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
epilepsy, cardiac dysfunction
Contraindications: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen
cautious before take with other CNS depressants (common because exacerbates the drowsiness - common: Put on skeletal muscle relaxant and opioid drowsiness more common), alcohol
Drug-drug: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen
drowsiness (need know how react to med before operate heavy machinery/drive - not drive when taking this med), dizziness, nausea, constipation, hypotension, urinary frequency
AE: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen
Many other drugs in class used for acute musculoskeletal disorders; monitor CNS; do not operate heavy machinery
Nursing: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen
The nurse is reviewing a medication list for a client. The combination of which medications causes concern for the nurse?
A.Lispro and glargine
B.Loratadine and pseudoephedrine
C.Acetaminophen and aspirin
D.Ibuprofen and prednisone
Answer: D
Lispro and glargine: insulin - long acting and rapid; lot pats on rapid acting and long acting
Loratadine and pseudoephedrine - antihistamine and decongestantant; sometimes put in same drug together
Acetaminophen and aspirin - non-opioid so not NSAID; not prob to take with aspirin - works differently than aspirin
Ibuprofen and prednisone - MoA - synergistic/oppose each other, AE: both cause that problematic; both can cause GI effects - sig increase risk for GI ulcers
Rationale: Taking an NSAID with prednisone increases the risk for gastrointestinal irritation, GI ulcers and GI bleeding.
DEA monitors used of controlled substances
Opioids under schedule II; very relevant for how utilized by pats and how admin, doc, and waste meds - high abuse potential
Controlled substances schedule for pain meds
Know policies and procedures on it and need follow appropriately at facility - safeguard to show not taking controlled for own use
Access to controlled substances limited to certain people:
Retrieve med(s) immediately prior to admin not admin immediately label with pat info (name, DOB and according to protocols)
May not leave medications at bedside (unless in locked container and properly labeled container) - witness taking med
Unused portions waste or return immediately (as appropriate)
Waste procedure:
Nurse role: managing controlled substances: adapted from SLHS Controlled Substance Policy
Licensed personnel: Nurses, physicians, advanced practice providers, pharmacists, RT
Authorized personnel: pharmacy technicians and pharmacy interns
Access to controlled substances limited to certain people:
Waste ASAP
Should not be disposed of in modalities where retrieval is possible
Not waste where other can access - where cannot be retrieved from anybody
Preferred method via wastewater (sink or toilet)
Topical transdermal patches flushed toilet or folded in half (adhered to itself) and placed in sharps container
Requires a witness wasting of med to ensure wasted med and not used for own use (licensed or authorized personnel); managers watch how much meds taking
Waste procedure:
Stimuli and pain transmission goes up SC up to brain
Way body Responds to pain is by releasing endogenous opioids - opioids in sys that goes to opioid receptors to help diminish pain
Opioid receptors throughout body:
Control number body sys: - speaks to AE
Opioids are agonists: Mimicking endogenous opioids to block pain; blocking pain but mimicking norm action of body; decreases pain and bind to opioid pain receptors but not done perfectly; find other pain receptors that have control over number things so have all AE with opioid agonists
Pain process and opioid receptors
CNS, periphery (PNS), GI tract
Opioid receptors throughout body:
Blood pressure
Pupil diameter
GI secretions
Nausea and vomiting
Cough
Respirations
Control number body sys: - speaks to AE
Mild to severe pain
Acute or chronic pain
Antitussive effects - decreasing cough (codeine)
Adjuvant for anesthesia (with this); benzodiazepeine med and fentanyl drip for anesthesthesia
Used for: Narcotic (opioid) agonists
Interact/work with opioid receptors to inhibit pain pathways in CNS - prob is bind to other receptors throughout body so have all AE
Depends on receptor affinity
Efficacy
Adverse effects
MoA: Narcotic (opioid) agonists
Codeine
Mild pain and/or cough suppression: Narcotic (opioid) agonists
Oxycodone
Mod-severe pain PO: Narcotic (opioid) agonists
Morphine
Fentanyl
Dilaudid
Mod-severe pain PO, IV, SL… - more potent opioids used: Narcotic (opioid) agonists
Drowsiness - common AE
Sedation - potentially severe; need action immediately; probs need intervene on
Respiratory depression - potentially severe; need action immediately; probs need intervene on
Constipation - common AE
Urinary retention - common AE
Nausea and vomiting - common AE
Hypotension - common AE
Itching - common AE
Euphoria (abuse) - less likely to occur; some meds when given IV can give high and will have pats that ask if can push narcotics faster because faster push it faster get euphoric feeling; if talking about it this or pushing things faster, investigate further or talk to HCP about referring person because abusing med than using for benefit
Hallucinations - less likely to occur
Bradycardia - less likely to occur
Lot Adverse Effects: - not just target specific opioid receptors: Narcotic (opioid) agonists
Hypersensitivity - not give drug if have this
Opioid naïve - not used taking lot opioids; everyone reacts differently; ask pat if taken opioid pain in past and idea where at
Respiratory disease - major AE is resp depression if have these is problematic
Pregnancy - cross placental-fetal barrier and impacts fetus
Caution: Narcotic (opioid) agonists
Asthma, COPD (not have lot resp reserve so if have resp depression more problematic because not have lot ability to make up for hypoventilation - harder treat resp depression and O2 not as helpful), PNA
Respiratory disease - major AE is resp depression if have these is problematic
Suffering from Respiratory depression not give more makes it worse
Severe heart disease - if have this and resp depression prob with oxygenation for tissue
Substance abuse - if history of this prescriping opioids needs be thoughtful; not mean administer meds because think abusing meds - is very problematic because not solve prob in shift and not give pain med - can send into withdrawal and very sick and number issues for pat; make sure prescriber know - know what thinking - get person more long term help - than withhold pain med for shift: prob stems further; tell someone about this so get help and get off in controlled manner; abuse other things outside opioids higher risk for developing opioids
Contraindications: Narcotic (opioid) agonists
CNS depressants – alcohol, sedatives, antipsychotics, skeletal muscle relaxants, benzodiazepines; anything else causes CNS depression: gabapentin, baclofen; more likely occur if taking multiple drugs together
Drug-Drug interactions: MANY!: Narcotic (opioid) agonists
Start with low dose esp if opioid naive to see how react to meds to see how react - need know how react
Discontinue gradually after long-term use to avoid withdrawal - even if suspect abuse cont admin meds and take diff avenue to address
Administration considerations: Narcotic (opioid) agonists
Big prob if resp depressed: not breathing enough times/min and O2 levels drop and O2 to cells and tissues decreased and not enough O2 to tissues/cells have issues
Assess VS, apply O2 if indicated - O2 sat: see if getting by or not and in dangerous zone because O2 levels compromised since not breathing enough - get enough O2 levels so help as much as well; anytime sedated/resp depression hold next dose and consider admin anatagonist
Hold next dose
Consideration antagonist - unsure to admin ask someone on unit if should admin; pain very hard control post-antagonist
Take vital signs, follow protocol and utilize standing orders
If respiratory depression (less than 10 breaths/minute) occurs….: Narcotic (opioid) agonists
Needs med to manage pain to help QOL and rebab and need to help manage probs
Constipation
Nausea and vomiting
Itching
Managing common adverse effects
Very common prob - often prescribed bowel regimen as well with opioids
Getting Plenty of fluids, high fiber diet, exercise - stimulates bowels
Very high doses can have ileus/sig bowel issues
Medication to soften stool and promote bowel movements: see GI lecture
Constipation
Suffer from this Take with food to try alleviate
Take with antiemetic meds
Medication to relieve nausea/vomiting
Nausea and vomiting
Difficult to treat as AE; lotions, cool compresses
Medications to relieve itching: loratadine (Claritin) - antihistamine common but not lot can do
More research needed
Itching
Codeine least potent opioid then fentanyl post potent opioid; when prescribed opioids need be balance between controlling pain and least amount of AE; more pain med more likely suffer AE
How control pain with least number of AE
Adverse effects decreases; pain control increases
Opioids In med by itself; Just by themself
Used for moderate to severe pain
No “maximum dose” for pat; suffer from sig affects know hitting max dose: sig resp depression then hitting max dose; based on pain control and AE
Can be given by many different routes
Short-acting for breakthrough
Long-acting for chronic pain
Need give right prep to pat
Single-agent opioids
Immediate release (IR)
Breakthrough pain/short durations of pain relief
Short-acting for breakthrough
Extended release (ER)
Chronic pain - taking every single day
Long-acting for chronic pain
Doses limited because opioid combined with another med like acetaminophen/ibuprofen
Acetaminophen with oxy: common, limits how much can take and same with ibuprofen
Orders for combo med and range for number med - make sure not over limit with either dose so not OD pat
Use: mild to moderate pain; breakthrough pain
Non-opioid component added
Combo PO Opioids
Dose limiting
Total APAP/24 hours
Most pts = 4 grams
Liver disease less
Total ibuprofen/24 hours
Most pts = 3200 mg (OTC max 1200 mg)
Kidney disease less
Non-opioid component added
Depresses pain transmission at spinal cord level by interacting with opioid receptors; ↓ cough reflex, ↓ GI motility
MoA: Opioid agonist: prototype: codeine
Mild to mod pain; off label use: diarrhea, nonproductive cough - treat lower doses so AE so dangerous with patients not seen
Use: Opioid agonist: prototype: codeine
Scheduled med - how much/dose depends falls; in controlled substances realm
Response can be very unpredictable
Opioid agonist: prototype: codeine
10% of codeine is metabolized to morphine by liver - some metabolize better than others so unpredictable - prob
Metabolism unpredictable, varies by race
CAUTION: Opioid agonist: prototype: codeine
Moderate to severe pain; acute and chronic pain
Use: Opioid agonist: prototype: oxycodone (OxyContin)
PO as needed or scheduled; know if need to know immediate or ER
Short acting (immediate release – IR)
Long acting (extended release - ER)
Route/Dose: Opioid agonist: prototype: oxycodone (OxyContin)
Breakthrough pain example (post-surgical): Oxycodone IR 5 mg PO every 6 hours as needed
Short acting (immediate release – IR): Opioid agonist: prototype: oxycodone (OxyContin)
Chronic pain example: Oxycodone ER 30 mg PO every 12 hours
Do not split, crush or chew ER tablets! - given at once versus over 12 hours; higher risk for unintentional OD: sedation, resp depression
Long acting (extended release - ER): Opioid agonist: prototype: oxycodone (OxyContin)
Acute and chronic pain
Use: Opioid agonist: prototype: morphine
sev diff routes
Morphine considered “gold standard” for dosing opioids - earlier ones created
not all opioids same potency - fentanyl very potent
IV push considerations:
Dose/route considerations: Opioid agonist: prototype: morphine
Follow facility protocol
Push slowly when given via IV push; Deliver over 4-5 min (do not infuse rapidly and not incurring AE during admin of med); some dilute via NS (follow protocol)
Monitor closely for adverse effects! Which is why push slowly
IV push considerations:
Potent med have; dosed in mcg; fast acting and short duration; utlized a lot for PCAs and medically induced comas
Most potent opioids and more abused drugs
Opioid agonist: prototype: fentanyl
Acute and chronic pain, adjunct to general anesthesia
Use: Opioid agonist: prototype: fentanyl
onset 1 minute, peak 3-5 min, duration 30-60 min
Common dose: 50 mcg every 1-2 hours PRN
Commonly used in PCA pumps
Push slowly
Same considerations as morphine for IVP
IV - Dose/route considerations: Opioid agonist: prototype: fentanyl
Half-life 13-22 hours
Common dose: 25 mcg/hour
Slowly releases med
No pill; ATC pain relief; biggest risk: one patch not taken off before replacing another; imp doc where put it and imp find old one and take it off because if do not getting pain med from old patch and OD from transdermal patches
Change patch every 72 hours
Transdermal - Dose/route considerations: Opioid agonist: prototype: fentanyl
Allows patient some control of pain administration at need
Provider’s order (admin IV): basal rate, delay in bolus, pt bolus dose
Indications: Acute pain states
Contraindications: Cognitive problems, hypoventilation syndromes, extremes of age (only pt can control pump)
Patient controlled analgesia (PCA)
Less sedation, less opioid consumption, decreases post-op complications
Better pain control
Allows patient some control of pain administration at need
Follow PCA policy/procedure for admin and documentation
Provider’s order (admin IV): basal rate, delay in bolus, pt bolus dose
Post-surgical pain, trauma, cancer pain, sickle cell crisis, burns
Indications: Acute pain states
Block opioid activity at opioid receptor - by blocking activity not allowing meds to bind receptors so block AE that occurring like resp depression; expect RR improves, sedation should improve; keep in mind pain comes back like vengeance and because drug blocking receptor sites and pain through roof; not happy because zero opioid activity and admin if needed because pain does come back and because incident where got too much pain med prescribers very hesitant to give lot pain med after so very diff to control pain so be thoughtful about when giving it so give when appropriate
MoA: Opioid antagonist: Prototype: naloxone (Narcan)
Reverse overdose due to opioid meds
Indication: Opioid antagonist: Prototype: naloxone (Narcan)
IV, inhaled
Route: Opioid antagonist: Prototype: naloxone (Narcan)
Repeat in 2-3 minutes if resp. status does not improve
Dose: Opioid antagonist: Prototype: naloxone (Narcan)
Onset: 1-2 min
Peak 5-15 min
Duration 45 min (IVP)
Acts quickly; may need 1+ dose because one dose may not be enough and may need a second dose
Opioid antagonist: Prototype: naloxone (Narcan)
rapid loss of analgesia (be prepared and HCP decide how much give - lot less than were getting), increased BP, tachycardia, hyperventilation, N/V/D, tremors, sweating
AE: Opioid antagonist: Prototype: naloxone (Narcan)
Careful monitoring of patient (fast acting med; respiratory status); have resuscitative equipment available; may need multiple doses
Nurse: Opioid antagonist: Prototype: naloxone (Narcan)
The nurse would expect to administer morphine as the analgesia of choice for which clients? Select all that apply.
A.A client with severe post-operative pain
B.A client with severe chronic obstructive pulmonary disease and difficulty breathing
C.A client with cancer and severe bone pain
D.A client with chronic leg pain from peripheral neuropathy
E.A client with chronic pain unresponsive to NSAIDs and adjuvants
Answer: A, C, E
Rationale: Opioids are used for moderate-severe pain. Opioids should be used only if other pain medications are ineffective. Opioids should be used with great caution in patients with underlying respiratory disorders. They should not be used to treat neuropathic pain.
The nurse is caring for a client with constipation. After reviewing the client’s medication list, the nurse knows constipation could be caused by which medication?
A.Gabapentin
B.Acetaminophen
C.Oxycodone
D.Ibuprofen
Answer: C
Rationale: Opioids commonly cause constipation.
Prior to admin assess: VS, LOC/CNS, respiratory status, I & O’s - biggest assessment is assess sedation and respiration; document sedation and tie in current RR: appropriate to give current meds; resp status assessment - for opioids
Pain assessment should be done (minimum):
Reassessment after intervention (pain medication) – very imp; need go back reassess pain to see if intervention was helpful; need know if med was effective and if not need know; do appropriate time and doc
Pain management: assessment and reassessment
Acute care setting (SLHS Policy and Procedure)
Every 4 hours (ICU) or shift (non-ICU)
Pre-and post-procedure
PRN
Weekly or monthly (outpatient)
Pain assessment should be done (minimum):
30-90 minutes after oral meds
15-30 minutes after IV med
24 hours after transdermal med
Reassessment after intervention (pain medication) – very imp; need go back reassess pain to see if intervention was helpful; need know if med was effective and if not need know; do appropriate time and doc
Initiate non-pharmacologic pain relief measures
Pain meds according to primary care provider orders
Manage pharmacologic interventions
Consider ethical and legal responsibility to relieve pain
Manage constipation:
Manage nausea/vomiting:
Education: - ensure to do this
Pain management: Nursing Interventions
Collaborate with care team to alter dose, route, frequency until goal met
Notify care provider of adverse effects, unrelieved pain
Collaborative effort between nurse, pat, perscriber
Pain meds according to primary care provider orders
Consider WHO ladder and collaborate with pt when choosing PRN meds
Admin IV push pain medications slowly (follow facility protocol)
Manage pharmacologic interventions
Scheduled or PRN docusate or bowel stimulant (see GI lecture)
Manage constipation:
Scheduled or PRN anti-emetic medication (see GI lecture)
Manage nausea/vomiting:
Pain scale - how appropriately use these
Early intervention (before severe pain) - keeping up on pain and ahead of it - once out of control so much harder to treat so need stay on top of it and tell pat this
Adverse effects (bowel regimen, overdose) - edu about this; constipation highly likely with amount pain med taking; AE and what can do for them
Non-pharm therapies as appropriately
Discharge pain management plan
Education: - ensure to do this
Evaluation:
Documentation:
Pain management: Nursing Eval
Therapeutic effect of medication:
Adverse effects:
Evaluation:
0/10 not achievable for most but need know pain goal
Chronic pain: achieve pain goal to participate, perform ADL’s, improve quality of life
Acute pain: achieve pain goal, participate in rehab
Therapeutic effect of medication:
Daily bowel movement
Nausea/vomiting, itching
CNS depression, respiratory depression
Adverse effects:
Assessment, intervention, reassessment, education
Waste procedure
Documentation:
The nurse is caring for a client prescribed oxycodone and baclofen. The nurse should prioritize which assessment?
A.Bowel sounds
B.Level of consciousness
C.Intake and output
D.Range of motion
Answer: B
Rationale: The nurse’s most immediate concern with the combination of these drugs is drowsiness. Drowsiness increases the risk for falls. Although bowel sounds and I&O are a priority for ondansetron, they are not a priority with baclofen. Range of motion should be assessed with the use of baclofen, but is not essential to ondansetron.
Both meds can cause CNS depression - assessment should prioritize is LOC
Read each drug, dose and order. Can you identify the concern or mistake?
1.Oxycodone/Acetaminophen 5 mg/325 mg. Take 2 tablets PO every 3 hours.
2.Fentanyl 50 mg. Administer via IVP every 2 hours as needed.
3.Oxycodone 60 mg ER. Administer tablet via PEG tube every 12 hours.
4.Morphine 10 mg. Administer via IVP over 1 minute every 3 hours as needed.
- Exceeds 24-hour time limit for acetaminophen; Two tablets every 3 hours - go over max dose
- Mg should be mcg
- Cannot crush ER; need alternative form of med (elixir); Cannot crush it - need elixir form
- Pushing too fast!
