Chapter 26- Narcotics, Narcotic Antagonists, and Antimigraine Agents

What order for naloxone would be appropriate for the nurse to administer for reversal of opioid effects?

0.1 mg IV repeat every 2 to 3 minutes 0.1 to 0.2 mg is given IV and then repeated every 2 to 3 minutes for reversal of opioid effects. If the patient has overdosed on opioids the dose would be 0.4 to 2 mg every 2 to 3 minutes.

The home care nurse administers oral morphine to the patient with cancer pain. When will the nurse expect this medication to reach peak activity?

60 minutes With oral administration, peak activity occurs in about 60 minutes.

The nurse receives an order for morphine sulfate 8 mg IV every 1 hour as needed for pain. For which patient would the nurse need to question this order?

A 78-year-old with osteoarthritis Older patients are more likely to experience the adverse effects associated with narcotics, including central nervous system, gastrointestinal, and cardiovascular effects. Furthermore, a strong narcotic analgesic would not be indicated for chronic osteoarthritis pain. For both of these reasons, the nurse would question the large dosage of a narcotic. The other patients could appropriately receive morphine 8 mg unless they were smaller than average adults.

The anatomy and physiology instructor is talking about pain sensations. What produces pain sensations when stimulated by generating nerve impulses? (Select all that apply)

A-delta fibers C fibers Two small-diameter sensory nerves, A-delta and C fibers, respond to stimulation by generating nerve impulses that produce pain sensations. Large-diameter sensory nerves (i.e., A fibers) transmit sensations associated with touch and temperature. Mu-receptors are primarily pain-blocking receptors; sigma-receptors cause papillary dilation and may be responsible for the hallucinations, dysphoria, and psychoses that can occur with narcotic use.

According to the Gate Control Theory, what interventions by the nurse could help to block pain impulses?

Back massage According to the gate control theory, the transmission of these impulses can be modulated or adjusted all along these tracts. All along the spinal cord, interneurons can act as gates by blocking the ascending transmission of pain impulses. It is thought that the gates can be closed by stimulation of the larger A fibers and by descending impulses coming down the spinal cord from higher levels in such areas as the cerebral cortex, the limbic system, and the reticular activating system. Administration of medications does not use the Gate Control Theory. Acupuncture uses the Gate Control Theory but is not performed by the nurse.

Before administering an ergot drug to the patient for the first time, the nurse would assess the patient's currently prescribed medications for what drug?

Beta adrenergic blockers The concurrent use of beta blockers and ergot preparations increases the patient's risk for peripheral ischemia and gangrene. This combination should be avoided. There is no indication for concern with the use of antidiabetic agents, SSRIs, and oral contraceptives with these drugs.

What is the nurse's priority assessment when administering narcotics to older adults? (Select all that apply.)

Central nervous system (CNS) effects Gastrointestinal effects Cardiovascular effects Older patients are more likely to experience the adverse effects associated with these drugs, including central nervous system, gastrointestinal (GI), and cardiovascular effects. Urinary and developmental effects are not areas of high concern.

What drug might the nurse administer for both analgesic and antitussive effects?

Codeine Codeine is a narcotic drug used for its analgesic and antitussive effects.

The health care provider orders oral (PO) codeine as an adjunctive therapy to pain control medication. What order would be appropriate for the nurse to administer?

Codeine 20 mg PO every 4 hour The correct dosage for codeine administered for pain by mouth is 15 to 60 mg q 4 to 6 hour. The other options are incorrect oral dosages because they are too low a dose or give an incorrect dosing frequency.

The nurse is administering morphine to a trauma patient for acute pain. Before administering the morphine, what common adverse effect should the nurse inform the patient about?

Drowsiness Common adverse effects include dizziness, drowsiness, and visual changes. Morphine does not commonly cause paresthesia in the lower extremities, an occipital headache, or increased intracranial pressure.

What medication would the nurse administer to the patient in severe pain?

Hydromorphone Hydromorphone is indicated for moderate-to-severe pain. Codeine is indicated for mild-to-moderate pain, hydrocodone is indicated for moderate pain, and opium is indicated for treatment of diarrhea and relief of moderate pain.

When evaluating the effects of narcotic agonist-antagonists on a patient, what adverse effects would the nurse monitor for?

Hypertension Monitor for adverse effects (e.g., central nervous system changes, gastrointestinal (GI) depression, respiratory depression, arrhythmias, hypertension). Bleeding, bone marrow suppression, and increased pulse pressure are not normally seen with these drugs.

The nurse is providing patient teaching about a prescribed opioid analgesic. What is an important teaching point related to a possible adverse effect of this drug?

Hypotension Orthostatic hypotension is commonly seen in association with some narcotics. Ataxia, blurred vision, and dysrhythmias are not commonly seen adverse effects of an opioid analgesic.

A patient with migraine headaches is changed from an ergot to a prescription for a triptan. The nurse has completed teaching related to the drug. What statement would indicate she has a clear understanding of the new drug?

I should not experience as many adverse effects from my new medication. Triptans are a new class of selective serotonin receptor blockers that cause vasoconstriction; they are not associated with as many systemic adverse effects experienced in ergot therapy. Triptan therapy will enable her to live a near normal life even during headaches. Although adverse effects are fewer than those associated with ergot therapy, triptans can still cause dizziness, feelings of strangeness, and vertigo, so the patient should not drive while taking the drug. Medications are often only taken once due to prolonged half-lives, but some may be repeated in 2 to 4 hours if the headache does not subside.

You are caring for a patient taking pentazocine (Talwin). What would be an appropriate nursing diagnosis for this patients care plan?

Impaired gas exchange related to respiratory depression Nursing diagnosis may include impaired gas exchange related to respiratory depression. The drug is more likely to cause constipation due to slowing of the GI tract instead of diarrhea, so that fluid volume deficit would not be appropriate. Monitoring timing of analgesic doses is an intervention and not a nursing diagnosis. If the patient is receiving pentazocine that would indicate he is experiencing pain and is not just at risk for pain, and that the pain is not caused by the drug.

A patient who is experiencing severe pain is administered a narcotic. What would the nurse write in the plan of care as a desirable and measurable outcome for this patient?

Increased autonomy in providing AM care Monitor patient response to the drug (e.g., relief of pain, sedation).When pain is being adequately managed with opioid therapy, a desirable and measurable outcome would be that the patient is able to be more autonomous in providing care in the morning. Shorter periods between requests for medication would not be a desirable outcome because it is not an indicator of pain control given that some patients are reluctant to ask for medicine even though they are in pain. Patients in pain tend not to move for fear of exacerbating the pain, so lack of movement can be an indication the patient is in pain. Just because the patient does not complain of pain doesn't mean he isn't experiencing pain.

Which narcotic analgesics can the nurse administer to a child because she has an established pediatric dose? (Select all that apply.)

Morphine Meperidine Hydrocodone Narcotics that have an established pediatric dose include codeine, fentanyl (but not the transdermal form), hydrocodone, meperidine, and morphine. Methadone is not recommended as an analgesic in children.

The nurse is caring for a patient who is receiving an opioid analgesic. What are the nurse's priority assessments?

Level of consciousness and respiratory rate The nurse should assess respiratory rate and level of consciousness because respiratory depression and sedation are adverse effects of opioid analgesics. Blood glucose levels, electrolytes, and urine output are not priority assessments with opioid ingestion.

The patient in labor receives morphine every 2 hours to manage labor pain. After 22 hours of labor the woman delivers a baby boy. What is the nurse's priority action related to the newborn?

Monitor for opioid effects. Morphine, meperidine, and oxymorphone are often used for analgesia during labor. The mother should be monitored closely for adverse reactions, and, if the drug is used during a prolonged labor, the newborn infant should be monitored for opioid effects. Naloxone would only be given if the newborn displays opioid effects. Withdrawal syndrome would not be seen with less than 24 hours of use. Every newborn is assessed for congenital anomalies but this would not be related to administration of morphine to the mother and so would not be the highest priority.

As the nurse settles the patient into his room after returning from the post-anesthesia care unit (PACU), the patient says he is in severe pain. The nurse checks the medical record and sees the patient has an order for morphine 4 to 8 mg every 1 to 2 hour IV as needed for pain. The nurse sees this medication has not been administered yet so the nurse administers 4 mg. After administering the drug, the PACU nurse calls to say a dose of morphine was given and not documented. What drug will the nurse be prepared to administer if the patient's respiratory rate is depressed?

Naloxone hydrochloride tartrate (Narcan) Naloxone is the drug of choice for treatment of opioid overdose. Butorphanol (INN) is amorphinan-type synthetic opioid analgesic that would not reverse the effects of an opioid. Buprenex (buprenorphine hydrochloride) is a narcotic-agonist-antagonist and would suppress respirations further. Nalbuphine is a synthetic opioid used commercially as an analgesic that would also depress respirations.

The nurse administers pentazocine cautiously to what population?

Patients with known heart disease Pentazocine must be administered cautiously to patients with known heart disease because the drug may cause cardiac stimulation including arrhythmias, hypertension, and increased myocardial oxygen consumption, which could lead to angina, myocardial infarction, or congestive heart failure. No indication exists that it must be given cautiously to patients with gastrointestinal, urinary, or respiratory diseases.

A geriatric patient received a narcotic analgesic before leaving the post-anesthesia care unit to return to the regular unit. What is the priority nursing action for the nurse receiving the patient on the regular unit?

Put side rails up and place bed in low position. Older patients are more susceptible to the central nervous system effects of narcotics; it is important to ensure their safety by using side rails and placing the bed in the low position in case the patient tries to get up unaided. Postoperative patients are allowed nothing by mouth until bowel function returns so an oral medication or encouraging fluids would not be appropriate. This patient will require careful observation for respiratory depression, so a dark room would be unsafe.

Narcotic agonists-antagonists have what function? (Select all that apply.)

Relief of moderate-to-severe pain Relief of pain during labor and delivery Adjuncts to general anesthesia These drugs have three functions: (1) relief of moderate-to-severe pain, (2) adjuncts to general anesthesia, and (3) relief of pain during labor and delivery. Adjunctive therapies to NSAIDs or specificity for orthopedic pain are not functions of this classification of medication.

A patient with a migraine took a dose of a prescribed triptan, eletriptan (Relpax), and 1 hour later the headache is still intense. The patient's husband calls the clinic and asks the nurse what they should do. What is an appropriate nursing response?

She can take another dose of the drug 2 hours after the initial dose if the headache continues. A patient taking eletriptan to relieve a migraine can take another dose in 2 hours if the headache is not relieved. The combination of ergot drugs with triptans is not indicated because of the vasoconstriction caused by both. The patient will not get relief by waiting it out. Ibuprofen is an anti-inflammatory that does not affect the mechanism associated with migraines.

By what route will the nurse administer methylnaltrexone (Relistor)?

Subcutaneously Relistor is only given by subcutaneous injection once each day.

The nurse receives an order for a triptan for a patient diagnosed with cluster headaches. What drug would be indicated for this purpose?

Sumatriptan (Imitrex) Sumatriptan, the first drug of this class, is used for the treatment of acute migraine attacks and for the treatment of cluster headaches in adults. No other triptans are approved for treatment of cluster headaches.

The patient is brought to the emergency department in respiratory arrest after overdosing on heroin. The person accompanying the patient says he has been using heroin for years. After being administered one dose of a narcotic antagonist, the patient begins to breathe spontaneously but remains nonresponsive to stimuli so another dose of narcotic antagonist is ordered. What symptoms would indicate the patient is experiencing acute narcotic abstinence syndrome? (Select all that apply.)

Tachycardia Hypertension Vomiting The most common adverse effect is an acute narcotic abstinence syndrome that is characterized by nausea, vomiting, sweating, tachycardia, hypertension, tremulousness, and feelings of anxiety. Confusion and sedation are not associated with acute narcotic abstinence syndrome.

A 72-year-old patient is admitted to the hospital for surgery. After the patient returns to the floor, the patient's daughter tells the nurse she is concerned that her mother will overdose on morphine because she keeps pressing the button on her patient-controlled anesthesia (PCA) pump. What is the nurse's best response?

The device is preset, so your mother cannot get more than a specific amount. A PCA system using morphine provides a baseline, constant infusion of morphine and gives the patient control of the system to add bolus doses of morphine if the patient believes that pain is not being controlled. The system prevents overdose by locking out extra doses until a specific period of time has elapsed. The PCA is for the patient to control the analgesia, not for a family member to control it because the patient will fall asleep when adequate pain control is reached. If the family keeps pushing the button while the patient's level of consciousness continues to decline, serious overdosage could occur. Not following directions could result in inadequate pain management but not overdosage. The button delivers small bolus dosages so it is not a placebo effect.

A patient, 6 days postoperative, is being weaned off an opioid analgesic. The patient reports he is getting no relief from the pain with the new non-opioid medication he is receiving. What might the nurse suspect is causing this patient's pain?

The patient has developed withdrawal syndrome. Caution should be used in cases of physical dependence on a narcotic because a withdrawal syndrome may be precipitated, the narcotic antagonistic properties can block the analgesic effect, and so intensify the pain. It is important to differentiate between addiction and dependence because addiction generally does not occur in patients receiving narcotics for medical reasons. There is no indication of a hypersensitivity reaction. Giving a higher dose of the opioid would eliminate the progress made to date on weaning the patient from the narcotic, so attempts should be made to avoid this intervention.

Before administering an opiate medication, what will the nurse assess?

The patient's respiratory rate Check the rate, depth, and rhythm of respirations before each dose. If the patient's heart rate is slower than 12 beats per minute, delay or omit the dose and report to the physician. Weight would be assessed before determining dosage. Heart rate would not be an essential assessment before administration. Drug tolerance is assessed by monitoring patient's response to the medication and could not be assessed before administration.

The nurse administers a narcotic analgesic to the postoperative patient. What is the best way for the nurse to evaluate response to the medication?

Use a pain assessment tool before and 30 minutes after administration. A standard pain assessment tool should be used both pre- and post-analgesia. Observing the patient when she is not aware you are watching, assessing vital signs, and measuring oxygen saturation may all contribute useful data but it would not be the best means of determining pain response following analgesic administration.

The nursing instructor asks the student nurse to explain the action of sumatriptan. What is the student's best response?

Vasoconstrictive on cranial blood vessels Sumatriptan binds to serotonin receptors to cause vasoconstrictive effects on cranial blood vessels.