Chapters+14-17+182-2010 - PAIN! Chapters 14­17 Candance...

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Unformatted text preview: PAIN! Chapters 14­17 Candance Tooley, MSN PNR 182 Spring 2010 Drugs used to Manage Drugs used to Manage PAIN PAIN • Pain is due to actual or potential tissue damage. It is subjective and must be taken seriously. Pain is known as the fifth vital sign and is very important to assess. (Display 14­1) There are three types of pain: • Acute pain­ • Chronic pain • Chronic pain related to a non­malignancy Non­Opioid Non­Opioid Analgesics ­ Used to treat pain with out risk of dependency. Three types: • Salicylates • Nonsalicylates • Non­steroidal anti­ inflammatory drugs. (NSAID’s) Salicylates Salicylates • Some common names you will see for salicylates are: Bayer, Ecotrin, Ascriptin, Bufferin, etc. Actions Actions Have: analgesic, antipyretic, and an anti­inflammatory effect. Uses Besides the ones listed above they decrease risk of MI in both sexes. Also decreases risk of TIA or strokes in men. Helps in high risk pregnancies when there is poor uterine­placental blood flow. ASPIRIN ASPIRIN • is the drug that has a greater anti­inflammatory effect than any other salicylate. • prolongs bleeding time by keeping platelets from sticking together than any other salicylate. When bleeding is prolonged it takes longer for the blood to clot. • This effect of ASA on platelets is irreversible and last for 7­10 days. Adverse Adverse Reactions • Gastric upset, heartburn, N&V, and GI bleeding –not bad if taken occ. But if taken over a long period of time can cause blood loss. •Allergies­hives, rash, angioedema, or anaphylactic reaction. •Salicylate toxicity is called salicylism. Symptoms are dizziness, tinnitus, flushing, tachycardia, and drowsiness. Is usually reversible with stopping or decreasing amount of drug taking. CONTRAINDICATIONS CONTRAINDICATIONS • These drugs are NOT to be given to those with bleeding tendencies, a GI bleed/PUD, Vitamin K deficiency, those on anticoagulant drugs, or children with the flu/chickenpox because can cause Reye’s syndrome. If given to children signs of Rey’s are initially vomiting/lethargy. Interactions Interactions • Avoid prunes, tea, licorice or raisins because they contain salicylates. • Activated charcoal and antacids decrease the actions/ absorption of salicylates. Non­Salicylates Non­Salicylates • Acetaminophen (Tylenol) • USES ­ASA substitute for those that develops GI problems or allergic to ASA. Has analgesic and antipyretic properties only. Drug of choice for children with fever/flu symptoms. Adverse reactions Adverse reactions and Interactions •Adverse reactions occur with chronic use. Most dangerous is pancytopenia, jaundice due to hepatotoxicity, and hepatic failure. •Acute poisoning/toxicity causes the liver cells to die and the person will die from liver failure. Risk of liver failure increase with chronic ETOH abusers. • S/S is confusion, N/V, sweating, tired, liver tenderness, jaundice, hypotension, and acute liver and renal failure. Do not give to chronic alcoholics and only use for short­term treatment of pain/pyrexia. •Do not give Tylenol with other drugs that have high potential for causing liver problems­ ex. TB medications and loop diuretics. Assessment Assessment • • • • Assess pain as we discussed earlier. Examine any affected areas for color, edema, limitation of movement, etc and document. After medicating patient follow up as per route of administration and reassess the pain level and document. If the patient is not getting relief you may need to give them something else or call the doctor. Take VS every 4 hours and temperature more often if given for fever. If medication given rectally check temp in 30 minutes. Fevers can lead to dehydration. Patient may need cooling blanket. Usually medications are not ordered unless the temperature is greater than 102. Assess the joints to see if they are able to move them better. Some people have deformed joints due to diseases such as rheumatoid arthritis. Also check their stools /vomitus for blood (black, bright red) to ensure a GI bleed is not developing. Implementation Implementation • • • • Give salicylates with foods, milk, or a full glass of water to prevent GI upset. If upset develops call the MD for an antacid. Tell patients to stop taking salicylates 1 week before surgery (any type) and not to resume taking them until they have healed or the doctor has okayed. Monitor patient for signs of salicylism and call MD if they develop. The person will need to be provoked to throw up and /or a gastric lavage to remove any medications. Activated charcoal decreases ASA absorption if given within 2 hours. Monitor for hearing problems due to salicylate toxicity. If they develop stop the drug and tell them the symptoms will decrease gradually. Implementation Implementation • Acetaminophen – can be given with a full glass of water with or without food. • To try and stop liver damage if a patient develops toxicity: ­ it is treated with gastric lavage within 4 hours AND/OR ­Mucomyst (the antidote) and should be given by HHN within 24 hours. • A person should never take over 2 grams of Tylenol per day. • Monitor liver function test. EDUCATION EDUCATION • Take medications as prescribed. • BE careful when using OTC drugs­ they may have ASA/Tylenol in them which increases the risk of toxicity. • If pain persists more than 10 days and a fever more than three days they need to see their family doctor. • Tell them to buy salicylates in small amounts because they deteriorate fast, if they have a vinegar smell they are to be thrown away. • If being taken for chronic condition­ tell to take even if pain has subsided. • How to detect complications such as a GI Bleed. (Page 139). NSAID’s NSAID’s • Drugs that are similar to the salicylates. • They also have anti­ inflammatory, antipyretic, and analgesic effects. • Some common names you will see: Ansaid, Advil, Motrin, Indocin, Toradol, Relafen, and Aleve. (Pages 142­143) ACTION ACTION • They work by inhibiting the production of prostaglandins and the action of the enzyme COX. Actions of COX –1 protects the stomach and COX­ 2 triggers pain and inflammation (COX=cycloo1xygenase). • The old NSAID’s (Advil, ibuprofen, naprosyn) use to stop the release of both of these enzymes and that is why people developed GI problems. • Newer medications only stop the releases of COX 2 so that there is a decreased risk of GI effects with Celebrex. Uses Uses • Pain due to osteoarthritis, rheumatoid arthritis, and other MS disorders. • Can not give many drugs to children with juvenile arthritis and children under 12 years old with an elevated temp. Ibuprofen used for children with juvenile arthritis and fever reduction in children ages 6­ 12. • Mild to moderate pain • Menstrual cramps • Fever Adverse reactions­ Adverse reactions­ GI­ N&V, epigastric pain, bloating, jaundice. • CNS­Dizziness, HA • Acute Renal Function if has impaired renal function • Visual changes. Contraindications Contraindications • If allergic to any NSIDS or ASA high risk of being allergic to rest. • Do not take Celebrex if allergic to sulfonamides or have a history of heart disease or stroke can be life threatening. • Ibuprofen needs to be avoided in those with HTN, PUD, or GI Bleed. Assessment Assessment • Allergies, hx of GI bleed, PUD, renal, liver, cardiac problems or hx of a stroke. • Perform pain assessment. • Reassess pain as discussed earlier. • Assess for GI bleeds with continued administration. Implementation Implementation • Give with food, milk, or antacids. • Tell it may take several weeks to see a difference with these medications if being used for inflammatory conditions such as arthritis. But if they don’t see an improvement in 2 weeks to call their doctor. • Provide comfort measures by proper positioning/support of joints, ice/heat packs, and braces if ordered, assist with ADL’s. • Monitor for GI bleeding (most common) and visual disturbances (blurred vision, color changes) Education Education • Do not use other ASA or NSAID products while taking • Call MD if pain persists more than 10 days or fever more than 3 days. • Take the drug as prescribed whether the pain gets better or worse. Drugs Used to Treat Drugs Used to Treat Migraine Headaches •Pain caused by cranial vascular spasms. • Drugs are given to prophylactic ally to prevent spasms or treat the acute pain when a headache occurs. •Prophylactic drugs are Beta blockers, Calcium channel blockers, antidepressants, or anticonvulsants. (Discussed in other chapters) •Acute Drugs­ Selective serotonin will be discussed here. Imitrex, Zomig, Ergomar, Axert • The acute drugs cause vasoconstriction. During an acute phase GI motility decreases and the drugs may need to be given by a different route. Migrane Drugs Migrane Drugs Adverse reactions • • Most common: dizziness, nausea, fatigue, pain, dry mouth, and flushing. Contraindications­ Do not use if has hx of TIA, uncontrolled HTN, or on MAIO antidepressants. •Assess­ Pain assessment and HX. •Implementation­ Imitrex is give subcut on HA onset. If no pain relief another injection can be given in one hour. No more than 2 injections in 24 hours. • Education ­ Acute drugs cause photosensitivity­ care when outside/tanning. ­ These drugs do not prevent or decrease the occurrence of HA’s. Take on headache onset­ no more than 2 doses in 24 hours­ call MD if no relief. Opiod Analgesics/ Opiod Analgesics/ Antagonist • Drugs made from opium plant. • Controlled substance. • Narcotic analgesics are used to treat moderate to severe pain. • Does not cause tissue changes but changes the person’s perception of pain. Actions Actions • Relieve pain • Also causes respiratory depression, decreased GI motility and Miosis. • Morphine used to treat moderate severe to severe pain­ gold standand for pain treatment. Opiod analgesics are: Opiod analgesics are: Interactions • Morphine sulfate is the gold standard in moderate severe to severe pain management • Duragesic, Dilaudid, Demerol, MS­ Contin, Oxycontin. • Stadol • Nubain • Mixing with alcohol, antihistamines, sedatives, and barbiturates can cause an increase in respiratory depression. Uses Uses • To relieve moderate to severe acute and chronic pain. • Used to treat opiod dependence. • Preop to decrease anxiety and sedation, OB­delivery, pulmonary edema to relieve breathing, intrathecally/epidural for pain, used during MI’s (morphine), detoxification of narcotics, conscious sedation, diarrhea, and cough. Adverse Reactions Adverse Reactions • Weakness, headache, respiratory depression, constipation, and urinary retention. • Head injuries, asthma, seizures, and ICP. • Careful if having biliary surgery­ can cause spasm of the sphincter of oddie­ then the drug of choice is Demerol. • If breast feeding wait 4­6 hours after taking. Contraindicated Precautions Assessment Assessment • Before giving assess the patient’s health and allergy history and their current and past drug history. • Use the pain scale; follow up 30 min – 1 hour after medicating to see if the pain was relieved. (20­30 min if given SQ or IM, 30 min – 1 hour if given orally, and 5­10 minutes if given IV.) If not call the MD. • Always take the patients VS before and after medicating. A big side effect is hypotension and narcotics decrease the cough reflex so have them TCDB every two hours to prevent the pooling of secretions that can lead to pneumonia. Assessment Assessment continues • • • • • • Take care of comfort measures needed such as dim the lights, decrease the noise level, turn up or down the thermostat, etc. Do not make the patient wait for the medication and take their word on the pain. If the RR is less than 10/min or SBP is less than 100 monitor the patient and call the MD. Higher risk if elderly, cachectic, or is receiving for the first time. If the medication is giving for diarrhea – monitor and record stool number and characteristics. Narcotics also cause constipation and a decreased appetite. Weights and close monitoring of food/I&O’s is important. These medications also cause miosis (pinpoint pupils) that decreases the person ability to see so institute fall precautions. After giving medication raise the side rails and tell to call for assistance to get out of bed. PCA pumps­ Patient PCA pumps­ Patient Controlled Analgesia. • ­ The patient controls to an extent. The pump is programmed to give a certain amount of medication in a certain time frame. Usually used post – op. • While medicated encourage activities such as TCDB and leg exercises. • Tell the patient how to operate the control button, the type of drug, and how often they can receive a dose. Implementation Implementation • • • • • Morphine is used for the management of cancer/chronic severe pain more than any other drug. Medication for chronic pain must be given around the clock. The oral route is preferred as long as the patient can swallow because respiratory depression is less likely to occur. Oxycontin is a time­released form of oxycodone. The tablets are to be swallowed­ not crushed or chewed. Some people wear Fentanyl transdermal system for severe pain. This is a patch with time­released medication that is changed every 72 hours. It is applied to the skin of the upper torso and pressed in place for 10­20 seconds to ensure contact with the skin. Rotate sites and use only water to clean the skin before applying. Implementation Implementation continues • • Breakthrough pain is treated with a mixture of narcotic and other oral drugs and is called a Brompton’s mixture. When patients are medicated for severe pain it is important to treat the pain and not worry about addiction. Esp. in those with cancer. The most important thing is to keep them comfortable in their last days. Dependency can occur. S/S of dependence is frequent request for medications, personality changes, and constant complaints of pain and failure to receive relief. Newborns can be born addicted. Symptoms include irritability, excessive crying, yawning, and sneezing, increased RR and tremors. • Implementation Implementation continues • • Sometimes the medication is given as an epidural such as in pregnancy, post­ op, and cancer pain. A catheter is placed in the epidural space and the medication works on the dorsal horn of the spinal cord. This is a sterile procedure and the person that places the catheter is a skilled physician. The medication is given by bolus or as a continuous infusion. Advantages are that a lower dose is used, fewer adverse reactions, and the pain is controlled better. Assessment is very important in monitoring for respiratory depression/hypotension, VS are taken every 30 minutes, apnea monitors are used, and a narcotic antagonist (Narcan) is kept available. Drugs used to treat Drugs used to treat Opioid dependency • Levomethadyl and methadone. ­Levomethadyl is used in clinics for those addicted and have not responded to other treatment. It is given 3 times per week. ­Methadone­ can be used for pain relief but is used for detoxification and maintenance of those addicted to opioids. Detoxification involves withdrawing patients from the drugs with out the symptoms. It is important that these people receive their medications even while in the hospital. Education Education • Tell what drugs they have ordered for pain and how often. • Tell pt./family opioid can cause drowsiness, dizziness, blurred vision avoid certain tasks. • Avoid ETOH or other medications that can increase the effects of the opiod. Opioid Antagonist Opioid Antagonist Action/Uses • An antagonist counteracts the action of something else. Opioid antagonist reverses the action of narcotics. • Used to reverse respiratory depression post­op, opiod adverse reactions, and overdoses. BUT remember the reason it was given to them will return as well. Medications Medications Narcan and Revex. • Narcan can restore respiratory function in 1­2 minutes. • An adverse reaction for abrupt removal of the narcotic can be N&V and tachycardia. These reactions are not bad if given slow IV push. • Narcan can also produce withdrawal symptoms in those dependent on narcotics. • The patient must not have taken an opiate in the last 7­10 days to avoid withdrawal. Assess Assess • The VS every 5 minutes until the patient responds then the VS and LOC every 5­15 minutes afterwards until the effects of the narcotics wear off. • More than one dose of Narcan may be required. • Patient may need to be ventilated to ensure a patent airway. Keep suction ready in case patient vomits. THE END THE END ...
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This note was uploaded on 02/01/2011 for the course PNR 182 taught by Professor Toole during the Spring '10 term at Orangeburg-Calhoun Technical College.

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