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  • 1.
    • Analgesic Drugs
  • 2. Understanding Pain
    • Most common symptom prompting people to seek health care
    • Occurs when tissue damage activates free nerve endings of peripheral nerves
    • Cerebral cortex analyzes messages and determines actions
    • Activation of opiate receptors in CNS inhibits pain transmission
  • 3. Understanding Pain
    • Pain is a subjective experience
    • People differ in their perceptions, behavior and tolerance of pain
    • Stressors increase pain
    • Diversionary activities tend to decrease pain-
      • deep breathing, listening to music, visual imagery, others?
    • Acute pain can be super-imposed on chronic pain
  • 4.
    • Try alternative measures for pain control in addition to drugs
    • Promote circulation and musculoskeletal function
    • Use heat or cold as ordered
    • Relieve pain ASAP
    • Administer analgesic before pain producing activities
    • Use the least amount of the mildest drug likely to be effective
  • 5. Types of Pain
    • Acute pain
    • Chronic pain
    • Superficial pain
    • Deep pain
  • 6.
    • Opioid-any derivative of opium plant or any synthetic drug that imitates natural narcotics
    • Opioid agonists-include opium derivatives and synthetic drugs w/similar properties (Kee p.332)
    • Decrease pain without losing consciousness
    • Opioid antagonists
      • Block effects of opioid agnoists
      • Used to reverse drug reactions-RD, CNS depression
      • Narcan (always keep antagonist nearby)
    NARCOTICS OPIOIDS
  • 7.
    • Opioid agonists
      • Any route
      • Inhalation uncommon
      • Absorbed from GI tract
      • Transmucosal / intrathecal fast acting
      • IV provides most rapid and almost immediate
      • Sub Q and IM delayed absorption
        • Poor circulation can cause further delay
      • Metabolized extensively in the liver
        • Administration of meperedine > 48 hours increases risk of neurotoxicity and seizures from buildup
  • 8.
    • Pharmacodynamics
    • Reduce pain by binding to opiate receptors in PNS/CNS
    • Stimulation of opiate receptors-mimic effects of endorphins –the body’s naturally occurring opiates
    • Cause dilation of blood vessels in head, neck, face – could result in increased cranial pressure
    • With the exception of Demerol, suppress cough center to have antitussive effect
    • Adverse / Side effects include constipation, respiratory depression, nausea, vomiting, urinary retention, orthostatic hypotension
    • Morphine – relieve dyspna r/t pulmonary edema
  • 9.
    • Nursing process
      • Assess pain before and after administration
      • Monitor for adverse reactions / side effects
      • Monitor for tolerance dependence
        • Shortened duration of effect
      • Evaluate respiratory status before each dose
        • Respiratory depression
        • Restlessness
  • 10. Mechanisms by Which Opioid Analgesics Work
    • Reduce the perception of pain sensation
    • Produce sedation
    • Decrease emotional upsets associated with pain
  • 11. Characteristics of Opioid Analgesics
    • Most are Schedule II or III drugs
    • Morphine (MSO4) is the prototype
    • May be given PO, IV, IM, SQ, or topically
    • Oral drugs undergo significant first-pass metabolism
    • Metabolized by liver and excreted in urine
  • 12.
    • Exert CNS effects
    • Use cautiously in clients with renal or hepatic disease, respiratory depression or increased intracranial pressure
    • Exert depressant effect on GI tract
    • Not recommended for prolonged periods of use except with chronic pain or malignant diseases
  • 13. Morphine
    • Naturally occurring opium alkaloid
    • Used to relieve severe pain
    • Maximum analgesia occurs in 10-20 minutes with IV route
    • Controlled released tablets given for chronic pain
    • May be given intrathecally or epidurally
    • Route determines time interval or frequency of administration
  • 14. Hydromorphone (Dilaudid)
    • Synthetic derivative of morphine
    • Same actions, uses, adverse effects as morphine
    • More potent on a mg per mg basis
    • More effective orally than morphine
    • Effects last longer than morphine
  • 15. Meperidine (Demerol)
    • Synthetic drug similar to morphine
    • Dose of 100mg is equivalent to Morphine 10mg
    • Has shorter duration
    • Has less respiratory depression and little antitussive effect
    • Causes less smooth muscle spasm
  • 16. Codeine
    • Naturally occurring opium alkaloid
    • Used for milder pain
    • Acts as an antitussive (found in cough meds)
    • Often combined with acetaminophen
    • Preferred analgesic with head trauma
  • 17. Oxycodone
    • Semisynthetic derivative of codeine
    • Used to relieve moderate pain
    • More potent and more likely to produce abuse than codeine
    • Available in combination with acetaminophen
  • 18. Opioid Antagonists
    • Reverse or block analgesia, CNS and respiratory depression of opioid agonists
    • Compete with opioids for opioid receptor sites in brain
    • Do not relieve depressant effects of anti-anxiety drugs or antipsychotics
    • Naloxone - oldest, most commonly known
    • Nalmefene - newer with longer duration
    • Naltrexone - used in maintenance of opiate free states in opiate addicts
  • 19. Client Teaching For Opioid Analgesics
    • Narcotics may be alternated with a non-narcotic analgesic
    • If pain relief not achieved notify physician
    • Do not drink alcohol or take other drugs that cause drowsiness
    • Do not smoke, cook, drive a car or operate machinery after taking
  • 20.
    • Constipation is a common adverse effect
    • Do not crush or chew long acting tablets
    • Decrease dose or omit if adverse effects occur
  • 21. Use In Older Adults
    • Use cautiously if debilitated or hepatic, renal or respiratory impairment
    • Start with lower dose and increase gradually
    • Give less often?
    • Give opioid analgesic with short half-life (Oxycodone)
    • Monitor for sedation or confusion
    • Monitor urinary output
    • Assess ability to self-medicate
  • 22. Characteristics of Withdrawal From Opiates
    • Generalized body aches
    • Insomnia
    • Lacrimation
    • Rhinorrhea
    • Perspiration
    • Pupil dilation
    • Piloerection
    • Anorexia
    • N/V/D
    • Increased vital signs
    • Abdominal and other muscle cramps
  • 23. Treatment Of Withdrawal Syndrome
    • Gradually reduce the opioid over several days
    • Substitute methadone and slowly reduce dose over a longer time
    • Clonidine reduces withdrawal symptoms
  • 24.
    • Salicylates-produce peripheral blood vessel dilation
      • Most common pain reliever
      • Control pain
      • Reduce fever-stimulate hypothalmus
      • Reduce inflammation
      • ASA is oldest nonnarcotic analgesic
      • Bonus effect-inhibits platelet aggregrate
      • Guideline
        • Use lowest dose that produces analgesia
        • Highly protein bound-can interfere w/other drugs
          • Heparin,methotrexate, oral antidiabetic meds, insulin
    NONNARCOTICS SALICYLATES
  • 25.
    • Adverse reactions
      • Hearing loss
      • Diarrhea
      • Thirst
      • Sweating
      • Tinnitus
      • Confusion
      • Dizziness
      • Impaired vision
      • Hyperventilation
      • Reye’s syndrome-when given to children (do not use < 12 yrs old)
    • Common side effects
      • Gastric distress
      • Bleeding tendencies
      • NVD
  • 26.
    • Give w/food
    • May crush except enteric coated
    • Hold and notify MD for bleeding
    • Stop ASA 5-7 days before elective surgery
    • Salicylate hypersensitivity
      • Tinnitus or hearing loss
      • Vertigo
      • Bronchospasm
      • Urticaria
      • Need to avoid prunes, raisins, paprika, licorice
  • 27.
    • Acetaminophen
      • Antipyretic and analgesic
      • IS NOT ANTI INFLAMMATORY
      • Drug of choice for children with flulike symptoms
      • Risk of liver disease
        • Phenytoin, barbituates, INH, ETOH
      • Rarely cause GI distress-may cause LIVER toxicity
        • Monitor total daily dose (adults 4g max.)
    ACETAMINOPHEN
  • 28.
    • Phenazopyridine hydrochloride
      • Pyridium-now OTC
      • Dye used in commercial coloring-analgesic effect on urinary tract
      • Relieves pain, burning, itching, urgency,
    • Teach
      • Urine orange
      • Stains fabric-contact lenses
      • Notify in ineffective
  • 29.
    • Anti Inflammatory Drugs
  • 30.
    • Anti inflammatory agents
      • Reduce body temperature
      • Relief of pain
      • Anticoagulant (ASA)
      • Reduce inflammation
    • ASA – oldest
    • NSAIDS- reduce inflammation & pain for arthritic conditions
    • Inhibit enzyme COX
  • 31.
    • OTC
      • Ibuprofen, Motrin, Nuprin, Advil, Medipren
      • Naproxen (Aleve)
      • Motrin only available in 200 mg form
        • MD must prescribe higher dose
  • 32.
    • Second generation NSAIDS
      • COX-2 inhibitors
    • COX 1 inhibitor
      • Decreased protection of lining of stomach
      • Clotting time decreased-benefit cardiovascular patients
  • 33.
    • NSAIDS
      • Inhibit prostaglandin synthesis
        • Prostaglandins produced / released in inflammatory disorders
      • Ankylosing spondylitis
      • Moderate to severe arthritis
      • Osteoarthritis
      • Acute gouty arthritis
      • Dysmenorrhea
      • Migranes
      • Bursitis, tendonitis
  • 34.
    • Adverse reactions
      • Abdominal pain, bleeding
      • Anorexia
      • Diarrhea, nausea
      • Ulcers
      • Liver toxicity
      • Drowsiness
      • Headache
      • Tinnitus
      • Confusion
      • Vertigo
      • Depression
      • Blood in urine, bladder infection, kidney necrosis
      • Sodium & water retention
      • Heart failure
      • Pedal edema
  • 35.
    • Nursing implications
      • CBC, platelet count, PT
      • Monitor hepatic / renal function
      • Bronchospasm
      • Monitor for s/s of bleeding
      • Take w/meals
      • Avoid alcohol
  • 36.
    • Corticosteroids
      • prednisone / prednisolone / dexamethasone
      • Suppresses components of inflammatory process at the injured site
      • NOT THE DRUG OF CHOICE FOR ARTHRITIC CONDITIONS
      • USED TO CONTROL FLARE UPS
      • Must taper dose when D/C
  • 37.
    • DMARDS-disease modifying antirheumatic drugs
      • Toxic
      • Alter disease process
      • Gold/Gold Salts
        • IM/PO
    • Used for relief of symptoms
    • Immunosuppressive agents-used when antiinflammatories do not work-cytoxan, methotexrate/cancer drugs
    • Antimalarials-when all other tx fails
  • 38.
    • Antiinflammatory Gout Drugs
      • “ gouty arthritis”
      • Urinary calculi
      • Gouty nephrophaty
    • Increase fluid intake
    • Avoid foods rich in purine - organ meats, sardines, salmon, gravy, legumes
    • Avoid alcohol, caffeine, large doses of vitamin C
    • Zyloprim - inhibits final steps of uric acid
    • Colchicine - first drug, inhibits migration of leukocytes to the inflamed site
  • 39. Propionic Acid Derivatives
    • Ibuprofen (Motrin) - prototype; ketoprofen (Orudis), naproxen (Naprosyn)
    • Used as anti-inflammatory agents in gout, arthritis, tendonitis
    • Used as analgesic for dysmenorrhea, episiotomy, minor trauma
    • Used as antipyretic
  • 40.
    • Better tolerated than ASA but more expensive
    • Similar adverse affects as with ASA
    • May lead to renal impairment
    • Inhibits platelets only while drug molecules in bloodstream
    • Combined with other drugs
  • 41. Acetic Acid Derivatives
    • Indomethacin (Indocin) - prototype; Tolmetin (Tolectin), Sulindac (Clinoril)
    • Used to treat moderate to severe rheumatoid arthritis, osteo-arthritis, gouty arthritis, bursitis, pericarditis for anti-inflammatory effects
    • Prescription drug
    • Has increased incidence and severity of adverse effects
  • 42. Client Teaching Guidelines
    • Take ASA and NSAIDS with full glass of water and food
    • Drink 2-3 quarts of fluid daily with NSAIDS
    • Report signs of bleeding
    • Avoid or minimize alcoholic beverages
    • Do not take more than prescribed amount
    • Do not take more that 3 days for fever or 10 days for pain
    • Read labels of other OTC medications