1.9th editionAdriana TizianiHAVARDSTO DRUGSNURSINGGUIDESample chapter

2. HAVARDSNURSING GUIDE TO DRUGS9TH EDITIONADRIANA TIZIANIRN, BSC (MON), DIPED (MELB), MEDST (MON)Sample chapter 3. Mosbyis an imprint of ElsevierElsevier Australia. ACN 001 002 357(a division of Reed International Books Australia Pty Ltd)Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 2013 Elsevier AustraliaThis publication is copyright. Except as expressly provided in the Copyright Act 1968and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publicationmay be reproduced, stored in any retrieval system or transmitted by any means (includingelectronic, mechanical, microcopying, photocopying, recording or otherwise) without priorwritten permission from the publisher.Every attempt has been made to trace and acknowledge copyright, but in some casesthis may not have been possible. The publisher apologises for any accidental infringementand would welcome any information to redress the situation.This publication has been carefully reviewed and checked to ensure that the content is asaccurate and current as possible at time of publication. We would recommend, however, thatthe reader verify any procedures, treatments, drug dosages or legal content described in thisbook. Neither the author, the contributors, nor the publisher assume any liability for injuryand/or damage to persons or property arising from any error in or omission from this publication.National Library of Australia Cataloguing-in-Publication Data___________________________________________________________________Tiziani, Adriana, author.Havards nursing guide to drugs / Adriana Tiziani.9th edition9780729541411 (paperback)NursingHandbooks, manuals, etc.DrugsHandbooks, manuals, etc.615.1___________________________________________________________________Publishing Director: Luisa CecottiPublisher: Libby HoustonDevelopmental Editor: Elizabeth CoadyProject Manager: Liz MalcolmEdited by Margaret TrudgeonTechnical editing by Jerry Perkins BSc, BPharm and Lynne MacKinnon BPharmProofread by Tim LearnerIndexed by Robert SwansonCover and internal design by Darben DesignsTypeset by Midlands Typesetters, AustraliaPrinted in China by China Translation and Printing ServicesSample chapter 4. CONTENTS BY THERAPEUTIC CLASSPreface viiIntroduction ixAt a glance xxivPatient teaching and advice xxvAnalgesics, non-steroidal anti-inflammatory drugs (NSAIDs)and disease-modifyingantirheumatic drugs (DMARDs) 1Anorectics and weight-loss agents 43Antacids 46Anthelmintics 48Anti-Alzheimers agents 54Antianginal agents 59Antianxiety agents 72Antiarrhythmic agents 80Antiasthma agents andbronchodilators 94Antibacterial agents 119Anticoagulant andantithrombotic agents 180Antidepressants 201Antidiabetic agents 223Antidiarrhoeal agents 247Antidotes, antagonists andchelating agents 250Antiemetic agents 278Antiepileptics 291Antifungal agents 316Antigout and uricolytic agents 339Antihistamines 346Antihypertensive agents 355Antimalarial agents 394Antimigraine agents 404Antimycobacterial agents 417Antineoplastic agents 430Antineoplastic support agents 484Anti-Parkinsons agents 490Antiplatelet agents 509Antiprotozoal agents 521Antipsychotic agents 528Antiulcer agents 556Antiviral agents 567Bladder function disorder agents 605Bone- and calcium-regulatingagents 616Cardiac glycosides 634Cholinergic and anticholinergicagents 639Corticosteroids 648Cough suppressants, expectorantsand mucolytics 661Dermatological agents 667Diuretics 692Drug dependence 711Erectile dysfunction agents 723Eye, ear, nose and throat agents 729Fibrinolytic agents 774Gastrointestinal agents(miscellaneous) 780General anaesthetics 788Haemopoietic agents 797Haemostatics 804Hypothalamic and pituitaryhormones 816Immunomodifiers 837Laxatives 876Lipid-regulating agents 887Local anaesthetics 899Muscle relaxants 907Neuromuscular-blocking agents 914Opioid analgesics 922Pregnancy, childbirth andbreastfeeding 937Sedatives and hypnotics 963Sex hormones 973Stimulants 1003Sympathomimetic agents 1011Thyroid and antithyroid agents 1022Topical rectal medication 1031Vaccines, immunoglobulins andantivenoms 1034Vasodilators 1062Sample chapter 5. ivHAVARDS NURSING GUIDE TO DRUGSVitamins, minerals andelectrolytes 1070Miscellaneous agents 1099Appendix 1: Poisoning and itstreatment 1118Appendix 2: Poisons informationcentres and medicine informationcentres 1122Appendix 3: Alternative drugnames 1124Appendix 4: Normal referencevalues 1125Bibliography 1137Glossary 1143Index 1149Sample chapter 6. CONTENTS BY BODY SYSTEMCARDIOVASCULAR SYSTEMAntianginal agents 59Antiarrhythmic agents 80Anticoagulant and antithromboticagents 180Antihypertensive agents 355Antimigraine agents 404Antiplatelet agents 509Cardiac glycosides 634Diuretics 692Fibrinolytic agents 774Haemopoietic agents 797Haemostatics 804Lipid-regulating agents 887Sympathomimetic agents 1011Vasodilators 1062CENTRAL AND PERIPHERAL NERVOUSSYMPTOMSAnti-Alzheimers agents 54Antianxiety agents 72Antidepressants 201Antiemetic agents 278Antiepileptics 291Anti-Parkinsons agents 490Antipsychotic agents 528Cholinergic and anticholinergicagents 639Drug dependence 711General anaesthetics 788Local anaesthetics 899Opioid analgesics 922Sedatives and hypnotics 963Stimulants 1003RESPIRATORY SYSTEMAntiasthma agents andbronchodilators 94Cough suppressants, expectorantsand mucolytics 661DIGESTIVE SYSTEM, METABOLISM ANDNUTRITIONAnorectics and weight-loss agents 43Antacids 46Antidiarrhoeal agents 247Antiemetic agents 278Antiulcer agents 556Cholinergic and anticholinergicagents 639Gastrointestinal agents(miscellaneous) 780Laxatives 876Topical rectal medication 1031Vitamins, minerals andelectrolytes 1070MUSCULOSKELETAL SYSTEMAnalgesics, non-steroidal anti-inflammatory drugs (NSAIDs)and disease-modifyingantirheumatic drugs(DMARDs) 1Antigout and uricolytic agents 339Cholinergic and anticholinergicagents 639Muscle relaxants 907Neuromuscular-blocking agents 914ENDOCRINE SYSTEMAntidiabetic agents 223Bone- and calcium-regulatingagents 616Corticosteroids 648Hypothalamic and pituitaryhormones 816Thyroid and antithyroid agents 1022URINARY SYSTEMBladder function disorder agents 605Cholinergic and anticholinergicagents 639Diuretics 692REPRODUCTIVE SYSTEMErectile dysfunction agents 723Pregnancy, childbirth andbreastfeeding 937Sex hormones 973Sample chapter 7. viHAVARDS NURSING GUIDE TO DRUGSINTEGUMENTARY SYSTEMDermatological agents 667IMMUNE SYSTEMAntihistamines 346Antineoplastic agents 430Antineoplastic support agents 484Corticosteroids 648Immunomodifiers 837Vaccines, immunoglobulins andantivenoms 1034SPECIAL SENSESEye, ear, nose and throat agents 729INFECTION AND INFESTATIONSAnthelmintics 48Antibacterial agents 119Antifungal agents 316Antimalarial agents 394Antimycobacterial agents 417Antiprotozoal agents 521Antiviral agents 567MISCELLANEOUSAntidotes, antagonists andchelating agents 250Miscellaneous agents 1099Sample chapter 8. PrefaceThis is the 30th anniversary of the original Havards Nursing Guide to Drugs, thensimply called Nursing Guide to Drugs, written by Margaret Havard. Margaret was anurse educator and colleague who had worked for many years with hospital-trainednurses teaching pharmacology. Margarets recognition of a need for an Australianbook that would give nurses a guide to safe administration of medications to theirpatients gave her the impetus to write the first edition. Little did she imagine that 30years later this book would still be in production and being used in all types of patientsettings. This book is dedicated to Margaret.As with the original aim of the book, Havards Nursing Guide to Drugs continuesto be a guide only. This book is meant to be a companion guide to pharmacologytexts, something smaller and easier to transport around and reference in the clinicalsituation, especially now that it is available in electronic form as well. As with previouseditions, each drug has been reviewed to ensure it is still relevant to the healthcaresetting, with old and obsolete drugs deleted and new drugs (or old drugs with newuses) added. New to this edition is an expanded Patient teaching and advice sectionwhich highlights key points for teaching purposes.Sample chapter 9. Sample chapter 10. ixINTRODUCTIONTHE NURSES ROLE IN DRUG THERAPYThe aims of administering medicationare to do it safely and efficiently and toobserve the patient for both desirableand undesirable effects. Therefore thenurse needs to: assess the patient, including medica-tion history have an understanding of the legalrequirements associated with the ad-ministration of drugs have pharmacological knowledge ofthe medication(s) be able to safely administer medica-tions.ASSESSING THE PATIENTPatient assessment should be holistic,looking at the patients condition andpersonal circumstances as a whole, rath-er than simply as a disease to be treated.It should include: all current medical problems co-morbidities relevant past history physical assessment medication history (current medica-tions, over-the-counter preparations,herbal preparations, vitamin andmineral supplements).Medical history, co-morbidities andmedication history are intertwined asa person with multiple co-morbiditiesoften being prescribed multiple medi-cations simultaneously (polypharmacy)increasing the risk of adverse effects andinteractions. A person may see morethan one medical practitioner (e.g. gen-eral practitioner (GP) plus a numberof specialists) and they may not alwaysreview previous or current medications.Having prescriptions filled in multiplepharmacies may also be problematic asthere is no on-going record of medica-tions (and hence the possibility of thesame prescription being filled multipletimes using different brands).People may become confused be-cause medication can have more thanone brand/trade name for the same ge-neric drug and potentially end up tak-ing the same drug twice (e.g. a patienttaking Urex and Lasix (both trade namesfor frusemide) may become quickly de-hydrated).Unfortunately, people do not alwayscomplete courses of medications, espe-cially antibiotics, and keep the rest fornext time with no understanding of theramifications of doing this (e.g. bacteriabecoming resistant to that antibiotic andthe agent becoming ineffective in treat-ing that same infection if it recurs).Some people believe they are allergicto medications. It is important for thenurse to explore what form the supposedallergy takes (e.g. someone may mistak-enly believe that he/she is allergic tomorphine because he/she was nauseousand vomited after taking it (a commonside-effect), whereas another patientmay correctly describe an anaphylacticreaction with breathing difficulties afteradministration of an antibiotic).Many people also take over-the-counter (OTC) preparations or alter-native medicines, including herbalpreparations, either concurrently orinstead of traditional medication. OTCpreparations are those that are non-prescription and are generally intendedSample chapter 11. xHAVARDS NURSING GUIDE TO DRUGSfor short-term use only in self-limitingillnesses such as headache, heartburnand constipation. OTCs also include vi-tamins, minerals and herbal drugs andremedies (e.g. St Johns wort, ginseng)and unfortunately, many people con-sider them to be safe because they arenatural. However, many herbal drugsand remedies interact with prescrip-tion medications (e.g. St Johns wortinteracts with warfarin increasing itsmetabolism and decreasing its effective-ness); antacids can interfere with someoral medications if not taken 2 hoursapart; and non-prescription medicationssuch as aspirin and ibuprofen can causegastrointestinal bleeding and must onlybe taken at recommended doses. OTCsare readily available in pharmacies andsupermarkets, with the buyer not need-ing to seek advice before purchasingthese products.It is essential for the nurse to estab-lish if the patient is compliant/adherent/concordant with his or her medicationregimen, and if not, why not. While theseterms are sometimes used interchange-ably, they do have some important dif-ferences. Compliance suggests thatthe patient has little input into his/hermanagement strategy and follows doc-tors orders (power lies with the doctor),while concordance is at the other endof the spectrum, and is based on equal-ity and respect between the patient andthe health care practitioner. Adherencefalls somewhere in between as there isnegotiation between the patient and thehealth care professional which is basedaround the therapy (e.g. asthma manage-ment plan) (National Asthma Council,2005). One Australian study looking atthe use of antihypertensive medicationsfound that 19% of people failed to have asecond prescription filled. Furthermore,people persisted with their antihyper-tensive medications on average for only20 months (Simons, Ortiz and Calcino,2008).Adherence is a very complex issue.Some of the factors that may lead to apatient not being adherent with a medi-cation regimen may include: multiple medications complex dosing schedules (a personis more likely to remember a once-daily dosing schedule, compared to a34 times daily regimen) medication difficult to take or admin-ister (e.g. medications that have anunpleasant taste or are large in size;eye and ear drops that are difficult toinstil) impairments including: sight (e.g. unable to read direc-tions) dexterity (e.g. arthritis) may makeit difficult to open containers withchildproof lids or blister packs, or memory (e.g. unable to remem-ber instructions of how or whento take medication) adverse effects (i.e. the person maydecide that the side-effects of themedications are worse than thedisease itself) feeling better and therefore notneeding to take the medicationany longer not seeing any effects from themedication (e.g. effects of lipid-lowering agents are not visible andthese are commonly discontinuedby patients) cost and ease of filling prescrip-tions (e.g. decreased mobility orlack of transport to be able to goto the pharmacy)Sample chapter 12. xiINTRODUCTION lack of knowledge/understandingof the disease process and the roleof medication in disease manage-ment attitude towards medication, dis-ease and/or health (e.g. a devilmay care attitude or thoughtssuch as I have to die of some-thing) inconsistency in the messagesthat health providers are giving(e.g. one nurse advises the patientto take certain medications 3060minutes before food, while anoth-er nurse says that it doesnt matterwhen the medication is taken).Not only are these inconsistentmessages confusing for the patientbut they also damage the trust thepatient may have in the nurse(s),as well as potentially affecting theabsorption and effectiveness of themedication.Armed with all this information, thenurse is in an ideal position to supportand educate the patient (see section onPatient teaching and advice).CHILDREN AND THE ELDERLYChildren and the elderly require highlyspecialised nursing care and knowledgeregarding administration of medica-tions. Special care should be taken withdosages because overdose can occur eas-ily due to smaller weights (and surfaceratios), and differences in kidney andliver capacity. There are many special-ised texts available that cover both thesegroups in detail and take into accountthe differences in drug administration.Specific paediatric and geriatric dosagesare not generally included in this book.Doses are for the average adult patient.The only exceptions are when a particu-lar drug is mainly or specifically used inpaediatrics (e.g. drugs used for attentiondeficit disorder, growth hormone).Many older people require assistancewith the administration of medicationsand the nurse may consider splitting orcrushing tablets in order to make themeasier to take. Before doing this, investi-gate whether the medication is availablein a different oral form (e.g. liquid ratherthan solid) or a non-oral form (e.g. der-mal, rectal, intranasal). Tablets with anenteric coating should not be crushedas these are formulated to ensure themedication passes through the stomachintact (e.g. enteric aspirin is formulatedto prevent gastric irritation). Extended-release medications (often marked asCD, CR, SA, SR) are designed to releasethe active components over an extend-ed period and therefore should not becrushed. There is further discussion onextended-release medication under Oraladministration.DRUGS IN SPORTThe World Anti-Doping Agency(WADA) was established in 1999 tofoster a doping-free culture in sport by: conducting scientific research to de-velop new detection methods educating athletes and support per-sonnel raising awareness and providing in-formation about doping and its con-sequences conducting an unannounced out-of-competition testing program thatcomplements the programs of the In-ternational Sports Federations (IFs) developing an independent observerprogram (which randomly monitorsSample chapter 13. xiiHAVARDS NURSING GUIDE TO DRUGSand reports on all phases of dopingcontrol in an unbiased manner) monitoring acceptance and compli-ance with the World Anti-DopingCode, which ensures all athletes inall sports are governed by the sameanti-doping rules and regulations.Groups of drugs or methods prohibitedor restricted by WADA include: anabolicsteroids (e.g. stanozolol, testosterone),peptide hormones (e.g. erythropoietin,insulin, tetracosactrin), growth factorsand related substances (e.g. growth hor-mone), beta-2 adrenoceptor blockingagents (e.g. propranolol), beta-2 agonists(e.g. eformoterol, isoprenaline NOT sal-butamol or salmeterol), hormone antag-onists and modulators (e.g. clomiphene,aminoglutethimide, tamoxifen), diuretics(e.g. frusemide, acetazolamide, thiazidediuretics) and other masking agents (e.g.probenecid), substances enhancing oxy-gen transfer (e.g. haemoglobin products),blood doping (e.g. red blood cell productof any origin) and sample manipulationmethods (e.g. tampering with samples orurine substitution), stimulants (e.g. am-phetamines, adrenaline, pseudoephed-rine), opioids (e.g. heroin, morphine),cannabinoids (e.g. marijuana), glucocor-ticosteroids (e.g. dexamethasone, pred-nisolone) and alcohol.It is imperative that the athlete isaware of substances and methods thatare prohibited at all times, substancesthat are prohibited in-competition andsubstances that are prohibited in particu-lar sports (WADA, 2011).PREGNANCYAny medication (including OTCs, herb-al preparations, alternative therapiesor chemicals such as alcohol) has thepotential to reach the developing fetusvia the maternal circulation if taken dur-ing pregnancy. The risk to the fetus is de-pendentonanumberoffactors,includingfetal gestational age on exposure (i.e. thefetus is most at risk during the first tri-mester when cells are rapidly proliferatingandorgans,muscles,CNS,arms,legs,toesand fingers are developing), duration oftherapy (including dose, frequency andlength of therapy), as well as any othermedication taken concurrently (Bryant& Knights, 2011). Animal studies haveshown considerable differences in speciesresponse with regard to the teratogeniceffects of drugs and it may not be possibleto extrapolate this data to humans. Fetalabnormalities include missing digits,excessive development or duplication ofparts, splitting of parts abnormally, non-splitting of parts, fusion failure or over-fusion of some parts, openings failing toclose or open adequately or abnormalplacement of parts.Generally, medications should beavoided during pregnancy if possible.However, this is not always practicable.The woman who is pregnant (or consid-ering pregnancy) should work in partner-ship with her medical practitioner to de-velop a medication regimen that balancesthe benefits to the mother against thepotential risks to the fetus. For example,a woman with epilepsy may need to con-sider the potentially life-threatening risksassociated with uncontrolled epilepsyversus the benefits of controlling epilepsywith an agent that has an increased risk ofcausing fetal abnormalities.LACTATIONMost drugs taken by a mother who isbreastfeeding will be excreted to someSample chapter 14. xiiiINTRODUCTIONextent in the breast milk; however, theamount ingested by the infant will gener-ally be extremely small but is dependenton the age of the infant and the amountof breast milk consumed.However, some drugs are concen-trated in breast milk relative to the ma-ternal plasma concentration because oftheir chemical properties, including fatsolubility and may be toxic to the infantbecause of immaturity of the liver andkidney detoxification systems (Bryant &Knights, 2011).Administering the drug when or im-mediately after the infant feeds will resultin the lowest amount of drug in the milkat subsequent feedings. If a drug is es-sential for the mother, but of uncertaineffect on the infant, it may be necessaryto temporarily discontinue breastfeed-ing and remove contaminated breastmilk (via breast pump) which shouldbe discarded. Medications that shouldbe avoided during breastfeeding includeamiodarone, chloramphenicol, cocaine,cyclosporin, diazepam, heroin, radio-active iodine, lithium, tetracyclines andtheophylline (Bryant & Knights, 2011).If medication is taken during breast-feeding, the infant should always beclosely observed for any side-effects, in-cluding poor feeding, listlessness, with-drawal symptoms and other abnormalbehaviours that should be reported ifthey occur.RENAL AND LIVER IMPAIRMENTDose reduction is often required in thosewith any type of kidney and/or liver im-pairment because these organs are themain sites of drug metabolism and ex-cretion. Monitoring of kidney and liverfunction throughout any drug therapymay be recommended to ensure thatthere is no further deterioration causedby the drug therapy. Furthermore, somemedication may damage the liver or kid-neys (e.g. large doses of paracetamol arehepatotoxic, NSAIDs may be nephrotox-ic). If potentially nephrotoxic or hepato-toxic agents are given to those with renalor liver impairment, the risk of furtherdamage is greatly increased.LEGAL REQUIREMENTSBefore a drug can be administered safely,the nurse needs to be aware of the legalaspects of drug administrations. This in-cludes knowledge of the laws governingthe possession, use and dispensation ofdrugs and of the directives of the nursesregistering body on the administrationof medications to clients. It also meansobserving the employing health carefacilitys occupational health and safety(OHS) regulations that are designed topromote safe storage, handling and useof drugs.The Nursing and Midwifery Boardof Australia (NMBA) is one of the na-tional boards of the Australian HealthPractitioner Regulation Agency (AH-PRA). With the changes to registrationof nurses by AHPRA from 2010, it wasdecided that enrolled nurses no longerrequired endorsement for medicationadministration. The NMBAs goal is forall enrolled nurses to undertake relevantunits of study that will enable them toadminister medicines safely as part oftheir education program. However, forenrolled nurses who have not completedthe required units, a notation readingDoes not hold Board-approved qualifi-cations in administration of medicineswill appear on the national nursing reg-ister against that nurses name (NMBA,2010). Jurisdictional legislation andSample chapter 15. xivHAVARDS NURSING GUIDE TO DRUGSpolicy specifies the routes and schedulesof medicines that the enrolled nurse isable to administer and it is therefore ofparamount importance that the nurseand employer understand and complywith the drugs and poisons legislationand policy. Furthermore, to administerintravenous medication, the enrollednurse (Division 2) is required to havecompleted a separate NMBA-approvedunit on the administration and monitor-ing of intravenous medications (NMBA,2010).Legal Acts concerning poisons andthe poisons regulatory bodies in NewZealand and each state and territoryin Australia deal with the control of alldrugs, from prescription medicationthrough to agricultural poisons and re-search drugs. The laws and regulationsapply to sale, supply, storage, dispensingand labelling. The drugs and poisonsschedules divide drugs into groups ac-cording to their mode of action, thera-peutic use, potency, potential for abuseand addiction and safety. While thereis currently no national medicines andpoisons schedule in Australia, the rec-ommendations of two expert advisorycommittees (Advisory Committee onMedicines Scheduling and AdvisoryCommittee on Chemical Schedul-ing) in the form of the Standard forthe Uniform Scheduling of Medicinesand Poisons (SUSMP, Table 2) are usu-ally incorporated into the legislation andregulations of each state and territory ofAustralia and New Zealand (Austra-lian Government, TGA, 2010). Aims ofthis document include promoting uni-form scheduling, labelling and controlson availability and use of medicinesthroughout Australia and New Zealand(Australian Government, TGA, 2010).The recommendations of SUSMP applyfor all medicines and poisons in Austra-lia and medicines in Schedules 2, 3 and4 in New Zealand. New Zealand specificlegislation exists for medicines which falloutside these schedules.Nurse practitioners, as defined bythe Nurses Act 1993, are those whoseregistration has been endorsed as be-ing qualified to obtain and have in her/his possession and to use, sell or sup-ply Schedule 2, 3, 4 or 8 poisons, as de-scribed under the Drugs, Poisons andControlled Substances Act 1981 (VersionNo. 065, 1/12/2003).STORAGEAll medications in a ward or departmentshould be kept in a locked cupboard,medication trolley or some other type oflocked container, the key of which is keptby a nurse at all times. Victorias Drugs,Poisons and Controlled Substances Reg-ulations 1995 are very specific about thestorage requirements for Schedule 8 orSchedule 9 poisons (e.g. constructed ofsteel 10 millimetres thick; fitted with a6-lever lock; able to resist attack by handtools for 30 minutes or power tools for 5minutes) with other states having similarrequirements.Drugs or preparations for externaluse should be stored apart from thoseintended for internal use, so that errorsin administration do not occur. Sup-positories, pessaries, insulins, antisera,vaccines, some blood products, some in-travenous solutions and some antibiotics(particularly if reconstituted) should bestored in the refrigerator. Nothing elseshould be stored in the refrigerator (e.g.food) and it should also be kept locked.The trend towards single-dose unitsbeing dispensed contributes to accuracySample chapter 16. xvINTRODUCTIONin dosage, better economy and less riskof product contamination. Many insti-tutions have policies that discourage theuse of multi-dose vials because of therisk of cross-contamination betweenpatients.DRUG ORDERSIn 2004 the Australian health ministersadvised that to reduce the harm to pa-tients from medication errors, by June2006, all public hospitals will be using acommon medication chart. This meansthat the same chart will be used wherevera doctor or nurse works and whereverthe patient is within a hospital (AC-SQHC, n.d.). The result was the Nation-al Inpatient Medication Chart (NIMC).Since then there have been additionalnational charts developed, which haveincluded the National Aged Care Resi-dential Medication Chart (NRMC),National Interim Residential Medica-tion Administration Chart (NIRMAC),National Subcutaneous Insulin Chart,Paediatric Medication Chart and PrivateHospital and Private Hospital Day Sur-gery NIMC (ACSQHC, 2012a).A drug or preparation may be givenonly on written or verbal order from amedical officer, and must be clearly writ-ten and/or understood verbally. The lawin all states requires that a legal drug or-der must be legibly written in ink, datedand signed by the prescriber and mustinclude the patients name and identifi-cation number (if applicable), the nameand strength of the drug, the dose, routeof administration, frequency of admin-istration and duration of administration(if applicable). Any alteration to a drugorder should be initialled. An unusualdose, drug strength or quantity shouldbe underlined and initialled by theprescriber. If there is any doubt aboutthe meaning of the order, the medicalofficer should be contacted immediatelyfor clarification before administration.The policy of the institution shouldbe consulted before taking telephoneorders for drugs. A telephone ordershould only be taken if in the opinionof the medical practitioner, dentist ornurse practitioner, an emergency ex-ists (Drugs, Poisons and ControlledSubstances Regulations 2006, Reg.47,2 (C)). Errors may be eliminated ifthe nurse ensures that the drug has beenordered for the correct patient, writesit on the correct patients medicationchart, then asks a second nurse to readthe drug order back over the telephoneto the medical officer. The order shouldbe confirmed in writing by the prescrib-er as soon as practicable. However, in-stitutions may have their own policiesthat require their medical officers tosign the order within 24 hours. If anydoubt at all exists (e.g. the patient is un-well and requires reviewing, the nurseis unsure about the drug, dose etc.), thenurse should not take the telephone or-der and should ask the medical officerto review the patient or medication or-der as soon as practicable.LEGAL RESPONSIBILITYFollowing a medical officers order wasonce thought by many to absolve thenurse from all responsibility. However,legal judgements have shown that this isnot always the case. The question that isoften asked in situations of a drug erroroccurring is What would the reasonablenurse do in this situation?Given that administering drugs is aneveryday part of the role of most nurses,it is therefore not an unfair expectationSample chapter 17. xviHAVARDS NURSING GUIDE TO DRUGSthat they will have some knowledge ofthe drugs they are administering. Thisincludes the class of drug, why it is pre-scribed (purpose), how it works (action),recommended or usual dose range, howit is administered, contraindications,side-effects, potential for causing allergicreactions, any interactions with foods orother drugs and compatibility (especiallywhen multiple intravenous drugs are tobe administered).It is not necessary for the nurse tomemorise all this information; however,what is important is that the nurse hasready access to information and knowswhere or how to readily do so before ad-ministration. Information on any drugor preparation may be obtained from apharmacist, textbooks or reliable inter-net sources. Once in possession of thisknowledge the nurse can question an un-clear order, assess what skills are requiredto carry out the order and will understandwhat to observe in the patient in terms ofbeneficial and adverse effects.DRUG INCIDENTS (ERRORS)Drug incidents (or errors) may occur attheprescribing,dispensingor administer-ing stage of the process. A study by Leape,Bates and Cullen. (1995) found that doc-tors and nurses were responsible for 39%and 38% of errors respectively. Theyfound that the causes of errors includedlack of knowledge. A more recent studyby Nichols, Copeland, Craib et al. (2008)found that added to this lack of knowl-edge other causes of prescribing errorsincluded lack of supervision by seniorcolleagues when prescribing unfamiliarmedications, dealing with unfamiliar pa-tients, working on unfamiliar wards anda lack of communication.Administration incidents (errors)occur when: the wrong drug is administered, in-cluding the administration of thewrong intravenous fluid (e.g. drugswith similar names; use of abbrevia-tions for names) the wrong dose is given (e.g. misread-ing dosage or units; misinterpretingabbreviations used for units (e.g. mi-crograms)) the drug is given via the wrong route(e.g. an oral drug given intravenous-ly) the drug is given to the wrong patient the drug is given at the wrong time orfrequency, including omission an intravenous infusion is adminis-tered at the wrong rate.Since 2008, standard prescribing termi-nology, abbreviations and symbols havebeen introduced in an attempt to reducethe number of associated errors. Ab-breviations are used when referring tostrength of medications such as grams(g) and milligrams (mg). For example,the abbreviation for micrograms usingthe Greek letter (mu), that is, g, isnot recommended, nor is mcg, as thesemay lead to errors; microg is the pre-ferred and recommended abbreviation,or the whole word (microgram) shouldbe used. Other error prone abbreviationsand symbols that should be avoided in-clude IU (international units can bemistaken for IV), IVI (intravenous injec-tion mistaken for IV 1) and qd (everyday mistaken as qid (four times daily))(Australian Commission on Safety andQuality in Health Care, 2011).The use of dose administration aidscommonly found in aged care facilitiesmay not necessarily reduce the numberof administration errors. A 2006 studyconducted in New South Wales (Aus-tralia) found that dose administrationSample chapter 18. xviiINTRODUCTIONaids contained a significant number oferrors (incident rate 4.3% of packs and12% of residents), which included miss-ing medications, wrong medication orwrong strength of medication dispensed,incorrect dosage instructions suppliedor medications being supplied that hadbeen ceased by a doctor (Carruthers,Naughton & Mallarkey, 2008). Althoughon the surface this would appear to be adispensing and pharmacy-related prob-lem, it is also the responsibility of thenurse administering the medications tohave some idea of what medication a pa-tient has been prescribed (or no longerprescribed) and what the medication(s)actually looks like.An administration error may or maynot have an adverse effect. The serious-ness of the outcome (e.g. the adverse ef-fect or lack of) does not absolve the nursefrom the mistake that was made. It is im-portant to clearly document the error andoutcome. Some institutions may also havepolicies regarding further documentationrequirements when an error has occurred(e.g. a drug incident form).It is important for nurses to practisewithin their own limitations and withinthe policies and protocols of the institu-tion. If this is not done and an error oc-curs (especially a serious one), the nursemay find that the institution (and its in-surers) may abrogate any responsibilitybecause the nurse did not follow its poli-cies. The nurse may also be liable undercommon law.A LITTLE PHARMACOKINETICSFor extensive pharmacokinetics, refer topharmacology texts. Here are some basicconcepts that nurses need to understand.Pharmacology is the study of drugs,including their actions and effects onliving systems (Bryant & Knights, 2011,p. 2). Pharmacokinetics is the absorption,distribution, metabolism and excretionof these substances, and pharmacody-namics is concerned with the physiologi-cal effects that the substances have on theorganism.Pharmacokinetics and the olderpersonThere are many age-related changes tothe body that affect the way that a drugmay be absorbed, distributed, metabo-lised and excreted. Because of thesedifferences, all drug therapy should begiven cautiously and monitored carefullyin the older patient. Age-related changesthat may affect the pharmacokinetics ofa drug include: altered nutritional habits and inges-tion of non-prescription drugs (e.g.antacids and laxatives) may affectdrug absorption changes in the quantity and quality ofdigestive enzymes increase in gastric pH decrease in gastric motility decrease in intestinal blood flow delayed gastric emptying decreases in total body water, leanbody mass and increase in body fatmay all lead to an altered distributionof the drug decreases in plasma proteins, andtherefore decreased protein bindingof drugs, leading to higher levels offree drug (increasing the risk of ad-verse effects and/or toxicity) the greatest changes appear to be dur-ing Phase I metabolism in the liver,which involves microsomal enzymes the livers ability to recover from in-jury, such as hepatitis, is reduced withageSample chapter 19. xviiiHAVARDS NURSING GUIDE TO DRUGS hepatic function may also be affectedby severe nutritional deficiencies decreased cardiac output and reserve decreased blood flow to the liver andkidneys congestive heart failure reduces thecapacity of the liver to metabolisedrugs as well as reducing hepaticblood flow creatinine clearance decreases withage, resulting in a longer half-life ofmany drugs and the subsequent riskof accumulation (toxicity) decreased renal excretion.Drug dosageDosage depends on the age, weight, sex,renal and liver function and general con-dition of the patient and can be based onage, body weight or body surface area.As children usually require smaller dosesthan adults, various rules are used to es-timate the fraction of the adult dose (seeinside front cover).Dose interval is important (e.g. anti-infective agents are given at regular in-tervals, 4-, 6- or 8-hourly, to maintainadequate blood levels, while hormonesare given at the same time each day foruniform effect). The time of day must besuitable to the individuals lifestyle. Forexample, diuretics may be ordered twicedaily and normal convention would seethem administered at a regular interval(e.g. 810 hourly during the day); how-ever, for an older person it may be morepracticable to administer the diuretic inthe morning and at lunch time, so thatsleep is not disturbed by frequent mictu-rition, increasing the risk of falls.Drug half-lifeThe half-life of a drug is a function ofboth distribution and elimination. Ingeneral terms, it is the time required forone-half of the amount of drug in thebody to be eliminated. It is of practicaluse in calculating the frequency withwhich multiple doses of a drug can beadministered to keep the blood level be-tween the minimum effective concentra-tion and the threshold for toxicity (e.g.a drug with a very short half-life mayneed to be administered intravenously tomaintain levels, while another drug witha long half-life may be suitable for once-daily administration). Furthermore, adrug with a very long half-life may re-quire patient monitoring for some timeafter the drug has been discontinued.Therapeutic drug monitoringSome drugs have a narrow therapeuticrange (i.e. the difference between over-dosing and underdosing). Serum druglevels are measured to determine thattherapeutic levels are being achievedand/or to prevent toxicity. Informationaccompanying a request form shouldinclude the time the blood sample wastaken, the time the last dose of the drugwas given and its route of administra-tion. The main aim of therapeutic drugmonitoring is to optimise drug therapyby achieving adequate drug levels whileminimising toxicity. It is especially im-portant in those at the extremes of age(i.e. babies and the elderly).Why measure drug levels?Drug levels are measured for a numberof reasons, which include: to individualise the dose (e.g. lithium,phenytoin, warfarin) to avoid toxicity (e.g. digoxin, vanco-mycin) to ensure effective blood levels (e.g.prophylactic antiepileptics, gentami-cin)Sample chapter 20. xixINTRODUCTION to check adherence to regimen (e.g.antipsychotic agents) to check that co-morbidities that mayalter drug metabolism and elimina-tion (e.g. renal impairment, hepaticfailure, shock, sepsis) are not affectingblood levels to ensure that concurrent drug ad-ministration is not affecting bloodlevels to change the route of administrationor dosage (e.g. from IV or IM to oraladministration) if necessary whilemaintaining adequate serum levels.Drug routeThe effectiveness of a drug often dependson the route of administration. A drugmay have a systemic or local effect de-pending on whether it is taken orally, in-jected or applied topically (see Glossaryfor forms of preparations). Drugs areformulated to meet the requirements forrapid or slow absorption, metabolism orexcretion in order to obtain the requiredtherapeutic blood levels. The two mostcommon routes of drug administrationare oral and parenteral.Oral administrationMany oral preparations are given on anempty stomach because food may de-crease the absorption; however, if gastricirritation is a problem they may be givenwith or immediately after food.It is recommended that a capsule ispreceded by a small amount of waterand then taken with half a glass of wa-ter to prevent it becoming lodged in theoesophagus. A number of medicationsknown to cause oesophageal ulcerationinclude aspirin, bisphosphonates (e.g.alendronate), doxycycline, iron tablets,potassium chloride and zidovudine(Gowan & Roller, 2010). Enteric-coated,slow-release, extended-release, modi-fied-release, sustained-release and con-trolled-dosage tablets should be swal-lowed whole, not crushed or chewed, fora number of reasons, which may include: absorption will be altered (e.g. MSContin, Keflor CD, Efexor XR, Di-lantin) medication may become unstable(e.g. Augmentin Duo, Nimotop,Zoton) they may cause local irritation (e.g.Vibramycin, Fosamax, Cartia, Roac-cutane) they will not reach the site of the in-tended action (e.g. Creon, Dipentum,Salazoprin) unacceptable taste (e.g. Neoral, Co-loxyl) hazardous (e.g. Imuran, Myleran,Leukeran, Cycloblastin).Care must be taken to select the correctformulation of tablets when several dif-ferent formulations and/or dosages exist(e.g. Isoptin (verapamil) is available in 40mg, 80 mg, 120 mg or 160 mg tablets;Isoptin SR is available as 180 mg or 240mg), because the consequences may bevery serious if the wrong formulation isadministered (e.g. substituting Isoptin80 mg (3 tablets), which will act quicklycompared with Isoptin SR 240 mg, whichis a sustained-release preparation andwill act over 24 hours).Parenteral administrationParenteral medications are given eitheras injections or by infusion. The mostcommon routes are intramuscular (IM),subcutaneous (SC) and intravenous (IV).IntramuscularThe three main muscles used for intra-muscular injections are:Sample chapter 21. xxHAVARDS NURSING GUIDE TO DRUGS the lateral aspect of the thigh (middlethird when the thigh is divided intothree) the upper outer quadrant of thedorsogluteal the deltoid.No more than 5 mL should be admin-istered by intramuscular injection, andless into the deltoid muscle. If a volume> 5 mL is required, the dose should bedivided and given into different sites.Furthermore, the deltoid muscle is notrecommended for intramuscular injec-tion in children.SubcutaneousSubcutaneous injection sites include: upper outer aspect (middle third) ofthe upper arm upper anterior thigh abdomen below the costal marginsto the iliac crests (avoiding the areaaround the navel by about 5 cm).When frequent administration is re-quired (e.g. insulin administration ina patient with diabetes mellitus, dailyheparin injections), administration sitesshould be rotated and documented onthe medication chart to prevent atrophyof the subcutaneous tissue, increasedrisk of infection and pain.IntravenousA drug may be given by direct IV injec-tion as a bolus in a volume of 20 mL orless in under 1 minute, or by slow IVinjection over 515 minutes. It is impor-tant to check and adhere to the manu-facturers information regarding therequired administration time, becauseadministering some drugs too quicklycan cause pain, damage the blood ves-sel, as well as other adverse effectssuch as flushing, hyper- or hypoten-sion, syncope, arrhythmias, feelings ofwarmth or anxiety, depending on thedrug administered. This method is usedwhen an immediate effect is required orthe drug becomes unstable on recon-stitution or dilution. The intermittentinfusion method is used when a drug isdiluted, when interval dosing is desiredand when slow administration is re-quired. The drug is diluted in 50250 mLand infused over 15 minutes to 2 hours.This minimises stability and incompat-ibility problems and gives the peak andtrough effect in antibiotic therapy. Oneof the advantages of intermittent IVadministration is that the patient canhave an intermittent venous access port,which increases client mobility, comfortand safety, there is a cost benefit fromnot having continuous IV therapy andthe nurse does not have to continuouslymonitor flow rates.When a drug must be highly dilutedand a steady-state blood level is to bemaintained, the continuous infusionmethod is used, in which the drug is di-luted in 5001000 mL and infused over424 hours (e.g. potassium chloride re-quires high dilution and constant bloodlevels to prevent depression of cardiacfunction).The IV flow rate may be controlledby using an infusion pump, a microdripset or a burette. When a drug is addedto the burette during intermittent infu-sion, details of the additive are indicatedon a label that is stuck onto the burette.Any IV drug admixture must be pre-pared aseptically, mixed thoroughly andlabelled with the name and amount ofthe additive, name of person adding theagent, name of person checking the ad-dition and the time of starting the in-fusion. National recommendations foruser-applied labelling of injectable medi-cines, fluids and lines now exist and it isSample chapter 22. xxiINTRODUCTIONimperative that nurses understand andcomply with these as consequences ofnon-labelling can result in a potentiallylife-threatening situation for the patient.These recommendations include colourcoding the route of administration (e.g.red for intra-arterial, blue for intrave-nous, yellow for epidural or intrathecaland beige for subcutaneous), processfor medicine and label preparation (in-cluding label placement), when to dis-card containers of injectable medicinesand special circumstances (ACSQHC,2012b). While these labelling recom-mendations do not apply to enteral,topical or inhalation routes, the generalprinciples still apply as a way of improv-ing practice and decreasing the risk oferrors occurring.An IV admixture should not be ad-ministered if there are signs of physicalincompatibility such as a colour change,loss of clarity or precipitate formation.Chemical and physical compatibilityand stability of admixtures should bechecked before administration. If in anydoubt, consult a pharmacist, textbooks,manufacturers information or a druginformation centre.Drugs generally should not be mixedwith blood or blood products.Other methods of administeringmedications include: transdermal patches, which deliverdrugs through the skin at a steadyconcentration, avoiding first-passmetabolism in the liver and anygastric side-effects. Several types ofdrug, including glyceryl trinitrate,hormones and nicotine, are availableas transdermal patches. Advantagesinclude ease of application and fre-quency of application (once dailyor longer), but the disadvantagesinclude some skin reactions and thelow number of drugs available via thisroute. intradermal implants, which are sur-gically implanted subcutaneously.Advantages include the frequencyof administration (some may beimplanted for 68 weeks or longer);however, they require surgical im-planting and removal.GUIDE FOR SAFE ADMINISTRATIONCheck the order Check that the information on thedrug name (preferably generic ratherthan trade name), dose, route, fre-quency, time due and when the drugwas last given are all legible (if anydoubt exists, withhold the drug andcheck with the medical officer) andthat the order is signed by the medi-cal officer. Check that patient details are cor-rect, including any known allergies(it is important to discuss any allergy/sensitivity history with the patient ascross-sensitivity between productsdoes occur).Check the drug Check the container label against themedication order when selecting thepreparation, before measuring outand when replacing the preparation. Check the expiry date of the drug. Check the drug calculation with an-other registered nurse, a pharmacistor medical officer (ask the secondperson to do the calculation inde-pendently, then compare answers,remembering that it is rare to giveless than half a tablet or more than 2tablets or 1 ampoule at a time).Sample chapter 23. xxiiHAVARDS NURSING GUIDE TO DRUGS Mix liquid contents thoroughly, butrotate protein preparations gently toprevent denaturation and frothing. Note any discolouration, precipitateor foreign bodies (and do not admin-ister if they are present).Check the patient Check the patients identity care-fully (check wrist identity band orverbally), taking extra care if thereare patients with the same or similarnames, or if the patient is unknownto the nurse. Check if the patient has any knownallergies. Check that the patient knows the rea-son for the medication and discussany query with the medical officerbefore giving it. Only give medications that you, thenurse, have prepared or seen a phar-macist prepare (i.e. do not adminis-ter an IV drug that was drawn up bysomeone else without you present). Give the correct drug and dose. Give to the correct patient. Give at the correct time. Give by the prescribed route. Do not handle tablets. Wait until oral medications are swal-lowed (never leave medications onbedside tables, lockers or dinnertrays).Documentation Ensure that the drug administrationsheet is signed after administration. Document any discrepancies (e.g.patient unable or refuses to takemedication, patient absent, medica-tion not available). If Schedule 8 drugs are involved,ensure that the drug register is cor-rectly filled in (date, time, patient,drug (form, strength, amount to beadministered), persons administeringdrug, balance of drug remaining, anydrug discarded). Observe the patient and document inthe patients history. Note beneficial effects and/or reportand chart any adverse effects (seebrief discussion below). Correctly and safely dispose of equip-ment used (e.g. do not recap syringes and dispose of them safely in asharps container). A drug may produce more than oneeffect which may be beneficial or not: The desired action is the physi-ological response the drug is ex-pected to cause (e.g. antihyperten-sive medications are expected tolower blood pressure) Side-effects (also called adverseeffects or adverse reactions) aresecondary effects caused by mostdrugs and are generally unde-sirable. Although the terms aresometimes used interchangeably,side-effects tend to be mild innature, whereas adverse reactionsare more serious (e.g. an adverseeffect of acetylsalicylic acid (as-pirin) is increased bleeding time;and a common side-effect of mor-phine is nausea) Toxic effects develop after pro-longed administration of highdoses of medication, or when adrug accumulates in the bloodbecause of impaired metabolismor excretion. Some drugs such asdigoxin and lithium have a verynarrow safety margin and toxic-ity can occur at recommended ortherapeutic doses Allergic reactions are unpredict-able responses to a drug thatSample chapter 24. xxiiiSUMMARYacts as an antigen, triggeringthe release of antibodies. Aller-gic reactions may be mild, suchas urticaria (hives) and pruritus(itching), or they may be severe;for example, severe wheezing andrespiratory distress, or life-threat-ening anaphylactic reaction. Somereactions occur within minutes ofthe drug being given, while otherallergic reactions may be delayedfor hours or days (Roach, 2005) Idiosyncratic reactions are thosewhere the patients body eitheroverreacts or underreacts to adrug, or when the reaction is un-usual and there is no known cause(e.g. the antihistamine prometha-zine (Phenergan) is sometimesused for sedation, however, insome people (especially children)it can cause insomnia and agita-tion) Pharmacogenetic reactions oc-cur because a person may havea genetic trait which leads to ab-normal reactions to drugs (e.g.those with glucose-6-phosphatedehydrogenase (G6PD) deficien-cy may experience haemolysis ifgiven aspirin, chloramphenicolor sulphonamides) (Roach, 2005) Drug tolerance may also occurwhere a person has a decreasedresponse to a drug over time, ne-cessitating an increase in dosage toachieve the required response (e.g.tolerance to opioids such as mor-phine may occur if given for morethan 10 to 14 days) (Roach, 2005) Drug interactions occur when onedrugmodifiestheactionofanotherdrug; for example, a drug may ei-ther increase or decrease the actionof other drugs. A drug interactionmay be synergistic (enhances theeffects of another drug) (e.g. pro-benecid may be given orally beforeIM procaine penicillin to increaseand prolong the serum level ofpenicillin), antagonistic (opposesthe effects of another drug) (e.g.protamine sulphate can be givento neutralise the anticoagulant ef-fects of heparin) or additive (wherethe two drug actions are added to-gether (e.g. when alcohol is con-sumed by a person on heparin,the risk of bleeding is significantlyincreased)).SUMMARYAdministering medication is one of thenurses most important responsibilitiesand should be treated with the due careit demands. It is not a task merely to becompleted, but rather an opportunity fornurses to increase their own knowledge,to ensure that patients have been edu-cated regarding their medications andto observe patients for both expectedand unexpected responses part of ho-listic nursing care. The right patient hasa right to receive the right dose of theright medication in the right form at theright time by the right route for the rightduration of therapy. If any doubt exists,the medication should be withheld; re-member, WHEN IN DOUBT, DONT!!Sample chapter 25. xxivHAVARDS NURSING GUIDE TO DRUGSAT A GLANCEAVAILABLE FORMSThis section outlines the various formu-lations for the medication.ACTIONBecause this is not a pharmacology text,only a brief description of the action ofeach agent is included. For more detailedinformation, a pharmacology text shouldbe consulted.USEThe most common uses of drugs (includ-ing both hospital and community uses).DOSEDosages listed in this book are thosefor the average adult (unless otherwisestated). Occasionally a paediatric dosemay be included if that particular agentis used predominantly in children (e.g.growth hormone, agents used to treat at-tention deficit disorder).ADVERSE EFFECTSAdverse effects are generally unwanted ef-fects, some of which are predictable andoften dose related. Other adverse effectsmay be unpredictable and occur less fre-quently (e.g. anaphylaxis, anaphylactoidreaction). Very common adverse effectsare considered to be those occurring in10% or more of study participants. Com-mon adverse effects are found in 110%,uncommon in 10.1% and rare adverseeffects occur in less than 0.1%. The ad-verse effects listed in this book are gen-erally those that are common or verycommon, and rare or less common ad-verse effects are listed when they requiresome action to be taken. For example,thrombocytopenia may be a rare adverseeffect but there is a requirement for regu-lar monitoring of blood counts.INTERACTIONSInteractions occur when one drug altersthe action of the second drug or bothagents affect each other. As with theadverse effects, the interactions listedare those that occur commonly or arethe most dangerous. It should be noted,however, that interactions between anyagents are always possible and cautionshould be taken when multiple agentsare given. For detailed explanations ofhow and why interactions occur, a phar-macological text should be consulted.NURSING POINTS/CAUTIONSThe points in this section are those mostdirectly applicable to nurses and mayinclude: IV administration rate monitoring advice reconstitution and storage recom-mendations incompatibilitiesPATIENT TEACHING/ADVICEIncluded in this section is important in-formation that the patient should receiveabout his/her medication and includes: taking with food or fluids dividing of tablets grapefruit juice incompatibility driving warning when to seek medical advice (see fol-lowing section for detailed patientteaching and advice information)It is assumed that the nurse: will use an aseptic technique whenreconstituting medicationSample chapter 26. xxvPATIENT TEACHING AND ADVICE will inspect the solution for any par-ticulate matter or cloudiness will not use the medication if eitherparticulates or cloudiness is present will administer the medication usinga safe, aseptic and correct technique will dispose of sharps in a safe andresponsible manner.These points are not made for every par-enteral agent in the text: cautions are the equivalent of am-ber traffic lights go slow and takecare. For example, a person with re-nal impairment may not excrete themedication at the same rate as some-one with normal renal function, thusincreasing the risk of adverse effectsand toxicity. Therefore, a reduceddose may be required and/or closemonitoring of renal function anddrug excretion, as well as monitoringfor adverse effects contraindications are the equivalentof red traffic lights no go! hypersensitivity to the agent itself isnot listed for every agent as it is as-sumed that this will be checked rou-tinely before administration (i.e. thepatient will be asked Have you hadthis medication before? Did you haveany problems with it?). Althoughcautions and contraindications areoften more relevant to the personprescribing the medication, it is im-portant that the nurse is also awareof these factors.PATIENT TEACHING AND ADVICEPatient teaching and advice regardingmedications is an essential part of carewhich often involves the nurse, in ad-dition to the pharmacist, doctor and/or other members of a multidisciplinaryteam. If possible, take time to build a rap-port with the patient (and their signifi-cant other/carer/family member, if ap-propriate). It is easier to learn from andask questions of someone with whomyou are comfortable. Also, given theextent of this educational task, it shouldstart on admission rather than a few daysbefore (or on the day of) discharge.There are a number of factors whichmay impact on a persons ability to learn(Roach, 2005). Examples include: Environment and available time: Itmay be difficult to teach and/or learnin an area where there are constantdistractions or interruptions. Consid-er using a small room where the doorcan be closed and at a time when thenurse knows that there will not be anyinterruptions (e.g. not during mealbreaks or at other times of reducedstaffing or during visiting hours). Al-though accessing a small room maynot be possible, pulling the curtainaround the persons bed may alertothers that something is taking placeeven if it doesnt really afford pri-vacy (curtains are not soundproof).The nurse should also consider howmuch time she/he has available toconduct the session. A short sessioncrammed with too much informationmay cause confusion in the patient,as well as potentially overlooking im-portant information. Pain and/or Discomfort: Are you ableto concentrate if you are tired, inpain, need to go to the toilet, hungryor thirsty? All of these impact on aSample chapter 27. xxviHAVARDS NURSING GUIDE TO DRUGSpersons capacity to concentrate andshould be eliminated or minimisedbefore starting a teaching session Sensory deficits: Does the patienthave a hearing impairment? Doeshe/she have a hearing aid? Does he/she have it in (and is it turned on)?Can the person read the label on themedication bottle or graduations ona syringe? Is the person dexterousenough to open medication bottlesor operate an injector pen or glucom-eter? Does the person have sufficientcoordination to use an inhaler or is aspacer device required? Anxiety/stress/fear: These are similarto pain and discomfort and should beminimised or alleviated before start-ing a teaching session Learning styles: Not everyone learnsin the same manner. Some peoplelearn by reading, others require dem-onstration while others may requireboth (e.g. demonstrate injection orpuffer technique, get the patient topractise, as well as leaving literaturefor them to read). Consider your ownlearning style(s) how do you preferto learn about a new piece of equip-ment play with it until you work outhow it works, have it demonstratedto you, read the instruction manualfrom cover to cover or a combina-tion of two or more methods? Weoften teach others in the manner welike to learn, therefore we should alsoconsider teaching using the other,less comfortable, ways. In allow-ing the patient to practise the skills(e.g. injection technique, blood glu-cose monitoring, puffer technique),it gives the nurse an opportunity toobserve and anticipate any problems(e.g. patient may require follow-up bya district nurse on discharge to ensurethe technique is correct) Literacy: information should be pre-sented at a level which takes intoaccount the patients education andreading level Language and culture: Is an inter-preter required? Does considerationneed to be given of the nature of thematerial (e.g. contraception) and thegenders of the teacher and patient? Itis very difficult to give important in-formation to someone who does notspeak the same language as yourself,or may be able to understand butnot able to ask questions. Further,it is important to use a professionalinterpreter if possible as using fam-ily members (especially children oradults of the opposite sex) can putthem into situations where they arenot comfortable (e.g. teenage soninterpreting for his mother who istaking medication for gynaecologi-cal problems). There is also the issueof privacy and patient confidentialityto consider. It is also necessary to re-member these issues of language andculture if giving the patient writteninformation.Before starting any teaching session, itis important to lay down the groundrules (e.g. how long the session will last,what is going to be discussed, follow-up). Factors which can be alleviated orminimised should be attended to beforestarting the session. Other general con-siderations may include: use of appropriate language. Nurses(and medical professionals in gener-al) often use jargon (e.g. doing obs orthe meds) that can be confusing (anddaunting) for non-medical peopleSample chapter 28. xxviiPATIENT TEACHING AND ADVICE previous knowledge and skills of theperson. Even if the patient has beenprescribed the medication before,assessing knowledge and any misun-derstandings can be important as thismay improve the patients motivationto take the medication, thereby im-proving adherence with the regimen.If the medication is new, it is impor-tant to determine if the informationand/or skill (such as using an inhaleror administration of insulin) requiresmore than one session making dis-charge planning essential. This extratime gives the patient time not onlyto practise skills (supervised and/orunsupervised), but also ask questionsand seek clarification of anything thathe/she has not understand (Roach,2005) importantly, returning at an agreedtime to review information and fol-low up on any other questions theperson may have.Consideration should be given to includ-ing the following as part of patient teach-ing and advice: why the person is taking the medi-cation (including the benefits). If theperson has any concerns about tak-ing the medication, he/she should beencouraged to discuss these with his/her doctor before starting a simplified explanation of how themedication works importance of telling other healthprofessionals (e.g. dentist, special-ist, surgeon, anaesthetist) that he/she is taking medications (e.g. it maybe necessary to discontinue somemedications before a procedure).This should also include the patientreminding the health professional ofany allergies (including to food(s) orlatex) or other medical conditions(past or present) (such as kidney im-pairment, asthma, tuberculosis, hep-atitis B, heart failure, cancer, blooddisorders, gastric ulcer or bleed-ing, diabetes, high blood pressure),whether he/she smokes or regularlydrinks alcohol importance of telling doctor if the pa-tient is pregnant, planning to becomepregnant, breastfeeding or planningto breastfeed as many medicationscross the placental barrier and/or areexcreted in breast milk a recommendation that the patientcarries a list of current medication(with exact names) in wallet/purse sothat he/she can ensure that any otherhealth professional knows what isbeing taken rather than a general de-scription (e.g. small blue pill for myheart). This may also be important inthe event of an emergency.Dosage Name and strength of the medication(including information about differ-ing strengths and trade names) What the medication looks like (e.g.capsules, tablets, liquid, injection) Dose this may be straightforward(e.g. patient is ordered 10 mg and tab-lets are supplied as 10 mg) or not (e.g.patient is ordered 15 mg and tabletsare supplied as 10 mg which meanssplitting one tablet. Depending on thedexterity of the person, this may notbe a simple task) When to take (e.g. morning, evening,same time every day, in relation tofood or other tablets, once per week,once per month) Not increasing, decreasing or stop-ping medication without seeking ad-vice from doctorSample chapter 29. xxviiiHAVARDS NURSING GUIDE TO DRUGSHow to take Swallow whole with glass of water (orother fluids as recommended). Somefluids may interfere with the medi-cation and it is important to knowwhich ones to avoid Tablets/capsules should generallynot be chewed (unless the tablets arechewable) Techniques (such as inhalation usinga puffer or injection) will need to bedemonstrated and taught. If patientis unable to manage, considerationshould be given to teaching a carer/family member/significant other, in-volving a community based serviceor discussion with doctor regardingthe appropriateness of the medicationand the risk of non-adherence withthe regimen What to do if a dose is forgotten oromitted (e.g. seeking advice from apharmacist or doctor; not taking adouble dose to catch up) What to do if too much medicationis taken (e.g. contacting doctor, phar-macist or Poisons Information Centre(131 126 in Australia or 0800 764 766in New Zealand), going to the near-est Accident and Emergency Depart-ment) Length of time that the medicationwill be required (including emphasison completing the course and notstopping the medication abruptly orwithout seeking medical advice) Whether there is anything that shouldbe avoided while taking the medica-tion (e.g. certain foods or fluids, shak-ing some medications, standing upquickly)Adverse effects All medications cause some side/ad-verse effects. Some of these may becommon, mild and transient in na-ture, while others are more serious(and may be life threatening). It isimportant for the patient to be madeaware of any potential side/adverseeffects which may require immediatemedical attention. Caution should betaken with explaining side-effects. Itmay be safer and simpler to suggestseeing a doctor if anything unusualoccurs. However, sometimes it isimportant to give specific directionssuch as report to your doctor im-mediately if you develop any yellow-ing of the skin or whites of the eyes,your urine looks darker than usual,you develop nausea, vomiting or ab-dominal pain Life threatening side effects (suchas allergic reaction including devel-opment of wheezing, shortness ofbreath, rash, difficulty swallowing)should be emphasised as requiringurgent medical attentionStorage All medications should be kept out ofreach of children Medications should be correctlystored. If there are special storagerequirements (such as refrigeration)these should be emphasised (e.g. notusing if left out of the fridge for 12hours or more) Medications should not be stored in abathroom, near a sink, on a window-sill or in the car as heat and dampnessmay destroy them Most medications should not befrozen Medications should be kept in theoriginal containers/packets withlabels intact. Medication should notbe taken if the packaging/container isSample chapter 30. xxixPATIENT TEACHING AND ADVICEtorn or has signs of being tamperedwith If the medication changes colour,becomes cloudy, foreign particlesare present or develops an odour, themedication should not be used anda pharmacist consulted immediately Medications have a use by (or expi-ry) date and should not be used afterthis date. It is important to show thepatient where this information is lo-cated (it can be difficult to see on somecontainers). Any unused medicationshould be safely disposed of (e.g. re-turned to the pharmacy). Some medi-cations such as eye drops and oint-ments may have a very short life anddeteriorate chemically after this timeOther issues Following all instructions on pack-age/container (e.g. shake well beforeuse, keep refrigerated, take 1 hourbefore meals) Seeking advice from doctor if symp-toms do not improve or worsen Attending doctors appointments asrequested, including the need for reg-ular blood or other tests to monitordrug levels (e.g. some medications,such as warfarin, require regularmonitoring of the therapeutic bloodlevel and the dosage may be adjustedaccordingly) Importance of having a current pre-scription and getting it filled/refilledbefore the medication runs out Medications should not be given toothers with similar conditions, norkept for the next time the conditionrecurs (e.g. antibiotics used to treatrespiratory infection) Over-the-counter medications (suchas simple analgesics, antacids, laxa-tives, cold and flu preparations) andherbal preparations or vitamins/minerals may interact with prescribedmedications. It is important to con-sult with doctor or pharmacist beforetaking any of these preparations (in-cluding those bought from the super-market or health food stores) Consideration should be given towearing a Medic Alert pendant orbracelet or some other form of iden-tification for some conditions/medi-cations (e.g. diabetes, anticoagulants,corticosteroids, insulin) in case of anemergency Whether the patient is able to man-age the medications alone (e.g. itmay be appropriate to suggest usinga Dosette box or involving a carerin any discussions or referring toa community-based agency (suchas the district nursing service) formonitoring). This may also includethe ability to open containers or splittablets if needed. Most pharmacieswill provide a unit-dose packing ser-vice on request Warn patient against driving or oper-ating machinery until he/she knowshow the medication will affect them.This is particularly important if themedication has known side effectswhich affect vision, balance, co-ordi-nation or reaction time or increasesthe effects of alcohol. If this is a knownoccurrence, extra labels will be at-tached to containers/packages (e.g.this medication may cause drowsinessand may increase the effects of alco-hol. If affected, do not drive a motorvehicle or operate machinery) Other medication-specific consid-erations are discussed under patientteaching and advice in each section.Sample chapter 31. xxxHAVARDS NURSING GUIDE TO DRUGSTECHNICAL REVIEWERSLynne M MacKinnonBPharm, MACPJerry PerkinsBSc, BPharmREVIEWERSKarole HogarthRN, BSc (Hons), PhD (Anatomy)Senior Lecturer, Otago Polytechnic,Dunedin, NZAngela KuciaBN, MA, PhD, Grad Cert EdSenior Lecturer, School of Nursing andMidwifery, University of South Austra-lia, Adelaide; Clinical Practice Consul-tant, Acute Cardiac Assessment, The Ly-ell McEwin Hospital, Adelaide, AustraliaErica ODonoghue RNBachelor of Nursing, Grad Cert Emer-gency Nursing, Grad Cert in Nursing(Paediatric, Child and Youth HealthNursing), Cert IV Training and Asssess-ment (TAE), MACNLecturer in Acute Care, Bachelor ofNursing, Alfred Clinical School, LaTrobe University, MelbourneNadim RahmanMBBS, AMC (Primary assessment), PGT(General Practice), RN, BN, GCHPEFaculty of Medicine, Nursing and HealthSciences, Monash University, MelbourneSonia ReisenhoferRN, BN, PGDipEN, MCNSchool of Nursing & Midwifery, LaTrobe University, MelbourneSample chapter 32. 1ANALGESICS AND NON-STEROIDALANTI-INFLAMMATORY DRUGS (NSAIDs)Action and use (not paracetamol)During the inflammatory response, ara-chidonic acid is converted by the enzymecyclo-oxygenase (COX) to prostaglan-dins and thromboxane A2, and by theenzyme lipoxygenase to leukotrienes,which produce the pain, swelling, red-ness and heat associated with inflamma-tion (Brenner & Stevens, 2010). Cyclo-oxygenase is present in two forms thathave distinct properties. Cyclo-oxygen-ase-1 (COX-1) is found in the stomach,intestines, kidneys and platelets, andappears to be responsible for functionsinvolving prostaglandins, such as renalfunction, platelet aggregation and cy-toprotection of the stomach. NSAIDsinhibit COX-1 non-selectively, resultingin the common side-effects of gastriculceration and, to a lesser extent, renaltoxicity and increased risk of bleeding.Cyclo-oxygenase-2 (COX-2) is foundin fewer tissues (including the brain,renal glomeruli and vasculature) at lowlevels; however, during inflammation,pro-inflammatory substances lead to anincrease in COX-2 levels (Brenner & Ste-vens, 2010). Selectively inhibiting COX-2decreases the signs and symptoms of in-flammation and pain with less likelihoodof causing gastric or renal problems.Recently, cyclo-oxygenase-3 (COX-3)has been discovered. It is thought thatparacetamol inhibits COX-3. possiblyexplaining its lack of anti-inflammatoryaction (Brenner & Stevens, 2010).The NSAIDs are a heterogeneousgroup of compounds, often chemicallyunrelated, that share some therapeuticactions and side-effects because of theirnon-selective inhibition of cyclo-oxygen-ase. Not all drugs in this class possess theanti-inflammatory, antipyretic and anal-gesic characteristics to the same degree(Brenner & Stevens, 2010). When usedas analgesics, these drugs are usually ef-fective against low to moderate intensitypain only. As anti-inflammatory agents,they are used in treating musculoskeletaldisorders, providing symptomatic relieffrom pain and inflammation, but leav-ing the progression of the disease courseunchanged. As antipyretics, they arethought to inhibit hypothalamic pros-taglandins that act on the thermoregu-latory centre in the hypothalamus. TheANALGESICS, NON-STEROIDALANTI-INFLAMMATORY DRUGS(NSAIDS) AND DISEASE-MODIFYINGANTIRHEUMATIC DRUGS (DMARDS)Sample chapter 33. 2HAVARDS NURSING GUIDE TO DRUGSCOX-2 inhibitors are a newer class ofagents with similar properties to those ofother NSAIDs without having the sameside-effects (especially gastrointestinal),because of their selective inhibition.Most NSAIDs are taken orally, whilesome are applied topically to relievemuscular and/or rheumatic pain, andothers are used in ophthalmic prepara-tions to reduce ocular inflammation.Adverse effects (not paracetamol) epigastric pain, nausea, vomiting,diarrhoea, abdominal pain/cramps,heartburn, dyspepsia, flatulence,bloating, anorexia, constipation gastrointestinal bleeding and/orulceration rash, pruritus tinnitus, temporary deafness headache, dizziness, vertigo, fatigue,drowsiness prolonged bleeding time fluid retention, oedema hypertension (new, or worsening ofexisting) increased risk of cardiovascularthrombotic events (COX-2 inhibitors) elevated liver enzymes (ALT, AST),jaundice, hepatitis blood dyscrasias, iron-deficiencyanaemia may mask signs and symptoms ofinfection (prolonged therapy, high dose) visualdisturbances, acute interstitial ne-phritis with haematuria, proteinuria,nephrotic syndrome, renal papillarynecrosis, liver toxicity hypersensitivity reactions (especiallyinthosewithasthmaorfamilyhistory) (rare) anaphylactoid reactions, angio-edemaInteractions (not paracetamol) may increase blood lithium or digox-in levels (except ketoprofen), therebyincreasing the risk of toxicity; lithiumor digoxin levels should be closelymonitored, especially when startingor stopping therapy with NSAIDs use with aspirin or other NSAIDsis not recommended because of in-creased risk of gastrointestinal side-effects use caution and close monitoring ifwarfarin is given with NSAIDs be-cause of increased risk of haemor-rhage increased risk of nephrotoxicity ifcyclosporin or tacrolimus are givenwith NSAIDs methotrexate toxicity may occur ifNSAIDs are given within 24 hours ofmethotrexate therapy use of quinolone antibiotics andNSAIDs may lead to convulsions (notcelecoxib) risk of gastric ulceration is increasedif aspirin or NSAIDs are taken withalcohol and/or corticosteroids increased risk of bleeding if givenwith SSRIs, zidovudine or antiplate-let agents use of antacids may reduce absorp-tion of aspirin or NSAIDs (exceptketoprofen, ketorolac trometamol,sulindac and piroxicam) may decrease excretion of aminogly-coside antibiotics, increasing risk oftoxicity avoid use with other nephrotoxicagents plasma levels may be increased ifgiven with probenecid may increase serum potassium lev-els if given with potassium-sparingdiureticsSample chapter 34. 3ANALGESICS, NSAIDs AND DMADs may decrease diuretic, natriureticand antihypertensive effects of loop,potassium-sparing and thiazide di-uretics by inhibiting the synthesis ofrenal prostaglandin may potentiate effects of sulfonyl-ureas may reduce antihypertensive effectsof beta-adrenergic blocking agents,ACE inhibitors and angiotensin IIantagonists risk of renal impairment is increasedif NSAIDs, thiazide diuretics andACE inhibitors/angiotensin II antag-onists are given together, especially inthe elderly or those with pre-existingrenal impairment increased risk of bleeding if givenwith Ginkgo bilobaNursing points/Cautions(not paracetamol) before starting therapy, the patientshould be assessed for any allergicreactions after prior aspirin or otherNSAID therapy, as cross-sensitivityoccurs any history of asthma (may induceasthma attack in susceptible individ-uals) or gastric ulceration/bleeding(due to increased risk of both) shouldbe assessed before starting therapy if administered preoperatively, pa-tient should be carefully monitoredfor any signs of bleeding intra- orpostoperatively regular ophthalmological examina-tion, haematological and liver en-zyme monitoring should all be per-formed during prolonged therapy in patients with concurrent hyper-tension and managed with antihy-pertensive agents (beta-adrenergicblocking agents, ACE inhibitors andangiotensin II antagonists) regularmeasurement of BP is recommendedbefore starting therapy and then atregular intervals caution if used in those with hyper-tension, congestive cardiac failure orpre-existing oedema because of in-creased potential for fluid retentionand oedema caution if given to those with pre-existing renal disease, uraemia orbleeding disorders caution if used in those with in-flammatory bowel disease (IBD) asNSAIDs have been associated withexacerbation of IBD-associated spon-dyloarthropathies contraindicated in those with a his-tory of peptic or gastrointestinalulceration or bleeding contraindicated in those with salicy-late hypersensitivity or with aspi-rin triad (person with asthma whoexperiences rhinitis with/withoutnasal polyps, or experiences severebronchospasm after taking aspirin orNSAIDs)Patient teaching and advicefor NSAIDs recommend taking NSAIDs withfood or milk (e.g. after meals) to re-duce gastric irritation patients should be warned to imme-diately report to their doctor any: changes in hearing or visual dis-turbances nausea, tiredness, lethargy, itch-ing, yellowing of skin, eyes andurine, flu-like symptoms or ab-dominal tenderness (in upperouter right quadrant, as these aresigns of impending liver toxicity)Sample chapter 35. 4HAVARDS NURSING GUIDE TO DRUGS patient should be advised to imme-diately seek medical attention if skinrash, hives, blistering or peeling skin,mouth ulcers or swelling of face, lips,mouth, tongue or throat, or wheez-ing/difficulty breathing occurs caution patients not to drive or oper-ate machinery if dizziness, drowsi-ness or visual disturbances occur (gel) instruct patient to only applygel to intact skin, avoiding any areasof broken or infected skin and washhands after applying gel and avoidcontact with eyes or mouth counsel female patients not to takeNSAIDs during pregnancy, especial-ly during third trimester. If the pa-tient becomes pregnant, she shouldbe advised to tell doctor immediatelyuse of these agents during the latterstages of pregnancy may cause closureof the fetal ductus arteriosus, fetal renalimpairment, inhibition of platelet aggre-gation and may delay labour and birth.Therefore, continuous treatment withthese agents during the third trimesterof pregnancy should only be undertakenif the benets are thought to greatly out-weigh the disadvantagesnot recommended during labour ordeliverycaution should also be used duringbreastfeeding because some NSAIDsand/or their metabolites are excretedin breast milk and their actions on thenewborn may be unknownASPIRIN (Aspro preparations, AsproClear Extra Strength, Astrix 100, AstrixTablets, Cardiprin 100, Cartia, Disprinpreparations, Solprin)Available formsCapsules: 100 mg; Tablets: 100 mg, 300mg, 320 mg, 500 mg; Tablets (entericcoated): 100 mg, Tablets (effervescent):300 mg, 500 mgAction see general Action for NSAIDs (p. 1) antiplatelet (see Antiplatelet Agents) aspirin is converted to salicylatemainly in the GI tract absorption is dependent on formula-tion (e.g. soluble formulation increas-es rate of absorption) half-life of aspirin is about 30 minutes,half-life of salicylate is dose depen-dentUse relief of mild to moderate non-visceralpain headache, migraine acute febrile illnesses (not for childrenor teenagers) dysmenorrhoea rheumatic pain, including juvenilerheumatoid arthritis antiplatelet therapy (only on medicaladvice) cold and u symptoms toothacheDose (analgesic, antipyretic) 3001000 mgorally with food 46 hourly as required(up to 4 g/day) OR (effervescent tablets) 3001000 mgorally dissolved in glass of water4-hourly as required (up to 4 g/day) OR (antiplatelet) 100 mg dailyAdverse effects see general Adverse effects forNSAIDs (p. 2)Interactions see general Interactions for NSAIDs may increase blood levels of sodiumvalproate, phenytoin, sulfonamidesand methotrexate increasing risk oftoxicity and/or adverse effects aspirin absorption is increased bymetoclopramide during migraineattackSample chapter 36. 5ANALGESICS, NSAIDs AND DMADs action of probenecid may be reducedif given with aspirin hypoglycaemic action of sulfonyl-ureas may be increased if given withhigh-dose aspirin and therefore bloodglucose levels should be closely mon-itored excretion is increased if given withurinary alkalinisers may antagonise diuretic action ofspironolactone rate and extent of absorption isincreased by caffeine hydrocortisone may increase clear-ance. Further, when hydrocortisoneis ceased, blood levels of aspirin mayrise signicantly, increasing risk of ad-verse effects and/or toxicity may interfere with a number of labo-ratory tests, including measurementof heparin activity, urinary glucoseoxidase test in the presence of gly-cosuria, uorometric assay of 5-hy-droxyindole acetic acid, serum uricacid and phenylketonuriaNursing points/Cautions see general points for NSAIDs soluble, effervescent, buffered andenteric-coated salicylate preparationsreduce gastric irritation enteric-coated and sustained-actionpreparations have delayed absorp-tion, which is useful for regular long-term therapy elderly patients are at greater risk ofadverse effects, including tinnitus,nausea, anorexia and gastric irritation tinnitus (with normal hearing) is areliable index of therapeutic plasmalevel, but may not be detected in pa-tients with hearing loss symptoms of salicylism (chronic sa-licylate intoxication) are dizziness,tinnitus, deafness, sweating, nausea,vomiting, headache and mental con-fusion symptoms of acute salicylate poi-soning include hyperventilation anddisturbed acidbase balance. Othersymptoms include fever, dehydra-tion, gastrointestinal symptoms,hypoglycaemia, bleeding and en-cephalopathy. In severe poisoning,CNS symptoms such as delirium,tremor, hallucinations, restlessnessand coma are common. Treatmentinvolves determining salicylate lev-els, stomach emptying with/withoutforced alkaline diuresis (dependingon blood salicylate level), treatmentof hyperthermia and dehydrationand correction of any disturbance inacidbase balance, as well as main-tenance of renal function. If conditionworsens, haemodialysis, peritonealdialysis or exchange transfusion maybe necessary aspirin should be avoided in infants,children and adolescents, including forthe treatment of fever and/or musclepain associated with febrile, viral ill-ness because of the association withReyes syndrome (see Glossary)Patient teaching and advice see general Patient teaching andadvice (p. xxiii) and general Patientteaching and advice for NSAIDs stopping aspirin for any reason (e.g.donation of blood) should be dis-cussed with doctor before discon-tinuing therapy effervescent and soluble preparationsshould be dissolved in 1 glass ofwater for more rapid absorption warn patients that sustained-releaseand enteric-coated preparationsshould be swallowed whole and notcrushed or broken advise patient to avoid aspirin within30 minutes of alcohol instruct patient to stop aspirin a weekbefore any surgical procedure as therisk of bleeding is increased blood donors should not take aspirinin the week preceding the donationSample chapter 37. 6HAVARDS NURSING GUIDE TO DRUGS if patient is on a low sodium diet, he/she should be cautioned that effer-vescent preparations contain sodiumNote contained in Alka-Seltzer, AsasantinSR, Aspalgin, Clopidogrel WinthropPlus Aspirin, Codis, CoPlavix, DisprinForte, DuoCoverBENZYDAMINE (Difam Solution, Anti-inammatory Throat Spray and Gel)Available formsThroat spray: 1.5 mg/mL; Gel: 3%, 5%;Solution: 22.5 mg/15 mLAction analgesic, anti-inammatoryUse relief of inammatory conditions ofthe mouth and throat (e.g. tonsillitis,radiation mucositis) (see Eye, ear,nose and throat agents) (topically) rheumatic disordersDose (rheumatic disorders) 3% or 5% gelmassaged into affected area 36times daily (maximum 6 times daily insevere conditions) for up to 14 daysAdverse effects (topical application) erythema, rash,photosensitivityPatient teaching and advice patients should be advised to washhands after applying gel and avoidcontact with eyes or mouth see general Patient teaching andadvice (p. xxiii)Note contained in Difam preparations(Lozenges, Mouth Gel and Solution),Logicin Rapid Relief LozengesBUFEXAMAC (Paraderm Cream)Available formCream: 50 mg/gAction/Use/Dose/Adverse effects/Nursing points/Cautions topical anti-inammatory (see Derma-tological agents)Note contained in Paraderm Plus, ResolveBalmCELECOXIB (Celebrex)Available formsCapsules: 100 mg, 200 mgAction COX-2 inhibitor preventing prosta-glandin synthesis with actions similarto other NSAIDs half-life 415 hoursUse osteoarthritis, rheumatoid arthritis,ankylosing spondylitis primary dysmenorrhoea (short-term) pain management post-surgery or musculoskeletal/soft tissueinjuryDose (osteoarthritis, ankylosing spondylitis)200 mg orally daily as single dose or2 divided doses OR (rheumatoid arthritis) 200 mg orallydaily in 2 divided doses, increasingto 400 mg daily for short-term man-agement of disease ares/exacerba-tions OR (primary dysmenorrhoea) 400 mgorally daily as single dose or 2 divideddoses (rst day), then 200 mg dailyon following days for up to 5 daysmaximum OR (acute postsurgical pain, musculo-skeletal and/or soft tissue injury) ini-tially 400 mg orally daily, then 200 mg12 times daily on following days forup to 5 days maximumSample chapter 38. 7ANALGESICS, NSAIDs AND DMADsAdverse effects see general Adverse effects forNSAIDs, however, gastrointestinaladverse effects occur less frequently increased risk of cardiac and throm-botic eventsInteractions increased plasma levels may occur ifgiven with uconazole increased risk of renal impairment ifgiven with ACE inhibitor/angiotensinreceptor antagonist and thiazide di-uretic at same time may decrease antihypertensive ef-fects of ACE inhibitor or angiotensinreceptor antagonist may decrease natriuretic effect offrusemide and thiazide diuretics be-cause of renal prostaglandin synthe-sis inhibition increased risk of gastrointestinal ad-verse effects if given with oral gluco-corticoids, especially in the elderly increased risk of gastrointestinal ad-verse effects if given with aspirin may increase plasma levels of lithi-um and warfarin, thereby increasingrisk of toxicity; lithium and warfarinlevels should be closely monitored,especially when starting, stopping oraltering doses of celecoxib decreased plasma levels may occur ifgiven with aluminium- or magnesium-containing antacids not recommended with other NSAIDsNursing points/Cautions any dehydration should be correctedbefore starting therapy any skin reactions usually occur with-in 4 weeks of starting therapy to lessen the risk of cardiovascularevents, the lowest effective doseshould be used for the shortest pos-sible duration (long-term treatment) haemoglobin orhaematocrit levels should be moni-tored regularly for signs of anaemia contraindicated in those with sensitiv-ity to sulfonamides contraindicated in the treatment ofpain in those undergoing coronaryartery bypass graft (CABG) surgery contraindicated in those with unsta-ble or signicant ischaemic heart dis-ease, peripheral arterial disease and/or cerebrovascular disease; conges-tive heart failure; severe liver or kidneyimpairment or creatinine clearance< 30 mL/min see general Nursing points/Cautionsfor NSAIDs (p. 3)Patient teaching and advice advise patient to take antacids 2hours before or after celecoxib warn patient to seek medical adviceimmediately if fainting, collapse,shortness of breath, chest pain or ir-regular heart beat occurs see general Patient teaching andadvice (p. xxiii) and general Patientteaching and advice for NSAIDs (p. 3)CHOLINE SALICYLATE (Bonjela MouthUlcer Gel, Bonjela Teething Gel, HerronBaby Teething Gel)Available formGel: 15 gAction local analgesicUse painful oral irritation (e.g. teething) lesions of the mouthDose (adult) massage 1 cm gel to painfularea 3-hourly OR (infant > 4 months) massage 0.5 cmgel to painful area 3-hourly if required(up to 6 applications/24 hours)Adverse effects transient stinging on applicationSample chapter 39. 8HAVARDS NURSING GUIDE TO DRUGSNursing points/Cautions contraindicated in babies less than4 months old or children under 12 i