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LILLEY'S Pharmacology
for Canadian Health Care Practice
TABLE OF CONTENTS
About the Authors, v Reviewers, vii Preface, ix
Acknowledgements, xiii
PART 1 Pharmacology Basics
1 Nursing Practice in Canada and Drug Therapy, 1
2 Pharmacological Principles, 14
3 Legal and Ethical Considerations, 36
4 Patient-Focused Considerations, 47
5 Gene Therapy and Pharmacogenomics, 67
6 Medication Errors: Preventing and Responding, 75
7 Patient Education and Drug Therapy, 88
8 Over-the-Counter Drugs and Natural Health Products, 98
9 Vitamins and Minerals, 111
10 Principles of Drug Administration, 133
PART 2 Drugs Affecting the Central Nervous System
11 Analgesic Drugs, 164
12 General and Local Anaesthetics, 195
13 Central Nervous System Depressants and Muscle Relaxants, 214
14 Central Nervous System Stimulants and Related Drugs, 228
15 Antiepileptic Drugs, 244
16 Antiparkinsonian Drugs, 262
17 Psychotherapeutic Drugs, 278
18 Substance Misuse, 308
PART 3 Drugs Affecting the Autonomic Nervous System
19 Adrenergic Drugs, 325
20 Adrenergic-Blocking Drugs, 338
21 Cholinergic Drugs, 350
22 Cholinergic-Blocking Drugs, 361
PART 4 Drugs Affecting the Cardiovascular and Renal Systems
23 Antihypertensive Drugs, 371
24 Antianginal Drugs, 394
25 Heart Failure Drugs, 408
26 Antidysrhythmic Drugs, 423
27 Coagulation Modifier Drugs, 444
28 Antilipemic Drugs, 469
29 Diuretic Drugs, 485
30 Fluids and Electrolytes, 500
PART 5 Drugs Affecting the Endocrine System
31 Pituitary Drugs, 519
32 Thyroid and Antithyroid Drugs, 528
33 Antidiabetic Drugs, 537
34 Adrenal Drugs, 563
35 Women’s Health Drugs, 574
36 Men’s Health Drugs, 596
PART 6 Drugs Affecting the Respiratory System
37 Antihistamines, Decongestants, Antitussives, and Expectorants, 606
38 Respiratory Drugs, 621
PART 7 Drugs Affecting the Gastrointestinal System and Nutrition
39 Acid-Controlling Drugs, 640
40 Antidiarrheal Drugs and Laxatives, 654
41 Antiemetic and Antinausea Drugs, 667
42 Nutritional Supplements, 679
PART 8 Anti-infective and Anti-inflammatory Drugs
43 Antibiotics Part 1: Sulfonamides, Penicillins, Cephalosporins, Macrolides, and Tetracyclines, 691
44 Antibiotics Part 2: Aminoglycosides, Fluoroquinolones, and Other Drugs, 715
45 Antiviral Drugs, 731
46 Antitubercular Drugs, 753
47 Antifungal Drugs, 764
48 Antimalarial, Antiprotozoal, and Anthelmintic Drugs, 774
49 Anti-inflammatory and Antigout Drugs, 789
PART 9 Immune and Biological Modifiers and Chemotherapeutic Drugs
50 Immunosuppressant Drugs, 804
51 Immunizing Drugs and Pandemic Preparedness, 815
52 Antineoplastic Drugs Part 1: Cancer Overview and Cell Cycle–Specific Drugs, 832
53 Antineoplastic Drugs Part 2: Cell Cycle–Nonspecific and Miscellaneous Drugs, 859
54 Biological Response–Modifying Drugs and Antirheumatic Drugs, 872
PART 10 Miscellaneous Therapeutics: Hematological, Dermatological, Ophthalmic, and Otic Drugs
55 Anemia Drugs, 892
56 Dermatological Drugs, 903
57 Ophthalmic Drugs, 918
58 Otic Drugs, 939
Appendix: Pharmaceutical Abbreviations, 945 Answers to Review Questions, 946 Bibliography, 949 Index of Glossary Terms, 966 Drug Index, 973 General Index, 981
LILLEY'S Pharmacology
for Canadian Health Care Practice
Kara SEALOCK, RN, BN, MEd, EdD
Senior Instructor, Faculty of Nursing University of Calgary Calgary, Alberta
Cydnee SENEVIRATNE, RN, BScN, MN, PhD
Senior Instructor, Faculty of Nursing University of Calgary Calgary, Alberta
US Authors
Linda LANE LILLEY, RN, PhD
University Professor and Associate Professor Emeritus (Retired) School of Nursing Old Dominion University Norfolk, Virginia
Shelly RAINFORTH COLLINS, PharmD President, Drug Information Consultants Chesapeake, Virginia
Julie S. SNYDER, MSN, RN-BC Lecturer School of Nursing Regent University Virginia Beach, Virginia
LILLEY’S PHARMACOLOGY FOR CANADIAN HEALTH CARE PRACTICE, FOURTH EDITION
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Reproducing passages from this book without such written permission is an infringement of copyright law.
Every reasonable effort has been made to acquire permission for copyright material used in this text and to acknowledge all such indebtedness accurately. Any errors and omissions called to the publisher’s attention will be corrected in future printings.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
International Standard Book Number: 978-0-323-69480-3
VP Education Content: Kevonne Holloway
Content Strategist (Acquisitions, Canada): Roberta A. Spinosa-Millman
Director, Content Development Manager: Laurie Gower
Content Development Specialist: Theresa Fitzgerald
Publishing Services Manager: Julie Eddy
Senior Project Manager: Richard Barber
Design Direction: Amy Buxton
Printed in Canada
ABOUT THE AUTHORS
KARA SEALOCK
Dr. Kara Sealock completed a Bachelor of Nursing in 2000, a Masters of Education in 2012, and a Doctorate of Education, specializing in adult learning, in 2019. Kara has been a nursing educator since 2008 and has worked in various roles such as a preceptor, clinical instructor, and theory instructor with a focus in medical/surgical care, critical care, and gerontology. Kara teaches pathophysiology, assessment, and pharmacology at the University of Calgary. She has considerable years of clinical experience in medical/surgical environments, research experience working with cardiology and endocrinology clients; however, the majority of her career has been positioned in critical care with an adult focus in intensive care and coronary care environments. Kara has substantive experience in preparing undergraduate nursing students for NCLEX-RN as she has facilitated preparation workshops and mock examination opportunities, and assumes an active role in preparing students for success. She currently sits on the Nursing Education Program Approval Committee at the College and Association of Registered Nurses (CARNA). Kara’s knowledge in adult learning, combined with her clinical and theoretical experience contributes to an enhanced foundation of learning bridging theory and practice for undergraduate nursing education. Kara is currently a senior instructor with a specific focus in teaching for the Faculty of Nursing at the University of Calgary.
CYDNEE SENEVIRATNE
Dr. Cydnee Seneviratne received a diploma in Nursing in 1991 and has dedicated her career to advancing neuroscience nursing, chronic stroke care, and gerontology. She received a BScN from the University of Victoria in 1995 and a Master of Nursing in 1997 from the University of Calgary. Cydnee received a FUTURE Program for Cardiovascular Nurse Scientists Fellowship (a CIHR Strategic Training Program in Health Research) while completing her PhD in 2007 at the University of Calgary and completed a post-doctoral fellowship in 2010 funded by the Heart and Stroke Foundation of Canada. Cydnee has been a nursing instructor in clinical, laboratory, and classroom settings (specifically pharmacology and pathophysiology) at the University of Calgary for 19 years and has remained closely linked to the clinical setting during her time as the Associate Dean of Undergraduate Practice Education. In the Associate Dean role, she was chair of the Nursing Education Program Approval Committee at the College and Association of Registered Nurses (CARNA) where she was instrumental in crafting undergraduate and nurse practitioner program approval processes. Cydnee is currently a senior instructor and is a leader in Interprofessional Simulation Education for the Faculty of Nursing.
LINDA LANE LILLEY
Dr. Linda Lilley received her diploma from Norfolk General School of Nursing, BSN from the University of Virginia, Master of Science (Nursing) from Old Dominion University, and PhD in Nursing from George Mason University. As an Associate Professor Emeritus and University Professor at Old Dominion University, her teaching experience in nursing education spans over 25 years, including almost 20 years at Old Dominion. Linda’s teaching expertise includes drug therapy and the nursing process, adult nursing, physical assessment, fundamentals in nursing, oncology nursing, nursing theory, and trends in health care. The awarding of the university’s most prestigious title of University Professor reflects her teaching excellence as a tenured faculty member. She has also been a two-time university nominee for the State Council of Higher Education in Virginia award for excellence in teaching, service, and scholarship. Linda received the 2012 Distinguished Nursing Alumni Award from Old Dominion University School of Nursing for her “continued work on the successful pharmacology textbook published by Elsevier” and to recognize her “extraordinary work and the impact [the book] has had on baccalaureate education.” While at Old Dominion University, Linda mentored and taught undergraduate and graduate students as well as registered nurses returning for their BSN. Linda authored the MED ERRORS column for the American Journal of Nursing between 1994 and 1999, as well as numerous other peer-reviewed, published articles in professional nursing journals. Since retiring in 2005, Linda continues to be active in nursing, serving as a member on dissertation committees with the College of Health Sciences and maintaining membership and involvement in numerous professional and academic organizations. Since January of 2014, Dr. Lilley continues to serve on the volunteer review panel for the monthly newsletter publication Nurse Advise-ERR (ISMP affiliated; the ISMP [Institute for Safe Medication Practices] is a nonprofit organization educating the healthcare community and consumers about safe medication practices). Linda has served as a consultant with school nurses in the city of Virginia Beach and as a member on the City of Virginia Beach’s Health Advisory Board. Linda also served as an appointed member on the national advisory panel on medication error prevention with the U.S. Pharmacopeia in Rockville, Maryland. She continues to educate nursing students and professional nurses about drug therapy and the nursing process and speaks on the topics of drug therapy, safe medication use, humor and healing, and grief and loss.
SHELLY RAINFORTH COLLINS
Shelly Rainforth Collins received her Doctor of Pharmacy degree from the University of Nebraska, College of Pharmacy in 1985, with High Distinction. She then completed a clinical pharmacy residency at Memorial Medical Center of Long Beach in Long Beach, California. She worked as a pediatric
clinical pharmacist (neonatal specialist) at Memorial Medical Center before moving to Mobile, Alabama, where she was the Assistant Director of Clinical Pharmacy Services at Mobile Infirmary Medical Center. After moving to Chesapeake, Virginia, she served as the Clinical Pharmacy Specialist/Coordinator of Clinical Pharmacy Services at Chesapeake Regional Medical Center in Chesapeake, Virginia for 19 years. Her practice focused on developing and implementing clinical pharmacy services as well as medication safety and Joint Commission medication management standards and national patient safety goals. She is president of Drug Information Consultants, a business offering consultation and expert witness review for attorneys on medical malpractice cases. She holds certifications in Medication Therapy Management, Anticoagulation Management, and Immunizations. Shelly was awarded the Clinical Pharmacist of the Year Award in 2007 from the Virginia Society of Healthsystem Pharmacists. She led a multidisciplinary team that won the Clinical Achievement of the Year Award from George Mason University School of Public Health in 2007 for promoting safety with narcotics in patients with sleep apnea; this program has also received national recognition. She was awarded the Service Excellence Award from Chesapeake Regional Medical Center. Shelly’s professional affiliations include the American Society of Healthsystem Pharmacists, the Virginia Society of Healthsystem Pharmacists, and the American Pharmacists Association.
JULIE S. SNYDER
Julie Snyder received her diploma from Norfolk General Hospital School of Nursing and her BSN and MSN from Old Dominion University. After working in medical-surgical nursing, she worked in nursing staff development and community education. Later, she transferred to the academic setting and taught fundamentals of nursing, pharmacology, physical assessment, and adult medical-surgical nursing at a university school of nursing. Julie has recently worked as a Quality Initiative Coordinator and a Clinical Nurse Educator in a local hospital. She is now a Lecturer at the School of Nursing of Regent University in Virginia Beach, Virginia. She has been certified by the ANCC in Nursing Continuing Education and Staff Development and currently holds ANCC certification in Medical-Surgical Nursing. She is a member of Sigma Theta Tau International and was inducted into Phi Kappa Phi as Outstanding Alumni for Old Dominion University. She has worked for Elsevier as a reviewer, ancillary writer, and author since 1997. Julie’s professional service has included serving on the Virginia Nurses’ Association Continuing Education Committee, serving as Educational Development Committee chair for the Epsilon Chi chapter of Sigma Theta Tau, serving as an item writer for the ANCC, working with a regional hospital educators’ group, and serving as a consultant on various projects for local hospital education departments. In addition, she has conducted pharmacology review classes for recent nursing graduates.
Paula Crawford-Dickinson, RN, BScN, BA, BHA, MN-ACNP, EdD
Professor
Sally Horsfall-Eaton School of Nursing George Brown College Toronto, Ontario
Kerry Lynn Durnford, RN, MN Instructor School of Health and Human Services Aurora College Yellowknife, Northwest Territories
Joanna Gallacher, RN, MN Professor
Practical Nursing Program School of Health & Community Services Durham College Oshawa, Ontario
Stacy E. Hunt, RN, BSN, MSN Nursing Faculty
Saskatchewan Collaborative Bachelor of Science in Nursing Program School of Nursing Saskatchewan Polytechnic Regina, Saskatchewan
Lindsay MacFarlane, HBScN, MEd, OCT, RN Professor, Practical Nursing School of Health and Community Services Confederation College Thunder Bay, Ontario
Wanda Pierson, RN, BSN, MSN, MA, PhD Faculty, Faculty of Nursing Langara College Vancouver, British Columbia
Kelly Marie Power-Kean, RN, BN, MHS, NP Nurse Educator, Nurse Practitioner Nursing Education Centre for Nursing Studies, and Memorial University of Newfoundland St. John’s, Newfoundland
Heather Scarlett-Ferguson, BSP, MEd, EdD, RPh Instructor Psychiatric Nursing MacEwan University Edmonton, Alberta
Joy Shewchuk, RN, BSc, BSN, MSN Professor, Nursing School of Health Sciences
Humber College Institute of Technology and Advanced Learning Toronto, Ontario
Ruth Swart, EdD, MHS, RN, BN, BSc
Senior Instructor Faculty of Nursing University of Calgary Calgary, Alberta
Nadia Torresan-Doodnaught, BScN, RNC, MN Professor of Nursing Faculty of Health Sciences Seneca College of Applied Arts and Technology King City, Ontario
Kari Dawn Ubels, CD, HBScN, RN Associate Chair of Practical Nurse Curriculum Faculty of Health and Community Studies NorQuest College Edmonton, Alberta
Stephanie Zettel, RN, MN, BN, BSc (Honours) Associate Professor School of Health Sciences Department of Nursing School of Nursing and Midwifery Faculty of Health, Community and Education Mount Royal University Calgary, Alberta
PHARMD REVIEWERS
With special thanks to:
Grace Frankel, BSc Pharm, Pharm D, BCPS
Clinical Pharmacist
Primary Care/Hospital Practice, My Health Team, Southern Health Region
Steinbach, Manitoba
Thomas McFarlane, BSc Pharm, Pharm D Clinical Lecturer, Oncology School of Pharmacy, University of Waterloo Waterloo, Ontario
Karen Sutton, RN, BScN, MN, CNCC(C) Professor, Practical Nursing Program Coordinator, Critical Care Nursing Program Durham College Oshawa, Ontario
INTRODUCTION
The fourth edition of Lilley’s Pharmacology for Canadian Health Care Practice incorporates both the nursing process and evidence in practice as it is relevant to Canadian nursing. This text provides the most current and clinically relevant information in an appealing, understandable, and practical format. The clear writing style and full-colour design of Lilley’s Pharmacology for Canadian Health Care Practice are ideal for today’s busy nursing student. The book presents drug information that both RN and PN nursing students need to know for whatever exam they are preparing to take. It also provides information on what the professional nurse may encounter during drug administration in a variety of health care settings, including accounts of real-life medication errors and tips for avoiding those errors. Features that help set the book apart include:
• A focus on the role of prioritization in nursing care
• A strong focus on drug classes to help students acquire a better knowledge of how various drug classes work in the body, allowing them to apply this knowledge to individual drugs
• Canadian content relevant to Canadian students and educators that will strengthen their knowledge of the field
• Clinical practice guidelines produced or endorsed in Canada by national, provincial, or territorial medical or health organizations, or by professional societies, government agencies, or expert panels
• Ethnocultural examples that reflect the varied and complex ethnodemographic diversity of Canada
• Ease of readability to make this difficult content more understandable
For this edition, the author team has not only focused on providing the most “need-to-know” information but also the most up to date research related to pharmaceuticals while emphasizing the nursing process and prioritization. In addition, a brief discussion of pharmacology related to transgender men and women who may or may not be transitioning is included in this edition. In future editions a more fulsome discussion will be included in chapters 35 and 36. Many of the updates for this edition are in response to student and instructor feedback.
MARKET RESEARCH
To aid in the preparation of this text, nursing instructors from across Canada participated in extensive, detailed reviews of the Third Canadian Edition. These reviewers assessed changes that had occurred in the field of pharmacology since publication of the third edition and determined what was needed to better teach this subject to nursing students and how their evolving learning needs could be met.
This Canadian edition maintains the philosophy of making the challenging subject of pharmacology approachable and easy to understand. Additional concerns raised and enhancements suggested by educators and nursing students who served as
reviewers or consultants throughout the manuscript’s development, as well by the authors of this text, also have been addressed.
ORGANIZATION
This book includes 58 chapters presented in 10 parts, organized by body system. The 10 “concepts” chapters in Part 1 lay a solid foundation for the subsequent drug units and address the following topics:
• The nursing process and drug therapy
• Pharmacological principles
• Legal and ethical considerations
• Ethnocultural and lifespan considerations related to pharmacology
• Gene therapy and pharmacogenomics
• Preventing and responding to medication errors
• Patient education and drug therapy
• Over-the-counter drugs and natural health products
• Vitamins and minerals
• Drug administration techniques, including 100 drawings and photographs
Parts 2 through 10 present pharmacology and nursing management in a time-tested body systems and drug function framework. This approach facilitates learning by grouping functionally related drugs and drug groups. It provides an effective means of integrating the content into medical-surgical/adult health nursing courses or for teaching pharmacology in a separate course.
The 48 drug chapters in these 9 Parts constitute the main portion of the book. Drugs are presented in a consistent format with an emphasis on drug classes and key similarities and differences among the drugs in each class. Each chapter is subdivided into two discussions, beginning with (1) a brief overview of relevant anatomy, physiology, and pathophysiology and a complete discussion of pharmacology, followed by (2) a comprehensive yet succinct application of the nursing process.
Pharmacology is presented for each drug group in a consistent format:
• Mechanism of Action and Drug Effects
• Indications
• Contraindications
• Adverse Effects (often including Toxicity and Management of Overdose)
• Interactions
• Dosages
Drug class discussions conclude with specially highlighted Drug Profiles—brief narrative “capsules” of individual drugs in the class or group, including pharmacokinetics tables for each drug. Key drugs (prototypical drugs within a class) are identified throughout with a symbol for easy identification.
The pharmacology section is followed by a Nursing Process discussion that relates to the entire drug group. This nursing
content is covered in the following, familiar nursing process format:
• Assessment
• Nursing Diagnoses
• Planning (including Goals and Expected Patient Outcomes)
• Implementation
• Evaluation
At the end of each Nursing Process section is a Patient Teaching Tips box that summarizes key points for nursing students and practising nurses to include in the education of patients about their medications. These boxes focus on teaching how the drugs work, possible interactions, adverse effects, and other information related to the safe and effective use of the drug(s). The role of the nurse as patient educator and advocate continues to grow in importance in professional practice, so there is emphasis on this key content in each chapter in this edition.
Lilley’s Pharmacology for Canadian Health Care Practice also reflects the latest drug information and research through the following special boxes:
• Evidence in Practice
• Ethnocultural Implications
• Lab Values Related to Drug Therapy
• Legal and Ethical Principles
• Natural Health Products
• Preventing Medication Errors
• Special Populations: Adolescents
• Special Populations: Children
• Special Populations: The Older Adult
• Legal and Ethical Principles
• Pharmacokinetic Bridge to Nursing Process
NEW TO THIS EDITION
The hallmark readability and user-friendliness of Lilley’s Pharmacology for Canadian Health Care Practice helps students navigate easily through the textbook and thus the difficult subject of pharmacology and the nursing process.
This textbook continues to feature “need-to-know” content as well as up to date research related to pharmaceutical interventions and Canadian legislation. Information on drug adverse effects reflects only the most common and most serious adverse effects rather than listing all reported adverse effects. These adverse effects are listed in order of those most commonly seen. Another area continued from the previous addition is that of drug dosages; only those dosages that are seen in most common indications are included in the text and tables. (For other dosages, the student should refer to an up-to-date drug handbook or drug reference such as, Mosby’s Canadian Nursing Drug Reference.) This need-to-know approach to drug indications and adverse effects is crucial in helping the adult learner focus on the most essential content needed for safe drug administration.
Drugs included in the text are as up-to-date as possible and include related research to ensure students receive accurate information. The availability of drugs changes frequently because manufacturers discontinue production or as a result of shortages.
The use of abbreviations has been limited to the most common abbreviations. While the use of abbreviations is not encouraged overall, abbreviations are still approved and used by
agencies, and may also be part of the documentation method. The Institute of Safe Medication Practices (ISMP) Canada’s “Do Not Use List” of abbreviations, symbols, and dose designations has been adhered to within this text.
It is important to remember that although this textbook provides all of the need-to-know pharmacology content that students will need for an entry level of practice, it is first and foremost a nursing textbook rather than a pharmacology textbook, with a strong emphasis on the nursing process and professional nursing practice. The section on implementation also offers all of the most essential information, followed by a section on the evaluation of therapeutic and adverse effects. These changes highlight the significance of the nursing process as a foundation in drug therapy while helping the student to make strong cognitive connections among nursing diagnoses, goals, and expected patient outcomes.
The pharmacology and nursing content in each of the 58 chapters has been thoroughly revised and critically reviewed by nursing instructors, practising nurses, and PharmDs to reflect the latest drug information and nursing content. Key updates include:
• Updated population and incidence statistics in each chapter
• Summary of Canadian cannabis/marihuana regulations and the Cannabis Act in Chapter 3
• Revision of Chapters 4 and 7 include Indigenous health and healing practices, an explanation of the Indigenous medicine wheel, and alternative medicinal interventions in response to the Truth and Reconciliation Commission of Canada’s Calls to Action
• Revision of Chapter 11 includes an explanation of current practices when/if an opioid overdose occurs in the community, including a stepwise explanation of how to administer Naloxone
• Additional Examination Review Questions at the end of each chapter
ADDITIONAL TEACHING AND LEARNING FEATURES
The book also includes a variety of innovative teaching and learning features that prepare the student for important content to be covered in each chapter and encourage review and reinforcement of that content. Chapter-opener features include the following:
• Learning objectives
• Summary of Drug Profiles in the chapter, with page number references
• List of High-Alert Drugs in the chapter, with page number references
• Key terms with definitions and page number references (key terms being in bold type throughout the narrative to emphasize this essential terminology)
The following features appear at the end of each chapter:
• Patient Teaching Tips related to drug therapy
• Key Points boxes summarizing important chapter content
• Examination Review Questions, with answers provided at the end of the book for quick and easy review
• Critical Thinking activities
• List of Evolve Resources available to students
• References for works cited in the chapter
In addition to the special boxes listed previously, other special features that appear throughout the text include:
• Case Studies in every chapter, with answer guidelines provided on the Evolve website
• Dosages tables listing generic and trade names, pharmacological class, usual dosage ranges, and indications for the drugs
For a more comprehensive listing of the special features, please see the inside back cover of the book.
COLOUR
The use of colour continues to complement the text by making the book engaging for nursing students. Colour is used throughout to:
• Highlight important content
• Illustrate how drugs work in the body in numerous anatomical and drug process colour illustrations
• Improve the visual appearance of the content to make it more engaging and appealing to today’s more visually sophisticated reader
The use of colour and other visual engagement devices in these ways significantly improves students’ involvement and understanding of pharmacology.
SUPPLEMENTAL RESOURCES
A comprehensive ancillary package is available to students and instructors using Lilley’s Pharmacology for Canadian Health Care Practice. The following supplemental resources have been thoroughly revised for this edition and can significantly assist in the teaching and learning of pharmacology.
Study Guide
The student study guide—carefully aligned with the content and focus of the book—includes the following:
• Student Study Tips that reinforce the Study Skills available on the Evolve site and provide a “how to” guide to applying test-taking strategies
• Worksheets for each chapter, with Examination Review questions (with application-based, alternate-item, and dosage calculation questions), critical thinking and application questions, and other activities
• Case Studies followed by related critical thinking questions
• An updated Overview of Dosage Calculations with helpful tips for calculating doses, sample drug labels, practice problems, and a quiz
• Answers to all questions (provided in the back of the book) to facilitate self-study
Evolve Web Site
Located at http://evolve.elsevier.com/Canada/Lilley/pharmacology, the Evolve Web site for this book includes the following elements:
For Students
• More than 550 Review Questions for Exam Preparation
• Answers to Critical Thinking Activities from the book
• Printable Chapter Summaries for each chapter
• Answers to Case Studies from the book
• Audio Glossary
• Unfolding Case Studies
• Integrated Study Skills Tips present valuable study skills topics related to each Part within the text, including time management, note-taking, studying, test-taking and others. These tips help students learn the particularly demanding subject of pharmacology while also equipping them with tools that they can use in other courses and as lifelong learners who are building an evidence-based practice.
• Book-specific Next Generation NCLEX Case Studies (both single-episode and unfolding)
For Instructors
• TEACH for Nurses Lesson Plans that focus on the most important content from each chapter and provide innovative strategies for student engagement and learning. These new Lesson Plans include strategies for integrating nursing curriculum standards, links to all relevant student and instructor resources, and an original instructor-only Case Study in each chapter.
• ExamView® Test Bank that features more than 800 examination−format test questions (including alternate-item questions) with text page references, rationales, and answers coded for NCLEX® Client Needs category, nursing process step, and cognitive level (Bloom’s taxonomy). The robust ExamView® testing application, provided at no cost to faculty, allows instructors to create new tests; edit, add, and delete test questions; sort questions by NCLEX® Client Needs category, cognitive level, and nursing process step; and administer and grade tests online, with automated scoring and gradebook functionality.
• PowerPoint® Lecture Slides consisting of more than 2100 customizable text slides for instructors to use in lectures. The presentations include Unfolding Case Studies and applicable illustrations from the book’s Image Collection. Audience Response System Questions (three or more discussion-oriented questions per chapter for use with i>Clicker and other systems) are folded into these presentations.
• Generic Next Generation NCLEX Case Studies for Pharmacology (both single-episode and unfolding)
• An Image Collection with over 250 full-colour images from the book for instructors to use in lectures
• Access to all student resources listed above
Elsevier eBooks
More than just words on a screen, Elsevier eBooks on VitalSource come pre-loaded with interactive learning features that empower students to engage with course content in entirely new ways.
Ideal for use both inside the classroom and out, Elsevier eBooks on VitalSource gives students the ability to access textbook content any time, any place via desktop computer, laptop, tablet, or smartphone.
It includes study aids such as highlighting, e-note taking, and the ability to share notes with other students or with instructors. Even more importantly, it allows students and instructors to do a comprehensive search within the specific text or across a number of titles. Please check with your Elsevier sales representative for more information.
ICONS AT A GLANCE
ETHNOCULTURAL IMPLICATIONS
SPECIAL POPULATIONS: CHILDREN
NATURAL HEALTH PRODUCTS
SPECIAL POPULATIONS: OLDER ADULTS
DRUG PROFILES
HIGH-ALERT Drugs
LAB VALUES RELATED TO DRUG THERAPY
PREVENTING MEDICATION ERRORS
SPECIAL POPULATIONS: ADOLESCENTS
Key drug
NEXT GENERATION NCLEX
The National Council for the State Boards of Nursing (NCSBN) is a not-for-profit organization whose members include nursing regulatory bodies. In empowering and supporting nursing regulators in their mandate to protect the public, the NCSBN is involved in the development of nursing licensure examinations, such as the NCLEX-RN®. In Canada, the NCLEX-RN® was introduced in 2015 and is, as of the writing of this text, the recognized licensure exam required for practising RNs in Canada.
The NCLEX-RN® will, as of 2023, be changing in order to ensure that its item types adequately measure clinical judgement, critical thinking, and problem-solving skills on a consistent basis. The NCSBN will also be incorporating into the examination what they call the Clinical Judgement Measurement Model (CJMM), which is a framework that the NCSBN has created to measure a novice nurse’s ability to apply clinical judgement in practice.
These changes to the examination come as a result of research findings which indicated that novice nurses have a much higher-than-desirable error rate with patients (i.e., errors that cause patient harm) and, upon NCSBN’s investigation, the discovery that the overwhelming majority of these errors were caused by failures of clinical judgement.
Clinical judgement has been a foundation underlying nursing education for decades, based on the work of a number of nursing theorists. The theory of clinical judgement that most closely aligns to what NCSBN is basing their CJMM is the work by Christine A. Tanner.
The new version of the NCLEX-RN® is loosely being identified as the “Next-Generation NCLEX” or “NGN”, and will feature the following:
• 6 key skills in the CJMM: recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes.
• Approved item types as of June 2020: multiple response, extended drag and drop, cloze (drop-down), enhanced hotspot (highlighting), and matrix/grid. More question types may be added.
• All new item types are accompanied by mini-case studies with comprehensive patient information—some of it relevant to the question, and some of it not.
• Case information may present a single, unchanging moment in time (a “single episode” case study) or multiple moments in time as a patient’s condition changes (an “unfolding” case study).
• Single-episode case studies may be accompanied by 1-6 questions; unfolding case studies are accompanied by 6 questions.
For more information (and detail) regarding the NCLEX-RN® and changes coming to the exam, visit the NCSBNs website: https://www.ncsbn.org/11447.htm and https://ncsbn.org/Building _a_Method_for_Writing_Clinical_Judgment_It.pdf
For further NCLEX-RN® examination preparation resources, see Silvestri’s Canadian Comprehensive Review for the NCLEXRN Examination, Second Edition, ISBN 9780323709385. Prior to preparing for any nursing licensure examination, please refer to your provincial or territorial nursing regulatory body to determine which licensure examination is required in order for you to practice in your chosen jurisdiction.
WE WELCOME YOUR FEEDBACK
We always welcome comments from instructors and students who use this book so that we may continue to make improvements and be responsive to your needs in future editions. Please send any comments you may have for us to NHPInstructorPre mier@reedelsevier.com
Our part in this book would not have been possible without the original efforts of the American authors who conceptualized and wrote Pharmacology and the Nursing Process, which has shaped the content of Lilley’s Pharmacology for Canadian Health Care Practice. Linda Lane Lilley, RN, PhD; Shelly Rainforth Collins, PharmD; and Julie S. Snyder, MSN, RN, BC, are to be commended for their thorough and expert handling of a vast and complex subject matter and for creating an excellent foundation over which the Canadian content could be easily laid. We would like to express our gratitude to Beth Swart, the author of the inaugural Canadian editions of Pharmacology for Canadian Health Care Practice, 1ce–3ce. Over the years, she has written and revised an exemplar textbook used in nursing curricula across Canada. We thank her for her dedication and commitment to nursing education.
We dedicate Lilley’s Pharmacology for Canadian Health Care Practice to our students, both past and present, who inspire us with their curiosity for learning, passion for the nursing profession, and dedication to caring for the Canadian population. We could not have met the challenges of authoring this pharmacology textbook without the support and understanding from our families and colleagues.
We could not have accomplished this project without the assistance of Theresa Fitzgerald, who encouraged, altered deadlines to fit our busy schedules, reminded us of deadlines, and supported us throughout the huge task of co-editing this book. Roberta A. Spinosa-Millman, Content Strategist at Elsevier Canada, who provided this opportunity for both of us. Many individuals at Elsevier are responsible for this Canadian edition. Our thanks go to Laurie Gower, Content Director; Sherry Hinman, Copy Editor; Jerri Hurlbutt, Copy Editor; and Richard T. Barber, Senior Project Manager for handling all the details involved in the final production of the book.
Thanks are due to the Canadian reviewers who reviewed content of this book and gave their invaluable comments, expertise, and editing suggestions on the draft manuscript. As existing diseases and disorders and their treatments evolve, bringing with them new challenges and information in pharmacology, we will no doubt be looking forward to future editions of this textbook.
Dr. Kara Sealock, RN, EdD, MEd, BN, CNCC (C), CCNE Dr. Cydnee Seneviratne, RN, PhD, MN, BSc
About the Authors, v Reviewers, vii Preface, ix Acknowledgements, xiii
Basic Principles of Genetic Inheritance, 68 Discovery, Structure, and Function of DNA, 69 Gene Therapy, 70
Pharmacogenetics and Pharmacogenomics, 71
Application of Genetic Principles as a Result of Drug Therapy and the Nursing Process, 72
6 Medication Errors: Preventing and Responding, 75
General Impact of Errors on Patients, 75 Medication Errors, 76
Issues Contributing to Errors, 78
Preventing, Responding to, Reporting, and Documenting Medication Errors: A Nursing Perspective, 80
Other Ethical Issues, 83
Summary, 84
7 Patient Education and Drug Therapy, 88
Overview, 88
Assessment of Learning Needs Regarding Drug Therapy, 89
Nursing Diagnoses Regarding Learning Needs and Drug Therapy, 91
Planning Regarding Learning Needs and Drug Therapy, 91 Implementation Regarding Drug Therapy, 91 Evaluation of Patient Learning Regarding Drug Therapy, 94
8 Over-the-Counter Drugs and Natural Health Products, 98 Over-the-Counter Drugs, 98
Hematological, Dermatological, Ophthalmic, and Otic Drugs
55 Anemia Drugs, 892
Erythropoiesis, 892
Types of Anemia, 893
Erythropoiesis-Stimulating Agents, 895 Iron, 895
Folic Acid, 897
Other Anemia Drugs, 899 Assessment, 899
Pharmacokinetic Bridge To Nursing Practice, 899
Nursing Diagnoses, 899
Planning, 899
Implementation, 900 Evaluation, 900
56 Dermatological Drugs, 903
Skin Anatomy and Physiology, 904
Topical Dermatological Drugs, 904
Antimicrobials, 905
General Antibacterial Drugs, 906
Antiacne Drugs, 907
Antifungal Drugs, 908
Antiviral Drugs, 909
Topical Anaesthetics, 910
Topical Antipruritics and Anti-Inflammatories, 910
Antipsoriatic Drugs, 910
Miscellaneous Dermatological Drugs, 911
Wound Care Drugs, 913
Skin Preparation Drugs, 913 Assessment, 914
Nursing Diagnoses, 914 Planning, 914
Implementation, 915
Evaluation, 915
57 Ophthalmic Drugs, 918
Ocular Anatomy and Physiology, 919
Treatment of Eye Disorders, 921
Glaucoma, 922
Antiglaucoma Drugs, 922
Antimicrobial Drugs, 929
Anti-Inflammatory Drugs, 931
Topical Anaesthetics, 933
Diagnostic Drugs, 933
Antiallergic Drugs, 934 Assessment, 934
Nursing Diagnoses, 935 Planning, 935
Implementation, 935 Evaluation, 935
58 Otic Drugs, 939
Overview of Ear Anatomy, 939
Treatment of Ear Disorders, 940
Antibacterial and Antifungal Otic Drugs, 940 Assessment, 942
Nursing Diagnoses, 942 Planning, 942
Implementation, 942 Evaluation, 942
Appendix: Pharmaceutical Abbreviations, 945 Answers to Review Questions, 946
Bibliography, 949
Index of Glossary Terms, 966 Drug Index, 973 General Index, 981
PART 1 Pharmacology Basics
1 Nursing Practice in Canada and Drug Therapy
OBJECTIVES
After reading this chapter, the successful student will be able to do the following:
1. List the five phases of the nursing process.
2. Identify the components of the assessment process for patients receiving medications, including the collection and analysis of subjective and objective data.
3. Discuss the process of formulating nursing diagnoses for patients receiving medications.
4. Identify goals and outcome criteria for patients receiving medications.
KEY TERMS
Adherence Active, voluntary, and collaborative involvement of the patient in the mutually acceptable, prescribed course of treatment or therapeutic plan. (p. 3)
Critical thinking The ability to reason and think rationally in order to understand, solve problems, and make decisions; a major component of the nursing process, often considered the foundation on which to provide the best possible patient care, supported by current best evidence. (p. 2)
Evidence-informed practice (EIP) Continuous, interactive process involving the explicit, conscious, and judicious consideration of the best research evidence available to make collaborative decisions between the health care team and the patient and family when providing patient care. (p. 11)
Goals Statements that are time-specific and describe generally what must be accomplished to address a specific nursing diagnosis. (p. 2)
OVERVIEW
The nursing practice environment in Canada is increasingly demanding, due in part to the increased acuity and complexity of patient care and the aging population. Nurses are expected to keep up to date with the rising use of intricate pharmacological therapies, including natural health products and over-thecounter drugs. In addition to rising costs, other factors such as
5. Discuss the evaluation process involved in the administration of medications and reflected in the goals and outcome criteria.
6. Develop a collaborative plan of care using the nursing process and the principles of medication administration.
7. List and briefly discuss the Ten Rights associated with safe medication administration.
8. Discuss the professional responsibility and standards of practice for the professional nurse as a result of the medication administration process.
Medication error Any preventable adverse drug event involving inappropriate medication use by a patient or health care provider. (p. 10)
Nonadherence An informed decision by a patient not to adhere to or follow a therapeutic plan or suggestion. (p. 4)
Nursing process An organizational framework for the practice of nursing that encompasses all steps taken by the nurse in caring for a patient: assessment, nursing diagnoses, planning (with goals and outcome criteria), implementation of the plan (with patient teaching), and evaluation. (p. 2)
Outcome criteria Descriptions of specific patient behaviours or responses that demonstrate the meeting or achievement of goals related to each nursing diagnosis. (p. 6)
Prescriber Any health care provider licensed by the appropriate regulatory body to prescribe medications. (p. 4 )
professional shortages, advances in treatment modalities, and new technologies continue to challenge the health care system. In such an environment, knowledge of drugs, their adverse effects, and their interactions is crucial for nurses to provide safe, ethical, competent care. Nurses are expected to be more accountable, with increased attention focused on safe medication practices. Evaluating and promoting therapeutic effects,
as well as reducing the harm associated with adverse effects, adverse interactions, and drug toxicity, and making decisions about prn (pro re nata or “as needed”) medications require excellent critical thinking and decision-making skills.
The nursing process is a well-established, research-supported framework for professional nursing practice. It is a flexible, adaptable, and adjustable five-step process consisting of assessment, nursing diagnoses, planning (including establishment of goals and outcome criteria), implementation (including patient education), and evaluation. As such, the nursing process ensures the delivery of thorough, individualized, and quality nursing care to patients. Through use of the nursing process combined with knowledge and skills, the professional nurse can develop effective solutions to meet patients’ needs. The use of the nursing process is one way to organize nursing care and may be viewed as controversial in some educational and health care institutions that use other decision-making frameworks. Some view the nursing process as a repetitive tool developed prior to the technology era that may assist in developing an initial plan of care but is limited in assisting to make the detailed judgements and decision making required today. Others view it as the foundation of problem solving and believe it fits well with evidence-informed practice. However, it is still considered the major systematic framework for professional nursing practice.
Usually, the nursing process is discussed within nursing courses and in textbooks on the fundamentals of nursing practice, nursing theory, physical assessment, adult and pediatric nursing, and other nursing specialty areas. Because the nursing process is so important in the care of patients, the process in all its five phases, along with evidence-informed practice examples, will be included in each chapter of this book as they relate to specific drug groups and classifications.
Critical thinking is one part of the nursing process and is often considered the foundation on which to provide the best possible patient care, supported by current best practice. Clinical reasoning, a more specific term, and clinical judgement are key components of critical thinking in nursing. Clinical reasoning refers to the way nurses analyze and understand patient care issues such as determining, preventing, and managing patient problems. A nurse who is proficient at clinical reasoning will be able to make timely and effective patient-centred decisions. Sound clinical reasoning is essential for preserving the standards of the nursing profession and promoting good patient outcomes. Clinical reasoning involves applying ideas to experience in order to arrive at a valid clinical judgement.
The elements of the nursing process address the physical, emotional, spiritual, sexual, financial, cultural, and cognitive aspects of a patient. Attention to these many aspects allows a more holistic approach to patient care. For example, a cardiologist may focus on cardiac functioning and pathology, a physiotherapist on movement, and a chaplain on the spiritual aspects of patient care. However, it is the professional nurse who thinks critically about processes, incorporates all of these aspects and points of information about the patient, and then uses this information to develop and coordinate patient care. Therefore, the nursing process remains a central process and framework
for nursing care. Box 1.1 provides guidelines for nursing care planning related to drug therapy and the nursing process.
ASSESSMENT
During the initial assessment phase of the nursing process, data are collected, reviewed, and analyzed. Performing a comprehensive assessment allows the nurse to formulate a nursing diagnosis related to the patient’s needs—for the purposes of this textbook, specifically needs related to pharmacotherapy, of which one aspect is drug administration. Information about the patient may come from a variety of sources, including the patient; the patient’s family, caregiver, or significant other; and the patient’s chart. Methods of data collection include interviewing, direct and indirect questioning, observation, medical records review, head-to-toe physical examination, and nursing assessment. Data are categorized into objective and subjective data.
Subjective data include information obtained through a nursing history and shared through the spoken word by any reliable source, such as the patient, the spouse, another family member, a significant other, or a caregiver.
Objective data may be defined as any information gathered through the senses or that which is seen, heard, felt, or smelled. Objective data may also be obtained from a nursing physical assessment; past and present medical history; results of laboratory tests, diagnostic studies, or procedures; measurement of vital signs, weight, and height; and medication profile. Medication profiles include, but are not limited to, the following information: any and all drug use; use of home or folk remedies and natural health products or homeopathic treatments; intake of alcohol, tobacco, and caffeine; current or past history of illicit drug use; use of over-the-counter (OTC) medications (e.g., aspirin, acetaminophen, vitamins, laxatives, cold preparations, sinus medications, antacids, acid reducers, antidiarrheals, minerals, chemical elements); use of hormonal drugs (e.g., testosterone, estrogens, progestins, oral contraceptives); past and present health history and associated drug regimen(s); family history and racial, ethnic, or cultural attributes with attention to specific or different responses to medications as well as any unusual individual responses; and growth and developmental stage (e.g., Erikson’s developmental tasks) and issues related to the patient’s age and medication regimen. A holistic nursing assessment includes gathering of data about the whole individual, including physical and emotional realms, religious preference, health beliefs, sociocultural characteristics, race, ethnicity, lifestyle, stressors, socioeconomic status, education level, motor skills, cognitive ability, support systems, lifestyle, and use of any complementary and alternative therapies.
Assessment related to specific drugs is also important and involves the collection of specific information about prescribed, OTC, and natural health products or complementary and alternative therapeutic drug use, with attention to the drug’s actions; signs and symptoms of allergic reaction; adverse effects; dosages and routes of administration; contraindications; drug incompatibilities; drug–drug, drug–food, and drug–laboratory test interactions; and toxicities and available antidotes.
BOX 1.1
Guidelines for Nursing Care Planning
The sample in this study presents useful information for developing a nursing process–focused care plan for patients receiving medications. Brief listings and discussions of what must be contained in each phase of the nursing process are included. This sample may be used as a template for formatting nursing care plans in a variety of patient care situations or settings.
Assessment
Subjective Data
Subjective data include all spoken information shared by the patient as part of taking a nursing history, such as concerns, problems, or stated needs (e.g., patient reports “dizziness, headache, vomiting, and feeling hot for 10 days”).
Objective Data
Objective data include information available through the senses, that is, what is seen, felt, heard, and smelled. Among the sources of data are the chart, laboratory test results, reports of diagnostic procedures, physical assessment results, and examination findings. Examples of specific data are age, height, weight, allergies, medication profile, and health history.
Nursing Diagnoses
Once the assessment phase has been completed, the nurse analyzes subjective and objective data about the patient and the drug and formulates nursing diagnoses. The following is an example of a nursing diagnosis statement: “Deficient knowledge related to lack of experience with medication regimen and Grade 2 reading level as an adult, as evidenced by inability to perform a return demonstration and inability to state adverse effects to report to the prescriber.” This statement of the nursing diagnosis can be broken down into three parts, as follows:
• Part 1: “Deficient knowledge.” This is the statement of the human response of the patient to illness, injury, medications, or significant change. This can be an actual response, an increased risk, or an opportunity to improve the patient’s health status. The nursing diagnosis related to knowledge may be identified as either inadequate or ready for enhanced (knowledge).
• Part 2: “Related to lack of experience with medication regimen and Grade 2 reading level as an adult.” This portion of the statement identifies factors related to the response; often it includes multiple factors with some degree of connection between them. The nursing diagnosis statement does not necessarily claim that there is a cause-and-effect link between these factors and the response, only that there is a connection.
• Part 3: “As evidenced by inability to perform a return demonstration and inability to state adverse effects to report to the prescriber.” This statement
Nursing pharmacology textbooks provide a more nursing-specific knowledge base regarding drug therapy as a result of the nursing process. Use of current references or those dated within the last 3 years is highly recommended. Examples of authoritative resources include the Compendium of Pharmaceuticals and Specialties (CPS; a subscription-based e-CPS is also available online), the drug manufacturer’s insert, drug handbooks, and a licensed pharmacist. Some reliable online resources include Health Canada’s Drug Product Database (http://www.hc-sc. gc.ca/dhp-mps/prodpharma/databasdon/index-eng.php) and the Objective Comparisons for Optimal Drug Therapy (http:// www.rxfiles.ca/).Other online resources are cited throughout this textbook.
Gather additional data about the patient and a given drug by asking yourself these simple questions: What is the patient’s oral intake? Tolerance of fluids? Swallowing ability for pills, tablets, capsules, and liquids? If there is difficulty swallowing,
lists clues, cues, evidence, or data that support the nurse’s claim that the nursing diagnosis is accurate.
Nursing diagnoses are prioritized in order of criticality, based on patient needs or problems. The ABCs of care (airway, breathing, and circulation) are often used as a basis for prioritization. Prioritizing always begins with the most important, significant, or critical need of the patient. Nursing diagnoses that involve actual responses are always ranked above nursing diagnoses that involve only risks.
Planning: Goals and Expected Patient Outcome Criteria
The planning phase includes the identification of short-term and long-term goals and outcome criteria, provides time frames, and is patient oriented. Goals are objective, realistic, and measurable patient-centred statements with time frames and are broad, whereas outcome criteria are more specific descriptions of patient goals.
Implementation
In the implementation phase, the nurse intervenes on behalf of the patient to address specific patient problems and needs. This is done through independent nursing actions; collaborative activities such as physiotherapy, occupational therapy, and music therapy; and implementation of medical orders. Family, significant others, and caregivers assist in carrying out this phase of the nursing care plan. Specific interventions that relate to particular drugs (e.g., giving a particular cardiac drug only after monitoring the patient’s pulse and blood pressure), nonpharmacological interventions that enhance the therapeutic effects of medications, and patient education are major components of the implementation phase. See the previous text discussion of the nursing process for more information on nursing interventions.
Evaluation
Evaluation is the part of the nursing process that includes monitoring whether patient goals and outcome criteria related to the nursing diagnoses are met. Monitoring includes observing for therapeutic effects of drug treatment as well as for adverse effects and toxicity. Many indicators are used to monitor these aspects of drug therapy as well as the results of appropriately related nonpharmacological interventions. If the goals and outcome criteria are met, the nursing care plan may or may not be revised to include new nursing diagnoses; such changes are made only if appropriate. If goals and outcome criteria are not met, revisions are made to the entire nursing care plan with further evaluation.
what is the degree of difficulty and are there solutions to the problem, such as the use of thickening agents with fluids or the use of other dosage forms? What are the results of laboratory and other diagnostic tests related to organ functioning and drug therapy? What do kidney function studies (e.g., urea nitrogen, creatinine) show? What are the results of liver function tests (e.g., total protein, bilirubin, alkaline phosphatase, creatinine phosphokinase, other liver enzymes)? What are the patient’s white blood cell and red blood cell counts? Hemoglobin and hematocrit levels? Current as well as past health status and presence of illness? What are the patient’s experiences with use of any drug regimen? What has been the patient’s relationship with health care providers or experiences with previous therapeutic regimens? What are current and past values for blood pressure, pulse rate, temperature, and respiratory rate? What medications is the patient currently taking, and how is the patient taking and tolerating them? Are there issues with adherence (implying
collaboration and an active role between patients and their health care providers)? Has there been any use of traditional or folk medicines or remedies? What is the patient’s understanding of the medication? Are there any age-related concerns? If patients are not reliable historians, family members, significant others, or caregivers may provide answers to these questions.
Once assessment of the patient and the drug has been completed, the specific prescription or medication order (from any prescriber) must be checked for the following six elements: (1) patient’s name, (2) date the drug order was written, (3) name of drug(s), (4) drug dosage amount and frequency, (5) route of administration, and (6) prescriber’s signature.
It is also important during the assessment to consider the traditional, nontraditional, expanded, and collaborative roles of the nurse. Physicians and dentists are no longer the only practitioners legally able to prescribe and write medication orders. Registered nurses do not order medications; they follow standard orders established by physicians. In some cases, depending on agency and provincial or territorial regulatory body, registered nurses can administer medications without a physician’s order (e.g., registered nurses with an additional “certified practice”), according to agency-specific protocols, such as pyrexia protocols or bowel protocols, or certain classifications of drugs.
In some provinces (e.g., Ontario, British Columbia, Alberta), the scope of practice for registered nurses was expanded to allow nurses the authority to dispense certain medications under certain circumstances. Dispensing involves preparing and transferring a medication for a patient or the patient’s representative to be administered at a later date—for example, if a patient has a day pass and requires medication while absent or if a client is discharged from the emergency department and requires medication to be started. Dispensing entails ensuring that the medication is pharmaceutically and therapeutically appropriate for the intended use and that it will be used properly. It may also include accepting payment for a medication on behalf of a nurse’s employer.
Nurse practitioners and physician assistants have the professional privilege of legally prescribing medications. As of 2016, in Canada, there are 400 physician assistants (PAs), who support physicians in a variety of health care settings. The role for PAs began in Canada within the Canadian Forces Health Services 50 years ago, and physician assistants now practise in Manitoba, New Brunswick, Ontario, and Alberta. Physician assistants are meant to extend the role of the physician; they work under the supervision of physicians and are not independent practitioners. In Manitoba and New Brunswick, PAs are regulated through their respective College of Physicians and Surgeons; in Ontario and Alberta, PAs practise by delegation under the Medicine Act and the Medical Act, respectively. PAs are autonomous decision makers and perform a range of diagnostic and therapeutic services, including writing prescriptions. PAs must complete a two-year educational program that is accredited by the Canadian Medical Association (2019). Nurse practitioners (NPs) are registered nurses with an advanced degree who practise in the Extended Class. They have extra education and experience and are legally competent to diagnose, order, and interpret diagnostic tests; prescribe medications; and perform procedures.
ANALYSIS OF DATA
Once data about the patient and drug have been collected and reviewed, critically analyze and synthesize the information. Verify all information and document appropriately. It is at this point that the sum of the information about the patient and drug is used in the development of nursing diagnoses.
CASE STUDY
The Nursing Process and Pharmacology
Katie, a 27-year-old teacher, is visiting the clinic today for a physical examination. She states that she and her husband want to “start a family,” but she has not had a physical for several years. She was told when she was 22 years of age that she had “anemia” and was given iron tablets but states that she has not taken them for years. She said she “felt better” and did not think she needed them. She denies any use of tobacco or illegal drugs; she states that she may have a drink with dinner once or twice a month. She uses tea tree oil on her face twice a day to reduce acne breakouts. She denies using any other drugs.
1. During the physical assessment, what other questions does the nurse need to ask?
2. After laboratory work is performed, Katie is told she is slightly anemic. The prescriber recommends that she resume taking iron supplements as well as folic acid. She is willing to try again and says that she is “all about doing what’s right to stay healthy and become a mother.” What nursing diagnoses would be appropriate at this time?
3. Katie is given a prescription that reads as follows: “ferrous fumarate 300 mg, PO for anemia.” When she goes to the pharmacy, the pharmacist tells her that the prescription is incomplete. What is missing? What should be done?
4. After 4 weeks, Katie’s latest laboratory results indicate that she still has anemia. However, Katie states, “I feel so much better that I’m planning to stop taking the iron tablets. I hate to take medicine.” How should the nurse handle this?
For answers, see http://evolve.elsevier.com/Canada/Lilley/pharmacology/.
NURSING DIAGNOSES
Nursing diagnoses are developed by professional nurses and are used as a means of communicating and sharing information about the patient and the patient experience. Nursing diagnoses are the result of critical thinking, creativity, and analysis of the data collected about the patient and the drug. They are clinical judgements about how a person responds to health conditions and life processes or vulnerability for that response. Nursing diagnoses related to drug therapy will most likely develop out of data associated with the following: inadequate knowledge; risk of injury; nonadherence; various disturbances, deficits, excesses, or impairments in bodily functions; and other problems or concerns as a result of drug therapy. The development and classification of nursing diagnoses has been carried out by NANDA International (NANDA-I) (formerly North American Nursing Diagnosis Association [NANDA]). NANDA-I is the formal organization
