Medications for Pain & Inflammation

ATI 4.2Senior Class

Learning Objectives• Assess/monitor a need for pain med• Plan and provide care to meet the client’s need for pain interventions• Assess/monitor effectiveness of pain intervention• Advocate for the client’s needs • Provide appropriate client education• Reinforce client teachings regarding the purposes & possible effects of pain meds• Assess/monitor client for expected effects of meds• Assess/monitor client for side/adverse effects of meds• Assess/monitor client for actual/potential specific food & med interactions• Identify contraindications, actual/potential incompatibilities & interactions

between meds---intervene appropriately• Identify symptoms/evidence of an allergic reaction---respond appropriately• Evaluate/monitor and document the therapeutic and adverse/side effects of

meds• Assess/collect data regarding client’s med use over time

Key Points

Analgesics are meds that relieve painNarcoticsNSAIDsAnti-migraine agents

Anti-inflammatory agents are meds that reduce inflammationSalicylatesGlucocorticoidsAnti-gout medsDisease-modifying anti-rheumatic drugs (DMARDs)

Key Points• Certain anti-inflammatory meds have properties that reduce fever

(antipyretic) such as salicylates and ibuprofen• Salicylates and NSAID’s reduce platelet aggregation and can be used to

reduce a client’s risk of thrombosis. This anti-platelet effect can also pose a greater risk for bleeding and requires careful monitoring of clients

• Salicylates, NSAIDs, glucocorticoids pose the risk for gastric ulceration• Acetaminophen (Tylenol) has analgesic and antipyretic effects, does not

have anti-inflammatory effects, and does not reduce platelet aggregation• Tylenol overdose poses a risk for severe injury to the liver• Prolonged use of narcotic analgesic, such as morphine and/or meperidine

(Demerol) may result in:– Tolerance– Physical dependence– Addiction

NSAIDs

Expected Action:Inhibition of cyclooxygenase: COX-2 inhibition

results in inflammation, pain & feverInhibition of COX-1 results in the of platelet aggregation

NSAIDs

Therapeutic Uses:Inflammation suppressionAnalgesia for mild to moderate painFever reductionDysmenorrheaLow level suppression of platelet aggregation

NSAID’s Selective Protoype:

1st generation NSAIDs (COX-1 & COX-2 Inhibitors): aspirin ASA2nd generation NSAIDs (selective COX-2 Inhibitors):celecoxib (Celebrex)

Other Meds– 1st generation:

ibuprofen (Motrin, Advil), naproxen (Naprosyn), ketorolac (Toradol)

– 2nd generation: Valdecoxib (Bextra)

NSAIDs

Side/Adverse Effects:GI (dyspepsia, abd pain, heartburn, N)Aspirin-induced gastric ulcer, perforation & bleedingWeight gain, urine output, BUN & creatinine levelsSalicylism (tinnitus, sweating, headache & dizziness, resp.

alkalosisReye syndrome (occurs w/children in whom aspirin are used to

reduce fever who have viral illness like chicken pox or influenza Interactions: Meds & Food

WarfarinGlucocorticoidsAlcoholIbuprofen decrease anti-platelet effect of low-dose aspirin used

to prevent MI

NSAIDs

• Interventions & Education– Stop aspirin 1 week before an elective surgery or expected date of

childbirth– Take aspirin w/food, mild or a full glass of H2O to reduce gastric

discomfort– Don’t chew or crush enteric-coated or sustained-release aspirin tablets– Notify primary care provider if signs & symptoms of gastric discomfort or

ulceration occur– Client unable to tolerate due to GI ulceration, risk of bleeding, or renal

impairment:• Give Celebrex

– Toradol is used for short-term treatment of moderate to severe pain like w/postoperative recovery• Provides analegisa w/o anti-inflammatory effect• Used concurrently w/opioids increased effects of opioids w/o occurrence of

adverse effects• Used w/other NSAIDs serious adverse effects can occur use no more than 5 days

usually start as parenteral administration & then progress to oral doses

NSAIDs

Evaluation of EffectivenessReduction in inflammationReduction of feverRelief from mild to moderate pain or

dysmenorrheaPlatelet aggregation suppression

Acetaminophen

Selective Prototype: TylenolExpected Action:

Slows the production of prostaglandins in the CNSTherapeutic Uses:

Analgesic effectAnti-pyretic effect

Acetaminophen

Side/Adverse Effects:Acute toxicity—liver damage w/NVD, sweating, abd

discomfort progressing to liver failure, coma & deathContraindicated:

Use cautiously w/those who consume 3 or more alcoholic drinks/day & taking Warfarin

Interactions: Meds & FoodAlcoholWarfarin

Acetaminophen

Intervention & EducationKeep a running total of daily intake Follow recommended dosage as prescribed to prevent

toxicityDon’t exceed 4 g/day If overdose, liver damage can be reduced by administering

weight-based dosage of antidote:Acetylcysteine (Mucomyst) diluted via oroduodenal tube

Evaluation & Effectiveness:Relief of painReduction of fever

Opioid Agonist

Selective Prototype:Morphine Sulfate

Other Meds:fentanyl (Sublimaze, Duragesic)meperidine (Demerol)methadone (Dolophine)codeine oxycodone (OxyContin)

Opioid Agonist

• Expected Action:• Act on mu receptors & to a lesser degree on

kappa receptors• Activation of mu produces analgesia resp.

depression, euphoria & sedation• Activation of kappa produces analgesia,

sedation & GI motility

Opioid Agonist

Therapeutic UsesRelief of moderate to severe pain (postop, MI,

cancer)SedationReduction of bowel motilityCodeine: cough suppression

Opioid Agonist

Side/Adverse Effects:Respiratory depressionConstipationOrthostatic hypotensionUrinary retentionCough suppressionSedationEmesis, Biliary colicOpioid overdose triad: coma, resp. depression, &

pinpoint pupils

Opioid Agonist• Contraindications:

Biliary tract surgeryPremature InfantsAsthma, Emphysema and/or head injuries Infants and older adults (risk of resp. depression)Pregnant client risk of physical dependence of the fetus In labor risk of resp. depression (newborn) & inhibition of labor by

decreasing uterine contractionExtremely Obese greater risk for prolonged side effects due to

accumulation of med metabolized @ slower rate IBD due to risk of megacolon or paralytic ileusEnlarged prostate due to risk of Acute Urinary RetentionREPEATED USE OF DEMEROL results sin accumulation of normeperidine

which can result in seizures and neurotoxicityDon’t administer more than 600 mg/24 hr of Demerol & limit its use to

less than 48 hr.

Opioid Agonists

Interactions: Meds & FoodBarbituratesPhenobarbitalBenzpdiazepineAlcoholBenadryl TCA—Elavil amitriptylineAdditive anticholinergic agentsMAOIAnti-hypertensives

Opioid Agonists

• Interventions & Education: Assess pain regularly & document response Baseline vitals if RR < 12/min notify PCP & withhold Follow controlled substances procedures Double check opioid doses w/another nurse 1st Administer opioids IV slowly over a period of 4 to 5 mins have naloxone (Narcan) &

resuscitation equip. available Warn client not to dose w/o consulting PCP Administer opioids on fixed regular schedule around the clock to cancer clients &

supplemental doses PRN Advise client w/physical dependence not to discontinue abruptly taper & withdraw

slowly over 3 days Closely monitor PCA settings & reassure client of its safety but mainly to use prior to

activities Switching to Oral Dose ensure client receive PCA up to the onset of oral med Parenteral Duragesic is used primarily in surgery to induce anesthesia 100 x >

potent than morphine With 1st fentanyl will take many hours to achieve desired effect give short acting

opioids prior to onset of therapeutic effect & for breakthrough pain

Opioid Agonists

• Evaluation & EffectivenessRelief of moderate to severe painCough suppressionResolution of diarrhea