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Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 23 Drugs Treating Severe Pain

Ppt chapter 23-1

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Page 1: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 23

Drugs Treating Severe Pain

Chapter 23

Drugs Treating Severe Pain

Page 2: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pain Pain

• Pain is a multidimensional, subjective experience.

• Multiple studies over the years have shown that health care providers undertreat pain.

• Pain may be a major indication for drug therapy.

Page 3: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Physiology Physiology

• The peripheral nervous system (PNS) and central nervous system (CNS) comprise an integrated system that provides a pathway for pain transmission.

• The physiologic mechanisms involved in the pain response are complex and are not yet completely understood.

• Transduction is the term used to describe the phenomena associated with the initiation of a pain signal.

• Pain receptors are found on the peripheral end plates of afferent neurons.

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Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Components that Influence Pain Components that Influence Pain

• Pain has sensory-discriminative (physical) components and affective-motivational (emotional) components.

• The sensory dimension of pain encompasses pain’s location, intensity, and quality.

• Stimulation of the limbic system produces this emotional response to the physical stimulus of pain.

• Inhibition of pain and transmission of painful stimuli occur in various regions of the brain.

Page 5: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Components that Influence Pain (cont.)Components that Influence Pain (cont.)

• Inhibitory substances such as endogenous opioids, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) are released into nerve synapses.

• These substances bind with receptors on primary afferent and dorsal horn neurons to prevent further transmission of painful stimuli.

Page 6: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Pain Types of Pain

• Nociceptic pain is caused by the activation of the delta and C nociceptors in response to painful stimuli, such as injury.

• Neuropathic pain is the term used to represent pain in which the underlying pathology is abnormal processing of stimuli in the peripheral or central nervous systems.

• Acute pain, meaning the immediate phase of response to an insult or injury, results from tissue damage.

• Chronic pain may persist well beyond actual tissue injury and healing.

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Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nonpharmacologic Pain Management TechniquesNonpharmacologic Pain Management Techniques

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Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Narcotic Analgesics Narcotic Analgesics

• Narcotic analgesics are required for conditions, disorders, or treatments that are accompanied by moderate-to-severe pain.

• The narcotic analgesics include opiate agonists, mixed agonist-antagonists, and antagonists based on their activity at opioid receptors.

• Narcotics have an important role in pain management and control.

• Narcotics are typically underprescribed and underused.

• Prototype drug: morphine

Page 9: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Morphine: Core Drug Knowledge Morphine: Core Drug Knowledge

• Pharmacotherapeutics

– Moderate-to-severe acute or chronic pain

• Pharmacokinetics

– Metabolism: liver. Onset: 15 to 30 minutes. Duration: 3 to 7 hours.

• Pharmacodynamics

– Agonist at the mu, kappa, and possibly delta opiate receptors

Page 10: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Morphine: Core Drug Knowledge (cont.)Morphine: Core Drug Knowledge (cont.)

• Contraindications and precautions

– Hypersensitivity and respiratory conditions

• Adverse effects

– Respiratory depression, apnea, respiratory arrest, circulatory depression, cardiac arrest, shock, and coma

• Drug interactions

– Multiple drug interactions

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Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Morphine: Core Patient VariablesMorphine: Core Patient Variables• Health status

– Assess respiratory status

• Life span and gender

– Assess age, pregnancy, labor and delivery, and lactation

• Lifestyle, diet, and habits

– Assess for tolerance and/or dependence

• Environment

– Closely monitor patients receiving drug

• Culture and inherited traits

– Pain is what the patient says it is.

Page 12: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Morphine: Nursing Diagnoses and Outcomes Morphine: Nursing Diagnoses and Outcomes • Ineffective Breathing Pattern, Hypoventilation, related to

respiratory depression caused by the drug

– Desired outcome: The patient maintains effective breathing despite respiratory depression.

• Constipation secondary to activity of the drug

– Desired outcome: the patient remains free of constipation.

• Urinary Retention related to indirect anticholinergic effects of the drug on the urinary sphincters

– Desired outcome: The patient maintains normal urinary output.

Page 13: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Morphine: Nursing Diagnoses and Outcomes (cont.)Morphine: Nursing Diagnoses and Outcomes (cont.)

• Risk for Injury related to orthostatic hypotension or sedation secondary to drug effects

– Desired outcome: The patient remains free of injury.

• Ineffective Airway Clearance secondary to cough suppression by the drug

– Desired outcome: The patient’s airway remains patent and clear.

Page 14: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Morphine: Nursing Diagnoses and Outcomes (cont.)Morphine: Nursing Diagnoses and Outcomes (cont.)

• Acute pain related to trauma or disease process and insufficient analgesia

– Desired outcome: The patient remains free of pain

• Deficient Knowledge related to morphine therapy

– Desired outcome: The patient has adequate knowledge of the drug and its adverse effects and their management.

Page 15: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Morphine: Planning and InterventionsMorphine: Planning and Interventions

• Maximizing therapeutic effects

– Assess pain prior to and during therapy

– Use a pain assessment tool

• Minimizing adverse effects

– Conduct frequent assessment

– Provide additional pain medication for breakthrough pain

Page 16: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pain Rating ToolsPain Rating Tools

Page 17: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Morphine: Teaching, Assessment, and EvaluationsMorphine: Teaching, Assessment, and Evaluations

• Patient and family education

– Teach the purpose of the therapy

– Stress the importance of rating pain accurately

• Ongoing assessment and evaluation

– Assess patient’s pain level by using a pain scale

– Monitor for adverse effects

Page 18: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

QuestionQuestion

• When administering morphine, the nurse should assess what?

– A. Pain level

– B. Respiratory rate

– C. Blood Pressure

– D. Both A and B

– C. All of the above

Page 19: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

AnswerAnswer

• D. Both A and B

• Rationale: The nurse should always assess the level of pain the patient is experiencing prior to administration of morphine. Also morphine can cause significant respiratory depression, so respiratory rate should also be assessed.

Page 20: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mild Narcotic Agonists Mild Narcotic Agonists

• The mild narcotic agonists include codeine, hydrocodone, and propoxyphene.

• Prototype drug: codeine

Page 21: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Codeine: Core Drug Knowledge Codeine: Core Drug Knowledge

• Pharmacotherapeutics

– Treat mild-to-moderate pain

• Pharmacokinetics

– Absorbed from GI tract, peaks in 1 to 2 hours; crosses the placenta and secreted in breast milk

• Pharmacodynamics

– Acts at specific opioid receptors in the CNS to produce analgesia, euphoria, and sedation

Page 22: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Codeine: Core Drug Knowledge (cont.)Codeine: Core Drug Knowledge (cont.)

• Contraindications and precautions

– Not given with other narcotics

• Adverse effects

– Drowsiness, sedation, dry mouth, nausea and vomiting, and constipation

• Drug interactions

– Antihistamines, phenothiazines, barbiturates, tricyclic antidepressants, cimetidine, and alcohol

Page 23: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Codeine: Core Patient Variables Codeine: Core Patient Variables • Health status

– Assess the need for the patient to cough to maintain the airway

• Life span and gender

– Consider the age before administration

• Lifestyle, diet, and habits

– Can cause physical dependency

• Environment

– Assess environment where drug will be given

Page 24: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Codeine: Nursing Diagnoses and Outcomes Codeine: Nursing Diagnoses and Outcomes • Disturbed Sensory Perception related to drowsiness and

sedation

– Desired outcome: The patient will be protected from injury related to sedation and drowsiness.

• Risk for Ineffective Airway Clearance related to suppression of cough reflex

– Desired outcome: The patient will maintain baseline respiratory function.

• Constipation secondary to activity of the drug

– Desired outcome: The patient remains free of constipation.

Page 25: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Codeine: Planning and InterventionsCodeine: Planning and Interventions

• Maximizing therapeutic effects

– Actions are similar to those for morphine.

• Minimizing adverse effects

– Provide for patient safety

– Assess respiratory function prior to administration

– Do not administer to patients who need to cough to clear airway.

Page 26: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Codeine: Teaching, Assessment, and EvaluationsCodeine: Teaching, Assessment, and Evaluations

• Patient and family education

– Remind patients that drowsiness and impaired orientation can occur

– Tell patients not to take codeine with other CNS depressants

• Ongoing assessment and evaluation

– Monitor codeine’s effect on motor control and sedation, and the patient’s respiratory status

Page 27: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

QuestionQuestion

• For which patient would codeine be contraindicated?

– A. Postoperative patient with chest tubes

– B. Postoperative patient with pain after ORIF of left arm

– C. Patient with mild-to-moderate pain after breaking right tibia

– D. Patient who has nonproductive cough that is preventing normal sleep

Page 28: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

AnswerAnswer

• A. Postoperative patient with chest tubes

• Rationale: The patient who has chest tubes will need to cough and deep breath to facilitate lung expansion. Codeine also acts directly on the medullary cough center to depress the cough reflex.

Page 29: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Narcotic Agonist-Antagonists Narcotic Agonist-Antagonists

• Some narcotic analgesics have mixed opioid effects, being an agonist at some receptors and an antagonist at others.

• Prototype drug: pentazocine (Talwin)

Page 30: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pentazocine: Core Drug Knowledge Pentazocine: Core Drug Knowledge • Pharmacotherapeutics

– Agonist to control pain

• Pharmacokinetics

– Well absorbed orally and from SC and IM sites. Hepatic metabolism. Peak: 1-3 hours. Duration: 3 hours.

• Pharmacodynamics

– Mixed agonist-antagonist. It stimulates kappa receptors much as morphine does but also exhibits weak antagonist effects at the mu receptors.

Page 31: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pentazocine: Core Drug Knowledge (cont.)Pentazocine: Core Drug Knowledge (cont.)

• Contraindications and precautions

– Hypersensitivity. Use caution with respiratory conditions.

• Adverse effects

– Nausea, vomiting, dizziness or lightheadedness, respiratory depression, and euphoria

• Drug interactions

– Alcohol and CNS depressants

Page 32: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pentazocine: Core Patient Variables Pentazocine: Core Patient Variables • Health status

– Assess for contraindications and hepatic disease

• Life span and gender

– Pregnancy category C

• Lifestyle, diet, and habits

– Assess for abuse potential

• Environment

– Assess environment where drug will be given—oral forms can be given at home.

Page 33: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pentazocine: Nursing Diagnoses and Outcomes Pentazocine: Nursing Diagnoses and Outcomes

• Disturbed Sensory Perception related to dizziness and lightheadedness

– Desired outcome: The patient will not be injured from falls while taking pentazocine.

• Imbalanced nutrition secondary to nausea and vomiting

– Desired outcome: The patient’s nutrition will not be compromised while on pentazocine.

Page 34: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pentazocine: Nursing Diagnoses and Outcomes (cont.)Pentazocine: Nursing Diagnoses and Outcomes (cont.)

• Ineffective Health Maintenance related to abuse of pentazocine

– Desired outcome: The patient will use drug therapy appropriately.

• Deficient Knowledge related to pentazocine therapy

– Desired outcome: The patient has adequate knowledge of the drug and its adverse effects and their management.

Page 35: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pentazocine: Planning and InterventionsPentazocine: Planning and Interventions

• Maximizing therapeutic effects

– Provide environmental controls to reduce sensory stimuli and to aid relaxation

• Minimizing adverse effects

– Ensure that safety precautions are used

– In cases of overdosage, naloxone is indicated.

Page 36: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pentazocine: Teaching, Assessment, and EvaluationsPentazocine: Teaching, Assessment, and Evaluations

• Patient and family education

– Teach adverse effects

– Teach how to take medication properly

• Ongoing assessment and evaluation

– Monitor the effect of pentazocine on motor control, sedation, and pain

– Adequate pain control should be achieved without adverse effects.

Page 37: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

QuestionQuestion

• Patients with chronic liver disease should not be given pentazocine because of increased metabolism of the drug?

– A. True

– B. False

Page 38: Ppt chapter 23-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer Answer

• B. False

• Rationale: Chronic liver disease decreases metabolism of pentazocine.