0% found this document useful (0 votes)

237 views176 pages

Nursing Pharmacolocy Part 2

Uploaded by

We take content rights seriously. If you suspect this is your content, claim it here.

0% found this document useful (0 votes)

237 views176 pages

Nursing Pharmacolocy Part 2

Uploaded by

We take content rights seriously. If you suspect this is your content, claim it here.

You are on page 1/ 176

ANTIULCER DRUGS

295

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with systemic antibiotics.

Assessment
• Assess the patient’s infection before therapy and regularly
thereafter.
• Assess for signs and symptoms of the patient’s ulcer.
• Watch for edema, especially in the patient who’s also receiving
corticosteroids; antibiotics, such as metronidazole, may cause
sodium retention.
• Assess for adverse reactions and drug interactions.
• Identify risk factors for peptic ulcer disease, such as cigarette
smoking, stress, and drug therapy with irritating medications
(aspirin, other NSAIDs, corticosteroids, or antineoplastics).
• Assess the patient’s and family’s understanding of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to presence of suscep-
tible organisms
• Risk for deficient fluid volume related to drug-induced adverse
GI reactions
• Deficient knowledge related to drug therapy

Planning outcome goals Make sure

• The patient’s overall health status will improve. to evaluate for
adequate hydration
• Stable vital signs and the patient’s urine output will indicate
in the patient taking
improved fluid volume status. systemic antibiotics.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• The patient and his family will demonstrate an understanding of I think I might be more
drug therapy. than adequately
hydrated!
Implementation
• Administer drugs as appropriate for the patient’s condition and
diagnosis.
• Use measures to prevent or minimize peptic ulcer disease and
gastric acid–induced esophageal disorders.
• Observe the patient for improvement in signs and symptoms.
• Instruct the patient to take the full course of antibiotics.

Evaluation
• Patient is free from infection.
• Patient maintains adequate hydration throughout therapy.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about antiulcer drugs, page 296.)

Lippincott, & Springhouse, P. C. S. (2012). Nursing pharmacology made incredibly easy. ProQuest Ebook Central <a
onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a>
Created from sgugd on 2020-10-27 19:35:25.

Nursing Pharmacology_Chap07.indd 295 2/3/2012 7:21:01 PM

GASTROINTESTINAL DRUGS
296

Education edge

Teaching about antiulcer drugs

If antiulcer drugs are prescribed, review these points with • Swallow capsules whole unless otherwise instructed;
the patient and his caregivers: some medications can be sprinkled on applesauce if
• Elevate the head of the bed. they’re difficult to swallow.
• Avoid abdominal distention by eating small meals. • Take medications with or without food as prescribed,
• Don’t lie down for 1 to 2 hours after eating. when applicable.
• Decrease intake of fats, chocolate, citric juices, coffee, • Eat a well-balanced diet.
and alcohol. • Get adequate rest.
• Avoid smoking. • Exercise regularly.
• As possible, take steps to avoid obesity, constipation, • Avoid gastric irritants as well as nonsteroidal anti-
and other conditions that increase intra-abdominal pres- inflammatory drugs.
sure. • Reduce psychological stress; employ stress manage-
• Take medications with enough water to avoid irritating ment techniques as needed.
the esophagus. • Don’t take other medications, over-the-counter prepara-
• Take antiulcer drugs as directed; underuse decreases tions, or herbal remedies without first consulting with the
their effectiveness and overuse increases adverse effects. prescriber.

Antacids
Antacids are over-the-counter (OTC) medications used in combi-
nation with other drugs to treat peptic ulcers. Types of antacids
By reducing the
include: amount of acid in
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• aluminum carbonate gel the GI tract, ant-

• calcium carbonate acids allow peptic
• magaldrate (aluminum-magnesium complex) ulcers time to heal.
• magnesium hydroxide and aluminum hydroxide Which gives me some
• simethicone. time to relax…

Pharmacokinetics
Antacids work locally in the stomach by neutralizing gastric
acid. They don’t need to be absorbed to treat peptic ulcers.
Antacids are distributed throughout the GI tract and are elimi-
nated primarily in feces.

Pharmacodynamics
The acid-neutralizing action of antacids reduces the total
amount of acid in the GI tract, allowing peptic ulcers time to
heal.

Nursing Pharmacology_Chap07.indd 296 2/3/2012 7:21:01 PM

ANTIULCER DRUGS
297

Pepsin, a digestive enzyme, acts more effectively when the

stomach is highly acidic; therefore, as acidity drops, pepsin action Prototype
is also reduced. pro

Myth buster
Antacids:
Contrary to popular belief, antacids don’t work by coating peptic
ulcers or the lining of the GI tract. Aluminum
hydroxide
Pharmacotherapeutics Actions
Antacids are primarily prescribed to relieve pain and are used • Reduces total acid
adjunctively in peptic ulcer disease. load in the GI tract
• Elevates gastric pH to
Churn, churn, churn reduce pepsin activity
Antacids also relieve symptoms of acid indigestion, heartburn, • Strengthens the gas-
dyspepsia (burning or indigestion), and gastroesophageal reflux tric mucosal barrier
disease (GERD), in which the contents of the stomach and duode- • Increases esophageal
num flow back into the esophagus. sphincter tone
Foiling phosphate absorption Indications
Antacids may be used to control hyperphosphatemia (elevated • GI discomfort
blood phosphate levels) in kidney failure. Because calcium
Nursing considerations
binds with phosphate in the GI tract, calcium carbonate antac-
• Shake suspensions
ids prevent phosphate absorption. (See Antacids: Aluminum
hydroxide.) well.
• When administering
through a nasogastric
Drug interactions tube, make sure that
All antacids can interfere with the absorption of oral drugs if given the tube is patent and
at the same time. Absorption of digoxin, phenytoin, ketoconazole, placed correctly; after
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

iron salts, isoniazid, quinolones, and tetracycline may be reduced instilling, flush the tube
if taken within 2 hours of antacids. If a patient is taking an ant- with water to ensure
acid in addition to other drugs, separate the drugs’ administration passage to the stomach
times. and to clear the tube.
• Don’t give other oral
Adverse reactions drugs within 2 hours
All adverse reactions to antacids are dose-related and include: of antacid administra-
• diarrhea (magnesium-based antacids) tion. This may cause
• constipation (calcium- and aluminum-based antacids) premature release of
• electrolyte imbalances enteric-coated drugs in
• aluminum accumulation in serum. the stomach.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with antacids.

Nursing Pharmacology_Chap07.indd 297 2/3/2012 7:21:02 PM

GASTROINTESTINAL DRUGS
298

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter.
• Record the number and consistency of stools.
• Assess the patient for adverse reactions.
• Monitor the patient receiving long-term, high-dose aluminum
carbonate and aluminum hydroxide for fluid and electrolyte
imbalance, especially if he’s on a sodium-restricted diet.
• Monitor phosphate levels in the patient receiving aluminum car-
bonate or aluminum hydroxide.
• Watch for signs of hypercalcemia in the patient receiving cal-
cium carbonate.
• Monitor magnesium levels in the patient with mild renal impair-
ment who takes magaldrate.

Key nursing diagnoses

• Constipation or diarrhea related to adverse effects of antacids
• Ineffective protection related to drug-induced electrolyte
imbalance
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s underlying symptoms will improve.
• Laboratory studies will show normal electrolyte balance.
• The patient and his family will demonstrate an understanding of
antacid therapy.

Implementation Laxatives, stool

• Manage constipation with laxatives or stool softeners, or ask softeners, or
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

the prescriber about switching the patient to a magnesium prepa- antidiarrheals

ration. may be ordered
to counteract the
• If the patient suffers from diarrhea, obtain an order for an effects of antacids.
antidiarrheal as needed, and ask the prescriber about switching
the patient to an antacid containing aluminum.
• Shake the container of a liquid form well.
• When giving the drug through a nasogastric (NG) tube,
make sure that the tube is patent and placed correctly. After
instilling the drug, flush the tube with water to ensure pas-
sage to the stomach and to clear the tube.

Evaluation
• Patient regains a normal bowel elimination pattern.
• Patient maintains a normal electrolyte balance.
• Patient and his family demonstrate an understanding of
drug therapy. (See Teaching about antacids.)

Nursing Pharmacology_Chap07.indd 298 2/3/2012 7:21:03 PM

ANTIULCER DRUGS
299

Education edge

Teaching about antacids

If antacids are prescribed, review these points with the • Shake the suspension form well before taking it.
patient and his caregivers: • Some antacids, such as aluminum hydroxide, may color
• Don’t take antacids indiscriminately or switch antacids stools white or cause white streaks.
without the prescriber’s consent. • To prevent constipation, increase fluid and roughage
• Don’t take calcium carbonate with milk or other foods intake and increase activity level.
high in vitamin D.

H2-receptor antagonists
H2-receptor antagonists are commonly prescribed antiulcer drugs
in the United States. Drugs in this category include:
• cimetidine
• famotidine
• nizatidine
• ranitidine.

Pharmacokinetics
Cimetidine, nizatidine, and ranitidine are absorbed rapidly
and completely from the GI tract. Famotidine isn’t completely Food and antacids
absorbed. Food and antacids may reduce the absorption of H2- may reduce my
receptor antagonists. absorption, making
it more difficult for
H2-receptor antagonists are distributed widely throughout the
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

me to achieve my
body, metabolized by the liver, and excreted primarily in urine. peak performance.

Pharmacodynamics
H2-receptor antagonists block histamine from stimu-
lating the acid-secreting parietal cells of the stomach.

Really in a bind
Acid secretion in the stomach depends on the binding
of gastrin, acetylcholine, and histamine to receptors
on the parietal cells. If the binding of any one of these
substances is blocked, acid secretion is reduced. By
binding with H2 receptors, H2-receptor antagonists block the
action of histamine in the stomach and reduce acid secretion.
(See H2-receptor antagonists: Famotidine, page 300.)

Nursing Pharmacology_Chap07.indd 299 2/3/2012 7:21:03 PM

GASTROINTESTINAL DRUGS
300

Pharmacotherapeutics
Prototype
H2-receptor antagonists are used therapeutically to:
pro
• promote healing of duodenal and gastric ulcers
• provide long-term treatment of pathologic GI hypersecretory
conditions such as Zollinger-Ellison syndrome H2-receptor
• reduce gastric acid production and prevent stress ulcers in antagonists:
severely ill patients and in those with reflux esophagitis or upper
GI bleeding.
Famotidine
Actions
Drug interactions • Inhibits histamine’s
action at H2 receptors in
H2-receptor antagonists may interact with antacids and other
drugs: gastric parietal cells
• Antacids reduce the absorption of cimetidine, nizatidine, raniti- • Reduces gastric acid
dine, and famotidine. output and concentra-
• Cimetidine may increase the blood levels of oral anticoagulants, tion regardless of the
propranolol (and possibly other beta-adrenergic blockers), benzo- stimulating agent (his-
diazepines, tricyclic antidepressants, theophylline, procainamide, tamine, food, insulin,
quinidine, lidocaine, phenytoin, calcium channel blockers, cyclo- caffeine, betazole, or
sporine, carbamazepine, and opioid analgesics by reducing their pentagastrin) or basal
metabolism in the liver and their subsequent excretion. conditions
• Cimetidine taken with carmustine increases the risk of bone
Indications
marrow toxicity.
• Cimetidine inhibits ethyl alcohol metabolism in the stomach, • Gastroesophageal
resulting in higher blood alcohol levels. reflux disease
• Zollinger-Ellison syn-
drome
Adverse reactions • Duodenal ulcer
Using H2-receptor antagonists may lead to adverse reactions, • Gastric ulcer
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

especially in elderly patients or in patients with altered hepatic or • Heartburn

renal function:
Nursing considerations
A rash of reactions • Monitor for adverse ef-
• Cimetidine and ranitidine may produce headache, dizziness, fects such as headache.
malaise, muscle pain, nausea, diarrhea or constipation, rashes, • Monitor for signs of GI
itching, loss of sexual desire, gynecomastia (cimetidine), and bleeding such as blood
impotence. in the patient’s feces.
• Famotidine and nizatidine produce few adverse reactions, with
headache being the most common, followed by constipation or
diarrhea and rash.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with H2-receptor antagonists.

Nursing Pharmacology_Chap07.indd 300 2/3/2012 7:21:04 PM

ANTIULCER DRUGS
301

Assessment
• Assess for adverse reactions, especially hypotension and Be aware!
arrhythmias. Exceeding the
• Periodically monitor laboratory tests, such as complete blood recommended
infusion rates
count and renal and hepatic studies. when administering
H2-receptor
Key nursing diagnoses antagonists IV
• Impaired tissue integrity related to the patient’s underlying increases the
condition risk of adverse
cardiovascular
• Decreased cardiac output related to adverse cardiovascular
effects.
effects (cimetidine)
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s tissue integrity will improve as evidenced by a
reduction in underlying symptoms.
• The patient will maintain adequate cardiac output as evidenced
by stable vital signs and adequate urine output.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Administer a once-daily dose at bedtime to promote compli-
ance. Twice-daily doses should be administered in the morning
and evening; multiple doses, with meals and at bedtime.
• Don’t exceed the recommended infusion rates when adminis-
tering H2-receptor antagonists IV; doing so increases the risk of
adverse cardiovascular effects. Continuous IV infusion may
suppress acid secretion more effectively.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Administer antacids at least 1 hour before or after H2-receptor

antagonists. Antacids can decrease drug absorption.
• Anticipate dosage adjustments for the patient with renal
disease.
• Avoid stopping the drug abruptly.

Evaluation
• Patient experiences decrease in or relief from upper GI
symptoms with drug therapy.
• Patient maintains a normal heart rhythm.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about H2-receptor antagonists, page 302.)

Nursing Pharmacology_Chap07.indd 301 2/3/2012 7:21:04 PM

GASTROINTESTINAL DRUGS
302

Education edge

Teaching about H2-receptor antagonists

If histamine-2 (H2) receptor antagonists are prescribed, • Don’t take the drug for more than 8 weeks unless spe-
review these points with the patient and his caregivers: cifically ordered to do so by the prescriber.
• Take the drug with a snack if desired. • Don’t self-medicate for heartburn longer than 2 weeks
• Take the drug as prescribed; don’t stop taking the drug without consulting the prescriber.
suddenly. • Be aware of possible adverse reactions, and report un-
• If taking the drug once daily, take it at bedtime for best usual effects.
results. • Avoid smoking during therapy; smoking stimulates gas-
• Continue to take the drug even after pain subsides to al- tric acid secretion and worsens the disease.
low for adequate healing. • Immediately report black tarry stools, diarrhea, confu-
• If the prescriber approves, you may also take antacids, sion, or rash.
especially at the beginning of therapy when pain is severe. • Don’t take other drugs, over-the-counter products, or
• Don’t take antacids within 1 hour of taking an H2-receptor herbal remedies without first consulting with the prescrib-
antagonist. er or a pharmacist.

Proton pump inhibitors

Proton pump inhibitors disrupt chemical binding in stomach cells
to reduce acid production, lessening irritation and allowing peptic
ulcers to better heal. They include:
• esomeprazole
• lansoprazole
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• omeprazole
• pantoprazole
• rabeprazole.

Pharmacokinetics
Proton pump inhibitors are given orally in enteric-coated for-
mulas to bypass the stomach because they’re highly unstable
in acid. They dissolve in the small intestine and are rapidly
absorbed. Esomeprazole, lansoprazole, and pantoprazole can
also be given IV.

Bound and determined

These drugs are highly protein bound and extensively metabolized
by the liver to inactive compounds and then eliminated in urine.

Nursing Pharmacology_Chap07.indd 302 2/3/2012 7:21:04 PM

ANTIULCER DRUGS
303

Pharmacodynamics
Prototype
Proton pump inhibitors block the last step in gastric acid secre-
pro
tion by combining with hydrogen, potassium, and adenosine tri-
phosphate in the parietal cells of the stomach. (See Proton pump
inhibitors: Omeprazole.) Proton pump
inhibitors:
Pharmacotherapeutics Omeprazole
Proton pump inhibitors are indicated for:
Actions
• short-term treatment of active gastric ulcers
• Inhibits activity of acid
• active duodenal ulcers
• erosive esophagitis (proton) pump and binds
• symptomatic GERD that isn’t responsive to other therapies to hydrogen, potassium,
• active peptic ulcers associated with H. pylori infection (in com- and adenosine triphos-
bination with antibiotics) phate, located at the
• long-term treatment of hypersecretory states such as Zollinger- secretory surface of the
Ellison syndrome. gastric parietal cells,
to block gastric acid
formation
Drug interactions
Proton pump inhibitors may interfere with the metabolism of diaz- Indications
epam, phenytoin, and warfarin, causing increased half-lives and • Gastroesophageal
elevated plasma concentrations of these drugs. reflux disease
• Zollinger-Ellison syn-
Proton pump interpHerence drome
Proton pump inhibitors may also interfere with the absorption of • Duodenal ulcer
drugs that depend on gastric pH for absorption, such as ketocon- • Gastric ulcer
azole, digoxin, ampicillin, and iron salts. • Helicobacter pylori
infection
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Adverse reactions Nursing considerations

Adverse reactions to proton pump inhibitors include: • Monitor the patient for
• abdominal pain adverse effects, such
• diarrhea as headache, dizziness,
• nausea and vomiting. and nausea.
• Administer the drug 30
Nursing process minutes before meals.
These nursing process steps are appropriate for patients undergo-
ing treatment with proton pump inhibitors.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter.
• Assess the patient for adverse reactions and drug interactions.
• Monitor the patient’s hydration status if adverse GI reactions occur.
• Assess the patient’s and family’s knowledge of drug therapy.

Nursing Pharmacology_Chap07.indd 303 2/3/2012 7:21:05 PM

GASTROINTESTINAL DRUGS
304

Key nursing diagnoses

• Impaired tissue integrity related to upper gastric disorder
• Risk for deficient fluid volume related to drug-induced adverse
GI reactions
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s tissue integrity will improve as evidenced by a Remember:
reduction in presenting symptoms. Give proton
• The patient will maintain adequate fluid volume as evidenced by pump inhibitors
stable vital signs and urine output. 30 minutes before
• The patient and his family will demonstrate an understanding of meals.
drug therapy.

Implementation
• Administer the drug 30 minutes before meals.
• Dosage adjustments aren’t needed for patients with renal or
hepatic impairment.
• Tell the patient to swallow capsules whole and not to open or
crush them.
• When giving IV esomeprazole, lansoprazole, or pantoprazole,
check the package insert and your facility’s policy for reconstitu-
tion, compatibility, and infusion time information.

Evaluation
• Patient responds well to therapy.
• Patient maintains adequate hydration throughout therapy.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Education edge

Teaching about proton pump inhibitors

If proton pump inhibitors are prescribed, review these vegetable, or tomato juice. Capsule contents can also be
points with the patient and his caregivers: sprinkled on 1 tablespoon of applesauce, pudding, cottage
• Take the drug before eating; however, oral pantoprazole cheese, or yogurt. Swallow the mixture immediately with-
may be taken with or without food. out chewing the granules.
• Swallow the tablets or capsules whole; don’t crush or • Observe for the drug’s effects; if symptoms persist or ad-
chew them. These formulations are delayed-release and verse reactions (such as headache, diarrhea, abdominal
long-acting; opening, crushing, or chewing them destroys pain, and nausea or vomiting) occur, notify the prescriber.
the drug’s effects. • Don’t take over-the-counter preparations, other pre-
• If swallowing capsules is difficult, lansoprazole capsules scription drugs, or herbal remedies without first consulting
can be opened and mixed with 60 mL of apple, orange, with the prescriber.

Nursing Pharmacology_Chap07.indd 304 2/3/2012 7:21:05 PM

ANTIULCER DRUGS
305

• Patient and his family demonstrate an understanding of drug

therapy. (See Teaching about proton pump inhibitors.)

Other antiulcer drugs

Research on the usefulness of other drugs in treating peptic ulcer
disease continues. Two other antiulcer drugs currently in use are:
• misoprostol (a synthetic prostaglandin E1)
• sucralfate.

Pharmacokinetics
Each of these drugs has slightly different pharmacokinetic
properties.

An active acid
After an oral dose, misoprostol is absorbed extensively and
rapidly. It’s metabolized to misoprostol acid, which is clinically
active, meaning it can produce a pharmacologic effect. Misopro-
stol acid is highly protein bound and is excreted primarily in urine.

Goes on by the GI
Sucralfate is minimally absorbed from the GI tract. It’s excreted in Misoprostol
feces. reduces gastric acid
and boosts pro-
duction of gastric
Pharmacodynamics mucus—a natural
The actions of these drugs vary. defense against
peptic ulcers. That’s
Reduce and boost music to my ears!
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Misoprostol protects against peptic ulcers caused by NSAIDs by

reducing the secretion of gastric acid and by boosting the produc-
tion of gastric mucus, a natural defense against peptic ulcers.

A sticky situation
Sucralfate works locally in the stomach, rapidly reacting with
hydrochloric acid to form a thick, pastelike substance that
adheres to the gastric mucosa and especially to ulcers. By bind-
ing to the ulcer site, sucralfate actually protects the ulcer from
the damaging effects of acid and pepsin to promote healing.
This binding usually lasts for 6 hours.

Pharmacotherapeutics
Each of these drugs has its own therapeutic uses.

Nursing Pharmacology_Chap07.indd 305 2/3/2012 7:21:06 PM

GASTROINTESTINAL DRUGS
306

Attention to prevention
Misoprostol prevents peptic ulcers caused by NSAIDs in patients
at high risk for complications resulting from gastric ulcers.

To treat and prevent

Sucralfate is used for short-term treatment (up to 8 weeks) of duo-
denal or gastric ulcers and prevention of recurrent ulcers or stress
ulcers.

Drug interactions
Misoprostol and sucralfate may interact with other drugs:
• Antacids may bind with misoprostol or decrease its absorption.
However, this effect doesn’t appear to be clinically significant.
• Cimetidine, digoxin, norfloxacin, phenytoin, fluoroquinolones,
ranitidine, tetracycline, and theophylline decrease the absorption
of sucralfate.
• Antacids may reduce the binding of sucralfate to the gastric and
duodenal mucosa, reducing its effectiveness.

Adverse reactions
Adverse reactions to misoprostol include:
• diarrhea (common and usually dose-related)
• abdominal pain
• gas
• indigestion Since you are
• nausea and vomiting taking misoprostol,
• spontaneous abortion (women of childbearing age shouldn’t let's talk about
contraceptive
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

become pregnant while taking misoprostol).

Adverse reactions to sucralfate include: methods and
possible alternative
• constipation treatments. This
• nausea and vomiting drug can harm the
• metallic taste. fetus if pregnancy
occurs.
Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with the antiulcer drugs misoprostol and sucral-
fate.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter.
• Assess for adverse reactions and drug interactions.

Nursing Pharmacology_Chap07.indd 306 2/3/2012 7:21:06 PM

ANTIULCER DRUGS
307

Pregnancy precaution
• If a female patient is taking misoprostol, the drug can cause
danger to the fetus if pregnancy occurs; discuss contraceptive
methods or alternative treatment.
• Monitor the patient’s hydration status if adverse GI reactions
occur.
• Assess the patient’s and family’s understanding of drug therapy.

Key nursing diagnoses

• Impaired tissue integrity related to upper gastric disorder
• Risk for deficient fluid volume related to drug-induced adverse
GI reactions
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s tissue integrity will improve as evidenced by a No butts about it!
reduction in presenting symptoms. Cigarette smoking
• The patient will maintain adequate fluid volume as evidenced by may increase gastric
stable vital signs and urine output. acid secretions and
• The patient and his family will demonstrate an understanding of worsen ulcers.
drug therapy.

Implementation
• Administer sucralfate 1 hour before meals and at bedtime.
• Administer misoprostol with food.
• Tell the patient to continue the prescribed regimen at home
to ensure complete healing. Explain that pain and ulcerative
symptoms may subside within the first few weeks of therapy.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Urge the patient to avoid cigarette smoking because it may

increase gastric acid secretion and worsen the disease.

The spice of life

• Tell the patient to avoid alcohol, chocolate, spicy foods, or any-
thing that irritates his stomach.
• Elevate the head of the bed for comfort.
• Tell the patient to avoid large meals within 2 hours before bedtime.
• In women, start misoprostol therapy on the second or third
day of the next normal menses to ensure that the patient isn’t
pregnant and that she is using effective contraception.

Evaluation
• Patient responds well to therapy.
• Patient maintains adequate hydration throughout therapy.
• Patient and his family demonstrate an understanding of drug
therapy.

Nursing Pharmacology_Chap07.indd 307 2/3/2012 7:21:07 PM

GASTROINTESTINAL DRUGS
308

Adsorbent, antiflatulent, Adsorbent

drugs are used as
and digestive drugs antidotes to toxins.

Adsorbent, antiflatulent, and digestive drugs aid healthy GI func-

tion. They’re used to fight undesirable toxins, acids, and gases in
the GI tract.

Adsorbent drugs
Natural and synthetic adsorbent drugs, or adsorbents, are pre-
scribed as antidotes for the ingestion of toxins, substances that
can lead to poisoning or overdose.

It’s no picnic
The most commonly used clinical adsorbent is activated charcoal,
a black powder residue obtained from the distillation of various
organic materials.

Pharmacokinetics
Quick action required
Activated charcoal must be administered soon after toxic inges-
tion because it can only bind with drugs or poisons that haven’t
yet been absorbed from the GI tract. Activated charcoal, which
isn’t absorbed or metabolized by the body, is excreted unchanged
in feces.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

A vicious cycle
After initial absorption, some poisons move back into the intes-
tines, where they’re reabsorbed. Activated charcoal may be
administered repeatedly to break this cycle.

Pharmacodynamics
Because adsorbent drugs attract and bind toxins in the intestine,
they inhibit toxins from being absorbed from the GI tract. How-
ever, this binding doesn’t change toxic effects caused by earlier
absorption of the poison.

Pharmacotherapeutics
Activated charcoal is a general-purpose antidote used for many
types of acute oral poisoning. It isn’t indicated in acute poisoning
from mineral acids, alkalines, cyanide, ethanol, methanol, iron,

Nursing Pharmacology_Chap07.indd 308 2/3/2012 7:21:08 PM

ADSORBENT, ANTIFLATULENT, AND DIGESTIVE DRUGS
309

sodium chloride alkali, inorganic acids, or organic solvents. It

also shouldn’t be used in children younger than age 1. It shouldn’t Children younger
be used if the patient has a risk of GI obstruction, perforation, or than age 1 shouldn’t
hemorrhage; decreased or absent bowel sounds; or a history of be given activated
recent GI surgery. charcoal.

Drug interactions
Activated charcoal can decrease the absorption of oral medica-
tions; therefore, these medications (other than those used to treat
the ingested toxin) shouldn’t be taken orally within 2 hours of tak-
ing activated charcoal.

Adverse reactions
Activated charcoal turns stool black and may cause constipation.
A laxative such as sorbitol is usually given with activated charcoal
to prevent constipation and improve taste.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with adsorbent drugs.

Assessment
• Obtain a history of the substance reportedly ingested, including
time of ingestion, if possible. Activated charcoal isn’t effective for
all drugs and toxic substances.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s and family’s knowledge of drug therapy.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Key nursing diagnoses

• Risk for injury related to ingestion of toxic substance or
overdose
• Risk for deficient fluid volume related to drug-induced vomiting
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s risk of injury will be minimized.
• The patient will maintain adequate fluid volume status as evi-
denced by stable vital signs and urine output.
• The patient and his family will demonstrate an understanding of
drug therapy.

Nursing Pharmacology_Chap07.indd 309 2/3/2012 7:21:08 PM

GASTROINTESTINAL DRUGS
310

Implementation
• Don’t give the drug to a semiconscious or unconscious patient Here’s a tip: Once
unless the airway is protected and an NG tube is in place for you’ve mixed the
powdered form of
instillation.
the adsorbent with
• Mix the powdered form with tap water to form the consistency tap water, add a
of thick syrup. Add a small amount of fruit juice or flavoring to small amount of
make it more palatable. fruit juice to make it
• Give by NG tube after lavage if needed. more palatable.

Down with dairy

• Don’t give the drug in ice cream, milk, or sherbet; these may
reduce absorption.
• Repeat the dose if the patient vomits shortly after administration.
• Keep airway, oxygen, and suction equipment nearby.
• Follow treatment with a stool softener or laxative to prevent
constipation.
• Tell the patient that his stools will be black.

Evaluation
• Patient doesn’t experience injury from ingesting toxic substance
or from overdose.
• Patient exhibits no signs of deficient fluid volume.
• Patient and his family demonstrate an understanding of drug
therapy.

Antiflatulent drugs
Antiflatulent drugs, or antiflatulents, disperse gas pockets in the
GI tract. They’re available alone or in combination with antacids.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

The major antiflatulent drug currently in use is simethicone.

Pharmacokinetics
Simethicone isn’t absorbed from the GI tract. It’s distributed only
in the intestinal lumen and is eliminated intact in feces.

Pharmacodynamics
Simethicone creates foaming action in the GI tract. It produces a
film in the intestines that disperses mucus-enclosed gas pockets
and helps prevent their formation.

Pharmacotherapeutics
Simethicone is prescribed to treat conditions in which excess gas
is a problem, such as:
• functional gastric bloating
• postoperative gaseous bloating

Nursing Pharmacology_Chap07.indd 310 2/3/2012 7:21:09 PM

ADSORBENT, ANTIFLATULENT, AND DIGESTIVE DRUGS
311

• diverticular disease
• spastic or irritable colon Antiflatulent drugs
• the swallowing of air. treat excess air or
gas in the stomach
or intestine. What a
Drug interactions relief!
Simethicone doesn’t interact significantly with other drugs.

Adverse reactions
Simethicone doesn’t cause any known adverse reactions. It has,
however, been associated with excessive belching or flatus.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with antiflatulent drugs.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter.
• Assess for adverse GI reactions.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Acute pain related to gas in the GI tract
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s pain will decrease.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• The patient and his family will demonstrate an understanding of

drug therapy.
Here’s your
Implementation suspension—
shaken, not stirred.
• Make sure that the patient chews the tablet form before swal-
lowing.

A shaky situation
• If giving the suspension form, make sure to shake the bottle
or container thoroughly to distribute the solution.
• Inform the patient that the drug doesn’t prevent gas
formation.
• Encourage the patient to change his position frequently and
to ambulate to help pass flatus.

Nursing Pharmacology_Chap07.indd 311 2/3/2012 7:21:10 PM

GASTROINTESTINAL DRUGS
312

Evaluation
• Patient’s gas pain is relieved.
• Patient and his family demonstrate an understanding of drug
therapy.

Digestive drugs
Digestive drugs (also called digestants) aid digestion in patients
who are missing enzymes or other substances needed to digest
food. Digestive drugs that function in the GI tract, liver, and pan-
creas include:
• dehydrocholic acid
• pancreatic enzymes (pancreatin, pancrelipase, lipase, protease,
and amylase).

Pharmacokinetics
Digestive drugs aren’t absorbed; they act locally in the GI tract
and are excreted in feces.

Pharmacodynamics
The action of digestive drugs resembles the action of the body
substances they replace. Dehydrocholic acid, a bile acid, increases
the output of bile in the liver.

The enzyme effect Before you

The pancreatic enzymes replace missing or deficient normal pan- give that drug
creatic enzymes. They exert their effect in the duodenum and upper
Pancreatic
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

jejunum of the upper GI tract. These drugs contain trypsin to digest

proteins, amylase to digest carbohydrates, and lipase to digest fats. enzymes
warning
Pharmacotherapeutics
Pancreatic enzymes
Because their action resembles the action of the body substances
should be given before
they replace, each digestive drug has its own indication.
meals. This ensures that
Go with the flow the drug is available in
Dehydrocholic acid, a bile acid, provides temporary relief from the small intestine to
constipation and promotes bile flow. help digestion. Giving
pancreatic enzymes
For the enzyme impaired at another time, such
Pancreatic enzymes are administered to patients with insufficient as 1 hour or more after
levels of pancreatic enzymes, such as those with pancreatitis or eating or during a meal,
cystic fibrosis. They may also be used to treat steatorrhea (a disor- decreases the drug’s
der of fat metabolism characterized by fatty, foul-smelling stools). effectiveness.
(See Pancreatic enzymes warning.)

Nursing Pharmacology_Chap07.indd 312 2/3/2012 7:21:11 PM

ADSORBENT, ANTIFLATULENT, AND DIGESTIVE DRUGS
313

Drug interactions
Patients with
Antacids reduce the effects of pancreatic enzymes and shouldn’t
pancreatitis or
be given at the same time. Pancreatic enzymes may also decrease cystic fibrosis
the absorption of folic acid and iron. may require
pancreatic enzyme
administration
Adverse reactions because their bodies
Adverse reactions to dehydrocholic acid include: may not produce
• abdominal cramping enough on their own.
• biliary colic (with gallstone obstruction of the biliary duct)
• diarrhea.
Adverse reactions to pancreatic enzymes include:
• diarrhea
• nausea
• abdominal cramping.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with digestive drugs.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter. A decrease in the number of bowel movements and
improved stool consistency indicate effective therapy.
• Monitor the patient’s diet to ensure a proper balance of fat, pro-
tein, and starch intake. This helps avoid indigestion. The dosage
varies according to the degree of maldigestion and malabsorption,
the amount of fat in the diet, and the enzyme activity of the drug.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Assess the patient’s and family’s knowledge of drug therapy.

• Assess the patient’s and family’s knowledge and attitudes about
nutrition.

Key nursing diagnoses

• Imbalanced nutrition: Less than body requirements related to
the condition
• Noncompliance related to long-term therapy
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s nutritional status will improve as evidenced by
laboratory tests and weight.
• The patient will comply with the prescribed drug regimen.
• The patient and his family will demonstrate an understanding of
drug therapy.

Nursing Pharmacology_Chap07.indd 313 2/3/2012 7:21:11 PM

GASTROINTESTINAL DRUGS
314

Implementation
• Administer the drug before or with each meal as applicable. Education
• For older infants, the powdered form may be mixed with apple- edge
sauce and given before meals.
• Avoid contact with or inhalation of the powder form; it may be Teaching about
irritating.
• Older children may take capsules with food.
digestive drugs
• Tell the patient not to crush or chew enteric-coated dosage If digestive drugs are
forms. Capsules containing enteric-coated microspheres may be prescribed, review these
opened and their contents sprinkled on a small amount of soft points with the patient
food, such as applesauce. Follow administration with a glass of and his caregivers:
water or juice. • Exercise and stay ac-
• Review food preferences and diet orders with the patient and tive to aid the digestion
his family. and improve appetite.
• Provide food and fluids that the patient enjoys at times he pre- • Minimize the use of
fers, if possible.
strong pain medications
• Treat signs and symptoms or disorders that may interfere with
and sedatives because
nutrition, such as pain, nausea, vomiting, or diarrhea.
these drugs may cause
• Consult with a dietitian if special diets are ordered. Provide
drowsiness and deter
foods the patient likes, selecting nutritionally better choices that
eating and drinking.
fall within the prescribed diet.
• Have routine checkups
Evaluation to monitor weight, fluid
• Patient maintains normal digestion of fats, carbohydrates, and intake, urine output, and
proteins. laboratory studies and
• Patient complies with the prescribed drug regimen. to assess nutritional
• Patient and his family demonstrate an understanding of drug outcome.
therapy. (See Teaching about digestive drugs.)
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Antidiarrheal and laxative drugs

Diarrhea and constipation represent the two major symptoms
related to disturbances of the large intestine.
Antidiarrheals act systemically or locally and include:
• opioid-related drugs
• kaolin and pectin (a combination drug and the only one that
acts locally).
Laxatives stimulate defecation and include:
• hyperosmolar drugs
• dietary fiber and related bulk-forming substances
• emollients
• stimulants
• lubricants.
5-HT3-receptor antagonists are used to treat irritable bowel
syndrome (IBS), a disorder of the colon that’s characterized by
constipation or diarrhea.

Nursing Pharmacology_Chap07.indd 314 2/3/2012 7:21:12 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
315

Opioid-related drugs Opioid-related

Opioid-related drugs decrease peristalsis drugs decrease the
(involuntary, progressive wavelike intestinal wavelike movement
of peristalsis.
movement that pushes fecal matter along) in
Cowabunga!
the intestines and include:
• diphenoxylate with atropine
• loperamide.

Pharmacokinetics
Diphenoxylate with atropine is readily absorbed from the GI tract.
However, loperamide isn’t absorbed well after oral administration.
Both drugs are distributed in serum, metabolized in the liver,
and excreted primarily in feces. Diphenoxylate with atropine is
metabolized to difenoxin, its biologically active major metabolite.

Pharmacodynamics Prototype
Diphenoxylate with atropine and loperamide slow GI motility by pro
depressing the circular and longitudinal muscle action (peristal-
sis) in the large and small intestines. These drugs also decrease Antidiarrheals:
expulsive contractions throughout the colon.
Loperamide
Pharmacotherapeutics Actions
• Inhibits peristaltic ac-
Diphenoxylate with atropine and loperamide are used to treat
acute, nonspecific diarrhea. Loperamide is also used to treat tivity, prolonging transit
chronic diarrhea. (See Antidiarrheals: Loperamide.) of intestinal contents

Indications
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Drug interactions • Diarrhea

Diphenoxylate with atropine and loperamide may enhance the Nursing considerations
depressant effects of barbiturates, alcohol, opioids, tranquilizers, • Monitor the drug’s ef-
and sedatives. fect on bowel movements.
• If giving by nasogastric
Adverse reactions tube, flush the tube to clear
Adverse reactions to diphenoxylate with atropine and loperamide it and to ensure the drug’s
include: passage to the stomach.
• nausea • Oral liquids are avail-
• vomiting able in different con-
• abdominal discomfort or distention centrations. Check the
• drowsiness dosage carefully.
• fatigue • For children, con-
• central nervous system (CNS) depression sider an oral liquid that
• tachycardia doesn’t contain alcohol.
• paralytic ileus (reduced or absent peristalsis in the intestines).

Nursing Pharmacology_Chap07.indd 315 2/3/2012 7:21:12 PM

GASTROINTESTINAL DRUGS
316

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with opioid-related drugs.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter.
• Assess the patient’s diarrhea before therapy and regularly there-
after.
• Monitor the patient’s fluid and electrolyte balance.
• Monitor the patient’s hydration status if adverse GI reactions
occur.
• Evaluate the patient for adverse reactions.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Diarrhea related to the underlying condition
Before giving
• Risk for deficient fluid volume related to GI upset antidiarrheals, make
• Deficient knowledge related to drug therapy sure you correct
fluid and electrolyte
Planning outcome goals disturbances,
• The patient will have normal bowel movements. which may cause
dehydration.
• The patient will maintain adequate fluid balance as evidenced
by intake and output.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Administer the drug exactly as prescribed.

• Correct fluid and electrolyte disturbances before starting the
drug; dehydration may increase the risk of delayed toxicity in
some cases.
• Use naloxone to treat respiratory depression caused by over-
dose.
• Take safety precautions if the patient experiences adverse CNS
reactions.
• Notify the prescriber about serious or persistent adverse reac-
tions.

Evaluation
• Patient’s diarrhea is relieved.
• Patient maintains adequate hydration.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about antidiarrheals.)

Nursing Pharmacology_Chap07.indd 316 2/3/2012 7:21:13 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
317

Education edge

Teaching about antidiarrheals

If antidiarrheals are prescribed, review these points with • Avoid hazardous activities that require alertness if cen-
the patient and his caregivers: tral nervous system depression occurs.
• Take the drug exactly as prescribed; be aware that ex- • Maintain intake of fluids and electrolytes, about 2 to 3 qt
cessive use of opium preparations can lead to dependence. (2 to 3 L) per day.
• Notify your prescriber if diarrhea lasts for more than 2 • Avoid food and fluids that can irritate the GI tract while
days, if acute abdominal signs and symptoms occur, or if diarrhea is present.
the drug is ineffective. • Schedule rest periods and decrease activity while diar-
rhea persists to reduce peristalsis.

Kaolin and pectin

Kaolin and pectin mixtures are locally acting OTC antidiarrhe-
als. They work by adsorbing irritants and soothing the intestinal
mucosa.

Pharmacokinetics
Kaolin and pectin aren’t absorbed and, therefore, aren’t distrib-
uted throughout the body. They’re excreted in feces.

Pharmacodynamics
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Kaolin and pectin act as adsorbents, binding with bacteria, toxins,

and other irritants on the intestinal mucosa.

A kinder, gentler pH
Pectin decreases the pH in the intestinal lumen and provides a
soothing effect on irritated mucosa.

Pharmacotherapeutics
Kaolin and pectin are used to relieve mild to moderate acute diar-
rhea.

Just a stopgap
They also may be used to temporarily relieve chronic diarrhea
until the cause is determined and definitive treatment starts.

Nursing Pharmacology_Chap07.indd 317 2/3/2012 7:21:14 PM

GASTROINTESTINAL DRUGS
318

Drug interactions
Kaolin and
These antidiarrheals can interfere with the absorption of digoxin pectin may cause
or other drugs from the intestinal mucosa if administered at the constipation,
same time. especially in elderly or
debilitated patients.
Adverse reactions
Kaolin and pectin mixtures cause few adverse reactions.
However, constipation may occur, especially in elderly or
debilitated patients or in cases of overdose or prolonged use.

Nursing process
These nursing process steps are appropriate for patients
undergoing treatment with kaolin and pectin.

Assessment
• Assess the patient’s condition before therapy and regu-
larly thereafter.
• Assess the patient’s diarrhea before therapy and regularly there-
after.
• Monitor fluid and electrolyte balance.
• Assess the patient for adverse reactions.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Diarrhea related to the underlying condition
• Risk for deficient fluid volume related to GI upset
• Deficient knowledge related to drug therapy
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Planning outcome goals

• The patient will have normal bowel movements.
• The patient will maintain adequate fluid balance as evidenced
by intake and output.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Administer the drug exactly as prescribed.
• Correct fluid and electrolyte disturbances before starting the
drug; dehydration may increase the risk of delayed toxicity in
some cases.
• Take safety precautions if the patient experiences adverse CNS
reactions.
• Notify the prescriber about serious or persistent adverse
reactions.

Nursing Pharmacology_Chap07.indd 318 2/3/2012 7:21:14 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
319

Evaluation
• Patient’s diarrhea is relieved.
• Patient maintains adequate hydration.
• Patient and his family demonstrate an understanding of drug therapy.

Hyperosmolar laxatives
Hyperosmolar laxatives work by drawing water into the intestine,
thereby promoting bowel distention and peristalsis. They include:
• glycerin
• lactulose
• saline compounds, such as magnesium salts, sodium
biphosphate, sodium phosphate, polyethylene glycol (PEG), and
electrolytes
• sorbitol.

Pharmacokinetics
The pharmacokinetic properties of hyperosmolar laxatives vary.
Glycerin is placed directly into the colon by enema or suppository
and isn’t absorbed systemically.

Intestine marks the spot

Lactulose enters the GI tract orally and is minimally absorbed.
As a result, the drug is distributed only in the intestine. It’s metab-
olized by bacteria in the colon and excreted in feces.

Saline away
After saline compounds are introduced into the GI tract orally or
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

as an enema, some of their ions are absorbed. Absorbed ions are

excreted in urine, the unabsorbed drug in feces. I come bearing
water to help
And then there’s PEG promote peristalsis!
PEG is a nonabsorbable solution that acts as an osmotic drug but
doesn’t alter electrolyte balance.

Pharmacodynamics
Hyperosmolar laxatives produce a bowel movement by drawing
water into the intestine. Fluid accumulation distends the bowel
and promotes peristalsis and a bowel movement. (See Hyper-
osmolar laxatives: Magnesium hydroxide, page 320.)

Pharmacotherapeutics
The uses of hyperosmolar laxatives vary:
• Glycerin is helpful in bowel retraining.

Nursing Pharmacology_Chap07.indd 319 2/3/2012 7:21:14 PM

GASTROINTESTINAL DRUGS
320

Prototype pro

Hyperosmolar laxatives: Magnesium hydroxide

Actions Nursing considerations
• Reduces total acid in the GI tract • Monitor the drug’s effect on bowel
• Elevates gastric pH to reduce pepsin movements.
activity • Shake the suspension well. Give the
• Strengthens the gastric mucosal barrier drug with a large amount of water when
• Increases esophageal sphincter tone used as a laxative.
• When used with a nasogastric tube,
Indications
make sure the tube is placed properly and
• Upset stomach
is patent. After instilling the drug, flush the
• Constipation
tube with water to ensure passage to the
• Inadequate magnesium level
stomach and to maintain tube patency.

• Lactulose is used to treat constipation and help reduce ammo-

nia production and absorption from the intestines in liver disease.
• Saline compounds are used when prompt and complete bowel
evacuation is required.

Drug interactions
Hyperosmolar laxatives don’t interact significantly with other
drugs. However, the absorption of oral drugs administered 1 hour
before PEG is significantly decreased. Adverse reactions
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

to glycerin include
Adverse reactions weakness and
fatigue.
Adverse reactions to hyperosmolar laxatives involve fluid and
electrolyte imbalances.
Adverse reactions to glycerin include:
• weakness
• fatigue.
Lactulose may cause these adverse reactions:
• abdominal distention, gas, and abdominal cramps
• nausea and vomiting
• diarrhea
• hypokalemia
• hypovolemia
• increased blood glucose level.
Adverse reactions to saline compounds include:
• weakness
• lethargy

Nursing Pharmacology_Chap07.indd 320 2/3/2012 7:21:15 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
321

• dehydration
• hypernatremia
• hypermagnesemia
• hyperphosphatemia
• hypocalcemia
• cardiac arrhythmias
• shock.
These adverse reactions may occur with PEG:
• nausea
• abdominal fullness
• explosive diarrhea
• bloating.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with hyperosmolar laxatives.

Assessment
• Obtain a baseline assessment of the patient’s bowel patterns
and GI history before giving a laxative.
• Determine whether the patient maintains adequate fluid intake
and diet and whether he exercises.
• Assess the patient’s bowel pattern throughout therapy. Assess
bowel sounds and color and consistency of stools.
• Monitor the patient’s fluid and electrolyte status during admin-
istration.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s and family’s knowledge of drug therapy. Schedule laxative
administration so
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

that the drug’s

Key nursing diagnoses effects don’t
• Diarrhea related to adverse GI effects interfere with the
• Acute pain related to abdominal discomfort patient’s activities
• Deficient knowledge related to drug therapy or sleep.

Planning outcome goals

• The patient will maintain regular bowel movements.
• The patient’s pain will decrease.
• The patient and his family will demonstrate an understanding
of drug therapy.

Nursing Pharmacology_Chap07.indd 321 2/3/2012 7:21:16 PM

GASTROINTESTINAL DRUGS
322

• If administering the drug through an NG tube, make sure that

the tube is placed properly and is patent. After instilling the drug,
flush the tube with water to ensure passage to the stomach and to
maintain tube patency.
• Don’t crush enteric-coated tablets.
• Make sure that the patient has easy access to a bedpan or bathroom.
• Institute measures to prevent constipation.

Evaluation
• Patient regains normal bowel elimination pattern.
• Patient states that pain is relieved with stool evacuation.
• Patient and his family demonstrate an understanding of drug
therapy.

Dietary fiber and related bulk-forming laxatives A high-fiber diet

is the most natural
A high-fiber diet is the most natural way to prevent or treat consti-
way to prevent or
pation. Dietary fiber is the part of plants not digested in the small treat constipation,
intestine. but bulk-forming
laxatives can offer a
Close resemblance little help if nature
Bulk-forming laxatives, which resemble dietary fiber, contain isn’t cooperating!
natural and semisynthetic polysaccharides and cellulose. These
laxatives include:
• methylcellulose
• polycarbophil
• psyllium hydrophilic mucilloid.

Pharmacokinetics
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Dietary fiber and bulk-forming laxatives aren’t absorbed sys-

temically. The polysaccharides in these drugs are converted
by intestinal bacterial flora into osmotically active metabo-
lites that draw water into the intestine. Dietary fiber and
bulk-forming laxatives are excreted in feces.

Pharmacodynamics
Dietary fiber and bulk-forming laxatives increase stool mass and
water content, promoting peristalsis. (See Bulk-forming laxa-
tives: Psyllium.)

Pharmacotherapeutics
Bulk-forming laxatives are used to:
• treat simple cases of constipation, especially constipation
resulting from a low-fiber or low-fluid diet

Nursing Pharmacology_Chap07.indd 322 2/3/2012 7:21:17 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
323

Prototype pro

Bulk-forming laxatives: Psyllium

Actions congeals. Follow administration with another glass of
• Absorbs water and expands to increase bulk and mois- liquid.
ture content of stool, thus encouraging peristalsis and • Psyllium may reduce the patient’s appetite if taken be-
bowel movements fore meals.
• This drug isn’t absorbed systemically and is nontoxic.
Indications
• Psyllium is useful in debilitated patients and in patients
• Constipation
with postpartum constipation, irritable bowel syndrome,
Nursing considerations or diverticular disease. It’s also used to treat chronic laxa-
• Mix the drug with at least 8 oz (240 mL) of cold, tive abuse and combined with other laxatives to empty the
pleasant-tasting liquid such as orange juice to colon before barium enema examination.
mask grittiness. Stir only a few seconds. Have the • Advise patients with diabetes to check the drug’s label
patient drink the mixture immediately, before it and to use a brand that doesn’t contain sugar.

• aid patients recovering from acute myocardial infarction (MI)

or cerebral aneurysms who need to avoid Valsalva’s maneuver
(forced expiration against a closed airway) and maintain soft stool
• manage patients with IBS and diverticulosis.

Drug interactions
Decreased absorption of digoxin, warfarin, and salicylates occurs
if these drugs are taken within 2 hours of fiber or bulk-forming
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

laxatives.

Adverse reactions
Adverse reactions to dietary fiber and related bulk-forming laxa-
tives include:
• flatulence
• a sensation of abdominal fullness
• intestinal obstruction
• fecal impaction (hard feces that can’t be removed from the rectum)
• esophageal obstruction (if sufficient liquid hasn’t been adminis-
tered with the drug)
• severe diarrhea.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with dietary fiber and bulk-forming laxatives.

Nursing Pharmacology_Chap07.indd 323 2/3/2012 7:21:17 PM

GASTROINTESTINAL DRUGS
324

Assessment
• Obtain a baseline assessment of the patient’s bowel patterns
and GI history before giving a laxative.
• Assess the patient for adverse reactions and drug interactions.
• Monitor the patient’s bowel pattern throughout therapy. Assess
bowel sounds and color and consistency of stools.
• Assess the patient’s fluid and electrolyte status during adminis-
tration.
• Determine whether the patient maintains adequate fluid intake
and diet and whether he exercises regularly.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Diarrhea related to adverse GI effects
• Acute pain related to abdominal discomfort
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient will maintain regular bowel movements.
• The patient’s pain will decrease.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Time drug administration so that the drug’s effects don’t inter-
fere with scheduled activities or sleep.
• Mix drugs as directed and give with a large amount of water, as
applicable.
• Don’t crush enteric-coated tablets.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Keep in mind that the laxative effect usually occurs in 12 to 24

hours but may be delayed for up to 3 days.
• Make sure that the patient has easy access to a bedpan or bath-
room.
• Institute measures to prevent constipation.

Emollient laxatives
Emollient laxatives—also known as stool softeners—include the
calcium, potassium, and sodium salts of docusate.

Nursing Pharmacology_Chap07.indd 324 2/3/2012 7:21:17 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
325

Pharmacokinetics
Prepare to
Administered orally, emollient laxatives are absorbed and emulsify!
excreted through bile in feces.

Pharmacodynamics
Emollient laxatives emulsify the fat and water compo-
nents of feces in the small and large intestines. This
detergent action allows water and fats to penetrate the
stool, making it softer and easier to eliminate. Emol-
lients also stimulate electrolyte and fluid secretion
from intestinal mucosal cells. (See Emollient laxatives:
Docusate.)

Pharmacotherapeutics
Emollient laxatives are the drugs of choice for softening stools in
patients who should avoid straining during a bowel movement,
including those with:
• recent MI or surgery
• disease of the anus or rectum
• increased intracranial pressure (ICP)
• hernias.

Drug interactions
Taking oral doses of mineral oil with oral emollient laxatives
increases the systemic absorption of mineral oil. This increased
absorption may result in tissue deposits of the oil.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Prototype pro

Emollient laxatives: Docusate

Actions • Be alert for adverse reactions and drug interactions.
• Reduces surface tension of interfacing liquid contents of • This drug is the laxative of choice for patients who
the bowel, promoting incorporation of additional liquid into shouldn’t strain during defecation (including those recover-
stool, thus forming a softer mass ing from myocardial infarction or rectal surgery), for patients
with rectal or anal disease that makes passage of firm stool
Indications
difficult, and for patients with postpartum constipation.
• Stool softening for patients who should avoid straining
• Discontinue the drug if abdominal cramping occurs and
during a bowel movement
notify the prescriber.
Nursing considerations • Docusate doesn’t stimulate intestinal peristaltic movements.
• Monitor the drug’s effect on bowel movements.

Nursing Pharmacology_Chap07.indd 325 2/3/2012 7:21:17 PM

GASTROINTESTINAL DRUGS
326

Proceed with caution

Because emollient laxatives may enhance the absorption of many
oral drugs, drugs with low margins of safety (narrow therapeutic
index) should be administered cautiously.

Adverse reactions
Although adverse reactions to emollient laxatives seldom occur,
they may include:
• a bitter taste
• diarrhea
• throat irritation
• mild, transient abdominal cramping.

Nursing process Determine

whether the patient
These nursing process steps are appropriate for patients undergo- maintains adequate
ing treatment with emollient laxatives. fluid intake and
diet and whether he
Assessment exercises.
• Obtain a baseline assessment of the patient’s bowel patterns
and GI history before giving a laxative.
• Assess the patient for adverse reactions and drug interactions.
• Monitor the patient’s bowel pattern throughout therapy. Assess
bowel sounds and color and consistency of stools.
• Assess the patient’s fluid and electrolyte status during
administration.
• Determine whether the patient maintains adequate fluid intake
and diet and whether he exercises.
• Assess the patient’s and family’s knowledge of drug therapy.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Key nursing diagnoses

• Diarrhea related to adverse GI effects
• Acute pain related to abdominal discomfort
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient will maintain regular bowel movements.
• The patient’s pain will decrease.
• The patient and his family will demonstrate an understanding of
drug therapy.

Nursing Pharmacology_Chap07.indd 326 2/3/2012 7:21:18 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
327

Don’t forget to flush

• If administering the drug through an NG tube, make sure that
the tube is placed properly and is patent. After instilling the drug,
flush the tube with water to ensure passage to the stomach and to
maintain tube patency.
• Don’t crush enteric-coated tablets.
• Make sure that the patient has easy access to a bedpan or bath-
room.
• Institute measures to prevent constipation.

Stimulant laxatives
Stimulant laxatives, also known as irritant cathartics, include:
• bisacodyl
• cascara sagrada Stimulant
• castor oil laxatives are
• phenophthalein used to empty
• senna. the bowel before
general surgery,
sigmoidoscopic
Pharmacokinetics or proctoscopic
Stimulant laxatives are minimally absorbed and are metabolized in procedures,
and radiologic
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

the liver. The metabolites are excreted in urine and feces. procedures.

Pharmacodynamics
Stimulant laxatives stimulate peristalsis and produce a bowel
movement by irritating the intestinal mucosa or stimulating
nerve endings of the intestinal smooth muscle.

Powering up peristalsis
Castor oil also increases peristalsis in the small
intestine.

Pharmacotherapeutics
Stimulant laxatives are the preferred drugs for empty-
ing the bowel before general surgery, sigmoidoscopic
or proctoscopic procedures, and radiologic procedures
such as barium studies of the GI tract.

Nursing Pharmacology_Chap07.indd 327 2/3/2012 7:21:19 PM

GASTROINTESTINAL DRUGS
328

Conquering constipation
Besides their use before surgery and procedures, stimulant laxatives
are used to treat constipation caused by prolonged bed rest, neuro-
logic dysfunction of the colon, and constipating drugs such as opioids.

Drug interactions
No significant drug interactions occur with stimulant laxatives.
However, because stimulant laxatives produce increased intestinal
motility, they reduce the absorption of other oral drugs adminis-
tered at the same time, especially sustained-release forms.

Adverse reactions
Adverse reactions to stimulant laxatives include:
• weakness
• nausea
• abdominal cramps
• mild inflammation of the rectum and anus
• urine discoloration (with cascara sagrada or senna use).

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with stimulant laxatives.

• Monitor the patient’s bowel pattern throughout therapy. Assess

bowel sounds and color and consistency of stools.
• Assess the patient’s fluid and electrolyte status during
administration.
• Determine whether the patient maintains adequate fluid intake
and diet and whether he exercises.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Diarrhea related to adverse GI effects
• Acute pain related to abdominal discomfort
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient will maintain regular bowel movements.
• The patient’s pain will decrease.

Nursing Pharmacology_Chap07.indd 328 2/3/2012 7:21:20 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
329

• The patient and his family will demonstrate an understanding of

drug therapy.

Implementation
• Time drug administration so that bowel evacuation doesn’t
interfere with scheduled activities or sleep.
• Shake suspensions well; give with a large amount of water as
indicated.
• If administering the drug through an NG tube, make sure that
the tube is placed properly and is patent. After instilling the drug,
flush the tube with water to ensure passage to the stomach and to
maintain tube patency.
• Don’t crush enteric-coated tablets. Prototype
• Make sure that the patient has easy access to a bedpan or pro
bathroom.
• Institute measures to prevent constipation. Lubricant
Evaluation
laxatives:
• Patient regains normal bowel elimination pattern. Mineral oil
• Patient states that pain is relieved with stool evacuation.
Actions
• Patient and his family demonstrate an understanding of drug
• Increases water reten-
therapy.
tion in stool by creating
a barrier between the
colon wall and feces
Lubricant laxatives that prevents colonic
Mineral oil is the main lubricant laxative in current clinical reabsorption of fecal
use. water

Indications
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Pharmacokinetics • Constipation
In its nonemulsified form, mineral oil is minimally absorbed; the Nursing considerations
emulsified form is about half absorbed. • Monitor the drug’s
effect on bowel move-
Mineral oil on the move
ments.
Absorbed mineral oil is distributed to the mesenteric lymph • Be alert for adverse
nodes, intestinal mucosa, liver, and spleen. Mineral oil is metabo-
reactions and drug inter-
lized by the liver and excreted in feces. (See Lubricant laxatives:
actions.
Mineral oil.)
• Give the drug on an
empty stomach.
Pharmacodynamics • Give the drug with
Mineral oil lubricates the stool and the intestinal mucosa and pre- fruit juice or a carbon-
vents water reabsorption from the bowel lumen. The increased ated drink to disguise its
fluid content of feces increases peristalsis. Rectal administration taste.
by enema also produces distention.

Nursing Pharmacology_Chap07.indd 329 2/3/2012 7:21:20 PM

GASTROINTESTINAL DRUGS
330

Pharmacotherapeutics
You can minimize
Mineral oil is used to treat constipation and maintain soft stools drug interactions by
when straining is contraindicated, such as after a recent MI (to giving mineral oil at
avoid Valsalva’s maneuver), eye surgery (to prevent increased least 2 hours before
pressure in the eye), or cerebral aneurysm repair (to avoid other drugs.
increased ICP). Administered orally or by enema, mineral oil is
also used to treat patients with fecal impaction.

Drug interactions
To minimize drug interactions, administer mineral oil at least 2
hours before other drugs. These drug interactions may occur:
• Mineral oil may impair the absorption of many oral drugs,
including fat-soluble vitamins, hormonal contraceptives, and anti-
coagulants.
• Mineral oil may interfere with the antibacterial activity of non-
absorbable sulfonamides.

Adverse reactions
Adverse reactions to mineral oil include:
• nausea
• vomiting
• diarrhea
• abdominal cramping.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with lubricant laxatives.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Assessment
• Obtain a baseline assessment of the patient’s bowel patterns
and GI history before giving a laxative.
• Assess the patient for adverse reactions and drug interactions.
• Monitor the patient’s bowel pattern throughout therapy. Assess
bowel sounds and color and consistency of stools.
• Assess the patient’s fluid and electrolyte status during
administration.
• Determine whether the patient maintains adequate fluid intake
and diet and whether he exercises.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Diarrhea related to adverse GI effects
• Acute pain related to abdominal discomfort
• Deficient knowledge related to drug therapy

Nursing Pharmacology_Chap07.indd 330 2/3/2012 7:21:20 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
331

Education edge

Teaching about laxatives

If laxatives are prescribed, review these points with the • Stimulant laxatives may cause harmless urine
patient and his caregivers: discoloration.
• Therapy should be short term. Abuse or prolonged use • Include foods high in fiber, such as bran and other cere-
can result in nutritional imbalances. als, fresh fruit, and vegetables, in your diet.
• Diet, exercise, and fluid intake are important in maintaining • Frequent or prolonged use of some laxatives can result
normal bowel function and preventing or treating constipation. in dependence.
• Drink at least 6 to 10 glasses (8 oz each) of fluid daily, • Never take laxatives when experiencing acute abdomi-
unless contraindicated. nal pain, nausea, or vomiting. A ruptured appendix or other
• Exercise regularly to help with bowel elimination. serious complication may result.
• Stool softeners and bulk-forming laxatives may take • Notify the prescriber if signs and symptoms persist or if
several days to achieve results. the laxative doesn’t work.
• If using a bulk-forming laxative, remain active and drink
plenty of fluids.

Planning outcome goals

• The patient will maintain regular bowel movements.
• The patient’s pain will decrease.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Time drug administration so that bowel evacuation doesn’t

interfere with scheduled activities or sleep.
• When giving mineral oil by mouth, give it on an empty stomach.
• Perform rectal administration according to facility protocol.
• Make sure that the patient has easy access to a bedpan or bathroom.
• Institute measures to prevent constipation.

Selective 5-HT3-receptor antagonists

Alosetron, a selective antagonist of serotonin 5-HT3 receptors,
is used for short-term treatment of severe diarrhea-predominant

Nursing Pharmacology_Chap07.indd 331 2/3/2012 7:21:21 PM

GASTROINTESTINAL DRUGS
332

IBS in women. Blocking 5-HT3 receptors helps decrease the pain

associated with IBS. Access to alosetron, however, is limited. Because of the
potential for
Restricted use only serious adverse
effects, alosetron
The drug is available through a restricted marketing program
is prescribed only
because serious adverse bowel effects have been reported. Only by doctors enrolled
doctors enrolled in the prescribing program for alosetron can in the drug’s
write a prescription for it. prescribing program.

Pharmacokinetics
Alosetron is rapidly absorbed after oral administration. It’s
metabolized by the cytochrome P450 pathway.

Pharmacodynamics
Alosetron selectively inhibits 5-HT3 receptors on enteric
neurons in the GI tract. By inhibiting activation of these
cation channels, neuronal depolarization is blocked,
resulting in decreased visceral pain, colonic transit, and
GI secretions — factors that usually contribute to the
symptoms of IBS.

The fine print

Alosetron hasn’t been studied in pregnant women or nursing
mothers. The risks and benefits should be evaluated before
giving alosetron to these patients. Older adults may be sensitive
to the effects of alosetron, which may increase the risk of serious
constipation.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Pharmacotherapeutics
Alosetron is used for the short-term treatment of women with IBS
whose primary symptom is diarrhea that has lasted longer than 6
months and has not responded to conventional treatment. Don’t
give this drug if the patient is constipated. Stop the drug if consti-
pation develops. This drug is not indicated for men.

Drug interactions
Studies have shown that alosetron inhibits cytochrome P450 1A2
(CYP1A2) and N-acetyltransferase by 30%. Although clinical trials
haven’t been conducted, the inhibition of N-acetyltransferase may
have clinical significance when alosetron is given with such drugs
as isoniazid, procainamide, and hydralazine. Avoid using alosetron
with other drugs that decrease GI motility to prevent the risk of
constipation.

Nursing Pharmacology_Chap07.indd 332 2/3/2012 7:21:21 PM

ANTIDIARRHEAL AND LAXATIVE DRUGS
333

Adverse reactions
Alosetron has produced serious, and sometimes fatal, adverse
reactions, including:
• ischemic colitis
• serious complications of constipation, including obstruction,
perforation, and toxic megacolon.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with a selective 5-HT3-receptor antagonist.

Assessment
• Obtain a baseline assessment of the patient’s bowel patterns
and GI history before starting therapy.
• Assess the patient for adverse reactions and drug interactions.

A collection of contraindications
• Assess the patient for contraindications to alosetron, such as
constipation, intestinal obstruction, stricture, toxic megacolon,
GI perforation, GI adhesions, ischemic colitis, impaired intestinal
circulation, thrombophlebitis, hypercoagulable state, Crohn’s dis-
ease, ulcerative colitis, or diverticulitis.
• Monitor the patient’s bowel pattern throughout therapy. Assess
bowel sounds and color and consistency of stools.
• Assess the patient’s fluid and electrolyte status during adminis-
tration.
• Determine whether the patient maintains adequate fluid intake
and diet and whether she exercises.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Assess the patient’s and family’s knowledge of drug therapy.

Because you’re a
woman, alosetron
Key nursing diagnoses may be indicated for
• Diarrhea related to adverse GI effects your IBS.
• Acute pain related to abdominal discomfort
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient will maintain regular bowel movements.
• The patient’s pain will decrease.
• The patient and her family will demonstrate an under-
standing of drug therapy.

Implementation
• Time drug administration so that bowel evacuation
doesn’t interfere with scheduled activities or sleep.

Nursing Pharmacology_Chap07.indd 333 2/3/2012 7:21:21 PM

GASTROINTESTINAL DRUGS
334

• Make sure that the patient has easy access to a bedpan or

bathroom.
• Institute measures to prevent constipation.
• Inform the patient of the risks and benefits of the drug.
• Explain to the patient that she must enroll in the drug’s
prescribing program and sign a patient-physician agreement to
participate in therapy.

Evaluation
• Patient regains normal bowel elimination pattern.
• Patient states that pain is relieved with stool evacuation.
• Patient and her family demonstrate an understanding of drug
therapy.

Obesity drugs
Obesity drugs should be used in
combination with a
Obesity drugs can help morbidly obese patients who have health weight management
program that
problems that will likely improve with weight loss. These drugs includes diet,
are used in combination with a weight management program that physical activity,
includes diet, physical activity, and behavior modification. They and behavior
should be used only for improving health, not for cosmetic weight modification.
loss.
Obesity drugs include:
• appetite suppressants (phentermine hydrochloride)
• fat blockers (orlistat).

Pharmacokinetics
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Phentermine is rapidly absorbed from the intestine and

distributed throughout the body. It’s excreted in urine.
Orlistat isn’t absorbed systemically; its action occurs in
the GI tract, and it’s excreted in the feces.

Pharmacodynamics
The appetite suppressant phentermine increases the
amount of norepinephrine and dopamine in the brain,
which suppresses appetite.

Caught in a bind
The fat-blocking drug orlistat works differently. It binds to gastric
and pancreatic lipases in the GI tract, making them unavailable

Nursing Pharmacology_Chap07.indd 334 2/3/2012 7:21:22 PM

OBESITY DRUGS
335

to break down fats. This prevents absorption of 30% of the fat

ingested in a meal.

Pharmacotherapeutics
Appetite suppressants and fat blockers are used primarily in mor-
bidly obese patients for whom weight loss will improve health and
prevent death.

Drug interactions
Obesity drugs have the following interactions:
• Appetite suppressants taken with cardiovascular stimulants
may increase risk of hypertension and arrhythmias.
• When taken with CNS stimulants, appetite suppressants can
result in anxiety and insomnia.
• Appetite suppressants taken with serotonergic drugs (including
selective serotonin reuptake inhibitors such as fluoxetine, triptan
antimigraine drugs such as sumatriptan, lithium, and dextro-
methorphan, which is commonly found in cough syrup) can cause
agitation, confusion, hypomania, impaired coordination, loss of
consciousness, nausea, and tachycardia.
• Taking orlistat with fat-soluble vitamins blocks vitamin
absorption.

Adverse reactions
Phentermine hydrochloride can cause nervousness, dry mouth,
constipation, and hypertension.

In the short run

Orlistat causes abdominal pain, oily spotting, fecal urgency,

flatulence with discharge, fatty stools, fecal incontinence, and
increased defecation, although these effects usually subside after
a few weeks.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with obesity drugs.

Assessment
• Assess patient for factors and health risks related to excess
weight, such as cardiovascular disease, diabetes, and sleep apnea.
• Determine the patient’s blood pressure and pulse rate before
starting therapy with phentermine.

Nursing Pharmacology_Chap07.indd 335 2/3/2012 7:21:23 PM

GASTROINTESTINAL DRUGS
336

• Assess the patient for adverse reactions.

• Assess such laboratory values as cholesterol levels and blood
sugar.
• Assess the patient’s caloric intake before starting therapy.
• Measure the patient’s weight, waist circumference, and body
mass index.
• Assess the patient’s motivation to adhere to a weight-management
program.

Key nursing diagnoses

• Imbalanced nutrition: More than body requirements related to
excessive caloric intake
• Disturbed body image related to excessive weight
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient will decrease his caloric intake.
• The patient will experience a positive body image with weight
loss. Orlistat prevents
• The patient will verbalize an understanding of drug therapy. the absorption of
fat-soluble vitamins,
Implementation so make sure you
• Explain to the patient that phentermine is for short-term use administer us daily
2 hours before or
only. Don’t give this drug to a patient with hypertension, cardio-
after orlistat.
vascular disease, or a history of drug abuse.
• Assess the patient taking phentermine for agitation and anxiety.
• Because orlistat prevents absorption of fat-soluble vitamins—
including A, D, E, and K—make sure the patient takes a multivita-
min daily 2 hours before or after taking orlistat.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Monitor the blood pressure of the patient tak-

ing phentermine at regular intervals throughout
therapy.
• Promote exercise and healthy eating as part of an
overall strategy to lose weight.

Evaluation
• Patient decreases caloric intake and loses weight.
• Patient regains a positive body image.
• Patient verbalizes an understanding of drug therapy. (See
Teaching about obesity drugs.)

Nursing Pharmacology_Chap07.indd 336 2/3/2012 7:21:23 PM

ANTIEMETIC DRUGS
337

Education edge

Teaching about obesity drugs

If obesity drugs are prescribed, review these points with • Keep in mind that the drug may lose its effectiveness
the patient and his caregivers: over time; you should not use it for more than 3 months.
• Take an appetite suppressant in the morning to de- • If you’re taking orlistat, take one capsule with each main
crease your appetite during the day and to prevent the meal (or up to 1 hour after a meal) three times a day. If
drug from interfering with sleep at night. you miss a meal, skip that dose. Take a multivitamin that
• If you’re taking phentermine, take it 30 minutes before contains fat-soluble vitamins A, D, E, and K daily, at least 2
meals or as a single dose in the morning. Avoid caffeine. hours before or after taking orlistat.

Antiemetic drugs
Antiemetic drugs decrease nausea, reducing the urge to vomit.

Antiemetics
The major antiemetics include:
• antihistamines, including dimenhydrinate, diphenhydra-
mine hydrochloride, buclizine hydrochloride, cyclizine
hydrochloride, hydroxyzine hydrochloride, hydroxyzine
pamoate, meclizine hydrochloride, and trimethobenzamide
hydrochloride
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• phenothiazines, including chlorpromazine hydrochloride, per-

phenazine, prochlorperazine maleate, promethazine hydrochlo-
ride, and thiethylperazine maleate
• serotonin receptor (5-HT3) antagonists, including ondansetron,
dolasetron, granisetron, and palonosetron
• cannabinoids, including dronabinol and nabilone
• neurokinin receptor agonists, including aprepitant.

#1 nausea fighter
Ondansetron is currently the antiemetic of choice in the United
States.

Pharmacokinetics
The pharmacokinetic properties of antiemetics may vary slightly.
Oral antihistamine antiemetics are absorbed well from the GI tract
and are metabolized primarily by the liver. Their inactive metabo-
lites are excreted in urine.

Nursing Pharmacology_Chap07.indd 337 2/3/2012 7:21:24 PM

GASTROINTESTINAL DRUGS
338

Phenothiazines and serotonin receptor antagonists are

absorbed well and extensively metabolized by the liver. They are
excreted in urine and feces.

Pharmacodynamics
The action of antiemetics may vary.

Blocking action
Antihistamines block H1 receptors, which prevents acetylcholine
from binding to receptors in the vestibular nuclei.

The trigger zone

Phenothiazines produce their antiemetic effect by blocking the
dopaminergic receptors in the chemoreceptor trigger zone in the
Should have taken
brain. (This area of the brain, near the medulla, stimulates the that antihistamine
vomiting center in the medulla, causing vomiting.) These drugs antiemetic before we
may also directly depress the vomiting center. boarded the plane.

Two spots to block

The serotonin receptor antagonists block serotonin stimu-
lation centrally in the chemoreceptor trigger zone and
peripherally in the vagal nerve terminals, both of which
stimulate vomiting.

Pharmacotherapeutics
The uses of antiemetics may vary.

Motion potion
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

With the exception of trimethobenzamide, the antihista-

mines are specifically used for nausea and vomiting caused
by inner ear stimulation. As a consequence, these drugs
prevent or treat motion sickness. They usually prove most
effective when given before activities that produce motion sick-
ness and are much less effective when nausea or vomiting has
already begun.

Much more severe

Phenothiazines and serotonin receptor antagonists control
severe nausea and vomiting from various causes. They’re used
when vomiting becomes severe and potentially hazardous,
such as postsurgical or viral nausea and vomiting. Both types
of drugs are also prescribed to control the nausea and vomiting
resulting from cancer chemotherapy and radiotherapy. (See
Other antiemetics)

Nursing Pharmacology_Chap07.indd 338 2/3/2012 7:21:24 PM

ANTIEMETIC DRUGS
339

Other antiemetics
Here are other antiemetics currently in use.

Scopolamine Dronabinol
Scopolamine prevents motion sickness, but its use is lim- Dronabinol, a purified derivative of cannabis, is a schedule
ited because of its sedative and anticholinergic effects. II drug (meaning it has a high potential for abuse) used
One scopolamine transdermal preparation, Transderm- to treat the nausea and vomiting resulting from cancer
Scop, is highly effective without producing the usual chemotherapy in patients who don’t respond adequately to
adverse effects. conventional antiemetics. It’s also been used to stimulate
the appetite in patients with acquired immunodeficiency
Metoclopramide
syndrome. However, dronabinol can accumulate in the
Metoclopramide hydrochloride is principally used to treat
body, and the patient can develop tolerance or physical
GI motility disorders, including gastroparesis in diabetic
and psychological dependence.
patients. It’s also used to prevent chemotherapy-induced
nausea and vomiting. Aprepitant
Aprepitant is used to prevent chemotherapy-induced nau-
sea and vomiting. It works by blocking neurokinin recep-
tors in the brain. It’s given 1 hour before chemotherapy for
the first 3 days of treatment.

Drug interactions
Antihistamines
Antiemetics may have many significant interactions: and phenothiazines
• Antihistamines and phenothiazines can produce additive CNS can produce additive
depression and sedation when taken with CNS depressants, such CNS depression
as barbiturates, tranquilizers, antidepressants, alcohol, and opioids. and sedation when
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Antihistamines can cause additive anticholinergic effects, such taken with CNS
as constipation, dry mouth, vision problems, and urine retention, depressants.
when taken with anticholinergic drugs, including tricyclic antide-
pressants, phenothiazines, and antiparkinsonian drugs.
• Phenothiazine antiemetics taken with anticholinergic drugs
increase the anticholinergic effect and decrease antiemetic
effects.
• Droperidol plus phenothiazine antiemetics increase the risk
of extrapyramidal effects (abnormal involuntary movements).

Adverse reactions
The use of these antiemetic drugs may lead to adverse reactions:
• Antihistamine and phenothiazine antiemetics produce
drowsiness; paradoxical CNS stimulation may also occur.
• CNS effects associated with phenothiazine and serotonin recep-
tor antagonist antiemetics include confusion, anxiety, euphoria,

Nursing Pharmacology_Chap07.indd 339 2/3/2012 7:21:25 PM

GASTROINTESTINAL DRUGS
340

agitation, depression, headache, insomnia, restlessness, and

weakness.
• The anticholinergic effect of antiemetics may cause consti-
pation, dry mouth and throat, painful or difficult urination,
urine retention, impotence, and visual and auditory distur-
bances.
• Hypotension and orthostatic hypotension with an increased
heart rate, fainting, and dizziness are common adverse reactions
to phenothiazines.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with antiemetics.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s and family’s knowledge of drug therapy. It isn’t my
job! Don’t give
Key nursing diagnoses antiemetics
subcutaneously.
• Ineffective health maintenance related to the underlying
condition
• Risk for deficient fluid volume related to the underlying
condition
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient will exhibit improved health as evidenced by

decreased vomiting.
• The patient will maintain adequate fluid volume balance as
evidenced by intake and output, vital signs, and electrolyte
evaluations.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Monitor the patient for the drug’s effect.
• Administer the drug as directed to promote GI effectiveness and
relieve distress.
• Give IM injections deeply into a large muscle mass. Rotate injec-
tion sites.
• Don’t give antiemetics subcutaneously.

Nursing Pharmacology_Chap07.indd 340 2/3/2012 7:21:26 PM

QUICK QUIZ
341

• For prevention of motion sickness, tell the patient to take the

drug 30 to 60 minutes before travel.
• Warn the patient to avoid alcohol and hazardous activities until
the drug’s CNS effects are known.
• Stop the drug 4 days before allergy skin tests.

Evaluation
• Patient responds well to therapy.
• Patient maintains fluid volume.
• Patient and his family demonstrate an understanding of drug
therapy.

Quick quiz
1. A patient is taking calcium carbonate for peptic ulcer disease.
You should monitor the patient for:
A. hypercalcemia.
B. hypocalcemia.
C. hyperkalemia.
D. hypokalemia.
Answer: A. Watch for signs of hypercalcemia in the patient re-
ceiving calcium carbonate.
2. Which adverse reaction is common and usually dose-related
in patients taking misoprostol?
A. Diarrhea
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

B. Nausea
C. Vomiting
D. Bloating
Answer: A. Misoprostol commonly causes diarrhea. This reaction
is usually dose-related.
3. Which drug or drug type may interact with the H2-receptor
antagonist cimetidine?
A. Hormonal contraceptives
B. Antilipemic agents
C. Digoxin
D. Oral anticoagulants
Answer: D. Cimetidine may increase the blood levels of oral
anticoagulants by reducing their metabolism in the liver and
excretion.

Nursing Pharmacology_Chap07.indd 341 2/3/2012 7:21:26 PM

GASTROINTESTINAL DRUGS
342

4. A patient is admitted to the emergency department with sa-

licylate poisoning. Which drug should the nurse anticipate giving
the patient?
A. Chlorpromazine
B. Activated charcoal
C. Magnesium citrate
D. Docusate
Answer: B. Activated charcoal is a general-purpose antidote
that’s used for various types of acute oral poisoning.
5. Which drug is used to treat IBS in women whose primary
bowel symptom is diarrhea?
A. Alosetron
B. Bisacodyl
C. Famotidine
D. Docusate
Answer: A. Alosetron is a selective 5-HT3-receptor antagonist
that’s used for the short-term treatment of IBS in women whose
primary bowel symptom is severe diarrhea.

Scoring
✰✰✰ If you answered all five questions correctly, thumbs up! Your
knowledge of GI drugs is gastronomical.
✰✰ If you answered four questions correctly, nice work! You certainly
aren’t lacking learning in the laxative department.
✰ If you answered fewer than four questions correctly, don’t panic.
You may need some more time to digest the material.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Are you ready to

truck on over to
the next chapter?

Nursing Pharmacology_Chap07.indd 342 2/3/2012 7:21:27 PM

8
Genitourinary drugs

Just the facts

In this chapter, you’ll learn:
♦ classes of drugs used to treat genitourinary (GU)
disorders
♦ uses and varying actions of these drugs
♦ absorption, distribution, metabolization, and excretion
of these drugs
♦ drug interactions and adverse reactions to these drugs.

Drugs and the genitourinary system

The GU system consists of the reproductive system (the sex
I’m a
organs) and the urinary system, which includes the kidneys, master at
ureters, bladder, and urethra. The kidneys perform most of the multitasking!
work of the urinary system.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Multitalented
The kidneys perform several vital tasks, including:
• disposing of wastes and excess ions in the form of urine
• filtering blood, which regulates its volume and chemical makeup
• helping to maintain fluid, electrolyte, and acid-base balances
• producing several hormones and enzymes
• converting vitamin D to a more active form
• helping to regulate blood pressure and volume by secreting
renin.

Helping hands
Types of drugs used to treat GU disorders include:
• diuretics
• urinary tract antispasmodics
• erectile dysfunction therapy drugs
• hormonal contraceptives.

Nursing Pharmacology_Chap08.indd 343 1/28/2012 12:29:09 PM

GENITOURINARY DRUGS
344

Diuretics
Diuretics trigger the excretion of water and electrolytes from the
kidneys, making these drugs a primary choice in the treatment of
renal disease, edema, hypertension, and heart failure.

Thiazide and thiazide-like diuretics

Derived from sulfonamides, thiazide and thiazide-like diuretics are
used to treat edema and to prevent the development and recur-
rence of renal calculi. They’re also used for such cardiovascular
diseases as hypertension and heart failure.
Thiazide diuretics include:
• bendroflumethiazide
• chlorothiazide
• hydrochlorothiazide
• hydroflumethiazide
• methyclothiazide
• polythiazide.
Thiazide-like diuretics include:
• chlorthalidone
• indapamide
• metolazone.

Pharmacokinetics (how drugs circulate)

Thiazide diuretics are absorbed rapidly but incompletely from
the GI tract after oral administration. They cross the placenta and
are secreted in breast milk. These drugs differ in how well they’re
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

metabolized, but all are excreted primarily in urine. (See Thiazide

diuretics: Hydrochlorothiazide.)
Thiazide-like diuretics are absorbed from the GI tract. Chlor-
thalidone is 90% bound to erythrocytes; little is known about its
metabolism. Indapamide is distributed widely into body tissues
and metabolized in the liver. Little is also known about the metab-
olism of metolazone. All of these drugs are primarily excreted in
urine. (See Thiazide-like diuretics: Indapamide, page 346.)

Pharmacodynamics (how drugs act)

Thiazide and thiazide-like diuretics promote the excretion of
water by preventing the reabsorption of sodium in the kidneys. As
the kidneys excrete the excess sodium, they excrete water along
with it. These drugs also increase the excretion of chloride, potas-
sium, and bicarbonate, which can result in electrolyte imbalances.
With long-term use, thiazide diuretics also lower blood pressure
by causing arteriolar vasodilation.

Nursing Pharmacology_Chap08.indd 344 1/28/2012 12:29:09 PM

DIURETICS
345

Prototype pro

Thiazide diuretics: Hydrochlorothiazide

Actions Nursing considerations
• Interferes with sodium transport across tubules of the • Monitor for adverse effects, such as pancreatitis,
cortical diluting segment of the nephron hematologic disorders, and electrolyte imbalances,
• Increases renal excretion of sodium, chloride, water, especially hypokalemia (symptoms of
potassium, and calcium hypokalemia include leg cramps and muscle
• Increases bicarbonate, magnesium, phosphate, bromide, aches).
and iodide excretion • Frequently monitor weight and blood pressure.
• Decreases excretion of ammonia, causing increased • Assess for signs of orthostatic blood
serum ammonia levels pressure changes, which could lead to falls
and injuries.
Indications
• Edema
• Hypertension

Turning down the volume

Initially, diuretic drugs decrease circulating blood volume, leading
to reduced cardiac output. However, if therapy is maintained,
cardiac output stabilizes but plasma fluid volume decreases.

Pharmacotherapeutics (how drugs are used)

Thiazides are used for the long-term treatment of hypertension;
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

they’re also used to treat edema caused by kidney or liver disease,

mild or moderate heart failure, and corticosteroid and estrogen
therapy. Because these drugs decrease the level of calcium in
urine, they may be used alone or with other drugs to prevent the
development and recurrence of renal calculi.
Pointing out a paradox
In patients with diabetes insipidus (a disorder characterized by
excessive urine production and excessive thirst resulting from
reduced secretion of antidiuretic hormone), thiazides paradoxi-
cally decrease urine volume, possibly through sodium depletion
and plasma volume reduction.

Drug interactions
Drug interactions related to thiazide and thiazide-like diuretics
result in altered fluid volume, blood pressure, and serum electro-
lyte levels:

Nursing Pharmacology_Chap08.indd 345 1/28/2012 12:29:09 PM

GENITOURINARY DRUGS
346

Prototype pro

Thiazide-like diuretics: Indapamide

Actions • Diabetes insipidus, especially nephro-
• Interferes with sodium transport across genic diabetes insipidus
the tubules of the cortical diluting seg- • Edema from right-sided heart failure
ment in the nephron, thereby increasing • Mild to moderate left-sided heart failure
renal excretion of sodium, chloride, wa-
Nursing considerations
ter, potassium, and calcium
• Give the drug in the morning to prevent
Indications nocturia.
• Nephrotic syndrome • Indapamide may be used with a
• Edema and ascites caused by hepatic potassium-sparing diuretic to prevent
cirrhosis potassium loss.
• Hypertension

• These drugs may decrease excretion of lithium, causing lithium

toxicity. Administering
• Nonsteroidal anti-inflammatory drugs (NSAIDs), including thiazide diuretics
cyclooxygenase-2 (COX-2) inhibitors, may reduce the antihyper- along with
antihypertensives
tensive effect of these diuretics.
can result in additive
• Use of these drugs with other potassium-depleting drugs and hypotension. I don’t
digoxin may cause an additive effect, increasing the risk of like the way this is
digoxin toxicity. adding up!
• These diuretics may increase the response to skeletal muscle
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

relaxants.
• Use of these drugs may increase blood glucose levels, requir-
ing higher doses of insulin or oral antidiabetic drugs.
• These drugs may produce additive hypotension when used
with antihypertensives.

Adverse reactions
The most common adverse reactions to thiazide and thiazide-
like diuretics are reduced blood volume, orthostatic hypoten-
sion, hypokalemia, hyperglycemia, and hyponatremia.

Nursing process
These nursing process steps are appropriate for patients undergoing
treatment with thiazide and thiazide-like diuretics.

Nursing Pharmacology_Chap08.indd 346 1/28/2012 12:29:10 PM

DIURETICS
347

Assessment
• Monitor digoxin levels if the patient is receiving digoxin concur-
rently with a thiazide or thiazide-like diuretic.
• Monitor the patient’s intake, output, and serum electrolyte
levels regularly.
• Carefully monitor the patient for signs and symptoms of hypo-
kalemia, such as drowsiness, paresthesia, muscle cramps, and
hyporeflexia.
• Monitor blood pressure before administration and during therapy.

Weighing in
• Weigh the patient each morning immediately after he voids and
before breakfast, using the same scale and making sure he’s wear-
ing the same type of clothing. Weight provides a reliable indicator
of the patient’s response to diuretic therapy.
• If the patient has diabetes, monitor his blood glucose levels
because diuretics may cause hyperglycemia.
• Because these drugs aren’t as effective when serum creatinine
and blood urea nitrogen (BUN) levels rise to more than twice their
normal levels, monitor these levels regularly. Also monitor blood
uric acid levels. Don't forget
to remind your
patients taking
Key nursing diagnoses thiazide or thiazide-
• Risk for deficient fluid volume related to excessive diuresis like diuretics to
• Risk for injury related to postural hypotension and dizziness consume plenty
• Deficient knowledge related to diuretic therapy of potassium-rich
foods.
Planning outcome goals
• The patient will maintain a normal fluid volume as evidenced by
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

having a blood pressure and heart rate within the normal range.
• Adverse effects of the diuretic will be minimized.
• The patient will demonstrate correct drug administration.
• The patient will remain injury free.

Implementation
• Give the drug in the morning to prevent nocturia from disrupt-
ing the patient’s sleep.
• Consult a dietitian about providing the patient with a high-
potassium diet.
• Administer potassium supplements as prescribed to maintain
the patient’s serum potassium level within an acceptable range.
• Keep a urinal or bedpan within reach of the patient or ensure
that a bathroom is easily accessible.
• Prevent falls from dizziness.

Nursing Pharmacology_Chap08.indd 347 1/28/2012 12:29:11 PM

GENITOURINARY DRUGS
348

Education edge

Teaching about diuretics

If diuretics are prescribed, review these points with the gain (more than 2 lb [0.9 kg]) daily; or excess water loss
patient and his caregivers: (as evidenced by a weight loss of more than 2 lb daily).
• Make sure you understand the rationale for therapy and Also watch for photosensitivity reactions, which usually
the importance of following the prescribed regimen. occur 10 to 14 days after initial sun exposure.
• Take the drug at the same time each day to prevent noctu- • Avoid high-sodium foods (such as lunch meat, smoked
ria. You may take the drug with food to minimize GI irritation. meats, and processed cheeses) and don’t add table salt
• Seek your practitioner’s approval before taking any to foods.
other drug, including over-the-counter medications and • If you’re taking a potassium-depleting diuretic, include
herbal remedies. potassium-rich foods (such as bananas, oranges, and
• Record your weight each morning after voiding and be- potatoes) in your diet. If you’re taking a potassium-sparing
fore breakfast, in the same type of clothing, and using the diuretic, you don’t need to add extra potassium-rich foods.
same scale. • Keep follow-up appointments to monitor the effective-
• Be aware of adverse effects, and report signs and symp- ness of therapy.
toms promptly, especially chest, back, or leg pain; short- • Avoid hot beverages, excessive sweating, and the use of
ness of breath; increased fluid accumulation or weight hot tubs or saunas.

Evaluation
• Patient maintains adequate hydration.
• Patient states the importance of taking the diuretic early in the
day to prevent nocturia.
• Patient and his family demonstrate an understanding of diuretic
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

therapy. (See Teaching about diuretics.) Before you

give that drug

Loop diuretics Loop diuretics

Loop diuretics are highly potent drugs. They include bumetanide, warning
ethacrynic acid, furosemide, and torsemide.
Loop diuretics, with the
Pharmacokinetics exception of ethacrynic
Loop diuretics are absorbed well in the GI tract and are rap- acid, contain sulfa. A
idly distributed. These diuretics are highly protein bound. They patient who has an
undergo partial or complete metabolism in the liver, except for allergy to sulfa may
furosemide, which is excreted primarily unchanged. Loop diuret- experience an allergic
ics are excreted primarily by the kidneys. reaction to loop diuret-
ics. Use with caution,
Pharmacodynamics and alert the patient to
Loop diuretics are the most potent diuretics available, producing the this possibility.
greatest volume of diuresis (urine production). Bumetanide—which

Nursing Pharmacology_Chap08.indd 348 1/28/2012 12:29:11 PM

DIURETICS
349

Prototype pro

Loop diuretics: Furosemide

Actions Nursing considerations
• Inhibits sodium and chloride reabsorp- • Monitor for adverse effects, such as
tion in the ascending loop of Henle, thus pancreatitis, hematologic disorders,
increasing renal excretion of sodium, and electrolyte imbalances (especially
chloride, and water hypokalemia).
• Increases excretion of potassium (like • Monitor weight and blood pressure
thiazide diuretics) frequently.
• Produces greater maximum diuresis and • Signs of hypokalemia may include leg
electrolyte loss than a thiazide diuretic cramps and muscle aches.

Indications
• Acute pulmonary edema
• Edema
• Hypertension

is 40 times more potent than furosemide—is the shortest-acting

diuretic. Loop diuretics also have a high potential for causing
severe adverse reactions. (See Loop diuretics warning.)

The scoop on the loop

Loop diuretics received their name because they act primarily on
the thick ascending loop of Henle (the part of the nephron respon-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

sible for concentrating urine) to increase the excretion of sodium,

chloride, and water. These drugs also inhibit sodium, chloride,
and water reabsorption in the proximal tubule. They also activate
renal prostaglandins, which result in dilation of the blood vessels
of the kidneys, lungs, and the rest of the body.

Pharmacotherapeutics
Loop diuretics are used to treat edema associated with renal disease,
hepatic cirrhosis, and heart failure, as well as to treat hypertension
(usually with a potassium-sparing diuretic or potassium supplement
to prevent hypokalemia). (See Loop diuretics: Furosemide.)
Ethacrynic acid may also be used for the short-term manage-
ment of ascites due to malignancy, idiopathic edema, or lymph-
edema. Furosemide may be used with mannitol to treat cerebral
edema and is also used to treat hypercalcemia. Loop diuretics
increase the renal excretion of calcium.

Nursing Pharmacology_Chap08.indd 349 1/28/2012 12:29:12 PM

GENITOURINARY DRUGS
350

Drug interactions
Loop diuretics produce a variety of drug interactions:
• The risk of ototoxicity (damage to the organs of hearing)
increases when aminoglycosides and cisplatin are taken with loop
diuretics (especially with high doses of furosemide).
• Loop diuretics reduce the hypoglycemic effects of oral antidia-
betic drugs, possibly resulting in hyperglycemia.
• These drugs may increase the risk of lithium toxicity.
• The risk of electrolyte imbalances that can trigger arrhythmias
increases when cardiac glycosides and loop diuretics are taken
together.
• Use with digoxin may cause additive toxicity, increasing the risk
of digoxin toxicity and arrhythmias.
• Do not use if the patient has a history of allergy to sulfonamide
antibiotics.

Adverse reactions
The most common adverse reactions involve hyperglycemia and I said, loop
fluid and electrolyte imbalances, including metabolic alkalosis, hypo- diuretics may cause
volemia, hypochloremia, hypochloremic alkalosis, hyperuricemia, transient deafness!
dehydration, hyponatremia, hypokalemia, and hypomagnesemia.

The list goes on…

Loop diuretics may also cause transient deafness, tinnitus,
diarrhea, nausea, vomiting, abdominal pain, impaired glu-
cose tolerance, dermatitis, paresthesia, hepatic dysfunction,
photosensitivity, and orthostatic hypotension.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Nursing process
These nursing process steps are appropriate for patients
undergoing treatment with loop diuretics.

Assessment
• Monitor the patient’s blood pressure and pulse rate (especially
during rapid diuresis) to detect signs of hypovolemia. Establish base-
line values before therapy begins, and watch for significant changes.

Baseline basics
• Establish a baseline complete blood count (CBC) (including a
white blood cell [WBC] count), liver function tests, and levels of
serum electrolytes, carbon dioxide, magnesium, BUN, and creati-
nine. Review periodically.
• Assess the patient for evidence of excessive diuresis, including
hypotension, tachycardia, poor skin turgor, excessive thirst, and
dry or cracked mucous membranes.

Nursing Pharmacology_Chap08.indd 350 1/28/2012 12:29:12 PM

DIURETICS
351

• Monitor the patient for edema and ascites. Observe the legs of
ambulatory patients and the sacral area of patients on bed rest.
• Monitor and record the patient’s weight and intake and output
carefully every 24 hours.
• If the patient is receiving digoxin and loop diuretics concur-
rently, monitor serum digoxin levels.

Key nursing diagnoses

• Risk for deficient fluid volume related to excessive diuresis
• Risk for injury related to electrolyte imbalance
• Deficient knowledge related to diuretic therapy

Planning outcome goals

• The patient will maintain a normal fluid volume as evidenced by
having a blood pressure and heart rate within the normal range.
• The patient won’t exhibit adverse effects of electrolyte imbalance.
• The patient will demonstrate correct diuretic therapy
administration.

Implementation
• Give the diuretic in the morning to ensure that major diuresis
occurs before bedtime. To prevent nocturia, don’t administer later
than 6 p.m.
• Administer IV doses slowly over 1 to 2 minutes to prevent
hypotension.
• Watch closely for changes in the patient’s sodium and potas-
sium levels.

Dosage details Tell the patient

• If ordered, reduce the dosage for a patient with hepatic dysfunc- to use sunscreen
tion and increase the dosage for a patient with renal impairment, and wear protective
oliguria, or decreased diuresis. (Inadequate urine output may clothing to avoid
result in circulatory overload, causing water intoxication, pulmo- a photosensitivity
reaction.
nary edema, and heart failure.) If ordered, increase the dosage of
insulin or oral hypoglycemic in a diabetic patient and reduce the
dosage of other antihypertensive drugs.
• Weigh the patient each morning immediately after
he voids and before breakfast, using the same scale
and making sure he’s wearing the same type of cloth-
ing. Weight provides a reliable indicator of the patient’s
response to diuretic therapy.
• Keep a urinal or bedpan within reach of the patient or
ensure that the bathroom is easily accessible to prevent falls.
• Give the diuretic with food or milk to prevent GI upset.
• Instruct the patient to use sunscreen and wear protec-
tive clothing to prevent photosensitivity reactions.

Nursing Pharmacology_Chap08.indd 351 1/28/2012 12:29:12 PM

GENITOURINARY DRUGS
352

Evaluation
• Patient maintains adequate hydration.
• Patient’s electrolyte levels remain within normal limits.
• Patient and his family demonstrate an understanding of diuretic
therapy.

Potassium-sparing diuretics
Potassium-sparing diuretics (also referred to as aldosterone-
inhibiting diuretics) have weaker diuretic and antihypertensive
effects than other diuretics but provide the advantage of conserv-
ing potassium. These drugs include amiloride, spironolactone, and
triamterene.

Pharmacokinetics
Potassium-sparing diuretics are only available orally and are
absorbed in the GI tract. They’re metabolized by the liver (except for
amiloride, which isn’t metabolized) and excreted primarily in urine.

Pharmacodynamics
The direct action of potassium-sparing diuretics on the collecting
ducts and distal tubule of the kidneys results in urinary excre-
tion of sodium, water, bicarbonate, and calcium. The drug also
decreases the excretion of potassium and hydrogen ions. These
effects lead to reduced blood pressure and increased serum potas-
sium levels.

Compare and contrast

Structurally similar to aldosterone, spironolactone acts as an

aldosterone antagonist. Aldosterone promotes the retention of
sodium and water and the loss of potassium, whereas spirono-
lactone counteracts these effects by competing with aldosterone
for receptor sites. As a result, sodium, chloride, and water are
excreted and potassium is retained.

Pharmacotherapeutics
Potassium-sparing diuretics are used to treat:
• edema
• diuretic-induced hypokalemia in patients with heart failure
• cirrhosis
• nephrotic syndrome (abnormal condition of the kidneys)
• heart failure
• hypertension
• hyperaldosteronism.

Nursing Pharmacology_Chap08.indd 352 1/28/2012 12:29:13 PM

DIURETICS
353

A hairy situation
Spironolactone also is used to treat hyperaldosteronism and
hirsutism, including hirsutism associated with Stein-Leventhal
(polycystic ovary) syndrome. Potassium-sparing diuretics are
commonly used with other diuretics to potentiate their action or
counteract their potassium-wasting effects.

Drug interactions
Giving potassium-sparing diuretics with potassium supplements or
angiotensin-converting enzyme inhibitors increases the risk of hyper-
kalemia. Concurrent use of spironolactone and digoxin increases the
risk of digoxin toxicity. When given with lithium, lithium toxicity can
occur. NSAIDs cause a decrease in action of the potassium-sparing
diuretic.

Adverse reactions
Potassium-sparing effects can lead to hyperkalemia, especially if
given with a potassium supplement or high-potassium diet.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with potassium-sparing diuretics.

Assessment
• Monitor the patient’s blood pressure and heart rate, especially
during rapid diuresis. Establish baseline values before therapy Establish a
begins, and watch for significant changes. baseline blood
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

pressure value
• Establish a baseline CBC (including WBC count), liver function
before therapy
tests, and levels of serum electrolytes, carbon dioxide, magne- begins.
sium, BUN, and creatinine. Review periodically.
• Assess the patient for evidence of excessive diuresis: hypoten-
sion, tachycardia, poor skin turgor, excessive thirst, or dry and
cracked mucous membranes.
• Monitor the patient for signs and symptoms of hyperkalemia,
such as confusion, hyperexcitability, muscle weakness, flaccid
paralysis, arrhythmias, abdominal distention, and diarrhea.
• Monitor the patient for edema and ascites. Observe the legs of
ambulatory patients and the sacral area of patients on bed rest.
• Weigh the patient each morning immediately after he voids and
before breakfast, using the same scale and making sure he’s wear-
ing the same type of clothing. Weight provides a reliable indicator
of the patient’s response to diuretic therapy.
• Monitor and record the patient’s intake and output carefully
every 24 hours.

Nursing Pharmacology_Chap08.indd 353 1/28/2012 12:29:13 PM

GENITOURINARY DRUGS
354

Key nursing diagnoses

• Risk for deficient fluid volume related to excessive diuresis
• Risk for injury related to electrolyte imbalance
• Deficient knowledge related to diuretic therapy

Planning outcome goals

• The patient will maintain a normal fluid volume as evidenced by
having a blood pressure and heart rate within the normal range.
• The patient won’t demonstrate adverse effects of electrolyte
imbalance.
• The patient will demonstrate correct diuretic therapy
administration.

Implementation
• Give the diuretic in the morning or early afternoon to prevent
nocturia from disrupting the patient’s sleep.
• Keep a urinal or bedpan within reach of the patient or ensure
that a bathroom is easily accessible to prevent falls or injuries.
• If ordered, reduce the dosage for a patient with hepatic dysfunc-
tion and increase the dosage for a patient with renal impairment,
oliguria, or decreased diuresis. (Inadequate urine output may
result in circulatory overload, causing water intoxication, pulmo-
nary edema, and heart failure.) If ordered, increase the dosage of
Potassium-sparing
insulin or oral hypoglycemic in a diabetic patient and reduce the diuretics may
dosage of other antihypertensive drugs. cause dizziness and
headache. I’m not
Drop that banana! feeling very well…
• Instruct the patient to avoid salt substitutes and potassium-rich
foods, except with practitioner approval. Consult a dietitian.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• For maximum effectiveness, administer amiloride with food;

administer triamterene after meals.
• Because potassium-sparing diuretics may cause dizziness, head-
ache, or vision disturbances, advise the patient to avoid driving or
performing activities requiring mental alertness or physical
dexterity until his response to the diuretic is known.

Evaluation
• Patient maintains adequate hydration.
• Patient’s electrolyte levels remain within normal limits.
• Patient and his family demonstrate an understanding of diuretic
therapy.

Nursing Pharmacology_Chap08.indd 354 1/28/2012 12:29:14 PM

DIURETICS
355

Osmotic diuretics
Osmotic diuretics cause diuresis through osmosis, moving fluid
into the extracellular spaces. They include mannitol and urea.

Pharmacokinetics
Administered IV for rapid distribution, osmotic diuretics are freely
filtered by the glomeruli of the kidney—except for mannitol,
which is only slightly metabolized. Osmotic diuretics are excreted
primarily in urine.

Pharmacodynamics
Osmotic diuretics receive their name because they increase the
osmotic pressure of the glomerular filtrate, which inhibits the
reabsorption of sodium and water. They create an osmotic gradi-
ent in the glomerular filtrate and the blood. In the glomerular fil-
trate, the gradient prevents sodium and water reabsorption. In the
blood, the gradient allows fluid to be drawn from the intracellular
into the intravascular spaces.

Pharmacotherapeutics
Osmotic diuretics are used to treat acute renal failure and cere-
bral edema and to reduce intracranial and intraocular pressure.
Mannitol is used to promote diuresis in acute renal failure and to
promote urinary excretion of toxic substances.

Drug interactions
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

No significant drug interactions are known to be associated with

mannitol.

Adverse reactions
Osmotic diuretics can cause seizures, thrombophlebitis, and pul-
monary congestion. Other significant effects are headaches, chest
pains, tachycardia, blurred vision, chills, and fever.

The pressure’s building…

Mannitol may cause rebound increased intracranial pressure
(ICP) 8 to 12 hours after diuresis. It also may cause chest pain,
blurred vision, rhinitis, thirst, and urine retention.

Nursing Pharmacology_Chap08.indd 355 1/28/2012 12:29:14 PM

GENITOURINARY DRUGS
356

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with osmotic diuretics.

Assessment
• Monitor the patient’s blood pressure and heart rate, especially
during rapid diuresis. Establish baseline values before therapy
begins, and watch for significant changes.
• Monitor the patient’s vital signs, urine output, and central
venous pressure for signs of circulatory overload and fluid volume
depletion.
• Assess the patient for circulatory overload when urine output is
less than 30 mL/hour.
• Assess the patient’s neurologic status and ICP for signs of
increased ICP.

Key nursing diagnoses

• Risk for deficient fluid volume related to excessive diuresis
• Risk for injury related to electrolyte imbalance or circulatory
overload
• Deficient knowledge related to diuretic therapy

Planning outcome goals

• The patient will maintain a normal fluid volume as evidenced by
having a blood pressure and heart rate within the normal range.
• The patient won’t exhibit adverse effects of electrolyte imbal-
ance or circulatory overload.
• The patient will demonstrate correct diuretic therapy adminis-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

tration. To prevent
nocturia, don’t
Implementation administer diuretics
• Administer osmotic diuretics in an IV solution slowly over 3 after 6 p.m.
minutes to several hours, depending on the reason for giving the
drug and the concentration of the solution.

An irritating problem
• Take steps to avoid infiltration because osmotic diuretics may
cause mild irritation or even necrosis.
• Be especially alert for changes in the patient’s sodium and
potassium levels.
• Give the diuretic in the morning to ensure that major diuresis
occurs before bedtime. To prevent nocturia, don’t administer later
than 6 p.m.
• Monitor intake and output carefully. Use an indwelling catheter
for accurate evaluation of diuresis if necessary.

Nursing Pharmacology_Chap08.indd 356 1/28/2012 12:29:14 PM

DIURETICS
357

• Weigh the patient each morning immediately after he voids and

before breakfast, using the same scale and making sure he’s wear-
ing the same type of clothing. Weight provides a reliable indicator
of the patient’s response to diuretic therapy.

Evaluation
• Patient maintains adequate hydration.
• Patient’s electrolyte levels remain within normal limits.
• Patient and his family demonstrate an understanding of diuretic
therapy.

Carbonic anhydrase inhibitors

Carbonic anhydrase inhibitors are diuretics that block the action
of carbonic anhydrase. They include acetazolamide and methazol-
amide.

Pharmacokinetics
Carbonic anhydrase inhibitors are absorbed through the GI tract.
Some systemic absorption also occurs after ophthalmic admin-
istration. They’re distributed in tissues with high carbonic anhy-
drase content, such as erythrocytes, plasma, kidneys, eyes, liver,
and muscle. Carbonic anhydrase inhibitors are excreted by the Acetazolamide…
kidneys in urine. (huff)…may be
used… (puff)…to
treat high-altitude
Pharmacodynamics sickness…
In the kidneys, carbonic anhydrase inhibitors decrease the avail-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

ability of hydrogen ions, which blocks the sodium-hydrogen

exchange mechanisms. As a result, urinary excretion of sodium,
potassium, bicarbonate, and water increases.

Don’t lose your sense of humor

In the eyes, carbonic anhydrase inhibition reduces aque-
ous humor production, which reduces intraocular pres-
sure.

Pharmacotherapeutics
Carbonic anhydrase inhibitors are used for diuresis, to
decrease edema in heart failure, and to treat glaucoma.
Acetazolamide may also be used to treat epilepsy and
high-altitude sickness.

Nursing Pharmacology_Chap08.indd 357 1/28/2012 12:29:15 PM

GENITOURINARY DRUGS
358

Drug interactions
Carbonic anhydrase inhibitors produce a variety of drug
interactions:
• Salicylates may cause carbonic anhydrase inhibitor toxic-
ity, including central nervous system depression and metabolic
acidosis.
• Diflunisal may increase intraocular pressure when given with a
carbonic anhydrase inhibitor.
• Use with corticosteroids may cause hypokalemia.
• Use with oral antidiabetic agents may increase hypoglycemic
action.

Adverse reactions
Carbonic anhydrase inhibitors may cause hypokalemia, hematu-
ria, melena, metabolic acidosis, and other electrolyte imbalances.

Nursing process
These nursing process steps are appropriate for patients undergo- Establishing
ing treatment with carbonic anhydrase inhibitors. baseline serum
electrolyte levels
Assessment will help to highlight
• Monitor the patient’s blood pressure and heart rate, especially any imbalances that
may occur during
during rapid diuresis. Establish baseline values before therapy therapy.
begins, and watch for significant changes.
• Establish a baseline CBC (including WBC count), liver func-
tion test, and levels of serum electrolytes (especially potassium,
bicarbonate, chloride, and magnesium), carbon dioxide, BUN,
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

and creatinine. Review periodically.

• Assess the patient for evidence of excessive diuresis:
hypotension, tachycardia, poor skin turgor, excessive thirst,
or dry and cracked mucous membranes.
• Monitor and record the patient’s intake and output carefully.

Key nursing diagnoses

• Risk for deficient fluid volume related to excessive diuresis
• Risk for injury related to electrolyte imbalance
• Deficient knowledge related to diuretic therapy

Planning outcome goals

Nursing Pharmacology_Chap08.indd 358 1/28/2012 12:29:15 PM

URINARY TRACT ANTISPASMODICS
359

• The patient will demonstrate correct diuretic therapy adminis-

tration.

Implementation
• Use cautiously in patients who are allergic to sulfonamides
because a cross-sensitivity reaction may occur.

You’re feeling very sleepy…

• Give the diuretic in the morning or early afternoon, if possible,
to prevent nocturia from disrupting the patient’s sleep.
• Weigh the patient each morning immediately after he voids and
before breakfast, using the same scale and making sure he’s wear-
ing the same type of clothing. Weight provides a reliable indicator
of the patient’s response to diuretic therapy.
• Keep a urinal or bedpan within reach of the patient or ensure
that a bathroom is easily accessible.
• Tell the patient to take the medication with food to prevent GI
upset.

Evaluation
• Patient maintains adequate hydration.
• Patient’s electrolyte levels remain within normal limits.
• Patient and his family demonstrate an understanding of diuretic
therapy.

Urinary tract antispasmodics

Urinary tract antispasmodics help decrease urinary tract muscle

spasms. They include darifenacin, flavoxate, oxybutynin,
solifenacin, tolterodine, and trospium.

Pharmacokinetics
Flavoxate, oxybutynin, tolterodine, darifenacin, and solifenacin
are most often administered orally and are rapidly absorbed. Tro-
spium is administered orally but is poorly absorbed. Oxybutynin
is also available as a dermal patch. These drugs are all widely dis-
tributed, metabolized in the liver, and excreted in urine. Urinary
tract antispasmodics also cross the placenta and are excreted in
breast milk.

Nursing Pharmacology_Chap08.indd 359 1/28/2012 12:29:16 PM

GENITOURINARY DRUGS
360

Pharmacodynamics
Pharm
Urinary tract antispasmodics relieve smooth-muscle spasms by
function
inhibiting parasympathetic activity, which causes the detrusor and
urinary muscles to relax. Flavoxate and oxybutynin also exhibit
many anticholinergic effects. How oxybutynin
works
Pharmacotherapeutics When acetylcholine
Urinary tract antispasmodics are used for patients with overactive is released within the
bladders who have symptoms of urinary frequency, urgency, or bladder, it attaches to
incontinence. receptors on the surface
of smooth muscle in
Urgent symptoms the bladder, stimulating
Trospium is also indicated for patients with overactive bladders bladder contractions.
who have symptoms of urge urinary incontinence, and oxybutynin Oxybutynin suppresses
acts as an antispasmodic for uninhibited or reflex neurogenic these involuntary con-
bladder. (See How oxybutynin works.)
tractions by blocking the
release of acetylcholine.
Drug interactions This anticholinergic
Urinary tract antispasmodics have few drug interactions: effect is what makes
• Use with anticholinergic agents may increase dry mouth, consti- oxybutynin useful in the
pation, and other anticholinergic effects. treatment of overactive
• Urinary tract antispasmodics may decrease the effectiveness of bladder.
phenothiazines and haloperidol.
• Trospium may interfere with the elimination of certain drugs
excreted through the kidneys (such as digoxin, metformin, and
vancomycin), resulting in increased blood levels of these drugs.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Adverse reactions
Possible adverse reactions to urinary tract antispasmodics
include:
• blurred vision
• headache
• somnolence
• urine retention
• dry mouth
• dyspepsia
• constipation
• nausea
• vomiting
• weight gain
• pain
• acute and secondary angle-closure glaucoma.

Nursing Pharmacology_Chap08.indd 360 1/28/2012 12:29:16 PM

URINARY TRACT ANTISPASMODICS
361

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with urinary tract antispasmodics.

Assessment
• Assess the patient’s signs and symptoms before beginning
therapy.
• Make sure the patient undergoes periodic cystometry to evalu-
ate his response to therapy.
• Monitor the patient’s intake and output.

Key nursing diagnoses

• Risk for urge urinary incontinence related to overactive bladder
• Deficient knowledge related to drug therapy
• Situational low self-esteem related to incontinence It may sound
counterintuitive,
Planning outcome goals but it’s often
• The patient will demonstrate increased comfort and fewer epi- best to encourage
sodes of incontinence. your patient to
increase his fluid
• The patient will demonstrate correct drug administration. intake when taking
• The patient will voice feelings related to incontinence and its an antispasmodic
effect on self-esteem. to relieve urinary
incontinence.
Implementation
• Administer the drug as prescribed.
• Offer small, frequent meals to help prevent nausea.
• Administer trospium at least 1 hour before meals or on an
empty stomach.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Drink up!
• Unless contraindicated, encourage the patient to increase his
fluid intake to 2 to 3 L /day.

Evaluation
• Patient has relief from incontinence.
• Patient and his family demonstrate an understanding of urinary
tract antispasmodic therapy. (See Teaching about urinary tract
antispasmodics, page 362.)
• Patient has improved self-esteem.

Nursing Pharmacology_Chap08.indd 361 1/28/2012 12:29:16 PM

GENITOURINARY DRUGS
362

Education edge

Teaching about urinary tract antispasmodics

If urinary tract antispasmodics are pre- • Take the drug whole; don’t chew, crush,
scribed, review these points with the or cut the tablet.
patient and his caregivers: • Suck on hard candy or ice chips to re-
• Take the drug with meals to help de- lieve dry mouth while taking this drug.
crease GI upset. • Drink adequate fluids to help prevent
• This drug may decrease your ability constipation.
to sweat; use caution in a situation that • Notify the practitioner if you can’t uri-
could cause you to overheat. nate, develop a fever or severe constipa-
tion, or experience blurring of your vision.

Erectile dysfunction therapy drugs

Erectile dysfunction therapy drugs treat penile erectile dysfunc-
tion that results from a lack of blood flowing through the corpus
cavernosum. This type of erectile dysfunction usually stems from
vascular and neurologic conditions. Drugs used for erectile dys-
function include alprostadil, sildenafil, tadalafil, and vardenafil.

Pharmacokinetics
Erectile dysfunction drugs are well absorbed in the GI tract.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Distribution of these drugs isn’t known. The majority of these

drugs—including sildenafil, tadalafil, and vardenafil—are given
orally, metabolized in the liver, and excreted in feces.

An exceptional drug
Alprostadil is the exception: it’s administered directly into the cor-
pus cavernosum, metabolized in the lungs, and excreted in urine.

Pharmacodynamics
Sildenafil, tadalafil, and vardenafil selectively inhibit the phospho-
diesterase type 5 receptors, which causes an increase in blood
levels of nitric oxide. This increase in nitric oxide levels activates
the cGMP enzyme, which relaxes smooth muscles and allows
blood to flow into the corpus cavernosum, causing an erection.
Alprostadil acts locally, promoting smooth-muscle relaxation,
which causes an increase in blood flow to the corpus cavernosum
and produces an erection.

Nursing Pharmacology_Chap08.indd 362 1/28/2012 12:29:17 PM

ERECTILE DYSFUNCTION THERAPY DRUGS
363

Pharmacotherapeutics
Watch out!
Alprostadil, sildenafil, tadalafil, and vardenafil are all used in the Nitrates and alpha-
treatment of erectile dysfunction. Sildenafil is also indicated for adrenergic blockers
the treatment of pulmonary arterial hypertension. used with erectile
dysfunction drugs
can cause severe
Drug interactions hypotension and
Erectile dysfunction drugs may interact with other drugs in the potentially serious
following ways: cardiac events.
• Nitrates and alpha-adrenergic blockers used in combination
with erectile dysfunction drugs may cause severe hypotension and
potentially serious cardiac events.
• Ketoconazole, itraconazole, and erythromycin may result in
increased levels of vardenafil or tadalafil.
• Protease inhibitors, such as indinavir or ritonavir, may cause
increased tadalafil or vardenafil levels.

Adverse reactions
Sildenafil increases the risk of cardiovascular events by decreas-
ing supine blood pressure and cardiac output. Patients with
known cardiovascular disease have an increased risk of cardiovas-
cular events, including myocardial infarction (MI), sudden cardiac
death, ventricular arrhythmias, cerebrovascular hemorrhage, tran-
sient ischemic attack, and hypertension.
Other reactions to these drugs include headache, dizziness,
flushing, dyspepsia, and vision changes. Prolonged erections
(more than 4 hours) can result in irreversible damage to erectile
tissue. Alprostadil can cause penile pain.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Nursing process
These nursing process steps are appropriate for patients under-
going treatment with erectile dysfunction drugs.

Assessment
• Assess the patient’s cardiovascular risk.
• Monitor the patient’s blood pressure, heart rate, and electrocar-
diogram.

Tweaking the dosage

• Assess the effects of the particular dosage the patient is receiv-
ing; the dosage for these drugs is highly individualized and should
be adjusted based on the patient’s response.

Nursing Pharmacology_Chap08.indd 363 1/28/2012 12:29:17 PM

GENITOURINARY DRUGS
364

Key nursing diagnoses

• Risk for decreased cardiac output related to erectile dysfunc-
tion therapy
• Risk for injury related to prolonged erection
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient won’t exhibit signs of decreased cardiac output as
evidenced by a stable blood pressure and heart rate.
• Complications from prolonged erection will be diminished.
• The patient will demonstrate correct drug administration.

Implementation
• Explain to the patient that the drug won’t protect against preg-
nancy or the transmission of sexually transmitted diseases.
• If the patient is also taking human immunodeficiency virus med-
ications, warn him about the risk of adverse reactions, including
hypotension and priapism.
• If the patient is taking alprostadil, teach him how to prepare
and administer the drug. Review aseptic technique, warn him that
bleeding at the injection site can increase the risk of transmitting
blood-borne diseases to his partner, and explain that he should
take the drug as directed.

Evaluation
• Patient maintains adequate cardiac output as evidenced by
normal vital signs and adequate tissue perfusion.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Education edge

Teaching about erectile dysfunction drugs

If an erectile dysfunction drug is pre- • Tell all health care providers that you’re
scribed, review these points with the taking this drug.
patient and his caregivers: • Don’t take this drug if you’re also taking
• This drug won’t work without the pres- nitrates or alpha-adrenergic blockers for
ence of sexual stimulation. high blood pressure or angina.
• Take this drug 30 minutes to 4 hours be- • If you notice persistent or bother-
fore anticipated sexual activity. some adverse reactions, notify your
• If you have an erection that lasts longer practitioner.
than 4 hours, seek medical attention; this • Don’t take this drug with alcohol.
can become a medical emergency.

Nursing Pharmacology_Chap08.indd 364 1/28/2012 12:29:17 PM

HORMONAL CONTRACEPTIVES
365

• Patient has no serious injury from prolonged erection, if it

occurs.
• Patient and his family demonstrate an understanding of erec-
tile dysfunction drugs. (See Teaching about erectile dysfunction
drugs.)

Hormonal contraceptives
Hormonal contraceptives inhibit ovulation. Contraceptives typi-
cally contain a combination of hormones. For example, ethinyl
estradiol may be combined with desogestrel, drospirenone, levo-
norgestrel, norethindrone, norgestimate, or norgestrel. Also, mes-
tranol may be combined with norethindrone. Ethinyl estradiol or
ethynodiol diacetate may also be used alone as a contraceptive.

Pharmacokinetics
Hormonal contraceptives are absorbed from the GI tract and
are widely distributed. They’re metabolized in the kidneys and
excreted in urine and feces.

Patch power
Some forms of hormonal contraceptives are available in a trans-
dermal patch form. These contraceptives are absorbed through
the skin but have the same distribution, metabolism, and excre-
tion as orally administered contraceptives.

Pharmacodynamics
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

The primary mechanism of action of combination hormonal

contraceptives (estrogen and progestin) is the suppression of
gonadotropins, which inhibits ovulation. Estrogen suppresses It looks like
secretion of follicle-stimulating hormone, which blocks follicular we’re not
development and ovulation. Progestin suppresses the secretion of welcome here,
guys!
luteinizing hormone, which prevents ovulation, even if the follicle
develops. Progestin also thickens the cervical mucus; this inter-
feres with sperm migration and causes endometrial changes that
prevent implantation of a fertilized ovum.

Pharmacotherapeutics
The primary purpose for taking hormonal
contraceptives is the prevention of pregnancy in
women. The combination of ethinyl estradiol and
norgestimate is also used to treat moderate acne in
females under age 15.

Nursing Pharmacology_Chap08.indd 365 1/28/2012 12:29:18 PM

GENITOURINARY DRUGS
366

Drug interactions
Hormonal contraceptives can interact with other medications in
various ways:
• Antibiotics, oxcarbazepine, phenobarbital, phenytoin, topi-
ramate, and modafinil may decrease the effectiveness of oral
contraceptives. A patient taking these drugs with a hormonal con-
traceptive needs to use a barrier contraceptive.
• Atorvastatin may increase serum estrogen levels.
• Cyclosporine and theophylline have an increased risk of toxicity
when taken with hormonal contraceptives.
• Prednisone increases the therapeutic and possibly toxic effects
of hormonal contraceptives.
• Several herbal medications can affect serum levels of hormonal
contraceptives.

Adverse reactions
Potentially serious adverse reactions to hormonal contraceptives
include arterial thrombosis, thrombophlebitis, pulmonary embo-
lism, MI, cerebral hemorrhage or thrombosis, hypertension, gall-
bladder disease, and hepatic adenomas.
Other adverse reactions include:
• acne
• bleeding or spotting between menstrual periods
• bloating
• breast tenderness or enlargement I know hormonal
• changes in libido contraceptives can
cause unusual hair
• diarrhea
growth, but this is
• difficulty wearing contact lenses ridiculous!
• unusual hair growth
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• weight fluctuations
• upset stomach
• vomiting.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with hormonal contraceptives.

Assessment
• Monitor the patient’s vital signs, especially blood pressure.
• Obtain a patient history. Hormonal contraceptives are con-
traindicated in patients with a history of thrombophlebitis or
thromboembolic disorders, deep-vein thrombosis, cerebrovascu-
lar accidents, coronary artery disease, known carcinoma of the
breast, any estrogen-dependent neoplasm, abnormal genital bleed-
ing, or cholestatic jaundice with pregnancy.

Nursing Pharmacology_Chap08.indd 366 1/28/2012 12:29:18 PM

QUICK QUIZ
367

Proceed with caution

Education
• Also assess for a history of smoking, fibrocystic breast disease
edge
or abnormal mammogram, migraines, high blood pressure, and
diabetes. Hormonal contraceptives should be used with caution in
patients with these conditions. Teaching about
• Evaluate the patient’s knowledge of hormonal contraceptives. hormonal
Key nursing diagnoses
contraceptives
• Risk for ineffective protection related to contraceptive therapy If a hormonal contra-
• Risk for injury related to adverse reactions ceptive is prescribed,
• Deficient knowledge related to hormonal contraceptive therapy review these points
with the patient or her
Planning outcome goals caregivers:
• The patient won’t become pregnant. • Take this medication at
• The patient won’t experience adverse reactions. the same time each day
• The patient will demonstrate an understanding of hormonal and as directed by your
contraceptive therapy. practitioner.
• If you miss two periods
Implementation in a row, contact your
• Teach the patient how to take her pills (21-, 28-, or 91-day pack- practitioner; you may be
ets) or how to apply the patch. pregnant.
• Teach the patient about possible drug interactions and when • Notify your practitioner
she’ll need to use an additional form of contraception. immediately if you have
chest pain, difficulty
Evaluation breathing, leg pain, or
• Patient shows no evidence of pregnancy while on hormonal severe abdominal pain
contraceptives. or headache. These
• Patient is free from adverse reactions. symptoms could indi-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Patient and her family demonstrate an understanding of hor- cate a serious adverse
monal contraceptive therapy. (See Teaching about hormonal reaction.
contraceptives.) • Notify your practitioner
if you have persistent
or bothersome adverse
reactions.
Quick quiz • Don’t take this drug
if you think you’re
1. When caring for a patient taking hydrochlorothiazide, you pregnant.
should monitor the patient for:
A. hypertension.
B. hypernatremia.
C. hypokalemia.
D. hypoglycemia.
Answer: C. Watch for signs of hypokalemia in a patient receiving
hydrochlorothiazide.

Nursing Pharmacology_Chap08.indd 367 1/28/2012 12:29:18 PM

GENITOURINARY DRUGS
368

2. When teaching a patient about diuretics, you should tell him to:
A. take the drug in the evening.
B. call his practitioner if he loses more that 2 lb (0.9 kg)/
day.
C. eat a high-sodium diet.
D. avoid sun exposure for several hours after taking the
medication to prevent a photosensitivity reaction.
Answer: B. A weight loss of more than 2 lb/day indicates exces-
sive diuresis.
3. Urinary tract antispasmodics are used to treat:
A. overactive bladder.
B. erectile dysfunction.
C. hypertension.
D. seizures.
Answer: A. Urinary tract antispasmodics are used to treat an
overactive bladder.
4. When teaching a patient how to take hormonal contracep-
tives, which of the following instructions should you give?
A. Take the drug in the morning.
B. If you miss a dose, skip it and take it the next day.
C. If you miss one menstrual period, stop taking the drug
and take a pregnancy test.
D. Use an additional form of birth control if you’re taking
certain antibiotics.
Answer: D. Advise the patient taking hormonal contraceptives to
use an additional form of birth control if she’s also taking certain
antibiotics because antibiotics may decrease the effectiveness of
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

hormonal contraceptives.

Scoring
✰✰✰ If you answered all four questions correctly, terrific! Everything’s
flowing smoothly for you when it comes to GU drugs.
✰✰ If you answered three questions correctly, super! Your stream of
knowledge about GU drugs is impressive.
✰ If you answered fewer than three questions correctly, don’t spaz
out! Relax, review the chapter, and try again.

Nursing Pharmacology_Chap08.indd 368 1/28/2012 12:29:19 PM

9
Hematologic drugs

Just the facts

In this chapter, you’ll learn:
♦ strategies
classes of to
drugs
aid you
usedintointerviewing
treat hematologic
and obtaining
disorders
a de-
♦ tailed health
uses and history
varying from of
actions a patient
these drugs
♦
♦ questions
absorption,todistribution,
ask that pertain to each body
metabolization, system
and excretion of
♦ these
assessment
drugs techniques, including inspection, palpation,
♦ percussion, and auscultation.
drug interactions and adverse reactions to these drugs.

Drugs and the hematologic system

The hematologic system includes plasma (the liquid component
of blood) and blood cells, such as red blood cells (RBCs), white
blood cells, and platelets. Types of drugs used to treat disorders Hematinic drugs
of the hematologic system include: give me the tools I
• hematinic drugs need to take aim at
anemia.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• anticoagulant drugs
• thrombolytic drugs.

Hematinic drugs
Hematinic drugs provide essential building blocks for RBC pro-
duction. They do so by increasing hemoglobin, the necessary
element for oxygen transportation.

Taking aim at anemia

This section discusses hematinic drugs—iron, vitamin B12, and
folic acid—used to treat microcytic and macrocytic anemia, as
well as epoetin alfa and darbepoetin alfa, which may be used to
treat some normocytic anemias.

Nursing Pharmacology_Chap09.indd 369 1/28/2012 12:05:16 PM

HEMATOLOGIC DRUGS
370

Iron
Iron preparations are used to treat the most common form of
anemia—iron deficiency anemia. Iron preparations discussed in
this section include ferrous fumarate, ferrous gluconate, ferrous
sulfate, iron dextran, iron sucrose, and sodium ferric gluconate
complex.

Pharmacokinetics (how drugs circulate)

Iron is absorbed primarily from the duodenum and upper jejunum
of the intestine. The formulations don’t vary in their rate of
absorption, but they do vary in the amount of elemental iron
supplied.

What’s in store?
The amount of iron absorbed depends partially on the body’s
stores of iron. When body stores are low or RBC production is
accelerated, iron absorption may increase by 20% to 30%. On the
other hand, when total iron stores are large, only about 5% to 10%
of iron is absorbed.

Form and function

Enteric-coated preparations decrease iron absorption because, in
that form, iron isn’t released until after it leaves the duodenum. The
lymphatic system absorbs the parenteral form after IM injections.
Iron is transported by the blood and bound to transferrin, its Iron is transported
carrier plasma protein. About 30% of the iron is stored primarily as by the blood. It’s an
interesting way to
hemosiderin or ferritin in the reticuloendothelial cells of the liver,
travel!
spleen, and bone marrow. About 66% of the total body iron is con-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

tained in hemoglobin. Excess iron is excreted in urine, stool, and

sweat and through intestinal cell sloughing. Excess iron is also
secreted in breast milk.

Pharmacodynamics (how drugs act)

Although iron has other roles, its most important role is
the production of hemoglobin. About 80% of the iron in the
plasma goes to the bone marrow, where it’s used for erythro-
poiesis (production of RBCs).

Pharmacotherapeutics (how drugs are used)

Oral iron therapy is used to prevent or treat iron deficiency
anemia. It’s also used to prevent anemia in children ages
6 months to 2 years because this is a period of rapid growth
and development.

Nursing Pharmacology_Chap09.indd 370 1/28/2012 12:05:17 PM

HEMATINIC DRUGS
371

Baby makes two

A pregnant woman may need iron supplements to replace the iron
used by the developing fetus. She should take oral iron therapy in
the form of prenatal vitamins unless she’s unable to take iron.

An alternate route
Parenteral iron therapy is used for patients who can’t absorb oral
preparations, aren’t compliant with oral therapy, or have bowel
disorders (such as ulcerative colitis or Crohn’s disease). Patients
with end-stage renal disease who receive hemodialysis may also Before you
receive parenteral iron therapy at the end of their dialysis session. give that drug
Parenteral iron therapy corrects the iron store deficiency quickly;
however, the anemia isn’t corrected any faster than it would be Parenteral iron
with oral preparations.
Before administering
Two of a kind parenteral iron, be
There are two parenteral iron products available. Iron dextran is aware that it has been
given by either IM injection or slow continuous IV infusion. Iron associated with an
sucrose, indicated for use in the hemodialysis patient, is adminis- anaphylactoid reaction.
tered by IV infusion. Administer initial test
doses before a full-dose
Drug interactions infusion to evaluate
Iron absorption is reduced by antacids as well as by such foods for potential reactions.
as spinach, whole-grain breads and cereals, coffee, tea, eggs, and Continue to monitor the
milk products. Other drug interactions involving iron include the patient closely because
following: delayed reactions can
• Tetracycline, demeclocycline, minocycline, oxytetracycline, occur 1 to 2 days later.
doxycycline, methyldopa, quinolones, levofloxacin, norfloxacin, Signs and symptoms
ofloxacin, gatifloxacin, lomefloxacin, moxifloxacin, sparfloxacin, of an anaphylactoid
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

ciprofloxacin, levothyroxine, and penicillamine absorption may be reaction to parenteral

reduced when taken with oral iron preparations. iron include:
• Cholestyramine, cimetidine, magnesium trisilicate, and colesti- • arthralgia
pol may reduce iron absorption in the GI tract. • backache
• Cimetidine and other histamine-2 receptor antagonists may • chest pain
decrease GI absorption of iron. • chills
• dizziness
Adverse reactions • headache
The most common adverse reaction to iron therapy is gastric irri- • malaise
tation and constipation. Iron preparations also darken the stool. • fever
The liquid form can stain the teeth. Parenteral iron has been asso- • myalgia
ciated with an anaphylactoid reaction. (See Parenteral iron.) • nausea
• vomiting
Nursing process • hypotension
These nursing process steps are appropriate for patients under- • respiratory distress.
going treatment with iron.

Nursing Pharmacology_Chap09.indd 371 1/28/2012 12:05:18 PM

HEMATOLOGIC DRUGS
372

Assessment
• Assess the patient’s iron deficiency before starting therapy.
• Monitor the iron’s effectiveness by evaluating the patient’s
hemoglobin level, hematocrit, and reticulocyte count.
• Monitor the patient’s health status.
• Assess for adverse reactions and drug interactions.
• Observe the patient for delayed reactions from therapy.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to iron deficiency
• Risk for injury related to the underlying condition
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s iron deficiency will improve as evidenced by labo-
ratory studies.
• The risk of injury to the patient will be minimized.
• The patient and his family will demonstrate an understanding of
drug therapy.
To give iron IM, use
Implementation a 19G or 20G needle
• Don’t give iron dextran with oral iron preparations. that’s 2″ to 3″ long.

Testing, testing
• If IM or IV injections of iron are recommended, a test dose may
be required in the facility.
• If administering iron IM, use a 19G or 20G needle that’s 2″ to 3″
long. Inject into the upper outer quadrant of the buttock. Use the
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Z-track method to avoid leakage into subcutaneous tissue and

staining of the skin.
• Minimize skin staining with IM injections of iron by using a
separate needle to withdraw the drug from its container.
• IV iron is given if the patient has insufficient muscle mass for
deep IM injection, impaired absorption from muscle as a result of
stasis or edema, the potential for uncontrolled IM bleeding from
trauma (as in patients with hemophilia), or the need for massive
and prolonged parenteral therapy (as in patients with chronic sub-
stantial blood loss).
• Promote a varied diet that’s adequate in protein, calories, miner-
als, and electrolytes.
• Encourage foods high in iron as applicable to help delay the
onset of iron deficiency anemia.
• Administer IV fluids and electrolytes as necessary to provide
nutrients. Oral food intake or tube feedings are preferable to IV
therapy.

Nursing Pharmacology_Chap09.indd 372 1/28/2012 12:05:18 PM

HEMATINIC DRUGS
373

Education edge

Teaching about hematinic drugs

If hematinic drugs are prescribed, review these points • Keep follow-up appointments for periodic blood tests
with the patient and his caregivers: and procedures to make sure treatment is appropriate.
• The best source of minerals and electrolytes is a well- • Take the drug as prescribed. Iron supplements should
balanced diet that includes a variety of foods. be taken with or after meals with 8 oz (237 mL) of fluid.
• Don’t take over-the-counter preparations, other drugs, • Don’t crush or chew slow-release tablets or capsules.
or herbal remedies without first talking to the prescriber Liquid preparations can be diluted with water and
or a pharmacist. Adverse interactions can occur with sipped through a straw.
hematinic drugs. For example, herbal preparations of • Rinse the mouth after taking liquid preparations to
chamomile, feverfew, and St. John’s wort may inhibit iron prevent staining of the teeth.
absorption. • Iron preparations may cause dark green or black stools.
• Keep all mineral and electrolyte substances out of the • Get plenty of rest and rise slowly to avoid dizziness. Take
reach of children; accidental overdose can occur. rest periods during the day to conserve energy.

• Correct underlying disorders that contribute to mineral and

electrolyte deficiency or excess.
• Promote measures to relieve anorexia, nausea, vomiting, diar-
rhea, pain, and other signs and symptoms.
• Arrange for a nutritional consult as needed.

Evaluation
• Patient’s hemoglobin level, hematocrit, and reticulocyte counts
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

are normal.
• Patient doesn’t experience anaphylaxis.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about hematinic drugs.)

Vitamin B12
Vitamin B12 preparations are used to treat pernicious anemia.
Common vitamin B12 preparations include cyanocobalamin and
hydroxocobalamin.

Pharmacokinetics
Vitamin B12 is available in parenteral, oral, and intranasal forms.

A pernicious problem
A substance called intrinsic factor, secreted by the gastric
mucosa, is needed for vitamin B12 absorption. People who have

Nursing Pharmacology_Chap09.indd 373 1/28/2012 12:05:18 PM

HEMATOLOGIC DRUGS
374

a deficiency of intrinsic factor develop a special type of anemia

known as vitamin B12-deficiency pernicious anemia. Because Why is
people with this disorder can’t absorb vitamin B12, an injectable or vitamin B12 so
intranasal form of the drug is used to treat it. important?

Final destination: Liver

When cyanocobalamin is injected by the IM or subcutaneous
(subcut) route, it’s absorbed and binds to transcobalamin II for
transport to the tissues. It’s then transported in the bloodstream
to the liver, where 90% of the body’s vitamin B12 supply is stored.
Although hydroxocobalamin is absorbed more slowly from the
injection site, its uptake in the liver may be greater than that of
cyanocobalamin.

Slow release
With either drug, the liver slowly releases vitamin B12 as needed.
It’s secreted in breast milk during lactation. About 3 to 8 mcg of
vitamin B12 are excreted in bile each day and then reabsorbed in
the ileum. Within 48 hours after a vitamin B12 injection, 50% to 95%
of the dose is excreted unchanged in urine.

Pharmacodynamics
When vitamin B12 is administered, it replaces vitamin B12 that the
body normally would absorb from the diet.

A must for myelin maintenance

This vitamin is essential for cell growth and replication and for the Because I’m essen-
maintenance of myelin (nerve coverings) throughout the nervous tial for cell growth
and replication and
system. Vitamin B12 also may be involved in lipid and carbohy-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

for maintaining
drate metabolism. myelin throughout
the nervous system.
Pharmacotherapeutics
Cyanocobalamin and hydroxocobalamin are used to treat perni-
cious anemia, a megaloblastic anemia characterized by decreased
gastric production of hydrochloric acid and the deficiency of
intrinsic factor, a substance normally secreted by the parietal cells
of the gastric mucosa that’s essential for vitamin B12 absorption.

Common ground
Intrinsic factor deficiencies are common in patients who have
undergone total or partial gastrectomies or total ileal resection.
Oral vitamin B12 preparations are used to supplement nutritional
deficiencies of the vitamin.

Nursing Pharmacology_Chap09.indd 374 1/28/2012 12:05:19 PM

HEMATINIC DRUGS
375

Drug interactions
Alcohol, aspirin, aminosalicylic acid, neomycin, chloram-
phenicol, and colchicine may decrease the absorption of oral
cyanocobalamin.

Adverse reactions
No dose-related adverse reactions occur with vitamin B12 therapy.
However, some rare reactions may occur when vitamin B12 is
administered parenterally. Adverse reactions
to parenteral
Don’t be so (hyper)sensitive vitamin B12 can be a
Adverse reactions to parenteral administration can include hyper- real knockout.
sensitivity reactions that could result in mild diarrhea, itching,
transient rash, hives, hypokalemia, polycythemia vera, peripheral
vascular thrombosis, heart failure, pulmonary edema, anaphylaxis,
or even death.

Nursing process
These nursing process steps are appropriate for patients under-
going treatment with vitamin B12.

Assessment
• Assess the patient’s vitamin B12 deficiency before therapy.
• Monitor the drug’s effectiveness by evaluating the patient’s
hemoglobin level, hematocrit, and reticulocyte count.
• Monitor the patient’s health status.
• Assess for adverse reactions and drug interactions.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Observe the patient for delayed reactions to therapy.

• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to vitamin B12 deficiency
• Risk for injury related to the underlying condition
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s vitamin B12 deficiency will improve as evidenced
by laboratory studies.
• The risk of injury to the patient will be minimized.
• The patient and his family will demonstrate an understanding of
drug therapy.

Nursing Pharmacology_Chap09.indd 375 1/28/2012 12:05:19 PM

HEMATOLOGIC DRUGS
376

Implementation
• Promote a varied diet that’s adequate in protein, calories, miner-
als, and electrolytes.
• Encourage foods high in iron as applicable to help delay the
onset of iron deficiency anemia.
• Administer IV fluids and electrolytes as necessary to provide nutri-
ents. Oral food intake or tube feedings are preferable to IV therapy.
• Correct underlying disorders that contribute to mineral and
electrolyte deficiency or excess.
• Promote measures to relieve anorexia, nausea, vomiting, diar-
rhea, pain, and other signs and symptoms.

Evaluation
• Patient’s hemoglobin level, hematocrit, and reticulocyte counts
are normal.
• Patient’s underlying condition and neurologic signs and symp-
toms improve.
• Patient and his family demonstrate an understanding of drug
therapy.

Folic acid
Folic acid is given to treat megaloblastic anemia caused by folic Three cheers for
acid deficiency. This type of anemia usually occurs in infants, ado- synthetic folic acid!
lescents, pregnant and lactating women, elderly persons, alcohol- It’s readily absorbed
ics, and those with intestinal or malignant diseases. Folic acid is even in patients
also used as a nutritional supplement. with malabsorption
syndromes.

Pharmacokinetics
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Folic acid is absorbed rapidly in the first third of the small intes-
tine and distributed into all body tissues. Synthetic folic acid is
readily absorbed even in patients with malabsorption syndromes.
Folic acid is metabolized in the liver. Excess folate is excreted
unchanged in urine, and small amounts of folic acid are excreted
in feces. Folic acid is also secreted in breast milk.

Pharmacodynamics
Folic acid is an essential component for normal RBC production
and growth. A deficiency in folic acid results in megaloblastic
anemia and low serum and RBC folate levels.

Pharmacotherapeutics
Folic acid is used to treat folic acid deficiency. Patients who are
pregnant or undergoing treatment for liver disease, hemolytic

Nursing Pharmacology_Chap09.indd 376 1/28/2012 12:05:19 PM

HEMATINIC DRUGS
377

anemia, alcohol abuse, skin disorders, or renal disorders typically

need folic acid supplementation. Folic acid supplementation also
reduces the risk of neural tube defects and colon cancer. Serum
folic acid levels less than 5 mg indicate folic acid deficiency.

Drug interactions
These drug interactions may occur with folic acid:
• Methotrexate, sulfasalazine, hormonal contraceptives, aspirin,
triamterene, pentamidine, and trimethoprim reduce the effective-
ness of folic acid. Seize this warning!
Large doses of folic
The anti-anticonvulsant acid may counteract
• In large doses, folic acid may counteract the effects of anticon- the effects of
vulsants, such as phenytoin, potentially leading to seizures. anticonvulsants.

Adverse reactions
Adverse reactions to folic acid include:
• erythema
• itching
• rash
• anorexia
• nausea
• altered sleep patterns
• difficulty concentrating
• irritability
• overactivity.

Nursing process
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

These nursing process steps are appropriate for patients

undergoing treatment with folic acid.

Assessment
• Assess the patient’s folic acid deficiency before therapy.
• Monitor the therapy’s effectiveness by evaluating the patient’s
hemoglobin level, hematocrit, and reticulocyte count.
• Monitor the patient’s health status.
• Assess for adverse reactions and drug interactions.
• Observe the patient for delayed reactions to therapy.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to folic acid deficiency
• Risk for injury related to the underlying condition
• Deficient knowledge related to drug therapy

Nursing Pharmacology_Chap09.indd 377 1/28/2012 12:05:21 PM

HEMATOLOGIC DRUGS
378

Planning outcome goals

• The patient’s folic acid deficiency will improve as evidenced by If you’re using the
laboratory studies. IM route, don’t mix
• The risk of injury to the patient will be minimized. folic acid and other
drugs in the same
• The patient and his family will demonstrate an understanding of
syringe. You’ll need
drug therapy. both of us for proper
administration.
Implementation
• Promote a varied diet that’s adequate in protein, calories, miner-
als, and electrolytes.
• Administer IV fluids and electrolytes as necessary to provide
nutrients. Oral food intake or tube feedings are preferable to IV
therapy.
• Correct underlying disorders that contribute to mineral and
electrolyte deficiency or excess.
• Promote measures to relieve anorexia, nausea, vomiting, diar-
rhea, pain, and other signs and symptoms.
• If using the IM route, don’t mix folic acid and other drugs in the
same syringe.

Evaluation
• Patient’s hemoglobin level, hematocrit, and reticulocyte counts
are normal.
• Patient’s underlying condition improves.
• Patient and his family demonstrate an understanding of drug
therapy.

I don’t know about

Epoetin alfa and darbepoetin alfa you, but I find
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

this discussion
Erythropoietin is a substance that forms in the kidneys in response to on erythropoietin
hypoxia (reduced oxygen) and anemia. It stimulates RBC production to be incredibly
(erythropoiesis) in the bone marrow. For the patient experiencing stimulating.
decreased erythropoietin production, epoetin alfa and darbepoetin
alfa are glycoproteins that are used to stimulate RBC production.

Pharmacokinetics
Epoetin alfa and darbepoetin alfa may be given subcut or IV.

Reaching the peak

After subcut administration, peak serum levels of epoetin alfa
occur in 5 to 24 hours. The peak level of darbepoetin alfa occurs
within 24 to 72 hours. The circulating half-life is 4 to 13 hours for
epoetin alfa and 49 hours for darbepoetin alfa. The therapeutic
effect of these drugs lasts for several days after administration.
They’re eliminated through the kidneys.

Nursing Pharmacology_Chap09.indd 378 1/28/2012 12:05:21 PM

HEMATINIC DRUGS
379

Pharmacodynamics
Patients with conditions that decrease erythropoietin produc-
tion (such as chronic renal failure) typically develop normocytic
anemia. Epoetin alfa and darbepoetin alfa are structurally similar
to erythropoietin. Therapy with these drugs corrects normocytic
anemia within 5 to 6 weeks.

Pharmacotherapeutics
Epoetin alfa is used to:
• treat patients with anemia associated with chronic renal failure
• treat anemia associated with zidovudine therapy in patients
with human immunodeficiency virus infection
• reduce the need for allogenic blood transfusions in patients
undergoing surgery.
Darbepoetin alfa is indicated for anemia associated with
chronic renal failure.

Drug interactions
No known drug interactions exist.

Adverse reactions
Hypertension is the most common adverse reaction to epoetin
alfa and darbepoetin alfa. Other common adverse reactions may
include:
• headache
Epoetin alfa and
• joint pain darbepoetin alfa
• nausea and vomiting may cause skin
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• edema reactions at the

• fatigue injection site.
• diarrhea
• seizures
• chest pain
• skin reactions at the injection site
• stroke
• dizziness
• deep vein thrombosis
• transient ischemic attack.

Nursing process
These nursing process steps are appropriate for patients
undergoing treatment with epoetin alfa or darbepoetin alfa.

Assessment
• Assess the patient’s iron deficiency before starting therapy.

Nursing Pharmacology_Chap09.indd 379 1/28/2012 12:05:22 PM

HEMATOLOGIC DRUGS
380

• Monitor the drug’s effectiveness by evaluating the patient’s

hemoglobin level, hematocrit, and reticulocyte count.
• Monitor the patient’s health status.
• Assess vital signs, especially blood pressure.
• Assess for adverse reactions and drug interactions.
• Observe the patient for delayed reactions to therapy.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to iron deficiency
• Risk for injury related to the underlying condition
• Deficient knowledge related to drug therapy

Planning outcome goals

Implementation
• Give the IV form of the drug by direct injection.
• Additional heparin may be needed to prevent blood clotting if
the patient is on dialysis.
• Promote a varied diet that’s adequate in protein, calories, miner-
als, and electrolytes.

Delaying tactics
• Encourage foods high in iron as applicable to help delay the
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

onset of iron deficiency anemia.

• Administer IV fluids and electrolytes as necessary to provide
nutrients. Oral food intake or tube feedings are preferable to IV
therapy.
• Correct underlying disorders that contribute to mineral and
electrolyte deficiency or excess.
• Promote measures to relieve anorexia, nausea, vomiting, diar-
rhea, pain, and other signs and symptoms.
• Administer supplementation as necessary.

Nursing Pharmacology_Chap09.indd 380 1/28/2012 12:05:22 PM

ANTICOAGULANT DRUGS
381

Anticoagulant drugs Blood trying to

clot? I think not!
Anticoagulant drugs
Anticoagulant drugs are used to reduce the ability of the blood to
reduce the blood’s
clot. Major categories of anticoagulant drugs include: ability to clot.
• heparin
• oral anticoagulants
• antiplatelet drugs
• direct thrombin inhibitors
• factor Xa inhibitors.

Heparin and heparin derivatives

Heparin, prepared commercially from animal tissue, is an anti-
thrombolytic agent used to prevent clot formation. Because it
doesn’t affect the synthesis of clotting factors, heparin can’t
dissolve already formed clots.

The lightweights
Low-molecular-weight heparins, such as dalteparin sodium and
enoxaparin sodium, are derived by decomposing unfractionated
heparin into simpler compounds. They were developed to pre-
vent deep vein thrombosis (DVT), a blood clot in the deep veins Low-molecular-
(usually of the legs), in surgical patients. Their use is preferred weight heparins
because they can be given subcut and don’t require as much moni- can be given subcut
toring as unfractionated heparin. and don’t require
as much monitoring
as unfractionated
Pharmacokinetics heparin. So bring on
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

those fractions!
Because heparin and its derivatives aren’t absorbed well from
the GI tract, they must be administered parenterally. Unfrac-
tionated heparin is administered by continuous IV infusion.
Low-molecular-weight heparins have the advan-
tage of a prolonged circulating half-life. They can
be administered subcut once or twice daily. Dis-
tribution is immediate after IV administration, but
it isn’t as predictable with subcut injection.

IM is out
Heparin and its derivatives aren’t given IM
because of the risk of local bleeding. These drugs
metabolize in the liver. Their metabolites are
excreted in urine. (See Anticoagulant drugs:
Heparin and heparin derivatives, page 382.)

Nursing Pharmacology_Chap09.indd 381 1/28/2012 12:05:22 PM

HEMATOLOGIC DRUGS
382

Prototype pro

Anticoagulant drugs: Heparin and heparin

derivatives
Actions • Heart failure
• Accelerates formation of an antithrom- • History of embolism and atrial fibrillation
bin III–thrombin complex
Nursing considerations
• Inactivates thrombin and prevents the
• Monitor the patient for adverse effects,
conversion of fibrinogen to fibrin
such as hemorrhage, prolonged clotting
Indications time, thrombocytopenia, and hypersensi-
• Deep vein thrombosis tivity reactions.
• Pulmonary embolism • Regularly inspect the patient for bleed-
• Open-heart surgery ing gums, bruises, petechiae, epistaxis,
• Disseminated intravascular coagulation tarry stools, hematuria, and hematemesis.
• Unstable angina • Effects can be neutralized by protamine
• Post-myocardial infarction sulfate.
• Cerebral thrombosis in evolving stroke • Monitor partial thromboplastin time
• Left ventricular thrombi regularly.

Pharmacodynamics
Heparin and heparin derivatives prevent the formation of new
thrombi. Here’s how heparin works:
• Heparin inhibits the formation of thrombin and fibrin by activat-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

ing antithrombin III.

• Antithrombin III then inactivates factors IXa, Xa, XIa, and XIIa
in the intrinsic and common pathways. The end result is the pre-
vention of a stable fibrin clot.
• In low doses, heparin increases the activity of antithrombin III
against factor Xa and thrombin and inhibits clot formation.
• Much larger doses are necessary to inhibit fibrin formation after
a clot has been formed. This relationship between dose and effect
is the rationale for using low-dose heparin to prevent clotting.
• Whole blood clotting time, thrombin time, and partial thrombo-
plastin time (PTT) are prolonged during heparin therapy. How-
ever, these times may be only slightly prolonged with low or
ultra-low preventive dosages.

Nursing Pharmacology_Chap09.indd 382 1/28/2012 12:05:24 PM

ANTICOAGULANT DRUGS
383

Pharmacotherapeutics
Heparin may be used in many clinical situations to prevent the Monitoring
formation of new clots or the extension of existing clots. These heparin therapy
situations include:
Therapy with unfraction-
• preventing or treating venous thromboemboli, characterized by
ated heparin requires
inappropriate or excessive intravascular activation of blood clot-
ting as well as extending embolisms close monitoring. Dos-
• treating disseminated intravascular coagulation, a complication age adjustments may
of other diseases that results in accelerated clotting be needed to ensure
• treating arterial clotting and preventing embolus formation in therapeutic effective-
patients with atrial fibrillation, an arrhythmia in which ineffective ness without increasing
atrial contractions cause blood to pool in the atria, increasing the the risk of bleeding.
risk of clot formation Monitor partial thrombo-
• preventing thrombus formation and promoting cardiac circula- plastin time to measure
tion in an acute myocardial infarction (MI) by preventing further the effectiveness of
clot formation at the site of the already formed clot. unfractionated heparin
therapy. Also monitor
An out-of-body experience platelet count to watch
Heparin can be used to prevent clotting whenever the patient’s for heparin-induced
blood must circulate outside the body through a machine, such as thrombocytopenia.
the cardiopulmonary bypass machine and hemodialysis machine,
as well as during extracorporeal circulation and blood transfusions. When to switch
Heparin therapy
No bones about it is associated with
Heparin is also useful for preventing clotting during intra- thrombocytopenia. If
abdominal or orthopedic surgery. (These types of surgery, in heparin-induced throm-
many cases, activate the coagulation mechanisms excessively.) bocytopenia develops,
In fact, heparin is the drug of choice for orthopedic surgery. (See use thrombin inhibitors,
Monitoring heparin therapy.) such as lepirudin, arga-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

troban, or bivalirudin,
Pulling the plug on DVT instead of heparin.
Low-molecular-weight heparins are used to prevent DVT.

Drug interactions
Watch for these drug interactions in patients taking heparin or
heparin derivatives:
• Because heparin and heparin derivatives act synergistically with
all the oral anticoagulants, the risk of bleeding increases when the
patient takes both drugs together. The prothrombin time (PT) and
International Normalized Ratio (INR), used to monitor the effects
of oral anticoagulants, may also be prolonged.
• The risk of bleeding increases when the patient takes nonsteroidal
anti-inflammatory drugs (NSAIDs), iron dextran, clopidogrel, cilo-
stazol, or an antiplatelet drug, such as aspirin, ticlopidine, or dipy-
ridamole, while also receiving heparin or its derivatives.

Nursing Pharmacology_Chap09.indd 383 1/28/2012 12:05:24 PM

HEMATOLOGIC DRUGS
384

• Drugs that antagonize or inactivate heparin and heparin deriva-

tives include antihistamines, digoxin, penicillins, cephalosporins, Put out that
nitroglycerin, nicotine, phenothiazines, tetracycline hydrochlo- cigarette right now!
ride, quinidine, neomycin sulfate, and IV penicillin. Not only is smoking
• Nicotine may inactivate heparin and heparin derivatives. bad for you, but
the nicotine may
• Nitroglycerin may inhibit the effects of heparin and heparin inactivate heparin!
derivatives.
• Protamine sulfate and administration of fresh frozen plasma
counteract the effects of heparin and heparin derivatives.

Adverse reactions
One advantage of heparin and its derivatives is that they
produce relatively few adverse reactions. These reactions
can usually be prevented if the patient’s PTT is main-
tained within the therapeutic range (11/2 to 2 times the
control).

Reversal of fortune
Bleeding, the most common adverse effect, can be reversed easily
by administering protamine sulfate, which binds to heparin and
forms a stable salt with it. Other adverse effects include bruising,
hematoma formation, necrosis of the skin or other tissue, and
thrombocytopenia.

Nursing process
These nursing process steps are appropriate for patients under-
going treatment with heparin or heparin derivatives.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Assessment
• Assess the patient for bleeding and other adverse reactions.
• Assess the patient’s underlying condition before therapy.
• Monitor the patient’s vital signs, hemoglobin level, hematocrit,
platelet count, PT, INR, and PTT.
• Assess the patient’s urine, stool, and emesis for blood.

Key nursing diagnoses

• Ineffective protection related to the drug’s effects on the body’s
normal clotting and bleeding mechanisms
• Risk for deficient fluid volume related to bleeding
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient will have clotting times appropriate for drug
therapy.

Nursing Pharmacology_Chap09.indd 384 1/28/2012 12:05:25 PM

ANTICOAGULANT DRUGS
385

• The patient will maintain adequate fluid volume as evidenced by

vital signs and laboratory studies.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Carefully and regularly monitor PTT. Anticoagulation is present
when PTT values are 11/2 to 2 times the control values.
• Don’t administer heparin IM; avoid IM injections of any antico-
agulant, if possible.
• Keep protamine sulfate available to treat severe bleeding caused
by the drug.
• Notify the prescriber about serious or persistent adverse reactions.
• Maintain bleeding precautions throughout therapy.
• Administer IV solutions using an infusion pump, as appropriate.
• Avoid excessive IM injection of other drugs, to minimize the
risk of hematoma.

Evaluation
• Patient’s health status improves.
• Patient has no evidence of bleeding or hemorrhaging.
• Patient and his family demonstrate an understanding of drug
therapy.

Oral anticoagulants
The major oral anticoagulant used in the United States is the cou-
marin compound warfarin sodium.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Pharmacokinetics
Warfarin is absorbed rapidly and almost completely when it’s
taken orally. I’m extensively
bound to plasma
Why the delay? albumin. Stick with
Despite its rapid absorption, warfarin’s effects aren’t seen for me, buddy, and you’ll
about 36 to 48 hours and it may take 3 to 4 days for the full effect go places!
to occur. This is because warfarin antagonizes the production of
vitamin K–dependent clotting factors. Before warfa-
rin can exhibit its full effect, the circulating vitamin
K clotting factors must be exhausted.
Warfarin is bound extensively to plasma albu-
min, metabolized in the liver, and excreted in urine.
Because warfarin is highly protein bound and
metabolized in the liver, using other drugs at the
same time may alter the amount of warfarin in the

Nursing Pharmacology_Chap09.indd 385 1/28/2012 12:05:25 PM

HEMATOLOGIC DRUGS
386

body. This may increase the risk of bleeding and clotting, depend-
ing on which drugs are used. Prototype
pro
Pharmacodynamics
Oral anticoagulants alter the ability of the liver to synthesize Anticoagulant
vitamin K–dependent clotting factors, including factors II (pro- drugs: Warfarin
thrombin), VII, IX, and X. However, clotting factors already in
the bloodstream continue to coagulate blood until they become Actions
depleted, so anticoagulation doesn’t begin immediately. • Inhibits vitamin K–
dependent activation of
Pharmacotherapeutics clotting factors II (pro-
Oral anticoagulants are prescribed to treat thromboembolism and, in thrombin), VII, IX, and X
this situation, are started while the patient is still receiving heparin. formed in the liver
Warfarin, however, may be started without heparin in outpatients at Indications
high risk for thromboembolism. (See Anticoagulant drugs: Warfarin.) • Prevention of pulmo-
The chosen one nary embolism caused
by deep vein thrombosis,
Oral anticoagulants also are the drugs of choice to prevent DVT
myocardial infarction,
and treat patients with prosthetic heart valves or diseased mitral
rheumatic fever, pros-
valves. They sometimes are combined with an antiplatelet drug,
thetic heart valves, or
such as aspirin, clopidogrel, or dipyridamole, to decrease the risk
of arterial clotting. chronic atrial fibrillation

Nursing considerations
Drug interactions • Monitor the patient
Many patients who take oral anticoagulants also receive other for adverse reactions,
drugs, placing them at risk for serious drug interactions: such as hemorrhage,
• Many drugs, such as highly protein-bound medications, increase prolonged clotting time,
the effects of warfarin, resulting in an increased risk of bleed- rash, fever, diarrhea,
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

ing. Examples include acetaminophen, allopurinol, amiodarone, and hepatitis.

cephalosporins, cimetidine, ciprofloxacin, clofibrate, danazol, • Regularly inspect the
diazoxide, disulfiram, erythromycin, fluoroquinolones, gluca- patient for bleeding
gon, heparin, ibuprofen, isoniazid, ketoprofen, metronidazole, gums, bruises, pete-
miconazole, neomycin, propafenone, propylthiouracil, quinidine, chiae, epistaxis, tarry
streptokinase, sulfonamides, tamoxifen, tetracyclines, thiazides, stools, hematuria, and
thyroid drugs, tricyclic antidepressants, urokinase, and vitamin E. hematemesis.
• Drugs metabolized by the liver may increase or decrease the • The drug’s effects
effectiveness of warfarin. Examples include barbiturates, carba- can be neutralized by
mazepine, corticosteroids, corticotropin, mercaptopurine, naf-
vitamin K.
cillin, hormonal contraceptives containing estrogen, rifampin,
• Monitor prothrombin
spironolactone, sucralfate, and trazodone.
time regularly.
• A diet high in vitamin K reduces the effectiveness of oral
anticoagulants.
• The risk of phenytoin toxicity increases when phenytoin is
taken with warfarin. Phenytoin may increase or decrease the
effects of warfarin.

Nursing Pharmacology_Chap09.indd 386 1/28/2012 12:05:26 PM

ANTICOAGULANT DRUGS
387

• Chronic alcohol abuse increases the risk of clotting in patients

taking warfarin. Patients with acute alcohol intoxication have an Keep an eye on
increased risk of bleeding. your patient’s diet
• Vitamin K and fresh frozen plasma reduce the effects of if he’s taking oral
warfarin. anticoagulants. A
diet high in vitamin
K reduces the
Adverse reactions effectiveness of
these drugs.
The primary adverse reaction to oral anticoagulant therapy is
minor bleeding. Severe bleeding can occur, however, with the
most common site being the GI tract. Bleeding into the brain may
be fatal. Bruises and hematomas may form at arterial puncture
sites (for example, after a blood gas sample is drawn). Neurosis
or gangrene of the skin and other tissue can occur. Warfarin is
contraindicated during pregnancy.

In reverse
The effects of oral anticoagulants can be reversed with phytonadi-
one (vitamin K1).

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with oral anticoagulants.

Assessment
• Assess the patient’s underlying condition before starting therapy.
• Monitor the patient closely for bleeding and other adverse
reactions.
• Monitor the patient’s vital signs, hemoglobin level, hematocrit,
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

platelet count, PT, INR, and PTT.

• Assess the patient’s urine, stool, and emesis for blood.

Key nursing diagnoses

Planning outcome goals

• The patient’s clotting times will respond appropriately to drug
therapy.
• The patient will maintain adequate fluid volume as evidenced by
vital signs and laboratory studies.
• The patient and his family will demonstrate an understanding of
drug therapy.

Nursing Pharmacology_Chap09.indd 387 1/28/2012 12:05:26 PM

HEMATOLOGIC DRUGS
388

Education edge

Teaching about anticoagulant drugs

If anticoagulant drugs are prescribed, review these points • Institute ways to prevent bleeding during daily activities.
with the patient and his caregivers: For example, remove safety hazards from the home to
• Take the drug exactly as prescribed. If taking warfarin, reduce the risk of injury.
take it at night. • Don’t increase intake of green, leafy vegetables or other
• If taking warfarin, have blood drawn for prothrombin foods or multivitamins that contain vitamin K because vita-
time or International Normalized Ratio tests in the morning min K may antagonize the anticoagulant effects of the drug.
to ensure accurate results. • Report bleeding or other adverse reactions promptly.
• Consult the prescriber before taking other drugs, • Keep appointments for blood tests and follow-up exami-
including over-the-counter medications and herbal nations.
remedies. • Report planned or known pregnancy.

Implementation
• Carefully and regularly monitor PT and INR values.

Vital vitamin
• Keep vitamin K available to treat frank bleeding caused by
warfarin.
• Notify the prescriber about serious or persistent adverse reactions.
• Maintain bleeding precautions throughout therapy.
• Administer the drug at the same time each day.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Antiplatelet drugs
Antiplatelet drugs are used to prevent arterial thromboembolism,
particularly in patients at risk for MI, stroke, and arteriosclerosis
(hardening of the arteries). Antiplatelet drugs include:
• aspirin
• clopidogrel
• dipyridamole
• ticlopidine.

Nursing Pharmacology_Chap09.indd 388 1/28/2012 12:05:26 PM

ANTICOAGULANT DRUGS
389

IV instances
Elderly patients
IV antiplatelet drugs are used in the treatment of acute coronary and patients with
syndromes and include the medications abciximab, eptifibatide, renal failure may
and tirofiban. have decreased
clearance of
antiplatelet drugs,
Pharmacokinetics which can prolong
Oral antiplatelet drugs are absorbed very quickly and reach peak their antiplatelet
concentration between 1 and 2 hours after administration. Aspirin effects.
maintains its antiplatelet effect for approximately 10 days, or as
long as platelets normally survive. The effects of clopidogrel last
about 5 days.

Within minutes
Antiplatelet drugs administered IV are quickly distributed
throughout the body. They’re minimally metabolized and
excreted unchanged in urine. The effects of the drugs are
seen within 15 to 20 minutes of administration and last
about 6 to 8 hours. Elderly patients and patients with renal
failure may have decreased clearance of these drugs, pro-
longing their antiplatelet effect.

Pharmacodynamics
Antiplatelet drugs interfere with platelet activity in different
drug-specific and dosage-related ways.

Block that clot

Low dosages of aspirin appear to inhibit clot formation by block-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

ing the synthesis of prostaglandin, which in turn prevents for-

mation of the platelet-aggregating substance thromboxane A2.
Clopidogrel inhibits platelet aggregation by inhibiting platelet-
fibrinogen binding.

Prevent that platelet

IV antiplatelet drugs block platelet function by inhibiting the gly-
coprotein IIa-IIIb receptor, which is the major receptor involved
in platelet aggregation.
Dipyridamole may inhibit platelet aggregation through its abil-
ity to increase adenosine, which is a coronary vasodilator and
platelet aggregation inhibitor.

In the early stages

Ticlopidine inhibits the binding of fibrinogen to platelets during
the first stage of the clotting cascade.

Nursing Pharmacology_Chap09.indd 389 1/28/2012 12:05:27 PM

HEMATOLOGIC DRUGS
390

Pharmacotherapeutics
Antiplatelet drugs have many different uses.

A familiar face
Aspirin is used in patients with a previous MI or unstable angina
to reduce the risk of death, and in men to reduce the risk of tran-
sient ischemic attacks (TIAs; temporary reduction in circulation
to the brain).

Risky business
Clopidogrel is used to reduce the risk of an ischemic stroke or
vascular death in patients with a history of a recent MI, stroke,
or established peripheral artery disease. This drug is also used
to treat acute coronary syndromes, especially in patients who
undergo percutaneous transluminal coronary angioplasty (PTCA)
or coronary artery bypass grafting.

Dynamic duos
Dipyridamole is used with a coumarin compound to prevent
thrombus formation after cardiac valve replacement. Dipyrida-
mole with aspirin has been used to prevent thromboembolic disor-
ders in patients with aortocoronary bypass grafts (bypass surgery) Drugs that
or prosthetic (artificial) heart valves. interact with
Ticlopidine is used to reduce the risk of thrombotic stroke in antiplatelet drugs
high-risk patients (including those with a history of frequent TIAs) include NSAIDs,
and in patients who have already had a thrombotic stroke. heparin, oral
anticoagulants,
The list goes on methotrexate,
valproic acid,
Eptifibatide is indicated in the treatment of acute coronary syn- antacids, cimetidine,
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

drome and in those patients undergoing percutaneous coronary and salicylates in

intervention (PCI). Tirofiban is indicated in the treatment of acute over-the-counter
coronary syndrome. Abciximab is indicated as an adjunct to PCI. cold medicine
compounds.

Drug interactions
Several drug interactions can occur in patients taking antiplatelet
drugs:
• Antiplatelet drugs taken in combination with NSAIDs,
heparin, or oral anticoagulants increase the risk of bleeding.
• Aspirin increases the risk of toxicity of methotrexate and
valproic acid.
• Aspirin and ticlopidine may reduce the effectiveness of
sulfinpyrazone to relieve signs and symptoms of gout.
• Antacids may reduce the plasma levels of ticlopidine.
• Cimetidine increases the risk of ticlopidine toxicity and
bleeding.

Nursing Pharmacology_Chap09.indd 390 1/28/2012 12:05:27 PM

ANTICOAGULANT DRUGS
391

Don’t mix and match

Because guidelines haven’t been established for administering
ticlopidine with heparin, oral anticoagulants, aspirin, or fibrino-
lytic drugs, discontinue these drugs before starting ticlopidine
therapy.

Adverse reactions
Hypersensitivity reactions, particularly anaphylaxis, can occur.
Bleeding is the most common adverse effect of IV antiplatelet
drugs.
Adverse reactions to aspirin include:
• stomach pain
• heartburn
• nausea
• constipation
• blood in the stool
• slight gastric blood loss.
Clopidogrel may cause these adverse reactions:
• headache
• skin ulceration
• joint pain
• flulike symptoms
• upper respiratory tract infection.
These adverse reactions may occur with ticlopidine:
• diarrhea
• nausea
• dyspepsia
• rash
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• elevated liver function test results

• neutropenia.
Dipyridamole may cause:
• headache
• dizziness
• nausea
• flushing
• weakness and fainting
• mild GI distress.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with antiplatelet drugs.

Assessment
• Assess the patient’s underlying condition before starting therapy.

Nursing Pharmacology_Chap09.indd 391 1/28/2012 12:05:27 PM

HEMATOLOGIC DRUGS
392

• Monitor the patient closely for bleeding and other adverse

reactions. Patients receiving
• During long-term therapy with aspirin, monitor the patient’s long-term aspirin
serum salicylate level and perform hearing assessments. therapy need to
• Monitor the patient’s vital signs, hemoglobin level, hematocrit, have their serum
salicylate level
and platelet count. monitored and their
• Assess the patient’s urine, stool, and emesis for blood. hearing checked.

Key nursing diagnoses

Planning outcome goals

• The patient’s clotting times will respond appropriately
to drug therapy.
• The patient will maintain adequate fluid volume as evi-
denced by vital signs and laboratory studies.
• The patient and his family will demonstrate an under-
standing of drug therapy.

Implementation
• Notify the prescriber about serious or persistent adverse
reactions.
• Maintain bleeding precautions throughout therapy.
• Avoid excessive IV, IM, or subcut injection of other drugs to
minimize the risk of hematoma.
• Give aspirin with food, milk, an antacid, or a large glass of water Don’t crush
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

to reduce adverse GI reactions. enteric-coated

• Don’t crush enteric-coated products. drugs!
• Withhold the dose and notify the prescriber if bleeding, salicyl-
ism (tinnitus, hearing loss), or adverse GI reactions develop.
• Stop antiplatelet drugs 5 to 7 days before elective surgery as
appropriate.

Evaluation
• Patient has no adverse change in health status.
• Patient has no evidence of bleeding or hemorrhaging.
• Patient and his family demonstrate an understanding of drug
therapy.

Direct thrombin inhibitors

Direct thrombin inhibitors are anticoagulant drugs used to pre-
vent the formation of harmful blood clots in the body. Argatroban,

Nursing Pharmacology_Chap09.indd 392 1/28/2012 12:05:27 PM

ANTICOAGULANT DRUGS
393

bivalirudin, and lepirudin are examples of direct thrombin

inhibitors.

Pharmacokinetics
Direct thrombin inhibitors are usually administered IV, typically
by continuous infusion. They’re metabolized by the liver. Reduced
dosages may be necessary in individuals with hepatic impairment.
Effects on PTT become apparent within 4 to 5 hours of adminis-
tration. Platelet count recovery becomes apparent within 3 days.

When you’ll reach the peak

Direct thrombin inhibitors have a rapid onset after IV bolus admin-
istration. Bivalirudin reaches its peak response in 15 minutes and
has a duration of 2 hours. Argatroban reaches peak levels in 1 to
3 hours; its duration lasts until the infusion stops. Peak levels of
lepirudin occur in 10 minutes, and its duration also lasts until the
infusion stops. Argatroban is excreted primarily in feces through
biliary secretion. Bivalirudin and lepirudin are excreted renally.

Pharmacodynamics
Direct thrombin inhibitors interfere with the blood clotting mech-
anism by blocking the direct activity of soluble and clot-bound
thrombin. When these drugs bind to thrombin, they inhibit:
• platelet activation, granule release, and aggregation
• fibrinogen cleavage
• fibrin formation and further activation of the clotting cascade.

Creating a complex
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Lepirudin binds rapidly with thrombin to form tight complexes,

but it doesn’t inhibit other proteases.

No chance to react
Argatroban reversibly binds to the thrombin-active site and inhib-
its thrombin-induced reactions, including fibrin formation; coagu-
lation factors V, VIII, and XIII activation; protein C activation; and
platelet aggregation.

Hipper than heparin

Compared with heparin, direct thrombin inhibitors have three
advantages:

They have activity against clot-bound thrombin.

They have more predictable anticoagulant effects.

They aren’t inhibited by the platelet release reaction.

Nursing Pharmacology_Chap09.indd 393 1/28/2012 12:05:28 PM

HEMATOLOGIC DRUGS
394

Pharmacotherapeutics
Argatroban and lepirudin are used to treat heparin-induced throm-
bocytopenia (HIT). Argatroban is administered in combination
with aspirin to patients with HIT undergoing coronary interven-
tions, such as PTCA, coronary stent placement, and atherectomy.
However, the safety and effectiveness of argatroban for cardiac
indications haven’t been established for patients without HIT.

Bivalirudin bio
Bivalirudin has been approved for use in patients with unstable
angina who are undergoing PTCA. It should be used in conjunc-
tion with aspirin therapy.

Keep track of contraindications

Bivalirudin is contraindicated in patients with cerebral aneurysm,
intracranial hemorrhage, or general uncontrolled hemorrhage.
In addition, the dosage may need to be reduced in those with
impaired renal function because 20% of the drug is excreted
unchanged in urine. Bivalirudin also increases the risk of hemor-
rhage in those with GI ulceration or hepatic disease. Hypertension
may increase the risk of cerebral hemorrhage. Use bivalirudin
with caution after recent surgery or trauma and during lactation.

Drug interactions
In addition, keep these points in mind:
• Parenteral anticoagulants should be discontinued before admin-
istering argatroban. Don’t give direct
• Using argatroban and warfarin together has a combined effect thrombin inhibitors
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

on INR. with drugs that

• If the patient previously received heparin, allow sufficient time may enhance the
risk of bleeding.
for heparin’s effect on the PTT to decrease before starting argatro- Hemorrhage may
ban therapy. occur.
• The safety and effectiveness of using argatroban and thrombo-
lytic drugs together haven’t been established.

Adverse reactions
Don’t give direct thrombin inhibitors with drugs that may enhance
the risk of bleeding. Patients at greatest risk for hemorrhage
include those with severe hypertension; those undergoing lumbar
puncture or spinal anesthesia; those undergoing major surgery,
especially involving the brain, spinal cord, or eye; those with
hematologic conditions associated with increased bleeding ten-
dencies; and those with GI lesions. Use direct thrombin inhibitors
cautiously in these patients.

Nursing Pharmacology_Chap09.indd 394 1/28/2012 12:05:29 PM

ANTICOAGULANT DRUGS
395

The major adverse effect of direct thrombin inhibitors is bleed-

ing with the possibility of major hemorrhage, although this rarely
occurs.
Other adverse reactions include:
• intracranial hemorrhage
• retroperitoneal hemorrhage
• nausea, vomiting, abdominal cramps, and diarrhea
• headache
• hematoma at the IV infusion site.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with direct thrombin inhibitors.

Assessment
• Assess the patient’s underlying condition before starting
therapy.
• Monitor the patient closely for bleeding and other adverse reac-
tions.
• Check PT, INR, and PTT.
• Monitor the patient’s vital signs, hemoglobin level, hematocrit,
and platelet count.
• Assess the patient’s urine, stool, and emesis for blood.

Key nursing diagnoses

• Ineffective protection related to the drug’s effects on the body’s
normal clotting and bleeding mechanisms
• Risk for deficient fluid volume related to bleeding
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Deficient knowledge related to drug therapy

Planning outcome goals

Nursing Pharmacology_Chap09.indd 395 1/28/2012 12:05:29 PM

HEMATOLOGIC DRUGS
396

• Avoid excessive IM, IV, or subcut administration of other drugs

to minimize the risk of hematoma.

Evaluation
• Patient has no adverse change in health status.
• Patient has no evidence of bleeding or hemorrhaging.
• Patient and his family demonstrate an understanding of drug
therapy. There’s only one
factor Xa inhibitor
drug available in
the United States:
Factor Xa inhibitor drugs fondaparinux.
Factor Xa inhibitor drugs are used to prevent DVT in patients
undergoing total hip and knee replacement surgery or hip fracture
surgery. The only factor Xa inhibitor drug available in the United
States is fondaparinux.

Pharmacokinetics
Fondaparinux is administered subcut and absorbed rapidly and
completely. It’s excreted primarily unchanged in urine. The
peak effect is seen within 2 hours of administration and lasts for
approximately 17 to 24 hours.

Pharmacodynamics
Fondaparinux binds to antithrombin III and potentiates by about
300 times the natural neutralization of factor Xa by antithrombin III.

Pardon me for interrupting

Factor Xa neutralization interrupts the coagulation cascade,

which inhibits thrombin and thrombus formation.

Pharmacotherapeutics
Currently, fondaparinux is indicated for preventing DVT in
patients undergoing total hip and knee replacement surgery and
fractured hip surgery, and for the prevention or treatment of pul-
monary embolism.

Drug interactions
Avoid giving factor Xa inhibitors with drugs that may enhance the
risk of bleeding.

Nursing Pharmacology_Chap09.indd 396 1/28/2012 12:05:29 PM

ANTICOAGULANT DRUGS
397

Adverse effects
Adverse effects that can occur with factor Xa inhibitor therapy
include:
• bleeding
• nausea
• anemia
• fever
• rash
• constipation
• edema.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with factor Xa inhibitor drugs.

Assessment
• Assess the patient’s underlying condition before starting
therapy.
• Monitor the patient closely for bleeding and other adverse
reactions.
I don’t think this
• Check PT, INR, and PTT. is quite what they
• Monitor the patient’s vital signs, hemoglobin level, hematocrit, mean when they say
and platelet count. to “rotate” injection
• Assess the patient’s urine, stool, and emesis for blood. sites for subcut
administration of
fondaparinux!
Key nursing diagnoses
• Ineffective protection related to the drug’s effects on the body’s
normal clotting and bleeding mechanisms
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Risk for deficient fluid volume related to bleeding

• Deficient knowledge related to drug therapy

Planning outcome goals

Implementation
• Administer the drug by subcut injection into fatty tissue only;
rotate injection sites.
• Don’t mix the drug with other injections or infusions.
• Notify the prescriber about serious or persistent adverse
reactions.

Nursing Pharmacology_Chap09.indd 397 1/28/2012 12:05:29 PM

HEMATOLOGIC DRUGS
398

• Maintain bleeding precautions throughout therapy.

• Avoid excessive IV, IM, or subcut administration of other drugs
to minimize the risk of hematoma.

Evaluation
• Patient has no adverse change in health status.
• Patient has no evidence of bleeding or hemorrhaging. Thrombolytic
• Patient and his family demonstrate an understanding of drug drugs are commonly
used in acute
therapy.
or emergency
situations.

Thrombolytic drugs
Thrombolytic drugs are used to dissolve an existing clot or a
thrombus, commonly in an acute or emergency situation. Some
of the thrombolytic drugs currently used include alteplase,
reteplase, tenecteplase, urokinase, and streptokinase.

Pharmacokinetics
After IV or intracoronary administration, thrombolytic drugs
are distributed immediately throughout the circulation,
quickly activating plasminogen (a precursor to plasmin,
which dissolves fibrin clots).

In the blink of an eye

Alteplase, tenecteplase, reteplase, and urokinase are cleared rap-
idly from circulating plasma, primarily by the liver. Streptokinase
is removed rapidly from the circulation by antibodies and the
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

reticuloendothelial system (a body system involved in defend-

ing against infection and disposing products of cell breakdown).
These drugs don’t appear to cross the placental barrier.

Pharmacodynamics
Thrombolytic drugs convert plasminogen to plasmin, which lyses
(dissolves) thrombi, fibrinogen, and other plasma proteins. (See
How alteplase helps restore circulation.)

Pharmacotherapeutics
Thrombolytic drugs have several uses. They’re used to treat cer-
tain thromboembolic disorders (such as acute MI, acute ischemic
stroke, and peripheral artery occlusion) and have also been used
to dissolve thrombi in arteriovenous cannulas (used in dialysis)
and IV catheters to reestablish blood flow. (See Thrombolytic
drugs: Streptokinase, page 400.)

Nursing Pharmacology_Chap09.indd 398 1/28/2012 12:05:30 PM

THROMBOLYTIC DRUGS
399

Pharm function

How alteplase helps restore circulation

When a thrombus forms in an artery, it obstructs the blood supply, causing ischemia and necrosis. Alteplase can dis-
solve a thrombus in either the coronary or the pulmonary artery, restoring blood supply to the area beyond the blockage.

Obstructed artery
A thrombus blocks blood
Thrombus
flow through the artery,
causing distal ischemia. Blood
supply
Ischemic
Artery area
wall

Inside the thrombus

Alteplase
Alteplase enters the Active
thrombus, which consists Plasminogen plasmin
Break in
of plasminogen bound to Fibrin strand fibrin strand
fibrin. Alteplase binds to
the fibrin-plasminogen
complex, converting the
inactive plasminogen into
active plasmin. This active
plasmin digests the fibrin,
dissolving the thrombus.
As the thrombus dissolves,
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

blood flow resumes.

Here’s the breakdown

Thrombolytic drugs are the drugs of choice to break down newly
formed thrombi. They seem most effective when administered
within 6 hours after the onset of symptoms.

To be more specific…
In addition, each drug has specific uses:
• Alteplase is used to treat acute MI, pulmonary embolism, acute
ischemic stroke, and peripheral artery occlusion and to restore
patency to clotted grafts and IV access devices.

Nursing Pharmacology_Chap09.indd 399 1/28/2012 12:05:30 PM

HEMATOLOGIC DRUGS
400

• Streptokinase is used to treat acute MI, pulmonary embolism,

and DVT. Prototype
• Reteplase and tenecteplase are used to treat acute MI. pro
• Urokinase is used to treat pulmonary embolism and coronary
artery thrombosis and to clear catheters. Thrombolytic
drugs:
Drug interactions Streptokinase
These drug interactions can occur with thrombolytic drugs:
• Thrombolytic drugs interact with heparin, oral anticoagulants, Actions
antiplatelet drugs, and NSAIDs to increase the patient’s risk of • Dissolves clots by
bleeding. converting plasminogen
• Aminocaproic acid inhibits streptokinase and can be used to to plasmin
reverse its fibrinolytic effects.
Indications
• Deep vein thrombosis
Adverse reactions • Pulmonary embolism
The major reactions associated with the thrombolytic drugs are • Arterial thrombosis
bleeding and allergic responses, especially with streptokinase. and embolism
• Acute myocardial
Nursing process infarction
These nursing process steps are appropriate for patients undergo- Nursing considerations
ing treatment with thrombolytic drugs. • Monitor the patient for
adverse effects, such
Assessment as arrhythmias, bleed-
• Assess the patient’s underlying condition before starting ing, pulmonary edema,
therapy. and hypersensitivity
• Monitor the patient closely for bleeding and other adverse reactions.
reactions. • Monitor the patient’s
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Check PT, INR, and PTT. vital signs frequently.

• Monitor the patient’s vital signs, hemoglobin level, hematocrit, • Monitor the patient
and platelet count.
frequently for bleeding.
• Assess the patient’s urine, stool, and emesis for blood.
• Assess the patient’s cardiopulmonary status, including the elec-
trocardiogram and vital signs, before and during therapy.
• Monitor the patient for internal bleeding, and check puncture
sites frequently.

Key nursing diagnoses

• Risk for decreased cardiac tissue perfusion related to the
patient’s underlying condition
• Risk for deficient fluid volume related to adverse effects of drug
therapy
• Deficient knowledge related to drug therapy

Nursing Pharmacology_Chap09.indd 400 1/28/2012 12:05:33 PM

QUICK QUIZ
401

Planning outcome goals

• The patient’s cardiopulmonary assessment findings will
improve.
• The patient will maintain adequate fluid volume as evidenced by
vital signs and laboratory studies.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Notify the prescriber about serious or persistent adverse
reactions.
• Maintain bleeding precautions throughout therapy.
• Administer IV solutions using an infusion pump as appropriate;
reconstitute solutions according to facility protocol.
• Avoid excessive IM, IV, or subcut administration of other drugs
to minimize the risk of hematoma.
• Administer heparin with thrombolytics according to facility
protocol.
• Have antiarrhythmics available; monitor cardiac status closely.
• Avoid invasive procedures during thrombolytic therapy.

Evaluation
• Patient’s cardiopulmonary assessment findings demonstrate
improved perfusion.
• Patient has no evidence of bleeding or hemorrhaging.
• Patient and his family demonstrate an understanding of drug
therapy.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Quick quiz
1. Which administration method for parenteral iron helps avoid
leakage into subcutaneous tissue?
A. Z-track method
B. IM injection into the deltoid
C. Subcut injection
D. Intradermal injection
Answer: A. The Z-track method helps to avoid leakage into sub-
cutaneous tissue and staining of the skin.

Nursing Pharmacology_Chap09.indd 401 1/28/2012 12:05:33 PM

HEMATOLOGIC DRUGS
402

2. Which test should the nurse check in her assessment of a

patient receiving heparin?
A. Complete blood count
B. PTT
C. Arterial blood gas levels
D. Hemoglobin level
Answer: B. PTT should be monitored to measure the effective-
ness of heparin therapy.
3. What’s the most common adverse reaction experienced with
IV antiplatelet drugs?
A. Nausea
B. Joint pain
C. Headache
D. Bleeding
Answer: D. Bleeding is the most common adverse effect of IV
antiplatelet drugs.

Scoring
✰✰✰ If you answered all three questions correctly, magnificent! You’re
on top when it comes to managing clots.
✰✰ If you answered two questions correctly, way to go! You’re in the
know about drugs and blood flow.
✰ If you answered fewer than two questions correctly, stay calm.
Another look at this chapter with efficiency should reverse
any deficiencies.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Nursing Pharmacology_Chap09.indd 402 1/28/2012 12:05:34 PM

10
Endocrine drugs

Just the facts

In this chapter, you’ll learn:
♦ strategies
classes of to
drugs
aid you
thatinaffect
interviewing
the endocrine
and obtaining
system a de-
♦ tailed health
uses and history
varying from of
actions a patient
these drugs
♦
♦ questions
absorption,todistribution,
ask that pertain to each body
metabolization, system
and excretion of
♦ these
assessment
drugs techniques, including inspection, palpation,
♦ percussion, and auscultation.
drug interactions and adverse reactions to these drugs.

Ooooooooooom. The
Drugs and the endocrine system endocrine system,
made up of glands
and hormones, helps
The endocrine system consists of glands, which are specialized maintain the body’s
cell clusters, and hormones, the chemical transmitters secreted internal equilibrium.
by the glands in response to stimulation.

A delicate balance
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Together with the central nervous system, the endocrine sys-

tem regulates and integrates the body’s metabolic activities
and maintains homeostasis (the body’s internal equilibrium).
The drug types that treat endocrine system disorders include:
• natural hormones and their synthetic analogues, such as
insulin and glucagon
• hormonelike substances
• drugs that stimulate or suppress hormone secretion.

Antidiabetic drugs and glucagon

Insulin, a pancreatic hormone, and oral antidiabetic drugs are
classified as hypoglycemic drugs because they lower blood glu-
cose levels. Glucagon, another pancreatic hormone, is classified
as a hyperglycemic drug because it raises blood glucose levels.

Nursing Pharmacology_Chap10.indd 403 1/28/2012 12:05:55 PM

ENDOCRINE DRUGS
404

Low insulin = high glucose

Diabetes mellitus, known simply as diabetes, is a chronic disease
of insulin deficiency or resistance. It’s characterized by distur-
bances in carbohydrate, protein, and fat metabolism. This leads
to elevated levels of the sugar glucose in the body. The disease
comes in two primary forms:

type 1, previously referred to as insulin-dependent diabetes

mellitus

type 2, previously referred to as non-insulin-dependent dia-

betes mellitus.

Downward spiral
Situations that can decrease glucose levels too much in patients
with diabetes include:
• an antidiabetic drug dosage that’s too high
• an increase in activity (such as exercise) The amount of
• noncompliance with drug therapy (for example, taking an anti- insulin absorbed
depends on the
diabetic drug but not eating afterward).
injection site, the
patient’s blood sup-
ply, and the degree
Insulin of tissue hypertro-
phy at the injection
Patients with type 1 diabetes require an external source of insu- site.
lin to control blood glucose levels. Insulin may also be given to
patients with type 2 diabetes in certain situations.

Pick a rate, any rate

Types of insulin include:
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• rapid-acting, such as lispro

• short-acting, such as regular insulin
• intermediate-acting, such as NPH
• long-acting, such as glargine.

Pharmacokinetics (how drugs circulate)

Insulin isn’t effective when taken orally because the GI tract
breaks down the protein molecule before it reaches the blood-
stream.

Skin deep
All insulins, however, may be given by subcutaneous (subcut)
injection. Absorption of subcut insulin varies according to the
injection site, the blood supply, and the degree of tissue hyper-
trophy at the injection site.

Nursing Pharmacology_Chap10.indd 404 1/28/2012 12:05:56 PM

ANTIDIABETIC DRUGS AND GLUCAGON
405

In the IV league
Regular insulin may also be given IV as well as in dialysate fluid
infused into the peritoneal cavity for patients on peritoneal dialy-
sis therapy.

Far and wide

After absorption into the bloodstream, insulin is distributed
throughout the body. Insulin-responsive tissues are located in the
liver, adipose tissue, and muscle. Insulin is metabolized primarily
in the liver and, to a lesser extent, in the kidneys and muscle. It’s
excreted in feces and urine.

Pharmacodynamics (how drugs act) Okay, Team Insulin.

Let’s show this body
Insulin is an anabolic or building hormone that promotes:
what we building
• storage of glucose as glycogen (see How insulin aids glucose hormones can do!
uptake, page 406.)
• an increase in protein and fat synthesis
• a deceleration of the breakdown of glycogen, protein, and fat
• a balance of fluids and electrolytes.

Extracurricular activity
Although it has no antidiuretic effect, insulin can correct
the polyuria (excessive urination) and polydipsia (exces-
sive thirst) associated with the osmotic diuresis that can
occur with hyperglycemia by decreasing the blood glucose
level. Insulin also facilitates the movement of potassium
from the extracellular fluid into the cell.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Pharmacotherapeutics (how drugs are used)

Insulin is indicated for:
• type 1 diabetes
• type 2 diabetes when other methods of controlling blood glu-
cose levels have failed or are contraindicated
• type 2 diabetes when blood glucose levels are elevated during
periods of emotional or physical stress (such as during infection,
surgery, or medication therapy)
• type 2 diabetes when oral antidiabetic drugs are contraindicated
because of pregnancy or hypersensitivity.

Calming complications
Insulin is also used to treat two complications of diabetes: dia-
betic ketoacidosis (DKA), which is more common with type 1
diabetes, and hyperosmolar hyperglycemic nonketotic (HHNK)
syndrome, which is more common with type 2 diabetes.

Nursing Pharmacology_Chap10.indd 405 1/28/2012 12:05:56 PM

ENDOCRINE DRUGS
406

Pharm function

How insulin aids glucose uptake

These illustrations show how insulin allows a cell to use glucose for energy.

Glucose can’t enter the cell with- Normally produced by the beta These channels allow glucose to
out the aid of insulin. cells of the pancreas, insulin binds to enter the cell. The cell can then use
the receptors on the surface of the the glucose for metabolism.
target cell. Insulin and its receptor first
move to the inside of the cell, which
activates glucose transporter chan-
nels to move to the surface of the cell.

Glucose Glucose
Insulin Glucose available
transport Insulin
receptor for metabolism
channel
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Nondiabetic duty
Insulin can be used
Insulin is also used to treat severe hyperkalemia (elevated serum
in patients without
potassium levels) in patients without diabetes. Potassium moves diabetes to treat
with glucose from the bloodstream into the cell, lowering serum severe hyperkalemia.
potassium levels. (See Hypoglycemic drugs: Insulin.)

Drug interactions
Some drugs interact with insulin, altering its ability to decrease
the blood glucose level; other drugs directly affect glucose levels:
• Anabolic steroids, salicylates, alcohol, sulfa drugs, angiotensin-
converting enzyme inhibitors, propranolol, guanethidine, and
monoamine oxidase (MAO) inhibitors may increase the hypogly-
cemic effect of insulin.

Nursing Pharmacology_Chap10.indd 406 1/28/2012 12:05:57 PM

ANTIDIABETIC DRUGS AND GLUCAGON
407

• Corticosteroids, sympathomimetic drugs, isoniazid, thyroid

hormones, niacin, furosemide, and thiazide diuretics may reduce Prototype
the effects of insulin, resulting in hyperglycemia. pro
• Beta-adrenergic blockers may prolong the hypoglycemic effect
of insulin and may mask signs and symptoms of hypoglycemia. Hypoglycemic
drugs: Insulin
Adverse reactions
Adverse reactions to insulin include: Actions
• hypoglycemia (below-normal blood glucose levels) • Increases glucose
• Somogyi effect (hypoglycemia followed by rebound hyper- transport across muscle
glycemia) and fat cell membranes
• hypersensitivity reactions to reduce blood glucose
• lipodystrophy (disturbance in fat deposition) levels
• insulin resistance. • Promotes conversion
of glucose to its storage
Nursing process form, glycogen
• Triggers amino acid
These nursing process steps are appropriate for patients under-
uptake and conversion
going treatment with insulin.
to protein in muscle
cells and inhibits protein
Assessment
degradation
• Assess the patient’s glucose level before therapy and regularly
• Stimulates triglyceride
thereafter. Monitor the level more frequently if the patient is
formation and inhibits
under stress, unstable, pregnant, recently diagnosed with diabe-
the release of free
tes, undergoing dietary changes, under orders to have nothing by
fatty acids from adipose
mouth, experiencing nausea and vomiting, or taking drugs that
can interact with insulin. tissue
• Monitor the patient’s glycosylated hemoglobin level regularly. • Stimulates lipoprotein
• Monitor the patient’s urine ketone level when the glucose level lipase activity, which
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

is elevated. converts circulating

• Assess for adverse reactions and drug interactions. lipoproteins to fatty
• Monitor injection sites for local reactions. acids
• Assess the patient’s and family’s knowledge of drug therapy. Indications
• Type 1 diabetes
Key nursing diagnoses • Adjunct treatment in
• Ineffective health maintenance related to inexperience with type 2 diabetes
treatment process and medication for hyperglycemia • Diabetic ketoacidosis
• Risk for injury related to drug-induced hypoglycemia
• Deficient knowledge related to drug therapy Nursing considerations
• Monitor the patient for
Planning outcome goals adverse effects, such as
• Blood glucose levels will be maintained within normal limits. hypoglycemia and hy-
• The risk of injury to the patient will be minimized. persensitivity reactions.
• The patient and his family will demonstrate an understanding of
drug therapy.

Nursing Pharmacology_Chap10.indd 407 1/28/2012 12:06:00 PM

ENDOCRINE DRUGS
408

Implementation
• Use regular insulin in patients with circulatory collapse, DKA,
or hyperkalemia. Don’t use regular insulin concentration
(500 units/mL) IV. Don’t use intermediate- or long-acting insulins
for a coma or other emergency that needs rapid drug action.
• Insulin resistance may develop; large insulin doses are needed
to control signs and symptoms of diabetes in these cases. For
severe insulin resistance, U-500 insulin is available as regular insu-
lin (concentrated). Give the facility pharmacy sufficient notice
before you need to refill an in-house prescription because every
pharmacy may not stock it. Never store U-500 insulin in the same
area as other insulin preparations because of the danger of severe
overdose if given accidentally to other patients.
Shaking vials of
In the mix insulin suspension
causes bubbling and
• To mix the insulin suspension, swirl the vial gently or rotate it creates air in the
between your palms or between your palm and thigh. Don’t shake syringe—and those
the vial vigorously; doing so causes bubbling and creates air in the are not the kind of
syringe. bubbles you want to
• Lispro insulin has a rapid onset of action and should be given make!
within 15 minutes before meals.
• Insulin glargine can’t be diluted or mixed with any other insulin
or solution or given IV.
• Regular insulin may be mixed with NPH or lente insulins in any
proportion. When mixing regular insulin with NPH insulin, always
draw up regular insulin into the syringe first.
• Switching from separate injections to a prepared mixture may
alter the patient’s response.
• Whenever NPH or Lente is mixed with regular insulin in the
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

same syringe, give the mixture immediately to avoid a loss of

potency.
• Don’t use insulin that has changed color or become clumped or
granular.
• Check the expiration date on the vial before using.
• If administering IV, use only regular insulin. Inject directly at
the ordered rate into the vein, through an intermittent infusion
device, or into a port close to the IV access site. If giving continu-
ous infusion, infuse the drug diluted in normal saline solution at
the prescribed rate.
• If administering subcut, pinch a fold of skin with the fingers
starting at least 3² (7.6 cm) apart and insert the needle at a 45- to
90-degree angle. Press but don’t rub the site after injection. Rotate
and chart injection sites to avoid overuse of one area. A patient
with diabetes may achieve better control if injection sites are
rotated within the same anatomic region.

Nursing Pharmacology_Chap10.indd 408 1/28/2012 12:06:00 PM

ANTIDIABETIC DRUGS AND GLUCAGON
409

Highs and lows

Notify the
• Ketosis-prone type 1, severely ill, and newly diagnosed diabetic prescriber if your
patients with very high glucose levels may require hospitalization patient develops
and IV treatment with regular fast-acting insulin. glucose levels that
• Notify the prescriber of sudden changes in glucose levels, dan- are dangerously high
gerously high or low levels, or ketosis. or low.
• Be prepared to provide supportive measures if the patient devel-
ops DKA or HHNK.

Sustaining snacks
• Treat hypoglycemic reactions with an oral form of rapid-acting
glucose (if the patient can swallow) or with glucagon or IV glu-
cose (if the patient can’t be roused). Follow administration with a
complex carbohydrate snack when the patient is awake, and then
determine the cause of the reaction.
• Make sure that the patient is following an appropriate diet and
exercise program. Expect to adjust the insulin dosage when other
aspects of the regimen are altered.
• Discuss with the prescriber how to handle noncompliance.
• Teach the patient and his family how to monitor his glucose
level and administer insulin. (See Teaching about insulin.)

Education edge

Teaching about insulin

If insulin therapy is prescribed, review these points with • Accuracy of drug measurement is very important, es-
the patient and his caregivers: pecially with concentrated regular insulin. Aids, such as
• Insulin relieves signs and symptoms but doesn’t cure the a magnifying sleeve or dose magnifier, may improve ac-
disease; therapy is lifelong. curacy. Review with the prescriber and your family how to
• Glucose monitoring is an essential guide to determining measure and give insulin.
dosage and success of therapy; know the proper use of • Don’t alter the order in which insulin types are mixed or
equipment for monitoring glucose level. change the model or brand of the syringe or needle used.
• Follow the prescribed therapeutic regimen; adhere to • Learn to recognize signs and symptoms of hyperglyce-
specific diet, weight reduction, exercise, and personal mia and hypoglycemia and what to do if they occur.
hygiene programs—including daily foot inspection—and • Wear or carry medical identification at all times.
consult with the prescriber about ways to avoid infection. • Have carbohydrates (glucose tablets or candy) on hand
• Review the timing of injections and eating with the pre- for emergencies.
scriber; don’t skip meals.

Nursing Pharmacology_Chap10.indd 409 1/28/2012 12:06:01 PM

ENDOCRINE DRUGS
410

Evaluation
• Patient’s glucose level is normal. Prototype
• Patient sustains no injury from drug-induced hypoglycemia. pro
• Patient and his family demonstrate an understanding of drug
therapy. Oral
antidiabetic
Oral antidiabetic drugs drugs:
Types of oral antidiabetic drugs available include: Glyburide
• first-generation sulfonylureas (such as acetohexamide, chlor-
propamide, tolazamide, and tolbutamide) Actions
• second-generation sulfonylureas (such as glimepiride, glipizide, • Stimulates insulin
and glyburide) release from the pan-
• thiazolidinedione drugs (pioglitazone and rosiglitazone) creatic beta cells and
• metformin (a biguanide drug) reduces glucose output
• alpha-glucosidase inhibitors (acarbose and miglitol) by the liver
• meglitinides (such as repaglinide) • Extrapancreatic effect
• incretin modifiers (such as sitagliptin) increases peripheral
• nateglinide (an amino acid derivative) sensitivity to insulin and
• combination therapies (such as glipizide and metformin, gly- causes mild diuretic
buride and metformin, and rosiglitazone and metformin). effect

Indications
Pharmacokinetics
• Type 2 diabetes
Oral antidiabetic drugs are absorbed well from the GI tract and
distributed via the bloodstream throughout the body. They’re Nursing considerations
metabolized primarily in the liver and are excreted mostly in • Monitor the patient for
urine, with some excreted in bile. Glyburide is excreted equally adverse effects, such as
in urine and feces; rosiglitazone and pioglitazone are largely hypoglycemia, hyper-
excreted in both. (See Oral antidiabetic drugs: Glyburide.) sensitivity reactions, and
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

hematologic disorders.
Pharmacodynamics • During times of stress,
the patient may need
It’s believed that oral antidiabetic If the pancreas isn’t insulin; monitor for hypo-
drugs produce actions within and out- functioning properly, glycemia.
side the pancreas (extrapancreatic) to it’s believed that oral
regulate blood glucose. • Avoid use of alcohol,
antidiabetic drugs can
temporarily stimulate which produces a
To the pancreas… it to release insulin. disulfiram-like reaction.
Oral antidiabetic drugs probably stim-
ulate pancreatic beta cells to release
insulin in a patient with a minimally functioning pancreas.
Within a few weeks to a few months of starting sulfonylureas,
pancreatic insulin secretion drops to pretreatment levels but
blood glucose levels remain normal or near normal. Most
likely, the actions of the oral antidiabetic drugs outside of the
pancreas are responsible for maintaining this glucose control.

Nursing Pharmacology_Chap10.indd 410 1/28/2012 12:06:01 PM

ANTIDIABETIC DRUGS AND GLUCAGON
411

…and beyond!
Oral antidiabetic
Oral antidiabetic drugs provide several extrapancreatic actions to drugs also work in
decrease and control blood glucose. They can go to work in the liver the liver to decrease
and decrease glucose production (gluconeogenesis) there. Also, by glucose production.
increasing the number of insulin receptors in the peripheral tissues,
they provide more opportunities for the cells to bind sufficiently with
insulin, initiating the process of glucose metabolism. Meglitinides
have a short duration and are given preprandially for this reason.

Let’s get specific

These oral antidiabetic drugs produce specific actions:
• Pioglitazone and rosiglitazone improve insulin sensitivity.
• Metformin decreases liver production of glucose and intestinal
absorption of glucose and improves insulin sensitivity.
• Acarbose and miglitol inhibit enzymes, delaying glucose
absorption.
• Sitagliptin slows the breakdown of intestinal hormones that
allow insulin levels to increase after a meal.

Pharmacotherapeutics
Oral antidiabetic drugs are indicated for patients with type 2 dia-
betes if diet and exercise can’t control blood glucose levels. These
drugs aren’t effective in patients with type 1 diabetes because the
pancreatic beta cells aren’t functioning at a minimal level.

Calling all combos

Combinations of an oral antidiabetic drug and insulin therapy may be
indicated for some patients who don’t respond to either drug alone.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Drug interactions
Hypoglycemia and hyperglycemia are the main risks when oral
antidiabetic drugs interact with other drugs.

Low blow
Hypoglycemia may occur when sulfonylureas are combined with
alcohol, anabolic steroids, chloramphenicol, gemfibrozil, MAO
inhibitors, salicylates, sulfonamides, fluconazole, cimetidine, war-
farin, and ranitidine. It may also occur when metformin is com-
bined with cimetidine, nifedipine, procainamide, ranitidine, and
vancomycin. Hypoglycemia is less likely to occur when metformin
is used as a single agent.

High fly
Hyperglycemia may occur when sulfonylureas are taken with cor-
ticosteroids, rifampin, sympathomimetics, and thiazide diuretics.

Nursing Pharmacology_Chap10.indd 411 1/28/2012 12:06:02 PM

ENDOCRINE DRUGS
412

Metformin administration with iodinated contrast dyes can result

in acute renal failure. Doses should be withheld in patients under- Sun may not
going procedures that require IV contrast dyes. be fun for patients
using sulfonylureas.
Adverse reactions Photosensitivity
may occur.
Hypoglycemia is a major adverse reaction to oral antidiabetic
drugs, especially when combination therapy is used.
Adverse reactions specific to sulfonylureas include:
• nausea
• epigastric fullness
• blood abnormalities
• fluid retention
• rash
• hyponatremia
• photosensitivity.
Adverse reactions to metformin include:
• metallic taste
• nausea and vomiting
• abdominal discomfort.
Acarbose may cause these reactions:
• abdominal pain
• diarrhea
• gas.
Thiazolidinediones may cause:
• weight gain
• swelling.

Nursing process
These nursing process steps are appropriate for patients undergo-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

ing treatment with oral antidiabetic drugs.

Assessment
• Assess the patient’s blood glucose level regularly.
• Keep in mind that the patient transferring from insulin therapy
to oral antidiabetics needs glucose monitoring at least three times
daily before meals.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s compliance with drug therapy and other
aspects of treatment.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to inexperience with
treatment process and medication for hyperglycemia
• Risk for injury related to hypoglycemia
• Deficient knowledge related to drug therapy

Nursing Pharmacology_Chap10.indd 412 1/28/2012 12:06:02 PM

ANTIDIABETIC DRUGS AND GLUCAGON
413

Planning outcome goals

• Blood glucose level will be maintained within normal limits.
• The risk of injury to the patient will be minimized. The first bite
• The patient and his family will demonstrate an understanding of is just right.
Alpha-glucosidase
drug therapy.
inhibitors should be
taken with the first
Implementation bite of each main
• Micronized glyburide has a smaller particle size and isn’t bio- meal three times
equivalent to regular tablets. The dosage may need to be adjusted. daily.

Timing is everything
• Give sulfonylureas 30 minutes before the morning meal (once-
daily dosing) or 30 minutes before morning and evening meals
(twice-daily dosing). Give metformin with morning and evening
meals. Alpha-glucosidase inhibitors should be taken with the first
bite of each main meal three times daily.
• A patient who takes a thiazolidinedione should have liver
enzyme levels measured at the start of therapy, every 2 months for
the first year of therapy, and periodically thereafter.
• A patient transferring from one oral antidiabetic drug to another
(except chlorpropamide) usually doesn’t need a transition period.
• Although most patients take oral antidiabetic drugs once daily,
patients taking increased doses may achieve better results with
twice-daily dosing.
• Treat hypoglycemic reactions with an oral form of rapid-acting
carbohydrates (if the patient can swallow) or with glucagon or IV
glucose (if the patient can’t swallow or is comatose). Follow up
treatment with a complex carbohydrate snack when the patient is
awake, and determine the cause of the reaction.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Anticipate that the patient may need insulin therapy during peri-
ods of increased stress, such as with infection, fever, surgery, or Patients using oral
antidiabetics may
trauma. Increase monitoring, especially for hyperglycemia, during
need insulin therapy
these situations. during times of
• Make sure that adjunct therapy, such as diet and exercise, is stress, such as
being used appropriately. when they have
• Teach the patient how and when to monitor glucose levels and surgery.
to recognize signs and symptoms of hyperglycemia and hypoglyce-
mia. (See Teaching about antidiabetic drugs, page 414.)

Evaluation
• Patient maintains adequate hydration.
• Patient complies with therapy, as evidenced by a normal
or near-normal glucose level.
• Patient sustains no injury.
• Patient and his family demonstrate an understanding of
drug therapy.

Nursing Pharmacology_Chap10.indd 413 1/28/2012 12:06:03 PM

ENDOCRINE DRUGS
414

Education edge

Teaching about antidiabetic drugs

If antidiabetic drugs are prescribed, review these points • Don’t change the dosage without the prescriber’s
with the patient and his caregivers: consent.
• Therapy relieves signs and symptoms but doesn’t cure • Report adverse reactions.
the disease. • Don’t take other drugs, including over-the-counter
• Follow the prescribed therapeutic regimen; adhere to drugs and herbal remedies, without first checking with
specific diet, weight reduction, exercise, and personal the prescriber.
hygiene programs, and consult with the prescriber about • Avoid consuming alcohol during drug therapy.
ways to avoid infection. • Wear or carry medical identification at all times.
• Know how and when to monitor glucose levels.
• Learn to recognize signs and symptoms of hyperglyce-
mia and hypoglycemia and what to do if these occur.

Glucagon
Glucagon, a hyperglycemic drug that raises blood glucose levels,
is a hormone normally produced by the alpha cells of the islets of
Langerhans in the pancreas. (See How glucagon raises glucose
levels.)

Pharmacokinetics
After subcut, IM, or IV injection, glucagon is absorbed rapidly. It’s
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

distributed throughout the body, although its effect occurs primar-

ily in the liver.

Here, there, and (almost) everywhere

Glucagon is degraded extensively by the liver, kidneys, and
plasma and at its tissue receptor sites in plasma membranes. It’s
removed from the body by the liver and kidneys.

Pharmacodynamics
Glucagon regulates the rate of glucose production through:
• glycogenolysis, the conversion of glycogen back into glucose by
the liver
• gluconeogenesis, the formation of glucose from free fatty acids
and proteins
• lipolysis, the release of fatty acids from adipose tissue for con-
version to glucose.

Nursing Pharmacology_Chap10.indd 414 1/28/2012 12:06:03 PM

ANTIDIABETIC DRUGS AND GLUCAGON
415

Pharm function

How glucagon raises glucose levels

When adequate stores of glycogen are present, glucagon • This product initiates a series of reactions that result in
can raise glucose levels in patients with severe hypogly- an active phosphorylated glucose molecule.
cemia. Here’s what happens: • In this phosphorylated form, the large glucose molecule
• Initially, glucagon stimulates the formation of adenylate can’t pass through the cell membrane.
cyclase in the liver cell. • Through glycogenolysis (the breakdown of glycogen, the
• Adenylate cyclase then converts adenosine triphos- stored form of glucose), the liver removes the phosphate
phate (ATP) to cyclic adenosine monophosphate (cAMP). group and allows the glucose to enter the bloodstream,
raising blood glucose levels for short-term energy needs.

Glucagon Serum glucose

Glucagon receptor

Adenylate cyclase

ATP Glucose

Glucose-6-phosphatase
cAMP

Inactive kinase Glucose-6-phosphate

Phosphoglucomutase
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Active kinase

Inactive phosphorylase Glucose-1-phosphate

Active phosphorylase

Glycogen

L iv e r c e ll G ly c o g e n o ly s is

Nursing Pharmacology_Chap10.indd 415 1/28/2012 12:06:04 PM

ENDOCRINE DRUGS
416

Pharmacotherapeutics
Glucagon is used
Glucagon is used for emergency treatment of severe hypoglyce- during radiologic
mia. It’s also used during radiologic examination of the GI tract to examination of the
reduce GI motility. GI tract to reduce
GI motility. How
illuminating!
Drug interactions
Glucagon interacts adversely only with oral anticoagulants,
increasing the tendency to bleed.

Adverse reactions
Adverse reactions to glucagon are rare.

Nursing process
These nursing process steps are appropriate for patients
undergoing treatment with glucagon.

Assessment
• Assess the patient’s blood glucose level regularly. Increase
monitoring during periods of increased stress (infection, fever,
surgery, or trauma).
• Assess for adverse reactions and drug interactions.
• Monitor the patient’s hydration if vomiting occurs.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to inexperience with
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

treatment process and medication for hyperglycemia

• Risk for injury related to hypoglycemia
• Deficient knowledge related to drug therapy

Planning outcome goals

• Blood glucose will remain within normal limits.
• The risk of injury to the patient will be reduced.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• For IM and subcut use, reconstitute the drug in a 1-unit vial with
1 mL of diluent; reconstitute the drug in a 10-unit vial with 10 mL
of diluent.
• For IV administration, a drip infusion, such as dextrose solu-
tion, which is compatible with glucagon, may be used; the drug

Nursing Pharmacology_Chap10.indd 416 1/28/2012 12:06:05 PM

THYROID AND ANTITHYROID DRUGS
417

forms precipitate in chloride solutions. Inject the drug over 2 to

5 minutes. Inject the IV
• Arouse the lethargic patient as quickly as possible. Give addi- form of glucagon
tional carbohydrates orally to prevent a secondary hypoglycemic over 2 to 5 minutes.
episode, and then determine the cause of the reaction.
• Notify the prescriber that the patient’s hypoglycemic episode
required glucagon use.
• Be prepared to provide emergency intervention if the patient
doesn’t respond to glucagon administration. An unstable, hypogly-
cemic patient with diabetes may not respond to glucagon; give IV
dextrose 50% instead.
• Notify the prescriber if the patient can’t retain some form of
sugar for 1 hour because of nausea or vomiting.

Evaluation
• Patient maintains normal glucose level.
• Patient sustains no injury.
• Patient and his family demonstrate an understanding of drug
therapy.

Thyroid and antithyroid drugs

Thyroid and antithyroid drugs function to correct thyroid hor-
mone deficiency (hypothyroidism) and thyroid hormone excess
(hyperthyroidism).

Thyroid drugs
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Thyroid drugs can be natural or synthetic hormones and may con-

tain triiodothyronine (T3), thyroxine (T4), or both.

Nature’s own
Natural thyroid drugs are made from animal thyroid and include:
• thyroid USP (desiccated), which contains T3 and T4
• thyroglobulin, which also contains T3 and T4.

Synthesized from sodium

Synthetic thyroid drugs actually are the sodium salts of the
L-isomers of the hormones. These synthetic hormones include:
• levothyroxine sodium, which contains T4
• liothyronine sodium, which contains T3
• liotrix, which contains T3 and T4.

Nursing Pharmacology_Chap10.indd 417 1/28/2012 12:06:05 PM

ENDOCRINE DRUGS
418

Pharmacokinetics
Talk about
Thyroid hormones are absorbed variably from the GI tract, dis-
increasing
tributed in plasma, and bound to serum proteins. They’re metabo- productivity! Thyroid
lized through deiodination, primarily in the liver, and excreted hormones increase
unchanged in feces. my rate and
output in addition
to increasing the
Pharmacodynamics metabolic rate of
The principal pharmacologic effect is an increased metabolic rate body tissues.
in body tissues. Thyroid hormones affect protein and carbohy-
drate metabolism and stimulate protein synthesis. They promote
gluconeogenesis and increase the use of glycogen stores.

Taken to heart
Thyroid hormones increase heart rate and cardiac output (the
amount of blood pumped by the heart each minute). They may
even increase the heart’s sensitivity to catecholamines and
increase the number of beta-adrenergic receptors in the heart
(stimulation of beta receptors in the heart increases heart rate and
contractility).

More flow
Thyroid hormones may increase blood flow to the kidneys and
increase the glomerular filtration rate (the amount of plasma filtered
through the kidneys each minute) in patients with hypothyroidism,
producing diuresis. (See Thyroid hormones: Levothyroxine.)

Pharmacotherapeutics
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Thyroid drugs act as replacement or substitute hormones in these

situations:
• to treat the many forms of hypothyroidism
• with antithyroid drugs to prevent goiter formation (an enlarged
thyroid gland) and hypothyroidism
• to differentiate between primary and secondary hypothyroidism
during diagnostic testing
• to treat papillary or follicular thyroid carcinoma.

A winning choice
Levothyroxine is the drug of choice for thyroid hormone replace-
ment and thyroid-stimulating hormone (TSH) suppression therapy.

Drug interactions
Thyroid drugs interact with several common drugs:
• They increase the effects of oral anticoagulants, increasing the
tendency to bleed.

Nursing Pharmacology_Chap10.indd 418 1/28/2012 12:06:06 PM

THYROID AND ANTITHYROID DRUGS
419

• Cholestyramine and colestipol reduce the absorption of thyroid

hormones. Prototype
• Phenytoin may accelerate metabolism of levothyroxine. pro
• Taking thyroid drugs with digoxin may reduce serum digoxin
levels, increasing the risk of arrhythmias or heart failure. Thyroid
• Carbamazepine, phenytoin, phenobarbital, and rifampin
increase thyroid hormone metabolism, reducing the effectiveness. hormones:
• Serum theophylline levels may increase when theophylline is Levothyroxine
administered with thyroid drugs.
Actions
• Stimulates metabolism
Adverse reactions of all body tissues by
Most adverse reactions to thyroid drugs result from toxicity. accelerating the rate of
cellular oxidation
Gut reactions
Indications
Adverse reactions in the GI system include diarrhea, abdominal • Cretinism
cramps, weight loss, and increased appetite. • Myxedema coma
• Thyroid hormone re-
Cardiac concerns placement
Adverse reactions in the cardiovascular system include palpita-
tions, sweating, rapid heart rate, increased blood pressure, angina, Nursing considerations
and arrhythmias. • Monitor the patient
for adverse effects,
Effects all around such as nervousness,
General manifestations of toxic doses include: insomnia, tremor,
tachycardia, palpita-
• headache
tions, angina, arrhyth-
• tremor
mias, and cardiac
• insomnia
arrest.
• nervousness • Use with extreme
• fever
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

caution in elderly pa-

• heat intolerance tients and in patients
• menstrual irregularities. with cardiovascular
disorders.
Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with thyroid drugs.

Assessment
• Assess the patient’s thyroid function test results regularly.
• Assess the patient’s condition before therapy and regularly
thereafter. Normal levels of T4 should occur within 24 hours, fol-
lowed by a threefold increase in the T3 level in 3 days.
• Assess for adverse reactions and drug interactions.
• In a patient with coronary artery disease receiving thyroid hor-
mone, watch for possible coronary insufficiency.
• Monitor the patient’s pulse rate and blood pressure.

Nursing Pharmacology_Chap10.indd 419 1/28/2012 12:06:06 PM

ENDOCRINE DRUGS
420

• Monitor the patient for signs of thyrotoxicosis or inadequate

dosage, including diarrhea, fever, irritability, listlessness, rapid Don’t forget:
heartbeat, vomiting, and weakness. Patients are at risk
• Monitor prothrombin time (PT) and International Normalized for injury related to
Ratio; a patient taking anticoagulants usually needs lower doses. adverse reactions
to thyroid drugs.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to the presence of hypo-
thyroidism
• Risk for injury related to drug-induced adverse reactions
• Deficient knowledge related to drug therapy

Planning outcome goals

• Thyroid levels will be within normal limits.
• The risk of injury to the patient will be minimized.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Thyroid hormone dosages vary widely. Begin treatment at the
lowest level, adjusting to higher doses according to the patient’s
symptoms and laboratory data, until a euthyroid state is reached.
• When changing from levothyroxine to liothyronine, stop levo-
thyroxine and then start liothyronine. The dosage is increased in
small increments after residual effects of levothyroxine disappear.
When changing from liothyronine to levothyroxine, start levo-
Give thyroid
thyroxine several days before withdrawing liothyronine to avoid hormones at the
relapse. same time each day,
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Give thyroid hormones at the same time each day, preferably in preferably in the
the morning, to prevent insomnia. morning, to prevent
• Thyroid drugs may be supplied either in micrograms (mcg) or in insomnia.
milligrams (mg). Don’t confuse these dose measurements.
• Thyroid hormones alter thyroid function test results. A patient
taking levothyroxine who needs radioactive iodine uptake stud-
ies must discontinue the drug 4 weeks before the test.
• A patient taking a prescribed anticoagulant with thyroid hor-
mones usually needs a reduced anticoagulant dosage.
• If the patient has diabetes, he may need an increased antidia-
betic dosage when starting the thyroid hormone replacement.
• Instruct the patient never to stop the drug abruptly. Therapy is
usually for life.

Evaluation
• Patient’s thyroid hormone levels are normal.

Nursing Pharmacology_Chap10.indd 420 1/28/2012 12:06:07 PM

THYROID AND ANTITHYROID DRUGS
421

• Patient sustains no injury from adverse reactions.

• Patient complies with therapy as evidenced by normal thyroid
hormone levels and resolution of the underlying disorder.

Antithyroid drugs
A number of drugs act as antithyroid drugs, or thyroid antago-
nists. Used for patients with hyperthyroidism (thyrotoxicosis),
these drugs include:
• thioamides, which include propylthiouracil and methimazole
• iodides, which include stable iodine and radioactive iodine.

Pharmacokinetics
Thioamides and iodides are absorbed through the GI tract, con-
centrated in the thyroid, and metabolized by conjugation. They are
excreted in urine.

Pharmacodynamics
Drugs used to treat hyperthyroidism work in different ways.

Stopping synthesis
Thioamides block iodine’s ability to combine with tyrosine,
thereby preventing thyroid hormone synthesis.

Inhibited by iodine
Stable iodine inhibits hormone synthesis through the Wolff-
Chaikoff effect, in which excess iodine decreases the formation
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

and release of thyroid hormone.

Reduced by radiation
Radioactive iodine reduces hormone secretion by destroying
thyroid tissue through induction of acute radiation thyroiditis
(inflammation of the thyroid gland) and chronic gradual thyroid
atrophy. Acute radiation thyroiditis usually occurs 3 to 10 days
after administering radioactive iodine. Chronic thyroid atrophy
may take several years to appear.

Pharmacotherapeutics
Antithyroid drugs commonly are used to treat hyperthyroidism,
especially Graves’ disease (hyperthyroidism caused by autoimmu-
nity), which accounts for 85% of all cases.

Nursing Pharmacology_Chap10.indd 421 1/28/2012 12:06:07 PM

ENDOCRINE DRUGS
422

Thioamides
Propylthiouracil, which lowers serum T3 levels faster than Propylthiouracil
methimazole, is usually used for rapid improvement of severe use is preferred in
pregnant women
hyperthyroidism.
because its rapid
action reduces
Good for gravidas transfer of the
Propylthiouracil is preferred over methimazole in pregnant drug across the
women because its rapid action reduces transfer across the placenta…
placenta and because it doesn’t cause aplasia cutis (a severe
skin disorder) in the fetus.

Bad for breast-feeding

Propylthiouracil and methimazole are distributed in breast milk.
Patients receiving these drugs shouldn’t breast-feed. If nursing is
absolutely necessary, propylthiouracil is the preferred drug.

Once a day
Because methimazole blocks thyroid hormone formation for a
longer time, it’s better suited for administration once per day to
a patient with mild to moderate hyperthyroidism. Therapy may
continue for 12 to 24 months before remission occurs.

Iodides
To treat hyperthyroidism, the thyroid gland may be removed by
surgery or destroyed by radiation. Before surgery, stable iodine
is used to prepare the gland for surgical removal by firming it and
decreasing its vascularity. Stable iodine is also used after radioac- …and it doesn’t
tive iodine therapy to control signs and symptoms of hyperthy- put me at risk for
roidism while the radiation takes effect. aplasia cutis—
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

although I am pretty
cute!
Drug interactions
Iodide preparations may react synergistically with lithium, causing
hypothyroidism. Other interactions with antithyroid drugs aren’t
clinically significant.

Adverse reactions
The most serious adverse reaction to thioamide therapy is granu-
locytopenia. Hypersensitivity reactions may also occur.

(Not) a spoonful of sugar

The iodides can cause an unpleasant brassy taste and burning
sensation in the mouth, increased salivation, and painful swelling
of the parotid glands.

Nursing Pharmacology_Chap10.indd 422 1/28/2012 12:06:07 PM

THYROID AND ANTITHYROID DRUGS
423

Rare, but be aware

Rarely, IV iodine administration can cause an acute hypersensitivity
reaction. Radioactive iodine also can cause a rare—but acute—
reaction 3 to 14 days after administration.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with antithyroid drugs.

Assessment
• Assess the patient’s condition and thyroid function tests before
therapy and regularly thereafter. A euthyroid state may not be
reached until after 3 to 12 weeks of treatment with propylthiouracil.
• Assess for adverse reactions and drug interactions.
• Watch for signs of hypothyroidism (depression; cold intoler-
ance; hard, nonpitting edema); adjust the dosage as directed.
• Monitor complete blood count as directed to detect impending
leukopenia, thrombocytopenia, and agranulocytosis.
• Monitor the patient’s hydration status if adverse GI reactions
occur.
• Assess the patient’s and family’s knowledge of drug therapy. Stop the drug and
notify the prescriber
Key nursing diagnoses if a severe rash or
enlarged cervical
• Ineffective health maintenance related to the presence of a thy- lymph nodes develop.
roid condition
• Risk for injury related to drug-induced adverse reactions
• Deficient knowledge related to drug therapy
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Planning outcome goals

• Thyroid levels will be within normal limits.
• The risk of injury to the patient will be minimized.
• The patient and his family will demonstrate an understanding
of drug therapy.

Implementation
• Give propylthiouracil several times a day due to its short half-
life; methimazole is usually given once a day.
• Monitor for sore throat or fever with propylthiouracil.
• Give fruit juice to dilute the strong taste of iodine solution.

Nursing Pharmacology_Chap10.indd 423 1/28/2012 12:06:08 PM

ENDOCRINE DRUGS
424

Education edge

Teaching about thyroid and antithyroid drugs

If thyroid or antithyroid drugs are prescribed, review these • Ask the prescriber about using iodized salt and eating
points with the patient and his caregivers: shellfish, especially if taking antithyroid medications, to
• Take the drug exactly as prescribed. Take the dose at avoid possible toxic levels of iodine.
the same time each day, preferably in the morning before • If a stable response has been achieved, don’t change
breakfast, to maintain constant hormone levels. Taking the drug brands.
drug in the morning prevents insomnia. • Children may lose hair during the first months of therapy;
• Report signs and symptoms of thyroid hormone over- this is a temporary reaction.
dose (chest pain, palpitations, sweating, nervousness) or • Report unusual bleeding or bruising.
aggravated cardiovascular disease (chest pain, dyspnea, • Keep follow-up appointments, and have thyroid levels
tachycardia). tested regularly.
• If taking antithyroid drugs, report skin eruptions (signs of • Don’t use other drugs, over-the-counter products, or
hypersensitivity), fever, sore throat, or mouth sores (early herbal remedies without first consulting with the prescriber
signs of agranulocytosis). or a pharmacist.

A rash decision
• Discontinue the drug and notify the prescriber if the patient
develops a severe rash or enlarged cervical lymph nodes. Anterior pituitary
drugs control the
Evaluation function of endocrine
• Patient’s thyroid hormone levels are normal. glands. Posterior
pituitary drugs
• Patient sustains no injury from adverse reactions.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

regulate fluid volume

• Patient complies with therapy as evidenced by normal thyroid and stimulate
hormone levels and resolution of the underlying disorder. (See smooth-muscle
Teaching about thyroid and antithyroid drugs.) contraction.

Pituitary drugs
Pituitary drugs are natural or synthetic hormones that mimic the
hormones produced by the pituitary gland. The pituitary drugs
consist of two groups:

Anterior pituitary drugs may be used diagnostically or thera-

peutically to control the function of other endocrine glands, such
as the thyroid gland, adrenals, ovaries, and testes.

Nursing Pharmacology_Chap10.indd 424 1/28/2012 12:06:08 PM

PITUITARY DRUGS
425

Posterior pituitary drugs may be used to regulate fluid volume

and stimulate smooth-muscle contraction in selected clinical situ-
ations.

Anterior pituitary drugs

The protein hormones produced in the anterior pituitary gland
regulate growth, development, and sexual characteristics by stim-
ulating the actions of other endocrine glands. Anterior pituitary
drugs include:
• adrenocorticotropics, which include corticotropin, corticotropin
repository, and cosyntropin
• somatrem and somatropin, both growth hormones
• gonadotropics, which include chorionic gonadotropin and
menotropins
• thyrotropics, which include TSH, thyrotropin alfa, and pro-
tirelin.

Pharmacokinetics
Anterior pituitary drugs aren’t given orally because they’re
destroyed in the GI tract. Some of these hormones can be adminis-
tered topically, but most require injection.

Sometimes slower than Mother Nature

Usually, natural hormones are absorbed, distributed, and metabo-
In women, chorionic
lized rapidly. Some analogues, however, are absorbed and gonadotropin
metabolized more slowly. Anterior pituitary hormone drugs are and menotropins
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

metabolized at the receptor site and in the liver and kidneys. The are used to help
hormones are excreted primarily in urine. induce ovulation
during infertility
treatments.
Pharmacodynamics
Anterior pituitary drugs exert a profound effect on the body’s
growth and development. The hypothalamus controls secretions
of the pituitary gland. In turn, the pituitary gland secretes
hormones that regulate secretions or functions of other
glands.

Production managers
The concentration of hormones in the blood helps deter-
mine the hormone production rate. Increased hormone
levels inhibit hormone production; decreased levels raise
production and secretion. Anterior pituitary drugs, therefore,
control hormone production by increasing or decreasing
the body’s hormone levels.

Nursing Pharmacology_Chap10.indd 425 1/28/2012 12:06:09 PM

ENDOCRINE DRUGS
426

Pharmacotherapeutics
The clinical indications for anterior pituitary hormone drugs are
diagnostic and therapeutic:
• Corticotropin and cosyntropin are used diagnostically to differen-
tiate between primary and secondary failure of the adrenal cortex.
• Corticotropin is used as an anti-inflammatory drug in allergic
responses and can decrease symptoms of multiple sclerosis
exacerbations.
• Somatrem is used to treat pituitary dwarfism.
• In males, chorionic gonadotropin is used to evaluate testoster-
one production, treat hypogonadism, and treat cryptorchidism
(undescended testes).
• In women, chorionic gonadotropin and menotropins are used to
help induce ovulation during infertility treatments.
• Thyrotropin alfa is a synthetic TSH used to treat thyroid cancer.

Drug interactions
Anterior pituitary drugs interact with several different types of drugs:
• Administering immunizations to a person receiving corticotro-
pin increases the risk of neurologic complications and may reduce
the antibody response.
• Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)
increase the possibility of gastric ulcer formation.
• Enhanced potassium loss may occur when diuretics are taken
with corticotropins.
• Barbiturates, phenytoin, and rifampin increase the metabolism
of corticotropin, reducing its effects.
• Estrogen increases the effect of corticotropin.
• Taking estrogens, amphetamines, and lithium with cosyntropin
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

can alter results of adrenal function tests.

• Amphetamines and androgens (concurrently) administered with
somatrem may promote epiphyseal (cartilaginous bone growth
plate) closure.
• Concurrent use of somatrem and corticosteroids inhibits the
growth-promoting action of somatrem.
• Increased insulin and oral antidiabetic doses may be needed
with corticotropin.

Adverse reactions
The major adverse reactions to pituitary drugs are hypersensitivity
reactions. Long-term corticotropin use can cause Cushing’s syndrome.

Nursing process
These nursing process steps are appropriate for patients undergoing
treatment with anterior pituitary drugs.

Nursing Pharmacology_Chap10.indd 426 1/28/2012 12:06:10 PM

PITUITARY DRUGS
427

Assessment
• Assess the patient’s underlying condition before therapy and Children taking
regularly during therapy. anterior pituitary
drugs should
• If the patient is a child, assess growth before therapy and regu-
have their growth
larly thereafter. Monitor the patient’s height and blood with regu- assessed regularly.
lar checkups; radiologic studies may also be needed.
• Assess for hypersensitivity and allergic reactions and have
adrenal responsiveness verified before starting corticotropin treat-
ment.
• Assess for adverse reactions and drug interactions.
• Note and record weight changes, fluid exchange, and resting
blood pressures until the minimal effective dosage is achieved.
• Assess neonates of corticotropin-treated mothers for signs of
hypoadrenalism.
• Monitor the patient for stress.
• With somatrem, observe the patient for signs of glucose intol-
erance, hyperglycemia, and hypothyroidism. Periodic thyroid
function tests may be required.
• Assess the patient’s and family’s knowledge about the diag-
nostic test or drug therapy ordered.

Key nursing diagnoses

• Ineffective protection related to the underlying condition
• Risk for injury related to drug-induced adverse reactions
• Deficient knowledge related to drug test or therapy

Planning outcome goals

• The patient and his family will demonstrate an understanding of

the diagnostic test or drug therapy ordered.

Implementation
• Administer the drug as prescribed and monitor for effects.
• If administering corticotropin IV, dilute it in 500 mL of dextrose
5% in water and infuse over 8 hours.
• If administering corticotropin gel, warm it to room temperature
and draw it into a large needle. Replace the needle with a 21G or
22G needle. Give slowly as a deep IM injection. Warn the patient
that the injection is painful.
• Refrigerate reconstituted solution and use it within 24 hours.
• Counteract edema with a low-sodium, high-potassium diet;
nitrogen loss, with a high-protein diet; and psychotic changes,
with a reduction in corticotropin dosage or use of sedatives.

Nursing Pharmacology_Chap10.indd 427 1/28/2012 12:06:10 PM

ENDOCRINE DRUGS
428

• Stress to the patient the importance of informing health care

team members about corticotropin. Unusual stress may require
additional use of rapidly acting corticosteroids. When possible,
gradually reduce the corticotropin dosage to the smallest effective
dosage to minimize induced adrenocortical insufficiency. Therapy
can be restarted if a stressful situation, such as trauma, surgery,
or severe illness, occurs shortly after stopping the drug.

Evaluation
• Patient’s underlying condition improves with drug therapy.
• Patient doesn’t experience injury as a result of drug-induced
adverse reactions.
• Patient and his family demonstrate an understanding of the
diagnostic test or drug therapy. Posterior pituitary
drugs can’t be
given orally because
enzymes in the
Posterior pituitary drugs GI tract destroy
Posterior pituitary hormones are synthesized in the hypothalamus protein hormones.
and stored in the posterior pituitary, which, in turn, secretes the
hormones into the blood. Posterior pituitary drugs include:
• all forms of antidiuretic hormone (ADH), such as desmopressin
acetate and vasopressin
• the oxytocic drug oxytocin.

Pharmacokinetics
Because enzymes in the GI tract can destroy all protein hormones,
these drugs can’t be given orally. Posterior pituitary drugs may be
given by injection or intranasal spray.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

ADH on the move

ADH is distributed throughout extracellular fluid and doesn’t
appear to bind with protein. Most of the drug is metabolized
rapidly in the liver and kidneys. It’s excreted in urine.

Slower (or maybe faster) by a nose

Like other natural hormones, oxytocin is absorbed, distributed,
and metabolized rapidly. However, when oxytocin is administered
intranasally, absorption is erratic.

Pharmacodynamics
Under neural control, posterior pituitary hormones affect:
• smooth-muscle contraction in the uterus, bladder, and GI tract
• fluid balance through kidney reabsorption of water
• blood pressure through stimulation of the arterial wall muscles.

Nursing Pharmacology_Chap10.indd 428 1/28/2012 12:06:10 PM

PITUITARY DRUGS
429

On the rise
ADH increases cyclic adenosine monophosphate, which increases
the permeability of the tubular epithelium in the kidneys, promot-
ing reabsorption of water. High dosages of ADH stimulate contrac-
tion of blood vessels, increasing blood pressure.

Less…and more
Desmopressin reduces diuresis and promotes clotting by increas-
ing the plasma level of factor VIII (antihemophilic factor).

Mother’s little helper

In a pregnant woman, oxytocin may stimulate uterine contrac-
tions by increasing the permeability of uterine cell membranes to
sodium ions. It also can stimulate lactation through its effect on
mammary glands.

Pharmacotherapeutics
ADH is prescribed for hormone replacement therapy in patients
with neurogenic diabetes insipidus (an excessive loss of urine
caused by a brain lesion or injury that interferes with ADH synthe-
sis or release). However, it doesn’t effectively treat nephrogenic
diabetes insipidus (caused by renal tubular resistance to ADH).

The long and short of ADH therapy

Short-term ADH therapy is indicated for patients with transient
diabetes insipidus after head injury or surgery; therapy may be
lifelong for patients with idiopathic hormone deficiency.

The dirt on desmopressin

Desmopressin is the drug of choice for chronic ADH deficiency.

It’s also indicated for primary nocturnal enuresis. Desmopressin
is administered intranasally. It has a long duration of action and a
relative lack of adverse effects.

A lesson on vasopressin
Used for short-term therapy, vasopressin elevates blood pressure
in patients with hypotension caused by lack of vascular tone. It
also relieves postoperative gaseous distention. Additionally, vaso-
pressin may be used for transient polyuria resulting from ADH
deficiency related to neurosurgery or head injury.

Partum me, is this the OB?

Oxytocin is used to:
• induce labor and complete incomplete abortions
• treat preeclampsia, eclampsia, and premature rupture of the
membranes

Nursing Pharmacology_Chap10.indd 429 1/28/2012 12:06:11 PM

ENDOCRINE DRUGS
430

• control bleeding and uterine relaxation after delivery

• hasten uterine shrinking after delivery
• stimulate lactation.

It’s a chore Oxytocin may be

used under certain
Oxytocin is used to induce or reinforce labor only when: conditions to induce
• the mother’s pelvis is known to be adequate or reinforce labor.
• vaginal delivery is indicated
• the fetus is mature
• the fetal position is favorable
• critical care facilities and an experienced clini-
cian are immediately available.

Drug interactions
Various drugs may interact with posterior pitu-
itary drugs:
• Alcohol, demeclocycline, and lithium may
decrease ADH activity of desmopressin and vaso-
pressin.
• Chlorpropamide, carbamazepine, and cyclophosphamide
increase ADH activity.
• Synergistic effects may occur when barbiturates or cyclopro-
pane anesthetics are used concurrently with ADH, leading to coro-
nary insufficiency or arrhythmias.
• Cyclophosphamide may increase the effect of oxytocin.
• Concurrent use of vasopressors (anesthetics, ephedrine, meth-
oxamine) and oxytocin increases the risk of hypertensive crisis
and postpartum rupture of cerebral blood vessels.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Adverse reactions
Hypersensitivity reactions are the most common adverse reac-
tions to posterior pituitary drugs. With natural ADH, anaphylaxis
may occur after injection. Natural ADH can also cause:
• ringing in the ears
• anxiety
• hyponatremia (low serum sodium levels)
• proteins in the urine
• eclamptic attacks
• water intoxication
• pupil dilation
• transient edema.
Adverse reactions to synthetic ADH are rare.

Nursing Pharmacology_Chap10.indd 430 1/28/2012 12:06:11 PM

PITUITARY DRUGS
431

“Expecting” some problems

I know synthetic
Synthetic oxytocin can cause adverse reactions for pregnant oxytoxin can
women, including: cause severe
• bleeding after delivery water intoxication
• GI disturbances in pregnant
• sweating women, but this is
• headache ridiculous!
• dizziness
• ringing in the ears
• severe water intoxication.

Nursing process
These nursing process steps are appropriate for patients undergoing
treatment with posterior pituitary hormones.

Assessment
• Obtain a history of the patient’s underlying condition before
therapy.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Deficient fluid volume related to underlying condition Patients taking
posterior pituitary
• Risk for injury related to drug-induced adverse reactions drugs should be
• Deficient knowledge related to drug therapy weighed daily.

Planning outcome goals

• The risk of injury to the patient will be minimized.

• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Administer the drug according to the prescriber’s instructions,
and monitor for effect.
• Assess the effectiveness of ADH by checking the patient’s fluid
intake and output, serum and urine osmolality, and urine specific
gravity.
• Monitor the patient carefully for hypertension and water intoxi-
cation when giving ADH drugs. Seizures, coma, and death can
occur from water intoxication. Watch for excessively elevated
blood pressure or lack of response to the drug, which may be indi-
cated by hypotension. Weigh the patient daily.
• Use a rectal tube to facilitate gas expulsion after vasopressin
injection.

Nursing Pharmacology_Chap10.indd 431 1/28/2012 12:06:12 PM

ENDOCRINE DRUGS
432

• Desmopressin injection shouldn’t be used to treat severe cases

of von Willebrand’s disease or hemophilia A with factor VIII levels Education
of 0% to 5%. edge
• When desmopressin is used to treat diabetes insipidus, the dos-
age or frequency of administration may be adjusted according to
the patient’s fluid output. Morning and evening doses are adjusted
Teaching about
separately for adequate diurnal rhythm of water turnover. ADH
Ban the bolus If an antidiuretic
hormone (ADH) is pre-
• Oxytocin is administered only by IV infusion, not by IV bolus.
scribed, review these
• When administering oxytocin, monitor and record uterine con-
points with the patient
tractions, heart rate, blood pressure, intrauterine pressure, fetal
heart rate, and blood loss every 15 minutes. Also monitor the and his caregivers:
patient’s fluid intake and output. Antidiuretic effect may lead to • Clear the nasal pas-
fluid overload, seizures, and coma. sages before using the
• Have magnesium sulfate (20% solution) available for relaxation drug intranasally.
of the myometrium when administering oxytocin. • Report such conditions
• If contractions are less than 2 minutes apart, if they’re above 50 as nasal congestion, al-
mm Hg, or if they last 90 seconds or longer, stop oxytocin infu- lergic rhinitis, or upper
sion, turn the patient on her left side, and notify the prescriber. respiratory tract infec-
• Teach the patient and his caregivers how to properly measure tion; a dosage adjust-
and inhale the intranasal form of ADH. (See Teaching about ment may be needed.
ADH.) • If using subcutaneous
desmopressin, rotate
Evaluation injection sites to avoid
• Patient achieves normal fluid and electrolyte balance. tissue damage.
• Patient is free from injury. • Drink only enough wa-
• Patient and his family demonstrate an understanding of drug ter to satisfy thirst.
therapy. • Monitor fluid intake
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

and output.
• Wear or carry medical
Estrogens identification indicating
that you’re using ADH.
Estrogens mimic the physiologic effects of naturally occurring
female sex hormones. They’re used to correct estrogen-deficient
states and, along with hormonal contraceptives, to prevent preg-
nancy.

Natural and synthetic estrogens

Estrogens that treat endocrine system disorders include:
• natural conjugated estrogenic substances (estradiol and
estropipate)
• synthetic estrogens (esterified estrogens, estradiol cypionate,
estradiol valerate, and ethinyl estradiol).

Nursing Pharmacology_Chap10.indd 432 1/28/2012 12:06:12 PM

ESTROGENS
433

Prototype pro

Estrogens: Conjugated estrogenic substances

Actions • Atrophic vaginitis, kraurosis vulvae
• Increases synthesis of deoxyribonucleic acid, ribonucle- • Palliative treatment of inoperable prostate cancer
ic acid, and protein in responsive tissues • Vulvar and vaginal atrophy
• Reduces release of follicle-stimulating hormone and
Nursing considerations
luteinizing hormone from the pituitary gland
• Monitor the patient for adverse reactions, such as
Indications seizures, thromboembolism and increased risk of stroke,
• Abnormal uterine bleeding pancreatitis, pulmonary embolism, myocardial infarction,
• Palliative treatment of breast cancer at least 5 years endometrial cancer, hepatic adenoma, and breast cancer.
after menopause • Because of the risk of thromboembolism, therapy should
• Female castration be discontinued at least 1 month before procedures that
• Primary ovarian failure may cause prolonged immobilization or thromboembolism,
• Osteoporosis such as knee or hip surgery.
• Hypogonadism • Give oral forms at mealtime or at bedtime (if only one
• Vasomotor menopausal symptoms daily dose is required) to minimize nausea.

Pharmacokinetics
Estrogens are absorbed well and distributed throughout the body.
Metabolism occurs in the liver, and the metabolites are excreted
primarily by the kidneys.

Want to provide
The exact mechanism of action of estrogen isn’t clearly under- some relief from
stood. It’s believed to increase synthesis of deoxyribonucleic acid, those hot flashes?
ribonucleic acid, and protein in estrogen-responsive tissues in the Try hormone
replacement therapy
female breast, urinary tract, and genital organs. (See Estrogens:
with estrogen.
Conjugated estrogenic substances.)

Pharmacotherapeutics
Estrogens are prescribed:
• primarily for hormone replacement therapy in postmenopausal
women to relieve symptoms caused by loss of ovarian function
• less commonly for hormone replacement therapy in women
with primary ovarian failure or female hypogonadism (reduced
hormonal secretion by the ovaries) and in patients who have
undergone surgical castration
• palliatively to treat advanced, inoperable breast cancer in post-
menopausal women and prostate cancer in men.

Nursing Pharmacology_Chap10.indd 433 1/28/2012 12:06:12 PM

ENDOCRINE DRUGS
434

Drug interactions
Relatively few drugs interact with estrogens:
• Estrogens may decrease the effects of anticoagulants, increas-
ing the risk of blood clots.
• Carbamazepine, barbiturates, antibiotics, phenytoin, primidone,
and rifampin reduce estrogen’s effectiveness.
• Estrogens interfere with the absorption of dietary folic acid,
which may result in a folic acid deficiency.

Adverse reactions
Adverse reactions to estrogens include:
• hypertension
• thromboembolism (blood vessel blockage caused by a blood clot)
• thrombophlebitis (vein inflammation associated with clot formation)
• myocardial infarction
• vaginal bleeding.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with estrogens.

Assessment
• Obtain a history of the patient’s underlying condition before
therapy, and reassess regularly thereafter.
• Make sure that the patient has a thorough physical examination
before starting estrogen therapy.

Year in, year out

pelvic, and physical examinations. Periodically monitor lipid

levels, blood pressure, body weight, and liver function.
• Monitor the patient regularly to detect improvement or
worsening of symptoms.
• Assess for adverse reactions and drug interactions.
• If the patient has diabetes mellitus, watch closely for loss of dia-
betes control.
• If the patient is also receiving a warfarin-type anticoagulant,
monitor PT. If ordered, adjust the anticoagulant dosage.
• Assess the patient’s and family’s knowledge of drug therapy.
• Estrogens should be used for the shortest time necessary for
postmenopausal symptoms.

Key nursing diagnoses

• Ineffective health maintenance related to the underlying condition
• Risk of injury related to adverse effects
• Deficient knowledge related to drug therapy

Nursing Pharmacology_Chap10.indd 434 1/28/2012 12:06:13 PM

ESTROGENS
435

Planning outcome goals

• The patient’s underlying condition will improve. Stop estrogen
• The risk for injury to the patient will be minimized. therapy if a
thromboembolic
• The patient and her family will demonstrate an understanding of
event is suspected.
drug therapy.

Implementation
• Notify the pathologist about the patient’s estrogen therapy when
sending specimens for evaluation.
• Keep in mind that estrogens usually are given cyclically (once
daily for 3 weeks, followed by 1 week without drugs; repeated as
needed).
• Administer the drug as prescribed and monitor for effects.
• Withhold the drug and notify the prescriber if a thromboembolic
event is suspected; be prepared to provide supportive care as
indicated.
• Teach the patient how to apply estrogen ointments or trans-
dermal estrogen or how to insert an intravaginal estrogen sup-
pository. Also inform the patient of the signs and symptoms that
accompany a systemic reaction to ointments. (See Teaching about
estrogens.)

Education edge

Teaching about estrogens

patient and her caregivers: therapy.

• Take the drug with meals or at bedtime to relieve nau- • Males on long-term therapy may experience temporary
sea. Nausea usually disappears with continued therapy. gynecomastia and impotence, which will disappear when
• Review with the prescriber how to apply estrogen oint- therapy ends.
ments or transdermal estrogen. • Report abdominal pain; pain, numbness, or stiffness in
• Be aware of signs and symptoms that accompany a sys- the legs or buttocks; pressure or pain in the chest; short-
temic reaction to ointments. ness of breath; severe headaches; vision disturbances
• Use sanitary pads instead of tampons when using the (such as blind spots, flashing lights, or blurriness); vaginal
suppository. bleeding or discharge; breast lumps; swelling of hands or
• Stop taking the drug immediately if pregnancy occurs feet; yellow skin and sclera; dark urine; or light-colored
because estrogens can harm the fetus. stools to the prescriber immediately.
• Don’t breast-feed during estrogen therapy. • If diabetic, report symptoms of hyperglycemia or glycosuria.
• If receiving cyclic therapy for postmenopausal symptoms, • Keep follow-up appointments for gynecologic examina-
withdrawal bleeding may occur during the week off. How- tions, clinical breast examinations, and mammography.
ever, fertility isn’t restored and ovulation doesn’t occur. Perform breast self-examinations as instructed.

Nursing Pharmacology_Chap10.indd 435 1/28/2012 12:06:13 PM

ENDOCRINE DRUGS
436

Evaluation
• Patient’s condition improves.
• Patient doesn’t develop serious complications of estrogen
therapy.
• Patient and her family understand drug therapy.

Quick quiz
1. Which type of insulin would the nurse expect to administer
to a patient with DKA?
A. Regular
B. Intermediate-acting
C. Long-acting
D. Ultra-long-acting
Answer: A. Use regular insulin in a patient with circulatory col-
lapse, DKA, or hyperkalemia.
2. Which drug or drug type would likely cause hyperglycemia if
taken with glyburide?
A. Procainamide
B. Cimetidine
C. Warfarin
D. Thiazide diuretics
Answer: D. Hyperglycemia may occur if glyburide is taken with a
thiazide diuretic.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

3. Which drug is typically prescribed for a patient with diabe-

tes insipidus?
A. ADH
B. Oxytocin
C. Pitocin
D. Corticotropin
Answer: A. ADH is prescribed for hormone replacement therapy
in a patient with neurogenic diabetes insipidus.

Scoring
✰✰✰ If you answered all three questions correctly, perfect! There’s no
end to your endocrine drug knowledge!
✰✰ If you answered two questions correctly, marvelous! You’ve done
your homework on homeostasis and hormones.
✰ If you answered fewer than two questions correctly, don’t sink
too low. You can always give the chapter another go.

Nursing Pharmacology_Chap10.indd 436 1/28/2012 12:06:14 PM

11
Psychotropic drugs

Just the facts

In this chapter, you’ll learn:
♦ classes of drugs that alter psychogenic behavior and
promote sleep
♦ uses and varying actions of these drugs
♦ absorption, distribution, metabolization, and excretion of
these drugs
♦ drug interactions and adverse reactions to these drugs.

Drugs and psychiatric disorders

This chapter discusses drugs that are used to treat various sleep
and psychogenic disorders, such as anxiety, depression, attention
deficit hyperactivity disorder (ADHD), and psychotic disorders.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Sedative and hypnotic drugs Excuse me! When

given in large doses,
Sedatives reduce activity, tension, or excitement. Some degree of sedatives induce a
drowsiness commonly accompanies sedative use. state resembling
natural sleep.
You’re getting very sleepy…
When given in large doses, sedatives are considered hypnotic
drugs, which induce a state resembling natural sleep. The
three main classes of synthetic drugs used as sedatives and
hypnotics are:

benzodiazepines

barbiturates

nonbenzodiazepine-nonbarbiturate drugs.

Nursing Pharmacology_Chap11.indd 437 1/28/2012 12:35:15 PM

PSYCHOTROPIC DRUGS
438

Benzodiazepines
Benzodiazepines produce many therapeutic effects, including
some that aren’t classified as sedative or hypnotic.

“Chill” pills
Benzodiazepines used primarily for their primary or secondary
sedative or hypnotic effects include:
• alprazolam
• estazolam
• flurazepam
• lorazepam
• quazepam
• temazepam
• triazolam.

Pharmacokinetics (how drugs circulate)

Benzodiazepines are absorbed rapidly and completely from the GI
tract and distributed widely in the body. Penetration into the brain
is rapid. The rate of absorption determines how quickly the drug
will work. Flurazepam and triazolam have the fastest onset.

Distribution determines duration

The duration of effect is determined by the extent of distribution.
For example, triazolam is highly lipophilic and widely distributed;
therefore, it has a short duration of effect.

The ins and outs

Benzodiazepines
terally in certain situations, such as when a highly anxious patient increase total sleep
needs sedation. All benzodiazepines are metabolized in the liver time and decrease
and excreted primarily in urine. Some benzodiazepines have the number of
active metabolites, which may give them a longer action. awakenings.

Pharmacodynamics (how drugs act)

Researchers believe that benzodiazepines work by stimulating
gamma-aminobutyric acid (GABA) receptors in the ascending
reticular activating system (RAS) of the brain. This RAS is associ-
ated with wakefulness and attention and includes the cerebral
cortex and limbic, thalamic, and hypothalamic levels of the cen-
tral nervous system (CNS). (See How benzodiazepines work.)

Snooze inducer
When given in higher dosages, benzodiazepines induce
sleep, probably because they depress the RAS of the brain.

Nursing Pharmacology_Chap11.indd 438 1/28/2012 12:35:16 PM

SEDATIVE AND HYPNOTIC DRUGS
439

Pharm function

How benzodiazepines work

These illustrations show how benzodiazepines work at the cellular level.

Speed and passage

Chloride ion
The speed of impulses from a
GABA
presynaptic neuron across a syn-
Presynaptic
apse is influenced by the amount
neuron
of chloride in the postsynaptic
neuron. The passage of chloride
Impulses
ions into the postsynaptic neu-
ron depends on the inhibitory Postsynaptic
Synapse
neurotransmitter called gamma- neuron
aminobutyric acid, or GABA.

It binds
When GABA is released from
the presynaptic neuron, it travels
across the synapse and binds to
GABA
GABA receptors on the postsyn-
aptic neuron. This binding opens GABA receptor
the chloride channels, allowing
chloride ions to flow into the Impulses slow
down
postsynaptic neuron and causing Chloride ions
the nerve impulses to slow down.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

The result is another kind of

depression Enhanced
effect
Benzodiazepines bind to recep- allows Benzodiazepine
tors on or near the GABA recep- greater flow
tor, enhancing the effect of of chloride
GABA and allowing more chlo- ions
ride ions to flow into the post- Impulses
synaptic neuron. This depresses slow or stop
the nerve impulses, causing
them to slow down or stop.

Nursing Pharmacology_Chap11.indd 439 1/28/2012 12:35:16 PM

PSYCHOTROPIC DRUGS
440

Benzodiazepines increase total sleep time and produce a

reduced number of awakenings. Prototype
pro
(Not) a real eye opener
In most cases, benzodiazepines don’t decrease the time spent in rapid-
eye-movement sleep (the state of sleep in which brain activity resem-
Benzodia-
bles the activity it shows when awake; the body’s muscles relax, zepines:
and the eyes move rapidly). This gives benzodiazepines a significant Alprazolam
advantage over barbiturates. (See Benzodiazepines: Alprazolam.)
Actions
Pharmacotherapeutics (how drugs are used) • Enhances or facilitates
Clinical indications for benzodiazepines include: the action of gamma-
• relaxing the patient before surgery aminobutyric acid, an
• treating insomnia inhibitory neurotransmit-
• producing IV anesthesia ter in the central ner-
• treating alcohol withdrawal symptoms vous system (CNS)
• treating anxiety and seizure disorders • Acts at the limbic, tha-
• producing skeletal muscle relaxation. lamic, and hypothalamic
levels of the CNS
Drug interactions • Produces anxiolytic,
Except for other CNS depressants such as alcohol, few drugs sedative, hypnotic, skel-
interact with benzodiazepines. etal muscle relaxant,
• Triazolam may be affected by drugs that inhibit the cytochrome and anticonvulsant
P450 3A4 system, such as erythromycin and ketoconazole. effects
• Lorazepam may increase digoxin level, resulting in potential • Produces CNS
digoxin toxicity. depression
• Azole antifungals could increase or prolong anxiolytic levels.
Indications
A lethal combination • Anxiety
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

When benzodiazepines are taken with other CNS depressants • Panic disorders
(including alcohol and anticonvulsants), the result is enhanced Nursing considerations
sedative and CNS depressant effects, including reduced level of • Monitor the patient
consciousness (LOC), reduced muscle coordination, respiratory for adverse reactions,
depression, and death. such as drowsiness, dry
Hormonal contraceptives may reduce the metabolism of fluraz- mouth, diarrhea, and
epam, increasing the risk of toxicity. constipation.
• The drug isn’t
Adverse reactions recommended for long-
Benzodiazepines may cause: term use.
• amnesia • Don’t withdraw the
• fatigue drug abruptly; seizures
• muscle weakness may occur.
• mouth dryness
• nausea and vomiting
• dizziness
• ataxia (impaired ability to coordinate movement).

Nursing Pharmacology_Chap11.indd 440 1/28/2012 12:35:19 PM

SEDATIVE AND HYPNOTIC DRUGS
441

Feeling a little out of it?

Be careful! Taking
Unintentional daytime sedation, hangover effect (residual drowsi- benzodiazepines
ness and impaired reaction time on awakening), and rebound with other CNS
insomnia may also occur. Additionally, benzodiazepines have a depressants such
potential for abuse, tolerance, and physical dependence. as alcohol enhances
sedative and CNS
Senior alert! depressant effects.
Benzodiazepines with a long half-life or active metabolites may
accumulate and cause adverse effects in elderly patients and
should be avoided. If they must be used, start the patient at a
lower dosage and gradually increase it.

Nursing process
These nursing process steps are appropriate for patients under-
going treatment with benzodiazepines.

Assessment
• Assess the patient’s anxiety before therapy and frequently
thereafter.
• In the patient receiving repeated or prolonged therapy, monitor
liver, renal, and hematopoietic function test results periodically.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Anxiety related to the patient’s underlying condition
• Risk for injury related to drug-induced reactions
• Deficient knowledge related to drug therapy
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Benzodiazepines
shouldn’t be given
Planning outcome goals for more than
• The patient will state that his anxiety is reduced. 4 months.
• The risk of injury to the patient will be minimized.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Don’t give benzodiazepines for everyday stress or use them for
long-term therapy (more than 4 months).
• Check to see that the patient has swallowed tablets before leav-
ing his room.
• Expect to give lower doses at longer intervals in an elderly or a
debilitated patient.
• Don’t withdraw benzodiazepines abruptly after long-term use;
withdrawal symptoms (especially seizures) may occur. Abuse or
addiction is possible.

Nursing Pharmacology_Chap11.indd 441 1/28/2012 12:35:19 PM

PSYCHOTROPIC DRUGS
442

Evaluation
• Patient reports decreased anxiety. Are you paying
• Patient doesn’t experience injury from adverse CNS reactions. attention?
Barbiturates
• Patient and his family demonstrate an understanding of drug
reduce overall CNS
therapy. alertness.

Barbiturates
The major pharmacologic action of barbiturates is to reduce over-
all CNS alertness. Barbiturates used primarily as sedatives and
hypnotics include:
• butabarbital
• pentobarbital
• phenobarbital
• secobarbital.

The highs and lows

Low doses of barbiturates depress the sensory and motor cortex
in the brain, causing drowsiness. High doses may cause respira-
tory depression and death because of their ability to depress all
levels of the CNS.

Pharmacokinetics
Barbiturates are absorbed well from the GI tract. They’re distrib-
uted rapidly, metabolized by the liver, and excreted in urine.

As sedatives and hypnotics, barbiturates depress the sensory cor-

tex of the brain, decrease motor activity, alter cerebral function,
and produce drowsiness, sedation, and hypnosis. These drugs
appear to act throughout the CNS; however, the RAS of the brain,
which is responsible for wakefulness, is a particularly sensitive
site. (See Barbiturates: Phenobarbital.)

Pharmacotherapeutics
Barbiturates have many clinical indications, some of which go
beyond sedative and hypnotic uses. They’re used for:
• daytime sedation (for short periods only, typically less than
2 weeks)
• relief from insomnia
• preoperative sedation and anesthesia
• relief from anxiety
• anticonvulsant effects.

Nursing Pharmacology_Chap11.indd 442 1/28/2012 12:35:19 PM

SEDATIVE AND HYPNOTIC DRUGS
443

Prototype pro

Barbiturates: Phenobarbital
Actions • Raises the seizure threshold
• Induces an imbalance in central inhibitory and facilita-
Indications
tory mechanisms, which influence cerebral cortex and
• Epilepsy
reticular formation
• Febrile seizures
• Decreases presynaptic and postsynaptic membrane
• Need for sedation
excitability
• Produces all levels of central nervous system (CNS) de- Nursing considerations
pression (mild sedation to coma to death) • Monitor the patient for adverse reactions, such as
• Facilitates the action of gamma-aminobutyric acid, an drowsiness, lethargy, hangover, respiratory depression,
inhibitory neurotransmitter in the CNS apnea, Stevens-Johnson syndrome, and angioedema.
• Exerts a central effect, which depresses respiration and • Don’t withdraw the drug abruptly; seizures may worsen.
GI motility • Watch for signs of toxicity: coma, asthmatic breathing,
• Reduces nerve transmission and decreases excit- clammy skin, and cyanosis.
ability of the nerve cell as its principal anticonvulsant
mechanism of action

A little too good

Yikes! It says
Tolerance to barbiturates occurs more rapidly than tolerance to here that using
benzodiazepines. Physical dependence may occur even with a methoxyflurane
small daily dosage. In comparison, benzodiazepines are relatively and barbiturates
effective and safe and, for these reasons, have replaced barbitu- together may
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

rates as the sedatives and hypnotics of choice. stimulate

production of
metabolites that
Drug interactions are toxic
Barbiturates may interact with many other drugs: to the kidneys.
• They may reduce the effects of beta-adrenergic blockers (such
as metoprolol and propranolol), chloramphenicol, corticosteroids,
doxycycline, oral anticoagulants, hormonal contraceptives, quini-
dine, tricyclic antidepressants, metronidazole, theophylline, and
cyclosporine.
• Hydantoins, such as phenytoin, reduce the metabolism of
phenobarbital, resulting in increased toxic effects.
• Methoxyflurane, when taken with barbiturates, may stimulate
production of metabolites that are toxic to the kidneys.
• Barbiturate use with other CNS depressants may cause exces-
sive CNS depression.
• Valproic acid may increase barbiturate levels.

Nursing Pharmacology_Chap11.indd 443 1/28/2012 12:35:19 PM

PSYCHOTROPIC DRUGS
444

• Monoamine oxidase (MAO) inhibitors slow down barbiturate

metabolism, increasing sedative effects.
• When taken with acetaminophen, an increased risk of liver
toxicity results.

Adverse reactions
Barbiturates may have widespread adverse effects.

Draining the brain

CNS reactions include:
• drowsiness
• lethargy
• headache
• depression.

“Heart-y” responses
Cardiovascular effects include:
• mild bradycardia
• hypotension.

“Air” ways
Respiratory effects include: Barbiturates can
• hypoventilation cause spasm of
• spasm of the larynx (voice box) and bronchi the voice box—but
I need to keep my
• reduced rate of breathing voice box spasm-
• severe respiratory depression. free. LAAA!
And the rest of the story
Other reactions include:
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• vertigo
• nausea and vomiting
• diarrhea
• epigastric pain
• allergic reactions.

Nursing process
These nursing process steps are appropriate for patients under-
going treatment with barbiturates.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter.
• Assess the patient’s LOC and sleeping patterns before and dur-
ing therapy to evaluate the drug’s effectiveness. Monitor his neu-
rologic status for alteration or deterioration.

Nursing Pharmacology_Chap11.indd 444 1/28/2012 12:35:20 PM

SEDATIVE AND HYPNOTIC DRUGS
445

• Assess the patient’s vital signs frequently, especially during IV

administration.
• Assess for adverse reactions and drug interactions.

Key nursing diagnoses

• Risk for injury related to adverse drug reaction
• Risk for trauma related to the underlying condition
• Deficient knowledge related to drug therapy

Planning outcome goals

• The risk of injury to the patient will be minimized.
• The risk of trauma to the patient will be minimized.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• When giving parenteral forms, avoid extravasation, which may cause
local tissue damage and tissue necrosis; inject IV or deep IM only.
Don’t exceed 5 mL for any IM injection site to avoid tissue damage.
• Be prepared to resuscitate. Too-rapid IV administration may
cause respiratory depression, apnea, laryngospasm, or hypotension.
• Take seizure precautions as necessary. Monitor seizure charac-
ter, frequency, and duration for changes, as indicated.

Safety first
• Institute safety measures to prevent patient falls and injury.
Raise side rails, assist the patient out of bed, and keep the call
light within easy reach.
• Monitor blood levels of the drug closely. Therapeutic levels
range from 15 to 40 mcg/mL.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Observe the patient to prevent hoarding or self-dosing, espe-

cially if he’s depressed, suicidal, or drug dependent.
• Stop the drug slowly. Abrupt discontinuation may cause with-
drawal symptoms or worsen seizures.

Evaluation
• Patient sustains no injury from sedation.
• Patient sustains no trauma during therapy.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about barbiturates, page 446.)

Nonbenzodiazepines-nonbarbiturates
Nonbenzodiazepines-nonbarbiturates act as hypnotics for short-
term treatment of simple insomnia. These drugs, which offer no
special advantages over other sedatives, include:
• chloral hydrate
• eszopiclone

Nursing Pharmacology_Chap11.indd 445 1/28/2012 12:35:20 PM

PSYCHOTROPIC DRUGS
446

Education edge

Teaching about barbiturates

If barbiturates are prescribed, review these points with • Avoid hazardous tasks, driving a motor vehicle, or oper-
the patient and his caregivers: ating machinery while taking the drug. Review other safety
• Barbiturates can cause physical or psychological measures with your health care provider to prevent injury.
dependence. • The drug’s full effects don’t occur for 2 to 3 weeks,
• Take the drug exactly as prescribed. Don’t change the except when a loading dose is used.
dosage or take other drugs, including over-the-counter • Don’t stop taking the drug abruptly.
drugs or herbal remedies, without the prescriber’s approval. • If using hormonal contraceptives, consider using other
• A morning hangover is common after therapeutic use of birth control methods such as condoms.
barbiturates. • Report skin eruptions or other significant adverse effects.

• zaleplon
• zolpidem.

Shoring up sleep for the short term

With the exception of zolpidem, which may be effective for up to
35 days, nonbenzodiazepines-nonbarbiturates are for short-term
use only.

Pharmacokinetics
Nonbenzodiazepines-nonbarbiturates are absorbed rapidly from Nonbenzodiazepines-
the GI tract. They’re metabolized in the liver and excreted in nonbarbiturates
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

urine. are used for short-

term treatment of
insomnia and for
Pharmacodynamics sedation before
The mechanism of action for nonbenzodiazepines-nonbarbiturates surgery or EEG
isn’t fully known. They produce depressant effects similar to those studies.
of barbiturates.

Pharmacotherapeutics
Nonbenzodiazepines-nonbarbiturates are typically used for:
• short-term treatment of simple insomnia
• sedation before surgery
• sedation before EEG studies.

Drug interactions
Drug interactions involving nonbenzodiazepines-nonbarbiturates
primarily occur when they’re used with other CNS depressants,

Nursing Pharmacology_Chap11.indd 446 1/28/2012 12:35:20 PM

SEDATIVE AND HYPNOTIC DRUGS
447

causing additive CNS depression resulting in drowsiness,

respiratory depression, stupor, coma, and death.

These mixes don’t match

Chloral hydrate may increase the risk of bleeding in patients tak-
ing oral anticoagulants. Use with IV furosemide may produce
sweating, flushing, variable blood pressure, and uneasiness.

Adverse reactions
The most common dose-related adverse reactions involving
nonbenzodiazepines-nonbarbiturates include:
• nausea and vomiting
• gastric irritation
• hangover effects (possibly leading to respiratory depression or
even respiratory failure).

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with nonbenzodiazepines-nonbarbiturates.

Assessment
• Assess the patient’s underlying condition.
• Evaluate the drug’s effectiveness after administration.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Risk for injury related to adverse CNS reactions

• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s insomnia will improve.
• The risk of injury to the patient will be minimized.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Administer the drug as ordered and monitor for its effects.
• To minimize the unpleasant taste of liquid forms, dilute or give
the drug with liquid.
• Administer the drug immediately before bedtime.
• Refrigerate rectal suppositories.
• Long-term use isn’t recommended; nonbenzodiazepines-
nonbarbiturates lose their efficacy in promoting sleep after

Nursing Pharmacology_Chap11.indd 447 1/28/2012 12:35:21 PM

PSYCHOTROPIC DRUGS
448

14 days of continued use. Long-term use may cause drug depen-

dence. The patient may experience withdrawal symptoms if the Supervise
drug is suddenly stopped. patients taking
• Caution the patient about performing activities that require nonbenzodiazepines-
mental alertness or physical coordination. For an inpatient, super- nonbarbiturates
when they’re walking,
vise walking and raise bed rails, particularly for an elderly patient. especially if they’re
• Tell the patient to report adverse effects, such as severe elderly.
hangover or feelings of oversedation, so the prescriber can be
consulted to adjust the dosage or change the drug.

Evaluation
• Patient states drug effectively induced sleep.
• Patient’s safety is maintained.
• Patient and his family demonstrate an understanding of drug
therapy.

Antianxiety drugs
Antianxiety drugs, also called anxiolytics, include some of the
most commonly prescribed drugs in the United States. They’re
used primarily to treat anxiety disorders. The three main types of
antianxiety drugs are:
• benzodiazepines
• barbiturates
• buspirone.

Experiencing drug déjà vu?

chapter in regard to their sedative and hypnotic use, but they’re

also used to treat anxiety.

Anxiety “it” list

Benzodiazepines used primarily to treat anxiety include:
• alprazolam
• chlordiazepoxide
• clonazepam
• clorazepate
• diazepam
• lorazepam
• oxazepam.

Taking the edge off

When given in low dosages, these benzodiazepines decrease anxi-
ety by acting on the limbic system and other areas of the brain

Nursing Pharmacology_Chap11.indd 448 1/28/2012 12:35:21 PM

ANTIANXIETY DRUGS
449

that help regulate emotional activity. The drugs can usually calm
the patient without causing drowsiness.

Back to the barbiturates

Barbiturates used to treat anxiety include:
• pentobarbital
• secobarbital.

The difference is in the dosage

Benzodiazepines and barbiturates act the same way as when
they’re used as sedatives and hypnotics. However, the dosages
may vary.

Addendum for anxiolytic use

When these drugs are used to treat anxiety, the nursing process
steps are generally the same as when they’re used as sedatives
and hypnotics. However, keep these additional points in mind:
• Benzodiazepines and barbiturates are generally prescribed for
short-term use. Patients undergoing long-term therapy should be
referred to psychiatric counseling.
• The patient will need to identify and examine the source of his
anxiety in order to reduce or eliminate it.
• Teach the patient various relaxation techniques, such as deep
breathing and meditation, to help reduce anxiety. (See Teaching
about antianxiety drugs, page 450.)

sedation and a lower

as azaspirodecanedione derivatives. This drug’s structure and abuse potential.
mechanism of action differ from those of other antianxiety drugs. Now that’s a winning
combination!
Advantage, buspirone
Buspirone has several advantages, including:
• less sedation
• no increase in CNS depressant effects when taken with alco-
hol or sedative-hypnotics
• lower abuse potential.

Pharmacokinetics
Buspirone is absorbed rapidly, undergoes extensive first-pass
effect, and is metabolized in the liver to at least one active
metabolite. The drug is eliminated in urine and feces.

Nursing Pharmacology_Chap11.indd 449 1/28/2012 12:35:21 PM

PSYCHOTROPIC DRUGS
450

Education edge

Teaching about antianxiety drugs

If antianxiety drugs are prescribed, review these points • Avoid hazardous activities that require alertness and
with the patient and his caregivers: psychomotor coordination until the central nervous sys-
• These drugs help relieve symptoms temporarily but don’t tem effects of the drug are known.
cure or solve the underlying problem. Counseling or psy- • Avoid alcohol consumption and smoking while taking
chotherapy may help find ways to decrease nervousness the drug.
and assist with sleep. • Don’t take other drugs, over-the-counter products, or
• Use other methods to promote relaxation, such as physi- herbal remedies without first consulting the prescriber or
cal exercise, stress-management techniques, and relax- a pharmacist.
ation techniques. • Take the drug as prescribed; don’t stop taking it without
• Identify factors that cause symptoms. Avoiding such the prescriber’s approval.
products as caffeine, cold medications, and appetite sup- • Dependence on the drug may occur if it’s taken longer
pressants can help reduce symptoms of nervousness and than directed.
insomnia. • Take the drug later in the day or at night as indicated to
• Tell other health care providers what drugs you’re taking help decrease daytime drowsiness.
to avoid being prescribed other drugs with similar effects.

Pharmacodynamics
Although buspirone’s mechanism of action remains unknown, it’s
clear that buspirone doesn’t affect GABA receptors like benzodi-
azepines. Buspirone seems to produce various effects in the mid-
brain and acts as a midbrain modulator, possibly due to its high No, you’ve got
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

affinity for serotonin receptors. buspirone beat.

Your onset of action
is just a little bit
Pharmacotherapeutics slower!
Buspirone is used to treat generalized anxiety states. Patients
who haven’t received benzodiazepines seem to respond better to
buspirone.

Slow as a tortoise
Because of its slow onset of action, buspirone is ineffective when
quick relief from anxiety is needed.

Not for simple stress

Although buspirone hasn’t shown potential for abuse and hasn’t
been classified as a controlled substance, it isn’t recommended
for relief of everyday stress.

Nursing Pharmacology_Chap11.indd 450 1/28/2012 12:35:21 PM

ANTIANXIETY DRUGS
451

Drug interactions
Unlike other antianxiety drugs, buspirone doesn’t interact with
alcohol or other CNS depressants. However, when buspirone is
given with MAO inhibitors, hypertensive reactions may occur.

Adverse reactions
The most common reactions to buspirone include:
• dizziness
• light-headedness
• insomnia
• rapid heart rate
• palpitations
• headache.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with buspirone.

Assessment
• Obtain a history of the patient’s anxiety before therapy, and
reassess regularly thereafter.
• Assess for adverse reactions and drug interactions. Tell the patient to
• Assess the patient’s and family’s understanding of drug therapy. avoid activities that
require alertness
Key nursing diagnoses and psychomotor
• Anxiety related to the underlying condition coordination until
the CNS effects of
• Fatigue related to drug-induced adverse reactions buspirone are known.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient will state that his anxiety is reduced.
• The patient won’t experience fatigue.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Before starting therapy in the patient already being treated with
a benzodiazepine, make sure that he doesn’t stop the benzodiaz-
epine abruptly; a withdrawal reaction may occur.
• Give the drug with food or milk.
• The dosage may be increased in 2- to 4-day intervals as ordered.
• Warn the patient to avoid hazardous activities that require alert-
ness and psychomotor coordination until the CNS effects of the
drug are known.

Nursing Pharmacology_Chap11.indd 451 1/28/2012 12:35:22 PM

PSYCHOTROPIC DRUGS
452

• Signs of improvement usually appear within 7 to 10 days;

optimal results occur after 3 to 4 weeks of therapy.

Evaluation
• Patient’s anxiety is relieved.
• Patient’s fatigue is decreased.
• Patient and his family demonstrate an understanding of drug
therapy.

Antidepressant and mood stabilizer

drugs
Antidepressant and mood stabilizer drugs are used to treat affec-
tive disorders—disturbances in mood, characterized by depres-
sion or elation.

One pole
Unipolar disorders, characterized by periods of clinical depres-
sion, are treated with:
• selective serotonin reuptake inhibitors (SSRIs)
• MAO inhibitors
• tricyclic antidepressants (TCAs)
• other antidepressants.

Two poles
Lithium is used to treat bipolar disorders, characterized by alter- Good news! SSRIs
nating periods of manic behavior and clinical depression. treat depression
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

with fewer adverse

effects.
SSRIs
Developed to treat depression with fewer adverse effects, SSRIs
are chemically different from TCAs and MAO inhibitors. Some of
the SSRIs currently available are:
• citalopram
• escitalopram
• fluoxetine
• fluvoxamine
• paroxetine
• sertraline.

Pharmacokinetics
SSRIs are absorbed almost completely after oral administration
and are highly protein bound. They’re primarily metabolized in the
liver and excreted in urine.

Nursing Pharmacology_Chap11.indd 452 1/28/2012 12:35:22 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
453

Pharmacodynamics
Prototype
SSRIs inhibit the neuronal reuptake of the neurotransmitter sero-
pro
tonin. (See Selective serotonin reuptake inhibitors: Fluoxetine.)

Pharmacotherapeutics Selective sero-

SSRIs are used to treat major depressive episodes. They have the tonin reuptake
same degree of effectiveness as TCAs. inhibitors:
Here’s the (SSRI) scoop Fluoxetine
SSRIs may also be useful in treating panic disorders, eating disor- Actions
ders, personality disorders, impulse control disorders, and anxiety • Presumed to be linked
disorders. For example, paroxetine is indicated for social anxiety to the inhibition of
disorder. Fluoxetine is approved for the treatment of bulimia. Fluox- central nervous system
etine and sertraline are approved for the treatment of premenstrual (CNS) neuronal uptake
(dysphoric) disorder. Fluvoxamine, fluoxetine, sertraline, and par- of serotonin
oxetine are also used to treat obsessive-compulsive disorder, and
paroxetine and sertraline are used for posttraumatic stress disorder. Indications
• Depression
• Treatment of binge
Drug interactions
eating and vomiting
Drug interactions with SSRIs are associated with their ability to
behaviors in patients
competitively inhibit a liver enzyme that’s responsible for oxida-
with moderate to severe
tion of numerous drugs, including TCAs; antipsychotics, such as
bulimia nervosa
clozapine and thioridazine; carbamazepine; metoprolol; flecainide;
• Premenstrual dys-
and encainide.
phoric disorder
Danger ahead! • Anorexia nervosa
Using SSRIs with MAO inhibitors can cause serious, potentially • Panic disorder
fatal reactions. Individual SSRIs also have their own particular • Alcohol dependence
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

interactions: Nursing considerations

• Using citalopram and paroxetine with warfarin may lead to • Monitor the patient for
increased bleeding. adverse reactions, such
• Carbamazepine may increase the clearance of citalopram.
as anxiety, insomnia,
• Fluoxetine increases the half-life of diazepam and displaces
drowsiness, nausea,
highly protein-bound drugs, leading to toxicity.
diarrhea, dry mouth.
• Fluvoxamine use with diltiazem may cause bradycardia.
• Give the drug in the
• Paroxetine shouldn’t be used with tryptophan because this com-
bination can cause headache, nausea, sweating, and dizziness. morning to prevent
• Paroxetine may increase procyclidine levels, causing increased insomnia.
anticholinergic effects. • Warn the patient to
• Cimetidine, phenobarbital, and phenytoin may reduce parox- avoid hazardous activities
etine metabolism by the liver, increasing the risk of toxicity. that require alertness and
• Paroxetine and sertraline may interact with other highly psychomotor coordina-
protein-bound drugs, causing adverse reactions to either drug. tion until the CNS effects
• Dextromethorphan can precipitate visual hallucinations when of the drug are known.
combined with SSRIs.

Nursing Pharmacology_Chap11.indd 453 1/28/2012 12:35:22 PM

PSYCHOTROPIC DRUGS
454

SSRI discontinuation syndrome

Abrupt discontinuation of selective serotonin reuptake inhibitors (SSRIs) may result in a
condition called SSRI discontinuation syndrome. This syndrome is characterized by diz-
ziness, vertigo, ataxia, nausea, vomiting, muscle pains, fatigue, tremor, and headache.
The patient may also experience psychological symptoms, such as anxiety, crying
spells, irritability, sad feelings, memory problems, and vivid dreams.

The half-life of it
SSRI discontinuation syndrome occurs in up to one-third of patients taking SSRIs. It’s
more common in patients who are stopping SSRIs that have a short half-life, such as
paroxetine. Fluoxetine is the least likely to cause this problem because of its extremely
long half-life.

How to deal
This syndrome is self-limited. With treatment, it usually resolves within 2 to 3 weeks.
Tapering the drug dosage slowly over several weeks can help prevent it.

Adverse reactions
Anxiety, insomnia, somnolence, and palpitations may occur with
the use of an SSRI. Sexual dysfunction (anorgasmia and delayed
ejaculation) and various skin rashes have been reported. Decreased
glucose concentrations in plasma can occur with fluoxetine. Ortho-
static hypotension may occur with citalopram and paroxetine use.

aggression. More research is needed to prove a direct association

between SSRIs and these thoughts and behaviors.

Stopping…may be starting
Other symptoms may develop when a patient stops taking an
SSRI. (See SSRI discontinuation syndrome.)

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with SSRIs.

Assessment
• Assess the patient’s condition before therapy, and reassess
regularly throughout therapy.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s and family’s knowledge of drug therapy.

Nursing Pharmacology_Chap11.indd 454 1/28/2012 12:35:23 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
455

Key nursing diagnoses

• Ineffective coping related to the underlying condition Elderly or
• Insomnia related to drug therapy debilitated patients
and patients with
• Deficient knowledge related to drug therapy
renal or hepatic
dysfunction may
Planning outcome goals need lower dosages
• The patient’s ability to cope will improve. of SSRIs or less
• The patient’s insomnia will improve. frequent dosing.
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Elderly or debilitated patients and patients with renal or hepatic
dysfunction may need lower dosages or less frequent dosing.
• Give SSRIs in the morning to prevent insomnia.
• Give antihistamines or topical corticosteroids to treat rashes or
pruritus.
• Lower-weight children may need several weeks between dosage
increases.

Evaluation
• Patient behavior and communication indicate an improvement
of depression with drug therapy.
• Patient has no insomnia with drug use.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about SSRIs.)
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Education edge

Teaching about SSRIs

If selective serotonin reuptake inhibitors (SSRIs) are • Avoid activities that require alertness and psychomotor
prescribed, review these points with the patient and his coordination until the drug’s effects on the central nervous
caregivers: system are known.
• Take the drug as directed; don’t alter the dose, even • SSRIs may be taken without regard to food.
when symptoms subside. SSRIs are usually given for sev- • Take the drug in the morning to help avoid insomnia or
eral months — sometimes longer. nervousness, unless otherwise directed.
• Relief from symptoms may not occur until 2 to 4 weeks after • Report excessive drowsiness, dizziness, difficulty
the drug is started; don’t stop taking the drug prematurely. breathing, or other adverse reactions to the prescriber.
• Don’t take other drugs, over-the-counter products, or • Don’t stop taking the drug without first consulting with
herbal remedies without first consulting with the prescriber. the prescriber.
Serious drug interactions may occur. • Counseling, support groups, stress management tech-
• Tell other health care providers that you’re taking an niques, and relaxation techniques may be helpful in addi-
SSRI to avoid drug interactions. tion to drug therapy.

Nursing Pharmacology_Chap11.indd 455 1/28/2012 12:35:23 PM

PSYCHOTROPIC DRUGS
456

MAO inhibitors
MAO inhibitors are divided into two classifications based on their
chemical structure:

hydrazines, which include phenelzine

nonhydrazines, consisting of a single drug, tranylcypromine.

Pharmacokinetics
MAO inhibitors are absorbed rapidly and completely from the
GI tract and are metabolized in the liver to inactive metabolites.
These metabolites are excreted mainly by the GI tract and, to a
lesser degree, by the kidneys.

Pharmacodynamics
MAO inhibitors appear to work by inhibiting monoamine oxidase,
the widely distributed enzyme that normally metabolizes many We MAO inhibitors
don’t play well with
neurotransmitters, including norepinephrine and serotonin. This others.
action makes more norepinephrine, dopamine, and serotonin
available to the receptors, thereby relieving the symptoms of
depression.

Pharmacotherapeutics
Indications for MAO inhibitors are similar to those for
other antidepressants. They’re particularly effective in panic
disorder with agoraphobia, eating disorders, posttraumatic
stress disorder, and pain disorder.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Not a typical depression

MAO inhibitors are also thought to be effective in atypical
depression. Atypical depression produces signs opposite of those
of typical depression. For example, the patient gains weight,
sleeps more, and has a higher susceptibility to rejection.

Battling the blues

MAO inhibitors may be used to treat typical depression resistant
to other therapies or when other therapies are contraindicated.
Other uses include the treatment of:
• phobic anxieties
• neurodermatitis (an itchy skin disorder seen in some anxious
people)
• hypochondriasis (abnormal concern about health)
• refractory narcolepsy (sudden sleep attacks).

Nursing Pharmacology_Chap11.indd 456 1/28/2012 12:35:23 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
457

Drug interactions
MAO inhibitors interact with many drugs: Stopping MAO
• Taking MAO inhibitors with amphetamines, methylphenidate, inhibitors
levodopa, sympathomimetics, or nonamphetamine appetite sup-
Monoamine oxidase
pressants may increase catecholamine release, causing hyperten-
(MAO) inhibitors should
sive crisis.
• Using MAO inhibitors with fluoxetine, TCAs, citalopram, be discontinued 2 weeks
clomipramine, trazodone, sertraline, paroxetine, and fluvoxamine before starting an alter-
may result in an elevated body temperature, excitation, and native antidepressant.
seizures. (See Stopping MAO inhibitors.) If a patient is switching
• When taken with doxapram, MAO inhibitors may cause hyper- from another antidepres-
tension and arrhythmias and may increase the adverse reactions sant to an MAO inhibi-
to doxapram. tor, a waiting period of
• MAO inhibitors may enhance the hypoglycemic effects of anti- 2 weeks (5 weeks for
diabetic drugs. fluoxetine) is recom-
• Administering MAO inhibitors with meperidine may result in mended before starting
excitation, hypertension or hypotension, extremely elevated body the MAO inhibitor.
temperature, and coma.

Eat, drink, and…be careful

Certain foods can interact with MAO inhibitors and produce Patients taking
severe reactions. The most serious reactions involve tyramine- MAO inhibitors need
rich foods, such as red wine, aged cheese, and fava beans. Foods to watch what they
with moderate tyramine content—for example, yogurt and ripe eat. Tyramine-rich
bananas—may be eaten occasionally, but with care. Caffeine may foods—such as
aged cheese—can
also interact with MAO inhibitors, but the reactions aren’t as seri-
interact with these
ous as with tyramine-rich foods. drugs and produce
hypertensive crisis.
Adverse reactions
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Administering MAO inhibitors in small, divided doses may relieve

some of the following adverse reactions:
• hypertensive crisis (when taken with tyramine-rich foods)
• orthostatic hypotension
• restlessness, drowsiness, dizziness, and insomnia
• headache
• constipation, anorexia, and nausea and vomiting
• weakness and joint pain
• dry mouth
• blurred vision
• peripheral edema
• urine retention and transient impotence
• rash
• skin and mucous membrane hemorrhage.

Nursing Pharmacology_Chap11.indd 457 1/28/2012 12:35:24 PM

PSYCHOTROPIC DRUGS
458

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with MAO inhibitors.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter.
• Assess the patient for risk of self-harm.
• Obtain baseline blood pressure, heart rate, complete blood
count (CBC), and liver function test results before beginning ther-
apy; monitor these throughout treatment.
• Assess for adverse reactions and drug interactions.
• Assess the patient’s and family’s knowledge of drug therapy.

Key nursing diagnoses

• Ineffective coping related to presence of depression
• Risk for injury related to drug-induced adverse CNS reactions
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s ability to cope will improve.
• The risk of injury to the patient will be minimized.
• The patient and his family will demonstrate an understanding of
drug therapy. Signs of MAO
inhibitor overdose
Implementation include palpitations,
• The dosage is usually reduced to a maintenance level as soon as severe hypotension,
and frequent
possible. headaches.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Don’t withdraw the drug abruptly.

• Discontinue MAO inhibitors 14 days before elective surgery as
indicated to avoid interaction with anesthetics.
• If the patient develops symptoms of overdose (such as palpita-
tions, severe hypotension, or frequent headaches), withhold the
dose and notify the prescriber.
• Have phentolamine available to combat severe hypertension.
• Continue precautions for 10 days after stopping the drug
because it has long-lasting effects.

Evaluation
• Patient’s behavior and communication exhibit improved
thought processes.
• Patient doesn’t experience injury from adverse CNS reactions.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about MAO inhibitors.)

Nursing Pharmacology_Chap11.indd 458 1/28/2012 12:35:24 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
459

Education edge

Teaching about MAO inhibitors

If monoamine oxidase (MAO) inhibitors are prescribed, • Sit up for 1 minute before getting out of bed to avoid
review these points with the patient and his caregivers: dizziness.
• Avoid foods high in tyramine (such as aged cheese, • Avoid overexertion because MAO inhibitors may sup-
red wine, beer, avocados, chocolate, and meat tender- press angina.
izers) as well as large amounts of caffeine. Tranylcypro- • Consult the prescriber before taking other prescription
mine is the MAO inhibitor most commonly reported to or over-the-counter drugs. Severe adverse effects can
cause hypertensive crisis with ingestion of foods high in occur if MAO inhibitors are taken with cold or hay fever
tyramine. medications or diet aids.
• Don’t stop taking the drug suddenly.

TCAs
TCAs are used to treat depression. They include:
• amitriptyline hydrochloride
• amoxapine
• clomipramine
• desipramine
• doxepin
• imipramine hydrochloride
• imipramine pamoate
• nortriptyline
• protriptyline
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• trimipramine.

Pharmacokinetics
All of the TCAs are active pharmacologically, and some of their
metabolites are also active. They’re absorbed completely when
taken orally but undergo first-pass effect.

Passing it on
With first-pass effect, a drug passes from the GI tract to the liver,
where it’s partially metabolized before entering the circulation.
TCAs are metabolized extensively in the liver and eventually
excreted in urine as inactive compounds. Only small amounts of
active drug are excreted in urine.

Oh-so-soluble
The extreme fat solubility of these drugs accounts for their wide dis-
tribution throughout the body, slow excretion, and long half-lives.

Nursing Pharmacology_Chap11.indd 459 1/28/2012 12:35:24 PM

PSYCHOTROPIC DRUGS
460

Pharmacodynamics
Now, just relax.
Researchers believe that TCAs increase the amount of norepi-
I’m here to prevent
nephrine, serotonin, or both in the CNS by preventing their your reuptake of
reuptake (reentry) into the storage granules in the presynaptic norepinephrine and
nerves. Preventing reuptake results in increased levels of these serotonin, which
neurotransmitters in the synapses, relieving depression. TCAs also should help you feel
block acetylcholine and histamine receptors. less depressed.

Pharmacotherapeutics
TCAs are used to treat episodes of major depression. They’re
especially effective in treating depression of insidious onset
accompanied by weight loss, anorexia, or insomnia. Physical
signs and symptoms may respond after 1 to 2 weeks of ther-
apy; psychological symptoms, after 2 to 4 weeks.
Working together
TCAs may be helpful when used with a mood stabilizer in treating
acute episodes of depression in patients with type 1 bipolar disorder.
Additional assistance
TCAs are also used to prevent migraine headaches and to treat:
• panic disorder with agoraphobia
• urinary incontinence
• ADHD
• obsessive-compulsive disorder
• diabetic neuropathy
• enuresis. (See Tricyclic antidepressants: Imipramine.)
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

Prototype pro

Tricyclic antidepressants: Imipramine

Actions Nursing considerations
• May inhibit the reuptake of norepinephrine and serotonin • Monitor the patient for adverse reactions, such as seda-
in central nervous system (CNS) nerve terminals (presyn- tion, anticholinergic effects, and orthostatic hypotension.
aptic neurons), thus enhancing the concentration and • Don’t withdraw the drug abruptly; gradually reduce the
activity of neurotransmitters in the synaptic cleft dosage over several weeks.
• Exerts antihistaminic, sedative, anticholinergic, vasodila- • Warn the patient to avoid hazardous activities that
tory, and quinidine-like effects require alertness and psychomotor coordination until the
CNS effects of the drug are known.
Indications
• Depression
• Enuresis in children older than age 6

Nursing Pharmacology_Chap11.indd 460 1/28/2012 12:35:25 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
461

Drug interactions
TCAs interact with several commonly used drugs:
• TCAs increase the catecholamine effects of amphetamines and
sympathomimetics, leading to hypertension.
• Barbiturates increase the metabolism of TCAs and decrease
their blood levels.
• Cimetidine impairs the metabolism of TCAs by the liver,
increasing the risk of toxicity.

Temperature’s rising
• Using TCAs concurrently with MAO inhibitors may cause
an extremely elevated body temperature, excitation, and
seizures.
• An increased anticholinergic effect, such as dry mouth, urine
retention, and constipation, is seen when anticholinergic drugs are
taken with TCAs.
• TCAs reduce the antihypertensive effects of clonidine and gua-
nethidine.

Adverse reactions
Adverse reactions to TCAs include:
• orthostatic hypotension
• sedation
• jaundice TCAs increase
the effects of
• rashes and photosensitivity reactions anticholinergic
• resting tremor drugs, which can
• decreased sexual desire and inhibited ejaculation result in dry mouth,
• transient eosinophilia urine retention, and
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• reduced white blood cell (WBC) count constipation.

• manic episodes (in patients with or without bipolar disorder)
• exacerbation of psychotic symptoms in susceptible patients.

On the rare side

Although rare, TCA therapy may also lead to:
• granulocytopenia
• palpitations
• conduction delays
• rapid heartbeat
• impaired cognition and cardiovascular effects.

Deadly desipramine?
Sudden death has occurred in children and adolescents taking
desipramine. Obtain a baseline electrocardiogram (ECG) in these
patients before giving a TCA.

Nursing Pharmacology_Chap11.indd 461 1/28/2012 12:35:25 PM

PSYCHOTROPIC DRUGS
462

Education edge

Teaching about TCAs

If tricyclic antidepressants (TCAs) are prescribed, review • Avoid alcohol while taking TCAs.
these points with the patient and his caregivers: • Avoid hazardous tasks that require mental alertness until
• Know the risks and benefits of therapy. The full thera- the drug’s full effects are known.
peutic effect may not occur for several weeks. • Excessive exposure to sunlight, heat lamps, or tan-
• Take the drug exactly as prescribed. Don’t increase ning beds may cause burns and abnormal hyperpig-
the dosage, stop the drug, or take another drug (includ- mentation.
ing over-the-counter drugs and herbal remedies) without • If you have diabetes, monitor your glucose level care-
medical approval. fully because the drug may alter it.
• Because an overdose with TCAs is commonly fatal, • Chew sugarless gum, suck on hard candy or ice chips,
entrust a reliable family member with the drug and warn or use artificial saliva to relieve dry mouth.
him to store it safely away from children. • Report adverse reactions promptly.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with TCAs.

Assessment
• Check an ECG in children and adolescents and in patients older
than age 40 before starting therapy.
• Observe the patient for mood changes to monitor drug effective-
ness; benefits may not appear for 2 to 4 weeks.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Assess the patient’s vital signs regularly for decreased blood

pressure or tachycardia (fast heart rate); observe him carefully for
other adverse reactions, and report changes. In particular, assess
him for anticholinergic adverse reactions (dry mouth, urine reten-
tion, or constipation), which may require a dosage reduction.

Key nursing diagnoses

• Ineffective coping related to adverse effects
• Risk for injury related to sedation and orthostatic hypotension
• Noncompliance related to long-term therapy

Planning outcome goals

• The patient’s ability to cope will improve.
• The risk of injury to the patient will be minimized.
• The patient will comply with therapy.

Nursing Pharmacology_Chap11.indd 462 1/28/2012 12:35:26 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
463

Implementation
• Make sure that the patient swallows each dose; a depressed Withdraw TCAs
patient may hoard pills for a suicide attempt, especially when gradually over
several weeks to
symptoms begin to improve.
avoid a rebound
• Don’t withdraw the drug abruptly; gradually reduce the dosage effect or other
over several weeks to avoid a rebound effect or other adverse adverse reactions.
reactions.
• Follow the manufacturer’s instructions for reconstitution, dilu-
tion, and storage of drugs.

Evaluation
• Patient develops adequate coping mechanisms.
• Patient sustains no injury from adverse reactions.
• Patient complies with therapy. (See Teaching about TCAs.)

Miscellaneous antidepressants
Other antidepressants in use today include:
• maprotiline and mirtazapine, tetracyclic antidepressants
• bupropion, a dopamine reuptake–blocking drug
• venlafaxine and duloxetine, serotonin-norepinephrine reuptake
inhibitors
• trazodone, a triazolopyridine drug
• nefazodone, a phenylpiperazine drug.

Pharmacokinetics
The paths these antidepressants take through the body may vary:
• Maprotiline and mirtazapine are absorbed from the GI tract, dis-
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

tributed widely in the body, metabolized by the liver, and excreted

by the kidneys.
• Bupropion is well absorbed from the GI tract and metabolized
by the liver. Its metabolites are excreted by the kidneys. It appears
to be highly bound to plasma proteins.
• Venlafaxine and duloxetine are rapidly absorbed after oral
administration, metabolized in the liver, and excreted in urine.
• Venlafaxine is partially bound to plasma proteins; in contrast,
duloxetine is highly bound to albumin.
• Trazodone is well absorbed from the GI tract, distributed widely
in the body, and metabolized by the liver. About 75% is excreted in
urine. The rest is excreted in feces.
• Nefazodone is rapidly and completely absorbed but because
of extensive metabolism, only about 20% of the drug is available.
The drug is almost completely bound to plasma proteins and is
excreted in urine.

Nursing Pharmacology_Chap11.indd 463 1/28/2012 12:35:26 PM

PSYCHOTROPIC DRUGS
464

Pharmacodynamics
Nefazodone is
Much about how these drugs work has yet to be fully understood: effective in treating
• Maprotiline and mirtazapine probably increase the amount of both anxiety and
norepinephrine, serotonin, or both in the CNS by blocking their depression.
reuptake by presynaptic neurons (nerve terminals).

Rethinking reuptake
• Bupropion was once thought to inhibit the reuptake of the
neurotransmitter dopamine; however, its action is more likely on
nonadrenergic receptors.
• Venlafaxine and duloxetine are thought to potentiate neu-
rotransmitter activity in the CNS by inhibiting the neural reuptake
of serotonin and norepinephrine.
• Trazodone, although its effect is unknown, is thought to exert
antidepressant effects by inhibiting the reuptake of norepineph-
rine and serotonin in the presynaptic neurons.
• Nefazodone’s action isn’t precisely defined. It inhibits neuro-
nal uptake of serotonin and norepinephrine. It’s also a serotonin
antagonist, which explains its effectiveness in treating anxiety.

Pharmacotherapeutics
These miscellaneous drugs are all used to treat depression. Tra-
zodone may also be effective in treating aggressive behavior and
panic disorder. Nefazodone is sometimes used to treat anxiety.

Drug interactions
All of these antidepressants may have serious, potentially fatal
reactions when combined with MAO inhibitors. Each of these drugs
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

also carries individual, specific risks when used with other drugs:
• Maprotiline and mirtazapine interact with CNS depressants,
resulting in additive effects.
• Bupropion, when combined with levodopa, phenothiazines, or
TCAs, increases the risk of adverse reactions, including seizures.
• Trazodone may increase serum levels of digoxin and phenytoin.
Its use with antihypertensive drugs may cause increased hypo-
tensive effects. CNS depression may be enhanced if trazodone is
administered with other CNS depressants.
• Nefazodone may increase the digoxin level if administered with
digoxin, and it increases CNS depression when combined with
CNS depressants.

Adverse reactions
Adverse reactions to maprotiline include:
• seizures
• orthostatic hypotension

Nursing Pharmacology_Chap11.indd 464 1/28/2012 12:35:26 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
465

• tachycardia
• ECG changes.

Mirtazapine maladies
Mirtazapine may cause:
• tremors
• confusion
• nausea
• constipation.

Bupropion blues
These adverse reactions may occur with bupropion: Several of the
• headache antidepressants
can cause nausea.
• confusion
No, thank you!
• tremor
• agitation
• tachycardia
• anorexia
• nausea and vomiting.

Venlafaxine, duloxetine, and nefazodone negatives

Adverse reactions to venlafaxine, duloxetine, and nefazodone include:
• headache
• somnolence
• dizziness
• nausea.

• drowsiness
• dizziness.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with miscellaneous antidepressants.

Key nursing diagnoses

• Ineffective coping related to the underlying condition
• Insomnia related to drug therapy
• Deficient knowledge related to drug therapy

Nursing Pharmacology_Chap11.indd 465 1/28/2012 12:35:26 PM

PSYCHOTROPIC DRUGS
466

Planning outcome goals

• The patient’s ability to cope will improve. Antidepressants
• The patient’s insomnia will improve. such as bupropion
should be taken
• The patient and his family will demonstrate an understanding of
in the morning.
drug therapy. Otherwise, insomnia
may result—and
Implementation I’m tired of counting
• Elderly or debilitated patients and patients with renal or hepatic sheep.
dysfunction may need lower dosages or less frequent dosing.
• Give these drugs in the morning to prevent insomnia, unless
otherwise directed.
• Administer the drugs as prescribed.
• Monitor the patient for effects of drug therapy.

Evaluation
• Patient’s behavior and communication indicate improvement of
depression with drug therapy.
• Patient has no insomnia with drug use.
• Patient and his family demonstrate an understanding of drug
therapy.

Lithium
Lithium carbonate and lithium citrate are mood stabilizers used to
prevent or treat mania. The discovery of lithium was a milestone
in treating mania and bipolar disorders.
Yes, but we
I hear excessive lithium tablets
Pharmacokinetics may regulate
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

catecholamine
When taken orally, lithium is absorbed rapidly stimulation catecholamine
and completely and is distributed to body tis- results in mania, release to
and diminished treat mania
sues. An active drug, lithium isn’t metabolized
catecholamine and bipolar
and is excreted from the body unchanged. disorders.
stimulation causes
depression. Pretty cool, eh?
Pharmacodynamics
In mania, one theory is that the patient expe-
riences excessive catecholamine stimulation.
In bipolar disorder, the patient is affected by
swings between the excessive catecholamine
stimulation of mania and the diminished catechol-
amine stimulation of depression.

Nursing Pharmacology_Chap11.indd 466 1/28/2012 12:35:26 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
467

Curbing catecholamines
Lithium’s exact mechanism is unknown. A few of the ways it may
regulate catecholamine release in the CNS are by:
• increasing norepinephrine and serotonin uptake
• reducing the release of norepinephrine from the synaptic
vesicles (where neurotransmitters are stored) in the presynaptic
neuron
• inhibiting norepinephrine’s action in the postsynaptic neuron.

Under study
Researchers are also examining lithium’s effects on electrolyte
and ion transport. It may also modify actions of second messen-
gers, such as cyclic adenosine monophosphate.

Pharmacotherapeutics
Lithium is used primarily to treat acute episodes of mania and to
prevent relapses of bipolar disorders. Other uses of lithium being
researched include preventing unipolar depression and migraine
headaches and treating depression, alcohol dependence, anorexia
nervosa, syndrome of inappropriate antidiuretic hormone, and Lithium has a
neutropenia. narrow therapeutic
margin. A blood
level even a little
Drug interactions higher than the
Lithium has a narrow therapeutic margin of safety. A blood level therapeutic level
can be dangerous.
that’s even slightly higher than the therapeutic level can be dan-
gerous. Serious interactions with other drugs can occur because
of this narrow therapeutic range:
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• The risk of lithium toxicity increases when lithium is taken with

thiazide and loop diuretics and nonsteroidal anti-inflammatory
drugs.
• Administration of lithium with haloperidol, phenothiazines, and
carbamazepine may produce an increased risk of neurotoxicity.
• Lithium may increase the hypothyroid effects of potassium
iodide.
• Sodium bicarbonate may increase lithium excretion, reducing
its effects.
• Lithium’s effects are reduced when taken with theophylline.

Salt at fault?
• A patient on a severe salt-restricted diet is susceptible to lithium
toxicity. On the other hand, an increased intake of sodium may
reduce the therapeutic effects of lithium.

Nursing Pharmacology_Chap11.indd 467 1/28/2012 12:35:27 PM

PSYCHOTROPIC DRUGS
468

Adverse reactions
Common adverse reactions to lithium include:
• reversible ECG changes
• thirst
• polyuria
• elevated WBC count.

Toxic times
Toxic blood levels of lithium may produce:
• confusion
• lethargy
• slurred speech Remember: It may
• increased reflex reactions take 1 to 3 weeks
to notice lithium’s
• seizures.
beneficial effects.

Nursing process
These nursing process steps are appropriate for patients undergo-
ing treatment with lithium.

Assessment
• Assess the patient’s condition before therapy and regularly
thereafter. Expect a delay of 1 to 3 weeks before the drug’s benefi-
cial effects are noticed.
• Obtain a baseline ECG, thyroid and kidney studies, and elec-
trolyte levels. Monitor lithium blood levels 8 to 12 hours after the
first dose, usually before the morning dose, two or three times
weekly in the first month, and then weekly to monthly during
maintenance therapy.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Perform outpatient follow-up of thyroid and kidney function

every 6 to 12 months. Palpate the thyroid to check for enlargement.
• Assess for adverse reactions and drug interactions.

Key nursing diagnoses

• Ineffective coping related to manic disorder
• Ineffective health maintenance related to drug-induced endo-
crine dysfunction
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient’s ability to cope will improve.
• The patient’s health status will improve.
• The patient and his family will demonstrate an understanding of
drug therapy.

Nursing Pharmacology_Chap11.indd 468 1/28/2012 12:35:27 PM

ANTIDEPRESSANT AND MOOD STABILIZER DRUGS
469

Education edge

Teaching about lithium

If lithium is prescribed, review these points with the • Expect transient nausea, polyuria, thirst, and discomfort
patient and his caregivers: during the first few days of therapy.
• Take the drug with plenty of water and after meals to • Avoid activities that require alertness and good psycho-
minimize GI upset. motor coordination until the drug’s central nervous system
• Lithium has a narrow therapeutic margin of safety. effects are known.
A blood level that’s even slightly high can be dangerous. • Don’t switch brands or take other prescription or over-
• Watch for signs and symptoms of toxicity, such as diar- the-counter drugs without the prescriber’s approval.
rhea, vomiting, tremor, drowsiness, muscle weakness, and • Wear or carry medical identification.
ataxia. Withhold one dose of the drug and call the prescrib-
er if toxic symptoms appear. Don’t stop the drug abruptly.

Implementation
• Determination of lithium blood levels is crucial to safe use of
the drug. Lithium shouldn’t be used in a patient who can’t have his
blood levels checked regularly.
• Give the drug with plenty of water and after meals to minimize
GI reactions and metallic taste.
• Before leaving the bedside, make sure that the patient has swal-
lowed the drug.
• Notify the prescriber if the patient’s behavior hasn’t improved in
3 weeks or if it worsens.
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• Adverse reactions usually are mild when the blood level of

lithium remains below 1.5 mEq/L.
• If the patient has diuresis, check his urine specific gravity and
report a level below 1.005, which may indicate diabetes insipidus.
• Lithium may alter glucose tolerance in a patient with diabetes.
Monitor his glucose level closely.

Evaluation
• Patient develops adequate coping mechanisms.
• Patient maintains normal endocrine function throughout
therapy.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about lithium.)

Nursing Pharmacology_Chap11.indd 469 1/28/2012 12:35:27 PM

PSYCHOTROPIC DRUGS
470

Antipsychotic drugs Antipsychotic

drugs can
control psychotic
Antipsychotic drugs can control psychotic symptoms (delusions, symptoms, such
hallucinations, and thought disorders) that can occur with schizo- as delusions,
phrenia, mania, and other psychoses. hallucinations, and
thought disorders.
The name game
Drugs used to treat psychoses have several different names,
including:
• antipsychotic, because they can eliminate signs and symptoms
of psychoses
• major tranquilizer, because they can calm an agitated patient
• neuroleptic, because they have an adverse neurobiologic
effect that causes abnormal body movements.

One…or the other

Regardless of what they’re called, all antipsychotic drugs
belong to one of two major groups:

atypical antipsychotics

typical antipsychotics.

Atypical antipsychotics I‘m not your

run-of-the-mill
Atypical antipsychotics are drugs designed to treat schizophrenia. antipsychotic. I block
They include: the activity of two
• clozapine receptors, dopamine
Copyright © 2012. Wolters Kluwer Health. All rights reserved.

• olanzapine and serotonin, to

• risperidone treat schizophrenia.
• quetiapine
• ziprasidone
• aripiprazole.

Pharmacokinetics
Atypical antipsychotics are absorbed after oral administra-
tion. They’re metabolized by the liver. Metabolites of clozapine,
quetiapine, ziprasidone, and olanzapine are inactive, whereas
risperidone has an active metabolite. They’re highly plasma
protein–bound and eliminated in urine, with a small portion
eliminated in feces.

Nursing Pharmacology_Chap11.indd 470 1/28/2012 12:35:28 PM

Complete Bundle Discovering Behavioral Neuroscience An Introduction To Biological Psychology 5th Edition Freberg HQ File
No ratings yet
Complete Bundle Discovering Behavioral Neuroscience An Introduction To Biological Psychology 5th Edition Freberg HQ File
412 pages
Study Guide For Maternal Child Nursing Care (5th Edition) PDF
No ratings yet
Study Guide For Maternal Child Nursing Care (5th Edition) PDF
10 pages
Med-Surg Success: A Q&A Review Applying Critical Thinking To Test Taking
No ratings yet
Med-Surg Success: A Q&A Review Applying Critical Thinking To Test Taking
414 pages
Pharmacotherapeutics For Nurse Practitioner Prescribers Second Edition Wynne Complete Edition
No ratings yet
Pharmacotherapeutics For Nurse Practitioner Prescribers Second Edition Wynne Complete Edition
144 pages
April CXC Exam Plus Answers 2016 (30753)
91% (11)
April CXC Exam Plus Answers 2016 (30753)
15 pages
Testbank and Solutions For Davis Advantage For Townsends Essentials of Psychiatric Mental Health Nursing 9th Edition Morgan
No ratings yet
Testbank and Solutions For Davis Advantage For Townsends Essentials of Psychiatric Mental Health Nursing 9th Edition Morgan
18 pages
Growth and Development Across The Lifespan 3rd Edition Leifer Solution Manual Unlocked Test Bank
0% (1)
Growth and Development Across The Lifespan 3rd Edition Leifer Solution Manual Unlocked Test Bank
330 pages
GNR Nclex-Rn Review Book
No ratings yet
GNR Nclex-Rn Review Book
1,011 pages
Antacids: Nursing Pharmacology Guide
No ratings yet
Antacids: Nursing Pharmacology Guide
6 pages
Antacids: Antacids Are Used To Chemically React With and Neutralize The Acid in The Stomach. They Can
No ratings yet
Antacids: Antacids Are Used To Chemically React With and Neutralize The Acid in The Stomach. They Can
6 pages
Saunders Comprehensive Review For The NCLEX-PN® Examination (Angela Silvestri)
No ratings yet
Saunders Comprehensive Review For The NCLEX-PN® Examination (Angela Silvestri)
1,042 pages
AHA 2023 Focused Update On ACLS 1702938997
100% (2)
AHA 2023 Focused Update On ACLS 1702938997
20 pages
Testbank For Lehnes Pharmacology For Nursing Care 11th Edition Burchum Solution Manual
No ratings yet
Testbank For Lehnes Pharmacology For Nursing Care 11th Edition Burchum Solution Manual
19 pages
Chapter 1+2+GSCM
No ratings yet
Chapter 1+2+GSCM
45 pages
Psychiatric Care Plans
No ratings yet
Psychiatric Care Plans
652 pages
Pediatric Pharmacology 07
No ratings yet
Pediatric Pharmacology 07
45 pages
Nursing Pathophysiology Guide
100% (1)
Nursing Pathophysiology Guide
53 pages
A&P Coloring Workbook - The Urinary System PDF
No ratings yet
A&P Coloring Workbook - The Urinary System PDF
19 pages
Neuro Notes
No ratings yet
Neuro Notes
15 pages
Student Workbook For Med Dosage
No ratings yet
Student Workbook For Med Dosage
160 pages
Model Analysis
100% (3)
Model Analysis
7 pages
Fragile X Syndrome - Clinical Features A... in Children and Adolescents - UpToDate
No ratings yet
Fragile X Syndrome - Clinical Features A... in Children and Adolescents - UpToDate
23 pages
Renr Practice Test 9 Final
100% (2)
Renr Practice Test 9 Final
12 pages
Module 7 Intangibles
No ratings yet
Module 7 Intangibles
14 pages
Recovery CDs
No ratings yet
Recovery CDs
6 pages
Chapter 10 and 51: Fetal Development and Genetics Care of A Child With A Genetic Disorder
No ratings yet
Chapter 10 and 51: Fetal Development and Genetics Care of A Child With A Genetic Disorder
70 pages
Service Manual: Viewsonic Pjd6211
No ratings yet
Service Manual: Viewsonic Pjd6211
60 pages
Renr Practice Test 11
No ratings yet
Renr Practice Test 11
13 pages
Universal Shipbuilding Corporation: Single Loop Electro-Hydraulic Steering Gear S.No.038 TYPE
No ratings yet
Universal Shipbuilding Corporation: Single Loop Electro-Hydraulic Steering Gear S.No.038 TYPE
125 pages
Implementing Competency-Based Education
No ratings yet
Implementing Competency-Based Education
14 pages
Szymanowski List of Compositions
No ratings yet
Szymanowski List of Compositions
12 pages
Renr Practice Test 4 Final
100% (1)
Renr Practice Test 4 Final
12 pages
RENR Test Prep 2017
100% (4)
RENR Test Prep 2017
12 pages
9 A. Factory - Cost
No ratings yet
9 A. Factory - Cost
4 pages
Chapter 3 BJT
No ratings yet
Chapter 3 BJT
58 pages
Sample CV
No ratings yet
Sample CV
6 pages
HPS Tylenol Peds
100% (1)
HPS Tylenol Peds
3 pages
Peds Nursing Reference
No ratings yet
Peds Nursing Reference
6 pages
Preparation 7 - Ointments
No ratings yet
Preparation 7 - Ointments
8 pages
Lab Values
No ratings yet
Lab Values
1 page
Differential Diagnosis Book
No ratings yet
Differential Diagnosis Book
101 pages
Renr Practice Test 5 Final
No ratings yet
Renr Practice Test 5 Final
14 pages
Psychiatric Nursing Bullets Neurotransmission Theory
100% (1)
Psychiatric Nursing Bullets Neurotransmission Theory
4 pages
Tilting Vice PDF
No ratings yet
Tilting Vice PDF
33 pages
Renr Review Practice Test 9
100% (1)
Renr Review Practice Test 9
10 pages
Renr Practice Test 10 Final
100% (1)
Renr Practice Test 10 Final
13 pages
Nursing Exam Prep for Teens
67% (6)
Nursing Exam Prep for Teens
13 pages
Antidepressant Cheat Sheet: TCA Ssri Snri
No ratings yet
Antidepressant Cheat Sheet: TCA Ssri Snri
1 page
DELTA V PDS S-Series Horizontal Carriers
No ratings yet
DELTA V PDS S-Series Horizontal Carriers
7 pages
Management by Walking Around
100% (2)
Management by Walking Around
7 pages
Nursing Exam Prep: Gastrointestinal Focus
No ratings yet
Nursing Exam Prep: Gastrointestinal Focus
16 pages
Septic Shock NCLEX Review
No ratings yet
Septic Shock NCLEX Review
3 pages
Why Choose Jolly Phonics Flyer - 250125 - 035602
No ratings yet
Why Choose Jolly Phonics Flyer - 250125 - 035602
8 pages
MH Notes
100% (2)
MH Notes
28 pages
Nursing School Study Checklist Cheat Sheet
100% (1)
Nursing School Study Checklist Cheat Sheet
6 pages
AGBs Made Incredibly Easy
100% (1)
AGBs Made Incredibly Easy
5 pages
LSD Thesis Statement
100% (3)
LSD Thesis Statement
5 pages
NLN Pharmacology Study Guide
No ratings yet
NLN Pharmacology Study Guide
65 pages
Nursing Pharmacology 3
No ratings yet
Nursing Pharmacology 3
119 pages
9 RWS PT 4 Math Nida 202425
No ratings yet
9 RWS PT 4 Math Nida 202425
2 pages
Free Incoming Inspection Template
No ratings yet
Free Incoming Inspection Template
5 pages
Nursing Practice Test Prep
100% (1)
Nursing Practice Test Prep
13 pages
Survey-Questionnaire On Teachers Perception Re Distance Blended Learning
100% (1)
Survey-Questionnaire On Teachers Perception Re Distance Blended Learning
5 pages
Perry: Maternal Child Nursing Care, 4 Edition: Chapter 10: Anatomy and Physiology of Pregnancy Test Bank Multiple Choice
100% (3)
Perry: Maternal Child Nursing Care, 4 Edition: Chapter 10: Anatomy and Physiology of Pregnancy Test Bank Multiple Choice
13 pages
Medical Term Digestive System
No ratings yet
Medical Term Digestive System
65 pages
IIT JEE Organic Chemistry Solutions
100% (3)
IIT JEE Organic Chemistry Solutions
15 pages
$r2u158z PDF
No ratings yet
$r2u158z PDF
294 pages
$r2u158z PDF
No ratings yet
$r2u158z PDF
294 pages
Nursing Diagnosis Using NANDA
0% (1)
Nursing Diagnosis Using NANDA
9 pages
Maintenance of Capital
No ratings yet
Maintenance of Capital
36 pages
ENDOCRINE DISORDERS (Autosaved)
No ratings yet
ENDOCRINE DISORDERS (Autosaved)
81 pages
NTA IGNOU PHD Entrance Exam Syllabus
No ratings yet
NTA IGNOU PHD Entrance Exam Syllabus
85 pages
KEY April 1997 Paper 3 Functional Nursing Essay - Type Test Items Item 1
No ratings yet
KEY April 1997 Paper 3 Functional Nursing Essay - Type Test Items Item 1
6 pages
Arterial Blood Gases Analysis: Adult Health Ii
No ratings yet
Arterial Blood Gases Analysis: Adult Health Ii
16 pages
List - Ipynb - Colaboratory
No ratings yet
List - Ipynb - Colaboratory
4 pages
Simple Sabotage Field Manual
50% (2)
Simple Sabotage Field Manual
16 pages
ATI Fundamentals Proctored Exam
No ratings yet
ATI Fundamentals Proctored Exam
79 pages
Research On The Impact of E-Commerce On Offline Re
No ratings yet
Research On The Impact of E-Commerce On Offline Re
5 pages
October 1998 Paper 1 Clinical Nursing Essay - Type Test Items
No ratings yet
October 1998 Paper 1 Clinical Nursing Essay - Type Test Items
3 pages
Lab Values 63 Must Know Labs For Nurses PDF
No ratings yet
Lab Values 63 Must Know Labs For Nurses PDF
2 pages
Distance Learning Courses DLEN
No ratings yet
Distance Learning Courses DLEN
35 pages
Refelctive Journal Development 346
100% (1)
Refelctive Journal Development 346
2 pages
April 2001 Paper 3 Functional Nursing Essay - Type Test Items
No ratings yet
April 2001 Paper 3 Functional Nursing Essay - Type Test Items
2 pages
October 1997 Paper 1 Clinical Nursing Essay - Type Test Items
No ratings yet
October 1997 Paper 1 Clinical Nursing Essay - Type Test Items
2 pages
Nursing Functional Essay Test Items
No ratings yet
Nursing Functional Essay Test Items
2 pages
Key April 1997 Functional Nursing-Objective Type Questions
No ratings yet
Key April 1997 Functional Nursing-Objective Type Questions
1 page
Key October 2000 Functional Nursing-Objective Type Questions Paper Iv
No ratings yet
Key October 2000 Functional Nursing-Objective Type Questions Paper Iv
1 page
Key October 1998 Functional Nursing-Objective Type Questions Paper Iv
No ratings yet
Key October 1998 Functional Nursing-Objective Type Questions Paper Iv
1 page
Design & Implement Trash Rack Cleaning System
No ratings yet
Design & Implement Trash Rack Cleaning System
23 pages
Certified Safety Professional Certificat
No ratings yet
Certified Safety Professional Certificat
4 pages
Nursing Concepts and Historical Development
No ratings yet
Nursing Concepts and Historical Development
1 page
Maternal Hesi Q R
25% (4)
Maternal Hesi Q R
1 page
Maternity Antepartum Genetic Testing
No ratings yet
Maternity Antepartum Genetic Testing
21 pages
Renr Review Practice Test 3: Healthcare Services. What Is One of The Goals of Managed Care?
0% (1)
Renr Review Practice Test 3: Healthcare Services. What Is One of The Goals of Managed Care?
9 pages
Pediatric Study Guide
No ratings yet
Pediatric Study Guide
7 pages
Chapter 2: Assessments For The Resident Assessment Instrument (Rai)
100% (1)
Chapter 2: Assessments For The Resident Assessment Instrument (Rai)
69 pages
Davis Advantage For Basic Nursing Thinking Doing and Caring 3rd Edition Treas Full Download
No ratings yet
Davis Advantage For Basic Nursing Thinking Doing and Caring 3rd Edition Treas Full Download
406 pages
Pharmacotherapeutics For Advanced Practice Nurse Prescribers (Fifth Edition) Teri Moser Woo & Marylou V. Robinson PDF Download
100% (5)
Pharmacotherapeutics For Advanced Practice Nurse Prescribers (Fifth Edition) Teri Moser Woo & Marylou V. Robinson PDF Download
46 pages
Mechatronics Project: Linear Displacement Indicator
No ratings yet
Mechatronics Project: Linear Displacement Indicator
6 pages
McCance and Huethers Pathophysiology 9th Edition Rogers HQ File Fast Access
No ratings yet
McCance and Huethers Pathophysiology 9th Edition Rogers HQ File Fast Access
333 pages
Disease Management Overview
No ratings yet
Disease Management Overview
1 page
Medication: Expected Pharmacological Action Therapeutic Use
No ratings yet
Medication: Expected Pharmacological Action Therapeutic Use
1 page
Advanced Pathophysiology Study
No ratings yet
Advanced Pathophysiology Study
7 pages
Behavioral Health Care Plan: Assessment Data
No ratings yet
Behavioral Health Care Plan: Assessment Data
9 pages
Draft: Jurisprudence Learning Module & Examination
No ratings yet
Draft: Jurisprudence Learning Module & Examination
45 pages
TEAS V Summary Packet
100% (2)
TEAS V Summary Packet
8 pages
Independent Nurse Practitioner - Its Future & Scope
67% (3)
Independent Nurse Practitioner - Its Future & Scope
34 pages
Fundamentals of Nursing
No ratings yet
Fundamentals of Nursing
18 pages
N461 - Final Exam Study Guide - RN-BS - Spring 2017
No ratings yet
N461 - Final Exam Study Guide - RN-BS - Spring 2017
7 pages
Behavioral Health Care Plan
No ratings yet
Behavioral Health Care Plan
13 pages
Nur 411 Syllabus Fall 2011 Part 2
No ratings yet
Nur 411 Syllabus Fall 2011 Part 2
34 pages
NCLEXLaminate 2008
100% (1)
NCLEXLaminate 2008
2 pages
The Nursing Process - Powerpoint
No ratings yet
The Nursing Process - Powerpoint
39 pages