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What is an Analgesic?
Medications that relieve pain w/o causing loss of consciousness.
Medical definition of pain?
Pain is an unpleasant sensory or emotional experience related to tissue injury.
Nursing definition of pain?
Pain is whatever the experiencing person says it is, existing whenever he or she says it does.
Name the 5 vital signs.
What are the 3 aspects of the pain experience?
- Perception of pain
- Pain threshold
- Pain tolerance
Explain perception of pain.
it is subjective & highly individualized
Explain pain threshold.
The intensity at which the stimuli is judged as painful.
Explain pain tolerance.
The maximum degree of pain intensity a person is willing to endure (highly variable)
How is pain classified?
by; Duration & Origin
List the duration classifications & explain them.
- Acute Pain: suden onset; usually subsides with Tx.
- Chronic Pain: Persistant (can be difficult to Tx)
List the Origin classifications & explain them.
- Neuropathic pain: results from injury to peripheral nerve fibers
- Somatic (body): Originates in muscles, ligaments & bone.
- Superficial Pain: Originates from the skin & mucus membranes.
- Visceral Pain: Originates from organs & smooth muscle
- Vascular Pain: Migraines
- Referred Pain: Pain felt in other areas than those stimulated.
- Phantom Pain: pain perceived in an extremity that has been amputated (type of neuropathic pain)
Origin pain can be either ______ or ______
Acute or Chronic
Pain transmission is caused by certain substances in the body that stimulate nerve endings, starting the pain process. What are they?
Explain Gate Control Theory.
- Suggests that nervous system adjusts or varies the transmission of painful stimuli.
- suggests that pain impulses can be regulated or blocked by a gating mechanism in the dorsal horn of the spinal cord
What do Endorphins & Enkaphalins do for pain?
They are produced by the body & considered the body's painkillers.
What factors contribute to under-treatment of pain?
- Client not acknowledging pain
- Inability to measure pain
- Lack of assessment
- Attitudes of health care team
- don't believe client
- concerns r/t addiction & tolerance
- inadequate dose prescribed
What are the two basic types of treatment for pain?
Non pharm & pharm
What kinds of pain are Non-opioid analgesics use for?
Mild to moderate pain
What other effects can Non-opioid analgesics have on the body?
- Antipyretic - fever reducer (Tylenol)
- Anti-platelet - Aspirin
- Anti-inflammatory (NSAIDS only) - ibuprofen
What are the indications for Tylenol?
- Analgesic for mild to moderate pain
What are the contradictions for Tylenol?
- Known drug allergy
- Severe liver disease
- Genetic disease (G6PD enzyme deficiency)
What s/e or a/e can Tylenol have?
- Generally well tolerated
- rash, N/V
- Less common: blood disorders (anemia) & nephrotoxicities - especially if taken outside the recommended dose range.
Tylenol can be toxic, what is the lethal dosing & what does it do to the body?
- Long term ingestion of high doses can cause nephrotoxicity
- 150mg/kg is lethal
- causes tissue necrosis in liver
- a 165lb client = 75kg
- 75kg X 150mg = 11250mg
- 11250mg/325mg tab = 34.5 tabs
- to OD for the 165lb client
- Much easier for a small child of 22lb (only needs 4.6tabs to OD)
What is the treatment for toxicity of Tylenol?
Unrelieved pain can result in a number of physiological issues, name a few.
- ^Resp rate
- ^stress response
- Urinary retention
- Glucose intolerance
What types of pain are Nonopioids effective for?
dull, throbbing pain of headaches, dysmenorrhea, inflammation, minor abrasions, muscular aches & pain, mild to moderate arthritis
How do NSAIDs relieve pain?
By inhibiting biosynthesis of prostaglandin by different forms of the enzyme cyclooxygenase (COX)
By inhibiting COX-1 & COX-2 NSAIDs can contribute to what other effects on the body?
- Inhibiting COX-2 decreases inflammation & pain, but inhibiting COX-1 decreases the protection of the stomach lining.
- As a result NSAIDs can cause stomach ulcers and bleeding.
A common s/e of NSAIDs is gastric irritation. When should these drugs be taken?
- with food
- at mealtime
- or with a full glass of fluid
How can NSAIDs effect dysmenorrhea in the first 2 days?
It may cause excess bleeding
Some people are hypersensitive to Aspirin (any salicylate product.) What are the effects that can happen with hypersensitivity or overdose?
Certain foods also contain salicylates, name a few.
People who are hypersensitive to Aspirin & Salicylate products may also be sensitive to other ______
Opioid Analgesics (Opioid Agonists) are prescribed for what kind of pain?
Moderate to severe
A psychological & physical dependence upon a substance beyond normal voluntary control, usually after prolonged use of a substance.
Morphine is considered a "prototype opioid", where is morphine derived from?
the sap of seed pods of the opium poppy plant.
Where do Non-opioid analgesics act in the body?
on the peripheral nervous system at the pain receptor sites.
Where do opioid analgesics act?
- Mostly on the CNS.
- Primarily by activating the u receptors, while also exerting a weak activation of the kappa (k) recpetors.
Activation of the u receptor causes what effects?
- Resp depression
Activation of the kappa (k) receptors leads to what effects?
- (NO effect of resp. depression or euphoria)
Most opioids cause respiratory depression to some degree. Which allows the weaker ones to be classified as what?
- Antitussives (cough suppressant)
- (*except meperidine/Demerol)
Opioids have two isomers, levo & dextro. Explain the two.
- Levo-isomers produce an analgesic effect
- Levo & Dextro-isomers both produce an antitussive response.
- Levo-isomers: cause dependence
- Dextro-isomers: don't cause dependence
Opioids not only have analgesic & antitussive effects, but they also possess what other effect?
What are some s/e of opioids?
- Moderate <BP
- Orthostatic Hypotension
- Respiratory depression
- Urinary retention
- Antitussive effects
Morphine is a potent opioid analgesic & is effective for what types of pain?
- Acute pain from acute myocardial infarction (AMI)
- Dyspnea resulting from pulmonary edema
Meperidine (Demerol) is one of the first synthetic opioids. This class II drugs is primarily effective for what types of pain?
GI procedures & does NOT have the antitussive property.
Why is Meperidine (Demerol), preferred over morphine during pregnancy?
- It does NOT diminish uterine contractions
- Causes less neonatal respiratory depression
- Causes less constipation & urinary retention
What is Hydromorphone (Dilaudid)?
A semisynthetic opioid similar to morphine.
What makes Dilaudid a better choice than morphine in some cases?
- 6Xs more potent
- fewer hypnotic effects
- less GI distress
- faster onset & shorter duration of action
- readily absorbed into the body and excreted in the urine.
What will the nurse be monitoring for with a client on Dilaudid?
- adequate hydration
Why are opioids contraindicated for clients with head injuries?
Opioids <respirations, thus causing an accumulation of CO2. W/^ in CO2 retention, blood vessels dilate, especially cerebral vessels, which causes ^intracranial pressure.
What is Vicoprofin?
- A combination drug.
- Ibuprofen and Hydrocodone
What is a PCA
What is a Transdermal Opioid Analgesic (ie. Fentanyl patch) used for?
Provide a continuous "around-the-clock" pain control that is helpful to clients who suffer from chronic pain.
What opioids should be avoided for patients with <renal & hepatic fxn, d/t an ^ toxicity?
- Meperidine (Demerol)
- Pentazocine (Talwin)
- Propoxyphene (Darvon)
Analgesics are usually metabolized where?
The liver and excreted in the urine
What is Adjuvant Therapy?
It is usually used along w/a nonopioid & opioid. Adjuvant analgesics were developed for other purposes & later were found to be effective for pain relief in neuropathy.
What are some Adjuvant Analgesics?
- Local anesthetics
Adjuvant medications potentiate opioid analgesia for severe persistent pain in what types of pain?
- Diabetic Neuropathy
- Migraine headaches
- Rheumatoid arthritis
Explain the Methadone Tx program.
This program works by replacing opioids with methadone, also an opioid but one that causes less dependency than the opioids it replaces.
What is an Opioid Agonist-Antagonist?
- Medications in which an opioid antagonist is added to an opioid agonist.
- developed in hopes of decreasing opioid abuse
Name some Opioid Agonist-Antagonists.
- Butorphanol tartrate (Stadol)
- Buprenorphine (Buprenex)
- Nalbuphine hydrochloride (Nubain)
What are opioid antagonists used for?
overdoses of natural & synthetic opioid analgesics.
How does an Opioid Antagonist work?
By blocking the receptor & displaces any opioid that would normally be at the receptor, inhibiting the opioid action.
Name a few Opioid Antagonists
- Naloxone (Narcan)
- Naltrexone hydrochloride (ReVia)
- Nalmefene (Revex)
What characterizes a Migraine headache?
Unilateral throbbing head pain accompanied by nausea, vomiting, & photophobia
What causes a migraine headache?
Inflammation & dilation of the blood vessels in the cranium.
What foods can trigger a migraine?
What are the 2 types of migraines?
- Classic Migraines: are associated with an aura that occurs minutes to 1hr before onset.
- Common Migraines: not associated with an aura
Explain Cluster Headaches.
They are characterized by a severe unilateral nonthrobbing pain usually located around the eye. They occur in a series of cluster attacks; one or more attacks every day for several weeks.
Preventative Tx for migraines includes what types of drugs?
- Beta-adrenergic blockers:
- Propranolol (Inderal) & Atenolol (Tenormin)
- Valporic acid (Depakote) & Gabapentin
- Tricyclic Antidepressants:
- Amitriptyline (Elavil) & Imipramine (Tofranil)
What is the most recently developed group of drugs for Tx of migraines?
- The triptans (5-HT1 receptor agonists)
- ie. Sumatriptan (Imitrex)
What is the normal range for adult respirations?
Is MS Contin a long-acting or short-acting opioid?
Long-acting. "Contin" means "continuous"
Do Opioids have a "ceiling effect"? Meaning is there a point where the body simply won't use the extra med put in the body?
No, you can continue to gradually increase opioids with increased tolerance.
What are the side effects of opioids?
- CNS depression
- *Respiratory depression
- *Pupil constriction
- Orthostatic Hypotension: puts pt's at risk for falls.
- GI: N/V, constipation
- Urinary retention
What is the most commonly used Tx for opioid toxicity?
Narcan (Naloxone). Take aprox. 1hr to take effect.
What are the symptoms that occur with opioid withdrawal?
- Rebound pain
- Mental agitaion
- Joint pain
- Abdominal cramps
What does a nurse assess for with opioid therapy?
- Nature & type of pain
- Location of pain
- Duration of pain
- Rating of pain
- Precipitating & Relieving factors
- Remedies & other Tx's that help the pain
- Check vitals against baseline vitals
What is the pathophysiology of Migraines?
- Caused by inflammation & dilation of blood vessels
- Imbalance of serotonin
What drugs are used for prevention of migraines in a client that has chronic migraine issues?
- Beta-adrenergic blockers (Propranolol: Inderal)
- Anticonvulsants (Depakote, Neurontin)
- Tricyclic antidepressants (Amitriptyline: Elavil)
- Triptans (Suma Triptan: Imitrex)
What meds are used as Tx at onset of a migraine?
- Analgesics: ASA
- NSAIDs (Advil, Aleve)
- Opioids: Demerol
- Stadol NS (nasal spray)
- Ergot alkaloids
What meds are used to Tx acute migraines?
- Antimigraine drugs:
- The "Triptans Sisters"
- Almo Triptan
- Ele Triptan
- *Suma Triptan....ect. Anything with Triptan Tx is for acute migraines
How to the "Triptan Sister" work?
By causing vasoconstriction of cranial arteries.
What are the s/e of the "Triptan Sisters"?
- Dizziness, tingling, numbness, warm sensation, drowsiness, seizures
- Muscle cramps, N/V, diarrhea
- Hypertension, Dysrhythmias, thromboembolus, MI, stroke
What things will the nurse educate client on when using Triptans?
- The form of medication and how to take it.
- Trigger foods to avoid
- Client should keep a journal to monitor response to therapy
- May ^BP
- *Do NOT take other Triptans w/in 24hrs of Suma Triptan.
What are the cardinal signs of inflammation?
- Loss of Fxn
With the COX-2 Inhibitor, Celebrex, what is a severe possible s/e?
^Cardiac events such as MI's
What are the Anti-inflammatory Drug Groups?
- Disease-modifying Antirheumatic Drugs
- Antigout Drugs
What are the indications for Anti-inflammatory drugs?
- <inflammation & pain
- Platelet inhibition
- Rheumatoid & Osteoarthritis
- *ONLY aspirin & Ibuprofen are used for FEVER or headaches
What are the types of drugs used in the Disease-Modifying Antirheumatic Drugs (DMARDs) class?
- Gold Drug Therapy (Chrysotherapy)
- Immunosuppressive agents
DMARDs have severe s/e, what are they?
In Gold Drug Therapy Auranofin (Ridaura) is used, what is the action of this drug?
- Stops progression of joint degeneration
- Decreases leukocytes migration
- Suppresses prostaglandin activity
What is Ridaura (gold drug therapy), used for?
How long does it take for Gold Drug Therapy to work?
What are the s/e of Gold Drug Therapy?
- Anorexia, N/V, Diarrhea, Stomatitis, Photosensitivity, Metallic taste, Uriticaria, Severe rash, Corneal gold deposits, Bradycardia, Profound Hypotension, Hematuria, Proteinuria
- Life Threatening s/e: Nephrotoxicity, Agranulocytosis (not making WBCs), Thrombocytopenia (<platelets)
What is the pathophysiology of Gout?
It is an inflammatory disease of the joints & tendons.
Where does gout typically occur?
In the great toe.
What causes gout?
A defect in purine metabolism that leads to uric acid accumulation.
What foods have purine in them & should be avoided by clients with gout?
Name some Antigout drugs
- Allopurinol: a uric acid inhibitor
Which Antigout drug is used for an acute attack only?
How does Cholchicine work in the body?
It inhibits the migration of leukocytes to the inflamed site.
What are the main s/e of Cholchicine?
- N/V, Diarrhea, Abdominal pian
- *take with food to avoid GI distress
Cholchicine is contraindicated in patients with what kinds of health problems?
- Severe Renal problems
- GI problems
Which drugs are used to control gout or prevent an acute attack of gout?
Allopurinol (Zyloprim); a Uric acid inhibitor
What is the drug action of Allopurinol?
Decreases uric acid levels in blood
What are the nursing interventions for a client on Allopurinol?
- Monitor CBC, liver enzymes, renal fxn
- Yearly eye exams for visual changes
- Client needs to avoid alcohol, caffeine, & thiazide diuretics that ^uric acid levels
- & ^fluid intake to ^uric acid excretion
Are Uricosurics (Probenecid/Benemid) used for acute attacks or chronic of gout?
What are the s/e of Uricosurics?
- GI irriation
- *take w/food!
What are the nursing interventions for a patient on Uricosurics?
- ^fluid intake to ^uric acid excretion.
- Not to be given w/other highly protein bound drugs.
What are few other Antigout drugs that are not used as often?
- Febuxostat (Ulroic)
- Krystexxa (pegloticase)
What things should a nurse be teaching a client on Antigout therapy?
- Regularly scheduled labs
- *to assess kidney fxn, liver fxn, & CBC
- ^FLUID intake
- Report S/E
- Dietary changes: low purine diet, no alcohol, do NOT take large doses of Vit C.
Explain what happens during a seizure in the brain.
Abnormal electrical discharges from the cerebral neurons.
Explain the International Classifications of Seizures.
- Grand mal (tonic-clonic)
- most common
- generalized alternating muscle spasms & jerkiness
- Petit mal (absence)
- Brief loss of consciousness (10sec or <)
- Usually occurs in children
- Partial Psycomotor
- Repetitive behavior (chewing/swallowing
- Behavioral changes
- Motor seizures
Antiepileptic Drugs (Anticonvulsants) are indicated for use with what types of client issues?
- Control of seizure activity
- Status epilepticus
- Mood disorders (Bipolar, manic/depression)
- Neuropathic pain (migraines, diabetic, neuropathy)
Name some Anti-epileptic drugs.
- Phenytoin (Dilantin)
- Carbamazepine (Tegretol)
- Valproic Acid (Depakote):also for Bipolar dissorder
- Clonazepam (Klonopin)
- Lamotrigine (Lamictal): also for Bipolar dissorder
- Gabapentin (Neurontin): also for Neuropathic pain
- Topiramate (Topamax)
What is the therapeutic serum level for Dilantin?
What are the S/E to watch for with Dilantin?
- Nystagmus, diplopia
- HA, dizziness, slurred speech, <coordination, Alopecia
- Thrombocytopenia, stevens-johnson syndrome
What are the s/e of Depakote (Valproic acid)?
- Ataxia (common in elderly)
Do NOT give Depakote with what other type of drug?
Barbiturates; additive effect & ^ CNS depression
What are the s/e of Tegretol?
- Bone marrow suppression = <RBC, <WBC, <platelets
What are the s/e for Lamotrigine (Lamictal)?
- Ataxia (lack of muscle coordination during voluntary movements like walking)
- *can be used for Bipolar dissorder
What are the general nursing interventions for Anticonvulsants?
- Warn client NOT to d/c abruptly = statusepilepticus
- Teach client to take drug at same time daily
- Avoid certain herbs, alcohol, & other CNS depressants
- Monitor serum drug levels & liver fxn tests
- Safety: Protect from environmental hazards; driving
What are some of the specific nursing interventions for Dilantin?
- Frequent oral hygiene & dental check-ups
- Warn females to use additional contraception
- Monitor glucose level in diabetics
- Warn of harmless pinkish/brown urine
What drugs are used for Status Epilepticus?
- *Diazepam (Valium)
- *Lorazepam (Ativan)
- *Midazolam (Versed)
- Followed by fosphenytoin-Cerebyx (IV form of Dilantin)
What is the pathophysiology of Parkinsonism?
- Chronic neurologic disorder
- Degeneration of dopaminergic neurons
- Imbalance of the neurotransmitters (less dopamine)
What are the characteristics of Parkinsonism?
- Tremors of head & neck
- Rigidity (^muscle tone)
- Bradykinesia (slow movement)
- Postural changes: Head & chest thrown forward
- Shuffling walk
- Lack of facial expression
- Pill-rolling motion of hands
What are the Tx options for Parkinsonism?
- Dopaminergics: Convert to dopamine
- Dopamine Agonists: Stimulate dopamine receptors
- Anticholinergics: Block Cholinergic receptors
- MAO-B Inhibitors: Inhibit MAO-B enzyme that interferes w/dopamine
- COMT Inhibitors: Inhibit COMT enzyme that inactivates dopamine
What do Dopaminergics like Sinemet do in the body?
Carbidopa (a decarboxylase inhibitor) permits more levodopa to reach the striatum nerve terminals where levodopa is converted to dopamine & this decreases Sx of parkinsonism
What are the s/e of Dopaminergics like Sinemet?
- Involuntary choreiform movements (dance/squirm)
- N/V, Urinary retention
- Fatigue, Insomnia, dry mouth, blurred vision
- Orthostatic Hypotension, palpitations, dysrhythmias
- Dyskinesia, psychosis, severe depression
What are some other Anti-parkinsonism drugs to glance over?
- Anticholinergics: Cogentin, Artane
- Dopamine Agonist: Symmetrel, Parlodel
- COMT Inhibitors: Stalevo
- Others: Eldepryl, Requip
What are the nursing interventions for Anti-Parkinsonism drugs?
- DO NOT ABRUPTLY D/C
- Monitor for Orthostatic Hypotention
- Avoid excess vit B6
- Urine/sweat will be brown discoloration (normal)
- Assess s/s status & "on-off" phenomenon
- Monitor blood cell counts: liver & kidney fxn
- Teach r/t: Anticholinergic effects w/Benzotropine & Trihexyphenidyl
What is the pathophysiology of Alzheimer's Disease?
- Progressive, degenerative disease
- neuritic plaques form
- Neurofibrillary tangles are in neurons
- Cholinergic neurotransmitter abnomallity
What are some things that characterize Alzheimer's disease?
- Loss of memory
- Loss of logical thinking
- Loss of judgment
- Time disorientation
- Personality changes
- Tendency to wander
- Inability to express oneself
What meds are used to treat Alzheimer's Disease?
Acetylcholinesterase Inhibitors: Aricept, Exelon, Cognex
What is the goal with Tx of Alzheimer's Disease?
- NO CURE
- Improve memory
- Slow progression of disease
What are the s/e of Acetylcholinesterase Inhibitors used to Tx Alzheimer's?
Headache, dizziness, Dehydration, dry mouth, blurred vision, Depression, GI distress, Insomnia, HTN, Hypotension, dysrhythmias, Hepatotoxicity
What are the nursing interventions for the Acetylcholinesterase Inhibitors?
- Monitor VS
- Maintain consistency in care
- Monitor behavioral changes
- Provide safety when wandering
- Arise slowly to avoid dizziness
- Monitor for GI bleeding
What is the pathophysiology of Multiple Sclerosis (MS)?
It is an Autoimmune disorder: Attacks myelin sheath of nerve fibers & causes lesions or plaques.
What does a client with MS experience?
- Extremity weakness or spasticity
- Diplopia (double vision)
- has remissions & exacerbations
What meds are used for MS or spasicity associated with spinal cord injury?
- Centrally acting meds:
- Baclofen (Lioresal)
- Tzanidine (Zanaflex)
- Direct Acting:
- Dantrolene (Dantrium)
What meds are used for acute muscle spasms?
- Cyclobenzaprine (Flexeril)
- Carisoprodol (Soma)
What are the s/e of Skeletal Muscle Relaxants?
- Drowsiness, sedation, dizziness
- GI distress
- Drug dependence
What are the nursing interventions associated with Skeletal Muscle Relaxants?
- Take w/food
- Monitor liver fxn
- Check VS
- NO DRIVING
- Do NOT d/c abruptly (d/c over 1wk to avoid rebound spasms
- Avoid Alcohol & other depressants.