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1. Drugs Affecting the Central
Nervous System
Nelia B. Perez RN, MSN
PCU - MJCN

2. Pain
 Defined as an unpleasant sensory and
emotional experience associated with either
actual or potential tissue damage.
 Pain is what a client says it is.
 Pain exists whenever the patient says it does.

3. Acute Pain
 Pain that is sudden in onset, usually subsides
when treated, and typically occurs over less
than 6-week period of time.

4. Chronic Pain
 Persistent or recurring pain that is often
difficult to treat. Typically lasts longer than 3
months.

5. Pain Threshold
 Level of stimulus needed to produce a painful
sensation.

6. Pain Tolerance
 The amount of pain a client can endure
without it interfering with normal function.

7. Pain Source
 Somatic pain: originates from skeletal
muscles, ligaments and joints.
 Visceral pain: originates from organs and
smooth muscle.
 Superficial pain: originates from skin and
mucous membranes.

8. Cultural Implications
 Each culture has its own beliefs, thoughts,
and ways of approaching, defining, and
managing pain.
 Prayer
 Laying on of hands
 Healers

9. Implications for Transcultural Nursing
Practice
 Assessment of the type of intervention the
person desires.
 Does the person wish traditional
interventions, expressions of nurturance and
compassion, psychological support, physical
interventions (soothing, having a brow wiped,
relaxation)? cultural support? medication? Or
a combination of these?

10. Cultural Groups and Pain
 Stereotypes:
 Mexican Americans have a low pain tolerance.
 Italian Americans are very dramatic about their
pain
 Jewish Americans complain a lot about pain.
 African Americans report higher levels of chronic
pain and have a greater sensitivity to acute pain.
 Asian Americans do not express their pain.

11. Alternative Methods
 Acupuncture
 Massage
 Herbs
 Heat or ice application
 Relaxation techniques
 Psychological counseling

12. Acupuncture

13. Nerve Pain Tincture
 Recipe
 1 tsp Saint Johns Wort (flowering top), skull cap
leaves, fresh oats & licorice root.
 ½ gtt each tincture
 Ginger rhizome
 Vervain leaves

14. Nursing Responsibilities
 Do a thorough assessment that includes
questions about the patients cultural
background and practices is important in the
effective and individualized delivery of
nursing care.

15. JCAHO Pain Standards
 The Joint Commission's 2001 pain
management standards state that every
patient has a right to have his or her pain
assessed and treated.
 JCAHO standards dictate that a nurse will
evaluate the patients response to the pain
medication within 30 minutes to one hour
after administration of the pain medication.

16. Pain Tools
 Universal Pain Assessment Tool

19. Opioid Drugs
 Originate from the opium poppy.
 20 different alkaloids are obtained from the
unripe seed of the plant.

20. Opioid Analgesics
 Powerful pain relievers.
 Classified according to their chemical
structure and action.
 Simple chemical modifications of the opium
alkaloids produce three different drugs.
 morphine-like drugs
 meperidine-like drugs
 methadone-like drugs

21. Anesthetic Drugs
 Strong opioid analgesics used in combination
with anesthetics during surgery.
 fentanyl
 sufentanil
 alfentanil
 Goal: not only to relieve pain but also to maintain
a balanced state of anesthesia.

22. General Anesthesia
 Loss of sensation and usually of
consciousness without loss of vital functions
artificially produced by the administration of
one or more agents that block the passage of
pain impulses along nerve pathways to the
brain

23. Local Anesthesia
 Loss of sensation in a limited and usually
superficial area especially from the effect of a
local anesthetic.

24. Fentanyl
 Fentanyl injection has a rapid onset and short
duration.
 Transdermal fentanyl patch is used for long-
term pain management.

25. Opioids
 Opioids used to control moderate to severe
pain.

26. Schedule II Drugs
Classification – Opioid analgesics
 Morphine
 Codeine – often used in combination with
acetaminophen – Tylenol with codeine
 Hydrocodone – Vicodin - used in combination with
acetaminophen / aspirin / ibuprofen
 Hydromorphine – Dilaudid - More potent than
morphine
 Meperidine – Demerol
 Oxycodone – Percocet (with acetaminophen) or
Percodan (with aspirin)

27. Opioid Adverse Effects
 Cardiovascular: hypotension, palpitations, flushing
 Central nervous system: sedation, disorientation,
euphoria, light-headedness, tremors.
 Gastrointestinal: nausea, vomiting, constipation
 Genitourinary: urinary retention
 Respiratory: Respiratory depression and
aggravation of asthma.

28. Contraindications
 Known drug allergy
 Severe asthma
 Used with caution in:
 Patients with severe head injuries (mask level of
consciousness or LOC)
 Morbid obesity with sleep apnea (depress
respirations while asleep)
 Paralytic ileus (bowel paralysis) – opioids tend to
slow bowel

29. Psychologic Dependence
 Addiction: characterized by behaviors that
include one or more of the following:
 Impaired control over drug use
 Compulsive use
 Continued use despite harm
 Craving

30. Physical Dependency
 Physiological adaption
 Results in withdrawal symptoms when the
drug is discontinued.
 Withdrawal symptoms include:
 Mental agitation
 Tachycardia
 Elevated blood pressure
 Seizures

31. Opioid Tolerance
 State of adaption which results in reduced
effects of drug resulting on use of higher
dosing to get desired effect.

32. Toxicity
 Opioid antagonist bind to occupy all the
receptor sites blocking the action of the opiod
drug.
 nalaxone
 naltrexone

33. Naloxone
 Brand name: Narcan
 Classification Pharmacologic: opioid antagonist
 Classification Therapeutic: antidote for opioid
 Action: Competitively blocks the effects of opioids,
including CNS and respiratory depression, without
producing any agonist (opioid-like) effects.
 Therapeutic Effects: reversal of signs of opioid
excess.

34. Narcan
 Route IV
 onset in 2-3 minutes
 peak unknown
 duration 45 minutes
 IM, Subq
 onset 2-5 minutes
 peak unknown
 duration > 45 minutes

35. Drug Calculation
 The IV dose for naloxone (Narcan) is 0.02 to
0.2 mg q 2-3 minutes until response is
obtained.
 Physician orders 0.1 mg
 The drug is provided as 0.4 mg / mL
 How much would you draw up to give the
appropriate dose? ____________

36. Morphine Sulfate
 Classification Pharmacologic: Opioid agonist
 Classification Therapeutic: opioid analgesic
 Indications: severe pain (postoperative,
fractures, burns), pulmonary edema, and pain
associated with myocardial infarct (MI).

37. Morphine
 Action: Binds to opiate receptors in the CNS.
Alters the perception of and response to
painful stimuli while producing generalized
CNS depression Therapeutic Effects:
decrease in severity of pain
 Adverse Reactions: severe respiratory
depression, constipation

38. Morphine Effects
 IV maximal analgesia and respiratory
depression would occur within 10 to 20
minutes
 IM: within 30 minutes
 Sub Q: 60 to 90 minutes
 PO: peak activity occurs in about 60 minutes
* higher dosage needed due to metabolism of
drug in the liver

39. Morphine Dosing
 Tablets come in 15 mg or 30 mg
 Solution for IM, IV or sub Q: 10 mg/ml most
common

40. Medication Calculation
 Physician order 6 mg of morphine sulfate q 3-
4 hours prn for severe pain.
 The drug is provided as 10 mg / 1 mL.
 How much of the drug would you need to
draw up the give the appropriate dose?

41. Nursing Responsibilities
 Pain assessment
 Base-line vitals
 Re-assess vitals after pain med administered
 Assess bowel function
 Overdose: Narcan used to reverse
respiratory depression
 Constipation: ambulate! dietary fiber, fluids,
stool softener

42. Meperidine
 Therapeutic classification: opioid analgesic
 Pharmacologic classification: opioid agonist
 Schedule II drug
 Action: Binds to opiate receptors in the CNS.
Alters the perception of and response to
painful stimuli, while producing generalized
CNS depression
 Therapeutic effects: Decrease in severity of
pain.

43. Meperidine
 Demerol is a synthetic drug with the same
uses and adverse effects as morphine.
 Less nausea and vomiting.
 Use with caution due to neurotoxic
metabolism with chronic use
 CNS agitation (often exhibited as confusion)
 Hallucinations
 Tremors
 seizures

44. Meperidine Dosing
 IV or IM
 Provided as 10 mg/mL, 50 mg /mL, 75
mg/mL or 100 mg/mL
 Dosage for adults: 50 to 150 mg every 3-4
hours
 Dosage for pediatrics: 1 to 1.8 mg / kg q 3-4
hours (not to exceed 100 mg dose)

45. Medication calculation
 The physician order meperidine 75 mg prn q
3-4 hours for pain.
 The vial provided is 50 mg / 1 mL.
 How much of the mediation would you need
to draw up to give the appropriate dose?

46. Codeine
 Classification Pharmacologic: opioid agonist
 Classification Therapeutic: allergy, cold and
cough remedies, antitussives, opioid
analgesics
 Schedule II drug

47. Codeine
 Action: Binds to opiate receptors in the CNS.
Alters the perception of and response to
painful stimuli while producing generalized
CNS depression – decreases cough reflex –
decreases GI motility

48. Codeine
 Side Effects: confusion, sedation,
hypotension, constipation
 Nursing responsibilities - same as morphine
 Evaluation of effectiveness:
 Decrease in severity of pain without significant
alteration in level of consciousness
 Suppression of cough
 Control of diarrhea

49. Codeine Dosing
 Usually supplied in combination with other
analgesics
 Tylenol with codeine
 Tylenol # 2 = 15 mg codeine + 300 mg Tylenol
 Tylenol # 3 = 30 mg codeine + 300 mg Tylenol
 Tylenol # 4 = 60 mg codeine + 300 mg Tylenol
 Most often given po with food
 Most common side-effect: constipation

50. Methadone
 The drug of choice for detoxification
treatment for opioid addiction.

51. Nonopioid Analgesics
 Acetaminophen: Tylenol
 Salicylates: aspirin

52. Acetaminophen
 Action: blocks peripheral pain impulses by
inhibition of prostaglandin synthesis.
 Indication: treatment of mild to moderate
pain.
 Contraindications:
 Drug allergy
 Severe liver disease
 G6PD disease

53. Toxicity
 Ingestion of large amounts of
acetaminophen, as in acute overdose, or
even chronic unintentional misuse can cause
hepatic necrosis.
 Acute ingestion of acetaminophen doses of
150 mg / kg or more may result in hepatic
toxicity.

54. Treatment
 Acetylcysteine or Mucomyst
 Action: Works by preventing the hepatotoxic
metabolites of acetaminophen from forming.
 Initial loading dose of 140 mg / kg orally.
 Followed by 70 mg / kg every 4 hours for 17
additional doses.
 Note: if patient vomits within 1 hour the dose
should be given immediately.
 All 17 doses must be given.

55. Drug Calculation
 A teenage girl is admitted for Tylenol
overdose weight is 120 pounds.
 Mucomyst is ordered at 140 mg / kg for the
lst dose.
 Weight in kg ______
 What dose would you give __________ in
mg?
 What dose would you give ________ in
grams?

56. Anti-inflammatories
Chapter 44

57. Inflammation
 Localized protective response stimulated by
injury to tissues that serves to destroy, dilute,
or wall off both the injurious agent and the
injured tissue.

59. Inflammatory response
 Mediated by two pathways:
 Prostaglandin (PG)
 Leukotriene (TL)

60. Nonsteroidal anti-inflammatories
 Most commonly prescribed drugs.
 70 million prescriptions per year
 23 different NSAIDS

61. How do they work?
 Anti-inflammatories worth by inhibiting the
leukotriene (LT) and prostaglandin (PG)
pathways.
 Most NSAIDS act on one or both of the
pathways.
 Two important enzymes: Cox 1 and Cox 2
(they have a role in maintaining
gastrointestinal mucosa.

62. Side Effects of NSAIDs
 One of the more common complaints is
gastrointestinal distress
 Heart burn
 Gastrointestinal bleeding

63. NSAIDs
 Used to treat rheumatoid arthritis and
osteoarthritis.

64. Rheumatoid Arthritis
 Systemic inflammatory disease often
effecting multiple joints. Involves
inflammation of the tissue surrounding the
joints that can lead to destruction of the joint.
 Symptoms include pain, stiffness and
reduced range of motion.
 Goal of drug therapy is to reduce the
symptoms – no cure

65. Rheumatoid Arthritis

66. Drugs used in arthritis
 Drugs:
 Aspirin (has been placed by newer drugs due to
gastrointestinal bleeding)
 NSAIDs
 DMARDs (Disease-modifying antirheumatic
drugs)

67. Acetic Acid Drugs
 Most widely knows: Aspirin
 Aspirin (acetylsalicylic acid) was the first of
this drug classification (1899).
 Other acetic drugs:
 indomethacin (Indocin)
 diclofenac (Voltaren, Cataflam)

68. Reyes Syndrome
 The acetic classification of drugs (Aspirin) is
contraindicated in children.
 Reyes syndrome is a neurological disease
process thought to be trigger by the use of
aspirin in children (flu and chickenpox).
 Fever in children should always be managed
with acetaminophen (Tylenol).

69. naproxen
 Trade name: Naprosyn, Aleve
 Therapeutic classification: nonopioid
analgesic, NSAIDs
 Action: inhibits prostaglandin synthesis.
 Indications: dysmenorrhea, inflammatory
disorders including rheumatoid arthritis
 Therapeutic effects: decrease pain,
suppression of inflammation.

70. Antirheumatic Drugs
 Disease-modifying antirheumatic drugs
 Drugs have a slow onset of action often
taking up to several weeks to see results.
 A whole new group of IV meds have been
developed to control symptoms in patients
with multiple joint involvement.

71. Gout
When the body has to much uric acid, deposits
of uric acid crystals collect in tissue and joints

72. allopurinol
 Trade name: Lopurin, Aloprim
 Action: inhibits the production of uric acid.
 Client teaching:
 Advise patient to take with large glass of water.
 Alcohol may decrease effectiveness of the drug