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    analgesics analgesics Presentation Transcript

      • Analgesic Drugs
    • 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
    • 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
      • 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
    • Types of Pain
      • Acute pain
      • Chronic pain
      • Superficial pain
      • Deep pain
      • 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
      • 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
      • 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
      • 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
    • Mechanisms by Which Opioid Analgesics Work
      • Reduce the perception of pain sensation
      • Produce sedation
      • Decrease emotional upsets associated with pain
    • 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
      • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
      • Constipation is a common adverse effect
      • Do not crush or chew long acting tablets
      • Decrease dose or omit if adverse effects occur
    • 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
    • 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
    • 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
      • 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
      • 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
      • 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
      • 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
      • 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
      • Anti Inflammatory Drugs
      • 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
      • OTC
        • Ibuprofen, Motrin, Nuprin, Advil, Medipren
        • Naproxen (Aleve)
        • Motrin only available in 200 mg form
          • MD must prescribe higher dose
      • Second generation NSAIDS
        • COX-2 inhibitors
      • COX 1 inhibitor
        • Decreased protection of lining of stomach
        • Clotting time decreased-benefit cardiovascular patients
      • NSAIDS
        • Inhibit prostaglandin synthesis
          • Prostaglandins produced / released in inflammatory disorders
        • Ankylosing spondylitis
        • Moderate to severe arthritis
        • Osteoarthritis
        • Acute gouty arthritis
        • Dysmenorrhea
        • Migranes
        • Bursitis, tendonitis
      • 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
      • Nursing implications
        • CBC, platelet count, PT
        • Monitor hepatic / renal function
        • Bronchospasm
        • Monitor for s/s of bleeding
        • Take w/meals
        • Avoid alcohol
      • 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
      • 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
      • 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
    • 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
      • 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
    • 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
    • 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