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What is the organizational framework for nursing; which is orderly, systematic, but flexible & central to ALL nursing care?
The Nursing Process
What is critical thinking and how does it relate to the nursing process?
Critical thinking is a higher level of thinking (thinking about your thinking); which is important in knowing where to get info, when to step back, and allows for the reevaluation of your actions to talor your care to the individial client.
What are the steps of the nursing process?
Assessment, Nursing diagnosis, Planning, Implementation, and Evaluation (Ad Pie)
What are some sources of drug data?
Reference textbooks, drug manufacturer's inserts, drug handbook, licenced pharmacist, PDA reference, and PDR (Physician' s Desk Reference)
What is the goal of the "Assessment" step in the nursing process?
To collect data; both subjective, objective, and environmental.
Define subjective, objective, and environmental.
- Subjective - whatever the pt says.
- Objective - whatever you can record.
- Environmental - whatever can effect the pt.
What are some topics to ask about when taking a pt's medication history?
Perscriptions, reactions, OTCs, home remedies, herbal meds, alcohol, tobacco, caffeine, vitamines, supplements, birth control, street drugs, and ALLERGIES!
When doing a nursing assessment on your pt, what are some key focuses?
Head-to-toe, religion, health beliefs, sociocultural profile, educational level, motor skills, cognitive ability, and developmental stage.
Define: Data Analysis
The critical evaluation of all data
What is the goal of the "Nursing Diagnosis" step of the nursing process?
The goal is to use the data collected to make a judgment or conclusion about the risk for (or actual) problems/needs of the pt.
What is NANDA?
The North American Nursing Diagnosis Association; the formal organization responsible for developing nursing diagnosis.
What is the purpose of the "Planning" step of the nursing process?
After a diagnosis has been made, the purpose is to identify your PRIORTIES and plan for acting in a TIMELY manner to achieve your actual goals and projected outcomes.
What are the criterias of a "goal"?
A goal must be specific, objective, measurable, realistic, and within a specific time frame.
What are the criterias of an "outcome"?
Outcomes are specific standards of measure that are patient oriented.
What is the goal of the "Implementation" step in the nursing process?
To initiate and complete the nursing care plan as defined by the nursing diagnosis and outcome criteria.
What must the nurse need to follow, during the implementation phase of the nursing process?
The nurse must follow the "6 rights" of medication administration. Nurses are legally responsible for this, and so, they need to know and understand all the information about the meds and their pt.
List and define the "6 Rights" of Medication Administration.
- 1) Right drug - check drug orders and med labels, be familiar with generic & trade names. Use reliable sources for info!
- 2) Right dose - check at least 3x before giving the drug. If question, clarify the order. Always check for appropriate dosage, calculations, decimals, age & size.
- 3) Right time - follow institutional policy for times of adm, consider drug-drug & drug-food interactions, drug levels & military time.
- 4) Right route - never assume the route; check!
- 5) Right patient - ask name, check ID band, and allergies.
- 6) Right documentation - if it wasn't documented, it wasn't done.
What is the "7th Right" and how does it work?
The 7th right is "System Analysis"; which is an evaluation of the entire system of medication administration (aka a "double-check") - including ordering, dispensing, preparing, administration, and documentation. In other words, it is a look at the process to see what works and what doesn't (to increase safty) and involves the physician, nurse, nursing unit, pharmacy dept, and pt education.
What are the "8th & 9th Rights" and how do they work?
- The "Right to Refuse", which is the pt's right to refuse treatment; however, the nurse should find out why the pt is refusing and try to help convince the pt to comply.
- The "Right Reason" is the appropriate use of meds; misuse is considered chemical restraint.
What are some "other" rights?
the right to proper drug storage, proper documentation, accurate dosage calculation, accurate dosage preparation, careful checking or transcription of orders, pt safety, close consideration of special situations, prevention & reporting of med erros, pt teaching, and monitoring for therapeutic effects, adverse effects, and toxic effects.
What is the "goal" of "patient rights"?
The goal is to prevent any med errors, which are PREVENTABLE events that may cause or lead to inappropriate med use or pt harm while the med is in control of the health care professional, pt, or consumer.
List and describe pregnancy safety categories.
- Category A: (safest) studies show no risk to human fetus.
- Category B: no risk to animal fetus; info on human fetus not avaliable.
- Category C: adverse effects reported in animal fetus; info on human fetal risk no avaliable.
- Category D: possible fetal risk in humans reported; however, the benefits may out weigh the risk for using this drug in pregnant women.
- Category X: (bad) fetal abnormalities and evidence of fetal risk in human avaliable for both animals and humans. THIS DRUG SHOULD NOT BE USED IN PREGNANT WOMEN!
What are some common causes of med errors?
Similiar product names, abbreviations, labeling/packaging, unclear writting and nurses assuming, miscalcuation, being tired and rushed, order on wrong chart, wrong route, pt, or time; no documentation and 2nd dose given, and drug incompatibilites.
What are some ways to avoid med errors?
Repeat a verbal order, spell drug aloud, computer entry, purpose fo use with each product, avoid abbreviations, NEVER assume route - if any questions, check with pharmacy or prescriber; ALWAYS read labels 3x - do trailing zeros; don't assume prescriber is correct if a question, and listen to the pt!
What is the goal of the "evaluation" step in the nursing process?
The goal is to be an ongoing process of determining the status of the goals and outcomes and determing the need for education and monitoring the pt's response to drug thearpy (i.e expected & unexpected responses, therapeutic effects, side effects, and toxic effects) and outcome criteria.
Any chemical substance other than those required for normal sustenance (ex. water, food) that affects the processes of a living organism and produces a bilogical effect.
The study of science of the manner in which the function of living systems in affected by chemical substances (drugs).
What is the origins of the word "pharmacology"?
From the Greek "pharmakon" meaning poison or potion... all drugs can be posions.
What is ASA?
Aspirin (Acetylsalicylic Acid; ASA); which affects blood thickness and can cause allergic reations, GI issues, and acidosis.
What is the difference between a drugs chemical, generic, and trade names?
- Chemical name - drug's chemical composition & molecular structure
- Generic name - the nonpropritary name given by the US Adopted Name Council.
- Trade name - the proprietary name that is used for the drug's registerd trademark & restricted by the drug's owner/manufacturer.
study how drugs influence pharmacokinetic/pharmacodynamic activities
how drugs interact with cells, tissues, organs - what the drug does to the body
use of drugs and the clinical indications for drugs to prevent and treat
study of economic factors that influence cost of drug therapy
study of adverse affects of drugs/chemicals on living systems.
study of what the body does to the drug; how body interacts with drugs (absorption, distribution, metabolism, and exrection).
Which drug absorbs quickest: a coated tablet or an enteric-coated tablet?
A coated tablet will absorb FASTER than an enteric-coated tablet; which is designed to be survive the stomach acid and later be absorbed and broken down in the small intestine.
What are the parts of pharmacokinetics?
absorption, distribution, metabolism, and exrection
In pharmacokinetics, what is absorption?
the rate at which a drug leaves its site of administration (passage from adminitration site to blood stream) and extent to which absorption occus - how fast it gets to the site.
What is the difference between bioavailablity and bioequivalent?
- Bioavailability - quantifies the extent of drug absorption.
- Bioequivalent - when two drugs have the same bioavailability; meaning they are absorbed equally.
What are some factors that affect absorption?
Administration route of the drug, food/fluids administration with the drug (which slows absorption down), other drugs in stomach (esp. antacids), dosage formulation (i.e. special coatings), status of the absorptive surface, rate of blood flow to small intestine, acidity of the stomach, and status of GI motility/gastric emptying time.
A drug's route of administration affects the rate and extent of absorption of the drug. List and describe the 3 common routes.
- Enteral - drug is absorbed into systemic circulation through the oral or gastric mucosa, the small intestine, or rectum. (ex. oral, sublingual, buccal, and rectal)
- Parenteral - drug is absorbed in cells/tissues by administration (ex. intradermally, subcutaneously, intramusculary, intrathecally/spinal cord, etc.)
- Topical - application to body surfaces
What are some parenteral and topical routes?
- Parenteral route - Intravenous, intramuscular, subcutaneous, intradermal, intrathecal (epidural), intraarterial, intraosseous, and intraartcular.
- Topical route - skin (including transdermal patches), eyes, ears, nose, lungs (inhalation), and vaginal.
In pharmacokinetics, what is distribution?
the transport of drug in body by the bloodstream to site of action.
How does protein-binding affect distrubtion?
if the drug is bound by protein, then its not free to go to target tissue; however, if 2 or more drugs are highly protein bound, they are more likely to cause toxity and last longer in the body.
What is the 1st-pass effect and how can it effect some drugs?
1st-pass effect (aka 1st-pass metabolizim) is the amount of oral drug metabolized by the liver before reaching circulation; however, as this effect increases, the liver removes most of the drug and some drugs would be useless - so these drugs are given IV. In other words, the more metabolized, the higher the 1st-pass rate.
What is the blood-brain barriers effect on distribution?
it prevents many drugs from entering the CNS.
What are some things that can effect distribution?
water soluble vs fat soluble, as well as, circulation, cardiac output, and blood supply affect disturbution.
What are some areas of rapid or slow distribution?
- Rapid - heart, liver, kidneys, and brain
- Slow - muscle, skin, and fat
Can alcohol cross the blood-brain barrier?
In Pharmacokinetics, where are some locations where this metabolism done, what is the main location, and what is metabolism called?
This metabolism occurs in the kidneys, lungs, plasma, and intestinal mucosa, but mainly in the liver; it is called biotransformation.
the biologic transformation of drug into an inactive metabolite, a more soluble compound, or more potent metabolite.
What are some factors that affect metabolism of a drug?
- The condition of the liver
- 1st-pass effect
- chemicals/drugs that stimulate production of transforming enzymes which will speed metabolism of other drugs and possibly decrease their effects (ex. fast acetylator, barbiturates, rifampin therapy) -- more enzyme = less drug
- chemicals/drugs tha decrease production of transforming enzymes which will slow metabolism of other drugs and cause drug accumulation and increase advers effects (ex. cardio dysfunction, renal insufficeinecy, starvation, obstructive jaundice, slow acetatator erythromycin or ketoconazole drug therapy) -- less enzyme = more drug
What determines the fraction of the oral dose that will be bioavailable in systemic circulation and where does this oral dose enter the circulation?
The level of metabolism of a drug BEFORE it reaches the systemic circulation. Circulation is entered at the gut wall and liver.
What is a high 1st-pass?
When a po drug is extensivelly metabolized by the liver before reaching the systemic circulation.
How can you avoid the 1st-pass effect and how does this effect the amount in which the nurse should give a drug?
Drugs given IV are injected directly into the circulation system, and thus by-pass 1st-pass metablolism, allowing more drug to reach the circulation. However, a nurse would usually give a higher dose in po form than they would via IV, because po dose account for the less of active medication during 1st-pass; however, in an IV, no drug is lose - so a smaller amount is required. So, a po dose DOESN'T equal an IV dose.
What are some routes that bypass the liver and which of these undergoes some level of 1st-pass effect?
sublingual, transdermal, buccal, vaginal, intramuscular, intravenous, subcutaneous, intranasal, inhalation, and rectal - which undergoes a higher degree of 1st-pass effect than the others.
What is Cytochrome P450 and where is the greatest concentration?
A major enzyme system in the body for drug metabolism that uses the Red/ox reaction, which requires molecular oxygen. Humans have 17 families and 39 subfamilies of cytochrome P450 genes. Only 3 are dedicated to metabolising drugs, others maintain homeostasis or cholesterol, bile acids, steroid hormones, and vitamin D3. And though almost all tissues have some, the liver and gut wall have the greatest concentration of P450.
What are is delayed drug metabolism called and what are some results of it?
It is called inhibition, and can result in 2 drugs competing for the same enzyme - but the drug with greater affinity (proximity) typically wins, drugs that do get into active sites are slow to dissociate, drugs can accumlate and their actions/effects will be prolonged, and unmetabolized drugs can build to toxic levels.
What fruit can't people have when taking meds and why?
Grapefruits, which are suicide inhibitors - meaning they destroy some of the CYP3A4 enzyme in the small intestine cause the body to need to make more. However, it takes the body time (usually an entire day) to make more, so the effects can last long after the grapefruit passes through the small intestine and is eliminated. So the pt CANNOT avoid the grapefruit-drug interaction by staggering consumption, and so, this combo can lead to toxicity -- grapefruits and anti-hypertenstion meds are an especially bad combo!
What are some things that drug metabolism can lead to?
- Reversible increase in enzyme concentration resulting from administration of certain drugs.
- Potential to increase rate of the "inducing" drugs breakdown.
- May increase the metabolism of other drugs taken concurrently.
- Stimulating drug metabolism (inducing) causes diminished pharmacologic effects.
In pharmacokinetics, what is exrection, where does it happen, and how can this be effected by pH?
- The elimination of drugs from the body.
- The main organ for excretion is the kidneys, but the liver and bowels (specifically, biliary exreation and enteroheptic circulation) play a part.
- Changes in the pH of urine, usually caused by chemical, food, or drugs, can change excretion of some drugs (ex: the acidity of soda can change pH of urine and effect exrection of a drug).
What is "Half-Life" and how is it related to "Steady State"?
- Half-life is the time it takes for serum plasma concentrations to decrease by half; a measure of the rate at which drugs are removed from the body. It depends on the rate of excretion and determines the frequency of administration, but isn't dependent on dose.
- It takes 4-5 half-lives to reach a steady state, which is when the drug reaches a steady level in the body and is able to give a steady level of affect.
- After a pt stops taking a drug, it will take 4-5 half-lives before the drug want show up on a drug-screen.
Define absortion, distribution, metabolism (biotransformation), and excretion.
- Absortion - passage of med from administrative site to entry into the blood stream.
- Distribution - transport of med to target tissue, including binding to plasma protein albumin.
- Metabolism (biotransformation) - degradation of med preparation of exretion.
- Excretion - elimnation of med from the body
What are some important variables in pharmaokinetics?
Age (metablic difference), gender, ethnicty, pathologic alterations, and body size
In pharmacodynamic, what is drug actions, drug effect, onset, peak, trough and duration.
- Drug actions - the cellular processes involved in the drug and cell interaction
- Drug effect - physiologic reaction of the body to the drug.
- Onset - the time it takes for the drug to elicit a therapeutic response. In other words, how long does it take to start working.
- Peak - the maximum therapeutic response
- Trough - the lowest therapeutic response; occurs right before the next dose.
- Duration - the time a drug concentration is sufficient to elicit a therapeutic response. In other words, how long does it work.
What is "mechanism of action"?
The way by which drugs can produce therapeutic effects. Once the drug is at the site of action, it can modify the rate (increase or decrease) at which the cells or tissues function. A drug can't make a cell or tissue perform a function it wasn't designed to perform.
In pharmacodynamics' mechanism of action, what is receptor, enzyme, and nonspecific interactions.
- Receptor interactions - drug structure is essential. Involves selective joining of drug molecule with reactive site on surface of cell or tissue (a receptor).
- Enzyme interation - enzymes catalyze reactions. For a drug to alter a physiologic response it must inhibit action of specific enzyme.
- Nonspecific interations - no receptor or enzyme. Affect cell membranes or cellular processes. May physically/chemically interfere with cellular processes.
Define agonist, partial agonist, and antagonist.
- Agonist - drug binds to receptor and there is a response.
- Partial agonist - drug binds to receptor and ther is a dimished response compared with that elicited by the agonist.
- Antagonist - drug binds to receptor but there is no response. Drug prevents binding of agonist.
In pharmacotherapeutics, list and define the types of therapies.
- Acute - intensive, critically ill (the ER)
- Maintenance - doesn't eradicate disease, but prevents progression (HIV meds)
- Supplemental - supplies substance needed to maintain normal function because it can't be made or its in deficient supply (Vit C in smokers)
- Pallative - make pt as comfortable as possible (hospic)
- Supportive - maintains the integrity of the body function while the pt is recovering (fluids or anything to keep the pt going)
- Prophylactic - provided to prevent illness or other undersirable outcome (condoms)
- Empiric - provided on basis of practical experience. ("if it looks like a duck...")
In pharmacotherpeutics, what is the purpose of monitoring?
The effecitveness of the drug therapy must be evaluated (usually asseted via vital signs). So one must be familiar with the drug's intended therapeutic action (beneficial) and the drug's unintended but potential side effects (predicatable, adverse drug reactions).
Define therapeutic index, tolerance, dependence, and interactions.
- Therapeutic index - is the ratio between which a drug's therapeutic benefits and it's toxic effects. In other words, the range between where you want drugs to be. Some drugs have a narrow range.
- Tolerance - decreasing response to repetitive drug doses
- Dependence - a physiologic or psychological need for a drug
- Interactions - alteration of a drug by other meds (perscribed or OTC) or herbal remedies.
What are the things that must be monitored when giving meds?
Therapeutic index, drug concentration, pt condition, tolerance, dependence, and interations.
What are some types of drug interactions?
Additive effect, synergistic effect, antgoistic effect, and incompatibility.
What are some medication misadventures?
- Adverse drug events (aka med errors), which are all preventable and can result in pt harm.
- Adverse drug reactions (aka side effects), which are inherent - a nonpreventable event that occurs in the normal therapeutic use of a drug. Any reaction that is unexpected, undesirable, and occurs at doses normally used. These side effects may be idiosyncratic, hypersensitivity reactions, and drug interactions.
What are adverse effects and how do they relate to side effects?
- Adverse effects are any undesirable bodily effects that are a direct response to one or more drugs.
- May include side effects, which are expected, well-known reactions that result in little or no chage in pt management. They have predictable frequency, intensity and occurrence is related to the size of the dose (ex. dry mouth, constipation, diarrhea, utricaria, and drowsiness).
What is the difference between annoying side effects and serious/life-threating side effects?
- Annoying side effects can lead to noncompliance. However, if nurses educate the pt about these possible side effects and how to handle or avoid it, they are more likely to continue taking the med. These side effects include: upset stomach, nausea, diarrhea, dizziness, etc.
- Serious/life-threating side effects are things that a pt must be aware of because if they develop them they need to stop taking those meds ASAP! These side effects include: chest pain, dysrrhythmias, palpitations, protracted vomiting or diarrhea, sever headaches, fainting, seizures or convulsions, profound rash, jaundice or ANYTHING that cause breathing issues.
What is an allergic reaction and what is the differnce between a mild and severe reaction?
also known as hypersensitivity reactions and involves the pt's immune system. The range of reactions is mild (ie. skin erthems and mild rash) to sever (ie. life-threating issues such as anapylaxies/air-way constriction and tachycardia) and the use of these drugs are contradictory in pts who are allergic to them.
What is a black box warning?
A type of warning that appears in a drug's prescribing info, required by the FDA alerting prescribers of serious adverse events that have occurred with the given drug.
What are Iatrogenic response and what are some types?
things that happen as result of treatment (ex. change in fluid color, problems with muscles or cells, etc.). In other words, unintentional adverse effects that are treatment induced, which include: dermatologic, renal damage, blood dyscrasis ("blood gone wild"), and hepatic toxicity.
Define teratogenic, mutagenic, and carcinogenic.
- Teratogenic - results in structual defects in fetuses. (ex. viral disease, chemicals, drugs, etc.)
- Mutagenic - changes in genetic composition. In other words, a change in the structure or number of chromosomes. (ex. radiation, chemicals, drugs - common with chemo-theraphy)
- Carcinogenic - drugs cause caner (ex. drugs and smoking - mostly toxins)
Define additive effect, synergis/potentiation, interference, displacement, antagonism, and incompatibilty.
- Addictive effect - 2 drugs with similar mechanisms of action sum their effects. (Ex. alcohol & sedatives both make you drowsy, but together they make you SUPER drowsy) -- 1+1=2
- Synergism/potentiation - 2 drugs with differnent mechanisms produce greater effect (Ex. codeine and aspirin are both painkillers but together they are pain-overkill) -- 1+1=3
- Interference - 1 drug accelerates or slows the metabolism or exretion of another (Ex. Tagamet effects many other drugs)
- Displacement - 2 drugs compete for drug binding sites on albumin (protein)
- Antagonism - the effects of 2 drugs cancel each othe out. In other words, they are the antidote to toxins. (Ex. Narcan reverses an opiate toxicity by preventing their binding to CNS receptors) -- 1+1=0
- Incompatibility - physical interactions of drug interferes with another. In other words, something you can't mix together. (Ex. antacids inactivates antibiotic tetracycline if they are in the stomach) at the same time
What is an OTC painkiller that is just as good as perscription painkillers?
How does food effect med abosoption and what are the expections for foods containing the following?
Tyramine-containing foods and MAOIs
Foods with Vitamin K
- Food slows absorption of most drugs, but usually does not affect action of the drug. There are exceptions:
- Tryamine-containing foods & MAOIs can cause severe hypertension and cranial bleeding.
- Foods with Vit K antagonize action of anticoagulant warfarin (Coumadin)
- Dairy products and tetracyline form an insoluble nonabsorbable compound (chelation).
- Grapefruit juice inhibits metabolism of some drugs and can cause toxicty.
- Acidic foods increase absorption of iron.
What are some things that the nurse must be familiar with in regards to medication order interpretation?
Drug names (generic and trade), systems of measurement (metric, household, and apothecary), medical terminology, and following agency policy for abbreviations.
What is pain, what is its purpose, and what is another name for it?
- A vital sign that measures unpleasant sensory and emotional experience associated with either actual or potential tissue damage. Pain is personal and individiual. It is whatever the pt says it is and exists whenever the pt says it does.
- Pain stops you from hurting youself and signals that there is a problem.
- Nociception is another term for pain
Pain tolerance is a _____, not ______ variable.
Pain tolerance is a subjective, not physiological variable.
What are analgesics and what are their purpose?
- An analgesic is a "painkiller", a med that relieves pain without causing loss of consciousness.
- The purpose is to reduce pain without making the pt too drowsy - the goal isn't to know the pt out.
What is the difference between acute pain and chronic pain?
- Acute pain - sudden onset, usually subsides once treated. Generally subsides over less than 6 weeks.
- Chronic pain - persistent or recurring. Difficult to treat and last longer than 6 weeks.
List and describe the classifications of pain.
- Somatic - skeletal muscle, ligaments, and joints.
- Visceral - organs, smooth muscles
- Superficial - skin or mucous membranes
- Vascular - vascular/perivascular (ie. migrains)
- Referred - pain felt elsewhere (ex. gall bladder pain is felt on the back, near the scapula)
- Neropathic - injury to peripheral nerve fibers or CNS
- Phantom - in body part that is removed, burning, itching, tingling, or stabbing
- Cancer - multiple causes
- Psychogenic - real pain due to psychological factors
- Central - tumors, trauma, inflammation of CNS/brain
What does the mnemonic "PQRST" stand for?
- P - palliative/provactive factors for the pain (what makes it feel better or worse?)
- Q - quality of pain (burning, stabbing, aching, etc.)
- R - region of body affected
- S - severity of pain (on the pain scale)
- T- timing of pain (when did it start)
What is the most common theory of pain and what does the theory state?
The most common theory of pain is the Pain Transmission Gate Theory, or simply the Gate Theory, which uses the analogy of a gate to describe tissues are sensed in the brain via the dorsal horn of the spine. In other words, all tissues sensations must pass through the dorsal horn ("the gate") to be felt; however, if the gate is closed, then no pain in tissues can be felt.
How is the pain process started?
Pain transmission/tissue injury causes the release of bradykinin, histamine, potassium, prostaglandins, and serotonin; these substances stimulate nerve endings, starting the pain process.
Describe the two types of nerves stimulated by pain and what controls the "threshold" for pain?
- "A" fibers - these "close the gate" and are related to the Myelin sheath, large fiber size, fast conduction, pain transmission inhibition, and is sharp and well-localaized.
- "C" fibers - these "open the gate" and are related to no myelin sheath, small fiber size, slow conduction, facilitation of pain transmission, and is dull and nonlocalized.
- T-cells contl the threshold for pain. The more T-cells the harder it is to feel pain; the less T-cells the easier it is to feel pain.
Describe the process of pain transmission.
- Pain fibers enter the spinal cord via the dorsal horn (the gate).
- The gate regulates the flow of sensory impulses to the brain.
- Large "A" fibers close the gate (inhibit pain) while small "C" fibers open the gate and allows pain impulses. The innervated gate allows the brain some control over the gate via T-cells.
- Pain must overcome the threshold (T-cells) to be sent to the brain.
- The impulses travel from the spinal cord up to the brain. The brain evaluates, indentfies, and localizes the pain. It can also control the gate before the gate is open. If no impulses are transmitted to higher centers of the brain, there will be no perception of pain.
- If the brain detects pain, it signals the body to activate its endogenous neurtransmitters, enkephalins and endorphines, which are produced to fight pain by binding to opioid receptors and inhibiting the transmission of pain by closing the gate.
Why do people rub areas that are in pain, how does it work and how it it similar to taking an opioid?
- Rubbing painful areas (ie. message or liniment) stimulates large "A" fibers to close the gate and once the gate is closed, pain is reduced.
- This action is similar to taking opiates because it stimulates/uses the same pathways.
What lowers and raises your ability to tolerate pain?
- Lowered (more pain) - anger, anxiety, depression, discomfort, fear, isolation, chronic pain, sleeplessness, and tired.
- Raised (less pain) - diversion, empathy, rest, analgesics, anti-anxiety meds, and antidepressants
What are opiate/opioid analgesics and what is the difference between the two?
- They are pain relievers that contain opium, derived from the opium poppy or chemically related to opium, and are used for moderate to sever pain. They are also the most commonly used class of analgesics, next to NSAIDs. However, these drugs are narcotics (very strong pain relievers) most are schedule II drugs and can't be sold withou a medical prescription.
- Opiates - drugs derived from juice of opium poppy
- Opioids - synthetic substances that have opium-like properties.
What are the 3 classifications of opiate/opioid analgesics based on their actions?
- Agonist - bind to receptor and cause response
- Partial agonist -binds to receptors and causes limited response
- Antagonist - bind to receptor and exert not response or reverse the effects of agents on pain receptors.
Define both the legal and clinical definitions of Narcotics.
- The legal term established under the Harrison Antinarcotic Act of 1914 originally applied to drugs that produced insensibility and stupor, especially the opioids. (ex. morphine and heroin). Currently, it is used to refer to any illicit or street drug.
- The term currently used in clinical settings refers to any medically adminred controlled substance.
What are some examples of opioid analgesics?
- Natural opium alkaloids - codeine sulfate and morphine sulfate
- Semi-synthetic analogs - Hydromorphone (Dilaudid) and Oxycodone hydrochloride
- Synthetic Compounds - meperidine HCl (Demerol), Fentanyl (Sublimaze), and Methadone HCl (Dolophine)
- Opioid/Acetaminophen compounds - percocet/Tylox (oxycodone + acetaminophen), Vicodin (hydrocodone bitartrate + acetaminophen), and Darvocet
Why was Darvocet recently taken off the market?
Because it cause dysrhythmias.
What is the "golden standard" for pain meds, how does it work, and which meds are more effective than the golden standard when given po?
- Morphine is the golden standard for pain meds. It is a major narcotic of opium plant and is used to treat pain and relieve anxiety caused by myocardial infarction (MI) by decreasing the workload of the heart in pulmanary edema.
- Meperidine, codeine, and methodone are more effective than morphine when given po.
Which opioids is used for sever, moderate, and withdrawl pains.
- Severe- Morphine and meperidine (Demerol)
- Moderate - Codeine
- Withdrawl- Methadone (Dolophine)
__ to __mg merperidine is approxmately equivalent to 10mg of morphine and IV _____ is 100 times more potent than morphine.
- 80-100mg merpridine
- IV Fentanyl
Should you push IV narcotics and the line flush of a IV narcotic fast or slow?
Who shouldn't you use morphine for?
People with gall bladder problems.
What are the three types of opioid receptors?
Mu, Kappa, and Delta
What type of drug can be used both for cough center suppression and treatment of dirrhea? What are some side effects of this drug?
- Constipation, respiratory depression, inhibited cough reflex, postural hypotension (BP drops when standing), pupil constriction (miosis; "pinpoint" pupils), nausea and vomitting, euphoria (mu receptors), lethargy/sleepy/poor concentration, urinary retention, diaphresis/flushing, and itching/rash (related to histamine).
a fibrous matrial
What is the antidote for a narcodic?
What are some precautions and contraindictions related to taking narcodics?
- Drug allergies and sensitivites
- If there is a head injury or increased intracranial pressure look for things that may be masked by narcotics - monitor for consciouness, resp rate, altered reation to light.
- If pt has acute asthma, chronic airway problems, low resp rate due to COPD, obesity, pregancy, and prostate problems monitor extremley close.
- Use caution with elderly pts, or pts with severe renal, pulmonary disease, CHF, liver disease, alcoholism, undiagnosed pain, and BPH
- Discourage "PCA by Proxy", family members adminstering PCA doest for the pt. Caregivers need to be educated - tell the family NOT to push the button.
A pt can have no more than ___mg per dose of Meperidine; which is limited to less than ____ hours.
Define tolerance, physical dependence, and psychological dependence.
- Tolerance - a common physiologic result of chronic opioid treatment. Resulting in larger doses of opioids being required to maintain the same level of analgesia.
- Physical Dependence - the physiologic adaptation of the body to the presence of an opioid. NOT ADDICTION!
- Psychological dependence - addiction; a pattern of compulsive druge use characterized by a contiuned craving for an opioid and the need to use the opioid for effects other than pain relief.
When are opioid tolerance and physical dependence expected and what can misunderstanding of these terms lead to?
- Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychological dependence/addiction.
- Misunderstanding of these terms leads to ineffective pain managment and contributues to the problem of undertreatment.
When do we see physical dependency of opioids and what are the results?
When the opioid is abruptly discontinued or when an opioid atagonist is administered causing narcotic withdrawl and opioid abstinence syndrome.
What are adjuvan analgesic agents? Name some examples.
- something that assist the primary agent in relieving pain and allows the use of smaller doese of opioids, decreases side-effects, and approaches pain stimulus from another mechanism with synergistic effects.
- NSAIDS, Antidepressants, Anticonvulsants, and Coticosteriods
What is Ultram (Tramadol), what is its purpose, and what are some side effects and other important info about this drug?
- Ultram is a centrally acting analgesic with a dual mechanism of action that uses a weak bond to Mu-receptors and inhibits reuptake of serotonin and norepinephrine. It is not currently a controlled substance, but you need a perscription for it.
- It is for moderate to moderatly sever pain.
- Side effects are drowsiness, dizziness, headache, nausea, and constipation. It may cause seizures.
- Use caution with tricyclic antidperessants, SSRIs, MAOIs, neuroleptics, and other drugs that reduce the seizure threshold. Don't use if on psych drugs.
- It's not effected by food
What are the contents of Ultracet?
Ultrum and acetaminophen
What type of drugs are Talwin, Nubain, and Stadol?
What are 2 opiate antagonists? How long does it take them to work, how long do they last, and what are some things you have to monitor for?
- Naloxone (Narcan) and Naltrexone (Revia).
- Effects occur within minutes of parenteral adminstration and last 1-2 hours.
- Monitor BP, respt, rhythm, depth, pluse, LOC Q5min, and assess for relapse or resp depression every 10-20 min.
What is acetameinphen and how does it effect feer and inflammation? What are some things you need to know about these drug?
- Acetaminophen (Tylonal) is an analgesic for mild to moderate pain. It is commonly combined with opioids.
- It is antipyretic, meaning it reduces fever, but it is only weak anti-inflammatory.
- It doesn't effect cardio, resp, or platelets; nor does it cause acid-base and gastric problems.
- Do use for pts with Yellow Dye #5 or sacchrin allergies.
- Tell pt to take will full glass of water, and not to take with alcohol - which can cause liver damage.
Which drug slows metabloism of warfarin (Coumadin) thereby increasing the levels of Coumadin, putting the pt at risk for bleeding? What are signs that this may have happened?
- bruising, petechia, and hematuria
What is Ziconotide (Prialt)?
A newly approved intrathecal analgesic (not an opioid) syntheised from protein found in sea snails. Injected into subarachnoid space of the spinal cord. Given for sever chronic pain. Side effects are psychotic, mood changing, adn halluninations.
What should nurse remember about nursing implecations of opioid administration?
- Get a throughoug history
- Abtain baseline vital signs, I & O, and pain assessment.
- Medicate before pain is severe.
- Give meds with food.
- Withhold med and contact doctor if resp drops below 12 breath/min.
- Instruct pt to avoid alcohol and to make position changes slowly to avoid orthostatic hypotension.
- Administer IV meds slowly.
- Ask about constipation and monitor for other side effects.