Pain Management

Study Questions for Pain Management 

Opioid Analgesics 

1. Know the MOA of opioid analgesics and drug effects on mu and kappa receptors 

• MOA: Central Nervous system 

• Agonist on Mu Opioid receptor and kappa receptor 

2. Know how the analgesic dosage is based on 

• Based on patient response 

3. Know the uses of opioid analgesics 

• Severe acute pain, cough suppression, and hospice care; suppresses pain impulses & respiration 

4. Know the drug names of opioid analgesics 

1. Transdermal fentanyl patches – duration of action, onset, and peak 

Duration: 72 hours, Onset: 6-12 hours after use, Peak: 24-72 hours after first use 

2. Why is acetaminophen often combined with some opioids? Morphine and NSAID can be used concurrently for an additive analgesic effect with a lower dose of morphine 

5. Know the class of morphine: Pure opioid agonist 

6. Know the contraindications of morphine: Hypersensitivity, Respiratory depression 

7. Know the precautions of morphine: Seizures, asthma 

8. Know the SE/ADR of morphine:  

• Nausea, vomiting – may need antiemetic 

• Respiratory depression (<12 breaths/min) 

•  Orthostatic hypotension 

•  Constipation, urinary retention 

•  Pruritus 

•  Sedation 

•  confusion 

9. Know the toxicity of morphine: respiratory depression, miosis (pinpoint, constricted pupils), coma 

10. What are the nursing considerations for naloxone?  

• Intravenous preferred; if IV not available, administer via nasal spray, IM, or SQ 

• Assess patient frequently; opioid may last longer in system than naloxone, then respiratory depression may recur 

• Have equipment for resuscitation readily available 

11. Know what to teach patients regarding constipation associated with opioids:   

• Increase fiber/fluid; may need stool softeners or laxatives 

12. Know nursing process for opioids; what needs to be monitored; when nurses should not administer them; the warning for opioids: 

• Before administering, perform a history regarding allergies, use of other medications (previous analgesic use), including alcohol or other CNS depressants, medical history; Monitor PCA pump, baseline ; increased respiratory depression risk with concurrent use of other drugs that have CNS depressant actions including alcohol, benzodiazepines, barbiturates 

13. What can meperidine cause?  

• Hallucinations and confusion 

• may also lower seizure threshold 

14. Know miosis – what can it indicate? Constricted, pinpoint pupils – can indicate opioid overdose. 

15. Know naloxone, its class, use, how does it work, dosing, it works best on which drugs? 

• Class: opioid antagonist, works on pure opioid agonists. 

• MOA: antagonist (block) opioid receptor sites and block their effects. 

• Use: treatment of opioid overdose, reverses opioid-induced respiratory depression 

• What is the SE of naloxone? reversal of analgesia 

• What does opioid toxicity look like? Respiratory depression (slow or shallow breathing or no breathing), Pinpoint pupils (small, constricted pupils), Coma, loss of consciousness 

16. Know tolerance and what it means: A decrease in response to a drug that is used repeatedly 

17. Review mixed opioid agonists-antagonists:  

• Mixed action 

•  Decreases likelihood of substance use disorder 

•  Not strong enough to manage long term chronic pain 

•  Should not be given concurrently with full opioid agonists 

Drugs:  

• Buprenorphine, partial agonist at Mu; 

•  Nalbuphine, agonist at kappa, antagonist at Mu 

•  Pentazocine, agonist at kappa, antagonist at Mu 

Anti-inflammatory 

1. Know Aspirin and how it works and how it is different from other NSAIDs 

• Aspirin: inhibits COX-1 (irreversible) and COX-2 

• Inhibit platelet aggregation, inhibit clotting 

• Protection of MI and stroke 

2. Know drug names for first generation NSAIDs and second generation NSAIDs 

1. Aspirin (irreversible) 

2. Ibuprofen 

3. Naproxen  

4. Indomethacin 

5. Diclofenac 

6. Ketorolac 

Second generation 

Celecoxib 

Meloxicam 

3. Know the class for aspirin, its MOA, and its uses 

Class: Antiplatelet, analgesic, anti-inflammatory, antipyretic. First generation NSAID 

MOA: Inhibits platelet aggregation, decreases formation of prostaglandins involved in inflammation, pain, and fever.  

Acetylsalicylic acid, a type of salicylate  

Uses: 

Prophylactic medication to reduce risk of ischemic stroke and myocardial infarction 

Relieves low to moderate pain 

Decreases inflammation 

Reduces fever 

4. Know the contraindications for aspirin 

1. Hypersensitivity to salicylates 

2. History of GI ulcerations, peptic ulcer disease, hemophilia  

3. Thrombocytopenia (low platelets) 

4. Children with recent history of viral infection (influenza, chickenpox) has been associated with Reye syndrome 

5. Do not use during pregnancy, esp. 3^rd trimester 

5. Know the SE/ADR for aspirin 

1. Increases bleeding potential 

2. Epigastric distress, heartburn, nausea 

3. Aspirin overdose/toxicity  

6. Know what aspirin toxicity looks like 

Tinnitus (ringing in the ears), hearing loss 

Nausea/vomiting 

GI bleeding/GI ulceration 

Kidney failure (↓ urine output, ↑BUN and ↑creatinine levels > 1.2 mg/dL) 

Hyperthermia, sweating 

Dehydration with electrolyte imbalance 

Confusion 

7. Know drug/food interactions for aspirin 

Aspirin + NSAIDs: GI irritation, bleeding 

Aspirin + alcohol: ↑ bleeding 

Aspirin + anticoagulants: ↑ risk of bleeding 

Aspirin + corticosteroids: ↑ risk of GI ulcers 

8. Know the signs of bleeding 

Melena (dark-colored or tarry stools), severe abdominal pain, vomiting 

Vomit that looks like coffee grounds 

Need to obtain complete blood count: hemoglobin, hematocrit, guaiac occult stool test. 

9. Know the nursing care for aspirin – what to monitor, what to observe, teaching regarding surgery, how to take the aspirin 

Monitor for GI bleeding, impaired kidney function, and aspirin toxicity 

Observe that they do not chew or crush enteric-coated or sustained-release aspirin tablets. 

Patients should not take aspirin for at least 5-7 days before surgery 

Take with food or milk to reduce GI upset 

10. Know Reye’s syndrome 

•  Aspirin – contraindicated in children (<12Y) with flulike symptoms 

11. Know OTC drugs that contain aspirin and/or salicylates 

Bismuth subsalicylate, alka-seltzer, peptobismol, excedrin 

12. Know ketorolac and its timeframe for use  

  First generation NSAID, use for 5 days only. 

13. Know contraindications and precautions for first generation NSAIDs (non-aspirin) 

1. GI ulcerations, bleeding 

2. Can impair kidney function ↓ urine output, ↑BUN and ↑creatinine levels >1.2 

3. May increase risk of MI and stroke and CV events 

4. Do not use in patients with a history of hypertension, edema, heart failure, chronic kidney disease 

5. Do not take 5-7 days before major surgery 

14. Know SE/ADR for first generation NSAIDs (non-aspirin) 

1. GI irritation, nausea/vomiting, dyspepsia 

2. GI ulcers, GI bleeding, dizziness 

3. Kidney impairment, weight gain, fluid retention (edema) 

15. Which organ is at greatest risk of damage by NSAIDs? What tests/laboratory values would help the nurse determine if kidney damage is occurring? 

16. Know nursing care for first generation NSAIDs (non-aspirin) 

1. Monitor for GI bleeding, occult blood loss 

2. Take with food or milk to reduce GI upset. Avoid alcohol. 

3. Monitor for fluid retention (edema), weight gain, and renal/kidney impairment (↓ urine output, ↑BUN and ↑creatinine levels >1.2) 

4. Non-aspirin NSAIDs do not protect against MI and stroke; they may increase the risk. 

5. Aspirin, alcohol, or corticosteroids may increase risk of GI distress. 

6. Individual responses to NSAIDs vary from person to person. 

7. Combination drug available with H2 blockers or PPIs. 

8. Prophylaxis agent (misoprostol) may reduce GI distress. 

9. Do not take 5-7 days before major surgery. 

17. Know drug names, MOA, uses, contraindications/precautions, SE/ADR and nursing considerations for second generation NSAIDs (COX-2 inhibitors) 

Selective NSAIDs: celecoxib (Celebrex) & meloxicam 

MOA: inhibits prostaglandin synthesis by inhibiting COX-2, suppresses pain and inflammation while posing a lower risk of gastric ulceration 

Uses: 

Relieves low-to-moderate pain, decreases inflammation 

Contraindication and precautions: 

May increase risk of MI and stroke and CV events. 

Do not use in patients with a history of hypertension, edema, heart failure, chronic kidney disease. 

Can precipitate allergic reaction in those allergic sulfonamides. 

May impair kidney function. 

SE/ADR: nausea, vomiting, GI distress (less risk), dyspepsia, hypersensitivity (rash, urticaria, dyspnea, asthma), photosensitivity, edema, weight gain, GI bleeding (less risk) 

Nursing: give with food or milk; monitor GI irritation, bleeding, renal impairment. 

18. Know celecoxib and its contraindication 

Celecoxib is contraindicated for patients sulfa/sulfonamides; contains a sulfonamide 

19. Know what hypersensitivity looks like 

Uriticaria, wheezing, angioedema, anaphylaxis 

Gout 

1. Know acute gout treatment (colchicine, NSAIDs, glucocorticoids) 

1. Colchicine – know how it works; when it is used; when to expect pain relief; and what GI toxicity looks like 

Reduces inflammation caused by gout 

Treatment for acute gout attacks 

GI distress, can progress to GI toxicity (if severe GI distress, severe nausea, vomiting, diarrhea, stop and notify provider) 

Contraindicated in renal or hepatic impairment 

Oral therapy provides max relief within 24-48 hours. 

2. Know chronic gout treatment 

1. Allopurinol – know MOA and adverse effects 

MOA: inhibit uric acid production and prevent future gout attacks 

Adverse effects: hypersensitivity reaction, agranulocytosis (fever, sore throat, infection), Steven-Johnson syndrome – if rash or fever develops, stop and notify immediately 

2. Probenecid – know MOA  

MOA: increases excretion of uric acid 

Increase fluid intake (at least 2 to 3 L water daily) to keep uric acid flushed out of kidneys 

SE/ADR: GI upset, renal calculi, renal injury 

Acetaminophen 

1. Know its class and MOA. It does NOT do what? 

Class: nonopioid analgesic, antipyretic 

• Does NOT affect inflammation or platelet aggregation 

• Does NOT cause gastric ulceration 

• Does NOT impair renal blood flow or function 

2. Know its uses  

Relief of low to moderate pain, fever in adults and children 

Can be combined with opioid analgesic for synergistic effects 

Normal serum range: 5-25 mcg/mL 

3. Know its adverse effect and what can cause? 

Overdose (>4 g/day): liver damage/liver toxicity  

4. What are the signs of liver toxicity? 

Jaundice, fatigue, paleness 

5. Know the max daily dose for acetaminophen 

Max daily dose 4,000 mg/day  

6. Know its contraindications and precautions. 

Hypersensitivity 

Alcoholism, hepatitis 

7. Know what needs to be monitored and the antidote for acetaminophen 

Assess vital signs 

Draw acetaminophen levels to determine amount, liver function tests (LFTs) 

Antidote: acetylcysteine 

8. Know its nursing considerations for acetaminophen 

Teach patient to avoid concurrent use of alcohol to prevent liver damage 

Evaluate patient to determine purpose of medication—pain or fever 

Antidote for overdose is acetylcysteine 

Monitor medications that may contain acetaminophen, so as not to exceed maximum daily dose of 4,000 mg for most adults. 

Others  

1. Tramadol, Gabapentin, Dexamethasone, Amitriptyline  

• Tramadol 

• Centrally acting non-opioid analgesic with a dual MOA 

• Binds to Mu receptors 

• Release of serotonin 

• May cause seizures; do not use in those with a history of seizures 

• Warning: suicide risk in those who are suicidal or addiction-prone 

• Interaction: monoamine oxidase inhibitor (MAOI), can increase risk of a hypertensive crisis 

Gabapentin 

• Anticonvulsant drug 

• Inhibit neurons from firing 

• Used for neuropathic pain 

• Report edema, rapid weight gain 

• Dexamethasone 

• Suppress inflammation and immune response 

• Amitriptyline  

• Tricyclic antidepressant 

• Alter serotonin and norepinephrine activity at nerve synapses 

• Lidocaine 

• Block conduction of pain impulses; local anesthetic 

• May also be used to treat dysrhythmias