1. Copyright © 2011 by Elsevier Inc. All rights reserved.
Analgesics (p. 154)
Medications that relieve pain without causing loss of consciousness
“Painkillers”
Opioids
NSAIDs
Medications that relieve pain without causing loss of consciousness are classified as analgesics. They are also commonly referred to as painkillers. There are various classes of analgesics, determined by their chemical structures and mechanisms of action.
Adjuvant drugs assist primary drugs in relieving pain.
NURSING APPLICATION:
What medications have been ordered for Ms. Jackson that have analgesic properties?
Copyright © 2011 by Elsevier Inc. All rights reserved.

2. Opioid Analgesics: Indications (p. 158)
Main use: to alleviate moderate to severe pain
Opioids are also used for:
Cough center suppression
Treatment of diarrhea
Balanced anesthesia
An agonist binds to an opioid pain receptor in the brain and causes an analgesic response, the reduction of pain sensation.
An agonist-antagonist, also called a partial agonist or a mixed agonist, binds to a pain receptor but causes a weaker pain response than a full agonist.
Opioid analgesics are often given with adjuvant analgesic drugs to assist with pain relief.
NURSING APPLICATION:
Why would Ms. Jackson need something for pain?
Copyright © 2011 by Elsevier Inc. All rights reserved.

3. Opioid Analgesics: Contraindications (p. 160)
Known drug allergy
Severe asthma
Use with extreme caution if:
Respiratory insufficiency
Elevated intracranial pressure
Morbid obesity
Sleep apnea
Paralytic ileus
If tolerance develops, a larger dose is required to maintain the same level of analgesia.
NURSING APPLICATION:
Why should the nurse be cautious about giving Ms. Jackson an analgesic?
Copyright © 2011 by Elsevier Inc. All rights reserved.

4. Opioid Analgesics: Adverse Effects (p. 160)
Euphoria
CNS depression
Leads to respiratory depression
Most serious adverse effect
Nausea and vomiting
Urinary retention
Diaphoresis and flushing
Pupil constriction (miosis)
Constipation
Itching
Some of these unwanted effects can be explained by the respective drug's selectivity for the receptors listed in Table 11-5.
The various body systems that the opioids affect and their specific adverse effects are summarized in Table 11-6.
NURSING APPLICATION:
Is an opioid analgesic advisable for Ms. Jackson? Why or why not?
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5. Analgesics: Nursing Implications (p. 167)
Before beginning therapy, perform a thorough history regarding allergies and use of other medications, including alcohol, health history, and medical history
Obtain baseline vital signs and I&O
Assess for potential contraindications and drug interactions
Adequate analgesia requires a holistic, comprehensive, and individualized patient assessment with specific attention to the type, intensity, and characteristics of the pain.
Levels of comfort also should be assessed, with comfort defined as the extent of physical and psychologic ease that an individual experiences.
Perform a thorough pain assessment. Discuss pain scales.
NURSING APPLICATION:
How will the nurse assess Ms. Jackson's pain level?
Copyright © 2011 by Elsevier Inc. All rights reserved.

6. Copyright © 2011 by Elsevier Inc. All rights reserved.
Anesthetics (p. 179)
Drugs that depress the central nervous system (CNS)
Depression of consciousness
Loss of responsiveness to sensory stimulation (including pain)
Muscle relaxation
General anesthetics are drugs that induce general anesthesia and are most commonly used to induce anesthesia during surgical procedures. General anesthesia is achieved by the use of one or more drugs.
Often a synergistic combination of drugs is used, which allows for smaller doses of each drug and better control of the patient's anesthetized state.
Moderate sedation, conscious sedation, and procedural sedation are synonymous terms for anesthesia that does not necessarily cause complete loss of consciousness and does not normally cause respiratory arrest.
There are two types of anesthesia, general and local.
NURSING APPLICATION:
Why would moderate sedation be used?
Copyright © 2011 by Elsevier Inc. All rights reserved.

7. Adjunct Drugs (to Anesthetics) (p. 179)
Sedative-hypnotics
Barbiturates (pentobarbital, secobarbital)
Benzodiazepines (diazepam, midazolam)
Hydroxyzine
Promethazine
Opioid analgesics
Fentanyl, sufentanil, meperedine, morphine
NMBDs
Anticholinergics
Adjunct is a general term for any drug or procedure that enhances clinical therapy for a condition when used simultaneously with another drug or procedure.
Adjunct drugs can be considered “helper drugs” when their use complements the use of any other drug(s) and are used simultaneously with general anesthetics for anesthesia initiation (induction), sedation, reduction of anxiety, and amnesia.
NURSING APPLICATION:
When would adjunct drugs be given and why?
Copyright © 2011 by Elsevier Inc. All rights reserved.

8. Drug Effects: Paralysis (p. 179)
First, autonomic activity is lost
Then pain and other sensory functions are lost
Finally, motor activity is lost
As local drugs wear off, recovery occurs in reverse order (motor, sensory, then autonomic activity are restored)
General anesthesia normally involves complete loss of consciousness, loss of body reflexes, elimination of pain and other sensations throughout the entire body, and skeletal and smooth muscle paralysis, including paralysis of respiratory muscles.
NURSING APPLICATION:
Why would this drug effect be desirable?
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9. Copyright © 2011 by Elsevier Inc. All rights reserved.
Adverse Effects (p. 180)
Usually limited
Adverse effects result if:
Inadvertent intravascular injection occurs
Excessive dose or excessive rate of injection is given
Slow metabolic breakdown occurs
Injection into highly vascular tissue occurs
“Spinal headache,” treated with an epidural blood patch
The adverse effects of general anesthetics are dose dependent and vary with the individual drug.
With the development and use of newer drugs, many of the unwanted adverse effects characteristic of the older drugs (such as hepatotoxicity and myocardial depression) are now a thing of the past.
NURSING APPLICATION:
What observations are important when a patient has had an anesthetic medication(s)?
Copyright © 2011 by Elsevier Inc. All rights reserved.

10. Neuromuscular Blocking Drugs (cont’d) (p. 186)
When used during surgery, artificial mechanical ventilation is required
These drugs paralyze respiratory and skeletal muscles
Patient cannot breathe on his or her own
Do not cause sedation or pain relief
Patient may be paralyzed yet conscious
Prevent nerve transmission in skeletal and smooth muscles, leading to paralysis.
They are often used as adjuncts with general anesthetics for surgical procedures.
The patient is rendered unable to breathe on his or her own, and mechanical ventilation is required to prevent brain damage or death by suffocation.
Always assess past history of surgeries and response to anesthesia.
NURSING APPLICATION:
What nursing action will be a priority after a patient has had a neuromuscular blocking drug?
Copyright © 2011 by Elsevier Inc. All rights reserved.

11. Copyright © 2011 by Elsevier Inc. All rights reserved.
CNS Depressants (p. 196)
Sedatives
Hypnotics
Sedative-hypnotics
A sedative can become a hypnotic if it is given in large enough doses.
NURSING APPLICATION:
Discuss how sedatives can also be addictive.
Copyright © 2011 by Elsevier Inc. All rights reserved.

12. Benzodiazepines (p. 197) A commonly prescribed drug class
Favorable drug effect profiles, efficacy, and safety
Used to be the most commonly prescribed sedative-hypnotic drugs; however, the nonbenzodiazepine drugs are now the most commonly used.
Benzodiazepines are classified as either sedative-hypnotic or anxiolytic.
NURSING APPLICATION:
What safety measure should be implemented if Ms. Jackson is prescribed a benzodiazepine?
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13. CNS Depressants: Nonbenzodiazepine Hypnotics (p. 200)
Share many characteristics of benzodiazepines
Used to treat insomnia
Examples: zalepion (Sonata), zolpidem (Ambien), eszoplicone (Lunesta), and ramelteon (Rozerem)
Eszoplicone and extended-release zolpidem (Ambien CR) approved for long-term therapy
Lunesta is the first hypnotic to be FDA-approved for long-term use. It is designed to provide a full 8 hours of sleep.
Be sure to perform a focus assessment on some of the more common parameters.
Close monitoring is needed in those who are anemic, are suicidal, or have a history of abusing drugs, alcohol, or other substances.
NURSING APPLICATION:
If Ms. Jackson were anemic, why would the nurse need to monitor her for adverse side effects if Lunesta had been prescribed?
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14. Benzodiazepines: Toxicity and Overdose (p. 198)
Somnolence
Confusion
Coma
Diminished reflexes
Do not cause hypotension and respiratory depression unless taken with other CNS depressants
Treatment symptomatic and supportive
Flumazenil as an antidote
An overdose of benzodiazepines may result in one or all of the following symptoms: somnolence, confusion, coma, and diminished reflexes.
However, overdose of benzodiazepines alone rarely results in hypotension and respiratory depression.
Benzodiazepines can interact with other CNS depressants such as alcohol and opioids.
Gastric lavage is generally the most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered after gastric lavage to remove any remaining drug. Hemodialysis is not useful in the treatment of overdose.
NURSING APPLICATION:
What might happen to a patient's vital signs if the patient receives a toxic dose  of a benzodiazepine?
Copyright © 2011 by Elsevier Inc. All rights reserved.

15. Sedative-Hypnotics: Barbiturates (p. 201)
First introduced in 1903; were the standard drugs for insomnia and sedation
Habit forming; low therapeutic index
Only a few commonly used today due in part to the safety and efficacy of benzodiazepines
Their sedative and hypnotic effects are dose related, and they act by reducing the nerve impulses traveling to the area of the brain called the cerebral cortex.
All barbiturates have the same sedative-hypnotic effects but differ in their potency, time to onset of action, and duration of action.
Overdose frequently leads to respiratory depression and respiratory arrest.
NURSING APPLICATION:
Explain the meaning of a low therapeutic index to Ms. Jackson's family in terms they will understand.
Copyright © 2011 by Elsevier Inc. All rights reserved.

16. Muscle Relaxants (p. 203)
Act to relieve pain associated with skeletal muscle spasms
Majority are central-acting
CNS is the site of action
Similar in structure and action to other CNS depressants
Direct-acting
Act directly on skeletal muscle
Closely resemble GABA
Used for the relief of painful musculoskeletal conditions such as muscle spasms, often following injuries.
Work best when used with physical therapy.
NURSING APPLICATION:
Why would Ms. Jackson take a muscle relaxant? Would this help her abdominal pain?
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