LECTURE 7

CHAPTERS 10, 12 &15

ECPI University

CHAPTER 10 ANALGESIC MEDICATIONS

Overview

 Definition
 Unpleasant sensory/emotional experience
 Whatever/wherever the client says it is
 Categories
 Acute
 Activates the SNS (Fight or Flight)
 Usually temporary, sudden onset, easily localized
 Chronic
 Pain lasting more than 3 months or recurring for indefinite periods
 Onset is gradual, poorly localized, difficult to describe
Gate Theory
Pain Threshold

 Level of stimulus needed to produce the

perception of pain
 A measure of the physiologic response of
the nervous system
Attitudes/Perceptions

 Nurse’s attitude
 Do not assume
 Understand personal feelings regarding pain
 Pain often undertreated
 Addiction- A compulsive, uncontrollable dependence on a chemical substance,
habit, or practice to such a degree that either the means of obtaining or
ceasing use may cause severe emotional, mental, or physiological reactions
 Pseudoaddiction- Often as a result of undertreated pain
 Tolerance- A phenomenon by which the body becomes increasingly resistant to
a drug or other substance through continued exposure to the substance
 Physical Dependence- Substance dependence in which there is evidence of
tolerance, withdrawal, or both
Assessment

 PQRST
 P= precipitating factors
 Q= quality
 R= region/radiation
 S= severity
 T= timing
Assessment

 Location
 Pain Scale
 Nonverbal or Cognitively impaired clients
 Assess behavioral cues
 Family
 Pain scales
Pain Scales
Analgesics

 Medication Therapy
 Non-opioid medications
Nonsteroidal anti-inflammatory drugs
(NSAIDS)
Salicylates
Acetaminophen
 Opioid analgesics
Adjuvant Medicaitons

 Assist primary drugs in relieving pain

 NSAIDs
 Antidepressants
 Anticonvulsants
 Corticosteroids
 Example: adjuvant drugs for neuropathic pain
 Amitriptyline (antidepressant)
 Gabapentin or pregabalin (anticonvulsants)
World Health Organization
Three-Step Analgesic Ladder
 Step 1: nonopioids (with or without adjuvant medications)
after the pain has been identified and assessed. If pain
persists or increases, treatment moves to
 Step 2: opioids with or without nonopioids and with or
without adjuvants. If pain persists or increases,
management then rises to
 Step 3: opioids indicated for moderate to severe pain,
administered with or without nonopioids or adjuvant
medications.
Opioid Analgesics

 Actions
 Agonists- bind to opioid receptors
 Partial agonists- limited response
 Agonists-antagonists- contains properties of both agonists and
antagonists
 Uses
 Moderate to severe acute and chronic pain
 Opioid dependence
 Suppression of cough- codeine
Opioid Analgesics

 Adverse reactions
 CNS- lightheadedness, dizziness, sedation, increased
intracranial pressure
 Respiratory- depression of rate and depth of breathing
 Gastrointestinal- nausea, vomiting, dry mouth, constipation
 Cardiovascular- facial flushing, tachycardia, bradycardia,
palpitations, peripheral circulatory collapse
 Genitourinary- urinary retention, hesitancy, spasms
Opioid Analgesics

 Contraindications
 Acute bronchial asthma, emphysema, increased intracranial
pressure, convulsive disorders, severe renal or hepatic
dysfunction, acute ulcerative colitis
 Use cautiously in elderly, clients who are opioid naïve, biliary
surgery clients, lactation
Opioid Analgesics

 Nursing Considerations
 Oral forms should be taken with food to minimize gastric upset
 Ensure safety measures, such as keeping side rails up, to
prevent injury
 Constipation is a common adverse effect and
may be prevented with adequate fluid and
fiber intake- may need stool softener
 Instruct clients to follow directions for administration carefully
and to keep a record of their pain experience and response to
treatments
Opioid Analgesics

 Clients should be instructed to change positions slowly to

prevent possible orthostatic hypotension
 Methadone used to treat addictions to other narcotics
 If PCA pump instruct client on use
 Narcotics are counted and locked- reconciled each shift or once
a week
Opioid Analgesics

 Nursing Considerations
 Morphine may be used at end of life to increase aveolar gas exchange and
decrease workload of breathing
 Codeine may be used to suppress cough
 Hydromorphone is very strong (7x stronger than morphine) and may be used in
PCA pump- itching is common and Benadryl often prescribed
 If in patch form dispose of old patch in toilet
 If patch rotate sites- usually every three days
 Monitor for adverse effects
 Contact physician immediately if vital signs change, client’s condition declines, or pain
continues
 Respiratory depression may be manifested by respiratory rate of less than 10
breaths/min, dyspnea, diminished breath sounds, or shallow breathing
Opioid Antagonists

 Actions
 Reverses the effects of opioid drugs
 Uses
 Postoperative respiratory depression
 Opioid adverse effects reversal
 Opioid overdose
 Adverse reactions
 Nausea/vomiting
 Sweating
 Tachycardia
 Hypertension
 Tremors
Opioid Antagonists

 Contraindications
 Used cautiously during pregnancy and lactation
 Nursing Considerations
 Immediate return of pain
 Given slowly IV push
 Naloxone/Naltrexone
 Regardless of withdrawal symptoms, when a client
experiences severe respiratory depression, an opioid
antagonist should be given
Non-pharmacologic Pain Relief Measures
 Physical Measures
 Repositioning for comfort
 Decreases risk for skin breakdown
 Cutaneous stimulation (interrupt the pain pathway)
 Application of heat/cold
 Therapeutic touch
 Massage
 Psychological Measures
 Distraction
 Imagery
 Hypnosis
 TENS (Transcutaneous electrical nerve stimulator)
 Delivers small electrical impulses to area of pain
Codeine Sulfate

 Codeine sulfate
 Natural opiate alkaloid (Schedule II) obtained from
opium
 Ceiling effect
 More commonly used as an antitussive drug
 GI disturbance
Fentanyl

 Synthetic opioid (Schedule II) used to treat moderate to

severe pain
 Parenteral injections, transdermal patches (Duragesic),
buccal lozenges (Fentora), and buccal lozenges on a
stick (Actiq)
 Fentanyl in a dose of 0.1 mg intravenously is roughly
equivalent to 10 mg of morphine intravenously
Hydromorphone

 Hydromorphone: very potent opioid analgesic; Schedule

II drug
 One milligram of IV or IM hydromorphone is equivalent to
7 mg of morphine
 Itching is a common side effect- diphenhydramine given
to counteract.
Dolophine

 Synthetic opioid analgesic (Schedule II)

 Opioid of choice for the detoxification treatment of opioid
addicts in methadone maintenance programs
 Renewed interest in the use of methadone for chronic
(e.g., neuropathic) and cancer-related pain
 Prolonged half-life of the drug: cause of unintentional
overdoses and deaths
 Cardiac dysrhythmias
Morphine Sulfate

 Naturally occurring alkaloid derived from the opium poppy

 Drug prototype for all opioid drugs; Schedule II controlled
substance
 Indication: severe pain
 High abuse potential
 Oral, injectable, and rectal dosage forms; also extended-
release forms
Naloxone

 Pure opioid antagonist

 Drug of choice for the complete or partial reversal of
opioid-induced respiratory depression
 Indicated in cases of suspected acute opioid overdose
 Failure of the drug to significantly reverse the effects of
the presumed opioid overdose indicates that the condition
may not be related to opioid overdose.
Acetaminophen

 Analgesic and antipyretic effects

 Little to no antiinflammatory effects
 Available over the counter (OTC) and in combination
products with opioids
 Mechanism of action-
 Similar to salicylates
 Blocks pain impulses peripherally by inhibiting
prostaglandin synthesis
Acetaminophen

 Indications
 Mild to moderate pain
 Fever
 Alternative for those who cannot take aspirin products
 Maximum daily dose for healthy adult is 4000 mg/day.
 Inadvertent excessive doses may occur when different
combination drug products are taken together.
 Be aware of the acetaminophen content of all medications
taken by the client (OTC and prescription).
Acetaminophen: Overdose/Toxicity

 Even though available OTC, lethal when overdosed

 Overdose, whether intentional or resulting from chronic
unintentional misuse, causes hepatic necrosis:
hepatotoxicity
 Long-term ingestion of large doses also causes
nephropathy
 Recommended antidote: acetylcysteine regimen
Herbal Products: Feverfew

 Related to the marigold family

 Antiinflammatory properties
 Used to treat migraine headaches, menstrual cramps,
inflammation, and fever
 May cause GI distress, altered taste, muscle stiffness
 May interact with aspirin and other NSAIDs, as well as
anticoagulants
Evaluation

 Pain must be re-evaluated after any intervention is

performed and documented accordingly (Joint
Commission mandate)
 Pharmacologic
 Oral- within an hour
 IM- within 30 mins
 IV- within 15 mins
Community Care

 Home Care
 Teaching client and family regarding medications
and delivery
 Home health
 Hospice
 Resources
 Support groups
Question One

The client is receiving his first dose of an opioid analgesic

for pain. The nurse expects another medication will
probably be ordered concurrently for this client will be which
of the following?
A. Antacid Agent
B. Laxative or stool softener
C. Anti-anxiety agent
D. Breakthrough pain reliever
Answer

B
Rationale: Opioid analgesics often cause decreased
peristalsis which results in constipation
Question Two

Which of the following clients would benefit most from the use of a
client-controlled analgesia pump?
A. 75-year-old woman in the last stages of the dying process who
is experiencing occasional episodes of confusion
B. 60-year-old man who is mentally alert and is experiencing left-
sided weakness after a stroke
C. 42-year-old man who is mentally alert and is recovering from a
fractured femur
D. 15-year-old girl who is recovering from a head injury from an
automobile accident
Answer

C
Rationale: The 42-year-old can understand and manipulate
the PCA pump controller.
Question

A client is recovering from an appendectomy. She also has asthma and

allergies to shellfish and iodine. To manage her postoperative pain, the
physician has prescribed client-controlled analgesia (PCA) with
hydromorphone (Dilaudid). Which vital sign is of greatest concern?
A. Pulse
B. Blood pressure
C. Temperature
D. Respirations
Answer

Correct answer: D
Rationale: This client has a history of asthma and
allergies, and she will be receiving a drug that
can depress respirations.
Question

A client who has metastasized bone cancer has been on transdermal

fentanyl patches for pain management for 3 months. He has been
hospitalized for tests and has told the nurse that his pain is becoming
“unbearable.” The nurse is reluctant to give him the ordered pain
medication because the nurse does not want the client to get addicted to
the medication. The nurse’s actions reflect
A. Appropriate concern for the client’s best welfare.
B. Appropriate caution for a client who is already on a long-term opioid.
C. An uncaring attitude toward the client.
D. A failure to manage the client’s pain properly.
Answer

Correct answer: D
Rationale: Clients with severe pain, including metastatic
pain or bone pain, may need higher and higher doses of
analgesics. The nurse is responsible for ensuring that the
client experiences adequate pain relief.
Break

 2 med templates
CHAPTER 12
CENTRAL NERVOUS SYSTEM
DEPRESSANTS & MUSCLE RELAXANTS

ECPI University
CNS Depressants

Sedatives
 Drugs that have an inhibitory effect on the
CNS to the degree that they reduce:
 Nervousness
 Excitability
 Irritability

(Elsevier, 2017)
CNS Depressants (Cont.)

Hypnotics
 Cause sleep
 Much more potent effect on CNS than sedatives
 A sedative can become a hypnotic if it is given in large enough
doses.

(Elsevier, 2017)
CNS Depressants (Cont.)

 Sedative-hypnotics: dose dependent

 At low doses, calm the CNS without inducing sleep
 At high doses, calm the CNS to the point of causing sleep
 Classified into three main groups:
 Barbiturates
 Benzodiazepines
 Miscellaneous drugs

(Elsevier, 2017)
CNS Depressants: Benzodiazepines

 Formerly the most commonly prescribed sedative-hypnotic drugs

 Non-benzodiazepines are currently more frequently prescribed
 Favorable drug effect profiles, efficacy, and safety

(Elsevier, 2017)
CNS Depressants: Benzodiazepines (Cont.)

Classified as either:
Sedative-hypnotic
Calming effect
Induce sleep
Anxiolytic (medication that relieves anxiety)
Prevent feelings of tension and fear

(Elsevier, 2017)
 Psychological States Affected by
Anxiolytic and Hypnotic Drugs
 Anxiety
 Feeling of tension, nervousness, apprehension, or fear
 s/s: sweating, tachycardia, tachypnea, elevated BP
 Sedation
 Loss of awareness and reaction to environmental stimuli
 Maybe desirable for patients who are restless, nervous,
irritable, or overreacting to stimuli
 Hypnosis
 Extreme sedation resulting in further CNS depression and sleep
 Used to assist people to fall asleep

(Elsevier, 2017)
 Benzodiazepines

 Alprazolam
 Clonazepam
 Diazepam
 Temazepam
 Lorazepam

(Elsevier, 2017)
 Benzodiazepines: Drug Effects

 Calming effect on the CNS

 Useful in controlling agitation and anxiety
 Reduce excessive sensory stimulation, inducing sleep
 Induce skeletal muscle relaxation

(Elsevier, 2017)
 Benzodiazepines: Indications

 Anxiety
 Alcohol withdrawal
 Sedation/Anesthesia
 Sleep induction
 Seizures

(Elsevier, 2017)
 Benzodiazepines:
Adverse Effects
 CNS
 Sedation,
 Amnesia
 Confusion
 Fall Risk
 Very common to be drowsy upon starting medication
 GI and GU
 Dry mouth
 Constipation
 Nausea/vomiting
 Urinary retention

(Elsevier, 2017)
 Drug-to-Drug Interactions

 Increased risk of CNS depression

 Alcohol
 Other CNS depressants

(Elsevier, 2017)
 Benzodiazepines:
Toxicity and Overdose

 Somnolence
 Confusion
 Coma
 Diminished reflexes
 Hypotension and respiratory depression can occur
 If taken with other CNS depressants

*Treatment symptomatic and supportive*

 Flumazenil as an antidote

(Elsevier, 2017)
 Nursing Implications
 Why is the drug indicated?
 Asses for sedation
 Assess vital signs
 Especially if administered with other CNS depressants
 Monitor parenteral forms very closely
 Maintain client safety
 Bedrest may be indicated post-parenteral administration
 Flumazenil on standby for toxicity
 Long term therapy
 Never stop abruptly
 May result in withdrawal symptoms: irritable, restlessness,
increased heart rate, risk of seizures

(Elsevier, 2017)
 Patient Education

 Take medication exactly as directed

 Do not stop abruptly
 Monitor for adverse effects
 Maintain safety
 Can take medication with food if GI upset occurs
 Promote voiding and toileting

(Elsevier, 2017)
 Barbiturates

 First introduced in 1903; were the standard drugs for insomnia and
sedation
 Habit forming; low therapeutic index
 Only a handful commonly used today partly because of the safety
and efficacy of benzodiazepines

(Elsevier, 2017)
 Barbiturates: Indications

 Sedatives
 Anticonvulsants
 Anesthesia for surgical procedures

(Elsevier, 2017)
 Barbiturates

 Phenobarbital
 Pentobarbital
 Amobarbital

(Elsevier, 2017)
 Barbiturates: Adverse Effects

Body System Adverse Effects

Cardiovascular Vasodilation, hypotension,

bradycardia

CNS Drowsiness, lethargy, vertigo

Respiratory Respiratory depression, cough

(Elsevier, 2017)
 Barbiturates:
Toxicity & Overdose

 Overdose frequently leads to respiratory depression and

subsequent respiratory arrest
 Overdose produces CNS depression (sleep to coma and death)
 Can be therapeutic
 Anesthesia induction
 Uncontrollable seizures: “phenobarbital coma”

(Elsevier, 2017)
Barbiturates:
Toxicity & Overdose (Cont.)

 Treatment of overdose
 Symptomatic and supportive
 Maintain adequate airway
 Assisted ventilation or oxygen therapy
 Fluids
 Vasopressor support
 Activated charcoal

(Elsevier, 2017)
 Barbiturates: Drug Interactions

 Alcohol
 Antihistamines
 Tranquilizers
 CNS depressants

(Elsevier, 2017)
 Nursing Implications

 Physical Assessment
 Respiratory
 Cardiovascular
 Neurological
 Only give parenteral dose if oral forms are not feasible
 Have emergency equipment on standby
 Not stop abruptly
 Medication can be highly addictive
 Medication discontinuation can result in severe withdrawal
symptoms
 Maintain client safety

(Elsevier, 2017)
 Patient Education

 Take medication as directed

 Maintain safety
 Driving
 Occupation
 Can take medication with food
 Never stop abruptly
 Avoid other medications that cause sedation
 If used for sleep – take 30-60 minutes prior to bedtime

(Elsevier, 2017)
 Non-benzodiazepine Hypnotics

 Zaleplon
 Zolpidem
 Eszoplicone
 Ramelteon

(Elsevier, 2017)
 Nursing Implications

 Indication
 Insomnia
 Monitor for CNS depression
 Monitor for abuse
 Ramelteon
 Does not cause CNS depression
 No potential for abuse
 No withdrawal signs and symptoms

(Elsevier, 2017)
 Over-the-Counter Hypnotics

 Nonprescription sleeping aids often contain antihistamines, which

have CNS depressant effect.
 Diphenhydramine
 As with other CNS depressants, concurrent use of alcohol can
cause respiratory depression or arrest.

(Elsevier, 2017)
 Muscle Relaxants

 Act to relieve pain associated with skeletal muscle spasms

 Majority are centrally acting
 CNS is the site of action
 Similar in structure and action to other CNS depressants
 Direct acting
 Enter muscle fibers directly

(Elsevier, 2017)
 Muscle Relaxants: Indications

 Relief of painful musculoskeletal conditions

 Muscle spasms
 Management of spasticity of severe chronic disorders (multiple
sclerosis, cerebral palsy)
 Work best when used along with physical therapy

(Elsevier, 2017)
 Common Muscle Relaxants

 Baclofen
 Cyclobenzaprine
 Metaxalone
 Tizanidine
 Carisoprodol
 Methocarbamol

(Elsevier, 2017)
 Muscle Relaxants:
Adverse Effects

 CNS is most common

 Euphoria
 Lightheadedness
 Dizziness
 Drowsiness
 Fatigue
 Muscle weakness, others

(Elsevier, 2017)
Drug-Drug Interactions

 Alcohol
 CNS depressants

(Elsevier, 2017)
 Nursing Implications

 Monitor effectiveness
 Is pain relieved?
 Provide additional comfort measures
 Rest, heat NSAIDs, positioning
 Assess sedation
 Maintain safety

(Elsevier, 2017)
 Patient Education

 Educate on other measures to relieve pain

 Take medication directly as prescribed
 Avoid alcohol and other CNS depressants
 Report adverse reactions
 i.e. confusion, hypotension, arrhythmias
 Maintain safety
 Driving
 Occupation

(Elsevier, 2017)
 Direct-Acting Skeletal Muscle Relaxants

 Dantrolene
 Botulinum

(Elsevier, 2017)
 Indications

 Muscle spasticity
 Acts directly on the muscle – injection
 Malignant hyperthermia
 Dantrolene only

(Elsevier, 2017)
 Adverse Effects

 CNS – most common

 Drowsiness
 Confusion
 Photosensitivity
 Botulinum as been associated with anaphylactic reactions

(Elsevier, 2017)
 Nursing Implications

 Assess CNS
 Monitor for anaphylaxis
 Botulinum
 Assess integument prior to injection
 Monitor for extravasation
 IV dantrolene
 Institute life saving measures if anaphylaxis occurs

(Elsevier, 2017)
 Patient Education

 Report adverse effects

 Educate on signs and symptoms of anaphylaxis
 Maintain safety
 Driving
 Photosensitivity
 Wear sunscreen
 Appropriate clothing

(Elsevier, 2017)
 Universal Nursing Implications

 Safety is important:
 Keep side rails up or use bed alarms.
 Assist patient with ambulation
 Keep call light within reach.
 Monitor for adverse effects.
 Respiratory
 Cardiovascular
 Neurological

(Elsevier, 2017)
 Nursing Implications (Cont.)

 Monitor for therapeutic effects:

 Increased ability to sleep at night
 Fewer awakenings
 Shorter sleep-induction time
 Few adverse effects, such as “hangover” effects
 Improved sense of well-being because of improved sleep
 For muscle relaxants: decreased spasticity, decreased rigidity

(Elsevier, 2017)
 BREAK

 2 med templates
 Chapter 10 Antiparkinsonian Drugs

ECPI
 Reference

 Lilley, L., Rainforth Collins, S. & Synder, J. (2017). Pharmacology and the
Nursing Process, Eighth Edition. Saint Louis, Missouri: Elsevier, Inc.

(Elsevier, 2017)