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Prepare your students for successful practice and NCLEX-PN success with this updated 11th Edition of Roach’s Introductory Clinical Pharmacology. Developed by nurses for nurses, this practice-oriented text not only helps students learn about drugs and their effect on real people, but also models how to relay this information to patients. Known for its impeccably accurate drug content, this bestseller focuses on basic principles and the nurse's responsibility in medication management. The book’s easy-to-understand writing style combines with empowering online resources, including videos, NCLEX-PN-style review questions, and drug monographs, to help students hone their critical thinking and problem-solving skills as they master one of the most challenging content areas in the curriculum.


NEW! Unique Concept Mapping introduced in Chapter 5, Patient Education help students both process and visualize important concepts.
NEW! A List of Abbreviations is now on the inside back cover for easy reference.
NEW! Concept Mastery Alerts highlight and clarify commonly misunderstood concepts.
Pharmacology in Practice Case Studies focus on assessment, administration, or teaching issues that affect real-life patients and are revisited in the Think Critically questions which ask students to explore options and make clinical judgments related to the administration of drugs.
The Nursing Process framework presents care of the patient as it relates to the drug and drug regimen, as well as Checklists of Relevant Nursing Diagnoses.
Patient Case Study scenarios threaded through each chapter offer a “simulation-focus” to help students get a sense of real world nursing.
Nursing Alerts quickly identify urgent nursing actions that may be required when managing a patient receiving a specific drug or drug category through.
Drug Interaction Tables provide at-a-glance information about the likelihood of a patient problem when multiple drugs are given.
Summary Drug Tables list drugs from the classes discussed in each chapter, including names, uses, frequent adverse reactions, and general dosing information.
Lifespan Considerations boxes meet the needs of specific populations at risk or needing specific drug administration considerations through practical.
Herbal Considerations boxes provide information on herbs and complementary and alternative remedies.
Chronic Care Considerations prepare for situations that may arise during drug therapy for patients with chronic illnesses, such as diabetes, hypertension, or epilepsy, including issues of polypharmacy through.
Know Your Drugs (matching questions), Calculate Medication Dosages (dosage calculation questions), and Prepare for NCLEX-PN (NCLEX-style questions), appear at the end of each drug chapter.
Learning Objectives, Key Terms, and Drug Class lists identify potential errors and safety concerns to help students focus their reading and enhance their mastery of course concepts.
An updated Appendix H (NCLEX-PN test plan) addresses he latest test plan, as well as the concept-based curricula through additional definitions and links to content items in the text that correspond to concept-based teaching strategies
This leading content is also incorporated into Lippincott CoursePoint, a dynamic learning solution that integrates this book’s curriculum, adaptive learning tools, real-time data reporting, and the latest evidence-based practice content together into one powerful student education solution. Lippincott CoursePoint improves the nursing students’ critical thinking and clinical reasoning skills to prepare them for practice. Learn more at www.NursingEducationSuccess.com/CoursePoint.
11th Edition
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책에 대한 리뷰를 작성하거나 귀하의 독서 경험을 공유할 수 있습니다. 다른 독자들이 귀하가 읽은 책에 대한 의견에 귀를 기울일 것입니다. 개인적으로 책이 마음에 들었거나 그렇지 않았거나 정직하고 상세한 호평은 다른 독자들이 자신에게 적합한 책을 찾는데 도움이 됩니다.

Susan M. Ford, MN, RN, CNE
Professor Emeritus, Former Associate Dean for Nursing
Tacoma Community College
Tacoma, Washington


Acquisitions Editor: Natasha McIntyre Development Editor: Greg Nicholl Editorial Coordinator: Annette
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11th Edition
Copyright © 2018 Wolters Kluwer.
Copyright © 2014, 2010, 2008, 2004, 2000 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Copyright © 1996 by Lippincott-Raven Publishers. Copyright © 1992, 1987, 1982, 1975 by J. B. Lippincott
Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced
or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic
copies, or utilized by any information storage and retrieval system without written permission from the
copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing
in this book prepared by individuals as part of their official duties as U.S. government employees are not
covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two
Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via
our website at lww.com (products and services).
Printed in China
Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico, and U.S. Virgin
Library of Congress Cataloging-in-Publication Data
Names: Ford, Susan M., author.
Title: Roach’s introductory clinical pharmacology / Susan M. Ford.
Other titles: Introductory clinical pharmacology Description: 11th edition. | Philadelphia : Wolters Kluwer,
[2018] |
Preceded by Roach’s introductory clinical pharmacology / Susan M. Ford, Sally S. Roach; . 10th ed.
c2014. | Includes bibliographical references and index.
Identifiers: LCCN 2017024279 | ISBN 9781496380098.
Subjects: | MESH: Pharmacological Phenomena | Pharmacology, Clinical–methods | Drug Therapy |
Pharmaceutical Preparations–administration & dosage | Nurses’ Instruction
Classification: LCC RM301.28 | NLM QV 37 | DDC 615.1–dc23
LC record available at https://lccn.loc.gov/2017024279
This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied,
including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’
examination of each patient and consideration of, among other things, age, weight, gender, current or prior
medical conditions, medication history, laboratory data and other factors unique to the patient. The
publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare
professionals, and not the publisher, are solely responsible for the use of this work including all medical
judgments and for any resulting diagnosis and treatments.
Given continuous, rapid advances in medical science and health information, independent professional
verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and
treatment options should be made and healthcare professionals should consult a variety of sources. When
prescribing medication, healthcare professionals are advised to consult the product information sheet (the
manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use,

warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if
the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the
maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any
injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise,
or from any reference to or use by any person of this work.

I dedicate the 11th edition to three women.
My future—Pyrola Grothford, my first grandchild, who I hope may see health
care in your lifetime as a right for all, not just a privilege for those who can pay.
My past—Sylvia Jones, my mother and the nurse who suggested the nursing
profession as a career to me. Aunt Vi (Viola Oberholtzer), whose words
encouraged me to look at the community college pathway to become a
Registered Nurse where I studied, taught, and lead for most of my nursing

I would like to extend my gratitude to the many reviewers of this edition of
Roach’s Introductory Clinical Pharmacology. Know that your feedback helps me
grow and to look at ways to improve communication of this vital clinical drug
information. At the same time I hope your experience helps you to become a
better facilitator of information and inspire life-long learning in your students.
Christi Blair, MSN, RN
Nursing Faculty
Holmes Community College Goodman, Mississippi
Linda Canon, MSEd, BS, RN
Practical Nursing Coordinator
Genesee Valley Educational Partnership Batavia, New York
Sarah Chapin, MSN, RN
LPN Faculty
Galen College of Nursing Louisville, Kentucky
Mary Chavez, PharmD
Professor, Interim Vice Dean and Chair of Pharmacy Practice
Texas A&M University Rangel College of Pharmacy Kingsville, Texas
Kelly Claycomb, MSN, RN
Level I Program Coordinator
North Central Missouri College Trenton, Missouri
Kathleen Dolin, DNP, MSN, RN
Professor of Nursing
Northampton Community College Tannersville, Pennsylvania Patricia Donovan, MSN, RN
Director of Practical Nursing and Curriculum Chair
Porter and Chester Institute Rocky Hill, Conneticut
Janis Grimland, BSN, RN
Vocational Nursing Program Director
Hill College
Hillsboro, Texas
Valerie Jenkins, BSN, RN
Course Coordinator
Galen College of Nursing San Antonio, Texas
Ruby Johnson, MSN, RN

Allied Health Division Chair/Faculty
Ozarka College
Melbourne, Arkansas
Laura Kanavy, MSN, RN
Director of Practical Nursing
Career Technology Center of Lackawanna County Scranton, Pennsylvania
Maria Membrebe, MSN-Ed, RN
Assistant Professor
Baltimore, Maryland
Julie Monsegur, CSE, MSN-Ed, RN
Lab/Clinical Simulation Instructor
Pasco-Hernando State College Spring Hill, Florida
Judith Pahlck, MSN, RN
Jersey College
Teterboro, New Jersey
Debra Pitzer, MSN, RN
Faculty in Practical Nursing Program
Hutchinson Community College McPherson, Kansas
Cheryl Puckett, MSN, RN
Associate Professor
Bluegrass Community and Technical College Danville, Kentucky
Roxane Reid, DNP, MSN-Ed, RN
Assistant Professor Nursing
LaGuardia Community College Long Island City, New York Carolyn Santiago, MSN, NP-C, RN
Director of Nursing
Bakersfield, California Marla Schlesinger, MSN, ACNP, RN
Nursing Instructor
Concorde Career College North Hollywood, California Becky Shuttlesworth
Simulation Supervisor
San Jacinto College South Houston, Texas
Shayna Turner, MS, RN
Isabella Graham Hart School of Practical Nursing Rochester, New York
Elizabeth Villanueva, DNP, RN
Dean Emeritus
Jersey College
Jacksonville, Florida

oach’s Introductory Clinical Pharmacology is one in a series of texts
designed to assist beginning nursing students in acquiring a foundation of
basic nursing theory and for developing clinical skills. Many publishers give you
choices of texts offering information on drug action and activity. Yet, this text is
uniquely written by nurses for nurses in easy-to-read language, not only to teach
the novice provider about the drugs but also to role model how to relay this
information to patients.


The 11th edition of Roach’s Introductory Clinical Pharmacology is organized
into 13 units. Specific changes within these units include:
• Unit 1: Nursing Foundation of Clinical Pharmacology—Introduction to
the new FDA drug labeling system for pregnancy, lactation, and reproduction
as well as better clarity to the connection between math concepts and dosage
calculation in Chapter 3.
• Unit 2: Drugs Used to Fight Infections—Antibacterial chapters (Chapters 6
to 9) group the drugs according to what they do to a bacterial cell. This
presentation helps in understanding how the different classes are similar and
what to look for in terms of similar actions or adverse reactions. Highlight of
combination drugs used with diseases such as TB or HIV (Chapters 10 and
11) emphasizes methods to increase adherence to drug therapy and improving
quality of life. Chapter 11 includes the expanding number of drugs to treat
once acute illness (such as HIV and Hep C) shifting care to that of chronic
• Unit 3: Drugs Used to Manage Pain—Greater emphasis on learning painassessment strategies as well as the drugs for pain relief is threaded through
Chapters 13 to 15. Inclusion of information on medical marijuana—written
with neither the intent to support nor dismiss the use of marijuana—for
conditions such as pain management. Rather, as nurses we need to agree that
many of our patients will have used this drug for medical or recreational
purposes. Therefore, it is important to provide knowledge of this drug and its
uses as well as its effects and interactions. Many nurses never enter the
operating room suites, therefore Chapter 17 is written for a better
understanding about the effects of anesthetics used in the surgical arena to
effectively treat patients and teach family members postoperatively when you
are most likely to deal with reactions produced by these drugs.
• Unit 4: Drugs That Affect the Central Nervous System—When patients
become stressed, mental health issues may surface. This can be a surprising
experience for providers in non-psychiatric settings such as acute med-surg
floors. The chapters of this unit provide explanation and information to help
reduce the stigma associated with patients labeled with a psychiatric
• Unit 5: Drugs That Affect the Peripheral Nervous System—Repetition
and clarification of terminology in all chapters in this unit help students









understand the importance of the neurologic system in many facets of drug
Unit 6: Drugs That Affect the Neuromuscular System—Drug
reclassification of anticonvulsant to antiepileptic terminology provides
consistency in AED understanding and treatment.
Unit 7: Drugs That Affect the Respiratory System—Over-the-counter
products make self-treatment for respiratory conditions a growing concern.
Both drugs and strategies for patient teaching are updated in these chapters.
Unit 8: Drugs That Affect the Cardiovascular System—Encouraging
students to use their skills at concept mapping with Pharmacology in Practice
Case Studies in each chapter, helps the student to discover the poly
pharmacology issues when cardiac medications are prescribed with most any
other category of drug.
Unit 9: Drugs That Affect the Gastrointestinal System—Biologics used to
treat inflammatory bowel diseases are listed in Chapter 41 as well as
strategies for self-treatment of both upper and lower gastrointestinal issues.
Unit 10: Drugs That Affect the Endocrine System—Expansion of
antidiabetic medications is provided in Chapter 42, which corresponds with
the rise of patients being diagnosed with diabetes.
Unit 11: Drugs That Affect the Urinary System—Clarity of new
information to help patients remain safe while using medications supporting
healthy aging is included in Chapter 47.
Unit 12: Drugs That Affect the Immune System—New information on
biologic and targeted drug therapies for multiple chronic conditions as well as
updated immunization schedules in easy-to-read versions makes information
suitable to share with patients.
Unit 13: Drugs That Affect Other Body Systems—Chapter 54 includes
more information on intravenous therapy as well as how to use equal
analgesic conversion charts to prepare patients for good pain management
when medications change from IV to oral routes.

Written with patient outcomes in mind, complex concepts are introduced in
simplified language, helping learners to grasp concepts quicker and to use
patient teaching information right from the text leading to better understanding
on the part of the patient and adherence to treatment strategies.

Benefit to the Instructor
The basic explanations presented in the text are not intended to suggest that
pharmacology is an easy subject. As we know it, drug therapy is one of the most
important and complicated treatment modalities in modern health care. This text
is written to help you teach the latest pharmacologic information available by
• Clear, concise language to introduce learners to the basics of pharmacology.
• Presentation of drugs in a way to make integration of this text into conceptbased curricula seamless and effortless.
• Comprehensive bibliography entries that link the text to the latest evidencebased information and practice.
The new, or improved, features that make this the best pharmacology text for
teaching your students include:
• Nursing diagnoses, which are updated to 2015–2017 NANDA-I terminology.
• Special features such as Alerts and Considerations, which include
information to care for a more diverse patient population.
• Removal of old drug brand names that have lost their exclusive patents and
confuse learners when used.
• New to this edition are Concept Mastery Alerts, which clarify fundamental
nursing concepts to improve the reader’s understanding of potentially
confusing topics, as identified by Misconception Alerts in Lippincott’s
Adaptive Learning Powered by prepU. Data from thousands of actual
students using this program in courses across the United States identified
common misconceptions for the authors to clarify in this new feature.

Benefit to the Student
As a novice provider, this text gives you the introduction you need to begin your
journey to gain knowledge and competently practice medication management.

This text is written to help you learn the latest pharmacologic information
available by including:
• Drug therapy explained uniquely from a nursing perspective.
• Connection of drug therapy to the basic nursing theory you are learning in
your nursing curriculum.
• Presentation in an easy-to-read and follow format that helps you understand
the drugs and their effects on the human body, which in turn motivates you to
continue to learn more about this subject independently and helps you to
provide better care, educate patients, and improve outcomes.
• A nursing process section in each chapter that uses a familiar step-by-step
method to show how medications are used in the care of patients. Elements of
the nursing process—assessment, analysis, planning, intervention, and
evaluation—illustrate basic and practical nursing skills to help people
understand the treatment, to meet their health care needs, and to improve
adherence to treatment, all designed for better patient outcomes.
• Medication calculation using principles of safe practice rather than
mathematical formulas used in traditional math classes. Learning focuses on
reducing medication errors that result from mathematical mistakes rather than
on the traditional arithmetic exercises.
• Seven patients introduced in Chapter 5, whose health issues are woven into
subsequent chapters in order to build a story of how drugs impact real people.
Your ability to use outcome strategies and communicate what you do to
support patient and family confidence in learning self-management skills of
medication administration is highlighted using health literacy principles and
appreciation of cultural diversity using one of these seven patients
individually featured in each chapter.
• Specific quiz review items that are directly linked to the latest NCLEX test
• A list of abbreviations on the inside back cover for easy reference.
• Informational data to construct concept maps of the case study patients when
used in conjunction with the Study Guide to Accompany Roach’s Introductory
Clinical Pharmacology, 11th Edition, providing you opportunities to identify
potential drug–drug interactions.

What My Nursing Experiences Offer in this Text
To learn skills one needs repetitive practice, and nurses gain this in the clinical
setting. This means as elders we must step aside so that new nurses may gain

that experience. Retiring from paid clinical positions does not mean we stop
learning; I now gain teaching experience as a volunteer scripted/standardized
patient in the Nursing Simulation Center at Swedish RN Residency Program and
learn about patient experiences as a volunteer facilitator in chronic illness
workshops at Kaiser Foundation Health Plan of Washington. I hear directly what
new nurses and patients need in our ever-changing health care systems. These
experiences help me to appreciate what novice nurses need in their
pharmacologic education and how patients understand what we say as we
communicate about drugs in our interventions and teaching. This text is a
blending of this newly gained insight with well over 40 years of nursing practice
and teaching experience in mental health, acute care, operating room,
ambulatory care, home health, and hospice settings, as well as holding nursing
certification in areas such as oncology, medical-surgical clinical nurse specialist,
and as a certified nurse educator.

As You Learn and Enter Practice
You may find that certain drugs or drug dosages described in this publication
may no longer be available. Likewise, there may be new drugs on the market
that were not approved by the U.S. Food and Drug Administration (FDA) at the
time of publication. With the availability of computers, smart phones, and other
Internet resources, current information is always there for verification of any
drug question and should be checked when you do have a question before
administering a drug. Don’t forget that your colleagues, clinical pharmacists, and
primary health care providers are also resources for information concerning a
specific drug including dosage, adverse reactions, contraindications, precautions,
interactions, or administration.

To facilitate mastery of this text’s content, a comprehensive teaching and
learning package has been developed to assist faculty and students.

Resources for Instructors
Tools to assist you with teaching your course are available upon adoption of this
text at http://thePoint.lww.com/Ford11e
• A Test Generator lets you put together exclusive new tests from a bank
containing hundreds of questions to help you in assessing your students’
understanding of the material. Test questions link to chapter learning
• PowerPoint Presentations provide an easy way for you to integrate the
textbook with your students’ classroom experience, either via slide shows or
handouts. Multiple-choice and true/false questions are integrated into the
presentations to promote class participation and allow you to use i-clicker
• An Image Bank lets you use the photographs and illustrations from this
textbook in your PowerPoint slides or as you see fit in your course.
• Case Studies with related questions (and suggested answers) give students an
opportunity to apply their knowledge to a client case similar to one they
might encounter in practice.
• Pre-Lecture Quizzes (and answers) are quick, knowledge-based assessments
that allow you to check students’ reading.
• Guided Lecture Notes walk you through the chapters, objective by
• Discussion Topics (and suggested answers) can be used as conversation
starters or in online discussion boards.
• Plus Syllabi, Lesson Plans, QSEN Competency Maps, and Assignments.

Resources for Students
An exciting set of free resources is available to help students review material and
become even more familiar with vital concepts. Students can access all these
resources at http://thePoint.lww.com/Ford11e using the codes printed in the front
of their textbooks.

• NCLEX-Style Review Questions for each chapter help students review
important concepts and practice for the NCLEX.

Concepts in Action Animations bring pharmacology concepts to life.
Watch & Learn Video Clips explain how to prepare unit dose-

packaged medications as well as administering oral medication, subcutaneous
injections, and intramuscular injections. (Icons in the textbook direct readers
to relevant videos.)
• Journal Articles provided for each chapter offer access to current research
available in Wolters Kluwer journals.
• Plus Learning Objectives, Drug Monographs, Carrington Professional
Guide, Dosage Calculation Quizzes, and an Audio Glossary.

Study Guide
The Study Guide to Accompany Roach’s Introductory Pharmacology, 11th
Edition, offers exercises, puzzles, and multiple-choice questions to quiz your
pharmacologic knowledge. In the 11th edition, the same seven patients as the
text are included to continue the real-life case studies connected to situations in
the text. Concept mapping templates are provided to help you learn visually as
you go. These maps, which correlate to each of the text case study patients, give
you a visual method to see drug–drug interactions, and anticipate problems of
polypharmacy as you follow the stories of these seven patients in the text and
study guide.

We are pleased to offer an expanded suite of digital solutions and ancillaries to
support instructors and students using Roach’s Introductory Clinical
Pharmacology, 11th Edition. To learn more about any solution, please contact
your local Wolters Kluwer representative.

Lippincott CoursePoint+ is an integrated digital learning solution designed for
the way students learn. It is the only nursing education solution that integrates:
• Leading content in context: Content provided in the context of the student
learning path engages students and encourages interaction and learning on a
deeper level.
• Powerful tools to maximize class performance: Course-specific tools, such
as adaptive learning powered by prepU, provide a personalized learning
experience for every student.
• Real-time data to measure students’ progress: Student performance data
provided in an intuitive display let you quickly spot which students are
having difficulty or which concepts the class as a whole is struggling to
• Preparation for practice: Integrated virtual simulation and evidence-based
resources improve student competence, confidence, and success in
transitioning to practice.
• vSim for Nursing: Codeveloped by Laerdal Medical and Wolters Kluwer,
vSim for Nursing simulates real nursing scenarios and allows students to
interact with virtual patients in a safe, online environment.
• Lippincott Advisor for Education: With over 8500 entries covering the
latest evidence-based content and drug information, Lippincott Advisor for
Education provides students with the most up-to-date information possible,
while giving them valuable experience with the same point-of-care content
they will encounter in practice.
• Training services and personalized support: To ensure your success, our
dedicated educational consultants and training coaches will provide expert
guidance every step of the way.

To my literary team at Wolters Kluwer—there are so many people involved, it is
impossible to single out the importance of one person over another—thank you
for making every edition better than the one before.
To my extended family, friends, colleagues, and students-turned fellow nurses:
thank you for being there with ideas and stories to share.
To my sister, Nancy Rauch, high school math and science teacher: thank you
for helping make math skills real to these students. To my friends, Bonnie, Pam,
and Marion: thank you for keeping my BPM and motivation up as I worked on
this project.
Most importantly, to my family—Jerry, Stephanie, Eric, Peter, and Lexy—
who inspire me on a daily basis to be the best person and nurse possible!
—S. F. (87ord)

User’s Guide
Learners are more successful when they know how to use the text as well as
what is in the text. Here are some quick tips on how to use your text more
effectively. Thirteen units offer 54 chapters providing information in learnable
segments that are not overwhelming to the learner. Organization of the text in
this manner allows you to move about the chapters easily when these specific
areas of content are covered in your program curriculum.
The text starts with the basic fundamentals of drug therapy. Then units about
infection and pain, followed by units about drugs related to different body
systems. These units are written in a head-to-toe sequence, making the specific
drugs easier to find.
Learning about drug therapy is easier when you can connect the information
with life-like clinical experiences. In Chapter 5 you will be introduced to a group
of clients in the clinic setting. Their stories establish for you a context in which
to begin learning about the selected drugs and their real-world application.

The chapter opening page is designed to guide you, the learner, in organizing
your study routine as you learn the essential elements of drug therapy in each
Learning Objectives
These define what you will learn in a specific chapter. Review the
objectives first to help you understand what you need to learn after reading
the chapter.
Key Terms
With accompanying definitions, the Key Terms help you build your
vocabulary. Look for bold type in the text at first mention of the word in
the chapter to remind you of the definition.
Drug Classes
This gives you a sense of how drugs are grouped according to similar
properties. Learning these groupings helps you identify potential errors and
safety concerns.
Pharmacology in Practice
Each chapter features a case study individual dealing with an issue related
to drugs featured in the chapter. Scenarios focus on assessment,
administration, or teaching issues that have an impact on real-life patients.
Their stories help you to focus your attention on the concepts important to
patient care.

Consistent Framework
Each chapter presents the drugs in such a way that you learn to recognize and
respond to patient questions quickly and accurately. Illustrated concepts guide
you as each chapter features information about the drug class in a logical and
sequential order as Action, Uses, and Adverse Reactions—the concepts you,
the nurse, deal with on a consistent basis. This is followed by
Contraindications, Precautions, and Interactions—all items typically
reviewed earlier and considered by other health providers, yet at the same time
important for you to know to provide safe drug administration to your patients.

Special Features
Special features are sprinkled throughout the text to direct you to priority
information about the drugs or individuals who will receive the drugs.
Nursing Alerts
Quickly identify urgent nursing actions in the management of the patient
receiving a specific drug or drug category.
Lifespan Considerations
Draw your attention to specific populations at risk or needing specific
administration considerations (e.g., gerontology and pediatric). Because
texts are written dealing specifically with obstetrical and pediatric patients,
the primary focus of these alerts is for geriatric patients, or when specific
populations (e.g., women of childbearing age or transgender persons) take a
medication that will interact differently than the general population.
Drug Interaction Tables
A quick visual scan of these tables can tell you if a patient is likely to have
a problem when multiple drugs are given. Using these tables as you
construct concept maps on the case study patients in each chapter will help
you identify harmful interactions, before you see them happen in practice.
Herbal Considerations
Provide information on herbs and complementary and alternative remedies

used by patients under your care. Additional information is provided in
Appendix D where examples of a number of natural products are provided.

Uniquely presented, nursing actions regarding drug information are provided in
the context of a nurse’s clinical practice. The nursing process is featured as a
practical guide to connect patients and drug therapy.

Here is where you determine what you have learned from reading each chapter.
Information is summarized in an easy-to-read format, giving you the opportunity
to demonstrate what you learned by applying information in the chapter case
study. Once you review the chapter, use the review questions to demonstrate
your skill as you would when you take the NCLEX examination.
Pharmacology in Practice: Think Critically
Each chapter ends with a return to the case study patient. Realistic patient care
situations help learners apply the material contained in the chapter by exploring
options and making clinical judgments related to the administration of drugs.
The case histories of seven patients are used, and different aspects of care are
presented in different chapters like puzzle pieces, making connections for
learners to appreciate the complex issues in providing care to both individuals
and families. Coupled with information from the Study Guide to Accompany
Roach’s Introductory Clinical Pharmacology the learner is encouraged to map
out patient problems discovering potential complications or areas for improved
patient care.
Key Points
Key points are summarized and the important concepts of the chapter are listed
to help you determine if you have mastered the learning objectives.
Summary Drug Tables
Conveniently placed, these tables provide a list of drugs from the classes
discussed in each chapter. Current names (generic and, when appropriate, brand
names), uses, frequent adverse reactions, and general dosing information are
given in an accessible, easy-to-read format.

Know Your Drugs
Use the matching exercise to identify drug names and connect generic with
brand names to help you recognize the potential for and prevention against using
the wrong drug.
Calculate Medication Dosages
Practice the math skills to learn accurate drug dosing and recognize the potential
for error, thus ensuring that you give the correct dose.
Prepare for the NCLEX
Here questions allow you to test your knowledge of the material.
1. Build Your Knowledge—information- and fact-based questions are
presented to get you “warmed up” to apply what you’ve learned.
2. Apply Your Knowledge—keyed to the latest NCLEX-PN test plan (see
examples in Appendix H), these application and analysis questions about
concepts in the chapter help you apply what you’ve learned as well as
prepare for the NCLEX examination.
3. Alternate-Format Questions—provide you experience in applying what
you’ve learned in a different manner.
Special Features Questions are structured like the NCLEX examination. The
design helps you become familiar with the language and format of NCLEX
Patient or Client In this section of each chapter, you see wording change from
“patient” to “client.” In your course of study the terms patient, resident,
consumer, or client may be used. The change is intentional and designed to help
you recognize the interchange of words so you may adapt to testing format more
Numbered (1, 2, 3, 4) Distractors The NCLEX provides a single question on a
computer screen. The options you are given are listed as numbers. Distractor
options in these questions are labeled 1, 2, 3, 4 instead of A, B, C, D—again, to
simulate the NCLEX examination.

Box, Table, and Figure Credits
Box 1.2. Adapted with permission from Herbal products and supplements: What
you should know. Retrieved June 19, 2012, from the American Academy of
Family Physicians FamilyDoctor.org website:
Figures 2.8 and 2.9. From Timby, B. K. (2017). Fundamental nursing skills and
concepts (11th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams
& Wilkins.
Figure 2.10. Adapted from Lynn, P. (2015). Lippincott’s photo atlas of
medication administration (5th ed.). Philadelphia, PA: Wolters Kluwer.
Figure 2.12. Photo by Rick Brady.
Table 2.1. © The Joint Commission, 2015, reprinted with permission.
Figures 3.1, 3.3, and 3.5. Courtesy of GlaxoSmithKline.
Figure 3.2. Courtesy of Lilly Company.
Box 4.1. Reprinted with permission from Carpenito-Moyet, L. J. (2006). Nursing
diagnosis: Application to clinical practice (11th ed., pp. 473–480).
Philadelphia, PA: Lippincott Williams & Wilkins.
Box 7.1. Adapted from Levy-Hara, G. et al. (2011). Ten commandments for the
appropriate use of antibiotics by the practicing physician in an outpatient
setting. Front Microbiology, 2: 230.
Figure 10.1. Adapted from Rubin, E., & Farber, J. L. (1999). Pathology (3rd
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Figure 10.2. From Allendar, J. A., Rector, C., & Warner, K. D. (2014).
Community & public health nursing: Promoting the public’s health (8th
ed.). Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams &
Figure 11.1. Courtesy of Anatomical Chart Co.
Figure 11.2. Adapted from Anatomical Chart Co.
Figure 13.1. Adapted from Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2015).
Fundamentals of nursing (8th ed.). Philadelphia, PA: Wolters Kluwer.
Figure 14.1. From Smeltzer, S. C., & Bare, B. G. (2000). Brunnar & Suddarth’s
textbook of medical-surgical nursing (9th ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.
Figure 14.2. Courtesy of Anatomical Chart Co.
Figure 14.3. © 1983, Wong-Baker FACES Foundation,
www.WongBakerFACES.org. Used with permission, originally published in
Whaley & Wong’s nursing care of infants and children. © Elsevier Inc.
Figure 15.1. Adapted with permission from the World Health Organization
Figure 16.1. Photo by B. Proud.
Figure 17.1. Adapted from Timby, B. K. (2017). Fundamental nursing skills and
concepts (11th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams
& Wilkins.
Box 19.1. Adapted from Jack, C. R. Jr., Albert, M. S., Knopman, D. S.,
McKhann, G. M., Sperling, R. A., Carrillo, M. C., et al. (2011).
Introduction to the recommendations from the National Institute on Aging
—Alzheimer’s Association workgroups on diagnostic guidelines for
Alzheimer’s disease. Alzheimer’s & Dementia: The Journal of the

Alzheimer’s Association, 7(3), 257–262.
Figure 20.1. Adapted from Bear, M. F., Connors, B. W., & Parasido, M. A.
(2001). Neuroscience—Exploring the brain (2nd ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.
Figure 24.1. Adapted from Cohen, B. J. (2003). Medical terminology (4th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Figure 24.3. From Timby, B. K., & Smith, N. E. (2009). Introductory medicalsurgical nursing (10th ed.). Philadelphia, PA: Lippincott Williams &
Figure 25.1. Adapted from Cohen, B. J. (2003). Medical terminology (4th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Figure 26.1. Adapted from Cohen, B. J. (2003). Medical terminology (4th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Figure 27.1. From Cohen, B. J. (2003). Medical terminology (4th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Figure 29.1. Courtesy of Anatomical Chart Co.
Figure 30.1. From Bickley, L. S., & Szilagyi, P. (2017). Bates’ guide to physical
examination and history taking (12th ed.). Philadelphia, PA: Wolters
Figure 31.1. Courtesy of Anatomical Chart Co.
Figures 32.1, 32.2, and 32.3. Courtesy of Anatomical Chart Co.
Figure 32.4. Reprinted with permission from The Asthma Action Plan,

developed by a committee facilitated by the Regional Asthma Management
and Prevention (RAMP) Initiative, a program of the Public Health Institute.
Retrieved from http://www.rampasthma.org/actionplan. Accessed June 1,
2016. This publication was supported by Cooperative Agreement Number
1U58DP001016-01 from the CDC. Its contents are solely the responsibility
of the authors and do not necessarily represent the official views of the
Box 32.1. Expert Panel Report 3: Guidelines for the Diagnosis and Management
of Asthma, National Heart, Lung, and Blood Institute, 2007.
Figure 34.1. Courtesy of Anatomical Chart Co.
Table 34.1. From 2013 ACC/AHA Prevention Guidelines.
Figure 35.1 and Table 35.1. Adapted from National Heart, Lung and Blood
Institute. (2014). The eighth report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Bethesda, MD: National Institutes of Health. Retrieved May 7, 2009, from
Figure 37.2. Adapted from Timby, B. K. (2017). Fundamental nursing skills and
concepts (11th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams
& Wilkins.
Figure 39.1. Courtesy of Anatomical Chart Co.
Figure 40.1. Courtesy of Anatomical Chart Co.
Figure 41.1. Courtesy of Anatomical Chart Co.
Figures 42.1 and 42.2. Courtesy of Anatomical Chart Co.
Figure 42.3. Reprinted with permission from American Association of Clinical
Endocrinologists © 2016 AACE. Garber, A. J., Abrahamson, M. J.,
Barzilay, J. I., Blonde, L., Bloomgarden, Z. T., Bush, M. A., et al. (2016).

Consensus statement by the American Association of Clinical
Endocrinologists and American College of Endocrinology on the
comprehensive type 2 diabetes management algorithm—2016 Executive
Summary. Endocrine Practice, 22(1), 84–113.
Figure 42.5. From Carter, P. J. (2016). Lippincott textbook for nursing assistants
(4th ed.). Philadelphia, PA: Wolters Kluwer.
Table 42.2. Adapted from ADA, 2012
Figure 43.1. From Cohen, B. J., & Taylor, J. J. (2005). Memmler’s the human
body in health and disease (10th ed.). Baltimore, MD: Lippincott Williams
& Wilkins.
Figure 43.2. Courtesy of Anatomical Chart Co.
Figure 44.1. Courtesy of Anatomical Chart Co.
Figure 45.1. From Bear, M. F., Connors, B. W., & Parasido, M. A. (2001).
Neuroscience—Exploring the brain (2nd ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.
Figure 46.1. From Premkumar, K. (2004). The massage connection: Anatomy
and physiology. Baltimore, MD: Lippincott Williams & Wilkins.
Figure 47.1. Asset provided by Anatomical Chart Co.
Figure 49.3. Photo courtesy of U.S. Department of Agriculture.
Table 50.1. Polovich, M. (Ed.). (2011). Safe handling of hazardous drugs (2nd
ed.). Pittsburgh, PA: ONS publisher.
Figure 51.1. From McConnell, T. H. (2007). The nature of disease pathology for
the health professions. Philadelphia, PA: Lippincott Williams & Wilkins.
Figure 51.2. From Kronenberger, J., & Ledbetter, J. (2016). Lippincott Williams

& Wilkins’ comprehensive medical assisting (5th ed.). Philadelphia, PA:
Wolters Kluwer.
Figure 52.1. From Cohen, B. J. (2003). Medical terminology (4th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Figure 53.1. From Bear, M. F., Connors, B. W., & Parasido, M. A. (2001).
Neuroscience—Exploring the brain (2nd ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.
Box 54.3. Kishner, S., & Schraga, E. (2016). Opioid equivalents and
conversions. Medscape. Retrieved from
http://emedicine.medscape.com/article/2138678-overview. Accessed March
1, 2017.

User’s Guide
Box, Table, and Figure Credits

Nursing Foundation of Clinical Pharmacology

General Principles of Pharmacology
Administration of Drugs
Making Drug Dosing Safer
The Nursing Process
Patient and Family Teaching

Drugs Used to Fight Infections

Antibacterial Drugs: Sulfonamides
Antibacterial Drugs That Disrupt the Bacterial Cell Wall
Antibacterial Drugs That Interfere With Protein Synthesis
Antibacterial Drugs That Interfere With DNA/RNA Synthesis
Antitubercular Drugs
Antiviral Drugs
Antifungal and Antiparasitic Drugs


Drugs Used to Manage Pain

Nonopioid Analgesics: Salicylates and Nonsalicylates
Nonopioid Analgesics: Nonsteroidal Anti-Inflammatory Drugs
(NSAIDs) and Migraine Headache Medications
15 Opioid Analgesics
16 Opioid Antagonists
17 Anesthetic Drugs

Drugs That Affect the Central Nervous System

Central Nervous System Stimulants
Cholinesterase Inhibitors
Antianxiety Drugs
Sedatives and Hypnotics
Antidepressant Drugs
Antipsychotic Drugs

Drugs That Affect the Peripheral Nervous

Adrenergic Drugs
Adrenergic Blocking Drugs
Cholinergic Drugs
Cholinergic Blocking Drugs

Drugs That Affect the Neuromuscular System

Antiparkinson Drugs
Skeletal Muscle, Bone, and Joint Disorder Drugs

Drugs That Affect the Respiratory System

Upper Respiratory System Drugs
Lower Respiratory System Drugs

Drugs That Affect the Cardiovascular System

Antihyperlipidemic Drugs
Antihypertensive Drugs
Antianginal and Vasodilating Drugs
Anticoagulant and Thrombolytic Drugs
Cardiotonic and Inotropic Drugs
Antiarrhythmic Drugs

Drugs That Affect the Gastrointestinal System

Upper Gastrointestinal System Drugs
Lower Gastrointestinal System Drugs

Drugs That Affect the Endocrine System

Antidiabetic Drugs
Pituitary and Adrenocortical Hormones
Thyroid and Antithyroid Drugs
Male and Female Hormones
Uterine Drugs

UNIT 11
Drugs That Affect the Urinary System

Menopause and Andropause Drugs
Urinary Tract Anti-Infectives and Other Urinary Drugs

Drugs That Affect the Immune System

Immunologic Agents
Antineoplastic Drugs and Targeted Therapies
Immunomodulating Drugs

Drugs That Affect Other Body Systems

Skin Disorder Topical Drugs
Otic and Ophthalmic Preparations
Fluids, Electrolytes, and Parenteral Therapy
Appendix A Drug Categories: Controlled Substances and Outgoing
FDA Pregnancy Risk
Appendix B FDA and ISMP Lists of Look-Alike Drug Names with
Recommended Tall Man Letters
Appendix C Typical Immunization Schedules
Appendix D Select Herbs and Natural Products Used for Medicinal
Appendix E Improving Patient Outcomes Using Standardized Drug
Appendix F Less Frequently Used Calculations, Measurements, and
Basic Mathematical Review
Appendix G Answers to Review Questions and Medication Dosage
Appendix H NCLEX-PN Prep


Nursing Foundation of Clinical Pharmacology

s you become a nurse, you will realize that medication management is
one of the most significant tasks of your practice. Individuals rely
heavily on the knowledge and instruction of nurses to learn how to
become good managers of their own health care needs. When you work
in an institutional setting, the patients rely on nurses to accurately administer and
monitor medications to keep them safe and promote health. Both situations
require a competent nursing professional who has a strong foundation of clinical
Unit 1 provides you with the foundation for understanding pharmacology in
the context of nursing clinical practice. Three of the five chapters in this unit
specifically discuss concepts focal to nursing: drug administration, nursing
process, and patient teaching. The general principles of pharmacology and the
mathematics involved in dosage calculation are concepts used by all providers.
These concepts are included in their own chapters. Here is a brief summary of
the content in each chapter of Unit 1.
Basic principles are covered in Chapter 1, beginning with how drugs are
derived from natural sources, such as plants, or made synthetically. Other key
concepts include facts about drug categories and the differences between a
prescription drug (those given under the supervision of a licensed health care
provider) and a nonprescription drug (those obtained over the counter and
designated as safe when taken as directed). Finally, you will gain an
understanding of how drugs undergo a series of steps to be processed, utilized,
and eliminated by the body—this is the basis for the study of pharmacology for
health care providers.
Administration of a drug is primarily the responsibility of the nurse and is
discussed in Chapter 2. Nurses have the duty to safely provide patient care by
correctly administering the medication prescribed by the primary health care


provider. This is achieved by learning and following the principles of drug
administration, proper technique, and using medication systems correctly.
Your ability to correctly calculate mathematical problems is one of the most
important steps in providing safe care to patients. Mastering steps in drug
administration and delivery help to ensure accuracy in those math calculations.
Chapter 3 provides both the opportunity to practice calculations and an overview
of the tasks that you will undertake to be sure drug doses are correct before

Most patients experience problems of anxiety or lack knowledge regarding
new medication routines. The nursing process is used to help members of the
health care team provide effective patient care. This process is used to develop
an individualized care and teaching plan for use when medications are ordered.
Nursing process concepts are covered in Chapter 4.
It is crucial that the patient understand the important information about the
medication prescribed, including the dosage, how to take the medication, the
expected effect, and adverse reactions. In Chapter 5, components needed for
successful patient teaching are described. Additionally, a group of individuals
receiving nursing care in an ambulatory setting are introduced. Their stories are
designed to help you understand how all this information is used in the nursing
care of patients receiving drug therapy. You will learn how concepts are put into
practice using case studies throughout the textbook.
By understanding the basic principles of pharmacology, you can build a sound
knowledge base of the drugs used to help patients maintain their highest levels
of wellness.

General Principles of Pharmacology
Learning Objectives
On completion of this chapter, the student will:
1. Define the term pharmacology.
2. Identify the different names assigned to drugs.
3. Distinguish between prescription drugs, nonprescription drugs, and
controlled substances.
4. Discuss drug development in the United States.
5. Discuss the various types of drug activity and reactions produced in the
6. Identify factors that influence drug action.
7. Define drug tolerance, cumulative drug effect, and drug idiosyncrasy.
8. Discuss the types of drug interactions that may be seen with drug
9. Discuss the nursing implications associated with drug actions, interactions,
and effects.
10. Discuss the use of herbal medicines.

Key Terms
absorption a drug is moved from site of administration to body fluids;
first process during pharmacokinetics
adverse reaction undesirable drug effect
allergic reaction immediate hypersensitive reaction by the immune
system; it presents as itching, hives, swelling, and difficulty breathing
anaphylactic shock sudden, severe hypersensitivity reaction with
symptoms that progress rapidly and may result in death if not treated; also
called anaphylactic reaction or anaphylactoid reaction
angioedema localized wheals or swellings in subcutaneous tissues or
mucous membranes, which may be caused by an allergic response; also
called angioneurotic edema

controlled substances drugs that have the potential for abuse and
dependency, both physical and psychological
cumulative drug effect when the body is unable to metabolize and
excrete one dose of a drug before the next is given
complementary/alternative medicine (CAM) group of diverse medical
practices or products not presently part of conventional medicine
distribution drug moves from circulation to body tissue or a target site
drug idiosyncrasy any unusual or abnormal response that differs from the
response normally expected to a specific drug and dosage
drug tolerance decreased response to a drug, requiring an increase in
dosage to achieve the desired effect
excretion elimination of a drug from the body
first-pass effect action by which an oral drug is absorbed and carried
directly to the liver, where it is inactivated by enzymes before it enters the
general bloodstream
half-life time required for the body to eliminate 50% of a drug
herbal medicine type of complementary/alternative therapy that uses
plants or herbs to treat various disorders; also called herbalism
hypersensitivity undesirable reaction produced by a normal immune
metabolism drug is changed to a form that can be excreted
metabolite inactive form of the original drug
nonprescription drugs drugs designated by the U.S. Food and Drug
Administration (FDA) to be safe (if taken as directed) and obtainable
without a prescription; also called over-the-counter (OTC) drugs
pharmaceutic pertaining to the phase during which a drug dissolves in the
pharmacodynamics study of the drug mechanisms that produce
biochemical or physiologic changes in the body
pharmacokinetics study of drug transit (or activity) after administration
physical dependency habitual use of a drug, where negative physical
withdrawal symptoms result from abrupt discontinuation
prescription drugs drugs the federal government has designated as

potentially harmful unless their use is supervised by a licensed health care
provider, such as a nurse practitioner, physician, or dentist
psychological dependency compulsion or craving to use a substance to
obtain a pleasurable experience
receptor in pharmacology, a reactive site on the surface of a cell; when a
drug binds to and interacts with the receptor, a pharmacologic response
risk evaluation and mitigation strategies (REMS) program of the FDA,
designed to monitor drugs that have a high risk compared to benefit ratio
teratogen drug or substance that causes abnormal development of the
fetus, leading to deformities
toxic poisonous or harmful

harmacology is the study of drugs and their action on living organisms.
A sound knowledge of basic pharmacologic principles is essential for
nurses to administer medications safely and monitor patients who
receive these medications. The first task in learning about drug therapy
is to understand how drugs are named. Once you understand this concept it will
be easier to understand classes and categories of drugs, as well as federal
regulations pertaining to drugs and how they are developed. This chapter
presents a basic overview of the pharmacologic principles needed to understand
medication administration. Lastly, it discusses herbal medicines as they relate to
Over the last century, drugs have changed the way health care providers treat
patients. In the early 1900s, individuals died from infections and medical and
surgical complications partly because of a lack of sanitary conditions and the
fact that medicines used to combat infection did not exist at the time. The
discovery of drug substances has changed an infection from being a death
sentence into an acute or chronic health condition. Drug therapy also means that
patients lacking certain substances in their bodies, such as insulin, or those
diagnosed with cancerous tumors can now live long and productive lives.
Medications are either derived from natural sources, such as plants and
minerals, or they are synthetically produced in a laboratory. An example of a
drug derived from a natural source includes digitalis, which is an extract from


the foxglove plant that acts as a potent heart medication. On the other hand,
mipomersen (brand name Kynamro) is a chemically engineered drug designed to
target specific cell components in people with high cholesterol.

Throughout the process of development, drugs may have several names assigned
to them: a chemical name, a generic (nonproprietary, official) name, and a trade
(or brand) name. These different names can be confusing. Therefore, you have a
clear understanding of the different names used, you promote patient safety by
reducing errors.
The chemical name is the scientific term that describes the molecular structure
of a drug; it typically is the chemical component of the drug. The generic name
is considered the official name of a drug and is the name given to a drug that can
be made or marketed by any company; it is nonproprietary, meaning it is not
owned by any specific agency. The generic name is the official name that is
given a drug by the U.S. Food and Drug Administration (FDA). It also is the
name found in the National Formulary (NF) or the U.S. Pharmacopeia (USP)
for an approved drug. Table 1.1 identifies the various chemical, generic, and
trade names and provides an example and explanation for each name.
When a drug name is followed by a trademark symbol ™ or a registered
trademark symbol ®, this signifies that it is the trade or brand name. The trade
name is selected by a specific company producing the drug for marketing
purposes. To avoid confusion, it is best to use the generic name.

A drug may be classified by the chemical type of the active ingredient or by the
way it is used to treat a particular condition. Each drug can be classified into one
or more drug classes. For instance, in Unit 2, drugs that retard or destroy
pathogens are classified as anti-infectives. In each chapter, these drugs are
further categorized by the way they work (such as antivirals) or their chemical
structure (e.g., penicillins). Additionally, once a drug is approved for use, the
FDA assigns it to one of the following categories: prescription, nonprescription,
or controlled substance. To help you learn these classes, a list is included at the
start of each chapter.
TABLE 1.1 Drug Names

Study the patterns used in the naming of drugs. This may help you to
identify names and prevent medication errors. Certain portions of the drug name
may be similar in specific drug classes or categories. For example, betaadrenergic (β-adrenergic) blocking drug names end with “lol.” Atenolol,
metoprolol, and propranolol are all antihypertensive drugs from the same

Prescription Drugs
Prescription drugs, also called legend drugs, are the largest category of drugs.
Prescription drugs are prescribed by a licensed health care provider. The
prescription (Fig. 1.1) contains the name of the drug, the dosage, the method and
times of administration, and the electronic signature of the licensed health care
provider prescribing the drug. Typically, the health care provider writes the

prescription electronically and it is transmitted to the pharmacy. A paper copy
may be printed for a patient if a pharmacy outside the health care system will be
used to obtain the medication.

FIGURE 1.1 Example of an electronically transmitted prescription form.

Prescription drugs are designated by the federal government as potentially
harmful unless their use is supervised by a licensed health care provider, such as
a nurse practitioner, physician, or dentist. Supervision is important because,
although these drugs have been tested for safety and therapeutic effect,
prescription drugs may cause different reactions in some individuals.
In institutional settings, the nurse administers the drug and monitors the
patient for therapeutic effect and adverse reactions (undesirable effect). Some
drugs have the potential to be toxic (harmful). As a nurse, you will play a critical
role in evaluating the patient for toxic effects. When these drugs are prescribed
to be taken at home, you will provide patient and family education about the

Nonprescription Drugs
Nonprescription drugs are designated by the FDA as safe (when taken as
directed) and can be obtained without a prescription. These drugs are also
referred to as over-the-counter (OTC) drugs and may be purchased without a
prescription in a variety of settings, such as a drugstore, local supermarket, or a
large warehouse retailer (e.g., Costco or Sam’s Club). OTC drugs include those
given for symptoms of the common cold, minor aches and pains, constipation,
diarrhea, heartburn, and minor fungal infections.
Labeling requirements give the consumer important information regarding the
drug, dosage, contraindications, precautions, and adverse reactions. Consumers
are urged to read the directions carefully before taking OTC drugs. Yet, these
drugs are not without risk. For example, acetaminophen, commonly used for
pain relief, is also found in many OTC products, such as cough and cold
remedies. When taken for both pain and in a cold remedy, this accumulative
amount of the drug can potentially harm a person’s liver.

Controlled Substances
Controlled substances are the most carefully monitored class of drugs. These
drugs have a high potential for abuse and may cause physical or psychological
dependency. Physical dependency is defined as the habitual use of a drug in
which negative physical withdrawal symptoms result from abrupt
discontinuation; it is the body’s dependence on repeated administration of a
drug. Psychological dependency is a compulsion or craving to use a substance
to obtain a pleasurable experience. It is the mind’s desire for the repeated
administration of a drug. Physical and psychological dependence do not always
occur together, yet one type of dependency may lead to the other.
The Controlled Substances Act of 1970 established a classification system for
drugs with abuse potential. The act regulates the manufacture, distribution, and
dispensing of these drugs. The Controlled Substances Act divides drugs into five
groups, called schedules, which are based on the substance’s potential for abuse
and physical and psychological dependence. Appendix A describes the five
Prescription practices of the primary health care provider for controlled
substances are monitored by the Drug Enforcement Agency (DEA). Under
federal law, limited quantities of certain schedule V drugs may be purchased
without a prescription, with the purchase recorded by the dispensing pharmacist.
In some cases, state laws are more restrictive than federal laws and impose

additional requirements for the sale and distribution of controlled substances. In
hospitals or other agencies that dispense controlled substances, the scheduled
drugs are counted every 8 to 12 hours to account for each injectable, tablet, or
other form of the drug. Any discrepancy in the number of drugs must be
investigated and explained immediately.

Drug development is a long and arduous process that can take from 7 to 12
years, and sometimes longer. The FDA has the responsibility for approving new
drugs and monitoring drugs currently in use for adverse or toxic reactions. The
development of a new drug is divided into the pre-FDA phase and the FDA
phase. During the pre-FDA phase, a manufacturer conducts in vitro testing
(testing in an artificial environment, such as a test tube) using animal and human
cells to discover new drug compounds. This testing is followed by studies in live
animals. The manufacturer then makes application to the FDA for
Investigational New Drug (IND) status.
During the FDA phase, clinical (i.e., human) testing of the new drug begins.
Clinical testing consists of three phases, with each phase involving a larger
number of people (Fig. 1.2). In all phases the effects, both pharmacologic and
biologic, are studied. Phase 1 involves 20 to 100 individuals who are healthy
volunteers. This phase of testing is designed to see what the drug substance does
to healthy tissue. If Phase 1 studies are successful, the testing moves to Phase 2,
where the drug is given to people who have the disease or condition for which
the drug is thought to be effective. If those results are positive for helping to
reduce or eliminate the problem and adverse reactions are not too great, the
testing progresses to Phase 3, in which the drug is given to large numbers of
patients in medical research centers to provide information about adverse
reactions. Phase 3 studies offer additional information on dosing and safety.
Because of this extensive process, clinical trial studies can extend for many
Concept Mastery Alert
A reason for a drug to enter a Phase 3 study is to determine any unanticipated
effects. A reason for a drug to enter a Phase 2 study would be to test the potential
drug on patients with the disease the drug is designed to treat.
A New Drug Application (NDA) is submitted after the investigation of the
drug in Phases 1 to 3 is complete and the drug is found to be safe and effective.
With the NDA, the manufacturer submits all data collected concerning the drug
during the clinical trials. A panel of experts, including pharmacologists,
chemists, physicians, and other professionals, reviews the application and makes
a recommendation to the FDA. The FDA then either approves or denies approval
of the drug for use.

FIGURE 1.2 Phases of drug development.
BOX 1.1

MedWatch and Reporting Adverse Events

• The FDA established a program called MedWatch for reporting safety and
adverse events. Nurses or other health care providers can report
observations of serious adverse drug effects or find safety information.
Anyone can access the website
(http://www.fda.gov/medwatch/index.html) to obtain safety alerts on
drugs, devices, or dietary supplements.
• The website provides a standardized form for reporting, which can be
submitted electronically or downloaded, filled out, and mailed/faxed in to
the program. Nurses play an important role in monitoring for adverse
reactions. Therefore, it is important to submit reports, even if there is
uncertainty about the cause–effect relationship. The FDA protects the
identity of those who voluntarily report adverse reactions.
• The FDA considers serious adverse reactions those that may result in
death, life-threatening illness, hospitalization, or disability or those that
may require medical or surgical intervention. This form also is used to
report an undesirable experience associated with the use of medical
products (e.g., latex gloves, pacemakers, infusion pumps, anaphylaxis,
blood, blood components).

After FDA approval, the company making the drug will give the new drug a
brand name. This allows the company to sell the specific drug using this name
for a limited time. The hope is that some of the research and development cost
will be defrayed by the sales of this brand name drug. After the specified time,
other companies may sell the drug using the generic name. The brand name is
reserved for the company that first produced the specific drug substance.
After FDA approval, continued surveillance is done to ensure safety.
Postmarketing surveillance (Phase 4) occurs after the manufacturer places the
drug on the market. During this surveillance, an ongoing review of the drug
occurs with particular attention given to adverse reactions. Health care providers
are encouraged to help with this surveillance by reporting adverse effects of
drugs to the FDA by using MedWatch (Box 1.1) or the Institute for Safe
Medication Practices (ISMP) Medication Errors Reporting Program (MERP).

Although it takes considerable time for most drugs to get FDA approval, the
FDA has special programs to meet different needs. Examples of these special
programs include the orphan drug program, accelerated programs for urgent
needs, and the Risk Evaluation and Mitigation Strategies (REMS) program.

Orphan Drug Program
The Orphan Drug Act of 1983 was passed to encourage the development and
marketing of products used to treat rare diseases. The act defines a rare disease
as a condition affecting fewer than 200,000 individuals in the United States or a
condition affecting more than 200,000 persons in the United States but for which
the cost of producing and marketing a drug to treat the condition would not be
recovered by sales of the drug.
The National Organization of Rare Disorders reports that there are more than
6800 rare disorders that affect approximately 30 million individuals. Examples
of rare disorders include amyloidosis, Gaucher disease, and phenylketonuria.
The act provides for incentives such as research grants, protocol assistance by
the FDA, and special tax credits to encourage manufacturers to develop orphan
drugs. If the drug is approved, the manufacturer has 7 years of exclusive
marketing rights. More than 360 new drugs have received FDA approval since
the law was passed. Examples of orphan drugs include Velcade for amyloidosis,
enzyme replacement therapy for Gaucher disease, and atiprimod for the
treatment of multiple myeloma.

Accelerated Programs
Accelerated approval of drugs is offered by the FDA as a means to make
promising products for life-threatening diseases available on the market, based
on preliminary evidence and before formal demonstration of patient benefit. The
approval that is granted is considered a “provisional approval,” with a written
commitment from the pharmaceutical company to complete clinical studies that
formally demonstrate patient benefit. This program seeks to make life-saving
investigational drugs available before granting final approval to treat diseases
that pose a significant health threat to the public. If the drug continues to prove
beneficial, the process of approval is accelerated.
Acquired immunodeficiency syndrome (AIDS) is an example of a disease that

qualified as posing a significant health threat, and finding new drugs qualified
for the accelerated program. When first discovered, AIDS was very devastating
to the individuals affected and health agencies feared the danger the disease
posed to public health. Therefore, the FDA and pharmaceutical companies
worked together to shorten the IND approval process for drugs that showed
promise in treating AIDS. This accelerated process allowed primary health care
providers to administer medications that indicated positive results in early Phase
1 and 2 clinical trials, rather than wait until final approval was granted. HIV is
now viewed as a chronic disease, partly because of the efforts of accelerating the
clinical trial process for drugs to treat AIDS.

Risk Evaluation and Mitigation Strategies
The Risk Evaluation and Mitigation Strategies (REMS) program is designed
to monitor drugs that have high risk compared to benefit. To use a drug included
in this program, there are specific educational requirements of the health care
providers (prescribing and administering techniques) and education and
monitoring for patients taking the drug. Therefore, only HCP-trained, enrolled,
and certified providers may prescribe drugs with REMS restrictions. You can see
the restrictions placed upon these drugs in a REMS program by visiting the
brand name drug’s website.

Once in the body, drugs act in certain ways or phases. Oral drugs go through
three phases: the pharmaceutic phase, pharmacokinetic phase, and the
pharmacodynamic phase (Fig. 1.3). Liquid and parenteral drugs (drugs given by
injection) go through the latter two phases only.

Pharmaceutic Phase
In the pharmaceutic phase, the drug is dissolved. Drugs must be a soluble
liquid to be absorbed by the body. Drugs that are liquid or drugs given by
injection (parenteral drugs) are already dissolved and are absorbed quickly. A
tablet or capsule (solid forms of a drug) goes through this phase in the
gastrointestinal (GI) tract as it disintegrates into small particles and dissolves
into the body fluids. Tablets that have an enteric coating and time-release
capsules do not disintegrate until they reach the alkaline environment of the
small intestine.

Pharmacokinetic Phase
Pharmacokinetics refers to the transportation activity of drugs in the body after
administration. These activities include absorption, distribution, metabolism, and
excretion. Subcomponents of these pharmacokinetic activities include transport,
first-pass effect during absorption, and half-life during excretion of the drug.

Absorption is the process by which a drug is made available for use in the body.
This process involves moving the drug from the site of administration into the
body fluids. It occurs after the solid form (e.g., a pill or tablet) of the drug
dissolves or after the administration of an oral liquid or parenteral drug. In this
process, the drug particles in the GI tract are moved into the body fluids. This
movement can be accomplished in several ways:
• Active transport—cellular energy is used to move the drug from an area of
low concentration to one of high concentration.
• Passive transport—no cellular energy is used as the drug moves from an area
of high concentration to an area of low concentration (small molecules
diffuse across the cell membrane).
• Pinocytosis—cells engulf the drug particle (the cell forms a vesicle to
transport the drug into the inner cell).

Drug activity
pharmacodynamic phases.







Several factors influence the rate of absorption, including the route of
administration, the solubility of the drug, and specific conditions of the body’s
tissues. The most rapid route of drug absorption occurs when the drug is given
by the intravenous (IV) route. Absorption occurs more slowly when the drug is
administered orally, intramuscularly, or subcutaneously. This is because the
complex membranes of the GI mucosal layers, muscle, and skin delay drug
passage. Conditions in the body, such as lipodystrophy (the atrophy of
subcutaneous tissue from repeated subcutaneous injections) inhibit absorption of
a drug given in the affected site.
The first-pass effect may also affect absorption. When a drug is absorbed by
the small intestine, it travels to the liver before being released to circulate within
the rest of the body. The liver may metabolize a significant amount of the drug
before releasing it into the body. When the drug is released into the circulation
from the liver, the remaining amount of active drug may not be enough to
produce a therapeutic effect, and the patient will need a higher dosage.

The systemic circulation transports and distributes drugs to various body tissues
or target sites. Distribution of an absorbed drug in the body depends on protein
binding, blood flow, and solubility.
When a drug travels through the blood, it comes into contact with proteins
such as the plasma protein albumin. The drug can remain free in the circulation
or bind to the protein. Only free drugs can produce a therapeutic effect. Drugs
bound to protein are pharmacologically inactive. Only when the protein
molecules release the drug can the drug diffuse into the tissues, interact with
receptors, and produce a therapeutic effect. A drug is said to be highly protein
bound when more than 80% of the circulating drug is bound to protein.
A drug is distributed quickly to areas with a large blood supply, such as the
heart, liver, and kidneys. In other areas, such as the internal organs, skin, and
muscle, distribution of the drug occurs more slowly.
Solubility, or the drug’s ability to cross the cell membrane, affects its
distribution. Lipid-soluble drugs easily cross the cell membrane, whereas watersoluble drugs do not.

Metabolism, also called biotransformation, is the process by which the body
changes a drug to a more or less active form that can be excreted. Usually the
resulting form is a metabolite (an inactive form of the original drug). In some
drugs, one or more of the metabolites may have some drug activity. Metabolites
may undergo further metabolism or may be excreted from the body unchanged.
Most drugs are metabolized by the liver, although the kidneys, lungs, plasma,
and intestinal mucosa also aid in the metabolism of drugs.

The elimination of drugs from the body is called excretion. After the liver
renders drugs inactive, the kidney excretes the inactive compounds from the
body. Also, some drugs are excreted unchanged by the kidney without liver
involvement. Patients with kidney disease may require a dosage reduction and
careful monitoring of kidney function. Children have immature kidney function
and may require dosage reduction and kidney function tests. Similarly, older
adults have diminished kidney function and require careful monitoring and lower
dosages. Other drugs are eliminated in sweat, breast milk, or breath, or by the GI
tract through the feces.
Half-life refers to the time required for the body to eliminate 50% of the drug.
Knowledge of the half-life of a drug is important in planning the frequency of
dosing. Drugs with a short half-life (2 to 4 hours) need to be administered

frequently, whereas drugs with a long half-life (21 to 24 hours) require less
frequent administration. For example, digoxin (Lanoxin) has a long half-life (36
hours) and requires once-daily dosing. However, aspirin has a short half-life and
requires frequent dosing. It takes five to six half-lives to eliminate approximately
98% of a drug from the body. Although half-life is fairly stable, patients with
liver or kidney disease may have problems excreting a drug. Difficulty in
excreting a drug increases the half-life and the risk of toxicity, because these
organs do not remove the substances and the drug remains in the body longer.
Older patients or patients with impaired kidney or liver function require frequent
diagnostic tests measuring renal or hepatic function.
Onset, Peak, and Duration

The therapeutic effect of a drug determines the timing of drug administration.
Three pharmacokinetic factors are important when considering how a drug acts
in the body:
• Onset of action—time between administration of the drug and onset of its
therapeutic effect
• Peak concentration—when absorption rate equals the elimination rate (not
always the time of peak response)
• Duration of action—length of time the drug produces a therapeutic effect
These factors are taken into consideration when determining the dose schedule
of a specific drug. This ensures that proper blood levels are maintained in the
body for the drug to work properly.

Pharmacodynamic Phase
Pharmacodynamics is the study of the drug mechanisms that produce
biochemical or physiologic changes in the body. Pharmacodynamics deals with
the drug’s action and effect in the body. After administration, most drugs enter
the systemic circulation and expose almost all body tissues to possible effects of
the drug. This exposure in all tissue causes the drug to produce more than one
effect in the body. The primary effect of a drug is the desired or therapeutic
effect. Secondary effects are all other effects, desirable or undesirable, produced
by the drug.
Most drugs have an affinity for certain organs or tissues and exert their
greatest action at the cellular level on those specific areas, which are called
target sites. A drug exerts its action by one of two main mechanisms:
1. Alteration in cellular function

2. Alteration in cellular environment
Alteration in Cellular Function

Most drugs act on the body by altering cellular function. A drug cannot
completely change the function of a cell, but it can alter the cell’s function. A
drug that alters cellular function can increase or decrease certain physiologic
functions, such as increasing heart rate, decreasing blood pressure, or increasing
urine output.
Receptor-Mediated Drug Action
Many drugs act through drug–receptor interaction. The function of a cell is
altered when a drug interacts with a receptor. This occurs when a drug molecule
selectively joins with a reactive site—the receptor—on the surface of a cell.
When a drug binds to and interacts with the receptor, a pharmacologic response
An agonist is a drug that binds with a receptor and stimulates the receptor to
produce a therapeutic response. An antagonist is a drug that joins with receptors
but does not stimulate the receptors. The therapeutic action in this case consists
of blocking the receptor’s function.
Receptor-Mediated Drug Effects
The number of available receptor sites influences the effects of a drug. When
only a few receptor sites are occupied, although many sites are available, the
response will be small. When the drug dose is increased, more receptor sites are
used, and the response increases. When only a few receptor sites are available,
the response does not increase when more of the drug is administered. However,
not all receptors on a cell need to be occupied for a drug to be effective. Some
extremely potent drugs are effective even when the drug occupies few receptor
Alteration in Cellular Environment

Some drugs act on the body by changing the cellular environment, either
physically or chemically. Physical changes in the cellular environment include
changes in osmotic pressure, lubrication, absorption, or the conditions on the
surface of the cell membrane.
An example of a drug that changes osmotic pressure is mannitol, which
produces a change in the osmotic pressure in brain cells, causing a reduction in
cerebral edema. A drug that acts by altering the cellular environment by
lubrication is sunscreen. An example of a drug that acts by altering absorption is
activated charcoal, which is administered orally to absorb a toxic chemical

ingested into the GI tract. The stool softener docusate is an example of a drug
that acts by altering the surface of the cellular membrane. Docusate has
emulsifying and lubricating activity that lowers the surface tension in the cells of
the bowel, permitting water and fats to enter the stool. This softens the fecal
mass, allowing easier passage of the stool.
Chemical changes in the cellular environment include inactivation of cellular
functions or alteration of the chemical components of body fluid, such as a
change in the pH. For example, antacids neutralize gastric acidity in patients
with peptic ulcers.
Other drugs, such as some anticancer drugs and some antibiotics, have as their
main site of action the cell membrane and various cellular processes. They
incorporate themselves into the normal metabolic processes of the cell and cause
the formation of a defective final product, such as a weakened cell wall, which
results in cell death, or reduce a needed energy substrate that leads to cell
starvation and death.

Most pharmacodynamic mechanisms deal with principles that affect each cell in
the same way, whereas pharmacogenomics is the study of how people’s
responses to medications are variable because of individual genetic variation. In
other words, the genetic makeup of a person can affect the pharmacodynamics of
a drug. This discovery was made during the Human Genome Project when many
scientists were able to determine the different components of the human genetic
code. Pharmacogenetics is the creation of individualized drug therapy that
allows for the best choice and dose of drugs.

With the abundance of self-help information on the internet, women of
childbearing age are bombarded with a large amount of information regarding
drug use, pregnancy, and lactation. In general, most drugs are contraindicated
during pregnancy and lactation unless the potential benefits of taking the drug
outweigh the risks to the fetus or the infant. Pregnant woman should not take any
drug, legal or illegal, prescription or nonprescription, unless the drug is
prescribed or recommended by the primary health care provider. Children born
of mothers using addictive drugs, such as methamphetamine or oxycontin, often
are born with a dependency to the drug abused by the mother. Although
promoted as a natural substance, herbal supplements can act like drugs, too.
Women should not take an herbal supplement without discussing it first with the
primary health care provider.
Smoking tobacco or drinking any type of alcoholic beverage carries risks, and
should be eliminated for the duration of pregnancy. Drinking alcohol is
associated with risks of low birth weight, premature birth, and fetal alcohol
syndrome. Inhalation of substances other than tobacco, such as electronic
cigarettes or marijuana, have not been studied to the extent of making
recommendations, yet most health care providers do not recommend use because
of potential effects on the fetus.
Both expectant mothers and drug manufactures are concerned about the risk
of causing birth defects in the developing fetus. The use of any medication
(prescription or nonprescription) carries this risk, particularly during the first
trimester (3 months), when the drug may have teratogenic effects. A teratogen is
any substance that causes abnormal development of the fetus, often leading to
severe deformation. Drugs known to cause fetal abnormalities are classified as
In 2015, requirements for prescribing information to health care professionals
by manufacturers changed. Subheadings within the Pregnancy and Lactation
subsections of drug labels such as risk summary, clinical considerations, and
data were now required. The old system to assign a drug’s risk during pregnancy
and breastfeeding used the letter categories of A, B, C, D, and X to classify the
amount of risk to the developing fetus; to date, the new classification system is
still transitioning into place and is not in routine use. Therefore, the older letterbased system is provided as reference for you in Appendix A.
The letter categories for drug labeling have been in use since the 1970s and

were often misinterpreted as a grading system of risk. The new method provides
explanations, based on available information, about the potential benefits and
risks for the mother, the fetus, children who are breastfeeding, and women and
men of reproductive age. The new system will be used as new drugs are
introduced to the market and as older drugs are reviewed by the FDA; therefore,
you will see the old system in this text and in drug information resources as well
as the new categories as they are developed.
A number of drugs are excreted in breast milk. Therefore, if a mother is
lactating (breastfeeding), some of the drug she is taking will travel through her to
the infant or child via the breast milk to be ingested and absorbed. It is important
for both mothers and nurses to know the potential of exposure to a breastfeeding
child when the mother is taking a drug.
The National Library of Medicine provides a free online database with
(http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT). This website is geared to
the health care practitioner and nursing mother and contains over 450 drug
records. It includes information such as maternal levels in breast milk, infant
levels in blood, and potential effects in breastfeeding infants. A pharmacist, Dr.
Thomas Hale, from Texas Tech University has developed a system of lactation
risk categories similar to that of the FDA pregnancy risk categories for drugs.
Drugs are assigned an L1 to L5 risk according to the drug’s transmission in
breast milk and the effect it may have on the child. Hale’s listing of certain drugs
may differ from those published by organizations such as the American
Academy of Pediatrics, yet it is a good starting point for discussion with mothers
who are breastfeeding.

Drugs produce many reactions in the body. The following sections discuss
adverse drug reactions, allergic drug reactions, drug idiosyncrasy, drug tolerance,
cumulative drug effect, and toxic reactions.

Adverse Drug Reactions
Patients may experience one or more adverse reactions or side effects when they
are given a drug. Adverse reactions are undesirable drug effects. Adverse
reactions may be common or may occur infrequently. They may be mild, severe,
or life-threatening. They may occur after the first dose, after a few doses, or after
many doses. Often, an adverse reaction is unpredictable, although some drugs
are known to cause certain adverse reactions in many patients. For example,
drugs used in treating cancer are very toxic and are known to produce adverse
reactions in many patients receiving them. Other drugs produce adverse
reactions in fewer patients. Some adverse reactions are predictable, but many
adverse drug reactions occur without warning.
There are some adverse reactions that you will see with each patient you
care for in your role as a nurse. Other adverse reactions are so infrequent you
may never see one. In this text we list both the common and unusual adverse
reactions, because as a nurse you see many patients and the likelihood that you
will care for a person experiencing a severe adverse reaction is much greater
than it is for other types of health care providers. If you could avert a lasting
complication or even a death through your knowledge of adverse reactions, it
would be a wonderful accomplishment in your career.
Some texts use both the terms side effects and adverse reactions, using side
effects to explain mild, common, and nontoxic reactions and adverse reactions to
describe more severe and life-threatening reactions. The newest addition of the
NCLEX-PN test plan has changed terminology of reaction to effect for testing
purposes. For the purposes of this text and to avoid confusion, only the term
adverse reaction is used, with the understanding that these reactions may be
mild, severe, or life-threatening and will be defined as such.

Allergic Drug Reactions

An allergic reaction is an immediate hypersensitivity reaction. Allergy to a
drug usually begins to occur when more than one dose of the drug has been
given. On occasion, the nurse may observe an allergic reaction the first time a
drug is given, because the patient has been exposed to the drug in the past.
A drug allergy occurs because the individual’s immune system responds to the
drug as a foreign substance called an antigen. When the body responds to the
drug as an antigen, a series of events occurs in an attempt to render the invader
harmless. Lymphocytes respond by forming antibodies (protein substances that
protect against antigens). Common allergic reactions occur when the individual’s
immune system responds aggressively to the antigen. Chemical mediators
released during the allergic reaction produce symptoms ranging from mild to
Even a mild allergic reaction produces serious effects if it goes unnoticed and
the drug is given again. Any indication of an allergic reaction is reported to the
primary health care provider before the next dose of the drug is given. Serious
allergic reactions require contacting the primary health care provider
immediately, because emergency treatment may be necessary.
Some allergic reactions occur within minutes (even seconds) after the drug is
given; others may be delayed for hours or days. Allergic reactions that occur
immediately often are the most serious.
Allergic reactions are manifested by a variety of signs and symptoms observed
by the nurse or reported by the patient. Examples of some allergic symptoms
include itching, various types of skin rashes, and hives (urticaria). Other
symptoms include difficulty breathing, wheezing, cyanosis, a sudden loss of
consciousness, and swelling of the eyes, lips, or tongue.
Anaphylactic shock is an extremely serious allergic drug reaction that usually
occurs shortly after the administration of a drug to which the individual is
sensitive. This type of allergic reaction requires immediate medical attention.
Symptoms of anaphylactic shock are listed in Table 1.2.
An anaphylactic reaction should be considered if all or only some of these
symptoms are present. Anaphylactic shock can be fatal if the symptoms are not
identified and treated immediately. The treatment goal is to raise the blood
pressure, improve breathing, restore cardiac function, and treat other symptoms
as they occur. Epinephrine (adrenalin) may be given by subcutaneous injection
in the upper extremity or thigh and may be followed by a continuous IV
infusion. Hypotension and shock may be treated with fluids and vasopressors.
Bronchodilators are given to relax the smooth muscles of the bronchial tubes.
Antihistamines and corticosteroids may also be given to treat urticaria and

angioedema (swelling). These are all drugs you will learn about in subsequent
chapters of this book.
TABLE 1.2 Symptoms of Anaphylactic Shock

Angioedema (angioneurotic edema) is another type of allergic drug reaction.
It is manifested by the collection of fluid in subcutaneous tissues. Areas that are
most commonly affected are the eyelids, lips, mouth, and throat, although other
areas also may be affected. Angioedema can be dangerous when the mouth and
throat are affected, because the swelling may block the airway and asphyxia may
occur. Difficulty in breathing and swelling in any area of the body are reported
immediately to the primary health care provider.

Drug Idiosyncrasy
Drug idiosyncrasy is a term used to describe any unusual or atypical reaction to
a drug. It is any reaction that is different from the one normally expected from a
specific drug and dose. For example, a patient may be given a drug to help him
or her sleep (e.g., a hypnotic). Instead of falling asleep, the patient remains wide
awake and shows signs of nervousness or excitement. This response is
idiosyncratic because it is different from what one expects from this type of
drug. Another patient may receive the same drug and dose, fall asleep, and after
8 hours be difficult to awaken. This, too, is abnormal and describes an
overresponse to the drug.
The cause of drug idiosyncrasy is not clear, although study in the science of

genetics can give us insight into possible explanations. The inability to tolerate
certain chemicals and drugs is believed to be because of a genetic deficiency.
Pharmacogenetics, the study of ways that specific genes can enhance sensitivity
or resistance to certain drugs, helps to explain some drug idiosyncrasies. A
pharmacogenetic disorder is a genetically determined abnormal response to
normal doses of a drug. This abnormal response occurs because of inherited
traits that cause abnormal metabolism of drugs. For example, individuals with
glucose-6-phosphate dehydrogenase (G6PD) deficiency have abnormal reactions
to a number of drugs. These patients exhibit varying degrees of hemolysis
(destruction of red blood cells) when these drugs are administered. More than
100 million people are affected by this disorder. Examples of drugs that cause
hemolysis in patients with a G6PD deficiency include aspirin, chloramphenicol,
and the sulfonamides.

Drug Tolerance
Drug tolerance is a term used to describe a decreased response to a drug,
requiring an increase in dosage to achieve the desired effect. Drug tolerance may
develop when a patient takes certain drugs, such as opioids and antianxiety
drugs, for a long time. The individual who takes these drugs at home increases
the dose when the expected drug effect does not occur. The development of drug
tolerance is a sign of physical drug dependence. Drug tolerance may also occur
in the hospitalized patient. When the patient begins to ask for the drug at more
frequent intervals, the nurse needs to assess whether the dose is not adequate
based on the disease process or whether the patient is building a tolerance to the
drug’s effects.

Cumulative Drug Effect
A cumulative drug effect may be seen in those people with liver or kidney
disease because these organs are the major sites for the breakdown and excretion
of most drugs. This drug effect occurs when the body is unable to metabolize
and excrete one (normal) dose of a drug before the next dose is given. Thus, if a
second dose of the drug is given, some drug from the first dose remains in the
body. A cumulative drug effect can be serious because too much of the drug can
accumulate in the body and lead to toxicity.
Patients with liver or kidney disease are usually given drugs with caution
because a cumulative effect may occur. When the patient is unable to excrete the
drug at a normal rate, the drug accumulates in the body, causing a toxic reaction.

Sometimes, the primary health care provider lowers the dose of the drug to
prevent a toxic drug reaction.

Toxic Reactions
Most drugs can produce toxic or harmful reactions if administered in large
dosages or when blood concentration levels exceed the therapeutic level. Toxic
levels build up when a drug is administered in doses that exceed the normal level
or if the patient’s kidneys are not functioning properly and cannot excrete the
drug. Some toxic effects are immediately visible; others may not be seen for
weeks or months. Some drugs, such as lithium or digoxin, have a narrow margin
of safety, even when given in recommended dosages. It is important to monitor
these drugs closely to detect and avoid toxicity.
Drug toxicity can be reversible or irreversible, depending on the organs
involved. Damage to the liver may be reversible, because liver cells can
regenerate. However, hearing loss from damage to the eighth cranial nerve
caused by toxic reaction to the anti-infective drug streptomycin may be
permanent. Sometimes drug toxicity can be reversed by administering another
drug that acts as an antidote. For example, when too much opiate is taken, the
drug naloxone (Narcan) may be given to counteract the effect.
Carefully monitor the patient’s blood level of drug to ensure that the level
remains within the therapeutic range. Any deviation should be reported to the
primary health care provider. Because some drugs can cause toxic reactions even
in recommended doses, you should be aware of the signs and symptoms of
toxicity of commonly prescribed drugs.

Minimizing Drug Reactions Through Pharmacogenomics
Drug developers are also researching ways to target cell structures and selected
cells to minimize reactions in other body tissues, thereby reducing or eliminating
adverse reactions. Genetic specialists search for genetic variations associated
with drug efficiency. The goal of pharmacogenomics is the creation of drugs that
can be tailor-made for individuals, target specific cells in the body, and adapt to
each person’s own individual genetic makeup.

It is important when administering medications to be aware of the various drug
interactions that can occur, especially drug–drug interactions and drug–food
interactions. This section gives a brief overview of drug interactions. Specific
drug–drug and drug–food interactions are discussed in subsequent chapters.

Drug–Drug Interactions
A drug–drug interaction occurs when one drug interacts with or interferes with
the action of another drug. For example, taking an antacid with oral tetracycline
causes a decrease in the effectiveness of the tetracycline. The antacid chemically
interacts with the tetracycline and impairs its absorption into the bloodstream,
thus reducing the effectiveness of the tetracycline. Drug categories known to
cause interactions with other drugs include oral anticoagulants, oral
hypoglycemics, anti-infectives, antiarrhythmics, cardiac glycosides, and alcohol.
Drug–drug interactions can produce effects that are additive, synergistic, or
Additive Drug Reaction

An additive drug reaction occurs when the combined effect of two drugs is equal
to the sum of each drug given alone. The equation 1 + 1 = 2 is sometimes used to
illustrate the additive effect of drugs. For example, taking the drug heparin with
alcohol will increase bleeding.
Synergistic Drug Reaction

Drug synergism occurs when drugs interact with each other and produce an
effect that is greater than the sum of their separate actions. The equation 1 + 1 =
3 may be used to illustrate synergism. Drug synergism is exemplified when a
person takes both a hypnotic and alcohol. When alcohol is taken shortly before
or after the hypnotic drug, the action of the hypnotic increases considerably. The
individual experiences a drug effect that is greater than each drug taken alone.
On occasion, the occurrence of a synergistic drug effect is serious and even fatal.
Antagonistic Drug Reaction

An antagonistic drug reaction occurs when one drug interferes with the action of
another, causing neutralization or a decrease in the effect of one of the drugs.
The equation 1 − 1 = 0 may be used to illustrate antagonistic reactions. For
example, protamine is a heparin antagonist. This means that the administration
of protamine completely neutralizes the effects of heparin in the body and blood

clotting will happen in the body.

Drug–Food Interactions
When a drug is given orally, food may impair or enhance its absorption. A drug
taken on an empty stomach is absorbed into the bloodstream more quickly than
when the drug is taken with food in the stomach. Some drugs (e.g., captopril)
must be taken on an empty stomach to achieve an optimal effect. Drugs that
should be taken on an empty stomach are administered 1 hour before or 2 hours
after meals. Other drugs—especially drugs that irritate the stomach, result in
nausea or vomiting, or cause epigastric distress—are best given with food or
meals. This minimizes gastric irritation. The nonsteroidal anti-inflammatory
drugs (NSAIDs) and salicylates are examples of drugs that are given with food
to decrease epigastric distress. Still other drugs combine with a food, forming an
insoluble food–drug mixture. For example, when tetracycline is administered
with dairy products, a drug–food mixture is formed that is not absorbable by the
body. When a drug cannot be absorbed by the body, no pharmacologic effect
TABLE 1.3 Factors Altering Drug Response in Children and Older

Certain factors may influence drug response and are considered when the
primary health care provider prescribes and the nurse administers a drug. These
factors include age, weight, sex, disease, and route of administration.

The age of the patient may influence the effects of a drug. Infants and children
usually require smaller doses of a drug than adults. Immature organ function,
particularly of the liver and kidneys, can affect the ability of infants and young
children to metabolize drugs. An infant’s immature kidneys impair the
elimination of drugs in the urine. Liver function is poorly developed in infants
and young children. Drugs metabolized by the liver may produce more intense
effects for longer periods. Parents must be taught the potential problems
associated with administering drugs to their children. For example, a safe dose of
a nonprescription drug for a 4-year-old child may be dangerous for a 6-monthold infant.
Elderly patients may also require smaller doses, although this may depend on
the type of drug administered. For example, the elderly patient may be given the
same dose of an antibiotic as a younger adult. However, the same older adult
may require a smaller dose of a drug that depresses the central nervous system,
such as an opioid. Changes that occur with aging affect the pharmacokinetics
(absorption, distribution, metabolism, and excretion) of a drug. Any of these
processes may be altered because of the physiologic changes that occur with
aging. Table 1.3 summarizes the changes that occur with aging and their possible
pharmacokinetic effects.
Polypharmacy is the taking of numerous drugs that can potentially react with
one another. This is seen particularly in elderly patients who may have multiple
chronic diseases; polypharmacy leads to an increase in the number of potential
adverse reactions. Although multiple drug therapy is necessary to treat certain
disease states, it always increases the possibility of adverse reactions. You need
good assessment skills to detect any problems when monitoring the geriatric
patient’s response to drug therapy.

In general, dosages are based on a weight of approximately 170 lb, which is
calculated to be the average weight of men and women. A drug dose may

sometimes be increased or decreased because the patient’s weight is significantly
higher or lower than this average. With opioids, for example, higher- or lowerthan-average dosages may be necessary, depending on the patient’s weight, to
produce relief of pain.

The sex of an individual may influence the action of some drugs. Women may
require a smaller dose of some drugs than men. This is because many women are
smaller and have a different body fat-to-water ratio than men.

The presence of disease may influence the action of some drugs. Sometimes
disease is an indication for not prescribing a drug or for reducing the dose of a
certain drug. Both hepatic (liver) and renal (kidney) diseases can greatly affect
drug response.
In liver disease, for example, the ability to metabolize or detoxify a specific
type of drug may be impaired. If the average or normal dose of the drug is given,
the liver may be unable to metabolize the drug at a normal rate. Consequently,
the drug may be excreted from the body at a much slower rate than normal. The
primary health care provider may then decide to prescribe a lower dose and
lengthen the time between doses because liver function is abnormal.
Patients with kidney disease may exhibit drug toxicity and a longer duration
of drug action. The dosage of drugs may be reduced to prevent the accumulation
of toxic levels in the blood or further injury to the kidney.

Route of Administration
The method used to get the drug into a person’s body will affect the drug
response. IV adm