reach for my dreams, and the Director of the School of Nursing and an Associate to my amazing children Andrew, Sarah, and Emily, who Dean in the College of Health and Human Services at have made me stronger, better, and more fulfilled than I George Mason University in Fairfax, Virginia. She has been could have ever imagined. I love you to the moon and back. on the faculty in the School of Nursing for over two decades —RES iii A01_ADAM7366_04_SE_FM.indd Page 4 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

Thank You

First Edition Contributors We extend a heartfelt thanks to our contributors, who gave foster our goal of preparing student nurses for evidence- their time, effort, and expertise so tirelessly to the develop- based practice. ment and writing of chapters and resources that helped Diane Benson, RN, EdD Denise Marie McEnroe-Ayers, RN, Janice Lynn Reilley, RN, C, MSN, Humboldt State University, Arcata, MSN EdD California Kent State University at Tuscarawas, Widener University, Chester, Chapter 29 New Philadelphia, Ohio Pennsylvania Rebecca Boehne, RN, PhD Chapters 67, 72, 75, 76, and 77 Chapter 63 Linfield College, Portland, Oregon Mariann Montgomery, RN, MSN Luann G. Richardson, RN, PhD Chapter 74 Kent State University at Tuscarawas, Duquesne University, Pittsburgh, Jacqueline Rosenjack Burchum, New Philadelphia, Ohio Pennsylvania APRN, BC Chapters 66, 67, 68, 75, 76, and 77 Chapter 60 The University of Tennessee Health Kim Alexander Noble, RN, PhD Roberta Shea, RN, CCNS, MSN Science Center, Memphis, Tennessee Temple University, Philadelphia, Indiana University School of Nursing, Chapter 73 Pennsylvania Bloomington, Indiana Pamela Evans-Smith, RN, MSN Chapter 46 Chapters 9, 66, 67, and 68 University of Missouri–Columbia, G. Elaine Patterson, RNC, MA, Pat Teasley, RN, MSN, APRN, BC Columbia, Missouri FNP-C EdD Central Texas College, Killeen, Texas Chapter 57 Ramapo College of New Jersey, Chapters 22, 23, 24, 25, 57, and 58 Geralyn Frandsen, RN, MSN, EdD Mahwah, New Jersey Maryville University, St. Louis, Missouri Chapters 10, 11, 12, 70, and 71 Chapters 26, 27, 28, 30, and 44

Third Edition Reviewers Our heartfelt thanks go out to our colleagues from schools Practice has reaped the benefit of your collective knowl- of nursing across the country who have given their time edge and experience as nurses and teachers, and we have generously to help create this exciting new edition of our improved the materials due to your efforts, suggestions, pharmacology textbook. These individuals helped us plan objections, endorsements, and inspiration. Among those and shape our book and resources by reviewing chapters, who gave their time generously to help us are the art, design, and more. Pharmacology: Connections to Nursing following: Wanda Barlow, MSN, RN, FNP-BC Dearborn, Michigan Trinity Valley Community College Instructor Staci M. Boruff, PhD, RN Kaufman, Texas Winston-Salem State University Professor Katrina Coggins, MSN, RN, CEN Winston-Salem, North Carolina Walters State Community College Assistant Professor Carole Berube, MA, MSN, BSN, RN Morristown, Tennessee Western Carolina University Professor Emerita Sharon Burke, EdD, MSN, RNC Cullowhee, North Carolina Bristol Community College Assistant Professor Tamara Condrey, DNP, RN, Fall River, Massachusetts The Pennsylvania State University ACNS-BC, CCRN, CNE Sophia Beydoun, MSN, RN Abington, Pennsylvania Assistant Professor Instructor Judy Callicoatt, RN, MS, CNS Columbus State University Henry Ford College ADN Instructor Columbus, Georgia iv A01_ADAM7366_04_SE_FM.indd Page 5 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

Thank You v

Rebecca A. Crane, MSN, RN, CHPN, Chattanooga State Community Vanderbilt University Medical Center, CLNC College School of Nursing Assistant Professor Chattanooga, Tennessee Nashville, Tennessee Ivy Tech Community College Susan Growe, DNP, RN Elizabeth L. Law, MSN, NP-C, RN Bloomington, Indiana Lecturer Assistant Professor Lynette DeBellis, RN, MA Nevada State College Ivy Tech Community College Assistant Professor Henderson, Nevada Indianapolis, Indiana Westchester Community College Jeanne Hately, PhD, MSN, RN Connie Lawrence, MS, FNP-BC, Valhalla, New York Owner DNP Debra Dickman, MS, RN, CNE Professional Nurse Consultants, LLC Director of RN-BSN Program Assistant Professor Aurora, Colorado The College at Brockport Blessing-Rieman College of Nursing Antonie Hiemer, MS, RN Brockport, New York Quincy, Illinois Assistant Professor Dr. Euphemia Marlene C. Lazarus Teresa Dobrzykowski, PhD, APRN, Morrisville State College Professor BC Morrisville, New York Camden County College Assistant Professor Susan Holland, MSN, APRN, Blackwood, New Jersey Indiana University GNP-BC Carol Isaac MacKusick, PhDc, RN, South Bend, Indiana Clinical Assistant Professor CNN, CNE Deborah Dye, RN, MSN Sam Houston State University Assistant Professor Department Chair and Assistant Huntsville, Texas Western Carolina University Professor Molly Jackson, RN, MSN APRN, NP-C Cullowhee, North Carolina Ivy Tech Community College Instructor Shayne A. Mason, RN, BSN, Lafayette, Indiana Case Western Reserve University PMHNP(BC) Nancy W. Ebersole, PhD, RN Cleveland, Ohio Instructor Direct-Entry MSN Program Sara K. Kaylor, EdD, RN University of San Francisco Coordinator Assistant Professor San Francisco, California Salem State University The University of Alabama Vicki McCalmont RN, MS, ANP-BC, Salem, Massachusetts Tuscaloosa, Alabama CNS, CCTC Anita Fitzgerald, RN, A/GNP Amy Mitchell Kennedy, MSN, RN Professor Lecturer, Director, Learning Center Adjunct Faculty, RN and PN Program San Diego State University California State University ECPI University San Diego, California Long Beach, California Newport News, Virginia Bethany Mello, DNP, MS, NP-C Suzanne Franzoni-Kleeman, MSN, Alice Kindschuh, DNP, RN, Assistant Professor RN, CEN APRN-CNS, CNE University of Jamestown Assistant Professor Adjunct Instructor Jamestown, North Dakota American International College Nebraska Methodist College James Mendez, MSN, CRNP Springfield, Massachusetts Omaha, Nebraska Adjunct Instructor Lola Goodson, RN, MSN, CRNI Vicky J. King, RN, MS, CNE Villanova University Instructor Nursing Faculty Villanova, Pennsylvania Ivy Tech Community College Cochise College Toby Nishikawa, MSN, RN Sellersburg, Indiana Sierra Vista, Arizona Assistant Professor Amy C. Graham, RN, MSN, FNP-BC Julie Ann Koch, DNP, RN, FNP-BC Weber State University Assistant Professor Assistant Professor and DNP Program Ogden, Utah James Madison University Coordinator Nola Ormrod, RN, MSN Harrisonburg, Virginia Valparaiso University Department Chair Crystal Graham, RN, CHSE, MSN-Ed Valparaiso, Indiana Centralia College Simulation Lab Director/Instructor of Angela M. Koller, DNP, MSN, RN Centralia, Washington Nursing Dean Mechelle Perea-Ryan, MS, FNP-BC, Francis Marion University Ivy Tech Community College PHN Florence, South Carolina Indianapolis, Indiana Associate Professor Yolanda J. Green, RN, MSN Stephen D. Krau, PhD, RN, CNE California State University, Stanislaus Associate Professor Associate Professor Turlock, California A01_ADAM7366_04_SE_FM.indd Page 6 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

vi Thank You

Beth Rowlands, DNP, GNP-BC Sabra H. Smith, DNP, MS, FNP-BC Florida SouthWestern State College Clinical Professor Clinical Assistant Professor Fort Myers, Florida University of Massachusetts University of South Carolina Diana White, RN, MS Boston, Massachusetts Columbia, South Carolina Professor Janet Czermak Russell, APN-BC Rebecca E. Sutter, DNP, APRN, BC- Tuskegee University Professor FNP Tuskegee, Alabama Essex County College Assistant Dean and Assistant Carol S. Whiteman, MSN, RN, Newark, New Jersey Professor CCRN Jennifer Brindisi Sipe, MSN, George Mason University Assistant Professor RN Fairfax, Virginia Ivy Tech Community College Assistant Professor Nanci Swan, RN, MSN, CCRN South Bend, Indiana LaSalle University Instructor Toni C. Wortham, RN, BSN, MSN Philadelphia, Pennsylvania The University of Alabama Part-time Instructor Michelle Taylor Skipper, DNP, Birmingham, Alabama Madisonville Community College FNP-BC Valerie Taylor, RN, C, MEd, MSN Madisonville, Kentucky Clinical Associate Professor Assistant Professor Benson Kar Leung Yeung, MSN, Director, A/GNP and FNP Lorain County Community College RN Concentrations Elyria, Ohio Full-time Instructor East Carolina University Angela Trawick, MSN, RN California State University Greenville, North Carolina Clinical Coordinator Los Angeles, California A01_ADAM7366_04_SE_FM.indd Page 7 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

Preface

Pharmacology is one of the most challenging and dynamic drugs. The role of complementary and alternative thera- subjects for professional nurses. Each month new drugs pies, which are used by many patients, is included in the are being introduced, and new indications are continually context of holistic care. being developed for existing medications. Some medica- Unit 2 connects pharmacology, the nurse, and the tions that were considered preferred drugs only a decade patient, with an emphasis on positive patient outcomes. ago are now rarely prescribed. Current knowledge of drug The four chapters in this unit recognize the essential role of actions, mechanisms, interactions, and legislation is man- nurse–patient interactions in providing optimal patient datory for nurses to provide safe and effective patient care care throughout the lifespan. The fact that individuals vary in all healthcare settings. Pharmacotherapeutics remains a in their responses to drug action is an important theme critical and ever-changing component of patient care. introduced in this unit. The subtitle of this text, Connections to Nursing Practice, Units 3 through 11 provide the concepts and connections has guided its continued development. At a fundamental that are necessary to understand the actions and adverse level, pharmacology is a series of interrelated essential con- effects of individual drugs on different body systems. Many cepts. Some key concepts are shared with the natural and of the units begin with a chapter that briefly reviews relevant applied sciences. Prediction of drug action requires a thor- anatomy and physiology, which is a useful feature for the ough knowledge of anatomy, physiology, chemistry, and student when studying drug actions. Each chapter clearly pathology as well as the social sciences of psychology and identifies the concepts and connections necessary for safe sociology. This interdisciplinary nature of pharmacology and effective pharmacotherapy. Pharmacology is intimately makes the subject difficult to learn but fascinating to study. related to the study of disease processes. The connections However, the discipline of pharmacology is far more between pharmacology and pathophysiology are clearly than a collection of isolated facts. To effectively learn this established for each drug class in every chapter. discipline, the student must make connections to nursing practice and, ultimately, connections to patient care. Patients expect to receive effective and safe medication Resources for Faculty and Student administration from a nurse who is competent in the study Success of pharmacology. Pharmacology: Connections to Nursing Practice identifies key pharmacologic concepts and mecha- nisms and clearly connects them to current nursing theory Resources for Faculty and practice for providing optimal patient care. Pearson is pleased to offer a suite of resources to support Pharmacology: Connections to Nursing Practice recognizes teaching and learning, including: that pharmacology is not an academic discipline to be learned • TestGen Test Bank for its own sake but is a critical tool to prevent disease and promote healing. This connection to patients, their assess- • Lecture Note PowerPoints ment, diagnoses, and interventions supports basic nursing • Instructor’s Resource Manual practice. Like other core nursing subjects, the focus of phar- macology must be to teach and promote wellness for patients. Resources for Students Online Resources for students that are available include: Structure of the Text • Making the Patient Connection case studies and This text is organized according to body systems (units) answers and diseases (chapters). Unit 1, the first seven chapters, • Additional Case Studies and answers identifies fundamental pharmacologic principles that are applied throughout the text. Although new drugs are con- • Answers to Patient Safety Questions stantly being developed, these chapters build the struc- • Suggested answers to Connection Checkpoints, and tural framework for understanding the applications of all more! vii M37_ADAM7366_04_SE_C37.indd Page 653 28/10/17 1:44 PM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

Chapter 37 Pharmacotherapy of Dysrhythmias 653

dysrhythmias including suppression of exercise-induced Therapeutic Effects and Uses: Approved in 1985, tachycardia, atrial dysrhythmias, ventricular dysrhyth- amiodarone is the most frequently prescribed Class III mias, premature ventricular contractions, and digoxin- antidysrhythmic. It is considered a broad-spectrum induced tachydysrhythmias. Propranolol exhibits few antidysrhythmic because it is effective in terminating both serious adverse effects at therapeutic doses. At high doses, atrial and ventricular dysrhythmias. It is approved for the patients may experience bradycardia, hypotension, HF, treatment of resistant ventricular tachycardia and recur- and bronchospasm. Propranolol is featured as a prototype rent fibrillation that may prove life threatening, and it has beta-adrenergic antagonist in Chapter 16. This drug is become a preferred medication for the treatment of atrial pregnancy category C. dysrhythmias in patients with HF. Amiodarone is available as PO tablets and as an IV CONNECTION Checkpoint 37.2 infusion. IV infusions are limited to short-term therapy

Both alpha1 blockers and beta1 blockers are used to treat HTN (2–4 days). Although its onset of action may take several

but only the beta1 blockers are antidysrhythmics. From what you weeks when the medication is given PO, its effects can last

learned in Chapter 16, explain why the selective alpha1 blockers are 4 to 8 weeks after the drug is discontinued because it has an M37_ADAM7366_04_SE_C37.indd Page 653 28/10/17 1:44 PM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801not used to treat dysrhythmias. ... Answers to Connection Checkpoint extended half-life that may exceed 100 days. Amiodarone is questions are available on the faculty resources site. Please consult a structural analog of thyroid hormone. The therapeutic with your instructor. serum level for amiodarone is 1 to 2.5 mcg/mL.

Mechanism of Action: Amiodarone exerts multiple, Chapter 37 Pharmacotherapy of Dysrhythmias 653 A01_ADAM7366_04_SE_FM.indd Page 8 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801Potassium Channel Blockers: Class III complex actions on the ... heart and its exact mechanism of action is not completely known. In addition to blocking 37.9 Potassium channel blockers prolong the dysrhythmias including suppression of exercise-induced Therapeutic Effects and Uses: Approved in 1985, potassium ion channels, some of this drug’s actions relate refractory period of the heart. tachycardia, atrial dysrhythmias, ventricular dysrhyth- amiodarone is the most frequently prescribed Class III to its blockade of sodium ion channels and inhibiting sym- mias, premature ventricular contractions, and digoxin- antidysrhythmic. It is considered a broad-spectrum The potassium channel blockers are a small but diverse pathetic activity to the heart. Repolarization is delayed, the class of drugs that have very important applications to the induced tachydysrhythmias. Propranolol exhibits few viiiantidysrhythmic Preface because it is effective in terminating both refractory period prolonged, and automaticity reduced. serious adverse effects at therapeutic doses. At high doses, atrial and ventricular dysrhythmias. It is approved for the treatment of dysrhythmias. After the action potential has In addition to prolonging the QT interval, amiodarone patients may experience bradycardia, hypotension, HF, treatment of resistant ventricular tachycardia and recur- passed and the myocardial cell is in a depolarized state, increases the PR interval and widens the QRS complex on and bronchospasm. Propranolol is featured as a prototype rent fibrillation that may prove life threatening, and it has repolarization depends on removal of potassium from the the ECG. beta-adrenergic antagonist in Chapter 16. This drug is Abecome Practical a preferred medication Approach for the treatment to Learningof atrial cell. The Pharmacology drugs in Class III exert their actions by blocking Pharmacokinetics: pregnancy category C. dysrhythmias in patients with HF. potassium ion channels in myocardial cells. Although there Amiodarone is available as PO tablets and as an IV are significant differences among the drugs, all have in Route(s) PO, IV CONNECTION Checkpoint 37.2 infusion. IV infusions are limited to short-term therapy common the ability to delay repolarization and prolong the Absorption Completely absorbed by the Both alpha blockers and beta blockers are used to treat HTN (2–4 days). Although its onset of action may take several refractory period. This action is reflected by an increase in gastrointestinal (GI) tract 1 1 UNIT 4 Pharmacology of the Central Nervous System but only the beta blockers are antidysrhythmics. From what you the QT interval on the ECG. Automaticity is also reduced. 1 CHAPTERweeks when 17 theReview medication of the Central is given Nervous PO, its effectsSystem can 218 last Distribution Widely distributed; crosses the learned in Chapter 16, explain why the selective alpha blockers are 1 CHAPTER4 to 8 weeks 18 afterPharmacotherapy the drug is discontinued of Anxiety becauseand Sleep it has an Most drugs in this class have multiple actions on the placenta; secreted in breast milk; not used to treat dysrhythmias. Answers to Connection Checkpoint extended half-lifeDisorders that may 227 exceed 100 days. Amiodarone is heart and also affect adrenergic receptors or sodium channels. concentrated in the lung, kidneys, questions are available on the faculty resources site. Please consult CHAPTERa structural 19 analogPharmacotherapy of thyroid hormone.of Mood Disorders The therapeutic 253 For example, in addition to blocking potassium channels, spleen, and adipose tissue with your instructor. CHAPTER 20 Pharmacotherapy of Psychoses 281 serum level for amiodarone is 1 to 2.5 mcg/mL. sotalol (Betapace) is considered a beta-adrenergic antagonist. Primary metabolism Hepatic to active metabolites; CHAPTER 21 Pharmacotherapy of Degenerative Diseases of the The◀ potassiumDisease and channel Body blockers System are Approach. listed in Table The 37.4. organiza- Central Nervous System 304 some enterohepatic recirculation; Mechanism of Action: Amiodarone exerts multiple, tionDrugs by bodyin this systems class have (units) limited and uses diseases due to potentially (chapters) CHAPTER 22 Pharmacotherapy of Seizures 330 inhibits some CYP450 enzymes Potassium Channel Blockers: Class III complex actions on the heart and its exact mechanism of places the drugs in context with how they are used ther- CHAPTER 23 Pharmacotherapy of Muscle Spasms and serious toxicity. Like other antidysrhythmics, potassium action is not completely known. In addition to blocking apeutically. This organization connects pharmacology Primary excretion Primarily biliary; some feces 37.9 Potassium channel blockers prolong the Spasticity 358 channel blockers slow the heart rate, resulting in bradycar- potassium ion channels, some of this drug’s actions relate Onset of action PO: 2–3 days; IV: 2 h refractory period of the heart. CHAPTER 24 Central Nervous System Stimulants and diaand and pathophysiology possible hypotension to nursing in a significant care. percentage of to its blockadeDrugs of sodium for Attention-Deficit/Hyperactivity ion channels and inhibiting sym- patients. These drugs can create or worsen dysrhythmias, Duration of action PO/IV; 10–150 days The potassium channel blockers are a small but diverse pathetic activityDisorder to the heart.375 Repolarization is delayed, the especially during the first few doses. Older adults with pre- CHAPTER 25 Pharmacotherapy of Severe Pain and Adverse Effects: Potentially serious adverse effects class of drugs that have very important applications to the refractory period prolonged, and automaticity reduced. existing HF must be carefully monitored because these Migraines 392 limit the use of amiodarone. Amiodarone may cause nau- treatment of dysrhythmias. After the action potential has In addition to prolonging the QT interval, amiodarone CHAPTER 26 Anesthetics and Anesthesia Adjuncts 422 patients are at higher risk for the cardiac adverse effects of passed and the myocardial cell is in a depolarized state, sea, vomiting, anorexia, fatigue, dizziness, and hypoten- CHAPTERincreases 27 the PRPharmacology interval and of widens Substance the Abuse QRS complex 447 on potassium channel blockers. repolarization depends on removal of potassium from the sion. Visual disturbances are common in patients taking M37_ADAM7366_04_SE_C37.inddthe ECG. Page 653 28/10/17 1:44 PM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... cell. The drugs in Class III exert their actions by blocking this drug for extended periods and include blurred potassium ion channels in myocardial cells. Although there Pharmacokinetics: PROTOTYPE DRUG Amiodarone (Pacerone) vision due to cornea deposits, photophobia, xerostomia, are significant differences among the drugs, all have in Route(s) PO, IV cataracts, and macular degeneration. Rashes, photosen- Classification Therapeutic: Antidysrhythmic, Class III sitivity, and other skin reactions occur in 10% to 15% of common the ability to delay repolarization and prolong the ▶ Updated!Absorption Prototype Approach.Completely Theabsorbed vast bynumber the of Pharmacologic: Potassium channel patients taking the drug. Certain tissues concentrate this refractory period. This action is reflected by an increase in gastrointestinal (GI) tract Chapter 37 Pharmacotherapy of Dysrhythmias 653 drugs that the practicing nurse must learn is staggering. blocker medication; thus, adverse effects may be slow to resolve, the QT interval on the ECG. Automaticity is also reduced. To facilitateDistribution learning, thisWidely text uses distributed; a prototype crosses approach the Most drugs in this class have multiple actions on the in whichdysrhythmias the most including representativeplacenta; suppression secreted medications of in exercise-induced breast in milk; each Therapeutic Effects and Uses: Approved in 1985, heart and also affect adrenergic receptors or sodium channels. classificationtachycardia, are atrial introduced dysrhythmias,concentrated in detail. ventricularin Thisthe lung, edition kidneys,dysrhyth fea- - amiodarone is the most frequently prescribed Class III For example, in addition to blocking potassium channels, turesmias, 194 prototypepremature drugs ventricularspleen, that include andcontractions, adipose detailed tissue and informa digoxin-- antidysrhythmic. It is considered a broad-spectrum sotalol (Betapace) is considered a beta-adrenergic antagonist. tionPrimaryinduced on therapeutic metabolism tachydysrhythmias. effects,Hepatic mechanism to Propranolol active metabolites; ofexhibits action, few antidysrhythmic because it is effective in terminating both The potassium channel blockers are listed in Table 37.4. pharmacokinetics,serious adverse effectsadversesome at therapeutic effects, enterohepatic contraindications, doses. recirculation; At high doses, atrial and ventricular dysrhythmias. It is approved for the Drugs in this class have limited uses due to potentially patients may experienceinhibits bradycardia, some CYP450 hypotension, enzymes HF, treatment of resistant ventricular tachycardia and recur- serious toxicity. Like other antidysrhythmics, potassium drug interactions, pregnancy category, and treatment of Primaryand bronchospasm. excretion PropranololPrimarily biliary;is featured some as feces a prototype rent fibrillation that may prove life threatening, and it has channel blockers slow the heart rate, resulting in bradycar- overdose. Onsetbeta-adrenergic of action antagonistPO: 2–3 in days; Chapter IV: 2 16.h This drug is become a preferred medication for the treatment of atrial dia and possible hypotension in a significant percentage of pregnancy category C. dysrhythmias in patients with HF. Duration of action PO/IV; 10–150 days patients. These drugs can create or worsen dysrhythmias, Amiodarone is available as PO tablets and as an IV especially during the first few doses. Older adults with pre- AdverseCONNECTION Effects: Checkpoint Potentially 37.2 serious adverse effects infusion. IV infusions are limited to short-term therapy existing HF must be carefully monitored because these limitBoth the alpha use1 blockersof amiodarone. and beta Amiodarone1 blockers are may used cause to treat nau HTN- (2–4 days). Although its onset of action may take several patients are at higher risk for the cardiac adverse effects of sea,but vomiting, only the beta anorexia,1 blockers fatigue, are antidysrhythmics. dizziness, and From hypoten what you- weeks when the medication is given PO, its effects can last potassium channel blockers. learned in Chapter 16, explain why the selective alpha blockers are M37_ADAM7366_04_SE_C37.inddsion. Visual disturbances Page 654 are28/10/17 common 1:44 PM in f-0046-new patients1 taking/207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 4 to 8 weeks after the drug is discontinued because it has an ... thisnot drugused to for treat extended dysrhythmias. periods Answers and to Connectioninclude blurred Checkpoint extended half-life that may exceed 100 days. Amiodarone is questions are available on the faculty resources site. Please consult PROTOTYPE DRUG Amiodarone (Pacerone) vision due to cornea deposits, photophobia, xerostomia, a structural analog of thyroid hormone. The therapeutic with your instructor. cataracts, and macular degeneration. Rashes, photosen- serum level for amiodarone is 1 to 2.5 mcg/mL. Classification Therapeutic: Antidysrhythmic, Class III sitivity, and other skin reactions occur in 10% to 15% of Mechanism◀ Updated! Blackof Action: Box Warnings.Amiodarone The exerts latest multiple, black box Pharmacologic: Potassium channel 654patients Unit taking 5 Pharmacology the drug. ofCertain the Cardiovascular tissues concentrate System this complexwarnings actions issued on by the the heart U.S. andFood its and exact Drug mechanism Administra of - blocker medication;Potassium thus, adverseChannel effects Blockers: may be slow Classto resolve, III actiontion are is notclearly completely identified known. for all In prototype addition medications. to blocking persisting37.9 Potassium long after channel the drug blockers has been prolong discontinued. the Nursing Responsibilities: Key nursing implica- potassium ion channels, some of this drug’s actions relate Blackrefractory Box Warning period (oral of theform heart. only): Amiodarone causes tions for patients receiving amiodarone are included in the to its blockade of sodium ion channels and inhibiting sym- a pneumonia-like syndrome in the lungs. Because the pul- Nursing Practice Application for Patients Receiving Phar- The potassium channel blockers are a small but diverse pathetic activity to the heart. Repolarization is delayed, the monary toxicity may be fatal, baseline and periodic as - macotherapy for Dysrhythmias. class of drugs that have very important applications to the refractory period prolonged, and automaticity reduced. sessments of lung function are essential. Amiodarone has treatment of dysrhythmias. After the action potential has In addition to prolonging the QT interval, amiodarone prodysrhythmic action and may cause bradycardia, car- passed and the myocardial cell is in a depolarized state, increases the PR interval and widens the QRS complex on diogenic shock, or AV block. Mild liver injury is frequent Drugs Similar to Amiodarone (Pacerone) repolarization depends on removal of potassium from the Otherthe ECG. Class III antidysrhythmics include dofetilide, drone- with amiodarone. cell. The drugs in Class III exert their actions by blocking darone, ibutilide, and sotalol. Contraindications/Precautions:potassium ion channels in myocardial cells. Amiodarone Although there is Pharmacokinetics: Dofetilide (Tikosyn): Approved in 1999, dofetilide is an contraindicatedare significant indifferences patients with among severe the bradycardia,drugs, all have car in- Route(s) PO, IV oral drug indicated for conversion of symptomatic atrial diogeniccommon shock, the ability sick tosinus delay syndrome, repolarization severe and sinus prolong node the Absorption Completely absorbed by the flutter or fibrillation to normal sinus rhythm. Like other dysfunction,refractory period. or third-degree This action AVis reflected block. Because by an increase amio -in gastrointestinal (GI) tract potassium channel blockers, dofetilide prolongs the daronethe QT contains interval iodineon the ECG.in its Automaticitychemical structure, is also patientsreduced. Distribution Widely distributed; crosses the refractory period and action potential duration, thus who haveMost hypersensitivity drugs in this class to thishave element multiple should actions not on re the- placenta; secreted in breast milk; increasing the QT interval. Dofetilide does not exhibit a ceiveheart the and drug. also affectIt should adrenergic be used receptors with caution or sodium in patients channels. concentrated in the lung, kidneys, negative inotropic effect, as do amiodarone and sotalol. withFor HFexample, because in additionit has a negativeto blocking inotropic potassium effect channels, that spleen, and adipose tissue The drug has no effect on the PR interval and it does not cansotalol worsen (Betapace) symptoms. is considered Electrolyte a beta-adrenergic imbalances, especially antagonist. widenPrimary the QRS metabolism complex. HepaticDofetilide to activehas many metabolites; potentially hypokalemiaThe potassium and channel hypomagnesemia, blockers are listed should in Table be corrected 37.4. serious adverse effects, andsome a enterohepaticblack box warning recirculation; states beforeDrugs administering in this class amiodarone have limited because uses thesedue to conditions potentially that therapy should begininhibits in a clinical some settingCYP450 under enzymes con- predisposeserious toxicity. the patient Like otherto the antidysrhythmics, development of dysrhyth potassium- tinuousPrimary monitoring excretion for aPrimarily minimum biliary; of 3 days. some The feces drug mias.channel Due blockers to the drug’s slow thepulmonary heart rate, toxicity, resulting it is in contrain bradycar- - exhibitsOnset significantof action dose-relatedPO: 2–3 prodysrhythmicdays; IV: 2 h effects, dicateddia and in possible patients hypotensionwith COPD orin respiratorya significant insufficiency. percentage of including heart block, ventricular tachycardia, and tors- Breastfeedingpatients. These during drugs amiodarone can create ortherapy worsen may dysrhythmias, cause in- Duration of action PO/IV; 10–150 days ades de pointes. The risk for drug-induced dysrhythmias fantespecially hypothyroidism; during the firstthus, few the doses. drug Older is contraindicated adults with pre- is Adverseincreased whenEffects: dofetilide Potentially is administered serious adverse concurrently effects duringexisting lactation. HF must be carefully monitored because these withlimit other the use medications of amiodarone. that Amiodaroneprolong the mayQT interval,cause nau - patients are at higher risk for the cardiac adverse effects of Drug Interactions: Amiodarone is metabolized by the includingsea, vomiting, Class Ianorexia, and Class fatigue, III antidysrhythmics. dizziness, and hypotenDofeti- - potassium channel blockers. cytochrome CYP450 enzymes and markedly inhibits the lidesion. may Visual accumulate disturbances to toxic are levels common in patients in patients with CKD.taking metabolism of many other drugs. This can raise the serum Therefore,this drug serum for extended creatinine periods levels and are includemonitored blurred fre - levels PROTOTYPE of these drugs DRUG and Amiodarone cause toxicity. (Pacerone) For example, quentlyvision duringdue to therapy.cornea deposits, Electrolyte photophobia, imbalances, xerostomia, especially amiodarone can increase serum digoxin levels by as much hypokalemiacataracts, and or macularhypomagnesemia, degeneration. should Rashes, be corrected photosen - asClassification 70%. Amiodarone Therapeutic: greatly enhances Antidysrhythmic, the actions Class of III beforesitivity, administering and other skin dofetilide reactions because occur these in 10% conditions to 15% of anticoagulants; thusPharmacologic: the dose of warfarin Potassium must channel be cut by as predisposepatients taking the patient the drug. to developing Certain tissues dysrhythmias. concentrate This this much as half. Use withblocker beta-adrenergic antagonists or cal- drugmedication; is pregnancy thus, category adverse C.effects may be slow to resolve, cium channel blockers (CCBs) may potentiate sinus brady- Dronedarone (Multaq): Approved in 2009, dronedarone cardia, sinus arrest, or AV block. Amiodarone may increase is given PO to reduce the risk of hospitalization in patients phenytoin levels two- to threefold. Caution must be used with atrial dysrhythmias and associated cardiovascular during therapy with loop diuretics because hypokalemia risk factors such as HTN, diabetes, or previous stroke. The can enhance the prodysrhythmic properties of amioda - drug has a black box warning that it is contraindicated in rone. Because of the large number of potential drug inter- patients with advanced HF with recent decompensation. It actions, the nurse should regularly check current reference is also contraindicated in patients with bradycardia (less sources when patients are taking amiodarone concurrently than 50 beats/min), prolonged QT interval, and severe with other medications. Herbal/Food: Use with echinacea hepatic impairment. The most common adverse effects are may increase the risk of hepatotoxicity. Aloe may increase diarrhea, nausea, abdominal pain, vomiting, and asthenia. the effect of amiodarone. When the drug is administered Dronedarone inhibits CYP450 enzymes and can partici - PO, grapefruit juice can increase serum amiodarone levels pate in multiple drug–drug interactions with other cardio- by over 80%. vascular medications. Dronedarone is a category X drug Pregnancy: Category D. and should not be taken during pregnancy or lactation.

Treatment of Overdose: Overdose will cause brady- Ibutilide (Corvert): Approved in 1995, ibutilide is only cardia, hypotension, and life-threatening dysrhythmias. administered as an IV infusion. Continuous ECG monitor- Supportive treatment is targeted to reversing hypoten - ing should be conducted for at least 4 hours following the sion with vasopressors and bradycardia with atropine or infusion to identify the potential development of new or isoproterenol. worsening dysrhythmias. Administered over 10 minutes, A01_ADAM7366_04_SE_FM.indd Page 9 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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Preface ix

Chapter 38 Pharmacotherapy of Coagulation Disorders 675

Table 38.5 Antiplatelet Drugs Drug Route and Adult Dose (Maximum Dose Where Indicated) Adverse Effects anagrelide (Agrylin) PO: 0.5 mg qid or 1 mg bid (max: 10 mg/day) Nausea, vomiting, diarrhea, abdominal pain, dizziness, headache ▶ Updated! Drug Tables. Easy-to- aspirin (ASA, acetylsalicylic acid) PO: 80 mg daily to 650 mg bid dipyridamole (Persantine) PO: 75–100 mg qid as adjunct to warfarin therapy Increased bleeding, central nervous system understand tables reflect the latest FDA- (CNS) effects (dipyridamole), anaphylaxis vorapaxar (Zontivity) PO: 2.08 mg/day (aspirin), interstitial lung disease (anagrelide) approved drugs and provide average ADP Receptor Blockers clopidogrel (Plavix) PO: 75 mg/day (max: 300 mg/day for life-threatening cases) Minor bleeding, dyspepsia, abdominal pain, headache, rash, diarrhea dosages for most medications. Unique to prasugrel (Effient) PO: 60-mg loading dose followed by 10 mg/day ticagrelor (Brilinta) PO: 180-mg loading dose followed by 90 mg bid Increased clotting time, GI bleeding, blood this text is a listing of the most common dyscrasias, angina and the most serious adverse effects for Glycoprotein IIb/IIIa Receptor Antagonists abciximab (ReoPro) IV: 0.25 mg/kg initial bolus over 5 min, then 0.125 mcg/kg/min for Dyspepsia, dizziness, pain at injection site, each drug or drug class. This allows the 12 h (max: 10 mcg/min) hypotension, bradycardia, minor bleeding eptifibatide (Integrilin) IV: 180 mcg/kg initial bolus over 1–2 min, then 2 mcg/kg/min for Major hemorrhage, thrombocytopenia student to immediately recognize impor- 24–72 h (max: 180 mcg/kg bolus, 2 mcg/kg/min infusion) tirofiban (Aggrastat) IV: 0.4 mcg/kg/min for 30 min, then 0.1 mcg/kg/min for 12–24 h tant safety information regarding the Drugs for Intermittent Claudication cilostazol (Pletal) PO: 100 mg bid Dyspepsia, nausea, vomiting, dizziness, drug(s) he or she is administering. myalgia, headache pentoxifylline (Trental) PO: 400 mg tid (max: 1200 mg/day) Tachycardia and palpitations (cilostazol), CNS effects (pentoxifylline), heart failure, MI

Note: Italics indicate common adverse effects. Underline indicates serious adverse effects.

membranes and their functions are complex. Chemicals require special medical or nursing interventions, such as

such as epinephrine, thromboxane A 2, thrombin, sero- suturing or applying a sandbag to a venipuncture site that tonin, and fibrinogen can bind to these receptors and mod- does not stop bleeding. ify coagulation through their interaction with the platelets. Following vessel injury, platelets become “sticky,” bind to exposed collagen, and release substances that PROTOTYPE DRUG Clopidogrel (Plavix) Connections to Nursingrecruit additionalPractice platelets to the site. One of these chemi- Classification Therapeutic: Antiplatelet drug cals is ADP, whose function is to promote platelet aggrega- Pharmacologic: ADP receptor blocker tion. The ADP receptor blockers comprise a small group of drugs that irreversibly alter the plasma membrane of plate- Therapeutic Effects and Uses: Approved in 1997, M24_ADAM7366_04_SE_C24.indd Page 375 23/11/17 8:01 AM f-0037 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801lets. For the M24_ADAM7366_04_SE_C24.inddremainder of their ... lifespan, Page 389 the 30/10/17 affected 8:05 plate-AM f-0051a clopidogrel/207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 is used for the prophylaxis of arterial throm- ... lets are unable to recognize the chemical signals required boembolism to reduce the risk of stroke, MI, and death in for them to aggregate. ◀ Making the Patientpatients with Connection acute coronary syndrome. is a Forfeature patients withthat Ticagrelor (Brilinta), clopidogrel (Plavix), and prasug- ST-elevation MI, this drug has been shown to reduce the rel (Effient) are ADP receptor blockersopens given ChapterPOeach to 24prevent Centralchapter Nervousrisk System of with death, Stimulants reinfarction, a and quote Drugs for or Attention-Deficit/Hyperactivity stroke.and Clopidogrel a photo hasDisorder simiof 389- a thrombi formation in patients who have experienced a lar anticoagulant activity to aspirin but is more expensive. “The school nurse recommended recent thromboembolic event suchpatient. as stroke orIt MI. reinforces The to the student that the focus of we consider Adderall for Clopidogrel is given PO and has the advantage of newer drugs in this class, ticagrelor and prasugrel, act more Jonathon. He’s just doing poorly Understandingpharmacology Chapter mustonce-daily always 24 dosing. be Inhibition on the of platelet patient. function To may drive per- in school and hates to do his rapidly than clopidogrel and achieve a more consistent and homework. Why would he need sist for 7 to 10 days after the drug is discontinued. When a drug for that?” effective antithrombotic effect. Adversethis importanteffects among the message possible, clopidogrelhome, shouldthe patient be discontinued who at least is 5intro days - Patient “Jonathon Hogan’s” mother Key Concepts Summary three drugs are similar. duced at the start priorof theto surgery chapter to avoid excessiveis revisited bleeding. at the end Drugs affecting platelet24.1 Central aggregation nervous systemincrease stimulants the risk increase 24.4 Several nonstimulants are effective in treating of bleeding should the patientalertness, sustainwith enhance trauma critical the ability or undergo to concentrate,thinking Mechanism and exercises. ofsymptoms Action: These of attention-deficit/hyperactivity Clopidogrel questions inhibits assist ADP dental or surgical procedures.delay These the symptoms drugs are of fatigue. sometimes receptors on plateletsdisorder. and prolongs bleeding time by Chapter 24 given concurrently with24.2 anticoagulants, Attention-deficit/hyperactivitythe student which can further to disorder apply is irreversibly the 24.5content inhibiting Narcolepsy platelet learned is characterized aggregation. in by theexcessive Clopidogrel chapter daytime increase bleeding risk. Prolongedcharacterized direct by inattention, pressure hyperactivity, over itself and has little activity;sleepiness however, and is treated it is withchanged central to nervous a highly Central Nervous System Stimulants impulsive behavior. system stimulants and antidepressants. injection or venipuncture sites mayto bea requiredrealistic to control patient active scenario. metabolite in An the liver additional through extensive case first-pass study and Drugs for Attention-Deficit/bleeding. Bleeding lasting24.3 Psychostimulants more than 10 are minutes central nervous may systemmetabolism. 24.6 Methylxanthines are central nervous system stimulantsis indicatedalso forincluded the treatment of ADHDfor further stimulantsapplication used for their abilityof knowledge to increase Hyperactivity Disorder and narcolepsy.learned. alertness or their effects on the respiratory system.

Chapter Outline Learning Outcomes

c Characteristics of Central Nervous After reading the chapter, the student should be able to: CASE STUDY: Making the Patient Connection System Stimulants 1. Describe the general actions and c Etiology and Pathophysiology of Attention-Deficit/ pharmacotherapeutic applications of central nervous Remember the patient “Jonathon school nurse suspects he may have ADHD. She has recom- Hyperactivity Disorder system stimulants. Hogan” at the beginning of the mended an appointment with Jonathon’s healthcare pro- c Pharmacotherapy of Attention-Deficit/ 2. Identify the signs and symptoms of attention- chapter? Now read the remain- vider and told his parents that Adderall may help Jonathon Hyperactivity Disorder deficit/hyperactivity disorder and narcolepsy. der of the case study. Based on focus on his schoolwork. Psychostimulants 3. Compare and contrast the central nervous system PROTOTYPE Amphetamine and Dextroamphetamine stimulants and nonstimulants in treating attention- the information presented (Adderall, Adderall XR), p. 380 deficit/hyperactivity disorder. within this chapter, respond to Critical Thinking Questions Nonstimulants 4. Compare and contrast the different the critical thinking questions pharmacotherapies available for narcolepsy. 1. What is ADHD and why would Jonathon be experi- PROTOTYPE Atomoxetine (Strattera), p. 382 that follow. c Pharmacotherapy of Narcolepsy 5. Describe the nurse’s role in the pharmacologic encing more difficulty as he becomes older? management of attention-deficit/hyperactivity PROTOTYPE Modafinil (Provigil), p. 384 disorder and narcolepsy. Jonathon Hogan has had trouble at school beginning in 2. How might amphetamine sulfate and dextroamphet- c Methylxanthines 6. For each class shown in the chapter outline, identify kindergarten and for the past year. His teachers have con- amine (Adderall) help Jonathon with his ADHD? PROTOTYPE Caffeine, p. 386 the prototype and representative drugs and explain sistently reported that he is easily distracted and wanders 3. What caregiver education would be appropriate the mechanism(s) of drug action, primary indications, contraindications, significant drug around the classroom even during a lesson. Getting him to regarding dextroamphetamine and amphetamine interactions, pregnancy category, and important do his homework after school has been a struggle. Jona- sulfate (Adderall)? adverse effects. thon loves art and does well at video games. Because he is 7. Apply the nursing process to care for patients 4. What are other nonpharmacologic treatments receiving pharmacotherapy with central nervous a happy-go-lucky child, his parents have assumed that for ADHD? system stimulants. Jonathon’s right-brain dominance has created trouble with left-brain logical work. With more homework now in sec- Answers to Critical Thinking Questions are available on the ond grade, Jonathon is struggling to keep up in school. The faculty resources site. Please consult with your instructor.

375

Additional Case Study

Anna Steinmetz has graduated from nursing school and is 2. What teaching will you provide to the patient working nights. She is having difficulty adjusting to her regarding this medication? night schedule. Her healthcare provider suggested she uti- 3. The patient reports feelings of lightheadedness with lize a medication to assist with her adjustment to shift position changes. What interventions will assist in work. She has been prescribed modafinil (Provigil). maintaining patient safety? 1. What effect does modafinil (Provigil) have on Answers to Additional Case Study questions are available on the patient’s ability to maintain alertness during the faculty resources site. Please consult with your instructor. shift work? A01_ADAM7366_04_SE_FM.indd Page 10 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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x Preface M67_ADAM7366_04_SE_C67.indd Page 1235 10/11/17 12:02 PM f-0037 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... 546 Unit 5 Pharmacology of the Cardiovascular System

CONNECTIONS: Preparing for Advanced Practice Chronic Kidney Disease and Prescribing Considerations ▶ New! Connections: Preparing for Case with CKD and AKI therefore require more thought, especially for Advanced Practice. Dramatic changes in Nolan is a 71-year-old African American man who was admitted medications that are renally excreted. For prescribing purposes, Chapter 67 Pharmacotherapy of Thyroid Disorders to 1235the hospital for altered mental status. His daughter Renee CKD is divided into three grades: the delivery of healthcare have placed an reported that her father had become progressively confused • Mild: GFR 20–50 mL/min; serum creatinine 150–300 μmol/L and had been having visual and auditory hallucinations, seeing • Moderate: GFR 10–20 mL/min; serum creatinine 300–700 Treatment of Overdose: The treatment of levothy- increasedliotrix over emphasis levothyroxine. on developing Its actions, the adversecrit- effects,and hearingand people and animals that were not really there. In the μmol/L past 24 hours, Nolan’s symptoms had become more persistent • Severe: GFR less than 10 mL/min; serum creatinine more roxine overdose is the same as the treatment of thyroid icalcontraindications thinking skills are and similar clinical to those decision- for endogenousand thyshe became- more and more concerned. Nolan has a 9-year than 700 μmol/L (GFR above 50 mL/min does not usually history of HF and type 2 diabetes, and was diagnosed require any dosage adjustment.) crisis or thyroid storm, as discussed later in Section 67.6. makingroid hormone. abilities This of drug nurses is pregnancy at both categorythe A. 10 months ago with stage V CKD, thought to be primarily due to his diabetic nephropathy. Drugs to which particular attention should be given include histamine H -receptor antagonists, specific antibiotics, anticon- Treatment is directed at reducing the level of circulating undergraduate and graduate levels. On admission, the nurse practitioner hospitalist, his bed- 2 Thyroid, desiccated (Armour thyroid, Thyroid USP): sideDes nurse,- and the unit’s Pharm D. reviewed his medications vulsants, digoxin, and NSAIDs. Prescribing any medication that thyroid hormone with antithyroid drugs and decreasing Through case studies, the authors use increases potassium levels, such as potassium supplements and iccated thyroid is an older formulation, approved inwith 1939, Renee. Nolan was taking 81 mg of aspirin, atenolol, atorv- astatin, calcium acetate, insulin, and had recently started potassium-sparing diuretics, is potentially very dangerous. sympathetic stimulation with corticosteroids and beta- strategies that promote the clinical deci- Additionally, methotrexate, enoxaparin, and metformin should no obtained from the dried thyroid glands of pigs. The300 mg drug of gabapentin 3 times daily for the diabetic neuropathy. adrenergic blockers. sion-making skills of advanced practice On physical examination, he was sleepy but arousable. His longer be prescribed even with a mild grade of CKD. With cardio- blood pressure was 136/86 mmHg; pulse was 72 beats/min vascular (e.g., atenolol), antidiabetic (e.g., glibenclamide), or anti- contains T3 and T4 in their natural proportions. Desiccated nurses. Particular attention is paid to (regular); respiratory rate was 14 breaths/min; and oxygen satu- convulsive (e.g., gabapentin) drugs, the recommendation is to Nursing Responsibilities: Key nursing implications thyroid is less pure and has less reliable content thanration syn 96%.- What pharmacologic factors should the team be use alternative medications, such as metoprolol, gliquidone, or advanced practice nurses who are prepar- considering for Nolan? carbamazepine, that are not renally excreted or are independent for patients receiving levothyroxine are included in the thetic formulations and has been replaced by levothyrox- of kidney function. Drug dose adjustments should be considered ing to work within specialty practice set- Discussion with antimicrobial (e.g., ampicillin), antiviral (e.g., acyclovir), and Nursing Practice Application for Patients Receiving Phar- ine. It is used only for patients who have taken Kidneyit for disease, both acute kidney injury (AKI) and CKD, affects some chemotherapeutic and cytotoxic drugs (e.g., cisplatin). tingsyears—newly and with vulnerable diagnosed populations. cases of hypothyroidismevery are organ system in the body. The number of patients with Products with a high sodium content (e.g., antacids) should be macotherapy with Thyroid Hormone Replacements. AKI and CKD has increased due to the aging populations and avoided because they may cause sodium and water retention in treated with synthetic thyroid hormone. medical advancements. Prescribing considerations for patients patients with CKD (Carville, Wonderling, & Stevens, 2014).

Drugs Similar to Levothyroxine (Levothroid, M60_ADAM7366_04_SE_C60.indd Page 1122 08/11/17 2:01 PM f-0037 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... The rapid excretion of large amounts of fluid has the prescribed for patients with moderate to severe fluid reten- Levoxyl, Synthroid, Unithroid) potential to produce serious adverse effects, including tion, such as acute pulmonary edema, or when thiazide dehydration and electrolyte imbalances. Signs of dehydra- diuretics have failed to achieve therapeutic goals. Other thyroid replacement medications include liothyro- tion include thirst, dry mouth, weight loss, and headache. PROTOTYPE DRUG Furosemide (Lasix) CONNECTIONS: Treating theDizziness1122 Unit and9 Pharmacology fainting can of resultthe Gastrointestinal from the fall System in blood nine, liotrix, and desiccated thyroid. All thyroid drugs pressure caused by the rapid fluid loss. Potassium deple- Classification Therapeutic: Antihypertensive drug for Diverse Patient tion can be serious and result in dysrhythmias. Potassium carry a black box warning stating they should not be used Serotonin (5-HT ) receptor antagonists: The serotonin rectal, and parenteralheart routesfailure that and alsoedema has significant anti- supplements are often3 prescribed concurrently with these antagonists include dolasetron (Anzemet), granisetron cholinergic properties.Pharmacologic: Loop- or high-ceiling- for weight loss or to treat obesity. Improved Kidney Function from Thyroiddiuretics to prevent hypokalemia. Potassium loss is of par- (Sancuso, Sustol), ondansetron (Zofran, Zuplenz), and type diuretic ticular concern to those concurrently taking digoxin (Lan- Benzodiazepines: The primary indication for benzodi- palonosetron (Aloxi). There are no significant differences Hormone Replacement oxin), because hypokalemia predisposes these patients to Therapeuticazepines is anxiety. Effects Benzodiazepines and Uses: An establishedare ineffective diuretic as Liothyronine (Cytomel, Triostat): Approved in 1954, lio- in effectiveness or toxicity of the serotonin receptor antag- dysrhythmias. With large doses, significant loss of sodium, approvedantiemetics in 1966,when furosemide used as monotherapy. is frequently usedHowever, in the treatthey- onists in treating acute nausea and vomiting. They are Because thyroid hormones affect nearly all bodymagnesium, systems, and calcium is possible. Continuous use of mentrelax theof acute patient edema and decreaseassociated the with anxiety liver associatedcirrhosis, CKD, with thyronine is a synthetic form of T 3 used in replacement available by the PO or parenteral route. Since the 1990s loop diuretics in postmenopausal women may affect bone orchemotherapy HF because it and has the the anticipationability to remove of severe large nausea amounts and of even slight changes in the amount of circulating hormonesthey have become the most widely prescribed drugs for therapy for hypothyroidism. Its actions, adverse effects, metabolism due to excessive calcium loss. Loop diuretics edemavomiting. fluid Lorazepam from the patient (Ativan) in ais short the drug time. in When this class given that IV, chemotherapy-induced nausea and vomiting. For severe may have profound effects, especially in the very youngcan cause andgout in some patients due to hyperuricemia, the diuresisis most frequentlybegins within used 5 minutes,as an off-label providing antiemetic rapid relief adjunct. from and contraindications are similar to those for endogenous symptoms, the serotonin receptor antagonists are com - accumulation of uric acid in◀ the Connections: blood. Treatingdistressing the symptoms Diverse such as dyspnea. Patient Unlike thefeatures thiazide the older adult populations. Recent research suggestsbined with that a corticosteroid such as dexamethasone. The Cannabinoids: Cannabinoids are drugs that contain the Although rare, loop diuretics may cause ototoxicity, diuretics, furosemide is able to increase urine output even thyroid hormone. It has a shorter onset, half-life, and dura- serotonin antagonists are most effective in the manage - same active ingredient as marijuana. Dronabinol (Marinol, which may manifest as tinnitus,identify vertigo, or gender, deafness. Use cultural, of when blood and flow ethicalto the kidneys influences is diminished, which that makes are thyroid hormone therapy may help preserve renal functionment of acute in nausea and vomiting but are less effective at Syndros) and nabilone (Cesamet) are given PO to reduce tion of action than levothyroxine and is more expensive. other ototoxic drugs such as the aminoglycoside antibiotics it of particular value in patients with low cardiac output or treating delayed symptoms.important The few adverse modifiers effects they ofpost-chemotherapy drug action. nausea and vomiting, with less eupho- older patients (Lu, Guo, Liu, & Zhao, 2016). Subclinicalshould hypo be avoided- during loop diuretic therapy due to the CKD. It is also approved for HTN, although it is not a pre- Liothyronine is readily converted to T in the bloodstream. cause include headache, constipation or diarrhea, and diz- ria compared to marijuana. Dronabinol is also indicated 3 potential for additive hearing impairment. Due to the risk ferred drug for this indication because of its short half-life thyroidism may have significant effects on chronic kidneyziness. In dis2014,- the combination drug Akynzeo (palonose- for the treatment of anorexia and weight loss in patients The injectable form of liothyronine is a preferred drug for for serious adverse effects, loop diuretics are normally andwith potential AIDS. Cannabinoids for serious adverse are effects.not as effective as other ease. Several theories exist as to why thyroid replacementtron with netupitant) was approved to treat nausea and vomiting caused by highly emetogenic chemotherapy. antiemetics. the treatment of myxedema coma. It is available in oral improves renal function, including improvement in cardiac Phenothiazines and related drugs (dopamine antago- Corticosteroids: Dexamethasone (Decadron) and meth- and IV formulations. This drug is pregnancy category A. ylprednisolone (Solu-Medrol) are used to prevent chemo- status, improvement in dyslipidemias, or the effect nists):on vascu The primary- indication for phenothiazines is the therapy-induced and postsurgical nausea and vomiting. treatment of psychoses (see Chapter 20), but they are also lar endothelium (Hataya, Igarashi, Yamashita, & Komatsu, They are reserved for acute cases due to the possibility of Liotrix (Thyrolar): Liotrix is a synthetic mixture of T and very effective antiemetics. Phenothiazines inhibit dopami- 4 serious adverse effects and are most often used in combi- 2013; Rhee et al., 2015; Shin et al., 2013). Individualizednergic receptors in the CTZ, and the severe nausea and nation with other antiemetics. Dexamethasone is used for T3, in a 4:1 ratio, available in PO form only for the treat - vomiting associated with antineoplastic therapy are often treatment for subclinical hypothyroidism should be consid- the treatment of delayed nausea and vomiting, which are treated with these drugs. Some of the phenothiazines may ment of hypothyroidism. Because levothyroxine is readily common problems with certain antineoplastic drugs. ered in older patients. cause sedation, and extrapyramidal symptoms (EPS) are a converted to T3, there is no apparent advantage in using concern with long-term therapy. Promethazine (Phener- Other drugs: Aprepitant (Emend) belongs to a class of gan) is an older phenothiazine that is available by the PO, antiemetics, called the neurokinin (NK) receptor antagonists,

CONNECTIONS: Complementary and Alternative Therapies Probiotics for Diarrhea ▶ Connections: Complementary and Description Evidence CONNECTIONS: NURSING PRACTICE APPLICATION Probiotics are live microorganisms that are taken in specified Most of the evidence supporting the efficacy of probiotics is Alternative Therapies features present amounts to confer a health benefit on the host. Most commercial related to their effects on the intestinal tract. Both Lactobacillus probiotics are bacteria from the genera Lactobacillus and Bifidobac- and Bifidobacterium are normal nonpathogenic inhabitants of a Patients Receiving Pharmacotherapy withherbal Thyroid therapies Hormone and Replacements dietary supplements terium; however, the yeast Saccharomyces is sometimes also used. healthy digestive tract. These are considered to be protective flora, inhibiting the growth of potentially pathogenic species such Assessmentthat may be considered as alternatives to History and Claims as E. coli, Candida albicans, Helicobacter pylori, and Gardnerella Baseline assessment prior to administration: Although probiotics have been used for thousands of years, only vaginalis. Probiotics restore the normal flora of the intestine fol- conventional drugs. These features include in the past 20 years has research begun to confirm their health lowing diarrhea, particularly diarrhea resulting from antibiotic • Obtain a complete health history including cardiovascular, GI, hepatic, anda kidneydescription disease; pregnancy; of the herb or breastfeeding. or supplement, Obtain a drug history benefits. Probiotics are claimed to improve immune function, therapy (National Center for Complementary and Integrative including allergies, current prescription and over-the-counter (OTC) drugs, herbal preparations, alcohol use, and smoking. Be alert to possible decrease cancer risk, lower blood cholesterol, reduce blood Health, 2016). A 2015 systematic review indicated that probiotics history of use, standardization of dose, and pressure, and prevent vaginal infections. Probiotic supplements do in fact reduce symptoms of IBS in patients (Didari, Mozaffari, drug interactions. are available in certain drinks, yogurts, and tablets. Although Nikfar, & Abdollahi, 2015). Probiotics have also been shown to be probiotics are safe, care must be taken not to exceed recom- effective at shortening episodes of acute infectious diarrhea and • Evaluate appropriate laboratory findings (e.g., 3T , T4, and TSH levels; completebrief blood description count [CBC]; of platelets, the scientific electrolytes, evidence glucose, and lipid levels). • Obtain baseline height, weight, and vital signs. Obtain an electrocardiogram (ECG) as needed. mended doses. may be considered an option for increasing eradication rates for supporting (or not supporting) the use of those with H. pylori (Dang, Reinhardt, Zhou, & Zhang, 2014). • Assess the patient’s ability to receive and understand instructions. Include family and caregivers as needed. Standardization Although probiotics have been used for many years, they Assessment throughout administration: the product. Supplements include capsules, tablets, and granules, as well as are not without risk. Infections (including sepsis), lactic acidosis, cultured dairy products that contain the probiotic bacteria. and other serious adverse effects have been noted (Doron & Doses are not standardized. Tablet doses range from 50 to Snydman, 2015). Because of these, probiotic supplements • Assess for desired therapeutic effects (e.g., 3T , T4, and TSH levels return to normal, associated symptoms ease). 500 mg, and not all dairy products contain active cultures. should be used with caution in critically ill patients. • Continue periodic monitoring of T3, T4, and TSH levels and glucose levels. • Continue monitoring height, weight, and vital signs. Monitor ECG as needed. • Assess for adverse effects: nausea, vomiting, diarrhea, epigastric distress, skin rash, itching, headache, tachycardia, palpitations, dysrhythmia, sweating, nervousness, paresthesia, tremors, insomnia, heat intolerance, and angina. Hypo- or hypertension, tachycardia, especially associated with dysrhythmia, or angina should be immediately reported to the healthcare provider. (continued) M37_ADAM7366_04_SE_C37.indd Page 656 28/10/17 1:44 PM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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656 Unit 5 Pharmacology of the Cardiovascular System

PharmFACT immediately after instillation of the medication is neces- sary due to its short half-life. Immediate medical assistance Sudden cardiac arrest (SCA) occasionally occurs in young must be nearby during the procedure. If the tachycardia athletes. About half of the athlete SCAs occurred in high has not been eliminated in 1 to 2 minutes, a second rapid school students and 82% occurred during competition or bolus may be given. The primary indication for adenosine training.Chapter Only 11% occurred66 Pharmacotherapy in females (Mozaffarian et al., of Diabetes Mellitus 1213 is PSVT, for which adenosine is a preferred drug. It is also 2015). used to assist in the diagnosis of coronary artery disease of dysrhythmias in patients who are unable to undergo a car- Miscellaneous Antidysrhythmics diac exercise stress test. It is not effective in treating ventricular dysrhythmias. Although the drug has prodys- CONNECTIONS: NURSING PRACTICE APPLICATION (continued) 37.11 Adenosine and digoxin are used for rhythmic effects and dyspnea is common, adverse effects specific dysrhythmias. A01_ADAM7366_04_SE_FM.indd Page 11 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801are generally self-limiting because of its 10-second half-life. ... ImplementationTwo other medications, adenosine and digoxin, are occa- In 2013, the FDA issued a safety alert that the use of ade - sionally used to treat specific dysrhythmias, but they do nosine may be associated with an increased risk of heart Interventions and (Rationales) Patient-Centerednot act by the mechanisms Care described above. Doses for attack and death. This drug is pregnancy category C. these miscellaneous drugs are listed in Table 37.4. • Rotate insulin administration sites weekly. If the patient is hospitalized, • Instruct the patient on the need to rotate insulinDigoxin injection (Lanoxin, sites Lanoxicaps): on a Although digoxin is pri- Adenosine (Adenocard, Adenoscan): Adenosine is a natu- marily used to treat HF, it is also prescribed for atrial flutter use sites that have been less used or are difficult for the patient to weeklyrally occurring basis nucleoside to prevent that activatestissue potassiumdamage chan or -to rotateor fibrillation subcutaneous and PSVT because of its ability to decrease reach. Insulin pump subcutaneous catheters should be changed every catheternels in the sitesSA and (insulin AV nodes, pumps) causing theevery potassium 2–3 days. to automaticity of the SA node and slow conduction through 2–3 days or as recommended by the healthcare provider. (Rotating leave cardiac muscle cells. When given as a rapid 1- to the AV node. The drug is not effective against ventricular 2-second IV bolus, adenosine blocks reentry pathways in dysrhythmias. Because excessive levels Prefaceof digoxin can proxi- injection sites weekly helps to prevent lipodystrophy. Use caution if the AV node and terminates the tachycardia. It is usually duce serious dysrhythmias, and interactions with other using a new site, especially if the previous site used by the patient followed by a 1- to 5-second period of asystole. Patients medications are common, patients must be carefully moni- exhibits signs of lipodystrophy. Insulin in an unused site may absorb should be laid supine prior to adenosine use and warned tored during therapy. Additional information on the mech- that they may feel faint. The IV site used to give adenosine anism of action, adverse effects, and nursing responsibilities ▶ Connections:more quickly than Nursing in a site with lipodystrophyPractice orApplications tissue changes, fea- should be antecubital or above, and an 18-gauge angio - for digoxin may be found in Chapter 36, where the drug is tures conciselyresulting in hypoglycemia. connect theInsulin nursing pump subcutaneous process cathetersto the majorshould catheter or larger should be used. A rapid saline flush featured as a prototype. be changed every 2–3 days to prevent infections at the site of insertion.) drug class(es) in each drug chapter and incorporate out- • Ensure proper storage of insulin to maintain maximum potency. • TeachCONNECTIONS: the patient NURSING methods PRACTICE for APPLICATION proper storage of insulin and for storage comes(Unopened from the insulin Quality may be and stored Safety at room Educationtemperature, but for avoid Nurses direct during travel. Patients Receiving Pharmacotherapy for Dysrhythmias sunlight and excessive heat. Opened insulin vials may be stored at Assessment (QSEN)room competencies temperature for up toof 1 month.patient-centered If noticeable change care, in solution team - Baseline assessment prior to administration: • Obtain a complete health history including cardiovascular (including previous dysrhythmias, HTN, MI, HF) and the possibility of pregnancy. Obtain a drug occurs or if precipitate forms, discard the vial.) history including allergies, current prescription and over-the-counter (OTC) drugs, herbal preparations, and alcohol use. Be alert to possible drug interactions. work and collaboration, patient safety, and evidence- • Obtain baseline weight, vital signs (especially blood pressure and pulse), ECG (rate and rhythm), cardiac monitoring (such as cardiac output if Patient understanding of drug therapy: • The patient,appropriate), and family, breath sounds. or caregiver Assess for location, should character, beand amountable of to edema, state if present. the reason for based practice. Each nursing intervention is patient • Evaluate appropriate laboratory findings: electrolytes, especially potassium, calcium, and magnesium levels; renal and liver function studies; and lipid profiles. • Use opportunities during administration of medications and during the• drug,Assess the appropriate patient’s ability to receive dose and understandand scheduling, instructions. Include what family and adverse caregivers as effects needed. to Assessment throughout administration: centeredassessments and includesto discuss the therationale rationale for drug therapy, and desired associated observe• Assess for desired and therapeutic when effects to report (e.g., control them, or elimination and of dysrhythmia,any special blood pressure requirements and pulse within established of limits). therapeutic outcomes, commonly observed adverse effects, the• medicationContinue frequent monitoring therapy of ECG (e.g., (continuous insulin if hospitalized). needs Check during pulse quality, exercise volume, and regularity,or illness). along with ECG. Assess for complaints patient and family teaching. Collaboration with other of palpitations and correlate symptoms with ECG findings. Assess for changes in level of consciousness (LOC). parameters for when to call the healthcare provider, and any necessary • Instruct• Continue the periodic patient monitoring to of carryelectrolytes, a especiallywallet potassium identification and magnesium. card and wear • Assess for adverse effects: lightheadedness or dizziness, hypotension, nausea, vomiting, headache, fatigue or weakness, flushing, sexual dysfunction, disciplines,monitoring such or precautions. as social (Using support time during services nursing care or helps dietary to medicalor impotence. identification Immediately report jewelry bradycardia, indicating tachycardia, or new diabetes. or different dysrhythmias to the healthcare provider. optimize and reinforce key teaching areas.) Implementation services, is also included in the interventions. Important Interventions and (Rationales) Patient-Centered Care Patient self-administration of drug therapy: • TheEnsuring patient, therapeutic family, effects: or caregiver is able to discuss• To alleviateappropriate possible anxiety, dosing teach the patient, family, or caregiver the lifespan and diverse patient considerations are noted • Continue frequent assessments as above for therapeutic effects. rationale for all equipment used and the need for frequent monitoring. • When administering the medication, instruct the patient, family, or and administration(Dysrhythmias have diminished needs or are eliminated.including: Blood pressure and caregiver in the proper self-administration of the drug followed by • Properpulse should preparation be within normal limits of or insulin:within parameters Rotate set by the vials gently between the palms throughout. The Nursing Practice Applications are healthcare provider.) teach-back. (Utilizing time during nurse administration of these drugs • andEncourage do appropriate not shake; lifestyle changes: if insulins lowered fatare intake, mixed, increased draw• Encourage up the the quickestpatient, family, or acting caregiver to adopt a healthy lifestyle exercise, limited alcohol intake, limited caffeine intake, and smoking of low-fat food choices, increased exercise, reduced caffeine intake, organizedhelps to to reinforce help teaching.)students learn to think like a nurse as insulincessation. Provideand forthen dietitian the consultation longer as needed. acting (Healthy one lifestyle if insulinsdecreased are alcohol compatible; consumption, and smoking cessation. they take students through the processes of drug admin- insulinchanges will glargine support and minimizeor insulin the need detemirfor drug therapy.) should not be mixed with any other type of insulin; use the appropriate syringe (100 unit) unless istration, nursing care, and teaching that are necessary small amounts of insulin are ordered, then obtain syringes with in pharmacotherapy. smaller volumes to ensure accurate dosing. • Proper subcutaneous injection techniques: selection and cleansing of the site with rotation every week, injecting at 90-deg angle, and applying a pad to the site after injection but not massaging the site. • Proper use of all equipment: blood glucose monitoring equipment, insulin pump.

College of Endocrinology (2015) are designed to target an A1C CONNECTIONS: Patient Safety level of 6.5% or less with an FPG of less than 110 g/dL. In gen- eral, all of the antidiabetic drugs are similar in their ability to Incorrect Insulin Dose ◀ Connections: Patient Safety, a QSEN competency, is a fea- lower A1C levels in the short term. There are some differences, A patient with diabetes has 30 units of Humulin R (regular) ture that presents a brief patient–nurse scenario that illus- insulin ordered for the morning dose. There are several patients however, in long-term control. For example, drugs in the thia- trates potential pitfalls encountered by nurses that can lead to with diabetes on the unit and the nurse has given many doses zolidinedione class appear to maintain glycemic control for of insulin that morning. The nurse prepares the insulin but 5 tomedication 6 years, while errors. the sulfonylureas Most scenarios peak end at 6 with months a question and asking draws up Humalog 30 units instead. The patient begins expe- slowlythe declinestudent in toefficacy. identify The whatadverse went effects wrong, observed what for the nurse riencing symptoms of hypoglycemia within 15 minutes and is eachshould class differ: do in Some the situation,cause hypoglycemia, what the whereas nurse shouldothers question treated successfully. causeabout weight the gain order, or GI or complaints what the such nurse as diarrhea. should Becausedo differently in What errors occurred and how could they be prevented thereorder is no to perfect prevent drug medication for type 2 diabetes, administration choice of therapy errors. is in the future? guided by the experiences of the prescriber and the results M44_ADAM7366_04_SE_C44.indd Page 795 27/10/17 11:17 AM F-0050 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... Answers to Patient Safety questions are available on the faculty achieved by the individual patient. A comparison of the anti- resources site. Please consult with your instructor. diabetic drug classes is presented in Table 66.4. Doses of the individual medications are listed in Table 66.5. medications used to treat type 2 diabetes require some Therapy for type 2 diabetes is usually initiated with a degree of pancreatic insulin secretion. These antidiabetic single drug. The AACE recommends metformin as the ini- Chapter 44 Pharmacotherapy of Asthma and Other Pulmonary Disorders 795 medications are not effective in treating type 1 diabetes tial therapy for most patients with type 2 diabetes (AACE & because these patients have a total lack of insulin secretion. American College of Endocrinology, 2015). If glycemic con- Treatment goals recommended by the American Associa- trol is not achieved with monotherapy, a second medication prevent or treat preterm labor because it has not been shown tion of Clinical Endocrinologists (AACE) and the American is added to CONNECTIONS: the therapeutic regimen. FailureUsing to achieveResearch to be effective and there is a potential for serious maternal in Practice heart problems and death. In very serious conditions, the Early Exposure to Allergens May Reduce injectable form of the drug may still be used but treatment is Asthma Risk limited to no longer than 48 to 72 hours to delay preterm ▶ New! Connections: Using Research in Practice features labor. This drug is pregnancy category B. illustrate connections to nursing or pharmacology research Allergen exposure has been noted to increase the risk for and severity of asthma in both children and adults (Custovic, 2015; and discuss the short- and long-term directions of pharma- Sheehan & Phipatanakul, 2016). What is not as clear is what CONNECTION Checkpoint 44.1 cotherapeutics. A critical thinking question is presented at roles the timing of initial exposure, ongoing exposure, types of The medications for asthma are selective for beta2-adrenergic the end of each feature to challenge the student to connect allergens, or amount of exposure play in the development of receptors. From what you learned in Chapter 15, what are the

scientific evidence to nursing practice. protection from conditions such as asthma and anaphylaxis primary indications for the drugs selective for beta1-adrenergic (Sheehan & Phipatanakul, 2016). receptors? Answers to Connection Checkpoint questions are available Lynch et al. (2014) noted that cumulative exposure to on the faculty resources site. Please consult with your instructor. allergens in the first 3 years of life seemed to decrease the risk of recurrent wheezing and allergies and that such early expo- sure may be beneficial. A subsequent study also noted that 44.6 The inhaled anticholinergics are used there was no increase in allergic rhinitis or sensitization to for preventing bronchospasm. indoor allergens such as dogs, cats, and house mites due to Although SABAs are the preferred drugs for treating acute such early exposure (Schoos, Chawes, Jelding-Dannemand, bronchospasm, anticholinergics (cholinergic blockers or Elfman, & Bisgaard, 2016). Recent research has demonstrated antagonists) are alternative bronchodilators. Although that early exposure to peanuts may dramatically reduce the anticholinergics such as atropine have been available for development of peanut allergy, which has been linked to both many decades, their adverse effect profile made them asthma and anaphylaxis (Togias et al., 2017). In 2015, the American Academy of Allergy, Asthma & Immunology and the poorly suited for the management of asthma. With the American Academy of Pediatrics published a consensus com- delivery of the anticholinergics by inhalation, however, munication, encouraging the early introduction of peanut prod- they have become important drugs in the arsenal of asthma ucts, based on research that demonstrated an absolute risk pharmacotherapy. Four inhalation anticholinergics are reduction in peanut allergy in high-risk infants by 11% to 25%, available for the treatment of respiratory disorders. The and a relative risk reduction of up to 80% when peanut prod- first to be developed was ipratropium (Atrovent), which is ucts were introduced between 4 and 11 months of age (DuToit considered a short-acting drug. Aclidinium (Tudorza Pres- et al., 2015;Fleischer et al., 2016). sair), umeclidinium (Incruse Ellipta), and tiotropium Further research is needed to determine what benefits (Spiriva) are newer, long-acting anticholinergics. might be gained by early exposure and by what types of aller- Anticholinergics block the parasympathetic nervous gens; what dose may be appropriate to elicit a positive system. Blocking the parasympathetic nervous system response; and whether other factors, such as genetics, might results in actions similar to those of stimulating the sympa- play a role in desensitization. Recent research offers tantalizing hope that severe allergies, asthma, and anaphylaxis may be thetic nervous system (see Chapter 14). It is predictable prevented with appropriate allergen exposure early in life. then that anticholinergic drugs would cause bronchodila- tion and have potential applications in the pharmacother- apy of asthma and COPD. Ipratropium is the only Terbutaline: An older drug approved in 1974, terbutaline anticholinergic with a rapid onset suitable for treating is indicated for the treatment of bronchospasm associated acute asthma. The others are indicated for the management with asthma or bronchitis. When given by the PO route, ter- of COPD and may be used off-label for chronic asthma butaline may take 30 minutes or longer to act; thus it is too when combined with other respiratory drugs. slow to be used for acute conditions. The subcutaneous Anticholinergics have actions that are similar to those form can relieve bronchospasm within 15 minutes. PO ter- of beta-adrenergic agonists, and drugs from the two classes butaline has a shorter duration of action than albuterol or may be combined to produce a greater and more prolonged salmeterol and it must be administered 3 times daily. Terbu- bronchodilation than either drug used separately. This

taline is moderately selective for beta2 receptors but may additive effect is particularly useful for patients with per-

produce some activation of beta1 receptors in the heart. sistent bronchospasm for whom either drug alone is inad- Adverse effects are similar to those observed with other equate to alleviate bronchoconstriction. Taking advantage drugs in this class. Terbutaline has been used off-label to of this increased effect, the pharmaceutical companies have delay premature labor contractions because its effects on developed inhalants that combine both an anticholinergic

beta2 receptors in the uterus cause smooth muscle relaxation and a beta agonist into a single canister. (see Chapter 69). However, in 2011 the FDA issued a black The inhaled anticholinergics are relatively safe medi- box warning that oral terbutaline should not be used to cations. The wide range of anticholinergic adverse effects M38_ADAM7366_04_SE_C38.indd Page 663 28/10/17 10:09 AM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

Chapter 38 Pharmacotherapy of Coagulation Disorders 663

contraceptives, have been associated with DVT in 38.2 Coagulation disorders are caused numerous studies. Selective estrogen receptor modu- by decreased numbers of platelets or by M38_ADAM7366_04_SE_C38.indd Page 668 28/10/17 10:09 AM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... lators (SERMs), such as raloxifene (Evista), are also deficiencies in specific clotting factors. associated with a higher risk of DVT. Whereas thromboembolic disorders are caused by too The second primary thromboembolic disorder is much clotting, coagulation disorders result from too little pulmonary embolism, which occurs when a venous clot clotting. Serious consequences result if the body does not 668 Unit 5 Pharmacology of the Cardiovascular System dislodges, migrates to the pulmonary vessels, and blocks form clots in a timely manner. The two most common eti- arterial circulation to the lungs. Pulmonary emboli are the ologies of coagulation disorders are decreased numbers of deoxyribonucleic acid (DNA) technology to secrete human heparin or the LMWHs. There is no specific antidote for most serious consequence of VTE because death may occur platelets and deficiencies in one or more clotting factors. antithrombin in their milk. The drug is then purified and overdose; administration of protamine is ineffective. This within minutes after the onset of symptoms. The factors Platelets are central to the process of coagulation. Rec- powdered for reconstitution as an IV infusion. drug is pregnancy category B. associated with an increased risk of pulmonary embolism ognizing a site of vessel injury, activated platelets release Levels of antithrombin activity in the blood must be are the same as those for patients with DVT: prolonged von Willebrand’s factor, which causes platelets to become monitored before, during, and immediately following ther- 38.5 Warfarin is a widely used drug for oral immobility, major trauma, lower extremity surgery, hyper- “sticky” and adhere to the site. Following adhesion, platelets apy. The initial and subsequent drug doses are based on the anticoagulant therapy. coagulability states, and estrogen therapy. Prevention of secrete substances such as adenosine diphosphate (ADP) level of antithrombin activity. The most common adverse Although parenteral anticoagulants have the advantage of pulmonary embolism is a primary goal for all patients with and thromboxane A that promote platelet aggregation and effects are hemorrhage and infusion site reaction. ATryn 2 an almost immediate onset of action, drugs given by this VTE and a major indication for pharmacotherapy. the formation of a platelet plug at the site. Procoagulation enhances the anticoagulant effect of heparin and LMWHs. route require close medical supervision because adverse Patients with DVT are sometimes asymptomatic, or factors become activated on the platelets and a fibrin mesh This drug is pregnancy category C. effects such as bleeding can rapidly ensue. When the report nonspecific symptoms such as pain, swelling, or clot results. Nearly every step of this pathway requires suf- Dalteparin (Fragmin): As an LMWH, dalteparin has patient’s condition allows, oral anticoagulants are used warmth of the legs. The disorder may be present for years, ficient numbers of properly functioning platelets. smaller glycosaminoglycan chains than unfractionated due to their convenience and greater safety. causing progressive damage to venous valves, thus wors- The most common coagulation disorder is a deficiency heparin. Approved in 1994, dalteparin is given by the sub- Warfarin (Coumadin) has been available as an antico- ening blood flow in the region and increasing the risk of an of platelets, or thrombocytopenia, which occurs when cutaneous route for the treatment and prophylaxis of DVT agulant for over 50 years and is the historical prototype for acute episode. A pulmonary embolism, however, produces platelet counts fall below 150,000 mm3. Thrombocytopenia or pulmonary embolism. Other approved indications oral anticoagulants. In acute situations, patients begin anti- a sudden onset of cough, chest pain, tachypnea, dyspnea, is the result of either decreased platelet production or include thrombosis prophylaxis in patients at increased coagulation therapy with heparin and are switched to war- tachycardia, and hemoptysis. Symptoms of pulmonary increased platelet destruction. Any condition or disease risk due to unstable angina, an acute MI, or cancer. It has a farin when their condition stabilizes. When transitioning, embolism resemble an MI, and rapid diagnosis and treat- that suppresses bone marrow function has the potential to longer half-life than heparin, which allows for less fre - the two drugs must be administered concurrently for 2 to ment are essential. cause decreased platelet production. Other common quent dosing. Like other LMWHs, bleeding is the most 3 days. This is because heparin has a brief half-life causes of decreased platelet production are folic acid or serious adverse effect and the drug should not be adminis- (90 minutes), and aPTT returns to normal within 2 to A01_ADAM7366_04_SE_FM.indd Page 12 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801PharmFACT vitamin B deficiencies ... and decreased production of tered to patients with active bleeding. This drug is preg - 3 hours following discontinuation of heparin. Warfarin, on 12 thrombopoietin by the liver during hepatic failure. nancy category B. the other hand, takes 1 to 3 days of therapy to achieve opti- Up to 30% of patients presenting with DVT have a malignancy. Increased destruction of platelets may occur in patients mal anticoagulation. Thus, concomitant pharmacotherapy This is because about 90% of patients with cancer have some Enoxaparin (Lovenox): Enoxaparin was the first LMWH with thrombocytopenic purpura, disseminated intravas- is necessary to ensure continuous anticoagulation. During abnormal clotting factors (Patel, 2016). approved by the U.S. Food and Drug Administration cular coagulation (DIC), or lupus. (FDA) in 1993. Indications include treatment and prophy- this transition, risk of bleeding increases, due to the addi- xii Preface Of special concern is thrombocytopenia caused by laxis of DVT and pulmonary embolism. Following hip or tive anticoagulant action of the two drugs. Arterial thromboembolism may deprive an area of drug therapy. A significant number of drugs have the lower extremity surgery, enoxaparin may be administered blood flow and is a medical emergency because tissue potential to increase platelet destruction, either by direct once daily for 7 to 10 days. Some orthopedic procedures hypoxia and cellular death will result soon after blood toxic effects on bone marrow or by inducing the immune such as repair of hip fractures require more prolonged CONNECTIONS: Lifespan ◀stoppage. Connections: The most Lifespan serious Considerations arterial thromboembolism features clearly dis- system to destroy them. When caring for patients receiving therapy. Enoxaparin may also be administered for the pro- Considerations orders are MI and stroke. these drugs, the nurse must be vigilant in assessing the phylaxis of coronary artery thrombosis and the prevention Miscarriage Prevention with Anticoagulants identify important considerations to ensure safe and effec- Arterial thrombi and emboli commonly result from results of blood laboratory tests and observing for signs of of ischemic complications in patients with acute coronary tive pharmacotherapy in the older adult and pediatric Miscarriage in pregnancy is devastating, and recurrent miscar- procedures involving arterial punctures such as angiogra- thrombocytopenia such as bleeding gums, nosebleeds, and syndrome, for patients with unstable angina, and patients populations. riage even more so. Autoimmune diseases are related to phy and stent placement. They may also originate from the having percutaneous coronary intervention (PCI). Bleed- extensive bruising. Selected drugs that cause thrombocyto- poorer obstetric outcomes than that of the general population, heart. Emboli are common complications of mitral valve ing is the most serious adverse effect and the drug should penia are listed in Table 38.1. Heparin-induced thrombocy- especially in mothers with undiagnosed thrombophilias disease, prosthetic heart valves, and atrial dysrhythmias. not be administered to patients with active bleeding. This topenia, a particularly serious form of this disorder, is (genetic hypercoagulability disorders) such as antiphospho- Emboli originating from the left side of the heart may lodge drug is pregnancy category B. lipid syndrome (APS). Antiphospholipid antibodies are present discussed in Section 38.4. in any organ in the body. Deficiencies in specific clotting factors may prolong Fondaparinux (Arixtra): Approved in 2001, fondaparinux in 15% of women with recurrent miscarriage, and there is a potential 90% risk of future fetal loss in those women if left coagulation and lead to excess bleeding. Deficiencies in is an anticoagulant used for many of the same indications untreated (Chetty & Duncan, 2015). Other obstetric and neo- CONNECTION Checkpoint 38.1 multiple coagulation factors occur frequently in patients as heparin and the LMWHs, but it has certain differences natal complications related to APS include preeclampsia; Coagulation occurs by intrinsic and extrinsic pathways. From what with serious hepatic impairment, because the liver synthe- that make it unique. Fondaparinux is a synthetic drug that M33_ADAM7366_04_SE_C33.indd Page 565 28/10/17 2:07 PM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... eclampsia; hemolysis, elevated liver enzymes, and low platelet you learned in Chapter 28, which pathway is activated when blood sizes most clotting factors. Deficiency in a single coagula- consists of only five saccharide units (a pentasaccharide) count (HELLP) syndrome; early delivery and subsequent pre- leaks from a vessel? Which is more complex and takes several min- tion factor suggests hemophilia, a series of coagulation that is structurally identical to the region of the heparin maturity; intrauterine growth restriction (IUGR); and placental utes? Which results in the formation of fibrin? Answers to Connection disorders caused by genetic deficiencies in specific clotting molecule that binds AT-III. The pentasaccharide unit is insufficiency (Begum, Ganguly, & Islam, 2015; de Jesús, Checkpoint questions are available on the faculty resources site. Please factors. Hemophilia disorders are typified by prolonged able to selectively inhibit Factor Xa without directly affect- Rodrigues, de Jesús, & Levy, 2014). consult with your instructor. ing thrombin. Fondaparinux is only given by the subcuta- Due to discrepancies in the research on treatment rec- Chapter 33 Pharmacotherapycoagulation of Fluid Imbalance, times, resulting Electrolyte, in and persistent Acid–Base bleeding Disorders that 565can neous route and is approved for the prophylaxis of VTE ommendations for the use of heparin, LMWH, or aspirin for ◀ following orthopedic surgery and the treatment of DVT or recurrent spontaneous abortion before 10 weeks of preg - ConnectionBlood products Checkpoints may be administered ask the student to restore to recall deficient past Therapeutic Effects and Uses: Normal serum pulmonary embolism. Like the LMWHs, fondaparinux is nancy, it is recommended that a woman experiencing such conceptsnumbers fromof blood previous cells or chapters proteins, that or areto increase related fluidto current vol- albumin is a protein extracted from whole human blood, administered as fixed doses based on the patient’s weight, loss discuss the situation with her provider and whether study.ume depending Unique to onthis the text, clinical these situation.reinforce Wholematerial blood learned is plasma, or placental plasma that contains 96% albumin genetic testing should be conducted. If genetic coagulation and routine laboratory monitoring is not required because inindicated previous for chapters the treatment that has of direct acute, application massive blood to the loss cur - and 4% globulins and other proteins. After extraction from abnormalities are found, heparin or LMWH may be considered aPTT and PT are not accurate measures of drug activity. (depletion of more than 30% of the total volume) when there as an option (Andreoli et al., 2013). rent chapter. blood or plasma, the albumin is sterilized to remove possi- Doses of fondaparinux are not interchangeable with is a need to replace plasma volume and to supply erythro- ble contamination by hepatitis viruses or HIV. Plasma pro- cytes to increase the blood’s oxygen-carrying capacity. tein fraction (Plasmanate) is another albumin product that contains 83% albumin and 17% plasma globulins. Albumin M30_ADAM7366_04_SE_C30.indd Page 513 28/10/17 9:15 AM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801PharmFACT is classified as both ... a blood product and a colloid. ▶ PharmFacts connect relevant statistics to the presented The functions of endogenous albumin are to maintain In the United States, over 13 million units of whole blood and material. They add interest to the subject and place it in plasma osmotic pressure and to bind certain substances red blood cells are donated each year. About 36,000 units of red perspective with other nursing concepts. blood cells are needed every day (American Red Cross, n.d.). traveling through the blood, including fatty acids, hor- mones, enzymes, and a substantial number of drug mole- Chapter 30 Pharmacotherapy with Calcium Channel Blockers 513 cules. Binding to albumin renders these substances inactive The administration of whole blood has been largely until they become unbound. replaced by the use of blood components. Whole blood is is beneficial for patients with myocardial ischemia. Veins Normal serum albumin may be administered to rarely administered for several reasons. If the patient needs CONNECTIONS: Community- and cardiac preload are not affected by drugs in this class. restore plasma volume and maintain cardiac output in only one specific component in blood, there is no need to Oriented Practice patients with hypovolemic shock. It may also be adminis- Effectsexpose onthe thepatient myocardium: to unnecessary Most components CCBs reduce that could the tered to restore the level of blood proteins in patients with Calcium Channel Blockers and Effects forcepotentially of myocardial trigger ancontraction. adverse effect. This Thenegative supply inotropic of blood hypoproteinemia, which occurs with hepatic cirrhosis. on Minerals effectproducts occurs depends because on these human drugs donors reduce and the requires inward move-careful Albumin is occasionally administered to bind and remove crossmatching2+ to ensure compatibility between the donor Patients may be concerned about taking calcium supplements ment of Ca during the plateau phase of the action poten- toxic bilirubin in hemolytic disease of the newborn. It may and the recipient. 2+ 2+ for osteoporosis prevention while taking CCBs. Calcium and tial. This delayed entry of Ca prevents the release of Ca also offer protection against kernicterus, a toxic accumula- magnesium supplements may actually help maintain a normal The most common complications of whole blood trans- from its storage depots in the sarcoplasmic reticulum, tion of bilirubin in infants that causes brain injury. It has an blood pressure or a lower high blood pressure, and as long as ◀fusion Connections: include febrile Community-Oriented nonhemolytic and Practicechill-rigor features reac- resulting in fewer actin–myosin cross bridges and a dimin- immediate onset of action and is available in concentra- normal doses are taken, do not appear to affect the antihyper- providetions. The important patient information experiences that symptoms nurses need of an to allergic convey ished force of contraction. tions of 5% and 25%. tensive effects of CCBs. More recent research suggests that toreaction theirFor verapamilpatients that include to andensure back diltiazem, that pain they and the receivelow-grade negative effective inotropicfever pharand - CCBs may affect the body’s mineral content (Suliburska, effectmacotherapychills. is Dizziness,clearly after apparent urticaria, leaving at therapeuticandthe hospitalheadache doses. or may clinical Theoccur remain- setting. during Mechanism of Action: Administered IV, normal Bogdanski, Szulinska, & Pupek-Musialik, 2014). CCBs, along deror ofimmediately the CCBs will after only the exhibittransfusion. this effect Symptoms at higher are dosesgener - serum albumin rapidly increases the osmotic pressure of with other antihypertensive drugs such as beta blockers and orally in overdose mild and situations. treated with acetaminophen (Tylenol) and the blood and causes fluid to move from the tissues to the angiotensin-converting enzyme (ACE) inhibitors, were found to diphenhydramine (Benadryl) as needed. general circulation. decrease serum zinc levels. Because depletion of some min- EffectsThe on most cardiac serious conduction: adverse effect In fromgeneral, administration CCBs exhibit of erals such as zinc may have long-term effects on glucose and Because human albumin is a nat- a wholenegative blood chronotropic is an acute effect hemolytic: the property transfusion of slowing reaction. the Pharmacokinetics: lipid metabolism, adequate mineral intake through diet or sup- ural substance, it is not possible to obtain accurate phar - speedThis occursof electrical when conduction the patient across receiving the themyocardium. transfusion plementation should be considered when a patient is taking Under normal conditions, the SA node automatically gen- macokinetic values. Endogenous albumin has a half-life of CCBs or other antihypertensives. develops antibodies against donor red blood cell (RBC) 17 to 19 days. eratesantigens. an action ABO potentialblood type because incompatibility of an inward is the movement most com- of Ca2+ through calcium channels. Blocking calcium entry mon cause of this rare, though sometimes fatal, disorder. Adverse Effects: Hypervolemia may occur if the dos- causes the SA node to generate fewer action potentials, N-type channels in the spinal cord to ease severe, chronic Another uncommon, though serious, adverse effect from age and rate of infusion are not carefully adjusted to the thus decreasing automaticity and slowing heart rate. Simi- pain. Although the drug has limited applications, in the whole blood is transfusion-related acute lung injury. This patient’s volume status. Signs of fluid overload include larly, some of the CCBs block calcium channels in the atrio- future other medications may be developed that target the injury occurs when the patient receives donor antibodies headache, dyspnea, rising blood pressure, and pulmonary ventricular (AV) node, reducing conduction velocity neuronal N-type calcium channels to achieve pain relief. that attack normal granulocytes in the lung. Acute respira- edema. Normal serum albumin is a natural blood product through this region of the heart and further slowing the tory symptoms develop and may be fatal. and the patient may have antibodies to the donor’s albu- spread of the action potential across the myocardium. Whole blood, despite being carefully screened, also min that cause allergic reactions. Because coagulation fac- Because of these actions on the cardiac conduction system, Consequences of Calcium has the potential to transmit serious infections such as hep- tors, antibodies, and most other blood proteins have been the CCBs are sometimes used to correct certain rhythm atitis, cytomegalovirus, malaria, or HIV. In addition, plate- removed, such allergic reactions from albumin are rare. Channel Blockade abnormalities of the heart (see Chapter 37). let concentrates are stored at room temperature, which may Signs of allergy include fever, chills, urticaria, rash, dys - Not all CCBs affect cardiac conduction to the same 30.3 Blocking calcium channels has significant promote the growth of bacteria in the sample. Although pnea, and, possibly, hypotension. physiologic effects on the heart and vascular degree.disease Verapamil transmission and diltiazemfrom donor exhibit to recipient this effect is atpossible, thera- smooth muscle. peuticthe risk doses, is very whereas low. the remainder of the CCBs exhibit a Contraindications/Precautions: The drug is contra- negative chronotropic effect only at high doses, or not at all. indicated in patients with severe anemia or cardiac failure The therapeutic applications of CCBs are the result of PROTOTYPE DRUG Normal Serum Albumin in the presence of normal or increased intravascular vol- actions of the drugs on vascular smooth muscle, cardiac CONNECTION Checkpoint(Albuminar, 30.2 Plasbumin, Others) ume and in those with known allergy to albumin. muscle, and the conduction system in the heart. Some From what you learned in Chapter 28, define afterload. If a drug CCBs have greater actions on the heart, whereas others Classification Therapeutic: Fluid replacement agent Drug Interactions: There are no clinically significant increases afterload, what effect would this likely have on cardiac Pharmacologic: Blood product, colloid interactions. Herbal/Food: Unknown. have more effect on arteriolar smooth muscle. None of the output? Answers to Connection Checkpoint questions are available on CCBs affects serum calcium levels. the faculty resources site. Please consult with your instructor. Effects on vascular smooth muscle: The influx of cal- cium ions into smooth muscle cells is essential for contrac- tion. Because the degree of contraction of arterioles Classification of Calcium controls peripheral resistance, the blockade of calcium Channel Blockers channels has significant physiologic effects on blood pres- 30.4 Calcium channel blockers are classified by sure. All CCBs dilate peripheral arterioles, causing sys - their chemical structures as dihydropyridines or temic blood pressure to decrease. Afterload is reduced, nondihydropyridines. resulting in lower myocardial oxygen demand and less workload for the heart. This is particularly important for Despite the fact that all CCBs affect L-type calcium chan- patients with angina, who will experience less chest pain nels, there are differences in actions and adverse effects due to the decrease in cardiac workload (see Chapter 35). among the specific drugs. This is because the drugs inter- Another important group of vessels affected by CCBs act with different subunits of the calcium channel. This are the coronary arteries. Dilation of the coronary arteries gives rise to a classification of calcium channel antagonists by the CCBs brings more blood to the myocardium, which based on their chemical structures. 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Chapter 39 Pharmacotherapy of Hematopoietic Disorders 701 susceptible to adverse bleeding events. Dosing is initiated Drug Interactions: Oprelvekin should not be admin- 6 to 24 hours after chemotherapy and continues daily until istered within 24 hours of chemotherapy because the the platelet count is greater than 50,000/mm 3. Dosing cytotoxic effects of the antineoplastic drugs decrease the beyond 21 days is not recommended. Platelet counts will effectiveness of the drug. Concurrent use with thiazide or remain elevated for about 7 days after the last dose. Ther- loop diuretics may cause serious hypokalemia. Herbal/ A01_ADAM7366_04_SE_FM.indd Page 13 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... apy with oprelvekin decreases the need for platelet infu- Food: Unknown. sion. Oprelvekin is only given by the subcutaneous route. Pregnancy: Category C. Mechanism of Action: Oprelvekin is equivalent to Treatment of Overdose: Overdose may result in seri- endogenous IL-11 and directly stimulates the synthesis ous adverse effects, and close monitoring of cardiovascu- and maturation of megakaryocytes into platelets. lar and renal function is necessary. No specific therapy is Preface xiii Pharmacokinetics: available. Route(s) Subcutaneous Nursing Responsibilities: Absorption 80% absorbed • Notify the prescriber prior to administration if the Distribution Well distributed to highly patient has a history of leukemia, multiple myeloma, perfused organs; unknown if it or other myeloid malignancies. crosses the placenta or is secreted • Monitor for and immediately report signs and symp- in breast milk toms of fluid overload, hypokalemia, and cardiac Primary metabolism Not metabolized dysrhythmias. Primary excretion Renal • Monitor patients with preexisting fluid retention con- Onset of action 5–9 days ditions carefully, such as HF, pleural effusion, or asci- Duration of action 7 days; half-life: 6.9 h tes, for worsening of symptoms. ◀ Nursing Responsibilities specific to some prototype • This drug has a black box warning for possible anaphy- Adverse Effects: Oprelvekin causes many adverse laxis. Promptly report any signs and symptoms of aller- drugs are provided in a bulleted list format. Nursing effects, although most are reversible upon discontinu - gic reaction to the provider and discontinue the drug. Responsibilities include important lifespan and diversity ation of therapy. The most common adverse effects considerations and patient and family education needs. include nausea, vomiting, edema, neutropenic fever, dys- Lifespan and Diversity Considerations: When a prototype drug does not have a correlating Nurs- pnea, mucositis, and diarrhea. Fluid retention is a seri - • Tachycardia, cardiomegaly, papilledema, conjunctival ous adverse effect that occurs in about 60% of patients ing Practice Application, a more complete Nursing Respon- redness, and bone changes may occur more frequently and can be a concern for patients with preexisting car - sibilities section follows the prototype drug section. in children taking oprelvekin than in adults. Carefully diovascular disease or CKD. Adverse effects related to monitor heart rate and heart sounds, changes in visual fluid retention may be severe and include pulmonary acuity or eye pain, and for complaints of bone pain or edema, pericardial effusion, and ascites. Cardiovascu - changes in gait. Further cardiac testing (e.g., echocar- lar adverse effects include transient atrial dysrhythmias, diography) and frequent eye exams may be warranted. sinus tachycardia, vasodilation, and peripheral edema. Papilledema (swelling of the optic nerve) can occur dur- Patient and Family Education: ing therapy and result in blurred vision, loss of visual • Do not take any other prescription or nonprescription acuity, and blindness, in rare cases. Black Box Warning: drugs, dietary supplements, or herbal products with- Although not common, allergic reactions, including ana- out the approval of the healthcare provider. phylaxis, have been reported with oprelvekin. The drug • Immediately report shortness of breath, swelling of should be permanently discontinued if a patient experi - feet or ankles, rapid weight gain, chest pain, unusual ences a hypersensitivity reaction. fatigue or weakness, irregular heartbeat, fever of 38°C

Contraindications/Precautions: Oprelvekin is con- (100.5°F) or higher, unusual bruising or bleeding, or M34_ADAM7366_04_SE_C34.indd Page 586 28/10/17 10:10 AM f-0046-new /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... traindicated in patients who have shown hypersensitiv- blurred vision. ity to the drug on a previous exposure. It should be used Learning• For self-administration, Through follow the procedure Visuals demon- with caution in patients with cardiac disease, especially strated to prevent contamination of the vial, syringe, 586 Unit 5 Pharmacology of the Cardiovascular System HF, dysrhythmias, and left ventricular dysfunction, since or medicine. Never touch the rubber stopper of the fluid retention is a common adverse effect that can worsen vial or the needle of the syringe with your fingers. Dis- Pharmacotherapy Illustrated 34.1 Mechanism of Action of Antihypertensive Drugs these conditions. Oprelvekin should not be used following pose of needles and syringes as directed by a health-

Alpha agonists myeloablative therapy because the drug exhibits increased care provider. 2 Decrease sympathetic toxicity. The drug should be used with caution in patients • Do not drive or perform other hazardous activities impulses from the CNS to the heart and arterioles, with preexisting visual impairment; papilledema is a dose- until the effects of the drug are known because this causing vasodilation limiting adverse effect in children receiving this drug. drug may cause drowsiness or dizziness. Arterioles a2 Alpha1 blockers Inhibit sympathetic activation in 2 arterioles, causing vasodilation Sympathetic a 1 2 nervous system Direct vasodilators ▶ Updated and Expanded! Pharmacotherapy Illus- 2 Act on the smooth b muscle of arterioles, trated features visually present the mechanism of Beta blockers 1 causing vasodilation Decrease the heart Ca21 rate and myocardial action for many of the prototype drugs, showing stu- contractility, 2 Calcium channel reducing cardiac blockers dents specifically how drugs counteract the effects of output 2 Block calcium ion channels in arterial smooth muscle, disease. Heart causing vasodilation

Angiotensin receptor blockers Prevent angiotensin II from reaching its receptors, causing Angiotensin II vasodilation Renin

Kidney

ACE inhibitors Diuretics Block formation of angiotensin II, causing Increase urine output and vasodilation, and block aldosterone decrease fluid volume secretion, decreasing fluid volume

– = Inhibitory Effect causing vasodilation

Eleven different drug classes are used to treat HTN, as Drugs for Initial Hypertension shown in Table 34.2. Each class has specific benefits and characteristic adverse effects. The mechanisms of action of Therapy the major classes of antihypertensive drugs are summarized The JNC-7 report recommended thiazide diuretics as initial in Pharmacotherapy Illustrated 34.1. Although many effec- drugs for the management of mild to moderate HTN. tive drugs are available, and the data supporting the benefits Although the thiazides are still preferred by some healthcare of therapy are strong, HTN remains a challenging disorder providers, the JNC-8 expanded this recommendation to also to treat successfully. Choice of therapy is often based on the include ACE inhibitors, ARBs, or CCBs for most patients. clinician’s experience. Although antihypertensive treatment Research has clearly demonstrated that these four primary varies, several principles guide pharmacotherapy. drug classes reduce HTN-related morbidity and mortality. A01_ADAM7366_04_SE_FM.indd Page 14 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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xiv Preface 604 Unit 5 Pharmacology of the Cardiovascular System exercise or hyperthyroidism, it is easy to understand why the heart needs more oxygen because it must beat more times per minute. Similarly, the heart will need more oxy- gen if it beats more forcefully (increased contractility). A patient with heart failure (HF) has a thickened myocar- dium (increased tension) that will require more work to contract. The heart of a patient with hypertension will have Platelets and fibrin deposit to work harder to overcome resistance and eject blood. It is on plaque and initiate clot formation important to remember that anything that makes the heart Smooth muscle ◀ Vivid, Colorful, and Effective Illustrations help students review beat faster or contract with more force will increase myo- M24_ADAM7366_04_SE_C24.indd Page 389 30/10/17 8:05 AM f-0051a /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... M24_ADAM7366_04_SE_C24.indd Page 389 30/10/17 8:05 AM f-0051aPlaque /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801the anatomy, physiology, and pathophysiology ... of a body system to cardial oxygen demand. Drugs that diminish these factors are of value in the treatment of angina, MI, and HF. better understand the impact of disease on that system.

Chapter 24 Central Nervous System Stimulants and Drugs for Attention-Deficit/Hyperactivity Disorder 389 Chapter 24 Central Nervous System Stimulants and Drugs for Attention-Deficit/Hyperactivity Disorder 389 Etiology of Coronary Moderate Thrombus Thrombus Understanding Chapter 24 Artery Disease Understandingnarrowing par Chaptertially completely 24 35.2 Coronary artery disease is the major cause of lumen occluding lumen occluding lumen Key Concepts Summary of myocardial ischemia. KeyFigure Concepts 35.1 Atherosclerosis Summary in the coronary arteries. Coronary artery disease (CAD) is one of the leading 24.1 Central nervous system stimulants increase 24.4 Several nonstimulants are effective in treating 24.1 Central nervous system stimulants increase 24.4 Several nonstimulantsalertness, are enhance effective the in ability treating to concentrate, and symptoms of attention-deficit/hyperactivity causes of mortality in the United States. The primary CONNECTIONalertness, enhance Checkpoint the ability to35.1 concentrate, and symptoms of delayattention-deficit/hyperactivity the symptoms of fatigue. disorder. defining characteristic of CAD is narrowing or occlusion delay the symptoms of fatigue. disorder. From what you learned in Chapter 28, predict what would happen to 24.2 Attention-deficit/hyperactivity disorder is 24.5 Narcolepsy is characterized by excessive daytime of one or more coronary arteries. Narrowing can result in 24.2the cardiac Attention-deficit/hyperactivity workload when plasma disorder volume is is increased by24.5 a rapidNarcolepsy ischaracterized characterized by by inattention, excessive daytime hyperactivity, and sleepiness and is treated with central nervous symptoms of angina pectoris, whereas occlusion results infusioncharacterized of normal bysaline. inattention, What effecthyperactivity, might thisand have on a patientsleepiness andimpulsive is treated behavior. with central nervous system stimulants and antidepressants. impulsive behavior. system stimulants and antidepressants. in MI. The two disorders are closely related, as most Understandingwith CAD? Answers to Connection Checkpoint questionsthe are availableChapter 24.3 Psychostimulants are central nervous system 24.6 Methylxanthines are central nervous system patients who experience an MI have narrowing of the The24.3on themost Psychostimulants faculty comprehensive resources are site. central Please nervous consult chapter system with your review instructor.24.6 in Methylxanthines its class!stimulants Understanding are central indicated nervous for system the treatment the Chapter of ADHD begins withstimulants a usedKey for Concepts their ability to increase Summary , stimulants indicated for the treatment of ADHD stimulants usedand for narcolepsy. their ability to increase alertness or their effects on the respiratory system. coronary vessels. whichand quickly narcolepsy. identifies the numbered key alertnessconcepts or their from effects onthe the chapter.respiratory system. The most common etiology of CAD in adults is athero- sclerosis, the presence of plaque—a fatty, fibrous material— Pathophysiology within the walls of the coronary arteries. Plaque develops of Angina Pectoris CASE STUDY: Making the Patient Connection progressively over time, producing varying degrees of CASE STUDY: Making the Patient Connection 35.3 intravascular narrowing that results in partial or total block- Angina pectoris is characterized by severe Remember the patient “Jonathon school nurse suspects he may have ADHD. She has recom- Remember the patient “Jonathon school nurse suspects he may have ADHD.Hogan” She at has the recom- beginning of the mended an appointment with Jonathon’s healthcare pro- age of the vessel. During periods of rest, demands on the chest pain brought on by physical exertion or ▶ emotionalMaking stress.the PatientHogan” at theConnection beginning of the recon mended- an appointment with Jonathon’schapter? healthcare Now read pro the- remain- vider and told his parents that Adderall may help Jonathon heart are reduced and a partially occluded artery may be chapter? Now read the remain- vider and told his parents that Adderall may help Jonathon nects the student to the patient presented der of the case study. Based on focus on his schoolwork. able to provide adequate oxygen. During exercise (or a Angina pectoris is deracute of the chest case painstudy. caused Based on by myocardialfocus on his schoolwork. the information presented the information presented Critical Thinking Questions pharmacology test), however, workload on the heart inischemia. the scenario The classic atpresentation the chapter of angina opening. pectoris is steady, within this chapter, respond to within this chapter, respond to Critical Thinking Questions the critical thinking questions 1. What is ADHD and why would Jonathon be experi- increases, the cardiac muscle distal to the obstruction intense pain, sometimesthe critical with thinking a crushing questions sensation in the The student learns additional details1. What is ADHD and why would Jonathonthat follow. be experi- encing more difficulty as he becomes older? receives insufficient oxygen supply, and ischemia results. anterior chest. Typically,that follow. the discomfort radiates to theencing left more difficulty as he becomes older? about the patient’s health history and par- Jonathon Hogan has had trouble at school beginning in 2. How might amphetamine sulfate and dextroamphet- A healthy heart responds to stress by changing the shoulder and proceeds down the left arm. It may also extend Jonathon Hogan has had trouble at school beginning in 2. How mightkindergarten amphetamine and sulfate for the and past dextroamphet- year. His teachers have con- amine (Adderall) help Jonathon with his ADHD? ticipates in critical thinking questionsamine (Adderall) help Jonathon with his ADHD? diameter of the coronary arteries. When the oxygen kindergartento the posterior and for thoracic the past year.region His orteachers move have upward con- to the jaw, sistently reported that he is easily distracted and wanders 3. What caregiver education would be appropriate demands of the heart increase, the vessels will immediately aboutsistentlyand in thereportedsome scenario. patients that he is the easily Thispain distracted is allowsexperienced and wanders applica in the3. epigas -What caregiver- around education the classroom would even be appropriate during a lesson. Getting him to regarding dextroamphetamine and amphetamine dilate to bring more oxygen to the myocardium. Plaque aroundtrium theor classroomabdominal even area. during Accompanying a lesson. Getting himthe todiscomfort regarding is dodextroamphetamine his homework after and school amphetamine has been a struggle. Jona- sulfate (Adderall)? tiondo his ofhomework knowledge after school has beenobtained a struggle. Jonain- the sulfate (Adderall)?thon loves art and does well at video games. Because he is impairs normal elasticity, and the coronary vessels are severe emotional distress—a feeling of panic with fear of 4. What are other nonpharmacologic treatments thon loves art and does well at video games. Because he is 4. What are othera happy-go-lucky nonpharmacologic child, treatments his parents have assumed that unable to dilate properly when the myocardium demands chapter.impending death. There is usually pallor, dyspnea with cya- for ADHD? a happy-go-lucky child, his parents have assumed that for ADHD?Jonathon’s right-brain dominance has created trouble with additional oxygen. Myocardial ischemia occurs when car- Jonathon’snosis, diaphoresis, right-brain dominancetachycardia, has createdand elevated trouble withblood pressure. left-brain logical work. With more homework now in sec- Answers to Critical Thinking Questions are available on the Answers to Critical Thinking Questions are available on the diac demands exceed the amount of oxygen that can be left-brainAnginal logical painwork. isWith usually more homework precipitated now inby sec- physical exer- ond grade, Jonathon is struggling to keep up in school. The faculty resources site. Please consult with your instructor. ond grade, Jonathon is struggling to keep up in school. The faculty resources site. Please consult with your instructor. supplied through the narrowed, inelastic vessels character- tion or emotional excitement—events associated with istic of CAD. increased myocardial oxygen demand. Angina pectoris Plaque accumulation occurs gradually, over periods of episodes are of short duration. With physical rest and men- Additional Case Study 40 to 50 years in some individuals, but actually begins to Additionaltal relaxation, theCase workload Study demands on the heart diminish accrue very early in life. The development of atherosclero- and the discomfort subsides within 5 to 10 minutes. Anna Steinmetz has graduated from nursing school and is 2. What teaching will you provide to the patient sis is illustrated in Figure 35.1. AnnaDescriptions Steinmetz hasof thegraduated four basic from nursingtypes ofschool angina and isfollow. 2. What teachingworking will nights.you provide She is to having the patient difficulty adjusting to her regarding this medication? working nights. She is having difficulty adjusting to her regarding this medication? night schedule. Her healthcare provider suggested she◀ uti- An3. Additional The patient reports Casefeelings ofStudy lightheadedness gives with stu - night schedule. Her healthcare provider suggested she uti- 3. The patientlize reports a medication feelings of to lightheadedness assist with her with adjustment to shift position changes. What interventions will assist in lize a medication to assist with her adjustment to shift position changes.work. She What has interventionsbeen prescribed will modafinil assist in (Provigil). dents anothermaintaining opportunity patient safety? to apply their work. She has been prescribed modafinil (Provigil). M24_ADAM7366_04_SE_C24.inddmaintaining1. patientWhat effect safety? does Page modafinil 390 30/10/17 (Provigil) 8:05 AM have f-0051a on /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... knowledgeAnswers to toAdditional patient Case Study care. questions are available on 1. What effect does modafinil (Provigil) have on the patient’s ability to maintain alertness during Answers to Additional Case Study questions are available on the faculty resources site. Please consult with your instructor. the patient’s ability to maintain alertness during the faculty resourcesshift work? site. Please consult with your instructor. shift work?

390 Unit 4 Pharmacology of the Central Nervous System

Chapter Review

1. An elementary school nurse is providing education to The world would be better off without me.” Which ▶ Chapter Review prepares students for the faculty on the use of central nervous system stim- action would the nurse take for this patient? ulants to treat attention-deficit/hyperactivity disor- 1. Tell the patient to stop taking atomoxetine course exams on chapter content and der. Of the following, which is most important for the immediately and not to take it until checking with ® nurse to convey to the faculty? gives exposure to NCLEX-RN -style the provider. questions. Answers and rationales are 1. Have the child bring the drug dose in a lunch bag 2. Assure the patient that these are normal symptoms and come to the office to take it to avoid being because the drug may take 3 or 4 weeks to work. teased. provided in Appendix A. 3. Alert the family or caregiver that immediate 2. Request that the parents leave an extra copy of the attention and treatment are needed for these prescription at the school in case the dose runs out. symptoms. 3. Suggest that the parents have two prescriptions 4. Have the patient increase intake of caffeine by filled, one for home and one to keep at school. consuming cola products, coffee, or tea to 4. Keep the drugs in a locked drawer, clearly labeled counteract the depressive effect. with the student’s name and only the number of doses allowed by school policy. 5. An office worker has made an appointment with a healthcare provider for heart palpitations, dysrhyth- 2. Which therapeutic outcome would the nurse consider mias, and facial tingling. The nurse is taking the most significant in evaluating a patient who started patient’s history. Which of the following does the atomoxetine (Strattera) 6 months ago? nurse note may explain the symptoms? 1. Decrease in attention 1. The patient takes zolpidem (Ambien) for 2. Decrease in hyperactivity occasional insomnia. 3. Development of mydriasis 2. The patient has been working late frequently and has relied on coffee to maintain alertness. 4. Elevated liver enzymes 3. The patient is taking gabapentin (Neurontin) for 3. A patient who has overdosed on amphetamine sulfate pain associated with herpes zoster. and dextroamphetamine (Adderall XR) is admitted to 4. The patient has been under stress at work and has the emergency department. The nurse would antici- switched to using herbal teas. pate which medications to be administered to assist in counteracting the effects of the overdosage? 6. A patient who is taking methylphenidate (Concerta, Metadate, Ritalin) for attention-deficit/hyperactivity 1. Chlorpromazine (Thorazine) disorder reports having insomnia. Which intervention 2. Phenytoin (Dilantin) will assist in the promotion of sleep? 3. Propofol (Diprivan) 1. Have a glass of wine with dinner. 4. Dexamethasone (Decadron) 2. Eat a chocolate bar at bedtime. 4. A high school student taking atomoxetine (Strattera) 3. Take the drug before 4 p.m. for attention-deficit/hyperactivity disorder visits the 4. Switch to decaffeinated coffee. school nurse’s office and confides, “I am so depressed. See Answers to Chapter Review in Appendix A.

References

Centers for Disease Control and Prevention. (2016a). medications and risk of serious cardiovascular events Attention-deficit/hyperactivity disorder (ADHD) data and in young and middle-aged adults. JAMA, 306, statistics in the United States. Retrieved from http:// 2673–2683. doi:10.1001/jama.2011.1830 www.cdc.gov/ncbddd/adhd/data.html Harvey, W., Wilkinson, S., Pressé, C., Joober, R., & Centers for Disease Control and Prevention. (2016b). Grizenko, N. (2014). Children say the darndest Attention-deficit/hyperactivity disorder (ADHD) symptoms things: Physical activity and children with attention- and diagnosis. Retrieved from https://www.cdc.gov/ deficit hyperactivity disorder. Physical Education and ncbddd/adhd/diagnosis.html Sport Pedagogy, 19, 205–220. doi:10.1080/17408989. Habel, L. A., Cooper, W. O., Sox, C. M., Chan, K. A., 2012.754000 Fireman, B., Arbogast, P., … Selby, J. V. (2011). ADHD M24_ADAM7366_04_SE_C24.indd Page 390 30/10/17 8:05 AM f-0051a /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

390 Unit 4 Pharmacology of the Central Nervous System

Chapter Review

1. An elementary school nurse is providing education to The world would be better off without me.” Which the faculty on the use of central nervous system stim- action would the nurse take for this patient? ulants to treat attention-deficit/hyperactivity disor- 1. Tell the patient to stop taking atomoxetine der. Of the following, which is most important for the immediately and not to take it until checking with nurse to convey to the faculty? the provider. 1. Have the child bring the drug dose in a lunch bag 2. Assure the patient that these are normal symptoms and come to the office to take it to avoid being because the drug may take 3 or 4 weeks to work. teased. 3. Alert the family or caregiver that immediate 2. Request that the parents leave an extra copy of the attention and treatment are needed for these prescription at the school in case the dose runs out. symptoms. 3. Suggest that the parents have two prescriptions 4. Have the patient increase intake of caffeine by filled, one for home and one to keep at school. consuming cola products, coffee, or tea to 4. Keep the drugs in a locked drawer, clearly labeled counteract the depressive effect. with the student’s name and only the number of doses allowed by school policy. 5. An office worker has made an appointment with a healthcare provider for heart palpitations, dysrhyth- 2. Which therapeutic outcome would the nurse consider mias, and facial tingling. The nurse is taking the most significant in evaluating a patient who started patient’s history. Which of the following does the atomoxetine (Strattera) 6 months ago? nurse note may explain the symptoms? 1. Decrease in attention 1. The patient takes zolpidem (Ambien) for 2. Decrease in hyperactivity occasional insomnia. 3. Development of mydriasis 2. The patient has been working late frequently and has relied on coffee to maintain alertness. 4. Elevated liver enzymes 3. The patient is taking gabapentin (Neurontin) for 3. A patient who has overdosed on amphetamine sulfate pain associated with herpes zoster. and dextroamphetamine (Adderall XR) is admitted to 4. The patient has been under stress at work and has the emergency department. The nurse would antici- switched to using herbal teas. A01_ADAM7366_04_SE_FM.inddpate which medications Page to 15be administered 1/5/18 11:26 to assist AM in f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... counteracting the effects of the overdosage? 6. A patient who is taking methylphenidate (Concerta, Metadate, Ritalin) for attention-deficit/hyperactivity 1. Chlorpromazine (Thorazine) disorder reports having insomnia. Which intervention 2. Phenytoin (Dilantin) will assist in the promotion of sleep? 3. Propofol (Diprivan) 1. Have a glass of wine with dinner. 4. Dexamethasone (Decadron) 2. Eat a chocolate bar at bedtime. 3. Take the drug before 4 p.m. M24_ADAM7366_04_SE_C24.indd4. A high school Page student 391 02/11/17 taking 1:48 atomoxetine PM f-0051a (Strattera)/207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ... for attention-deficit/hyperactivity disorder visits the 4. Switch to decaffeinated coffee. Preface xv school nurse’s office and confides, “I am so depressed. See Answers to Chapter Review in Appendix A.

References Chapter 24 Central Nervous System Stimulants and Drugs for Attention-Deficit/Hyperactivity Disorder 391

Centers for Disease Control and Prevention. (2016a). medications and risk of serious cardiovascular events March of Dimes. (2015). Caffeine in pregnancy. Retrieved cardiovascular risk and ADHD medications: Results Attention-deficit/hyperactivity disorder (ADHD) data and in young and middle-aged adults. JAMA, 306, from http://www.marchofdimes.com/pregnancy/ from the 2004–2005 National Epidemiologic Survey on statistics in the United States. Retrieved from http:// 2673–2683. doi:10.1001/jama.2011.1830 caffeine-in-pregnancy.aspx Alcohol and Related Conditions. Journal of Clinical www.cdc.gov/ncbddd/adhd/data.html Harvey, W., Wilkinson, S., Pressé, C., Joober, R., & National Institute of Neurological Disorders and Stroke. Psychiatry, 75, 181–182. doi:10.4088/JCP.13l08736 Centers for Disease Control and Prevention. (2016b). Grizenko, N. (2014). Children say the darndest (n.d.). Narcolepsy fact sheet. Retrieved from http:// U.S. Department of Justice, Drug Enforcement Attention-deficit/hyperactivity disorder (ADHD) symptoms things: Physical activity and children with attention- www.ninds.nih.gov/disorders/narcolepsy/detail_ Administration. (2016). Lists of: Scheduling actions, and diagnosis. Retrieved from https://www.cdc.gov/ deficit hyperactivity disorder. Physical Education and narcolepsy.htm controlled substances and regulated chemicals. Retrieved ncbddd/adhd/diagnosis.html Sport Pedagogy, 19, 205–220. doi:10.1080/17408989. Peyre, H., Hoertel, N., Hatteea, H., Limosin, F., Dubuc, C., from http://www.deadiversion.usdoj.gov/schedules/ Habel, L. A., Cooper, W. O., Sox, C. M., Chan, K. A., 2012.754000 & Delorme, R. (2014). Adulthood self-reported orangebook/orangebook.pdf Fireman, B., Arbogast, P., … Selby, J. V. (2011). ADHD

◀ Detailed References and a Selected Selected Bibliography Bibliography provide the foundation for Akutagava-Martins, G. C., Rohde, L. A., & Hutz, M. H. meta-analysis and meta-regression in over 9000 (2016). Genetics of attention-deficit/hyperactivity patients. Psychopharmacology, 233, 187–197. doi:10.1007/ evidence-based nursing practice and sup- disorder: An update. Expert Review of Neurotherapeutics, s00213-015-4099-3 port the currency and accuracy of the 16, 145–156. doi:10.1586/14737175.2016.1130626 Nallu, S. (2017). Narcolepsy. Retrieved from http:// Buoli, M., Serati, M., & Cahn, W. (2016). Alternative emedicine.medscape.com/article/1188433-overview textbook content. pharmacological strategies for adult ADHD treatment: National Institute of Mental Health. (2016). Attention deficit A systematic review. Expert Review of Neurotherapeutics, hyperactivity disorder. Retrieved from http://www. 16, 131–144. doi:10.1586/14737175.2016.1135735 nimh.nih.gov/health/topics/attention-deficit- Connolly, J. J., Glessner, J. T., Kao, C., Elia, J., & hyperactivity-disorder-adhd/index.shtml Hakonarson, H. (2015). Attention-deficit hyperactivity Pickett, J. (2015). ADHD drugs in preschool children. disorder & pharmacotherapy—Past, present, and Prescriber, 26(7), 5. doi:10.1002/psb.1329 future: A review of the changing landscape of drug Preda, A. (2015). Stimulants. Retrieved from http:// therapy. Therapeutic Innovation & Regulatory Science, 49, emedicine.medscape.com/article/289007-overview 632–642. doi:10.1177/2168479015599811 Torgersen, T., Gjervan, B., Lensing, M. B., & Rasmussen, K. Cunill, R., Castells, X., Tobias, A., & Capellà, D. (2016). (2016). Optimal management of ADHD in older adults. Efficacy, safety and variability in pharmacotherapy for Neuropsychiatric Disease and Treatment, 12, 79–87. adults with attention deficit hyperactivity disorder: A doi:10.2147/NDT.S59271

New to the Fourth Edition

• Updated Connections features cover current topics • More than 30 new drugs have been added to update that nurses will face in practice. medications approved by the FDA since the previous • New Connections: Preparing for Advanced Practice edition. features help students develop critical thinking and • Revised art program: More than 10 figures have been clinical decision-making skills. added or revised in this edition to enhance the clarity • New Connections: Using Research in Practice features of difficult pharmacologic concepts. illustrate connections to nursing or pharmacology research. A01_ADAM7366_04_SE_FM.indd Page 16 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

MyLab Nursing

MyLab Nursing is an online learning and practice environment that works with the text to help students master key con- cepts, prepare for the NCLEX-RN exam, and develop clinical reasoning skills. Through a new mobile experience, students can study Pharmacology: Connections to Nursing Practice anytime, anywhere. New adaptive technology with remediation personalizes learning, moving students beyond memorization to true understanding and application of the content. MyLab Nursing contains the following features: Dynamic Study Modules New adaptive learning modules with remediation that personalize the learning experience by allowing students to increase both their confidence and their performance while being assessed in real time.

NCLEX-Style Questions Practice tests with more than 1000 NCLEX-style questions of various types build student confidence and prepare them for success on the NCLEX-RN exam. Questions are organized by Chapter.

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Decision Making Cases Clinical case studies that provide opportunities for students to practice analyzing information and making important decisions at key moments in patient care scenarios. These 10 unfolding case studies are designed to help prepare students for clinical practice.

Pearson eText Enhances student learning both in and outside the classroom. Students can take notes, highlight, and bookmark important content, or engage with interactive and rich media to achieve greater conceptual understanding of the text content. Interac- tive features include audio clips, pop-up definitions, figures, questions and answers, the nursing process, hotspots, and video animations. A01_ADAM7366_04_SE_FM.indd Page 18 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

Contents

Unit 1 Fundamental Principles of 5 Adverse Drug Effects and Drug Pharmacology Interactions 55 1 Introduction to Pharmacology: Concepts Adverse Drug Effects 56 Drug Interactions 62 and Connections 2 Brief History of Pharmacology 3 6 Medication Errors Pharmacology: The Study of Medicines 4 and Risk Reduction 70 Characteristics of an Ideal Drug 5 Medication Errors and Their Impact on Healthcare 71 Classification of Drugs 6 Factors Contributing to Medication Errors 73 Prototype Drugs 6 Drug Names and Medication Errors 74 Naming Drugs 7 Reporting Medication Errors 75 Connecting Pharmacology to Clinical Nursing Strategies for Reducing Medication Errors 76 Practice 9 2 Drug Regulations 13 7 The Role of Complementary and Alternative Therapies in Patent Medicines 14 Pharmacotherapy 84 Brief History of Drug Legislation 15 Drug Standards 17 Types of Complementary and Alternative The U.S. Food and Drug Administration 17 Therapies 85 Drug Approval 18 History of Herbal Therapies 86 Changes to the Drug Approval Process 20 Standardization of Herbal Products 86 Prescription and Over-the-Counter Drugs 21 Dietary Supplement Regulation 88 Drug Schedules 22 Herb–Drug Interactions 90 Prescriptive Authority for Nurses 22 Specialty Supplements 92

3 Pharmacokinetics 26 Unit 2 Pharmacology and the Nurse–Patient Introduction to Pharmacokinetics 27 Relationship Primary Processes of Pharmacokinetics 28 Route of Administration 29 8 Pharmacotherapy During Pregnancy Drug Concentration and Dose 33 and Lactation 98 GI Tract Environment 33 Rationale for Drug Use During Pregnancy and Blood Flow to the Absorption Site 33 Lactation 99 Drug Ionization 34 Pharmacotherapy During Pregnancy 99 Drug Interactions 34 Pharmacotherapy During Lactation 104 Surface Area 34 Time–Response Relationships 40 9 Pharmacotherapy of the Pediatric Patient 110 4 Pharmacodynamics 45 Testing and Labeling of Pediatric Drugs 111 Interpatient Variability 46 Pharmacokinetic Variables in Pediatric Patients 113 Therapeutic Index 47 Pharmacologic Implications Associated with Growth Dose–Response Relationship 48 and Development 114 Potency and Efficacy 48 Medication Safety for Pediatric Patients 117 Receptor Theory 50 Determining Pediatric Drug Dosages 117 Agonists and Antagonists 51 Adverse Drug Reactions in Children and Promoting Pharmacogenetics 51 Adherence 118

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10 Pharmacotherapy of the Geriatric Nicotinic Antagonists: Neuromuscular Patient 123 Blockers 177 PROTOTYPE DRUGS: Succinylcholine (Anectine, Polypharmacy 124 Quelicin) 178 Physiologic Changes Related to Aging 125 CONNECTIONS: Nursing Practice Application Pharmacokinetic and Pharmacodynamic Changes Patients Receiving Pharmacotherapy with in Older Adults 125 Cholinergic (Muscarinic) Antagonists 181 Adherence and Drug Misuse Among Older Adults 127 15 Adrenergic Agonists 185 Adverse Drug Reactions in Older Adults 128 Actions of Adrenergic Agonists 186 11 Individual Variations in Drug Mechanisms of Action of Adrenergic Agonists 186 Classification of Adrenergic Agonists 187 Responses 133 Nonselective Adrenergic Agonists 188 Psychosocial Influences 134 PROTOTYPE DRUG: Epinephrine (Adrenalin) 190 Cultural and Ethnic Variables 134 Alpha-Adrenergic Agonists 192 Genetic Influences 136 PROTOTYPE DRUG: Phenylephrine Gender Influences 137 (Neo-Synephrine) 193 Beta-Adrenergic Agonists 194 Unit 3 Pharmacology of the Autonomic PROTOTYPE DRUG: Isoproterenol (Isuprel) 195 Nervous System CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with 12 Review of Neurotransmitters and the Adrenergic Agonists 197 Autonomic Nervous System 142 Overview of the Nervous System 143 16 Adrenergic Antagonists 201 Structure and Function of the Autonomic Nervous Actions of Adrenergic Antagonists 202 System 144 Alpha-Adrenergic Antagonists 202 Synaptic Transmission 146 PROTOTYPE DRUG: Prazosin (Minipress) 205 Cholinergic Transmission 148 Beta-Adrenergic Antagonists 206 Cholinergic Receptors and Neurotransmitters 149 PROTOTYPE DRUG: Propranolol (Inderal, Termination of Acetylcholine Action 150 InnoPran XL) 208 Adrenergic Transmission 150 PROTOTYPE DRUG: Metoprolol (Lopressor, Alpha-Adrenergic Receptors 151 Toprol XL) 211 Beta-Adrenergic Receptors 151 CONNECTIONS: Nursing Practice Application Termination of Norepinephrine Action 151 Patients Receiving Pharmacotherapy with Regulation of Autonomic Functions 152 Adrenergic Antagonists 213 Classifying Autonomic Drugs 152

13 Cholinergic Agonists 155 Unit 4 Pharmacology of the Central Nervous System Cholinergic Receptors 156 Muscarinic Agonists 158 17 Review of the Central Nervous PROTOTYPE DRUGS: Bethanechol (Urecholine) System 218 159 Cholinergic Crisis 161 Scope of Central Nervous System Pharmacology 219 Pharmacotherapy of Myasthenia Gravis 161 Neurons and Neurotransmission 220 PROTOTYPE DRUGS: Pyridostigmine (Mestinon, Structural Divisions of the Central Nervous Regonol) 163 System 222 CONNECTIONS: Nursing Practice Application Functional Systems of the Central Nervous Patients Receiving Pharmacotherapy with System 224 Cholinergic Agonists 164 Nicotinic Agonists 166 18 Pharmacotherapy of Anxiety and Sleep Disorders 227 14 Cholinergic Antagonists 170 Anxiety Disorders 228 Classification of Cholinergic Antagonists 171 Sleep Disorders 231 Muscarinic Antagonists 172 Management of Anxiety and Sleep Disorders 234 PROTOTYPE DRUGS: Atropine (Atropen) 174 Pharmacotherapy of Anxiety and Insomnia 237 Nicotinic Antagonists: Ganglionic Blockers 176 PROTOTYPE DRUG: Lorazepam (Ativan) 238 A01_ADAM7366_04_SE_FM.indd Page 20 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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PROTOTYPE DRUG: Zolpidem (Ambien, Edluar, Pharmacotherapy of Parkinson’s Disease 307 Others) 241 PROTOTYPE DRUG: Levodopa and Carbidopa PROTOTYPE DRUG: Phenobarbital (Sinemet, Parcopa) 308 (Luminal) 246 PROTOTYPE DRUG: Pramipexole (Mirapex) 311 CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Benztropine (Cogentin) 314 Patients Receiving Pharmacotherapy for Anxiety Alzheimer’s Disease 315 or Sleep Disorders 248 Pharmacotherapy of Alzheimer’s Disease 317 19 Pharmacotherapy of Mood PROTOTYPE DRUG: Donepezil (Aricept) 319 Disorders 253 Multiple Sclerosis 320 PROTOTYPE DRUG: Interferon Beta-1b (Betaseron, Categories of Mood Disorders 254 Extavia) 322 Major Depressive Disorder 254 Amyotrophic Lateral Sclerosis 325 Pathophysiology of Depression 255 CONNECTIONS: Nursing Practice Application Assessment of Depression 256 Patients Receiving Pharmacotherapy for Nonpharmacologic Therapies for Depression 257 Neurodegenerative Disorders 325 Pharmacotherapy of Depression 258 Selective Serotonin Reuptake Inhibitors 259 22 Pharmacotherapy of Seizures 330 PROTOTYPE DRUG: Fluoxetine (Prozac) 261 Characteristics of Seizure Disorders 331 Atypical Antidepressants 263 Classification of Seizure Disorders 334 PROTOTYPE DRUG: Venlafaxine (Effexor) 264 Generalized Seizures 334 Tricyclic Antidepressants 267 Partial Seizures 335 PROTOTYPE DRUG: Imipramine (Tofranil) 268 Antiepileptic Drugs 339 Monoamine Oxidase Inhibitors 269 PROTOTYPE DRUG: Diazepam (Valium) 342 PROTOTYPE DRUG: Phenelzine (Nardil) 270 PROTOTYPE DRUG: Phenytoin (Dilantin, CONNECTIONS: Nursing Practice Application Phenytek) 344 Patients Receiving Pharmacotherapy with PROTOTYPE DRUG: Carbamazepine (Carbatrol, Antidepressants 272 Tegretol, Others) 346 Bipolar Disorder 273 Drugs for Bipolar Disorder 274 PROTOTYPE DRUG: Ethosuximide (Zarontin) 347 PROTOTYPE DRUG: Lithium Carbonate (Eskalith, Lithobid) 274 PROTOTYPE DRUG: Gabapentin (Neurontin) 348 20 Pharmacotherapy of Psychoses 281 PROTOTYPE DRUG: Valproic Acid (Depacon, Depakene, Depakote) 349 Characteristics of Psychoses 282 Other Miscellaneous Drugs 350 Symptoms of Schizophrenia 283 Etiology of Schizophrenia 284 CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy for Management of Psychoses 284 Seizures 353 Antipsychotic Drugs 286 First-Generation Antipsychotics 288 23 Pharmacotherapy of Muscle Spasms and PROTOTYPE DRUG: Chlorpromazine 290 Spasticity 358 PROTOTYPE DRUG: Haloperidol (Haldol) 291 Second-Generation (Atypical) Antipsychotics 293 Etiology and Pathophysiology of Muscle Spasms and Spasticity 359 PROTOTYPE DRUG: Risperidone (Risperdal) 293 Nonpharmacologic Therapies for Muscle Spasms and PROTOTYPE DRUG: Aripiprazole (Abilify) 297 Spasticity 360 CONNECTIONS: Nursing Practice Application Pharmacotherapy of Muscle Spasms 361 Patients Receiving Pharmacotherapy with Antipsychotics 299 PROTOTYPE DRUG: Cyclobenzaprine (Amrix) 363 21 Pharmacotherapy of Degenerative Pharmacotherapy of Muscle Spasticity 366 Diseases of the Central Nervous PROTOTYPE DRUG: Dantrolene (Dantrium, System 304 Revonto) 366 Skeletal Muscle Relaxants as Surgical Adjuncts 370 Degenerative Diseases of the Central Nervous CONNECTIONS: Nursing Practice Application System 305 Patients Receiving Pharmacotherapy for Muscle Parkinson’s Disease 306 Spasms and Spasticity 370 A01_ADAM7366_04_SE_FM.indd Page 21 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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24 Central Nervous System Stimulants PROTOTYPE DRUG: Lidocaine (Anestacon, and Drugs for Attention-Deficit/ Xylocaine, Zingo, Others) 439 Adjuncts to Anesthesia 441 Hyperactivity Disorder 375 CONNECTIONS: Nursing Practice Application Characteristics of Central Nervous System Patients Receiving Local Anesthesia 442 Stimulants 376 Etiology and Pathophysiology of Attention-Deficit/ 27 Pharmacology of Substance Abuse 447 Hyperactivity Disorder 377 Fundamental Concepts of Substance Abuse 448 Pharmacotherapy of Attention-Deficit/Hyperactivity Legislation of Controlled Substances 449 Disorder 378 Addiction and Dependence 449 PROTOTYPE DRUG: Amphetamine and Tolerance 451 Dextroamphetamine (Adderall, Adderall XR) 380 Central Nervous System Depressants 452 PROTOTYPE DRUG: Atomoxetine (Strattera) 382 Sedatives and Antianxiety Drugs 452 Pharmacotherapy of Narcolepsy 384 Opioids 453 PROTOTYPE DRUG: Modafinil (Provigil) 384 PROTOTYPE DRUG: Buprenorphine with Naloxone Methylxanthines 386 (Suboxone, Zubsolv, Others) 454 PROTOTYPE DRUG: Caffeine 386 Alcohol (Ethanol) 455 CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Disulfiram (Antabuse) 457 Patients Receiving Pharmacotherapy with Central Marijuana and Related Substances 458 Nervous System Stimulants 387 Hallucinogens 459 LSD and Similar Hallucinogens 459 25 Pharmacotherapy of Severe Pain and Club Drugs and Miscellaneous Hallucinogens 460 Migraines 392 Central Nervous System Stimulants 461 General Principles of Pain Management 393 Amphetamines and Methylphenidate 461 Pain Management with Opioids 398 Cocaine 462 PROTOTYPE DRUG: Morphine Sulfate (Astramorph Caffeine 463 PF, Duramorph RF, Roxanol, Others) 402 Nicotine 463 Pain Management with Nonopioids 406 PROTOTYPE DRUG: Varenicline (Chantix) 464 PROTOTYPE DRUG: Tramadol (Ultram, Others) 406 Inhalants 465 CONNECTIONS: Nursing Practice Application CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy for Pain 408 Patients Receiving Pharmacotherapy for Substance Pharmacotherapy with Opioid Antagonists 412 Abuse Disorders 466 Pharmacotherapy of Migraines 413 Anabolic Steroids 467 PROTOTYPE DRUG: Sumatriptan (Imitrex, Onzetra) 415 Unit 5 Pharmacology of the Cardiovascular CONNECTIONS: Nursing Practice Application System Patients Receiving Pharmacotherapy for Migraines 417 28 Review of the Cardiovascular System 474 26 Anesthetics and Anesthesia Adjuncts 422 Structure and Function of the Cardiovascular System 475 Types of Anesthesia 423 Functions and Properties of Blood 475 Principles of General Anesthesia 423 Cardiac Structure and Function 478 Intravenous Anesthetics 424 Hemodynamics and Blood Pressure 483 PROTOTYPE DRUG: Fentanyl (Sublimaze) 425 PROTOTYPE DRUG: Midazolam (Versed) 427 29 Pharmacotherapy of Hyperlipidemia 488 PROTOTYPE DRUG: Propofol (Diprivan) 428 Types of Lipids and Lipoproteins 489 Inhalation Anesthetics 430 Measurement and Control of Serum Lipids 492 PROTOTYPE DRUG: Nitrous Oxide 430 Drugs for Dyslipidemias 494 PROTOTYPE DRUG: Isoflurane (Forane) 432 PROTOTYPE DRUG: Atorvastatin (Lipitor) 496 Local Anesthetics 433 PROTOTYPE DRUG: Cholestyramine CONNECTIONS: Nursing Practice Application (Questran) 500 Patients Receiving General Anesthesia 434 PROTOTYPE DRUG: Gemfibrozil (Lopid) 502 PROTOTYPE DRUG: Procaine (Novocaine) 438 Miscellaneous Drugs for Dyslipidemias 503 A01_ADAM7366_04_SE_FM.indd Page 22 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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CONNECTIONS: Nursing Practice Application CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy for Patients Receiving Pharmacotherapy with Hyperlipidemia 505 Diuretics 555

30 Pharmacotherapy with Calcium Channel 33 Pharmacotherapy of Fluid Imbalance, Blockers 510 Electrolyte, and Acid–Base Disorders 561 Physiologic Role of Calcium Channels in Muscle Principles of Fluid Balance 562 Contraction 511 Fluid Replacement Agents 563 Types of Calcium Channels 512 PROTOTYPE DRUG: Normal Serum Albumin Consequences of Calcium Channel Blockade 513 (Albuminar, Plasbumin, Others) 565 Classification of Calcium Channel Blockers 513 PROTOTYPE DRUG: 5% Dextrose in Water PROTOTYPE DRUG: Nifedipine (Adalat CC, (D5W) 566 Procardia XL) 515 PROTOTYPE DRUG: Dextran 40 (Gentran 40, PROTOTYPE DRUG: Verapamil (Calan, Isoptin, Others) 567 Verelan) 517 Physiology of Electrolytes 568 CONNECTIONS: Nursing Practice Application Pharmacotherapy of Electrolyte Imbalances 569 Patients Receiving Pharmacotherapy with Calcium PROTOTYPE DRUG: Sodium Chloride (NaCl) 571 Channel Blockers 519 PROTOTYPE DRUG: Potassium Chloride (KCl) 572 PROTOTYPE DRUG: Magnesium Sulfate 31 Drugs Affecting the Renin-Angiotensin- (MgSO4) 574 Aldosterone System 523 Pharmacotherapy of Acid–Base Imbalances 575 PROTOTYPE DRUG: Sodium Bicarbonate 576 Components of the Renin-Angiotensin-Aldosterone PROTOTYPE DRUG: Ammonium Chloride 577 System 524 Physiologic Actions of the Renin-Angiotensin- CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy for Fluid and Aldosterone System 526 Electrolyte Imbalances 578 Drugs Affecting the Renin-Angiotensin-Aldosterone System 527 34 Pharmacotherapy of Hypertension 582 PROTOTYPE DRUG: Lisinopril (Prinivil, Zestril) 529 Etiology and Pathogenesis of Hypertension 583 PROTOTYPE DRUG: Losartan (Cozaar) 532 Nonpharmacologic Management of Hypertension 584 CONNECTIONS: Nursing Practice Application Guidelines for the Management of Hypertension 584 Patients Receiving Pharmacotherapy with Pharmacotherapy of Hypertension 585 Angiotensin-Converting Enzyme Inhibitors and Drugs for Initial Hypertension Therapy 586 Angiotensin Receptor Blockers 534 Adding Drugs to the Antihypertensive Regimen 587 Enhancing Patient Adherence 587 32 Diuretic Therapy and the Antihypertensives in African Americans 588 Pharmacotherapy of Chronic Kidney Drug Classes for Hypertension 588 Disease 539 PROTOTYPE DRUG: Hydralazine 593 Management of Hypertensive Emergency 594 Review of Renal Physiology 540 PROTOTYPE DRUG: Nitroprusside Sodium Pharmacotherapy for Patients with Chronic Kidney (Nitropress) 595 Disease 541 CONNECTIONS: Nursing Practice Application Diuretic Therapy 543 Patients Receiving Pharmacotherapy with Direct Loop (High-Ceiling) Diuretics 545 Vasodilators 596 PROTOTYPE DRUG: Furosemide (Lasix) 546 Thiazide and Thiazide-Like Diuretics 548 35 Pharmacotherapy of Angina Pectoris PROTOTYPE DRUG: Hydrochlorothiazide and Myocardial Infarction 602 (Microzide) 549 Pathophysiology of Myocardial Ischemia 603 Potassium-Sparing Diuretics 550 Myocardial Oxygen Supply 603 PROTOTYPE DRUG: Spironolactone Myocardial Oxygen Demand 603 (Aldactone) 551 Etiology of Coronary Artery Disease 604 Osmotic Diuretics 552 Pathophysiology of Angina Pectoris 604 PROTOTYPE DRUG: Mannitol (Osmitrol) 553 Nonpharmacologic Therapy of Coronary Artery Carbonic Anhydrase Inhibitors 554 Disease 605 PROTOTYPE DRUG: Acetazolamide (Diamox) 554 Pharmacologic Management of Angina Pectoris 606 A01_ADAM7366_04_SE_FM.indd Page 23 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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Drug Classes for Angina Pectoris 607 Anticoagulants 665 PROTOTYPE DRUG: Nitroglycerin (Nitrostat, PROTOTYPE DRUG: Heparin 666 Nitro-Bid, Nitro-Dur, Others) 609 PROTOTYPE DRUG: Warfarin (Coumadin) 669 PROTOTYPE DRUG: Atenolol (Tenormin) 611 PROTOTYPE DRUG: Dabigatran (Pradaxa) 671 Pathophysiology of Myocardial Infarction 612 CONNECTIONS: Nursing Practice Application Pharmacologic Management of Myocardial Patients Receiving Pharmacotherapy with Infarction 613 Anticoagulants 672 Aspirin 614 Antiplatelet Drugs 674 Anticoagulants and Antiplatelet Drugs 614 PROTOTYPE DRUG: Clopidogrel Nitrates 616 (Plavix) 675 Beta-Adrenergic Antagonists 616 PROTOTYPE DRUG: Abciximab (ReoPro) 677 Angiotensin-Converting Enzyme Inhibitors 616 Drugs for Intermittent Claudication 679 Pain Management 617 Thrombolytics 680 CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Alteplase (Activase) 681 Patients Receiving Pharmacotherapy with Organic CONNECTIONS: Nursing Practice Application Nitrates for Angina and Myocardial Infarction 617 Patients Receiving Pharmacotherapy with Thrombolytics 682 36 Pharmacotherapy of Heart Failure 622 Hemostatics 684 Etiology of Heart Failure 623 PROTOTYPE DRUG: Aminocaproic Acid Pathophysiology of Heart Failure 623 (Amicar) 684 Drugs for Hemophilia 686 Ventricular Hypertrophy 624 Activation of the Sympathetic Nervous System 625 Increased Plasma Volume and Preload 625 39 Pharmacotherapy of Hematopoietic Natriuretic Peptides and Neurohumoral Factors 625 Disorders 691 Pharmacologic Management of Heart Failure 626 Physiology of Hematopoiesis 692 Drugs for Heart Failure 627 Hematopoietic Growth Factors 692 PROTOTYPE DRUG: Digoxin (Lanoxin, PROTOTYPE DRUG: Epoetin Alfa (Epogen, Lanoxicaps) 632 Procrit) 693 PROTOTYPE DRUG: Milrinone (Primacor) 635 CONNECTIONS: Nursing Practice Application CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with Patients Receiving Pharmacotherapy for Heart Erythropoietin 696 Failure 635 PROTOTYPE DRUG: Filgrastim (Granix, Neupogen, Zarxio) 697 37 Pharmacotherapy of Dysrhythmias 641 CONNECTIONS: Nursing Practice Application Etiology of Dysrhythmias 642 Patients Receiving Pharmacotherapy with Colony- Phases and Measurement of the Cardiac Action Stimulating Factors 699 Potential 642 PROTOTYPE DRUG: Oprelvekin Classification of Dysrhythmias 645 (Neumega) 700 General Principles of Dysrhythmia Management 646 Classification of Anemias 702 Drugs for Dysrhythmias 646 Antianemic Drugs 703 Sodium Channel Blockers: Class I 647 PROTOTYPE DRUG: Ferrous Sulfate (Feosol, Feostat, Others) 705 PROTOTYPE DRUG: Procainamide 649 Beta-Adrenergic Antagonists: Class II 652 PROTOTYPE DRUG: Cyanocobalamin (Nascobal) 708 Potassium Channel Blockers: Class III 653 PROTOTYPE DRUG: Amiodarone (Pacerone) 653 Calcium Channel Blockers: Class IV 655 Unit 6 Pharmacology of Body Defenses CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy for 40 Review of Body Defenses and the Dysrhythmias 656 Immune System 714 Miscellaneous Antidysrhythmics 656 Organization of the Lymphatic System 715 Innate (Nonspecific) Body Defenses 715 38 Pharmacotherapy of Coagulation Inflammation 718 Disorders 661 Specific (Adaptive) Body Defenses 719 Disorders of Hemostasis 662 Humoral Immune Response 720 Overview of Coagulation Modifiers 664 Cell-Mediated Immune Response 720 A01_ADAM7366_04_SE_FM.indd Page 24 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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41 Pharmacotherapy of Inflammation Varicella Zoster 774 and Fever 723 Human Papillomavirus 775 Rotavirus 776 Pathophysiology of Inflammation and Fever 724 Passive Immunity 776 Pharmacotherapy of Inflammation 724 PROTOTYPE DRUG: Rho(D) Immune Globulin Nonsteroidal Anti-Inflammatory Drugs 725 (RhoGAM) 776 Salicylates 725 CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Aspirin (Acetylsalicylic Patients Receiving Immunizations 779 Acid) 728 Ibuprofen-Like Drugs 730 PROTOTYPE DRUG: Ibuprofen (Advil, Motrin, Unit 7 Pharmacology of the Respiratory Others) 731 System and Allergy Cyclooxygenase-2 Inhibitors 733 44 Pharmacotherapy of Asthma and Other PROTOTYPE DRUG: Celecoxib (Celebrex) 734 Antipyretic and Analgesic Drugs 735 Pulmonary Disorders 786 PROTOTYPE DRUG: Acetaminophen (Tylenol) 735 Physiology of the Lower Respiratory Tract 787 CONNECTIONS: Nursing Practice Application Pathophysiology of Asthma 788 Patients Receiving Pharmacotherapy for Administration of Pulmonary Drugs via Inflammation and Fever 737 Inhalation 788 Principles of Asthma Pharmacotherapy 790 42 Immunostimulants and PROTOTYPE DRUG: Albuterol (Proventil HFA, Immunosuppressants 741 Ventolin HFA, VoSpire ER) 792 PROTOTYPE DRUG: Ipratropium (Atrovent) 796 Immunostimulants 743 PROTOTYPE DRUG: Beclomethasone (Beconase PROTOTYPE DRUG: Interferon Alfa-2b (Intron A) 743 AQ, Qvar) 797 PROTOTYPE DRUG: Aldesleukin (Proleukin) 746 PROTOTYPE DRUG: Cromolyn 799 Immunosuppressants 747 PROTOTYPE DRUG: Montelukast (Singulair) 800 PROTOTYPE DRUG: Cyclosporine (Gengraf, Neoral, Sandimmune) 751 PROTOTYPE DRUG: Theophylline 802 Chronic Obstructive Pulmonary Disease 803 PROTOTYPE DRUG: Azathioprine (Azasan, Imuran) 753 CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy for Asthma PROTOTYPE DRUG: Basiliximab (Simulect) 755 and COPD 804 CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with Immunomodulators 757 45 Pharmacotherapy of Allergic Rhinitis and the Common Cold 810 43 Immunizing Agents 762 Physiology of the Upper Respiratory Tract 811 Discovery of Vaccines 763 Pathophysiology of Allergic Rhinitis 812 Vaccines and the Immune System 763 Pharmacotherapy of Allergic Rhinitis 813 Types of Vaccines 764 PROTOTYPE DRUG: Fexofenadine General Principles of Vaccine Administration 765 (Allegra) 816 Active Immunity: Bacterial Immunizations 766 PROTOTYPE DRUG: Fluticasone (Flonase, Diphtheria 766 Veramyst) 818 Pertussis (Whooping Cough) 766 CONNECTIONS: Nursing Practice Application Tetanus 768 Patients Receiving Pharmacotherapy with Antihistamines 819 Pneumococcus 768 Decongestants 822 Meningococcus 769 Active Immunity: Viral Immunizations 769 PROTOTYPE DRUG: Pseudoephedrine (Sudafed) 823 Hepatitis B 769 Drugs for the Common Cold 824 PROTOTYPE DRUG: Hepatitis B Vaccine Antitussives 825 (Engerix-B, Recombivax HB) 770 PROTOTYPE DRUG: Dextromethorphan (Delsym, Hepatitis A 771 Robitussin DM, Others) 826 Influenza 771 Expectorants and Mucolytics 826 Rabies 772 CONNECTIONS: Nursing Practice Application Measles, Mumps, and Rubella 772 Patients Receiving Pharmacotherapy for Polio 773 Symptomatic Cough and Cold Relief 827 A01_ADAM7366_04_SE_FM.indd Page 25 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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Unit 8 Pharmacology of Infectious and 48 Antibiotics Affecting Bacterial Protein Neoplastic Diseases Synthesis 868 Mechanisms of Antibiotic Inhibition of Bacterial 46 Basic Principles of Anti-Infective Protein Synthesis 869 Pharmacotherapy 834 Tetracyclines 870 Pathogenicity and Virulence 835 PROTOTYPE DRUG: Tetracycline (Sumycin, Describing and Classifying Bacteria 836 Others) 872 Classification of Anti-Infectives 836 Macrolides 874 Mechanisms of Action of Anti-Infectives 838 PROTOTYPE DRUG: Erythromycin (EryC, Inhibition of Cell Wall Synthesis 838 Erythrocin, Others) 875 Inhibition of Protein Synthesis 838 Aminoglycosides 876 Disruption of the Plasma Cell Membrane 839 PROTOTYPE DRUG: Gentamicin (Garamycin, Others) 878 Inhibition of Nucleic Acid Synthesis 839 Miscellaneous Inhibitors of Bacterial Protein Inhibition of Metabolic Pathways Synthesis 880 (Antimetabolites) 839 CONNECTIONS: Nursing Practice Application Other Mechanisms of Action 839 Patients Receiving Pharmacotherapy with a Acquired Resistance 839 Tetracycline, Macrolide, or Aminoglycoside Mechanisms of Resistance 839 Antibiotic 882 Promotion of Resistance 840 Prevention of Resistant Strains 841 49 Fluoroquinolones and Miscellaneous Indications and Selection of Specific Antibacterials 887 Anti-Infectives 844 Host Factors Affecting Anti-Infective Selection 844 Bacterial DNA Replication 888 Host Defenses 845 Inhibition of DNA Replication 888 Local Tissue Conditions 845 Fluoroquinolones 889 Allergy History 845 Adverse Effects 890 Other Host Factors 845 PROTOTYPE DRUG: Ciprofloxacin (Cipro) 891 Superinfections 845 Miscellaneous Antibacterials 893 CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with 47 Antibiotics Affecting the Bacterial Fluoroquinolones 895 Cell Wall 848 50 Sulfonamides and the Structure of Bacterial Cell Walls 849 Pharmacotherapy of Urinary Tract Penicillins 850 Natural Penicillins 852 Infections 900 PROTOTYPE DRUG: Penicillin G 852 Pathophysiology of Urinary Tract Infections 901 Broad-Spectrum Penicillins Pharmacotherapy of Urinary Tract Infections 901 (Aminopenicillins) 854 Acute Uncomplicated Cystitis 902 PROTOTYPE DRUG: Ampicillin 854 Complicated Urinary Tract Infection 902 Extended-Spectrum (Antipseudomonal) Infants and Children 903 Penicillins 855 Pregnancy 903 Penicillinase-Resistant (Antistaphylococcal) Older Adults 903 Penicillins 855 Patients with Recurring Urinary Tract Cephalosporins 856 Infections 904 PROTOTYPE DRUG: Cefazolin Sulfonamides 904 (Ancef, Kefzol) 858 Adverse Effects 906 Carbapenems 859 PROTOTYPE DRUG: Trimethoprim- PROTOTYPE DRUG: Imipenem-Cilastatin Sulfamethoxazole (Bactrim, Septra) 907 (Primaxin) 860 Urinary Antiseptics 908 Miscellaneous Cell Wall Inhibitors 862 PROTOTYPE DRUG: Nitrofurantoin (Furadantin) PROTOTYPE DRUG: Vancomycin (Vancocin) 862 and Nitrofurantoin Macrocrystals (Macrobid, CONNECTIONS: Nursing Practice Application Macrodantin) 908 Patients Receiving Pharmacotherapy with CONNECTIONS: Nursing Practice Application a Penicillin, Cephalosporin, or Vancomycin Patients Receiving Pharmacotherapy for Urinary Antibiotic 863 Tract Infection 910 A01_ADAM7366_04_SE_FM.indd Page 26 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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51 Pharmacotherapy of Mycobacterial Drugs for Herpesviruses 979 Infections 915 PROTOTYPE DRUG: Acyclovir (Zovirax) 980 Drugs for Influenza Viruses 982 Types of Mycobacterial Infections 916 PROTOTYPE DRUG: Amantadine (Symmetrel) 984 Pathogenesis and Diagnosis of Tuberculosis 916 Drugs for Hepatitis Viruses 985 Pharmacotherapy of Tuberculosis 918 PROTOTYPE DRUG: Tenofovir (Vemlidy, Viread) 989 Standard Regimen 919 CONNECTIONS: Nursing Practice Application Patients Who Are HIV Positive 921 Patients Receiving Pharmacotherapy with Pregnant Patients 921 Antivirals for Non-HIV Viral Infections 992 Chemoprophylaxis Patients 921 PROTOTYPE DRUG: Isoniazid (INH) 922 55 Pharmacotherapy of HIV Infection and CONNECTIONS: Nursing Practice Application AIDS 996 Patients Receiving Pharmacotherapy for Tuberculosis 927 Pathogenesis of HIV Infection 997 Drugs for Leprosy 928 General Principles of HIV Pharmacotherapy 999 PROTOTYPE DRUG: Dapsone (DDS) 929 Classification of Antiretroviral Drugs 1001 Drugs for Mycobacterium avium Complex Antiretroviral Drugs 1003 Infections 930 PROTOTYPE DRUG: Zidovudine (AZT, Retrovir) 1004 52 Pharmacotherapy of Fungal PROTOTYPE DRUG: Efavirenz (Sustiva) 1006 Infections 934 PROTOTYPE DRUG: Lopinavir with Ritonavir (Kaletra) 1008 Characteristics of Fungi and Fungal Infections 935 Prophylaxis of HIV Infections 1010 Drugs for Systemic Fungal Infections 938 CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Amphotericin B Deoxycholate Patients Receiving Pharmacotherapy with (Fungizone) 939 Antiretrovirals 1011 Drugs for Both Systemic and Superficial Fungal Pharmacotherapy of Opportunistic Infections Infections 941 Associated with HIV and AIDS 1015 PROTOTYPE DRUG: Fluconazole (Diflucan) 941 Drugs for Superficial Fungal Infections 943 56 Basic Principles of Antineoplastic PROTOTYPE DRUG: Nystatin (Nystop) 947 Therapy 1020 CONNECTIONS: Nursing Practice Application Characteristics of Cancer 1021 Patients Receiving Pharmacotherapy with Etiology of Cancer 1022 Antifungals 948 Detection and Prevention of Cancer 1023 Goals of Chemotherapy 1023 53 Pharmacotherapy of Protozoan and Staging and Grading of Cancer 1024 Helminthic Infections 952 The Cell Cycle and Growth Fraction 1025 Classification and Pathogenesis of Protozoan Cell Kill Hypothesis 1027 Infections 953 Improving the Success of Chemotherapy 1028 Drugs for Malaria 954 Combination Chemotherapy 1028 PROTOTYPE DRUG: Chloroquine (Aralen) 956 Dosing Schedules 1028 Drugs for Nonmalarial Protozoan Infections 958 Route of Administration 1028 PROTOTYPE DRUG: Metronidazole (Flagyl) 960 Toxicity of Antineoplastic Drugs 1029 Hematologic System 1029 PROTOTYPE DRUG: Pyrimethamine (Daraprim) 964 Classification and Pathogenesis of Helminthic Gastrointestinal Tract 1030 Infections 965 Cardiopulmonary System 1031 Drugs for Helminthic Infections 968 Urinary System 1031 PROTOTYPE DRUG: Mebendazole (Vermox) 968 Reproductive System 1031 CONNECTIONS: Nursing Practice Application Nervous System 1031 Patients Receiving Pharmacotherapy for Protozoan Skin and Soft Tissue 1032 and Helminthic Infections 970 Other Effects 1032

54 Pharmacotherapy of Non-HIV Viral 57 Pharmacotherapy of Neoplasia 1036 Infections 975 Classification of Antineoplastic Drugs 1037 Characteristics of Viruses 976 Antineoplastic Medications 1037 Pharmacotherapy of Non-HIV Viral Infections 978 Alkylating Agents 1037 A01_ADAM7366_04_SE_FM.indd Page 27 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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PROTOTYPE DRUG: Cyclophosphamide Miscellaneous Drugs Used for Peptic Ulcer Disease (Cytoxan) 1038 and Gastroesophageal Reflux Disease 1097 Antimetabolites 1043 CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Methotrexate (MTX, Patients Receiving Pharmacotherapy for Peptic Rheumatrex, Trexall) 1044 Ulcer Disease 1098 Antitumor Antibiotics 1048 PROTOTYPE DRUG: Doxorubicin 60 Pharmacotherapy of Bowel (Adriamycin) 1048 Disorders and Other Gastrointestinal Hormones and Hormone Antagonists 1051 Conditions 1103 PROTOTYPE DRUG: Tamoxifen 1053 Pathophysiology of Constipation 1104 Natural Products 1056 Pharmacotherapy with Laxatives 1105 PROTOTYPE DRUG: Vincristine (Marqibo, PROTOTYPE DRUG: Psyllium Mucilloid Oncovin) 1057 (Metamucil, Naturacil, Others) 1107 CONNECTIONS: Nursing Practice Application Pathophysiology of Diarrhea 1108 Patients Receiving Cancer Chemotherapy 1060 Pharmacotherapy of Diarrhea 1109 Biologic Response Modifiers and Targeted PROTOTYPE DRUG: Diphenoxylate with Atropine Therapies 1063 (Lomotil) 1110 Miscellaneous Antineoplastics 1066 CONNECTIONS: Nursing Practice Application Drugs for Reducing Adverse Effects 1069 Patients Receiving Pharmacotherapy with Preparing and Administering Antineoplastics 1069 Laxatives or Antidiarrheals 1111 Pharmacotherapy of Inflammatory Bowel Unit 9 Pharmacology of the Gastrointestinal Disease 1112 System PROTOTYPE DRUG: Sulfasalazine (Azulfidine) 1115 Pharmacotherapy of Irritable Bowel Syndrome 1117 58 Review of the Gastrointestinal Pathophysiology of Nausea and Vomiting 1118 System 1074 Pharmacotherapy of Nausea and Vomiting 1119 Overview of the Digestive System 1075 PROTOTYPE DRUG: Ondansetron (Zofran, Physiology of the Upper Gastrointestinal Zuplenz) 1123 Tract 1075 Pharmacotherapy of Pancreatitis 1123 Physiology of the Lower Gastrointestinal CONNECTIONS: Nursing Practice Application Tract 1077 Patients Receiving Pharmacotherapy with Antiemetics 1124 Physiology of the Accessory Organs of Digestion 1077 PROTOTYPE DRUG: Pancrelipase (Creon, Regulation of Digestive Processes 1079 Pancreaze, Zenpep) 1126 Nutrient Categories and Metabolism 1080 61 Vitamins and Minerals 1130 59 Pharmacotherapy of Peptic Ulcer Role of Vitamins in Health and Disease 1131 Disease 1082 Regulation of Vitamins 1132 Recommended Dietary Allowance 1133 Physiology of the Upper Gastrointestinal Tract 1083 Fat-Soluble Vitamins 1134 Etiology and Pathogenesis of Peptic Ulcer Disease 1084 Vitamin A (Aquasol A) 1134 Etiology and Pathogenesis of Gastroesophageal Reflux Vitamin D (Calcijex, Rocaltrol) 1135 Disease 1086 Vitamin E (Aquasol E, Vita-Plus E, Others) 1136 Pharmacotherapy of Peptic Ulcer Disease and Vitamin K (AquaMEPHYTON) 1136 Gastroesophageal Reflux Disease 1088 Water-Soluble Vitamins 1137

Pharmacotherapy with Proton Pump Thiamine: Vitamin B1 1137 Inhibitors 1088 Riboflavin: Vitamin B2 1138

PROTOTYPE DRUG: Omeprazole (Prilosec) 1090 Niacin: Vitamin B3 1138

Pharmacotherapy with H2-Receptor Antagonists Pyridoxine: Vitamin B6 1138 1092 Folic Acid (Folate): Vitamin B9 1139 PROTOTYPE DRUG: Ranitidine (Zantac) 1093 Cyanocobalamin: Vitamin B12 1140 Pharmacotherapy with Antacids 1094 Vitamin C: Ascorbic Acid 1140 PROTOTYPE DRUG: Aluminum Hydroxide Minerals 1141 (AlternaGEL, Others) 1095 CONNECTIONS: Nursing Practice Application Pharmacotherapy of Helicobacter pylori Patients Receiving Pharmacotherapy with Vitamin Infection 1096 or Mineral Supplements 1143 A01_ADAM7366_04_SE_FM.indd Page 28 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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62 Enteral and Parenteral Nutrition 1147 66 Pharmacotherapy of Diabetes Enteral Nutrition 1149 Mellitus 1200 Enteral Formulations 1149 Physiology of Serum Glucose Control 1201 Elements of Enteral Nutrition 1149 Pathophysiology of Diabetes Mellitus: Types of Complications of Enteral Therapy 1150 Diabetes 1202 Drug and Food Interactions 1152 Symptoms and Diagnosis of Diabetes 1203 Parenteral Nutrition 1152 Complications of Diabetes Mellitus 1204 Components of Total Parenteral Nutrition PROTOTYPE DRUG: Glucagon (GlucaGen) 1205 Solutions 1153 Insulin Therapy 1207 Complications of Parenteral Therapy 1154 Insulin Adjunct 1209 Drug and Food Interactions 1155 PROTOTYPE DRUG: Human Regular Insulin CONNECTIONS: Nursing Practice Application (Humulin R, Novolin R) 1209 Patients Receiving Pharmacotherapy with Enteral Antidiabetic Drugs for Type 2 Diabetes 1211 and Parenteral Nutrition 1156 CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with 63 Weight Reduction Strategies and the Insulin 1211 Pharmacotherapy of Obesity 1162 Sulfonylureas 1215 Etiology of Obesity 1163 PROTOTYPE DRUG: Glyburide (DiaBeta, Pathogenesis of Obesity 1164 Glynase) 1215 Measurement of Obesity 1164 Biguanides 1217 Nonpharmacologic Therapies for Obesity 1165 PROTOTYPE DRUG: Metformin (Glucophage, Pharmacotherapy of Obesity 1166 Glumetza, Others) 1217 PROTOTYPE DRUG: Orlistat (Alli, Xenical) 1168 Meglitinides 1218 Adjuncts to Obesity Therapy 1171 PROTOTYPE DRUG: Repaglinide (Prandin) 1218 Thiazolidinediones 1219 Unit 10 Pharmacology of the Endocrine PROTOTYPE DRUG: Rosiglitazone (Avandia) 1219 System Alpha-Glucosidase Inhibitors 1220 64 Review of the Endocrine System 1176 PROTOTYPE DRUG: Acarbose (Precose) 1220 Incretin Therapies 1221 Overview of the Endocrine System 1177 Hormone Receptors 1177 PROTOTYPE DRUG: Sitagliptin (Januvia) 1221 Negative Feedback Mechanisms 1178 Miscellaneous Antidiabetic Drugs 1223 Hormone Pharmacotherapy 1180 CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy for Type 2 Diabetes 1223 65 Hypothalamic and Pituitary Drugs 1183 67 Pharmacotherapy of Thyroid Functions of the Hypothalamus 1184 Disorders 1229 Functions of the Pituitary Gland 1185 Physiology of the Thyroid Gland 1230 Pharmacotherapy of Growth Hormone Diagnosis of Thyroid Disorders 1231 Disorders 1186 Pathophysiology of Hypothyroid Disorders 1232 PROTOTYPE DRUG: Somatropin (Genotropin, Pharmacotherapy of Hypothyroid Disorders 1233 Humatrope, Norditropin, Nutropin, Saizen, PROTOTYPE DRUG: Levothyroxine (Levothroid, Serostim, Zorbtive) 1188 Levoxyl, Synthroid, Unithroid) 1233 PROTOTYPE DRUG: Octreotide CONNECTIONS: Nursing Practice Application (Sandostatin) 1190 Patients Receiving Pharmacotherapy with Thyroid CONNECTIONS: Nursing Practice Application Hormone Replacements 1235 Patients Receiving Pharmacotherapy with Growth Pathophysiology of Hyperthyroid Hormone 1192 Disorders 1237 Pharmacotherapy of Antidiuretic Hormone Pharmacotherapy of Hyperthyroid Disorders 1193 Disorders 1237 PROTOTYPE DRUG: Desmopressin (DDAVP, PROTOTYPE DRUG: Propylthiouracil Noctiva, Stimate) 1194 (PTU) 1238 CONNECTIONS: Nursing Practice Application CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with Patients Receiving Pharmacotherapy with Antidiuretic Hormone 1196 Antithyroid Drugs 1240 A01_ADAM7366_04_SE_FM.indd Page 29 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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68 Corticosteroids and Drugs Affecting the Emergency Contraception 1300 Adrenal Cortex 1245 Drugs for Pharmacologic Abortion 1301 PROTOTYPE DRUG: Mifepristone (Mifeprex) 1302 Physiology of the Adrenal Gland 1246 Overview of Corticosteroid Pharmacotherapy 1247 71 Drugs for Disorders and Conditions of Adverse Effects of Corticosteroids 1248 Replacement Therapy with Corticosteroids 1250 the Male Reproductive System 1307 PROTOTYPE DRUG: Hydrocortisone (Cortef, Regulation of Male Reproductive Function 1308 Solu-Cortef, Others) 1252 Pharmacotherapy with Androgens 1308 Corticosteroids for Nonendocrine Conditions 1253 PROTOTYPE DRUG: Testosterone 1311 CONNECTIONS: Nursing Practice Application CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with Systemic Patients Receiving Pharmacotherapy with Corticosteroids 1255 Androgens 1312 Mineralocorticoids 1257 Anabolic Steroids 1313 PROTOTYPE DRUG: Fludrocortisone 1257 Etiology of Male Sexual Dysfunction 1314 Antiadrenal Drugs 1258 Pharmacotherapy of Male Infertility 1315 Pharmacotherapy of Erectile Dysfunction 1316 69 Estrogens, Progestins, and Drugs PROTOTYPE DRUG: Sildenafil (Viagra) 1317 Modifying Uterine Function 1262 Pathophysiology of Benign Prostatic Hyperplasia 1319 Pharmacotherapy of Benign Prostatic Hormonal Regulation of Female Reproductive Hyperplasia 1321 Function 1263 Estrogens 1263 PROTOTYPE DRUG: Finasteride (Proscar) 1322 CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Conjugated Estrogens Patients Receiving Pharmacotherapy for Benign (Cenestin, Enjuvia, Premarin) 1265 Prostatic Hyperplasia 1323 CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with Estrogen 1267 Unit 11 Additional Drug Classes Progestins 1267 PROTOTYPE DRUG: Medroxyprogesterone 72 Pharmacotherapy of Bone and Joint (Depo-Provera, Depo-SubQ-Provera, Provera) 1269 Disorders 1328 CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy with Role of Calcium in Body Homeostasis 1329 Progestin 1270 Regulation of Calcium Balance 1330 Hormone Replacement Therapy 1271 Pharmacotherapy of Calcium Imbalances 1332 Uterine Stimulants: Oxytocics 1273 Treatment of Hypocalcemia 1332 PROTOTYPE DRUG: Oxytocin (Pitocin) 1274 PROTOTYPE DRUG: Calcium Salts 1333 CONNECTIONS: Nursing Practice Application Treatment of Hypercalcemia 1334 Patients Receiving Pharmacotherapy with Oxytocin CONNECTIONS: Nursing Practice Application (Pitocin) 1276 Patients Receiving Pharmacotherapy for Uterine Relaxants: Tocolytics 1277 Osteoporosis 1335 Pharmacotherapy of Female Infertility and Female Pathophysiology of Metabolic Bone Disease 1336 Sexual Desire Disorder 1278 Pharmacotherapy of Metabolic Bone Disease 1338 PROTOTYPE DRUG: Clomiphene (Clomid, PROTOTYPE DRUG: Calcitriol (Calcijex, Serophene) 1281 Rocaltrol) 1338 PROTOTYPE DRUG: Alendronate (Fosamax) 1340 70 Drugs for Modifying Conception 1287 PROTOTYPE DRUG: Raloxifene (Evista) 1343 Options and Choices for Birth Control 1288 Pathophysiology and Pharmacotherapy of Joint Combination Oral Contraceptives 1288 Disorders 1345 PROTOTYPE DRUG: Estradiol and Norethindrone PROTOTYPE DRUG: Adalimumab (Humira) 1350 (Ortho-Novum, Others) 1292 Other DMARDS for Rheumatoid Arthritis 1351 Adverse Effects of Combination Oral Contraceptives 1293 CONNECTIONS: Nursing Practice Application Progestin-Only Oral Contraceptives 1295 Patients Receiving Pharmacotherapy for Long-Acting Reversible Contraceptives 1295 Rheumatoid Arthritis and Osteoarthritis 1353 Spermicides 1298 Pharmacotherapy of Gout and Hyperuricemia 1355 PROTOTYPE DRUG: Nonoxynol-9 1298 PROTOTYPE DRUG: Colchicine (Colcrys) 1356 CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Allopurinol (Lopurin, Patients Receiving Hormonal Contraceptives 1299 Zyloprim) 1357 A01_ADAM7366_04_SE_FM.indd Page 30 1/5/18 11:26 AM f-0036 /207/PH03350/9780134867366_ADAMS/ADAMS_CONNECTIONS_TO_NURSING_PRACTICE01_SE_97801 ...

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CONNECTIONS: Nursing Practice Application PROTOTYPE DRUG: Timolol (Betimol, Timoptic, Patients Receiving Pharmacotherapy for Gout 1359 Others) 1396 Miscellaneous Drugs for Treating Glaucoma 1398 73 Pharmacotherapy of Dermatologic CONNECTIONS: Nursing Practice Application Disorders 1364 Patients Receiving Pharmacotherapy for Glaucoma 1398 Anatomy of the Integumentary System 1365 Pharmacotherapy for Eye Examinations 1399 Classification of Skin Disorders 1367 Pharmacotherapy for Other Eye Conditions 1401 Pharmacotherapy of Skin Infections 1367 Anatomy of the Ear 1402 Scabicides and Pediculicides 1368 Pharmacotherapy with Otic Preparations 1402 PROTOTYPE DRUG: Permethrin (Acticin, Elimite, CONNECTIONS: Nursing Practice Application Nix) 1369 Patients Receiving Pharmacotherapy for Otitis 1405 Pharmacotherapy of Acne and Rosacea 1370 Acne Vulgaris 1370 75 Emergency Preparedness: Bioterrorism CONNECTIONS: Nursing Practice Application Patients Receiving Pharmacotherapy for Lice or and Management of Poisoning 1409 Mite Infestation 1371 Emergency Preparedness, Bioterrorism, and Rosacea 1373 Nursing 1410 PROTOTYPE DRUG: Tretinoin (Avita, Retin-A, Biologic Agents 1412 Others) 1373 Chemical and Physical Agents 1414 CONNECTIONS: Nursing Practice Application Management of Poisoning 1416 Patients Receiving Pharmacotherapy for Acne and PROTOTYPE DRUG: Activated Charcoal Related Skin Conditions 1375 (CharcoAid) 1418 Pharmacotherapy of Dermatitis 1376 PROTOTYPE DRUG: Edetate Calcium Disodium Pharmacotherapy of Psoriasis 1378 (Calcium EDTA) 1419 Topical Drugs 1381 PROTOTYPE DRUG: Dimercaprol (BAL in Oil) 1419 Systemic Drugs 1381 CONNECTIONS: Nursing Practice Application Pharmacotherapy of Minor Skin Burns 1383 Patients Receiving Pharmacotherapy for Poisoning PROTOTYPE DRUG: Benzocaine (Americaine, or Overdose 1420 Anbesol, Others) 1384 Pharmacotherapy of Alopecia 1385 Appendices A Answers to Chapter Review 1425 74 Pharmacotherapy of Eye and Ear B ISMP List of High-Alert Medications in Acute Care Disorders 1389 Settings 1457 Anatomy of the Eye 1390 Glossary 1458 Pathophysiology of Glaucoma 1392 Credits 1477 Pharmacotherapy of Glaucoma 1393 PROTOTYPE DRUG: Latanoprost (Xalatan) 1393 Index 1478