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OB > 5.1d Pharmacological Pain Management > Flashcards

5.1d Pharmacological Pain Management Flashcards

1
Q

Pharmacologic Pain Management

A
  • Implemented before pain gets severe to prevent catecholamines from prolonging labor
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2
Q

Sedatives

A
  • Relieve anxiety and induce sleep

- Can augment analgesics and reduce nausea from opiates

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3
Q

Barbiturates (Seconal)

A
  • Crosses placenta and has long half-life
  • Can cause respiratory/vasomotor depression (patient and fetus)
  • Can cause neonate CNS depression
  • Avoided if birth is anticipated within 12-24 hours
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4
Q

Phenothiazines (Phenergan)

A
  • Does not relieve pain
  • Adjunct medication with opiates to enhance analgesic effects
  • Decreases anxiety, Increase sedation, Reduce n/v

Metoclopramide (Reglan) - Antiemetic can potentiate effects of analgesics. May be better choice than Phenergan

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5
Q

Benzodiazepines (Valium, Ativan)

A
  • Enhances pain relief and reduces n/v with opiates
  • Causes maternal amnesia
  • Disrupts thermoregulation of newborns

Flumazenil (Romazicon) - Antidote for Benzo sedation/respiratory depression.

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6
Q

Analgesia

A
  • Pain relief without loss of consciousness
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7
Q

Anesthesia

A
  • Analgesia, amnesia, relaxation and reflex activity
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8
Q

First Stage of Labor Medications

A
  • Opioid agonist analgesics
  • Opioid agonist-antagonist analgesics
  • Epidural block
  • Spinal epidural
  • Nitrous oxide
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9
Q

Second Stage of Labor Medications

A
  • Nerve block analgesia/anesthesia
  • Local infiltration anesthesia
  • Pudendal block
  • Spinal block
  • Epidural block
  • CSE analgesia
  • Nitrous Oxide
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10
Q

Vaginal Birth Medications

A
  • Local infiltration anesthesia
  • Pudendal block
  • Epidural block
  • Spinal block
  • CSE analgesia
  • Nitrous Oxide
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11
Q

C-Section Medication

A
  • Spinal block
  • Epidural block
  • General anesthesia
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12
Q

Opioids (Systemic Analgesia)

A
  • IV/IM/PCA (Patient Controlled Analgesia)
  • Effective in early labor but limited in late labor

SIDE EFFECTS

  • Respiratory depression
  • Sedation
  • N/V, Dizziness, Altered Mental Status, Euphoria
  • Decreased gastric motility, delayed gastric emptying, urinary retention
  • Aspiration
  • Maternal and Fetal Bradycardia/Hypotension/Hypoxemia

CROSSES PLACENTA EASILY AND CAN CAUSE RESPIRATORY DEPRESSION IN FETUS AFTER BIRTH

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13
Q

Opioid Agonist Analgesics

A
  • Meperidine, Fentanyl, Remifentanil
  • Meperidine and normeperidine can cross placenta and cause neonatal sedation and neurobehavioral changes. CANNOT BE REVERSED WITH NALAXONE
  • No Amnesic Effect
  • Enhances ability to rest in between contractions
  • Do not administer until labor has been established EXCEPT to enhance rest during prolonged early labor
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14
Q

Opioid Agonist-Antagonist Analgesic

A
  • Nalbuphine (Limited analgesic contribution)
  • Produces withdrawal symptoms in women with opioid dependence
  • Provides adequate analgesic with less n/v or respiratory depression
  • Sedation may be greater
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15
Q

Opioid Antagonist

A
  • Naloxone (Narcan)

- Reverses respiratory depression

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16
Q

Nerve Block Analgesia/Anesthesia

A
  • Produces sensory/motor block over a specific region of the body
  • Variety of local anesthesia used to produce regional analgesia/anesthesia (some analgesia/complete analgesia)
  • Interruption of conduction of nerve impulses
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17
Q

Local Perineal Infiltration Anesthesia

A
  • Lidocaine/Chloroprocaine injection
  • Epinephrine usually added to localize and intensify effects and prevent bleeding
  • Used for episiotomy or repairing lacerations.
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18
Q

Pudendal Nerve Block

A
  • Local anesthetic used to relieve lower vagina, vulva, and perineal pain
    SECOND STAGE
  • If episiotomy, forceps, or vacuum are to be used
    THIRD STAGE
  • If episiotomy or lacerations are preformed
  • Does not affect hemodynamic or respiratory function
  • Does not affect vital signs
  • Patients lose the bearing down reflex
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19
Q

Spinal Anesthesia/General Anesthesia

A

General - Only used when spinal is contraindicated or emergency (completely asleep)
Spinal - Preferred method and safer.

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20
Q

Spinal Anesthesia Risks

A
  • Bleeds
  • Infection (Greatly reduced with use of disinfectant)
  • Spinach Headache
  • Nerve damage (very rare)
  • Nausea (from blood pressure changes)
  • Shivering (from extra adrenaline)
  • SOB
  • Chest Pain/Shoulder Pain
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21
Q

Spinal Anesthesia

A
  • Used for cesarean birth and numbs from the nipple (T6) to the feet
  • Used for vaginal birth and numbs from hips (T10) to feet
  • Patient sits or side lying with back curved to widen intervertebral space
  • Higher levels of anesthesia for cesarean births require patient be supine with head and shoulders elevated. Placing wedge under patients hips prevents supine hypotension
  • Effects will occur within 5-10 min (can possibly take 20+ min)
  • Lasts about 1-3 hours
  • For vaginal birth needle is inserted between contractions
22
Q

Nursing Interventions Spinal Anesthesia

A
  • Prior to injection Vitals should be assessed every 20-30 min. Fluid balance is assessed. Bolus IV is also administered 15-30 min before induction.
  • After injection BP/Pulse/RR/FHR must be assessed every 5-10 min
  • Hypotension (below 100 or 20% of baseline) or fetal distress is cause for emergency care
    RISKS
  • CSF leakage from puncture site can cause Post Dural Puncture Headache (PDPH)
    TREATMENT
  • Epidural blood patch is the best way to treat PDPH
  • Oral analgesics and Methylxanthines (caffeine) can also be used
23
Q

Hypotension and Decreased Placental Perfusion

A
  • 20% decrease in pre-block baseline or less than 100 systolic pressure
  • Fetal bradycardia
  • Absent/minimal FHR variability
24
Q

Nursing Interventions for Hypotension/Decreased Placental Perfusion

A
  • Lateral position or pillow under hip to displace uterus
  • IV infusion at specific rate
  • Non-rebreather mask 10-12 L/min
  • Elevate legs
  • Notify OB and Anesthesiologist
  • Administer vasopressor (if other treatment fails)
  • Monitor BP and FHR every 5 minutes
  • Combination of local anesthetics and opioids reduces motor function loss and enhances patients ability to push effectively.
25
Q

Neuraxial Anesthetic Symptoms (Needs to be Assessed)

A
  • Hypotension, lightheadedness, dizziness, fever, pruritis
  • Loss of consciousness, convulsions, slurred speech, bizarre behavior
  • Limited movement, numbness of tongue/mouth, metallic taste,
  • Urinary retention
  • Local anesthetic toxicity
  • Tinnitus
  • Longer Second Stage of Labor
  • Increase Oxytocin Use
  • Increased likelihood of forceps or vacuum assisted birth
26
Q

Spinal Epidural Risks

A
  • Bleeding
  • Headache (most common)
  • Back discomfort (rare)
  • Infection (low due to sterile procedure)
  • Paralysis (rare)
27
Q

Spinal Epidural

A
  • Most effective pharmacologic pain relief for labor
  • Local anesthetic, Opioid analgesic, or both injected into epidural space
  • Injected between 4th and 5th lumbar vertebrae
  • Combination of Local and Opioid reduces anesthetic requirement and provides greater degree of motor function.
  • Done in modified SIMS position
28
Q

Spinal Epidural Process

A
  • After catheter is inserted, a test dose is used to verify positioning of catheter.
  • Likelihood of misplacement is greater in obese patients
  • After catheter is initiated, preferred position is side lying to prevent supine hypotension
29
Q

Spinal Epidural Considerations

A
  • O2 should be available incase of hypotension
  • Ephedrine/Phenylephrine can be used to vasoconstrict for hypotension
  • FHR and contractions must be monitored carefully due to patient being less aware of their contractions
  • Continuous Infusion Epidural (CIE) is most common
  • CIE with opioids reduces motor block allowing more patient mobility
  • PCEA (Patient Controlled Epidural Analgesia) can also be used
30
Q

Spinal Block Advantages/Disadvantages

A

Advantages

  • Ease
  • Absence of Fetal Hypoxia
  • Maintenance of maternal blood pressure
  • Conscious
  • Good muscular relaxation
  • Blood loss is not excessive

Disadvantages

  • Hypotension
  • Impaired breathing, Cardiopulmonary resuscitation may be needed
  • Increased likelihood of episiotomy/forceps/vacuum
  • Bladder/Uterine Atony (Lowered Tone) and PDPH risk is higher
31
Q

Epidural Advantages/Disadvantages

A

Advantages

  • Most effective pain relief
  • Good relaxation
  • Airway reflexes remain intact
  • Only partial motor paralysis
  • Fetal complications are rare but can occur with rapid absorption of medication or maternal hypotension

Disadvantages

  • Patient mobility and control over labor is limited
  • Orthostatic Hypotension/Dizziness/Sedation/Weakness of Legs
  • CNS Effects if medication is administered into blood vessel by accident
  • Respiratory arrest can occur if high dose is injected into subarachnoid space
  • Higher rate of fever
  • Urinary Retention/Pruritis
  • Increased use of oxytocin/forceps/vacuum
32
Q

Combined Spinal and Epidural

A
  • Blocks pain without compromising motor function
  • Opioid is mixed with local anesthetic
  • Patient maintains better motor function
33
Q

Epidural and Intrathecal (Spinal) Opioids

A
  • Fentanyl, Sufentanil, Preservative-Free Morphine
  • Used for post-operative pain
  • Eliminates need for local anesthetic and only uses opioids
  • Does not cause maternal hypotension or affects VS
34
Q

Epidural Morphine After C-Section

A
  • Early Ambulation
  • Facilitated bladder emptying
  • Enhanced peristalsis
  • Helps prevent clot formation in lower extremities

SIDE EFFECTS

  • N/V
  • Pruritis
  • Urinary Retention
  • Delayed Respiratory Depression
35
Q

Contraindications of Spinal/Epidural Analgesia

A
  • Risk of hemorrhage which can cause hypovolemia and hypotension (dangerous)
  • If patient is receiving anticoagulants (heparin within last 12 hours)
  • Infection at needle insertion site
  • Intracranial pressure caused by mass/lesion
  • Allergy, Refusal, Cardiac Conditions
36
Q

Nitrous Oxide

A
  • Patient controlled analgesia/anesthesia
  • Diminishes pain and anxiety
    BENEFITS
  • Low cost
  • Less invasive
  • Less intensive monitoring
  • Does not limit mobility
  • Does not affect uterine cavity
  • Rapid onset
  • Quick clearance (through exhalation)
  • Self administered
    SIDE EFFECTS
  • N/V, dizziness, drowsiness
37
Q

General Anesthesia

A
  • Rarely used for vaginal birth
  • Necessary if epidural/spinal block is contraindicated
    RISKS
  • Difficult to intubate patient
  • Aspiration of gastric contents
    PROCESS
  • Patient is pre-medicated with antacids to neutralize acidic contents
  • Sometimes they are also given H2-Receptor Blockers to decrease gastric acid contents
  • Prevent supine hypotension with wedge under the hips
  • Patient is pre-oxygenated with non-rebreather mask for 2-3 min
38
Q

Informed Consent

A
  • Advantages/Disadvantages must be explained
  • Patient must agree
  • Consent must be given freely
39
Q

Neuraxial Anesthesia Nursing Interventions

A 
PRIOR TO BLOCK
- Assess VS, hydration, labor progress, FHR and pattern 
- IV Bolus of fluid if ordered
- Obtain lab results 
- Assess pain levels 
- Assist patient to void 
DURING BLOCK
- Assist patient maintaining proper position
- Guide patient through experiences
- Assist with Documentation of VS, Time, Amount of Medication Given 
- Oxygen suction readily available 
- Monitor for Local Anesthetic Toxicity 
WHILE BLOCK IN EFFECT
- Continue monitoring VS and FHR
- Continue assessing pain levels
- Monitor for bladder distension (bed pan, catheter, position change) 
- Promote safety (bed rails up, call light, monitor anesthetic effects) 
AFTER BLOCK IS WEARING OFF
- Bed rails up
- Call light in reach
40
Q

Epidural Benefits

A
  • Better pain relief and continuous pain relief throughout labor
  • Will not become groggy but allows for rest and sleep
41
Q

Epidural Drawbacks

A
  • Must remain in bed and limits position change
  • Needs foley catheter
  • Lengthened labor due to lack of urge to bear down
  • May affect newborn breastfeeding behaviors
  • Hypotension from uteroplacental insufficiency and FHR deceleration
  • PDPH
  • Fever which may trigger neonatal sepsis
42
Q

IV Pain medication Benefits

A
  • Easy and Rapid Onset
  • Limited duration (patient can walk once medication wears off)
  • Allows rest
43
Q

IV Pain Medication Drawbacks

A
  • Grogginess/Sleepiness/Disorientation
  • Decrease variability of FHR
  • Neonatal Respiratory Depression if given close to birth
  • May negatively impact newborn breastfeeding behavior
44
Q

Nursing Interventions for IV Pain Medication

A
  • Encourage patient to void prior
  • Siderails should be up on bed
  • Explain she will be sleepy and to encourage rest
  • Maintain quiet atmosphere
  • Position in left lateral
45
Q

Metoclopramide (Reglan)

A
  • Reduces Anxiety
  • Potentiates Analgesics
  • Relieves Nausea
46
Q

Hydrochloride (Nubain)

A
  • Unlikely to cause respiratory depression
47
Q

Naloxone

A
  • If used, assess patients pain level because it may abruptly return
48
Q

Continuous Epidural Block Interventions

A
  • Assist into modified SIMS to administer the block
  • Alternate position side to side every hour
  • Assist patient in urinating every 2 hours to prevent bladder distension
  • Assess BP frequently due to hypotension risk
49
Q

Opioid Abstinence Syndrome Manifestations

50
Q

Spinal Block BP Drop

A
  • Change position from supine to lateral

OB (96 decks)

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