NURS 1950 Pharmacology Nancy Pares, RN, MSN Metro Community College 1

 Pain is:  Pain tolerance is: 2

 Objective 2: Identify the factors which affect the individual’s response to pain 3

 What are the assessments?  What is included in a pain history? 4

 Objective 4: Describe scheduled drugs 5

 Schedule I: high potential for abuse ◦ No accepted medical use in US  Schedule II: ◦ high potential for abuse ◦ Opiate analgesics 6

 Schedule III: lower potential for abuse than schedule II. ◦ Tylenol with codeine  Schedule IV: lower potential for abuse than schedule III. ◦ Librium, Valium 7

 Schedule V: lowest potential for abuse ◦ Usually antidiarrheal and antitussive ◦ Lomotil ◦ Robitussin A-C 8

 What are analgesics? 9

 Bind to opiate receptors in the CNS ◦ This inhibits transmission of pain impulse and alters pain perception ◦ Also produce euphoria 10

 Some are opioid agonists ◦ What is an agonist?  Some are agonist-antagonists 11

 Side effects of opioids ◦ N/V ◦ Constipation ◦ Respiratory depression ◦ Dependence ◦ Tolerance 12

 When the opioids are discontinued: ◦ Sweating, restlessness, diarrhea 13

 Signs and symptoms of overdose ◦ Respirations under 12/minute ◦ Pin-point pupils ◦ Coma  What drug can be used to reverse these effects?  Why does it work? 14

 Objective 7: Compare the many effects of morphine sulfate (MS) and meperidine (Demerol) 15

 MS ◦ Oral ◦ Subc ◦ IV ◦ IM ◦ Rectal ◦ Sublingual ◦ “mother” of all narcotics  Demerol ◦ Oral ◦ Subc ◦ IV ◦ IM 16

 MS  5-20 mg dose q 4 hr  min onset  Longer duration of action than Demerol  Demerol ◦ mg q 3- 4 hr ◦ min onset ◦ Shorter duration of action than MS 17

 Assessment of pain  Assessment of respirations  MS can be used in cancer pain  Meperidine (Demerol) metabolite is normeperidine: causes hallucinations 18

 What narcotic agents have you given? 19

 Many narcotic agents available  Given by every route  Some are only in oral form 20

 Some narcotic analgesics are ◦ Hydrocodone + acetaminophen (Vicodin) ◦ Fentanyl (Duragesic) ◦ Oxycodone + ASA (Percodan) 21

 A client is receiving MSContin q 12 hr-30 mg  At the next dose time, there is break through pain.  Can the client also have the MSIR dose? 22

 Narcotics work in the CNS and affect the nociceptors (nerve endings) and the neurotransmitter pathways of pain transmission  Acetaminophen, ASA, and the NSAIDs work in the periphery and interfere with prostaglandins 23

 Nonopioid drugs are also readily available (OTC) and inexpensive  Are antipyretic and ASA and some NSAIDs have antiplatelet activity  No tolerance or dependence is caused as is the case with opiates 24

 Double lock  Sign out  Use non-drug interventions  Assess pain  Give meds before pain severe  Don’t under treat pain 25

 Objective 11describe the use of salicylates 26

 Peripherally acting  Interfere with synthesis of prostaglandins ◦ What are prostaglandins? 27

 Acetylsalicylic acid (aspirin, ASA) used over 100 years  Analgesic  Antipyretic  Anti-inflammatory  Antiplatelet 28

 What are the doses for ASA? ◦ As analgesic ◦ As anti-inflammatory ◦ As antipyretic ◦ As antiplatelet 29

 Contraindicated if: on anticoagulants  if gastric ulcer  pregnancy  children with viral infections  Hypersensitive—teach client to read OTC labels 30

 Client must take adequate fluids  If GI upset, take with food or antacid ◦ Options: buffered ◦ enteric coated 31

 What does it mean when the label says the ASA is buffered?  What does enteric coating mean? ◦ Can EC drugs be crushed or chewed? 32

 ASA can cause false + for glycosuria  SE: tinnitus and vertigo with high doses  Store ASA in closed, child proof container  Overdose needs prompt treatment 33

 Objective 13: identify the signs of salicylate poisoning 34

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 Acetaminophen (Tylenol) ◦ Nonopioid analgesic ◦ Antipyretic ◦ Available as a liquid 36

 Disadvantage of Tylenol: ◦ Hepatotoxicity (over 4 gm/day) ◦ Nephrotoxicity 37

 Objective 15: list some non- narcotic analgesics 38

 Buprenophine HCl (Buprenex)  Butophanol tartrate (Stadol)  Pentazocine HCl (Talwin)  Ibuprofen (Motrin)  Naproxin (Aleve) 39

 If your client is taking Percocet and also has Tylenol ordered, what precautions will you take? 40

 Objective 16: identify some nonsteroidal anti-inflammatory agents 41

 Nonsteroidal anti- inflammatory agents modify inflammation response ◦ Inhibit prostaglandin synthesis ◦ Includes Aspirin as well as Motrin, Aleve, indomethacin (Indocin), oxaprozin ( Daypro), ketoralac (Toradol)  Toradol only one given IM, IV 42

 New NSAIDs are the COX-2 inhibitors  Vioxx off the market 2004  Celecoxib (Celebrex) and its cousin Bextra under review 43

 Advantage of COX-2 inhibitors: ◦ Less GI bleeding than other NSAIDs ◦ Once a day or BID dosing  Disadvantages: ◦ Can’t use if allergic ◦ expensive 44

 Gouty arthritis: ◦ caused by uric acid crystals ◦ Deposit in joints and subq tissue ◦ Treat ASAP when acute attack occurs ◦ Treat acute attack with colchicine  IV, oral 45

 think it prevents migration of granulocytes to inflamed area so no lactic acid released 46

 Adverse effects of colchicine ◦ N/V ◦ Diarrhea ◦ GI bleeding ◦ Neuritis ◦ Myopathy ◦ Alopecia ◦ Bone marrow depression 47

 NSAIDs may be used for inflammation, pain and fever  Two other types of drugs used for gout ◦ Uricosurics increase excretion of uric acid 48

 Adverse effects: ◦ kidney stones can develop  Examples: probenecid (Benemid) and sulfinpyrazone (Anturane) 49

 With Benemid keep urine alkaline  No ASA  Anturane works like Benemid but also affects clotting time ◦ Can cause GI bleeding, skin rash and blood dyscrasias 50

 Allopurinol (Zyloprim) prevents formation of uric acid ◦ Usually 300 mg dose 1x daily ◦ Can be given with colchicine or a NSAID ◦ SE of allopurinol: skin rash, hepatotoxicity 51

 Assessment  Nursing diagnoses ◦ Pain ◦ Chronic pain ◦ Risk for injury ◦ Deficient knowledge 52

 Goals ◦ Pain to be controlled ◦ Chronic pain will be controlled ◦ Demonstrate a proactive approach to pain management ◦ No injury from pain management ◦ Verbalize knowledge ◦ Implement plan 53

 Use pain-relieving measures  Pain history  Be proactive  Don’t under treat  Record pain relief  Assess respirations  Assess nausea, vomiting and decreasing BP 54

 Acetaminophen: no substitute for ASA  If allergic to ASA, avoid some NSAIDs  Indomethacin: ulcerogenic, aggravate epilepsy, psychiatric disorders 55

Nursing for anti-gout medications Assess those on colchicine Start colchicine at first sign Avoid those things that aggravate gout: High-fat diet, purine-rich foods, thiazide diuretics, liver extracts, nicotinic acid, penicillin, cancer chemotherapeutic agents, levodopa, ethambutol, egotamine 56