Analgesics, Muscle relaxants, Anti-epileptic, Anti-parkinson

When administering pain medications, always know the -- before administering them

level of pain

Best way to assess pain?

How to validate patients response about pain?

* use of the pain scale and patients verbal response
* check VS to see if they are in as much pain as they claim they are

Patients with -- pain may not have much change in VS

chronic

\*typically acute pain causes changes in VS

Analgesics medications?

* Nonopiood
* Opioid agonists
* Adjunct meds
* Miscellaneous

Nonopioid analgesics?

Nonsteroidal Anti-inflammatory Drugs

NSAIDs can be caustic to the-- and trigger -- when taken too much

kidneys; asthma attacks

NSAIDs are used for -- pain

mild/moderate

NSAIDs are more appropriate to use if the cause of pain is…

inflammatory

First generation NSAIDs?

* aspirin
* ibuprofen (advil, motrin)
* naproxen
* indomethacin
* diclofenac
* ketorolac

Uses of first generation NSAIDs?

* inflammation suppression
* mild pain
* fever reduction
* dysmenorrhea
* platelet aggregate inhibition

We don’t want to give children aspirin because…

it can cause reyes sydrome - brain and liver damage

NSAIDs are GI irritants so give them with…

food

Aspirin can be given -- for pain management or -- for prevention

q4hours (325 mg); as a daily dose (81 mg)

Aspirin has what three effects?

* anti-inflammatory
* anti-pyretic
* analgesic

When can Indomethacin be good and bad?

**GOOD:** if baby is born with PDA open it can help to close it

**BAD:** should not be given to pregnant women after 32 weeks because it can cause the ductus arteriousus to close early

Ketorlac is very -- and can be given to patients if --

potent; they do not respond well to opioids

Ketorlac can be scheduled…

q6-8 hours

Ketorlac is given…

IV or PO; for short term use

Ketorlac is great for…

post op gynecological surgeries as well as other surgeries

\*used in OB a lot

Naproxen can be given for…

* arthritis
* tendonitis
* menstrual cramps

Diclofenac can be given for…

arthritis in the hands, elbows, knees, and feet

\*given PO or a gel

Complications of NSAIDs?

* ==damage to gastric mucosa==
* inhibits enzyme protection of GI mucosa
* ==interaction with other anticoagulants causes an increased risk for bleeding==
* ==stop taking a week prior to surgery==
* life span of a platelet is 7 days
* ==Don’t chew SR or ER tabs==

Signs of GI bleeding?

* black tarry stools
* spontaneous epistaxis
* hematuria
* abdominal pain/distention

Second generation NSAID?

Celecoxib

Celecoxib should be used cautiously in clients with --

heart disease

* can increase their risk for MI and stroke due to suppression of vasodilation

Celecoxib can cause…

* osteoarthritis
* rheumatoid arthritis
* ankylosing spondylitis
* type of arthritis that causes inflammation of the joints and ligaments in the spine

Acetaminophen is more commonly used if the cause of the patients pain is…

non-inflammatory

Acetaminophen can be used for relief of…

pain and fever

* anti-pyretic and analgesic effects

Acetaminophen is very…

safe at therapeutic dosages

* can take it q4 hours or q6 hours if a higher dose

Patients should not exceed -- of acetaminophen because it is --

4 g/day; caustic to liver so can cause hepatotoxicity and can also cause nephrotoxicity

Early symptoms of acetaminophen toxicity?

* abdominal discomfort
* nausea
* vomiting
* sweating
* diarrhea
* liver damage results in 48-72 hours following overdose

If the patient develop acetaminophen toxicity they can be given the antidote which is…

acetylcysteine - a mucolytic

Acetaminophen can be given in combination with -- to make the opioid effect last longer

oxycodone or hydrocodone

Acetaminophen can be given as an -- on a daily schedule

adjunct medication

Opioid agonists are also called…

Narcotics

Opioids are Scheduled Two Drugs under the Controlled Substance Act which means that…

* nurse must verify with another nurse when taking medications out and wasting dosages


* physical dependence can occur

Opioids attach to -- and -- receptors in the CNS, altering --

mu and kappa; perception and response to pain

List the types of Opioids?

* morphine
* fentanyl - ==strongest==
* meperidine (Demerol)
* methadone
* codeine
* oxycodone (Oxycontin)
* hydrocodone
* hydromorphone (Dilaudid) - ==stronger than morphine==

Opioids can be administered…

* PO
* IV
* SQ
* IM
* Epidural
* Transdermal

Morphine is commonly used for…

breakthrough pain - a flare of pain that happens even though you are already taking regular pain medicine for chronic pain

Morphine has a very short…

half life so providers can order it every 1-2 hours (with clinical judgement)

Fentanyl is given as a --

Be sure to wear -- when administering the patch

patch; gloves

Fentanyl patch can be used for -- hours before switching it because --

72 hours; it works slower on the body so it has a more sustained, longer effect

You MUST discard fentanyl patches in -- and you MUST --

the sharps container; document where you threw it away

NEVER put a new fentanyl patch on a patient until… and be sure to…

you take the old one off; rotate the site of placement

Meperidine can cause…

* cardiotoxicity
* neurotoxicity

methadone prevents…

withdrawal symptoms

codeine is a -- so it can make you --

cough suppressant; drowsy

Positive of opioids?

Negative of opioids?

**POSITIVE:** produces analgesia and euphoria

**NEGATIVE:** can cause…

* euphoria (==not always good because can lead to addiction to that feeling==)
* sedation
* decreased GI motility (==constipation and urine retention are common findings==)

Complications of Opioids?

* Respiratory depression
* Constipation
* Orthostatic hypotension
* Urinary retention
* Nausea/vomiting
* Overdose: ==coma, respiratory depression, pinpoint pupils==

Antidote for Opioids?

Naloxone (Narcan)

PCA pumps can be used for patients who are receiving which opioid medications?

* morphine
* hydromorphone
* fentanyl

Most important thing with PCA pumps?

only the client can push the button

Adjunct meds for pain?

* **Tricyclic Antidepressants**
* ==amitriptyline:== can be used for fibromyalgia, ==neuropathy==
* **Anticonvulsant**
* ==gabapentin:== can be used for ==neuropathy==
* **Glucocorticoid**
* ==dexamethasone:== more commonly used if we are trying to ==reduce severe inflammation and swelling==
* used often in spinal surgeries
* **NSAID**
* ==ketorlac:== can be scheduled every 6-8 hours in combination with PRN opioids

Migraines occur because of…

inflammation and vasodilation of cerebral blood vessels

Purpose of migraine medications is to…

Complication with migraine meds…

decrease cerebral blood flow

causes vasoconstriction so be careful if giving them to patients with cardiac issues

First line treatment for Migraines?

Serotonin receptor agonist: ==Sumatriptan==

Second line treatment for Migraines?

Ergot Alkaloid: ==Ergotamine==

Preventative meds for Migraines?

* BB
* ==propanolol==
* Anticonvulsant
* ==divalproex==
* Tricyclic antidepressant
* ==amitriptyline==
* Estrogens
* ==if hormone related==
* Caffeine or Excedrin
* ==both cause vasoconstriction==

Local Anesthetic medications?

* lidocaine
* tetracaine
* procaine
* EMLA: (lidocaine/prilocaine)

Local anesthetics block…

conduction of pain impulses at the site

Local anesthetics can be used parenterally for…

* dental procedures
* L&D
* minor procedures
* controls esophageal reflexes prior to endoscopic procedures, minor procedures

With topical local anesthetics watch for…

* skin and mucous membrane problems

How can we make local anesthetics last longer?

use them along with epinephrine

A lidocaine patch has a -- onset but -- duration of effect

slower; longer

Only use lidocaine patches for -- hours in a day and be sure to put name and date on the patch

12

Centrally acting muscle relaxants antispasmodics?

centrally acting = acts on the CNS

* diazepam
* ==baclofen==
* ==cyclobenzaprine==
* methocarbamol

Peripherally acting muscle relaxants antispasmodics?

* dantrolene
* can be used for emergency malignant hyperthermia
* push over 2-3 min for IV emergency
* can be used if a patient does not respond well to general anesthesia

Muscle relaxants are good for patients who have…

* MS or cerebral palsy
* fractured bones
* pain

muscle relaxants can cause…

* constipation due to less peristaltic movement
* hypotension since it is a smooth muscle relaxant and causes vasodilation

What does baclofen do?

* enhances GABA (Gamma-aminobutyric acid)
* produces sedative effects
* depresses hyperactive spasticity of muscles

Cyclobenzaprine IV is great for…

post op back surgery

Complications of muscle relaxants?

* CNS depression
* Hepatotoxicity
* Physical dependence
* Nausea, constipation

Diazepam can specifically cause…

* hepatotoxicity
* dependence

Nursing considerations for Muscle relaxants r/t GI?

* Take with meals if GI upset


* Increase fiber and fluids if constipation occurs

With Parkinson’s disease we want to increase…

dopamine levels

Medications for Parkinson’s disease aim to maintain…

balance between dopamine and acetylcholine in the extrapyramidal nervous system

Do not give dopamine IV because…

it cannot cross the blood brain barrier

Medications for Parkinson’s disease do not…

stop the disease process, they just aid in slowing down progression

Medications for Parkinson’s disease relieve…

==dyskinesiasis==

* bradykinesia, resting tremors, muscle rigidity

Safety concerns in patients who have Parkinson’s disease?

* falls
* dysphagia
* aspiration
* muscle weakness

Downside to Parkinson disease medications?

they wear off and don’t work after a certain amount of years so you continuously need to switch them up

Parkinson’s disease medications?

* levodopa
* carbidopa
* dopamine agonists
* pramipexole
* ropinirole
* selegiline
* rasagiline
* amantadine

Most effective Parkinson’s disease medications?

* levodopa
* carbidopa

Nursing considerations for all Parkinson’s disease medications?

* Instruct about eventual loss of effects
* Initially, no effects for weeks to month
* Medication “holidays”
* Avoid high protein meals
* medications like to attach to protein
* Do not discontinue abruptly

Levodopa is picked by -- and converted to --

nerve terminals; dopamine once it crosses the blood brain barrier

Since levodopa is easily deactivated it is combined with…

carbidopa to help increase amount of levodopa reaching the CNS

Beneficial effects of Levodopa and Carbidopa diminish by…

5th year

Levodopa and Carbidopa must be given at…

regular scheduled times

* if not symptoms will immediately come back

Levodopa and Carbidopa should be given in the…

morning

Avoid administering levodopa and carbidopa with…

==protein foods== - give proteins for lunch and dinner

==pyridoxine foods== - beans, legumes, fish, organ meats, potatoes

SE of levodopa and carbidopa?

* ==dyskinesiasis==
* head bobbing, tics, grimacing, tremors
* ==cardiovascular effects from beta1 stimulation==
* tachycardia, palpitations, irregular HR
* ==psychosis==
* hallucinations, nightmares, paranoia

Levodopa toxicity can specifically cause…

eyelid twitching

dopamine agonists activate…

dopamine receptors

Dopamine agonist medications?

* pramipexole
* ropinirole
* selegiline
* rasagiline
* amantadine

Pramipexole and Ropinirole are used -- early in the disease, and then as an adjunct with -- and --

mono-therapy; levodopa and carbidopa

SE of pramipexole and ropinirole?

* DAYTIME drowsiness
* postural hypotension

When administering pramipexole or ropinirole, check…

BP and LOC

Ropinirole is teratogenic so use cautiously with --

pregnant women

Selegiline and Rasagiline prevent…

dopamine breakdown