Pain and Inflammation UAB NUR 328 2.0

A nurse is teaching a client about calcitonin-salmon intranasal spray to treat osteoporosis. Which of the following information should the nurse include? (Select all that apply.)

• Report rash or itching

• Prime the pump before the first dose

• Report nasal irritation

A nurse is teaching a client who is taking etanercept for rheumatoid arthritis. The nurse should instruct the client to monitor for which of the following indications of an adverse reaction to this medication?

Skin rash

A nurse is caring for a client who is taking alendronate to treat postmenopausal osteoporosis. The nurse should explain to the client that alendronate increases bone mass by which of the following actions?

Decreases activity of osteoclasts

A nurse is caring for a client who is currently taking methotrexate for rheumatoid arthritis. The nurse should identify that which of the following is an adverse effect of this medication?

Thrombocytopenia

A nurse should instruct a client who is taking alendronate to monitor for which of the following adverse effects? (Select all that apply.)

• Jaw pain

• Blurred vision

• Muscle pain

A nurse is teaching a client about raloxifene therapy to prevent osteoporosis. The nurse should instruct the client to monitor for which of the following indications of an adverse reaction to this medication?

Calf pain

Which of the following is a therapeutic action of raloxifene?

Mimics the effects of estrogen on bone tissue

A nurse is teaching a client about the adverse effects of etanercept. Which of the following statements by the client indicates understanding of the teaching?

"I will need to get my blood drawn periodically while on this medication."

A nurse is caring for a client who has a prescription for etanercept. The nurse should identify that etanercept treats rheumatoid arthritis by which of the following actions?

Inactivation of tumor necrosis factor

A nurse is teaching a client who has a prescription for calcium citrate about manifestations of hypercalcemia. Which of the following manifestations should the nurse include in the teaching?

Vomiting

A nurse is caring for a client who was diagnosed with postmenopausal osteoporosis. Which of the following actions should the nurse take prior to administering calcitonin-salmon to the client for the first time?

Use skin testing to check the client for allergies.

A nurse is caring for a client who is treating rheumatoid arthritis by taking etanercept. The nurse should monitor the client for which of the following indications of a serious adverse reaction to the medication?

Shortness of breath

A nurse is teaching a client who has a prescription for prednisone and takes 1,500 mg/day of calcium carbonate to reduce the risk of osteoporosis. Which of the following information should the nurse include? (Select all that apply.)

• Drink 240 mL (8 oz) of water with the calcium tablets

• Chew calcium tablets before swallowing them

• Take the medications 1 hr apart

• Divide the daily dosage of calcium into three 500-mg doses

A nurse is teaching a client about methotrexate therapy for rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? (Select all that apply.)

• Avoid being near people who are sick with a communicable illness

• Periodic laboratory tests are required

• Report bruising or petechiae

• Avoid drinking alcohol

A nurse is caring for a client who has a new prescription for etanercept. Which of the following actions should the nurse take?

Administer a tuberculin skin test prior to starting the medication.

A nurse is teaching a client who has a new prescription for etanercept. Which of the following statements should the nurse include in the teaching?

"You should immediately report signs of infection to your provider."

A nurse is caring for a client who has a prescription for methotrexate. Which of the following medications would likely be prescribed in conjunction during the initial treatment for rheumatoid arthritis?

Ibuprofen

A nurse should identify that a client who has diabetes mellitus and is taking etanercept is at an increased risk for which of the following adverse effects?

Infection

Alendronate is contraindicated for administration to clients who have which of the following conditions?

Inability to sit upright

A nurse is planning care for a client who has a new prescription for methotrexate. The nurse should plan to monitor the client for which of the following adverse effects?

Bone marrow depression

A nurse is teaching a client about methotrexate therapy for rheumatoid arthritis. Which of the following statements by the client indicates understanding of the teaching?

"I will take my prescribed birth control pill every day."

A nurse is teaching about self-administering methotrexate to a client who has rheumatoid arthritis. Which of the following statements should the nurse make?

"Drink a minimum of 2 liters of water per day to promote the excretion of the medication."

A nurse is caring for a client on a MedSurg unit. Client is unresponsive has had a chest tube insertion. He's had two tablets of hydrocodone acetaminophen 5 mg and morphine 4 mg IV bolus. Which of the following actions should the nurse take? (Select all that apply.)

• administer naloxone 0.4 mg IV bolus

• assess for opioid withdrawal manifestations

• cardiac rhythm

• prepare ventilation resuscitation equipment

A nurse is caring for a client who is receiving morphine to relieve severe pain. The nurse should monitor the client for which of the following adverse drug reactions. (Select all that apply.)

• Urinary retention

• Respiratory depression

• Sedation

• Orthostatic hypotension

A nurse is teaching a client who is taking allopurinol about minimizing adverse effects. Which of the following instructions should the nurse include?

Eat a small meal before taking the medication.

A nurse is caring for a client who has a new prescription for butorphanol. The nurse should monitor the client for which of the following adverse medication reactions? (select all that apply.)

• Nausea

• Dizziness

• Headache

A nurse is reviewing the medical record of a client who reports taking acetaminophen at home. The nurse should identify that which of the following client reactions is a contraindication for acetaminophen?

Alcohol use disorder

A nurse is teaching a client who has a new prescription for allopurinol. The nurse should instruct the client to report which of the following adverse medication reactions? (Select all that apply.)

• Sore throat

• Vertigo

• Bruising

• Vision changes

A nurse is planning care for a client who has started taking prednisone which of the following interventions should the nurse include?

Monitor the client's blood glucose

A nurse is reviewing the medical record of a client who has a new prescription for celecoxib. The nurse should identify that which of the following conditions is a contraindication to celecoxib?

Sulfonamide allergy

A nurse is caring for a client who currently takes furosemide and has a new prescription for prednisone. The nurse should monitor the client for which of the following manifestations during concurrent use of the two medications?

Hypokalemia

A nurse is reviewing the medical record of a client who has a new prescription for tramadol. The nurse should identify that which of the following conditions is a contraindication for tramadol?

Seizure disorder

A nurse is caring for a client who has a prescription for aspirin to treat an ankle sprain. The nurse should instruct the client to report which of the following adverse drug reactions?

Weight gain

A nurse is caring for a client who is taking allopurinol to treat gout. The nurse should monitor the client for which of the following manifestations of hypersensitivity syndrome?

Fever

A nurse is teaching a client who has a new prescription for tramadol. Which of the following instructions should the nurse include? (select all that apply)

• Increase fiber and fluid intake

• Take the medication with food

• Change position gradually

• Avoid driving after taking the medication

A nurse is caring for a client who asks about taking acetaminophen. The nurse should identify that acetaminophen is indicated for which of the following conditions? (select all that apply.)

• To reduce fever

• To relieve mild pain

A nurse is caring for a child who has a viral infection. The nurse that should identify that which of the following medication can increase the risk of rise syndrome and children who have viral infections?

Aspirin

A nurse is caring for a group of postoperative clients. The nurse should identify that morphine is contraindicated for which of the following clients?

A client who had a cholecystectomy.

A nurse is caring for a client who has a new prescription for prednisone for long-term treatment of rheumatoid arthritis. The nurse should monitor the client for which of the following adverse medication reactions?

Bone loss

A nurse is caring for a client who takes low-dose aspirin to prevent cardiovascular events. The client asked the nurse about taking ibuprofen to treat rheumatoid arthritis. Which of the following responses should the nurse make?

"Ibuprofen will reduce the cardio protective effects of low-dose aspirin"

A nurse is reviewing the medication list for a client who has a new prescription for allopurinol. The nurse should identify that which of the following medication interacts with allopurinol?

Warfarin

A nurse is caring for a client who has a new prescription for celecoxib. The nurse should tell the client to report which of the following adverse drug reactions?

Chest Pain

A nurse is caring for a client who is opioid dependent and has a new prescription for butorphanol. The nurse and monitor the client for which of the following manifestations of withdrawal? (Select all that apply.)

• Tremors

• Abdominal cramps

• Muscle pain

A nurse is teaching a client who has a new prescription for prednisone. Which of the following instructions should the nurse include? (Select all that apply.)

• D/C the drug gradually

• Report illness or infection

• Increase intake of calcium and Vit

• Monitor signs of gastric bleeding

A nurse is teaching a client who has a new prescription for allopurinol. Which of the following instructions should the nurse include?

Avoid driving or activities that require mental alertness.

NSAIDS (COX 1 and 2 Inhibitors)

Aspirin (PO)

Aspirin Uses

• Higher Doses (325 mg):

  • HA, pain relief, fever/ inflammation reduction, reducing further clotting for pts w/ hx of MI/CVA

• Lower Doses (81 mg):

  • prevent complications for CAD/CVA

Aspirin MOA

inhibits COX-1 and COX-2 enzymes that produce prostaglandins

Aspirin AE

• GI upset/ bleeding

• clotting impairment (bruising, bleeding from trauma or aneurysm)

• Nephrotoxicity

• Salicylism - caused by excess intake of salicylates leading to tinnitus (due to CNVIII stimulation) nausea/vomiting, diarrhea, and confusion

Aspirin CI/C

• Do not give to children due to Reye syndrome

• Pregnancy/lactation

• Alcohol

Aspirin Labs

• Test for H. pylori before long-term treatment

• Kidney function labs (BUN, creatinine, GFR)

• Bleeding indicators (CBC - platelets, RBC count, HGB, and HCT)

Aspirin NI

• Take w/ food / milk / 8 oz water - minimize GI effects

• Must stop taking 7-10 days before surgery → potential clotting impairment

• Report persistent gastric irritation / signs of bleeding.

• Report changes in urine output, weight gain, or signs of fluid retention.

• Report ringing or buzzing in the ears, sweating, and dizziness.

  • If these symptoms develop, stop taking and call the provider.

• Report chest pain, sternal heaviness, SOB, sudden and severe HA, numbness, weakness, visual disturbances, or confusion.

NSAIDS (COX 1 and 2 Inhibitors)

Ibuprofen (PO, IV)

Ibuprofen Uses

• mild-to-moderate pain

• arthritis

• dysmenorrhea

• reduces swelling/ fever

Ibuprofen MOA

inhibits COX-1 and COX-2 enzymes that make prostaglandins

Ibuprofen AE

• GI upset/ bleeding, NSAID-induced PUD

• clotting impairment (bruising, bleeding from trauma or aneurism)

• nephrotoxicity

• bone marrow suppression

• rash

• oral sores

Ibuprofen CI/C

• black box warning for increased CV risk

  • so caution if CVD risk is high of Hx of CVD

• Pregnancy/lactation

• Alcohol

Ibuprofen Monitor

• Kidney function labs (BUN, creatinine, GFR)

• bleeding (CBC - platelets, RBC, HGB, and HCT)

• blood in stool

• test for H. pylori infection pre long-term treatment

Ibuprofen DI

• Antagonizes BP meds due to vasoconstrictive properties

• loop diuretics (furosemide), beta-blockers (olols), and ACE inhibitors

  • Uncontrolled HTN

Ibuprofen NI

• Take with food, milk, or 8 oz of water to minimize GI effects.

• Must stop taking 7-10 days before surgery → potential clotting impairment

• Report persistent gastric irritation and signs of bleeding.

• Report changes in urine output, weight gain, or signs of fluid retention such as edema or bloating.

Nonopioid Analgesics - COX 2 Inhibitors

Celecoxib (PO)

Celecoxib Uses

• mild-to-moderate pain

• arthritis

• reduces swelling/ fever

• dysmenorrhea

Celecoxib MOA

COX-2 Inhibitor -> enzymes that make prostaglandins

Celecoxib AE

• GI upset/ bleeding

• clotting impairment (bruising, bleeding from trauma or aneurism)

• nephrotoxicity

• CV/ CVA event

• NSAID-induced PUD (heartburn precedes this)

Celecoxib CI/C

• black box warning for increased CV risk

  • so contraindicated if CVD risk is high or Hx of CVD or cardiac surgery

• Sulfonamide allergy

• Pregnancy/lactation

Celecoxib Monitor

• Kidney function labs (BUN, creatinine, GFR)

• bleeding (CBC - platelets, RBC, HGB and HCT)

• blood in stool

Celecoxib DI

• Antagonizes BP meds due to vasoconstrictive properties

• Loop diuretics (furosemide), beta blockers (olols), and ACE inhibitor

  • Uncontrolled HTN

Celecoxib NI

• Must stop taking 7-10 days before surgery → potential clotting impairment

Non-Opioid Analgesic

Acetaminophen

Acetaminophen Uses

• mild-to-moderate pain

• arthritis

• fever (works directly on thermoregulatory cells in the hypothalamus)

• NOT ANTI-INFLAMMATORY

Acetaminophen MOA

weak COX-2 Inhibition -> enzyme that makes prostaglandins

Acetaminophen AE

• Liver damage

• HTN w/ daily use (higher risk in biological females)

• Hemolytic anemia

Acetaminophen CI/C

• Extreme caution if hepatic dysfunction

• Extreme caution of ETOH use due to possible hepatic damage

• Pregnancy/lactation (risk vs reward)

Acetaminophen Antidote

Acetylcysteine

Acetaminophen Labs

• LFTs (AST, ALT)

• s/s of liver failure - itchy skin, easy bruising, CP, Jaundice/confusion -> late sign

• CBC - for anemia

Acetaminophen NI

• Overdose is very common due to being OTC

• Overdose is the most common cause of acute liver failure

• Max daily dosage - 4000 mg

  • If hepatic dysfunction, 2000 mg/day

Opioid Agonists

Morphine (Many routes)

Morphine Uses

• moderate to severe pain

• sedation

• treatment during acute MI

• cough suppressants

Morphine MOA

acts at specific opioid receptors in CNS producing analgesia sedation, and euphoria, and antitussive effects

Morphine AE

• Respiratory depression

• orthostatic hypotension

• constipation

• CNS depressant (falls)

• GU effects (urinary retention)

• dependence

Morphine CI/C

• Extreme caution in respiratory dysfunction

• Extreme caution in presence of hypotension or possible hypotension

• diarrhea r/t to toxic poisons, post-biliary surgery, or anastomosis procedures (GI surgery)

• Caution after recent GI/GU surgery - due to risk of constipation/ urinary retention, respiratory dysfunction/hypotension

• Pregnancy/lactation (risk vs reward)

Morphine Monitor

• Kidney function

• Balance

• Confusion

• I/O

• GI function (constipation)

• Sedation

• SpO2 / Resparations

• BP

Morphine Antidote

Naloxone

Morphine DI

Watch for additive effects of any drug that has similar effects:

• MAOIs

• barbiturates

• anesthesia

• phenothiazines (antipsychotics)

• antiseizure drugs

• muscle relaxers

• antihistamines

Morphine NI

• Take the lowest dose for the shortest time-period needed for pain management

• Fall precautions and avoid dangerous activities like driving etc.

• Increase fluids and fiber to prevent/treat constipation

• Watch for signs of dependency / depression

Opioid Antagonists

Naloxone

Naloxone Uses

Emergency reversal of opiate medication

Naloxone MOA

Binds to opioid receptors without activating them -> blocks the effects of those receptors & reverses the effects of narcotic drugs

Naloxone AE

Nothing but immediately reverses opioid effects and activates SNS -> tachycardia, sweating, GI upset, anxiety, HTN

Naloxone CI/C

• Caution if the pt has a diagnosis of acute narcotic abstinence syndrome

Naloxone DI

• Can decrease effectiveness of opioids several hrs after admin, depending on dosage

Naloxone NI

• The half-life is relatively short, around 1 hour.

  • Some long-acting opioids can remain in the body for over 12 hours, which may necessitate additional doses of naloxone and close monitoring.

• Monitor for the need for additional doses, hypertension, and heart rate.

Opioid Agonist-Antagonist

Pentazocine (PO, SQ, IM, IV)

Pentazocine Uses

• moderate-severe pain

• adjunct to general anesthesia/ pain relief in L&D

• can also be used in the treatment of opioid dependence/addiction

Pentazocine MOA

• Acts at some opioid receptors to produce analgesia, sedation & euphoria while also blocking some opioid receptors (preventing analgesia, sedation & euphoria)

• Everything is pretty similar to Morphine

Pentazocine AE

• Respiratory depression

• orthostatic hypotension

• constipation

• CNS depressant (falls)

• GU effects (urinary retention)

• dependence

  • but not as strong

Duel Mechanism Analgesic Agents

Tramadol

Tramadol Uses

moderate-severe pain

Tramadol MOA

Binds opioid receptors an inhibits noradrenaline and serotonin re-uptake to produce analgesia

Tramadol AE

• Sedation, dizziness (falls)

• Constipation, n/v

• Respiratory depression (though much lower risk than opiate agonists)

• urinary retention and seizures