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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
Analgesics medications?
Nonopioid
Opioid agonists
Adjunct meds
Miscellaneous
Nonopioid analgesics?
Nonsteroidal Anti-inflammatory Drugs
NSAIDs can be -- and trigger -- when taken too much
caustic to the kidneys; asthma attacks
NSAIDs are used for -- pain
moderate
NSAIDs are more appropriate to use if the cause of pain is…
inflammatory
First generation NSAIDs?
aspirin
ibuprofen (advil)
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
Aspirin can trigger an ______ attack
asthma
NSAIDs are GI irritants so give them with…
food
Aspirin can be given -- for pain management or -- for prevention clots
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
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
Do we want to take NSAIDs and acetaminophen together?
NO
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
NSAIDs interact with other _______ and increase the risk of bleeding
anticoagulants
Stop taking NSAIDs _____ prior to surgery
a week
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
2nd generation NSAIDs have less negative effects on GI and ____ the risk for clots?
increase
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…
oxycodone or hydrocodone to make the opioid effect last longer
Acetaminophen can be given as an…
adjunct medication on a daily schedule
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
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
DO NOT USE FOR MORE THAN 48hrs
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 getting…
morphine
hydromorphine
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
Side effects of migraine meds?
HTN
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
With topical local anesthetics watch for…
skin and mucous membrane problems
control esophageal reflexes prior to endoscopic procedures, minor procedures
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 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
weakness
decreased respirations
Disorders with muscle spasms?
MS
Cerebral Palsy
What does baclofen do?
enhances GABA (Gamma-aminobutyric acid)
produces sedative effects
depresses hyperactive spasticity of muscles
Cyclobenzaprine IV is great for…
IV-post op back surgery
Very effective muscle relaxant in general
Complications of muscle relaxants?
CNS depression
Hepatic toxicity
Physical dependence
Nausea, constipation
Diazepam can specifically cause…
hepatotoxicity
dependence
Nursing consideration for Muscle relaxants?
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
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