NU 307 Pharmacology Pain and Inflammation

Overview of Medications

• Drug therapy options for pain include NSAIDs (first and second generation), acetaminophen, centrally acting nonopioids, opioid agonists, opioid agonists-antagonists, and opioid antagonists.
• Drug therapy options for inflammation include antihyperuricemics and glucocorticoids.

Overview of Pain Medications

• Pain has many types with the potential for many causes.
• Pain medications act on pain receptors to stimulate them to cause anesthesia or relief.
• These medications also can cause respiratory depression, euphoria, sedation, and physical dependence.

Pain Review

• Factors can affect pain.
• Pain can be categorized by cause: acute or chronic.
• Subjective and objective assessments of pain should be considered.
• Pain has different types.
• Assessment and reassessment of pain are important.
• Reasons exist for poor treatment and undertreatment of pain.

Reasons for Undertreatment of Pain

• Culture or societal beliefs can influence pain treatment.
• Lack of knowledge contributes to undertreatment.
• Fear, especially among infants, children, and geriatric populations, is a factor.
• Clients with substance abuse histories may also experience undertreatment.

Nonoioid Analgesics

• Nonopioid analgesics include NSAIDs, COX1 and COX2 inhibitors, acetaminophen, dual mechanism agents, and tramadol.

NSAIDs - First Generation

• Uses include suppressing inflammation and providing mild to moderate pain relief.
• They can reduce fever and alleviate dysmenorrhea.
• They inhibit platelet aggregation, acting as an anticoagulant which involves weighing benefits versus risks.

NSAIDs

• ASA, ibuprofen, naproxen, and ketorolac are classifications of NSAIDs.
• NSAIDs inhibit COX 1 (cyclooxygenase), which usually decreases platelet aggregation, protects gastric mucosa, and promotes renal function.

NSAIDs Pharm Action

• COX-2 stimulates the inflammatory response.
• COX-1 selective NSAIDs include ketorolac, indomethacin, ibuprofen, and naproxen.
• COX-2 selective NSAIDs include diclofenac and celecoxib.

NSAIDs Adverse Drug Reactions

• Adverse drug reactions include gastric upset, heartburn, nausea, gastric ulceration, and bleeding tendencies.
• Overdose can lead to salicylism, a buildup of aspirin in the body.
• Reye's Syndrome can occur when giving ASA to children, therefore it is not recommended for those under 18 years old.

NSAID Nursing Interventions

• Thinking about adverse effects and how to monitor for them are key.
• Interventions include monitoring for signs of bleeding and monitoring I+O, BUN/CRE.
• Monitor for overdose when giving ASA.
• Be alert to tinnitus, dizziness, headache, sweating, and tachypnea

NSAIDs Nursing Administration

• Client instructions include swallowing enteric/SR tablets without crushing or chewing, taking with food to prevent GI upset, and avoiding ETOH.
• Instruct clients to report ringing or buzzing in ears.
• Discontinue before surgery.

NSAIDs Contraindications/Precautions/Interactions

• Contraindications and precautions include pregnancy risk, bleeding disorders, peptic ulcer disease, ETOH disorders, kidney disease, and hypertension.
• Interactions can occur with anticoagulants and steroids.
• There is increased bleeding with ETOH.
• NSAIDs decrease ACE and ARBs, increase renal failure, and decrease antihypertensive effects.

NSAIDs 2nd Generation

• Fewer adverse reactions occur with second generation NSAIDs.
• The intended usage of NSAIDs is to supress pain and inflammation.
• Complications include gastric upset, heartburn, nausea, kidney dysfunction, and cardiovascular and cerebrovascular events.
• Contraindications include a risk of premature closure of the ductus arteriosus, severe hepatic impairment, and advanced kidney disease.
• Contraindicated for those younger than 18, with GI bleeding, anemia, and allergies to sulfa, sulfonamides, and celecoxib.
• Diuretic effects of furosemide decreases, fluconazole increases celecoxib levels, and anticoagulants increase effects of warfarin.
• Glucocorticoids and alcohol increase the risk of bleeding, and antihypertensive effects of ACE inhibitors decrease.
• Decreased risk of lithium carbonate toxicity can occur.
• It is effective for inflammation suppression, mild to moderate pain reduction, fever reduction, and dysmenorrhea.

Acetaminophen

• It is classified in its own category, and is a nonopioid.
• It provides mild to moderate pain relief, and reduces fever.
• It does not have anti-inflammatory or anticoagulant effects, and has similar benefits to NSAIDs with fewer ADRs.

Acetaminophen Adverse Drug Reactions

• Liver damage can occur.
• The toxic dose is 4 grams max.

Acetaminophen Nursing Interventions

• Monitor for signs and symptoms of overdose. Abdominal discomfort, nausea, vomiting, sweating, and diarrhea can occur quickly within 48-72 hours.
• The antidote is mucomyst/Acetadote.

Acetaminophen Administration/Education

• There are many routes of administration.
• Count all meds with Acetaminophen.
• Education for clients is to take the appropriate dose, and to report signs and symptoms of overdose, N/V, and discomfort.

Acetaminophen Contraindications/Precautions

• Using it is cautioned for patients with certain conditions.
• Avoid alcohol and nonprescribed drugs.
• ETOH, anemia, and hepatic disease should be considerations for caution.

Pain Case Study - 1

• A 70-year-old male is admitted to the orthopedic floor with severe pain reported in his hands, feet, and right knee.
• He has a history of joint inflammation and has taken several NSAIDs over the years to reduce the pain.
• However, the pain seems relentless; he presented to his primary care provider for care and is now admitted to the unit.

Pain Case Study - 2

• The home medications include aspirin 325 mg every 8 hours as needed for pain, calcium carbonate 500 mg tabs as needed for indigestion.
• The home medications also include ibuprofen 200mg every 8 hours as needed for pain, and a multivitamin 1 tab every morning.

Pain Case Study - 3

• Determine the mechanism of action for the pain medications.
• Determine what lab work needs to be assessed for this patient for each medication.
• Figure out how to measure the effectiveness of each medication.
• Determine how NSAIDs affect the kidneys.

Pain Case Study - 4

• Physical assessment findings are as follows.
• The patient is alert, PERRLA, steady gait.
• SR is at 78, BP 100/50, trace BLE edema.
• LS clear, RR 18, unlabored.
• Bowel sounds are positive X 4.
• The patient reports having a "little problem", BUN 30, CRE 1.1.
• The patient walks everyday, and reports joint pain.
• The patient has warm, dry, scattered bruising to arms and legs.
• Pain is reported as 3/10, and patient grimaces when asked to squeeze both hands.

Pain Case Study - 5

• Determine what labs needs to be additionally known.
• Find out which medications should be stopped.
• Discover which medications should be added.

Opioid Agonists

• They bind to opioid receptors.
• They produce analgesic effects for moderate to severe pain.
• These can cause sedation and reduction in anxiety.

Opiod Agonists Examples

• Examples include morphine, fentanyl, meperidine, and methadone.
• They bind to sites to cause analgesia and/or sedation.
• These medications can also cause euphoria and respiratory depression.

Opioid Adverse Drug Reactions

• Respiratory depression, sedation, dizziness/lightheadedness, drowsiness, constipation, nausea/vomiting, urinary retention, cough suppression, tolerance, and cross-tolerance can occur.

Opioid Agonist Nursing Interventions

• Monitor VS, specifically pulse ox and RR.
• RR less than 12? Hold medication and notify provider.
• May need to reverse with naloxone.
• Monitor bowel function and encourage fiber, water, and stool softeners.
• Be alert to possible orthostatic hypotension.
• Monitor I+O and urinary retention.

Opioid Nursing Interventions

• Respiratory depression is a huge concept.
• Implement fundamental concepts, turn cough and deep breath, use incentive spirometer.

Opioid Nursing Administration

• Obtain baseline vitals.
• Continue to monitor I+O.
• Use the correct route.
• Give low and slow.
• Have Narcan (naloxone) and resuscitation equipment available.
• Administer around the clock.

Opioid Contraindications/Precautions/Interactions

• They are contraindicated in a pregnant woman.
• They are contraindicated with renal failure and with a controlled substance.
• Use with caution with respiratory disease, other CNS depressants, and other anticholinergics.
• Avoid use with ETOH and benzos.

Opioid Agonists-Antagonists

• The medications are an adjunct to anesthesia with milder effects.
• It turns on the receptor, but just a little!
• It causes less adverse effects.
• Do not administer with RR less than 12.

Opioid Antagonists

• These reverse the effects of opioids by blocking opioid receptors.
• They reverse opioid overdose and respiratory depression.
• Naloxone (Narcan) is a treatment for opioid abuse.

Naloxone Adverse Drug Reactions

• Ventricular arrhythmias may occur.
• HR and RR will increase.
• Abstinence syndrome.
• Withdrawal.
• Hypertension.
• Vomiting.
• Tremors.

Naloxone Administration/Interventions

• Monitor VS, increasing BP, and respiration.
• Monitor heart rate and rhythm!
• Multiple routes exist.
• It increases pain.
• Monitor for WD symptoms.
• Administer every 2 to 3 minutes until reversal.
• The half life of opioid may be longer than that of Narcan! Watch out!

Opioid Overdose Case Study

• A 21-year-old male client has a chief complaint of pain and is found by the triage nurse in the emergency department to be minimally responsive.
• It is important to recognize cues of a client at risk for opioid overdose, recognize cues of an opioid overdose, plan and prioritize care for a client experiencing an opioid overdose, and implement an appropriate treatment plan.

Overview of Inflammatory Medications

• Inflammation is a response to damage and pain-mediating chemicals.
• The body's response is inflammatory response, pain, inflammation, edema, and fever.
• Uricosuric is used to treat gout.
• Corticosteroids are used for inflammation and autoimmune conditions.

Uricosurics/Antihyperuricemics

• Gout is a condition when there are high levels of uric acid.
• Crystals develop and are deposited in the joints, usually small joints.

Gout - Allopurinol (Zyloprim)

• It inhibits conversion of enzymes into uric acid.
• It promotes excretion of uric acids in the kidneys.
• Adverse reactions include hypersensitivity, fever, rash, increase in WBC (eosinophils), N/V/D, CNS: drowsy, headache, bone marrow depression, and agranulocytosis to decrease in WBC.

Allopurinol Nursing Interventions

• Monitor for hypersensitivity.
• Stop immediately with rash.
• Give with meals/fluid.
• Implement fall precautions.
• Monitor CBC.
• Check liver and kidney tests.

Allopurinol Patient Education

• Report fever, rash, abdominal pain, swelling, or poor urine output!
• Use OTC analgesics.
• Metallic taste in mouth.
• Can develop cataracts - use sun protections!
• Ingest in 3L fluid per day.

Steriods

• Corticosteroids are also called glucocorticoids or steroids.
• Regardless of what they are called they are potent, fast-working anti-inflammatories.
• Do not confuse them with anabolic steroids, which some athletes take to improve their performance.

Steriods

• Corticosteroids have two types: gluco and mineral -corticoids.
• These are produced in response to stress.
• These produce anti-inflammatory effects in the body and immune system.

Corticosteroids Adverse Drug Reactions

• It can cause a suppression of adrenal function.
• Can cause hyperglycemia, myopathy, GI distress/peptic ulcer, and risk for infection.
• F+E Imbalances, fat redistribution/deposit, and truncal obesity can occur.

Corticosteroids Nursing Interventions

• Monitor for adrenal insufficiency with hypotension and fatigue.
• Monitor blood glucose.
• Observe for GI bleed.
• Observe for infection.
• Monitor I+O.

Corticosteroids Nursing Admin

• Multiple routes of administration.
• Give the largest dose first day, then taper!
• Do not stop abruptly.

Corticosteroid Patient Education

• Know pill schedule.
• Gradually taper, do not stop abruptly.
• Discuss S/S of hyperglycemia.
• Avoid NSAIDs due to GI distress.
• Teach patient about S/S infection.
• Prevent hypokalemia.
• Take calcium and vitamin D.
• Know about possible cataract development.

Corticosteroid Contra/Precautions

• Be careful with vaccines.
• Hypokalemia and potassium wasting diuretics are a concern.
• Avoid NSAIDs.
• May need more insulin.

Care of the Surgical Patient

• Drug therapy that supports anesthesia includes:
• Local Anesthesia: lidocaine (Xylocaine).
• Use: Local and/or topical.
• Benzodiazepine: midazolam (Versed).
• Use: Post op pain, or can be used for sedation.
• Opioid: fentanyl.
• Use: Post op pain, or can be used for sedation.