Pain Management Flashcards by Kelsey Klipfel

When managing pain - lot room for how much and when admin meds; for drugs specific order for drugs but for pain meds are PRN and when do orders for pain meds are list for diff pain meds and then ranges of doses for meds and determine med and how much give; lot more decision making in terms administering drugs for pain management; not make them decisions alone - manage pain collab effort between nurse and client; see what nurses on previous shifts giving and if doc well and see how pain been controlled
Ladder: no where else to start how manage client in pain
Non-opioid:
Adjuvants
Opioids
Place start and way go; start with non-opioids; watch doc and how pain controlled in previous shifts

Pharmacologic pain relief measures: WHO ladder

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+/-adjuvant for pain: varies widely depending on type pain is
NSAIDS
Acetaminophen
First step

Non-opioid:

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Anticonvulsants
Muscle relaxants

Adjuvants

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For mild/moderate pain - second step: often PO
Pain not managed up to 3rd step give more opioids: increase dose or move to more potent opioid to manage pain

Opioids

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Aspirin contraindicated in children - Risk of Reye syndrome (results in severe neurologic deficits that can be permanent and part is liver damage; sig disorder) – avoid aspirin and use with caution (esp viral illness) - risk for syndrome increases with viral illnesses - imp edu point
Acetaminophen is most used analgesic/antipyretic drug for children (safest choice for children; give at very young age); best used and use NSAIDS if acetaminophen not meet needs and 6+ months
NSAIDS approved for children 6+ months

CHILDREN: Acetaminophen/NSAIDs: Drug Therapy Across the Lifespan

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Report use of OTC drugs to avoid drug-drug interaction (all OTC drugs have a yellow highlight if contains acetaminophen); read labels carefully
Getting OTC use from adults because many OTC preparations can contain acetaminophen/ibuprofen

Adults: Acetaminophen/NSAIDs: Drug Therapy Across the Lifespan

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NSAIDs should be avoided if possible
Use acetaminophen in older adults - if not effective move onto opioids because poses less risk to them than NSAIDs

Older Adults: Acetaminophen/NSAIDs: Drug Therapy Across the Lifespan

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reduces fever by direct action of hypothalamus and dilation of peripheral blood vessels

MoA: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)

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Reduce pain and fever (No effect on inflammation); Not a NSAID

Indications: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)

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chronic alcoholism, reduced liver function

Contraindication: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)

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C: headache, skin rash (generally well-tolerated if taken as directed and taken intermittently) Rare (not take as directly/too much med): risk for liver toxicity - go into acute liver failure - monitor how much taking in 24 hours so not OD whether intentional/not (overdose or liver disease)

AE: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)

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delirium, n/v, chills; acute liver failure; antidote: acetylcysteine (binds to metabolite causing toxicity and injury to liver) - OD have antidote drug
Watch for potential for Toxicity: - risk for toxicity and acute liver failure

Toxicity manifestations: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)

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max dose is 4 grams/day (4000 mg/day); consider combo meds

Nursing: Non-opioid analgesic: prototype: acetaminophen (Tylenol) (APAP)

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Cyclooxygenase: is an enzyme; 2 pathways NSAIDS help to block and by doing so helps reduce pain and inflammation; 2 diff enzymatic pathways lead to prostaglandin synthesis leading to inflammation
Promotes inflammatory prostaglandins - MoA in blocking pathway: reducing inflammation - block process of inflammatory prostaglandins; not just block one part but block large portion so have other issues - big issues come in; Cox-1 provides gastric mucosa integrity and one major AE of NSAIDS is peptic ulcers and bleeding ulcers and that is where big prob comes in
Maintains renal func
Provides gastric mucosa integrity
Promotes vascular hemostasis - block that decrease platelet aggregation helpful in some conditions
Assists in fever

Effects of cyclooxygenase-1 (Cox-1) pathway

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Decrease swelling, pain, inflammation - goal
Decrease fever - goal
Increased bleeding - good and bad; aspirin used to prevent blood clots but too much bleeding is a bad thing
Na retention, edema, HTN - AE; effects on kidney
GI erosion, bleeding - AE

Effects of blocking Cox-1 pathway

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Promotes inflammatory - decrease pain, swelling inflammation
Maintains renal func - Na retention, edema, HTN
Provides gastric mucosa integrity - GI erosion, bleeding
Promotes vascular hemostasis - increased bleeding
Assists in fever - decrease fever

Summary of Cox-1 pathway

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Increases pain and inflammation
Results in Vasodilation
Blocks platelet clumping

Effects of cyclooxygenase-2 (Cox-2) pathway

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Decrease pain and inflammation - good
Prevent protective vasodilation - probs
Allows platelet clumping - aids in blood clotting which is a bad thing; probs
Skin rxns: Steven’s Johnson syndrome - probs

Effects of blocking cyclooxygenase-2 (Cox-2) pathway

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Increases pain and inflammation - Decrease pain and inflammation
Vasodilation - Prevent protective vasodilation
Blocks platelet clumping - Allows platelet clumping

Summary of Cox-2 pathway

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Analgesia (pain) relief
Fever - reduce
Musculoskeletal disorders/inflammatory (OA, RA, ankle sprain, etc.) - really beneficial in inflammatory type disorders; esp in MS disorders; helps with all pain and inflammation from acute and chronic MS disorders

Indications: Non-steroidal anti-inflammatory drugs (NSAIDS)

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Nausea, vomiting, gastritis/epigastric pain, peptic ulcers, upper GI bleeding
All GI - sig part NSAIDS and cannot be missed/negated; high doses can be lethal from sig AE and death from upper GI bleeding; sig
Blocking COX pathway so gatric mucosa not have protection and allows med free rain into lining for stomach resulting in ulcers and bleeding

Common adverse effects: Non-steroidal anti-inflammatory drugs (NSAIDS)

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Renal disease - kidneys susceptible to toxicity from NSAIDS, active/history acquiring peptic ulcer (disease) from use of NSAIDS - not safe to use NSAIDS anymore, alcohol use - risk for developing GI ulcers

Contraindications: Non-steroidal anti-inflammatory drugs (NSAIDS)

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Anticoagulants (use aspirin to affect way blood clots formed and anticaogs do in diff manner but this sig increases risk for bleeding and potentially severe/fatal bleeding), corticosteroids (very hard on the stomach so take with food and that is one big interaction to consider - taken together risk sig increases to have GI probs), other NSAIDs: not take aspirin and ibuprofen together etc, not taken at once, two taken together sig increases risk for AE esp to kidneys and GI sys and GI bleeding

Drug-drug: Non-steroidal anti-inflammatory drugs (NSAIDS)

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used for ability Decrease inflammation and good ability to decrease platelet aggregation (process for blood clotting: platelets form then have clotting cascade and then have blood clotting) (can use for pain and inflammation but risk at doses to help pain and inflammation outweighs benefits - rarely used for pain most pats on baby one for CVD prevention (81mg): dose decreases aggregation to prevent MI/stroke caused by a clot - see used more for CVD prevention) (non-selective COX inhibitor)
Salicylates - part chemical makeup

MoA: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)

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Mild pain, inflammation (high dose: 325-650 mg po prn); Anticoagulation (platelet inhibitor) for CVD (low dose: 81 mg or 325 mg po daily)

Indications: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)

Viral illness children (Reyes)

Contraindications: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)

easy bruising - inhibits platelet aggregation (platelets not stick together as readily as should so more bruising as apparent), all related to NSAIDS

AE: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)

Hold 1 week prior to procedures/surgery - not hold med pat higher risk for extensive bleed for procedure; hold for period because that is how long takes for aspirin effects to be negated

Nursing: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)

take as prescribed; may take with food to help with GI discomfort, full glass of water (8oz); report any GI pain &/or dark/bloody stools (indicates upper GI bleeding); monitor H/H if UG bleed - if suspected UGI bleed because bleeding out so can monitor it out

Teach: Anti-inflammatory: NSAID/Salicylates: prototype: aspirin (ASA)

Risk: Greater for toxicity when taking greater than 4 gm/days - taking lot aspirin at one time: intentionally/not Salicylism - CM: Severe toxicity (tx) go on: dialysis to get out of sys quickly in severe cases Nurse:

Salicylate toxicity (rare)

Tinnitus (ringing in the ears - first signs seen in pat that suffering from toxicity) and/or hearing loss Dizziness, HA, drowsiness Tachycardia Hypoglycemia Sweating Metabolic acidosis

Salicylism - CM: (Salicylate toxicity (rare)

Stop admin of drug Evaluate CNS Monitor: CBC, renal, liver labs

Nurse: (Salicylate toxicity (rare)

Suppresses inflammation (non-selective COX inhibitor) - anti-inflammatory

MoA: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)

3200 mg/day in divided doses (prescription - high doses if feel like appropriate); 1200 mg/day in divided doses (OTC - self treatment)

Max dose: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)

GI bleeding; CV: increased risk of MI, stroke - dosage and frequency; higher doses on and taken for prolonged period time higher risk for suffering CV events - high doses not appropriate for those who have had multiple MI

Black box - all NSAIDS: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)

chronic use: Na/water retention (edema), hypertension; Rare: AKI (dangerous to kidneys)

AE: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)

OTC

Nursing: Anti-inflammatory agents: NSAIDS: prototype: ibuprofen (Advil)

Baseline assessment H&P including allergies (any NSAID) and medications - check allergy list - if allergic to any cannot take any others Focused assessment: pain, fever, GI - why giving med; indic for meds and GI assessment: biggest risk for pat is GI effects Lab values as appropriate (suspect GI bleeding/toxicity) not lab value routine; look at LFTs and kidney fun as baseline

Assess: Nursing responsibilities for NSAIDS

Take with food and 8 oz. water Max dose, combination drugs Adverse effects

Teach: - teach on these: Nursing responsibilities for NSAIDS

Therapeutic effect (depending on indication): - why taking med; adequately eval Adverse effects - monitor for these and these are major ones to look for

Evaluate:: Nursing responsibilities for NSAIDS

Decreased temp Decreased pain

Therapeutic effect (depending on indication): - why taking med; adequately eval

Gastrointestinal effects UGI bleeding (coffee ground emesis; dark bloody stools) Bleeding/bruising

Adverse effects - monitor for these and these are major ones to look for

Do not directly provide direct analgesia Often used for chronic pain - help manage pain without having use high amounts of opioids; sometimes in acute period Caution: cause Sedation

Adjuvant drugs

Often for diabetic neuropathy; opioids not helpful for neuropathic pain; gabapentin helps with this type of pain binds receptor sites hippocampus (chemical analogue of GABA: endogenous inhibitory neurotransmitter - initially used for seizure disorders, GABA helps to slow seizure activity; acts like GABA - inhibitory neurotransmitter)

MoA: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)

post herpetic neuralgia; anticonvulsant; off label: neuropathies - not approved by FDA but prescribers use it as such

Uses: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)

PO/Titrate as directed

Route/Dose: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)

drowsiness (inhibitory neurotransmitter and slows down brain activity - slows down brain func (helpful for seizures); dose limiting AE for pats - never get to high enough dose to help with neuropathic pain without becoming too drowsy - a lot experience drowsiness but not want sleeping all day long because not good quality of life), confusion, unsteady gait, impaired cognition

AE: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)

CNS depressants - acts like inhibitory neurotransmitter; anything else that depresses the CNS - exacerbating prob

Drug-drug: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)

slow titration when increasing and decreasing doses - be very when careful increasing/decreasing doses that affect NS - esp neurotransmitters; never just pull people off cold turkey; can put them into withdrawal often

Nursing: Adjuvant for neuropathic pain: prototype: gabapentin (Neurontin)

inhibits spinal reflexes in CNS - helps with muscle spasms

MoA: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen

spinal cord injury, multiple sclerosis, spinal cord disease

Indications: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen

epilepsy, cardiac dysfunction

Contraindications: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen

cautious before take with other CNS depressants (common because exacerbates the drowsiness - common: Put on skeletal muscle relaxant and opioid drowsiness more common), alcohol

Drug-drug: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen

drowsiness (need know how react to med before operate heavy machinery/drive - not drive when taking this med), dizziness, nausea, constipation, hypotension, urinary frequency

AE: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen

Many other drugs in class used for acute musculoskeletal disorders; monitor CNS; do not operate heavy machinery

Nursing: Adjuvant: Central skeletal muscle relaxant: prototype: baclofen

The nurse is reviewing a medication list for a client. The combination of which medications causes concern for the nurse? A.Lispro and glargine B.Loratadine and pseudoephedrine C.Acetaminophen and aspirin D.Ibuprofen and prednisone

Answer: D Lispro and glargine: insulin - long acting and rapid; lot pats on rapid acting and long acting Loratadine and pseudoephedrine - antihistamine and decongestantant; sometimes put in same drug together Acetaminophen and aspirin - non-opioid so not NSAID; not prob to take with aspirin - works differently than aspirin Ibuprofen and prednisone - MoA - synergistic/oppose each other, AE: both cause that problematic; both can cause GI effects - sig increase risk for GI ulcers Rationale: Taking an NSAID with prednisone increases the risk for gastrointestinal irritation, GI ulcers and GI bleeding.

DEA monitors used of controlled substances Opioids under schedule II; very relevant for how utilized by pats and how admin, doc, and waste meds - high abuse potential

Controlled substances schedule for pain meds

Know policies and procedures on it and need follow appropriately at facility - safeguard to show not taking controlled for own use Access to controlled substances limited to certain people: Retrieve med(s) immediately prior to admin not admin immediately label with pat info (name, DOB and according to protocols) May not leave medications at bedside (unless in locked container and properly labeled container) - witness taking med Unused portions waste or return immediately (as appropriate) Waste procedure:

Nurse role: managing controlled substances: adapted from SLHS Controlled Substance Policy

Licensed personnel: Nurses, physicians, advanced practice providers, pharmacists, RT Authorized personnel: pharmacy technicians and pharmacy interns

Access to controlled substances limited to certain people:

Waste ASAP Should not be disposed of in modalities where retrieval is possible Not waste where other can access - where cannot be retrieved from anybody Preferred method via wastewater (sink or toilet) Topical transdermal patches flushed toilet or folded in half (adhered to itself) and placed in sharps container Requires a witness wasting of med to ensure wasted med and not used for own use (licensed or authorized personnel); managers watch how much meds taking

Waste procedure:

Stimuli and pain transmission goes up SC up to brain Way body Responds to pain is by releasing endogenous opioids - opioids in sys that goes to opioid receptors to help diminish pain Opioid receptors throughout body: Control number body sys: - speaks to AE Opioids are agonists: Mimicking endogenous opioids to block pain; blocking pain but mimicking norm action of body; decreases pain and bind to opioid pain receptors but not done perfectly; find other pain receptors that have control over number things so have all AE with opioid agonists

Pain process and opioid receptors

CNS, periphery (PNS), GI tract

Opioid receptors throughout body:

Blood pressure Pupil diameter GI secretions Nausea and vomiting Cough Respirations

Control number body sys: - speaks to AE

Mild to severe pain Acute or chronic pain Antitussive effects - decreasing cough (codeine) Adjuvant for anesthesia (with this); benzodiazepeine med and fentanyl drip for anesthesthesia

Used for: Narcotic (opioid) agonists

Interact/work with opioid receptors to inhibit pain pathways in CNS - prob is bind to other receptors throughout body so have all AE Depends on receptor affinity Efficacy Adverse effects

MoA: Narcotic (opioid) agonists

Codeine

Mild pain and/or cough suppression: Narcotic (opioid) agonists

Oxycodone

Mod-severe pain PO: Narcotic (opioid) agonists

Morphine Fentanyl Dilaudid

Mod-severe pain PO, IV, SL… - more potent opioids used: Narcotic (opioid) agonists

Drowsiness - common AE Sedation - potentially severe; need action immediately; probs need intervene on Respiratory depression - potentially severe; need action immediately; probs need intervene on Constipation - common AE Urinary retention - common AE Nausea and vomiting - common AE Hypotension - common AE Itching - common AE Euphoria (abuse) - less likely to occur; some meds when given IV can give high and will have pats that ask if can push narcotics faster because faster push it faster get euphoric feeling; if talking about it this or pushing things faster, investigate further or talk to HCP about referring person because abusing med than using for benefit Hallucinations - less likely to occur Bradycardia - less likely to occur

Lot Adverse Effects: - not just target specific opioid receptors: Narcotic (opioid) agonists

Hypersensitivity - not give drug if have this Opioid naïve - not used taking lot opioids; everyone reacts differently; ask pat if taken opioid pain in past and idea where at Respiratory disease - major AE is resp depression if have these is problematic Pregnancy - cross placental-fetal barrier and impacts fetus

Caution: Narcotic (opioid) agonists

Asthma, COPD (not have lot resp reserve so if have resp depression more problematic because not have lot ability to make up for hypoventilation - harder treat resp depression and O2 not as helpful), PNA

Respiratory disease - major AE is resp depression if have these is problematic

Suffering from Respiratory depression not give more makes it worse Severe heart disease - if have this and resp depression prob with oxygenation for tissue Substance abuse - if history of this prescriping opioids needs be thoughtful; not mean administer meds because think abusing meds - is very problematic because not solve prob in shift and not give pain med - can send into withdrawal and very sick and number issues for pat; make sure prescriber know - know what thinking - get person more long term help - than withhold pain med for shift: prob stems further; tell someone about this so get help and get off in controlled manner; abuse other things outside opioids higher risk for developing opioids

Contraindications: Narcotic (opioid) agonists

CNS depressants – alcohol, sedatives, antipsychotics, skeletal muscle relaxants, benzodiazepines; anything else causes CNS depression: gabapentin, baclofen; more likely occur if taking multiple drugs together

Drug-Drug interactions: MANY!: Narcotic (opioid) agonists

Start with low dose esp if opioid naive to see how react to meds to see how react - need know how react Discontinue gradually after long-term use to avoid withdrawal - even if suspect abuse cont admin meds and take diff avenue to address

Administration considerations: Narcotic (opioid) agonists

Big prob if resp depressed: not breathing enough times/min and O2 levels drop and O2 to cells and tissues decreased and not enough O2 to tissues/cells have issues Assess VS, apply O2 if indicated - O2 sat: see if getting by or not and in dangerous zone because O2 levels compromised since not breathing enough - get enough O2 levels so help as much as well; anytime sedated/resp depression hold next dose and consider admin anatagonist Hold next dose Consideration antagonist - unsure to admin ask someone on unit if should admin; pain very hard control post-antagonist Take vital signs, follow protocol and utilize standing orders

If respiratory depression (less than 10 breaths/minute) occurs….: Narcotic (opioid) agonists

Needs med to manage pain to help QOL and rebab and need to help manage probs Constipation Nausea and vomiting Itching

Managing common adverse effects

Very common prob - often prescribed bowel regimen as well with opioids Getting Plenty of fluids, high fiber diet, exercise - stimulates bowels Very high doses can have ileus/sig bowel issues Medication to soften stool and promote bowel movements: see GI lecture

Constipation

Suffer from this Take with food to try alleviate Take with antiemetic meds Medication to relieve nausea/vomiting

Nausea and vomiting

Difficult to treat as AE; lotions, cool compresses Medications to relieve itching: loratadine (Claritin) - antihistamine common but not lot can do More research needed

Itching

Codeine least potent opioid then fentanyl post potent opioid; when prescribed opioids need be balance between controlling pain and least amount of AE; more pain med more likely suffer AE How control pain with least number of AE

Adverse effects decreases; pain control increases

Opioids In med by itself; Just by themself Used for moderate to severe pain No “maximum dose” for pat; suffer from sig affects know hitting max dose: sig resp depression then hitting max dose; based on pain control and AE Can be given by many different routes Short-acting for breakthrough Long-acting for chronic pain Need give right prep to pat

Single-agent opioids

Immediate release (IR) Breakthrough pain/short durations of pain relief

Short-acting for breakthrough

Extended release (ER) Chronic pain - taking every single day

Long-acting for chronic pain

Doses limited because opioid combined with another med like acetaminophen/ibuprofen Acetaminophen with oxy: common, limits how much can take and same with ibuprofen Orders for combo med and range for number med - make sure not over limit with either dose so not OD pat Use: mild to moderate pain; breakthrough pain Non-opioid component added

Combo PO Opioids

Dose limiting Total APAP/24 hours Most pts = 4 grams Liver disease less Total ibuprofen/24 hours Most pts = 3200 mg (OTC max 1200 mg) Kidney disease less

Non-opioid component added

Depresses pain transmission at spinal cord level by interacting with opioid receptors; ↓ cough reflex, ↓ GI motility

MoA: Opioid agonist: prototype: codeine

Mild to mod pain; off label use: diarrhea, nonproductive cough - treat lower doses so AE so dangerous with patients not seen

Use: Opioid agonist: prototype: codeine

Scheduled med - how much/dose depends falls; in controlled substances realm Response can be very unpredictable

Opioid agonist: prototype: codeine

10% of codeine is metabolized to morphine by liver - some metabolize better than others so unpredictable - prob Metabolism unpredictable, varies by race

CAUTION: Opioid agonist: prototype: codeine

Moderate to severe pain; acute and chronic pain

Use: Opioid agonist: prototype: oxycodone (OxyContin)

PO as needed or scheduled; know if need to know immediate or ER Short acting (immediate release – IR) Long acting (extended release - ER)

Route/Dose: Opioid agonist: prototype: oxycodone (OxyContin)

Breakthrough pain example (post-surgical): Oxycodone IR 5 mg PO every 6 hours as needed

Short acting (immediate release – IR): Opioid agonist: prototype: oxycodone (OxyContin)

Chronic pain example: Oxycodone ER 30 mg PO every 12 hours Do not split, crush or chew ER tablets! - given at once versus over 12 hours; higher risk for unintentional OD: sedation, resp depression

Long acting (extended release - ER): Opioid agonist: prototype: oxycodone (OxyContin)

Acute and chronic pain

Use: Opioid agonist: prototype: morphine

sev diff routes Morphine considered “gold standard” for dosing opioids - earlier ones created not all opioids same potency - fentanyl very potent IV push considerations:

Dose/route considerations: Opioid agonist: prototype: morphine

Follow facility protocol Push slowly when given via IV push; Deliver over 4-5 min (do not infuse rapidly and not incurring AE during admin of med); some dilute via NS (follow protocol) Monitor closely for adverse effects! Which is why push slowly

IV push considerations:

Potent med have; dosed in mcg; fast acting and short duration; utlized a lot for PCAs and medically induced comas Most potent opioids and more abused drugs

Opioid agonist: prototype: fentanyl

Acute and chronic pain, adjunct to general anesthesia

Use: Opioid agonist: prototype: fentanyl

onset 1 minute, peak 3-5 min, duration 30-60 min Common dose: 50 mcg every 1-2 hours PRN Commonly used in PCA pumps Push slowly Same considerations as morphine for IVP

IV - Dose/route considerations: Opioid agonist: prototype: fentanyl

Half-life 13-22 hours Common dose: 25 mcg/hour Slowly releases med No pill; ATC pain relief; biggest risk: one patch not taken off before replacing another; imp doc where put it and imp find old one and take it off because if do not getting pain med from old patch and OD from transdermal patches Change patch every 72 hours

Transdermal - Dose/route considerations: Opioid agonist: prototype: fentanyl

Allows patient some control of pain administration at need Provider's order (admin IV): basal rate, delay in bolus, pt bolus dose Indications: Acute pain states Contraindications: Cognitive problems, hypoventilation syndromes, extremes of age (only pt can control pump)

Patient controlled analgesia (PCA)

Less sedation, less opioid consumption, decreases post-op complications Better pain control

Allows patient some control of pain administration at need

Follow PCA policy/procedure for admin and documentation

Provider's order (admin IV): basal rate, delay in bolus, pt bolus dose

Post-surgical pain, trauma, cancer pain, sickle cell crisis, burns

Indications: Acute pain states

Block opioid activity at opioid receptor - by blocking activity not allowing meds to bind receptors so block AE that occurring like resp depression; expect RR improves, sedation should improve; keep in mind pain comes back like vengeance and because drug blocking receptor sites and pain through roof; not happy because zero opioid activity and admin if needed because pain does come back and because incident where got too much pain med prescribers very hesitant to give lot pain med after so very diff to control pain so be thoughtful about when giving it so give when appropriate

MoA: Opioid antagonist: Prototype: naloxone (Narcan)

Reverse overdose due to opioid meds

Indication: Opioid antagonist: Prototype: naloxone (Narcan)

IV, inhaled

Route: Opioid antagonist: Prototype: naloxone (Narcan)

Repeat in 2-3 minutes if resp. status does not improve

Dose: Opioid antagonist: Prototype: naloxone (Narcan)

Onset: 1-2 min Peak 5-15 min Duration 45 min (IVP) Acts quickly; may need 1+ dose because one dose may not be enough and may need a second dose

Opioid antagonist: Prototype: naloxone (Narcan)

rapid loss of analgesia (be prepared and HCP decide how much give - lot less than were getting), increased BP, tachycardia, hyperventilation, N/V/D, tremors, sweating

AE: Opioid antagonist: Prototype: naloxone (Narcan)

Careful monitoring of patient (fast acting med; respiratory status); have resuscitative equipment available; may need multiple doses

Nurse: Opioid antagonist: Prototype: naloxone (Narcan)

The nurse would expect to administer morphine as the analgesia of choice for which clients? Select all that apply. A.A client with severe post-operative pain B.A client with severe chronic obstructive pulmonary disease and difficulty breathing C.A client with cancer and severe bone pain D.A client with chronic leg pain from peripheral neuropathy E.A client with chronic pain unresponsive to NSAIDs and adjuvants

Answer: A, C, E Rationale: Opioids are used for moderate-severe pain. Opioids should be used only if other pain medications are ineffective. Opioids should be used with great caution in patients with underlying respiratory disorders. They should not be used to treat neuropathic pain.

The nurse is caring for a client with constipation. After reviewing the client's medication list, the nurse knows constipation could be caused by which medication? A.Gabapentin B.Acetaminophen C.Oxycodone D.Ibuprofen

Answer: C Rationale: Opioids commonly cause constipation.

Prior to admin assess: VS, LOC/CNS, respiratory status, I & O’s - biggest assessment is assess sedation and respiration; document sedation and tie in current RR: appropriate to give current meds; resp status assessment - for opioids Pain assessment should be done (minimum): Reassessment after intervention (pain medication) – very imp; need go back reassess pain to see if intervention was helpful; need know if med was effective and if not need know; do appropriate time and doc

Pain management: assessment and reassessment

Acute care setting (SLHS Policy and Procedure) Every 4 hours (ICU) or shift (non-ICU) Pre-and post-procedure PRN Weekly or monthly (outpatient)

Pain assessment should be done (minimum):

30-90 minutes after oral meds 15-30 minutes after IV med 24 hours after transdermal med

Reassessment after intervention (pain medication) – very imp; need go back reassess pain to see if intervention was helpful; need know if med was effective and if not need know; do appropriate time and doc

Initiate non-pharmacologic pain relief measures Pain meds according to primary care provider orders Manage pharmacologic interventions Consider ethical and legal responsibility to relieve pain Manage constipation: Manage nausea/vomiting: Education: - ensure to do this

Pain management: Nursing Interventions

Collaborate with care team to alter dose, route, frequency until goal met Notify care provider of adverse effects, unrelieved pain Collaborative effort between nurse, pat, perscriber

Pain meds according to primary care provider orders

Consider WHO ladder and collaborate with pt when choosing PRN meds Admin IV push pain medications slowly (follow facility protocol)

Manage pharmacologic interventions

Scheduled or PRN docusate or bowel stimulant (see GI lecture)

Manage constipation:

Scheduled or PRN anti-emetic medication (see GI lecture)

Manage nausea/vomiting:

Pain scale - how appropriately use these Early intervention (before severe pain) - keeping up on pain and ahead of it - once out of control so much harder to treat so need stay on top of it and tell pat this Adverse effects (bowel regimen, overdose) - edu about this; constipation highly likely with amount pain med taking; AE and what can do for them Non-pharm therapies as appropriately Discharge pain management plan

Education: - ensure to do this

Evaluation: Documentation:

Pain management: Nursing Eval

Therapeutic effect of medication: Adverse effects:

Evaluation:

0/10 not achievable for most but need know pain goal Chronic pain: achieve pain goal to participate, perform ADL’s, improve quality of life Acute pain: achieve pain goal, participate in rehab

Therapeutic effect of medication:

Daily bowel movement Nausea/vomiting, itching CNS depression, respiratory depression

Adverse effects:

Assessment, intervention, reassessment, education Waste procedure

Documentation:

The nurse is caring for a client prescribed oxycodone and baclofen. The nurse should prioritize which assessment? A.Bowel sounds B.Level of consciousness C.Intake and output D.Range of motion

Answer: B Rationale: The nurse’s most immediate concern with the combination of these drugs is drowsiness. Drowsiness increases the risk for falls. Although bowel sounds and I&O are a priority for ondansetron, they are not a priority with baclofen. Range of motion should be assessed with the use of baclofen, but is not essential to ondansetron. Both meds can cause CNS depression - assessment should prioritize is LOC

Read each drug, dose and order. Can you identify the concern or mistake? 1.Oxycodone/Acetaminophen 5 mg/325 mg. Take 2 tablets PO every 3 hours. 2.Fentanyl 50 mg. Administer via IVP every 2 hours as needed. 3.Oxycodone 60 mg ER. Administer tablet via PEG tube every 12 hours. 4.Morphine 10 mg. Administer via IVP over 1 minute every 3 hours as needed.

1. Exceeds 24-hour time limit for acetaminophen; Two tablets every 3 hours - go over max dose 2. Mg should be mcg 3. Cannot crush ER; need alternative form of med (elixir); Cannot crush it - need elixir form 4. Pushing too fast!

Pain Management Flashcards

(129 cards)