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About the Authors
Mohamed Toufic El-Hussein, RN, BSN, MSN, PhD, NP, is an Joseph Chinyere Osuji, RN, BScN, MN, PhD, is Professor at the
Associate Professor of Nursing in the Department of Health, School of Nursing & Midwifery, Mount Royal University,
Community & Education at Mount Royal University in Calgary. Calgary. He is a Carnegie scholar and holds a visiting scholar
Dr. El-Hussein is a recipient of the distinguished teaching faculty appointment with the University of Nigeria, Nsukka. His current
award in the Bachelor of Nursing program at Mount Royal teaching assignments are Medical-Surgical Nursing,
University, School of Nursing & Midwifery. Dr. El-Hussein is Pharmacology, Pathophysiology, Community Health, Chronic
also an adjunct Associate Professor at the University of Calgary Disease Management, and Advanced Biostatistics. Dr. Osuji has
in the faculty of Nursing. published widely, has authored and contributed chapters on
He has initiated and implemented several innovative teaching Medical/Surgical Nursing, Research Methods, Pharmacology,
approaches that have contributed immensely to the critical and Chronic Disease Management. Professor Osuji has received
thinking, analytical, and clinical skills of nursing students. major fellowship awards, research nominations, and academic
Dr. El-Hussein’s passion for teaching emerged while working as a awards for his work. He is interested in research questions that
Registered Nurse in critical care settings, where he was selected deal with the social determinants of health, homelessness, social
to facilitate and deliver lectures in the Department of In-Service justice and poverty, soft computing modelling and informatics,
Education at different hospitals. He completed his Master’s in teaching and learning processes in students, clinical reasoning
Critical Care and Trauma at the University of KwaZulu-Natal, among Registered Nurses, and nursing workforce turnover and
South Africa, and earned a PhD in Nursing from the University retention determinants. He has been published in several
of Calgary, then enrolled in the post-Master’s Nurse Practitioner peer-reviewed journals and has presented on related topics in
(NP) program at the University of Calgary and earned his NP conferences, both locally and internationally. Dr. Osuji is the
diploma. Currently, Dr. El Hussein practices as an Acute Care proud husband of Mrs. Genevieve Osuji and the father of three
Nurse Practitioner in the Medical Cardiology Coronary Care Unit girls and two boys.
at Rockyview General Hospital. His research program focuses on
clinical reasoning in nursing practice and the use of innovative
teaching strategies to enhance critical thinking among nursing
students. Dr. El-Hussein has authored several publications and
conference presentations that discuss clinical reasoning processes
and highlight innovative teaching strategies designed to bridge
the theory-practice gap in nursing and to help students
deconstruct and assimilate complex concepts.
v
xii Preface
Teaching Through Visuals

For nearly all students, learning is a highly visual process. Therefore, we use numerous visuals to help you review the anatomy and physi-
ology of body systems as well as understand the principles of drug action on the body.
CHAPTER 38 Pharmacotherapy of Asthma, Common Cold, and Other Pulmonary Disorders 479
Pharynx Nasal cavity
Vocal cord Tongue
Esophagus Larynx
Trachea Expired air

Right lung
Left lung
Right bronchus b Vivid and Colourful Illustrations
Left bronchus
Alveoli
help you to review specific anatomy,
physiology, and pathophysiology for
a body system and better understand
the impact of disease on that system.
O2
CHAPTER 3 Pharmacokinetics 27
eliminated. AfterOxygenated
four half-lives, 94% of theCO drug Deoxygenated
2 has been elimi-
nated. In the blood procaine, which has a half-life of only blood
case of circulated 8 min- from
back to the heart the heart
Plasma drug concentration ( g/mL)

utes, the drug is considered eliminated in 32 minutes. Although 80
some drug remains, the amount is too small to produce any benefi-
Alveoli cial or toxic effect. Note, however, that this “rule of thumb” does
Diaphragm not apply to all drugs; it certainly does not apply to medications 60
(a) administered to(b)clients with renal or hepatic impairment. Drug B Therapeutic

range
D7 D8 D9
40
D6
Figure 38.1 The respiratory system. Loading Doses and Maintenance D5
Doses 20
D4
3.9 Repeated dosing allows a plateau drug plasma D3 Drug A
level to be reached. Loading doses allow a D2
Administration of Pulmonary Ittherapeutic

should bedrug levelunderstood
clearly to be reached rapidly.
that agents delivered by0 12 24 36 48 60 72 84 96 108 120 132
Drugs via Inhalation inhalation

Few drugscan produce systemic
are administered effects
as a single dose. Repeateddue to result
doses absorption. Time (hours)
For inexample,
an accumulation of drugsuch
anesthetics in theasbloodstream,
nitrous oxide as shown
and in halothane
Figure 3.9 Multiple-dose drug administration: drug A and
38.3 Inhalation is a common route of Figure
(Fluothane)
3.9. Eventually, a plateau will be reached where
are delivered via the inhalation route anddrug
the level of
areB are administered every 12 hours; drug B reaches the
Putting It All Together

drug in the plasma is maintained continuously within the thera-
administration for pulmonary drugs because it rapidly
peuticdistributed to cause
range. At this level, central
the amount nervous
of drug system
administered
therapeutic range faster because the first dose is a loading dose.
has (CNS)
delivers drugs directly to the site of action. depression (see Chapter
reached equilibrium with the24). Solvents
amount of drugsuch
being as paint thinners
eliminated, drop back toward zero, intermittent maintenance doses are given
and resulting
glues are in a sometimes
continuous therapeutic level of drug
intentionally being and
inhaled distrib- to keep the plasma drug concentration in the therapeutic range.
can cause
Nebulizers, MDIs, and DPIs are devices used for uted to body tissues. Theoretically, it takes approximately four Although blood levels of the drug fluctuate with this approach, the
serious adverse effects on the nervous system, or even death.
aerosol
The therapies.
tools at the end of each chapter and on MyLab Nursing
Thecontinuous
nurse must help
always
infusion,
youcanto
monitor
the plateau befor
test your
half-lives to reach this equilibrium. If the medication is given as a
systemic
reached quickly and
understanding
effects
be from of the drugs and nursing care pre-
equilibrium state can be reached almost as rapidly as with a continu-
ous infusion. Loading doses are particularly important for drugs
sented in that
The respiratory chapter.
system offers aUsing
rapid andthese tools
efficient will helpinhalation
mechanism you todrugs.
maintained succeed influctuation
with little or no your pharmacology
in drug plasma levels. course, in the
with prolonged clinical
half-lives setting,
and for situations on
in which it is the
criticalNCLEX
to
for delivering drugs. The enormous surface area of the bron- The plateau
Several devices may are
be reached
used faster by the administration
to deliver drugs via ofthe load- raise drug plasma levels quickly, as might be the case when adminis-
inhalation
exam, and ultimately in your professional
chioles and alveoli and the rich blood supply to these areas nursing practice.
ing doses followed by regular maintenance doses. A loading dose
route. Nebulizers are small machines that vaporize a liquid medi-
tering an antibiotic for a severe infection. In Figure 3.9, notice that
is a higher amount of drug, often given only once or twice, that is it takes almost five doses (48 hours) before a therapeutic level is
result in an almost instantaneous onset of action for inhaled cation into a fine
administered mist that
to “prime” can be inhaled
the bloodstream using
with a level a face
sufficient to mask or using a routine dosing schedule. With a loading dose, a
reached
substances. handheld
quickly device.
induce a If the drug
therapeutic is a solid,
response. Beforeitplasma
may levels
be administered
can therapeutic level is reached within 12 hours.
Pulmonary drugs are delivered to the respiratory system by using a dry powder inhaler (DPI). A DPI is a small device that
aerosol therapy. An aerosol is a suspension of minute liquid is activated by the process of inhalation to deliver a fine powder
droplets or fine solid particles suspended in a gas. Aerosol therapy directly to the bronchial tree. Turbohalers and rotahalers are types
Keyimmediate
can give
c Concepts Summary
relief for bronchospasm , a condition during
provides of DPIs. Metered dose inhalers (MDIs) are a third type of
which the bronchiolar smooth muscle contracts, leaving the client device commonly used to deliver respiratory drugs. MDIs use a
expanded summaries
gasping for breath. Drugs mayofalsoconcepts
be given tothat
loosen viscous propellant
C H Ato
P Tdeliver
ER a measured dose of drug to the lungs during
3
correlate to sections
mucus in the bronchial within
tree. The the chap-
major advantage of aerosol ther- each breath. The client times the inhalation to the puffs of drug
apy is that it delivers the drugs to their immediate site of action, emitted from the MDI. Understanding the Chapter
ter. You can use this succinct sum-
thus reducing systemic side effects. To produce the same thera- There are disadvantages to administering aerosol therapy. The
mary to ensure
peutic action, an oral drugthat
wouldyou understand
have to be given at higher doses, precise dose received by the client is difficult to measure because
and it would be distributed to all body tissues. it depends on the client’s breathing pattern and the correct use of
the concepts before moving on to the Key Concepts Summary
next chapter. The numbering of these The numbered key concepts provide a succinct summary of the 3.3 Absorption is the process of moving a drug from the
important points from the corresponding numbered section site of administration to the bloodstream. Absorption
concepts helps you to easily locate that within the chapter. If any of these points are not clear, refer to of a drug molecule depends on its size, lipid solubility,
section within the chapter if you need the numbered section within the chapter for review. degree of ionization, and interactions with food or other
medications.
3.1 Pharmacokinetics focuses on the movement of drugs
further review. throughout the body after they are administered. The four 3.4 Distribution represents how drugs are transported
M38_ADAM2628_03_SE_C38.indd 479 processes of pharmacokinetics are absorption, metabolism 11/02/20 9:49 AM
throughout the body. Distribution depends on the
(biotransformation), distribution, and excretion. formation of drug-protein complexes and special
3.2 The physiological properties of plasma membranes barriers such as the fetal-placental and blood-brain
determine movement of drugs throughout the body. barriers.
M03_ADAM2628_03_SE_C03.indd 27 06/02/20 12:36 PM

3. How will the IV or inhalation drug therapy affect the absorption of
his medications?
Five days ago, John’s daughter noticed that he was becoming increas-
4. John will receive a loading dose of IV antibiotic and then be placed
ingly weak and lethargic. Last night, when his temperature reached
on maintenance doses every 6 hours. What is the purpose of this
38.8°C and he became confused, John’s daughter took him to the
regimen? Why would this client be a candidate for a loading dose?
emergency department, and he was admitted to the medical unit. A Preface xiii
chest x-ray this morning revealed bilateral pneumonia. John is See Answers to Critical Thinking Questions in Appendix B.
NCLEX Practice Questions

1 A nurse is teaching a client about a newly prescribed medica- c. Decreased absorption
tion. Which statement by the client would indicate the need d. Enhanced distribution
for further medication education?
4 The nurse is monitoring the therapeutic drug level for a client
a. “The liquid form of the drug will be absorbed faster than
on vancomycin (Vancocin) and notes that the level is within
the tablets.”
the accepted range. What does this indicate to the nurse?
b. “If I take more, I’ll have a better response.” (Select all that apply.)
c. “Taking this drug with food will decrease how much of it a. The drug should cause no toxicities or adverse effects.
c NCLEX Practice Questions allow gets in my system.”
b. The drug level is appropriate to exert therapeutic effects.
d. “I can consult my healthcare provider if I experience
you to test your knowledge. Answers unexpected adverse effects.”
c. The dose will not need to be changed for the duration of
treatment.
are available in Appendix A at the end 2 A nurse is caring for several clients. Which client will the d. The nurse will need to continue monitoring because each
of your text. Selected questions are nurse anticipate to be most likely to experience an alteration client response to a drug is unique.
in drug metabolism?
also available for use in class with our a. A 3-day-old premature infant
e. This drug will effectively treat the client’s condition
5 A nurse is caring for a client with hepatitis and resulting
Learning Catalytics tool. b. A 22-year-old pregnant female
hepatic impairment. The nurse would expect the duration of
c. A 32-year-old man with kidney stones action of most of the client’s medications to
d. A 50-year-old executive with hypertension a. Decrease
3 A client is receiving multiple medications, including one drug b. Improve
specifically used to stimulate gastric peristalsis. What influ- c. Be unaffected
ence could this drug have on additional oral medications?
d. Increase
a. Increased absorption
See Answers to NCLEX Practice Questions in Appendix A.
b. Reduced excretion
M03_ADAM2628_03_SE_C03.indd 28 06/02/20 12:36 PM
CHAPTER 2 Drug Classes and Schedules in Canada 15
Chapter 2 Scenario
Josh Remming is a 23-year-old student in his first semester Critical Thinking Questions
of nursing school. He thought that nursing would provide 1. What is the difference between therapeutic classification and
him with a great career and many opportunities. He enjoys pharmacological classification?
helping people and has always been fascinated by health
c Criticalcare.
Thinking Questions helpfirst
youpharmacology
to apply the essential 2. What classification is a barbiturate? Macrolide? Birth control
However, after the class, Josh is
components of nursing care through case-based scenarios. pills? Laxatives? Folic acid antagonist? Antianginal agent?
worried because there seems to be an overwhelming
Appendix amount
B provides answers to
of content tolearn
theseinquestions.
just one semester. 3. What is a prototype drug, and what advantages does a prototype
approach to studying pharmacology offer?
At the end of the class, Josh talks with other students who are also 4. Why do nurses need to know all of this pharmacology?
concerned and a bit anxious. Much of the conversation centres on lec-
ture content provided by the professor. Following are some of the ques- See Answers to Critical Thinking Questions in Appendix B.
tions posed by Josh’s classmates. How would you respond?
NCLEX Practice Questions

1 The nurse is using a drug handbook to determine the c. Primarily the concern of the healthcare provider and not
indications for the drug furosemide (Lasix). The term included in nursing care
indications is defined as the d. Substances that should be relied on for health and
a. Way a drug works on the target organs wellness
b. Amount of the drug to be administered 4 A nurse is looking up a drug that has been prescribed and
c. Conditions for which a drug is approved wants to know its therapeutic classification. Which of the
d. Reason that the drug should not be given following indicates a therapeutic classification?
a. Beta-adrenergic antagonist
2 As a member of an interprofessional team, what key
responsibilities does the nurse have to ensure effective b. Antihypertensive
pharmacotherapy? (Select all that apply.) c. Diuretic
a. Monitoring the client’s condition before and during d. Calcium channel blocker
pharmacotherapy
5 A nurse is asked by a family member, “They’re giving Mom
b. Teaching the client about self-administration and any Motrin, but she takes Advil. Hasn’t the wrong drug been
required monitoring of drug effects ordered?” The nurse will respond, knowing that
c. Ensuring that all drug and treatment options have been a. There has been an error in the order, so the nurse will
considered before beginning pharmacotherapy contact the healthcare provider
d. Frequently conducting a medication reconciliation to b. There may be a reason the healthcare provider is ordering
verify current medications in use a different drug
e. Determining the ideal drug to be prescribed to the client c. Not all healthcare agencies buy the same generic drugs,
Contents
UNIT 1 Fundamental Concepts and Principles Pharmacology of the Future: Customizing Drug
of Pharmacology Therapy 35
CONNECTIONS: Treating the Diverse Client Enzyme
CHAPTER 1 Introduction to Pharmacology and Drug Regulations Deficiencies in Ethnic Populations 36
in Canada 1
Pharmacology: The Study of Medicines 2
Pharmacology and Therapeutics 2 UNIT 2 Pharmacology and the Nurse-Client Relationship
Classification of Therapeutic Agents as Drugs, Biologics, CHAPTER 5 The Nursing Process in Pharmacotherapy 38
or Natural Health Products 2 Review of the Nursing Process 39
Prescription and Over-the-Counter Drugs 3 Assessing the Client in Relation to Drug
Drug Regulations and Standards 3 Administration 40
Federal Drug Legislation 3 Diagnosing for the Client Receiving Medications 41
Approval Process for Prescription Drugs 4 CONNECTIONS: Special Considerations Clients with
Pricing and Access to Prescription Drugs Across Speaking, Visual, or Hearing Impairments 42
Canada 5 Setting Goals and Outcomes for Drug
CHAPTER 2 Drug Classes and Schedules in Canada 8 Administration 42
Characteristics of an Ideal Drug 9 Key Interventions for Drug Administration 43
Therapeutic and Pharmacological Classification of Evaluating the Effects of Drug Administration 44
Drugs 9 CONNECTIONS: Cultural Considerations Non-English-
Chemical, Generic, and Trade Names of Drugs 10 Speaking and Culturally Diverse Clients 45
Differences Between Brand Name Drugs and Their CHAPTER 6 Lifespan Considerations in Pharmacotherapy 47
Generic Equivalents 11 Pharmacotherapy Across the Lifespan 48
Drug Schedules 11 PHARMACOTHERAPY DURING PREGNANCY
Controlled Drugs and Substances 12 AND LACTATION 48
Connecting Pharmacology to Clinical Nursing Pharmacotherapy During Pregnancy 48
Practice 12 Pharmacokinetics During Pregnancy 49
CHAPTER 3 Pharmacokinetics 16 Gestational Age and Pharmacotherapy 49
Pharmacokinetics: How the Body Handles Pregnancy Drug Categories 50
Medications 17 Pharmacotherapy During Gestation 51
The Passage of Drugs Through Plasma Membranes 17 Pharmacotherapy During Lactation 52
Primary Processes of Pharmacokinetics: Absorption of PHARMACOTHERAPY DURING
Medications 19 CHILDHOOD 53
Distribution of Medications 21 Pharmacotherapy in the Pediatric Population 53
Metabolism of Medications 22 Medication Safety for Pediatric Clients 55
Nursing Actions and Guidelines 55 • Nursing Education
Excretion of Medications 24
and Communication 55
Drug Plasma Concentration and Therapeutic
Calculating Drug Dosages for the Pediatric Client 55
Response 25
Adverse Drug Reactions in Children and Promoting
CONNECTIONS: Lifespan Considerations Adverse Drug Adherence 57
Effects and the Older Client 25
Pharmacotherapy of Toddlers 57
Plasma Half-Life and Duration of Drug Action 26
Pharmacotherapy of Preschoolers and School-Aged
Loading Doses and Maintenance Doses 27
Children 58
CHAPTER 4 Pharmacodynamics 29 Pharmacotherapy of Adolescents 58
Pharmacodynamics and Inter-Individual Variability 30 PHARMACOTHERAPY IN ADULTHOOD 59
Therapeutic Index Describes a Drug’s Margin of Pharmacotherapy of Young and Middle-Aged
Safety 30 Adults 59
The Graded Dose-Response Relationship and Pharmacotherapy of Older Adults 59
Therapeutic Response 31 CONNECTIONS: Special Considerations Altered
Potency and Efficacy 32 Pharmacokinetics During Older Adulthood 60
Cellular Receptors and Drug Action 33 Adherence to the Therapeutic Regimen 61
Types of Drug-Receptor Interactions 35 Adverse Drug Reactions in Older Adults 62
xv
xvi Contents
UNIT 3 Professional, Personal, and Cultural Influences Parenteral Drug Administration 96

Intradermal and Subcutaneous Administration 97
on Pharmacotherapy
• Intramuscular Administration 99 • Intravenous
CHAPTER 7 Individual, Psychosocial, and Cultural Influences on Administration 100
Drug Responses 65
CHAPTER 10 Medication Incidents and Risk Reduction 104
The Concept of Holistic Pharmacotherapy 66
Medication Incidents 105
Psychosocial Influences on Pharmacotherapy 66
National Programs for Monitoring Medication Incidents
CONNECTIONS: Special Considerations Alcoholism:
and Reducing Risk 105
Cultural and Environmental Influences 67
Ethics and Standards of Nursing Practice 107
Cultural and Ethnic Influences on Pharmacotherapy 67
Factors Contributing to Medication Incidents 108
CONNECTIONS: Special Considerations Medication
Drug Names and Medication Errors 109
Refusal for Religious, Moral, or Dietary Reasons 68
The Impact of Medication Incidents 109
Community and Environmental Influences on
Documenting and Reporting Medication Incidents 110
Pharmacotherapy 69 Documenting in the Client’s Medical Record 110 •
Genetic Polymorphisms and Their Influence on Completing a Written Incident Report 110 • Reporting at
Pharmacotherapy 69 the National Level 110
Gender Influences on Pharmacotherapy 70 Medication Reconciliation 110
Strategies for Preventing Medication Incidents 111
CHAPTER 8 Drug Effects, Adverse Reactions, and Interactions 73
Providing Client Education for Safe Medication Usage 112
The Nurse’s Role in Preventing and Managing Adverse
Risk Management to Prevent Medication Errors 113
Drug Effects 74
The Canadian Adverse Drug Reaction Information CHAPTER 11 Complementary and Alternative Therapies and Their
System 75 Roles in Pharmacotherapy in Canada 116
Allergic Reactions 75 Types of Complementary and Alternative Therapies 117
Idiosyncratic Reactions 75 Brief History of Natural Health Products 117
Drugs That Have the Ability to Induce Cancer or Cause Regulation of Natural Health Products (NHPs) 119
Birth Defects 76 Herbal Product Formulations 120
Drug Toxicity 77 CONNECTIONS: Special Considerations Herbal
Nephrotoxicity 77 • Neurotoxicity 77 • Hepatotoxicity Products 120
77 • Dermatological Toxicity 78 • Bone Marrow Toxicity
CONNECTIONS: Lifespan Considerations Dietary
78 • Cardiotoxicity 78 • Skeletal Muscle and Tendon
Supplements and the Older Adult 120
Toxicity 79
Herb-Drug Interactions: The Pharmacological Actions
Drug Interactions 79
and Safety of Natural Products 121
Pharmacokinetic Drug Interactions 79
Absorption 79 • Distribution 80 • Metabolism 80 CONNECTIONS: Preparing for Advanced
• Excretion 81 Practice Older Adults at Risk for Polyherbacy 123
Pharmacodynamic Drug Interactions 81 Specialty Supplements Used to Promote Wellness 123
Food, Nutrient, and Dietary Supplement
Interactions 82
UNIT 4 Pharmacology of Alterations
CHAPTER 9 Principles of Drug Administration 85 in the Autonomic Nervous System
NURSING MANAGEMENT OF DRUG
ADMINISTRATION 86
CHAPTER 12 Brief Review of the Autonomic Nervous System and
Medication Knowledge, Understanding, and
Neurotransmitters 126
OVERVIEW OF THE NERVOUS SYSTEM 127
Responsibilities of the Nurse 86
The Two Major Subdivisions of the Nervous
The Rights of Drug Administration 86
System 127
Client Adherence and Successful Pharmacotherapy 87
The Peripheral Nervous System 127
CONNECTIONS: Special Considerations The Challenges
Structure and Function of the Autonomic Nervous
of Pediatric Drug Administration 88
System 127
Drug Orders and Time Schedules 88
Structure and Function of Synapses 129
Systems of Measurement 89
Acetylcholine and Cholinergic Transmission 132
ROUTES OF DRUG ADMINISTRATION 89
Norepinephrine and Adrenergic Transmission 133
Enteral Drug Administration 89
Tablets and Capsules 90 • Sublingual and Buccal Drug AUTONOMIC DRUGS 134
Administration 91 • Elixirs, Syrups, and Suspensions 91 Classification and Naming of Autonomic Drugs 134
• Nasogastric and Gastrostomy Drug Administration 92
CHAPTER 13 Pharmacotherapy with Cholinergic Agonists and
Topical Drug Administration 92
Transdermal Delivery System 92 • Ophthalmic
Antagonists 136
Administration 94 • Otic Administration 94 • Nasal Cholinergic Agonists 137
Administration 94 • Vaginal Administration 96 • Rectal Clinical Applications of Cholinergics 138
Administration 96 PROTOTYPE DRUG: Bethanechol (Duvoid) 139
Contents xvii
Nicotinic Agonists (Nicotine) 139 Use of Barbiturates as Sedatives 175

Indirect-Acting Cholinergics 140 • Direct-Acting PROTOTYPE DRUG: Phenobarbital (Phenobarb) 175
Cholinergics 140
Other CNS Depressants for Anxiety and Sleep
Anticholinergics 141
Disorders 176
Nursing Implications for Practice 142
PROTOTYPE DRUG: Zopiclone (Imovane) 178
CONNECTIONS: Special Considerations Impact of
Anticholinergics on Male Sexual Function 142 CHAPTER 17 Pharmacotherapy of Emotional and Mood
Clinical Applications of Anticholinergics 142 Disorders 180
CONNECTIONS: Natural Therapies Valerian 143 DEPRESSION 181
PROTOTYPE DRUG: Atropine 143 Categories of Mood Disorders 181
The Characteristics of Depression 181
CHAPTER 14 Pharmacotherapy with Adrenergic Agonists and
Assessment and Treatment of Depression 183
Antagonists 146
ANTIDEPRESSANTS 184
Adrenergic Agonists and Antagonists 147
CONNECTIONS: Lifespan Considerations Depression
Clinical Applications of Adrenergics 147
Across the Lifespan 184
Mechanism of Action of Antidepressants 185
PROTOTYPE DRUG: Phenylephrine (Neo-Synephrine) 151
Treating Depression with Tricyclic
CONNECTIONS: Client Safety Prompt Use of the Antidepressants 186
Epinephrine Autoinjector in the School Setting 152 Nursing Implications for Practice 187
Adrenergic Antagonists 152
PROTOTYPE DRUG: Imipramine (Impril) 188
Clinical Applications of Adrenergic Antagonists 153
Treating Depression with SSRIs 188
PROTOTYPE DRUG: Prazosin (Minipress) 154
PROTOTYPE DRUG: Fluoxetine (Prozac) 190
CONNECTIONS: Treating the Diverse Client Ethnic
Treating Depression with MAO Inhibitors 191
Differences in Antihypertensive Response 154
PROTOTYPE DRUG: Phenelzine (Nardil) 192
UNIT 5 Pharmacology of Alterations Atypical Antidepressants 195
in the Central Nervous System PROTOTYPE DRUG: Venlafaxine (Effexor) 195
BIPOLAR DISORDER 196
CHAPTER 15 Brief Review of the Central Nervous System 158
Lithium 196
How Medications Affect the Central Nervous
System 159 PROTOTYPE DRUG: Lithium (Carbolith, Lithane) 197
Neurons and Neurotransmission 159 Nursing Implications for Practice 197
Structural Divisions of the Central Nervous CHAPTER 18 Central Nervous System Stimulants and
System 161 Pharmacotherapy of Attention Deficit and Hyperactive
Functional Systems of the Central Nervous Disorders 200
System 163 Central Nervous System Stimulants 201
CHAPTER 16 Pharmacotherapy of Anxiety and Sleep Attention Deficit/Hyperactivity Disorder 202
Disorders 166 Pharmacotherapy of Attention Deficit/Hyperactivity
ANXIETY DISORDERS 167 Disorder 202
Drugs for Attention Deficit/Hyperactivity Disorder 203
Types of Anxiety Disorders 168
Regions of the Brain Responsible for Anxiety and CONNECTIONS: Lifespan Considerations Zero Drug
Tolerance in Schools 203
Wakefulness 168
Sleep Disorders 169 CONNECTIONS: Using Research in Practice Assessing
Cardiovascular Risk of Attention Deficit/Hyperactivity
Anxiety Management Through Pharmacological and
Disorder Medications 204
Non-Pharmacological Strategies 170
INSOMNIA 170
PROTOTYPE DRUG: Methylphenidate (Ritalin, Concerta,
Insomnia and the Role of Melatonin 172
Biphentin) 204
CENTRAL NERVOUS SYSTEM
Methylxanthines 205
DEPRESSANTS 172
PROTOTYPE DRUG: Caffeine 205
Treating Anxiety and Insomnia with CNS
Depressants 172 CHAPTER 19 Pharmacotherapy of Psychoses 209
BENZODIAZEPINES 173 The Nature of Psychoses 210
Treating Anxiety and Insomnia with Signs and Symptoms of Schizophrenia 210
Benzodiazepines 173 CONNECTIONS: Lifespan Considerations Schizophrenia
Nursing Implications for Practice 174 Across the Lifespan 211
PROTOTYPE DRUG: Lorazepam (Ativan) 174 Pharmacological Management of Psychoses 212
BARBITURATES 175 ANTIPSYCHOTIC AGENTS 214
xviii Contents
Treating Psychoses with Phenothiazines 215 Treating Seizures with Benzodiazepines 250
Nursing Implications for Practice 216 Nursing Implications for Practice 251
PROTOTYPE DRUG: Chlorpromazine 217 PROTOTYPE DRUG: Diazepam (Valium) 251
Treating Psychoses with Non-Phenothiazines 217 DRUGS THAT SUPPRESS SODIUM INFLUX 251
Nursing Implications for Practice 217 Treating Seizures with Hydantoins and Phenytoin-Like
PROTOTYPE DRUG: Haloperidol (Haldol) 218 Drugs 252
ATYPICAL ANTIPSYCHOTIC AGENTS 220 Nursing Implications for Practice 252
Treating Psychoses with Atypical Antipsychotics 220 PROTOTYPE DRUG: Phenytoin (Dilantin) 253
Nursing Implications for Practice 221 PROTOTYPE DRUG: Valproic Acid (Depakene, Epival) 254
PROTOTYPE DRUG: Clozapine (Clozaril) 221 DRUGS THAT SUPPRESS CALCIUM INFLUX 255
Treating Psychoses with Dopamine System Stabilizers 223 Treating Seizures with Succinimides 255
PROTOTYPE DRUG: Aripiprazole (Abilify) 223 Nursing Implications for Practice 255
PROTOTYPE DRUG: Ethosuximide (Zarontin) 256
CHAPTER 20 Pharmacotherapy of Degenerative Diseases of the
Nervous System 226 CHAPTER 22 Pharmacotherapy of Muscle Spasms and Spasticity 258
Degenerative Diseases of the Central Nervous System 227 MUSCLE SPASMS 259
CONNECTIONS: Special Considerations Degenerative Causes of Muscle Injury and Spasms 259
Diseases of the Central Nervous System 227 Pharmacological and Non-Pharmacological Treatment
PARKINSON’S DISEASE 227 of Muscle Spasms 259
Characteristics of Parkinson’s Disease 227 CENTRALLY ACTING SKELETAL MUSCLE
DRUGS FOR PARKINSONISM 228 RELAXANTS 260
Treating Parkinsonism with Dopaminergic Drugs 228 Treating Muscle Spasms at the Level of the Central
Nursing Implications for Practice 230 Nervous System 260
PROTOTYPE DRUG: Carbidopa-Levodopa (Sinemet) 231 CONNECTIONS: Natural Therapies Cayenne for
Treating Parkinsonism with Anticholinergics 233 Muscular Tension 262
Nursing Implications for Practice 233 PROTOTYPE DRUG: Cyclobenzaprine (Flexeril) 262
PROTOTYPE DRUG: Benztropine (Cogentin) 234 SPASTICITY 262
ALZHEIMER’S DISEASE 234 Causes and Treatment of Spasticity 262
Characteristics of Alzheimer’s Disease 234 Treating Muscle Spasms Directly at the Muscle
DRUGS FOR ALZHEIMER’S DISEASE 235 Tissue 263
Treating Alzheimer’s Disease with Acetylcholinesterase CONNECTIONS: Community-Oriented Practice Botox:
Inhibitors 235 Beyond Wrinkles 264
PROTOTYPE DRUG: Dantrolene (Dantrium) 264
PROTOTYPE DRUG: Donepezil (Aricept) 237 Nursing Implications for Practice 265
CONNECTIONS: Special Considerations Living with Skeletal Muscle Relaxants as Surgical Adjuncts 266
Alzheimer’s or Parkinson’s Disease 238
CHAPTER 23 Pharmacotherapy of Pain and Migraine 269
MULTIPLE SCLEROSIS 238
Drugs for Modifying the Progression of Multiple General Principles of Pain Management 270
Sclerosis 238 Pharmacological Therapies 270 • Management of Cancer
Pain 271 • Patient-Controlled Analgesia 271
PROTOTYPE DRUG: Interferon Beta-1b (Betaseron,
Assessment and Classification of Pain 271
Extavia) 239
CONNECTIONS: Lifespan Considerations Pain
AMYOTROPHIC LATERAL SCLEROSIS 239
Assessment in the Very Young 271
CHAPTER 21 Pharmacotherapy of Seizures 242 Pain Transduction 272 • Pain Transmission 272
SEIZURES 243 CONNECTIONS: Lifespan Considerations Pain in
Causes of Seizures 243 Infants and Older Adults 273
CONNECTIONS: Lifespan Considerations Seizure Pain Perception 273 • Pain Modulation 273
Causes Based on Age-Related Factors and Genetics 244 Non-Pharmacological Techniques for Pain Management 273
CONNECTIONS: Complementary and Alternative CONNECTIONS: Cultural Considerations Cultural
Therapies The Ketogenic Diet 244 Influences on Pain Expression and Perception 273
Types of Seizures 244 The Neural Mechanisms of Pain 274
Partial Seizures 245 • Generalized Seizures 245 • Special OPIOID (NARCOTIC) ANALGESICS 274
Epileptic Syndromes 245 Classification of Opioids 274
General Concepts of Epilepsy Pharmacotherapy 246 Pharmacotherapy with Opioids 275
Drugs That Potentiate GABA 246 Nursing Implications for Practice 276
Treating Seizures with Barbiturates and Miscellaneous CONNECTIONS: Lifespan Considerations The Influence
GABA Agents 248 of Age on Pain Expression and Perception 276
Nursing Implications for Practice 248 PROTOTYPE DRUG: Morphine (Kadian, M-Eslon, MS Contin,
PROTOTYPE DRUG: Phenobarbital (Phenobarb) 249 MS-IR, Statex) 277
Contents xix
Pharmacotherapy with Opioid Antagonists 278 Withdrawal Syndrome 307

Nursing Implications for Practice 278 Tolerance 308
PROTOTYPE DRUG: Naloxone (Narcan) 278 CNS Depressants 308
Treatment for Opioid Dependence 280 Sedatives 308
NON-OPIOID ANALGESICS 280 Opioids 309
Pharmacotherapy with NSAIDs 280 PROTOTYPE DRUG: Buprenorphine with Naloxone
Nursing Implications for Practice 281 (Suboxone) 309
Ethyl Alcohol 310
PROTOTYPE DRUG: Acetylsalicylic Acid (Aspirin) 282
Cannabinoids 311
TENSION HEADACHES AND MIGRAINES 283
Marijuana 312
Classification of Headaches 283
Hallucinogens 312
Drug Therapy for Migraine Headaches 283
LSD 312 • Other Hallucinogens 313
CNS Stimulants 313
CONNECTIONS: Natural Therapies Feverfew for Amphetamines and Methylphenidate 313 • Cocaine 314
Migraines 286
CONNECTIONS: Natural Therapies Herbal Stimulants
PROTOTYPE DRUG: Sumatriptan (Imitrex) 288 and Ephedra 314
Caffeine 314
CHAPTER 24 Pharmacology of Local and General Nicotine 314
Anesthesia 290 Tobacco Use and Nicotine 315
Regional Loss of Sensation Using Local CONNECTIONS: Special Considerations Ethnic Groups
Anesthetics 291 and Smoking 315
LOCAL ANESTHETICS 291 Inhalants 316
Mechanism of Action of Local Anesthetics 291 Anabolic Steroids 316
CONNECTIONS: Natural Therapies Clove and Anise as CONNECTIONS: Lifespan Considerations Abuse of
Natural Dental Remedies 293 Volatile Inhalants by Children and Adolescents 316
CONNECTIONS: Lifespan Considerations Postoperative The Nurse’s Role in Substance Addiction 317
Cognitive Dysfunction and Delirium in the Older Adult
After Surgery 293
Classification of Local Anesthetics 293
in the Endocrine System
CONNECTIONS: Lifespan Considerations Effects of CHAPTER 26 Brief Review of the Endocrine System 320
Anesthesia on Children and Older Adults 294 Overview of the Endocrine System 321
PROTOTYPE DRUG: Lidocaine (Xylocaine) 295 Hormone Receptors 321
Characteristics of General Anesthesia 295 Negative Feedback Mechanism 322
Neuronal Stimuli 322 • Humoral Stimuli 322
GENERAL ANESTHETICS 296
• Hormonal Stimuli 322
Pharmacotherapy with Inhaled General Anesthetics 296
Hormone Pharmacotherapy 322
Gaseous General Anesthetics 297 • Nursing Implications
for Practice 297 CHAPTER 27 Pharmacotherapy of Hypothalamic and Pituitary
PROTOTYPE DRUG: Nitrous Oxide 297 Disorders 324
Volatile Liquid General Anesthetics 297 • Nursing Functions of the Hypothalamus 325
Implications for Practice 297 Functions of the Pituitary Gland 325
CONNECTIONS: Using Research in Practice Malignant Pharmacotherapy of Growth Hormone
Hyperthermia and Anesthetic Agents 298 Disorders 327
PROTOTYPE DRUG: Halothane (Fluothane) 298 DISORDERS OF THE HYPOTHALAMUS AND
INTRAVENOUS ANESTHETICS 298 PITUITARY GLAND 328
Pharmacotherapy with IV Anesthetics 298 Pharmacotherapy with Pituitary and Hypothalamic
Nursing Implications for Practice 299 Hormones 328
PROTOTYPE DRUG: Propofol (Diprivan) 299 CONNECTIONS: Preparing for Advanced
NON-ANESTHETIC DRUGS AS ADJUNCTS TO Practice Traumatic Brain Injury and Hormones 329
SURGERY 301 PROTOTYPE DRUG: Somatropin (Genotropin, Humatrope,
Nursing Implications for Practice 301 Omnitrope, Saizen, Serostim) 329
PROTOTYPE DRUG: Succinylcholine (Quelicin) 302 Antidiuretic Hormone 330
CHAPTER 25 Pharmacotherapy in Substances of Abuse and PROTOTYPE DRUG: Vasopressin (Pressyn) 331
Addiction 304
Overview of Substances of Addiction 305 CHAPTER 28 Pharmacotherapy of Diabetes Mellitus 335
Neurobiological and Psychosocial Components Normal Functions of the Pancreas 336
of Substance Addiction 305 Etiology and Characteristics of Type 1 and Type 2
Physical and Psychological Dependence 306 Diabetes Mellitus 337
xx Contents
CONNECTIONS: Lifespan Considerations Pediatric Corticosteroids in Inflammation 370

Type 2 Diabetes 338 Arthritis 370 • Inflammatory Bowel Disease 370
CONNECTIONS: Lifespan Considerations • Asthma 371 • Allergies 371 • Transplant Rejection
Pregestational Diabetes 338 Prophylaxis 371 • Dermatological Conditions 371
Insulin 339 • Neoplasms 371 • Edema 371
CONNECTIONS: Special Considerations What Does the CONNECTIONS: Lifespan Considerations Corticosteroid
Diabetes Charter Mean for Canada? 339 Use by Mothers at Risk for Preterm Labour 371
Mineralocorticoids in Adrenal Insufficiency 371
CONNECTIONS: Lifespan Considerations Gestational
Diabetes 339 Pharmacotherapy of Cushing’s Syndrome 372
CONNECTIONS: Lifespan Considerations Diabetes in
CONNECTIONS: Lifespan Considerations Treatment of
the Geriatric Population 339
Cushing’s Syndrome During Pregnancy 372
Pharmacotherapy with Insulin 339
Nursing Implications for Practice 341 CHAPTER 31 Pharmacotherapy of Disorders of the Female
CONNECTIONS: Lifespan Considerations Diabetes in Reproductive System 376
the School Setting 342 Hypothalamic and Pituitary Regulation of Female
CONNECTIONS: Client Safety Incorrect Insulin Reproductive Function 377
Dose 343 Ovarian Control of Female Reproductive
PROTOTYPE DRUG: Regular Insulin (Humulin R, Novolin ge Function 377
Toronto) 343 CONTRACEPTION 377
CONNECTIONS: Lifespan Considerations Psychosocial Estrogens and Progestins as Oral
Impacts on the Young Person with Diabetes 343 Contraceptives 380
CONNECTIONS: Special Considerations Carbohydrate Nursing Implications for Practice 382
Counting: Flexible Carbohydrate Plan 344
PROTOTYPE DRUG: Ethinyl Estradiol with Norethindrone
Pharmacotherapy with Oral Antihyperglycemics 345
(Ortho-Novum 1/35) 383
Sulfonylureas 347 • Biguanides 347 • Alpha-Glucosidase
Inhibitors 347 • Thiazolidinediones 348 • Meglitinides 348 CONNECTIONS: Community-Oriented Practice Macular
• Incretin Enhancers 348 Edema in Women on Oral Contraceptives 383
PROTOTYPE DRUG: Sitagliptin (Januvia) 348 CONNECTIONS: Preparing for Advanced
Nursing Implications for Practice 349 Practice Contraceptive Choices 385
Drugs for Long-Term Contraception and Newer
PROTOTYPE DRUG: Glyburide (DiaBeta) 349
Contraceptive Delivery Methods 385
CHAPTER 29 Pharmacotherapy of Thyroid Disorders 353 Transdermal Delivery Method 385 • Vaginal Delivery
Method 385 • Depot Injection Methods 386
Normal Function of the Thyroid Gland 354
• Intrauterine Devices 386 • Spermicides 387
Diagnosis of Thyroid Disorders 355
Emergency Contraception and Pharmacological
Hypothyroid Disorders 355
Abortion 387
CONNECTIONS: Community-Oriented Practice The
MENOPAUSE 388
Effects of Soy Intake 356
Hormone Replacement Therapy 388
Pharmacotherapy of Hypothyroid Disorders 356 Nursing Implications for Practice 389
CONNECTIONS: Natural Therapies Treatments for
PROTOTYPE DRUG: Conjugated Estrogens
Thyroid Disease 357
(Premarin) 390
CONNECTIONS: Special Considerations Shift Workers, UTERINE ABNORMALITIES 391
Hypothyroidism, and Drug Adherence 357
Pharmacotherapy with Progestins 391
CONNECTIONS: Special Considerations Estrogen Use
PROTOTYPE DRUG: Levothyroxine (Eltroxin,
and Psychosocial Issues 392
Synthroid) 359
CONNECTIONS: Natural Therapies Chaste Berry for
Hyperthyroid Disorders 359
Premenstrual Syndrome and Menopause 392
Pharmacotherapy of Hyperthyroid Disorders 360 Nursing Implications for Practice 392
PROTOTYPE DRUG: Medroxyprogesterone
PROTOTYPE DRUG: Propylthiouracil (PTU) 361
(Provera) 393
CHAPTER 30 Corticosteroids and Pharmacotherapy of LABOUR AND BREASTFEEDING 394
Adrenal Disorders 364 Pharmacological Management of Uterine
Physiology of the Adrenal Gland 365 Contractions 394
Mineralocorticoids 365 • Glucocorticoids 366 Nursing Implications for Practice 395
• Gonadocorticoids 366 PROTOTYPE DRUG: Oxytocin (Pitocin) 396
Overview of Corticosteroid Pharmacotherapy 366 CONNECTIONS: Complementary and Alternative
Adverse Effects of Corticosteroids 367 Therapies Soy as a Phytoestrogen 396
Replacement Therapy with Corticosteroids 368 FEMALE INFERTILITY 397
PROTOTYPE DRUG: Hydrocortisone (Cortef, Solu-Cortef) 369 Pharmacotherapy of Female Fertility 397
Contents xxi
CHAPTER 32 Pharmacotherapy of Disorders of the Male Reproductive ANTACIDS 428

System 401 Pharmacotherapy with Antacids 428
CONNECTIONS: Special Considerations Male Nursing Implications for Practice 429
Reproductive Conditions and Disorders 402 PROTOTYPE DRUG: Aluminum Hydroxide (Amphojel) 430
Hypothalamic and Pituitary Regulation of Male ANTIBIOTICS 430
Reproductive Function 402 Pharmacotherapy with Combination Antibiotic
MALE HYPOGONADISM 403 Therapy 430
Pharmacotherapy with Androgens 403 MISCELLANEOUS DRUGS FOR PEPTIC ULCER
PROTOTYPE DRUG: Testosterone Base (Andriol, Androderm, DISEASE 430
AndroGel, Testim) 404
Nursing Implications for Practice 404 CHAPTER 35 Pharmacotherapy of Bowel Disorders and Other
Gastrointestinal Alterations 433
CONNECTIONS: Special Considerations Androgen
Abuse by Athletes 404 CONSTIPATION 434
MALE SEXUAL DYSFUNCTION 405 Pathophysiology of Constipation 434
MALE INFERTILITY 406 Pharmacotherapy with Laxatives 435
Pharmacotherapy of Male Infertility 406
ERECTILE DYSFUNCTION 407 PROTOTYPE DRUG: Psyllium Mucilloid (Metamucil,
Pharmacotherapy of Erectile Dysfunction 407
Psyllium) 436
Nursing Implications for Practice 407 DIARRHEA 436
Pathophysiology of Diarrhea 437
PROTOTYPE DRUG: Sildenafil (Viagra) 408
Pharmacotherapy with Antidiarrheals 438
BENIGN PROSTATIC HYPERPLASIA 408
Pharmacotherapy of Benign Prostatic Hyperplasia 409
Nursing Implications for Practice 410 CONNECTIONS: Using Research in Practice Fecal
Microbiota Transplant 439
CONNECTIONS: Natural Therapies Saw Palmetto 411
PROTOTYPE DRUG: Diphenoxylate with Atropine (Lomotil) 439
PROTOTYPE DRUG: Finasteride (Proscar) 411
CONNECTIONS: Natural Therapies Probiotics for
Diarrhea 439
UNIT 7 Pharmacology of Alterations CONNECTIONS: Lifespan Considerations Management
in the Gastrointestinal System of Diarrhea 439
CONNECTIONS: Special Considerations Treatment for
CHAPTER 33 Brief Review of the Gastrointestinal System 414
Watery Diarrhea in Infants and Children 441
The Function of the Digestive System 415
NAUSEA AND VOMITING 441
Physiology of the Upper Gastrointestinal Tract 415
Pathophysiology of Nausea and Vomiting 441
Physiology of the Lower Gastrointestinal Tract 416
Pharmacotherapy with Antiemetics 441
The Large Intestine 416
Physiology of the Accessory Organs of Digestion 417
PROTOTYPE DRUG: Prochlorperazine (Stemetil) 442
Regulation of Digestive Processes 418
INFLAMMATORY BOWEL DISEASE 443
Nutrient Categories and Metabolism 418
PROTOTYPE DRUG: Sulfasalazine (Salazopyrin) 444
CHAPTER 34 Pharmacotherapy of Peptic Ulcer Disease 420 IRRITABLE BOWEL SYNDROME 446
CONNECTIONS: Special Considerations Peptic Ulcer Lifestyle Changes, Diet, and Aggravating Medications 446
Disease 421 • Dietary Fibre and Laxatives 446 • Antidepressant
Therapy 446 • Drug-Specific Therapies 446
Acid Production by the Stomach 421
PANCREATITIS 446
Pathogenesis of Peptic Ulcer Disease 421
Pharmacotherapy of Pancreatitis 446
CONNECTIONS: Lifespan Considerations Ulcers 422 Nursing Implications for Practice 447
Pathogenesis of Gastroesophageal Reflux Disease 423
CONNECTIONS: Special Considerations Psychosocial and
Pharmacotherapy of Peptic Ulcer Disease 424
Community Impacts of Alcohol-Related Pancreatitis 447
CONNECTIONS: Natural Therapies Ginger’s Tonic
PROTOTYPE DRUG: Pancrelipase (Lipancreatin,
Effects on the GI Tract 424
Pancrease) 447
H2-RECEPTOR ANTAGONISTS 424
Pharmacotherapy with H2-Receptor Antagonists 425 CHAPTER 36 Pharmacotherapy of Obesity and Weight
Nursing Implications for Practice 425 Management 450
PROTOTYPE DRUG: Ranitidine (Zantac) 427 Etiology of Obesity 451
PROTON PUMP INHIBITORS 427 Measurement of Obesity 451
Pharmacotherapy with Proton Pump Inhibitors 427 Non-Pharmacological Therapies for Obesity 452
Nursing Implications for Practice 427 Pharmacotherapy with Drugs for Weight Loss 452
CONNECTIONS: Lifespan Considerations H2-Receptor Nursing Implications for Practice 453
Antagonists and Vitamin B12 in Older Adults 427 PROTOTYPE DRUG: Orlistat (Xenical) 453
PROTOTYPE DRUG: Omeprazole (Losec) 428 Adjuncts to Obesity Therapy 453
xxii Contents
CHAPTER 37 Pharmacotherapy of Nutritional Disorders 456 Pharmacotherapy of Asthma with Glucocorticoids 485
VITAMINS 457 Nursing Implications for Practice 486
Role of Vitamins in Maintaining Health 457 PROTOTYPE DRUG: Beclomethasone (QVAR) 486
Classification of Vitamins 457 MAST CELL STABILIZERS 487
Recommended Dietary Reference Intakes 458 Treating Asthma with Mast Cell Stabilizers 487
Indications for Vitamin Pharmacotherapy 459 LEUKOTRIENE MODIFIERS 487
LIPID-SOLUBLE VITAMINS 459 Treating Asthma with Leukotriene Modifiers 487
Pharmacotherapy with Lipid-Soluble Vitamins 459 Monoclonal Antibodies 487
Nursing Implications for Practice 460 COMMON COLD 488
PROTOTYPE DRUG: Vitamin A 461 Pharmacotherapy with Antitussives 488
WATER-SOLUBLE VITAMINS 462 Nursing Implications for Practice 488
Pharmacotherapy with Water-Soluble Vitamins 462 PROTOTYPE DRUG: Dextromethorphan (Koffex DM) 489
Nursing Implications for Practice 463 Pharmacotherapy with Expectorants and Mucolytics 489
CONNECTIONS: Natural Therapies Vitamin C and the CHRONIC OBSTRUCTIVE PULMONARY
Common Cold 464 DISEASE 489
PROTOTYPE DRUG: Folic Acid 464 Pharmacotherapy of COPD 489
MINERALS 465 CONNECTIONS: Special Considerations Respiratory
Pharmacotherapy with Minerals 466 Distress Syndrome 490
Pharmacotherapy with Macrominerals 466
UNIT 9 Pharmacology of Alterations in Body Defences
PROTOTYPE DRUG: Magnesium Sulfate 467
Pharmacotherapy with Microminerals 468 CHAPTER 39 Brief Review of Body Defences and the Immune
NUTRITIONAL SUPPLEMENTS 469 System 493
Etiology of Undernutrition 469 The Lymphatic System 494
Enteral Nutrition 469 Innate (Nonspecific) Body Defences 494
Total Parenteral Nutrition 470 Physical Barriers 494 • Cellular Barriers 495 • Process
Carbohydrates 471 • Lipids 471 • Amino Acids 471 Barriers 495
• Electrolytes and Minerals 471 • Vitamins 471 Inflammation 495
COMPLICATIONS OF PARENTERAL Chemical Mediators of Inflammation 495
THERAPY 472 Specific (Adaptive) Body Defences 497
Selected Complications of Total Parenteral Nutrition Humoral Immune Response 497
and Nursing Considerations 472 Cell-Mediated Immune Response 497
Drug and Food Interactions 473
CHAPTER 40 Pharmacotherapy with Immunostimulants and
Immunosuppressants 500
UNIT 8 Pharmacology of Alterations in the Respiratory
Immunomodulators 501
System
Pharmacotherapy with Biological Response
CHAPTER 38 Pharmacotherapy of Asthma, Common Cold, and Other Modifiers 501
Pulmonary Disorders 477 Nursing Implications for Practice 502
Physiology of the Respiratory System 478 PROTOTYPE DRUG: Interferon Alfa-2 (Intron A) 502
Bronchiolar Smooth Muscle 478 PROTOTYPE DRUG: Aldesleukin (Proleukin) 504
Administration of Pulmonary Drugs via IMMUNOSUPPRESSANTS 504
Inhalation 479 Antibodies 504
ASTHMA 480 CONNECTIONS: Natural Therapies Echinacea for
Pathophysiology of Asthma 480 Boosting the Immune System 507
BETA-ADRENERGIC AGONISTS 481
PROTOTYPE DRUG: Basiliximab (Simulect) 507
Treating Asthma with Beta-Adrenergic Agonists 482
Immunosuppressants to Prevent Transplant
Rejection 507
PROTOTYPE DRUG: Salmeterol (Serevent Diskhaler Nursing Implications for Practice 507
Disk) 483
PROTOTYPE DRUG: Cyclosporine (Neoral, Sandimmune) 509
METHYLXANTHINES AND
Corticosteroids as Immunosuppressants 510
ANTICHOLINERGICS 483
Treating Asthma with Methylxanthines and CHAPTER 41 Pharmacotherapy of Immune System Modulation and
Anticholinergics 483 Immunization 512
Nursing Implications for Practice 483 Administration of Vaccines and the Immune
CONNECTIONS: Using Research in Practice Early System 513
Exposure to Allergens May Reduce Asthma Risk 485 Types of Vaccines 514
PROTOTYPE DRUG: Ipratropium (Atrovent) 485 Active Immunity: Bacterial Immunizations 514
GLUCOCORTICOIDS 485 Pneumococcus 514 • Meningococcus 517 • Tetanus 517
Contents xxiii
Active Immunity: Viral Immunizations 518 UNIT 10 Pharmacology of Infectious Diseases

Hepatitis B 518 • Varicella-Zoster 518
PROTOTYPE DRUG: Hepatitis B Vaccine (Recombivax, CHAPTER 43 Basic Principles of Anti-Infective Pharmacotherapy 543
Engerix-B) 519 Pathogenicity and Virulence 544
CONNECTIONS: Cultural Considerations Immunization 519 Describing and Classifying Bacteria 544
Classification of Anti-Infectives 545
CHAPTER 42 Pharmacotherapy of Inflammation, Fever, and Mechanisms of Action of Anti-Infectives 546
Allergies 522 Structure of Bacterial Cell Walls 546 • Inhibition of Cell
The Function of Inflammation 523 Wall Synthesis 546 • Inhibition of Protein Synthesis 547
The Role of Histamine in Inflammation 524 • Disruption of the Plasma Cell Membrane 548
Histamine Receptors 525 • Inhibition of Nucleic Acid Synthesis 548 • Inhibition of
Metabolic Pathways (Antimetabolites) 548 • Other
NONSTEROIDAL ANTI-INFLAMMATORY
Mechanisms of Action 548
DRUGS 525
Acquired Resistance 549
CONNECTIONS: Lifespan Considerations Mechanisms of Resistance 549 • Promotion of Resistance
NSAID Use 525 550 • Prevention of Resistant Strains 550
Treating Inflammation with NSAIDs 526 Selection of Antibiotics 551
Nursing Implications for Practice 526 Indications for and Selection of Specific Anti-Infectives 552
PROTOTYPE DRUG: Ibuprofen (Motrin, Advil) 527 Use of Anti-Infectives to Prevent Infections 552
CONNECTIONS: Natural Therapies Fish Oils for Host Factors That Affect Anti-Infective Selection 552
Inflammation 527 Host Defences 553 • Local Tissue Conditions 553
PROTOTYPE DRUG: Celecoxib (Celebrex) 527 • Allergy History 553 • Other Host Factors 553
SYSTEMIC GLUCOCORTICOIDS 528 Superinfections 553
Treating Acute or Severe Inflammation with Systemic CHAPTER 44 Pharmacotherapy of Bacterial Infections 555
Glucocorticoids 529 ANTIBACTERIAL AGENTS 556
Nursing Implications for Practice 529 PENICILLINS 556
PROTOTYPE DRUG: Prednisone 530 Pharmacotherapy with Penicillins 557
FEVER 530 CONNECTIONS: Cultural Considerations Cultural
Treating Fever with Antipyretics 530 Beliefs and Antibacterials 557
CONNECTIONS: Cultural Considerations Ethnic PROTOTYPE DRUG: Penicillin G Potassium 558
Considerations in Acetaminophen Metabolism 531 BROAD-SPECTRUM PENICILLINS
PROTOTYPE DRUG: Acetaminophen (Tylenol) 531 (AMINOPENICILLINS) 558
ALLERGY 532 EXTENDED-SPECTRUM (ANTIPSEUDOMONAL)
Pharmacotherapy of Allergic Rhinitis 532 PENICILLINS 559
H1-RECEPTOR ANTAGONISTS PENICILLINASE-RESISTANT
(ANTIHISTAMINES) 532 (ANTISTAPHYLOCOCCAL) PENICILLINS 559
Treating Allergic Rhinitis with H1-Receptor CEPHALOSPORINS 560
Antagonists 533 Pharmacotherapy with Cephalosporins 561
PROTOTYPE DRUG: Diphenhydramine (Benadryl) 535 PROTOTYPE DRUG: Cefotaxime (Claforan) 562
PROTOTYPE DRUG: Fexofenadine (Allegra) 536 Carbapenems 562
INTRANASAL GLUCOCORTICOIDS 536 PROTOTYPE DRUG: Imipenem-Cilastatin (Primaxin) 562
Treating Allergic Rhinitis with Intranasal TETRACYCLINES 563
Glucocorticoids 536 Pharmacotherapy with Tetracyclines 564
PROTOTYPE DRUG: Fluticasone (Flonase) 537 PROTOTYPE DRUG: Tetracycline 566
ADRENERGICS 537 MACROLIDES 566
Treating Nasal Congestion with Adrenergics 537 Pharmacotherapy with Macrolides 566
CONNECTIONS: Special Considerations Drugs in the Nursing Implications for Practice 567
Community: Pseudoephedrine and Drug Abuse 538 PROTOTYPE DRUG: Erythromycin (Eryc) 567
Nursing Implications for Practice 538 AMINOGLYCOSIDES 568
ANAPHYLAXIS 538 Pharmacotherapy with Aminoglycosides 568
Pharmacotherapy of Anaphylaxis 539 Nursing Implications for Practice 569
Nursing Implications for Practice 539 PROTOTYPE DRUG: Gentamicin (Garamycin) 569
PROTOTYPE DRUG: Epinephrine (Adrenalin) 539 FLUOROQUINOLONES 570
Antitussives 540 Pharmacotherapy with Fluoroquinolones 570
PROTOTYPE DRUG: Dextromethorphan (Delsym, Robitussin Nursing Implications for Practice 571
DM, Koffex DM, Others) 540 PROTOTYPE DRUG: Ciprofloxacin (Cipro) 571
xxiv Contents
SULFONAMIDES 572 Pharmacotherapy of Herpesvirus Infections 603

Pharmacotherapy with Sulfonamides 573 Nursing Implications for Practice 603
Nursing Implications for Practice 573 PROTOTYPE DRUG: Acyclovir (Zovirax) 604
PROTOTYPE DRUG: Trimethoprim-Sulfamethoxazole INFLUENZA 604
(Bactrim, Septra) 574 Pharmacotherapy of Influenza 605
Miscellaneous Antibacterials 574 HEPATITIS 605
PROTOTYPE DRUG: Vancomycin (Vancocin) 575 Pharmacotherapy of Hepatitis 605
Urinary Antiseptics 576 PROTOTYPE DRUG: Tenofovir (Vemlidy, Viread) 608
CONNECTIONS: Natural Therapies Antibacterial Drugs Similar to Tenofovir (Vemlidy, Viread) 608
Properties of Goldenseal 577
CHAPTER 47 Pharmacotherapy of HIV-AIDS 611
PROTOTYPE DRUG: Nitrofurantoin (Macrobid, HIV-AIDS 612
Macrodantin) 577 Transmission 612 • Replication Cycle 612 • Symptoms 613
TUBERCULOSIS 577 CONNECTIONS: Lifespan Considerations HIV in
Pharmacotherapy of Tuberculosis 578 Pregnant, Pediatric, and Geriatric Populations 613
General Principles of HIV Pharmacotherapy 613
PROTOTYPE DRUG: Isotamine 579 Classification of Drugs for HIV-AIDS 614
Drugs for Leprosy 580 REVERSE TRANSCRIPTASE INHIBITORS 616
PROTOTYPE DRUG: Dapsone 581 Pharmacotherapy with Reverse Transcriptase
CHAPTER 45 Pharmacotherapy of Fungal, Protozoan, and Helminthic Inhibitors 616
Infections 584 PROTOTYPE DRUG: Zidovudine (AZT, Retrovir) 616
Characteristics of Fungi 585 Drugs Similar to Zidovudine (AZT, Retrovir) 617
Classification of Mycoses 585 Non-Nucleoside Reverse Transcriptase Inhibitors 618
Mechanism of Action of Antifungal Drugs 586 PROTOTYPE DRUG: Efavirenz (Sustiva) 618
DRUGS FOR SYSTEMIC ANTIFUNGAL Drugs Similar to Efavirenz (Sustiva) 618
INFECTIONS 586 PROTEASE INHIBITORS 619
Pharmacotherapy of Systemic Fungal Diseases 587 Pharmacotherapy with Protease Inhibitors 619
Nursing Implications for Practice 587 CONNECTIONS: Special Considerations Cultural and
PROTOTYPE DRUG: Amphotericin B (Fungizone) 587 Psychosocial Issues with Antiretroviral Drug
AZOLES 589 Adherence 619
Pharmacotherapy with the Azole Antifungals 589
Nursing Implications for Practice 589 CONNECTIONS: Natural Therapies Complementary and
DRUGS FOR SUPERFICIAL FUNGAL Alternative Medicine for HIV 620
INFECTIONS 589 PROTOTYPE DRUG: Lopinavir with Ritonavir (Kaletra) 621
Drugs Similar to Lopinavir with Ritonavir (Kaletra) 621
PROTOTYPE DRUG: Fluconazole (Diflucan) 590
Entry Inhibitors and Integrase Inhibitors 624
CONNECTIONS: Natural Therapies Remedies for Fungal
PROPHYLAXIS OF HIV INFECTIONS 624
Infections 590
Post-Exposure Prophylaxis of HIV Infection 625
Superficial Fungal Infections 590 • Reducing the Risk for Perinatal Transmission of HIV 625
Pharmacotherapy of Opportunistic Infections
PROTOTYPE DRUG: Nystatin (Nyaderm) 591 Associated with HIV-AIDS 626
PROTOZOAN INFECTIONS 592
Pharmacotherapy of Malaria 593
Pharmacotherapy of Non-Malarial Protozoan Infections 594
in the Cardiovascular Systemes
Nursing Implications for Practice 594 CHAPTER 48 Brief Review of the Cardiovascular System 629
CONNECTIONS: Special Considerations Parasitic Structure and Function of the Cardiovascular System 630
Infections in Children 595 Functions and Properties of Blood 630
PROTOTYPE DRUG: Metronidazole (Flagyl) 595 Hemostasis 631
DRUGS FOR HELMINTHIC INFECTIONS 596 Cardiac Structure and Function 632
Pharmacotherapy of Helminthic Infections 596 The Coronary Arteries 632
CONNECTIONS: Lifespan Considerations Prevention of The Cardiac Conduction System 632
Childhood Helminthic Infections 596 Cardiac Output 634
Nursing Implications for Practice 597 Hemodynamics and Blood Pressure 635
PROTOTYPE DRUG: Mebendazole (Vermox) 597 Neural Regulation of Blood Pressure 636
Hormonal Effects on Blood Pressure 637
CHAPTER 46 Pharmacotherapy of Non-HIV Viral Infections 601
Characteristics of Viruses 602 CHAPTER 49 Pharmacotherapy of Lipid Disorders 640
Pharmacotherapy of Non-HIV Viral Infections 602 Types of Lipid 641
HERPESVIRUSES 603 Lipoproteins 641
Contents xxv
Achieving and Maintaining Desirable Lipid Levels 643 Drugs for Symptoms and Complications of Acute
CONNECTIONS: Lifespan Considerations Pediatric Myocardial Infarction 667
Dyslipidemia 643 Pathogenesis of Cerebrovascular Accident 668
Controlling Lipid Levels Through Lifestyle Changes 644 Pharmacotherapy of Thrombotic CVA 668
HMG-CoA REDUCTASE INHIBITORS CONNECTIONS: Special Considerations Cultural,
(STATINS) 644 Gender, and Age Considerations in Stroke 668
Pharmacotherapy with Statins 646 CONNECTIONS: Natural Therapies Ginseng 668
CHAPTER 51 Pharmacotherapy of Hypertension 671
PROTOTYPE DRUG: Atorvastatin (Lipitor) 648
Risk Factors for Hypertension 672
BILE ACID RESINS 648
Factors Responsible for Blood Pressure 672
Bile Acid Resins for Reducing Cholesterol and LDL
Normal Regulation of Blood Pressure 673
Levels 648
Nursing Implications for Practice 649 Indications and Guidelines for Hypertension
Therapy 674
PROTOTYPE DRUG: Cholestyramine (Olestyr,
Adding Drugs to the Antihypertensive Regimen 676
Questran) 649
Non-Pharmacological Therapy of Hypertension 676
NICOTINIC ACID 649
CONNECTIONS: Special Considerations Lifestyle
Pharmacotherapy with Nicotinic Acid 649
Recommendations for the Management of
Hypertension 676
CONNECTIONS: Natural Therapies Coenzyme Q10 and
Risk Factors and Selection of Antihypertensive
Cardiovascular Disease 650
Drugs 677
FIBRIC ACID AGENTS 650
CONNECTIONS: Special Considerations Strategies to
Pharmacotherapy with Fibric Acid Agents 651
Promote Adherence with HTN Pharmacotherapy 677
DIURETICS 678
PROTOTYPE DRUG: Gemfibrozil (Lopid) 651
Treating Hypertension with Diuretics 679
MISCELLANEOUS AGENTS 651 Nursing Implications for Practice 679
Ezetimibe (Ezetrol) 651 • Omega-3 Fatty Acids 651
PROTOTYPE DRUG: Hydrochlorothiazide (HCTZ,
Miscellaneous Drugs for Dyslipidemias 651
Urozide) 681
CHAPTER 50 Pharmacotherapy of Angina Pectoris, Myocardial CALCIUM CHANNEL BLOCKERS 682
Infarction, and Cerebrovascular Accident 654 Treating Hypertension with Calcium Channel
Etiology of Coronary Artery Disease and Myocardial Blockers 682
Ischemia 655 Nursing Implications for Practice 682
Blood Supply to the Myocardium 656 PROTOTYPE DRUG: Nifedipine (Adalat) 684
Pathogenesis of Angina Pectoris 656 DRUGS AFFECTING THE RENIN-
Non-Pharmacological Management of Angina 656 ANGIOTENSIN-ALDOSTERONE SYSTEM 684
CONNECTIONS: Special Considerations The Influence Pharmacotherapy with ACE Inhibitors and
of Gender and Ethnicity on Angina 657 Angiotensin II Receptor Blockers 684
Goals for the Pharmacotherapy of Angina 657 Nursing Implications for Practice 686
Treating Angina with Organic Nitrates 657 PROTOTYPE DRUG: Enalapril (Vasotec) 686
CONNECTIONS: Special Considerations Nitroglycerin CONNECTIONS: Special Considerations Ethnicity and
Sublingual Tablets and Spray in Chest Pain 659 ACE Inhibitor Action 686
ADRENERGIC AGENTS 688
PROTOTYPE DRUG: Nitroglycerin (Nitro-Dur, Minitran, Pharmacotherapy with Adrenergic Agents 689
Nitrostat, Trinipatch) 661 Nursing Implications for Practice 689
Treating Angina with Beta Blockers 661
PROTOTYPE DRUG: Doxazosin (Cardura) 690
DIRECT VASODILATORS 691
PROTOTYPE DRUG: Atenolol (Tenormin) 662 Treating Hypertension with Direct Vasodilators 691
PROTOTYPE DRUG: Metoprolol (Lopressor) 663 Nursing Implications for Practice 691
Treating Angina with Calcium Channel Blockers 663 CONNECTIONS: Natural Therapies Hawthorn for
Nursing Implications for Practice 664 Hypertension 691
PROTOTYPE DRUG: Diltiazem (Cardizem, Tiazac) 664 PROTOTYPE DRUG: Hydralazine (Apresoline) 693
Diagnosis of Myocardial Infarction 664 Management of Hypertensive Emergency 693
Treating Myocardial Infarction with Thrombolytics 666 PROTOTYPE DRUG: Nitroprusside (Nipride) 694
PROTOTYPE DRUG: Reteplase (Retavase) 666 CHAPTER 52 Diuretic Therapy and Pharmacotherapy of Renal
Treating Myocardial Infarction with Antiplatelets and Failure 697
Anticoagulants 667 Brief Review of Renal Physiology 698
Treating Myocardial Infarction with Beta Blockers 667 Changes in Renal Filtrate Composition as a Result of
Nursing Implications for Practice 667 Reabsorption and Secretion 699
xxvi Contents
RENAL FAILURE 699 Pharmacotherapy of Alkalosis 727

Pharmacotherapy of Renal Failure 699 Nursing Implications for Practice 727
CONNECTIONS: Natural Therapies Cranberry for CONNECTIONS: Natural Therapies Sea Vegetables for
Urinary Tract Infections 700 Acidosis 727
DIURETICS 700 PROTOTYPE DRUG: Ammonium Chloride 728
Mechanism of Action of Diuretics 700
CHAPTER 54 Pharmacotherapy of Heart Failure 730
Pharmacotherapy with Loop (High-Ceiling)
The Etiology of Heart Failure 731
Diuretics 702
Cardiovascular Changes in Heart Failure 731
Natriuretic Peptides and Neurohumoral Factors 732
CONNECTIONS: Lifespan Considerations Diuretic PHARMACOTHERAPY OF HEART FAILURE 733
Therapy in Older Adult Clients 703
ACE INHIBITORS AND ANGIOTENSIN
PROTOTYPE DRUG: Furosemide (Lasix) 703 RECEPTOR BLOCKERS 734
Pharmacotherapy with Thiazide and Thiazide-Like Pharmacotherapy with ACE Inhibitors and ARBs 736
Diuretics 704 Nursing Implications for Practice 736
CONNECTIONS: Special Considerations Points to
PROTOTYPE DRUG: Chlorothiazide (Diuril) 705 Consider in Educating Clients with HF 736
Pharmacotherapy with Potassium-Sparing Diuretics 706 PROTOTYPE DRUG: Lisinopril (Prinivil, Zestril) 737
Sodium Ion Channel Inhibitors 706 • Aldosterone
BETA-ADRENERGIC BLOCKERS
Antagonists 706 • Nursing Implications for Practice 706
(ANTAGONISTS) 737
PROTOTYPE DRUG: Spironolactone (Aldactone) 707
Pharmacotherapy with Beta-Adrenergic Blockers 737
Miscellaneous Diuretics for Specific Indications 707 Nursing Implications for Practice 737
Carbonic Anhydrase Inhibitors 707
PROTOTYPE DRUG: Carvedilol (Coreg) 738
PROTOTYPE DRUG: Acetazolamide (Diamox) 708
VASODILATORS 738
Osmotic Diuretics 708
Pharmacotherapy with Direct Vasodilators 738
PROTOTYPE DRUG: Mannitol (Osmitrol) 709
PROTOTYPE DRUG: Isosorbide Dinitrate (Isordil, ISDN) 738
CARDIAC GLYCOSIDES 738
CHAPTER 53 Pharmacotherapy of Fluid and Electrolyte Imbalances
Pharmacotherapy with Cardiac Glycosides 739
and Acid-Base Disorders 713
FLUID BALANCE 714 CONNECTIONS: Natural Therapies Hawthorn for Heart
Failure 739
Body Fluid Compartments 714
Osmolality, Tonicity, and the Movement of Body Fluids 714
PROTOTYPE DRUG: Digoxin (Lanoxin, Toloxin) 740
Regulation of Fluid Intake and Output 715
DIURETICS 741
FLUID REPLACEMENT AGENTS 715
Pharmacotherapy with Diuretics 741
Intravenous Therapy with Crystalloids and Colloids 715
Transfusions of Blood Products 716
Nursing Implications for Practice 718 PROTOTYPE DRUG: Furosemide (Lasix) 742
PHOSPHODIESTERASE INHIBITORS 742
PROTOTYPE DRUG: Normal Serum Albumin (Albuminar,
Plasbumin) 718 Pharmacotherapy with Phosphodiesterase
Inhibitors 742
PROTOTYPE DRUG: Dextran 40 718
ELECTROLYTES 720
CONNECTIONS: Special Considerations Psychosocial
Normal Functions of Electrolytes 720
Issues and Adherence in Clients with HF 742
Pharmacotherapy of Sodium Imbalances 720
Nursing Implications for Practice 721 PROTOTYPE DRUG: Milrinone 743
PROTOTYPE DRUG: Sodium Chloride 722 CHAPTER 55 Pharmacotherapy of Dysrhythmias 745

Pharmacotherapy of Potassium Imbalances 722 Frequency of Dysrhythmias in the Population 746
Nursing Implications for Practice 723 Classification of Dysrhythmias 746
PROTOTYPE DRUG: Potassium Chloride (K-Dur, Slow-K, CONNECTIONS: Lifespan Considerations Dysrhythmias 746
Micro-K) 723 Conduction Pathways in the Myocardium 747
Magnesium Imbalances 724 The Electrocardiograph 748
Hypomagnesemia 724 • Hypermagnesemia 724 Sodium, Potassium, and the Myocardial Action Potential 749
PROTOTYPE DRUG: Magnesium Sulfate 724 Non-Pharmacological Therapy of Dysrhythmias 750
CONNECTIONS: Special Considerations Laxatives and Classification of Dysrhythmias and Antidysrhythmic
Fluid-Electrolyte Balance 725 Drugs 750
ACID-BASE BALANCE 725 SODIUM CHANNEL BLOCKERS (CLASS I) 752
Buffers and the Maintenance of Body pH 725 Treating Dysrhythmias with Sodium Channel Blockers 753
Pharmacotherapy of Acidosis 725 Nursing Implications for Practice 753
Nursing Implications for Practice 726 PROTOTYPE DRUG: Procainamide (Procan) 753
PROTOTYPE DRUG: Sodium Bicarbonate 726 BETA-ADRENERGIC BLOCKERS (CLASS II) 753
Contents xxvii
Treating Dysrhythmias with Beta-Adrenergic Blockers 754 Pharmacotherapy with Erythropoietin 784
PROTOTYPE DRUG: Propranolol (Inderal) 754 PROTOTYPE DRUG: Epoetin Alfa (Epogen, Eprex) 786
POTASSIUM CHANNEL BLOCKERS (CLASS III) 754 Pharmacotherapy with Colony-Stimulating Factors 786
CONNECTIONS: Cultural Considerations Asian Clients’ Nursing Implications for Practice 786
Sensitivity to Propranolol 755 PROTOTYPE DRUG: Filgrastim (Neupogen, Grastofil) 787
Treating Dysrhythmias with Potassium Channel Pharmacotherapy with Platelet Enhancers 787
Blockers 755 Nursing Implications for Practice 787
Nursing Implications for Practice 755 ANEMIAS 787
PROTOTYPE DRUG: Amiodarone (Cordarone) 755 Classification of Anemias 788
CALCIUM CHANNEL BLOCKERS (CLASS IV) 755 ANTIANEMIC AGENTS 788
Treating Dysrhythmias with Calcium Channel Blockers 756 Pharmacotherapy with Vitamin B12 and Folic
Nursing Implications for Practice 756 Acid 788
PROTOTYPE DRUG: Verapamil (Isoptin) 756 Nursing Implications for Practice 789
TREATING DYSRHYTHMIAS WITH DIGOXIN PROTOTYPE DRUG: Cyanocobalamin: Vitamin B12 790
AND MISCELLANEOUS DRUGS 756 IRON 790
CONNECTIONS: Natural Therapies Magnesium for Pharmacotherapy with Iron 790
Dysrhythmias 757 CONNECTIONS: Lifespan Considerations Iron
Deficiency in Children 791
CHAPTER 56 Pharmacotherapy of Coagulation Disorders 760 Nursing Implications for Practice 792
The Process of Hemostasis 761 PROTOTYPE DRUG: Ferrous Sulfate (Fer-In-Sol) 792
Removal of Blood Clots 761
Diseases of Hemostasis 762 CHAPTER 58 Pharmacotherapy of Shock 795
CONNECTIONS: Special Considerations Secondary Characteristics of Shock 796
Causes of Thrombocytopenia 763 Causes of Shock 796
Mechanisms of Coagulation Modification 764 FLUID REPLACEMENT AGENTS 798
ANTICOAGULANTS 764 Treatment Priorities for Shock 798
Pharmacotherapy with Parenteral and Oral Treating Shock with Crystalloids and Colloids 798
Anticoagulants 764 Nursing Implications for Practice 799
Nursing Implications for Practice 766 PROTOTYPE DRUG: Normal Human Serum Albumin
PROTOTYPE DRUG: Heparin 769 (Albuminar, Alburex, Plasbumin) 800
VASOCONSTRICTORS 800
PROTOTYPE DRUG: Warfarin (Coumadin) 769
Drugs Similar to Warfarin (Coumadin) 770 Treating Shock with Vasoconstrictors 800
The Direct Thrombin and Factor Xa Inhibitors 770
PROTOTYPE DRUG: Norepinephrine (Levophed) 801
PROTOTYPE DRUG: Dabigatran (Pradaxa) 770
Drugs Similar to Dabigatran (Pradaxa) 771 CARDIOTONIC AGENTS 801
ANTIPLATELET AGENTS 771 Treating Shock with Cardiotonic Agents 802
Inhibition of Platelet Function 772
Adenosine Diphosphate Receptor Blockers 773 PROTOTYPE DRUG: Dopamine 802
PROTOTYPE DRUG: Clopidogrel (Plavix) 773
Drugs Similar to Clopidogrel (Plavix) 774 UNIT 12 Pharmacology of Neoplastic Disorders
Glycoprotein IIb/IIIa Receptor Inhibitors 774 CHAPTER 59 Basic Principles of Antineoplastic Therapy 805
Glycoprotein IIb/IIIa Inhibitors 775 Characteristics of Cancer 806
THROMBOLYTICS 775 Etiology of Cancer 807
CONNECTIONS: Natural Therapies Garlic for Goals of Chemotherapy 808
Cardiovascular Health 776 Staging and Grading of Cancer 808
Pharmacotherapy with Thrombolytics 776 The Cell Cycle and Growth Fraction 809
Cell Kill Hypothesis 810
PROTOTYPE DRUG: Alteplase (Activase) 777 Improving the Success of Chemotherapy 811
Drugs Similar to Alteplase (Activase) 777 Combination Chemotherapy 811 • Dosing Schedules 812
ANTIFIBRINOLYTICS 779 • Route of Administration 812
Pharmacotherapy with Antifibrinolytics 779 Toxicity of Antineoplastic Agents 813
Nursing Implications for Practice 779 Hematological System 813 • Gastrointestinal Tract 814
PROTOTYPE DRUG: Aminocaproic Acid (Amicar) 779 • Cardiopulmonary System 814 • Urinary System 814
• Reproductive System 814 • Nervous System 815 • Skin
CHAPTER 57 Pharmacotherapy of Hematopoietic Disorders 782 and Soft Tissue 815 • Other Effects 815
Hematopoiesis 783 CONNECTIONS: Special Considerations General
HEMATOPOIETIC GROWTH FACTORS 783 Guidelines for Extravasation 815
xxviii Contents
CHAPTER 60 Pharmacotherapy of Neoplasia 818 Pharmacotherapy of Paget’s Disease 847

Treatment of Cancer: Surgery, Radiation Therapy, and JOINT DISORDERS 847
Chemotherapy 819 CONNECTIONS: Natural Therapies Glucosamine and
Antineoplastic Agents 819 Chondroitin for Osteoarthritis 848
ALKYLATING AGENTS 820 Pharmacotherapy of Arthritis 848
Pharmacotherapy with Alkylating Agents 820 Other DMARDS for Rheumatoid Arthritis 849
Nursing Implications for Practice 820 PROTOTYPE DRUG: Hydroxychloroquine (Plaquenil) 852
PROTOTYPE DRUG: Cyclophosphamide (Procytox) 821 Pharmacotherapy of Gout 852
ANTIMETABOLITES 822 Nursing Implications for Practice 853
Pharmacotherapy with Antimetabolites 822 PROTOTYPE DRUG: Colchicine 854
CHAPTER 62 Pharmacotherapy of Dermatological Disorders 857
PROTOTYPE DRUG: Methotrexate 823
Structure and Function of the Skin 858
ANTITUMOUR ANTIBIOTICS 824
Causes of Skin Disorders 858
Pharmacotherapy with Antitumour Antibiotics 824
Nursing Implications for Practice 824 SKIN INFECTIONS 861
Pharmacotherapy of Bacterial, Fungal, and Viral Skin
PROTOTYPE DRUG: Doxorubicin (Adriamycin) 825
Infections 861
PLANT-DERIVED ANTINEOPLASTIC
SKIN PARASITES 861
AGENTS 825
Pharmacotherapy with Scabicides and
Pharmacotherapy with Plant-Derived Antineoplastic
Pediculicides 862
Agents 826
Nursing Implications for Practice 826 CONNECTIONS: Special Considerations Psychosocial
and Community Impact of Scabies and
PROTOTYPE DRUG: Vincristine 827
Pediculosis 862
ANTITUMOUR HORMONES AND HORMONE Nursing Implications for Practice 863
ANTAGONISTS 827
PROTOTYPE DRUG: 1%–5% Permethrin
Pharmacotherapy with Antitumour Hormones and
(Nix, Kwellada-P) 864
Hormone Antagonists 827
SUNBURN AND MINOR BURNS 864
Selective Estrogen Receptor Modifiers 828 • Aromatase
Pharmacotherapy of Sunburn and Minor Skin
Inhibitors 829 • Gonadotropin-Releasing Hormone
Analogues 829 • Androgen Receptor Blockers 829 Irritation 865
• Nursing Implications for Practice 829 Nursing Implications for Practice 865
PROTOTYPE DRUG: Tamoxifen (Nolvadex) 830 PROTOTYPE DRUG: Lidocaine (Xylocaine, Lidoderm,
BIOLOGICAL RESPONSE MODIFIERS AND Betacaine) 865
MISCELLANEOUS ANTINEOPLASTICS 830 ACNE AND ROSACEA 865
Drugs for Reducing Adverse Effects 832 Pharmacotherapy of Acne and Acne-Related
Preparing and Administering Antineoplastics 833 Disorders 866
CONNECTIONS: Lifespan Considerations Chemotherapy
in Older Adults 833 CONNECTIONS: Natural Therapies Burdock Root for
Acne and Eczema 867
PROTOTYPE DRUG: Isotretinoin (Accutane) 869
UNIT 13 Additional Drug Classes
DERMATITIS 869
CHAPTER 61 Pharmacotherapy of Bone and Joint Disorders 837 Pharmacotherapy of Dermatitis 869
Normal Calcium Physiology and Vitamin D 838 PSORIASIS 870
CALCIUM-RELATED DISORDERS 839 Pharmacotherapy of Psoriasis 870
Pharmacotherapy of Hypocalcemia 839
Nursing Implications for Practice 840 CHAPTER 63 Pharmacotherapy of Eye and Ear Disorders 874
PROTOTYPE DRUG: Calcium Gluconate 840 Anatomy of the Eye 875
Pharmacotherapy of Osteomalacia 841 GLAUCOMA 875
Nursing Implications for Practice 842 Types of Glaucoma 876
PROTOTYPE DRUG: Calcitriol (Calcijex, Rocaltrol) 843 General Treatment of Glaucoma 876
Pharmacotherapy of Osteoporosis 843 Pharmacotherapy of Glaucoma 877
Hormone Replacement Therapy 844 • Calcitonin 844 Cholinergic Agonists 878 • Non-Selective Adrenergics 878
• Selective Estrogen Receptor Modulators 844 • Nursing • Prostaglandins 878 • Beta-Adrenergic Blockers 878
Implications for Practice 844 • Alpha2-Adrenergic Agonists 878 • Carbonic Anhydrase
Inhibitors 878 • Osmotic Diuretics 878 • Nursing
CONNECTIONS: Special Considerations The Impact of
Implications for Practice 878
Ethnicity and Lifestyle on Osteoporosis 845
PROTOTYPE DRUG: Latanoprost (Xalatan) 879
PROTOTYPE DRUG: Raloxifene (Evista) 845
Bisphosphonates 845 • Nursing Implications for CONNECTIONS: Lifespan Considerations Ophthalmic
Practice 845 Drugs in the Home Setting 879
PROTOTYPE DRUG: Fosamax 845 PROTOTYPE DRUG: Timolol (Timoptic) 881
Contents xxix
Pharmacotherapy for Eye Exams and Minor Eye The Nature of Bioterrorism 890
Conditions 881 Role of the Nurse in Emergency Preparedness 890
EAR CONDITIONS 882 National Emergency Stockpile System 891
CONNECTIONS: Natural Therapies Bilberry for Eye AGENTS USED IN BIOTERRORISM 891
Health 882 Biological Agents 892
Pharmacotherapy with Otic Preparations 883 Viruses 893
Nursing Implications for Practice 883 Toxic Chemical and Physical Agents 894
Ionizing Radiation 894
CHAPTER 64 Toxicology, Bioterrorism, and Emergency
Preparedness 886 Appendices
PREVENTING AND CONTROLLING A Answers to Chapter Review 898
TOXICITY 887 B Suggested Answers to Critical Thinking Questions
Toxicology 887 in Chapter Scenarios 916
Management of Poisoning 888
Glossary 928
Effectiveness of Activated Charcoal in
Poisoning 889 Selected Bibliography and References 946
PROTOTYPE DRUG: Activated Charcoal 889
EMERGENCY PREPAREDNESS 889 Index 975
CHAPTER
1 Introduction to Pharmacology and

Drug Regulations in Canada
LEARNING OUTCOMES CHAPTER OUTLINE

After reading this chapter, the student should be able to:
▶▶ Pharmacology: The Study
1. Define pharmacology. of Medicines
2. Discuss the interdisciplinary nature of pharmacology.
3. Compare and contrast therapeutics and pharmacology. ▶▶ Pharmacology and
4. Compare and contrast conventional drugs, biologics, and natural Therapeutics
health products.
▶▶ Classification
of Therapeutic
5. Identify the advantages and disadvantages of prescription and
over-the-counter (OTC) drugs. Agents as Drugs, Biologics,
6. Identify key Canadian drug regulations that help to ensure the or Natural Health Products
safety and efficacy of medications.
▶▶ Prescription
and Over-the-
7. Discuss the role of Health Canada and the Health Products and
Food Branch (HPFB) of Health Canada and its Therapeutic Counter Drugs
Products Directorate in the drug approval process.
▶▶ Drug
Regulations and
8. Describe the stages of approval for therapeutic and biologic
drugs in Canada. Standards
▶▶ Federal Drug Legislation
▶▶ ApprovalProcess for
Prescription Drugs
▶▶ Pricing
and Access to
Prescription Drugs Across
Canada
KEY TERMS
biologics, 2 medication, 2
clinical trials, 4 natural health products (NHPs), 2
Compendium of Pharmaceuticals and New Drug Submission (NDS), 4
Specialties (CPS), 5 Notice of Compliance (NOC), 4
complementary and alternative patent protection, 4
therapies, 2
pharmacology, 2
drug, 2
pharmacotherapy
Drug Identification Number (DIN), 4 (pharmacotherapeutics), 2
Drug Product Database, 5 preclinical investigation, 4
formulary, 5 Special Access Program (SAP), 6
Health Canada, 3 therapeutics, 2
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memory of Burns,—every man’s, every boy’s and girl’s head carries
snatches of his songs, and they say them by heart, and, what is
strangest of all, never learned them from a book, but from mouth to
mouth. The wind whispers them, the birds whistle them, the corn,
barley, and bulrushes hoarsely rustle them, nay, the music-boxes at
Geneva are framed and toothed to play them; the hand-organs of the
Savoyards in all cities repeat them, and the chimes of bells ring them
in the spires. They are the property and the solace of mankind.[213]
XXIII
REMARKS
AT THE CELEBRATION OF THE THREE

HUNDREDTH ANNIVERSARY OF THE BIRTH OF
SHAKSPEARE BY THE SATURDAY CLUB AT THE
REVERE HOUSE, BOSTON, 1864
England’s genius filled all measure

Of heart and soul, of strength and pleasure,
Gave to mind its emperor
And life was larger than before;
And centuries brood, nor can attain
The sense and bound of Shakspeare’s brain.
The men who lived with him became
Poets, for the air was fame.
SHAKSPEARE
’Tis not our fault if we have not made this evening’s circle still
richer than it is. We seriously endeavored, besides our brothers and
our seniors, on whom the ordinary lead of literary and social action
falls—and falls because of their ability—to draw out of their
retirements a few rarer lovers of the muse—“seld-seen flamens”—
whom this day seemed to elect and challenge. And it is to us a
painful disappointment that Bryant and Whittier as guests, and our
own Hawthorne,—with the best will to come,—should have found it
impossible at last; and again, that a well-known and honored
compatriot, who first in Boston wrote elegant verse, and on
Shakspeare, and whose American devotion through forty or fifty
years to the affairs of a bank, has not been able to bury the fires of
his genius,—Mr. Charles Sprague,—pleads the infirmities of age as
an absolute bar to his presence with us.
We regret also the absence of our members Sumner and Motley.
We can hardly think of an occasion where so little need be said.
We are all content to let Shakspeare speak for himself. His fame is
settled on the foundations of the moral and intellectual world.
Wherever there are men, and in the degree in which they are civil—
have power of mind, sensibility to beauty, music, the secrets of
passion, and the liquid expression of thought, he has risen to his
place as the first poet of the world.
Genius is the consoler of our mortal condition, and Shakspeare
taught us that the little world of the heart is vaster, deeper and richer
than the spaces of astronomy. What shocks of surprise and
sympathetic power, this battery, which he is, imparts to every fine
mind that is born! We say to the young child in the cradle, ‘Happy,
and defended against Fate! for here is Nature, and here is
Shakspeare, waiting for you!’
’Tis our metre of culture. He is a cultivated man—who can tell us
something new of Shakspeare. All criticism is only a making of rules
out of his beauties. He is as superior to his countrymen, as to all
other countrymen. He fulfilled the famous prophecy of Socrates, that
the poet most excellent in tragedy would be most excellent in
comedy, and more than fulfilled it by making tragedy also a victorious
melody which healed its own wounds. In short, Shakspeare is the
one resource of our life on which no gloom gathers; the fountain of
joy which honors him who tastes it; day without night; pleasure
without repentance; the genius which, in unpoetic ages, keeps
poetry in honor and, in sterile periods, keeps up the credit of the
human mind.
His genius has reacted on himself. Men were so astonished and
occupied by his poems that they have not been able to see his face
and condition, or say, who was his father and his brethren; or what
life he led; and at the short distance of three hundred years he is
mythical, like Orpheus and Homer, and we have already seen the
most fantastic theories plausibly urged, as that Raleigh and Bacon
were the authors of the plays.
Yet we pause expectant before the genius of Shakspeare—as if
his biography were not yet written; until the problem of the whole
English race is solved.
I see, among the lovers of this catholic genius, here present, a
few, whose deeper knowledge invites me to hazard an article of my
literary creed; that Shakspeare, by his transcendant reach of
thought, so unites the extremes, that, whilst he has kept the theatre
now for three centuries, and, like a street-bible, furnishes sayings to
the market, courts of law, the senate, and common discourse,—he is
yet to all wise men the companion of the closet. The student finds
the solitariest place not solitary enough to read him; and so
searching is his penetration, and such the charm of his speech, that
he still agitates the heart in age as in youth, and will, until it ceases
to beat.
Young men of a contemplative turn carry his sonnets in the pocket.
With that book, the shade of any tree, a room in any inn, becomes a
chapel or oratory in which to sit out their happiest hours. Later they
find riper and manlier lessons in the plays.
And secondly, he is the most robust and potent thinker that ever
was. I find that it was not history, courts and affairs that gave him
lessons, but he that gave grandeur and prestige to them. There
never was a writer who, seeming to draw every hint from outward
history, the life of cities and courts, owed them so little. You shall
never find in this world the barons or kings he depicted. ’Tis fine for
Englishmen to say, they only know history by Shakspeare. The
palaces they compass earth and sea to enter, the magnificence and
personages of royal and imperial abodes, are shabby imitations and
caricatures of his,—clumsy pupils of his instruction. There are no
Warwicks, no Talbots, no Bolingbrokes, no Cardinals, no Harry Fifth,
in real Europe, like his. The loyalty and royalty he drew were all his
own. The real Elizabeths, Jameses and Louises were painted sticks
before this magician.
The unaffected joy of the comedy,—he lives in a gale,—contrasted
with the grandeur of the tragedy, where he stoops to no contrivance,
no pulpiting, but flies an eagle at the heart of the problem; where his
speech is a Delphi,—the great Nemesis that he is and utters. What a
great heart of equity is he! How good and sound and inviolable his
innocency, that is never to seek, and never wrong, but speaks the
pure sense of humanity on each occasion. He dwarfs all writers
without a solitary exception. No egotism. The egotism of men is
immense. It concealed Shakspeare for a century. His mind has a
superiority such that the universities should read lectures on him,
and conquer the unconquerable if they can.
There are periods fruitful of great men; others, barren; or, as the
world is always equal to itself, periods when the heat is latent,—
others when it is given out.
They are like the great wine years,—the vintage of 1847, is it? or
1835?—which are not only noted in the carte of the table d’hôte, but
which, it is said, are always followed by new vivacity in the politics of
Europe. His birth marked a great wine year when wonderful grapes
ripened in the vintage of God, when Shakspeare and Galileo were
born within a few months of each other, and Cervantes was his exact
contemporary, and, in short space before and after, Montaigne,
Bacon, Spenser, Raleigh and Jonson. Yet Shakspeare, not by any
inferiority of theirs, but simply by his colossal proportions, dwarfs the
geniuses of Elizabeth as easily as the wits of Anne, or the poor
slipshod troubadours of King René.
In our ordinary experience of men there are some men so born to
live well that, in whatever company they fall,—high or low,—they fit
well, and lead it! but, being advanced to a higher class, they are just
as much in their element as before, and easily command: and being
again preferred to selecter companions, find no obstacle to ruling
these as they did their earlier mates; I suppose because they have
more humanity than talent, whilst they have quite as much of the last
as any of the company. It would strike you as comic, if I should give
my own customary examples of this elasticity, though striking
enough to me. I could name in this very company—or not going far
out of it—very good types, but in order to be parliamentary, Franklin,
Burns and Walter Scott are examples of the rule; and king of men, by
this grace of God also, is Shakspeare.
The Pilgrims came to Plymouth in 1620. The plays of Shakspeare
were not published until three years later. Had they been published
earlier, our forefathers, or the most poetical among them, might have
stayed at home to read them.
XXIV
HUMBOLDT
AN ABSTRACT OF MR. EMERSON’S REMARKS

MADE AT THE CELEBRATION OF THE
CENTENNIAL ANNIVERSARY OF THE BIRTH OF
ALEXANDER VON HUMBOLDT, SEPTEMBER 14,
1869
“If a life prolonged to an advanced period bring with it

several inconveniences to the individual, there is a
compensation in the delight of being able to compare older
states of knowledge with that which now exists, and to see
great advances in knowledge develop themselves under our
eyes in departments which had long slept in inactivity.”
Humboldt, Letter to Ritter.
HUMBOLDT
Humboldt was one of those wonders of the world, like Aristotle,
like Julius Cæsar, like the Admirable Crichton, who appear from time
to time, as if to show us the possibilities of the human mind, the force
and the range of the faculties,—a universal man, not only possessed
of great particular talents, but they were symmetrical, his parts were
well put together. As we know, a man’s natural powers are often a
sort of committee that slowly, one at a time, give their attention and
action; but Humboldt’s were all united, one electric chain, so that a
university, a whole French Academy, travelled in his shoes. With
great propriety, he named his sketch of the results of science
Cosmos. There is no other such survey or surveyor. The wonderful
Humboldt, with his solid centre and expanded wings, marches like
an army, gathering all things as he goes. How he reaches from
science to science, from law to law, folding away moons and
asteroids and solar systems in the clauses and parentheses of his
encyclopædic paragraphs! There is no book like it; none indicating
such a battalion of powers. You could not put him on any sea or
shore but his instant recollection of every other sea or shore
illuminated this.
He was properly a man of the world; you could not lose him; you
could not detain him; you could not disappoint him, for at any point
on land or sea he found the objects of his researches. When he was
stopped in Spain and could not get away, he turned round and
interpreted their mountain system, explaining the past history of the
continent of Europe. He belonged to that wonderful German nation,
the foremost scholars in all history, who surpass all others in
industry, space and endurance. A German reads a literature whilst
we are reading a book. One of their writers warns his countrymen
that it is not the Battle of Leipsic, but the Leipsic Fair Catalogue,
which raises them above the French. I remember Cuvier tells us of
fossil elephants; that Germany has furnished the greatest number;—
not because there are more elephants in Germany,—oh no; but
because in that empire there is no canton without some well-
informed person capable of making researches and publishing
interesting results. I know that we have been accustomed to think
they were too good scholars, that because they reflect, they never
resolve, that “in a crisis no plan-maker was to be found in the
empire;” but we have lived to see now, for the second time in the
history of Prussia, a statesman of the first class, with a clear head
and an inflexible will.
XXV
WALTER SCOTT
REMARKS AT THE CELEBRATION BY THE

MASSACHUSETTS HISTORICAL SOCIETY OF
THE CENTENNIAL ANNIVERSARY OF HIS BIRTH,
AUGUST 15, 1871
Scott, the delight of generous boys.
As far as Sir Walter Scott aspired to be known for a fine

gentleman, so far our sympathies leave him.... Our concern is
only with the residue, where the man Scott was warmed with
a divine ray that clad with beauty every sheet of water, every
bald hill in the country he looked upon, and so reanimated the
well-nigh obsolete feudal history and illustrated every hidden
corner of a barren and disagreeable territory.
Lecture, “Being and Seeing,” 1838.
WALTER SCOTT
The memory of Sir Walter Scott is dear to this Society, of which he
was for ten years an honorary member. If only as an eminent
antiquary who has shed light on the history of Europe and of the
English race, he had high claims to our regard. But to the rare tribute
of a centennial anniversary of his birthday, which we gladly join with
Scotland, and indeed with Europe, to keep, he is not less entitled—
perhaps he alone among literary men of this century is entitled—by
the exceptional debt which all English-speaking men have gladly
owed to his character and genius. I think no modern writer has
inspired his readers with such affection to his own personality. I can
well remember as far back as when The Lord of the Isles was first
republished in Boston, in 1815,—my own and my school-fellows’ joy
in the book.[214] Marmion and The Lay had gone before, but we
were then learning to spell. In the face of the later novels, we still
claim that his poetry is the delight of boys. But this means that when
we reopen these old books we all consent to be boys again. We
tread over our youthful grounds with joy. Critics have found them to
be only rhymed prose. But I believe that many of those who read
them in youth, when, later, they come to dismiss finally their school-
days’ library, will make some fond exception for Scott as for Byron.
It is easy to see the origin of his poems. His own ear had been
charmed by old ballads crooned by Scottish dames at firesides, and
written down from their lips by antiquaries; and finding them now
outgrown and dishonored by the new culture, he attempted to dignify
and adapt them to the times in which he lived. Just so much thought,
so much picturesque detail in dialogue or description as the old
ballad required, so much suppression of details and leaping to the
event, he would keep and use, but without any ambition to write a
high poem after a classic model. He made no pretension to the lofty
style of Spenser, or Milton, or Wordsworth. Compared with their
purified songs, purified of all ephemeral color or material, his were
vers de société. But he had the skill proper to vers de société,—skill
to fit his verse to his topic, and not to write solemn pentameters alike
on a hero or a spaniel. His good sense probably elected the ballad to
make his audience larger. He apprehended in advance the immense
enlargement of the reading public, which almost dates from the era
of his books,—which his books and Byron’s inaugurated; and which,
though until then unheard of, has become familiar to the present
time.
If the success of his poems, however large, was partial, that of his
novels was complete. The tone of strength in Waverley at once
announced the master, and was more than justified by the superior
genius of the following romances, up to the Bride of Lammermoor,
which almost goes back to Æschylus for a counterpart as a painting
of Fate,—leaving on every reader the impression of the highest and
purest tragedy.[215]
His power on the public mind rests on the singular union of two
influences. By nature, by his reading and taste an aristocrat, in a
time and country which easily gave him that bias, he had the virtues
and graces of that class, and by his eminent humanity and his love
of labor escaped its harm. He saw in the English Church the symbol
and seal of all social order; in the historical aristocracy the benefits to
the state which Burke claimed for it; and in his own reading and
research such store of legend and renown as won his imagination to
their cause. Not less his eminent humanity delighted in the sense
and virtue and wit of the common people. In his own household and
neighbors he found characters and pets of humble class, with whom
he established the best relation,—small farmers and tradesmen,
shepherds, fishermen, gypsies, peasant-girls, crones,—and came
with these into real ties of mutual help and good will. From these
originals he drew so genially his Jeanie Deans, his Dinmonts and
Edie Ochiltrees, Caleb Balderstones and Fairservices, Cuddie
Headriggs, Dominies, Meg Merrilies, and Jenny Rintherouts, full of
life and reality; making these, too, the pivots on which the plots of his
stories turn; and meantime without one word of brag of this
discernment,—nay, this extreme sympathy reaching down to every
beggar and beggar’s dog, and horse and cow. In the number and
variety of his characters he approaches Shakspeare. Other painters
in verse or prose have thrown into literature a few type-figures; as
Cervantes, De Foe, Richardson, Goldsmith, Sterne and Fielding; but
Scott portrayed with equal strength and success every figure in his
crowded company.
His strong good sense saved him from the faults and foibles
incident to poets,—from nervous egotism, sham modesty or
jealousy. He played ever a manly part.[216] With such a fortune and
such a genius, we should look to see what heavy toll the Fates took
of him, as of Rousseau or Voltaire, of Swift or Byron. But no: he had
no insanity, or vice, or blemish. He was a thoroughly upright, wise
and great-hearted man, equal to whatever event or fortune should try
him. Disasters only drove him to immense exertion. What an
ornament and safeguard is humor! Far better than wit for a poet and
writer. It is a genius itself, and so defends from the insanities.
Under what rare conjunction of stars was this man born, that,
wherever he lived, he found superior men, passed all his life in the
best company, and still found himself the best of the best! He was
apprenticed at Edinburgh to a Writer to the Signet, and became a
Writer to the Signet, and found himself in his youth and manhood
and age in the society of Mackintosh, Horner, Jeffrey, Playfair,
Dugald Stewart, Sydney Smith, Leslie, Sir William Hamilton, Wilson,
Hogg, De Quincey,—to name only some of his literary neighbors,
and, as soon as he died, all this brilliant circle was broken up.
XXVI
SPEECH
AT BANQUET IN HONOR OF THE CHINESE

EMBASSY BOSTON, 1860
Nature creates in the East the uncontrollable yearning to

escape from limitation into the vast and boundless, to use a
freedom of fancy which plays with all works of Nature, great
or minute, galaxy or grain of dust, as toys and words of the
mind; inculcates a beatitude to be found in escape from all
organization and all personality, and makes ecstasy an
institution.
SPEECH
AT THE BANQUET IN HONOR OF THE CHINESE EMBASSY
Mr. Mayor: I suppose we are all of one opinion on this

remarkable occasion of meeting the embassy sent from the oldest
Empire in the world to the youngest Republic. All share the surprise
and pleasure when the venerable Oriental dynasty—hitherto a
romantic legend to most of us—suddenly steps into the fellowship of
nations. This auspicious event, considered in connection with the
late innovations in Japan, marks a new era, and is an irresistible
result of the science which has given us the power of steam and the
electric telegraph. It is the more welcome for the surprise. We had
said of China, as the old prophet said of Egypt, “Her strength is to sit
still.” Her people had such elemental conservatism that by some
wonderful force of race and national manners, the wars and
revolutions that occur in her annals have proved but momentary
swells or surges on the pacific ocean of her history, leaving no trace.
But in its immovability this race has claims. China is old, not in time
only, but in wisdom, which is gray hair to a nation,—or, rather, truly
seen, is eternal youth. As we know, China had the magnet centuries
before Europe; and block-printing or stereotype, and lithography, and
gunpowder, and vaccination, and canals; had anticipated Linnæus’s
nomenclature of plants; had codes, journals, clubs, hackney
coaches, and, thirty centuries before New York, had the custom of
New Year’s calls of comity and reconciliation. I need not mention its
useful arts,—its pottery indispensable to the world, the luxury of
silks, and its tea, the cordial of nations. But I must remember that
she has respectable remains of astronomic science, and historic
records of forgotten time, that have supplied important gaps in the
ancient history of the western nations. Then she has philosophers
who cannot be spared. Confucius has not yet gathered all his fame.
When Socrates heard that the oracle declared that he was the wisest
of men, he said, it must mean that other men held that they were
wise, but that he knew that he knew nothing. Confucius had already
affirmed this of himself: and what we call the Golden Rule of
Jesus, Confucius had uttered in the same terms five hundred years
before. His morals, though addressed to a state of society unlike
ours, we read with profit to-day. His rare perception appears in his
Golden Mean, his doctrine of Reciprocity, his unerring insight,—
putting always the blame of our misfortunes on ourselves; as when
to the governor who complained of thieves, he said, “If you, sir, were
not covetous, though you should reward them for it, they would not
steal.” His ideal of greatness predicts Marcus Antoninus. At the same
time, he abstained from paradox, and met the ingrained prudence of
his nation by saying always, “Bend one cubit to straighten eight.”
China interests us at this moment in a point of politics. I am sure
that gentlemen around me bear in mind the bill which the Hon. Mr.
Jenckes of Rhode Island has twice attempted to carry through
Congress, requiring that candidates for public offices shall first pass
examinations on their literary qualifications for the same. Well, China
has preceded us, as well as England and France, in this essential
correction of a reckless usage; and the like high esteem of education
appears in China in social life, to whose distinctions it is made an
indispensable passport.
It is gratifying to know that the advantages of the new intercourse
between the two countries are daily manifest on the Pacific coast.
The immigrants from Asia come in crowds. Their power of
continuous labor, their versatility in adapting themselves to new
conditions, their stoical economy, are unlooked-for virtues. They
send back to their friends, in China, money, new products of art, new
tools, machinery, new foods, etc., and are thus establishing a
commerce without limit. I cannot help adding, after what I have heard
to-night, that I have read in the journals a statement from an English
source, that Sir Frederic Bruce attributed to Mr. Burlingame the merit
of the happy reform in the relations of foreign governments to China.
I am quite sure that I heard from Mr. Burlingame in New York, in his
last visit to America, that the whole merit of it belonged to Sir
Frederic Bruce. It appears that the ambassadors were emulous in
their magnanimity. It is certainly the best guaranty for the interests of
China and of humanity.
XXVII
REMARKS
AT THE MEETING FOR ORGANIZING THE FREE

RELIGIOUS ASSOCIATION, BOSTON MAY 30,
1867
In many forms we try

To utter God’s infinity,
But the Boundless hath no form,
And the Universal Friend
Doth as far transcend
An angel as a worm.
The great Idea baffles wit,

Language falters under it,
It leaves the learned in the lurch;
Nor art, nor power, nor toil can find
The measure of the eternal Mind,
Nor hymn nor prayer nor church.
REMARKS
AT THE MEETING FOR ORGANIZING THE FREE RELIGIOUS ASSOCIATION
Mr. Chairman: I hardly felt, in finding this house this morning, that
I had come into the right hall. I came, as I supposed myself
summoned, to a little committee meeting, for some practical end,
where I should happily and humbly learn my lesson; and I supposed
myself no longer subject to your call when I saw this house. I have
listened with great pleasure to the lessons which we have heard. To
many, to those last spoken, I have found so much in accord with my
own thought that I have little left to say. I think that it does great
honor to the sensibility of the committee that they have felt the
universal demand in the community for just the movement they have
begun. I say again, in the phrase used by my friend, that we began
many years ago,—yes, and many ages before that. But I think the
necessity very great, and it has prompted an equal magnanimity, that
thus invites all classes, all religious men, whatever their connections,
whatever their specialties, in whatever relation they stand to the
Christian Church, to unite in a movement of benefit to men, under
the sanction of religion. We are all very sensible—it is forced on us
every day—of the feeling that churches are outgrown; that the
creeds are outgrown; that a technical theology no longer suits us. It
is not the ill will of people—no, indeed, but the incapacity for
confining themselves there. The church is not large enough for the
man; it cannot inspire the enthusiasm which is the parent of
everything good in history, which makes the romance of history. For
that enthusiasm you must have something greater than yourselves,
and not less.
The child, the young student, finds scope in his mathematics and
chemistry or natural history, because he finds a truth larger than he
is; finds himself continually instructed. But, in churches, every
healthy and thoughtful mind finds itself in something less; it is
checked, cribbed, confined. And the statistics of the American, the
English and the German cities, showing that the mass of the
population is leaving off going to church, indicate the necessity,
which should have been foreseen, that the Church should always be
new and extemporized, because it is eternal and springs from the
sentiment of men, or it does not exist.[217] One wonders sometimes
that the churches still retain so many votaries, when he reads the
histories of the Church. There is an element of childish infatuation in
them which does not exalt our respect for man. Read in Michelet,
that in Europe, for twelve or fourteen centuries, God the Father had
no temple and no altar. The Holy Ghost and the Son of Mary were
worshipped, and in the thirteenth century the First Person began to
appear at the side of his Son, in pictures and in sculpture, for
worship, but only through favor of his Son. These mortifying
puerilities abound in religious history. But as soon as every man is
apprised of the Divine Presence within his own mind,—is apprised
that the perfect law of duty corresponds with the laws of chemistry, of
vegetation, of astronomy, as face to face in a glass; that the basis of
duty, the order of society, the power of character, the wealth of
culture, the perfection of taste, all draw their essence from this moral
sentiment, then we have a religion that exalts, that commands all the
social and all the private action.
What strikes me in the sudden movement which brings together
to-day so many separated friends,—separated but sympathetic,—
and what I expected to find here, was some practical suggestions by
which we were to reanimate and reorganize for ourselves the true
Church, the pure worship. Pure doctrine always bears fruit in pure
benefits. It is only by good works, it is only on the basis of active
duty, that worship finds expression. What is best in the ancient
religions was the sacred friendships between heroes, the Sacred
Bands, and the relations of the Pythagorean disciples. Our Masonic
institutions probably grew from the like origin. The close association
which bound the first disciples of Jesus is another example; and it
were easy to find more. The soul of our late war, which will always
be remembered as dignifying it, was, first, the desire to abolish
slavery in this country, and secondly, to abolish the mischief of the
war itself, by healing and saving the sick and wounded soldiers,—
and this by the sacred bands of the Sanitary Commission. I wish that
the various beneficent institutions which are springing up, like joyful
plants of wholesomeness, all over this country, should all be
remembered as within the sphere of this committee,—almost all of
them are represented here,—and that within this little band that has
gathered here to-day, should grow friendship. The interests that grow
out of a meeting like this should bind us with new strength to the old
eternal duties.
XXVIII
SPEECH
AT THE SECOND ANNUAL MEETING OF THE

FREE RELIGIOUS ASSOCIATION, AT TREMONT
TEMPLE FRIDAY, MAY 28, 1869
Thou metest him by centuries,

And lo! he passes like the breeze;
Thou seek’st in globe and galaxy,
He hides in pure transparency;
Thou ask’st in fountains and in fires,
He is the essence that inquires.
SPEECH
AT SECOND ANNUAL MEETING OF THE FREE RELIGIOUS ASSOCIATION
Friends: I wish I could deserve anything of the kind expression of

my friend, the President, and the kind good will which the audience
signifies, but it is not in my power to-day to meet the natural
demands of the occasion, and, quite against my design and my will, I
shall have to request the attention of the audience to a few written
remarks, instead of the more extensive statement which I had hoped
to offer them.
I think we have disputed long enough. I think we might now
relinquish our theological controversies to communities more idle
and ignorant than we. I am glad that a more realistic church is
coming to be the tendency of society, and that we are likely one day
to forget our obstinate polemics in the ambition to excel each other in
good works. I have no wish to proselyte any reluctant mind, nor, I
think, have I any curiosity or impulse to intrude on those whose ways
of thinking differ from mine. But as my friend, your presiding officer,
has asked me to take at least some small part in this day’s
conversation, I am ready to give, as often before, the first simple
foundation of my belief, that the Author of Nature has not left himself
without a witness in any sane mind: that the moral sentiment speaks
to every man the law after which the Universe was made; that we
find parity, identity of design, through Nature, and benefit to be the
uniform aim: that there is a force always at work to make the best
better and the worst good.[218] We have had not long since
presented us by Max Müller a valuable paragraph from St.
Augustine, not at all extraordinary in itself, but only as coming from
that eminent Father in the Church, and at that age, in which St.
Augustine writes: “That which is now called the Christian religion
existed among the ancients, and never did not exist from the planting
of the human race until Christ came in the flesh, at which time the
true religion which already existed began to be called Christianity.” I
believe that not only Christianity is as old as the Creation,—not only
every sentiment and precept of Christianity can be paralleled in other
religious writings,—but more, that a man of religious susceptibility,
and one at the same time conversant with many men,—say a much-
travelled man,—can find the same idea in numberless
conversations. The religious find religion wherever they associate.
When I find in people narrow religion, I find also in them narrow
reading. Nothing really is so self-publishing, so divulgatory, as
thought. It cannot be confined or hid. It is easily carried; it takes no
room; the knowledge of Europe looks out into Persia and India, and
to the very Kaffirs. Every proverb, every fine text, every pregnant
jest, travels across the line; and you will find it at Cape Town, or
among the Tartars. We are all believers in natural religion; we all
agree that the health and integrity of man is self-respect, self-
subsistency, a regard to natural conscience. All education is to
accustom him to trust himself, discriminate between his higher and
lower thoughts, exert the timid faculties until they are robust, and

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Teaching Through Visuals

Pharynx Nasal cavity

Vocal cord Tongue

Trachea Expired air

Plasma drug concentration ( g/mL)

(a) administered to(b)clients with renal or hepatic impairment. Drug B Therapeutic

3.9 Repeated dosing allows a plateau drug plasma D3 Drug A

level to be reached. Loading doses allow a D2

Administration of Pulmonary Ittherapeutic

Drugs via Inhalation inhalation

Putting It All Together

M03_ADAM2628_03_SE_C03.indd 27 06/02/20 12:36 PM

NCLEX Practice Questions

M03_ADAM2628_03_SE_C03.indd 28 06/02/20 12:36 PM

CHAPTER 2 Drug Classes and Schedules in Canada 15

NCLEX Practice Questions

UNIT 3 Professional, Personal, and Cultural Influences Parenteral Drug Administration 96

Nicotinic Agonists (Nicotine) 139 Use of Barbiturates as Sedatives 175

Pharmacotherapy with Opioid Antagonists 278 Withdrawal Syndrome 307

CONNECTIONS: Lifespan Considerations Pediatric Corticosteroids in Inflammation 370

CHAPTER 32 Pharmacotherapy of Disorders of the Male Reproductive ANTACIDS 428

Active Immunity: Viral Immunizations 518 UNIT 10 Pharmacology of Infectious Diseases

SULFONAMIDES 572 Pharmacotherapy of Herpesvirus Infections 603

RENAL FAILURE 699 Pharmacotherapy of Alkalosis 727

PROTOTYPE DRUG: Sodium Chloride 722 CHAPTER 55 Pharmacotherapy of Dysrhythmias 745

CHAPTER 60 Pharmacotherapy of Neoplasia 818 Pharmacotherapy of Paget’s Disease 847

1 Introduction to Pharmacology and

LEARNING OUTCOMES CHAPTER OUTLINE

AT THE CELEBRATION OF THE THREE

England’s genius filled all measure

AN ABSTRACT OF MR. EMERSON’S REMARKS

“If a life prolonged to an advanced period bring with it

REMARKS AT THE CELEBRATION BY THE

As far as Sir Walter Scott aspired to be known for a fine

AT BANQUET IN HONOR OF THE CHINESE

Nature creates in the East the uncontrollable yearning to

Mr. Mayor: I suppose we are all of one opinion on this

AT THE MEETING FOR ORGANIZING THE FREE

In many forms we try

The great Idea baffles wit,

AT THE SECOND ANNUAL MEETING OF THE

Thou metest him by centuries,

Friends: I wish I could deserve anything of the kind expression of

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