YES BOOK Pain meds Flashcards
What are analgesics?
Medications that relieve pain.
What is the analgesic ladder?
Step 1: Nonopiods for mild pain
Step 2: Opioids for mild to moderate pain
Step 3: Opioids for moderate to severe pain
Nonopiod Analgesic
There is a ceiling affect to their analgesic properties, increasing the dose to the upper limit provides no greater analgesia
What are NSAIDS used for?
Commonly used to relieve pain and reduce inflammation.
How do NSAIDs work?
Work by inhibiting enzymes called cyclooxygenases, inhibit synthesis of prostaglandins.
What is responsible for many of the side effects of NSAIDs?
Cyclooxygenases enzyme inhibition
What are the two types of NSAIDs?
nonselective/selective
What are nonselective NSAIDS?
NSAIDS that inhibit both COX-1 and COX2
What are COX1 enzymes responsible for?
Normally found in stomach, blood platelets, blood vessels
What are COX2 enzymes reponsible for?
Found at sites of inflammation, less likely to cause gastrointestinal injury.
What do selective NSAIDS do?
Inhibit COX2 only
Who is not recommended to take NSAIDs?
Not recommended for people with kidney disease, heart failure, cirrohosis, those who take diuretics, allergic to aspirin. Nsaids may also cause worsening of asthma
What would patients with mild pain (No 1-3) Receive?
Nonselective NSAIDS
COX 1/2 inhibitors
What are the main things about NSAIDs the nurse should know?
- Response varies to specific NSAIDs, if one is not effective try another.
- Do not take a second NSAID at the same time because of increased risk of side effects.
- Short Term use can cause stomach upset. (Dyspepsia)
- Long term use, especially at high doses can cause peptic ulcer disease
- Use of NSAIDs even for a short period can harm the kidneys.
- They are commonly available without a prescription
What is the max dose of ibuprofen?
3,200 mg/day
What is the max dose of Naproxen?
1500 mg/day
What is the max dose of naproxen sodium?
Do not exceed 1650 mg/day
Available in immediate and delayed release formations
What does the nurse have to remember about ketorolac tromethamine?
It is injectable
It is an NSAID
Limit the treatment to 5 days, many adverse effects
contraindicated with renal impairment, aspirin allergy
Can cause renal insufficiency in dehydrated patients
What does the nurse have to remember about COX2 inhibitors?
Sometimes recommended for patients with history of peptic ulcer, GI bleeding, GI upset.
- Less potential to cause ulcers or GI bleeding
- Should be avoided in patients with known coronary artery disease, history of stroke, narrowed arteries to the brain or those at high risk.
What is the max dose of Celecoxib (COX2) inhibitor?
Maximum dose of 200 mg a day.
What are the types of aspirin?
Acetylsalicyclic acid. (Aspirin, Ecotrin, Bayer)
Buffered aspirin products (Alka seltzer, bufferin, Ascriptin)
What does the nurse need to remember about Salicyclates?
- Inhibits both COX 1 and COX 2
- The combination of low dose aspirin and an NSAID can increase the risk of bleeding. Aspirin should be taken at least two hours before the NSAID.
- Can cause exacerbation of bronchospasm, rhinitis (With nasal polyps, asthma)
- Has antiplatelet effects (Increased risk of bleeding)
- Increased risk of bleeding when combined with oral anticoagulants, heparin)
- Increased risk of GI ulceration with steroids, alcohol, NSAIDs.
- Use cautiously with impaired renal functioning.
- Maximum doses vary according to indications for use. Up to 4 g/day
What is the nonaspirin pain reliever?
Acetaminophen
What should the nurse remember about acetaminophen?
It does not affect platelets
Not an anti-inflammatory agent
Doses of greater then 4g/day can cause acute overdose.
Patients with alcoholism or liver disease are at risk for hepatotoxicity
Increased toxicity with long term excessive ethanol ingestion.
What type of drugs would you expect to administer to a patient with mild to moderate pain? (4-7)
Opiod Agonists Analgesics - Codiene + acetaminophen, Hydrocodone + acetaminophen (Vicodin), Oxycodone + aspirin (Percodan), Codiene phosphate, Oxycodone, Hydrocodone
Opiod analgesic - Tramadol hydrochloride (Ultram, Ultram ER)
What does the nurse need to remember about drugs in the opiod agonist class? (Codiene + acetaminophen, Hydrocodone + acetaminophen (Vicodin), Oxycodone + aspirin)
Binds to opioid receptors in the CNS to produce analgesia.
No defined maximum dose; Ceiling determined by the side effects
Use with caution respiratory depression may occur in the elderly, the very ill, or those with respiratory problems
- Codiene phosphate, Oxycodone, Hydrocodone
Usually prescribed with a nonopioid - reduces the opioid dose:
- Codiene + acetaminophen, Hydrocodone +
acetaminophen (Vicodin), Oxycodone + aspirin
(Percodan)
What does the nurse need to remember about Tramadol hydrochloride?
Binds to mu-opioid receptors, inhibits the reuptake of norepinephrine and serotonin
Causes many similar effects to the opioids - dizziness, somnolence, nausea, constipation
Does not have the respiratory depressant effect
Less occurance of tolerance, physical dependency, addiction
Roughly the same efficiacy of tylenol #3
Also used for moderate to severe relief of chronic pain ATC
What are the drugs that the nurse would expect to be prescribed for moderate to severe pain (8-10)?
Morphine sulfate, Fentanyl, Hydromorphone, meperidine, methadone.
How is morphine sulfate delivered?
Timed release - Avinza, MS contin, Oramorph SR
Oral solution - Roxanol, MSIR
Rectal suppositories - RMS
Injection - Astramorph PF, Duramorph
How is fentanyl delivered?
Transdermal System - Duragesic patch
Lozenge on a stick, buccal, sublingual, nasal spray(Actiq, Abstral, Fentora)
What does the nurse need to know about meperidine?
Do not use for longer then 2 days because of risk of neurotoxicity.
IM route preferred for repeated injections.
What does the nurse need to remember about the use of methadone?
Relief of severe pain not responsive to non-opioid analgesics.
Dextoxification and temporary maintenance (Treatment of opioid addiction)
Oral methadone is approximately 1/2 as potent as parenteral methadone.
Oxycodone + methadone (Percocet)
What are the major side effects of opioids?
Constipation (Most common)
Nausea, vomiting, pruiritis.
Sedation, respiratory depression - at risk population (opioid naive, the elderly or those with underlying lung disease)
Less common: Urinary retention, myoclonus, dizziness, confusion, hallucinations.
Physical tolerance and dependence can occur - Addiction occurs in less than 1% of patients.
How are adjuvant drugs used in the treatment of pain?
They enhance the effect of opiods, providing additional pain relief.
How do adjuvant drugs enhance pain therapy/
- Enhance the effects of opioids and non-opioids.
- Possess analgesic properties
- Counteract the side effects of other analgesics.
How do anticonvulsants work to relieve pain?
Effective for neuropathic pain and prophylactic treatment of headaches.
What is included in anticonvulsants used to treat pain?
Gabapentin (Neurontin) - idiosyncratic side effects - ankle swelling, ataxia
Carbamazepine (Tegretol)
Clonazepam (Klonopin) - Start with low doses and increase slowly. Baseline liver functions, renal functions, and blood counts needed.
How do antidepressants work to relieve pain?
Thought to work by increasing the levels of certain chemicals (norephinephrine, serotonin) at nerve endings that help to inhibit pain signals. Neuropathic pain, migraines, fibromyalgia, rheumatoid arthritis.
What is included in the antidepressants used to treat pain?
Amitriptyline (Elavil)
Doxepin (Sinequan)
Nortriptyline (Pamelor)
Imipramine (Tofranil - PM)
What are the side effects of the antidepressants used to treat pain?
Dry mouth, urinary retention, constipation, drowsiness, confusion especially in the elderly.
What are the indications for use of corticosteroids for pain
- Acute and chronic cancer pain
- Pain secondary to spinal cord compression
- Some neuropathic pain syndromes
What are the corticosteroids used to treat pain?
- Dexamethasone
- Methylprednisone
What are the side effects of corticosteroids used to treat pain?
- Hyperglycemia, fluid retention, dyspepsia, GI bleeding
- Impaired healing, muscle wasting, osteoporosis.
- Susceptability to infection, mood swings, psychosis.
