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

2.  Pain is:  Pain tolerance is: 2

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

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

5.  Objective 4: Describe scheduled drugs 5

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

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

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

9.  What are analgesics? 9

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

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

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

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

14.  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

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

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

17.  MS  5-20 mg dose q 4 hr  10-60 min onset  Longer duration of action than Demerol  Demerol ◦ 50-100 mg q 3- 4 hr ◦ 10-45 min onset ◦ Shorter duration of action than MS 17

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

19.  What narcotic agents have you given? 19

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

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

22.  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

23.  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

24.  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

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

26.  Objective 11describe the use of salicylates 26

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

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

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

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

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

32.  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

33.  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

34.  Objective 13: identify the signs of salicylate poisoning 34

35. 35

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

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

38.  Objective 15: list some non- narcotic analgesics 38

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

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

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

42.  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

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

44.  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

45.  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

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

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

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

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

50.  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

51.  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

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

53.  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

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

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

56. 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