Fall 2024 Nursing 488 Analgesic & Anti-inflammatory Meds PDF

Analgesic and Anti- inflammatory Medications Fall 2024 Nursing 488 Catherine Fox RN, MN, CON(C) Shelley de Boer, RN, MN Bemi Lawal RN,MSN/ADM Hillary Selkirk RN, MN, NP Lesson Objectives By the end of this lesson, you will:  Develop an understanding of the nursing process across the life...

Analgesic and Anti- inflammatory Medications Fall 2024 Nursing 488 Catherine Fox RN, MN, CON(C) Shelley de Boer, RN, MN Bemi Lawal RN,MSN/ADM Hillary Selkirk RN, MN, NP Lesson Objectives By the end of this lesson, you will:  Develop an understanding of the nursing process across the lifespan for individuals experiencing acute pain through exploring anti-inflammatory medications and analgesics.  Explore, discuss and identify common pharmacological interventions in caring for individuals experiencing acute pain, including anti-inflammatory medications,  Remember: Pain is defined by the individual Pain Classification Pain is a complex sensory and emotional experience Acute pain Chronic pain Sudden onset, short-term, Long-lasting, often persisting related to specific injury or beyond typical healing time cause (over 3-6 months). Often difficult to treat  Pain Pathways Nociceptive Pain Neuropathic Pain Central Pain Psychogenic Pain Referred Pain  Inflammation and Pain Inflammation is a localized protective response stimulated by injury to tissues, which serves to destroy, dilute, or wall off both the injurious agent and the injured tissue Chemicals like prostaglandins and bradykinin are released, sensitizing pain receptors (nociceptors) and increasing pain sensation. Pain encourages rest and protection of the injured area, allowing healing. Anti-inflammatory agents reduce both inflammation and associated pain, making them key in managing pain that stems from inflammation (e.g., arthritis, injury).  PAIN MANAGEMENT LADDER Step 3 Opioid for moderate Step 2 to severe pain WHO Pain +/- Non-opioid +/- Adjuvant Opioid for mild Management Step 1 to moderate pain +/- Non-opioid Ladder Non-opioid +/- +/- Adjuvant Adjuvant Increasing pain Address psychosocial and spiritual issues: consider adjuvant therapies  Pain Assessment and Tools: Review PQRSTU Common Pain Scales Location: Where is the pain? Numerical Rating Scale (NRS): 0 to 10 scale; quick Provoking: Aggravating/Relieving Factors -- What and commonly used. makes it worse or better? Visual Analog Scale (VAS): Patients mark pain level Quality: Describe the pain (e.g., sharp, dull, on a line from "No Pain" to "Worst Pain.” burning). Wong-Baker FACES Scale: Facial icons from happy Radiates: Where is the pain? Does it radiate to other to crying; ideal for children or non-verbal patients. areas? Severity: How severe is the pain? Often rated on a scale from 0 to 10. Time: How long has it lasted? Is it intermittent or constant? Understanding/Impact: How does pain affect daily activities and functioning? Monitoring and Evaluating Pain Management Monitor response to medication(s) Vital Signs Therapeutic or sub therapeutic response Give medications with meals to eliminate GI upset Monitor adverse effects such as hallucinations and treat accordingly May have increased effects of medication in the elderly and children (dose reduction) Pharmacological Management of Inflammation and Pain NSAIDs Anti-inflammatory Medications Corticosteroids Opioids Acute Pain Medication Non-Opioids Adjuvant Analgesic Therapies  Definition of inflammation: a localized protective response stimulated by injury to tissues, which serves to destroy, dilute, or wall off both the injurious agent and the injured tissue Anti- inflammatory Medications Anti-inflammatory Medications: Mechanism of Action: Anti-Inflammatory medications: Blocks the arachidonic acid Nonsteroidal or Corticosteroids pathway Anti-inflammatory Salicylates (e.g., aspirin) Acetic Acid Derivatives (e.g., Diclofenac sodium (Voltaren), Medications: NSAIDS Ketorolac) Cyclooxygenase-2 Inhibitors Enolic Acid Derivatives Clinical Uses of NSAIDS (e.g., Celecoxib (Celebrex) (Meloxicam, Piroxicam) Pain relief Anti-inflammatory uses Antipyretic Propionic Acid Derivatives Anti-arthritic effects (e.g., Ibuprofen (Advil, Motrin), Naproxen (Naprolen, Post-surgical or injury-related pain Naprosyn, Aleve)) NSAIDS: Contraindication s  Known drug allergy  Conditions that place the patient at risk for bleeding  Epistaxis  Vitamin K deficiency  Peptic ulcer disease  Children and teenagers with viral infections (risk of Reye’s syndrome, particularly with aspirin)  Not recommended for breastfeeding mothers  Exercise caution of use during pregnancy  NSAIDS Gastrointestinal Issues: These are the most frequently reported, including: Cardiovascular Risks: NSAIDs, especially selective COX-2 : Advers inhibitors, can increase the risk of hypertension, MI, and stroke. e Effect Renal Impairment: NSAIDs can reduce blood flow to the kidneys, potentially leading to AKI, fluid retention. Hematologic Effects: NSAIDs can alter blood clotting, s increasing the risk of bleeding, especially with concurrent anticoagulant use.  NSAIDS: Drug Interactions Anticoagulants (e.g., Warfarin, Heparin) ACE Inhibitors, ARBs, and Diuretics Lithium Methotrexate Corticosteroids SSRIs and SNRIs (e.g., Sertraline, Venlafaxine) NSAIDS: Important Lab Values Lab Values: Hemoglobin, Hematocrit, Platelets Creatinine and BUN AST and ALT Potassium Anti- Inflammator y Medications Mineralocorticoids Glucocorticoids : Corticoster oids  Anti-inflammatory Action Inhibits inflammatory mediators Reduces immune response Immunosuppressive Effect Decreases lymphocyte activity Glucocorticoids Inhibition of Vascular Permeability Stabilizes blood vessels Metabolic Effects Increases blood glucose Catabolic effects  Prednisone: oral (intermediate acting); commonly used for chronic inflammatory and autoimmune conditions. Dexamethasone: oral and IV (long acting); approximately 6-7 times more potent than prednisone and 25 times Systemic more potent than cortisol. Frequently used for acute inflammation, cerebral edema, and as an antiemetic Glucocortic in chemotherapy. oids Solu-Cortef (hydrocortisone sodium): IV; short-acting; closest to natural cortisol. Ideal for adrenal insufficiency and emergency situations requiring rapid cortisol replacement. Solu-Medrol (methylprednisolone sodium): IV; intermediate-acting; 4-5 times stronger than Solu-Cortef; often used in severe inflammatory and allergic reactions, including autoimmune flares and high-dose therapy.  Glucocorticoids: Indications Inflammatory Allergic Autoimmune Conditions Reactions Disorders Oncology and Respiratory Endocrine Hematologic Conditions Disorders Disorders  Glucocorticoids: Contraindications & Drug Interactions Contraindications Drug allergy Drug Interactions NSAIDs Active infections Antidiabetic medications Systemic fungal infections Anticoagulants (e.g., Warfarin) Live vaccinations Diuretics (especially non- Uncontrolled diabetes potassium-sparing) Peptic ulcer disease Vaccines (especially live vaccines) Hypertension and cardiovascular disease Osteoporosis Pregnancy Psychiatric conditions Glaucoma  Glucocorticoids: Adverse Events Metabolic/endocrine effects Immune system effects Musculoskeletal effects Gastrointestinal effects CNS effects Other: cardiovascular, ocular, and integumentary effects Glucocorticoids: Patient Teaching and Nursing Management Patient Teaching Nursing Management  Do not stop abruptly Administration routes: oral, IM, IV, intranasal, and inhalation  Take with food  Surgery considerations Gradual tapering  Recognize signs of infection Avoid concurrent NSAIDs and Aspirin Administer with food or milk  Monitor blood glucose (especially for diabetic patients). Monitor for therapeutic and adverse effects  Calcium and vitamin D intake to support bone health if on long-term therapy Acute Pain Medication Opioids Mechanism of Action: Opioids bind to specific receptors (mu, delta, and kappa) in the CNS and peripheral nervous system, altering the perception and response to pain. They can act as agonists (fully activate receptors), partial agonists (partially activate receptors), antagonists (block receptors), or endorphins (mimic natural endorphins) allowing for varied effects and applications in pain management. Indication: Opioids are a class of drugs primarily used to manage moderate to severe acute pain. They are often used for acute pain management post-surgery, injury, and severe pain conditions, particularly when other analgesics are insufficient. Also used in chronic pain management, palliative care, and severe pain related to cancer. Opioids Pain Potency Examples Strong (Full Agonists) Fentanyl: Extremely potent; used in surgical, post operative, procedural, and incidental pain due to its rapid onset and short duration. Morphine: Gold standard for severe pain. Used in surgical, post operative, and chronic pain. Hydromorphone (Dilaudid): Potent opioid for severe pain, often used post-operatively. Methadone: Used for chronic pain and addiction treatment. Moderate (Full Agonists) Oxycodone: Effective for moderate to severe pain; available alone or in combination with non-opioid analgesics. Tramadol: Has additional effects on serotonin and norepinephrine, offering moderate pain relief with a lower risk of respiratory depression. Mild (Weak Agonists or Codeine: Commonly combined with acetaminophen (Tylenol 3) for mild to moderate Partial Agonists) pain. Opioids: Adverse Effects Central Nervous System (CNS): sedation, dizziness, euphoria/dysphoria Respiratory: respiratory depression Gastrointestinal (GI): constipation, nausea/vomiting Cardiovascular: hypotension, bradycardia Urinary: urinary retention Other: pruritus, tolerance and dependence, anaphylaxis  Opioids: CNS Depression CNS Depression: opioids can cause CNS depression by binding to opioid receptors in the brain, which slows down brain activity, leading to sedation, slowed breathing, and, in severe cases, loss of consciousness. What is the antidote? Naloxone is an opioid antagonist that works by binding to opioid receptors and displacing the opioid, reversing the effects of CNS depression and restoring normal breathing. Administration routes: Intranasal: Quick and easy to administer; common in emergency settings and first-response kits. IV or IM: Provides rapid onset; IV administration is typically used in hospital settings. Naloxone works quickly but has a shorter duration than most opioids, so multiple doses may be needed in cases of prolonged opioid effects. Opioids: CNS Depression Opioids: Drug Interactions Anticholinergic CNS Depressants (e.g., Tricyclic (e.g., Antidepressants benzodiazepines, (e.g., Monoamine Oxidase alcohol, amitriptyline), Inhibitors (MAOIs) antihistamines, antipsychotics, muscle relaxants, antihistamines with barbiturates). anticholinergic properties) Other Opioids and Serotonergic Drugs CYP3A4 Inhibitors Mixed (e.g., SSRIs, and Inducers Agonists/Antagonist SNRIs) s Opioids: Lab Values to Monitor Liver Function (ALT, Alk Phos, Bilirubin) Most opioids are metabolized in the liver. Impaired liver function can lead to slower metabolism, causing opioids to accumulate in the body, which increases the risk of sedation, respiratory depression, and toxicity. Renal Function (Creatinine, BUN) The kidneys play a significant role in excreting opioid metabolites. If kidney function is impaired, these metabolites can build up, increasing the risk of adverse effects and toxicity.  Patient Controlled Analgesic (PCA) A method that allows patients to self-administer small doses of opioid analgesics through an IV pump. Programmed with the following: Concentration: drug concentration (e.g., hydromorphone 2 mg/mL) Dose: The amount of opioid the patient can receive with each dose. Lockout Interval: prevents the patient from administering another dose too soon, reducing the risk of overdose. Dose Limit: maximum dose that can be administered in a time period as per physician’s orders. Continuous Infusion (optional): provides a continuous background infusion along with patient- controlled doses. Monitoring: pain, RR, sedation: q1hx4, q2hx8, then q4h for the duration. At the end of each 8-hour shift: # of attempts recorded, dose given over the shift. Log is reset for each shift on PCA. Students are not allowed to handle or program PCAs but should understand their purpose, safety mechanisms, and the nurse’s role in patient monitoring. Opioids commonly used in PCAs include morphine, hydromorphone, and fentanyl.  Non-Opioids Non-opioid analgesics are pain-relieving medications that work through mechanisms other than opioid receptors. They are commonly used for mild to moderate pain and can be combined with opioids for enhanced pain relief. Effective for pain associated with inflammation, headaches, minor injuries, and musculoskeletal conditions. Main types of non-opioids includes acetaminophen (Tylenol) and Nonsteroidal Anti- Inflammatory Drugs (NSAIDs)  Non-Opioids: Acetaminophen Acetaminophen Mechanism of Action Blocks peripheral pain impulses by inhibiting prostaglandin synthesis Antipyretic effects by acting on hypothalamus Weak anti-inflammatory response Indications Mild to moderate pain May be used in the place of aspirin with reduced side effects Antipyretic effect for adults and children with the flu  Acetaminophen: Contraindications and Adverse Effects Contraindications Adverse Effects Drug allergy Hepatotoxcity Severe liver impairment or GI distress (N/V, abdominal liver disease pain) Renal impairment (high, prolonged doses) Rash, Uticaria Acetaminophen Toxicity Overdose and toxicity: Life-threatening and potentially lethal Maximum dose 4000 mg per 24 hr period Acute ingestion results in liver toxicity Long term ingestion results in nephrotoxicity Acetaminophen is the leading cause of serious liver injury in Canada, mostly due to unintentional overdoses Management Activated Charcoal N-Acetylcysteine (NAC) Liver Function Monitoring Acetaminophen: Monitoring and Patient Education Regularly assess liver function tests (e.g., ALT, Alk Phos, bilirubin) for patients on acetaminophen, especially those with existing liver conditions. Watch for signs of gastrointestinal distress and renal impairment during therapy. Advise patients not to exceed a maximum daily dose of 4 grams to prevent liver toxicity. Encourage reporting of any unusual symptoms, especially signs of liver distress (e.g., jaundice) or severe gastrointestinal issues.  Acetaminophen: Drug Interactions Alcohol (increased risk of hepatotoxicity) Hepatotoxic drugs Warfarin (potential for enhanced bleeding risk) Phenytoin, Rifampin, Barbiturates Caution with other combination products with acetaminophen (e.g., OTC cold medications)  Adjuvant Analgesic Therapy Adjuvant drugs are often added to enhance pain management in specific pain types, like neuropathic or inflammatory pain, that may not respond fully to traditional analgesics alone. Examples: Antidepressants – neuropathic, complex pain Antiseizure agents – neuropathic pain Glucocorticoids – inflammation Muscle relaxants – neuropathic pain/muscle spasms Local anesthetics – localized pain NSAIDS – inflammation Bisphosphonates – pain related to bone loss or metastasis Non-Pharmacological Management of Pain Physical Therapies Mind-Body and Psychological Therapies Complementary Therapies Distraction and Sensory Techniques Herbal and Natural Supplements Non-Pharmacological Therapy for Pain Physical Therapies Hot or Cold Packs: can be effective for managing acute and chronic pain, especially for inflammation (cold) and muscle relaxation (heat). Massage: Proven to relieve muscle tension, reduce stress, and improve circulation, making it valuable for musculoskeletal pain. Transcutaneous Electrical Nerve Stimulation (TENS): Effective for neuropathic and chronic pain, TENS provides a non-invasive option that patients can sometimes use at home. Physiotherapy: Important for improving mobility, strength, and overall function, especially for chronic pain conditions.  Non-Pharmacological Therapy for Pain Mind-Body and Psychological Therapies Cognitive and Behavioral Therapy (CBT): Teaches coping strategies, reframing thoughts, and managing stress to improve pain tolerance. Biofeedback: Allows patients to control physiological responses, like muscle tension, to manage pain more effectively. Relaxation Techniques (e.g., meditation, imagery, hypnosis): Useful for reducing stress and improving pain management through mental relaxation and focused breathing. Mindfulness and Meditation: Effective for chronic pain, especially in reducing the emotional and psychological impact of pain.  Non-Pharmacological Therapy for Pain Complementary Therapies Acupuncture and Acupressure: Commonly used for chronic pain, acupuncture and acupressure are supported by research in certain pain types, such as osteoarthritis and back pain. Yoga: Combines movement, breathing, and mindfulness, which helps with flexibility and reduces stress. Especially beneficial for chronic conditions. Non-Pharmacological Therapy for Pain Distraction and Sensory Techniques Distraction (e.g., music therapy, art therapy, pet therapy): Reduces the perception of pain by redirecting attention; music therapy and pet therapy are often used to ease pain and anxiety. Therapeutic Communication: Establishing trust and providing emotional support can help patients feel more comfortable, reducing the overall perception of pain. Non-Pharmacological Therapy for Pain: Nursing Interventions Comfort: Frequent re-positioning Cold/ice therapy Warm blanket Verbal reassurance Deep breathing Presence  Understanding Tolerance, Dependence, and Addiction Tolerance: A physiological adaptation where the body requires higher doses to achieve the same effect over time. Dependence: A state in which the body adapts to the drug, resulting in withdrawal symptoms if the drug is suddenly stopped. Addiction: A psychological condition characterized by compulsive drug- seeking behavior and use, despite harm. Why Things Hurt Lorimer Moseley – Why Things Hurt Pain as protection: Pain isn’t always tied to injury; it’s the brain’s response to perceived threat. Brain constructs pain: Pain is influenced by past experiences, context, and perceived danger. Neuroplasticity and chronic pain: The brain can "learn" pain, prolonging it even after healing. Education helps: Understanding pain reduces its impact and improves coping.  PAIN MANAGEMENT LADDER Step 3 Opioid for moderate Step 2 to severe pain WHO Pain +/- Non-opioid +/- Adjuvant Opioid for mild Management Step 1 to moderate pain +/- Non-opioid Ladder Non-opioid +/- +/- Adjuvant Adjuvant Increasing pain Address psychosocial and spiritual issues: consider adjuvant therapies Effective pain management requires a stepped approach, acknowledging the individual’s unique experience and the complex sensory and emotional nature of pain. Thank you!