Analgesics Chapters 20, 19, & 9 Chapter 20 Nonopioid Analgesics Pain Physiological and emotional experience characterized by unpleasant feelings Usually associated with trauma or disease The same degree and type of pain can be

described differently by different peoplereaction to pain is a subjective experience Numerical scales or survey instruments can be used to: Assess pain Measure progress of pain therapy Pain 19-4 Inflammation

20-5 Nonpharmacological Techniques When used with pharmacotherapy can allow: Lower doses of the drug Examples Acupuncture Biofeedback therapy Massage Heat/cold packs

Meditation Relaxation therapy Art or music therapy Imagery Chiropractic manipulations Hypnosis Therapeutic touch Transcutaneous electric nerve stimulation (TENS) Energy therapies Analgesics

Medications used to relieve pain 2 basic categories 1. Non-opioids NSAIDS ASA, COX-2 Inhibitors, Traditional NSAIDs Acetaminophen 2. Opioids natural or synthetic morphine-like substance responsible for reducing severe pain Narcotic substances-they produce analgesia and CNS depression

Nonopioids Nonopioids differ from opioids in the following ways Not chemically related to morphine Produce analgesia

Not effective through CNS against and sharp pain peripheral MOA Do not produce tolerance or

dependence 20-8 Nonsteroidal anti-inflammatory drugs (NSAIDS) Inhibit cyclooxygenase type one and/or two, an enzyme responsible for the formation prostaglandins When cyclooxygenase is inhibited, inflammation and pain are reduced Drugs of choice for mild to moderate pain, especially associated with inflammation

Have anti-inflammatory, analgesic, and anti-pyretic properties (the 3 As) Many are OTC and inexpensive Nonopioids (NSAIDs) There are two groups within this class distinguished by their pharmacologic action: Salicylates Aspirin (ASA) Nonsteroidal anti-inflammatory drugs -Traditional NSAIDs

2010 Nonopioids (NSAIDs) There are two groups within this class distinguished by their pharmacologic action: Salicylates Aspirin (ASA) Nonsteroidal anti-inflammatory drugs -Traditional NSAIDs 2011

NSAIDs: Salicylates Aspirin and salicylic acid are the main salicylates: Oldest and most frequently used nonopioid analgesics, for mild to moderate pain Discovered from Native Americans use of willow tree bark Used as analgesics, antipyretics, and antiinflammatories Also used for inhibit platelet aggregation 2012

NSAIDs: Salicylates Salicylates produce analgesia and antipyresis by affecting the hypothalamic centers in the brain. Aspirin is a potent inhibitor of prostaglandin synthesis, which decreases inflammation (MOA) Salicylates block COX-1: Protective environment in stomach is altered Gastric ulcers can result NC: Monitor for GI Bleeding, take Enteric Coated(EC) for long term use and/or take2013

with milk NSAIDs: Salicylates Aspirin (prophylactic use): Helps reduce risk of reinfarction Prevents cardiovascular issues (MI and CVA) (Used) for mild to moderate pain, osteoarthritis, and rheumatoid arthritis Reduces inflammation SE: Bleeding, esp GI Bleeding

frank bleeding or black tarry stools, ecchymosis, petechia Nursing Consideration: Aspirin should not be given to children: Reyes syndrome 2014 Traditional NSAIDS Ibuprofen and Ibuprofen-like (Nonsalicylates) MOA: Are nonselective- inhibit both COX

1&2 USE: anti-pyretic, anti-inflammatory, and analgesic Profile Drugs: Ibuprofen (Advil, Motrin) Naproxen sodium (Aleve) Traditional NSAIDs All anti-inflammatory drugs may produce (SE): Nausea, GI distress, and ulceration (GI bleeding) Vertigo, vomiting, mental confusion, and headaches

Overdose of NSAIDs is similar to salicylate overdose. No specific antidote for NSAID poisoning NSAID use is discouraged in elderly patients. 2016 Acetaminophen (Tylenol) Class: Synthetic non-opiate analgesic MOA: Inhibits prostaglandin synthesis, but the exact site and mechanism of action are unknown!

Use: Anti-pyretic effectiveness and analgesic potency are similar to aspirin No anti-inflammatory activity- not effective in the relief of symptoms of inflammation Nonopioid Anaglgesic: Acetaminophen Acetaminophen is effective in treating headaches, fever, and minor musculoskeletal pain. Inhibits prostaglandin synthetase Considered an aspirin substitute

Does not have anti-inflammatory properties Not useful in the treatment of arthritis 2018 acetaminophin (Tylenol) Side Effects: Hepatotoxicity Nursing Considerations: Maximum Tylenol dosage is 4 grams daily Be careful of combination meds

Reversal agent is acetylcysteine (Mucomyst) Preferred Therapy Aspirin: Fever, headaches, inflammation including arthritis, prophylaxis of heart attack or stroke Ibuprofen: Aches, pains, inflammation

Acetaminophen: Fever and headache, aspirin substitute 2020 Tension Headache HA is one of the most common complaints of patients Tension HAs are most common kind Occurs when muscles of head and neck tighten in response to stress

Tightness causes steady and lingering pain Usually end when stress is resolved Treated with OTC analgesics like ASA, acetaminophen, or ibuprofen Migraines Most painful type of HA Characterized by throbbing or pulsating pain, sometimes proceeded by an aura (similar to those that warn of a seizure) Most patients also experience N and V

2 primary goals for pharmacology therapy 1. Stop migraines in progress 2. Prevent migraines from occurring Drug therapy is more effective if begun before migraine has reached severe level Triptans MOA: Constrict certain vessels within the brain in order to stop migraine Vasoconstricts the cranial arteries Example:

Sumatriptan (Imitrex) Side Effects: Dizziness, drowsiness Nursing Considerations: Due to vasoconstriction, use cautiously in pts with recent MI, HTN, DM, or CVA Ergot Alkaloids Use: for patients who are unresponsive to triptans to stop migraines Example: Ergotamine (Ergostat)

MOA: interacts with dopaminergic, adrenergic, and serotonin receptors SE: Dizziness, N/V NC: may cause physical dependence, monitor for withdrawal symptoms Pregnancy Category X Other drugs for migraine prevention Examples beta-adrenergic blockers calcium channel blockers

antidepressants antiseizure drugs Question 1 A nurse is caring for an older adult client who is taking large doses of Tylenol four times a day for pain. For which of the following should the nurse monitor the client? A. B. C.

D. Hepatotoxicity Renal impairment Reyes syndrome Ischemic stroke Question 2 A nurse is caring for a toddler who was just admitted for an acetaminophen overdose. Which of the following medications should the nurse

anticipate being administered to the client? A. B. C. D. Acetylcysteine (Mucomyst) Perfilgrastim (Neulasta) Misoprostol (Cytotec) Naltrexone (ReVia)

Question 3 A mother of a 26-month-old child calls. He child is coughing, has nasal congestion, and is running a fever. She would like to know how much aspirin she should give her child. The child weighs 22 pounds. What should the nurse tell the mother? Question 4 When a healthcare provider is asked to explain why Tylenol is used more often

than aspirin, the response is that aspirin can cause: A. Dependence B. Increased platelet adhesiveness C. CNS depression D. GI bleeding

Question 5 When asked why NSAIDS are better than acetaminophen for arthritis, the healthcare provider responds, Compared with aspirin, acetaminophen has ___________.

A. Less analgesic activity B. No antipyretic activity C. No anti-inflammatory D. The same effect on blood coagulation Chapter 19 Opioid Analgesics Opioid Analgesics (Uses):

Opioids are considered first-line therapy for: Pain associated with procedures Pain due to trauma or cancer Visceral pain (appendicitis) Used to relieve acute or chronic pain analgesic Suppress cough Treat diarrhea (slow GI motility) 1932

Opioid Analgesics: (MOA) Opioid analgesics act by binding to opioid receptors and mimicking the effects of the analgesic peptides. (SE) Opioids influence CNS activity: Decrease mental alertness Euphoria Dysphoria Respiratory depression

1933 Opioid Analgesics (SE): Opioids have direct action on smooth muscle in the GI tract, which can lead to constipation. Nausea, vomiting Constipation They can also cause: Bronchoconstriction Decreased urination

Bradycardia 1934 Drug Administration Because opioid analgesics are CNS depressants at any dose, patients should be closely monitored for overdose. NC: Monitor for Respiratory Depression Opioid analgesics are metabolized by the

liver and then excreted by the kidneys. Anything that causes alkaline urine increases the concentration of opioids in the blood. 1935 Opioid Agonists Bind to opioid receptors and produce multiple responses Morphine is the representative drug used to treat severe pain- the standard

against which the effectiveness of every other opioid is compared Opioids Drugs of choice for moderate to severe pain that cannot be controlled with other classes of analgesics More than 20 different opioids are available as medications Most commonly classified by effectiveness, which places opiates into categories of strong or

moderate narcotic activity Common Opioid Agonists with High Effectiveness Hydromorphone hydrochloride (Dilaudid) Meperidine hydrochloride (Demerol) Morphine sulfate (Duramorph) Hydrocodone oxycodone hydrochloride (OxyContin) Codiene

Combinations It is common practice to combine opioids and nonnarcotic analgesics Two classes work synergistically to relieve pain What is the benefit to this? Common Combinations Vicodin (hydrocodone 5 mg; acetaminophen 500 mg) Percocet (oxycodone HCl 5 mg;

acetaminophen 325 mg) Tolerance and Physical Dependence Methadone is used in the treatment of opioid addiction: Satisfies opioid hunger Does not produce severe withdrawal symptoms Buprenorphine: Pushes opioids out of receptors Blocks attachment of opioids to receptors

1941 Opioid Antagonists Opioid poisoning presents with coma, depressed respiration, cyanosis, and hypotension. MOA: Antagonists are drugs that attach to opioid receptors and displace the analgesic, rapidly reversing poisoning. Pure

Partial 1942 Opioid Antagonists Acute opioid intoxication Medical emergency Respiratory depression is most serious problem Naloxone (Narcan) Class: Pure Opioid Antagonist

Used for complete or partial reversal of opioid effects when acute opioid overdose is suspected Rapid onset of action SE: In reversing the effects of opioids, patient may experience rapid loss of analgesia! Opioid Antitussives Antitussives are drugs that suppress the cough reflex: Codeine

Hydrocodone Dextromethorphan Expectorants are commonly combined with antitussives to aid in the removal of mucus. 1945 Question 1 A nurse is caring for a client who has been receiving

morphine for postoperative pain for the past few days. For which of the following should the nurse monitor the client? (Select all that apply) A. Dilated pupils B. Urinary retention C. Orthostatic hypotension D. Constipation E. Nausea F. Respiratory depression

Question 2 During tolerance to opioid analgesics, the following is happening: A. Fewer receptors are available to produce a response. B. Increased pain by the patient requires greater doses of medication. C. The body reacts to removal of opioid analgesic. D. Histamine release causes hypotension Question 3

Postoperative pain and cancer pain may be considered predictable. How can the nurse increase the effectiveness of the analgesics? A. Give them PRN B. Administer once per day

C. Plan around-the-clock dosing D. Administer twice a day Question 4 The drug of choice in the treatment of acute opioid poisonings is : A. Butorphanol B. Nalbuphine C. Naloxone D. Pentazocine

Question 5 The following preoperative medications have been ordered: morphine 5 mg with atropine 0.4 mg IM on call to the OR. The nurse would explain to the client that the purpose of these medications is to: A. Assist the client to sleep and not be aware of his

surroundings during transport to the OR B. Reduce client anxiety and cause amnesia during the preoperative period C. Reduce the clients oral and respiratory secretions, and promote induction of anesthesia in surgery D. Reduce the possibility of the client being nauseated and vomiting during and after surgery Question 6 A client goes to the ER with an overdose of morphine. What would the priority nursing

assessment be? A. Dilated pupils B. Depressed respiration C. Hypertension D. Diarrhea

Chapter 9 Skeletal Muscle Relaxants Skeletal Muscle Relaxants There are two ways skeletal muscle can be relaxed: By blocking conduction to the spinal cord By inhibiting contraction of the neuromuscular junction 9-54

Peripherally/Direct Acting Relaxants Neuromuscular blockers inhibit skeletal muscle contraction. There are two types of neuromuscular blockers: Nondepolarizing Depolarizing 9-55 Direct-Acting Relaxants dantrolene (Dantium) interferes with calcium

ion release in the muscle fibers, which inhibits muscle contraction. (MOA) dantrolene is used in the treatment of malignant hyperthermia and spastic conditions To relieve muscle spasms and pain associated with injuries MS, Huntingtons, Cerebral Palsy, stroke 9-57 Direct-Acting Relaxants

The adverse effects seen from dantrolene include: Dizziness Vomiting

Fatigue Weakness Hepatotoxicity Respiratory muscle paralysis 9-58 Centrally Acting Relaxants MOA: Drugs that relax skeletal muscle by a central mechanism depress reflex impulse conduction within the spinal

cord. This change in conduction reduces the number of impulses available to produce muscle contraction. 9-59 Centrally Acting Relaxants Used to treat spastic contraction from: Overexertion Trauma

Nervous tension Adverse effects include: Blurred vision Lethargy Decreased mental alertness Respiratory muscle paralysis 9-60 Skeletal Muscle Relaxants Direct acting muscle relaxant

Dantrolene sodium (Dantrium) Centrally acting muscle relaxants Cyclobenzaprine (Flexeril) Baclofen (Lioresal) Teaching (NC): Do not stop abruptly, taper to avoid rebound spasm Do not drive or operate heavy machinery Avoid ETOH and other CNS deperessants Adverse and Toxic Effects The major toxicity of neuromuscular

blockers is respiratory muscle paralysis. Additional adverse effects include: Malignant hyperthermia Increased neuromuscular blockade with drugs that inhibit skeletal muscle function 9-62 Question 1 A nurse is caring for a client who has a prescription for

tizanidine (Zanaflex) , a direct acting muscle relaxant, for relief of muscle spasm following a back injury. Which of the following lab values should the nurse expect to monitor while the patient is taking this medicaiton? A. Serum creatinine B. Liver enzymes C. WBC count D. RBC count Question 2

A nurse is caring for a client who has been taking oral baclofen (Lioresal) three times daily for the past 8 months. The client says to the nurse, Ive been having problems with constipation, so I'm just going to stop taking this medicaiton. What should the be the nurses response? Why? Question 3 Skeletal muscle relaxants may alter control of respirations because: A. The diaphragm is a skeletal muscle.

B. Succinylcholine stimulates the respiratory centers of the brain. C. Like dantrolene, all muscle relaxants inhibit the action of norepinephrine at the neuromuscular junction. D. Relaxation of the muscles in the lower extremities pulls blood away form the lungs.

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