Analgesics, Anti-Inflammatory Agents

Front 1

Fibromyalgia

Back 1

Pain all over body, every gate open and more, clusters of pain.

Front 2

PQRST

Back 2

Palliative/Provoking, Quality, Radiation, Severity, Timing

and LOCATION

Front 3

Analgesics: Types, Fundamental use

Back 3

Narcotic (Opioid)
Non-narcotic (non-opioid)
Anti-inflammatory
Anti-migraine
Used for pathophysiological pain NOT emotional or neuropathic pain

Front 4

Pain: Types

Back 4

Acute
Cancer
Chronic
Somatic
Superficial
Vascular
Visceral
Neuropathic

Front 5

Hydrocodone

Back 5

Percocet

Front 6

Hydromorphone

Back 6

Dilaudid: 5x power of morphine.

Front 7

Nursing Interventions: Controlled Substances

Back 7

Account for ALL controlled drugs
Use special records for controlled subs.
COUNTERSIGN all discarded/waste meds
Ensure records & drugs on hand MATCH (counts)
Keep all controlled drugs LOCKED UP
Only AUTHORIZED access

Front 8

Narcotic Analgesics

Back 8

Schedule II drugs: potential for abuse
Suppress CNS
Relieve pain, promote sleep
Opiates: juice of opium poppy
Opioids: synthetic subs w/opium properties

Front 9

Narcotic Analgesics: S/Es

Back 9

Respiratory Depression: ↓ sensitivity to CO2 in brain stem (cf. COPD)
Inhibit cough reflex: ↓ sens of neurons in medulla that respond to cough
Postural hypotension: d/t vasodilation
Constipation: ↓ peristalsis
Constricted (pinpoint) pupils: oculomotor nucleus - ennervation by mu & kappa receptors

Front 10

Narcotic Analgesics: receptors

Back 10

Mu, Kappa, Alpha receptors (pain) in brain, ↓ sensitivity:
↓ peristalsis
Can l/t impacted fecal matter - relieved w/ cathartics

Front 11

Narcotic Analgesic Usage: May lead to

Back 11

Drug tolerance: start low, over time body more tolerant w/ S/Es
Drug dependence: result of above, means cannot D/C immediately, will l/t withdrawal. Need to be weaned off.
Drug addiction: "lie, cheat, steal" to get drug. Addicted to euphoric feelings, NOT taking drug for pain relief.

Front 12

Narcotic W/D: S/S

Back 12

A/N/V
Intestinal cramps
Fever
Syncope
Lightheadedness
[Remember Pace's story re. PT on honeymoon]

Front 13

Prototype opioid: Morphine Sulphate: Class, Trade Names

Back 13

Narcotic opiate analgesic
Duramorph, MSIR (Immediate release), MS Contin (extended/continuous release)

Front 14

Morphine Sulphate: Uses

Back 14

Relief of severe pain
Tx pain and anxiety in MI
Smaller doses relieve dyspnea
Drug of choice for pulmonary edema (↓ preload)

Front 15

Morphine Sulphate: Action

Back 15

CNS depression, depression of pain impulses d/t binding w/ opiate CNS receptors
(Mu, Kappa, Alpha)

Front 16

MS (Duramorph)

Back 16

IV, intrathecal (Spine), preservative free, heavy duty (childbirth)

Front 17

MSIR/MSSR

Back 17

MS immediate release
MS sustained release
Enteric coating - w/ stoma, crush and halve dose
Sustained/extended release 12 hr/24 hr

Front 18

Morphine Sulfate: PO Dose/Administration

Back 18

Adult 10-30 mg q 2-4 hrs PRN w/ limit on no. w/in 24hrs
HOWEVER: Pace - best to write order for every 2 hours, aiming to relieve pain w/in 3 to 4 doses.
Don't want to be chasing the pain. Peak is w/in 2 hrs.

Front 19

Morphine Sulfate: Dosing naive PT

Back 19

Dosage based on two-week pain diary. PT notes how many tabs/day. Average/day starting dose.
No max dose; based on tolerance and reported pain.

Front 20

Morphine Sulfate: Dosing SC/IM

Back 20

Adult: 5 - 15 mg q4hr PRN
Onset 15 - 30 min
Peak SC: 50 - 90 min
Peak IM: 0.5 - 1 hr
Duration: 3 - 5 hr

Front 21

Morphine Sulfate: Dosing IV

Back 21

Adult: 4-10mg q4hr PRN (can be diluted; inject over 5 min)
Onset: RAPID
Peak: 20 min
Duration: 3 - 5 hr

Front 22

Morphine Sulfate: ICU notes

Back 22

"Brain dead" PT
Wean from ventilator
Test response as controls are turned down.
Fentanyl (analgesic) and Ativan (anxiolytic) q 5 mins: relieves dyspnea and pain
Give as ordered, do not wait to see distress (as per Pace's colleague with 25 weanings)

Front 23

Morphine Sulfate: Pharmacodynamics

Back 23

Absorption: PO varies d/t first hep. pass
IV rapid
Distribution: PB 30%, crosses placenta, breast milk
Metabolism: T 1/2 2.5 - 3 hr
Excretion: 90% urine (need functional L and Ks)

Front 24

Morphine Sulfate: Contraindications

Back 24

Asthma w/ respiratory depression
↑ ICP (receptors acting differently)
Shock (sporadic vasc system)
(also last two effect breathing drive)

Front 25

Morphine Sulfate: Caution

Back 25

Repiratory, renal, hepatic Dx
MI
Elderly
Infants/children

Front 26

Morphine Sulfate: Drug/Drug

Back 26

↑ effects alcohol, sedatives-hypnotics, antipsychotics, muscle relaxants
↑ sedation w/ kava kava, valerian, St John's Wort

Front 27

Morphine Sulfate: Drug/Lab

Back 27

↑ AST, ALT

Front 28

Morphine Sulfate: S/Es

Back 28

A/N/V
Constipation, U retention (↑ sphincter tone)
Drowsiness, sedation, confusion
Dizziness, blurred vision (receptors in eye)
Rash
Bradycardia, flushing
Euphoria
Pruritus

Front 29

Morphine Sulfate: A/Rx

Back 29

Hypotension
Urticaria
Seizures
Life-threatening: Resp. Depression, ↑ ICP

Front 30

Morphine Sulfate: Antidote

Back 30

Naloxone (Narcan)

Front 31

PCA: Summary

Back 31

PT self-admins analgesics
Vial locked in pump, basal rate/hr
Loading (rescue) or continual (basal) dose
Predet. no./hr to prevent O/D
Morphine w/ dilution 1mg/mL (200 mL bag can ↑ to 10 mg/mL)

Front 32

PCA: Drugs

Back 32

Morphine Sulfate
Fantanyl (Sublimaze) - 5x power morphine
Hydromorphone (Dilaudid) - 3x power morphine
Check no. times PT hits PCA: e.g., 24x basal rate is too low.

Front 33

PCA: Nursing Interventions

Back 33

Doc. Tx & effectiveness q2-4 hr
Assess pain & S/Es
Record amount of drug infused
PT to push button on pump before pain severe
Remember non-pharm pain relief
NO PCA by PROXY

Front 34

Brompton's Cocktail

Back 34

Mixture:
Morphine
Cocaine
Dextroamphetamine
Alcohol
For SEVERE pain at EOL

Front 35

Dr Flexner

Back 35

5 mL/q15 mins at bedside
Locked away from away from families
Still occasionally used. But usually control w/ opioids and intrathecal instead.

Front 36

Analgesics and children, elderly

Back 36

All these drugs can be administered to children/elderly just titrated down and in smaller doses
Insurance regulates what can be Rx
MS cheap, Oxycodone 5 - 10x $$$

Front 37

Meperidine HCl (Demerol)

Back 37

Synth narcotic
Moderate - severe pain
NOT LT (buildup of metabolites: normaperidine) - causes ↑ stim. and seizures

Front 38

Meperidine HCl vs MS

Back 38

Dose: 80-100mg Demerol = 10mg MS (MS 8 - 10x stronger)

Front 39

Meperidine HCl (Demerol): Routes

Back 39

PO 1/2 effect of IM/SC/IV
Approx 50% metab'd in L and never reaches systemic circ.
(used for post-surg anesthesia)

Front 40

Meperidine HCl cf. w/ MS

Back 40

Demerol shorter duration than MS
No ↓ uterine contractions in labor
< smooth muscle spasm
< respiratory depression in newborn for OB analgesia

Front 41

Meperidine HCl: S/Es; Drug/Drug

Back 41

Constipation, U retention
Possibly S/E: CNS tox.
May l/t: tremors, hallucinations, seizures
MAOIs
Antipsychotics

Front 42

Older Adults & Opioids: Problems

Back 42

↓ dose, not always effective
Drug/Drug risks and S/Es
↓ R and L Fx
PT may not report pain
Difficult to assess pain
Usual doses may l/t ↑ sedation and ↑ duration
Comorbs assessment

Front 43

Analgesics: Those More Toxic in Older Adults

Back 43

W/ ↓ renal Fx:
Meperidine (Demerol)
Pentazocine (Talwin)
Propoxyphene (Darvon): this no longer available d/t cardiac tox.

Front 44

Codeine Sulfate: Summary

Back 44

Mild - moderate pain
Combo'd w/ aspirin, acetaminophen
In cough meds. ↓ cough reflex

Front 45

Oxycodone: Summary, Class, Schedule

Back 45

Semisynthetic > potent than codeine
Opioid agonist, analgesic opioid
Schedule II

Front 46

Percocet

Back 46

Oxycodone + acetaminophen
[Builds up and damages liver, then switch to pure opioid]

Front 47

Percodan

Back 47

Oxycodone + aspirin
[Risk of GI bleed]

Front 48

Lortab, Vicodin

Back 48

Hydrocodone + acetaminaphen

Front 49

Fentanyl (Sublimaze): Class, Route

Back 49

Opioid analgesic (esp. w/ general anesthesia)
IM, IV,
Transdermal patch (continuous)

Front 50

Fentanyl (Sublimaze): Uses

Back 50

Adjunct to general anesthesia
Continuous chronic pain control (patch)
In Open Heart Surg to limit O2 demands of myocardium

Front 51

Fentanyl (Sublimaze): Dosing Note

Back 51

In mcg (micrograms NOT milligrams)

Front 52

Narcotic Agonists-Antagonists

Back 52

Opiates stim some opiate receptors while antagonizing others.
↓ CNS - changes pain perception

Front 53

Narcotic Agonists-Antagonists: Cf w/ opiates

Back 53

Antagonists - ↓ risk of abuse
< GI S/Es
Safe in labour but not clear if safe early in PG

Front 54

Narcotic-Agoists-Antagonists: Uses, S/Es, A/Rx, W/D

Back 54

Moderate - severe pain
S/Es and A/Rx sim to opiate agonists
W/D S/S
Precautions w/ LF, RF
Freq Narcotic use/dependence: NOT for chronic pain [stop gap for PT not able to have opioid]

Front 55

Nalbuphine (Nubain): Narcotic opiate agonist-antagonist: Uses

Back 55

Moderate - severe pain
Labor pain

Front 56

Nalbuphine (Nubain): S/Es, A/Rx

Back 56

S/Es sim to narcotic agonists
A/Rx [Rx depends on sens of PT]:
Bradycardia
Tachycardia
Hypotension
Hypertension

Front 57

Narcotic opiate agonist-antagonists: examples

Back 57

Nalbuphine (Nubain)
Butorphanol (Stadol)

Front 58

Narcotic/Opioid Analgesics: Nursing Interventions: Respiratory, BP, Safety

Back 58

Monitor RR W/H if:
RR <10/min
Breathing shallow/labored
HAVE ANTIDOTE ON HAND [Naloxone (Narcan)]
Monitor BP W/H if systolic < 90mmHg
Client Safety: Bed low, side rails up

Front 59

Narcotic/Opioid Analgesics: Nursing Interventions: Pain rating

Back 59

0-10 scale adults, older children
0-5 smiley face scale younger children

Front 60

Nursing Diagnoses: Narcotic Analgesics

Back 60

Acute pain r/t surgical tissue injury
Ineffective breathing pattern r/t excess morphine dosage

Front 61

Narcotic analgesics: Nursing interventions

Back 61

Assess bowel Fx
↑ fluids & bulk diet
Stool softeners, laxatives PRN
Antiemetics PRN
Check for drug tolerance: switch drug PRN

Front 62

IMPORTANT Narcotic Analgesics: Nursing interventions

Back 62

Medicate B4 pain severe (never chase it)
Change PT position slowly
Avoid driving/operating machinery, etc., at start of Tx
No alcohol or other CNS depressants
ORAL hygiene to ↓ dry mouth
Best if routinely sched. NOT PRN: e.g., MS, Oxycod. Dilaudid q4hrs - give PT chance to say they don't need it.

Front 63

Non-narcotic Analgesics: Uses, Examples, Action/Effect

Back 63

Mild-moderate pain
Non-addictive, less potent than narcotics
OTC Aspirin, Acetaminophen, Ibuprofen, Naproxen
Most antipyretic, antiplatelet (aspirin, ibuprofen, naproxen)

Front 64

Anti-inflammatory drugs

Back 64

Prostaglandin inhibitors (↓ biosynth of prostaglandin, affect inflamm.)
Other properties: analgesic, antipyretic, anticoagulant

Front 65

Prostaglandins

Back 65

Released in inflamm process
Chem mediators affecting:
vasodilation
smooth muscle relaxation
>capillary permeability
sensitize nerve cells to pain

Front 66

Cyclooxygenase (COX-1 and COX-2)

Back 66

Enzyme ↑ synth of prostaglandins
Prostaglandins cause pain and inflamm at tissue injury site

Front 67

Cyclooxygenase (COX-1, COX-2)

Back 67

COX-1 protects stomach lining, regs. clotting
COX-2 triggers inflamm & pain at site of injury

Front 68

NSAIDS

Back 68

Inhibit/block both COX-1 and COX-2 unless selective for COX-2 only

Front 69

NSAIDS: 1st Generation

Back 69

Salicylates: Aspirin
Propionic acids: Ibuprofen (Motrin, Advil)

Front 70

NSAIDS: 2nd Generation

Back 70

COX-2 Inhibitors: Celecoxib (Celebrex)
[Rofecoxib (Vioxx) off-market 2004 d/t deaths MI, stroke, etc. - Pace's seminar friend's wife]
PTs taking ASA to ↓ MI, stroke NO benefit from COX-2 inhibs (d/t ASA ↓ serum levels of NSAIDS)

Front 71

Ibuprofen (Motrin, Advil)

Back 71

1st generation NSAID
Proprionic acid
Action: Inhibs prostaglandin synth
Uses: anti-inflamm
analgesic
antipyretic

Front 72

Ibuprofen: Dosage

Back 72

Adult: 200-800mg PO 2x/day
MAX: < 3.2g/day
CHILD DOSE based on WT, AGE

Accumulates in liver

Front 73

Acetaminophen (Tylenol): Max dose

Back 73

Up to 4g/day

Accumulates in liver

Front 74

Ibuprofen: Absorption, Distribution, Metabolism, Excretion

Back 74

Absorp: PO well absorb
Distr: PB: 98%
Metab: T 1/2 2 - 4 hr
Excr: U and some bile

Front 75

Acetaminophen, Ibuprofen: Toxicity notes

Back 75

Accumulates in liver, not excreted.
LFTs

Front 76

Ibuprofen: Contraindications

Back 76

Severe R or H Dx
Asthma
PUD

Caution: Bleeding D/Os
Early PG, BFing
SLE

Front 77

Ibuprofen: Drug/Drug

Back 77

>bleeding time w/ PO anticoags
> effects phenytoin, sulfonamides, warfarin
< effect w/ aspirin
May ↑ severe S/Es LITHIUM

Front 78

Ibuprofen: S/Es

Back 78

A/N/V/D
Edema
Rash, purpura
Tinnitus
Fatigue, dizziness, lightheadedness
Anxiety, confusion

Front 79

Ibuprofen: A/Rx

Back 79

GI bleed
Lf-Thrntng:
Blood dyscrasias
Cardiac dysrrhythmias
Nephrotoxicity
Anaphylaxis

Front 80

NSAIDS: Nursing Interventions

Back 80

Assess: pain PQRST; Temp
Give w/ glass water/food/antacids if GI irritation
Monitor: CBC (inc. Hgb, Hct, pltlts)
[check gums, petechiae, eccyhmosis, tarry stools]
NOT B4 surg (24-48hrs prior) unless ordered
Monitor for O/D and Tx PRN
NEVER crush enteric coated
Avoid alcohol

Front 81

Aspirin

Back 81

1st Gen. NSAID, prostaglandin synth inhibitor
Analgesic
anti-inflamm (less eff. here than other NSAIDS)
Antipyretic (works at hypothal.)
Antiplatelet
ACTION: Inhibs prostaglandin synth & hypothalamic heat reg. center

Front 82

Aspirin: Dosage

Back 82

Antiplatelet, Analgesic:
ADULT: 81 mg/day; 325-650mg PO q4hr PRN (MAX 4g/day)
Arthritis: ADULT higher, selectively Rx divided doses based on PT; up to 3 - 5 g (3000 - 5000mg)/24hrs

Front 83

Aspirin: Pharmacodynamics

Back 83

Abs: PO 80-100%
Distr: PB 59-90% (crosses placenta)
Metab: T 1/2 2 -3h (low dose0
T 1/2 2 - 20h (hi dose)
Excr: 50% U

Front 84

Aspirin: Contraindications, Caution

Back 84

Hypersens to salicylates/NSAIDS
Flu/virus S/S in children (Reyes S - non-inflamm enceph)
3rd trim. PG (bleeding)
Caution: R or H D/Os