Controlled Substances, Nsaids

Front 1

Acute pain

Back 1

Pain that is sudden in onset, usually subsides when treated and usually lasts less than 6 weeks

Front 2

Chronic pain

Back 2

Persistent/recurring pain that is diff to treat. Usually lasts longer than 3 - 6 mos. or lasts longer than 1 month after healing of the injury, or accompanies a non-healing tissue injury

Front 3

Analgesics

Back 3

Medications that relieve pain w/o causing loss of consciousness

Front 4

Somatic pain

Back 4

Originates from skeletal muscles, ligaments, or joints

Front 5

Classes of Opioids

Back 5

--Morphine-like drugs

--Meperidine-like drugs

Methadone-like drugs

Front 6

Indications for Opioid Analgesics

Back 6

--Moderate to severe pain
--Can be used w/ anesthetics during surgery
--Mangmnt of post-op pain
--Mangmnt of chronic pain
--Immed & Sustained release form
--Suppress the cough center
--Trtmnt of diarrhea

Front 7

Contraindications for Opioids

Back 7

--Drug allergy
--Be specific when obtaining a drug Hx
--Severe asthma
--Resp insufficiency
--Elevated Intracranial pressure
--Morbid Obesity &/or sleep apnea
--Paralytic ileus

Front 8

Adverse Effects of Opioids

Back 8

--Strong potential for abuse
--Psychological dependence
--Itching, rash
--Orthostatic hypotension
--CNS depression
--Resp depression
--Nausea, vomiting, constipation
--Urinary retention
--True anaphylaxis rare

Front 9

Opioid Antagonists
Toxicity & Management of
Overdose

Back 9

--Bind to and occupy all of the receptor sites that opiods would normally occupy
--Reverse the effects of respiratory depression and other adverse effects
--opiod withdrawal
--"opioid-naive" patients

Front 10

Drug Interactions

Back 10

--Alcohol
--CCNS depressants
--Antihistamines
--Barbiturates
--Benzodiazepines
--Phenothiazine

Front 11

Morphine Sulfate

Back 11

Opioid Agonist
--Schedule II controlled substance
--Oral, injectable, rectal & epidural

Front 12

Morphine sulfate
Examples

Back 12

MS Contin
oxycodone - immed release (OxyIR)
OxyContin (Cont Release)
MSIR
Hydromorphone (Dilaudid)-8X stronger than Morphine

Front 13

Codeine sulfate

Back 13

Opioid Agonist
--Less effective than morphine sulfate
--Antitussive drug
--Codeine w/ acetaminophen (sch III drug)
--Mild to moderate pain
--GI upset

Front 14

Fentanyl citrate
Examples

Back 14

-Sublimaze
--Duragesic
--Fentora
--Actiq

Front 15

Constipation r/t Opioids
Adverse effects

Back 15

Opioids decrease GI tract peristalsis b/c of CNS depression
Stool becomes excessively dehydrated r/t remaining in the GI tract longer

Front 16

Opioid Agonists

Back 16

Codeine sulfate
-Less effective than morphine sulfate
-Antitussive drug
-Codeine with acetaminophen
-Schedule lll drug
-Mild to moderate pain
-GI upset

Front 17

Fentanyl citrate

Back 17

-Synthetic opioid
-Moderate to severe pain
-Injectable, patches, buccal lozenges, lozenges on a stick (lollipops)

Front 18

Meperidine hydrochloride
(Demerol)
Cautions

Back 18

-Can become toxic quickly
-Not for long-term pain management
-Not for elderly
-Not for patients with kidney dysfunction
-Post-operative pain, acute migraines

Front 19

Methadone hydrochloride

Back 19

-Detox treatment
-Chronic and cancer pain
-24-hour dosing

Front 20

Oxycodone hydrochloride

Back 20

-Combined with acetaminophen/aspirin (Percocet, percodan)
-Oxy IR, OxyContin, hydrocodone with acetaminophen (Vicodin)

Front 21

Opioid Agonists-Antagonists

Mixed actions

Back 21

Buprenex
Stadol
Nubain
Talwin
Used frequently for obstetrical pain relief
Do not give with opioid agonists
Work like opioid drugs, but lower risk of misuse and addiction

Front 22

Opioid Antagonists

Back 22

Compete with opioids for CNS receptor sites

Front 23

Naloxone hydrochloride (Narcan)

Back 23

-Drug of choice for reversal of opioid-induced respiratory depression
-Can cause opioid withdrawal syndrome

Front 24

Acetaminophen

Back 24

Nonopioid Analgesic
Blocks peripheral pain impulses
Lowers febrile body temperature
Lacks antiinflammatory effects
Not an NSAID
Doesn’t cause bleeding, GI tract irritation, or edema
Can be used as a substitute for aspirin
OTC
Reye’s syndrome

Front 25

Acetaminophen

Toxicity and Management of overdose

Back 25

-Hepatotoxic and nephrotoxic
-No more than 4000 mg/day; less better
-Combo drugs
-Antidote
-Acetylcysteine
-Interactions
-Alcohol

Front 26

Best types of dosage schedule for pain medication:

Back 26

1. As needed
2. Around the clock
3. On schedule during waking hours
4. Around the clock, with additional doses for breakthrough pain

Front 27

Muscle Relaxants

Back 27

-Act within the CNS to relieve pain from skeletal muscle spasms
-Work best with rest and therapy
-Don’t take with alcohol, caution with CNS depressants

Front 28

Muscle Relaxants

Adverse effects

Back 28

Euphoria
muscle weakness
dizziness
drowsiness,
fatigue

Front 29

Muscle Relaxants

Examples:

Back 29

Dantrolene (Dantrium)
baclofen (Lioresal),
cyclobenzaprine (Flexeril),
carisoprodol (Soma),
metaxolone (Skelaxin)
methocarbomol (Robaxin)

Front 30

Salicylate
toxicity

Back 30

--Tinnitus and hearing loss
--Hypoglycemia
--May need hemodialysis

Front 31

NSAID toxicity

Back 31

1) Constipation
2) Nausea & vomiting
3) Tremors
4) Urinary retention

Front 32

Constipation
Preventative measures:

Back 32

--Increase fluid intake
--stool softeners (docusate sodium) or mild cathartics (senna)
--psyllium

Front 33

Nausea & Vomiting r/t Opioids

Back 33

Opiods decrease GI tract peristalsis
Some stimulate the vomiting center in CNS

Front 34

Sedation & Mental Clouding
r/t Opioids

Back 34

May be managed w/ a decrease in opioid dosage or change in drug used.
Prescriber may also order various CNS stimulants

Front 35

Muscle Relaxants

Assessment:

Back 35

Note drug allergies

With elderly, risk of CNS toxicity

Front 36

Muscle Relaxants
Nursing Diagnoses

Back 36

Deficient knowledge R/T inadequate information about CNS drugs
Risk for injury and falls
Risk for injury R/T possible drug overdose or adverse reactions

Front 37

Muscle Relaxants
Planning Goals

Back 37

Patient complies with drug therapy
Patient remains free of or experiences minimal adverse effects and toxic effects from muscle relaxants

Front 38

Muscle Relaxants
Outcome Criteria

Back 38

Patient states the common adverse effects R/T use of muscle relaxants such as euphoria, dizziness, drowsiness, and fatigue
Patient states the common drug interactions with alcohol and other meds (tranquilizers, analgesics) that may be life threatening

Front 39

Muscle Relaxants

Implementation

Back 39

Assist with ambulation if dizzy
Use of side rails, bed alarms
Monitor for airway, breathing, circulation
Monitor for toxicity
Change positions slowly
Check for hypotension after medicating
Educate re: potential for injury and adverse reactions

Front 40

Muscle Relaxants

Evaluation:

Back 40

Look for decreased spasticity, decreased rigidity, relief of pain
Patient has no injuries or adverse reactions from effects of muscle relaxants

Front 41

(NSAIDs)

Back 41

Nonsteroidal Antiinflammatory Drugs
Analgesic
Antiinflammatory
Antipyretic

Front 42

NSAIDs

Uses

Back 42

Mild to moderate headaches
Myalgia
Neuralgia
Arthralgia
Post-op pain
Arthritic disorders
Platelet aggregation inhibition (Aspirin)

Front 43

NSAIDs

Mechanism of Action and Drug Effects

Back 43

-NSAIDs relieve pain, headache, and inflammation by blocking cycloxygenase (COX).
-Most NSAIDs both COX-1 and COX-2 inhibitors (inhibit prostaglandins)
-COX-2 inhibitor only (Celebrex)
-All NSAIDs can be ulcerogenic (GI bleeding (COX-1 inhibitors)

Front 44

NSAIDs

Indications

Back 44

Rheumatoid arthritis
Osteoarthritis
Fever
Mild to moderate pain
Combined frequently with opioids (need less opioid for good effect)

Front 45

NSAIDs

Contraindications

Back 45

-Allergy (aspirin)
-History of bleeding problems (Ulcer, vitamin K deficiency)
-Severe renal or hepatic disease
-Don’t use during 3rd trimester of pregnancy
-Excreted in breast milk
-Stop 1 week prior to surgery

Front 46

NSAIDs
Adverse Effects

Back 46

OTC
Heartburn
GI bleeding
Can cause acute renal failure
Black Box Warning
See Box 44-3

Front 47

NSAID Overdose

Back 47

Drowsiness
Lethargy
Mental confusion
Seizures
Nausea/vomiting
GI bleeding
Cardiac arrest
Hemodialysis doesn’t work
Watch for hyperkalemia or hyponatremia

Front 48

Salicylates

Back 48

Aspirin
Comes in tablets, capsules, creams, suppositories, oral liquids
Enteric-coated ASA
81mg ASA

Front 49

Acetic Acid Derivatives

Back 49

Indomethacin
Ketorolac

Front 50

Ketorolac

Back 50

Toradol

--Has strong analgesic qualities
--Not addictive
--Can only be used for 5 days (kidney & GI tract issues)

Front 51

Indomethacin

Back 51

Indocin

Used for:
--rheumatoid arthritis
--osteoarthritis
--acute bursitis

Front 52

Propionic Acid Derivatives

Back 52

Ibuprofen
Naproxen

Front 53

Ibuprofen

Back 53

Motrin, Advil (Trade names)
Rheumatoid arthritis
Osteoarthritis
Gout
Dental pain
Musculoskeletal disorders
Antipyretic

Front 54

What are the manifestations of NSAID toxicity

Back 54

1. Constipation
2. Nausea and vomiting
3. Tremors
4. Urinary retention

Front 55

Cyclooxygenase-2 Inhibitors

Back 55

Less effects on the GI tract
Vioxx and Bextra no longer on the market

Front 56

Celecoxib

Back 56

Celebrex (Trade name)
Rheumatoid arthritis
Acute pain symptoms
Dysmenorrhea
Reduction of colon polyps in certain people
Little effect on platelet function
Don’t give if sulfa allergy
Watched closely by FDA

Front 57

Respiratory Depression
r/t Opioids

Back 57

Long-term use is generally associated w/ tolerance to respiratory depression

Front 58

Respiratory Depression
Preventative measures

Back 58

For severe resp depression, opioid antagonists may be used to improve resp status and, if they are titrated in small amounts, the resp depression may be reversed w/o analgesia reversal

Front 59

Subacute Overdose
r/t Opioids

Back 59

Subacute overdose may be more common than acute resp dep and may progress slowly (over hrs to days), w/ somnolence and resp dep. Before analgesic dosages are changed or reduced, advancing disease must be considered--esp in the dying

Front 60

Subacute Overdose
Preventative measures

Back 60

Holding 1 or 2 doses of an opioid is enought to judge if the mental/resp dep are associated w/ the opioid.
If there is improvement w/ holding - often dosage is decreased by 25%

Front 61

Other opioid Adverse Effects

Back 61

Dry mouth, urinary retention, pruritus, myoclonus, dysphoria,
euphoria,
sleep dist,
sexual dysfunction, inappropriate secretion of antidiuretic hormone

Front 62

Salicylates

Back 62

aspirin
diflunisal (Dolobid)
salsalate (Salistab)
choline salicylate (Arthropan)

Front 63

Acetic Acid Derivatives

Back 63

--diclofenac sodium (Voltaren)
--indomethacin (Indocin)
--sulindac (Clinoril)
--tolmetin (Tolectin)
--etodolac (Lodine)
--ketorolac (Toradol)
--meclofenamate (generic only)
--mefenamic acid (Ponstel)

Front 64

Cyclooxygenase-2 Inhibitors

Back 64

--celecoxib (Celebrex)

Front 65

Enolic Acid Derivatives

Back 65

--nabumetone (Relafen)
--meloxicam (Mobic)
--piroxicam (Feldene)

Front 66

Propionic Acid Derivatives

Back 66

--fenoprofen (Nalfon)
--flurbiprofen (Ansaid)
--ibuprofen (Motrin, Advil, etc)
--ketoprofen (Orudis KT)
--naproxen (Naprosyn, Aleve)
--oxaprozin (Daypro)

Front 67

NSAIDs
FDA-approved indications

Back 67

--Acute gout & gouty arthritis
--Ankylosing spondylitis
--Bursitis
--Fever
--Juvenile rhematoid arthritis
--Mild to moderate pain
--Osteoarthritis
--Primary dysmenorrhea
--Tendinitis & various ophtalmic uses

Front 68

NSAIDs:Adverse Effects
Cardiovascular

Back 68

Moderate to severe noncardiogenic pulmonary edema

Front 69

NSAIDs:Adverse Effects
Gastrointestinal

Back 69

--Most frequent:
dyspepsia, heartburn, epigastric distress,
nausea
--Less frequent: vomiting, anorexia, abdominal pain, gastrointestinal bleeding, mucosal lesions (erosions or ulcerations)

Front 70

NSAIDs:Adverse Effects
Hematologic

Back 70

Altered hemostasis through effects on platelet function

Front 71

NSAIDs:Adverse Effects
Hepatic Renal

Back 71

--Reduction in creatinine clearanc
--acute tubular necrosis w/ renal failure

Front 72

NSAIDs:Adverse Effects
Others

Back 72

--Skin eruption
--Sevsitivity reactions
--Tinnitus
--Hearing loss

Front 73

Suggested NSAIDs for:
Ankylosing spondylitis

Back 73

indomethacin
dictofenac

Front 74

Suggested NSAIDs for:
Diabetic neuropathy

Back 74

Sulindac

Front 75

Suggested NSAIDs for:
Dysmenorrhea

Back 75

Fenamates
naproxen
ibuprofen

Front 76

Suggested NSAIDs for:
Gout

Back 76

indomethacin
naproxen
sulindac

Front 77

Suggested NSAIDs for:
Headache

Back 77

aspirin
naproxen
ibuprofen

Front 78

Suggested NSAIDs for:
Hepatotoxicity

Back 78

tolmetin
naproxen
ibuprofen
piroxicam
fenamates

Front 79

Suggested NSAIDs for:
History of aspirin or NSAID allergy

Back 79

Avoid if possible
If deemed necessary, consider a nonacetylated salicylate

Front 80

Suggested NSAIDs for:
Hypertension

Back 80

sulindac
nonacetylated salicylate
ibuprofen
etodolac

Front 81

Suggested NSAIDs for:
Osteoarthritis

Back 81

diclofenac
oxaprozin
indomethacin

Front 82

Suggested NSAIDs for:
Risk for GI toxicity

Back 82

COX-2 inhibitors (celecoxib)
nonacetylated salicylate
enteric-coated aspirin
diclofenac
nabumetone
etodolac
ibuprofen
oxaprozin

Front 83

Suggested NSAIDs for:
Risk for nephrotoxicity

Back 83

sulindac
nonacetylated salicylate
nabumetone
etodolac
diclofenac
oxaprozin

Front 84

Suggested NSAIDs for:
Warfarin therapy

Back 84

sulindac
tometin
naproxen
ibuprofen
oxaprozin

Front 85

NSAIDs
Black Box Warning
Cardiovascular Risk

Back 85

may cause an inc risk of serious cardiovascular thrombotic events, MI, and stroke, which can be fatal. This risk may inc w/ duration of use. Pts w/ CD or risk factors for CD may be at greater risk

Front 86

NSAIDs
Black Box Warning
GI Risk

Back 86

cause an inc risk of serious GI adverse events, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal
These events can occur at any time during use & w/o warning symptoms. Elderly pts are at greater risk for serious GI events

Front 87

NSAIDs
Black Box Warning
Perioperative pain

Back 87

contraindicated for the treatment of perioperative pain in the setting of coronary arter bypass graft surgery