Powerpoints

Question 1

Analgesics

Answer 1

• Medications that relieve pain without causing loss of consciousness
• “Painkillers”
• Opioid analgesics
• Adjuvant analgesic drugs

Question 2

Pain

Answer 2

• An unpleasant sensory and emotional experience associated with actual or potential tissue damage
• A personal and individual experience
• Whatever the patient says it is
• Exists when the patient says it exists

Question 3

Nociception

Pain Threshold

Pain Tolerance

Answer 3

.

Question 4

Classification of Pain by Onset and Duration

Answer 4

• Acute pain
• Sudden onset
• Usually subsides once treated
• Chronic pain
• Persistent or recurring
• Lasts 3 to 6 months
• Often difficult to treat
• Tolerance
• Physical dependence

Question 5

Classification of pain

Answer 5

Referred
Neuropathic
Phantom
Cancer
Central
 Somatic
Visceral
Superficial
Deep
Vascular

Question 6

A patient with bone cancer tells the nurse that he is in pain. The nurse knows that bone pain is classified as which type of pain?

Somatic pain
Referred pain
Visceral pain
Neuropathic pain

Answer 6

Somatic pain
Answer: A
Rationale: Somatic pain, which includes bone pain, originates from the skeletal muscles, ligaments, and joints. Referred pain occurs when visceral nerve fibers synapse at a level in the spinal cord close to fibers that supply specific subcutaneous tissues in the body. Visceral pain originates from organs and smooth muscles. Neuropathic pain usually results from damage to peripheral or CNS nerve fibers or injury, but may also be idiopathic.

Question 7

Gate Theory of Pain Transmission

Answer 7

Most common and well-described theory
Uses the analogy of a gate to describe how impulses from damaged tissues are sensed in the brain
Many current pain management strategies are aimed at altering this system
teory of Pain Transmission

Question 8

Pain Transmission

Answer 8

Pain TransTissue injury causes the release of the following:
 Bradykinin
 Histamine
 Potassium
 Prostaglandins
 Serotonin
These substances stimulate nerve endings, starting the pain process.
mission

Question 9

Treatment of Pain in Special Situations

Answer 9

PCA and “PCA by proxy”
Patient comfort vs. fear of drug addiction
Opioid tolerance
Use of placebos
Recognizing patients who are opioid tolerant
Breakthrough pain
Synergistic effect

Question 10

Adjuvant Drugs

Answer 10

Assist primary drugs in relieving pain
NSAIDs
Antidepressants
Anticonvulsants
Corticosteroids
Example: adjuvant drugs for neuropathic pain
Amitriptyline (antidepressant)
Gabapentin or pregabalin (anticonvulsants

Question 11

World Health OrganizationThree-Step Analgesic Ladder

Answer 11

Step 1: nonopioids (with or without adjuvant medications) after the pain has been identified and assessed. If pain persists or increases, treatment moves to
Step 2: opioids with or without nonopioids and with or without adjuvants. If pain persists or increases, management then rises to
Step 3: opioids indicated for moderate to severe pain, administered with or without nonopioids or adjuvant medications

Question 12

Opioid Analgesics:Mechanism of Action

Answer 12

Three classifications based on their actions
Agonists
Agonists-antagonists
Antagonists (nonanalgesic

Question 13

Opioid Analgesics:Indications

Answer 13

Main use: to alleviate moderate to severe pain
Often given with adjuvant analgesic drugs to assist primary drugs with pain relief
Opioids are also used for:
Cough center suppression
Treatment of diarrhea
Balanced anesthesia

Question 14

Opioid Analgesics: Contraindications

Answer 14

Known drug allergy
Severe asthma
Use with extreme caution in patients with:
Respiratory insufficiency
Elevated intracranial pressure
Morbid obesity or sleep apnea
Paralytic ileus
Pregnancy

Question 15

A patient is recovering from an appendectomy. She also has asthma and allergies to shellfish and iodine. To manage her postoperative pain, the physician has prescribed patient-controlled analgesia (PCA) with hydromorphone (Dilaudid). Which vital sign is of greatest concern?

Pulse
Blood pressure
Temperature
Respirations

Answer 15

Respirations
Correct answer: D
Rationale: This patient has a history of asthma and allergies, and she will be receiving a drug that can depress respirations.

Question 16

Opioid Analgesics: Adverse Effects

Answer 16

CNS depression
Leads to respiratory depression
Most serious adverse effect
Nausea and vomiting
Urinary retention
Diaphoresis and flushing
Pupil constriction (miosis)
Constipation 
Itc

Question 17

Opioids: Opioid Tolerance

Answer 17

Opioid Tolerance

Physical Dependence

Opioids: Psychologic Dependence

Question 18

A patient who has metastasized bone cancer has been on transdermal fentanyl patches for pain management for 3 months. He has been hospitalized for tests and has told the nurse that his pain is becoming “unbearable.” The nurse is reluctant to give him the ordered pain medication because the nurse does not want the patient to get addicted to the medication. The nurse’s actions reflect

appropriate concern for the patient’s best welfare.
appropriate caution for a patient who is already on a long-term opioid.
an uncaring attitude toward the patient.
a failure to manage the patient’s pain properly

Answer 18

a failure to manage the patient’s pain properly
- Correct answer: D
Rationale: Patients with severe pain, including metastatic pain or bone pain, may need higher and higher doses of analgesics. The nurse is responsible for ensuring that the patient experiences adequate pain relief.

Question 19

Opioid Analgesics: Toxicity and Management of Overdose

Answer 19

Naloxone (Narcan)
Naltrexone (ReVia)
Regardless of withdrawal symptoms, when a patient experiences severe respiratory depression, an opioid antagonist should be given.

Question 20

Toxicity and Management of Overdose (Cont.)

Answer 20

Opioid withdrawal or opioid abstinence syndrome
Manifested as:
Anxiety, irritability, chills and hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramps, diarrhea, confusion

Question 21

Opioid Analgesics: Interactions

Answer 21

Alcohol
Antihistamines
Barbiturates
Benzodiazepines
Monoamine oxidase inhibitors
Others

Question 22

Opioid Analgesic

Answer 22

Codeine Sulfate 
Morphine Sulfate 
Fentanyl 
Dilaudid 
Methadone Hydrochloride (Dolophine)

Question 23

Nonopioid Analgesics:Acetaminophen (Tylenol)

Answer 23

• Analgesic and antipyretic effects
• Little to no antiinflammatory effects
• Available over the counter (OTC) and in combination products with opioids

Question 24

Acetaminophen

Answer 24

Acetaminophen: Mechanism of Action

Acetaminophen: Indications

Acetaminophen: Dosage
Acetaminophen: Contraindications and Interactions
Acetaminophen: Toxicity and Managing Overdose

Question 25

Analgesics:Nursing Implications

Answer 25

• Before beginning therapy, perform a thorough history regarding allergies and use of other medications, including alcohol, health history, and medical history.
• Obtain baseline vital signs and I&O.
• Assess for potential contraindications and drug interactions
• Perform a thorough pain assessment, including pain intensity and character, onset, location, description, precipitating and relieving factors, type, remedies, and other pain treatments.
• Pain is now considered a “fifth vital sign”
• Rate pain on a 0 to 10 or similar scale

Question 26

Analgesics:Nursing Implications

Answer 26

Be sure to medicate patients before the pain becomes severe so as to provide adequate analgesia and pain control.
Pain management includes pharmacologic and nonpharmacologic approaches; be sure to include other interventions as indicated.

Question 27

Analgesics:Nursing Implications

Answer 27

• Patients should not take other medications or OTC preparations without checking with their physicians.
• Instruct patients to notify physician about signs of allergic reaction or adverse effects.

Question 28

Analgesics:Nursing Implications

Answer 28

Oral forms should be taken with food to minimize gastric upset.
Ensure safety measures, such as keeping side rails up, to prevent injury.
Withhold dose and contact physician if there is a decline in the patient’s condition or if vital signs are abnormal, especially if respiratory rate is less than 10 to 12 breaths/min.

Question 29

Analgesics:Nursing Implications

Answer 29

Check dosages carefully.
Follow proper administration guidelines for IM injections, including site rotation.
Follow proper guidelines for IV administration, including dilution, rate of administration, and so on.

Question 30

Analgesics:Nursing Implications

Answer 30

• Constipation is a common adverse effect and may be prevented with adequate fluid and fiber intake.
• Instruct patients to follow directions for administration carefully and to keep a record of their pain experience and response to treatments.
• Patients should be instructed to change positions slowly to prevent possible orthostatic hypotension

Question 31

Analgesics:Nursing Implications

Answer 31

Monitor for adverse effects
Contact physician immediately if vital signs change, patient’s condition declines, or pain continues.
Respiratory depression may be manifested by respiratory rate of less than 10 breaths/min, dyspnea, diminished breath sounds, or shallow breathing.

Question 32

Analgesics:Nursing Implications

Answer 32

Monitor for therapeutic effects
Decreased complaints of pain
Decreased severity of pain
Increased periods of comfort
Improved activities of daily living, appetite, and sense of well-being
Decreased fever (acetaminophen

Question 33

Anesthetics

Answer 33

Drugs that reduce or eliminate pain by depressing nerve function in the central nervous system (CNS) and peripheral nervous system
Anesthesia
A state of reduced neurologic function
Three types
General anesthesia: complete loss of consciousness and loss of body reflexes, including paralysis of respiratory muscles.
Local anesthesia: no paralysis of respiratory function; elimination of pain sensation in the tissues innervated by anesthetized nerves
Balanced anesthesia

Question 34

Indications

Answer 34

General anesthetics are used during surgical procedures to produce:
Unconsciousness
Skeletal muscular relaxation
Visceral smooth muscle relaxation
Rapid onset; quickly metabolized
Also used in electroconvulsive therapy treatments for depression

Question 35

Adverse Effects for anethesia

Answer 35

• Vary according to dosage and drug used
• Sites primarily affected
  
  • Heart, peripheral circulation, liver, kidneys, respiratory tract
• Myocardial depression is commonly seen
• Malignant hyperthermia
  
  • Occurs during or after volatile inhaled general anesthesia or use of the neuromuscular blocking drug (NMBD) succinylcholine
  • Sudden elevation in body temperature (greater than 104° F)
  • Tachypnea, tachycardia, muscle rigidity
  • Life-threatening emergency
  • Treated with cardiorespiratory supportive care and dantrolene (skeletal muscle relaxant)

Question 36

General anesthetics: interactions

Answer 36

Antihypertensives: increased hypotensive effects

Beta blockers: increased myocardial depression

Question 37

Moderate Sedation

Answer 37

Also called conscious sedation and procedural sedation
Does not cause complete loss of consciousness and does not normally cause respiratory arrest.
Combination of an IV benzodiazepine (e.g., midazolam) or propofol and an opiate analgesic (e.g., fentanyl or morphine)
Anxiety and sensitivity to pain are reduced, and the patient cannot recall the procedure

Question 38

Local Anesthetics

Answer 38

• Also called regional anesthetics
• Used to render a specific portion of the body insensitive to pain
• Interfere with nerve impulse transmission to specific areas of the body
• Do not cause loss of consciousness
• Topical
  
  • Applied directly to skin or mucous membranes
  • Creams, solutions, ointments, gels, ophthalmic drops, powders, suppositories
• Parenteral
  
  • Injected intravenously or into the CNS by various spinal injection techniques

Question 39

Nursing Implications for anesthetics

Answer 39

Always assess past history of surgeries and response to anesthesia.
Assess past history, allergies, and medications.
Assess use of alcohol, illicit drugs, and opioids Assessment is vital during preoperative, intraoperative, and postoperative phases
Vital signs
Baseline lab work, ECG
Oxygen saturation
ABCs (airway, breathing, circulation)
Monitor all body systems

Question 40

Nursing Implications for anesthetics

Answer 40

During recovery, monitor for cardiovascular depression, respiratory depression, and complications of anesthesia.
Implement safety measures during recovery, especially if motor or sensory loss occurs because of local anesthesia.

Reorient patient to his or her surroundings.
Teach the patient about postoperative turning, coughing, and deep breathing.

Question 41

When assessing a patient under general anesthesia, which change to organ systems does the nurse expect?

Nystagmus
Skeletal muscle contraction
Hypertension
Decreased intracranial pressure

Answer 41

Nystagmus
Correct answer: A
Rationale: Nystagmus can occur as a result of the use of general anesthesia. Other findings include skeletal muscle relaxation, hypotension, and increased intracranial pressure.

Question 42

During surgery, the anesthetist notes that the patient’s heart rate is gradually increasing and becoming more irregular, the patient’s blood pressure is becoming unstable, and the patient is starting to sweat profusely. What other assessment should the anesthetist note immediately?

Pupillary reactions
Respiratory effort
Temperature
Urinary output

Answer 42

Temperature
Correct answer: C
Rationale: These are indications of malignant hyperthermia, which can progress rapidly.

Question 43

The nurse anesthetist is planning to use balanced anesthesia during a surgical procedure. A characteristic of this type of anesthesia is the

administration of minimal doses of multiple anesthetic drugs.
administration of inhaled anesthetics.
intravenous (IV) administration of anesthetics.
administration of anesthetics to cause muscle relaxation.

Answer 43

administration of minimal doses of multiple anesthetic drugs.
Correct answer: A
Rationale: The use of a combination of drugs allows less of each drug to be used and a more balanced, controlled state of anesthesia to be achieved.

Question 44

Which statement regarding conscious sedation does the nurse identify as being accurate?

The IV route of drug administration is commonly used in pediatric patients to provide conscious sedation.
Mild amnesia is a common effect of midazolam.
Patients receiving conscious sedation must be intubated with an endotracheal tube.
Effects of propofol include relief of anxiety and pain.

Answer 44

Mild amnesia is a common effect of midazolam.
Correct answer: B
Rationale: Midazolam allows the patient to relax and have markedly reduced or no anxiety yet still maintain his or her open airway and response to verbal commands while producing mild amnesia. The oral route of drug administration for conscious sedation is preferred for pediatric patients; patients receiving conscious sedation are able to maintain their own airway. Propofol will relieve anxiety; however, pain medications must be used along with propofol therapy for situations that can cause a pain response

Question 45

The nurse is administering medications. One patient has an order for aspirin 325 mg by mouth daily and another patient has an order for aspirin 650 mg 4 to 6 times daily (maximum 4 g/day). The nurse understands that the indication for the 325 mg of aspirin once daily is 
	pain management.
	fever reduction.
	treatment of osteoarthritis.
	thromboprevention.

Answer 45

thromboprevention

“Low-dose” aspirin, such as 81 or 325 mg once daily, is given for thromboprevention. Dosages for pain, fever, or arthritis are much higher usually.

Question 46

Indications for Acetic Acid Derivatives (NSAIDs): indomethacin (Indocin)
ketorolac (Toradol)

Answer 46

• Used to treat rheumatoid arthritis, osteoarthritis, acute bursitis or tendonitis, ankylosing spondylitis, and acute gouty arthritis
• Promote closure of patent ductus arteriosus, a heart defect that sometimes occurs in premature infants
• Ketorolac (Toradol) has powerful analgesic effects

Question 47

The main adverse effects of ketorolac include?

Answer 47

renal impairment, edema, gastrointestinal pain, dyspepsia, and nausea. It is important to note that the drug can only be used for 5 days because of its potential adverse effects on the kidney and gastrointestinal tract.

Question 48

When opioid analgesics, or any other CNS depressants, are prescribed, focus assessment on?

Answer 48

vital signs, allergies, respiratory disorders, respiratory function, presence of head injury, neurologic status, gastrointestinal tract functioning, and genitourinary functioning

Question 49

Opioids or any analgesic must be given before the pain

reaches its?

Answer 49

peak to help maximize the effectiveness of the opioid or other analgesic

Question 50

Crucial safety measures with analgesics include?

Answer 50

keeping bed side rails up, turning bed alarms on (depending on the policies and procedures of the health care institution), and making sure the call bell is within reach.
-monitor pt frequently for fall prevention

Question 51

Antidote for acetaminophen overdose

Answer 51

Acetylcysteine is the antidote for acetaminophen overdose. It must be administered as a loading dose followed by subsequent doses every 4 hours for 17 additional doses and started as soon as possible after the acetaminophen ingestion (ideally within 12 hours).

Question 52

analgesics nursing implications

Answer 52

Monitor for adverse effects
Contact physician immediately if vital signs change, patient’s condition declines, or pain continues.
Respiratory depression may be manifested by respiratory rate of less than 10 breaths/min, dyspnea, diminished breath sounds, or shallow breathing.

Question 53

Malignant hyperthermia

Answer 53

• Occurs during or after volatile inhaled general anesthesia or use of the neuromuscular blocking drug (NMBD) succinylcholine
• Sudden elevation in body temperature (greater than 104° F)
• Tachypnea, tachycardia, muscle rigidity
• Life-threatening emergency
• Treated with cardiorespiratory supportive care and dantrolene (skeletal muscle relaxant)

Question 54

Moderate Sedation

Answer 54

• Also called conscious sedation and procedural sedation
• Does not cause complete loss of consciousness and does not normally cause respiratory arrest.
• Combination of an IV benzodiazepine (e.g., midazolam) or propofol and an opiate analgesic (e.g., fentanyl or morphine)
• Anxiety and sensitivity to pain are reduced, and the patient cannot recall the procedure

Question 55

During surgery, the anesthetist notes that the patient’s heart rate is gradually increasing and becoming more irregular, the patient’s blood pressure is becoming unstable, and the patient is starting to sweat profusely. What other assessment should the anesthetist note immediately?

Pupillary reactions
Respiratory effort
Temperature
Urinary output

Answer 55

Correct answer: C

Rationale: These are indications of malignant hyperthermia, which can progress rapidly.

Question 56

The most commonly used drugs for moderate sedation

include?

Answer 56

a benzodiazepine, usually midazolam, with an

opioid, usually fentanyl or morphine.

Question 57

For any form of anesthesia and during any phase of anesthesia,
the major parameters to assess are?

Answer 57

airway, breathing, and circulation (ABCs)

Question 58

For patients undergoing general anesthesia, assessing the patient’s temperature is especially important because of the?

Answer 58

risk of malignant hyperthermia, and close monitoring is
required if malignant hyperthermia occurred during the anesthesia process. The tendency is inherited, so questions about related signs and symptoms in the family’s and patient’s medical histories are important to document and report. Malignant hyperthermia may be fatal if not promptly recognized and aggressively treated.
- Signs and symptoms include rapid rise in body temperature, increased pulse rate (tachycardia)/respiratory
rate (tachypnea), muscle rigidity, and unstable blood pressure. The patient who has undergone general
anesthesia should be constantly monitored for the occurrence of adverse effects of the anesthesia. These may include myocardial depression, convulsions, respiratory depression, allergic rhinitis, and decreased renal or liver function.

Question 59

Immunosuppressants inhibit?

Answer 59

T-lymphocyte synthesis, thus preventing an immune response to organ transplants.

Question 60

Immunosuppressants: Both basiliximab and daclizumab, both injectable dosage forms, are associated with?

Answer 60

an allergic-like reaction known as cytokine release syndrome. It may be severe and even involve anaphylaxis, so patients are usually premedicated with corticosteroids (e.g., IV methylprednisolone) to try to avoid or alleviate this problem.

Question 61

Common drug interactions to assess for when patients take cyclosporin include?

Answer 61

estrogens, protease inhibitors, HMG-CoA reductase inhibitors, clarithromycin, phenytoin, phenobarbital, St. John’s wort, nonsteroidal antiinflammatory drugs, and grapefruit juice.