How to Use Davis's Drug Guide For Nurses

General

Davis's Drug Guide for Nurses provides comprehensive, current drug information in well-organized, nursing-focused monographs. It also includes extensive supplemental material in 14 appendices, addresses the issue of safe medication administration, and educates the reader about 45 different therapeutic classes of drugs. In this 19th edition, we continue to focus on safe medication administration by including Medication Safety Tools and even more information about health care's most vulnerable patients: children, the elderly, pregnant women, and breast feeding mothers. Look for more  Pedi,  Geri,  OB,  Lactation, and  Rep headings in the monographs. A BEERS label appears at the top of applicable drug monographs for those medications listed in the most recent Beers Criteria developed by the American Geriatrics Society. These medications are potentially inappropriate for use in older adults because they are associated with more risk than benefit in this patient population. For Canadian students and nurses, we include an appendix comparing Canadian and U.S. pharmaceutical practices, more Canada-only combination drugs in the Combination Drugs appendix, and additional Canadian brand names in the drug monographs. To help you find this information quickly, a maple leaf icon (Canadian Tradename) appears in the index next to each Canadian entry. We have added pharmacogenomic information, marked with a double helix icon (Genetic Implications), in many monographs to help the nurse select and monitor various drug therapies. The following sections describe the organization of Davis's Drug Guide for Nurses.

Safe Medication Use Articles

This book includes several articles that describe the medication safety issues that confront clinicians and patients. "Medication Errors: Improving Practices and Patient Safety" familiarizes you with the systems issues and clinical situations repeatedly implicated in medication errors and suggests means to avoid them. It also teaches you about  high alert medications, which have a greater potential to cause patient harm than other medications. "Detecting and Managing Adverse Drug Reactions" explains and provides guidance on identifying and managing adverse reactions. "Risk Evaluation and Mitigation Strategies (REMS)" explains strategies developed by the pharmaceutical industry and required by the Food and Drug Administration (FDA) to minimize adverse drug reactions from potentially dangerous drugs. We highlight the drugs that currently have approved REMS programs associated with their use by adding a REMS label at the top of applicable drug monographs. "Special Dosing Considerations" identifies the patient populations, such as neonates and patients with renal impairment, who require careful dose adjustments to ensure optimal therapeutic outcomes. "Educating Patients About Medication Use" reviews the most important teaching points for nurses to discuss with their patients and their families. Other critical information is  highlighted in red in each drug monograph. In addition to these articles, please refer to the Medication Safety Tools in the back of the book for the BEERS criteria drug list, proper dosing for pediatric intravenous medications, confused drug names, FDA-approved Tall Man letters, and more.

Classifications

Medications in the same therapeutic class often share similar mechanisms of action, assessment guidelines, precautions, and interactions. The Classifications section provides summaries of the major therapeutic classifications we cover. It also provides patient teaching information common to all agents within the class. A list of drugs within each class can be found in the Comprehensive Index.

Drug Monographs

Drug monographs are organized in the following manner:

High Alert Status:

Some medications, such as chemotherapeutic agents, anticoagulants, and insulins, have a greater potential for harm than others. These medications are identified by the Institute for Safe Medication Practices as high alert drugs. Davis's Drug Guide for Nurses includes a High Alert tab in the upper right corner of the monograph header in appropriate medications to alert the nurse to the medication's risk. The term "high alert" is used in other parts of the monograph to help the nurse administer these medications safely. See the article "Medication Errors: Improving Practices and Patient Safety" for a complete list of high alert medications in Davis's Drug Guide for Nurses.

Generic/Brand Name:

The generic name appears first, with a pronunciation key, followed by an alphabetical list of trade names. Canadian trade names are preceded by a maple leaf (Canadian Tradename). Many brand names have been discontinued by the manufacturer, requiring nurses to know the generic names of drugs. Brand names that have been discontinued have a slash through them (Decadron).

Classification:

The therapeutic classification, which categorizes drugs by the disease state they are used to treat, appears first, followed by the pharmacologic classification, which is based on the drug's mechanism of action.

Controlled Substance Schedule:

All drugs regulated by federal law are placed into one of five schedules, based on the drug's medicinal value, harmfulness, and potential for abuse or addiction. Schedule I drugs, the most dangerous and having no medicinal value, are not included in Davis's Drug Guide for Nurses. (See controlled substances schedules for Controlled Substances Schedules.)

Pregnancy Category:

The FDA discontinued the Pregnancy Category system (A, B, C, D, and X) because this categorization may not appropriately communicate the risk that a drug may have during pregnancy or breast feeding. Therefore, Pregnancy Categories have been removed from all drug monographs and replaced with a Rep tag in drug prescribing information and Patient/Family Teaching sections. Here you will find information on the potential risk of using the drug during pregnancy and breast feeding, contraception suggestions, and potential impairment of fertility in women and men of reproductive potential.

Indications:

Medications are approved by the FDA for specific disease states. This section identifies the diseases or conditions for which the drug is approved and includes significant unlabeled uses as well.

Action:

This section contains a concise description of how the drug produces the desired therapeutic effect.

Pharmacokinetics:

This section provides information on how the body processes a medication by absorption, distribution, metabolism, and excretion and includes information on the drug's half-life.

Absorption:

Absorption is the process that follows drug administration and its subsequent delivery to systemic circulation. If only a small fraction is absorbed following oral administration (diminished bioavailability), then the oral dose must be much greater than the parenteral dose. Absorption into systemic circulation also follows other routes of administration such as topical, transdermal, intramuscular, subcutaneous, rectal, and ophthalmic routes. Drugs administered intravenously are 100% bioavailable.

Distribution:

This section comments on the drug's distribution in body tissues and fluids. Distribution becomes important in choosing one drug over another, as in selecting an antibiotic that will penetrate the central nervous system to treat meningitis or in avoiding drugs that cross the placenta or concentrate in breast milk. Information on protein binding is included for drugs that are >95% bound to plasma proteins, which has implications for drug-drug interactions.

Metabolism and Excretion:

Drugs are primarily eliminated from the body either by hepatic conversion to active or inactive compounds (metabolism or biotransformation) and subsequent excretion by the kidneys, or by renal elimination of unchanged drug. Therefore, drug metabolism and excretion information is important in determining dose regimens and intervals for patients with impaired renal or hepatic function. The creatinine clearance (CCr) helps quantify renal function and guides dose adjustments. Formulas to estimate CCr are included in dose calculation formulas.

Half-Life:

The half-life of a drug is the amount of time it takes for the drug concentration to decrease by 50% and roughly correlates with the drug's duration of action. Half-lives are given for drugs assuming the patient has normal renal or hepatic function. Conditions that alter the half-life are noted.

Time/Action Profile:

The time/action profile table provides the drug's onset of action, peak effect, and duration of activity for each route. This information can aid in planning administration schedules and allows the reader to appreciate differences in choosing one route over another.

Contraindications and Precautions:

Situations in which drug use should be avoided are listed as contraindications. In general, most drugs are contraindicated in pregnancy or lactation, unless the potential benefits outweigh the possible risks to the mother or baby (e.g., anticonvulsants, antihypertensives, and antiretrovirals). Contraindications may be absolute (i.e., the drug in question should be avoided completely) or relative, in which certain clinical situations may allow cautious use of the drug. The precautions portion includes disease states or clinical situations in which drug use involves risks or in which dose modification may be necessary. Extreme cautions are noted separately to draw attention to conditions under which use of the drug results in serious, potentially life-threatening consequences.

Adverse Reactions/Side Effects:

It is not possible to list all reported reactions, but major side effects for all drugs are included. Life-threatening adverse reactions or side effects are  CAPITALIZED, and the most frequent side effects are underlined. Those underlined generally have an incidence of >10%. Those not underlined occur in <10% but >1% of patients. Although life-threatening reactions may be rare (<1%), they are included because of their significance. For each body system, the most frequent adverse reactions are listed first alphabetically (including life-threatening); then all other reactions are subsequently listed alphabetically (including life-threatening). The following abbreviations are used for body systems:

  • CV: cardiovascular
  • Derm: dermatologic
  • EENT: eye, ear, nose, and throat
  • Endo: endocrinologic
  • F and E: fluid and electrolyte
  • GI: gastrointestinal
  • GU: genitourinary
  • Hemat: hematologic
  • Local: local
  • Metab: metabolic
  • MS: musculoskeletal
  • Neuro: neurologic
  • Resp: respiratory
  • Misc: miscellaneous

Interactions:

Drug interactions are a significant risk for patients. As the number of medications a patient receives increases, so does the likelihood of drug-drug interactions. This section provides the most important drug-drug interactions and their physiological effects. Significant drug-food and drug-natural product interactions are also noted as are recommendations for avoiding or minimizing these interactions.

Route/Dosage:

This section includes recommended doses for adults, children, and other more specific age groups by route. Dose units are expressed in the terms in which they are usually prescribed. For example, the penicillin G dose is given in units rather than in milligrams. Dosing intervals are also provided in the way they are frequently ordered. If a specific clinical situation (indication) requires a different dose or interval, this is listed separately for clarity. Specific dosing regimens for hepatic or renal impairment are also included.

Availability:

This section lists the strengths and concentrations of available dose forms, which is useful in planning more convenient regimens (fewer tablets/capsules, less injection volume) and in determining whether certain dose forms are available (suppositories, oral concentrates, sustained- or extended-release forms). Flavors of oral liquids and chewable tablets have been included to improve compliance and adherence in pediatric patients.

Nursing Implications:

This section helps the nurse apply the nursing process to pharmacotherapeutics. The subsections provide a guide to clinical assessment, implementation (drug administration), and evaluation of the outcomes of pharmacologic therapy.

Assessment:

This section includes guidelines for assessing patient history and physical data before, during, and following drug therapy. Assessments specific to the drug's various indications are also included. Lab Test Considerations provide information regarding which laboratory tests to monitor and how the results may be affected by the medication. This section also includes dose modifications required for changes in lab values. Toxicity and Overdose identifies therapeutic serum drug concentrations that must be monitored, as well as signs and symptoms of toxicity. The antidote and treatment for toxicity or overdose are also included.

Implementation:

Provides guidelines for administering medication.  High Alert information relates to preventing medication errors with inherently dangerous drugs. Sound-alike look-alike name confusion alerts are also included here. Other headings in this section provide data regarding routes of administration. Dose modifications for side effects are included for drugs that provide this information. PO describes when and how to administer an oral drug, whether tablets may be crushed or capsules opened, and when to administer the medication in relation to food. The Do Not Crush (DNC) tag identifies drugs that should be swallowed whole. We have also identified which opioids have abuse deterrent properties and describe the mechanism of these properties. In the IV Administration section, bold, red headings are included to highlight the recommended  reconstitution,  dilution, and  concentration. These headings complement the  rate heading and make this critical information easy to find. IV Push, which refers to administering medications from a syringe directly into a saline lock, Y-site of IV tubing, or a 3-way stopcock, provides details for reconstitution, concentration, dilution, and rate. Rate is also included for other methods of IV administration. Intermittent and Continuous Infusion specify standard dilution solutions and amounts, stability information, and rates. In addition, a quick reference for information about dilution amounts in neonates and infants, who are extremely sensitive to excess fluids, is contained in the new Medication Safety Tools section. Y-Site Compatibility/Incompatibility identifies medications compatible or incompatible with each drug when administered via Y-site injection or 3-way stopcock in IV tubing. Information for drugs not included in these lists is conflicting or unavailable. Compatibility information is compiled from Micromedex and the manufacturer's package insert.

Patient/Family Teaching:

This section includes information that should be taught to patients and/or families of patients. Side effects that should be reported, information on minimizing and managing side effects, details on administration, and follow-up requirements are presented. The nurse also should refer to the Implementation section for specific information to teach to the patient and family about taking the medication. The Rep tag identifies information on contraception, breast feeding, monitoring parameters for infants exposed to the drug, and fertility data. Home Care Issues discusses aspects to be considered for medications taken in the home setting.

Evaluation:

Outcome criteria for determination of the effectiveness of the medication are provided.