ch 14

Introduction to Clinical Pharmacology 

Chapter 14

Nonopioid Analgesics: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Migraine Headache Medications

Learning Objectives

Here’s a structured, nursing-focused breakdown of each topic:

1. Importance of Good Pain Assessment

Accurate pain assessment is critical because it directly affects:

• Treatment effectiveness (right drug, dose, timing)

• Patient safety (avoiding over- or undertreatment)

• Quality of life (pain impacts sleep, mobility, mood)

Why it matters:

• Pain is subjective—the patient’s report is the most reliable indicator.

• Poor assessment can lead to:

  • Undertreatment (unrelieved suffering)

  • Overtreatment (toxicity, dependence risks)

• Establishes a baseline to evaluate therapy effectiveness

• Helps identify underlying causes (injury, inflammation, disease)

2. Standardized Pain Assessment Methods

Different populations require different tools:

A. Self-Report Scales (Most reliable when possible)

• Numeric Rating Scale (0–10)

• Visual Analog Scale (VAS)

• Verbal Descriptor Scale

Best for: alert adults and older children

B. Behavioral Scales (Nonverbal patients)

Infants

• FLACC Scale (Face, Legs, Activity, Cry, Consolability)

Older adults with dementia

• PAINAD Scale (Pain Assessment in Advanced Dementia)

Nonverbal/intubated patients

• Behavioral Pain Scale (BPS)

Comparison Highlights

3. NSAIDs Overview

Common Examples

• Ibuprofen

• Naproxen

• Ketorolac

Uses

• Mild to moderate pain

• Inflammation (arthritis, injury)

• Fever

• Dysmenorrhea

Mechanism of Action

• Inhibit COX-1 and COX-2 enzymes

• Decrease prostaglandin synthesis
  → reduces pain, inflammation, and fever

Common Adverse Reactions

• GI irritation (nausea, ulcers, bleeding)

• Renal impairment

• Fluid retention, hypertension

• Increased cardiovascular risk

Contraindications

• Peptic ulcer disease

• Active GI bleeding

• Severe renal impairment

• NSAID allergy

Precautions

• Older adults

• Cardiovascular disease

• Hypertension

• Concurrent anticoagulant use

Interactions

• Anticoagulants → ↑ bleeding risk

• Corticosteroids → ↑ GI ulcer risk

• ACE inhibitors/diuretics → ↓ kidney function

• Alcohol → ↑ GI irritation

4. Migraine Medications

Types

A. Acute (Abortive) Therapy

• Triptans (e.g., Sumatriptan)

• NSAIDs

• Ergot derivatives (e.g., Ergotamine)

B. Preventive (Prophylactic)

• Beta-blockers

• Antidepressants

• Anticonvulsants

Mechanism of Action

Triptans

• Stimulate serotonin receptors

• Cause vasoconstriction of cranial vessels

Ergots

• Constrict blood vessels

• Reduce neurogenic inflammation

Adverse Reactions

• Triptans: chest tightness, dizziness

• Ergots: nausea, hypertension

• NSAIDs: GI effects

Contraindications

• Cardiovascular disease (triptans, ergots)

• Uncontrolled hypertension

• Pregnancy (ergots)

Interactions

• Triptans + SSRIs → risk of serotonin syndrome

• Ergots + triptans → severe vasoconstriction

5. Nursing Assessment for NSAIDs

Before Administration

• Assess:

  • Pain characteristics

  • GI history (ulcers, bleeding)

  • Renal function

  • Current medications

Ongoing Monitoring

• Pain relief effectiveness

• Signs of GI bleeding:

  • Black/tarry stools

  • Vomiting blood

• Kidney function (urine output, labs)

• Blood pressure (fluid retention)

6. Nursing Diagnoses (NSAIDs)

• Acute pain

• Chronic pain

• Risk for bleeding

• Risk for impaired renal function

• Risk for fluid volume excess

• Deficient knowledge

7. Promoting Optimal Therapy & Patient Education

Promote Best Outcomes

• Use lowest effective dose

• Take with food or milk

• Avoid long-term use unless prescribed

Managing Adverse Effects

• GI upset → take with meals

• Monitor for early bleeding signs

• Encourage hydration (kidney protection)

Patient Education

Key Teaching Points

• Avoid alcohol

• Do not combine multiple NSAIDs

• Check OTC products for hidden NSAIDs

• Report:

  • Stomach pain

  • Blood in stool/vomit

  • Decreased urine

Safety Reminders

• Older adults = higher risk for complications

• Long-term use requires monitoring

• Always follow prescribed dosing

Pain Assessment #1

A key component to good pain management is the pain assessment. 

Pain is subjective.

The location and intensity of the pain should be assessed—pain can be localized or referred.

Pain is often referred to as the “5th vital sign.”

Pain Assessment #2

Sample Assessment Questions

Does the pain keep you awake at night? Prevent you from falling asleep or staying asleep?

What makes your pain worse? What makes it better?

Can you describe what your pain feels like? Sharp, stabbing, burning, or throbbing.

Does the pain affect your mood? Are you depressed? Irritable? Anxious?

What over-the-counter medications or herbal remedies have you used for the pain?

Does the pain affect your activity level? Are you able to walk? Perform self-care activities?

Pain Assessment #3

Populations at Higher Risk for Poor Pain Assessment

Infants and children

Older adults, especially those cognitively impaired

Developmentally disabled children and adults

Those with communication problems such as limited English proficiency or limited health literacy 

Those unable to communicate due to the illness or treatment process 

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Actions #1

Analgesic and antipyretic

Exact mechanism of action unknown; thought to work by inhibiting action of enzyme cyclooxygenase responsible for prostaglandin synthesis; NSAIDs inhibit two related enzymes 

Thought to inhibit prostaglandin synthesis by blocking the action of cyclooxygenase: Enzyme controls the process of inflammation

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Actions #2

NSAIDs inhibit the activity of two cyclooxygenase enzymes:

cyclooxygenase-1 (COX-1): Enzyme helps to maintain the stomach lining

cyclooxygenase-2 (COX-2): Enzyme triggers pain and inflammation 

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Actions #3

Ibuprofen and naproxen: block COX-2, produces pain relief; inhibit COX-1, causes adverse reactions including unwanted GI reactions such as stomach irritation and ulcers 

Celecoxib: inhibits only COX-2; less potential for GI adverse reactions

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Uses

Mild to moderate pain

Primary dysmenorrhea

Fever reduction

Pain associated with musculoskeletal disorders (osteoarthritis and rheumatoid arthritis)

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Adverse Reactions #1

Gastrointestinal System Reactions: 

Nausea, vomiting, dyspepsia

Anorexia, dry mouth

Diarrhea, constipation

Epigastric pain, indigestion, abdominal distress or discomfort, bloating

Intestinal ulceration, stomatitis

Jaundice

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Adverse Reactions #2

Central Nervous System Reactions: 

Dizziness, anxiety, lightheadedness, vertigo

Headache

Drowsiness, somnolence, insomnia

Confusion, depression

Stroke, psychic disturbances

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Adverse Reactions #3

Cardiovascular System Reactions: 

Hypotension or hypertension

Congestive heart failure

Cardiac arrhythmias

Myocardial infarction

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Adverse Reactions #4

Renal System Reactions: 

Polyuria, dysuria, oliguria

Hematuria, cystitis

Elevated blood urea nitrogen

Acute renal failure in those with impaired renal function

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Adverse Reactions #5

Hematologic System Reactions: 

Pancytopenia

Thrombocytopenia

Neutropenia

Eosinophilia

Leukopenia

Agranulocytosis

Aplastic anemia

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Adverse Reactions #6

Integumentary System Reactions: 

Rash, erythema, irritation, skin eruptions

Ecchymosis, purpura

Exfoliative dermatitis

Stevens–Johnson syndrome

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Adverse Reactions #7

Metabolic/Endocrine System Reactions: 

Decreased appetite, weight loss or increase

Flushing, sweating

Menstrual disorders, vaginal bleeding

Hyperglycemia or hypoglycemia

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Adverse Reactions #8

Sensory System and Other Reactions: 

Taste change

Rhinitis

Tinnitus

Visual disturbances

Thirst, fever, chills

Vaginitis

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Contraindications

Contraindicated in clients with:

known hypersensitivity to NSAIDs or aspirin

cross-sensitivity with other NSAIDs

pregnancy (third trimester) and lactation

postoperative pain from CABG surgery

rheumatoid arthritis or osteoarthritis (ketorolac, mefenamic, and meloxicam)

allergy to sulfonamides or a history of cardiac disease or stroke (celecoxib)

Hypertension, peptic ulceration, or GI bleeding (ibuprofen)

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Precautions

Used cautiously in clients with:

pregnancy (pregnancy category B)

older adults (risk of ulcer formation)

bleeding disorders, renal disease, cardiovascular disease

hepatic impairment 

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)—Interactions

Pharmacology in Practice Exercise #1

Why is celecoxib not used to relieve postoperative pain for a client who has undergone coronary artery bypass graft (CABG) surgery?

Increased risk of duodenal ulcer

Increased risk of gastric bleeding

Increased risk of myocardial infarction

Increased risk of diarrhea

Migraine Headaches

Pain associated with migraine headaches is believed to be caused by chemical changes in the brain. Drugs used to treat migraine headaches are given: 

Prophylactically to reduce brain chemical changes

To treat the acute pain when a migraine occurs 

Drugs Used in the Treatment of Migraine Headaches—Actions and Uses #1

Preventative Migraine Drugs:

Work to block the process of various chemicals in the brain to reduce stimulation of nerve fibers that cause acute pain, vasodilation, and other cellular events

Most block serotonin, GABA, or calcium 

CGRP antagonists block the Calcitonin Gene–Related Peptide from attaching to other proteins or neurons  

block nociception so nerves are not stimulated, and pains and vasodilation do not occur

Drugs Used in the Treatment of Migraine Headaches—Actions and Uses #2

Acute Migraine Drugs:

Activation of the 5-HT receptors causes vasoconstriction and reduces the neurotransmission, which in turn produces pain relief

Selective serotonin drugs are used for the relief of moderate to severe pain and inflammation related to migraine headaches 

Drugs Used in the Treatment of Migraine Headaches—Adverse Reactions

Common Adverse Reactions (Mild and Transient):

Dizziness, nausea, fatigue, pain, dry mouth, and flushing

Cardiovascular System Reactions

Coronary artery vasospasm

Cardiac arrhythmias and tachycardia

Myocardial infarction

Drugs Used in the Treatment of Migraine Headaches—Contraindications and Precautions

Contraindicated in clients:

with known hypersensitivity to selective serotonin agonists

with ischemic heart disease, transient ischemic attacks, uncontrolled hypertension, or clients taking monoamine oxidase inhibitors (5-HT agonists)

with HIV using protease inhibitors (ergot derivatives)

taking macrolide antibiotics (ergot derivatives)

Used cautiously in clients with:

hepatic or renal impairment

elderly 

dialysis

pregnancy (pregnancy category C) 

lactation

Drugs Used in the Treatment of Migraine Headaches—Interactions

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #1

Preadministration Assessment

Objective Data

Location of pain

Description of site which is the cause of pain

Palpate for tenderness in the location of pain, examine the joints if involved

Vital signs 

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #2

Preadministration Assessment (continued)

Subjective Data

Pain experience (onset, type, radiation, location, intensity, and duration)

Type and duration of symptoms

If febrile, describe the type and duration of symptoms

Allergy history

History of GI bleeding, cardiovascular disease, stroke, hypertension, peptic ulceration, or impaired hepatic or renal function

Remedies attempted before seeking care

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #3

Ongoing Assessment

Monitor pain relief; reassess pain rating 30 to 60 minutes following administration of the drug

Use the same pain scale for each assessment of pain

Persisting pain: assess and document severity, location, and intensity; monitor vital signs at least every 4 hours

Assess for decrease in inflammation and mobility in joints 

Report any adverse reactions (dark stools, prolonged bleeding)

Pharmacology in Practice Exercise #2

A client is prescribed an NSAID for osteoarthritis. What assessments should the nurse perform before administration of the NSAID?

Document limitations in mobility

Examine the level of consciousness in the client

Check the level of mental stability of the client

Determine the client’s body temperature

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #4

Nursing Diagnoses

Acute or Chronic Pain related to peripheral tissue damage caused by the disease process or GI bleeding or inflammation from NSAID therapy

Impaired Physical Mobility related to muscle and joint stiffness

Risk for Injury related to adverse reaction of NSAID causing damage to optical field

Impaired Skin Integrity related to photosensitivity when using 5-HT agonist for migraine.

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #5

Planning

Expected client outcomes depend on the reason for administration of the drug but may include:

Optimal response to therapy (relief of pain and fever)

Management of common adverse drug reactions

Confidence and understanding of the prescribed medication regimen

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #6

Implementation

Promoting an optimal response to therapy—Oral Administration

NSAID administered with food, milk, or antacids

If relief is not achieved with one NSAID, client, may have success switching to another NSAID

Several weeks of treatment: full therapeutic response

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #7

Implementation

Promoting an optimal response to therapy—Subcutaneous Injection Administration (Migraine)

Teach client to use the specific pre-filled syringe or administration device

Instruct the client never to use medication that is yellow or cloudy in the dispenser

Administration of sumatriptan should be given at the onset of headache, but can be given during the attack; second injection can be given after 1 hour if no pain relief

No more than two injections in a 24-hour period

Nurse should observe the client’s first self-administration of drug to ensure proper technique

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #8

Implementation

Monitoring and Managing Client Needs

Acute or Chronic Pain

Elderly more vulnerable to GI bleeding due to higher incidence of rheumatoid arthritis and osteoarthritis and use of NSAIDs on long-term basis—monitor for GI bleeding

Encourage to take drug with a full glass of water and food

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #9

Implementation

Monitoring and Managing Client Needs

Impaired Physical Mobility

Provide comfort measures, support limbs, apply heat or cold, rest joint, avoid overuse

Assistive mobility devices such as canes, crutches, walkers

Walk with the client to encourage ambulation and assess mobility after NSAID administration

Clients with osteoarthritis—observe range of motion and monitor pain, tenderness, and swelling 

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #10

Implementation

Monitoring and Managing Client Needs

Risk for Injury

Observe for adverse drug reactions, GI bleeding, and cardiovascular reactions

Monitor for visual disturbances (diminishes or changes in vision)—clients on long-term therapy need periodic eye examinations

Monitor for serotonin syndrome in clients taking medications for migraines and using antidepressants (SSRI or SNRI): mental changes, tachycardia, blood pressure or temperature elevation, tightness in muscles, and difficulty waking

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #11

Implementation

Monitoring and Managing Client Needs

Impaired Skin Integrity: Photosensitivity

Skin can become sensitive to light when taking 5-HT agonists for migraine relief

Teach client to wear protective clogging and sunscreen when outside

Teach that ultraviolet light from tanning salon beds can also cause a reaction—tanning should be discouraged 

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #12

Implementation—Educating the Client and Family

Develop a teaching plan for the client and family to include:

Long-term use: the client and family need to understand the fact that the drug needs to be taken correctly even if symptoms are relieved

Take drug exactly as prescribed

Take drug with food or full glass of water unless otherwise indicated

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #13

Implementation—Educating the Client and Family (continued)

Develop a teaching plan for the client and family to include:

Teach client to inform all health care providers of NSAID use (dentists)

If using NSAID for fever, to notify the primary health care provider if the client is febrile for more than 24 hours after taking the drug

Not to self-treat chronic pain with an over-the-counter drug—contact primary health care provider

The drug may take several days to produce an effect; contact the provider if no relief after 2 weeks 

Notify primary provider of any adverse effects

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication #14

Implementation—Educating the Client and Family (continued)

Develop a teaching plan for the client and family to include:

If taking a selective serotonin agonist for migraine headache pain, the drugs are used to treat and not to reduce or prevent migraines.

Administer the drug at the onset of symptoms. Dose can be repeated after 1 hour.

Never take more than two doses in a 24-hour period and notify the primary health care provider if the migraine is not relieved.

Nursing Process—Client Receiving an NSAID Drug or Migraine Medication

Evaluation

Was the therapeutic response achieved? Is the pain relieved or discomfort reduced?

Were adverse reactions: identified, reported, and managed? 

Client reports reduced or eliminated pain

Client reports improved mobility

Client is free from injury or uses adaptive devices for visual deficits

Did client and family express confidence and demonstrate understanding of drug regimen?

Turn and Talk—Case Study

A 55-year-old client presents to the physician’s office today complaining of pain in the knees and hips. The client has hypertension and diabetes. Current medications include lisinopril 20 mg every day, metformin ER 500 mg twice a day, and aspirin 81 mg every day. The client has tried acetaminophen in the past to treat joint pain, but with little relief. The physician diagnoses the client with osteoarthritis and writes a prescription for ibuprofen 800 mg every 8 hours as needed for pain. The physician has asked you, the nurse, to bring the prescription and provide client teaching.

What should the nurse tell the client about taking the ibuprofen with other medications?

How should the nurse advise the client to take the ibuprofen?

What side effect should the nurse discuss with the client about ibuprofen?