Pain Management Flashcards
When managing pain - lot room for how much and when admin meds; for drugs specific order for drugs but for pain meds are PRN and when do orders for pain meds are list for diff pain meds and then ranges of doses for meds and determine med and how much give; lot more decision making in terms administering drugs for pain management; not make them decisions alone - manage pain collab effort between nurse and client; see what nurses on previous shifts giving and if doc well and see how pain been controlled
Ladder: no where else to start how manage client in pain
Non-opioid:
Adjuvants
Opioids
Place start and way go; start with non-opioids; watch doc and how pain controlled in previous shifts
Pharmacologic pain relief measures: WHO ladder
+/-adjuvant for pain: varies widely depending on type pain is
NSAIDS
Acetaminophen
First step
Non-opioid:
Anticonvulsants
Muscle relaxants
Adjuvants
For mild/moderate pain - second step: often PO
Pain not managed up to 3rd step give more opioids: increase dose or move to more potent opioid to manage pain
Opioids
Aspirin contraindicated in children - Risk of Reye syndrome (results in severe neurologic deficits that can be permanent and part is liver damage; sig disorder) – avoid aspirin and use with caution (esp viral illness) - risk for syndrome increases with viral illnesses - imp edu point
Acetaminophen is most used analgesic/antipyretic drug for children (safest choice for children; give at very young age); best used and use NSAIDS if acetaminophen not meet needs and 6+ months
NSAIDS approved for children 6+ months
CHILDREN: Acetaminophen/NSAIDs: Drug Therapy Across the Lifespan
Report use of OTC drugs to avoid drug-drug interaction (all OTC drugs have a yellow highlight if contains acetaminophen); read labels carefully
Getting OTC use from adults because many OTC preparations can contain acetaminophen/ibuprofen
Adults: Acetaminophen/NSAIDs: Drug Therapy Across the Lifespan
NSAIDs should be avoided if possible
Use acetaminophen in older adults - if not effective move onto opioids because poses less risk to them than NSAIDs
Older Adults: Acetaminophen/NSAIDs: Drug Therapy Across the Lifespan
reduces fever by direct action of hypothalamus and dilation of peripheral blood vessels
MoA: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)
Reduce pain and fever (No effect on inflammation); Not a NSAID
Indications: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)
chronic alcoholism, reduced liver function
Contraindication: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)
C: headache, skin rash (generally well-tolerated if taken as directed and taken intermittently) Rare (not take as directly/too much med): risk for liver toxicity - go into acute liver failure - monitor how much taking in 24 hours so not OD whether intentional/not (overdose or liver disease)
AE: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)
delirium, n/v, chills; acute liver failure; antidote: acetylcysteine (binds to metabolite causing toxicity and injury to liver) - OD have antidote drug
Watch for potential for Toxicity: - risk for toxicity and acute liver failure
Toxicity manifestations: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)
max dose is 4 grams/day (4000 mg/day); consider combo meds
Nursing: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)
Cyclooxygenase: is an enzyme; 2 pathways NSAIDS help to block and by doing so helps reduce pain and inflammation; 2 diff enzymatic pathways lead to prostaglandin synthesis leading to inflammation
Promotes inflammatory prostaglandins - MoA in blocking pathway: reducing inflammation - block process of inflammatory prostaglandins; not just block one part but block large portion so have other issues - big issues come in; Cox-1 provides gastric mucosa integrity and one major AE of NSAIDS is peptic ulcers and bleeding ulcers and that is where big prob comes in
Maintains renal func
Provides gastric mucosa integrity
Promotes vascular hemostasis - block that decrease platelet aggregation helpful in some conditions
Assists in fever
Effects of cyclooxygenase-1 (Cox-1) pathway
Decrease swelling, pain, inflammation - goal
Decrease fever - goal
Increased bleeding - good and bad; aspirin used to prevent blood clots but too much bleeding is a bad thing
Na retention, edema, HTN - AE; effects on kidney
GI erosion, bleeding - AE
Effects of blocking Cox-1 pathway
Promotes inflammatory - decrease pain, swelling inflammation
Maintains renal func - Na retention, edema, HTN
Provides gastric mucosa integrity - GI erosion, bleeding
Promotes vascular hemostasis - increased bleeding
Assists in fever - decrease fever
Summary of Cox-1 pathway
Increases pain and inflammation
Results in Vasodilation
Blocks platelet clumping
Effects of cyclooxygenase-2 (Cox-2) pathway
Decrease pain and inflammation - good
Prevent protective vasodilation - probs
Allows platelet clumping - aids in blood clotting which is a bad thing; probs
Skin rxns: Steven’s Johnson syndrome - probs
Effects of blocking cyclooxygenase-2 (Cox-2) pathway
Increases pain and inflammation - Decrease pain and inflammation
Vasodilation - Prevent protective vasodilation
Blocks platelet clumping - Allows platelet clumping
Summary of Cox-2 pathway
Analgesia (pain) relief
Fever - reduce
Musculoskeletal disorders/inflammatory (OA, RA, ankle sprain, etc.) - really beneficial in inflammatory type disorders; esp in MS disorders; helps with all pain and inflammation from acute and chronic MS disorders
Indications: Non-steroidal anti-inflammatory drugs (NSAIDS)
Nausea, vomiting, gastritis/epigastric pain, peptic ulcers, upper GI bleeding
All GI - sig part NSAIDS and cannot be missed/negated; high doses can be lethal from sig AE and death from upper GI bleeding; sig
Blocking COX pathway so gatric mucosa not have protection and allows med free rain into lining for stomach resulting in ulcers and bleeding
Common adverse effects: Non-steroidal anti-inflammatory drugs (NSAIDS)
Renal disease - kidneys susceptible to toxicity from NSAIDS, active/history acquiring peptic ulcer (disease) from use of NSAIDS - not safe to use NSAIDS anymore, alcohol use - risk for developing GI ulcers
Contraindications: Non-steroidal anti-inflammatory drugs (NSAIDS)
Anticoagulants (use aspirin to affect way blood clots formed and anticaogs do in diff manner but this sig increases risk for bleeding and potentially severe/fatal bleeding), corticosteroids (very hard on the stomach so take with food and that is one big interaction to consider - taken together risk sig increases to have GI probs), other NSAIDs: not take aspirin and ibuprofen together etc, not taken at once, two taken together sig increases risk for AE esp to kidneys and GI sys and GI bleeding
Drug-drug: Non-steroidal anti-inflammatory drugs (NSAIDS)
used for ability Decrease inflammation and good ability to decrease platelet aggregation (process for blood clotting: platelets form then have clotting cascade and then have blood clotting) (can use for pain and inflammation but risk at doses to help pain and inflammation outweighs benefits - rarely used for pain most pats on baby one for CVD prevention (81mg): dose decreases aggregation to prevent MI/stroke caused by a clot - see used more for CVD prevention) (non-selective COX inhibitor)
Salicylates - part chemical makeup
MoA: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)
Mild pain, inflammation (high dose: 325-650 mg po prn); Anticoagulation (platelet inhibitor) for CVD (low dose: 81 mg or 325 mg po daily)
Indications: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)
Viral illness children (Reyes)
Contraindications: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)
easy bruising - inhibits platelet aggregation (platelets not stick together as readily as should so more bruising as apparent), all related to NSAIDS
AE: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)
Hold 1 week prior to procedures/surgery - not hold med pat higher risk for extensive bleed for procedure; hold for period because that is how long takes for aspirin effects to be negated
Nursing: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)
take as prescribed; may take with food to help with GI discomfort, full glass of water (8oz); report any GI pain &/or dark/bloody stools (indicates upper GI bleeding); monitor H/H if UG bleed - if suspected UGI bleed because bleeding out so can monitor it out
Teach: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)
Risk: Greater for toxicity when taking greater than 4 gm/days - taking lot aspirin at one time: intentionally/not
Salicylism - CM:
Severe toxicity (tx) go on: dialysis to get out of sys quickly in severe cases
Nurse:
Salicylate toxicity (rare)
Tinnitus (ringing in the ears - first signs seen in pat that suffering from toxicity) and/or hearing loss
Dizziness, HA, drowsiness
Tachycardia
Hypoglycemia
Sweating
Metabolic acidosis
Salicylism - CM: (Salicylate toxicity (rare)
Stop admin of drug
Evaluate CNS
Monitor: CBC, renal, liver labs
Nurse: (Salicylate toxicity (rare)
Suppresses inflammation (non-selective COX inhibitor) - anti-inflammatory
MoA: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)
3200 mg/day in divided doses (prescription - high doses if feel like appropriate); 1200 mg/day in divided doses (OTC - self treatment)
Max dose: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)
GI bleeding; CV: increased risk of MI, stroke - dosage and frequency; higher doses on and taken for prolonged period time higher risk for suffering CV events - high doses not appropriate for those who have had multiple MI
Black box - all NSAIDS: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)
chronic use: Na/water retention (edema), hypertension; Rare: AKI (dangerous to kidneys)
AE: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)
OTC
Nursing: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)
Baseline assessment H&P including allergies (any NSAID) and medications - check allergy list - if allergic to any cannot take any others
Focused assessment: pain, fever, GI - why giving med; indic for meds and GI assessment: biggest risk for pat is GI effects
Lab values as appropriate (suspect GI bleeding/toxicity) not lab value routine; look at LFTs and kidney fun as baseline
Assess: Nursing responsibilities for NSAIDS
Take with food and 8 oz. water
Max dose, combination drugs
Adverse effects
Teach: - teach on these: Nursing responsibilities for NSAIDS
Therapeutic effect (depending on indication): - why taking med; adequately eval
Adverse effects - monitor for these and these are major ones to look for
Evaluate:: Nursing responsibilities for NSAIDS
Decreased temp
Decreased pain
Therapeutic effect (depending on indication): - why taking med; adequately eval
Gastrointestinal effects
UGI bleeding (coffee ground emesis; dark bloody stools)
Bleeding/bruising
Adverse effects - monitor for these and these are major ones to look for
Do not directly provide direct analgesia
Often used for chronic pain - help manage pain without having use high amounts of opioids; sometimes in acute period
Caution: cause Sedation
Adjuvant drugs
Often for diabetic neuropathy; opioids not helpful for neuropathic pain; gabapentin helps with this type of pain
binds receptor sites hippocampus (chemical analogue of GABA: endogenous inhibitory neurotransmitter - initially used for seizure disorders, GABA helps to slow seizure activity; acts like GABA - inhibitory neurotransmitter)
MoA: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)
post herpetic neuralgia; anticonvulsant; off label: neuropathies - not approved by FDA but prescribers use it as such
Uses: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)
PO/Titrate as directed
Route/Dose: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)
drowsiness (inhibitory neurotransmitter and slows down brain activity - slows down brain func (helpful for seizures); dose limiting AE for pats - never get to high enough dose to help with neuropathic pain without becoming too drowsy - a lot experience drowsiness but not want sleeping all day long because not good quality of life), confusion, unsteady gait, impaired cognition
AE: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)
CNS depressants - acts like inhibitory neurotransmitter; anything else that depresses the CNS - exacerbating prob
Drug-drug: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)
slow titration when increasing and decreasing doses - be very when careful increasing/decreasing doses that affect NS - esp neurotransmitters; never just pull people off cold turkey; can put them into withdrawal often
Nursing: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)
inhibits spinal reflexes in CNS - helps with muscle spasms
MoA: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen
spinal cord injury, multiple sclerosis, spinal cord disease
Indications: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen