Ppt chapter 24

Chapter 24
Drugs Treating Mild to Moderate
Pain, Fever, Inflammation, and
Migraine Headache
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fever
• Temperature regulation is a function of the
hypothalamus.
• Normally, a homeostatic balance exists between body
heat generated and body heat lost.
• Fever is the result of fever-inducing substances called
pyrogens.
• Fever causes activation of monocytes/macrophages,
which in turn secrete cytokines.
• Cytokines increase the synthesis and secretion of
prostaglandin in the hypothalamus.
• This causes the hypothalamus to reset the body
temperature.

Inflammation
• Numerous types of stimuli cause the inflammatory
response.
• The classic signs of local inflammation are swelling, heat,
redness, pain, and loss of function.
• Acute inflammation is divided into vascular and cellular
responses.
• The vascular response occurs almost immediately after
the injury.

Inflammation (cont.)
• The cellular response is divided into four phases:
– Margination of white blood cells (WBCs) to the
periphery of the blood vessels
– Emigration of WBCs—the WBCs migrate into the
tissue spaces.
– Chemotaxis—cellular debris become more
“attractive” to the WBCs.
– Phagocytosis—neutrophils and monocytes engulf
cellular debris.

Prostaglandin Synthesis
• Prostaglandins modulate some components of
inflammation, body temperature, pain transmission, platelet
aggregation, and many other body actions.
• They are derived from arachidonic acid, which is liberated
from the cell membrane in response to physical, chemical,
hormonal, bacterial, or other stimuli.
• They are converted from arachidonic acid to prostaglandins
by the enzyme cyclooxygenase (COX).
• There are two forms of the COX enzyme: COX-1 and COX-
2.
• COX-1 synthesizes prostaglandins that are involved in the
regulation of normal cell activity.
• COX-2 appears to produce prostaglandins mainly at the
sites of inflammation.

Prostaglandin Synthesis (cont.)

Pain
• The physiologic mechanisms involved in the pain
response are complex.
• The sensation of peripheral pain begins in afferent
neurons called nociceptors.
• These receptors are activated by chemical mediators,
such as prostaglandins, histamine, bradykinin, and
serotonin.

Platelet Aggregation
• Simply speaking, platelet aggregation is the clumping
together of platelets in the blood.
• Platelet aggregation can be a beneficial process.
• Platelet aggregation can also be harmful. It is the first
step in a sequence of events that leads to the formation
of a thrombus.
• The risk of platelet aggregation is increased in patients
who smoke and have hypercholesterolemia.

Migraine Headache
• The two major types of migraine headache:
– Migraine with aura
– Migraine without aura
• It is postulated that migraine begins when intracranial
blood vessels dilate.
• This dilation stimulates the trigeminovascular system,
resulting in abnormally excitable neurons that send pain
impulses to the brain’s pain receptors.

Drugs to Treat Inflammation and Fever
• Salicylates, NSAIDs, and para-aminophenol derivative
drugs are used to treat inflammation and fever in a
variety of conditions.
• Salicylates are used in managing conditions ranging from
a simple headache to acute myocardial infarction (MI).
• NSAIDs are used primarily as anti-inflammatory drugs
but are also used extensively as analgesics.
• Prototype drug: acetylsalicylic acid (aspirin)

Aspirin: Core Drug Knowledge
• Pharmacotherapeutics
– Treat mild-to-moderate pain, prevent platelet
aggregation
• Pharmacokinetics
– Absorbed in the stomach and small intestines; highly
protein bound
• Pharmacodynamics
– Fever: inhibited PGE2 synthesis in the hypothalamus
– Inflammation: peripheral inhibition of prostaglandin
– Antiplatelet: irreversible inhibition of thromboxane
A2

Aspirin: Core Drug Knowledge (cont.)
• Contraindications and precautions
– Hypersensitivity, peptic ulcer disease, or bleeding
disorders, and children with illness
• Adverse effects
– Renal failure, abnormal bleeding, GI upset,
drowsiness, and confusion
• Drug interactions
– Other drugs that are highly protein bound

Aspirin: Core Patient Variables
• Health status
– Assess for contraindications to therapy.
• Life span and gender
– Contraindicated in the last trimester of pregnancy
• Lifestyle, diet, and habits
– Assess use of OTC medications.
• Environment
– Assess understanding of drug therapy.

Aspirin: Nursing Diagnoses and Outcomes
• Acute or chronic pain related to ineffectiveness of aspirin
– Desired outcome: The patient will contact the
prescriber if pain persists.
• Risk for Injury: GI bleeding, hepatic or renal toxicity
related to aspirin therapy
– Desired outcome: The patient will avoid injury by
contacting the prescriber if any signs of toxicity
occur.

(cont.)
• Disturbed Sensory Perception (visual and auditory)
related to blurred vision or tinnitus
prescriber if blurred vision or tinnitus occurs.
• Ineffective Protection related to blood dyscrasias or rash
prescriber if any signs of blood dyscrasias or rash
occur.

(cont.)
• Deficient Fluid Volume related to nausea and vomiting
– Desired outcome: The patient will avoid
dehydration by contacting the prescriber if persistent
nausea or vomiting occurs.
• Risk for Injury related to self-medication
– Desired outcome: The patient will avoid injury by
taking aspirin as prescribed.

Aspirin: Planning and Interventions
• Maximizing therapeutic effects
– Give with milk or food to decrease GI upset.
– When giving aspirin for its cardiovascular properties,
use uncoated aspirin.
• Minimizing adverse effects
– Do not administer aspirin to a patient with a medical
condition that contraindicates its use.
– It is important to monitor closely patients with pre-existing
medical conditions or those on drug therapy
that may interact with aspirin.

Aspirin: Teaching, Assessment, and
Evaluations
• Patient and family education
– Teach proper administration of medication.
– Discuss side effects of therapy.
• Ongoing assessment and evaluation
– Monitor the patient who is taking aspirin for signs
and symptoms of GI distress or bleeding, anemia,
hepatotoxicity, and renal failure.

Question
• Why is aspirin contraindicated in children with varicella?
– A. Can cause bleeding from skin lesions
– B. Will decrease effectiveness of antibiotic therapy
– C. Can cause increased fever
– D. Can cause Reye syndrome

Answer
• D. Can cause Reye syndrome
• Rationale: Aspirin is contraindicated in children with
varicella or flu-like illness because it is associated with
the occurrence of Reye syndrome.

Nonsteroidal Anti-Inflammatory Drugs
• The NSAIDs are grouped by chemical classes.
• NSAIDs all inhibit COX and prostaglandin synthesis.
• The therapeutic efficacy of an NSAID in a particular
patient is based on clinical response and usually cannot
be predicted before its use.
• All NSAIDs carry a Black Box warning stating that they
increase the risk of MI and stroke.
• Prototype drug: ibuprofen

Ibuprofen: Core Drug Knowledge
– Arthritis, mild-to-moderate pain, primary
dysmenorrhea, migraine headache, and fever
– Absorbed from the GI system. Peak: 1 to 2 hours.
Highly protein bound and is metabolized in the liver
– Inhibited synthesis or release of prostaglandins

Ibuprofen: Core Drug Knowledge (cont.)
– GI disease
• Adverse effects
– GI upset and bleeding, hepatotoxicity, and acute
renal failure. Increases risk of CVA or MI with
prolonged use.
– Similar to those of salicylates

Ibuprofen: Core Patient Variables
• Health status
– Assess for contraindications to therapy.
– Assess age before administration of drug.
– Assess other OTC use.
• Environment
– Assess environment where drug will be given.

Ibuprofen: Nursing Diagnoses and
Outcomes
• Acute or Chronic Pain related to ineffectiveness of
ibuprofen
prescriber if pain persists.
• Increased Risk for Injury related to incorrect self-administration
or to drug-induced GI bleeding or hepatic
and renal toxicity
– Desired outcome: The patient will remain free of
injury by taking the drug only as directed. In
addition, the patient will be able to explain the
importance of contacting the health care provider
immediately if any adverse effects occur.

Outcomes (cont.)
• Increased Risk for Deficient Fluid Volume related to
nausea and vomiting
prescriber immediately if intractable nausea or
vomiting occurs.
• Disturbed Sensory Perception (visual) related to blurred
vision
– Desired outcome: The patient will discontinue
ibuprofen immediately and contact the health care
provider if vision is affected.

Outcomes (cont.)
• Ineffective Protection related to blood dyscrasias
prescriber immediately if any signs and symptoms of
blood dyscrasias occur.

Ibuprofen: Planning and Interventions
– Give ibuprofen with milk or food to decrease gastric
distress.
– Closely monitor patients with pre-existing medical
conditions or drug therapy that may interact with
ibuprofen.

Ibuprofen: Teaching, Assessment, and
Evaluations
– Teach patient about cardiovascular risk from
medication.
– Teach about side effects of drug therapy.
– Monitor for side effects of therapy.
– Therapy is considered effective if the patient is free
of fever, pain, or inflammation and is free from
adverse effects.

Question
• Why were all NSAIDs given a Black Box warning by the
FDA?
– A. Risk of MI and CVA is increased with use of
NSAIDs.
– B. Risk of GI bleeding is increased with use of
NSAIDs.
– C. NSAIDs can cause kidney failure.
– D. NSAIDs can cause hepatic failure.

Answer
• A. Risk of MI and CVA is increased with use of
NSAIDs.
• Rationale: All NSAIDs have a risk of causing MI or
CVA; the risk increases with prolonged use of the
medication.

Para-Aminophenol Derivatives
• Para-aminophenol derivative is an analgesic and
antipyretic available in the United States.
• Prototype drug: acetaminophen (Tylenol)

Acetaminophen: Core Drug Knowledge
– Used to treat fever or mild pain
– Administered orally. Absorbed: GI tract. Peak: 60
minutes. T1/2: 1 to 3.5 hours
– Primarily centrally acting; inhibits prostaglandin
synthesis in the CNS

Acetaminophen: Core Drug Knowledge
(cont.)
– Hepatic disease, viral hepatitis, or alcoholism
• Adverse effects
– Generally well tolerated; overdose of medication can
be fatal
– Activated charcoal, antacids, ethanol, hydantoins,
warfarin, and sulfinpyrazone

Acetaminophen: Core Patient Variables
• Health status
– Assess pain level and current medical conditions.
– Pregnancy category B
– Ask about other OTC medication use.
• Environment
– Determine patient’s understanding of drug use.

Acetaminophen: Nursing Diagnoses and
Outcomes
• Acute or Chronic Pain related to ineffectiveness of
acetaminophen
– Desired outcome: The patient will contact the health
care provider if pain persists.
• Risk for Injury related to drug-induced hepatic and renal
toxicity or to improper self-medication
– Desired outcome: The patient will take drug as
directed and contact the health care provider if any
signs of toxicity occur.
• Ineffective Protection related to potential blood dyscrasias
– Desired outcome: The patient will contact the health
care provider if any signs of blood dyscrasias occur.

Acetaminophen: Planning and
Interventions
– Acetaminophen can be administered without regard
to meals.
– Assess patients for medical conditions that contradict
the use of acetaminophen.
– Coordinate periodic CBC, platelet count, and liver and
renal function tests for patients on long-term
therapy.

Acetaminophen: Teaching, Assessment,
and Evaluations
– Teach patient to take medication as prescribed.
– Teach side effects of medication.
– Instruct that many OTC medications contain Tylenol.
– Monitor patient for side effects from the medication.
– Therapy is considered effective if patient is free of
fever and pain.

Question
• Which of the following patients is Tylenol contraindicated
in?
– A. 25 year old with headache
– B. 45 year old with GI bleeding
– C. 52 year old with hepatitis C
– D. 62 year old with osteoarthritis

Answer
• C. 52 year old with hepatitis C
• Rationale: Tylenol is contraindicated in patients with
impaired liver/hepatic function.

Serotonin-Selective Drugs
• Serotonin-selective drugs are used to relieve pain and
inflammation related to migraine headache.
• They are not useful for other types of headache or
inflammation that occur elsewhere in the body.
• These drugs are also known as “triptans” because the
generic name of these drugs ends as such.
• The triptans are considered first-line drugs for the
treatment of acute migraine headache.
• Prototype drug: sumatriptan (Imitrex)

Sumatriptan: Core Drug Knowledge
– Acute migraine headache and cluster headache
– Administered orally, intranasally, or subcutaneously.
Metabolized in the liver and excreted by the kidneys.
– Selective for 5-HT1B/1D receptors located on cranial
blood vessels and sensory nerves of the
trigeminovascular system.
– Stimulation of these receptors results in
vasoconstriction.

Sumatriptan: Core Drug Knowledge
(cont.)
– Coronary artery disease and ischemic cardiac
diseases
• Adverse effects
– Coronary artery vasospasm, cardiac dysrhythmias
angina, myocardial ischemia, and dizziness
– Selective serotonin reuptake inhibitors and
monoamine oxidase inhibitors

Sumatriptan: Core Patient Variables
• Health status
– Assess the characteristics of the headache.
– Pregnancy category C
– Identify trigger factors for headaches.
• Environment
– Given in the outpatient setting

Sumatriptan: Nursing Diagnoses and
Outcomes
• Risk for Tissue Perfusion, Impaired, related to
cardiovascular or cerebrovascular events
– Desired Outcome: The patient will recognize the
signs and symptoms of cardiovascular or
cerebrovascular events and seek medical assistance
immediately.
• Risk for Injury related to weakness, dizziness or syncope,
or lightheadedness
– Desired Outcome: The patient will remain free of
injury while taking sumatriptan.

Sumatriptan: Planning and Interventions
– Confirm diagnosis of type of headache the patient is
having.
– Administer drug as soon as headache begins.
– Assess the patient for a history of cardiovascular or
cerebrovascular disorder.
– After administering sumatriptan, monitor for signs
and symptoms of vasospasm and allergy.

Sumatriptan: Teaching, Assessment, and
Evaluations
– Teach how to take medication properly.
– Teach side effects of medication.
– Teach patient to identify triggers.
– Evaluate patients taking sumatriptan for the
cessation of headache and for signs and symptoms of
vasospastic events.

Question
• Which of the following is the most serious adverse effect
of sumatriptan?
– A. Cardiac event
– B. Respiratory event
– C. Urinary event
– D. GI event

Answer
• A. Cardiac event
• Rationale: The most serious adverse effect is cardiac
events, however, they rarely occur.

Ppt chapter 24

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