McKenna's Pharmacology for Nursing, 2e

Alpha-adrenergic blockers phenoxybenzamine phentolamine Alpha 1 -blockers doxazosin

ered to it by a series of liver reak the drug into metabo- tive and cause effects in the are deactivated and can be lt, a large percentage of the his point and never reaches on is known as the first-pass drug that gets through the to the circulatory system for dy. gs absorbed from sites other a similar biotransformation e liver. Because some of the a chance to reach the respon- the liver, the injected drug is er dose than the oral equiva- d dose for oral drugs can be e recommended dose for par- st-pass effect into account. valence e proportion of drug that circulation after oral admin- ount both absorption and lates to the total proportion stemic circulation. The use bility is limited as it relates of the drug that reaches the glects the rate of absorption. e decisions about the “generic roducts. The concept of bio- provide evidence that a new y similar to the existing one ut causing clinical problems al changes that can sed blood volume, sorption, reduced anges in receptor- ten have a variety can be receiving a o be evaluated for ith various central heimer’s disease or ficulty swallowing dication. Through- ross the Lifespan to the drug class fically to children, . These boxes high- ife should consider each age group. ion r handbook relation to the ssment provides before giving that te the effects of should supplement ich include social, ther factors. and peripheral nervous systems ovement of a drug to the As with absorption, factors include the drug’s lipid solu- e perfusion of the responsive rfusion is a factor in caring who has a lower-leg infec- o destroy the bacteria in the drugs may not be effective process involves changes in ed blood flow to some areas, bs. If there is not adequate e antibiotic can be delivered iotic effect will be seen. g drug name, inistration; fects; warning lems; safety etting g making rtant papers; luation to ut drug . drug (relief of anges, GI rrhythmias,

Links to Laerdal clinical simulations enable students to link theory to practice, prepare for clinical placement and acquire the knowledge and skills essential for pro- fessional practice. Test your curr nt knowledge of antibiotics with a PrepU Practice Quiz! Many drugs are bound to proteins and are not lipid soluble. These drugs cannot be distributed to the central nervous system (CNS) because of the effective blood– brain barrier (see later discussion), which is highly selective in allowing lipid solubl substances to pass into the CNS. Pharmacology: Di tr bution and set of interventions. H althcare priorities reflect identified alterations in a person’s function based on the assessment of the clinical situation. Because drug therapy is nly a small part of the verall person’s situ- ation, priorities that are related to drug therapy must be incorporated into a total picture of the pers . Implementation nvolves taking th information ga red and synthesised to plan care. This process includes setting goals and desired outcomes to assure safe and effective drug therapy. These outcomes usually involve ensuring effective response to drug therapy, minimising adverse effects and understanding the drug regimen. Three types of interventions are frequently involved in drug therapy: drug dministration, provision of comfort easures and education of the person and their family. Proper drug administration T he cardiovascular sy tem is a closed sys m of blood vessels that is responsible for delivering oxy enated bl od to the tissues an removing waste products from the tiss es. The blood in this system flows from areas f higher pressure to areas of lower pr ssure. The area of highest pressure in th system is always e left ventri- cle during systole. The pr ssure in this area p opel the blood out of the aorta and into the system. The lowest pressure is in the right atrium, which collects all of the deoxygenated blood fr m the body. The maint nance of this pressure system is controlled by specific areas of the brain nd various hormones. If the pressure becomes too high, t person is said to be hypertensive. If the pressure becomes to low and blood cannot be delivered effectively, the person is said to be hypotensive. Helping the erson t maintain the blood pressure within ormal limits is the oal of drug therapy. Cardiovascular health is one of the Australia g vernment’s nine National Health Priority Areas (AIHW, 2013). Assessing blood pressure Thiazide and thiazide-like diuretics chlorthalidone hydrochlorothiazide indapamide Potassium-sparing diuretics amiloride spiron lactone triamterene Beta-blockers atenolol betaxolol metoprolol nadolol nebivolol pindolol propranolol timolol Alpha- a d beta-blockers carvedilol prazosin terazosin Alpha 2 clonidine methyldopa moxonidine TABLE 38.2 Drug name insuli (various typ s) Glossary of key terms aerobic: bacteria that depend on oxygen for survival Icons for Concepts in action animations depicting pharmacological concepts, Watch and learn video clips, Practice and learn activities and clinical simulation case studies guide students to online resources to further enhance understanding of complex topics. Many drugs are extensively bound to proteins and it should be noted that only the unbound fraction of the drug can reach the site of action in responsive tissues. Some drugs compete with each other for protein binding sites, al ering effectiveness or causing toxicity wh n the two drugs are given together. The toxicity is attributed to sudden increase in the fraction of the previously pro- tein-bound drug that is now free. Pharmacology: Drug binding Nurses and midwives must consider a ser es of points, or “rights”, t ensure safe and effective drug admin- istration. These are correct drug and person, correct storage of drug, correct and most effective route, corr ct dose, correct preparation, correct timing and correct ec r ing of admin s r i n. Se the later section on the prevention of medication errors for a det iled xplana- tion of the nurse’s and midwife’s role in implementing these rights. Remembering to review each point before administering a drug will help to prevent medication errors and improve care outcomes. Medications: The Three Checks and the Five Ri hts of Medication Administration AMINOGLYCOSIDES amikacin framycetin gentamicin neomycin tobramycin CARBAPENEMS doripenem ertapenem imipenem-cilastatin meropenem Blood–brain barrier The blood–brain barrier is a protective system of cellular membranes that keep many things (e.g. foreign invaders, poisons) away from the CNS. The fundamental structural difference of the membranes forming the blood-brain barrier is the use of so called tight-junctions between cells, leaving no gaps between the cells. Drugs that are highly lipid soluble are more likely to pass through the blood–brain barrier and reach the CNS. Drugs that are not lipid soluble are not able to pass the blood–brain barrier. This is clinically significant in treating a brain infection with antibiotics. Almost all antibiotics are not lipid soluble and cannot cross the blood–brain barrier. Effective antibiotic treatment can occur only when the infection is severe enough to damage the blood–brain barrier and allow antibiotics to cross. Although many drugs can cause adverse CNS effects, these are often the result of indirect drug effects and not the actual reaction of the drug with CNS tissue. For example, alterations in glucose levels and electro- lyte changes can interfere with nerve functioning and produce CNS effects such as dizziness, confusion or changes in thinking ability. CEPHALOSPORINS First-generation cefalotin cephalexin cephazolin Second-generation cefaclor cefoxitin cefuroxime Contraindications and cautions Opioid antagonists are contraindicated in the presence of any know allergy to any opioid antagonist to avoid hypersensitivity react ons . Caution should be used in the following circumstances: duri g pregn ncy and breastfeeding because of potential adverse effects on the f tus and neonate ; with opioid addiction because of the precipitation of a withdrawal syndrome ; and with cardiovascular (CV) disease, which could be exacerbated by the reversal of the depressive effects of opioids. Adverse effects The most frequently seen adverse effects associated with these drugs relate to the blocking effects of the opioid receptors. The most common effect is an acute opioid abstinence syndrome that is characterised by nausea, vomiting, sweating, tachycardia, hypertension, tremu- lousness and feelings of anxiety. A naloxone challenge should be administered before giving naltrexone to help to avoid acute reactions. CNS excitement and reversal of analgesia are espe- cially c mmon after surgery. Cardiovascular (CV) effects related to the reversal of the opioid depr ssion can inclu e tac yc rdia, blood pressure changes, dys- rhythmias and pul onary oedema. Drug–d ug interacti ns To reverse the effects of buprenorphine or dextropro- poxyphene, larger doses of opioid antagonists may be needed. therapeutic effect from drugs intended to react with those tissues. REVIEW OF BLOOD PRESSURE CONTROL Text highlights • In the Care considerations section of each chap er, italics highlight the rationale for each a e intervention, helping the student to apply the information in a clinical situation. Elsewhere in the text, the rationale is consistently provided for therapeutic drug actions, co traindicati ns and adverse effects. The pressure in the cardiovascular system is determined by three elements: • Heart rate • Stroke volume , or the amount of blood that is pumped out of the ventricle with each heartbeat (primarily determined by the volume of blood in the system) • Total peripheral resistance , or the resistance of the muscular arteries to the blood being pumped through. The small arterioles are though to be the most important factors in determini g peripheral resistance. Because they have the smallest diameter, they are able to almost stop blood flow into capillary beds when they constrict, building up tremendous pressure in the arteries Car considerations for people receiving antimigraine agents Assessment: History and examination ■ ■ Assess for contraindications or cautions: any known allergies to any components of the dr gs to avoid hypersensitivity reactions ; history of MI, CAD or hypertension, which may be exacerbated by the drug ; hepatic or renal dysfunction, which could alter the metabolism and excretion of the drug ; pruritus or malnutrition, which could be exacerbated by ergot derivatives ; and current status of pregnancy and breastfeeding, which would be cautions to the use of these drugs . ■ ■ Perform a physical assessment to establish baseline status before beginning therapy, determine drug effectiveness and evaluate for any potential adverse effects. ■ ■ Assess neurological status, including level of orientation, affect and reflexes, to evaluate CNS effects of the drugs . ■ ■ Monitor for complaints of extremity numbness and tingling to identify effects on vascular constriction. ■ ■ Inspect the skin for localised oedema, itching or breakdown with ergot derivatives to evaluate potential dermatological effects. ■ ■ Assess vital signs, including pulse rate and blood pressure; obtain an ECG as appropriate to evaluate cardiac status for changes. • In the Drug list at the beginning of each chapter, a special icon appears next to the drug that is considered the prototype drug of each class. In each chapter, prototype summary boxes spotlight need-to- morphine oxycodone pethidine remifentanil tapentadol tramadol Opioid agonists–antagonists buprenorphine Opioid antagonists aloxon naltrexone ANTIMIGRAINE AGENTS Ergot derivatives ergotamine naratriptan rizatriptan sumatriptan zolmitriptan Prototype summary: Naloxone Indications: Complete or partial reversal of opioid depression; diagnosis of suspected opioid overdose. Actions: Pure opio d antagonist; re rses the effects of the opioids, including respiratory depression, sedation and hypotension. Pharmacokinetics: Route Peak Onset Duration

Preface 5–30 mg PO q 6 hours or 30 mg PR q 6–8 hours as needed Adult: 5–20 mg IM or SC or 15–30 mg PO q 4–6 rs Paediatric: 0.1–0.2 g/kg IM or SC Adult: 25–100 mg IM, SC or 25–50 mg slow IV q 3–4 hours Paediatric: 0.5–2 g/kg IM or SC q 3–4 hours Adult a chil ren >2 years: dos determined by general anaesthetic being used

midodrine Sympathetic adrenergic agonists or vasopressors adrenaline dobutamine ADULTS Adults being treated for acute pain should be reassured that the risk of add tion to an opioid during treatment is remote.They should b encouraged to ask for pain medication before the pain is acute, to get better coverage for their pain. Many institutions allow people to self-regulate intravenous drips to control their pain postoperatively. PREGNANCY AND BREASTFEEDING The opioid ar contraindicated or should only be used with caution during pregnancy because of the potential for morphine (Anamorph, Kapanol, MS Contin) oxycodone (OxyContin, Oxynorm, Endone, Proladone) pethidine (generic) remifentanil (Ultiva) dopamine ephedrine • Drugs in focus tables clearly summarise and identify the drugs within a class, highlighting them by generic and trade names, usual dosage and indications. The icon appears in these tables next to each drug that is considered to be the prototype for its specific class. isoprenaline metaraminol noradrenaline phenylephrine

5. Outline care considerations for people receiving each class of antibiotic.

ix Because older impairment, they levels of the drug and excretion.Th measures in effec ambulate—when hospital setting. effects associated nervous system, effects.

-blockers

Simulation-based learning On completion of the chapter, explore the scenario of Kenneth Bronson (Part 1) who has been diagnosed with a strep throat. Continue onto the second scenario (Part 2) as his condition deteriorates into an emergency situation. Consider the medication management of Kenneth’s condition throughout his episode of care. What learning from the chapter, can be applied to the case? Protein binding Most drugs are bound to some extent to proteins in the blood to be carri d into circulation. The protei –drug complex is relatively large and c nnot enter into capil- laries and then into tissues to react. The drug m st be freed from the protein’s binding site at the tissues. DRUGS IN FOCUS Insulin TABLE 26.1 Drug ame tapentadol (Pal xia SR) tramadol (Durotram XR, Lodam) 94 P A R T 2 Chemotherapeutic agents

579

C H A P T E R 3 8 Agents to control blood glucose levels

Adult: 50 mg PO b.d.

DRUGS IN FOCUS Opioids

Usual indications Adult: rapid relief of pain: 50-100 mg PO q 4–6 hours to a maximum 400 mg/day Chronic pain: 25 mg/day PO titrated slowly to a maximum 400 mg/day Dosage/route

Third-generation cefotaxime ceftazidime ceftriaxone Fourth-generation cefepime Fifth-generation ceftaroline Baroreceptors As the blood leaves the left ventricle through the aorta, it influences specialised cells in the arch of the aorta called baroreceptors (pressure receptors). Similar cells are lo ated in the carotid arteries, which deliver blood to the brain. If ther is sufficient pressure in these vessels, the baroreceptors are stimulated, sending that informa- tion t the brain. If the pressure falls, the stimulation of the barorec ptors falls off. That information is also sent to the brain. The sensory input from the baroreceptors is received in the medulla in an area called the cardiovascular centre or vasomotor centre. If the pressure is high, the medulla stimul tes vasodilation and a decrease in cardiac rate and ou put, causing the pressure in the system to drop. If the p essure is low, the medulla directly stimulates an increase i cardiac rate and output, and vasoconstriction; this increases total peripheral resistance and raises the blood pressure. The medulla mediates these effects through the autonomic nervous system (see Chapter 29). Th baroreceptor reflex functions continually to maintain blood pressure within a predetermined range of normal. For example, if you have been lying down flat and suddenly stand up, the blood will rush to your feet (an effect of gravity). You may even feel light-headed or dizzy for a short time. When you stand and the blood flow drops, the baroreceptors are not stretched. The medulla senses this drop in stimulation of the baroreceptors and stimulates a rise in heart rate and cardiac output, and C H A P T E R 2 6 Opioids, opioid antagonists and antimig aine agents 413 ■ ■ Provide thorough teaching, including drug name, prescribed dose and schedule for administration; measures to avoid adverse effects; warning dextropropoxyphene (Doloxene) fentanyl (Actiq, Duragesic, Sublimaze) naltrexone (ReVia) 24 Drug swallowed Safe medication administration The e idence BOX 9.3 BOX 31.1 Adren rgic blocking agents CHILDREN behind t em a they prevent t e blood fro flowing through. The arterioles are very responsive to stimula- tion from the sympathetic nervous system; they constrict when the sympathetic system is stimulated, increasing total peripheral resistance and blood pressure. The body us s th s responsiveness to regulate blood pressure on a onstant basis, to ensure that there is enough pressure in the system to deliver sufficient blood to the brain. Dosage/route Varies based on response, diet, and activity level Opioid agonists alfentanil (Rapifen) codeine (generic) Opioid agoni ts–antagonists buprenorphine (Norspan, Temgesic) BACTERIA AND RESISTANCE TO ANTIBIOTICS

pathogens, such antibiotics (parti bacteria in the

PENICILLINS AND PENICILLINASE-RESISTANT ANTIBIOTICS Penicillins benzathine penicillin benzylpenicillin synthesis of glycogen from glucose, of fats from lipids and of proteins from amino acids. Insulin does these things by reacting with specific receptor sites on the cell. Figure 38.3 shows the sites of action of replacement insulin and other drugs used to treat diabetic conditions. See Table 38.2 for indications. Pharmacokinetics Various preparations of insulin are available to provide short- and long-term coverage. These preparations are processed within the body like endogenous insulin. However, the peak, onset and duration of each vary because of the placement or addition of glycine and/or arginine chains. Maintenance doses are given by the subcutaneous route only, and injection sites need to be rotated regularly to avoid damage to muscles and to pr vent subcutaneous atrophy. Regular insulin is given intramuscularly or intravenously in emergency situations. Insulin is available in various preparations with a wide range of peaks and durations of action. A person may receive a combination of regular and isophane insulin in the morning to cover the glucose peak from breakfast (regular onset, 30 to 60 minutes) and the lunch and dinner glucose peaks. The person may then require another injection before bed. The types of insulin used are determined by the anticipated eating and exercise activities of any particular individual. It is very important to make sure that one is using the correct insulin preparation when administering the drug. Insulin glargine ( Lantus ) and insulin detemir ( Levemir ) cannot be mixed in solution with any other drug, including other insulins. Contraindications and cautions Because insulin is used as a replacement hormone, there are no contraindications. Care should be taken during surgery; 0.05–0.1 mg postop ratively; 5 mcg/kg transmucosally; for transdermal patch, calculate the previous day’s opioids need and use table to convert to patch strength; ionic delivery system, 40 mcg over 10 minutes Paediatric (>2 years): 2–3 mcg/kg IM or IV; base transmucosal dose on weight and do not exceed 400 mcg well-being. Thes sives and as adj rapid analgesia, Indications for acute or chronic during anaesthe depending on th usual indication culation of a dos In deciding uation, it is imp the person’s con most effective in effects. Each p to a drug is als Half-lif The half-life of a of drug in the b it previously ac 20 mg of a dru the drug will r Two hours later, level); in 2 more information is i ate timing for a of a drug’s effec calculations.) The absorpt the speed of bio excreted are ll mining the half indicated in an a healthy pers estimate the half or liver dysfunct formation and drug), allowing dosing schedule. The timing achieve the mo midwives can u explain the imp administration i shows the effects concentration of Not dissolved, lost in faeces Lost in acid Lost in food, acid, digestion Biotransformed to non-effective state Bound to plasma proteins Determining drug levels A person is taki You are trying to drug will be gon • In 12 hours, ha body. BOX 2.1 ■■ The goal of an population of human immun ■■ Bacteria can b f und in respir (frequently fou also be classifi or aerobic (de ■■ Culture and se antibiotic is ch that may help resistant-strai KEY POINTS regimen ofte le b cteria. Using people saving u infections or to s • Tell people that exposures to cer to people that sa they think they n development of tests that could i • Offer other medi decongestants, request antibioti something to ta respond to antib people who re The publicity t bacteria have rece message across t course of an antib they are app opri C H A P T E R (MI). Table 31. these agents. Drug therap across the lifespan m re centr l nerv other adrenergic complications alr while taking an a a different agent. PREGNANCY AN In ge eral, there a of adre ergic bloc and th y shoul b the benefit to the fetu or ne nate. and babies born t adverse cardiovas Many of these dru Because of a simil breastfeeding mot baby if an adrener OLDER ADULTS Older people are effects ass ciated GI a d respirator also have renal or likely to have toxi in metabolism an be started on low monitored very cl or blood pressure choice for older p for hypertension problems in the e be used. Herbal and alternative therapies Treatment of type 1 diabetes mellitus; treatment of type 2 diabetes mellitus in people whose diabetes cannot be controlled by diet or other agents; treatment of severe ketoacidosis or diabetic coma; treatment of hyperkalaemia (in conjunction with a glucose infusion to produce a shift of potassium into the cells [polarising solution]); also used for short courses of therapy during periods of stress (e.g. surgery, disease) in people with type 2 diabetes, for newly diagnosed people being stabilised, for people with poor control of glucose levels, and for people with gestational diabetes Spontaneous ventilation: 7 mcg/kg by slow IV injection Controlled ventilation: 20-50 mcg/kg by slow IV injection Adult: 15–60 mg PO, IM, IV or SC q 4–6 hours; 10–20 mg PO q 4–6 hours for cough Paediatric: 0.5 mg/kg PO, IM or SC q 4–6 hours; 2.5–10 mg PO q 4–6 hours for cough 100 mg PO q 4 hours as needed Adult: 0.05–0.1 mg IM, 30–60 minutes before surgery; 0.002 mg/kg IV or IM during 200–400 mcg SL q 6–8 hours, 300–600 mcg M or IV q 6–8 hours or 1 transdermal patch every 7 days Adult: 0.4–2 mg IV, IM or SC q 2–3 minutes as needed Paediatric: 0.01 mg/kg IV, IM or SC Neonatal: 0.01 mg/kg IV, IM or SC q 2–3 minutes or 0.06 mg/kg IM immed at birth opportunistic inv are destroyed o nothing to preve In most cases th effect (e.g. vagina but in some case t an the infectio ment of the sup and the potentia cycle of treatmen

FLUOROQUINOLONES ciprofloxacin moxifloxacin norfloxacin ofloxacin dysfunction can lead to toxic lev ls of a drug in the bod because he drug nnot be excreted. Figure 2.3 outlines the pharmacokinetic proc ss that occur when a drug is administe ed orally. Pharmacology: Excretion Bacteria have survived for hundreds of years because they can adapt to their environment. They do this by altering their cell wall or enzyme systems to become r sistant to (i.e. protect themselves from) unfavourable conditions or situations. Many species of bacteria have developed resistance to certain antibiotics. For example, bacteria that were once very sensitive to penicillin have devel ped an enzyme called penicillinase, which effec- tively inactivates many of the penicillin-type drugs. New drugs have had to be developed t effectively reat infec- tions involving these once-controlled bacteria. It is very important to use these drugs only when the identity and se sitivity of he offending bacterium h ve been est b- lished. Indiscriminate use of these new drugs can lead to the dev lopment of more re istant strains for which there is no effective antibiotic (see later discussion of new antibiotics for additio al information on linezolid). The longer an antibio ic has been i se, the great r is the chance that the bacteria will develop into a resist- ant strain. Efforts to control the mergence of r sistant strains involve intensive educational programs that advocate the use of antibiotics only when necessary and effective and not for the treatment of viral infections such as the common cold (Box 9.3). In addition, the use of antibiotics may result in the devel ment of superinfections or overgrowth of resistant Children are at greater risk for complications associated with the use of adrenergic blocking agents, including bradycardia, difficulty breathing and ch ges in gluco e metabolism.The safety and efficacy for use of these drugs has not been established for children younger than 18 years of age. If one f these drugs is used, the do e for these agents needs to be calculated from the child’s ody weight and age. It is good practice to have a second person check t e dose calculation before administering the drug to avoid potential toxic effects.Two adrenergic blocking agents have es a li hed paediatric doses, and the migh be he drugs to c nsider whe one is eeded: praz s n is used to t eat hypert nsi n, and phentolamine, which is used during surgery for phaeochromocytoma. Children should be carefully monitored and supported when these drugs are given. ADULTS Adults being treated with adrenergic blocking agents should be cautioned about the many adverse effects a sociated with the rugs. People with diabetes need to be re-educated about ways to m nitor themselves f r hyperglyca mia and hypoglycaemia because the sympathetic reaction (sweating, feeling tense, increased heart rate, rapid breathing) usually alerts people that there is a problem with their glucose levels. People with severe thyroid disease are also at high risk for serious adverse effects when taking these drugs, and if one of the is need d, the person sh uld be monitored very closely. Propranolol and metoprolol are associated with control is determined by the relative ability of each drug to cause physical dependence. Opioid agonists include alfentanil ( R pifen ), c dei e (ge eric), dextro- propoxyphene ( Doloxe e ), fentanyl ( Actiq , Duragesic , Sublimaze ), hydromorphone ( Dilaudid , Jurnista ), meth- adone ( Biodone , Physeptone ), morphine ( Anam rph , Sevredol , MS Contin and others), oxyco one ( Endone , OxyContin , Oxynorm , Proladone ), pethidine (generic), remifentanil ( Ultiva ), tapent d l ( Palexia SR ) (not avail- able in New Zealand) and tramadol ( Durotram XR , Lodam , Tramal and others). Therapeutic actions and indications The opioid agonists act at specific opioid receptor sites in the CNS to produce analgesia, sedation and a sense of Adult: 50 mg/day PO • Focu on s fe medication admini tration boxes present important safety information to help keep the person safe, prevent medication errors and increase the therapeutic effectiveness f the drugs. The liver is very important in metabolising drugs in the body and the kidneys are responsible for a large part of the excretion of drugs from the body. One should get into the habit of always checking a person’s live nd renal fu ction before they start a drug r gimen. If the liver is not functioning properly, the drug may no be metabolised correctly and may reach toxic levels in the body. If the kidneys are not functioning properly, the drug may not be excreted properly and could accumulate in the body. Dose djustment ne ds to be considered if a person has problems with either the liver or the kidneys. • Focus on the evidence boxes compile information based on research to identif th best clinical practices assoc ated with specific rug therapy. P A R T 1 Introduction to nursing pharmacol gy Usi g antibiotics properly In 2003, the US Food and Drug Administration (FDA) nd Centers for Disease Control and Prevention (CDC) joined efforts to educate the public and healthcare providers about the dangers of inappropr ate use of antibiotics. The evidence-based practice guidelines combine data fro many studies to outline the most efficacious use of antibiotics.To review some of the studies, review the references listed in the Bibliography. Nurs s and mi wives should include some of th following points about the risks and dangers of antibiotic abuse in each person’s education plan: • Explain clearly that a particular antibiotic is effective against only certain bacteria and that a culture needs to be taken to identify the bacteria. • Explain that bacteria can develop resistant strains that will not be affected by antibiotics in the future, so use of antibiotics now may make them less effective in situations in which they are really necessary. • Ensure that people understand the importance of taking the full course of medication as prescribed, even if they feel better. Stopping an antibiotic midway through a • Focus on herbal and alternative therapies boxes highlight known eract n with sp cific herbs or alternative therapies that could affect the actions of the drugs being discussed. signs that may indicate possible problems; signs of ergotism if taking ergot derivatives; safety measures such as avoiding driving and avoiding overdose; and importance of follow-up monitoring nd evaluation to enhance the person’s knowledge about drug therapy and to promote compliance. Evaluation ■ ■ Monitor the person’s response to the drug (relief of acu e migraine headaches). ■ ■ Monitor for adverse effects (CV changes, arrhythmias, hypertension, CNS changes). ■ ■ Evaluate the effectiveness of the teaching plan (person can give the drug name and dosage and describe possible adverse effects to watch for, specific measures to prevent them and warning signs to report). ■ ■ Monitor the effectiveness of comfort measures and compliance with the regimen. Drug dissolved in gastrointestinal fluids Dissolved drug reaches intestine Drug absorbed by portal system Drug in liver Drug in circulation Drug distributed throughout body • Celery, coriander, Di huang, fenugreek, goldenseal, Java plum, xuan seng—lower blood glucose (increased risk of severe hypoglycaemia) • Saw palmetto—increased urinary tract complications People who are pr cribe n adrenergic blocking drug should be cautioned about the use of herbs, teas and alternative medicines. If a person feels that one of Broken down in tissues Bound to plasma proteins People who use alternative therapies as part of their daily regimen should be cautio ed abou potential increased adren rgic blocking effects if the f llowing alternative therapi s are combi ed with adrenergic blocking agents: • Ginseng, age—increased antihypertensive effects (risk of hypotensio and increased CNS effects) • Xuan shen, nightshade—slow heart rate (risk of severe bradycardia and reflex arrhythmias) Reaches reactive tissue Excreted by kidneys, lungs, skin, etc. Bound to f t tissue ■■ Migraine headaches are severe, throbbing headaches on one side of the head that may be associated with an aura or warning syndrome. These headaches are thought to be caused by arterial dilation and hyperperfusion of the brain vessels. Drug “does its thing”

anaerobic: bacteria that survive without oxygen, which are often seen when blood flow is cut off to an area of the body antibiotic: chemical that is able to inhibit the growth of specific bacteria or cause the death of susceptible bacteria gram-negative: bacteria that accept a negative stain and are frequently associated with infections of the genitourinary or GI tract gram-positive: bacteria that take a positive stain and are frequently associated with infections of the respiratory tract and soft tissues synergistic: drugs that work together to increase drug effectiveness Opioid antagonists nal xone (Narcan)

of insulin delivery that are available or under study for future use. Hyperglycaemic crisis Therapeutic actions and indications Insulin is a hormone that promotes the storage of the body’s fuels, facilitates the transport of various metabo- lites and ions acr ss cell membranes and stimul tes the In 2009, l nte insulin was removed from the market as name confusion had occurred between Lantus insulin and lente insulin. The pharmacokinetics and dose of insulins vary greatly. Use caution to make sure you know which insulin is intended for the individual person. Lantus and Levemir insulin cannot be mixed in a syringe with any other insulin or any other drug. Use particular caution when working with these two insulins. The DHBNZ Safe and Quality Use of Medicines has released an alert informing healthcare professionals to take extra care when giving insulin Humalog preparation. There are three Humalog preparations available in Australia and New Zealand: Humalog, Humalog Mix25 and Humalog Mix50. Potential harm can result if a person is given Humalog rapid release as opposed to Humalog intermediate release. The Australian Commission on Safety and Quality in Health Care (ACSQHC) has developed 10 National Safety and Quality Health Service Standards. These Standards aim to improve the quality of health service provision across Australia and provide a national statement of the level of care consumers should be able to expect from health services. Awareness and knowledge of Standard 4 on Medication Safety is an important part of the nurse’s and midwife’s clinical repertoire. For more information, see www.safetyandquality.gov.au/our-work/accreditation/nsqhss. Triptans eletriptan BOX 31.2 Safe medication administration

hing plan dosage and atch for, d warning

measures and

know information for each prototype drug. acting on the central and peripheral nervous systems

drugs that bind t activate them. eceptors and are ny opioids in the include naloxon ReVia ).

• In another 12 h would remain i • After 36 hours, • After 48 hours, remain. • After 60 hours, • After 72 hours, • After 84 hours, • Twelve more h reduce the dru • Finally, 12 mor amount of the would be quite Pharmacokinet These drugs are are distributed t orally. Th y re faeces and urine. drug and prepar Contraindicatio The non-selecti contraindicated tivity to any co serious hyperse

hene

ptors and reverse tory depression, potension.

KEY POINTS

, is a sensory and emotional experi- actual or potential tissue damage. pain is part of the clinical pres- isorders and is one of the hardest sal of the adverse atory depression id overdose. (See ch opioid antag- do ot have an ividual who are

the tissue damage has occurred. In some cases so-called referred pain occurs. A person experiencing pain f om damage to the heart muscle may actually feel the pain in the neck or jaw. The sensation of pain is experienced in