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63 Cards in this Set

  • Front
  • Back
common aminoglycosides
vancomycin, gentamicin

Side effects: hearing and renal impairment
Epogen or Procrit
treatments for anemia and prevent post-op blood transfusion by increasing RBC
Abnormal labs for someone at greater risk for SOB or respiratory problems
Low hemoglobin, low RBC count, ABG’s
Abnormal labs for client at risk for arrhythmias before surgery
Potassium levels, Must be corrected prior to surgery
Hypokalemia-increase cardiac irritability
Hyperkalemia-increase risk of disrhythemias with anesthesia.
Hyponatremia- can cause tachycardia
respiration, energy, airway, circulation, temperature
reduces nausea after surgery, laying on side b4 raising head of bed helps.
Drugs that put you at greater risk for complications intraoperterivly and post operatively
Antihypertensive, Tricyclic antidepressants, Anticoagulants, Non-steroidal anti-inflammatory drugs (NSAIDS)
Drugs that cause greater risk for bleeding
anticoagulants, NSAIDS, Steriods
1. Non-prescription acetaminophen and aspirin
2. NSAIDS (ibuprofen)
3. Work at peripheral nervous system at site of injury
1. Morphine
2. meperidine (Demerol)
3. hydromorphone (Dilaudid)
4. Codeine
5. propoxyphene (Darvon)

Work at CNS level-attach to opioid receptor sites
Adjuvant Analgesics:
anticonvulsants – Dilantin
corticosteroids antidepressants – Elavil
helpful in relieving neuropathic pain
Individualization and its Application
1. Individualizing the analgesic increases titration or adjustment of the dose.
a. Dose must be titrated (increased/decreased) for every patient.
b. Same dose may not be effective or safe for everyone.
c. The interval between doses must be adjusted as some people will experience a longer duration of pain relief than others.
d. The choice of drug needs to be matched to the patient’s response to it.
e. Route of administration needs to be individualized.

*Oral route is preferred except when pain is sudden and severe.
The Action of the 3 Analgesic Groups:Non-opioids
a.Salicylates (aspirin)


c.Most common: aspirin, acetaminophen, ibuprofen

d.Others: Narcosis, Ketoprofon

i. Cost: OTC is less expensive than prescription.
ii. Route of Administration
iii. Patient compliance.
iv. Bleeding problems or ulcer. (Minimum effect on gastric mucosa –cetaminophen.)
v. Past history with NSAIDS.
vi. Administration in elderly patients: problems include fluid retention especially w/Renal insufficiency, CHF, and hypertension.
vii. How they relieve pain: reduce PGE2 @ site of injury.

f. We underestimate the effectiveness of non-opioids...

...we overestimate the effectiveness of low doses of opioid analgesics.

...we can combine 2 groups for safe and effective pain relief.
The Action of the 3 Analgesic Groups: Opioids
Opioids work at CNS level.

Opioids may result in physical dependence or withdrawal once the drug is stopped.
Tolerance may occur to analgesic effect of opioids.
Opioids may cause respiratory depression.
No ceiling/limit to analgesia of most opioids.
The Action of the 3 Analgesic Groups: Adjuvant
Tricyclic Antidepressants



Antidepressants & anticonvulsants are indicated
for depression or seizure disorder.

Effective for neuropathic pain including:
nerve tumors
injuries caused by surgical trauma
infiltration of a malignancy into a nerve

TCA’s (Elavil & Sinequan) often prescribed for lingering pain.

Important to express that drug is being used to relieve pain and not depression.

Antidepressants are started at low doses at night because of sedation.

Targetol or Dilantin are anticonvulsants.

Used for neuropathic pain.
Started at low doses, escalated gradually.

Corticosteroids used for spinal cord compression pain.
Also used for cancer pain.
Special Considerations in the Elderly Patient
Older patients may be subject to under-treatment of pain.
Elderly patients tend to have difficulty in metabolizing and excreting drugs.
Shorter acting opioids are suggested.
Older the patient – the longer the duration of action.
Demerol should be avoided.
a.If given IM, severe fibrosis may occur.
b.Normeperidene may accumulate in patients with renal insufficiency
Routes: Opioid
preferred by WHO and APS
a. slow onset – may take 1.5-2 hours to peak.
Routes: Opioid
IV bolus
When pain is sudden and severe, an IV bolus is preferred.

Can reach effect within 15-30 minutes or sooner.
Severe pain can be controlled with IV boluses q 15 min. or so.
Continuous IV infusion: once pain is controlled.
Routes: Opioid
Repetitive IM/SC injections
Repetitive IM/SC injections, disadvantages
a. With IM:
1. May be fluctuations in absorption.
2. Onset and peak effect can’t be reliably predicted.
3. Injections are costly and painful for patient.
Routes: Opioid
Convenient, inexpensive alternative; good for patients with dysphagia or nausea.
a. Available for: morphine, hydromorphone, oxymorphone.
b. Some oral opioids may be used rectally:
-MS Contin
Routes: Opioid
SQ infusion is an alternative to IV continuous infusion:
a. May be less expensive and easier to manage than IV.
b. Morphine and Dilaudid most common for SQ infusion.
c. Equianalgesic conversion is the same 24 hour dose that was given by repetitive IM or SQ injections IV.
Routes: Opioid
a. Epidurally: between duramater and muscle.
b. Intrathecal: subarachnoid space.
c. Used with post op and chronic cancer pain.
Routes: Opioid
a. Fentanyl: chronic cancer pain.
b. onset is slow-may take up to 24 hours to peak.
c. Patients may require rescue doses of analgesic by another route to take care of brief doses of increased pain.
Promethazine (Phenergan) (a phenothiazine)
Except for levoprome, the other phenothiazines neither relieve pain nor potentiate opioid analgesia.

1.Can be used to treat opioid-induced nausea.
2.Exacerbates the hypertensive, sedating and respiratory depressing effects of opioids.
3.Evaluate the administration of phenothiazine and opioid combos.
Hydroxyzine (Vistril)
i.When given IM, has an analgesic effect.
ii.50 mg or more produces as much analgesia as 5 mg morphine IM.

1.Change needle after drawing up medication.
2.Use Z-track method.
3.Use long needle.
4.Avoid large doses and repeated injections
Meperidine (Demerol)
Accumulation of normeperidine may cause neuroexcitation.

Observe for signs such as:
1.tremor, twitching, jerking.
Equianalgesic chart
Can be helpful in establishing dosage when switching from one opioid to another.

Also in switching from IM or IV to po analgesics.

When opioids give orally:
More needs to be given to achieve the same effect as IM, IV, or especially spinal doses.

Switching routes:
Assess pain relief from IM/IV before making a change.

Administration the prescribed po non-opioid around the clock.
Determine the approximate amount of prescribed opioid that will be needed.
Decrease the IM/IV dose by small amounts at the same time that the po dose is administered.
Calculate how much po opioid needed to replace the IM/IV.
Side effects: Opioids
Nausea, vomiting.

All patients taking opioids are at risk for constipation.

Patients can have far more discomfort from constipation than they did from original pain.
PAIN IN CHILDREN:Multidimensional assessment approach
1. Self report tools: body outlines, faces, numeric scale, oucher scale, poker chips, visual analogue scale.
2. Pain behaviors: verbalizations, facial responses, motor response, body/torso response, vocalizations.
3. Physiologic response.
Topical: Lidocaine + Prilocaine
Adverse Effects of Opioids and misc info:
*Nausea and Vomiting
*Drowsiness and confusions
*Respiratory Depression

Less Common:
*Psychological Dependence

NSAIDS – good for bone pain
a.Anti-inflammatory and antipyretic effects.
b.Adverse effects: bleeding, GI irritation.
2. Adjuvants: TCAs-Corticosteroids-Neuroleptics
Non-pharmacological interventions
Physical: Heat, Cold, massage, exercise, etc.

Cognitive behavioral Distraction, relaxation, guided imagery.
opioid analgesics: Hydromorphone
-Most common IV for postop pain
-Respiratory depression(esp in naïve patients) constipation and sedation
-It & morphine are better tolerated than Demerol because they are safer
Oral=7.5mg q 3-4hr (6mg starting dose)
Parental = 1.5mg q3-4hr

-assessing patient's pain level and assessing for signs of pain (example: guarding, elevated b/p).
opioid analgesics: Morphine
-To decrease pain associated with postop procedures
-confusion, sedation and nausea
-morphine is better tolerated than Demerol because they are safer
Oral=30mg q 3-4hr
Parental = 10mg q3hr
opioid analgesics: Demerol (meperidine)
-relief of moderate to severe pain
-respiratory depression, n/v, sedation

Oral=300mg q 2-3hr
Parental = 100mg q3hr
opioid analgesics: Vicodin
(Hydrocodone & Acetaminophen)
-manage postoperative pain
-Respiratory depression(esp in naïve patients) constipation and sedation

Oral=30mg q 3-4hr
Parental = 10mg q3-4hr
opioid analgesics: Duragesic
(Fentanly path)
-post-op :Moderate to severe chronic pain requiring long-
term therapy.
-Medication is primarily used in cancer patients due to the 72-hour path deliver of medication. Other meds may be prescribed for break through pain
-Apnea, confusion, sedation
-The key with Duragesic is that it will not give the person immediate relief. By giving this as Fentanyl patch, then the patient may actually end up having to take less other pain meds po.
opioid analgesics: Percocet
(combination of oxycodone & acetaminophen)
-postoperative pain management
-Confusion, sedation, and constipation
-oxycodone & acetaminophen is also found in Tylox
-Perioperative prophylactic anti-infective
-hypokalemia/hypernatremia - bleeding - rationale - drug causes prolonged prothrombin and partial thromboplastin
time and arrhythmias
-penicillin derivative so should not be given to someone with penicillin allergy.
-WBC, Temp assessment, incision assessment,
negative pneumonia findings.
ANTI-INFECTIVE: levofloxacin/Levaquin
-Postoperative, treat
bacterial infections especially urinary tract infections and skin infections
-Abdominal pain and seizures
-UTI and a negative urine
ANTI-INFECTIVE: Ancef (cefazolin)
-preoperative & q 6-8 hr for 24hrs post-operative
-Diarrhea, nausea and vomiting

Make sure to get a history of allergies to
cephalosporins and penicillins because ancef is in cephalosporin family
Preoperative As a prophylaxis to prevent future infections.
Nephrotoxicity (due to renal insufficiencies),Chills, Fever Rash (due to hypersensitivity), Phlebitis (infused too rapidly).
(Red man syndrome)

Vanco is usually given when patient is in an environment that makes patient more
susceptible to MRSA or has MRSA.
count, collect any necessary wound, sputum, or stool cultures.
prevention and treatment of postopertive nausea and vomiting.

Headache, dizziness and fatigue

It and reglan are less sedating than phenegran

patient has bowel
sounds, no nausea, vomiting or bladder distention.
treatment and prevention of postoperative gastric
stasis and nausea

drowsiness, extrapyramidal effects, restlessness

nausea/abd pain, bowel sounds
Pre-Operative treatment and prevention of nausea and vomiting, Preoperative sedation

Uncontrollable movements of eyes, lips, tongue, face, arms, and legs, Disorientation, Blurred vision

Promethazine tends to be the most sedating of all the antiemtics which is why ANzemet is being used more now to control post op nausea
Elderly tend not to do well with promethazine. It often worsens confusion and can be the cause of confusion in elderly postop. So for your elderly patient, weigh on the side of using less mg. of this drug if range of mg. offered in your order, such as Administer 12.5mg. to 25mg. prn nausea.

Assess allergy symptoms such as rhinitis, hives and conjunctivitis
Assess patient for nausea and vomiting
antianemics: Epoetin (Procrit)
To prevent the need for postoperative blood transfusions

seizures, hypertension and headache

epoetin is prescribed to stimulate the production of red blood cells.

Assess for hypersensitivity to albumin, uncontrolled hypertension and for epoetin levels of more than 200mU/ml as these are contraindications
antianemics: Ferrous Sulfate (Iron)
To replace iron that was lost with blood in surgery.

constipation, diarrhea, and epigastric pain.

Iron also will promote healing of incision if patient had been anemic

monitor hemoglobin, hematocrit,reticulocyte values. serum ferritin and iron levels.
Heartburn symptoms

Abdominal Pain, Flatulence, Diarrhea

Both Protonix and Pepcid used to prevent stress ulcers after surgery & prevent aspiration of stomach contents r/t GERD dur & after surg

Epigastric or abdominal pain, blood in stool, emesis, or gastric aspirate.
ANTIULCER: Famotidine
Preoperative / Prophylaxis of Aspiration Pneumonitis

Confusion, dizziness and drowsiness
ANTICOAGULANT: Lovenox (enoxaparin)
preoperative prophylaxis and postoperatively Prophylaxis DVT of thrombosis and embolism

Bleeding/hemorrhage, Fever, Dizziness

Main lab to check with is platelets

anticholinergics:Atropine (Atro-Pen)
Preoperative / Used to decrease oral and respiratory secretions

drowsiness, dry mouth, tachycardia, urinary retention

Heart rate/Blood Pressure, Urine Output, and Bowel
anticholinergics: Robinul
decreases secretions of the upper respiratory tract and inhibits salivation

Dry mouth, difficulty urinating, and tachycardia

assess heart rate, blood pressure, and respiratory rate
preoperative aids in the induction of anesthesia as
well as part of the balanced anesthesia (sedation, anxiolysis, amnesia)

drowsiness, excess sedation, and headache

The major thing with midazolam or any of these -am drugs is to watch for respiratory depression, over sedation and thus safety concerns for patient.

monitor BP, P, and R.
NSAIDS: Ibuprofen
post-op pain relief after an operation and/or fever reduction

GI bleeding, renal dysfunction, hypersenstivity

more often used for bone or musculoskeletal pain. In same class as Toradol
which is given IV or IM after major joint surgery to decrease musculoskeletal swelling. IBUPROFEN taken frequently before surgery could affect labs and make
person susceptible to bleeding. Remember to take NSAIDS with food and never on an empty stomach.

check temperature, pain level
NSAIDS: Toradol (ketoralac)
postoperative period used in the management of acute pain and inflammation.

heartburn, nausea, and GI bleeding

more often used for bone or musculoskeletal pain.

which is given IV or IM after major joint surgery to decrease musculoskeletal swelling

assess vital signs and pain (location, type, and (duration).
SEDATIVE: droperidol
preoperative tranquilization and adjunction to general and regional anesthesia as well as the suppression of post of nausea and vomiting

Dizziness- Hypotension-

reduced motor activity
and decreased nausea and vomiting.
QUEST principals of pain assesment
Question the child

Use pain rating scales

Evaluate behavior and physiologic changes

Secure parents’ involvement

Take cause of pain into account
Take action and evaluate results
Is an opioid antagonist that is used to reverse side effects of opioids
Barriers to the treatment of pain in children include the following:
1. The myth that children, especially infants, do not feel pain the way adults do, of if they do, there in untoward consequence.
2. Lack of assessment and reassessment for the presence of pain.
3. Misunderstanding of how to conceptualize and quantify a subjective experience.
4. Lack of knowledge of pain treatment.
5. The notion that addressing pain in children takes too much time and effort.
6. Fears off adverse effects of analgesic medications, including respiratory depression and addiction.
How to observe pain in children:
Facial expressions, body
posture, activity and appearance can express that the patient is in pain.

Infants may exhibit facial expression of pain by lowering their brows, closing their eyes tightly and draw their knees to their chest.

Toddlers may be verbally aggressive, cry intensely, exhibit regressive behavior or withdraw and guard painful area of body.

School age children might have muscular rigidity such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, or wrinkled forehead.

Adolescents may exhibit muscle tension and body control and display regressive behavior in presence of family.
Pain therapy
Pain medication, nerve blockers (anesthetics), electrical stimulation, physical therapy,
surgery, psychological counseling and behavior modification.
Problems with substance abuse and pain:
Pain sensitivity is increased and more meds are needed for relief.

Substance abusers often receive inadequate pain management.
Procedure for pain:
1. A full H&P on the patient including a pain assessment.
2. Report document and report findings to the physician.
3. Receive verbal or written order for pain medication.
4. Administer pain medication according to physician order and facility policy.
5. Reassess patient's pain status according to facility policy.
6. Contact physician if the patient feels the current order is not sufficient for new orders.
7. If the physician feels drug seeking behavior is taking place, it is
the physician's responsibility to take it up with the patient.