Analgesics & Musculoskeletal

Nursing Process Assessment

Know what is given & why

Pain is often subjective and patient stated utilize correct pain scale & PQRST

Objective signs - increased HR, BP, & RR

Wong-Baker FACES used for infants

Nursing Process Implementation

5 Rights (patient, medication, dose, route, time) & check for allergies prior

Consider best route for the patient at the time (if N/V do not give oral & administer an antiemetic)

Opioids - controlled substances with special regulations, know agency policy for storage, auditing counts, & disposal

Use least invasive method

Nursing Process Evaluation

Evaluate the patient’s pain response to the medication after administration

IV - assess for pain decrease after 30 minutes

PO - assess for pain decrease after 60 minutes

Unacceptable pain levels - investigate alternate treatment (nonpharmacological)

Respiratory Depression - adverse effect of opioids, evaluate RR, SpO2, & BP after administration

Constipation/Nausea - Common side effects of opioids, encourage high fiber and water intake

Non-Opioid Analgesics

Acetaminophen (Tylenol)

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Acetaminophen (Tylenol)

Use - mild pain & fever, NO anti-inflammatory properties

Action - inhibits synthesis of prostaglandins that serve as mediators of pain & fever in the CNS

Side effects - Reddened skin, blisters, rash, hepatotoxicity (monitor liver function & jaundice)

Route - PO, IV, rectal

Teaching - Take as directed, do not take more than 10 days, avoid alcohol

Administration - safe for all ages, assess pain prior & after use, give with a full glass of water

Max doses - 4000 mg/day (adults); 3200 mg (Geriatric); 2000 mg (Alcoholic pts)

Antidote - acetylcysteine

Nonsteriodal Anti-Inflammatory Drugs (NSAIDs)

Use - Analgesic, antipyretic, & anti-inflammtory actions

Aspirin & some others - have an antiplatelet effect

Inhibition of COX1 - decreased protection of stomach lining, gastric irritation & bleeding may occur (take w food, lowest effective dose for shortest time)

Aspirin

Class - Platelet Aggregation Inhibitor, NSAID

Use - mild pain & fever, reduce risk of heart attack & stroke

Action - Inhibits production of prostaglandins by COX1 & COX2 to reduce inflammation, fever & platelet aggregation

Side effects - Allergic (hives, facial swelling, shock, wheeze); stomach bleeding

Black Box Warning - Pediatric patients should not take aspirin to treat viral infection (chickenpox) due to risk of Reye’s Syndrome

Stomach bleeding risk factors - taking a higher dose for a longer time than directed, taking other NSAIDs concurrently, prior stomach ulcers/bleeding, takes anticoagulants or steroid drugs, above 60 y/o, has more than 3 alcholic drinks a day during use

Teaching - Report tinnitus (early toxicity sign), unusual bleeding, or fever to the HCP, take w a full glass of water & remain upright for 15-30 minutes after, take with food for GI upset

Administration - stop 7 days prior to surgery to reduce risk of bleeding

Contraindications - Bleeding disorder (hemophilia), history of bleeding of stomach

Interactions - Alcohol increase gastric irritation

Reye’s Syndrome

Extremely serious pathological condition associated with swelling of the liver & brain.

Ibuprofen

Class - NSAID

Use - mild to moderate pain & fever, inflammatory disorders like rheumatoid arthritis, osteoarthritis, & pain with dysmenorrhea

Action - inhibits prostaglandin synthesis

Side effects - headache, GI bleed, constipation, dyspepsia, N/V, SJ syndrome, renal failure, allergies, stomach bleeding warning

Nursing Consideration - safe for infants >= 6months

Contraindications - women in the last 3 months of pregnancy due to complications during delivery

Opioid Analgesics & Antagonists

Morphine (Opioid)

Naloxone (Narcan, Antagonist)

Opioids

Use - moderate to severe pain, cancer pain, end of life pain

WHO ladder - Step 1 – Mild Pain (non-opioid analgesics), Step 2 – Moderate Pain (Non-opioid + adjuvants), Step 3 – Severe Pain
(strong opioid)

No ceiling effect - higher dose = high analgesia

Commonly used in PCA - morphine, hydromorphone, fentanyl

PCA - patient controlled, lockout mechanisms to prevent OD, do not activate PCA during sleep

Opioid tolerance - Decrease in the analgesic effect for the dose

Ventilator support is possible

S/S of over sedation - Drowsy, lethargic, respiratory rate < 8, low BP

Morphine

Class - Analgesic Opioid Agonists (Schedule II, risk for abuse)

Use - Moderate to severe pain

Action - binds to opioid receptors in the CNS & alters perception & response to painful stimuli whilst producing CNS depression

Side Effects - Respiratory Depression, Hypotension, Light-headedness, dizziness, sedation, constipation, N/V, Sweating

Black box - slow/difficulty breathing or death when combining CNS depressants & morphine

Teaching - do not drink alcohol or drive on this medication, safe for ages

Antidote - Naloxone (Narcan)

Naloxone (Narcan)

Class - Opioid Antagonist & Reversal Agent

Use - complete/partial reversal of opioid respiratory depression

Routes - IV, IM, Inhaled, IN

Action - Competes with opioid receptor sites in the brain preventing binding of opioids with receptors & displaces opioids already occupying receptor sites to reverse effects

Side Effects - tremors, drowsiness, sweating, decreased respirations, hypertension, N/V

Acute Withdrawal Syndrome - body aches, fever, sweating, runny nose, sneezing, piloerection, yawning, weakness, shivering, trembling, nervousness, restlessness, irritability, diarrhea, N/V, high BP, tachycardia

Neonate withdrawl - convulsion, excessive crying, hyperactive reflexes

Consideration - shorter duration of action than opioids, repeated doses are neccessary

Adjuvant Analgesics (Muscle Relaxants)

Baclofen

Cyclobenzaprine

Tizanidine

Cyclobenzapine

Class - skeletal muscle relaxant

Use - Acute muscle spasms

Action - reduces tonic somatic muscle activity at the level of the brainstem, similar to tricyclic antidepressants

Side effects - Dizziness, blurred vision, drowsiness, dry mouth, urinary retention, constipation

Teaching - Take as prescribed, change positions slowly, avoid alcohol & CNS depressants, increase fluids to prevent constipation

Administration - Safe for patients 15 & older, do not stop abruptly

Contraindications - Concomitant use with MAO inhibitors is contraindicated

Interactions - serotonin syndrome with antidepressents (SSRI, SNRI, TCA, MAOIs)

Allopurinal

Class: Hyperuricemia

Use: Prevention & treatment of gouty arthritis & neuropathy; treatment of secondary hyperuricemia

Action - blocks production of uric acid by inhibiting action of xanthine oxidase

Side effects - hypotension, flushing, hypertension, drowsiness, N/V, diarrhea, hepatitis, renal failure, DRESS syndrome, hypersensitivity

Teaching - Take as prescribed, alkaline diet & increase fluids to prevent kidney stones

Administration - Report rashes or blood in urine to HCP promptly

Interactions - Alcohol increases uric acid levels & decreases effectiveness of the medication

Why use acetaminophen (Tylenol)?

Mild to moderate pain, fever

Safe for most people

No GI Irritation

What are some of the teaching points you give for Allopurinol?

Alkaline diet

Increase fluids

Report rash & blood in urine'

Avoid alcohol

General anesthesia

Causes complete loss of consciousness and sensation; used during major surgeries.

What teaching education would you give to a patient prescribed a muscle relaxant?

Avoid alcohol, don’t drive, may cause drowsiness or dizziness

Why use ibuprofen?

Reduces pain, inflammation, & fever, good for arthritis pain

When is ketorolac contraindicated?

With kidney issues, GI bleeding, or if used >5 days

caution in elderly

What is the most important take away when a patient is taking/prescribed Tylenol?

Don’t exceed 4,000 mg/day to avoid liver damage.

What is the most important take away when a patient is taking/prescribed Aspirin?

Watch for bleeding

avoid in kids (risk of Reye’s syndrome)

Avoid with GI ulcers.

Stomach bleeding!

What is the difference between Acetaminophen & Ibuprofen

Ibuprofen (NSAID) has anti-inflammatory properties.

What assessment is neccessary before stepping up on the WHO ladder

Determine patient’s RR, pain level, amount of non-opioid analgesic taken for the day

Baclofen Teaching

Take as direct

Do not stop abruptly

Dizziness/drowsiness

Change positions slowly

Avoid alcohol & CNS depressants