1. Narcotic Analgesic Medications Narcotic Analgesics

2. Opioids Actions –Analgesia –Euphoria –Sedation

3. Opioids Primary Use –Moderate Pain –Severe Pain –Acute Pain –Chronic Pain –Breakthrough Pain

4. Opioids Other Uses –Pre-Op Sedation –Adjunct Anesthesia –Anti Anxiety –Diarrhea –Opiate Dependence

5. Opioids Common Opioids –Morphine sulfate –Codeine –meperidine HCl (Demerol) –hydromorphone (Dilaudid) –fentanyl (Duragesic) –oxycodone (OxyContin)

6. Opioids Common Routes –IV –IM –Subcutaneous –Oral –Transdermal –Epidural

7. Opioids Adverse Reactions Euphoria, dysphoria, confusion, sedation Nausea, vomiting, constipation Hypotension, bradycardia or tachycardia Urinary hesitancy, dysuria Respiratory depression, cough depression Allergic reactions, pruritisPain, irritation at injection site

8. Opioids Contraindications Opiate allergies Head injuries, increased intracranial pressure Convulsions Ulcerative colitis Pulmonary diseases (asthma, COPD) Renal or hepatic dysfunction

9. Opioids Not recommended during labor Use caution with elderly Not recommended for biliary surgery Not recommended during lactation Precautions

10. Opioids Opioid Naive ToleranceAddiction Precautions

11. Opioids Precautions Opioids and Acetaminophen Daily acetaminophen intake should NOT EXCEED 4 grams

12. Opioids Interactions CNS Depressants Use caution whenever two or more CNS depressants given

13. Opioids Special Circumstances Opiates of Choice Codeine Persistent Cough Morphine Myocardial Infarct Meperidine Biliary Surgery

14. Opioids Opiate Poisoning miosis Respirations < 10 / min hypoxia

15. Opioids Opiate Antagonist

16. Opioids Patient Controlled Analgesia (PCA)

17. Opioids Epidural

18. Opioids Transdermal

19. Narcotic Analgesics Nursing Process Assessment –Pain assessment –Precipitating factors –Nonpharmacological medications –Time last medicated –Response to last pain medication –Allergies –Bowel history

20. Narcotic Analgesics Nursing Process Planning –Adverse reactions –Expected pain relief –Route of administration

21. Narcotic Analgesics Nursing Process Suggested Nursing Diagnoses –Pain, acute –Pain, chronic –Constipation r/t adverse drug effects

22. Narcotic Analgesics Nursing Process Implementation –Identify patient –Observe 6 Rights

23. Narcotic Analgesics Nursing Process Evaluation –Response to medication –Evidence of adverse reactions –Evidence of tolerance, addiction

24. Narcotic Analgesics Key Points Side Effects –Lethargy, Confusion –Constipation Adverse Reactions –Respiratory Depression (Opiate Naïve) –Opiate Poisoning Combination Drugs –Be mindful of acetaminophen toxicity

25. Narcotic Analgesics Key Points Addiction –Not likely to happen when purpose of drug is to relieve pain Tolerance –Likely to occur, especially with morphine PCA’s –PCA’s are PATIENT controlled, not nurse controlled

26. Narcotic Analgesics Key Points Opioids are drugs of choice for SOME pains Not ALL pain should be managed with Opioids Review: Thumbs Up? Thumbs Down?

27. Narcotic Analgesics Key Points Pain associated with Myocardial Infarction –Morphine is the drug of choice

28. Narcotic Analgesics Key Points Pain associated with Ulcerative Colitis –Opioids should be avoided

29. Narcotic Analgesics Key Points Pain associated with Gall Bladder surgery –Avoid morphine –Meperidine is drug of choice

30. Narcotic Analgesics Key Points Pain associated with Labor –May prolong labor –May cause respiratory depression in the newborn

31. Narcotic Analgesics Key Points Pain associated head injury –Opioids may increase intracranial pressure (ICP)

32. Narcotic Analgesics Key Points Pain in patients with COPD –Opioids cause respiratory depression

33. Narcotic Analgesics Key Points Pain in patients with seizure disorders –Opioids may precipitate seizures

34. Anesthestic Medications

35. Anesthetic Medications Topical –Application to body surface –Cream, lotion, spray, gel, etc. –May be given prior to an injection

36. Anesthetic Medications Local Infiltration –Injection of anesthetic into tissue –Example: Novacaine

37. Anesthetic Medications Regional Anesthesia –Spinal Subarachnoid space –Conduction Near a nerve

38. Anesthetic Medications Regional Anesthesia - Spinal –Injected into subarachnoid space of spinal cord –Most commonly 2 nd lumbar vertebra –Loss of feeling and movement Lower abdomen Perineum Lower extremities

39. Anesthetic Medications Regional Anesthesia – Conduction Blocks –Epidural block –Caudal block –Brachial plexus block

40. Anesthetic Medications Preparing the patient for local or regional anesthetics –Positioning –Teaching –Emotional Support

41. Anesthetic Medications Providing care after local or regional anesthesia –Safety r/t lack of sensation –Loss of body functions –Hemorrhage –Infection

42. Anesthetic Medications Preanesthesia Medications –Opioids to decrease anxiety / apprehension Fentanyl (Sublimaze) Meperidine (Demerol) Morphine

43. Anesthetic Medications Preanesthesia Medications –Barbiturates to decrease anxiety / apprehension Pentobarbital (Nembutal) Secobarbital (Seconal)

44. Anesthetic Medications Preanesthesia Medications –Benzodiazepines to decrease anxiety / apprehension Chlordiazepoxide (Librium) Diazepam (Valium) Midazolam (Versed) Lorazepam (Ativan)

45. Anesthetic Medications Antiemetic Medications –Decrease nausea / vomiting and side effect of drowsiness / antianxiety Hydroxizine (Vistaril) Promethazine (Phenergan)

46. Anesthetic Medications Antiemetic Medications –Cholinergic blocking agents to decrease respiratory secretions and mucous production Atropine sulfate Robinul Scopolamine

47. Anesthetic Medications General Anesthesia –Cause loss of consciousness –Except for very short procedures, patient must be intubated –Profound analgesia

48. Anesthetic Medications Types of General Anesthesia –Barbiturates Methotrexital (Brevital) Propofol (Diprivan)

49. Anesthetic Medications Types of General Anesthesia –Benzodiazepines Midazolam (Versed)

50. Anesthetic Medications Types of General Anesthesia –Ketamine (Ketalar) Street Drug Special K

51. Anesthetic Medications Types of General Anesthesia –Gases and Volatile Liquids Nitrous oxide

52. Anesthetic Medications Types of General Anesthesia –Opioids Fentanyl (Sublimaze) Given as adjunct to other medications to produce reduced motor activity and profound analgesia

53. Anesthetic Medications Types of General Anesthesia –Skeletal Muscle Relaxants Deep abdominal or chest surgery Facilitate endotracheal insertion Succinylcholine (Anectine)

54. Anesthetic Medications 4 Stages of Anesthesia –Stage 1 – Analgesia –Medication given to induce anesthesia –Lasts 5 – 10 seconds

55. Anesthetic Medications 4 Stages of Anesthesia –Stage 2 – Delerium –Delerium –Keep room quiet

56. Anesthetic Medications 4 Stages of Anesthesia –Stage 3 – Surgical Analgesia –Deep coma –Surgery takes place

57. Anesthetic Medications 4 Stages of Anesthesia –Stage 4 – Respiratory Paralysis –ABNORMAL – Severe Complication –Respiratory and Cardiac Arrest

58. Anesthetic Medications Nursing Responsibilities –Preanesthesia Check Allergies Administer Pre-op medications observing 5 rights Provide safety after medications given

59. Anesthetic Medications Nursing Responsibilities –Post Anesthesia: PACU Check airway for patency Observe for hypoxia, especially if nitrous oxide administered Position patient to prevent aspiration Check patient every 5 – 10 minutes, suctioning as needed

60. Anesthetic Medications Nursing Responsibilities –Post Anesthesia: PACU (cont.) Exercise caution in administering opioids Record all medications given

61. Anesthetic Medications Nursing Responsibilities –Post Anesthesia: Post-op Continue to exercise caution with opioid medications Refrain from barbiturates and benzodiazepines during first 24 hours Administer supplemental oxygen as needed

62. Anesthesia Medications Key Points Anesthesia can be –Local –Regional –General

63. Anesthesia Medications Key Points Many different kinds of medications can induce anesthesia –Barbiturates (Nembutal, Seconal) –Benzodiazepines (Versed) –Ketamine –Nitrous oxide –Opioids (Inapsine) –Skeletal muscle relaxants (Anectine)

64. Anesthesia Medications Key Points Many different kinds of medications can induce anesthesia –Barbiturates (Nembutal, Seconal) –Benzodiazepines (Versed) –Ketamine –Nitrous oxide –Opioids (Inapsine) –Skeletal muscle relaxants (Anectine)

65. Anesthesia Medications Key Points Nursing Responsibilities are dependent upon type of anesthesia given, but always focus on –Airway (respiratory depression, aspiration) –Safety (confusion, lethargy) –Comfort (without reentering anesthesia state)