Lilley Chapter 10: Analgesic Drugs

Toxicity and Managing Overdose

Even though available OTC, lethal when overdosed Overdose, whether intentional or due to chronic unintentional misuse, causes hepatic necrosis Long-term ingestion of large doses also causes nephropathy. Recommended antidote: acetyl cysteine regimen Slide

PCA by proxy

Family/friends controlling the PCA pump

special pain situations

General term for a pain control situation that is complex and whose treatment typically involves multiple medications and non-pharmacological therapeutic modalities.

Opioid Analgesics: Contraindications

Known drug allergy Severe asthma Use with extreme caution if: Respiratory insufficiency Elevated intracranial pressure Morbid obesity Sleep apnea Paralytic ileus

Schedule 4 Drug

Low potential for physical/psych dependence

Schedule 5

Lowest potential for dependence antidiarrheal

Opioid Analgesics: Indications

Main use: to alleviate moderate to severe pain Often given with adjuvant analgesic drugs to assist the primary drugs with pain relief NSAIDs, acetaminophen, Antidepressants, Anticonvulsants, Corticosteroids

Dosage

Maximum daily dose for healthy adults is 4000 mg per day. Inadvertent excessive doses may occur when different combination drug products are taken together. Be aware of the acetaminophen content of all the medications taken by the patient (OTC & prescription.

analgesics

Medications that relieve pain without causing loss of consciousness

Schedule 2 Drug

Meds w/high potential for abuse/dependence, dangerous - methadone (Dilaudid)

Tramadol hydrochloride (ultram)

Miscellaneous analgesic centrally acting analgesic with dual mechanism of action creates me bonds to mu opioid receptors and inhibits three uptake in both norepinephrine and serotonin indicated for the treatment of moderate to moderately severe pain. Rapidly absorbed and unaffected by food. Metabolized in the liver and a eliminated via renal excretion. Seizures can occur from tramadol and antidepressants(SS R I, MAOI, neuroleptic) only available in oral forms combination with acetaminophen(Ultracet) as well as extended release formulation (con zip,ryzolt,ultram ER) and oral disintegrating tablets (Rybix)

Opiates

Misunderstanding of these terms leads to ineffective pain management and contributes to the problem of undertreatment. Physical dependence is seen when the opioid is abruptly discontinued or when an opioid antagonist is administered. Opioid withdrawal/opioid abstinence syndrome.

Coding sulfate

Natural opioid alkaloid(schedule 2) about 10% of coding does is metabolize the morphine of the body. Codeine is less effective as analgesic and is the only agonist to possess a ceiling effect. Codeine with acetaminophen it Is classified as a schedule 3 controlled substance. Used for mild to moderate pain and cough. Codeine is not is not recommended for use in pediatric patients

Usually results from damage to peripheral or central nervous system (CNS) nerve fibers by disease or injury but may also be idiopathic (unexplained).

Neuropathic pain

Schedule 1 Drug

No accepted medical use, high potential for abuse (heroine)

analgesic ceiling effect

Occurs when a given pain drug no longer effectively controls a patient's pain despite the administration of highest safe dosages

Naltrexone hydrochloride

Opioid antagonist used as an adjunct for the maintenance of an opioid free state in former opioid addicts. Indicated as an adjunct to psychosocial treatments of alcoholism an opioid induced respiratory depression. Nausea and tachycardia our common adverse effects. Related to the reversal of opioid effect. Hunter indicated in cases of known drug allergy and patients with hepatitis or liver dysfunction. Only for oral use.

Toxicity and Management of Overdose (cont'd)

Opioid withdrawal/opioid abstinence syndrome Manifested as: Anxiety, irritability, chills and hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramps, diarrhea, confusion

What are Opioid Analgesics?

Pain relievers that contain opium, derived from the opium poppy or chemically related to opium. Narcotics: very strong pain relievers

central pain

Pain resulting from any disorder that causes central nervous system damage.

cancer pain

Pain resulting from any of a variety of causes related to cancer and/or the metastasis of cancer.

referred pain

Pain that is felt at a place other than the origin of the pain is known as

deep pain

Pain that occurs in tissues below skin level; opposite of superficial pain.

somatic pain

Pain that originates from skeletal muscles, ligaments, or joints.

neuropathic pain

Pain that results from a disturbance of function in a nerve.

PCA

Patient Controlled Analgesia

Chapter 10 (Analgesic Drugs)

Power-point information

What is the definition of Nociception? [no″se-sep´shun] (pg. 142)

Processing of pain signals in the brain that gives rise to the feeling of pain.

nociception

Processing of pain signals in the brain that gives rise to the feeling of pain.

Pain Transmission (cont'd)........ Rubbing a painful area with massage or liniment stimulates large sensory fibers and also results in the following: (*hint...there are two listed on power point)

Recognition of p reduced Same pathway used by opiates

Occurs when visceral nerve fibers synapse at a level in the spinal cord close to fibers that supply specific subcutaneous tissues in the body.

Referred pain

Regardless of the patient's withdrawal symptoms, when a pt experiences _________________________, an opioid antagonist (naloxone, naltrexone) should be given.

SEVERE RESPIRATORY DISTRESS

Codeine Sulfate

Schedule 2 - obtain from opium - less effective = ceiling effect - used as antitussive drug

Morphine sulfate

Schedule 2 indicated for severe pain. Available oral, Injectable, and a rectal dosage. Extended release include MS cotton and kadian. Toxic metabolite morphine- Six-glucuronide. More like likely seen in renal impairment.

Methadone hydrochloride(dolphine)

Schedule 2 it is the opioid of choice for the detoxification treatment of opioid addicts and methadone maintenance programs. The drug is readily absorbed through the G.I. tract with peak plasma concentrations at four hours.'s unique in that it's half life is longer than its duration of action because it is found into the tissues of liver kidneys and the brain. Eliminated through the liver.

Fentanyl

Schedule 2 med - moderate to SEVERE pain - parenteral, transdermal, buccal lozenge - Fentanyl 0.1 mg IV - is roughly equivalent to 10 mg of morphine IV - comes on fast, goes away fast

Hydromorphine(dilaudid)

Schedule 2. Seven times more potent than morphine. exalgo is the osmotic extended release oral delivery system

meperidine hydrochloride (demerol)

Schedule 2. Used with caution in older adults who require long-term analgesia or kidney dysfunction. Active metabolite, normepridine and accumulate a toxic levels lead to seizures Area Houston emergency department for acute migraine headaches and postoperativeperiod to reduce shivering.

Originates from skeletal muscles, ligaments, and joints.

Somatic pain

Pt with bone cancer tells nurse he is in pain. The nurse knows that bone pain is classified as which type of pain?

Somatic pain

WHO 3-step ladder

Step 1 - NONOPIODS (with or without adjuvant meds) - try to do anything except opiods Step 2 - Opiods (with or without adjuvant meds) - not super strong/dangerous Step 3 - STRONGER opiods - for severe pain that is not going away (with or without adjuvant meds)

agonists-antagonists

Substances that bind to a receptor and cause a partial response that is not as strong as that caused by an agonist (also known as a partial agonist)

Originates from the skin and mucous membranes.

Superficial pain

Fentnyl

Synthetic opioid (schedule 2) treats moderate to severe pain. Dosage forms include for rental, Transdermal, buccal.'s injectable form is commonly used in preoperative settings and ICU settings for sedation during mechanical ventilation. Transdermal has been shown to be highly effective and treatment of various chronic pain syndromes. Difficult to titrate. Take 6 to 12 hours to reach steady-state pain control. I need patches applied every 72 hours

pain threshold

The level of a stimulus that results in the sensation of pain.

gate theory

The most well-described theory of pain transmission and pain relief. It uses a gate model to explain how impulses from damaged tissues are sensed in the brain.

opioid tolerant

The opposite of opioid naïve; describes patients who have been receiving opioid analgesics (legally or otherwise) for a period of time (1 week or longer) and who are at greater risk of opioid withdrawal syndrome upon sudden discontinuation.

opioid withdrawal

The signs and symptoms associated with abstinence from or withdrawal of an opioid analgesic when the body has become physically dependent on the substance

What do Agonists do?

They bind to an opioid pain receptor in the brain and cause an analgesic response (reduction of pain sensation).

What happens in Pain TRANSMISSION; one of the four processes of nociception?

Tissue injury causes the release of these four substances that stimulate nerve endings to start the process of pain: * Bradykinin * Histamine * Prostaglandins * Serotonin

Lidocaine(Transdermal)

Topical anesthetic and placed on painful painful areas of the skin. Indicated for the treatment of postherpetic neuralgia. Patches not to be warm for longer than 12 hours. Adverse effects are minimal skin at treatment site may develop redness or edema. Only apply patch to intact skin with no blisters.

What are the two (2) endogenous neurotransmitters that the body has?

Two endogenous neurotransmitters that the body has are 1) Enkephalins 2) Endorphins

Believed to originate from the vascular or perivascular tissues and is thought to account for a large percentage of migraine headaches

Vascular pain

Visceral pain originates from organs and smooth muscles.

Visceral pain

Naloxone hydrochloride(Narcan)

Your opioid antagonist. works as a blocking drug where the opioid drugs. Does not produce analgesia or respiratory depression. Drug of choice for complete or partial reversal of opioid and do's respiratory depression. Adverse effect is opioid withdrawal syndrome. Only an injectable dosage forms. Contraindicated in patients with history of hypersensitivity to it.

addiction

a chronic neurbiologiv disease whose deelopment is influenced by genetic, psychosocial and enviromental factors.

opioids

a class of drugs used to treat pain. this term is often used interchangeably with the term narcotic

physical dependence

a condition in which a patient takes a drug over a period of time and unpleasant physical symptoms occur if the drug is stopped abruptly or smaller doses are given. the physical adaption of the body to the presence of an opioid or other addictive substances

partial agonist

a drug that binds to a receptor and causes a response that is less than that caused by a full agonist

nonsteroidal anti inflammatory drugs (NSAIDs)

a large chemically diverse group of drugs that are analgesics and also possess anti inflammatory and antipathetic activity

narcotics

a legal term that originally applied to drugs that produce insensibility or stupor especially the opioids. currently used to refer to any medicinally used controlled substance and to refer to any illicit or street drugs

nociceptors

a subclass of sensory nerves that transmit pain signals to the central nergous system from other body parts.

agonist

a substance that binds to a receptor and causes a response

pain

a unpleasant sensory and emotional experience associated with accrual or potential tissue damage

Many current pain management strategies are aimed at

altering the GATE SYSTEM - analgesics - acupuncture - distraction If too much good gets through the gate, then the bad cannot get through

world health organization (WHO)

an international body of health care professionals that studies and responds to health needs and trends worldwide

adjuvant analgesic drugs

drugs that are added for combined therapy with a primary drug and many additives or independent analgesic properties or both

Meperidine is NOT RECOMMENDED

for long-term use because of accumulation of NEUROTOXIC METABOLITE (called nromeperidine) which causes SEIZURES

Alcoholic will die before a

heroine addict

Nonanalgesics - acetaminophen

inhibits prostaglandin synthesis - mild to moderate pain - fever - for those who cannot take ASA - Max dose for healthy adult - 3000 mg/day - causes LIVER disease - often in combination drugs - Be aware of ALL contents of meds taken by a pt to be sure there is no hiding acetaminophen

Toxicity and Management of Overdose

naloxone (Narcan) naltrexone (Revia) These drugs bind to opiate receptors and prevent a response. Used for complete or partial reversal of opioid induced respiratory depression. Regardless of withdrawal symptoms, when a patient experiences severe respiratory depression, an opioid antagonist should be given.

phantom pain

pain experienced in the area of a body part that has been surgically or traumatically removed

acute pain

pain that is sudden in onset, usually subsides when treated, and typically occurs over less that a 6-week period

visceral pain

pain that originates from organs or smooth muscles

superficial pain

pain that originates from the skin or mucous membranes

vascular pain

pain the results from pathology of the vascular or perivascular tissues

chronic pain

persistent or recurring pain that is often difficult to treat. includes any pain lasting longer than 3 days to 6 months, pain lasting longer than 1 month after healing of an acute injury or pain that accompanies a non healing tissue injury.

Nociception

receptors trasmit pain from various body regions to SPINAL CORD

opioid analgesics

synthetic drugs that bind to opiate receptors to relieve pain.

The point of spinal cord entry is

the GATE - the dorsal horn in spinal cord

Transduction is

the blockage step of pain - brain sends neurotransmittors to help block pain

tolerance

the general term for a state in which repetitive exposure to a given drug over time induces changes in drug receptors that reduce the drugs effects

What are Opioids Analgesics used for?

◾ Cough center suppression ◾ Treatment of diarrhea ◾ Balanced anesthesia

What are the "ADVERSE EFFECTS" of Opioid Analgesics?

◾ Euphoria ◾ CNS depression - Leads to respiratory depression - Most series adverse effect ◾ Nausea and vomiting ◾ Urinary retention ◾ Diaphoresis and flushing ◾ Pupil constriction (miosis) ◾ Constipation ◾ Itching

What are the "Indications"?

◾ Mild to moderate pain ◾ Fever ◾ Alternative for those who cannot take aspirin product. ◾ Mild-to-moderate pain

What occurs with CHRONIC pain?

◾ Persistent or recurring ◾ Lasting 3-6 months or longer ◾ Often difficult to treat

What is the purpose of the two endogenous neurotransmitters (Enkephalins and Endorphins)?

◾ Produced by body to fight pain ◾ Bind to opioid receptors

What occurs with ACUTE pain?

◾ Sudden in onset ◾ Usually subsides once treated

What are Analgesics?

◾Medications that relieve pain without causing loss of consciousness.

Opiod Analgesics - Interactions include:

- Alcohol - Antihistamines - Barbituates - Benzodiazepines - Monoamine oxidase inhibitors - herbals, etc.

Adjuvant Drugs

- Assist primary drugs in relieving pain - NSAIDs - ANtidepressants - Anticonvulsants - Corticosteroids

Analgesics - Nursing Implciations

- Baseline everything - thorough assessment - assess for potential contraindications, etc. - Get in-depth pain assessment (use scale, words, etc.) - MEDICATE BEFORE PAIN BECOMES TOO SEVERE - a lot less drugs, less frequently if 3/10 than if 9/10 - pain management is pharmacologic AND nonpharmacologic - be sure to include alternative interventions - KNOW other meds or OTC drugs - pt should NOT take without checking w/physician first - oral forms w/food to avoid GI upset - Ensure safety measures (siderails up if high to prevent injury - NEED ORDER) - Withhold dose/contact MDM if there is decline in pt's condition or vital signs are abnormal - ESPECIALLY if resp rate less than 10-12 breath/min - Check dose carefully - Follow proper administration guidelines for IM injections including site rotation - Follow proper IV admin, dilution, rate of admin, etc. - Constpation - adequate fluid/fiber intake - Keep record of pain, response to tx - Pt to change positions slowly

Opiod Analgesics - Adverse Effects

- CNS depression - MOST SERIOUS (leads to respiratory depression) - Nausea, vomiting - Urinary retentioin - Diaphoresis, flusing - Pupil constriction (miosis) - Constipation - Itching

endogenous neurotransmitters

- Enkephalins - Endorphins

Acetaminophen - Toxicity, Managing Overdose

- LETHAL when overdosed - Causes hepatic nocrosis, hepatotoxicity - Long-term ingestion causes nephropathy - ANTIDOTE: acetylcysteine regimen

Opiod Analgesics - Indications

- MAIN - alleviate moderate to severe pain - often given w/adjuvant analgesic to assist w/primary drug for pain relief - Cough center supression - Treatment of diarrhea - Balanced anesthesia

Schedule 3 Drug

- Moderate to low rissk for physical/psych addiction

Special pain situations

- PCA, PCA by proxy - Pt comfort vs fear of drug addiction (pt may not verbalize fear of addiction, may further assess - add comfort measures like massage, etc.) - Opiod tolerance (build tolerance to drug) - Use of placebos - Recognize pts who are opiod tolerant - Breakthrough pain (pain above and beyond - as in flare up) - Synergistic effect (sum is greater than parts - meds added together may give better effect)

Endogenous neurotranmitter purposes

- Produced by body to fight pain - BIND to opiod receptors - INHIBIT tranmission of pain by CLOSING the GATE

Opioid - Methods of Action - Antagonist

- Reverse the effects of these drugs on pain receptors (naloxone/Narcan) - Bind of pain receptors, but exert no response - blocks off pain receptor

Classification of Pain

- Somatic - Visceral - Superficial - Deep - Vascular - Referred - Neuropathic - Phantom - Cancer - Central

acetaminophen contraindications

- alcoholic - liver dysfunction - G6PD deficiency - drug allergy - dangerous interactions w/other drugs

Adjuvant drugs for enruopathic pain

- amitriptyline (antidepressant) - gabapentin, pregabalin (anticonvulsants)

When someone is going through withdrawal, symptoms include

- anxiety - irritability - chillls - hot flashes - joint pain - lacrimation - rhinorrhea - diaphoresis - nausea

Equianalgesia

- based on morhpine - (just because science said so) - ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration - Hydromorphone - 7 times more potent than morphine (everything measured by morphine - 10 mg morphine, 1 hour later hydromorphone 1 mg, then pt would have received 17 mg of morphine) hydrocodone 1 mg = 7 mg of morphine - equivalent doses for certain types of meds - this is one (morphine)

Opioid - Methods of Action - Agonist

- bind to opioid pain receptor in brain (blocks gates in brain) - Causes analgesic response (REDUCTION OF PAIN SENSATION)

Tissue injury causes release of

- bradykinin - histamine - potassium - prostaglandings - serotonin Helpful to know what drugs affect these (work with, work against, enhance, etc.) These substances STIMULATE nerve endings, STARTING pain process

Gate Theory of Transmission

- certain stimuli will cause gate to open, allowing pain (or other sensations) to get through - certain stimuli will cause gain to close, blocking pain (or other sensations) to get through

Opiod Analgesics - Physical Dependence

- different than opioid tolerance - physiologic adaptation of body to presence of an opiod - tolderance and dependence EXPECT long-term opioid - different than psychological addiction - Can't get up and move, go through physical withdrawal symptoms if don't get the med

Dilaudid

- hydromorphone - schedule 2 - very potent

linament

- like Icy/Hot, capsaicin cream, etc.

Feverfew - Herbal

- marigold family - migraines, inflmamation, fever - antiinflammatory - may cause GI distress, altered taste, muscle stiffness - may INTERACT with ASA, other NSAIDs, anticoagulants

If a patient in withdrawal has severe respiratory depression, use

- naloxone - naltrexone (both opioid antagnosts)

Opiod Analgesics - Toxicity, Managing Overdose

- naloxone (Narcan) - naltrexone (ReVia) - Regardless of withdrawal symtpoms, when a patient experiences SEVERE RESPIRATORY DEPRESSION - opioid antagonist should be given

morphine sulfate

- natural alkaloid from opium poppy - Schedule 2 - drug prototype for ALL opioid drugs - Indications: SEVERE PAIN - High abuse potential - Oral, injectable, rectal dosage; also Extended-Relief

Opiods

- synthetic drugs that bind to the opiate receptors to relieve pain - MILD AGONISTS (codeine, hydrocodone) - STRONG AGONISTS 9morphine, hydromorphone, oxycodone, oxymorphone, meperidine, fentanyl, methadone)

methadone hydrochloride (Dolophine)

- synthetic opioid - schedule 2 - detox opiod of choice for dpioid addicts - perhaps for chronic/neuropathic and CANCER-related pain - Prolonged half-life of drug - causes UNINTENTIONAL OVERDOSES and DEATHS - tends to build up in system because it stays in body longer - Cardiac dysrhythmias

Opiod Ceiling Effect

- the opiod has reached ITS FULL POTENTIAL - does not matter how much more you give, it does not work - Pain does not improve

What are the two (2) classification's of pain by onset and duration?

1) ACUTE pain 2) CHRONIC pain

What are the three (3) classifications of opioid analgesics, based on their actions?

1) Agonist 2) Partial agonist 3) Antagonist

List the eight (8) examples of Opioid Analgesics?

1) Codeine sulfate 2) Meperidine HCl (Demerol) 3) Methadone HCl (Dolophine) 4) Morphine sulfate 5) Propoxyphene HCl 6) Hydromorphone 7) Oxycodone 8) Fentanyl

What are the five (5) types of Opioid Receptors? (See pg. 148, Table 10-5)

1) Mu * 2) Kappa * 3) Delta * 4) Sigma 5) Epsilon

What are the four processes of Nociception? (pg. 142)

1) TRANSDUCTION - Injured tissue releases chemicals that propagate pain message. - Action potential moves along an afferent fiber to the spinal cord. 2) TRANSMISSION - The pain impulse moves from the spinal cord to the brain. 3) PERCEPTION OF PAIN 4) MODULATION - Neurons from the brain stem release neurotransmitters that block the pain impulse.

History of alcohol use - max acetaminophen dose is

2000 mg

Max adult dose for acetaminophen

3000 mg/day

Nonopioid Analgesics:

>Acetaminophen >Analgesic and antipyretic effects. >Little to no antiinflammatory effects. >Available OTC and in combination products with opioids.

opioid tolerance

A normal physiologic condition that results from long-term opioid use, in which larger doses of opioids are required to maintain the same level of analgesia and in which abrupt discontinuation of the drug results in withdrawal symptoms (same as physical dependence).

What is the "Psychological Dependence" of Opioids?

A pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief.

psychologic dependence

A pattern of compulsive use of opioids or any other addictive substance characterized by a continuous craving for the substance and the need to use it for effects other than pain relief (also called addiction).

The nurse in the postanesthesia care unit (PACU) notes that a patient has a respiratory rate of 6 breaths/min 30 minutes after surgery. Which action should the nurse implement next? A. Check the timing of the last opioid B. Initiate resuscitative measures C. Give flumazenil (Romazicon) D. Prepare naloxone (Narcan) IV

A. Check the timing of the last opioid To complete the patient assessment for the planning of suitable nursing care, the PACU nurse checks the anesthesia record to determine the time and dosage of opioid analgesics and other anesthetics used in the operating room (OR). This is because many of the anesthetic agents used in the OR can induce respiratory depression. The patient's respiratory depression may be due to the residual effects of a muscle relaxant, an opioid (for which naloxone is the antidote), a benzodiazepine (for which flumazenil is the antidote), a barbiturate, or an anesthetic gas. The nurse needs to know which agent or agents are most likely causing the respiratory depression to complete the assessment.

When assessing a patient for adverse effects related to morphine sulfate, which effects would the nurse expect to find? (Select all that apply)

A. Decreased peristalsis C. Delayed gastric emptying D. Urinary retention

The patient has been taking morphine for postoperative pain. Before discharge, what patient teaching should be provided to prevent constipation? (Select all that apply.) A. Increase fluid intake throughout the day B. Increase rest periods C. Take a stool softener D. Decrease the medication dosage with constipation E. Eat more animal protein and dairy

A. Increase fluid intake throughout the day C. Take a stool softener Constipation may be managed with increased intake of fluids, use of stool softeners such as docusate sodium, or use of stimulants such as bisacodyl or senna. Agents such as lactulose, sorbitol, and polyethylene glycol (Miralax) have been proven effective. Less commonly used are bulk-forming laxatives such as psyllium, for which increased fluid intake is especially important to avoid fecal impactions or bowel obstructions.

When assessing for the most serious adverse reaction to a narcotic analgesic, what does the nurse monitor for in the patient? A. Respiratory rate B. Heart rate C. Blood pressure D. Mental status

A. Respiratory rate

A patient is receiving an anticonvulsant but has no history of seizures. The nurse suspects that the patient is receiving this drug for which condition? A. Pain associated with peripheral neuropathy B. Inflammation pain C. Depression associated with chronic pain D. Prevention of possible seizures

ANS: A Anticonvulsants are often used as adjuvants for treatment of neuropathic pain to enhance analgesic efficacy. The other indications listed are not correct.

A patient has been treated for lung cancer for 3 years. Over the past few months, the patient has noticed that the opioid analgesic is not helping as much as it had previously and more medication is needed for the same pain relief. The nurse is aware that this patient is experiencing opioid a. addiction. b. tolerance. c. toxicity. d. abstinence syndrome.

ANS: B Opioid tolerance is a common physiologic result of long-term opioid use. Patients with opioid tolerance require larger doses of the opioid agent to maintain the same level of analgesia. This situation does not describe toxicity (overdose), addiction, or abstinence syndrome (withdrawal)

A patient was diagnosed with pancreatic cancer last month, and has complained of a dull ache in the abdomen for the past 4 months. This pain has been gradually increasing, and the pain relievers taken at home are no longer effective. What type of pain is the patient experiencing? a. Acute pain b. Chronic pain c. Somatic pain d. Neuropathic pain

ANS: B Chronic pain is associated with cancer and is characterized by slow onset, long duration, and dull, persistent aching. The patient's symptoms are not characteristics of acute pain, somatic pain, or neuropathic pain.

A 57-year-old woman being treated for end-stage breast cancer has been using a transdermal opioid analgesic as part of the management of pain. Lately, she has been experiencing breakthrough pain. The nurse expects this type of pain to be managed by a.administering NSAIDs. b. administering an immediate-release opioid. c. changing the opioid route to the rectal route. d. not changing the current therapy.

ANS: B If a patient is taking long-acting opioid analgesics, breakthrough pain must be treated with an immediate-release dosage form that is given between scheduled doses of the long-acting opioid. The other options are not appropriate actions

A patient is recovering from abdominal surgery, which he had this morning. He is groggy but complaining of severe pain around his incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient? a. His pulse rate b. His respiratory rate c. The appearance of the incision d. The date of his last bowel movemen

ANS: B One of the most serious adverse effects of opioids is respiratory depression. The nurse must assess the patient's respiratory rate before administering an opioid. The other options are incorrect

Vicodin (acetaminophen/hydrocodone) is prescribed for a patient who has had surgery. The nurse informs the patient that which common adverse effects can occur with this medication? Select all that apply. A. Diarrhea B. Constipation C. Lightheadedness D. Nervousness E. Urinary retention F. Itching

ANS: B, C, E, F Constipation (not diarrhea), lightheadedness (not nervousness), urinary retention, and itching are some of the common adverse effects that the patient may experience while taking Vicodin.

A patient is to receive acetylcysteine (Mucomyst) as part of the treatment for an acetaminophen (Tylenol) overdose. Which action by the nurse is appropriate when giving this medication? A. Giving the medication undiluted for full effect B. Avoiding use of a straw when giving this medication C. Disguising the flavor with soda or flavored water D. Preparing to give this medication via a nebulizer

ANS: C Acetylcysteine has the flavor of rotten eggs and so is better tolerated if it is diluted and disguised by mixing with a drink such as cola or flavored water to help increase its palatability. The use of a straw helps to minimize contact with the mucous membranes of the mouth and is recommended. The nebulizer form of this medication is used for certain types of pneumonia, not for acetaminophen overdose.

A 38-year-old man has come into the urgent care center with severe hip pain after falling from a ladder at work. He says he has taken several pain pills over the past few hours but cannot remember how many he has taken. He hands the nurse an empty bottle of acetaminophen (Tylenol). The nurse is aware that the most serious toxic effect of acute acetaminophen overdose is A. tachycardia. B. depression of the central nervous system. C. hepatic necrosis. D. nephropathy.

ANS: C Hepatic necrosis is the most serious acute toxic effect of an acute overdose of acetaminophen. The other options are not correct.

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 9 per minute. The nurse prepares for which action at this time? A. Close observation of signs of opioid tolerance B. Immediate intubation and artificial ventilation C. Administration of naloxone (Narcan), an opioid reversal agent D. Administration of an agonist opioid such as fentanyl

ANS: C Naloxone, an opioid-reversal agent, is used to reverse the effects of acute opioid overdose and is the drug of choice for reversal of opioid-induced respiratory depression. This situation is describing an opioid overdose, not opioid tolerance. Intubation and artificial ventilation are not appropriate because the patient is still breathing at nine breaths per minute. It would be inappropriate to administer an opioid agonist.

A patient will be discharged with a 1-week supply of an opioid analgesic for pain management after abdominal surgery. The nurse will include which information in the teaching plan? a. How to prevent dehydration due to diarrhea b. Importance of taking the drug only when the pain becomes severe c. How to prevent constipation d. Importance of taking the drug on an empty stomach

ANS: C Gastrointestinal adverse effects, such as nausea, vomiting, and constipation, are the most common adverse effects associated with opioid analgesics. Physical dependence usually occurs in patients undergoing long-term treatment. Diarrhea is not an effect of opioid analgesics. Taking the dose with food may help minimize GI upset

A 38-year-old man has come into the urgent care center with severe hip pain after falling from a ladder at work. He says he has taken several pain pills over the past few hours but cannot remember how many he has taken. He hands the nurse an empty bottle of acetaminophen (Tylenol). The nurse is aware that the most serious toxic effect of acute acetaminophen overdose is which condition? a. Tachycardia b. Central nervous system depression c. Hepatic necrosis d. Nephropathy

ANS: C Hepatic necrosis is the most serious acute toxic effect of an acute overdose of acetaminophen. The other options are incorrect.

The nurse is assessing a patient for contraindications to drug therapy with acetaminophen (Tylenol). Which patient should not receive acetaminophen? a. A patient with a fever of 101 F (38.3 C) b. A patient who is complaining of a mild headache c. A patient with a history of liver disease d. A patient with a history of peptic ulcer disease

ANS: C Liver disease is a contraindication to the use of acetaminophen. Fever and mild headache are both possible indications for the medication. Having a history of peptic ulcer disease is not a contraindication

A patient arrives at the urgent care center complaining of leg pain after a fall when rock climbing. The x-rays show no broken bones, but he has a large bruise on his thigh. The patient says he drives a truck and does not want to take anything strong because he needs to stay awake. Which statement by the nurse is most appropriate? a. "It would be best for you not to take anything if you are planning to drive your truck." b. "We will discuss with your doctor about taking an opioid because that would work best for your pain." c. "You can take acetaminophen, also known as Tylenol, for pain, but no more than 1000 mg per day." d. "You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg per day.

ANS: D Acetaminophen is indicated for mild to moderate pain and does not cause drowsiness, as an opioid would. Currently, the maximum daily amount of acetaminophen is 3000 mg per day. The 1000-mg amount per day is too low. Telling the patient not to take any pain medications is incorrect

An 18-year-old basketball player fell and twisted his ankle during a game. The nurse will expect to administer which type of analgesic? a. Synthetic opioid, such as meperidine (Demerol) b. Opium alkaloid, such as morphine sulfate c. Opioid antagonist, such as naloxone HCL (Narcan) d. Nonopioid analgesic, such as indomethacin (Indocin)

ANS: D Somatic pain, which originates from skeletal muscles, ligaments, and joints, usually responds to nonopioid analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs). The other options are not the best choices for somatic pain

Sudden onset and usually subsides once treated. Lasts no more that 3 months.

Acute Pain

Oxycodone hydrochloride

Analgesic drug structurally related to morphine. Schedule 2. Commonly combined in tablets with acetaminophen(Percocet) and aspirin(percodan) available in immediate release formulations(oxyContin). Weaker but commonly used opioid is hydrocodone only in tablet form commonly combination with acetaminophen(Vicodin, Norco)

nonopioid analgesics

Analgesics that are not classified as opioids.

The nurse prepares morphine sulfate IV for a patient but decides to consult with the pharmacist before administering the medication. Which condition is the most likely reason the nurse has decided to consult the pharmacist? A. Cancer B. Asthma C. Diarrhea D. Anorexia

B. Asthma Morphine should be used with caution in patients with asthma because naturally occurring opioids cause the release of histamine; a release of histamine in a patient with asthma can trigger bronchoconstriction. Because morphine is bound to protein 20% to 35%, the patient's cancer and anorexia are causes for concern because both conditions can result in hypoproteinemia and a lack of protein-binding sites for morphine and, therefore, altered pharmacokinetics of the medication. The administration of morphine can help diminish diarrhea.

A patient was diagnosed with pancreatic cancer last month, and has complained of a dull ache in the abdomen for the past 4 months. This pain has been gradually increasing, and the pain relievers taken at home are no longer effective. What type of pain is the patient experiencing? A. Acute Pain B. Chronic Pain C. Somatic Pain D. Neuropathic Pain

B. Chronic Pain Chronic pain is associated with cancer and is characterized by slow onset, long duration, and dull, persistent aching. The patient's symptoms are not characteristics of acute pain, somatic pain, or superficial pain.

A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse why she is receiving codeine when she does not have any pain. The nurse's response is based on the knowledge that codeine also has what effect?

B. Cough suppressant

Massage therapy is ordered as adjunct treatment for a patient with musculoskeletal pain. The patient asks the nurse how "rubbing my muscles" will help the pain go away. The nurse responds based on the knowledge that: A. Massaging muscles decreases the inflammatory response that initiates the painful stimuli. B. Massaging muscles activates large sensory nerve fibers that send signals to the spinal cord to close the gate, thus blocking painful stimuli from reaching the brain. C. Massaging muscles activates small sensory nerve fibers that send signals to the spinal cord and allow endorphins to reach the muscles and relieve the pain. D. Massaging muscles helps to relax the contracted fibers and decrease painful stimuli.

B. Massaging muscles activates large sensory nerve fibers that send signals to the spinal cord to close the gate, thus blocking painful stimuli from reaching the brain.

The nurse is preparing to administer an injection of morphine to a patient. Assessment notes a respiratory rate of 10 breaths/min. Which action will the nurse perform? A. Administer a smaller dose and record the findings B. Notify the physician and delay drug administration C. Administer the prescribed dose and notify the physician D. Hold the drug, record the assessment, and recheck in 1 hour

B. Notify the physician and delay drug administration

A patient is recovering from abdominal surgery, which he had this morning. He is groggy but complaining of severe pain around his incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient? A. Pulse Rate B. Respiratory Rate C. The appearance of his incision D. The date of his last bowel movement

B. Respiratory Rate One of the most serious adverse effects of opioids is respiratory depression. The nurse must assess the patient's respiratory rate before administering an opioid. The other options are not correct.

A patient's admission vital signs are temperature 37.6° C, heart rate 96 beats/min, respirations 22 breaths/min, and blood pressure 140/90 mm Hg. Later, the patient requests pain medication, and the nurse records vital signs before administering codeine 15 mg with acetaminophen 300 mg (Tylenol 2) two tablets by mouth. Before administering the medication, which patient assessment is the nurse's priority? A. Heart rate 110 B. Respiratory rate 10 C. Temperature 38.0°Celsius D. Blood pressure 160/86 mm Hg

B. Respiratory rate 10 The priority patient assessment is the respiratory rate because it has decreased by more than 50%. Opioids can cause respiratory depression, and breathing is more important than circulation issues. To prevent respiratory failure, the nurse withholds the analgesic and plans follow-up nursing interventions.

The nurse administers oxycodone 5 mg with acetaminophen 500 mg (Percocet) to a patient for postoperative pain. Which patient teaching about the analgesic agent is the nurse's priority before the nurse leaves the patient's room? A. The patient may chew ice chips to relieve dry mouth. B. The patient should call for help before getting up. C. The patient should report any nausea or vomiting. D. The patient may feel flushed or diaphoretic.

B. The patient should call for help before getting up. The nurse instructs the patient to call for help before getting up because oxycodone is an opioid that can cause relaxation of vascular smooth muscle through the release of histamine, thereby blunting the baroreceptor reflex. Because the baroreceptors are less responsive, orthostatic hypotension may result from the pooling of blood in the dilated blood vessels as the system's compensatory mechanism for position changes is impaired. The available blood volume that the cardiovascular system can shunt to the brain when the patient stands is reduced; as a result, the blood pressure falls transiently when the patient stands, increasing the risk of falls and injury. Nausea, constipation, dry mouth, and flushing are common adverse effects of oxycodone; however, they are secondary in importance because the risk of patient injury is a more immediate and serious consequence of therapy.

What is the primary indication for the administration of morphine? A. To diminish feelings of anxiety B. To relieve acute and chronic pain C. To induce a state of unconsciousness D. To increase cardiac filling pressures

B. To relieve acute and chronic pain The principal indication for morphine is the relief of moderate to severe pain, including postoperative pain and cancer pain. In addition, morphine is used during acute myocardial infarction to relieve pain, anxiety, and dypsnea and to promote relaxation of vascular smooth muscle. Morphine may also be administered before surgery for sedation.

While admitting a patient for treatment of an acetaminophen overdose, the nurse prepares to administer which medication to prevent toxicity? A. naloxone (Narcan) B. acetylcysteine (Mucomyst) C. methylprednisolone (Solu-Medrol) D. vitamin K

B. acetylcysteine (Mucomyst)

A patient is admitted to the psychiatric unit for treatment of narcotic addiction. The nurse would anticipate administration of which medication? A. morphine B. methadone C. meperidine D. naloxone

B. methadone

What are Agonists-Antagonists?

Bind to a pain receptor z Cause a weaker neurologic response than a full agonist z Also called partial agonist or mixed agonist

Somatic pain

Body tissue pain (broken ankle) as long as not referred

A patient has been admitted after overdosing on acetaminophen (Tylenol), with a total ingested dose of 14g over a period of 1 hour. The nurse plans to monitor this patient for development of which of the following signs and symptoms related to the overdose? A. Renal failure B. Kidney stones C. Acute hepatic necrosis D. Metabolic alkalosis

C. Acute hepatic necrosis

The nurse teaches a patient prescribed the fentanyl (Duragesic), transdermal delivery system to change the patch at what interval? A. When pain recurs B. Every 24 hours C. Every 72 hours D. Once a week

C. Every 72 hours

In developing a plan of care for a patient receiving morphine sulfate, which nursing diagnosis is a priority? A. Acute pain B. Risk for injury related to central nervous system side effects C. Impaired gas exchange related to respiratory depression D. Constipation related to gastrointestinal side effects

C. Impaired gas exhange related to respiratory depression

The nurse plans pharmacologic therapy for a patient with pain based on the knowledge that: A. Narcotic analgesics should not be used for more than 24 hours secondary to the risk of addiction B. Analgesics should be administered as needed (pm) to minimize side effects C. Pain relief is best obtained by administering analgesics around the clock D. Patients should request analgesics when the pain level reaches a "6" on a scale of 1 to 10

C. Pain relief is best obtained by administering analgesics around the clock

In monitoring a patient for adverse effects related to morphine sulfate, the nurse assesses for stimulation of: A. Autonomic control over circulation B. The cough reflex center C. The chemoreceptor trigger zone D. Respiratory rate

C. The chemoreceptor trigger zone

Persistent or recurring and often difficult to treat. Lasts 3 to 6 months.

Chronic Pain

Opiod Analgesics - Psychologic dependence

Continued craving to get the EFFECTS OTHER THAN PAIN RELIEF - compulsive drug use - not because in pain

A patient receiving narcotic analgesics for chronic pain can minimize the gastrointestinal (GI) side effects by: A. Taking Lomotil with each dose B. Eating foods high in lactobacilli C. Taking the medication on an empty stomach D. Increasing fluid and fiber in diet

D. Increasing fluid and fiber in diet

The nurse prepares to administer morphine sulfate 5 mg IV to a patient who underwent surgery 30 minutes earlier. What is the most important reason for the nurse to record baseline vital signs before administering this drug? A. Morphine sulfate causes release of histamine. B. Morphine sulfate reduces the level of consciousness. C. Morphine sulfate dilates vascular smooth muscle. D. Morphine sulfate depresses the respiratory center.

D. Morphine sulfate depresses the respiratory center. Respiratory depression is the most important reason that the nurse records baseline vital signs before administering morphine IV: Opioid analgesics can cause respiratory depression and death when administered in standard dosages and in an overdose, respectively. Because this patient is in the immediate postoperative period and is likely to experience residual effects of anesthesia, including inability to maintain an airway and respiratory depression, the risk for respiratory depression is high. The patient is also at risk because the route of administration is IV. IV administration of an opioid means that the onset of action occurs quickly, the peak drug level occurs more quickly, and the risk of respiratory depression increases as a result of a generally high plasma drug level. The nurse records baseline data for comparison to vital signs taken 15 minutes after IV administration of morphine to determine whether the patient is experiencing adverse effects of therapy. Morphine dilates vascular smooth muscle, releases histamine, and causes sedation; however, airway and breathing issues are more important. Death following overdose is almost always a result of respiratory arrest.

An 18-year-old basketball player fell and twisted his ankle during a game. The nurse will expect to administer which type of analgesic? A. Synthetic opioid, such as meperidine (Demerol) B. Opium alkaloid, such as morphine sulfate C. Opioid antagonist, such as naloxone HCL (Narcan) D. Nonopioid analgesic, such as indomethacin (Indocin)

D. Nonopioid analgesic, such as indomethacin (Indocin) Somatic pain, originating from skeletal muscles, ligaments, and joints, usually responds to nonopioid analgesics, such as nonsteroidal antiinflammatory drugs (NSAIDs). The other options are not the best choices for somatic pain.

For which type of pain is a fentanyl (Duragesic) transdermal patch best suited? A. Pain after abdominal surgery B. Acute treatment of a migraine headache C. Lower back pain related to lumbar strain D. Severe pain resulting from cancer metastasis

D. Severe pain resulting from cancer metastasis Transdermal fentanyl (Duragesic) is indicated only for persistent severe pain in patients who are already opioid tolerant because fentanyl can cause fatal respiratory depression in patients who are opioid naive. For this reason, the patch is not indicated for acute pain such as postoperative pain, intermittent pain, or pain that responds to a less powerful analgesic.

A patient needs to switch analgesic drugs secondary to an adverse reaction to the present regimen. The patient is concerned that he will not receive an effective doese of a new drug to control pain. The nurse responds based on knowledge that potencies of analgesics are determined using an equianalgesic table comparing doses of these drugs with what prototype? A. meperidine B. fentanyl C. codeine D. morphine

D. morphine

naloxone hydrochloride (Narcan)

DRUG OF CHOICE for complete or partial REVERSAL of opioid-induced respiratory depression - opioid antagonist - Indicated in cases of suspected acute opioid overdose - FAILURE of drug to reverse effects of opioid - indicates condition may not be related to opioid overdose - YOU JUST RULED OUT OPIOIDS AS THE PROBLEM

Interactions

Dangerous interactions may occur if taken with alcohol or other drugs that are hepatotoxic. Should not be taken in the presence of: >Drug allergy >Liver dysfunction >Possible liver failure >G-6-PD deficiency

opioid naive

Describes patients who are receiving opioid analgesics for the first time and therefore are not accustomed to their effects

synergistic effects

Drug interactions in which the effect of a combination of two or more drugs with similar actions is greater than the sum of the individual effects of the same drugs given alone

Explain the Opioid Ceiling Effect:

Drug reaches a maximum analgesic effect Analgesia does not improve, even with higher doses pentazocine nalbuphine

Acetaminophen (Tylenol)

Effective and relatively safe non-opioid analgesic used for mild to moderate pain relief. Avoid and patients were alcoholic or hepatic disease. Available in oral, Rectal, Intravenously.'s component of combination drug hydrocodone- Acetaminophen and oxycodone- Acetaminophen

What is the "Opioid Tolerance" of Opiates?

* A common physiologic result of chronic opioid treatment. * Result: larger dose of opioids is required to maintain the same level of analgesia.

What is the "Physical Dependence" of Opioids?

* Physiologic adaptation of the body to the presence of an opioid. * Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychological dependence (addiction).

What do Antagonists do?

* Reverse the effects of these drugs on pain receptors. * Bind to a pain receptor and exert no response. Note: Are also known as competitive antagonists.

What is the "Mechanism of Action" for Opiates?

* Similar to salicylates * Blocks pain impulses peripherally by inhibiting prostaglandin synthesis.

Opiod Analgesics - CONTRAINDICATIONS

- ALLERGY to them - Severe ASTHMA (respiratory depression) USE CAUTION WITH - Respiratory insufficiency - Elevated intracranial pressure - Morbid obesity/sleep apnea - Paralytic ileus - Pregnancy

Name 4 examples of Analgesics:

1) "Painkillers" 2) Opioids 3) Acetaminophen 4) NSAIDs

Which medication is used to treat a patient suffering from severe advers effects of a narcotic analgesic? A. naloxone (Narcan) B. acetylcysteine (Mucomyst) C. methylprednisolone (Solu-Medrol) D. flumazenil (Romazicon)

A. naloxone (Narcan)

The antidote to acetaminophen is

ACETYLCYSTEINE regimen - hard to get - expensive

A patient is to receive codeine, 40 mg subcutaneously, every 6 hours as needed for pain. The solution is available in a concentration of 30 mg/mL. How many milliliters of codeine will be drawn up for this dose? Round to the nearest tenth.

ANS: 1.3 mL 30 mg : 1 mL :: 40 mg : x mL Solve for x to equal 1.3 mL.

The nurse is reviewing herbal therapies. Which is a common use of the herb feverfew? A. Muscle aches B. Migraine headaches C. Leg cramps D. Incision pain after surgery

ANS: B Feverfew is commonly used for migraine headaches, menstrual problems, arthritis, and fever. Possible adverse effects include muscle stiffness and muscle and joint pain.

A 57-year-old woman being treated for end-stage breast cancer has been using a transdermal opioid analgesic as part of the management of pain. Lately, she has been experiencing breakthrough pain. The nurse should expect this type of pain to be managed by A. administering NSAIDs. B. administering an immediate-release opioid. C. changing the opioid route to the rectal route. D. not changing the current therapy.

ANS: B If a patient is taking long-acting opioid analgesics, breakthrough pain must be treated with an immediate-release dosage form that is given between scheduled doses of the long-acting opioid. The other options are not appropriate actions.

The nurse is reviewing herbal therapies. Which is a common use of the herb feverfew? a. Muscle aches b. Migraine headaches c. Leg cramps d. Incision pain after surgery

ANS: B Feverfew is commonly used for migraine headaches, menstrual problems, arthritis, and fever. Possible adverse effects include muscle stiffness and muscle and joint pain.

A patient is receiving gabapentin (Neurontin), an anticonvulsant, but has no history of seizures. The nurse expects that the patient is receiving this drug for which condition? a. Inflammation pain b. Pain associated with peripheral neuropathy c. Depression associated with chronic pain d. Prevention of seizures

ANS: B Anticonvulsants are often used as adjuvants for treatment of neuropathic pain to enhance analgesic efficacy. The other indications listed are not correct

Vicodin (acetaminophen/hydrocodone) is prescribed for a patient who has had surgery. The nurse informs the patient that which common adverse effects can occur with this medication? (Select all that apply.) a. Diarrhea b. Constipation c. Lightheadedness d. Nervousness e. Urinary retention f. Itching

ANS: B, C, E, F Constipation (not diarrhea), lightheadedness (not nervousness), urinary retention, and itching are some of the common adverse effects that the patient may experience while taking Vicodin

A patient will be discharged with a 1-week supply of an opioid analgesic for pain management after abdominal surgery. The nurse should include which information in the teaching plan? A. Management of diarrhea B. Drug addiction programs C. Prevention of constipation D. Dehydration due to polyuria

ANS: C Gastrointestinal adverse effects, such as nausea, vomiting, and constipation, are the most common adverse effects associated with opioid analgesics. Physical dependence usually occurs in patients undergoing long-term treatment. Diarrhea and polyuria are not effects of opioid analgesics.

A patient has been treated for lung cancer for 3 years. Over the past few months, she has noticed that the opioid analgesic she has been taking is not helping as much as it had previously and says she needs to take more medication for the same pain relief. The nurse is aware that this patient is experiencing opioid A. toxicity. B. addiction. C. tolerance. D. abstinence syndrome.

ANS: C Opioid tolerance is a common physiologic result of long-term opioid use. Patients with opioid tolerance require larger doses of the opioid agent to maintain the same level of analgesia. This situation does not describe toxicity (overdose), addiction, or abstinence syndrome (withdrawal).

The nurse is assessing a patient who has been admitted to the emergency department for a possible opioid overdose. Which assessment finding is characteristic of an opioid drug overdose? a. Dilated pupils b. Restlessness c. Respiration rate of 6 breaths/minute d. Heart rate of 55 beats/minute

ANS: C The most serious adverse effect of opioid use is CNS depression, which may lead to respiratory depression. Pinpoint pupils, not dilated pupils, are seen. Restlessness and a heart rate of 55 beats per minute are not indications of an opioid overdose.

A patient is to receive acetylcysteine (Mucomyst) as part of the treatment for an acetaminophen (Tylenol) overdose. Which action by the nurse is appropriate when giving this medication? a. Giving the medication undiluted for full effect b. Avoiding the use of a straw when giving this medication c. Disguising the flavor with soda or flavored water d. Preparing to give this medication via a nebulizer

ANS: C Acetylcysteine has the flavor of rotten eggs and so is better tolerated if it is diluted and disguised by mixing with a drink such as cola or flavored water to help increase its palatability. The use of a straw helps to minimize contact with the mucous membranes of the mouth and is recommended. The nebulizer form of this medication is used for certain types of pneumonia, not for acetaminophen overdose

A patient is suffering from tendonitis of the knee. The nurse is reviewing the patient's medication administration record and recognizes that which adjuvant medication is most appropriate for this type of pain? a. Antidepressant b. Anticonvulsant c. Corticosteroid d. Local anesthesia

ANS: C Corticosteroids have an antiinflammatory effect, which may help to reduce pain. The other medications do not have antiinflammatory properties

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 per minute. The nurse prepares for which priority action at this time? a. Assessment of the patient's pain level b. Immediate intubation and artificial ventilation c. Administration of naloxone (Narcan) d. Close observation of signs of opioid tolerance

ANS: C Naloxone, an opioid-reversal agent, is used to reverse the effects of acute opioid overdose and is the drug of choice for reversal of opioid-induced respiratory depression. This situation is describing an opioid overdose, not opioid tolerance. Intubation and artificial ventilation are not appropriate because the patient is still breathing at 7 breaths per minute. It would be inappropriate to assess the patient's level of pain.

The drug nalbuphine (Nubain) is an agonist-antagonist (partial agonist). The nurse understands that which is a characteristic of partial agonists? a. They have antiinflammatory effects. b. They are given to reverse the effects of opiates. c. They have a higher potency than agonists. d. They have a lower dependency potential than agonists

ANS: D Partial agonists such as nalbuphine are similar to the opioid agonists in terms of their therapeutic indications; however, they have a lower risk of misuse and addiction. They do not have antiinflammatory effects, nor are they given to reverse the effects of opiates. They do not have a higher potency than agonists

Occurs in tissues below skin level.

Deep pain

breakthrough pain

Pain that occurs between doses of pain medication

antagonist

a drug that binds to a receptor and prevents a response

pain tolerance

amount of pain a patient endures without its interference of ADLs