McKenna's Pharmacology for Nursing, 2e

4. Compare and contrast key drugs for each class of antibiotics wit 5. Outline care considerations for people receiving each class of a

A COMPREHENSIVE PACKAGE FOR LEARNING AND TEACHING Online resources To further facilitate learning and teaching, an exten- sive suite of online resources is available for lecturers and students whose institutions have adopted this text. These may be accessed at the text’s accompanying website located on thePoint* (http://thePoint.lww.com). ■■ Information about drugs can be obtained from a variety of sources, including the drug label, reference books, journals and Internet sites. Knowing your strengths and weaknes es helps you to study more effectively. Take a PrepU Practice Quiz to find out how you measure up! In the same way, people in a cold environment may have constricted blood vessels (vasoconstriction) in the extremities, which would prevent blood flow to those ar as. The circulating blood would be unable to deliver drugs to those areas and the person would receive little therap utic effect from drugs intended to react with those tissues. Ma y drugs are bound to proteins and are not lipid solubl . These drugs cannot be distributed to the central nerv us system (CNS) b cause of the effective blood– brain barrier (see later discussion), which is highly selective in allowing lipid soluble substances to pass into the CNS. Pharmacology: Distribution a thorough respiratory evaluation would not be war- ranted in a person with no known pulmonary disease who is taking a drug with little or no known effects on the respiratory system. The nurse or midwife has the greatest direct and continued contact with the person and is in the best position to detect minute changes that ultimately determine the course of drug therapy—ther- apeutic success or discontinuation because of adverse or unacceptable responses. Identifying health problems I form tion athered during assessment i analysed to arrive at some onclusions hat lea to particular goal and set of interventions. Healthcare priorities reflect id tified alterations in a p rson’s functi n base on the assessment f th clinical situation. Becaus drug therapy is only a small part of the overall person’s situ- tion, priorit es t at are rel ted to drug therapy must be incorporat d into a total picture of the person. Implem ntation involves taking the information gathered and synthesised to plan care. This process includes setting goals and desired outcomes to assure safe and effective drug therapy. These outcomes usually inv lve ensuring effective response to drug therapy, minimising adv rse effects and understanding the ug regimen. Thre typ s of i tervent ons are frequently involved in drug therapy: drug administratio , provision of comfort measures a d education of the person and their family. Proper drug administration TABLE 38.2 DRUGS IN FOCUS Insulin Drug name Dosage/route ■■ Orphan drugs are chemicals that have been discovered to have some therapeutic effect but that are not financially advantageous to develop into drugs. ■■ OTC drugs are available without prescription for the self-treatment of various complaints. ONLINE RESOURCES An extensive range of additional resources to enhance teaching and learning and to facilitate understanding of this chapter may be found online at the text’s accompanying website, located on thePoint at http://thepoint.lww.com. These include Watch and Learn videos, Concepts in Action animations, journal articles, review questions, case studies, discussion topics and quizzes. WEB LINKS Students can access journal articles, learning objec- tives and a wide range of concepts in action animations, watch and learn videos, and clinical simulation case studies. Instructors can access journal articles, Power- Point presentations, image banks, guided lecture notes, case studies, pre-lecture quizzes, assignments, discus- sion topics and testbank questions. Protein binding Most drugs are b und to some xtent to proteins in the bl od to be arried in o circulation. The protein–drug complex is relatively large and cannot enter into capil- laries and then into tissues to react. The drug must be freed from the protein’s binding site at the tissues. Many drugs are exte sively bound to pr teins 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, altering effectiveness or causing toxicity when 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 series of points, or “rights”, to ensure safe and effective drug admin- istration. These are correct drug and person, correct storage of drug, correct and most effective route, correct d se, correct preparation, c rrect timing and correct recording of administration. See the later section on the prevention of medication errors for a detailed explana- 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 Rights of Medication Administration insulin (various ypes) Healthcare providers and students may want to consult the following Internet sources: www.anztpa.org Home page of the Australia New Zealand Therapeutic Product Agency (ANZTPA). www.australianprescriber.com Australian Prescriber home page. www.medsafe.govt.nz Home page of MEDSAFE New Zealand. www.nps.org.au Home page of MedicineWise, National Prescribing Service. www.tga.gov.au Home page of the Therapeutic Goods Administration. Barton, J. H. & Emanuel, E. J. (2005). The patient-based pharmaceutical development process: rationale, problems and potential reforms. JAMA, 294, 2075–2082. Cardinale, V. (1998). Consumers looking for more answers, clearer directions. Drug Topics Supplement, 142 (11), 23a. Davies, C. A. (2004). Keeping advertisers honest—An overview of the regulation of the advertising of medicines and medical devices in Australia. Australian Prescriber, 27 , 124–127. Dempsey, J., Hillege, S. & Hill, R. (2014). Fundamentals of Nursing and Midwifery: A Person-centred Approach to Care (2nd Australian and New Zealand edn). Sydney: Lippincott Williams & Wilkins. Safe medication administration Simulation-based learning Interactive, simulation-based learning is a vital compo- nent in nursing education today. It empowers students to develop their knowledge and skills an to integrate the ry with practice in realistic clinical settings, it offers a rich, content-based immersive learning experi­ ence in a risk-free environment. This new editi n of McKenna’s Pharmacology for Nursing and Health Pro- fessionals offers studen s and lecturers an abunda t and diverse learning and teaching experience through unique access to Laerdal scenarios. Wolters Kluwer H alth’s partnership with leading healthcare simulation experts Laerdal enables this edition to provide references to the Australian and New 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 infecti n 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. 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 across cell membr nes and stimulates the In 2009, lente 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 *thePoint and PrepU are trademarks of Wolters Kluwer Health BIBLIOGRAPHY

rmacology pectrum—children dose adjustments liver and kidneys rgans. The child’s o alert the health- ith drug delivery, r follow directions he child’s develop- rmacokinetics and er may not metab- dult or the kidneys n adult. As people 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 fficulty swallowing dication. Through- ross the Lifespan to the drug class fically to children, . These boxes high- ife should consider each age group. a wide range of atic guides, such rmacology. These ted literature and ursing and Mid- ed alphabetically portant teaching g and midwifery nurs ng pharmacology thr u h the liver on th ir spirin and alcohol are two absorbed from the lower end veins deliver these absorbed ich immediately transforms ered to it by a series of liver re k the drug into metab - tive and cause effects in the are deactivated and can be lt, 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 ody. gs absorbed from sites other a similar biotransformatio 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 a count. valence he proportion f drug that circulation after oral admin- ount both absorption and elates to the total proportion ystemic circulation. The use bility is limited as it relates of the drug that reaches the glects he rate of absorption. e decisions about the “generic roducts. The concept of bio- rovide evidence that a new y simil to the existing one ut ca ing clinical problems ion r handbook relation to the ssment provides before givin that te the effects of should supplement ich includes social, other factors. are also on the es and midwives in drug informa- ter is a monthly nd specific treat- g and midwifery rugs, drug errors criber is a useful logy information et as a source of ses and midwives available on the rencing, and have se sources. ced into the nge. plants, animals, parations. and marketing y in Australia. tential drugs on ir therapeutic and n healthy human ovement of drug to the As with absorption, factors i clu e the drug’s lipid solu- perfusi n of he responsive rfusion is a factor in car ng who has a lower-leg inf c- o des roy the bacteria in the drugs may not be effective pro ess involves changes in d lood flow to some areas, bs. If there is not adequate le antibiotic can be delivered biotic effect will be seen. on individuals esigned to treat. nical setting ts or lack of he potential or emical names, er but are not ugs.

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Preface

Zealand Nursing Education scenarios developed by Laerdal Australia, The Council of Deans of Nursing and Midwifery (Australia & New Zealand) and the National League for Nursing. Test your current knowledge of antibiotics with a PrepU Practice Quiz!

Simulation-based learning On completion of the chapter, explore the scenario of Kenneth Bronson (Pa throat. Continue onto the second scenario (Part 2) as his condition deterior the medication management of Kenneth’s condition throughout his episod can be applied to the case?

C H A P T E R 3 8 Agents to control blood glucose levels The simulation scenarios address major learning objectives and different levels of complexity. They are pedagogically designed to facilitate acquisition of knowledge and skills in all key spects of nursing care, from assessment to patient management, prioritisation of patient problems a d identification f nursing inter- ventions. The scenarios form the basis of the extensive learning experience that case-based learning in a simu- lated environ ent provides to nursing students, enabling them to link theory to practice, prepare for clinical placement and acquire the knowledge and skills essen- tial for professional registration and practice in today’s complex healthcare nvironment. These scenarios are available to subscribers. PrepU PrepU* is an adaptive quizzing engine consisting of a database of calibrated questions, with a difficulty level based on actual student responses. Built by teachers and tested in the classroom, PrepU offers students per- sonalised quizzes that help them learn, and that enable educators to gain insight into student progress. PrepU is available to subscribers. Learning objectives Upon completio of the chapt r, you should be able to: 1. Define anticholin rgic agents. 579 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 prevent 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. Gl s a y of key terms anticholinergic: drug that opposes the effects of acetylcholine at acetylcholine receptor belladonna: a plant that contains atropine as an alkaloid; used to dilate the pupils as a fa medicine much as atropine is used today cycloplegia: inability of the lens in the eye to accommodate to near vision, causing blurri mydriasis: relaxation of the muscles around the pupil, leading to pupil dilation parasympatholytic: lysing or preventing parasympathetic effects Test your current knowledge of anticholinergic agents with a PrepU Practice Q ANTICHOLINERGIC AGENTS/ PARASYMPATHOLYTICS atropine cyclopentolate glycopyrrolate hyoscine hyoscyamine ipratropium propantheline tiotropium D rugs that are used to block the effects of acetylcho- line are called anticholinergic drugs. Because this action lyses, or blocks, the effects of the parasympathetic nervous system, they are also called parasympatholytic agents. This class of drugs was once very widely used to decrease gastrointestinal (GI) activity and secretions in the treatment of ulcers and to decrease other para- sympathetic activities to allow the sympathetic system to become more dominant. Today, more specific and less is the only wide discusses the us ANTICHOLI PARASYMPA Anticholinergic A POWERFUL RESOURCE FOR STUDENTS AND INSTRUCTORS With this new edition of McKenna’s Pharmacology for Nursing and Health Professionals , lecturers and students alike can rely on a dynamic teaching and learning resource—a unique combination of the authoritative text, complemented by an extensive suite of resources in every format, all designed to extend the student learner’s understanding and to assist the instructor i teaching preparation. Usual indications Anticholinergic agents 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 cephalexin cephazolin Second-generation cefaclor cefoxitin cefuroxime 2. Describe the therapeutic a tions, indications, pharmacokinetics, common advers reactions and important drug–drug interactio 3. Discuss the use of anticholinergic agents across the lifespan. 4. Compare and contrast the prototype drug atropine with other a 5. Outline the care considerations, including important teaching po agents. Glossary of key terms aerobic: bacteria that depend on oxygen for survival anaerobic: bacteria that survive without oxygen, which are often seen when blood flow antibiotic: chemical that is able to inhibit the growth of specific bacteria or cause the d gram-negative: bacteria that accept a negative stain and are frequently associated with gram-positive: bacteria that take a positive stain and are frequently associated with inf synergistic: drugs that work together to increase drug effectiveness AMINOGLYCOSIDES amikacin framycetin gentamicin neomycin tobramycin CARBAPENEMS doripenem ertapenem imipenem-cilastatin meropenem CEPHALOSPORINS First-generation cefalotin Third-generation cefotaxime ceftazidime ceftriaxone Fourth-generatio cefepime Fifth-generation ceftaroline

Varies based on response, diet, and activity level