Nr203 4Th Semester Meds Pain

Front 1

Opioids, Narcotic analgesic, narcotic agonist,
morphine type

Fentanyl (duragesic)

Back 1

Indications Manage chronic pain, Tran dermal patch NOT recommended for post op, mild, intermit. pain
Actions Binds at opiate receptor sites within CNS, reducing stimuli from sensory nerve endings.
Therapeutic Effect: Increases pain threshold, alters pain reception, inhibits ascending pain pathways

SIDE EFFECTS
FREQUENT: Headache, pruritus, nausea, vomiting, diaphoresis, difficulty breathing, confusion, dizziness, drowsiness, diarrhea, constipation, decreased appetite. Postop drowsiness, nausea, vomiting. OCCASIONAL: Chest pain, palpitations, skin irritations, fainting, agitation. IV: Postop confusion, blurred vision, chills, orthostatic hypotension, constipation, difficulty urinating.
APNEA, confusion, sedation, weak, constipation, dry mouth, N/V, sweating

Nursing Implications
BASELINE ASSESSMENT: Resuscitative equipment, opiate antagonist (naloxone 0.5 mcg/kg) must be available. Establish baseline B/P, respirations. Assess type, location, intensity, duration of pain.

INTERVENTION/EVALUATION :Assist with ambulation. Encourage pt to turn, cough, deep breathe q2h. Monitor respiratory rate, B/P, heart rate, oxygen saturation. Assess for relief of pain. Assess level of sedation, bowel function.

Patient Teaching
Avoid alcohol; do not take other medications without consulting physician. Do not perform activities requiring alertness, coordination. Teach pt proper transdermal application. Use as directed to avoid overdosage; potential for physical dependence with prolonged use. After long-term use, must be discontinued slowly.
Wear patch 2 doses before increase dose. Pt w/ FEVER OR EXPOSED TO HEAT (BATH) INCREASES THE RELEASE OF DRUG.

Front 2

morphine sulfate
Astramorph, Avinza, DepoDur, Duramorph, Infumorph, Kadian, M-EslonJ, MS Contin, MSIR, Oramorph SR, RMS, Roxanol, Statex

Back 2

morphine sulfate
Astramorph, Avinza, DepoDur, Duramorph, Infumorph, Kadian, M-EslonJ, MS Contin, MSIR, Oramorph SR, RMS, Roxanol, Statex

Indications
Severe pain, pulmonary edema, pain association with MI
Actions Binds with opioid receptors within CNS. Therapeutic Effect: Alters processes affecting pain perception, emotional response to pain; produces generalized CNS depression.

Side Effects
Alert: Effects depend on dosage amount, route of administration. Ambulatory pts, those not in severe pain may experience dizziness, nausea, vomiting, hypotension more frequently than those in supine position or who have severe pain. FREQUENT: Sedation, decreased B/P, diaphoresis, flushed face, constipation, dizziness, drowsiness, nausea, vomiting. OCCASIONAL: Allergic reaction (rash, itching), difficulty breathing, confusion, palpitations, tremors, decreased urination, abdominal cramps, vision changes, dry mouth, headache, decreased appetite, pain/burning at injection site. RARE: Paralytic ileus. RESPIRATORY DEPRESSION,

Nursing
Implications
Baseline assessment: Pt should be in a recumbent position before drug is given by parenteral route. Assess onset, type, location, duration of pain. Obtain vital signs before giving medication. If respirations are 12/min or less (20/min or less in children), withhold medication, contact physician. Effect of medication is reduced if full pain recurs before next dose.

Intervention/Evaluation: Monitor vital signs 5–10 min after IV administration, 15–30 min after subcutaneous, IM. Be alert for decreased respirations, B/P. Check for adequate voiding. Monitor bowel activity; avoid constipation. Initiate deep breathing,coughing exercises, particularly in those with pulmonary impairment. Assess for clinical improvement, record onset of pain relief. Consult physician if pain relief is not adequate.

Patient Teaching Discomfort may occur with injection. Change positions slowly to avoid orthostatic hypotension. Avoid tasks that require alertness, motor skills until response to drug is established. Avoid alcohol, CNS depressants. Tolerance/dependence may occur with prolonged use of high doses.

Front 3

Analgesic/Opioid Antagonists
Naloxone (Narcan)

Back 3

Naloxone (Narcan)
Actions Competitively blocks the effects of opioids, including CNS and respiratory depression.

Indications
Reversal of CNS depression and respiratory depression because of suspected opioid overdosage.

Side Effects
CV: hypertension, hypotension N/V V-FIB, V-TACH

Nursing Implications Monitor respiratory rate, rhythm, and depth; pulse, ECG, blood pressure; and level of consciousness frequently for 3–4 hr after the expected peak of blood concentrations. Patients who have been receiving opioids for >1 wk are extremely sensitive to naloxone. Naloxone decreases respiratory depression but also reverses analgesia.

Patient Teaching
As medication becomes effective, explain purpose and effects of naloxone to patient.

Expected Outcomes Alertness without significant pain or withdrawal symptoms

Front 4

Anticonvulsant
carbamazepine (Tegretol)

Back 4

Anticonvulsant
carbamazepine (Tegretol)

Actions
Decreases sodium, calcium ion influx into neuronal membranes, reducing posttetanic potentiation at synapse. Therapeutic Effect: Produces anticonvulsant effect.

Side Effects/Contraindications
Anticonvulsants:
Blood dyscrasias----------regular blood tests. CBC
Drowsiness, dizziness, nausea, vomiting. OCCASIONAL: Visual abnormalities (spots before eyes, difficulty focusing, blurred vision), dry mouth/pharynx, tongue irritation, headache, water retention, diaphoresis, constipation/diarrhea.

Nursing Implications Pt teaching
Neuralgia: Avoid triggering tic douloureux (draft, talking, washing face, jarring bed, hot/warm/cold food or liquids). Therapeutic serum level: 4–12 mcg/ml; toxic serum level: greater than 12 mcg/ml.
Drowsiness usually disappears during continued therapy. Avoid tasks that require alertness, motor skills until response to drug is established. Report visual disturbances. Blood tests should be repeated frequently during first 3 mos of therapy and at monthly intervals thereafter for 2–3 yrs. Do not take oral suspension simultaneously with other liquid medicine. Do not take with grapefruit juice.

Front 5

Antidepressant
duloxetine hydrochloride Cymbalta

Back 5

Antidepressant
duloxetine hydrochloride Cymbalta

Actions
Appears to inhibit serotonin and norepinephrine reuptake at CNS neuronal presynaptic membranes, less potent inhibitor of dopamine reuptake.
Therapeutic Effect: Produces antidepressant effect.

Side Effects/Contraindications
FREQUENT (20%–11%): Nausea, dry mouth, constipation, insomnia.
OCCASIONAL (9%–5%): Dizziness, fatigue, diarrhea, somnolence, anorexia, diaphoresis, vomiting.
RARE (4%–2%): Blurred vision, erectile dysfunction, delayed or failed ejaculation, anorgasmia, anxiety, decreased libido, hot flashes.

INTERVENTION/EVALUATION
For those on long-term therapy, serum chemistry profile to assess hepatic function should be performed periodically. Supervise suicidal risk pt closely during early therapy (as depression lessens, energy level improves, increasing suicide potential).

PATIENT/FAMILY TEACHING
Therapeutic effect may be noted within 1–4 wks. Do not abruptly discontinue medication. Avoid tasks that require alertness, motor skills until response to drug is established. Inform physician if intention of pregnancy or if pregnancy occurs. Inform physician if anxiety, agitation, panic attacks, worsening of depression occurs. Avoid heavy alcohol intake (associated with severe hepatic injury). The selective serotonin and norepinephrine reuptake inhibitors (SNRIs) appear to be more effective analgesics than the selective serotonin reuptake inhibitors. Duloxetine (Cymbalta) has been shown to be analgesic in several studies. Duloxetine (Cymbalta), the newest of the SNRIs has been the first antidepressant approved by the FDA as a treatment for pain due to diabetic neuropathy.

Front 6

Antidepressant Medications: Selective Serotonin Reuptake inhibitors
fluoxetine Prozac

Back 6

Antidepressant Medications: Selective Serotonin Reuptake inhibitors
fluoxetine Prozac

Indications:
Diabetic Neuropathy
Fibromyalgia

ACTIONS
Block reuptake of neurotransmitters serotonin, norepinephrine, and/or dopamine in body.

S.E.
Can occur with all antidepressants:
Dry mouth -----sugarless candy, sips of water frequently Ice, oral hygiene.
Sedation ----order to give med at bedtime, instruct pt to not drive, decrease dosage.
Nausea------give with food.

SEIZURES, ANTICHOLENERGIC EFFECTS
anxiety H/A, Diarrhea, tremor, dry mouth

NR implications
Assess for sensitivity reactions (urticaria, fever, edema, rash, resp. distress)

Pt. Teaching
Decreased libido, call dr. if sensitivity rx, H/A, N, anorexia, anxiety, or insomnia persist. Don't stop. Avoid ETOH.

Front 7

Antidepressant Medications: Tricyclic: (TCA’s)
amitriptyline (Elavil)

Back 7

Antidepressant Medications: Tricyclic: (TCA’s)
amitriptyline (Elavil)

Actions: Block reuptake of neurotransmitters serotonin, norepinephrine, and/or dopamine in body.

S.E.
Commonly occurs with TCAs
1. Blurred vision---------------symptoms should subside in few wks. Do not drive until vision clear.
2. Constipation-----------------high fiber diet, monitor fluid & food intake increase exercise, if possible.
3. Urinary retention-----------pt report hesitancy or inability to urinate, monitor intake & output, instruct pt to see Dr.
4. Orthostatic hypotension---------rise slowly from lying to sitting, Monitor BP (lying & sitting), avoid hot showers and tub baths.
*  Seizure threshold---------observe closely if history of seizures, institute seizure precautions.
* Tachycardia, arrthythmias------Carefully monitor BP, pulse rate & rhythm, report any change to Dr.
• Photosensitivity-------------------wear protective sunscreens, clothing, sunglasses.
* Priapism (with Desyrel)---withhold drug & notify Dr.
* Weight gain---------------------encourage  activity,
instructions on reduced calorie diet.

Nursing Implications/Pt teaching
Effective for migraine headache, tension-type headache, postherpetic neuralgia, painful diabetic neuropathy, arthritis, low back pain, and other painful conditions.