mosby's 2011 nursing drug reference 24e samplechapter

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Mosby’s 2011 Nursing Drug ReferenceLinda Skidmore-Roth, RN, MSN, NP

Available via Skyscape: www.skyscape.com

Bonus material includes:

• Nursing drug dosage calculations

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• And more!

Take drug information with you on the job! Powered by Skyscape, this PDA software offers instant access to all of the content found in Mosby’s 2011 Nursing Drug Reference – with key information on more than 1,300 generic and 4,500 trade-name drugs, thousands of new drug facts, and approximately 25 drugs recently approved by the FDA.

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Linda Skidmore-Roth, RN, MSN, NPConsultant

Littleton, Colorado

Formerly, Nursing FacultyNew Mexico State University

Las Cruces, New Mexico;El Paso Community College

El Paso, Texas

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Mosby’s 2011 Nursing Drug Reference, 24e Skidmore Roth MOSBY An imprint of Elsevier 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103‐2899 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. All rights reserved. No part of this publication may by reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information retrieval system, without written permission from the publisher. Original ISBN: 978‐0‐323‐06918‐2 This edition of Mosby’s 2011 Nursing Drug Reference, 24e by Linda Skidmore‐Roth, RN, MSN, NP is published by an arrangement with Elsevier Inc. Indian Reprint ISBN: 978‐81‐312‐2844‐9 First Reprinted in India 2011 Published by Elsevier, a division of Reed Elsevier India Private Limited. Registered Office: 622, Indraprakash Building, 21 Barakhamba Road, New Delhi‐110001. Corporate Office: 14th Floor, Building No. 10B, DLF Cyber City, Phase‐II, Gurgaon‐122 002, Haryana, India. Printed and bound in India at Sanat Printers, (Kundli).

This edition is for sale in Bangladesh, Bhutan, India, Maldives, Nepal,

Pakistan and Sri Lanka only. This edition is not authorized for export outside these territories.

Circulation of this edition outside these territories is unauthorized and illegal.

Restricted South Asia Edition

Notice

Medical Knowledge is constantly changing. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered, to verify the recommended dose, the method and the duration of administration, and the contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the Publisher nor the Authors assume any liability for any injury and/or damage to persons or property arising from this publication.

The Publisher

Consultants

Timothy L. Brenner, PharmD,

BCOP

Clinical Pharmacy SpecialistUPMC Cancer CentersPittsburgh, Pennsylvania

Claudia Chiesa, PhD

Marana, Arizona

David S. Chun, PharmD, BCPS

Richmond Heights, Missouri

Jeffrey J. Fong, PharmD, BCPS

Assistant Professor of Pharmacy PracticeMassachusetts College of Pharmacy and

Health SciencesWorcester, Massachusetts

Amanda Gross, RPh

Clinical PharmacistUniversity of Colorado HospitalAurora, Colorado

Dana H. Hamamura,PharmD

Clinical Pharmacist, EmergencyDepartment

University of Colorado HospitalAurora, Colorado

Rose Knapp, DNP, RN, APRN-C

Assistant Professor of Nursing/Pharmacology

New York UniversityNew York, New York

Michael J. Koronkowski,PharmD, CGP

Clinical Assistant Professor, GeriatricsUniversity of Illinois, College of

PharmacyChicago, Illinois

Shalini S. Lynch, PharmD

Assistant Clinical Professor of PharmacyUniversity of California, San Francisco

School of PharmacySan Francisco, California

Michele Matthews, PharmD

Assistant ProfessorMassachusetts College of PharmacyClinical PharmacistBrigham and Women’s HospitalBoston, Massachusetts

Sandra Meeker, MSN, RN

Assistant ProfessorUniversity of Mary Hardin BaylorBelton, Texas

Joshua J. Neumiller,PharmD, CDE, CGP, FASCP

Assistant ProfessorWashington State UniversitySpokane, Washington

Christopher T. Owens,PharmD, BCPS

Associate Professor and ChairIdaho State University College of

PharmacyPocatello, Idaho

v

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Brenda Pavill, PhD, RN, FNP,

IBCLC

Associate ProfessorUniversity of North Carolina at

WilmingtonWilmington, North Carolina

Adam B. Pesaturo, PharmD,

BCPS

Critical Care PharmacistBaystate Medical CenterSpringfield, Massachusetts

Kimberly A. Pesaturo,PharmD, BCPS



Sarah Reidunn Pool, MS, RN

Nurse ManagerMayo ClinicRochester, Minnesota

Randolph Eldon Regal, BS,

PharmD, RPh

Clinical Associate ProfessorAdult Internal MedicineUniversity of MichiganAnn Arbor, Michigan

Sheila M. Seed, PharmD, RPh,

MPH



Stephen M. Setter, PharmD,

DVM, CDE, CGP, FASCP

Associate Professor of PharmacotherapyElder Services/Visiting Nurses

AssociationWashington State UniversitySpokane, Washington

Travis E. Sonnett, PharmD

Clinical Assistant ProfessorWashington State UniversityPullman, Washington

Patricia R. Teasley, MSN, RN

Nursing Programs CoordinatorProfessorCentral Texas CollegeKilleen, Texas

Juanita C. Widener, MAEd,

BSN, RN

Instructor of NursingBainbridge CollegeBainbridge, Georgia

vi Consultants

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Preface

Since the first publication of Mosby’s Nursing Drug Reference in 1988, more than100 U.S. and Canadian pharmacists and consultants have reviewed the book’s contentclosely. Today, Mosby’s 2011 Nursing Drug Reference is more up to date than ever—with features that make it easy to find critical information fast!

New Features• Twenty-five recent FDA-approved drugs located throughout the book and in Appen-

dix A (see Table of Contents for a complete list). Included are monographs for:• asenapine (Saphris)—used for schizophrenia• dronedarone (Multaq)—used for atrial fibrillation or atrial flutter• everolimus (Affinitor)—used for advanced renal cell carcinoma• pitavastatin (Livalo)—used for hypercholesterolemia• telavancin (Vibatin)—used for complicated gram-positive infections

• A companion CD-ROM that offers complete and printable monographs for 100 ofthe most commonly prescribed drugs in the United States, numerous patient teach-ing guides in English and Spanish for these same drugs, hundreds of normal labo-ratory values, an English-to-Spanish guide for drug phrases and terms, 30 calcula-tors, and Canadian resources

New FactsThis edition features more than 2000 new drug facts, including:• New drugs and new dosage information• Newly researched side effects and adverse reactions• New Black Box Warnings• The latest precautions, interactions, and contraindications• IV therapy updates• Revised nursing considerations• Updated patient/family teaching guidelines

OrganizationThis reference is organized into four main sections:• Drug categories• Full-color insert• Individual drug monographs (in alphabetical order by generic name)• Appendixes (identified by the wide, dark blue thumb tabs on the edge)

The guiding principle behind this book is to provide fast, easy access to drug informa-tion and nursing considerations. Every detail—from the paper, typeface, cover, bind-ing, use of color, and appendixes—has been carefully chosen with the user in mind.

vii

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Color InsertThis insert features 14 detailed, four-color illustrations to help enhance the understand-ing of the mechanism or site of action for the following select drugs and drug classes:• ACE inhibitors• Adrenocortical steroids• Antidepressants• Antidiabetic agents• Antifungal agents• Antiinfective agents• Antiplatelet agents• Antiretroviral agents• Benzodiazepines• Diuretics• Drugs used to treat GERD• Narcotic agonist-antagonist analgesics• Narcotic analgesics• Sympatholytics

Also included in the color insert are the 2010 recommended childhood and adoles-cent immunization schedules for the United States.

Individual Drug MonographsThis book contains monographs for more than 1300 generic and 4500 trade medica-tions. Common trade names are given for all drugs regularly used in the United Statesand Canada, with drugs available only in Canada identified by a maple leaf .

The following information is provided, whenever possible, for safe, effective ad-ministration of each drug:

High-alert status: Identifies high-alert drugs with a label and icon. Visit theInstitute for Safe Medication Practices (ISMP) at http://www.ismp.org/tools/highalertmedications.pdf for a list of medications and drug classes with the greatestpotential for patient harm if they are used in error.

‘‘Tall Man’’ lettering: Uses the capitalization of distinguishing letters to avoidmedication errors and is required by the FDA for drug manufacturers.

Pronunciation: Helps the nurse master complex generic names.]/OTC: Identifies prescription or over-the-counter drugs.Functional and chemical classifications: Allows the nurse to see similarities

and dissimilarities among drugs in the same functional but different chemical classes.Controlled-substance schedule: Includes schedules for the United States and

Canada.Do not confuse: Presents drug names that might easily be confused, within each

appropriate monograph.Action: Describes pharmacologic properties concisely.Uses: Lists the conditions the drug is used to treat.Unlabeled uses: Describes drug uses that may be encountered in practice but

are not yet FDA-approved.Dosages and routes: Lists all available and approved dosages and routes for

adult, pediatric, and geriatric patients.Available forms: Includes tablets, capsules, extended-release, injectables (IV,

IM, SUBCUT), solutions, creams, ointments, lotions, gels, shampoos, elixirs, suspen-sions, suppositories, sprays, aerosols, and lozenges.

viii Preface

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Side effects: Groups these reactions by alphabetical body system, with commonside effects italicized and life-threatening reactions (those that are potentially fataland/or permanently disabling) in bold type for emphasis.

Contraindications: Lists conditions under which the drug absolutely should notbe given, including FDA pregnancy safety categories D or X.

Precautions: Lists conditions that require special consideration when the drugis prescribed, including FDA pregnancy safety categories A, B, or C.

Black box warnings: Identifies FDA warnings that highlight serious and life-threatening adverse effects.

Pharmacokinetics: Outlines metabolism, distribution, and elimination.Interactions: Includes confirmed drug interactions, followed by the drug or

nutrient causing that interaction, when applicable.Drug/herb: Highlights more than 400 potential interactions between herbal prod-

ucts and prescription or OTC drugs.Drug/food: Identifies many common drug interactions with foods.Drug/lab test: Identifies how the drug may affect lab test results.Nursing considerations: Identifies key nursing considerations for each step of

the nursing process: Assess, Administer, Perform/Provide, Evaluate, and Teach Patient/Family. Instructions for giving drugs by various routes (e.g., PO, IM, IV) are included,with route subheadings in bold.

Compatibilities: Lists syringe, Y-site, and additive compatibilities and incompat-ibilities. If no compatibilities are listed for a drug, the necessary compatibility testinghas not been done and that compatibility information is unknown. To ensure safety,assume that the drug may not be mixed with other drugs unless specifically stated.

‘‘Nursing Alert’’ icon : Highlights a critical consideration.Treatment of overdose: Provides drugs and treatment for overdoses where

appropriate.

AppendixesSelected new drugs: Includes comprehensive information on 22 key drugs ap-proved by the FDA during the last 12 months.

Ophthalmic, otic, nasal, and topical products: Provides essential informa-tion for more than 140 ophthalmic, otic, nasal, and topical products commonly usedtoday, grouped by chemical drug class.

Vaccines and toxoids: Features an easy-to-use table with generic and tradenames, uses, dosages and routes, and contraindications for 39 key vaccines andtoxoids.

Antitoxins and antivenins: Provides names, uses, dosages, and contraindica-tions.

Combination products: Provides details on the forms and uses of more than550 combination products.

FDA pregnancy categories: Explains the five FDA pregnancy categories.Abbreviations: Lists abbreviations alphabetically with their meanings.

Preface ix

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I am indebted to the nursing and pharmacology consultants who reviewed the manu-script and thank them for their criticism and encouragement. I would also like tothank Nancy O’Brien and Angela Perdue, my editors, whose active encouragementand enthusiasm have made this book better than it might otherwise have been. I amlikewise grateful to Joy Moore and Graphic World Inc. for the coordination of theproduction process and assistance with the development of the new edition.

Linda Skidmore-Roth

x Preface

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Contents

Drug categories, 1

α-Adrenergic blockers, 1Anesthetics—general/local, 1Antacids, 2Anti-Alzheimer agents, 4Antianginals, 4Antianxiety agents, 6Antiasthmatics, 7Anticholinergics, 9Anticoagulants, 10Anticonvulsants, 11Antidepressants, 12Antidiabetics, 14Antidiarrheals, 15Antidysrhythmics, 16Antiemetics, 17Antifungals (systemic), 18Antihistamines, 20Antihypertensives, 21Antiinfectives, 23Antilipidemics, 24Antineoplastics, 25Antiparkinson agents, 28Antiplatelets, 29Antipsychotics, 29Antipyretics, 31

Antiretrovirals, 32Antituberculars, 33Antitussives/expectorants, 34Antivirals, 35β-Adrenergic blockers, 36Bone resorption inhibitors, 37Calcium channel blockers, 38Cardiac glycosides, 39Cholinergics, 40Cholinergic blockers, 41Corticosteroids, 42Diuretics, 44Histamine H2 antagonists, 46Immunosuppressants, 46Laxatives, 47Neuromuscular blocking agents, 48Nonsteroidal antiinflammatories, 49Opioid analgesics, 50Salicylates, 52Sedatives/hypnotics, 53Skeletal muscle relaxants, 54Thrombolytics, 55Thyroid hormones, 56Vasodilators, 58Vitamins, 59

Color insertMechanisms and sites of action illustrations, 60Recommended 2010 United States immunization schedule for persons

aged 0-6 years, 75Recommended 2010 United States immunization schedule for persons

aged 7-18 years, 76

Individual drugs, 77

Continued

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Appendixes, 1194

A. Selected new drugs, 1194abobotulinumtoxinAasenapinecanakinumabdexlansoprazoledronedaroneeltrombopageverolimusfebuxostatfenofibric acidferumoxytolfibrinogen, concentrate, humanfospropofolgolimumab

hylan G-F 20iloperidonepitavastatinplerixaforpralatrexateprasugrelsaxagliptintapentadoltelavancintolvaptanustekinumabvigabatrin

B. Ophthalmic, otic, nasal, and topical products, 1199C. Vaccines and toxoids, 1213D. Antitoxins and antivenins, 1219E. Combination products, 1220F. FDA pregnancy categories, 1251G. Abbreviations, 1252

Index, 1255

Evolve Website• Bibliography• Calculators for Drug Dosages• Canadian Resources (high-alert Canadian medication, Canadian controlled

substance chart, Canadian recommended immunization schedule for infantsand children)

• Color Pill Atlas• Content Updates• Controlled Substance Chart• Drug Monographs• Drug Name Safety• Drugs Metabolized by Known P450s• English-to-Spanish Translations• FDA Alerts• Herbal Products• Medications that May Be Inappropriate for Geriatric Patients• Orphan Drugs and Biologicals• Patient Teaching Guidelines• Recently Approved Drugs• Safety in Handling Chemotherapeutic Agents• Selected Prescription Drugs with Potential for Abuse• Weblinks• Weights and Equivalents

xii Contents

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�-ADRENERGIC BLOCKERS

Action: α-Adrenergic blockers actby binding to α-adrenergic recep-tors, causing dilation of peripheralblood vessels. Lowers peripheral re-sistance, resulting in decreased B/P.Uses: α-adrenergic blockers areused for benign prostatic hyperpla-sia, pheochromocytoma, preventionof tissue necrosis and sloughing asso-ciated with extravasation of IV vaso-pressors.Side effects: The most commonside effects are hypotension, tachycar-dia, nasal stuffiness, nausea, vomit-ing, and diarrhea.Contraindications: Hypersensi-tive reactions may occur, and aller-gies should be identified before theseproducts are given. Patients with MI,coronary insufficiency, angina, orother evidence of CAD should not usethese products.Pharmacokinetics: Onset, peak,and duration vary among products.Interactions: Vasoconstrictive andhypertensive effects of epinephrineare antagonized by α-adrenergicblockers.Possible nursing diagnoses:• Risk for injury [adverse reac-tions]• Sleep deprivation [adverse reac-tions]• Ineffective tissue perfusion [uses]• Impaired urinary elimination[uses]

Nursing Considerations

Assess:• Electrolytes: K, Na, Cl, CO2

• Weight daily, I&O

• B/P lying, standing before startingtreatment, q4hr thereafter• Nausea, vomiting, diarrhea• Skin turgor, dryness of mucousmembranes for hydration statusAdminister:• Starting with low dose, graduallyincreasing to prevent side effects• With food or milk for GI symp-tomsEvaluate:• Therapeutic response: decreasedB/P, increased peripheral pulsesTeach patient/family:• To avoid alcoholic beverages• To report dizziness, palpitations,fainting• To change position slowly or faint-ing may occur• To take product exactly as pre-scribed• To avoid all OTC products (cough,cold, allergy) unless directed by pre-scriber

Selected Generic Names

phentolamine� 1 blockerssilodosintamsulosin

ANESTHETICS—GENERAL/LOCAL

Action: Anesthetics (general) act onthe CNS to produce tranquilizationand sleep before invasive procedures.Anesthetics (local) inhibit conduc-tion of nerve impulses from sensorynerves.Uses: General anesthetics are usedto premedicate for surgery, induc-tion and maintenance in general an-esthesia. For local anesthetics, refer

anesthetics—general/local 1

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to individual product listing for indi-cations.Side effects: The most commonside effects are dystonia, akathisia,flexion of arms, fine tremors, drows-iness, restlessness, and hypotension.Also common are chills, respiratorydepression, and laryngospasm.Contraindications: Persons withcerebrovascular accident, increasedintracranial pressure, severe hyper-tension, cardiac decompensationshould not use these products sincesevere adverse reactions can occur.Precautions: Anesthetics (general)should be used with caution inthe geriatric, CVD (hypotension,bradydysrhythmias), renal/hepaticdisease, Parkinson’s disease, children<2 yr. The precaution for anesthetics(local) is pregnancy.Pharmacokinetics: Onset, peak,and duration vary widely amongproducts. Most products are metabo-lized in the liver and excreted inurine.Interactions: MAOIs, tricyclics,phenothiazines may cause severe hy-potension or hypertension when usedwith local anesthetics. CNS depres-sants will potentiate general and lo-cal anesthetics.Possible nursing diagnoses:General:• Risk for injury [adverse reac-tions]• Deficient knowledge [teaching]Local:• Deficient knowledge [teaching]• Acute pain [uses]


Assess:• VS q10min during IV administra-tion, q30min after IM dose

Administer:• Anticholinergic preoperatively todecrease secretions• Only with crash cart, resuscitativeequipment nearbyPerform/provide:• Quiet environment for recovery todecrease psychotic symptomsEvaluate:• Therapeutic response: mainte-nance of anesthesia, decreased pain

Selected Generic Names(Injectables Only)

General anestheticsdroperidoletomidatefentanylfentanyl/droperidolfentanyl transdermalfospropofolmidazolampropofolthiopentalLocal anestheticslidocaineprocaineropivacainetetracaine

ANTACIDS

Action: Antacids are basic com-pounds that neutralize gastric acidityand decrease the rate of gastric emp-tying. Products are divided into thosecontaining aluminum, magnesium,calcium, or a combination of these.Uses: Antacids decrease hyperacid-ity in conditions such as peptic ulcerdisease, reflux esophagitis, gastritis,and hiatal hernia.Side effects: The most commonside effect caused by aluminum-containing antacids is constipation,

2 antacids



which may lead to fecal impac-tion and bowel obstruction. Diar-rhea occurs often when magnesiumproducts are given. Alkalosis mayoccur when systemic products areused. Constipation occurs more fre-quently than laxation with calciumcarbonate. The release of CO2 fromcarbonate-containing antacids causesbelching, abdominal distention, andflatulence. Sodium bicarbonate mayact as a systemic antacid and pro-duce systemic electrolyte distur-bances and alkalosis. Calcium car-bonate and sodium bicarbonate maycause rebound hyperacidity and milk-alkali syndrome. Alkaluria may oc-cur when products are used on along-term basis, particularly in per-sons with abnormal renal function.Contraindications: Sensitivity toaluminum or magnesium productsmay cause hypersensitive reactions.Aluminum products should not beused by persons sensitive to alumi-num; magnesium products shouldnot be used by persons sensitive tomagnesium. Check for sensitivity be-fore administering.Precautions: Magnesium productsshould be given cautiously to patientswith renal insufficiency, and duringpregnancy and breastfeeding. Sodiumcontent of antacids may be signifi-cant; use with caution for patientswith hypertension, congestive heartfailure, or those on a low-sodiumdiet.Pharmacokinetics: Duration is20-40 min. If ingested 1 hr after meals,acidity is reduced for at least 3 hr.Interactions: Products whose ef-fects may be increased by some ant-acids: quinidine, amphetamines,pseudoephedrine, levodopa, valproicacid, dicumarol. Products whose ef-

fects may be decreased by some ant-acids: cimetidine, corticosteroids,ranitidine, iron salts, phenothi-azines, phenytoin, digoxin, tetracy-clines, ketoconazole, salicylates, iso-niazid.Possible nursing diagnoses:• Constipation [adverse reactions]• Diarrhea [adverse reactions]• Chronic pain [uses]


Assess:• Aggravating and alleviating factorsof epigastric pain or hyperacidity;identify the location, duration, andcharacteristics of epigastric pain• GI symptoms, including constipa-tion, diarrhea, abdominal pain; if se-vere abdominal pain with fever oc-curs, these products should not begiven• Renal symptoms, including in-creasing urinary pH, electrolytesAdminister:• Not to take other products within1-2 hr of antacid administration,since antacids may impair absorp-tion of other products• All products with an 8-oz glass ofwater to ensure absorption in thestomach• Another antacid if constipation oc-curs with aluminum productsEvaluate:• Therapeutic response: absence ofepigastric pain, and decreased acid-ity


aluminum hydroxidebismuth subsalicylatecalcium carbonatemagaldratemagnesium oxidesodium bicarbonate

antacids 3



ANTI-ALZHEIMER AGENTS

Action: Anti-Alzheimer agents im-prove cognitive functioning by in-creasing acetylcholine and inhibitingcholinesterase in the CNS. Do notcure condition, but improve symp-toms.Uses: Anti-Alzheimer agents are usedfor the treatment of Alzheimer’ssymptoms.Side effects: The most commonside effects are nausea, vomiting, di-arrhea, dry mouth, insomnia, dizzi-ness, as well as urinary frequency, in-continence, and rash. The most seri-ous side effects are seizures anddysrhythmias.Contraindications: Persons withhypersensitivity reactions should notuse these products.Precautions: Anti-Alzheimer agentsshould be used cautiously in preg-nancy (C), breastfeeding, sick sinussyndrome, GI bleeding, bladder ob-struction, and seizures.Pharmacokinetics: Onset, peak,and duration vary widely amongproducts. Most products are metabo-lized in the liver and excreted by thekidneys.Interactions: Increased synergis-tic reactions may occur with succinyl-choline, cholinesterase inhibitors,and cholinergic agonists. There maybe a decrease in the action of anti-cholinergics, and there may be addi-tive effects when used with choliner-gic agents.Possible nursing diagnoses:• Chronic confusion [uses]• Deficient knowledge [teaching]• Noncompliance [teaching]


Assess:• B/P, hypotension, hypertension• Mental status: affect, mood, behav-ioral changes, depression, confusion• GI status: nausea, vomiting, an-orexia, diarrhea• GU status: urinary frequency, in-continenceAdminister:• Lowest possible dose for therapeu-tic result; adjust dose to responsePerform/provide:• Assistance with ambulation duringbeginning therapy if dizziness, ataxiaoccurEvaluate:• Therapeutic response: decrease inconfusion, improved moodTeach patient/family:• To report side effects, adverse re-actions to health care provider• To use exactly as prescribed, atregular intervals• Not to increase or abruptly de-crease dose; serious consequencesmay result• That product is not a cure, but re-lieves symptoms


donepezilgalanthaminememantinerivastigmine

ANTIANGINALS

Action: Antianginals are divided intothe nitrates, calcium channel block-ers, and β-adrenergic blockers. Thenitrates dilate coronary arteries, caus-ing decreased preload, and dilate sys-temic arteries, causing decreased af-

4 anti-Alzheimer agents



terload. Calcium channel blockers di-late coronary arteries and decreaseSA/AV node conduction. β-Adrenergicblockers decrease heart rate so thatmyocardial O2 use is decreased. Dipyr-idamole selectively dilates coronary ar-teries to increase coronary blood flow.Uses: Antianginals are used inchronic stable angina pectoris, unsta-ble angina, vasospastic angina. Some(i.e., calcium channel blockers andβ-blockers) may be used for dys-rhythmias and in hypertension.Side effects: The most commonside effects are postural hypotension,headache, flushing, dizziness, nausea,edema, and drowsiness. Also commonare rash, dysrhythmias, and fatigue.Contraindications: Persons withknown hypersensitivity, increased in-tracranial pressure, or cerebral hem-orrhage should not use some of theseproducts.Precautions: Antianginals shouldbe used with caution in postural hy-potension, pregnancy, breastfeeding,children, renal disease, and hepaticinjury.Pharmacokinetics: Onset, peak,and duration vary widely among cor-onary products. Most products aremetabolized in the liver and excretedin urine.Interactions: Interactions varywidely among products. Check indi-vidual monographs for specific infor-mation.Possible nursing diagnoses:• Decreased cardiac output [adversereactions]• Risk for injury [uses]• Deficient knowledge [teaching]• Acute pain [uses]• Ineffective tissue perfusion [uses]


Assess:• Orthostatic B/P, pulse• Pain: duration, time started, activ-ity being performed, character• Tolerance if taken over long period• Headache, light-headedness, de-creased B/P; may indicate a need fordecreased dosagePerform/provide:• Storage protected from light, mois-ture; place in cool environmentEvaluate:• Therapeutic response: decrease,prevention of anginal painTeach patient/family:• To keep tabs in original container• Not to use OTC products unless di-rected by prescriber• To report bradycardia, dizziness,confusion, depression, fever• To take pulse at home, advise whento notify prescriber• To avoid alcohol, smoking, sodiumintake• To comply with weight control, di-etary adjustments, modified exerciseprogram• To carry emergency ID to identifyproduct that you are taking, allergies• To make position changes slowlyto prevent fainting


Nitratesamyl nitriteisosorbidenitroglycerin�-Adrenergic blockersatenololdipyridamolemetoprololnadololpropranolol

antianginals 5



Calcium channel blockersamlodipinebepridildiltiazemniCARdipineNIFEdipineverapamilMiscellaneousranolazine

ANTIANXIETY AGENTS

Action: Benzodiazepines potentiatethe action of GABA, including anyother inhibitory transmitters in theCNS resulting in decreased anxiety.Most agents cause a decrease in CNSexcitability.Uses: Anxiety is relieved in condi-tions such as generalized anxiety dis-order and phobic disorders. Benzo-diazepines are also used for acute al-cohol withdrawal to prevent deliriumtremens, and some products are usedfor relaxation before surgery.Side effects: The most commonside effects are dizziness, drowsiness,blurred vision, and orthostatic hypo-tension. Most adverse reactions aremediated through the CNS. There isthe potential for abuse and physicaldependence with some products.Contraindications: These prod-ucts are contraindicated in hypersen-sitivity, acute closed-angle glaucoma,children <6 mo, hepatic disease(clonazepam), and breastfeeding (di-azepam).Precautions: Antianxiety agentsshould be used cautiously in geriat-ric or debilitated patients. Usuallysmaller doses are needed since me-tabolism is slowed. Persons withrenal/hepatic disease may show de-

layed excretion. Clonazepam may in-crease the incidence of seizures.Pharmacokinetics: Most of theseagents are metabolized by the liverand excreted via the kidneys.Interactions: Increased CNS de-pression may occur when given withother CNS depressants. These prod-ucts should be used together cau-tiously. Alcohol should not be used,as fatal reactions have occurred. Theserum concentration and toxicity maybe increased when used with benzo-diazepines.Possible nursing diagnoses:• Anxiety [uses]• Risk for injury [adverse reac-tions]• Deficient knowledge [teaching]


Assess:• B/P (lying and standing), pulse; ifsystolic B/P drops 20 mm Hg, holdproduct and notify prescriber; ortho-static hypotension can be severe• Hepatic/renal studies: AST, ALT, bil-irubin, creatinine, LDH, alk phos• Physical dependency and with-drawal with some products, includ-ing headache, nausea, vomiting, mus-cle pain, and weakness after long-term useAdminister:• With food or milk for GI symp-toms; may give crushed if patient isunable to swallow whole (tabs only,no controlled- or sustained-releaseproducts)Evaluate:• Therapeutic response: decreasedanxiety, increased relaxationTeach patient/family:• That product should not be usedfor everyday stress or long-term use;not to take more than prescribed

6 antianxiety agents



amount since product is habit form-ing• To avoid driving and activities thatrequire alertness since drowsinessand dizziness may occur• To abstain from alcohol, other psy-chotropic medications unless di-rected by prescriber• Not to discontinue abruptly; afterextended periods, withdrawal symp-toms may occur


BenzodiazepinesalprazolamchlordiazepoxideclonazepamdiazepamlorazepammidazolamoxazepinetemazepinetriazolamMiscellaneousbusPIRonedoxepinhydrOXYzinemeprobamateparoxetinevenlafaxine

ANTIASTHMATICS

Action: Bronchodilators are dividedinto anticholinergics, α/β-adrenergicagonists, β-adrenergic agonists, andphosphodiesterase inhibitors. Also in-cluded in antiasthmatic agents arecorticosteroids, leukotriene antago-nists, mast cell stabilizers, and mono-clonal antibodies. Anticholinergicsact by inhibiting interaction ofacetylcholine at receptor sites onbronchial smooth muscle. α/β-

Adrenergic agonists act by relaxingbronchial smooth muscle and in-creasing diameter of nasal passages.β-Adrenergic agonists act by actionon β2-receptors, which relaxes bron-chial smooth muscle. Phosphodies-terase inhibitors act by blockingphosphodiesterase and increasingcAMP, which mediates smooth mus-cle relaxation in the respiratory sys-tem. Corticosteroids act by decreas-ing inflammation in the bronchial sys-tem. Leukotriene receptor antagonistsdecrease leukotrienes, and mast cellstabilizers decrease histamine; bothact to decrease bronchospasm.Uses: Antiasthmatics are used forbronchial asthma; bronchospasm as-sociated with bronchitis, emphysema,or other obstructive pulmonary dis-eases; Cheyne-Stokes respirations;and prevention of exercise-inducedasthma. Some products are used forrhinitis and other allergic reactions.Side effects: The most commonside effects are tremors, anxiety, nau-sea, vomiting, and irritation in thethroat. The most serious adverse re-actions are bronchospasm and dys-pnea.Contraindications: Persons withhypersensitivity, closed-angle glau-coma, tachydysrhythmias, and severecardiac disease should not use someof these products.Precautions: Antiasthmatics shouldbe used with caution in breastfeed-ing, pregnancy, hyperthyroidism, hy-pertension, prostatic hypertrophy,and seizure disorders.Pharmacokinetics: Onset, peak,and duration vary widely amongproducts. Most products are metabo-lized by the liver and excreted inurine.

antiasthmatics 7



Interactions: Interactions varywidely among products. Check indi-vidual monographs for specific infor-mation.Possible nursing diagnoses:• Activity intolerance [uses]• Ineffective airway clearance [uses]• Risk for injury [adverse reac-tions]• Deficient knowledge [teaching]• Noncompliance [teaching]


Assess:• Respiratory function: vital capac-ity, forced expiratory volume, ABGs,lung sounds, heart rate and rhythm,aggravating and alleviating factorsAdminister:• Inhaled product after shaking; ex-hale, place mouthpiece in mouth,inhale slowly, hold breath, remove,exhale slowly• PO product with meals to decreasegastric irritationPerform/provide:• Storage of inhaled product in light-resistant container; do not expose totemps over 86° F (30° C)• Gum, small sips of water for drymouthEvaluate:• Therapeutic response: decrease se-verity and number of asthma attacks;absence of dyspnea, wheezingTeach patient/family:• To avoid hazardous activities;drowsiness or dizziness may occurwith some products• To obtain blood work as required;some products require blood levelsto be drawn• Avoid all OTC medications unlessapproved by provider• To report side effects, including in-

somnia, heart palpitations, light-headedness; these side effects mayoccur with some products


BronchodilatorsalbuterolarformoterolatropinebitolteroldyphyllineformoterolipratropiumisoproterenollevalbuterolmetaproterenolpirbuterolterbutalinetheophyllinetiotropiumAdrenergicsepinephrineCorticosteroidsbeclomethasonebetamethasonebudesonidecortisonedexamethasoneflunisolidefluticasonehydrocortisonemethylPREDNISolonepredniSONEtrimicinoloneLeukotriene antagonistszafirlukastMast cell stabilizerscromolynnedocromilMonoclonal antibodiesomalizumab

8 antiasthmatics



ANTICHOLINERGICS

Action: Anticholinergics inhibit themuscarinic actions of acetylcholine atreceptor sites in the autonomic ner-vous system. Anticholinergics are alsoknown as antimuscarinic products.Uses: Anticholinergics are used fora variety of conditions: decreasing in-voluntary movements in parkinson-ism (benztropine, trihexyphenidyl);bradydysrhythmias (atropine); nau-sea and vomiting (scopolamine); andas cycloplegic mydriatics (atropine,homatropine, scopolamine, cyclo-pentolate, tropicamide). Gastrointes-tinal anticholinergics are used to de-crease motility (smooth muscle tone)in the GI, biliary, and urinary tractsand for their ability to decrease gas-tric secretions (propantheline, glyco-pyrrolate).Side effects: The most commonside effects are dry mouth, constipa-tion, urinary retention, urinary hesi-tancy, headache, and dizziness. Alsocommon is paralytic ileus.Contraindications: Persons withclosed-angle glaucoma, myastheniagravis, or GI/GU obstruction shouldnot use some of these products.Precautions: Anticholinergicsshould be used with caution in pa-tients who are geriatric, pregnant, orbreastfeeding or in those with pros-tatic hypertrophy, congestive heartfailure, or hypertension; use with cau-tion in presence of high environmen-tal temperature.Pharmacokinetics: Onset, peak,and duration vary widely amongproducts. Most products are metabo-lized in the liver and excreted inurine.Interactions: Increased anticholin-ergic effects may occur when used

with MAOIs and tricyclics and aman-tadine. Anticholinergics may cause adecreased effect of phenothiazinesand levodopa.Possible nursing diagnoses:• Decreased cardiac output [uses]• Constipation [adverse reactions]• Deficient knowledge [teaching]


Assess:• I&O ratio; retention commonlycauses decreased urinary output• Urinary hesitancy, retention; pal-pate bladder if retention occurs• Constipation; increase fluids, bulk,exercise if this occurs• For tolerance over long-term ther-apy, dose may need to be increasedor changed• Mental status: affect, mood, CNSdepression, worsening of mentalsymptoms during early therapyAdminister:• Parenteral dose with patientrecumbent to prevent postural hypo-tension• With or after meals to prevent GIupset; may give with fluids other thanwater• Parenteral dose slowly; keep in bedfor at least 1 hr after dose; monitorvital signs• After checking dose carefully; evenslight overdose can lead to toxicityPerform/provide:• Storage at room temperature• Hard candy, frequent drinks, sug-arless gum to relieve dry mouthEvaluate:• Therapeutic response: decreasedsecretions, absence of nausea andvomitingTeach patient/family:• To avoid driving or other hazard-ous activities; drowsiness may occur

anticholinergics 9



• To avoid OTC medication: cough,cold preparations with alcohol, anti-histamines unless directed by pre-scriber


atropinebenztropinebiperidendicyclomineglycopyrrolatehyoscyaminepropanthelinescopolamine (transdermal)solifenacintrihexyphenidyl

ANTICOAGULANTS

Action: Anticoagulants interfere withblood clotting by preventing clot for-mation.Uses: Anticoagulants are used fordeep vein thrombosis, PE, MI, open-heart surgery, disseminated intravas-cular clotting syndrome; atrial fibril-lation with embolization, transfusion,and dialysis.Side effects: The most serious ad-verse reactions are hemorrhage,agranulocytosis, leukopenia, eosino-philia, and thrombocytopenia, de-pending on the specific product. Themost common side effects are diar-rhea, rash, and fever.Contraindications: Persons withhemophilia and related disorders,leukemia with bleeding, peptic ulcerdisease, thrombocytopenic purpura,blood dyscrasias, acute nephritis, andsubacute bacterial endocarditisshould not use these products.

Precautions: Anticoagulants shouldbe used with caution in alcoholism,geriatric patients, and pregnancy.Pharmacokinetics: Onset, peak,and duration vary widely among prod-ucts. Most products are metabolizedin the liver and excreted in urine.Interactions: Salicylates, steroids,and nonsteroidal antiinflammatorieswill potentiate the action of antico-agulants. Anticoagulants may causeserious effects; check individualmonographs.Possible nursing diagnoses:• Risk for injury [side effects]• Deficient knowledge [teaching]• Ineffective tissue perfusion [uses]


Assess:• Blood studies (Hct, platelets, oc-cult blood in stools) q3mo• Partial PT, which should be 11⁄2-2× control PPT daily, also APTT, ACT• B/P; watch for increasing signs ofhypertension• Bleeding gums, petechiae, ecchy-mosis; black, tarry stools; hematuria• Fever, skin rash, urticaria• Needed dosage change q1-2wkAdminister:• At same time each day to maintainsteady blood levels• In abdomen between pelvic bone,rotate sites; do not massage area oraspirate when giving SUBCUT injec-tion; do not pull back on plunger,leave in for 10 sec, apply gentle pres-sure for 1 min• Without changing needles• Avoiding all IM inj that may causebleedingPerform/provide:• Storage in tight container

10 anticoagulants



Evaluate:• Therapeutic response: decrease ofDVTTeach patient/family:• To avoid OTC preparations thatmay cause serious product interac-tions unless directed by prescriber• That product may be held duringactive bleeding (menstruation), de-pending on condition• To use soft-bristle toothbrush toavoid bleeding gums; avoid contactsports, use electric razor• To carry emergency ID identifyingproduct taken• To report any signs of bleeding:gums, under skin, urine, stools


ardeparinargatrobandalteparindanaparoiddesirudinenoxaparinfondaparinuxheparinlepirudintinzaparinwarfarin

ANTICONVULSANTS

Action: Anticonvulsants are di-vided into the barbiturates, benzodi-azepines, hydantoins, succinimides,and miscellaneous products. Barbitu-rates and benzodiazepines are dis-cussed in separate sections. Hydanto-ins act by inhibiting the spread of sei-zure activity in the motor cortex.Succinimides act by inhibiting spike

and wave formation; they also de-crease amplitude, frequency, dura-tion, and spread of discharge in sei-zures.Uses: Hydantoins are used in gener-alized tonic-clonic seizures, statusepilepticus, and psychomotor sei-zures. Succinimides are used forabsence (petit mal) seizures. Bar-biturates are used in generalizedtonic-clonic and cortical focal sei-zures.Side effects: Bone marrow depres-sion is the most life-threateningadverse reaction associated with hy-dantoins or succinimides. The mostcommon side effects are GI symp-toms. Other common side effects forhydantoins are gingival hyperplasiaand CNS effects such as nystagmus,ataxia, slurred speech, and mentalconfusion.Contraindications: Hypersensi-tive reactions may occur, and aller-gies should be identified before theseproducts are given.Precautions: Persons with renal/hepatic disease should be watchedclosely.Pharmacokinetics: Onset, peak,and duration vary widely amongproducts. Most products are metabo-lized in the liver and excreted inurine, bile, and feces.Interactions: Decreased effects ofestrogens, oral contraceptives (hy-dantoins).Possible nursing diagnoses:• Injury, risk for [uses]• Noncompliance [teaching]• Sleep deprivation [adverse reac-tions]

anticonvulsants 11




Assess:• Renal studies, including BUN, cre-atinine, serum uric acid, urine creat-inine clearance before and duringtherapy• Blood studies: RBC, Hct, Hgb, retic-ulocyte counts q wk for 4 wk then qmo• Hepatic studies: AST, ALT, biliru-bin, creatinine• Mental status, including mood, sen-sorium, affect, behavorial changes; ifmental status changes, notify pre-scriber• Eye problems, including need forophthalmic exam before, during, andafter treatment (slit lamp, fundus-copy, tonometry)• Allergic reactions, including red,raised rash; if this occurs, productshould be discontinued• Blood dyscrasia, including fever,sore throat, bruising, rash, jaundice• Toxicity, including bone marrowdepression, nausea, vomiting, ataxia,diplopia, CV collapse, Stevens-Johnson syndromeAdminister:• With food, milk to decrease GIsymptomsPerform/provide:• Good oral hygiene as it is impor-tant for hydantoinsEvaluate:• Therapeutic response: decreasedseizure activity; document on patient’schartTeach patient/family:• To carry emergency ID statingproducts taken, condition, prescrib-er’s name, phone number• To avoid driving, other activitiesthat require alertness


BarbituratesphenobarbitalprimidonethiopentalHydantoinsfosphenytoinphenytoinSuccinimidesethosuximideMiscellaneousacetaZOLAMIDEcarbamazepineclonazepamdiazepamfelbamategabapentinlacosamidelamotriginemagnesium sulfateparaldehydeparamethadionephenacemiderufinamidetiagabinetopiramatevalproate/valproic acid, divalproex

sodiumvigabatrinzonisamide

ANTIDEPRESSANTS

Action: Antidepressants are dividedinto the tricyclics, MAOIs, and miscel-laneous antidepressants (SSRIs). Thetricyclics work by blocking reuptakeof norepinephrine and serotonin intonerve endings and increasing actionof norepinephrine and serotonin innerve cells. MAOIs act by increasingconcentrations of endogenous epi-nephrine, norepinephrine, serotonin,DOPamine in storage sites in CNS by

12 antidepressants



inhibition of MAO; increased concen-tration reduces depression.Uses: Antidepressants are used fordepression and, in some cases, en-uresis in children.Side effects: The most serious ad-verse reactions are paralytic ileus,acute renal failure, hypertension, andhypertensive crisis, depending on thespecific product. Common side ef-fects are dizziness, drowsiness, diar-rhea, dry mouth, urinary retention,and orthostatic hypotension.Contraindications: The contrain-dications to antidepressants are sei-zure disorders, prostatic hypertro-phy and severe renal/hepatic/cardiacdisease depending on the type ofmedication.Precautions: Antidepressantsshould be used cautiously in suicidalpatients, severe depression, schizo-phrenia, hyperactivity, diabetes melli-tus, pregnancy, and geriatric patients.Pharmacokinetics: Onset, peak,and duration vary widely amongproducts. Most products are metabo-lized in the liver and excreted inurine.Interactions: Interactions varywidely among products. Check indi-vidual monographs for specific infor-mation.Possible nursing diagnoses:• Ineffective coping [uses]• Risk for injury [uses/adverse reac-tions]• Deficient knowledge [teaching]


Assess:• B/P (lying, standing), pulse q4hr;if systolic B/P drops 20 mm Hg, holdproduct, notify prescriber; take VSq4hr in patients with cardiovasculardisease

• Blood studies: CBC, leukocytes, dif-ferential, cardiac enzymes if patientis receiving long-term therapy• Hepatic studies: AST, ALT, biliru-bin, creatinine• Weight q wk; appetite may increasewith product• EPS, primarily in geriatric patients:rigidity, dystonia, akathisia• Mental status: mood, sensorium,affect, suicidal tendencies, increasein psychiatric symptoms: depression,panic• Urinary retention, constipation;constipation is more likely to occurin children, geriatric patients• Withdrawal symptoms: headache,nausea, vomiting, muscle pain, weak-ness; do not usually occur unlessproduct was discontinued abruptly• Alcohol consumption; if alcohol isconsumed, hold dose until morningAdminister:• Increased fluids if urinary reten-tion occurs, bulk in diet, if constipa-tion occurs• With food or milk for GI symp-tomsPerform/provide:• Storage in tight container at roomtemperature; do not freeze• Assistance with ambulation duringbeginning therapy since drowsiness,dizziness occur• Safety measures including side railsprimarily in geriatric patients• Checking to see PO medicationswallowed• Gum, hard candy, or frequent sipsof water for dry mouthEvaluate:• Therapeutic response: decreaseddepressionTeach patient/family:• That therapeutic effects may take2-3 wk

antidepressants 13



• To use caution in driving, other ac-tivities requiring alertness because ofdrowsiness, dizziness, blurred vision• To avoid alcohol ingestion, otherCNS depressants• Not to discontinue medicationquickly after long-term use; maycause nausea, headache, malaise• To wear sunscreen or wide-brimmed hat since photosensitivitymay occur


TetracyclicsmirtazapineTricyclicsamitriptylineamoxapineclomiPRAMINEdesipraminedoxepinimipraminenortriptylinetrimipramineMiscellaneousbuPROPionduloxetinetrazodonevenlafaxineMAOIsphenelzinetranylcypromineSSRIscitalopramescitalopramfluoxetinefluvoxamineparoxetinesertraline

ANTIDIABETICS

Action: Antidiabetics are dividedinto the insulins that decrease blood

glucose, phosphate, and potassiumand increase blood pyruvate andlactate; and oral antidiabetics thatcause functioning β-cells in the pan-creas to release insulin, improve theeffect of endogenous and exogenousinsulin.Uses: Insulins are used for ketoaci-dosis and diabetes mellitus types 1and 2; oral antidiabetics are used forstable adult-onset diabetes mellitustype 2.Side effects: The most commonside effect of insulin and oral antidia-betics is hypoglycemia. Other adversereactions to oral antidiabetics includeblood dyscrasias, hepatotoxicity, andrarely, cholestatic jaundice. Adversereactions to insulin products includeallergic responses and, more rarely,anaphylaxis.Contraindications: Hypersensi-tive reactions may occur, and aller-gies should be identified before theseproducts are given. Oral antidiabet-ics should not be used in juvenile orbrittle diabetes, diabetic ketoacido-sis, or severe renal/hepatic disease.Precautions: Oral antidiabeticsshould be used with caution in thegeriatric patient, in cardiac disease,pregnancy, breastfeeding, and in thepresence of alcohol.Pharmacokinetics: Onset, peak,and duration vary widely amongproducts. Oral antidiabetics are me-tabolized in the liver, with metabo-lites excreted in urine, bile, and feces.Interactions: Interactions varywidely among products. Check indi-vidual monographs for specific infor-mation.Possible nursing diagnoses:• Imbalanced nutrition: more thanbody requirements [uses]

14 antidiabetics




Assess:• Blood, urine glucose levels duringtreatment to determine diabetes con-trol (oral products)• Fasting blood glucose, 2 hr PP(60-100 mg/dl normal fasting level)(70-130 mg/dl normal 2-hr level)• Hypoglycemic reaction that can oc-cur during peak timeAdminister:• Insulin after warming to room tem-perature by rotating in palms to pre-vent lipodystrophy from injecting coldinsulin• Human insulin to those allergic tobeef or pork• Oral antidiabetic 30 min beforemealsPerform/provide:• Rotation of inj sites when giving in-sulin; use abdomen, upper back,thighs, upper arm, buttocks; rotatesites within one of these regions; keepa record of sitesEvaluate:• Therapeutic response: decrease inpolyuria, polydipsia, polyphagia,clear sensorium; absence of dizzi-ness; stable gaitTeach patient/family:• To avoid alcohol and salicylates ex-cept on advice of prescriber• Symptoms of ketoacidosis: nausea,thirst, polyuria, dry mouth, decreasedB/P; dry, flushed skin; acetone breath,drowsiness, Kussmaul respiration• Symptoms of hypoglycemia: head-ache, tremors, fatigue, weakness; thatcandy or sugar should be carried totreat hypoglycemia• To test urine for glucose/ketonestid if this product is replacing insulin

• To continue weight control, di-etary restrictions, exercise, hygiene• Obtain yearly eye exams


chlorproPAMIDEglipiZIDEglyBURIDEinsulin aspartinsulin detemirinsulin glargineinsulin glulisineinsulin lisproinsulin, regularinsulin, regular concentratedinsulin, zinc suspension (Lente)insulin, zinc suspension extended

(Ultralente)metforminmiglitolnateglinidepioglitazonerepagliniderosiglitazonesaxagliptansitagliptin

ANTIDIARRHEALS

Action: Antidiarrheals work by vari-ousactions, includingdirect actiononintestinal muscles to decrease GIperistalsis; by inhibiting prostaglan-din synthesis responsible for GI hy-permotility; by acting on mucosal re-ceptors responsible for peristalsis; orbydecreasingwater contentof stools.Uses: Antidiarrheals are used for di-arrhea of undetermined causes.Side effects: The most serious ad-verse reactions of some products areparalytic ileus, toxic megacolon, andangioneurotic edema. The most com-mon side effects are constipation,nausea, dry mouth, and abdominalpain.

antidiarrheals 15



mosby's 2011 nursing drug reference 24e samplechapter

Education

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