x
Preface
•
Focus on calculations
reviews are designed to help the
student hone calculation and measurement skills while
learning about the drugs for which doses might need
to be calculated.
eneration
cephazo-
cef
).
effective
s well as
enes
and
cond-gen-
-positive
xitin and
are effec-
rains, are
a but are
i, as well
PeCKS
).
ftazidime
develop-
axipime
),
ive organ-
hylococci
in devel-
esistance.
inforo
) is
ve organ-
hlococcus
ptococcus
bacterio-
cific drug
basically
f bacteria
bacteria
cell walls.
and burst
e cell (see
atment of
Table 9.3
Selection
the sen-
of choice
ortant to
situations
appearing
, perform
causative
the GI tract: the first-generation drug cephalexin; the
second-generation drugs cefaclor and cefuroxime; the
third-generation drug cefotaxime; and the fourth-
generation drug cefepime. The others are absorbed
well after IM injection or IV administration. (Box 9.4
provides calculation practice using cefaclor.)
The cephalosporins are primarily metabolised in the
liver and excreted in the ur ne. These drugs cross the
placenta and enter breast milk (see contraindications
and cautions).
You are caring for a 20-kg child with a severe case
of tonsillitis. An order is written for cefaclor (Ceclor)
20 mg/kg/day q 8 hours for 10 days.The drug comes in
an oral suspension 125 mg/5 mL. What amount should
you administer at each dose?
The order is for 20 mg/kg, so 20 mg/kg
×
20 = 400 mg
per day.
stock required
stock strength
×
volume
1
400
125
×
5
1
=
2000
125
= 16 mL/day
therefore, each dose = 16/3 = 5.3 mL per dose
Calculations
BOX 9.4
Contraindications and cautions
Avoid the use of cephalosporins in people with known
allergies to cephalosporins or penicillins
because
cross-sensitivity is common.
Use with caution in people
with hepatic or renal impairment
because these drugs
are toxic to the kidneys and could interfere with the
metabolism and excretion of the drug.
In addition,
use with caution in pregnant or breastfeeding women
because potential effects on the fetus and infant are not
known; use only if the benefits clearly outweigh the
potential risk of toxicity to the fetus or infant.
Reserve cephalosporins for appropriate situations
because cephalosporin-resistant bacteria are appearing
in increasing numbers. Before therapy begins, perform
a culture and sensitivity test to evaluate the causative
organism and appropriate sensitivity to the antibiotic
being used.
Adverse effects
The most common adverse effects of the cephalo-
sporins involve the GI tract and include nausea,
•
Focus on drug therapy across the lifespan
boxes
concisely summarise points to consider when using
the drugs of each class with children, adults, pregnant
and breastfeeding women, and the elderly.
C H A P T E R 2 6
Opioids, opioid antagonists and antimigraine agents
401
BOX 26.1
Drug therapy across the lifespan
Opioids
CHILDREN
The safety and effectiveness of many of these drugs have
not been established in children. If an opioid is used,
the dose should be calculated very carefully, and the
child should be monitored closely for the adv se effects
associated with opioid use.
Opioids that have an established paediatric dose
include codeine, fentanyl (but not transdermal fentanyl),
hydrocodone, pethidine and morphine. Oxycodone and
dextropropoxyphene are not recommended for children.
Methadone is not recommended a an an lgesic in
children. If a hild older than 16 ye rs of age requires an
opioid agonist-antagonist, buprenorphine-naloxone is the
preparation of choice. Naloxone is the drug of choice for
reversal of opioid effects and opioid overdose in children.
ADULTS
Adults being treated for acute pain should be reassured
that the risk of addiction to an opioid during treatment
is remote.They should be 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 opioids are contraindicated or should only be used
with caution during pregnancy because of the potential for
adverse effects on the fetus.These drugs enter breast milk
and can cause opioid effects in the baby, so caution should
be used during breastfeeding. Morphine and pethidine
are often used for analgesia for labour.The mother should
be monitored closely for adverse reactions, and, if the
drug is used over a prolonged labour, the newborn infant
should be monitored for opioid effects such as respiratory
depression. Naloxone should be readily available for the
baby if the mother has received an opioid in the hours
immediately prior to the birth.
OLDER ADULTS
Elderly people should be specifically asked whether they
require pain medication. Because many older people can
recall a time when nurses were able to spend more time
with people, they may tend to believe that the nurse will
meet their needs.
Older people are more likely to experience the adverse
effects associated with these drugs, including central
nervous system, gastrointestinal and cardiovascular
effects.
Because older people often have renal or hepatic
impairment, they are also more likely to have toxic
levels of the drug related to changes in metabolism
and excretion.The older person should have safety
measures in effect—side rails, call light, assistance to
ambulate—when receiving one of these drugs in the
hospital setting.
TABLE 26.1
DRUGS IN FOCUS Opioids
Drug name
Dosage/route
Usual indicatio
Opioid agonists
alfentanil (Rapifen)
Spontaneous ventilation: 7 mcg/kg by slow IV
injection
Controlled ventilation: 20-50 mcg/kg by slow
IV injection
Analgesic supplement and anaesthetic
induction agent in inpatient surgery
codeine (generic)
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
Relief of mild to moderate pain; relief
of coughing induced by mechanical or
chemical irritation of the respiratory tract
dextropropoxyphene
(Doloxene)
100 mg PO q 4 hours as needed
Relief of mild to moderate pain in adults
Special considerations:
limit use in
suicid
fentanyl (Actiq, Duragesic,
Sublimaze)
Adult: 0.05–0.1 mg IM, 30–60 minutes
before surgery; 0.002 mg/kg IV or IM during
surgery; 0.05–0.1 mg postoperatively;
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
For analgesia before, during and
after
ansdermal patch for
management of chronic pain; control of
breakthrough pain
•
Focus on gender considerations
and
Focus on
ultural considerations
discussio s encourage the
student to t ink ab ut cultural awaren ss and to
consider the person as a unique individual with a
special se of characte istics that not only influences
vari tions in drug e fectiveness, but also could
influence a person’s perspective on drug therapy.
410
P A R T 4
Drugs acting on the central and peripheral nervous systems
Migraines are generally classified as common or
classic. Common migraines, which occur without an
aura, cause severe, unilateral, pulsating pain that is
frequently accompanied by nausea, vomiting and sensi-
tivity to light and sound. Such migraine headaches are
often aggravated by physical activity. Classic migraines
are usually preceded by an aura—a sensation involving
sensory or motor disturbances—that usually occurs
about half an hour before the pain begins. The pain and
adverse effects are the same as those of the common
migraine.
It is believed that the underlying cause of migraine
headaches is arterial dilation. Headaches accompanied
by an aura are associated with hypoperfusion of the
brain during the aura stage, followed by reflex arterial
dilation and hyperperfusion. The underlying cause
and continued state of arterial dilation are not clearly
understood, but they may be related to the release of
bradykinins or serotonin, or as a response to other
hormon s a d chemicals.
ANTIMIGRAINE AGENTS
For many years, the one standard treatment for migraine
headaches was acute analgesia, often involving an
opioid, together with control of lighting and sound and
the use of ergot derivatives. In the late 1990s, a new class
of drugs, the triptans, was foun
-
tive in treating migraine headaches without the adverse
effects associated with ergot derivative use. Because
these agents are associated with many syst mic adverse
effects, their usefulness is limited in some p ople (see
Box 26.5). Table 26.2 includes additional information
about each class of antimigraine agents.
E
rgot dErivativEs
The
ergot derivatives
cause constriction of cranial blood
vessels and decrease the pulsation of cranial arteries.
As a result, they reduce the hyperperfusion of the basilar
artery vascular bed.
Available ergot derivatives include ergotamine
(
Cafergot
) (no longer a
n Austr lia).
Therapeutic actions and indications
The ergot derivatives block alpha-adrenergic and sero-
tonin receptor sites in the brain to cause a constriction
of cranial vessels, a
al artery pulsa-
tion and a decrease in the hyperperfusion of the basilar
Headache distribution
Headaches are dis ributed in the general pop lation in a
definite gender-related pattern. For example:
• Migraine headaches are thr e times more likely to
occur in women than men.
• Cluster headaches are more likely to occur in men than
in women.
• Tension headaches are more likely to occur in women
than in men.
There is some speculation that the female
predisposition to migraine headaches may be related
to the vascular sensitivity to hormones. Some women
can directly plot migraine occurrence to periods of
fluctuations in their menstrual cycle.The introduction
of the triptan class of antimigraine drugs has been
beneficial for many of these women.
Gen er considerations
BOX 26.4
C H A P T E R 3 8
Agents to control blood glucose levels
577
increase in type 2 diabetes in young people. The treat-
ment of Type 2 diabetes usually begins with changes
in diet and exercise. Di ting controls the amount and
timing of glucose introduction into the body, and weight
loss decreases the number of insulin receptor sites that
need to be stimulated, as well as the intra-abdominal fat
that blocks adiponectin release. Exercise increases the
movem nt of glucose i to the cells by ympathetic nervous
system (SNS) activation and by t e increase pot ssium
in the blood that occurs directly after exercising. Potas-
sium acts as part of a polarising system during exercise
that pushes glucose into the cells. Clinical studies have
shown that controlling serum glucose levels can d crease
th risk of complication by up to 40% (ADA, 2008).
When diet and exercise no longer work, other agents
(discussed later) are used to stimulate the production
of insulin in the pancreas, increase the sensitivity of the
insulin receptor sites, or control the entry of glucose
into the system. Injection of insulin may eventually
be needed. This co cept is oft n
fusing for people
who are learning abo t iabetes. Type 2 diabetes often
evolves until insulin is needed. Timing of the injections
of insulin is correlated wit food intake a d anticipated
increases in blood glucose levels, as well as exercise
levels and anticipated stress (ADA, 2008). See Box 38.4
Diabetes and blood glucose variations
Certain ethnic groups tend to have a genetically
predetermined variation in blood glucose levels, possibly
caused by a variation in metabolism. In New Zealand,
certain ethnic groups (particularly Ma– ori, Pacific Islanders
and South Asians) are at a higher risk of developing
diabetes and data suggests that the incidence of diabetes
for Ma– ori and Pacific peoples are more than three
times higher than the European rates and Ma– ori and
Pacific peoples are more than five times as likely to die
from type 2 diabetes. Similarly, it has been estimated
that Indigenous Australians have a three times higher
incidence of type 2 diabetes than the non-Indigenous
population, and are twice as likely to die from a diabetes-
related condition. People in these groups should be
screened regularly for t pe 2 diabetes.They ca also
benefit from teaching about warning signs of diabetes.
Beyond Australia and New Zealand, similar problems
exist for many cultural groups including First Nation
people in Canada, and African and Native Americans.
The clinical importance of this relates to proper
screening of individuals for hypoglycaemia and diabetes
mellitus. Individuals in these groups who have fasting
glucose tolerance tests need to hav the standard
readjusted before a diagnosis is made. Such people
also require an understanding of potential diff rences in
normal levels on hom blood glucos monitoring units
Cultural considerations
BOX 38.3
Managing glucose levels during stress
The body has many compensatory mechanisms for
ensuring that bloo glucose levels stay within a safe
range.The sympath tic stress reaction elevates blood
glucose levels to provide ready energy for fight or
flight (see Chapter 29).The stress reaction causes the
breakdown of glycogen to release glucose and the
breakdown of fat and proteins to release other energy.
STRESS REACTIONS
The stress reactio elevates the blood glucose
concentration above the normal range. In severe stress
situations—such as an acute myocardial infarction or
a car c ash—the blood glucose level can be very high
(above 8.0 mmol/L).The body uses that energy to fight
the in ult or flee from th ressor.
Nurses and midwives in acute care situations need
to be ware of this refl x elevation in glucos when
caring for people in cute stress, specially people
in emergency situations whose medical hist ry is
unknown.The usual medical re p nse to a blood
glucose concentration of above 8.8 mmol/L would be
the administration of insuli . In many situatio s, that is
exactly what is done, especially if the person’s history
is not known and the effects of such a high glucose
level could cause severe systemic reactions. Insulin
ad inistration causes a drop in the blood gluc se level
as glucose enters cells to be either used for energy or
converted to glycogen for storage.
However, a problem may arise in the acute care
s tting, particularly in a non-diab tic person. Relieving
the stress r act on can also drop g
stimulus to increase these levels is lost and the glucose
that was there is used for energy. A person in this
situation who has been treated with insulin is at risk for
development of potentially severe hypoglycaemia.The
body’s response to low glucose levels is a sympathetic
stress reaction, which again elevates the blood glucose
c ncentration. If tre ted, the person potentially can enter
a cycle of high and low glucose levels.
BEST CARE PRACTICE
Nurses and midwives are often the ones in closest
contact with the highly
n the
emergency room, the intensive care unit, the post-
anaesthesia room—and should be constantly aw re of
the normal and refl x changes in blo d g ucose t at
accompany stress. Car
of stress and the relief of stress, can prevent a prolonged
treatment program to maintain blood glucose levels
within the range of nor
ation that is not
“normal” during a stress reaction.
Diabetic people who
s situations
require changes in thei
y should be
allowed some elevation of blood glucose, even though
their inability to produce sufficient insulin will make
it difficult for their cells
use of the
increased glucose level
allenge to
The evide ce
BOX 38.4
•
Focus on individual and family teaching
boxes
review i portant points to c ver as par of individual
and family education.
C H A P T E R 8
Anti-infective agents
85
Preventing resistance
Because the emergence of resistant strains of microbes is
s rious publi health roblem that continues to grow,
healthcare providers must work together to prevent the
emergence of resistant pathogens. Exposure to an anti-
micr bial agent lea s to the development of resistance,
so it is important to limit the use of antimicrobial agents
to the treatment of specific pathogens known to be sen-
sitive to the drug being used.
Drug dosing is important in preventing the develop-
ment of resistance. Doses shoul be high enough and
the uration of rug therapy should be long enough to
eradicate ev n slightly re istant microorganisms. The
recommended dosage for a specific anti-infective agent
takes this issue i to account. Around-the-clock dosing
eliminates the peaks and valleys in drug concentration
and helps to maintain a constant therapeutic level to
prevent the emergence of resistant microbes during times
of low concentration. The duration of drug use is critical
to ensure that the microbes are completely, not partially,
eliminated and are not given the chance to grow and
develop resistant strains. It has proved to be difficult
to convince people who are taking anti-infective drugs
that the timing f doses an the length of time they
continue to take the drug are important. Many people
stop taking a drug once they start to feel better and then
keep the rem ining pills to treat themselves at s time
in e futur when they do not feel well. This practice
favours the emergence of resistant strains. Box 8.4 gives
ti s on teachi g about this.
H alth are providers should also be cautious about
the in iscriminate use of anti-infectives. Antibiotics
are not effective in the treatment of viral infections
or illnesses such as the common cold. However, many
people seek prescriptions for these drugs when they visit
practitioners because they are convinced that they need
to take som thing to f el better. Healthcare providers
who prescribe anti-infectives without knowing the caus-
ative organism and which drugs might be appropriate
are promoting the emergence of resistant strains of
microbes. With many serious illnesse , including pneu-
monias for which the causative organism is suspected,
antibiotic therapy may be started as soon as a sample of
the bacteria, or
culture
, is taken and before the results
are known. Healthcare provid rs also tend to try newly
introduced, m re powerful drugs wh n more estab-
lished drug may be just as eff ctive. Use of a powerful
drug in this way leads to the rapid emergence of resistant
strains to that drug, perhaps limiting its potential use-
fulness when it might be truly nece sary.
KEY POINTS
■■
The goal of anti-infectiv therapy is th r duction
of the invading organisms to a point at which
the human immune response can take care of the
infection.
■■
Anti-infectives can act t de troy an infective
pathogen (bactericidal) or to prevent the pathogen
from repro ucing (bacteriostatic).
■■
Anti-infectives can have a small group of pathogens
against which they are effective (narrow spectrum),
or they ca be eff ctive against many pathogens
(broad spectrum).
Using anti-infective agents
Anti-infective agents are used to tr at systemic infec-
tions and sometimes as a means of prophylaxis (to
prevent infections before they oc
Treatment of systemic inf ctions
Many infections that once led to l ngthy, organ-damaging
or even fatal illnesses are n w managed quickly and effi-
ciently with the use of systemic anti-infective agents.
Before the introduction of penicillin to treat strepto-
coccal infections, many people developed rheumatic
fever with serious cardiac complications. Today, rheu-
matic fever and the re
alve defects are
seldom seen. Several factors should be considered efore
beginning one of these chem therapeutic r gimens
to ensure that the person obtains the greatest benefit
possible with th few
rs
include identificati n of the correct pathogen and selec-
tion of a drug that is
ely to (1) c use the least
complications for that person and (2) be most effective
against the pathogen i
Identification of the pathogen
Identificat on f the infecting pathoge is d ne by cul-
turing a tissue sample
d area. Bacteri l
cultures re performed in a laboratory, i which a sw b
KEY POINTS
U ing anti-infective agents
When teaching people who are prescribed an anti-
infective agent, it is important to alw ys include some
general points:
• This drug is prescribed for treating the particular
infection that you have now. Do not use this drug to
treat other infections.
• This d ug needs to be ken as prescribed—for the
correct number of times each day and for the full
Individual and family teaching
BOX 8.4
•
Critical thinking scenarios
tie each chapter’s content
together by presenting clinical scenarios about a
person using a particular drug from the class being
discussed. Included in the case study are hints to guide
critical thinking about the case and a discussion of
drug- and nondrug-related care considerations for that
particular person and situation. Most importantly,
the case study also provides a plan of care specifically
developed for that person.
■■
Beta-blockers are drugs use
receptors within the SNS. T
a wide range of conditions,
stage fright, migraines, angi
■■
Non-selective blockade of al
a loss o the reflex bronchod
sympathetic stimulation. Th
drugs in individuals who sm
seasonal rhinitis, asthma or
KEY POINTS
CNS effects occur
to prevent injury;
provide small,
frequent meals and mouth care
to help relieve the
discomfort of GI effects
; establish a daily activity
program, spacing activities
to help the person deal
with activity intolerance
.
■
■
Offer support and encouragement
to help the
person deal with the drug regimen.
■
■
Provide thorough teaching, including drug name,
dose and schedule of administration; use of
drug with food or meals, if appropriate; possible
adverse effects and measures to prevent them;
warning signs to report; safety measures, such
as changing position slowly, avoiding driving or
using hazar ous machinery, and pacing activities;
and the need for follow-up evaluation and
watch for and specific mea
■
■
Monitor the effectiveness o
compliance with the regim
CRITICAL THINKING SCENARIO
Non-selective beta-blockers (propranolol)
THE SITUATION
M.R., a 59-year-old man, has been seen several times
complaining of tremor in his hands that eventually made it
very difficult for him to work as a computer programmer.
A diagnosis of essential tremor was made, and he was
prescribed propranolol (
Inderal
) 40 mg twice daily. M.R. had
good effects with the drug and had no further problems
until the following June, when acute respiratory distress
developed while he was picnicking in a stat park with his
family. On the way to the emergency room, he suffered
an apparent respirat ry arrest. He was admitted to the
hospital nd placed in he respiratory intensive care unit.
It was found that M.R. had a history of hay fever and allergic
rhinitis during the pollen season but had never experienced
such a severe reaction.
CRITICAL THINKING
Why did M.R. have such a severe r
measures should be taken to e
fully and does not re-experien
What sort of support will M.R. an
going through such a frighten
about the children who may h
respiratory arrest and how the
depending on their ages.
Thin
wife may need and the fear that
with M.R.’s condition. M.R. has b
for several months and needs to
continue the drug with modifica
addition of other drugs to deal
What kind of teaching program
to help M.R. deal with this dru
effects?
that occurs when th SNS is stimulate . When the pollen
react d with M.R.’s airways, causing them to swell and
become narrower, his swollen bronchial tubes were
unable to allow air to flow through them. The result
was bronchial constriction and respiratory distress that,
in M.R.’s case, progressed to a respiratory arrest. Before
he began taki g propranolol, M.R. probably had been
eff ctively compensating for the swelling of the bronchi
through bronchodilation and had never experienced
such a reaction. There are few other drugs for treating
essential tremor. M.R. and his healthcare providers will
eed to decide whether the benefit that the drug has
brought t him is wo th the potential for adverse effects.
They might be able to suggest additional drugs to deal
with the seasonal allergic reactions to make the use of the
propranolol safer for M.R.
M.R. may want to discuss this frightening incident
with his healthcare provider. He also may want to include
his family in this discussion. It should be stressed that
he did so well up to this point because he had not
been exposed to pollen and th refore had not had the
problem that brought him into the hospital this time. M.R.
probably never reported the occurrence of hay fever to
his healthcare provider when the drug was prescribed
because it had never been a problem and probably did not
seem significant to him. M.R. and his family should receive
support a d be encouraged to talk about what happened
and how they reacted to it. It i normal to feel frightened
and unsure when love one is in distress. They should e
involved in the discussion of wh medical regimen would
be mo t appropriate for M.R. at this point.
CARE GUIDE FOR M.R.: PROPRANOLOL
Assessment: History and ex mination
Review the person’s history for allergy to propranolol, HF,
shock, bradycardia, heart block, hypotension, COPD,
thyroid disease, diabetes, respiratory impairment, and
concurrent use of barbiturates, non-steroidal anti-
inflammatory drugs, piroxicam, sulindac, lignocaine,
cimetidine, phenothiazines, clonidine, theophylline and
rifampicin.
Focus the physical examination on the following:
CV: blood pressure, pulse, peripheral perfusion, ECG
CNS: orientation, affect, reflexes, vision
throughout dru
Taper the drug gra
decrease the ris
related to abrup
Provide support an
and discomfort,
Provide teaching r
precautions an
Evaluatio
Evaluate drug effec
d crease i ess
Monitor for advers
confusion; sexu
respiratory prob
Monitor for drug–
Evaluate the effecti
Evaluate the effecti
TEACHING FOR
• The drug that ha
is a non-selective
beta-adrenergic
stim lating activi
response to such
It stabilis s c rtai
decrease your tre
You should lear
writing the pulse
rate is 82 beats/
• Never discontinu
find that your pre
healthcare provi
tapered over tim
us is disc ntinu
may occur:
•
F tigue, weakne
throughout the
•
Dizziness, drows
avoid driving, o
delicate tasks.
spells.
•
Change in sexu
effect and disc
The care plan is followed by a checklist of
teaching points designed for the person presented in
the ca e study. This approach helps the student to see
how assessment and the collected data are applied in
the clinical situation.
C H A P T E R 3 1
Adrenergic blocking antagonists
481
DISCUSSION
Pro ranolol, a non-s lective beta- l ck r, was prescribed
to decrease the tremor he was experiencing. The exact
action of this drug to decrease the tremor is thought to
be related to its membrane-stabilising properties. The
desired therapeutic effect is the reduction of the tremor,
but all of the beta-blocking effects will occur and need to
be monitored. He did well on the drug until pollen season
arrived. That is because propranolol, a non-selective beta-
blocker, prevented the compensatory bronchodilatio
that occurs whe the SNS is stimulated. When the pollen
reacted with M.R.’s airways, causing them to swell and
bec me arrower, his swollen bronchial tubes were
unable to allow air to flow through them. The result
was bronchial constriction and respiratory distress that,
in M.R.’s case, progressed to a respiratory arrest. Before
he egan t king propranolol, M.R. probab y had b en
effectively compensating for the swelling of the bronchi
through bronchodilation and had never experienced
such a reaction. There are few other drugs for treating
essential tremor. M.R. and his healthcare providers will
need to de ide whether the benefit that the drug has
brought to him is worth the potential for adverse effects.
They might be able to suggest additional drugs to deal
with the seasonal allergic reactions t make the use of the
propranolol safer for M.R.
M.R. may want to discuss this frightening incident
with his healthcare provider. He also may want to include
his family in this discussion. It should be stressed that
he id so well up to th s int because e had not
been exposed to pollen a d therefore had not had th
problem that brought him into the hospital this time. M.R.
probably nev r reported th occurrence of hay fever to
his healthcare provider when the drug was prescribed
because it had never been a problem and probably did not
seem significant to him. M.R. and his family should r ceive
support and be encouraged to talk about what happened
and how they reacted to it. It is normal to feel frightened
and unsure when a loved one is in distress. They should be
involved in the dis ussi n of what medical regimen would
be most appr priate for M.R. at this point.
CARE GUIDE FOR M.R.: PROPRANOLOL
Assessment: History and examination
R view the p rso ’s istory for allergy to propranolol, HF,
shock, bradycardia, heart block, hypotension, COPD,
thyroid disease, diabetes, respiratory impairment, and
concurrent use of barbiturates, non-steroidal anti-
inflammatory drugs, piroxicam, sulindac, lignocaine,
cimetidine, phenothiazines, clonidine, th ophylline and
rifampicin.
Focus the physical examination on the following:
CV: blood pressure, pulse, peripheral perfusion, ECG
CNS: orientation, affect, reflexes, vision
Skin: colour, lesions, texture
GU: urinary output, sexual function
GI: abdominal, liver evaluation
Respiratory: respirations, adventitious sounds
Implement tion
E sure safe and appropriate admini tr tion of the drug.
Provide comfort a d safety measures: assistance/side rails;
temperature control; rest peri ds; mouth care; small,
frequent meals.
Monitor blood pressure, pulse, and respir tory status
throughout drug therapy.
Tap r the drug gra ually if it is to b discontinued to
dec ease the risk of severe hypertension, MI or stroke
rel ted to abrupt withdrawal.
Provide support and reassuranc to deal with drug effects
and dis omfort, sexual dysfunction and fatigue.
Pro i e teaching regarding drug name, dosage, side effects,
precautions and warning signs to report.
Evaluation
Evaluate rug effects: blood pressure within normal limits,
decrease in essential tr mors, stabilised cardiac rhythm.
Monitor for adverse ffect : CV effects: HF, blo ; dizziness,
confusion; exual dy funct on; GI eff ct ; hypoglycaemia;
resp ratory probl ms.
Monitor for drug–drug interactions as indicated.
Evaluate the effectivene s of the teaching program.
Evaluate the effectiveness of comfort and safety measures.
TEACHING FOR M.R.
• The drug that has been prescribed for you, propranolol,
is a non-selective beta-ad energic blocking agent. A
beta-adrenergic blocking agent works to prevent certain
timulating tivities that ormally occur in the body in
response o such fact rs as stress, injury or excitement.
It s abilises cer ai ner e membranes, which helps to
decrease your tremor.
You should learn to take your pulse and monitor it daily,
writing the pulse rate on the calendar. Your current pulse
rate is 82 beats/minute.
• Never discontinue thi medi tion suddenly. If you
find that your prescription is running low, notify your
healthcare provider at once. This drug needs to be
tap r d over time t prevent severe reactions when its
us is discontinued. Some of the following adverse effects
ay occur:
•
Fatigue, weakness
: Try to stagger your activities
throughout the day to allow rest periods.
iness
: If these should occur, take care to
avoid driving, operating dangerous machinery or doing
delicate tasks. Change position slowly to avoid dizzy
•
Change in sexual functi n
: Be assured that this is a drug
an discuss it with your healthcare provider.
•
Web links
alert the student to electronic sources
of drug information and sou ces of drug therapy
information for specific diseases.
12
P A R T 1
Introduction to nursin pharmacology
Therapeutic G idelines
provides a wide range of
drug information in a series of systematic guides, such
as antibiotics and gastr intestinal pharmacology. These
guidelines draw upon a range of evaluated lit rature and
re arch.
McKenna’s Drug Handbo k for Nursing and Mid-
wifery
has dr g monographs organised alphabetically
and includes care implications and import nt teaching
points specifically releva t to nursing nd midwifery
ractice.
Numerous other drug handbooks are also on the
market and readily available for nurses and midwives
to use.
Jou nals
Variou journals can be used to obtain drug informa-
tion. F r xamp e, t e
Medical Letter
is a mo thly
review of n w drugs, drug classes and specific treat-
m nt protocols. Many cli ical nursing and midwifery
journals
offer information on new drugs, drug errors
and care im li ations.
Austral an Prescriber
is a usef l
source of easily interpreted pharmacology information
nd is freely avail ble onli e.
Internet information
Many individuals now use the Internet as a source of
medical information and advice. Nurses and midwives
need to become familiar with what is available o the
Inter et and what people may be referencing, and h ve
skills in critiquing the credibility of th se s urces.
CHAPTER SUMMARY
■■
Drugs re chemicals that are introduced into the
body to bring about some sort of change.
■■
Drugs can come from many sources: plants, animals,
inorganic eleme ts and synthetic preparations.
■■
The TGA reg lates the development and marketing
of drugs to ensure safety and efficacy in Australia.
■■
Orphan drugs are chemicals that hav been
d scovered to have some therapeutic effect but at
are not financially advantageou t develop int
drugs.
■■
OTC drugs are available with ut prescription for the
self-treatment of various complaints.
■■
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 weaknesses helps you to
study more effectively. Take a PrepU Practice Quiz
to find out how you measure up!
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 ccompanying website, located on
thePoint at
. These include Watch and
Learn videos, Concepts in Action animations, journal articles,
review questions, case studies, discussion topics and quizzes.
WEB LINKS
Healthcare providers and students may want to consult
the following Internet sources:
Home pag of the Australia New Zealand Therapeutic
Product Agency (ANZTPA).
Austr lian Prescriber home p ge.
dsafe.govt.nz
Home p ge of MEDSAFE New Zealand.
Home page of MedicineWise, National Prescribing
Service.
