Anti-inflammatory and Analgesic Medications PDF

Focus on Medications for altered comfort Analgesics and Anti-inflammatory medications Pain  An unpleasant sensory and emotional experience associated with actual or potential tissue damage  A personal and individual experience  Whatever the patient says it is (Margo McCaffery)  Exis...

Focus on Medications for altered comfort Analgesics and Anti-inflammatory medications Pain  An unpleasant sensory and emotional experience associated with actual or potential tissue damage  A personal and individual experience  Whatever the patient says it is (Margo McCaffery)  Exists when the patient says it exists  Pain involves:  Physical factors  Psychologic factors  Cultural factors 2  Nociception  Pain results from stimulation of sensory nerve fibers called nociceptors.  These receptors transmit pain signals from various body regions to the spinal cord and brain. 3  Pain Tolerance  The amount of pain a person can endure without it interfering with normal function  Varies from person to person  Subjective response to pain, not a physiologic function  Varies by attitude, environment, culture, ethnicity 4  1 2 3 Step 1: nonopioids (with or Step 2: opioids with or Step 3: opioids indicated for without adjuvant without nonopioids and with moderate to severe pain, medications) after the pain or without adjuvants. If pain administered with or without has been identified and persists or increases, nonopioids or adjuvant assessed. If pain persists or management then rises to medications. increases, treatment moves (hydrocodone + APAP) (hydromorphone) to (NSAID – meloxicam) World Health Organization Three-Step Analgesic Ladder 5 Case Study  Angela, a 33 year old female has been having mild headache pain intermittently for 2 days. Patient is in provider office. Provider encourages patient to take acetaminophen as soon as headache pain begins. The provider teaches relaxation techniques as well to assist with the headache pain. Patient states she has been taking acetaminophen 1000 mg every 4 hours as needed for headache pain. She does not always take it, but she states she took it fairly often yesterday. Angela was also diagnosed with Hepatitis A after eating contaminated lettuce as part of a salad at her favorite restaurant. Non-opioid analgesics - acetaminophen  Analgesic and Antipyretic effects  Routes – PO, PR, IV  Maximum daily dose for healthy adult 4000mg/24h.  2000 mg for older adults and those with liver disease  Inadvertent excessive doses may occur when different combination drug products are taken together.  Be aware of the acetaminophen content of all medications taken by the patient (OTC and prescription). 7  Drug allergy Should not be Liver taken in the dysfunction Acetaminophen: presence of: G6PD deficiency Contraindication s and Dangerous interactions may Interactions occur if taken with alcohol or other drugs that are hepatotoxic. 8  Even though available OTC, lethal when overdosed Acetaminophe Overdose, whether intentional or resulting from chronic unintentional misuse, causes hepatic n: necrosis: hepatotoxicity Toxicity and Long-term ingestion of large doses also causes Managing nephropathy. Overdose Recommended antidote: acetylcysteine regimen 9  Can it be Does APAP given to Drug have a ceiling Common SE’s infant/children interactions? effect? ? Acetaminophen Stop use if skin rash appears Do not mix with ETOH Careful use if taking other meds which affect liver – phenytoin,rifampin Count doses from all medication Patient Teaching  Large and chemically diverse group of drugs with the following properties:  Analgesic Nonsteroidal  Anti-inflammatory Antiinflammato  Antipyretic ry Drugs  Aspirin-decreases platelet (NSAIDs) aggregation* 12 NSAIDs  NSAIDs are also used for the relief of:  Mild to moderate headaches  Myalgia  Neuralgia  Arthralgia  Alleviation of postoperative pain  The pain associated with arthritic disorders, such as rheumatoid arthritis (RA), juvenile arthritis, ankylosing spondylitis, and osteoarthritis (OA)  Treatment of gout and hyperuricemia 13  Known drug allergy  Conditions that place the patient at risk for bleeding: NSAIDs:  Vitamin K deficiency Contraindicatio  hemophilia ns  Peptic ulcer disease 14 NSAIDs and Renal Function  Renal function depends partly on prostaglandins.  Disruption of prostaglandin function by NSAIDs is sometimes strong enough to precipitate acute or chronic renal failure.  Use of NSAIDs can compromise existing renal function.  Renal toxicity can occur in patients with dehydration, heart failure, liver dysfunction, or use of diuretics or angiotensin- converting enzyme (ACE) inhibitors. 15 Cyclooxygenase Inhibitors  Mechanism of action  Inhibit cyclooxygenase (COX), the enzyme that converts arachidonic acid into prostanoids (prostaglandins and related compounds)  Inhibition of COX-1 (“good COX”)  Gastric ulceration  Bleeding  Renal impairment 16 Cyclooxygenase Inhibitors  Inhibition of COX-1: Beneficial effects  Protection against myocardial infarction (MI) and stroke  Inhibition of COX-2 (“bad COX”): Largely beneficial effects:  Suppression of inflammation  Alleviation of pain and reduction of fever  Protection against colorectal cancer 17 GI: heartburn Noncardiogen Increased risk Acute renal to severe GI ic pulmonary of MI and failure bleeding edema stroke Skin eruption, Tinnitus, Altered Hepatotoxicit sensitivity hearing loss hemostasis y reaction (aspirin) NSAIDs: Adverse Effects 18  Serious interactions can occur when given with  Anticoagulants  Aspirin NSAIDs:  Corticosteroidsand other ulcerogenic drugs Interactions  Protein bound drugs  Diureticsand ACE inhibitors (decrease effectiveness) 19 NSAIDs: Black Box Warning  AllNSAIDs (except aspirin) share a black box warning regarding an increased risk of adverse cardiovascular thrombotic events, including fatal MI and stroke.  NSAIDs may counteract the cardioprotective effects of aspirin. 20 Take med with milk or food Do not exceed recommended dosage Using with some meds may increase risk adverse GI effects s/s GI bleeding (think like a nurse) Patient Teaching Ketoralac  Trade name: Toradol  Short-term management of pain  Total duration of all routes should not exceed 5 days  Use lowest effective dose for shortest period of time to minimize risk fo cardiovascular thrombotic events  Do not administer with other NSAIDS  May have an additive effect to opioid therapy  Begin with IV or IM administration (PO should only be a continuation)  Intranasal route 22 Opioid Drugs  Synthetic drugs that bind to the opiate receptors to relieve pain  Mild agonists: codeine, hydrocodone  Strong agonists: morphine, hydromorphone, oxycodone, meperidine, fentanyl, and methadone  Meperidine: not recommended for long-term use because of the accumulation of a neurotoxic metabolite, normeperidine, which can cause seizures 23 Opioid Analgesics: Indications  Main use: to alleviate moderate to severe pain  Often given with adjuvant analgesic drugs to assist primary drugs with pain relief  Opioids are also used for:  Cough center suppression  Treatment of diarrhea  Balanced anesthesia 24 Opioid Analgesics: Contraindications  Known drug allergy  Severe asthma  Use with extreme caution in patients with:  Respiratory insufficiency  Elevated intracranial pressure  Morbid obesity or sleep apnea  Paralytic ileus  Pregnancy 25 Audience Response System A patient is recovering from an appendectomy. She also has asthma and allergies to shellfish and iodine. To manage her postoperative pain, the physician has prescribed patient-controlled analgesia (PCA) with hydromorphone. Which vital sign is of greatest concern? A. Pulse B. Blood pressure C. Temperature D. Respirations 26  CNS depression  Leads to respiratory depression  Most serious adverse effect   Hypotension/OH Opioid Nausea and vomiting  Urinary retention Analgesics:  Diaphoresis and flushing Adverse   Euphoria Effects Pupil constriction (miosis)  Constipation  Itching 27  Result: larger A common dose is required physiologic to maintain the result of chronic same level of opioid treatment analgesia Opioids: Opioid Tolerance 28  Physiologic adaptation of the body Opioids: to the presence of an opioid Physical Opioid tolerance and physical Dependenc dependence are expected with long-term opioid treatment and e should not be confused with psychologic dependence (addiction). 29  A pattern of compulsive drug use characterized by a continued craving for an opioid and the Opioids: need to use the opioid for effects other than pain relief Psychologic Dependence 30  Opioid Naloxone (Narcan)  Naltrexone (ReVia) Analgesics:  Regardless of withdrawal symptoms, Toxicity and when a patient experiences severe Management respiratory depression, an opioid antagonist should be given. of Overdose 31  Opioid Opioid withdrawal or opioid abstinence syndrome Analgesics: Toxicity and  Manifested as:  Anxiety, irritability, chills and hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramps, diarrhea, confusion Management of Overdose 32 Opioid Analgesics: Interactions  Alcohol  Antihistamines  Barbiturates  Benzodiazepines  Monoamine oxidase inhibitors 33 Opioid Agonist-Antagonists (pentazocine, buprenorphine)  Stimulate or block opioid action at Mu and Kappa receptors  Administered alone = analgesic affect  If administered to a patient taking and opioid agonist = decreased analgesic affect  If administered to long-term opioid user = may induce withdrawl sx  Uses: mod-severe pain, labor pain, sedation before surgery, supplement balanced anesthesia  Route: po, IM/SQ, IV  Butorphanol – intranasal option  Similar side effect profile to opioids  The nurse is administering medications to clients on an orthopedic unit. Which medication should the nurse question?  1. Ibuprofen to a client diagnosed with back pain and a history of gastric ulcers  2. Morphine to a client diagnosed with back pain rates as “7”  3. Methocarbamol to a client diagnosed with chronic back pain  4. Acetaminophen with codeine to a client diagnosed with mild back pain Practice Question #1  The client diagnosed with osteoarthritis who is taking celecoxib calls the clinic and report having black, tarry stools. Which intervention should the clinic nurse implement?  1. Ask if the client is taking any type of iron preparation.  2. Tell the client not to take any more celecoxib  3. Instruct the client to bring a stool specimen to the clinic.  4. Explain that this is a side effect of the medication. Practice Question #2