Unit 3

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acute pain

less than 3-6 months

chronic pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

salicylates

drugs derived from salicylic acid; used in pain management due to analgesic, antipyretic, and anti-inflammatory effects

salicylates: actions and uses

lower body temp
inhibit prostaglandins
used for mild to moderate pain; reducing elevated body temp; treat inflammatory conditions; risk of myocardial infarction; reducing risk of transient ischemic attacks

aspirin

inhibits prostaglandin synthesis and has greater anti-inflammatory effects; prolongs bleeding time

Salicylates adverse effects

GI:
- gastric upset, heartburn, nausea, vomiting, anorexia, GI bleeding, allergy
- significant blood loss
- allergic: hives, rash, angioedema, bronchospasm, anaphylactioid reactions

Salicylates: Contraindications and Cautions

contraindicated in:
- known hypersensitivity; bleeding disorders, children or teenagers with chickenpox or influenza
Cautiously:
- with hepatic and/or renal disease; during pregnancy; pre-existing hypoprothrombinemia; with vitamin K deficient; with GI irr

salicylates herbal consideration

willow bark from willow trees or shrubs grows in moist places
- use with caution with patients with peptic ulcers and medical conditions in which aspirin is contraindicated

nonsalicylates: actions and uses

- analgesic and antipyretic activity; no anti-inflammatory action
- used to treat moderate pain; reduce elevated body temp; manage pain or discomfort - arthritic disorders
- useful for people with aspirin allergy; bleeding disorders, receiving anticoagula

Nonsalicylates: Adverse Reactions

Skin eruptions; urticaria; hemolytic anemia; pancytopenia; hypoglycemia; jaundice; hepatotoxicity; hepatic failure. Overdose: Causes acute acetaminophen poisoning or toxicity

Nonsalicylates: contraindications and precautions

contraindicated in patients with hypersensitivity
- use cautiously with severe or recurrent pain or high or continued fever
- acetaminophen used cautiously during pregnancy and lactation

T/F: Pain is the unpleasant sensory and emotional perception associated with actual or potential tissue damage

true

primary adverse reaction of salicylates

gastric distress. long-term users should be monitored for potential bleeding from the GI tract. Ringing in ears (tinnitus) can be early sign of toxic reaction. Children should refrain from aspirin due to Reye syndrome

pain assessment

An evaluation of the factors that alleviate or exacerbate patient's pain; pain is subjective and effort is taken with standardized pain measurement tools to help the patient relay information needed to provide pain relief

assessment guidelines

- pt subjective description of pain
- location of pain
- intensity, severity, and duration
- any factors that influence pain
- quality of pain
- patterns of coping
- effects of previous therapy
- nurses observation of patients behavior

T/F: patients at risk for inadequate pain management are frequently those who are not assessed well

true

population at higher risk for poor pain assessment

- infants/children
- older adults, cognitively impaired
- developmentally disabled
- communication problems such as limited english proficiency or limited health literacy
- those unable to communicate due to illness or treatment process

nonsteroidal anti-inflammatory drugs (NSAIDs) actions and use

- thought to work by inhibiting action of an enzyme responsible for prostaglandin synthesis; NSAIDS inhibit two related enzymes
- inhibit activity of an enzyme that is responsible in maintaining the lining to the stomach
- inhibit activity of another enzy

ibuprofren and naproxen

blocks enzyme that triggers pain (therefore reducing symptoms of pain), causes adverse reactions such as unwanted GI reactions of stomach irritation and ulcers

celecoxib

inhibits pain triggers however with less potential for GI adverse reactions
- used for osteoarthritis, RA, and other musculoskeletal disorders, mild to moderate pain, fever reduction

NSAID adverse reactions

GI: nausea, vomiting, dyspepsia, diarrhea, constipation, epigastric pain, indigestion, abdominal distress or discomfort, intestinal ulceration, stomatitis, jaundice, bloating, anorexia, dry mouth
CNS: anxiety, lightheadedness, vertigo, headache, drowsines

NSAID adverse reactions

CV: congestive heart failure, +/- BP, cardiac arrhythmias, myocardial infarction
Renal: hematuria, cystitis, elevated blood urea nitrogen, polyuria, dysuria, oliguria, acute renal failure in those with impaired renal function
sensory: blurred vision, dipl

NSAID adverse reactions

hematologic: neutropenia, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, agranulocytosis, aplastic anemia
skin: rash, erythema, irritation, skin eruptions, exfoliative dermatitis, Stevens Johnson syndrome, ecchymosis, purpura
metabolic: decreas

NSAID contraindications

cross-sensitivity, increased risk of allergic reactions to others; hypersensitivity to aspirin, for post-op pain following CABG; during third trimester of pregnancy

ibuprofen contraindications

hypertension, peptic ulceration, or GI bleeding

celecoxib

allergic to sulfonamides, or history of cardiac disease or stroke

NSAID precautions

pregnancy (category B), elderly pts, pts w/ bleeding disorders, renal disease, cardiovascular disease, hepatic impairment

NSAID interactions

- anticoagulants: increased risk of bleeding
- lithium: increased effectiveness of and possible toxicity of lithium
- cyclosporine: increased effectiveness of the cyclosporine
- hydantoins: increased effectiveness of the anticonvulsant
- diuretics: decrea

Migraine treatment

caused by vascular spasms: prophylactically to prevent the spasms
to treat the acute pain when migraine occurs

actions and use of migraine treatment

symptoms of migraine: local cranial vasodilation and stimulation of trigeminal nerves
- activation of nerve receptors causes vasoconstriction and reduces the neurotransmission, which in turn produces pain relief
- selective serotonin drugs are used for re

migraine treatment adverse reactions

- dizziness, nausea, fatigue, pain, dry mouth, flushing
- CV: coronary artery vasospasm, myocardial infarction, cardiac arrhythmias and tachycardia

migraine treatment contraindications

in pt with known hypersensitivity to selective serotonin agonists and should only be used when a clear diagnosis of migraine headache has been established
- 5-HT agonists shoudl not be used in patients iwth ischemic heart disease (such as angina or myocar

migraine treatment cautions

patients with hepatic or renal function impairment, such as the elderly or patients requiring dialysis

migraine treatment herbal considerations

capsicum (hot pepper)

know following medications: trade and generic name, uses, and adverse reactions

- ibuprofen
- meloxicam
- naproxen
- diclofenac/misoprostol
- celecoxib
- rizatriptan
- sumatriptan

opioid analgesics

- controlled substances
- do not change tissues where pain originates
- change patient's perception of pain
- treat pain centrally in the brain

opioid analgesics include:

opiates, morphine, heroin, synthetic opioids

opiod analgesics: actions

cells within CNS
- mu and kappa receptors
- opioid analgesic
- agonist
- partial agonist
- agonist-antagonist
- nonintended responses
- page 174

most widely used opioid

morphine sulfate

gold standard for pain management

morphine sulfate

opioid analgesics: uses

- treat pain
- manage opiate dependence
- decrease anxiety
- support anesthesia adjunct
- promote obstetric analgesia
- administered intrathecally/epidurally
- treats severe diarrhea; intestinal cramping; severe, persistent cough

opioid analgesics: adverse reactions

CNS: sedation, increased intracranial pressure (euphoria, weakness, headache, tremor, insomnia, agitation)
Respiratory: depressed breathing rate/depth (depression of rate and depth)
GI: constipation, anorexia, biliary tract spasms (N/V, dry mouth, biliary

Opioid Analgesics: Adverse Effects

CV: tachycardia, bradycardia (facial flushing, peripheral circulatory collapse)
GU: urinary retention/hesitancy (bladder and ureter spasms)
allergic reactions: pruritus, rash, urticaria
Other: sweating, pain at injection site, local tissue irritation

Opioid Analgesics: Contraindications

- patients with hypersensitivity to drugs
- acute bronchial asthma, emphysema, or upper airway obstruction
- patients with head injury or increased intracranial pressure
- convulsive disorders; severe renal or hepatic dysfunction; actue ulcerative colitis

opioid antagonist (narcotic) actions:

prevents or reverses the effect of opioid drugs
no opioid: antagonist has no drug activity

opioid antagonist (narcotic) uses:

postoperative acute respiratory depression, reversal of opioid adverse effects, suspected acute opioid overdose

opioid antagonist (narcotic) adverse:

nausea, vomiting, sweating, tachycardia, increased BP, tremors

opioid antagonist (narcotic) contraindications & cautions:

hypersensitivity, pregnancy category B, infants of opioid-dependent mothers, patients with opioid dependency, cardiovascular disease, and lactation.

opioid antagonists (narcotic) withdrawal

opioid dependent

most common opioid antagonist

naloxone

naloxone used for treatment

postoperative acute respiratory depression, reversal, suspected acute opioid overdose

types of anesthesia

local anesthesia, general anesthesia

local anesthesia

topical: application of the anesthesia to surface of skin, open area, mucous membrane
local infiltration: injection of anesthesia into tissue (dental procedures, suturing, incision in small area)

local anesthesia

regional: injection of anesthesia around nerves to prevent sending pain signals
spinal: injection of anesthesia into the subarachnoid space of the spinal cord
conduction blocks: injection of anesthesia into or near a nerve trunk

preparing patients for local anesthesia

- taking patients allergy history
- prepare the area to be anesthetized
- cleaning area w/ antiseptic, shaving area
- requires fasting
- may administer IV sedative

administering local anesthesia

- mixed w/ epinephrine to cause local vasoconstriction
- epinephrine contraindicated when used on an extremity
- be aware of when to and when not to use epinephrine

pre-anesthetic drug

given before administration of anesthesia
may consist of one drug or a combo of drugs

pre-anesthetic drug: uses

- used to decrease anxiety and apprehension immediately before surgery
- used to decrease secretions of the upper respiratory tract
- used to lessen the incidence of nausea and vomiting during the immediate postoperative recovery period

selection of preanesthetic drugs

- may consist of one or more drugs
- opioid or barbiturate may be given to relax the patient
- cholinergic blocking drug is given to dry secretions in the upper respiratory tract
- drug diazepam (valium) used for pre-op sedation

general anesthesia

depends on: general physical condition of the patient, area, organ, system being operated on, anticipated length of surgical procedure

drugs used for general anesthesia

barbiturates (methohexital, etomidate, propofol)
benzodiazepines (midazolam)
ketamine
gases and volatile liquids (nitrous oxide, sevoflurane, isoflurane, desflurane)

opioids used for general anesthesia

opioids (analgesic fentanyl, droperidol, remifentanil, neuroleptic drug)
skeletal muscle relaxants (anectine, nimbex)

stages of general anesthesia

stage 1: anesthesia
stage 2: delirium and excitement
stage 3: surgical analgesia
stage 4: respiratory paralysis

nursing responsibilities

postanesthesia:
- admitting the patient to the unit according to hospital procedure or policy
- positioning the patient to prevent aspiration of vomitus and secretions
- checking the airway for patency, assessing the respiratory status, and giving oxygen

nursing responsibilities

- check BP and pulse, IV lines, catheters, drainage tubes, surgical dressings, and casts
- review the patients surgical and anesthesia records
- monitor the BP, pulse, and respiratory rate every 5-15 mins until the patient is discharged from the area

nursing responsibilities

- check the patient every 5-15 minutes for emergence from anesthesia. suctioning is provided as needed
- exercise caution in administering opioids
- discharge the patient from the area to his or her room or other specified area

antabuse (disulfiram)

A drug that causes intense nausea, vomiting, increased heart rate, and dizziness when taken with alcohol. It is often taken by people who are trying to refrain from drinking alcohol.

methadone (dolophine)

given for abstinence from opioids. Pain reliever similar to morphine. Undesirable effects:
Hives
Urticaria
Rash
The RR drops
Seizures

naltrexone (vivitrol)

blocks effects of other narcotic medicines and alcohol. undesirable effects:
Bleeding disorder
Educate to avoid alcohol containing products
Addiction to alcohol or narcotics is indication to take the medicine
Take tablet with water and food to decrease GI

buprenorphine

for opioid dependency, used in detoxification.
Cravings are decreased
Heroin and other opioids
Adrenal insufficiency, alcoholism, abdominal pain
Increase in CNS depression with alcohol, antidepressants, sedatives
Narcan is antidote
Sublingual is route dur