Lesson 2

Medications that relieve pain w/o causing loss of consciousness.

Pain is an unpleasant sensory or emotional experience related to tissue injury.

Pain is whatever the experiencing person says it is, existing whenever he or she says it does.

• Bp
• pulse
• temp
• respirations
• pain

• Perception of pain
• Pain threshold 
• Pain tolerance

it is subjective & highly individualized

The intensity at which the stimuli is judged as painful.

The maximum degree of pain intensity a person is willing to endure (highly variable)

by; Duration & Origin

• Acute Pain: suden onset; usually subsides with Tx.
• Chronic Pain: Persistant (can be difficult to Tx)

• Cancer
• Neuropathic pain: results from injury to peripheral nerve fibers
• Somatic (body): Originates in muscles, ligaments & bone.
• Superficial Pain: Originates from the skin & mucus membranes.
• Visceral Pain: Originates from organs & smooth muscle
• Vascular Pain: Migraines
• Referred Pain: Pain felt in other areas than those stimulated.
• Phantom Pain: pain perceived in an extremity that has been amputated (type of neuropathic pain)

Acute or Chronic

• Bradykinin
• Histamine
• Potassium
• Prostaglandins
• Serotonin

• Suggests that nervous 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

They are produced by the body & considered the body's painkillers.

• Client not acknowledging pain
• Inability to measure pain
• Lack of assessment
• Attitudes of health care team
•       don't believe client
•       concerns r/t addiction & tolerance
•       inadequate dose prescribed

Non pharm & pharm

Mild to moderate pain

• Antipyretic - fever reducer (Tylenol)
• Anti-platelet - Aspirin
• Anti-inflammatory (NSAIDS only) - ibuprofen

• Analgesic for mild to moderate pain
• Antipyretic

• Known drug allergy
• Severe liver disease
• Genetic disease (G6PD enzyme deficiency)

• Generally well tolerated
• rash, N/V
• Less common: blood disorders (anemia) & nephrotoxicities - especially if taken outside the recommended dose range.

• Long term ingestion of high doses can cause nephrotoxicity
• 150mg/kg is lethal
• causes tissue necrosis in liver
•    a 165lb client = 75kg
•    75kg X 150mg = 11250mg
•    11250mg/325mg tab = 34.5 tabs 
• to OD for the 165lb client
• Much easier for a small child of 22lb (only needs 4.6tabs to OD)

Acetylcysteine

• ^Resp rate
• ^HR
• HTN
• ^stress response
• Urinary retention
• Glucose intolerance
• Pneumonia
• Weakness
• Constipation

dull, throbbing pain of headaches, dysmenorrhea, inflammation, minor abrasions, muscular aches & pain, mild to moderate arthritis

By inhibiting biosynthesis of prostaglandin by different forms of the enzyme cyclooxygenase (COX)

• Inhibiting COX-2 decreases inflammation & pain, but inhibiting COX-1 decreases the protection of the stomach lining. 
• As a result NSAIDs can cause stomach ulcers and bleeding.

• with food
• at mealtime
• or with a full glass of fluid

It may cause excess bleeding

• Tinnitus
• Vertigo
• Bronchospasm
• Urticaria

• Prunes
• Raisins
• Paprika
• Licorice

NSAIDs

Moderate to severe

A psychological & physical dependence upon a substance beyond normal voluntary control, usually after prolonged use of a substance.

the sap of seed pods of the opium poppy plant.

on the peripheral nervous system at the pain receptor sites.

• Mostly on the CNS.  
• Primarily by activating the u receptors, while also exerting a weak activation of the kappa (k) recpetors.

• Analgesia 
• Resp depression
• Euphoria
• Sedation

• Sedation
• Analgesia
• (NO effect of resp. depression or euphoria)

• Antitussives (cough suppressant)
• (*except meperidine/Demerol)

• Levo-isomers produce an analgesic effect 
• Levo & Dextro-isomers both produce an antitussive response.
• Levo-isomers: cause dependence
• Dextro-isomers: don't cause dependence

Antidiarrheal effects

• N/V
• Constipation
• Moderate <BP
• Orthostatic Hypotension
• Respiratory depression
• Urinary retention
• Antitussive effects

• Acute pain from acute myocardial infarction (AMI)
• Cancer
• Dyspnea resulting from pulmonary edema
• Preoperative

GI procedures & does NOT have the antitussive property.

• It does NOT diminish uterine contractions
• Causes less neonatal respiratory depression
• Causes less constipation & urinary retention

A semisynthetic opioid similar to morphine.

• 6Xs more potent
• fewer hypnotic effects
• less GI distress
• faster onset & shorter duration of action
• readily absorbed into the body and excreted in the urine.

• Respirations
• adequate hydration

Opioids <respirations, thus causing an accumulation of CO2.  W/^ in CO2 retention, blood vessels dilate, especially cerebral vessels, which causes ^intracranial pressure.

• A combination drug.
• Ibuprofen and Hydrocodone

Patient-Controlled Analgesia

Provide a continuous "around-the-clock" pain control that is helpful to clients who suffer from chronic pain.

• Meperidine (Demerol)
• Pentazocine (Talwin)
• Propoxyphene (Darvon)

The liver and excreted in the urine

It is usually used along w/a nonopioid & opioid.  Adjuvant analgesics were developed for other purposes & later were found to be effective for pain relief in neuropathy.

• Anticonvulsants
• Antidepressants
• Corticosteroids
• Antidysrhythmics
• Local anesthetics

• Diabetic Neuropathy
• Cancer
• Migraine headaches
• Rheumatoid arthritis

This program works by replacing opioids with methadone, also an opioid but one that causes less dependency than the opioids it replaces.

• Medications in which an opioid antagonist is added to an opioid agonist.
• developed in hopes of decreasing opioid abuse

• Butorphanol tartrate (Stadol)
• Buprenorphine (Buprenex)
• Nalbuphine hydrochloride (Nubain)

overdoses of natural & synthetic opioid analgesics.

By blocking the receptor & displaces any opioid that would normally be at the receptor, inhibiting the opioid action.

• Naloxone (Narcan)
• Naltrexone hydrochloride (ReVia)
• Nalmefene (Revex)

Unilateral throbbing head pain accompanied by nausea, vomiting, & photophobia

Inflammation & dilation of the blood vessels in the cranium.

• Cheese
• Chocolate
• Red wine

• Classic Migraines: are associated with an aura that occurs minutes to 1hr before onset.
• Common Migraines: not associated with an aura

They are characterized by a severe unilateral nonthrobbing pain usually located around the eye.  They occur in a series of cluster attacks; one or more attacks every day for several weeks.

• Beta-adrenergic blockers: 
•       Propranolol (Inderal) & Atenolol (Tenormin)
• Anticonvulsants:
•      Valporic acid (Depakote) & Gabapentin   
•      (Neurontin)
• Tricyclic Antidepressants: 
•      Amitriptyline (Elavil) & Imipramine (Tofranil)

• The triptans (5-HT1 receptor agonists)
•    ie. Sumatriptan (Imitrex)

12-20/min

Long-acting.  "Contin" means "continuous"

No, you can continue to gradually increase opioids with increased tolerance.

• CNS depression
•     *Respiratory depression
•     *Pupil constriction
•     Tachycardia
•     Drowsiness
•     Confusion
•     Euphoria
• Orthostatic Hypotension: puts pt's at risk for falls.
• GI: N/V, constipation
• Urinary retention

Narcan (Naloxone).  Take aprox. 1hr to take effect.

• Rebound pain
• Tachycardia
• ^BP
• Mental agitaion
• Anxiety
• Irritability
• Chills
• Joint pain
• Lacrimation
• Rhinorrhea
• Diaphoresis
• N/V
• Abdominal cramps
• Diarrhea

• Nature & type of pain
• Location of pain
• Duration of pain
• Rating of pain
• Precipitating & Relieving factors
• Remedies & other Tx's that help the pain
• Check vitals against baseline vitals

• Caused by inflammation & dilation of blood vessels
• Imbalance of serotonin

• Beta-adrenergic blockers (Propranolol: Inderal)
• Anticonvulsants (Depakote, Neurontin)
• Tricyclic antidepressants (Amitriptyline: Elavil)
• Triptans (Suma Triptan: Imitrex)

• Analgesics: ASA
•  Acetaminophen
•  NSAIDs (Advil, Aleve)
• Opioids: Demerol
•  Stadol NS (nasal spray)
• Ergot alkaloids
•  Ergostat

• Antimigraine drugs:
•   The "Triptans Sisters"
• Almo Triptan
• Ele Triptan
• *Suma Triptan....ect.  Anything with Triptan Tx is for acute migraines

By causing vasoconstriction of cranial arteries.

• Dizziness, tingling, numbness, warm sensation, drowsiness, seizures
• Muscle cramps, N/V, diarrhea
• Hypertension, Dysrhythmias, thromboembolus, MI, stroke

• The form of medication and how to take it.
• Trigger foods to avoid
• Client should keep a journal to monitor response to therapy
• May ^BP
• *Do NOT take other Triptans w/in 24hrs of Suma Triptan.

• Redness
• Swelling
• Heat
• Pain
• Loss of Fxn

^Cardiac events such as MI's

• Nonsteroidal
• Corticosteroids
• Disease-modifying Antirheumatic Drugs
• Antigout Drugs

• <inflammation & pain
• Gout
• Fever
• Platelet inhibition
• Rheumatoid & Osteoarthritis
• *ONLY aspirin & Ibuprofen are used for FEVER or headaches

• Gold Drug Therapy (Chrysotherapy)
• Immunosuppressive agents
• Immunomodulators
• Antimalarials

• <WBC
• <Immune System

• Stops progression of joint degeneration
• Decreases leukocytes migration
• Suppresses prostaglandin activity

Rheumatoid Arthritis

3-6 months

• Anorexia, N/V, Diarrhea, Stomatitis, Photosensitivity, Metallic taste, Uriticaria, Severe rash, Corneal gold deposits, Bradycardia, Profound Hypotension, Hematuria, Proteinuria
• Life Threatening s/e: Nephrotoxicity, Agranulocytosis (not making WBCs), Thrombocytopenia (<platelets)

It is an inflammatory disease of the joints & tendons.

In the great toe.

A defect in purine metabolism that leads to uric acid accumulation.

• Salmon
• Liver
• Sardines
• Alcohol

• Colchicine
• Allopurinol: a uric acid inhibitor
• Uricosurics

Colchicine

It inhibits the migration of leukocytes to the inflamed site.

• N/V, Diarrhea, Abdominal pian
• *take with food to avoid GI distress

• Severe Renal problems
• Cardiac
• GI problems

Allopurinol (Zyloprim); a Uric acid inhibitor

Decreases uric acid levels in blood

• Monitor CBC, liver enzymes, renal fxn
• Yearly eye exams for visual changes
• Client needs to avoid alcohol, caffeine, & thiazide diuretics that ^uric acid levels
• & ^fluid intake to ^uric acid excretion

Chronic

• GI irriation
• *take w/food!

• ^fluid intake to ^uric acid excretion.
• Not to be given w/other highly protein bound drugs.

• Febuxostat (Ulroic)
• Krystexxa (pegloticase)

• Regularly scheduled labs
•     *to assess kidney fxn, liver fxn, & CBC
• ^FLUID intake
• Report S/E
• Dietary changes: low purine diet, no alcohol, do NOT take large doses of Vit C.

Abnormal electrical discharges from the cerebral neurons.

• Generalized:
•   Grand mal (tonic-clonic)
•      most common
•      generalized alternating muscle spasms &          jerkiness
•   Petit mal (absence)
•      Brief loss of consciousness (10sec or <)
•      Usually occurs in children
• Partial
•    Psycomotor
•      Repetitive behavior (chewing/swallowing 
•      motions)
•     Behavioral changes
•     Motor seizures

• Control of seizure activity
• Status epilepticus
• Mood disorders (Bipolar, manic/depression)
• Neuropathic pain (migraines, diabetic, neuropathy)

• Phenytoin (Dilantin)
• Carbamazepine (Tegretol)
• Valproic Acid (Depakote):also for Bipolar dissorder
• Clonazepam (Klonopin)
• Lamotrigine (Lamictal): also for Bipolar dissorder
• Gabapentin (Neurontin): also for Neuropathic pain
• Topiramate (Topamax)

10-20mcg/ml

• Gingivitis
• Nystagmus, diplopia
• HA, dizziness, slurred speech, <coordination, Alopecia
• Thrombocytopenia, stevens-johnson syndrome
• Hepatotoxicity

• Ataxia (common in elderly)
• Thrombocytopenia
• Hepatotoxicity

Barbiturates; additive effect & ^ CNS depression

• Bone marrow suppression = <RBC, <WBC, <platelets
• Dysrhythmias

• Rash
• Ataxia (lack of muscle coordination during voluntary movements like walking)
• *can be used for Bipolar dissorder

• Warn client NOT to d/c abruptly = statusepilepticus
• Teach client to take drug at same time daily
• Avoid certain herbs, alcohol, & other CNS depressants
• Monitor serum drug levels & liver fxn tests
• Safety: Protect from environmental hazards; driving

• Frequent oral hygiene & dental check-ups
• Warn females to use additional contraception
• Monitor glucose level in diabetics
• Warn of harmless pinkish/brown urine

• Benzodiazapines
•  *Diazepam (Valium)
•  *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 head & neck
• Rigidity (^muscle tone)
• Bradykinesia (slow movement)
• Postural changes: Head & chest thrown forward
• Shuffling walk
• Lack of facial expression
• Pill-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 interferes w/dopamine
• COMT Inhibitors: Inhibit COMT enzyme that inactivates dopamine

Carbidopa (a decarboxylase inhibitor) permits more levodopa to reach the striatum nerve terminals where levodopa is converted to dopamine & this decreases Sx of parkinsonism

• Involuntary choreiform movements (dance/squirm)
• N/V, Urinary retention
• Fatigue, Insomnia, dry mouth, blurred vision
• Orthostatic Hypotension, palpitations, dysrhythmias
• Dyskinesia, psychosis, severe depression

• Anticholinergics: Cogentin, Artane
• Dopamine Agonist: Symmetrel, Parlodel
• COMT Inhibitors: Stalevo
• Others: Eldepryl, Requip

• DO NOT ABRUPTLY D/C
• Monitor for Orthostatic Hypotention
• Avoid excess vit B6
• Urine/sweat will be brown discoloration (normal)
• Assess s/s status & "on-off" phenomenon
• Monitor blood cell counts: liver & kidney fxn
• Teach r/t: Anticholinergic effects w/Benzotropine & Trihexyphenidyl

• Progressive, degenerative disease
• neuritic plaques form
• Neurofibrillary tangles are in neurons
• Cholinergic neurotransmitter abnomallity

• Loss of memory
• Loss of logical thinking
• Loss of  judgment
• Time disorientation
• Personality changes
• Hyperactivity
• Tendency to wander
• Inability to express oneself

Acetylcholinesterase Inhibitors: Aricept, Exelon, Cognex

• NO CURE
• Improve memory
• Slow progression of disease

Headache, dizziness, Dehydration, dry mouth, blurred vision, Depression, GI distress, Insomnia, HTN, Hypotension, dysrhythmias, Hepatotoxicity

• Monitor VS
• Maintain consistency in care
• Monitor behavioral changes
• Provide safety when wandering
• Arise slowly to avoid dizziness
• Monitor for GI bleeding

It is an Autoimmune disorder: Attacks myelin sheath of nerve fibers & causes lesions or plaques.

• Extremity weakness or spasticity
• Diplopia (double vision)
• has remissions & exacerbations

• Centrally acting meds:
• Baclofen (Lioresal)
• Tzanidine (Zanaflex)

• Direct Acting:
• Dantrolene (Dantrium)

• Cyclobenzaprine (Flexeril)
• Carisoprodol (Soma)

• Drowsiness, sedation, dizziness
• Headaches
• GI distress
• Drug dependence

• Take w/food
• Monitor liver fxn
• Check VS
• NO DRIVING
• Do NOT d/c abruptly (d/c over 1wk to avoid rebound spasms
• Avoid Alcohol & other depressants.