pharmacology

Medications that relieve pain without causing loss of consciousness

-medical definition: pain is an unpleasant sensory or emotional experience related to tissue injury

• -nursing definition: pain is whatever the experiencing person says it is, existing whenever he or she says it does.
• -the Fifth Vital sign- always check pain

Subjective and highly individualized

Intensity at which the stimuli is judged as painful

Maximum degree of pain intensity a person is willing to endure - highly variable

persistant pain, can be difficult to treat

sudden onset, usually subsides after treatment, usually specific tissue injury

acute, chronic or both

• results from injury to inflammation or injury to nerve
• feels like pins and needles, burning, triggered by light touch

sensory pain receptors

originates in muscles, ligaments and bones. refers to body

originates from the skin and mucous membranes, lower scale of intensity

originates from organs and smooth muscle

• interuption of blood flow to tissue, organs or nerves.
• example: migraine

pain felt in areas other than those stimulated

• pain percieved in an extremity that has been amputated.
• normal feeling

• *tissue injury causes the release of
• -bradykinin
• -histamine
• *potassium iv potassium- leaking into        tissue cause pain
• -prostaglandins
• -serotonin
• These substances stimulate the nerve endings, starting the pain process

• -suggests that nervous e system adjusts or varies the transmission of painful stimuli
• -suggests that pain impulses can be regulated or blocked by a gating mechanism in the dorsal horn of the spinal cord
• *heat/cold or massage helps

• -Produced by the body- considered the body's painkillers "runners high"
• -natural pain killers
• -neurohormones

• -client not acknowledging pain 
• -inability to measure pain
• -lack of assessment
•   -rank pain 0-10 scale
• -attitudes of health care team
•   -don't believe client
•   -concerns re: addiction & tolerance
•   -inadequate does prescription

Non pharm & pharmacological measures

• -multi srtengths
• -uses: mild to moderate pain
•   *arthritis, HA, menstral cramps, inflammation, minor abrasions, muscular aches & pains
• -other effects: 
•         -antipyretic
•         -anti platelet (aspirin)
•         -anti inflammatory (NSAIDS only)

fever reducer

blood thinner, prevents blood clots

decrease swelling

• -mild to moderate pain
• -Fever
• -analgesic and antipyretic effects
• -NO anti inflammatory effect
• -available in oral & now injectable forms

• -known drug allergy
• -severe liver disease
• -genetic disease (G6PD enzyme deficiency- no enzyme to break it down)

• -generally well tolerated
• -may experience: rash, nausea, vomiting
• -less common: blood disorders (anemia), and nephrotoxicities- especially if taken outside the recommended dosage ranges

• -Potentially lethal when over dosed (150 mg/kg or more a one time)
• -tissue necrosis in liver (kills liver)
• -long term ingestion of high doses causes nephrotoxicity
• -treatment for toxicity: acetylcysteine
• interactions: alcohol and other hepatoxic drugs

• 165 # pt = 75 kg
• 75 x 150= 11250
• 11250/325 (one tab)= 34.6 tabs (to kill)

• child 22 # = 10 kg
• 10x150 = 1500
• 1500/325 =4.6 tabs (to kill)

• -take as directed
• -maximum dose per day?
• -** 3250 mg **
• -geriatric patients and people with liver problems- 2400 mg or less
• Be aware of other meds that end in "cet"
• -percocet, darvocet, lorcet, deocet, dolocet...
• -other combo drugs: vicodin, tylox, wygesic

• -moderate to severe pain
• -SE: N7V, constipation, HA, anxiety, seizures
• -pregnancy c

• -pain tolerance
• -not to exceed 4g/day
• -check liver enzymes
• -keep out of reach of children
• effectiveness

• -pain relievers that contain opium
• -or derived from opium poppy
• -or chemically related to opium
• -Act primarily in the CNS

-5 "schedule" categories- based on their potential for abuse

• -schedule I- high potential for drug abuse. No accepted medical use...heroin,hallucinogens
• -schedule II-high potential for drug abuse.accepted medical. Can lead to physical/psychological dependency...morphine
• -schedule III-medically excepted drugs. May cause dependence. Less likely abused...codiene prep meds
• -schedule IV-medically accepted. May cause dependence...lorazepam
• -schedule V-medically accepted. Very limited potential for dependence... Opioid for cough

- a pattern of compulsive drug use characterized by a continued crawving for an opioid and the need to use the opioid for effects other than pain relief

** physical dependence...taper off

• -relieve moderate to severe pain 
•    -codiene- mild to moderate pain
• -cough suppression
• -relieve diarrhea
• **no ceiling effect** (no limit on how high can go)

continuous or long lasting- do not crush

• -morphine sulfate (roxanol)-effective against acute pain from mi,ca,dyspnea-po, iv, im, sq, sl, rectal (ms contin)
• -hydromorphone (dilaudid)-stronger than morphine- po, iv, sc, im, rectal
• -meperidine (demerol)-primarily effecive in gi procedures. Short term use 48-72 hrs- po, im, iv
• -fentanyl (duragesic)po, iv, im, transdermal, lozenge (lollipop)- duragesic patch
• -oxycodone- po
•   *oxycontin
•   *percocet= oxycodone+acetaminophen
•   *percodan= oxycodone+aspirin
• -hydrocodone- po
•   *vicodin= hydrocodone+acetaminophen
• -codiene sulfate- po, sq, im
•   *tylenol #3=codiene+acetaminophin

• -CNS depression**
•   -respiratiory depression 1st thing seen. low resp rate
•     -treatment-opiod antagonist
•      ***naloxone(narcan)** (most common)(reassess after 1 hr)

•       naltrexone (revia)
•       nalmefene (revex)
• -Orthostatic hypotension
•   -risk for heart failure

• -**pupil constriction** 
• -tachycardia
• -drowsiness
• -confusion
• -euphoria
• -gi side effects (common) n&v, constipation- should be assessed for & pattern
• -urinary retention- risk for bladder infection

• -drug allergy
• -increased intracranial pressure
• -severe asthma
• -other respiratory insufficiency
• -clients with very low bp (shock)

• -CNS depressants
• -alcohol
• -sedative-hypnotics
• -muscle relaxants
• -major tranquilizers
• -antipsychotic agents

meds used with other non opioid  or opioid med

opioid less dependency used to replace abused opioid

opioid antagonist is used with opioid agonist to help decrease abuse

blocks the receptor and displaces any opioid that would normally be at the receptor and inhibiting the opioid action

• -Rebound pain, tachycardia, elevated bp, mental agitation, anxiety, irritability, chills, joint pain, lacrimation, rhinorrhea, diaphoresis, n&v, abdominal cramps, diarrhea
• -occur within 24-48 hrs after stopped

• -a common physiological result of chronic opioid treatment
• -desensitizing...reduces effect of drug

Respirations (VS), pain level, description, location, last dose

assessment: perform thorough pain assessment including nature type, precipitating and relieving factors, remedies, other pain tx, fifth VS.

dx and plan

• -have rank pain
• -patient teaching
•   oral forms should be taken with food to minimize gastric upset
• -ensure safety measures
• -assess vs 
•    Low BP or Low Respiration- hold dose and contact md
•     may need to give opioid antagonist
• -monitor other side effects- constipation ortho hypotension
• -instruct pt to not take with other mds to otc preparation
• -follow proper administration
• **CHECK DOSAGE CAREFULLY**
• -special populations -geriatrics pediatrics may need additional therapy
• -adjuvant therapy-addiction concerns
• *eval for effects f/u assessment

• -unilateral(sometimes bilateral) throbbing pain disrupting adls
• -other symptoms: aura, n&v, photophobia (sensitive to light)
• -triggers: cheese, chocolate, red wine, hormones
• -lasts for hours or days
• - affects women 20-30's, decrease or absent during preg and menapause

• -caused by inflammation and dilation of blood vessels
• -imbalance of serotonin

classic: associated with aura

common: no aura

• -beta adrenergic blockers
•   'propranolol (Inderal)
• -anticonvulsants
•   'valproic acid (Depakote)
•   'gabapentin (Neurontin)
• -tricyclic antidepressants
•   'amitriptyline (Elavil)
• -triptans

• -analgesics
•   'aspirin, acetaminophen
•   'NSAIDs: ibuprofen, naproxen (aleve)
• -opioid analgesics
•   'meperidine (Demerol)
•   'butorphanol nasal spray (stadol NS)
• -erogot alkaloids
•   'erogotamine tartrate (erogostat)

• -almo triptan(axert)
• -ele triptan (relpax)
• -frova triptan (frova)
• -nara triptan (amerge)
• -riza triptan (maxalt)
• -suma triptan (imitrex) 1st- most common
• -zolmi triptan (zomig)

-action: causes vasoconstriction of cranial arteries

-uses: treat migraine headaches

-side effects: dizziness, tingling, numbness, warm sensation, drowsiness, seizures, muscle cramps, nausea,vomiting, diarrhea, **most serious: hypertension, dysrhythmias, thromboembolus, MI, stroke

• teaching regarding:
•  -dissolving wafers, nasal spray, self injectable forms (provide specific teaching)
•  -avoid trigger foods
•  -keep journal to monitor effects to therapy
•  -may increase bp
•  -do not take other triptans within 24 hr of sumatriptan- more side effects

• -severe, unilateral, NON throbbing pain around eye
• -1 or more attacks every day for several weeks
• -more common in men
• -treatment: similar to migraine headaches

• -Inflammation
•   'reaction to tissue injury & infection
•   'caused by release of chemical mediators
•   'leads to vascular response
•   'fluid and WBCs migrate to injured site
• -Chemical mediators
•   'histamines
•   'kinins
•   'prostaglandins

response to tissue injury and infection

caused by microorganisms and results in inflammation

• -redness
• -swelling
• -heat
• -pain
• -loss of function

enzyme responsible for converting arachidonic acid into prostaglandins and their products

protects stomach lining & regulates blood platelets- dec fever promote platelet aggregation

triggers inflammation & pain

• -non steroidal anti-inflammatory drugs (NSAIDs)
• -corticosteroids
• -Disease modifying anti rheumatic drugs DMARDS
• -anti gout drugs

potent anti inflammatory effect not related to corticosteroidal

• -reduce inflammation and pain
• -gout, inflammation, fever, platelet inhibition, rheumatoid & osteoarthritis
• -Not recommended for fever or headaches
•   'EXCEPT aspirin, ibuprofen

• -Salicylates: aspirin
• -Parachlorobenzoic acid: indomethocin(Indocin), sulindac (clinoril)
• -propionic acid derivatives:ibuprofen (advil),naproxen (Naprosyn)
• -fenamates
• -oxicams: piroxicam (feldene)
• -phenylacetic acid derivatives: diclofenac sodium (voltaren), ketorolac (toradol)

-COX-2 inhibitors: celecoxib (Celebrex)- doesn't cause GI problems or bleeding

• -action: anti inflammatory, antiplatelet, antipyretic, analgesic
• ** know there are levels to draw-therapeutic serum salicylate level 10-30 mg/dl
• -toxic serum salicylate level >30mg/dl

NEVER say ASA daily 81 or 325 mg is for pain. its NOT it is for anti platelet effect

• -anticoagulants (Coumadin) increases anticoagulants
• -hypoglycemia with oral hypoglycemic drugs
• -increases gastric ulcer risk with glucocorticoids

• -increase PT, INR, bleeding time, uric acid
• -decrease potassium, cholesterol, T3 and T4 levels

prunes, raisins, licorice, certain spices

• -do not take with other NSAIDs
• -avoid during third trimester of pregnancy
• - do not give to children with flu or virus symptoms (may cause potentially fatal reye syndrome

• -tinnitus- ringing in ears
• -gastric distress (heartburn), peptic ulcer
• -urticaria- hives
• -life threatening: agranulocytosis, hemolytic anemia, anaphylaxis, thrombocytopenia, hepatotoxicity, bronchospasms, renal failure

tinnitus, dizziness, bronchospasms

tinnitus, dizziness, headache, confusion, sweating, drowsy, thirst, nausea, vomiting, diarrhea

convulsions, cardiovascular collapse, coma

• -nonselective Cox inhibitors
• -brand/trade names: ibuprofen (motrin, advil)
• -drug interactions: increase effects of warfarin, phenytoin
• side effects: gastric distress
• Naproxen (Naprosyn)

• -action: selectively inhibits COX-2 enzyme without inhibition of COX-1
• -Use: decrease inflammation and pain
• -drug agents: celecoxib (Celebrex)
• -Similar agents: nabumetone(Relafen), meloxicam (Mobic) (some COX-1 inhibition)

• -Caution: avoid during third trimester of pregnancy- premature closure
• -side effects: mild headache, dizziness, nausea, diarrhea, sinusitis, peripheral edema, assess renal function and GI status

• -inform of drug and herbal interactions
• -avoid alcohol
• -inform surgeon and dentist before procedures of NSAID use
• -avoid NSAIDs 1-2 days prior to menstruation
• -do not take if pregnant
• -inform of SE
• -take with food decrease GI upset

• -gold drug therapy- used to be standard not so much now
• -immunosuppressive agent
• -immunomodulators
• -antimalarials

• -Auranofin (ridaura)
• -Action:
•   'stops progression of joint degeneration
•   'decreases leukocytes migration
•   'suppresses prostaglandin activity
• -Use: rheumatoid arthritis

• **may take 3-6 mos to work
• 'anorexia, N&V, diarrhea, stomatitis, photosensitivity, metallic taste, uritica, severe rash,
•  'cornel gold deposits, bradycardia, profound hypotension, hematuria, proteinuria

nephrotoxicity, agranulocytosis, thrombocyopenia

• -severe renal or hepatic disease
• -pregnancy, blood dyscrasias, colitis
• -systemic lupus erythematosis

used to treat refractory rheumatoid arthritis

concern with immune suppressions & increase risk for serious infections & different cancers

• -teaching
• -assess for side effects/adverse reactions:
•  'instruct patient regarding side effects
•  'instruct patient to report symptoms of toxicity

treat moderate to severe rheumatoid arthritis disrupting inflammatory process and delaying disease progression

• -Entanercept (enbral) given SQ
• -Infliximab (Remicade) given IV
• -Adalimumab (Humira) given SQ
• -Action: neutralize TNF, disrupt inflammatory process, delay disease progression

• -side effects/adverse reactions: HA, dizziness, chills, hot flashes, depression, N&V, diarrhea, urinary frequency, hypotension, hypertension, altered liver enzymes, severe infections
• -Contraindications: renal or hepatic disease, immunosuppression, infection
• **predisposes the client to __________

• -used to treat RA unresponsive to anti inflammatory drugs
• -ex: azathioprine (Imuran), Cyclophosphamide (Cytoxan), methotrexate
• -many serious side effects

• -inflammatory disease of joints, tendons
• -usually occurs in great toe
• -defect in purine metabolism leads to uric accumulation (purine containing foods, salmon, liver, sardines, alcohol

• -colchicine
• -uric acid inhibitors (allopurinol)
• -uricosurics- crystals

• -inhibit migration of leukocytes to inflamed site
• -side effects: N&V, diarrhea, abdominal pain
• -taken with food to avoid GI distress
• -Contraindications: severe renal, cardiac, or GI distress
• ** USED FOR ACUTE ATTACK

• -Allopurinol (Zyloprim) Not an NSAID
• -Action: decreases uric acid levels, used to prevent gout
• -Nrsg interventions:
•  'monitor CBC, liver enzymes, renal function
•  'yearly eye exams for visual changes
•  'client to avoid alcohol, caffeine, and thiazide diuretics that increase uric acid level
• -increase fluid intake to increase uric acid excretion

increase the rate of uric acid excretion by inhibiting its absorption

• -probenecid (Benemid)
• -used for chronic gout NOT acute attacks
• -Side effects: gastric irritation, take with food
• -Nrsg intervention:
•  'Increase fluid intake to increase uric acid excretion
•  'not to be given with other highly protein bound drugs

side/adverse effects: upper respiratory tract infections, musculoskeletal, connective tissue or joint signs and symptoms, headache and diarrhea

-side/adverse effects: painful gout flare ups or reactions to injections, breathing problems, headaches and nausea

• -regular scheduled lab tests: assess kidney, liver function & CBC
• -increase fluid intake
• -report SE
• -Dietary changes: low purine diet, alcohol, do not take large doses of vit c

- abnormal electric discharges from cerebral neurons

• -loss of consciousness
• -convulsive movements

• -unknown
• -secondary to trauma, anoxia, infection, stroke
• -isolated seizures due to fever, electrolyte, or acid based imbalance

-most common-generalized alternating muscle spasms and jerkiness

• -brief loss of consciousness (10 seconds or less)
• -usually occurs in children

• -Psychomotor
•  'repetitive behavior-chewing or swallowing motions
•  'behavior changes
•  'motor seizures

TO KNOW HOW TO EVAL ADEQUATELY

• -action-
• -indications
•  'control of seizure activity
•  'status epilepticus
•  'mood disorders (bipolar disorder--manic/depression)
•  'neuropathic pain (migraines, diabetic, neuropathy)

• -phenytoin (dilantin)
• -carbamazepine ( tegretol)
• -valpropic acid (depakote)-used for bipolar disorder
• -clonazepam (klonopin)
• -lamotrigine (Lamictal)-used for bipolar disease
• -gabapentin (neurotin)- also used for neuropathic pain
• -topiramate (topamax)

safe & toxic plasma levels close

• -contraindications: pregnancy (teratogenic)
• -therapeutic serum level:10-20 mcg/ml
• -side effects/adverse reactions: gingivitis, gingival hyperplasia, nystagmus- eyes jumpy indication of too much in system, diplopia, HA, dizziness, slurred speach, decreased coordination, alpecia, thrombocytopenia, steven-johnson syndrome

**ALWAYS CHECK LEVELS

• -side/adverse effects: ataxia (common in elderly), thrombocytopenia, hepatotxicity
• -interactions: barbiturates- additive effect (increase CNS depression)

• -side/adverse effects: bone marrow suppression, dysrhymias
• -interaction:all blood cells effected, several drugs when used in combination with this drug may lead to toxicity, other bone marrow depressants-additive effect

• -used a lot for bipolar disorders
• -side/adverse effects: rash-common- hold med call md pt to be seen asap,
• ataxia
• -interactions: other anticonvulsants

• -assessment: document type of seizure seen, assess liver function tests, CBC
• -nrsg dx: risk for injury
• -planning
• -implementation

• -warn client do NOT discontinue abruptly
• -teach client to take drug at same time every day
• -avoid certain herbs, alcohol, & other CNS depressants
• -monitor serum drug levels & liver function tests
• -safety: protect from environmental hazards, driving

• -need frequent oral hygiene and dental check ups
• -warn females taking oral contraceptives to use additional contraception
• -monitor glucose level in diabetics
• -warn of harmless pinkish red or brown urine

• -Benzodiazepines
•  'diazepam (valium)- most common used to stop status epileptics
•  'lorazepam (Ativan)
•  'midazolam (versed)
•  'followed by fosphenytoin--cerebyx (iv form of dilantin

• -chronic neurologic disorder
• -degeneration of dopaminergic neurons
• -imbalance of the neurotransmitters
•  'less dopamine

• -tremors of the head and neck
• -rigidity (increase muscle tone)
• -bradykinesia (slow movement)
• -postural changes-head and chest thrown forward
• -shuffling walk
• -lack of facial expression
• -pillow rolling motion of hands

• -dopaminergics: convert to dopamine
• -dopamine agonists: stimulate dopamine receptors
• -anticholinergics: block cholinergic receptors
• -MAO-B inhibitors: inhibit MAO-B enzyme that interfere with dopamine
• -COMT inhibitors: inhibit COMT enzyme that inactivates dopamine

• -Carbidopa-levadopa (sinemet)
• -action: converted to dopamine-short duration of action, must be taken 3-4 times/day. extended release 2-4 times/day
• -side effects: involuntary choreiform movements, N&V, urinary retention, fatigue, dry mouth, bluured vision, ortho hypotension, palpitations, dysrhythmias,dyskinesia, psychosis, severe depression
• -drug interactions: phenytoin, benzodiazepines, anticholinergics

• -anticholinergics: benztropine (Cogentin), trihexyphenidyl HCL (artane)
• -dopamine agonist: amantadine (symmetrel), bromocriptine (parlodel)
• -COMT: entacapone (stalevo)
• -others: seleginine (eldepryl), ropinirole (requip) also used for restless legs syndrome

• -DO NOT ABRUPTLY DISCONTINUE
• -monitor for ortho hypotension
• -avoid excess vit B6
• -warn of urine/sweat getting harmless brown discoloration
• -assess symptom status and "on-off" phenomenon
• -monitor blood cell counts, liver function & kidney function
• -teaching re: anticholingerics effects with benztropine & trihexphenidyl

• -progressive, degenerative disease
• -neuritic plaques form
• -neurofibrillary tangles are in neurons
• -cholinergic neurotransmitter abnormallity

• -loss of memory, logical thinking,judgement
• -time disorientation
• -personality changes
• -hyperactivity
• -tendency to wander
• -inability to express oneself

• Acetycholinesterase inhibitors: Donepezil (Aricept), Rivastigmine (exelone), tacrine (cognex)
• -use: mild to moderate Alzheimer's Disease
• -goal: NOT a cure, improve memory, slow progression of disease

headache, dizziness, dehydration dry mouth, blurred vision, depression, GI distress, insomnia, hypertension, hypotension, dysrhythmias, hepatotoxicity

• -monitor VS
• -maintain consistency in care
• -monitor behavior changes
• -provide safety when wandering
• -arise slowly to avoid dizziness
• -monitor for GI bleed

• -autoimmune disorder
• -attacks myelin sheath of nerve fibers
• -cause lesions or plaques

• -remissions and exacerbations
• -extremity weakness or spasticity
•  'spasticity: muscular hyperactivity that cause contraction of the muscles.
• -diplopia

• -glucocorticoid (prednisone)
• -biologic response modifiers (interferon-B)
• -immunosuppressant
•  'azathioprine (Imuran)
•  'cyclophosphamide (Cytoxan)
• -skeletal muscle relaxants

• -central acting
•  'baclofen (lioresal)
•  'tizanidine (Zanaflex) 
• **USED FOR MS OR FOR OTHER SPASTICITY WITH SPINAL CORD INJURY
•  'cyclobenzaprine (flexeril)
•  'carisoprodol (soma)
• **USED FOR MUSCLE SPASMS
• -direct acting 
•  'dantrolene (dantrium)
• **USED FOR MS  & SPINAL CORD INJURY
• -use
•  'suppress muscular hyperactivity
•  'relax muscles in spasm

drowsiness, sedation, dizziness- MOST COMMON WITH ALL, headaches, GI distress, drug dependence

• -take with food
• -monitor liver function
• -check VS
• -do not allow to drive
• -do not stop abruptly: discontinue over 1 week to avoid rebound spasms
• -avoid alcohol and other depressants

• -autoimmune disease
• -lack of nerve impulses and muscle responses at myoneural junction
• -lack of acetylcholine reaching cholinergic receptors

• -muscular weakness and fatigue
• -respiratory muscle paralysis, ptosis, difficulty chewing and swallowing

• -Neostigmine (prostigmin): short acting
• -edrophonium (tensilon): ultra short acting (used for diagnosing MG)
• -pyridostigmine (mestinon): intermediate acting
• -action: transmission of neuromuscular impulses by preventing destruction of Ach
• -use: control and treat MG

• -similar symptoms
• -muscle weakness, dyspnea
• -dysphasia, abdominal crapping
• -drooling, increases tearing, sweating
• -bradycardia

 -myasthenia crisis: severe muscle weakness, improves after edrophonium

-Cholinergic crisis: overdosed: severe muscle weakness

• pupil consriction
• GI distress, abd crapping
• excess saliva, sweating
• headache, dizziness, seizures
• hypotension, bradycardia, dysrhythmias
• bronchospasms, respiratory depression

• administer doses on time
• take drug before meals if possible
• monitordrug effectiveness
• have antidote available for cholinergic crisis:atropine