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Non-Opioid Analgesics

• Aspirin and Ibuprofen are prototypes
• COX-1 and COX-2 inhibitors reduce fever, relieve dysmenorrhea, inhibit platelet aggregation, and suppress inflammation, and mild to medium pain

Aspirin

• Used for fever reduction, dysmenorrhea (moderate to severe menstrual pain), inhibition of platelet aggregation (aspirin), analgesia (relief of pain) for mild to moderate pain (osteoarthritis and rheumatoid arthritis), and inflammation suppression
• Can cause gastric upset, heartburn, nausea, and gastric ulceration
• Can cause bleeding (less with non-aspirin NSAIDs)
• Can cause kidney dysfunction
• Salicylism (aspirin) occurs if too much aspirin is taken
• Reyes syndrome (aspirin) occurs when aspirin is given to a child with a viral infection

Aspirin - Contraindications/Precautions

• Teratogenic
• Hypersensitivity to aspirin and other NSAIDs
• Peptic ulcer disease
• Bleeding disorders (hemophilia, vitamin K deficiency)
• Children or adolescents with chicken pox or influenza
• Perioperative use prior to coronary artery bypass grafting (non-aspirin NSAIDs)
• Should be discontinued within 1 week before any elective surgery

Aspirin - Interactions

• Risk of bleeding increases with alcohol, anticoagulants, and glucocorticoids
• Antiplatelet effect of low-dose aspirin decreases with Ibuprofen
• Risk of kidney failure increases with ACE inhibitors and angiotensin receptor blockers
• Risk of lithium carbonate and methotrexate toxicity increases and antihypertensive effects of ACE inhibitors decrease

Aspirin - Nursing & Client Information

• Ensure enteric-coated or sustained-release forms are swallowed whole
• Discontinue one week before scheduled surgery
• Monitor for initial and continued therapeutic effects
• PO administration
• Reduced fever, reports of lower-level pain, and decreased inflammation indicate medical effectiveness
• First generation NSAIDs include naproxen, indomethacin, ketorolac, meloxicam, and diclofenac
• Take with food, milk, or 8oz of water to minimize gastrointestinal effects
• Avoid alcohol
• Report gastric irritation and manifestations of bleeding
• Report prolonged bleeding
• Report changes in output, weight gain, or manifestations of fluid retention
• Report ringing or buzzing in the ears, sweating, headache, and dizziness
• Do not give to children 19 years of age and under due to risks of viral infection
• Use acetaminophen instead for children under 19 years of age
• Report chest pain, heaviness, shortness of breath, sudden and severe headache, numbness, weakness, visual disturbances, or confusion
• If prescribed, take aspirin once daily to reduce the risk of heart attack and stroke
• Salicylism S/S are tinnitus, sweating, headache, dizziness, and respiratory alkalosis

Ketorolac

• Unique administration principles

Celecoxib

• Unique type of NSAID
• Monitor for manifestations of myocardial infarction and cerebrovascular accident due to the risk of thromboembolic events
• Give 2 hours before or after magnesium or aluminum-based antacids

Acetaminophen

• Used as a COX inhibitor but its effects are limited to the CNS
• Does not affect the gastric mucosa or platelets, decreasing the risk for gastric ulcers and cardiovascular events
• Rare complications but acute toxicity can happen
• Pregnancy risk category B for oral and rectal, and C for IV use
• Anemia, Immunosuppression, hepatic or kidney disease are contraindications/precautions

Acetaminophen - Interactions, Nursing & Client Information

• Risk of liver damage increases with alcohol
• Acetaminophen slows the metabolism of warfarin, leading to increased levels of warfarin, which places the client at risk for bleeding
• Administered orally or rectally
• No more than 4g a day
• Reduced fever and client reports of reduced pain denote medical effectiveness
• Acetylcysteine is the antidote
• Teach to read labels carefully to determine proper doses
• Only take one product at a time that contains acetaminophen
• Acetaminophen toxicity can happen, resulting in liver damage

Opioid Agonists and Antagonists

Morphine

• An opioid agonist
• Used as an analgesic for moderate to severe pain, pre-op sedation, anxiety reduction, cough suppression (codeine), and reduction of bowel motility relief of diarrhea

Morphine - Complications & Contraindications

• Respiratory depression, constipation, nausea/vomiting, dizziness/lightheaded or drowsy, orthostatic hypotension (BP drops when going from lying to standing/sitting), urinary retention, cough suppression, the potential for misuse along with tolerance/cross-tolerance may occur
• Pregnancy, renal failure, increased cranial pressure, biliary colic (pain caused by gallstones blocking the cystic duct), biliary surgery, and clients in preterm labor are contraindications

Morphine - Interactions

• Effects of CNS depressants such as barbiturates, phenobarbital, benzodiazepines, and alcohol increase
• Anticholinergic effects increase when given with anticholinergic agents such as antihistamines and tricyclic antidepressants
• Hypotensive effects increase when given with other antihypertensive medications
• Sedation can increase when given with St. John's wort

Morphine - Nursing & Client Information

• PO, IM, IV, subcutaneous, rectally, or epidurally administration
• Ordered intravenously, give slowly over 4 to 5 minutes
• Ask patient to rate pain (30-60 mins after oral)
• Resolution of diarrhea and cough
• Only take when needed on a short-term basis
• Do not take before driving or any activity requiring mental alertness
• If feeling lightheaded, sit or lie down immediately
• Increase fluid and fiber intake as well as activity and exercise to prevent or treat constipation
• Other opioid agonists: Fentanyl, meperidine, methadone, codeine, oxycodone, and hydromorphone
• Avoid taking with other CNS depressants, and avoid consumption of alcohol, anticholinergic agents, antihistamines, and tricyclic antidepressants to minimize the risk of adverse effects
• Closely monitor pump settings (dose, lockout, interval, 4-hr limit) and inform the client that safeguards are there to reduce the risk of excessive doses when using a patient-controlled analgesia (PCA) pump

Fentanyl

• Unique routes of administration

Naloxone

• Interferes with the action of opioids by competing for opioid receptors
• Opioid antagonists have no effect in the absence of opioids
• Temporarily reverses euphoria and respiratory depression
• Tachycardia and tachypnea are complications
• Abstinence syndrome may happen when physically dependent clients are suddenly withdrawn the medication
• Pregnancy can cause withdrawal syndrome in a client who has opioid dependence and is contraindicated
• Reverses effects of opioids

Naloxone - Nursing Information

• IV, IM, subcutaneous administration only
• Rapid infusion can cause hypertension, tachycardia, nausea, and vomiting
• Give until crisis has passed
• Respirations return to regular
• Respiratory rate in adults is 12 to 20/min and 30 to 60/min in newborns

Ibuprofen

• Given with another primary pain medication, usually an opioid agonist, to increase pain relief while reducing the dosage of opioid agonists
• Treats inflammation and fever, and relieve mild to moderate pain and dysmenorrhea
• Bone marrow suppression, Gl distress, and MI or stroke are complications
• Avoid after 30 weeks of gestation and with clients with a history of bronchospasms with aspirin or other NSAIDs and those who have severe kidney/hepatic disease
• Use cautiously with clients with bleeding, GI, or cardiac disorders, and with older adults

Sumatriptan

• A migraine-specific medication that reduces pain, nausea, and sensitivity to light and sounds by narrowing the blood vessels around the brain and reducing substances that trigger headaches
• Chest pressure and dizziness or vertigo are potential complications
• Concurrent use of MAOIs can lead to toxicity, ergotamine or another triptan can cause vasospastic reactions, and SSRIs can cause serotonin syndrome
• Oral, subcutaneous, inhalation, transdermal administration
• Reduction in intensity and termination of migraines
• Educate on early signs of migraines, inform of potential side effects and when to seek medical attention, and prevent sumatriptan misuse

Lidocaine

• Decreases pain by managing pain in dental procedures, labor and delivery, minor surgical and diagnostic procedures by blocking the conduction of pain impulses
• Loss of consciousness does not occur
• CNS excitation and seizures followed by respiratory depression leading to unconsciousness is a complication
• Hypotension, cardiosuppression, bradycardia, heart block, reduced contractile force, and cardiac arrest also can occur
• Clients with hypersensitivity to local anesthetics, severe liver disease, heart block, or a history of malignant hyperthermia should exercise caution
• Can have additive effects with beta-blockers and antiarrhythmics

Lidocaine - Nursing & Client Information

• Administer parenterally, and monitor for adverse effects
• Numbness and relief in affected site, no excessive redness, swelling, or irritation should occur if medically effective
• Avoid activities requiring alertness until effects worn off
• Avoid hot food or drinks if applied in the mouth

EMLA

• Topical cream for anesthesia before procedures
• Apply to smallest surface area needed to minimize systemic absorption
• Apply to intact skin 1-2 hours before the procedure
• Remove the dressing and clean the skin with an aseptic solution prior to the procedure

Medications Affecting Urinary Output

• Used to treat edema, hypercalcemia, and heart failure

Furosemide

• A high ceiling loop diuretic that blocks reabsorption of sodium & chloride and is used when emergent and rapid mobilization of fluid is needed
• Dehydration, hypotension, ototoxicity, and electrolyte imbalances
• Contraindicated in clients who are pregnant, lactating, and/or have anuria
• Use oral (w/out food), IV, IM administrations
• Obtain baseline, monitor BP and I&O, and notify provider if potassium levels are low.

Hydrochlorothiazide

• Is a thiazide diuretic that works in the early distal convoluted tubule to block reabsorption of of sodium and chloride to promote diuresis
• Indicated hypertension BP control, and post menopausal osteoperosis
• S/S and C/I similar to Furosemide
• Use oral (w/or w/out food), IV administration.

Spironolactone

• A potassium sparing diuretic which blocks aldosterone action to retain potassium and excrete sodium and water
• Can be used to treat hypertension edema and heart failure
• Watch for hyperkalemia to avoid deep voice deepening, impotence, menstrual disorder, gynecomastia
• Take oral dosing w/ food and maintain potassium levels

Mannitol

• A osmotic directed which reduces intercranial and intraocular pressure by raising volume of intravascular
• Watch S/S of heart failure, pulmonary edema and eletrolyte imbalance
• Use IV infusion, filter to administer in the IV.
• Creatinine for males is 0.6 to 1.3 mg/dL and for women is .5 to 1.1 mg/dL. BUN levels is 10 to 20 mg/dL

Captopril

• An ACE Angiotensin-converting enzyme inhibitor used to control hypertension, heart failure, myocardial infraction, diabetic conditions.
• Works by blocking the conversion of angiotensin and increasing bradykinin and potassium
• Watch for first dose orthostatic hypotension, cough and angioedema
• Oral administration EXCEPT for enalprilat
• Take captopril/moexipiril an hour before mean and other without or with food

Losartan

• An ARB Angiotensin 2 receptor blocker works to block angiotensin 2 to vasodialate and increase water excretion
• Is an antihypertensive medication used to prevent risks of heart failure, stroke and nephropathy
• ARBs do not cause hyperkalemia or cough.
• Watch for angioedema, hypotension
• Can administer with/without food

Verapamil, Diltiazem

• Calcium channel blocker cause vasodilation to decrease periphial arterial resistance.
• Treats Dysrhythmias, angina pectoris and hypertension
• Adverse effects can vary from Orthostatic hypotension, constipation and suppress cardiac function
• Administermeds by oral route, avoid grapefruit, avoid with hypotension, and with caution with pregnancy
• Monitor BP

Clonidine

• Centrally acting alpha 2, decrease sympathetic out flow to decrease BP
• Treats primary hypertension, severe cancer and management and ADHD
• Watch for dowsiness, dry mouth, rebound hypertension if abruptly stopped.
• Clonidine given oral epidural twice a day; trans dermal patch given every 7 days.
• Monitor BP, fall risk and sedation

Metoprolol, Propranolol

• Blocks beta, and reduce myocardial heart electrical system
• Decrease HR, Muscle contractility, conduction
• Use with food, and monitor HR
• Beta adrenergic blockers

Nitroprusside

• For emergency hypertension
• Adverse excessive hypotension

Digoxin

• Cardiac glycosides, to treat heart failure
• Nursing: 0.5 or .2 ng/L is TOXIC

Epinephrine

• Adrenergic agent treat block, heart shock arrested etc
• Nursing continuously IV infusion.

Dopamine

• Treatment of heart failure
• Low dose: renal failure patients
• Interventions: continuous fluid monitoring

Dobutamine

• Treatment of heart failure .
• Continuously monitor heart

Nitroglycerin

• Causes venous return, used for patients with angina.
• Check for heart failure and administer if needed.
• Teach patient sit down.

Atorvastatin

• Nursing Obtain baseline function lab and periodic test during procedure

Gemfibrozil

• Fibric acid derivative
• Side effect: myopathy

Amiodarone

• Interventions: Monitor patients toxicity and baseline function
• Treat dysrhythmias

Adenosine

• Slow down heart rate Medication, IV bolus 1- 5-10 seconds

Heparin

• An anticoagulant
• Heparin toxicity administer Protamine slowly

Enoxaparin

• Low molecular blood weight

Warfarin

• K inhibitors, treat venous thrombosis
• Complications of hemorrhaging and monitor
• Toxic Admin vitamin 1, synthic coagulation

Clopidogrel

• Primary prevention of acute myocardial

Alteplase

• Complication bleeding internal Gu or GL

Epoetin alfa

Anemia

Fligrastim

• Reduce risk infection

Allogenic bone Marrow

• Anemia blood count