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63 Cards in this Set
- Front
- Back
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NSAIDS
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Non-Steroidal Anti-Inflammatory Drugs
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NSAIDS
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inhibit prostaglandin synthesis by inhibiting action of COX - cyclooxygenase (needed for prostaglandin synthesis)
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NSAIDS indications
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anti-inflammatory
analgesic anti-pyretic |
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TX of NSAIDS
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Therapeutic indications
Mild to moderate pain Fever Osteoarthritis Rheumatoid arthritis Menstrual cramps Headaches Others |
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S/e of NSAIDS
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GI: n/v, abd pain, ulceration
renal impairment/failure hepatotoxicity bleeding CNS s/e : dizziness, visual changes, confusion, seizures edema inreased BP allergic rx |
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Acetaminophen
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Relieves pain and discomfort
(analgesic) Relieves fever (antipyretic) (NOT anti-inflamm) |
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toxic effects of acetaminophen
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hepatotoxicity
*problem w/ ETOH use* |
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Salicylates
important* |
An important contraindication: Not to be given to children with flu symptoms/fever due to risk of Reye’s syndrome.
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Salicylates
nursing* |
Monitor:
For signs of toxicity/hypersensitivity For gastric distress For signs of bleeding Other Nursing Considerations: Give with food Needs to be discontinued 5-7 days prior to surgery/procedures Counsel patient to avoid ETOH |
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ASA dosage
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325-650mg q4hours prn;
max: 4 gm/day |
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Salicylates (ASA)
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Antipyretic
Anti-inflammatory Analgesic Anti-platelet |
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Propionic Acids
ibuprofen (Advil, Motrin)/Naproxex (Naprosyn) |
Pharmacokinetics
Rapid absorption Extensively protein bound (99%) (interactions) |
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Acetic Acids
indomethacin (Indocin) |
Pharmacokinetics
Complete oral absorption Protein bound (90%) Excreted in urine, feces, bile Unique s/e: severe frontal head |
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Phenylacetic acids
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Dicolfenac (voltaren), etodolac (Lodine),
ketorolac (Toradol) Indicated for use in short term pain management – post-op for no more than 5 days |
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Toradol
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only injectable NSAID (IM)
*Very high incidence of bleeding |
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COX-2 inhibitors
celecoxib (Celebrex) |
off market?
less GI upset |
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NSAIDS nursing*
monitor for bleeding,GI distress, edema, BP, caution w/ HTN,CNS effects -be aware of cross-sensitivity between classses of NSAID’s & ASA & other classes of NSAID’s |
-remember…these drugs are highly protein bound and may
displace other highly protein bound drugs like coumadin, dilantin, sulfonamides. -metabolized by liver/excreted by the kidney…caution with liver or kidney impairment -give with food -discontinued prior to surgery -avoid ETOH while taking these drugs. |
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acetaminophen (Tylenol)
Antipyretic and analgesic NO INFLAMMATORY EFFECTS No gastric distress/no bleeding problems Complete oral absorption Uniformly distributed throughout body |
Extensive hepatic metabolism
Excreted in urine Skin rashes Fatal hepatic necrosis with acute overdose AVOID ETOH Antidote is acetylcysteine (Mucomyst) |
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Acetaminophen Dosage:
324-650mg q4-6 hours (extra-strength tablets are 500mg…may take two tabs Not more often than q6 hours) |
MAXIMUM: 4gm daily!!!!!!
Watch out for hidden acetaminophen in combination products!! |
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Narcotic Analgesics
moderate --> severe pain |
Opioid
Morphine Codeine Synthetic narcotics Meperidine (Demerol)** Hydromorphone (Dilaudid)** |
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Narcotic Agonists
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Work by binding with opioid receptors: mu, kappa, sigma, delta,
epsilon….mu and kappa are most important in terms of pain management. |
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Actions of Opiod Agonists
opioid agonist has many effects beyond relieving pain. |
Analgesia
Suppresss the cough reflex (except demerol) Respiratory depression **** Slow the GI tract miosis CNS depression: sedation Urinary retention Some patients experience euphoria or intense relaxation (which is why narcotics may become drugs of abuse) |
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Respiratory Depression
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suppress cough reflex*
post-op: pneumonia/urine retention * make them cough/monitor BM |
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MU:
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Analgesia
Decreased GI motility Respiratory depression Sedation euphoria Tolerance/Physical dependence |
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Kappa:
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Analgesia
Decreased GI motility Sedation |
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Morphine Sulfate
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normal dose: 5-15mg
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Morphine Sulfate
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Be aware: tolerance does develop and in patients who have been receiving
the drug for extended periods of time, high doses may be required. There is no “ceiling” with this drug like there is with NSAIDs/tylenol |
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s/e: know ALL*
Resp.Depression, Constipation, Hypotension, N/V,Sedation (drowsiness/confusion) Dependence Urinary retention Tolerance Miosis (blurred vision) Withdrawal Increased intracranial pressure |
Rash/pruritis
Flushing Euphoria Seizures Hallucinations Dysphoria:restlessness/depression/anxiety |
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Contraindications:
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head injuries, high intracranial pressure,respiratory disorders
shock,hypotension,previous allergic response |
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Other Narcotic Agonists:
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Codeine: PO, SC/ mild to mod pain/in cough preparations
15-60mg q 4-6 hours. A weaker narcotic Hydrocodone bitartrate (In Vicodin along with tylenol): PO/mod to mod/severe pain also used in the antitussive Tussionex 5-10mg q 4-6 hours |
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Other Narcotic Agonists:
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**Hydromorphone HCL (Dilaudid): PO/SC/IV/mod to severe pain
1-4mg q 4-6 hours **Meperidine (Demerol): PO/IM/IV (50-150mg q3-4 hours) **Oxycodone hydrochloride (oxycontin):5-10mg qid prn (DO NOT CRUSH OR CHEW) Oxycodone terephthalate (Percodan (ASA)/Percocet(Tylenol) 1-2 Tabs every 4-6 hours. |
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Other Narcotic Agonists:
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Propoxyphene napsyllate (Darvon-N)100mg q4-6hours/contains
tylenol. synergistic effect: tylenol: peripheral Darvon: CNS |
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Fentanyl (Duragesic) Transdermal System
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Narcotic delivered through skin
Indicated in patients with chronic pain requiring opioid analgesia Onset is slow Duration is long Long half life May take 6 days to reach equilibrium |
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Some Non-narcotic/Narcotic Combinations
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Take advantage of synergy between peripherally acting agents and opioids
Tylenol #3 – acetaminophen 325mg + codeine 30 mg 1 to 2 tabs Q4-6 hours Vicodin – acetaminophen + hydrocodone bitartrate 5 mg 1 to 2 tabs Q6 hours Percocet – acetaminophen + oxycodone 5 mg 1 to 2 tabs Q 4-6 hours |
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Antagonist*
naloxone (Narcan) |
higher affinity for opiate receptors than narcotics. Displace opioid agonists from their receptor sites to reverse opiod induced adverse effects.
Reverses effects of morphine in 1 to 3 minutes Will normalize respirations, LOC, pupil size, and bowel activity` Short duration of action – need repeated doses because the narcotic will outlast it. |
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Narcan - given when pt. OD on narcotic
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*short duration of action
-- caution: narcan gone, other narcotics still circulate |
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Nursing considerations
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assess your patient’s pain level frequently
Monitor Resp. rate. Hold if <12 Know where the narcan is Monitor vs/BP, be aware of orthostatic hypotension and encourage patient to change position slowly Monitor LOC Bed low position/Side rails/call light/assist with ADL’s: amb as necessary |
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Nursing considerations
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monitor urinary output/urinary retention, monitor bowels
Be aware that N/V are frequent side effects/Vistaril is often added to regimen to combat this Caution with other CNS depressants (counsel patients to avoid ETOH) Administer before pain reaches its peak monitor for tolerance be aware of the possibility of physical dependence |
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Treating Addiction
Legally* Methodone Clinics |
Methadone
-similar to morphine -longer duration -Does not cure but avoids withdrawal symptoms -Treatment is long term (months/years) |
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Newer Tx: Like methodone
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Early treatment: buprenorphine (Subutex)
Mixed opioid agonist-antagonist Sublingual route Later maintenance: Suboxone |
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PAIN
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multifactorial phenomenon
factors: anxiety, fatigue, prior experience subjective experience *groaning, hypersensitivity to palpation, high BP, P |
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other factors effecting pain
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culture
-past experience -attitudes and beliefs |
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Acute pain
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defined period of time
intense |
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Chronic pain
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over 6 months duration, effects ADLs, psychological effects - (depression) - no end time, never goes away
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Nocioceptor Pain
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due to injury to tissues,
sharp, localized dull, throbbing, aching -pick up impulse |
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Neuropathic pain
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due to injury of nerves,
burning, shooting, numbing |
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pain transmission
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Nociceptor stimulation
Spinal cord receives pain impulse through A∂ fibers (myelin - fast) C fibers (unmyelin - slower) |
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Interruption of pain transmission
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*several target areas*
- peripheral level @ site -CNS level - in brain |
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Interruption of pain transmission
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pharmacological, or nonpharmacological
together for lower dose |
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substance P
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Neurotransmitter
Passes on pain message Affected by other neurons |
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Endogenous Opioids
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May modify sensory information, interrupting pain transmission
Endorphins, dynorphins, ekaphalins makes pain bearable: |
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Phamacological Pain Agents
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NSAIDS – traumatized cells release prostaglandins that sensitize afferent fibers; NSAIDS inhibit prostaglandin synthesis and interrupt the pain signal at the peripheral level
peripheral - nocioceptors |
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Phamacological Pain Agents
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Opioids – bind to opioid receptors and inhibit release of neurotransmitters(substanceP), and interfere with the relay of the pain signal across the neuronal synapse.
CNS |
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nonpharmacological :
Few or no side effects In place of or as an adjunct to pain medication Lower doses of pain medication may be needed |
Acupuncture, massage, heat or cold
Relaxation, chiropractic manipulation, TENS |
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Migrane Headaches
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Possibly r/t inflammation/dilation of blood vessels
Maybe imbalance in serotonin (5-hydroxytryptamine-5-HT) that causes vasoconstriction |
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Goals:
abortive |
Stop migraines in progress
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Goals:
prophylactic therapy |
prevent from occurring
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Triptans:
Selective for 5-HT receptor subtypes Act by constricting certain blood vessels in brain Abortive therapy 5-HT1 receptor agonists..aka the triptans |
sumatriptan (imitrex)almotriptan (Axert)
rizatriptan (Maxalt) zolmitriptan (Zomig) |
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Triptans
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oral, nasal, injectable preparations
-taken at first sign of h.a. -well tolerated -s.e./adverse rx: dizziness,numbness/tingling, warm sensation, n/v, abd pain, possibly CV events -avoid in those with heart disease |
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Ergot Alkaloids
bind to more sites - more s/e |
Interact with adrenergic, dopaminergic, and serotonin receptors
Promote vasoconstriction, stop ongoing migraines Abortive therapy |
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aura
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warning side of headache:
smell, taste, lights, wavy lines |
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Triptans: more -
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Prototype drug: sumatriptan (Imitrex)
Mechanism of action: to act as serotonin agonists, constricting certain intracranial vessels Primary use: to abort migraines with or without auras |
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Ergot Alkaloids - more
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Mechanism of action: to promote vasoconstriction
Primary use: to terminate ongoing migraines Adverse effects: GI upset, weakness in the legs, myalgia, numbness and tingling in fingers and toes, angina-like pain, tachycardia |
