PHARMACOLOGY MODULE 2

ACETYLSALICYLIC ACID: ASPIRIN Contraindications:

Pregnancy (especially third trimester) children and teenagers with viral symptoms, should be stopped 7 days prior to surgery

Ibuprofen •Contraindications:

Pregnancy (especially third trimester), should be stopped 7 days prior to surgery, renal failure​

A substance that binds to a receptor and causes a response

agonist

When a drug no longer effectively controls pain despite administration of the highest safe dose

anagelestic ceiling

A substance that binds to a receptor and causes a response

antagonist

Opioid Analgesics Chemical structure:

morphine-like drugs, meperidine like drugs and methadone like drugs

An opioid-antagonists used to reverse opioid toxicity and overdose

nalaxone

Pain that results from disturbance in nerve function

neuropathic pain

Classic signs and symptoms of inflammation

•Pain​ •Fever​ •Loss of function​ •Redness​ •Swelling

Anti-Gout Drugs •Antigout Medication General Education​

•Patient's need to increase fluid intake to 3L per day (if not contraindicated)​ •Patient's should avoid caffeine and alcohol as they increase production of uric acid​ •Patient should avoid foods high in purines (organ meats and alcohol-especially beer)

Anti-Gout Drugs •Probenecid​

Inhibits the reabsorption of uric acid, increasing elimination of uric acid in the urine​

Cox-2 Inhibitors: Celecoxib •Caution:

Hypertension, renal/hepatic dysfunction, heart disease​

A patient with acute gout is receiving anti-gout therapy. The patient is prescribed to continue the allopurinol as prescribed at home and colchicine 0.6 mg PO every hour until pain is relieved or cumulative dose of 6 mg has been reached. What patient education should be provided to the patient? SELECT ALL THAT APPLY

Increase fluid intake to 3 liters per 24 hours Avoid alcohol because it increases the uric acid levels Fluid should be increased to a minimum of 3 L per 24 hours while on anti-gout medications as it helps with the excretion of the uric acid crystals. Alcohol, organ meats, and caffeine should be avoided because they increase the uric acid levels in the blood, which can lead to acute gout attacks. Colchicine is not commonly used as long-term treatment for chronic gout because of the risk of short-term leukopenia. The prescribed dose and frequency of colchicine is appropriate for acute gout attacks. If taken for chronic gout, a smaller dose is given. This is the health-care provider's decision, and not a nursing role.

ACETYLSALICYLIC ACID •Interactions:

Increased bleeding with other NSAID's and anticoagulants; prolonged bleeding times

Cox-2 Inhibitors: Celecoxib •Mechanism of action:

Selectively inhibits COX-2 enzyme without inhibition of COX-1​

. A patient will be taking enteric coated aspirin 81 mg orally daily to help prevent heart attacks. What teaching should the nurse provide the patient?

Take the aspirin with food, either a snack or a meal Correct answer commentsNSAID's should be taken with food, if possible. Chewing an enteric coated aspirin increases the chance of gastric ulceration. Stopping aspirin prior to any medical or dental procedure is not accurate. Prior to surgery or dental procedures, the patient needs to notify the surgeon or the dentist of the aspirin. If that surgeon or dentist wants the medication stopped, it is their responsibility to tell the patient. It is not in the scope of practice of an RN to discontinue medications.It is not recommended to take multiple NSAID's together, as this increases the chance of GI bleeding.

Medication reconciliation is

a process in which medications are reviewed and reconciled at all points of entry and exit from a health care entetiy (clinic, hospital, physician's office...)​ In order to reconcile the medications- the patient must provide a list of current medications (prescription, OTC, and herbals). The prescriber then assesses those medication and decides if they should be continued.​ •Verification​ •Clarification​ •Reconciliation

Based on the admitting diagnoses, past medical history, and past surgical history, which medication orders might you want to question and why? Hydrocodone with acetaminophen

-- Implanted morphine pump see how this is scheduled every 6 hours. If patient has morphine from the morphine pump 24/7, this can quickly lead to an overdose . It is an opioid, so the best answet is not a drug interaction with opioids)

Based on the admitting diagnoses, past medical history, and past surgical history, which medication orders might you want to question and why? Morphine sulfate

-- No dose provided

What are some strategies to help prevent medication errors? Select All That Apply:

-Compare the medication label 3 times with the medication administration record prior to administering -Do not administer medication drawn up by another nurse -Avoid distractions -Never use trailing zeros -Always use leading zeros -Use current drug references to look up medications before administering -Clarify any unclear or illegible orders Some strategies for preventing medication errors: Assess patient using 2 patient identifiers, Never give medications you did not personally prepare, or are prepared and properly labeled by the pharmacy, minimize the use of vernal and telephone orders, Avoid abbreviations, do not try to decipher illegible orders, call and clarify the order; Never use trailing zeros and always use leading zeros; read all labels; check labels 3 times prior to administering a medication, listen to concerns by patients and check the orders, and use current resources for information regarding medications.

Based on the admitting diagnoses, past medical history, and past surgical history, which medication orders might you want to question and why? Cyclobenzaprine-

-Drug interaction with opioid analgesics This is a CNS depressant, it has a drug interaction with opioids, additive effects)

Responding and reporting​

1. If error does occur, it must be reported​ 2. Assess the patient and address any urgent safety issues (can use charge nurse for assistance)​ 3. Once you have assured the patient is safe, you must notify the prescriber and nursing manager. If you cannot leave pt alone due to condition, another nurse can provide appropriate care to the patient while the nurse contacts the prescriber.​ 4. Follow-up procedures or antidotes may be prescribed​ Most important is patient safety during this process.​ 5. Part of reporting is completing appropriate forms (such as an incident report). ​

Documenting​​

1. Make sure it is accurate, thorough and objective​ 2. Avoid judgmental words such as "error". ​ 3. Chart factual information​ 4. Note any observed changes in patient status (physical and mental)​ 5.Document that the prescriber was notified and any follow-up actions that were implemented​ 6.Document ongoing monitoring of the patient​

Preventing​

1. Multiple system check and balances​ 2. Prescribers must write legible orders or it must be entered electronically​ 3. Consult pharmacists or recent drug references if any concern​ 4. Check medication 3 times before administering​ 5. Follow the "rights" of medication administration​ 6. Page 68 :Safety and Quality Improvement: Preventing Medication Errors​

How medication errors are classified:​

1. No error but circumstances could have led to an error​ 2.Error occurred but no harm to patient​ 3. Error caused harm​ 4.Error resulted in death​

An opioid-agonist that is not recommended for long-term pain control due to the risk of seizures

meperidine

The amount of acetaminophen recommended in a 24-hour period for a patient with liver disease .

2000 mg

The amount of acetaminophen recommended in a 24-hour period by the maker of Tylenol

3000 mg`

The amount of acetaminophen allowed in a 24-hour period by the FDA.

4000 mg

Opioid Analgesics •Adverse effects

: Constipation, nausea, vomiting, sedation and mental clouding, respiratory depression, dry mouth, urinary retention, pruritis, dysphoria, euphoria, bradycardia, and hypotension

ACETYLSALICYLIC ACID: ASPIRIN •Dosage

: For cardiovascular health, 81 mg daily

Cox-2 Inhibitors: Celecoxib •Adverse effects

: GI distress, Peripheral edema, heart attack, stroke

ACETYLSALICYLIC ACID: ASPIRIN Adverse effects

: GI ulceration, GI bleeding

Opioid Analgesics Mechanism of action

: binds to opioid receptors in the central nervous system and causes an analgesic response

ACETYLSALICYLIC ACID: ASPIRIN •Mechanism of action

: inhibits COX-1 and COX- 2.​

A patient has been advised to take ibuprofen . when teaching the patient about ibuprofen, which instruction should the nurse include? (Select all that apply.)​ A.Avoid taking aspirin with ibuprofen.​ B.Take with food to reduce gi upset.​ C.Monitor for bleeding gums, nosebleeds, black tarry stools.​ D.Take herbs, such as ginkgo and garlic, with ibuprofen.​ E.Take NSAIDs 2 days before menstruation to decrease discomfort.

A.Avoid taking aspirin with ibuprofen.​ B.Take with food to reduce gi upset.​ C.Monitor for bleeding gums, nosebleeds, black tarry stools.​

Which herb is associated with the development of bleeding if taken with nonsteroidal anti-inflammatory drugs?​ A.Garlic​ B.Echinacea ​ C.St. John's wort​ D.Cinnamon

A.Garlic​

The nurse assesses a patient receiving morphine via a PCA pump. The patient has a respiratory rate of 6 breaths/min. The nurse anticipates administration of which of the following drugs?​ A.Naloxone ​ B. Sumatriptan ​ C. Nalbuphine hcl ​ D. Hydromorphone

A.Naloxone

Leukopenia

Abnormally low white blood cell count

Based on the admitting diagnoses, past medical history, and past surgical history, which medication orders might you want to question and why? Ibuprofen

Acute renal failure and chronic renal failure (remember that ibuprofen can cause kidney damage. If a patient has kidney disease, they should not take ibuprofen.)regular

Psychological dependence, where there is a strong desire to obtain and use a substance

Addiction

An antigout medication used to prevent acute gout attacks

Allopurinol

The nurse administers a 10 mg of morphine intravenously. When documenting on the medication record, the nurse notices that the prescribed dose was for oral morphine. What action should the nurse implement next? (Test-taking tip, when asked what to do next, make sure you understand what has already been done. Often, following the nursing process will let you know what needs to happen. Since the nurse has administered a wrong dose of medication, the first thing is "evaluation" of the implemented action-another word for evaluation is "re-assessment"; how do you know the patient needs naloxone if you do not assess them first?)

Assess the patient for any adverse effects -When a medication error has occurred, the nurse should first assess the patient and address safety concerns. Page 65 (the nurses highest priority at all times during the mediation administration process and during a medication error is the patient's physiologic status and safety). Part of documentation of medications errors is patient status, which cannot be identified if you do not first assess your patient. If needed, the nurse should have another nurse monitor the patient (the charge nurse). The health care provider should be notified next and the orders implemented once received. After all these steps are completed, the nurse should complete all required forms (such as an incident report).

Criteria for Over-the-Counter ​Status

Indication of use:​: •Consumer must be able to easily:​ •Diagnose condition​ •Monitor effectivenes Safety Profile:​: •Drugs must have:​ •Favorable adverse event​ •Limited interaction with other drugs​ •Low potential for abuse​ •Low risk for toxicity​ Practicality :​ •Drugs muse be:​ •Easy to use​ •Easy to monitor

An older adult patient takes ibuprofen for arthritis pain. Which statement made by the patient is of most concern to the nurse?​ A."I feel like I am coming down with a cold."​ B."My stomach aches and burns."​ C."I have a bad headache."​ D."I feel dizzy when I get up fast."

B."My stomach aches and burns."​

A patient with gout is prescribed colchicine. It is most important for the nurse to give which instruction to the patient?​ A.Increase vitamin C intake.​ B.Avoid alcohol and caffeine.​ C.Increase foods high in purines.​ D.Take colchicine 2 hours before meals.

B.Avoid alcohol and caffeine.​

A patient is ordered to receive low-dose aspirin to prevent a heart attack. Which assessment, if found in the patient, is the highest priority for the nurse?​ A.Otitis externa​ B.Multiple bruises​ C.Dry mouth​ D.Aches in the joints

B.Multiple bruises​

A patient is providing you with a list of their home medications. See the medication list below. If the patient took each medicine on the list that contains acetaminophen as many times as allowed in a 24 hour period, how many mg of acetaminophen would the patient receive in a 24-hour period? Enter a numeric value only.Medication ListAcetaminophen 325 mg tablets x 2 tablets orally every 6 hours as needed for pain Hydrocodone 5 mg/ acetaminophen 325 mg 1 tablet orally every 6 hours as needed for pain Ibuprofen 200 mg tablets x 3 tablets orally every 6 hours as needed for joint pain Tylenol Cold and sinus (contains acetaminophen 325 mg) tablet x 2 tablets orally every 4 hours as needed for sinus symptoms-Do not exceed 10 tablets in 24 hours .Tylenol PM (500 mg acetaminophen/25 mg diphenhydramine) tablets x 1 tablet orally every night at bedtimeCorrect

Between 7650.0 and 7650.0 Correct answer comments 2600 mg in first row (650 x 4) -dose taken at 0001, 0601,1201,1801 (24 hours starts when first dose taken) 1300 mg in second row (325x4) 0 mg in third row 3250 mg in fourth row (325 x10)- while 2 tabs could be taken 6 times in 24 hours period which equals 12, the maximum allowed in 24 hours is 10 per day .500 mg in fifth row (500 mg)7650 mg in total

The nurse is caring for a patient who is 3 days post-operative with a mid-line abdominal incision who is receiving ketorolac every 8 hours intravenously for pain. The urine output is decreased today, and the patient is complaining of new-onset, severe abdominal pain, near the epigastric region. See vital signs in table below. What does the nurse suspect to be the underlying cause of the patient's change in status? Vital signsResults Heart rate135 Blood pressure95/50 Temperature98.9 Respirations24

Bleeding gastric ulcer Ketorolac is an injectable NSAID. The most common adverse effect of NSAID's is GI ulceration and bleeding. The data points towards a bleeding gastric ulcer (new onset epigastric pain, low urine output, increased heart rate, decreased blood pressure).The patient is 3 day's post-operative, blood loss from surgery is generally seen within the first 24 hours after surgery. The patient's blood pressure is low, and the heart rate is high, showing a compensatory mechanism by the body to sustain the blood pressure. This could be from dehydration or blood loss. Acute pain would cause and increase in heart rate and blood pressure.

Prior to assuming care on a patient, you review the patient's medical records found below. Admitting diagnosis: Nausea and vomiting, Acute Renal failure, Acute on Chronic pain Past medical history: Stage 1 Chronic Kidney Disease, Spinal cord injury with paraplegia, diabetes mellitus type 2, chronic pain Past surgical history: Back surgery, implanted morphine pump Admitting Medication orders: morphine sulfate intravenously Q 2 hours PRN severe pain rating greater than 7 on 0-10 pain scalehydrocodone 5 mg with acetaminophen 325 mg PO Q 6 hours scheduled for chronic pain ibuprofen 800 mg PO Q 8 hours PRN moderate pain rating between 4-8 on 0-10 pain scale regular insulin 5 units subcutaneously with meals cyclobenzaprine 5 mg PO Twice Daily for muscle spasms Based on the prescribed medications and past medical history, what assessments would you plan to implement when you assume care of the patient? SELECT ALL THAT APPLY

Blood pressure Respiratory rate Oxygen saturation Urine output Heart rate Pain level Bowel Sounds Sedation level Because the patient is prescribed opioid, the nurse would want to assess: blood pressure, respiratory rate, oxygen saturation, heart rate, pain level, bowel sounds and sedation level.Because the patient is prescribed ibuprofen and has acute renal failure, the nurse would want to assess the urine output. The kidneys are the main site of excretion and the risk is for toxicity to occur due to lack of excretion of the drugs from the system.

The nurse identifies which of the following as a common side effect/adverse effect of morphine therapy?​ A.Diarrhea​ B.Hypertension​ C.Urinary retention​ Tachypnea

C. Urinary retention

Affects most common sign of chronic salicylate toxicity in adults

Central Nervous System Effects

Prior to assuming care on a patient, you review the patient's medical records found below.Admitting diagnosis: Nausea and vomiting, Acute Renal failure, Acute on Chronic painPast medical history: Stage 1 Chronic Kidney Disease, Spinal cord injury with paraplegia, diabetes mellitus type 2, chronic painPast surgical history: Back surgery, implanted morphine pumpAdmitting Medication orders:morphine sulfate intravenously Q 2 hours PRN severe pain rating greater than 7 on 0-10 pain scalehydrocodone 5 mg with acetaminophen 325 mg PO Q 6 hours scheduled for chronic painibuprofen 800 mg PO Q 8 hours PRN moderate pain rating between 4-8 on 0-10 pain scaleregular insulin 5 units subcutaneously with mealscyclobenzaprine 5 mg PO Twice Daily for muscle spasms Based on the medication orders, what assessment data is most concerning to you and would cause you to contact the healthcare provider for new orders? SELECT ALL THAT APPLY

Chronic Kidney Acute Renal Failure Implanted Morphine Pump Because ibuprofen can cause acute renal failure and kidney damage, the fact that the patient is ordered ibuprofen and has chronic kidney disease and acute renal failure is concerning.Because the patient is being prescribed morphine for severe pain, and hydrocodone scheduled around the clock every 6 hours, the fact that the patient has an implanted morphine pump is concerning because of the risk of opioid overdose. While chronic pain and diabetes are important, neither of these are concerning based on the current orders or the past medical history. The patient will be receiving insulin, which treats the diabetes and the patient is receiving multiple pain medications to control this chronic pain condition.

Ibuprofen •Mechanism of action:

Inhibits COX-1 and COX-2​

Ketorolac Adverse effects:

GI ulceration, GI bleeding, renal dysfunction

Ibuprofen •Adverse effects:

GI ulceration, GI bleeding, renal failure​

Ketorolac •Duration of therapy:

Not to exceed 5 days by all routes​

The nurse is providing education about newly prescribed medications to a patient who does not speak the same language as the nurse. What best practice technique should the nurse implement?

Obtain a trained interpreter to translate the information to the patient when providing education to a patient who speaks a different language than the nurse, the best action is to get a trained interpreter to translate the information. Providing written instructions in the native language is also great, but does not replace the education that should be provided through an interpreter. Pictures and hand gestures may help the patient understand but the nurse will not be able to evaluate if the patient truly understands the education. Speaking louder and repeating the information is not going to help a patient understand if they do not speak the same language as the nurse.

Issues contributing to medical errors

Organizational issues​ Errors can occur in any step of the medication process​: 1.Procuring​ 2.Prescribing (Most common area for errors and half of all preventable errors occur in this step)​ 3.Transcribing (4th most common area)​ 4.Dispensing (Third Common area)​ 5.Administering( Second common area for errors to occur)​ 6.Monitoring​

Ibuprofen •Indication:

Pain and fever​

ACETYLSALICYLIC ACID: ASPIRIN •Indication:

Pain; fever; antiplatelet for patients at risk for heart attack and stroke​

Ketorolac •Dosage: ​

Pediatric patients will receive a weight-based dose (MG/KG)​ Geriatric patients should receive a lower dose due to increased risk of GI bleeding

An adverse effect of aspirin administration to children with flu-like symptoms

Reye syndrome

Miscellaneous Analgesics

Tramadol​ •Mechanism of action: weak bond to opioid receptors; inhibits the reuptake of norepinephrine and serotonin​ •Schedule IV controlled substance (federal, however, some states classify it as II or III)​ •Indications: moderate to moderately severe pain​ •Adverse effects: •Drowsiness, dizziness, headache, nausea, constipation and respiratory depression, seizures​ •Drug interactions: •MAOI, SSRI, antipsychotic drugs (all lower the seizure threshold and increase chance of seizures while on tramadol)

Anti-Gout Drugs •Allopurinol​

Used for prophylaxis (prevention) but can still be administered during acute attacks (it can be given ALL the time)​ Prevents uric acid production​

Persistent or recurring pain that is often difficult to treat

chronic pain

An antigout drug most commonly used to treat acute gout attacks

colchicine

An opioid-agonist that is 100 times more potent than morphine

fentanyl

The most common adverse effect of NSAIDs

gastric ulceration

Opioid Analgesics Use caution:

head injury, respiratory insufficiency, morbid obesity, sleep apnea, myasthenia gravis, paralytic ileus, and pregnancy

An opioid-agonists that is 7 times more potent than morphine

hydromorphone

Describes patients who are receiving opioid medications for the first time

opioid naive

Describes patients how have used opioids long term, which results in the need for larger doses over time.

opioid tolerance

The level of stimulus that results in the sensation of pain

pain threshold

The amount of pain a patient can endure without interfering with normal function

pain tolerance

Pain experienced in an part of the body that has been removed

phantom pain

When a patient takes a drug over long periods of time and the body becomes adapted to the presence of the drug.

physical dependency

Ketorolac •Mechanism of action: inhibits

prostaglandin synthesis (inhibits COX-1 and COX-2)​

Ketorolac Indication:

short-term pain management

The most common sign of chronic salicylate toxicity in adults

tinnitus

Opioid Analgesics Indications:

treat moderate to severe pain and post-operative pain; suppression of cough

Acetaminophen •Toxicity and managemen

t​ •Acetylcysteine (IV is better tolerated)​

Acetaminophen •Safe dosage

​ •FDA limits to 4000 mg per day​ Manufacturer recommends 3000 mg per day

Opioid Analgesics •Controlled substance schedule​

• Schedule II: codeine, morphine, hydrocodone, meperidine, methadone, etc...​ •Schedule III: codeine/hydrocodone mixed with other medications (hydrocodone and acetaminophen)

Opioid Analgesics Contraindications:

• known allergy, severe asthma​

Herbal and Dietary Supplements

•50% of U.S. adults using some form of alternative medicine​ •25% of those using alternative medicines experience adverse reactions​ •Many supplements are viewed as "natural" and "harmless"

Types of Pain

•ACUTE ​ •CHRONIC​ •SOMATIC ​ •VISCERAL​ •SUPERFICIAL ​ •DEEP​ •VASCULAR​ •REFERRED​ •NEUROPATHIC​ •PHANTOM ​ •CANCER​ •CENTRAL

NON-opioid Analgesics

•Acetaminophen​ •Mechanism of action: inhibits prostaglandin synthesis decreasing pain impulses; also decreases body temperature(antipyretic)​ •Indications: mild to moderate pain and fever​ •Contraindications: severe liver disease, known allergy, and G6PD deficiency​ •Adverse effects: normally well tolerated, however, can cause nausea and vomiting, hepatotoxicity, nephrotoxicity, blood disorders (anemias)

Adjuvant pain therapies

•Adjuvant therapy is usually used along with a non-opioid and opioid​ •Examples of adjuvant analgesics include anticonvulsants, antidepressants, corticosteroids, anti-dysrhythmics, and local anesthetics.

Opioid Analgesics •Interactions​

•Alcohol, antihistamines, barbiturates, benzodiazepines, phenothiazine, centrally acting muscle relaxer (cyclobenzaprine) and other CNS depressants​ •Monoamine oxidase inhibitors (MAOI'S)

Acetaminophen •Interactions​

•Alcohol​ •Phenytoin, barbiturates, isoniazid, rifampin

Opioid Analgesics •Common opioid analgesics:​

•Codeine, fentanyl, hydromorphone, meperidine, methadone, morphine, oxycodone​

Patient-controlled analgesia

•Commonly used in the hospital setting​ •Self-medicate by pushing a button​ •Lock out doses do not allow patient to receive more than maximum amount​ •1 ml every 6 minutes​ •Patient pushes the button 10 times in 6 minutes, they only receive 1 ml​ •Morphine and hydromorphone commonly used​ •Only patient should push button​ •Deaths have occurred with PCA's​ •Monitor respiratory status closely​ •Continuous pulse oximetry is recommended •Monitors oxygen saturation (normal greater than 95% on room air)

Cox-2 Inhibitors: Celecoxib Indication:

•Decrease inflammation and pain (no antiplatelet effect)​

Team work and Collaboration: Discharge Education

•Do not assume patient has received adequate education​ •Begin discharge teaching as soon as patient is ready (may be as soon as patient is admitted)​ •Minimize distractions​ •Written and verbal instructions for discharge medications should include purpose of the drug, dosages, when to take medication, and side effects to report​ •Use the "teach back" method​ •Document strategies used​ •Document what you taught, who was present, what written instructions were provided, patient response to education, and nursing actions​ •Document follow-up education needs.

General Teaching and Learning Principles

•Individualize to each patient​ •Adult learning principles​ •New information will draw on past experience​ •Simple, fun, easy, thorough, effective​ •Repetition and demonstration​ •Consider language

Ketorolac

•Injectable NSAID​

Overview of Pain

•Most common reason for people to seek treatment​ •Nurses need to be aware of pharmacologic treatment as well as nonpharmacologic treatment​ •Definition of pain​ •Pain threshold​ •Pain tolerance​ •Cultural implications​ •Nociception

Opioid Analgesics •Toxicity and management of overdose​

•Naloxone​ •Short duration, about 1 hour​ •May need more than one dose if long acting opioid ​

Other Non-opioid Analgesics

•Non-steroidal anti-inflammatory drugs​ •Ibuprofen​ •Aspirin​ •Naproxen​

Pain Treatment

•Nonpharmacologic treatment​ •Acupressure/Acupuncture​ •Distraction​ •Hot or cold packs​ •Massage​ •Music therapy​ •Pet therapy

Ethical Considerations

•Notification of patients regarding errors​ •Consequences of errors​ •Patient​ •Nurse​ •Institution

Transdermal Fentanyl Patches

•Only for opioid tolerant patients​ •Wear gloves (or you'll get some of the medication, too)​ •Remove old patch and wash site to prevent irritation​ •Apply new patch and rotate sites​ •Patch is applied for 72 hours ​ •No heating pads should be applied over patch as this increases absorption and could cause an overdose​ •Proper disposal is important: recommendation is to fold the patch in half then flush it​ •Keep patches out of reach of children and pets

ACETYLSALICYLIC ACID •Toxicity and management​

•Signs and symptoms of salicylate intoxication:​ •Tinnitus and hearing loss most common in adults​ •Hyperventilation and CNS effects (dizziness, drowsiness and behavioral changes) most common in children​ •Toxic Salicylate level: greater than 30 mg/dL​ •Treatment: discontinuation of salicylate (or dose reduction), prevention of absorption(activated charcoal) and possibly hemodialysis to enhance elimination of salicylate​

Ibuprofen •Toxicity and management of overdose:​

•Similar to aspirin, however, hemodialysis is not effective

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAID'S)

•Some of the most commonly prescribed drugs​ •23 different types of NSAID's available in the US​ •Many beneficial therapeutic effects:​ •Analgesic​ •Anti-inflammatory​ •Anti-pyretic (not all NSAID's have an anti-pyretic property) •Blackbox warning for all NSAIDS •Gastrointestinal risk •Cardiovascular risk (Except aspirin, which helps prevent cardiovascular events)

Patient Education

•Teach to let health care providers (physicians, nurses, dentists) know all OTC and Herbal supplements patient is taking​ •Teach how to read labels on OTC medications and to seek clarification with pharmacist or HCP if unsure of amount to be taken​ •Teach that drug interactions may occur with OTC/herbal therapies​ •Teach how to measure liquid medications​ •Teach to seek help if symptoms are not relieved​ •Teach to look for duplications of medication in OTC medications (Tylenol Cold and Sinus, Tylenol PM, Tylenol).

Gate Theory

•Tissue injury causes release of substances ​ •Causes nerve impulses at the distal end of sensory nerve fibers through pain receptors (nociceptors)​ •Travel to the dorsal horn of the spinal cord (where gate is located)​ •Regulates the flow of sensory nerve impulses​ •Large A fibers close gate​ •Small C fibers open the gate​ •If gate is open, pain sensation is transmitted to brain; if closed, pain sensation is not transmitted.

Acetaminophen •Routes​

•Traditionally, only oral and rectal routes available​ •Ofirmev IV (FDA approval in 2010)

Anti-Gout Drugs •Colchicine ​

•Use for acute attacks, used for short term because causes leukopenia​ •Decreases the inflammatory response to the deposits of urate crystals in the joint tissues​

Opioid Antagonist

•Use: Antidote for opiate overdoses​ •Reversal of overdose effects including: respiratory depression, sedation, hypotension, respiratory distress •Naloxone ​ •Side effects​ •Tremors, sweating, hypertension, tachycardia, dysrhythmias​ •Nausea, vomiting​ •Reversal of analgesia​ •Elevated PTT, bleeding​ •Naltrexone

Pain Scales

•WONG-BAKER FACES SCALE​ •VISUAL ANALOG​ •NUMERIC PAIN SCALE​ •PEDIATRIC ASSESSMENT (FLACC)