Exam 3 Patho: Pain Management

Nociceptors

Pain receptors

•free nerve endings throughout the body

acetaminophen therapeutic use

-Analgesia for mild to moderate pain

-Fever reduction

** no anti-inflammatory or anticoagulant effects

acetaminophen adverse drug reactions

•Liver damage (overdose)

•Hypertension (with daily use, particularly clients assigned female at birth)

acetaminophen nursing interventions

• Monitor for early manifestations of overdose/poisoning (abdominal discomfort, nausea, vomiting, sweating, diarrhea); liver damage results in 48 to 72 hr following overdose.

• Prepare to administer acetylcysteine orally or IV to counteract overdose and reduce liver injury.

• Monitor blood pressure.

• Do not exceed 4 g/day (adults)

acetaminophen contraindications

alcohol use disorder

tramadol classification

Opioid Analgesic

tramadol mechanism of action

Binds to select opioid receptors & blocks reuptake of norepinephrine and serotonin in the CNS

tramadol therapeutic use

Relieves moderate to moderately severe pain

tramadol adverse drug reactions

-Sedation, dizziness

-Headache, n/v, constipation

-Urinary retention

-Respiratory depression & Seizures (rare)

tramadol nursing interventions

• give with food/milk

• monitor for urinary retention

• Monitor respirations (give opioid antagonist, naloxone to restore respiratory rate)

• monitor patients when ambulating

tramadol contraindications

•Toxicity with alcohol, opioids, psychotropic meds

•Seizure disorders

•Respiratory depression

tramadol precautions

• substance use disorder history

• Liver or kidney disease

• Older adults

• Increased Intracranial pressure

tramadol interactions

-MAOIs risk for HTN crisis

-Risk for serotonin syndrome (with certain medications)

opioid agonists prototype drug

morphine

morphine purpose

Acts on the mu receptors to produce analgesia, euphoria, and sedation.

morphine therapeutic use

• Analgesia for moderate to severe pain

• Preoperative sedation and anxiety reduction

opioid agonist examples

•Codeine

•Hydrocodone (Vicodin)

•Morphine

•Hydromorphone (Dilaudid)

•Fentanyl

•Buprenorphine

morphine interventions

• Monitor vital signs, pulse oximetry, lung sounds.

• For respiratory rates below 12/min, withhold the medication and stimulate breathing.

• Administer an opioid antagonist such as naloxone to restore respiratory rate.

• Monitor clients when ambulating.

• Monitor bowel function.

• Administer fiber supplement and/or stool softeners.

• Administer an antiemetic.

• For vomiting, ensure adequate hydration.

• Monitor blood pressure.

• Monitor intake and output, watching for manifestations of urinary retention, such as bladder distention.

• Encourage clients to urinate every 4 hr.

• Prepare to insert a urinary catheter to drain the bladder.

• Auscultate lung sounds regularly.

• Encourage clients (especially postoperatively) to cough frequently to prevent a buildup of respiratory secretions.

• Have suction equipment available.

• Recommend the lowest possible effective dose and short-term only.

• Advise clients who have a physical dependence not to discontinue opioids abruptly; taper the dose over 3 days.

morphine administration

• Measure baseline vital signs before administration and monitor throughout therapy.

• Administer orally, IM, IV, SC, rectally, or epidurally.

• Make sure clients swallow sustained-release forms whole and do not crush or chew them.

• Administer IV opioids slowly and with recommended dilution over 4 to 5 min; have naloxone and resuscitation equipment available.

• Monitor PCA use and pump settings carefully.

• Administer to clients who have cancer on a fixed, around-the-clock dosing schedule, not PRN.

Morphine patient education

• Take the medication only when needed and short-term.

• Do not take prior to driving or activities requiring mental alertness.

• Sit or lie down if feeling lightheaded.

• Change positions gradually.

• Increase fluid and fiber intake.

• Increase activity/exercise.

• Take the medication with food or milk (oral forms).

• Sit or lie down if feeling lightheaded.

• Rise slowly from a reclining or sitting position.

• Report any inability to urinate or difficulty urinating.

• Cough regularly to clear secretions from the throat and chest.

morphine contraindications

• Pregnancy risk (long-term use, high doses, near term)

• Kidney failure

• Increased intracranial pressure

• Biliary colic

• Preterm labor

morphine precautions

• Schedule II controlled substance

• Older adults, infants

• Reduced respiratory reserve

• Head injury

• Inflammatory bowel disease

• Prostatic enlargement

• Hypotension

• Hepatic or kidney disease

morphine interactions

• CNS depressants (barbiturates, phenobarbital, benzodiazepines, and alcohol) increase CNS depression.

• Anticholinergic agents, such as antihistamines, and tricyclic antidepressants increase anticholinergic effects (constipation, urinary retention).

• MAOIs can cause hyperpyrexia syndrome (excitation, seizures, respiratory depression, coma) with meperidine.

• Antihypertensives increase hypotensive effects.

• St. John's wort can increase sedation.

Opioid Agonists-Antagonists drugs

Butorphanol, Pentazocine

Butorphanol, Pentazocine mechanism of action

Mixed actions - mu receptor antagonists and kappa receptor agonists.

Butorphanol, Pentazocine therapeutic use

•Relieves moderate to severe pain

•Anesthesia adjunct

Butorphanol, Pentazocine adverse drug reactions

• Respiratory depression (limited)

• Sedation, dizziness, lightheadedness, drowsiness, headache

• Nausea

• Increased cardiac workload

• Abstinence syndrome (hypertension, vomiting, cramping in opioid-dependent clients)

Butorphanol, Pentazocine interventions

• Measure baseline vital signs.

• Monitor respirations.

• For respiratory rates below 12/min, withhold the medication and stimulate breathing.

• Monitor clients when ambulating.

• Consider alternative medication if nausea does not resolve.

• Do not administer to clients with myocardial infarction or cardiac insufficiency.

• Ask clients about opioid use before administration.

Butorphanol, Pentazocine administration

• Administer butorphanol IM, IV, or intranasally and pentazocine orally (in combination with acetaminophen or naloxone), subcutaneously, IM, or IV.

• Measure baseline vital signs before administration and monitor throughout therapy. Do not give the medication if the respirations are slower than 12/ min.

• Have naloxone and resuscitation equipment available.

• For intranasal administration, give one spray and repeat every 60 to 90 min as needed.

• For preoperative IM administration, give 60 to 90 min before surgery.

• Monitor therapeutic effects.

• Do not discontinue the medication abruptly.

Butorphanol, Pentazocine patient education

• Use the medication only when needed and short-term.

• Do not take prior to driving or activities requiring mental alertness.

• Sit or lie down if feeling lightheaded.

• Change positions gradually.

• Lie down when feeling nauseated.

• Do not use for anginal pain.

• Do not take opioids while taking butorphanol.

Butorphanol, Pentazocine contraindications

• Acute myocardial infarction

• Opioid dependence

Butorphanol, Pentazocine precautions

• Schedule IV controlled substance

• History of substance abuse

• Cardiac insufficiency

• Reduced respiratory reserve

• Hypertension

• Head injury, increased intracranial pressure

• Hepatic or kidney disease

Butorphanol, Pentazocine interactions

• CNS depressants (barbiturates, phenobarbital, benzodiazepines, and alcohol) increase CNS depression and increase the risk of respiratory depression.

• Opioid effects decrease.

Opioid Antagonists drugs

naloxone

naloxone therapeutic use

• Reversal of opioid effects, overdose

• Reversal of neonatal respiratory depression (from maternal analgesia)

naloxone adverse drug reactions

• Ventricular arrhythmias

• Increased respiratory rate, blood pressure, heart rate

• Abstinence syndrome (hypertension, vomiting, cramping in opioid-dependent clients)

naloxone interventions

• Monitor vital signs for these expected indications of opioid reversal, in particular blood pressure to elevate.

• Monitor heart rhythm for manifestations of tachycardia.

• Have oxygen and resuscitation equipment ready.

• Expect these manifestations in opioid-dependent clients.

naloxone administration

• Administer IM, IV, or SC.

• Titrate doses carefully.

• Monitor vital signs.

• Be aware that the medication might increase pain by reducing opioid effects and precipitate acute withdrawal for clients who are opioid dependent.

• Prepare to administer every 2 to 3 min until reversal of undesirable effects.

• Prepare to begin administration again, as the effects of opioids might persist beyond the effects of the reversal agent. • Observe for nausea, vomiting, tachycardia, and diaphoresis (indications of opioid reversal).

naloxone contraindications

• Opioid dependence

• Respiratory depression due to nonopioid medications

naloxone precautions

• Cardiac irritability

• Head injury, increased intracranial pressure

• Brain tumor

• Seizure disorders

naloxone interactions

Opioid effects decrease