NUR 3320 Exam 3: Pain
How do we assess pain?
OLDCART Onset Location Duration Characteristics Aggravating factors Relieving factors Treatment
A nurse is reviewing nursing actions for emergency treatment of malignant hyperthermia with a group of nursing students. Which statement by a student indicates a need for further teaching? A. "Analgesics should be given to help with muscle pain." B. "Dantrolene helps to slow the metabolic activity in skeletal muscles." C. "If malignant hyperthermia occurs, the succinylcholine must be stopped immediately." D. "The patient may need an intravenous infusion of cold saline."
A Malignant hyperthermia is a rare but potentially fatal adverse reaction that can be triggered by succinylcholine. Muscle pain is an expected adverse effect of succinylcholine that is thought to be caused by the muscle contractions that occur during induction; analgesics can be given, but this effect usually occurs 10 to 12 hours after the procedure and is not an emergency. Dantrolene is given because it slows metabolic activity in skeletal muscles, resulting in decreased heat production. Succinylcholine should be stopped immediately if malignant hyperthermia occurs. Cold saline, given intravenously, often is necessary to lower a patient's temperature.
After surgery, a patient has morphine prescribed for postoperative pain. It is most important for the nurse to make which assessment? A.Respiratory rate B.Heart rate C.Pain level D.Constipation
A Rationale: Monitoring the respiratory rate in all patients who are receiving morphine is a priority. If the respiratory rate is 12 or fewer breaths per minute, the nurse should withhold the medication and notify the prescriber.
The patient has received isoflurane [Forane] as a general anesthetic. What should the nurse closely observe the patient for during the immediate postoperative period? A.Elevated blood pressure B.Decreased respiratory rate C.Malignant hyperthermia D.Decreased pulse rate
B Isoflurane causes respiratory depression and hypotension. Malignant hyperthermia occurs in genetically predisposed patients; the use of succinylcholine with halothane may produce malignant hyperthermia
A patient reports having taken morphine for the past 6 months. Which medication, if ordered by the physician, should the nurse question? A.Promethazine [Phenergan] B.Pentazocine [Talwin] C.Methylnaltrexone [Relistor] D.Dextromethorphan [Delsym]
B Pentazocine is an agonist-antagonist opioid. If pentazocine is given to a patient who is physically dependent on a pure opioid agonist such as morphine, withdrawal or abstinence syndrome will occur. Before an agonist-antagonist is administered, the patient should be slowly withdrawn from the opioid agonist.
Tx for Headache
Abortive Therapy : eliminate H/A and suppress associated N&V. 1. Aspirin like drugs: acetaminophen + aspirin + caffeine 2. Sumatriptan - Triptans are the first line drug for terminating migraine headache 3. Opioid Analgesics: preferred butorphanol nasal spray - less side effects [meperidine - adverse effects (resp depression, sedation, constipation)] Ergotamine (prototype): the seond line if haven't responded to triptan Limit abortive mx to 1-2 days/week; more frequent can lead to mx overuse H/A Antiemetics: metoclopramide preferred- reduce N&V
Non-Opioid Analgesic Prototypes
Acetaminophen (Tylenol) NSAIDS: Meloxicam (Mobic) Naproxen (Aleve, Midol) Radiopharmaceuticals: Strontium-89 Chloride (Metastron) Herbals Salicylates: Aspirin
Drug Interactions and Adverse Effects of Inhaled Anesthetics
Adverse Reactions: An exaggerated patient response to a normal dose. Malignant hyperthermia •characterized by a sudden and usually lethal increase in body temperature •is a serious and unexpected reaction to inhalation anesthetics - risk increases with succinylcholine (neuromuscular blocking agent) •It occurs in the genetically susceptible patient only Antidote: •The skeletal muscle relaxant Dantrolene is used to treat this condition. Drug Interactions: Other CNS, cardiac or respiratory depressant drugs
What effects can Opioids produce?
Analgesia Euphoria Sedation Respiratory depression Physical dependence Constipation
The patient asks the nurse about spinal headaches. She wants to know how the headache would be treated if she got one. How should the nurse reply?
Headaches after spinal anesthesia usually occur between 6 and 48 hours after the procedure. If a patient experiences a spinal headache, it is most often treated with analgesics, increased fluids, bed rest, and sometimes caffeine. Sometimes a small amount of the patient's blood is injected into the spinal area; this is known as a blood patch.
Neuromuscular Blocking Agent Drug Interactions
Antibiotics Effects can be intensified by aminoglycosides, tetracyclines, and other non-penicillin antibiotics Cholinesterase Inhibitors Potentiate (intensity) the effects of succinylcholine CI are contraindicated for patients receiving succinylcholine.
Opioid Prototypes
Morphine Codeine Other Opioids: Hydrocodone (Vicodin); Butorphanol; Fentanyl; Hydropmorphone; Demerol; Dolophine; Oxycodone; Percocet; Tramadol (Ultram); Nubain; Oxymorphone; Pentazocine; Remifenanil; Nucynta; Sefenta
Nursing Interventions for Pain of Oncological Disorders Continued
Assess the client's pain Pain is what the client says it is Do not under medicate the client with cancer who is in pain. Manage Side Effects •Respiratory depression --Most serious side effect. Death can result. •Constipation --Occurs in most patients •Sedation --Common early in therapy, but tolerance develops quickly •Nausea and Vomiting --Initial doses. Can pretreat with antiemetic. •Orthostatic hypotension •Urinary retention
The nurse administers the preoperative medication midazolam [Versed]. The nurse will monitor the patient for which intended effect of this medication? A.Decreased bronchial secretions B.Reduction in anxiety C.Respiratory depression D.Suppression of cough
B Benzodiazepines (e.g., midazolam) are given preoperatively to reduce anxiety and promote amnesia. Midazolam does not cause respiratory changes. Atropine will decrease bronchial secretions. Opioids may cause respiratory depression and the suppression of cough.
The nurse is caring for a patient who is receiving intravenous propofol [Diprivan]. Which action by the nurse is most appropriate? A.Discard any unused solution within 6 hours. B.Assess the patient for malignant hyperthermia. C.Make the environment quiet to prevent delirium. D.Keep a written record of the dispensing of this drug.
B Benzodiazepines (e.g., midazolam) are given preoperatively to reduce anxiety and promote amnesia. Midazolam does not cause respiratory changes. Atropine will decrease bronchial secretions. Opioids may cause respiratory depression and the suppression of cough.
Opioid Educaton
Be care walking and getting up from bed Avoid hazardous activities No alcohol Increase fiber in diet and use a stool softener to prevent constipation Breathe deeply, cough, and change position every 2 hours Report continued pain
What mx did we discuss to help with post op urinary retention?
Bethanecol
When do you withhold Aspirin and notify provider
Bleeding Salicylism (salicylate poisoning characterized by tinnitus or hearing loss) Adverse GI reactions Stop aspirin 5-7 days before elective surgery is ordered.
An adult patient receives lidocaine by injection before a procedure. Which finding indicates that the patient is experiencing a systemic reaction and toxicity? A.Mean arterial pressure of 75 mm Hg B.Temperature of 100.8º F (38.2º C) C.Heart rate of 42 beats/min D.Respiratory rate of 12 breaths/min
C Absorption into the general circulation can cause systemic toxicity, and effects on the central nervous system and the heart are of greatest concern. Central nervous system toxicity manifests as a brief period of excitement, possibly including convulsions; this is followed by central nervous system depression, which can result in respiratory depression. Cardiotoxicity can manifest as bradycardia, atrioventricular heart block, and cardiac arrest.
The nurse cares for a patient who received nitric oxide along with a primary anesthetic. The nurse should assess the patient for which adverse effect of nitric oxide? A.Urinary retention B.Elevated temperature C.Nausea and vomiting D.Depressed respiratory rate
C At therapeutic concentrations, nitrous oxide has no serious adverse effects. The major concern with nitrous oxide is postoperative nausea and vomiting, which occur more often with this agent than with any other inhalation anesthetic. The drug does not cause cardiovascular or respiratory depression, and it is not likely to precipitate malignant hyperthermia.
A patient has an allergy to procaine [Novocain]. What local anesthetic would be safe to administer to this patient? A.Cocaine B.Benzocaine [Americaine] C.Lidocaine [Xylocaine] D.Tetracaine
C Individuals who are allergic to procaine should be considered allergic to all other ester-type anesthetics but not to the amides. Procaine, benzocaine, cocaine, and tetracaine are all esters. Lidocaine is an amide.
A patient receives a neuromuscular blocking agent before a procedure. The patient's eyes close. The nurse knows this is a sign that the patient: A. has fallen asleep. B. has received a toxic dose of the medication. C. is beginning to feel the drug's effects. D. may need mechanical ventilation.
C Neuromuscular blocking agents relax skeletal muscle to produce flaccid paralysis; the first muscles to be affected are the levator muscle of the eyelids and the muscles of mastication.
A patient is prescribed ergotamine tartrate [Ergomar] for migraine headaches. Which statement made by the patient indicates a need for further teaching? A. "I should place the tablet under my tongue." B. "I need to use birth control pills while taking this medication." C. "I am not at risk for physical dependence with this drug." D. "I should avoid drinking grapefruit juice with this medication."
C The regular daily use of ergotamine, even in moderate doses, can cause physical dependence. Withdrawal symptoms include headache, nausea, vomiting, and restlessness.
Which patient would be at highest risk for systemic toxicity from the topical administration of a local anesthetic? A. A 42-year-old patient who receives epinephrine with a local anesthetic B. A 72-year-old patient who receives a local anesthetic that is topically applied to intact skin C.A 58-year-old patient who receives a local anesthetic to a 10×20-cm abrasion D.A 34-year-old patient given an injection of bupivacaine as a nerve block
C The risk of toxicity is less if epinephrine is administered, because blood flow will be decreased (vasoconstriction), thus delaying the systemic absorption of the anesthetic. The risk of toxicity increases with a large surface area or an abraded area
The nurse is caring for a patient with migraine headaches. Which assessment best indicates that sumatriptan [Imitrex] is exerting the desired therapeutic effect? A. The patient experiences decreased frequency of migraine headaches. B. The patient does not experience any more migraine headaches. C. The patient reports the termination of the migraine headache after the drug is is administered. D. The patient experiences decreased nausea associated with the migraine headache.
C The therapeutic goal for triptans such as sumatriptan is to abort an ongoing migraine headache
A patient receives a bupivacaine [Marcaine] injection for infiltration anesthesia. When would the nurse expect the onset of local anesthesia to occur? A.30 seconds B.2 minutes C.5 minutes D.10 minutes
C Bupivacaine administered by infiltration anesthesia has an onset of 5 minutes
Adverse Effects of Salicylates
Most Common: •Gastric distress (give with food, milk or a large glass of water to reduce GI reactions) •N&V •Bleeding tendencies Other: Hearing loss, diarrhea, thirst, tinnitus, confusion, dizziness, impaired vision, hyperventilation, Reye's syndrome (when given to children w the chickenpox or flulike symptoms)
Drug Interactions of Opioids
CNS Depressants Intensify sedation and respiratory depression Anticholinergic Drugs Exacerbate constipation and urinary retention Antihypertensive Drugs Exacerbate hypotension Agonist-Antagonist Opioids Can precipitate withdrawal syndrome if given to physically dependent individual Opioid Antagonists Treats opioid overdose Counteracts actions of morphine.
Opioid Antagonist - Nalaxone
Can be used to treat opioid toxicity (with ventilatory support) Opioid Toxicity: Classic Triad Respiratory depression, pinpoint pupils, coma Nalaxone can be used to treat the respiratory depression. Since it reverses the analgesic effects of opioids, pt who is given an opioid drug for pain relief may complain of pain or even experience withdrawal symptoms; once Nalaxone is given, additional narcotics cannot be given until the Nalaxone effects have passed.
Cancer's Early Warning Signs - CAUTION
Change in bowel/bladder A lesion that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficult swallowing Obvious changes in wart/mole Nagging cough or persistent hoarseness
A postoperative patient who received an intravenous infusion of morphine has a respiratory rate of 8 breaths per minute and is lethargic. Which as-needed medication should the nurse administer to the patient? A.Methadone [Dolophine] B.Nalbuphine [Nubain] C.Tramadol [Ultram] D.Naloxone [Narcan]
D After surgery, naloxone may be used to reverse the excessive respiratory and central nervous system depression that can be caused by opioids.
A postoperative patient who received an intravenous infusion of morphine has a respiratory rate of 8 breaths per minute and is lethargic. Which as-needed medication should the nurse administer to the patient? A.Methadone [Dolophine] B.Nalbuphine [Nubain] C.Tramadol [Ultram] D.Naloxone [Narcan]
D After surgery, naloxone may be used to reverse the excessive respiratory and central nervous system depression that can be caused by opioids.
The physician prescribes propranolol [Inderal] for a patient with migraine headaches. It is most important for the nurse to do what? A.Determine whether the patient has an allergy to rizatriptan [Maxalt]. B.Inform the patient that the medication is immediately effective. C.Teach the patient that the medication may cause dependence. D.Instruct the patient that the medication will prevent migraines.
D Beta blockers (for example, propranolol) are first-line drugs for migraine prevention. Benefits take a few weeks to develop. If rizatriptan is used for abortive therapy, its dosage must be reduced
What do you give for malignant hyperthermia??
Dantrolene: the skeletal muscle relaxant will treat this
Vascular headache suppressants
Directly stimulate alpha-adrenergic and seroternergic receptors, producing smooth muscle vasoconstriction (ergot derivatives); narrowing dilated blood vessels and block nerves from transmitting signals of pain to the brain (5HT1- agonists) Tx vascular headaches (migraines and cluster headaches)
Acetaminophen
Drug of choice for fever or flulike symptoms Be aware that high doses or unsupervised long-term use can cause liver damage (excessive alcohol use increases risk) Liver toxicity increased with: phenytoin, barbiturates, carbamezapine, rifampin, and isoniazid are combined with acetaminophen Monitor for hepatic damage (N&V, diarrhea, abdominal pain) Antidote: Acetylcysteine
Local Anesthetics
Drugs that suppress pain. Pain is suppressed without causing generalized depression of the entire nervous system. Usually preferred to general anesthetics for surgery in elderly or debilitated patients or in patients with disorders that affect respiratory function, such as chronic obstructive pulmonary disease and myasthenia gravis. Procaine: •Not effective topically, must be injected •Administration with epinephrine delays absorption Lidocaine: •Most widely used - both topical and by injection •Effects are extended with coadministration with epinephrine.
Adverse Effects of NSAIDs
Dysrhythmias Cardiovascular thrombotic events Gastric irritation Tinnitus Fluid retention Elevated liver enzymes -Hepatotoxicity Nephrotoxicity Thrombocytopenia Interventions: Take with food to reduce GI symptoms Watch for signs of bleeding Avoid alcohol Check liver, renal, and CBC labs
Salicylate Poisoning
Fever Tinnitus N&V Lethargy/Excitability Hyperventilation leading to respiratory alkalosis When severe: Metabolic Acidosis Seizures Toxic Level for a 30lb child: 12 adult aspirin; or 48 baby aspirin
Anesthetic drugs' 3 groups
General Local Topical
Nursing Implications and Vascular H/A Suppressants
Goal - termination of migraine headache Baseline Data Age at onset, frequency, location, intensity, quality, aura Trigger (stress, anxiety, fatigue, alcohol, tyramine containing foods). Administration (oral, subcutaneous, intranasal, transdermal meds) Enhance Therapeutic Effects Relaxation techniques, quiet, dark room, ice pack to neck, scalp Minimize Adverse Effects Triptans - monitor coronary vasospasm with resultant anginal pain. Avoid triptans with patients - heart disease, prior MI Don't administer triptan and ergotamine together = vasospasm. Must wait 24 hours Avoid SSRI/SNRI with triptan = serotonin syndrome risk Ongoing evaluation and interventions
Opioid Precautions
Head injury -increased ICP Hepatic disease Renal disease CNS depression Pregnant and breast-feeding patients Older aged adults -dosage may need to be reduced for all these patients
Neuromuscular Blocking Agents
Pancuronium (prototype): muscle relaxation during surgery, intubation and mechanical ventilation Succinylcholine (prototype): muscle relaxation (short onset; peak 1 minute after IV injection and fades 4-10 minutes)); primary use for muscle relaxation during endotracheal intubation
Non-pharmacological forms of pain relief
Heat and cold applications TENS Massage Distraction Relaxation techniques Biofeedback techniques Enables control of autonomic responses (tachycardia, muscle tension) to pain through electrical feedback
How do inhaled anesthetics work?
Inhalation anesthetics work primarily by depressing the CNS: producing loss of consciousness loss of responsiveness to sensory stimulation (including pain) muscle relaxation
General Anesthetics
Inhaled Anesthetics: Isoflurone - most widely used: •Weak analgesic, coadministration of strong analgesic •Muscle relaxation - inadequate for surgery - concurrent use of neuromuscular blocking agent (Pancuronium) •Adverse Effects - hypotension, respiratory depression, N&V Nitrous Oxide: •Many patients undergoing general anesthesia receive nitrous oxide to supplement the analgesic effects of the primary anesthetic. •Can also reduce the amount of primary anesthetic needed.
What will occur if mixed agonist-antagonists are administered to a patient already taking narcotics?
Initiation of withdrawal symptoms: Tremors Agitation N&V
Pain Control - Oncological Disorders
Objective is to maximize comfort Psychological and physiologic dependence are minimal concerns; pt's should be given as much mx as needed to relieve pain. Good news: pain can be relieved in 90% of pt's Bad news: pain goes unrelieved/undertreated Causes of pain: •Radiation, surgery •Bone destruction •Obstruction of an organ •Compression of nerves •Infiltration, distention of tissue •Inflammation, necrosis •Psychological factors: •Fear, anxiety
Adverse Effects of Neuromuscular Blocking Agents
Malignant Hyperthermia Rare, potentially fatal condition triggered by succinylcholine Muscle rigidity, elevation of temp Treat - d/c succinylcholine, cool pt with external ice pack and IV cold saline, administer IV Dantrolene What else is Dantrolene used for? Relieves spasm by suppressing release of calcium from sarcoplasmic reticulum; Relieves spasticity with MS, cerebral palsy, spinal cord injury Post op muscle pain Neck, shoulders, and back, reassure this is a usual response Occurs 12-24 hours after surgery, may persist several hours/days Hyperkalemia Succinylcholine promotes release of potassium from tissues Most likely to occur: patients with major burns, multiple trauma, Watch cardiac arrest
Pain Management for Cancer
Mild to Moderate: Non-Opioid Analgesics - NSAIDs and acetaminophen Moderate to Severe: Opioid Analgesics - Moderate: Oxycodone Severe: Morphine **Avoid meperidine (demerol): if taken chronically, toxic metabolite - normeperidine can accumulate putting the pt at risk for adverse CNS effects (seizures, agitation)
MORPHINE Mnemonic
Mioisis Orthostatic Hypotension Respiratory depression Physical dependence Histamine release Increased ICP nausea Euphoria Sedation
Butorphanol (Stadol)
Mixed agonist-antagonist analgesic resulting in good analgesia but with less respiratory depression, nausea, and vomiting compared with opioid agonist analgesics.
Nursing Implications for Inhaled Anesthesia
Monitor VS (check for hypotension, respiratory depression) CNS: return is gradual, side rails up, safety first GI: constipation, N&V Urinary Retention: Monitor I&Os, catheter may be needed
NSAIDs Contraindications Mnemonic
Nursing & pregnancy Serious bleeding Asthma/ Allergy/ Angioedema Impaired renal function Drug (anticoagulant)
Celebrex (celecoxib)
NSAID - COX 2 Selective Inhibitor COX-2 produces the analgesic and anti-inflammatory effects without causing the adverse GI effects Greater risk of thrombotic events Monitor for S&S of MI
Non-Opioids What to Know
Nice to Know: Analgesia for mild to moderate pain NSAIDS - pain relief, suppression of inflammation, and reduction of fever Acetaminophen - analgesia but lacks anti-inflammatory Good to Know: Strontium-89 chloride is a radiopharmaceutical is given intravenously to help relieve the bone pain associated with some cancers. Really Important to Know: Acetaminophen is found in more than 600 (!) over-the-counter drugs. Educate your clients to read labels and reinforce the recommended maximum daily dose is 4000 mg.
Vascular Headache Suppressants - What to Know
Nice to Know: Controlled studies have shown the herb feverfew reduces the frequency of migraine attacks. Feverfew leaves are available in capsules or tablets. Good to Know: When taken regularly, these medications can reduce the number of migraine attacks: amitriptyline (antidepressant); propranolol (beta blocker); verapamil (calcium channel blocker); valproic acid, gabapentin and topiramate (seizure medications). Really Important to Know: The serotonin receptor agonists (the "triptans") do not prevent migraines. Taken at the first signs of a migraine, they prevent symptoms from getting worse (severe throbbing, nausea, and sensitivity to sound and light). The ergots (Ergotamine) also help stop migraine attacks. (treat and prevent). --Do not take ergotamine if you also take macrolide antibiotics (eg, erythromycin), certain HIV protease inhibitors (eg, ritonavir), or certain azole antifungals (eg, ketoconazole,). --A serious and sometimes fatal decrease in blood flow to the extremities (eg, hands, feet) or brain may occur
NSAIDs - What to Know
Nice to Know: NSAIDs decrease the ability of blood to clot and therefore increase bleeding; all NSAID medicines should be stopped prior to surgery. Good to Know: Take with a full (6-8 oz.) glass of water. If stomach upset occurs, take with food, milk, or an antacid (yes, really... unlike other medications, they are okay to take with an antacid). Really Important to Know: Teach your client to check labels on all medications since many medications contain aspirin or other aspirin-like NSAIDs.
What to Know Opioids
Nice to Know: Oral transmucosal fentanyl citrate and fentanyl buccal tablets are rapid-onset opioids that do not have to be swallowed. They are approved for the treatment of cancer-related breakthrough pain. All opioids cause miosis EXCEPT for meperidine.Because meperidine has muscarinic blocking activity. it actually causes mydriasis Good to Know: Opioid medications can cause respiratory arrest. Monitor LOC, RR, and O2 sat in patients receiving opioid meds. Assess initial VS and withhold and notify provider if patient has a decreased LOC or RR <12 breaths per minute Really Important to Know: The opioid antagonist drug naloxone (Narcan) is given IV push to reverse respiratory depression of opioid drugs. Opioid Overdose-Known or Suspected: An initial dose of 0.4 mg to 2 mg of NARCAN (naloxone) may be administered intravenously.
What drugs cannot be combined with acetaminophen due to risk of hepatotoxicity?
Phenytoin Barbiturates Carbamezapine Rifampin Isoniazid Antidote: Acetylcysteine
Physical and Psychosocial Interventions for Oncological Disorder Pain
Physical: Heat Cold Massage Exercise Psychosocial: Relaxation Imagery Cognitive distraction Support groups
Tx for Headache continued
Preventateie therapy Beta blockers (propranolol): first line for migraine prevention Antiepileptics (Depakote, Topamax, Gabapentin) Tricyclic Antidepressants
IV Anesthetics
Propofol (Diprivan) •Most widely used for induction and maintenance of general anesthesia as part of balanced anesthesia technique. •Also can be used to sedate patients undergoing mechanical ventilation, radiation therapy, diagnostic procedures (endoscopy, MRI) •No analgesic actions •Low therapeutic index •Monitor - CNS depression Benzodiazepines (Diazepam) - prototype: •Given to induce anesthesia •Monitor - Respiratory depression, cardiovascular depression, CNS depression Ketamine •Used for minor surgical and diagnostic procedures •Produces dissociative anesthesia. •Avoid with patients with history of psychiatric illness due to adverse psychologic effects (hallucinations, disturbing dreams, and delirium).
Opiods- what will you monitor?
Respiratory Status: Tis may last longer than the analgesic effect and nalaxone and resuscitative equipment should be nearby Pain relief BP: hypotension HR: bradycardia Other Adverse Reactions: Constipation, urinary retention Tolerance and Dependence: the first sign is usually a shortened duration of drug effectiveness
What are the 4 side effects of narcotic medications?
Respiratory depression CNS depression N&V Constipation
Adverse Effects of Opioids
Respiratory depression Constipation Orthostatic Hypotension Urinary Retention (Monitor I&O; palpate the abdomen q4-6h) Cough Suppression Emesis (Pretreatment: Prochlorperazine) Elevated Intracranial Pressure: (Occurs with suppressed respirations; increases CO2 in blood, dilates cerebral vasculature, causes ICP to rise) Euphoria (contributes to potential for abuse) Sedation Miosis
Therapeutic Uses of NSAIDs
Rheumatoid arthritis Cancer pain Osteoarthritis Gouty arthritis Dysmenorrhea Migraines Bursitis, tendinitis Mild to moderate pain
Mixed Opioid Agonist-Antagonists
Some opioid analgesics have agonist and antagonist properties. The agonist component relieves pain while the antagonist decreases risks of toxicity and dependence; thus reducing the risk for respiratory depression and drug abuse Prototypes: pentazocine hydrochloride butorphanol tartrate (Stadol)
NSAIDs Pt Education
Some types of therapy may not be achieved for 2-4 weeks Take the drugs with milk or meals to reduce GI effects Don't excess daily dosage, or give to children under 12 Using the drug with aspirin, alcohol or corticosteroids may increase risk of GI effects Recognize and report S&S of GI bleeding (dark stools, blood in urine, and unusual bleeding (i.e in the gums) Use sun block, and protective clothing and avoid prolonged time in the sun If long term therapy, check with prescriber about monitoring lab values especially BUN, Cr, LFTs, and CBCs Don't take other mx, OTCs, or herbal products without consulting provider.
NSAID Contraindications and Interactions
Taken with thiazide diuretics cause cause reduced antihypertensive and diuretic effects: BP must be checked regularly and be aware of signs of fluid retention Contraindicated: Hypersensitivity Liver or renal disease ASA and NSAID should not be taken together Aspirin decreases the blood level and effectiveness of NSAID but increases risk of bleeding NSAID increases effect of: warfarin, sulfonamides, cephalosporins, phenytoin
Neuromuscular Blocking Agents & Safety
The Institute for Safe Medication Practices (ISMP) includes neuromuscular blocking agents among its list of high-alert medications. High alert medications are those drugs that can cause devastating effects to patients in the event of a medication error.
Nursing Implications for Opioids
The goal is to relieve moderate to severe pain while causing minimal respiratory depression, constipation, urinary retention and other adverse effects Obtain Baseline data: pain, VS, identify high risk pt's Administer as ordered Evaluate therapeutic effects (1 hour after administration) Minimize adverse effects and interactions
The nurse is caring for a patient who had extensive abdominal surgery 3 days ago. Morphine is being administered to the patient via a patient-controlled analgesia pump for pain control. What reversal agent should the nurse have available in case the patient experiences the severe adverse effects of morphine therapy for pain control? What is the action of this agent?
The nurse should have naloxone readily available in case the patient experiences the severe adverse effects of morphine therapy. Naloxone is the drug of choice for treating overdose with a pure opioid agonist. Naloxone is an opioid antagonist that reverses respiratory depression, coma, and other signs of opioid toxicity by blocking the effects of opioid agonists.
A patient in labor requests a spinal anesthetic. The patient has many questions to ask the nurse. How should the nurse respond to the following question from the patient? "I want to be awake during the birth. Will I fall asleep after I have the spinal?"
The nurse should inform the patient that she will not lose consciousness after she has the spinal anesthetic. She will be awake and will feel no pain. The anesthetic will affect regions of her spine that result in the absence of pain, but it will not affect her level of awareness
The nurse assesses the patient's respiratory rate to be 6 breaths per minute. The nurse reviews the order for naloxone, which states the following: Administer 0.1 mg naloxone by mouth for a respiratory rate of less than 8 breaths per minute. What is the most appropriate response by the nurse?
The nurse should question this order. Although the 0.1 mg dose of naloxone is the recommended dose for an adult, the drug cannot be administered by mouth. Naloxone cannot be used orally because of its rapid first-pass inactivation. Routes for naloxone administration include intravenous, intramuscular, and subcutaneous. For the treatment of postoperative opioid effects, Initial therapy for adults consists of 0.1 to 0.2 mg given intravenously and repeated every 2 to 3 minutes until an adequate response has been achieved. Additional doses may be required at 1- to 2-hour intervals.
The patient says that the anesthesiologist told her that there were some risks associated with spinal anesthesia regarding blood pressure. She asks the nurse to explain them. How should the nurse respond?
The spinal anesthetic is administered immediately before delivery, when the baby's head is on the perineum and the cervix is fully dilated. If the patient's blood pressure drops, fluids can be administered, and the patient can be positioned with a wedge under the hip to help raise the blood pressure
NSAIDs
These medications block the cyclooxygenase (COX-1 & COX-2) enzymes and reduce prostaglandins throughout the body, reducing inflammation, pain, and fever (antipyretic). Used to control mild to moderate pain, reduce fever and to treat various inflammatory conditions such as osteoarthritis. Examples: Motrin, Advil, Aleve, Toradol, Salicylates, Celebrex
Opioid Analgesics
These medications interact with opioid receptors in the central nervous system, acting as agonists of endogenously occurring opioid peptides. Principal indication is for pain relief; post op pain, L&D, chronic pain; pain for an MI Moderate to Severe Pain** These are Schedule II drugs
Non-Opioid Analgesics
These meds target and block the chemical substances released by the brain (particularly prostaglandin) in response to injury. Used to control mild to moderate pain and/or fever
Serotonin Receptor Agonists (Triptans)
Triptans can cause vasoconstriction and coronary vasospasm. These drugs should not be administered to patients with coronary artery disease, current symptoms of angina, or uncontrolled hypertension. Prototype: Sumatriptan
Pain Management in Cancer Patients
Two major forms of Pain: Nocioceptive: Injury to tissues- Somatic: bones, joints, muscles (described as sharp and localized) Visceral: injury to visceral organs (i.e. small intestine) (vaguely localized with a diffuse, aching quality) Neuropathic: Injury to peripheral nerves
Nursing Interventions for Pain of Oncological Disorders
•Pain management program - collaborate with health care team •Oral preparations if possible and if they provide adequate relief •Transdermal may also be provided •Fentanyl patch - available in 5 strengths •Mild - Moderate Pain --Salicylates, NSAIDs •Severe Pain --Codeine sulfate, morphine sulfate, hydromorphone hydrochloride •Subcutaneous Injections and continuous IV infusion of opioids provide rapid pain control •Monitor VS and for side effects •Monitor effectiveness of meds and assess/manage breakthrough pain Provide non-pharmacologic techniques of pain control
Salicylates (Aspirin)
Used to control pain, reduce fever, reduce inflammation One salicylate, Aspirin, inhibits platelet aggregation (thus prevents clotting) and as a result can enhance blood flow during an MI and prevent an event such as a recurrent MI
Neuromuscular Blocking Agents & State of Consciousness
•Patient may appear unresponsive due to drug induced paralysis, however, they are fully alert, conscious, and can feel pain. •Nurse - Administer prescribed meds (sedatives, analgesics) on a regular basis to prevent undue suffering.
Local and Topical Anesthetic Uses
•relieve or prevent pain ---especially minor burn pain •relieve itching and irritation •anesthetize an area before an injection is given •numb mucosal surfaces before a tube, such as a urinary catheter, is inserted •alleviate sore throat or mouth pain when used in a spray or solution
IV anesthetics
barbiturate (methohexital, thiopental) benzodiazepine (diazepam) dissociative (ketamine) hypnotic (propofol) opiate (fentanyl) Because of the short duration of action of IV anesthetics, they're used in shorter surgical procedures, including outpatient surgery.