Sedative & Analgesic Medications Flashcards
Morphine
Pure agonist opioid analgesic
MOA: acts primarily on mu receptor to mimic endogenous opioid peptide actions
Indications:
- Severe pain relief
- Myocardial infarction
- Pre-op sedation
- Anxiety
Adverse Effects:
- Respiratory depression and cough suppression
- Constipation & emesis
- Sedation & increased ICP
- Orthostatic hypotension
- Physical dependence, euphoria, abuse potential
Nursing Considerations:
- Monitor for tolerance, physical dependence, and abuse
- Assess and reassess pain, respiratory status, and GI function
- More effective if administered ATC vs PRN
- Monitor use with other CNS depressants, anticholinergics, antihypertensives, etc.
- If OD, admin naloxone (Narcan)
Fentanyl
Pure agonist opioid analgesic
MOA: acts primarily on mu receptors to mimic endogenous opioid peptide actions
- Administered IM, IV, transdermal, transmucosal, & nasal spray
Indications:
- Chronic pain relief
- Surgical analgesia
- PRN breakthrough pain relief
Adverse Effects:
- Same as morphine
- Respiratory depression and cough suppression
- Constipation & emesis
- Sedation & increased ICP
- Orthostatic hypotension
- Physical dependence, euphoria, abuse potential
Nursing Considerations:
- Higher potency than morphine (100x)
- Transmucosal for breakthrough pain in patients with cancer and opioid tolerance only!
- Same as morphine
- Monitor for tolerance, physical dependence, and abuse
- Assess/reassess pain, respiratory function, and GI function
- Monitor use with other CNS depressants, anticholinergics, antihypertensives, etc.
- If OD, admin naloxone (Narcan)
Methadone
Pure agonist opioid analgesic
MOA: acts primarily on mu receptors to mimic endogenous opioid peptide actions
- Administered PO, IM, & IV
Indications:
- Pain relief
- Opioid addiction
Adverse Effects:
- Same as morphine & fentanyl plus:
- QT prolongation (fatal dysrhythmias)
- Respiratory depression and cough suppression
- Constipation & emesis
- Sedation & increased ICP
- Orthostatic hypotension
- Physical dependence, euphoria, abuse potential
Nursing Considerations:
- Same as morphine & fentanyl plus:
- Monitor heart rhythm on telemetry as well as s/s
- Establish baseline EKG
- Obtain thorough history and assessment of opioid abuse prior to use for addiction and ensure proper dosing
- Monitor for tolerance, physical dependence, and abuse
- Assess and reassess pain, respiratory status, and GI function
- More effective if administered ATC vs PRN
- Monitor use with other CNS depressants, anticholinergics, antihypertensives, etc.
- If OD, admin naloxone (Narcan)
Codeine
MOA: moderate to strong opioid that acts primarily on mu receptors to mimic endogenous opioid peptide actions but with less analgesic effects vs morphine
Indications:
- Mild-moderate pain (similar to 325mg ASA or 325mg acet.)
- Cough (not for children < 6 years)
Adverse Effects:
- Similar to morphine, but to slightly lesser degree
- Excessive sleepiness, breathing difficulties, lethargy, and poor feeding in infants from nursing mothers on codeine
Nursing Considerations:
- Same as morphine
- Monitor for tolerance, physical dependence, and abuse
- Assess and reassess pain, respiratory status, and GI function
- More effective if administered ATC vs PRN
- Monitor use with other CNS depressants, anticholinergics, antihypertensives, etc.
- If OD, admin naloxone (Narcan)
- Lower doses as antitussive, higher doses for analgesia
- Combination products have a lower abuse potential
Oxycodone & Hydrocodone
MOA: pure agonist that acts primarily on mu receptors to mimic endogenous opioid peptide actions
- Combination products include aspirin, acetaminophen or ibuprofen
- Increased street drug abuse potential
Indications:
- Mild-moderate pain
Adverse Effects:
- Similar to morphine plus adverse effects related to combination drug (aspirin, acetaminophen, ibuprofen)
- Respiratory depression and cough suppression
- Constipation & emesis
- Sedation & increased ICP
- Orthostatic hypotension
- Physical dependence, euphoria, abuse potential
Nursing Considerations:
- Same as morphine
- Monitor for tolerance, physical dependence, and abuse
- Assess and reassess pain, respiratory status, and GI function
- More effective if administered ATC vs PRN
- Monitor use with other CNS depressants, anticholinergics, antihypertensives, etc.
- If OD, admin naloxone (Narcan)
- CR and IR formulation for ATC and breakthrough pain tx respectively
Pentazocine
MOA: agonist-antagonist opioid analgesic with agonist action at kappa receptors and antagonist action at mu receptors
Indications:
- Mild-moderate pain
Adverse Effects:
- Similar to morphine but to lesser degrees especially with respiratory depression
- Little to no euphoria and lower abuse potential and with limited withdrawal symptoms
- High doses may produce anxiety, nightmares, hallucinations, etc.
Nursing Considerations:
- Same as morphine
- Withdrawal can be seen if used with patients who have a history of pure opioid agonist abuse
Naloxone
Competitive antagonist at opioid receptors that block opioid action via IV, IM, SQ, and intranasal
Indications:
- Opioid overdose
- Reversal of post-op opioid effects
- Reversal of neonatal respiratory depression
Nursing Considerations:
- Will not see reversal if depression is caused by another agent (benzodiazepines, EtOH, etc.)
- Due to short half life, may need to repeat doses during overdose
- Patient will experience analgesia again
- Other formulations can help with management of opioid-induced constipation and opioid addiction
Tramadol
MOA: non-opioid centrally acting analgesic with pain relief achieved through weak mu receptor agonist activity and blocking of NE and 5-HT reuptake.
Indications:
- Moderate-severe pain
Adverse Effects:
- Due to weak mu activity, risk for respiratory depression is low and rare
- Sedation, dizziness, headache, dry mouth, and constipation common
- Serotonin syndrome if co-administered with SSRI, SNRI, etc.
Nursing Considerations:
- Abuse potential low
- Utilized in suicide attempts in combination with other CNS depressants
- Closely monitor and educate patients on use with SSRI, SNRI, TCA, MAOI, and triptan meds
Aspirin
MOA: irreversible non-selective cyclooxygenase inhibitor with inhibition of COX-1 leading to protection against MI and ischemic stroke, and COX-2 leading to reduction in inflammation, pain, and fever
Indications:
- Suppressing inflammation, analgesia, and fever in adults only!
- Suppression of platelet aggregation, dysmenorrhea, and possible colorectal cancer prevention
Adverse Effects:
- GI effects (take with food)
- Bleeding
- Renal impairment
- Salicylism
- Reye’s syndrome & toxicity
Nursing Considerations:
- Patient education on bleeding and concurrent use with other blood thinners
- Stop high-dose 7-10 days prior to surgery
- Numerous medication interactions, many with OTCs
Ibuprofen
MOA: reversible non-selective cyclooxygenase inhibitor propionic acid class NSAID with inhibition of COX-1 but does not lead to protection against thrombotic events and COX-2 leading to reduction in inflammation, pain, and fever Indications: - RA & OA - Pain & Fever in adults (possibly IV) - Dysmenorrhea - Bursitis - Tendinitis Adverse Effects: - GI effects (take with food) - Bleeding - Renal impairment - Increased risk for thrombotic events - Very rarely, SJS Nursing Considerations: - Patient education on bleeding and concurrent use with other blood thinners - Education on the lowest possible effective dose for the shortest amount of time - No CV protection against MI/CVA - Caution with renal impairment, monitor renal function
Acetaminophen
Narcotic analgesic, antipyretic MOA: acts directly on the hypothalamus to increase vasodilation and sweating Indications: - Pain or fever in children - Mild-moderate musculoskeletal pain Adverse Effects: - Hepatotoxicity - Renal Failure - Hypersensitivity - Myocardial damage Nursing Considerations: - If overdose occurs, gastric lavage & activated charcoal within 4 hours; administer antidote Acetylcystine (PO/IV) if after 8-10 hours (does not reverse existing damage)
Ketorolac
MOA: reversible non-selective cyclooxyrgenase inhibitor with inhibition of COX-1 but does not lead to protection against thrombotic events and COX-2 leading to reduction in inflammation, pain, and fever.
Indications:
- Short-term management of acute moderate-severe pain particularly in post-op (similar to morphine pain relief)
Adverse Effects:
- GI effects (take with food)
- Bleeding
- Renal impairment
Nursing Considerations:
- Patient education on bleeding and concurrent use with other blood thinners
- Medication is only used up tp five days total regardless of route used
- No CV protection against MI/CVA
- Caution with renal impairment, monitor renal function
Celecoxib
MOA: second generation selective cyclooxyrgenase inhibitor with inhibition of COX-3 leading to reduction in inflammation & pain.
Indications:
- RA & OA
- Ankylosing Spondylitis
- Juvenile idiopathic arthritis
- Acute pain
- Dysmenorrhea
Adverse Effects:
- Increased risk for MI, CVA, and other CV related events from increased unimpeded platelet aggregation and increased vasoconstriction
- Possible cross-allergy with sulfa medications
- Renal impairment, although decreased risk with 2nd generation
Nursing Considerations:
- Decreased risk for GI related effects due to selectivity to COX-2 at therapeutic doses, but GI effects can still occur
- No CV protection against MI/CVA; monitor and educate patient on s/s
- Caution with renal impairment, monitor renal function
Adjuvant Analgesics
Used in combination with other analgesics Antidepressants: - TCA - SNRI Antiseizure: - Tegretol - Gabapentin - Pregabalin Anesthetics/Antidysrhythmics - Lidocaine CNS stimulants: - Dextroamphetamine - Methylphenidate Glucocorticoids: - Dexamethasone - Prednisone Biphosphates: - Pamidronate - Zoledronic acid
Benzodiazepines
Indications: - DOC for anxiety & insomnia - Seizure disorder - Muscle spasm - Alcohol withdrawal - Perioperative applications Adverse Effects: - CNS depression - Anterograde amnesia - Sleep driving - Paradoxical effects - Respiratory depression - Abuse - Teratogenicity Drug Interactions: - CNS depressants
Benzodiazepine-Like Drugs (Zolpidem/Ambien)
Sedative-hypnotic Most widely used hypnotic Indications: - Short-term use for insomnia Adverse Effects: - Daytime drowsiness and dizziness Nursing Considerations: - No tolerance or increase in adverse effects in long-term use
Barbituates
Cause tolerance and dependence - High abuse potential - Multiple drug interactions - Powerful respiratory depression Barbituates are not used as often because of replacement with newer, safer drugs such as benzos Acute toxicity: - Respiratory depression - Coma - Pinpoint pupils - Treated with activated charcoal & O2 tx
Ramelteon
Melatonin agonist MOA: activates melatonin receptors Indications: - Chronic insomnia (difficulty with sleep onset, not maintenance) Nursing Considerations: - Rapid onset (30 minutes) - Safe (no tolerance risks)
Glucocorticoids (Cortisone, prednisone, etc.)
MOA: suppress inflammation
- Highly individualized treatment
Deemed empirically:
- If no immediate threat, start low and slow
- If immediate threat, start high; decrease as possible
Prolonged treatment with high doses only if disorder is life-threatening or has potential to cause permanent disability
- Administer before 0900; alternate day therapy; gradual weaning
Methotrexate
PO, IM, IV, and intrathecal folic acid analog antimetabolite
MOA: results in absence of thymidylate which makes cells unable to make DNA
Indications:
- Curative for women with choriocarcinoma
- Non-Hodgkin’s lymphoma
- Acute lymphoid leukemia
- Head, neck, and osteogenic sarcoma
- Rheumatoid arthritis
Adverse Effects:
- Bone marrow suppression
- Pulmonary infiltrates and fibrosis
- Oral & GI ulceration are dose-limiting
- Severe N/V
- Intestinal perforation and hemorrhagic enteritis
- Teratogenicity
Nursing Considerations:
- Monitor liver & kidney function, as well as CBC
Etanercept
Biologic DMARD
MOA: inhibits inflammation by neutralizing TNF to prevent TNF from interacting with receptors in synovium
Indications:
- RA
Adverse Effects:
- Milder AE at injection site, including erythema, itching, swelling, and pain
- Opportunistic infections, particularly fungal & TB
- SJS/TENS
- Heart failure
- Cancer
- Hematologic disorders
- Liver injury
- CNS demyelination
Nursing Considerations:
- Contraindicated with many pre-existing conditions
- Numerous drug interactions, particularly live vaccines
- Monitor and educate on adverse effects
- Neutropenic precautions, especially with concurrent immunosuppressant drug use
Gout Treatment
Gout Attack:
1. NSAIDs (1st line)
2. Glucocorticoids
3. Colchicine (if not responsive to first 2 drugs)
Chronic Gout:
1. Agents to decrease uric production
2. Agents that increase uric acid secretion
3. Agents that convert uric acid to allantoin
Allopurinol
PO Urate lowering class agent
MOA: inhibits xanthine oxidase enzyme to decrease uric acid production
Indications:
- Gout
- Cancer:
- Polycythemia Vera
- Myeloid metaplasia
- Leukemia
Adverse Effects
- Generally well-tolerated
- Mild GI reactions such as N/V/D and discomfort
- Neurologic effects, including drowsiness, headache, and metallic taste
- Cataracts with prolonged use
- Rare hypersensitivity syndrome
Nursing Considerations:
- Monitor vision and educate patients on periodic examinations
- Educate on place in therapy
- Increase fluid intake and avoid food triggers
Probenecid
PO Uricosuric class agent MOA: acts on renal tubules to inhibit reabsorption of uric acid; helps increase excretion of uric acid by the kidneys and reduce hyperuricemia Indications: - Gout Adverse Effects: - Generally well tolerated - Mild GI effects, N/V, & anorexia - Possible renal injury Nursing Considerations: - Increase fluid intake to reduce risk of renal injury; monitor I&O - Periodic monitoring of renal function - Administer with food to prevent GI upset
Pegloticase
IV Recombinate uric acid oxidase class agent
MOA: converts uric acid to allantoin, which is water soluble and is excreted by kidneys
Indications:
- Patients not responsive to other PO rate lowering tx, including allopurinol and probenecid
Adverse Effects:
- May experience gout flare initially during treatment
- Anaphylaxis more common
- Infusion reactions also common that can occur within 2 hours after infusion is completed and can include urticaria, dyspnea, chest discomfort, erythema, and pruritus
Nursing Considerations:
- Infusing medications slowly can help reduce AE intensity
- Pre-medicate with antihistamine and glucocorticoid & monitor closely
Sumatriptan
Enteral/parenteral abortive triptan class agent
MOA: causes selective activation of 5-HT 1B/1D binding to receptors causes vasoconstriction and suppresses release of CGRT to reduce release of inflammatory neuropeptide and neuromuscular inflammation
Indications:
- Migraine
Adverse Effects:
- Chest symptoms, non-ischemic related chest pressure and heavy arm sensation
- Coronary vasospasm in patients with CAD
- Teratogenic
Nursing Considerations:
- Educate patients to avoid triggers and recognize symptoms of aura that occur prior to onset
- Avoid in patients with CAD
- Educate on contraception due to risk of fetal harm
- Numerous medication interactions
