Preface
xi
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* (
.
rmacology
a wide range of
atic guides, such
rmacology. These
ted literature and
ursing and Mid-
ed alphabetically
portant teaching
g and midwifery
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
on individuals
esigned to treat.
nical setting
ts or lack of
he potential or
emical names,
er but are not
ugs.
■■
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.
■■
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. T
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 accompanying 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 page of the Australia New Zealand Therapeutic
Product Agency (ANZTPA).
Australian Prescriber home page.
Home page of MEDSAFE New Zealand.
Home page of MedicineWise, National Prescribing
Service.
Home page of the Therapeutic Goods Administration.
BIBLIOGRAPHY
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.
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.
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
ount both absorption and
elates to the total proportion
ystemic circulation.
bility is limited as it relates
of the drug that reac
glects he rate of absorption.
e decisions about the “generic
roducts. The concept
rovide evidence that a new
y simil to the existing one
ut ca ing clinical pr
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.
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 (
lood–
brain barrier (see later discussion), which is highly
selective in allowing lipid soluble substances to pass into
the CNS.
Pharmacology:
Distribution
Protein binding
d 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
ltering 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
Blood–brain barrier
The blood–brain barrier is a protective system of cellular
ranes that keep many things (e.g. foreign invaders,
poisons) away from the CNS. The fundamental structural
difference of the membranes forming the blood-brain
r 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.
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 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
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,
minimis
d 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
Nurses and midwives must consider series of points,
or “rights”, to ensure safe and effective drug admin-
are correct drug and person, correct
storage of drug, correct and most effective route, correct
d se, correct preparation, c rrect timing and correct
ee the later section on the
prevention of medication errors for a detailed explana-
tion of the nurse’s and midwife’s role in implementing
bering to review each point before
administering a drug will help to prevent medication
ove care outcomes.
Medications:
The Three Checks and the Five Rights
of Medication Administration
ion
r handbook
relation to the
ssment provides
before givin that
te the effects of
should supplement
ich includes social,
other factors.
C H A P T E R 3 8
Agents to control blood glucose levels
579
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
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.
TABLE 38.2
DRUGS IN FOCUS Insulin
Drug name
Dosage/route
Usual indications
insulin (various ypes)
Varies based on response, diet, and activity
level
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
Safe medication administration
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
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
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.
4.
Compare and contrast key drugs for each class of antibiotics wit
5.
Outline care considerations for people receiving each class of a
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
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?
AMINOGLYCOSIDES
amikacin
framycetin
gentamicin
neomycin
tobramycin
CARBAPENEMS
doripenem
ertapenem
imipenem-cilastatin
meropenem
CEPHALOSPORINS
First-generation
cefalotin
cephalexin
cephazolin
Second-generation
cefaclor
cefoxitin
cefuroxime
Third-generation
cefotaxime
ceftazidime
ceftriaxone
Fourth-generatio
cefepime
Fifth-generation
ceftaroline
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.
Anticholinergic agents
Learning objectives
Upon completio of the chapt r, you should be able to:
1.
Define anticholin rgic agents.
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.
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.
*thePoint and PrepU are trademarks of Wolters Kluwer Health
