Narcotic Analgesic Medications Narcotic Analgesics

Opioids Actions –Analgesia –Euphoria –Sedation

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

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

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

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

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

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

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

Opioids Opioid Naive ToleranceAddiction Precautions

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

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

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

Opioids Opiate Poisoning miosis Respirations < 10 / min hypoxia

Opioids Opiate Antagonist

Opioids Patient Controlled Analgesia (PCA)

Opioids Epidural

Opioids Transdermal

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

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

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

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

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

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

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

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?

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

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

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

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

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

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

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

Anesthestic Medications

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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)

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)