Pharm quiz 1 - 2 Flashcards
acute pain is how long?
up to 6 months
Nociceptive pain is caused by
stimulation of peripheral nerve fibers that respond only to
stimuli approaching or exceeding harmful
intensity (nociceptors) and may be classified
according to the mode of noxious stimulation; (chili peppers, etc)
neuropathic pain results from
any nerve that is NOT functioning. lesions or diseases affecting the somatosensory system or a nerve
๏จ Common Causes of Neuropathic Pain
๐ HIV
๐ Diabetes
๐ Alcoholism
๐ Chemotherapy
๐ Multiple Sclerosis
๐ Shingles
๐ Amputation
visceral pain, Like somatic pain, nociceptors
send signals to the spinal cord and brain when damage is detected. Unlike somatic pain, however, visceral pain is harder to pinpoint
Sometimes described as
generalized aching or squeezing. It is caused by compression in & around the organs, or by stretching of the
abdominal cavity
visceral pain examples
๐ Endometriosis
๐ Irritable bowel syndrome
๐ Bladder pain (cystitis)
๐ Prostate pain
๐ Fibroids
pain assessment (ABCDE)
๏จ Ask about pain- โWhat bought you to the Hospital?โ
๏จ Believe the patient and family
๏จ Choose appropriate options for management
๏จ Deliver timely and coordinated interventions
๏จ Empower patients to control options
who pain scale
๏จ Pain Description
๏ง โMild painโ - 1 to 3
๏ง โModerate painโ - 4 to 6
๏ง โSevere painโ 7 to 10
๏จ Opioid
- Inclusive termโ means โopiate likeโ, includes endogenous opioid-peptides, synthetic or semi-synthetic which have actions similar to those of morphine
morphine
Action
๐ OpioidAgonist Analgesic
๐ Mimics endogenous opioid peptides producing analgesia, euphoria& sedation
๐ Binds to the same receptor sites as opioid peptides (natural enkephalins & endorphins)
๐ Modulates pain perception in the brain and spinal cord
๏จ Use
๐ Analgesia, pain relief
๐ Anxiety reduction
๐ Sedation, drowsiness
๐ Sense of well being (*unlabeled use: MI pain relief)
**(Morphine Sulfate Extended release)
morphine precautions and adverse effects
๐ Respiratory suppression ***** ABC
๏ฎ Monitor in COPD, Asthma, obesity and sleep apnea
๐ Pregnancy or labor
๏ฎ Decreased uterine contraction, fetal depression
๐ Head Injury
๏ฎ Elevates ICP (intercranial)
๏จ Adverse Effects
๐ Opioid induced constipation (OIC)
๐ Orthostatic hypotension
๐ Urinary retention
๐ Cough suppression (post-oppneumonia risk)
morphine nursing considerations
๐ In pill / capsule form (ER/SR) do not crush, chew
before administering
๐ Make sure that a patient is observed for at least 24
hours in fully equipped and staffed environment
if morphine is given by epidural or intrathecal
route
๐ IV Push:Have pt lie down, dilute & push slowly to
minimize effects
๐ Reassure ptโs that they are unlikely to become addicted
when using opiates for medical purposes
morphine precautions and interactions
๐ Biliary Colic ? (spasms of the common bile duct)
๐ Nausea and Vomiting
๐ Miosisโpupil excessive constriction
๐ Neurotoxicity (agitation, delirium, hallucinations, increased pain)
๏จ Drug Interactions
๐ CNS depressants will intensify adverse effects
๏ฎ Alcohol, barbiturates, benzodiazepines
๐ Antihypertensives exaggerate orthostatic hypotension
๐ MAOIโs (tx Depression) may cause seizures and death
๏จ Antidote โ naloxone โ (Narcanยฎ)
Meperidine (Demerolยฎ) - think Sz
Meperidine (Demerolยฎ) - think Sz
๏จ Actions
๐ Opioid Analgesic
๐ May provide local anesthetic effects
๏จ Use
๐ Drug induced rigors
๐ Post anesthesia shivering
๐ Alternative to other opioid
demerol precautions and adverse effects
Precautions
๐ Vistaril (antihistamine) combowill intensify effect of Demerolยฎ
๐ Short ยฝ life
๐ Normeperidine metabolite is toxic
๐ NTE> 600mg / 24 hours for over 2 days
๏จ Adverse Effects
๐ Toxic seizures
๐ Blockade of Serotonin reuptake (mood hormone neurotransmitter)
demerol interactions and nursing considerations
Drug Interactions
๐ Others: MAOI combo can cause excessive activationof
serotonin receptors causing excitation, delirium,
hyperthermia, seizures, coma & death
๏จ Nursing Considerations
๐ Less respiratory depression, constipation and vomiting
as compared to morphine
๏จ Pregnancy Category B
difference btwen merperidine and morphinea
Meperidine is less apt to release histamine or to
increase biliary tract pressure
๏จ Meperidine has a shorter duration of action
๏จ Meperidine has poor oral bioavailability
๏จ Meperidine is metabolized in the liver to
normeperidine, a CNS neurotoxin, that is especially
dangerous to children and older adults
naloxone precautions and adverse effects
Precautions!
๐ Give IV, IM, Sub-Q (PO has rapid first pass effect)
However, PO form is used in addiction
treatment at 50 mg/day
๐ Administered in the absence of opioids has no effect
๐ Given prior to opioids will block opioid action
๐ Administered during opioid use will reverse effects
๐ Given to physically dependent opioid patients will cause an immediate acute withdrawal effect
๏จ Adverse Effects
๐ Pain, loss of analgesia
๐ Increased respiratory rate
๐ Restlessness, anxiety
naloxone drug interactions and nursing considerations
Drug Interactions
โฆ Cannabinoids:may cause enhancedcannabinoid effect(mechanism
unknown)
โฆ All opiate comboโs(Vicodinยฎ, Percocetยฎ, etc.)
โฆ Yohimbe:May result inadditive therapeutic or adverse effects (additive
effect)
โฆ Nursing Considerations
โฆ Monitor the patient continuously after useof naloxone, repeat dosesmaybe
needed
โฆ Maintainan open airway and be prepared to provide artificial ventilation
and cardiac supportif needed to counteractthe opioid overdose
๏จ Pregnancy Category: C
vicodin actions and use
Actions
๐ Opioid combo
๏จ Use
๐ Produces analgesia and antipyretic effects, hydrocodone binds to various opioid receptors producing analgesia and sedation
vicodin precautions and adverse effects
Precautions
๐ Cr at baseline for renal disease,
adjust as needed (Bun 7-20, Cr 0.84-1.21)
๐ LFTโs if severe hepatic disease(ALT 7-55u/L, AST 8-33u/L)
๏จ Adverse Effects
๐ Respiratory depression
๐ Hepatotoxicity
๐ Dependency, Abuse
vicodin drug interactions and nursing considerations
๐ Inhibitors: Amiodarone (cardiovascular drug)
๐ Inducers: barbiturates, tegretol
๏จ Nursing Considerations
๐ Avoid abrupt cessation to prevent withdrawal sx
๐ Name confusion: Hycodanยฎ, Percodanยฎ,
Hydro/ codone combos etc.
๏จ Pregnancy Category: C
methadone actions and use
Actions
๐ Opioid Analgesic
๐ Action similar to morphine
๏จ Use
๐ Relieve severe or chronic pain
๐ Methadone Maintenance
๏ฎ Treat opioid addicts, substitute methadone for the opioid
๏ฎ Withdrawal is accomplished by administering methadone
gradually in smaller doses
methadone use and precautions
๐ Methadone suppression: Prevents opioid induced
euphoria, by giving addicts larger doses of methadone
(>100 mg/day) pt will develop tolerance to other
opioids. Taking street drugs will not produce same
euphoric effects.
๏จ Precautions
๐ Severe dysrhythmias, prolongs the QT interval, V-fib
๐ Respiratory suppression
methadone adverse effects and pregnancy
Adverse Effects
๐ Severe dysrhythmias, prolongs QT interval, V-Fib
๏จ DrugInteractions
๐ Inhibitors: sertraline, rifampin
๐ Inducers: tegretol, phenobarb, phenytoin, barbiturate anesthetics
๐ Caution with many HIV ARVโs ( antiretroviral )
๏จ NursingConsiderations
๐ ChestPain-> EKG
๐ Patient should be in a medication program*
๏จ Pregnancy Category: C
issues affecting pain management
๏จ Tolerance
๐ A larger dose of medication is required to produce the
same effect previously elicited by a smaller dose
๐ CrossTolerance
๏ฎ Refers to a person tolerant of one drug being tolerant of
another dug in the same class(codeine, heroin, methadone,
oxycodone)
๏ฎ Will not be tolerant to other CNS depressants like alcohol,
barbiturates, benzodiazepines, general anesthetics
issues affecting pain management - physical dependence
Physical Dependence
๐ Withdrawal syndrome
will occur if the drug is abruptly discontinued
๐ Adaptive cellular changes occurdue to continuousdrug
exposure
๐ Body will require continued presence of drug to function normally
Abuse
Abuse
๐ Intentional misuseof drugs inconsistentwith medical or
social norms
Myths:
๐ Pain should be
treated, not prevented
Selected Nursing Diagnoses
Related to Opioid Therapy
Selected Nursing Diagnoses
Related to Opioid Therapy
๏จ Ineffective airway clearance related to cough reflex
suppression
๏จ Ineffective breathing pattern: hypoventilation related to
CNSdepressant effects of drug
๏จ Risk for deficient fluid volume related to nausea and/or
vomiting
๏จ Constipation
๏จ Urinary retention
๏จ Risk for injury related to sensory/perceptual alterations
Use of Opioids in Children
โฆ Children are left untreated or are inadequately treated for
pain
โฆ Pain assessment in children is more difficult
โฆ Consider giving children medications for pain in same
circumstances as an adult
โฆ Approach to child should be individualized
โฆ Growth and developmental characteristics of various
ages of children should be understood
โฆ Assessment tools that meet developmental age of child
(pain faces, stick figures, thermometer diagram) should be
used
โฆ Listen to parents, family members, and guardians about
childโs behavior when he or she is in pain
Use of Opioids in the Older Adult
โฆ Dosage and dosing intervals are required
โฆ Observe for enhanced medication responses
โฆ Older adults have multiple medical problems and
take numerous medications
โฆ Multiple assessment skills should be used
โฆ Height, weight, and body surface area are not
accurate measurements for analgesic dosing in the
older adult
โฆ Communicate, remembering cultural, physiologic,
and psychological differences
โฆ Assessments should be adapted to meet the needs of
the older adult
โฆ Some analgesics are inappropriate for the older adult
Frequently abused substances
and Street Drugs
๏จ Alcohol
๐ Action:
๏ฎ Central Nervous system depressant
๏ฎ Enhances serotonin โ mediated release of dopamine
๏ฎ Binds with GABA receptors-
๐ Uses:
๏ฎ Prolonged life (moderate usage)
๏ฎ Dementia risk reduction (moderate usage)
๏ฎ MI risk reduction (moderate usage)
๏ฎ IncreasesHDL
๏ฎ Suppresses inflammatory component of atherosclerosis
๏ฎ Dilates cutaneous blood vessels
Frequently abused substances
and Street Drugs
๏จ Alcohol
๐ Precautions:
๏ฎ Tolerance (needing more to achieve effect)
๏ฎ Dose dependent (Thiamine Deficiency)
๏ฎ Wernickeโs encephalopathy (confusion, nystagmus)
๏ฎ Korsakoffโs psychosis (memory gaps, polyneuropathy)
๐ Adverse effects
๏ฎ Damage to myocardium, HTN(dose dependent)
๏ฎ Respiratory depression
๏ฎ Liver damage, cirrhosis, cancer
๏ฎ Erosive gastritis, varices
Frequently abused substances
and Street Drugs
๏จ Alcohol
๐ Adverse effects
Frequently abused substances
and Street Drugs
๏จ Alcohol
๐ Adverse effects
๏ฎ Breast and colorectal cancer
๐ Drug Interactions
๏ฎ Inhibitors: Coffee, Milk (myths!)
๏ฎ Inducers: CNS depressants (barbiturates, benzodiazepines)
๏ฎ Interactions: NSAIDS = injury to gastric mucosa Tylenolยฎ =
liver damage with only 2-4 drinks per day (limit should not
exceed 2 grams per day)
๐ PregnancyCategory:
(moderate use?,No know safe alcohol level)
Frequently abused substances
and Street Drugs
๏จ Abuse Management of alcohol
๏จ โCAGEโ
Frequently abused substances
and Street Drugs
๏จ Abuse Management of alcohol
๏จ โCAGEโ
๐ Cut down โ have you ever thought about cutting down
on your drinking?
๐ Annoyed โ Have people annoyed you by criticizing
your drinking?
๐ Guilty โ have you ever felt guilty about your drinking?
๐ Eye opener โ Have you ever had a drink the first thing
in the morning to steady your nerves or get rid of a
hangover?
Frequently abused substances
and Street Drugs
๏จ Alcohol Withdrawal
๐ A set of symptoms that occur due to physiologic
response to alcohol dependence
๐ Low dependence:
๏ฎ 12 โ 24 hours:Anxiety, disturbed sleep, nausea, mild
tremors and weakness
๐ High dependence
๏ฎ 12-72 hours: Cramps, nausea, vomiting, intense tremors,
tachycardia, hypertension, fever
๐ Severe dependence
๏ฎ Delirium Tremens(DTโs)occur in less than 1%
๏ฎ Hallucinations, Disorientation,Tremors,Seizures
Frequently abused substances
and Street Drugs
๏จ Alcohol Withdrawal Management
๏จ Alcohol Withdrawal Management
๐ Benzodiazepines: (Libriumยฎ,Valiumยฎ, Ativanยฎ)
๏ฎ Decrease the w/d symptoms and stabilize vital signs.
Prevent seizures
๐ Beta-adrenergic blockers (Inderalยฎ, TenORminยฎ)
๏ฎ Improve vital signs, decrease autonomic component of
withdrawal
๐ Alpha-adrenergic blockers (CataPRESยฎ)
๏ฎ Improve vital signs, decrease autonomic component of
withdrawal
Chlor-DI-ze-POX-ide (Libriumยฎ)
Chlor-DI-ze-POX-ide (Libriumยฎ)
๏จ Action:
๐ Potentiates the actions of GABA, especially in the limbic
system, reticular formation
๏จ Uses:
๐ Short-term management of anxiety, acute alcohol
withdrawal, preoperatively for relaxation
Chlordizepoxide
๏จ Precautions:
Chlordizepoxide
๏จ Precautions:
๐ CNS: Dizziness, drowsiness, confusion, headache,
anxiety, tremors, stimulation, fatigue, depression,
insomnia, hallucinations
๐ CV: Orthostatic hypotension, edema, ECG changes,
tachycardia, hypotension
๏จ Adverse effects:
๐ Decrease: effectโcowslip, kava, Queen Anneโs lace, St.
Johnโs wort, valerian
Chlordizepoxide
๏จ NURSING CONSIDERATIONS
Chlordizepoxide
๏จ NURSING CONSIDERATIONS
๐ Assess: B/ P(lying, standing), pulse; if systolicB/ P
drops 20 mm Hg, hold product, notify prescriber
๐ Assistancewith ambulation during beginning therapy,
sincedrowsiness/dizziness occurs โข Checkto see PO
medication hasbeen swallowed if patient isdepressed,
suicidal
โฆ Stages of Sleep
โฆ Stages of Sleep
โฆ Nonโrapid eye movement (non-REM) sleep
๏ง Stage 1: 2% to 5%
๏ง Stage 2: 50%
๏ง Stage 3: 5%
๏ง Stage 4: 10% to 15%
โฆ REM sleep: 25-33%
Physiologic Functions
During Non-REM Sleep
๏จ Blood pressure falls
๏จ Pulse rate is slowed
๏จ Metabolic rate is decreased
๏จ Gastrointestinal tract activity is slowed
๏จ Urine formation slows
๏จ Oxygen consumptionand carbon dioxide production
are reduced
๏จ Body temperature decreases slightly
๏จ Respirations are slower and shallower
๏จ Body movement is minimal
Drug therapy in the treatment of
anxiety or insomnia
Drug therapy in the treatment of
anxiety orinsomnia
๏จWhat is the role of drug therapy in the treatment of
anxiety orinsomnia?
โฆ After nondrug interventions are attempted first a drug
therapy plan ischosen based onthe level of CNS
suppression desired
โฆ Antianxiety / Anxiolytic
โฆ Sedatives
โฆ Hypnotics
Lorazepam (Ativanยฎ)
Precautions
๐ Children <12 yr, geriatric patients, debilitated,
renal/hepatic disease, addiction, suicidal ideation,
abrupt discontinuation
๏จ Adverse Effects
๐ Dizziness, drowsiness, Orthostatic hypotension, ECG
changes, tachycardia, hypotension; apnea, cardiac
arrest (IV, rapid)
lorazepam nursing considerations
๏จ Nursing Considerations:
๐ That product may be taken with food
๐ Not to use product for everyday stress or longer than 4
mos. unless directed by prescriber
๐ May be habit forming
๐ Toavoid OTC preparations (cough, cold, hay fever)
unless approved by prescriber
๐ Toavoid driving, activities that require alertness, since
drowsiness may occur
๐ To rise slowly
Common Antianxiety and
Anxiolytic Agents
Benzodiazepines
(typically end with โ-zepamโ or โ-zolamโ)
โ Examples include alprazolam, oxazepam, midazolam, triazolam
Drug Therapy
๏จ Sedatives reduce nervousness, excitability, or
irritability by producing a calming or soothing
effect
๏ฑ Hypnotics are used to induce sleep with greater
CNS depression than sedatives
๐ Other than benzodiazepines, may include chloral
hydrate
alprazolam (xanax)
Actions
๐ Depresses subcortical levels of CNS, including limbic
system, reticular formation
๏จ Uses
๐ Anxiety, panic disorders with or without agoraphobia,
anxiety with depressive symptoms
๐ (Unlabeled use) Premenstrual dysphoric disorders
xanax - adverse effects
Adverse Effects
๐ Dizziness, drowsiness,orthostatic hypotension, blurred
vision,
๏จ Precautions
๐ Geriatric patients, debilitated, hepatic disease, obesity,
severe pulmonary disease
๏จ Contraindicated:
๐ Pregnancy (D), breastfeeding, hypersensitivity to
benzodiazepines, closed-angle glaucoma, psychosis,
addiction
xanax nursing considerations
๐ Assess:โข Mental status: anxiety, mood, sensorium,
orientation, affect, sleeping pattern, drowsiness, dizziness,
especially in geriatric patients prior to, and during
treatment
๐ B/ Plying, standing; pulse; if systolicB/ Pdrops 20 mm Hg,
hold product, notify prescribe
diazapam (valium)
Action
๐ Benzodiazepine
๐ Potentiates gamma-aminobutyric acid
๐ Depress neuronal function at multiple sites in the CNS
๏จ Uses
๐ IV forms used to treat status epilepticus
๐ Anxiety and Panic Disorders
๐ Insomnia
๐ Muscle Spasm
๐ ETOH withdrawal - #1
diazapam precautions
Precautions
๐ Pregnancy Category D
๐ Tolerance and Physical Dependence
๐ Inject slowly into a large vein (5mg/min)flush pre/post
with NSS
๏จ Adverse effects
๐ CNS depression
๐ Anterograde amnesia unable to make new memories after amnesia induced events
๐ Paradoxical effects
๐ Abuse
diazapam nursing considerations
Nursing Considerations: Assess
๐ For alcohol withdrawal symptoms, including hallucinations
(visual, auditory), delirium, irritability, agitation, fine to
coarse tremors
๐ For seizure control and type, duration, intensity of seizures
๐ For muscle spasms; pain relief
benzo utility
What are the advantages of benzodiazepines over
other agents?
โฆ Low fatality rates
โฆ Low Abuse Potential
โฆ More favorable adverse effect profiles
โฆ Fewer seriousdrug interactions
โฆ What are the indications for benzodiazepines?
๐Anxiety Disorders
๐Alcohol Withdrawal
๐ Preoperativemeds,Insomnia,Seizuresand NeuromuscularDisease
benzo interactions
Do the benzodiazepines interact significantly with
other drugs?
๐ Nursing attention to other CNS depressants and
benzodiazepine usage
๐ Check for alcohol use
๐ Combined with zidovudine(HIV antiviral) may increase
toxic levels as the drug isnot metabolized as well
alternatives to benzos?
Benzodiazepine-like Drugs
zolpidem tartrate
ZAL-e-plon
eszo-PIC-lone
๏จ Serotonergic Anxiolytics
buspirone
๏จ Antihistamine Anxiolytics
hydroxyzine
Use of Antianxiety, Sedative,
HypnoticAgents in Children
Limited
โ May cause paradoxical reactions
โ May be used in carefully selected situations (severe
anxiety with asthma, pre-anesthesia, during
seizures)
โ Requires close monitoring by health care team
Use of Antianxiety, Sedative,
HypnoticAgents in Older Adults
May also cause paradoxic reactions
โ Requires careful dosage titration
โ Requires careful monitoring by health care team
Role of Drug Therapy in
Treatment of Anxiety or Insomnia
Antianxiety or anxiolytic agents reduce feelings
of excessive anxiety (apprehension, fear,
nervousness, worry, or panic); used when
nondrug interventions are not effective or are
inappropriate for the degree of symptoms present
Significant Drug Interactions With
Benzodiazepines
(Enhanced CNS Depressant Effects)
๏จ Can occur when used with:
๏ง Alcohol
๏ง CNS depressants
๏ง Opioid analgesics
๏ง Anesthetics
๏ง Tricyclic antidepressants
๏จ Close monitoring is necessary because the dosage
of one or both drugs may need to be adjusted
nonceceptors respond to what types of pain?
๐ โthermalโ (heat or cold),
๐ โmechanicalโ(crushing, tearing, etc.) and
๐ โchemicalโ(iodine in a cut, chili powder in the eyes).
alprazolam
xanax
