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Pain

• Physiological and psychological experience for patients

• Can be seen as body’s defense mechanism physiologically

– Avoid damaging situation

– Seek help

• Psychological factors can increase or decrease perception of pain

– E.g., anxiety vs positive attitude and support


Pain Assessment

• Subjective experience for patients

• Numerical scales and surveys assist in assessment

• Effective pharmacotherapy depends on

– Assessment of degree of pain

– Determining underlying disorders


Acute Pain

• Intense

• Defined period of time


Chronic Pain

• Lasts longer than six months

• Interferes with daily activities


Nociceptive Pain

• Due to injury to tissues

– Somatic: Sharp, localized sensation

– Visceral: Dull, throbbing, aching pain


Figure 18.3 Mechanisms of pain transmission at the nociceptor level


Neuropathic Pain

• Due to injury to nerves

• Burning, shooting, numbing

• More difficult to manage


Neuropathic Pain - Examples

• Carpal tunnel syndrome

• Degenerative disk disease

• Diabetic retinopathy

• Intractable cancer pain

• Phantom limb pain

• Postsurgical pain

• Sciatica


Treatment for Intractable Cancer Pain

• Radiation or chemotherapy

• Relieving nerve stimulation

• Surgery

• Nerve block


Pain Transmission

• Nociceptor stimulation

• Spinal cord receives pain impulse through

– A fibers (myelin) —believed to signal sharp, well-defined pain

– C fibers (unmyelinated) —believed to conduct dull, poorly localized pain


Substance P

• Neurotransmitter

• Passes on pain message from spinalchord to brain

• Affected by other neurons


Endogenous Opioids

• Group of neurostransmitters

• May modify sensory information, interrupting pain transmission

• Endorphins, dynorphins, enkephalins


Interruption of Pain Transmission

• Several target areas

– Peripheral level NSAIDs

– CNS levelOpioids


Neural pathways for pain


• Analgesics: Medications used to relieve pain.

– Opioids

– Non-opioids


Opioids

• Natural or synthetic morphine-like substances responsible for reducing moderate to severe pain

• Obtained naturally from opium (10% morphine, 2% codeine).

• SyntheticMeperidine


Opioid Receptors

• Receptors: mu, kappa, delta, nociceptin/orphanin FQ peptide

– For pain management, mu and kappa receptors are most important

• Opioid agonist drugs: stimulate mu and kappa receptors

• Opioid antagonist drugs: block mu and kappa receptors


Opioid antagonists

• Agents that displace opioid molecules from their

neuroreceptors, and block opioids activating those

receptors.

• Used effectively to quickly reverse toxic effects of

opioid overmedication or overdose.

• The unexpected, paradoxical effects of opioid

antagonists as adjuvants for enhancing rather

than attenuating analgesic effects of opioids like

morphine, oxycodone, and others.


Responses Produced by Activation of Specific Opioid Receptors

Table 18.2 Responses Produced by Activation of Specific Opioid Receptors

Response Mu Receptor Kappa Receptor

Analgesia ✓ ✓

Decreased GI motility ✓ ✓

Euphoria ✓

Miosis ✓

Physical dependence ✓

Respiratory depression ✓

Sedation ✓ ✓


Opioid receptors


Table 18.3 Opioids for Pain Management (1 of 3)

Table 18.3 Opioids for Pain Management

Drug

Route and Adult Dose

(max dose where indicated) Adverse Effects

OPIOID AGONISTS WITH HIGH EFFECTIVENESS

fentanyl (Actiq, Abstral, Duragesic,

Fentora, Lazanda, Onsolis, Oralet)

Transdermal patch: 25 mcg/h

PO: 100 mcg initial dose (max: 100 mcg units

provided at a time)

Nasal spray: 100 mcg initial dose (max 800 mcg)

Buccal transmucosal: 200 mcg initial dose (max:

no more than six 200-mcg units should be in the

patient’s possession for titration)

Pruritus, constipation, nausea, sedation,

drowsiness, dizziness

Anaphylactoid reaction, cardiac arrest,

severe respiratory depression or arrest,

convulsions, abuse potential

hydromorphone (Dilaudid, Exalgo) PO/Subcutaneous/IM/IV: 1–4 mg every 4–6 h prn

levorphanol (Levo-Dromoran) PO: 2–3 mg tid—qid prn

Subcutaneous/IV: 1–2 mg q6-8h

meperidine (Demerol) PO: 50–150 mg q3–4h

IM: 50–100 mg q3–4h

IV: 1–1.5 mg/kg q3–4h

morphine (Astramorph PF,

Duramorph, others)

PO: 10–30 mg q4h prn

Sustained release: 15–30 mg q8–12h

IM: 10 mg q4h

IV: 2–10 mg q2–4h

oxymorphone (Opana) Subcutaneous: 1–1.5 mg q4–6h

Rectal: 1 suppository (5 mg) q4–6h

PO (extended release): 5–20 mg bid




Drug



OPIOID AGONISTS WITH MODERATE EFFECTIVENESS

codeine PO: 15–60 mg qid

IM: 15–30 mg q4–6h

Sedation, nausea, constipation,

dizziness

Hepatotoxicity, respiratory depression,

circulatory collapse, coma, abuse

potential

hydrocodone (Hycodan) PO: 5–10 mg q4–6h prn (max: 15 mg/dose)

oxycodone (OxyContin, Oxecta) PO: 5–10 mg qid prn

Controlled release: 10–20 mg q12h

OPIOID ANTAGONISTS

naloxone (Evzio, Narcan) IV: 0.4–2 mg; may be repeated q2–3min

up to 10 mg if necessary

Muscle and joint pain, sleep anxiety,

headache, nervousness, withdrawal

symptoms, vomiting, diarrhea, insomnia

naltrexone (ReVia, Trexan, Vivitrol) PO: 25 mg followed by another 25 mg in 1 h if no

withdrawal response (max: 800 mg/day)

Hepatotoxicity




Drug



OPIOIDS WITH MIXED AGONIST–ANTAGONIST EFFECTS

buprenorphine (Buprenex,

Butrans, Suboxone)

IM/IV: 0.3 mg q6h (max: 0.6 mg q4h)

Topical: one patch every 7 days

Sublingual: 12–16 mg/day

Drowsiness, dizziness, light-

headedness, euphoria, nausea, clammy

skin, sweating, insomnia, abdominal

pain, constipation

butorphanol (Stadol) IM: 1–4 mg q3–4h prn (max: 4 mg/dose)

IV: 2.5–10 mg (usually 5 mg) q2–4h

Respiratory depression, shock

dezocine (Dalgan) IM: 5–10 mg (usually 10 mg) q3–4h

nalbuphine (Nubain) Subcutaneous/IM/IV: 10–20 mg q3–6h prn (max:

160 mg/day)

pentazocine (Talwin) PO: 50–100 mg q3–4h (max: 600 mg/day)

Subcutaneous/IM/IV: 30 mg q3–4h (max: 360

mg/day)

Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.


Opioid Agonists

• Mechanism of action: to interact with specific receptors

• Primary use: to relieve moderate to severe pain; some used for anesthesia

• Examples: OxyContin, Percocet


Opioid (Narcotic) Agonist

• Prototype drug: Opioid agonists—morphine (Astramorph PF, Duramorph, others)

• Mechanism of action: interacts with mu and kappa receptor sites


Opioid (Narcotic) Agonist

• Primary use: for analgesia and anesthesia

• Adverse effects: respiratory depression, sedation, nausea, and vomiting


Opioid Antagonists

• Block opioid activity

– Compete for opioid receptor

• Reverse symptoms of addiction, toxicity, and overdose

– Naloxone (Evzio, Narcan) may be used to reverse respiratory depression and other acute symptoms

– Also used to diagnose overdose


Opioid Antagonists

• Prototype drug: naloxone (Evzio, Narcan)

• Mechanism of action: interact with receptors

• Primary use: to reverse respiratory depression and other acute symptoms of opioid addiction, toxicity, overdose


Role of the Nurse: Opioid Antagonist Therapy

• Continue careful monitoring of patient's condition

– Especially respiratory status

• Have resuscitative equipment available


Opioids with Mixed Agonist-Antagonist Activity

• Stimulate opioid receptor, thus causing analgesia

• Withdrawal symptoms and side effects not as intense as those of opioid agonists

• Example: pentazocine (Talwin)


Opioid Dependence

• Potential to cause physical and psychologic dependence

• Patient-controlled analgesia (PCA)

• Combinations with nonnarcotic analgesics


• Vicodin: Hydrocordone 5mg, acetaminophen

500mg

• Percodan:Oxycodone hyrdochloride 7.5mg

acetaminophen 325 mg)


Treatment for Opioid Dependence

• Switch from IV and inhalation forms to methadone, the oral form

• Methadone maintenance

– Does not cure but avoids withdrawal symptoms

– Treatment may be needed for many months or years


Newer Treatment

• Early treatment: buprenorphine (Buprenex, Butrans, Suboxone)

– Mixed opioid agonist-antagonist

– Sublingual or transdermal route

• Later maintenance: bunavail, Suboxone, and Zubsolv contain both buprenorphine and naloxone


Role of the Nurse: Opioid Therapy

• Assess potential for opioid dependency

– Have narcotic antagonists available to reverse negative effects

• Monitor urine output for retention

• Monitor patient's bowel habits for constipation


Nonopioid Analgesics

• Used for fever, inflammation, and analgesia

• Used for mild or moderate pain associated with inflammation

• Include NSAIDs, acetaminophen, and a few centrally acting drugs


Table 18.4 Nonopioid Analgesics (1 of 3)

Table 18.4 Nonopioid Analgesics

Drug



NSAIDs: ASPIRIN AND OTHER SALICYLATES

aspirin (acetylsalicylic acid, ASA) PO: 350–650 mg q4h (max: 4 g/day) Heartburn, stomach pains, ulceration

salsalate (Disalcid) PO: 325–3,000 mg/day in divided

doses (max: 4 g/day)

Bronchospasm, anaphylactic shock,

hemolytic anemia

NSAIDs: IBUPROFEN AND SIMILAR DRUGS

diclofenac (Cambia, Cataflam, Voltaren,

Zipsor)

PO: 50 mg bid–qid (max: 200

mg/day)

Indigestion, nausea, occult blood loss,

anorexia, headache, drowsiness, Dizziness

diflunisal PO: 1,000 mg followed by 500 mg

bid–tid

etodolac PO: 200–400 mg tid–qid

fenoprofen (Nalfon) PO: 200 mg tid–qid Aplastic anemia, drug-induced peptic

ulcer, GI bleeding, agranulocytosis,

laryngospasm, laryngeal edema;

peripheral edema, anaphylaxis, acute

renal failure; vomiting, constipation,

Diarrhea

flurbiprofen (Ansaid, Ocufen) PO: 50–100 mg tid–qid (max: 300

mg/day)




Drug



ibuprofen (Advil, Motrin, others) (see page

506 for the Prototype Drug box)

PO: 400 mg tid–qid (max: 1,200 mg/day)

indomethacin (Indocin, Tivorbex) PO: 25–50 mg bid–tid (max: 200 mg/day), or 75 mg

sustained release one to two times/day

ketoprofen (Actron, Orudis) PO: 12.5–50 mg tid–qid

ketorolac (Toradol) PO: 10 mg qid prn (max: 40 mg/day)

mefenamic acid (Ponstel) PO: Loading dose: 500 mg; Maintenance dose: 250 mg

q6h prn

meloxicam (Mobic) PO: 7.5 mg/day (max: 15 mg/day) 7.5–15 mg daily

nabumetone (Relafen) PO: 1,000 mg/day (max: 2,000 mg/day)

naproxen (Naprelan, Naprosyn) PO: 500 mg followed by 200–250 mg tid–qid (max: 1,250

mg/day)

naproxen sodium (Aleve, Anaprox, others) PO: 250–500 mg bid (max: 1,000 mg/day naproxen)

oxaprozin (Daypro) PO: 600–1,200 mg/day (max: 1,800 mg/day)

piroxicam (Feldene) PO: 10–20 mg one to two times/day (max: 20 mg/day)

sulindac (Clinoril) PO: 150–200 mg bid (max: 400 mg/day)

tolmetin (Tolectin) PO: 400 mg tid (max: 2 g/day)




Drug



NSAIDs: COX-2 INHIBITORS

celecoxib (Celebrex) PO: 100–200 mg q6-8h or 200 mg

qid

Abdominal pain, dizziness, headache,

sinusitis, hypersensitivity

Cautious use due to FDA review

CENTRALLY ACTING DRUGS

acetaminophen (Tylenol, others) (see page


PO: 325–650 mg q4–6h (max

3g/day)

Hypotension, dry mouth, constipation,

drowsiness, sedation, dizziness,

vertigo, fatigue, headache

tramadol (Ultram) PO: 50–100 mg q4–6h prn (max: 400

mg/day); may start with 25 mg/day,

and increase by 25 mg every 3 days

up to 200 mg/day

Anaphylactic reaction, hepatotoxicity,

hepatic coma, acute renal failure

ziconotide (Prialt) Intrathecal 0.1 mcg/h via infusion,

may increase by 0.1 mcg/h every 2–3

days (max: 0.8 mcg/h)



Salicylates

• Prototype drug: aspirin (ASA)

• Mechanism of action: Inhibits prostoglandin

synthesis by inhibiting cyclooxygenase (COX)

• Adverse effects: with high doses may cause GI distress and bleeding

• May increase action of oral hypoglycemic agents


Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• Prototype drug: ibuprofen (Motrin)

• Mechanism of action: to inhibit cyclooxygenase and prevent formation of prostaglandins

• Primary use: for mild or moderate pain and to reduce inflammation

• Adverse effects: GI upset, acute renal failure


Selective Cox-2 Inhibitors

• Prototype drug: celecoxib (Celebrex)

• Mechanism of action: similar to the NSAIDs

• Primary use: to relieve pain, fever, inflammation

• Adverse effects: mild and related to GI system


Centrally Acting Nonopioid Analgesics

• Prototype drug: acetaminophen (Tylenol)

• Mechanism of action: to treat fever at the level of the hypothalamus; causes dilation of peripheral blood vessels, enabling sweating and dissipation of heat



• Primary use: treatment of fever and to relieve pain

• Adverse effects: uncommon with therapeutic doses



• Prototype drug: tramadol (Ultram)

• Mechanism of action: inhibits reuptake of serotonin and norepinephrine in spinal neurons.

• Primary use: as centrally acting analgesic

• Adverse effects can include: dizziness, lethargy, constipation


Role of the Nurse: Drugs for Control of Pain

• Assessment

– Carefully monitor patient's condition

– Assess vital signs, especially respiratory status

– Assess patient's pain level: character, duration, location, intensity of pain

– Obtain history of medications, alcohol use


Drugs for Control of Pain

• Planning

– Goal is to explain proper use of medication

– Patient is to be free of pain without dependency



• Implementation

– Encourage compliance with medication regimen



• Evaluation

– Patient should have pain control with limited side effects, no dependency


Headache and Migraines

• Tension headache

– Most common

– Self-limiting annoyance rather than emergency

• Migraine

– Throbbing or pulsating pain

– Often causes nausea and vomiting

– Often have triggers that can be avoided


Goal for Migraine Therapy

• Stop migraines in progress

• Prevent migraines from occurring


Antimigraine Drugs

• Triptans

– Serotonin agonists

– Act by constricting certain intracranial vessels

• Ergot alkaloids

– Interact with adrenergic, dopaminergic, and serotonin receptors

– Act as vasoconstrictors

– Terminate ongoing migraines


Triptans

• Prototype drug: sumatriptan (Imitrex)

• Mechanism of action: to act as serotonin agonists, constricting certain intracranial vessels

• Primary use: to abort migraines

• Adverse effects: GI upset


Ergot Alkaloids

• Mechanism of action: to promote vasoconstriction

• Primary use: to terminate ongoing migraines

• Adverse effects: GI upset, weakness in the legs, numbness and tingling in fingers and toes, angina-like pain, tachycardia


Other Drugs for Migraine Prophylaxis

• Antiseizure drugs

• Beta-adrenergic blockers

• Calcium channel blockers

• Tricyclic antidepressants


Table 18.5 Antimigraine Drugs (1 of 4)

Table 18.5 Antimigraine Drugs

Drug



TRIPTANS

almotriptan (Axert) PO: 6.25–12.5 mg; may repeat in 2 h if necessary (max: 2

tabs/day)

Asthenia, tingling, warming sensation,

dizziness, vertigo

eletriptan (Relpax) PO: 20–40 mg; may repeat in 2 h if necessary (max: 80 mg/day) Coronary artery vasospasm, MI,

cardiac arrest

frovatriptan (Frova) PO: 2.5 mg; may repeat in 2 h if necessary (max: 7.5 mg/day)

naratriptan (Amerge) PO: 1–2.5 mg; may repeat in 4 h if necessary (max: 5 mg/day)

rizatriptan (Maxalt) PO: 5–10 mg; may repeat in 2 h if necessary (max: 30 mg/day);

5 mg with concurrent propranolol (max: 15 mg/day)

sumatriptan

(Imitrex)

PO: 25 mg for 1 dose (max: 100 mg)

zolmitriptan (Zomig) PO: 2.5–5 mg; may repeat in 2 h if necessary (max: 10 mg/day)

ERGOT ALKALOIDS

dihydroergotamine

(D.H.E. 45, Migranal)

IM/subcutaneous: 1 mg; may be repeated at 1-h intervals to a

total of 3 mg (max: 6 mg/wk)

Nasal: 1 spray (0.5 mg) each nostril, may repeat once in 15 min

Weakness, nausea, vomiting,

abnormal pulse, Pruritus

Delirium, convulsive seizures,

intermittent Claudication




Drug



ergotamine (Ergostat), ergotamine with

caffeine (Cafergot, Ercaf,

others)

PO: 1–2 mg followed by 1–2 mg every 30

min until headache stops (max: 6 mg/day or

10 mg/wk) Sublingual: 2 mg, may repeat in

30 min for total three doses/24 h

or five doses/wk

ANTISEIZURE DRUGS

topiramate (Topamax) PO: start with 50 mg/day, increase by 50

mg/wk to effectiveness (max: 1600 mg/day)

Nausea, vomiting, sedation, drowsiness,

Weakness

valproic acid (Depakene) (see page 192

for the Prototype Drug box)

PO: 250 mg bid (max: 100 mg/day) Liver failure, bone marrow depression

BETA-ADRENERGIC BLOCKERS

atenolol (Tenormin) (see page 422


PO: 25–50 mg/day (max: 100 mg/day) Bradycardia, hypotension, heart failure

(HF), confusion, drowsiness, insomnia

metoprolol (Lopressor) (see page


PO: 50–100 mg one to two times/day (max:

450 mg/day)

Bronchospasm, exfoliative dermatitis,

agranulocytosis, membrane irritation,

rash, heart block, cardiac arrest,

anaphylaxis, Stevens–Johnson syndrome

propranolol (Inderal) (see page 453


PO: 80–240 mg/day in divided doses; may

need 160–240 mg/day




Drug



timolol (Blocadren) (see page 871


PO: 10 mg bid; may increase to 60

mg/day in two divided doses

CALCIUM CHANNEL BLOCKERS

nifedipine (Procardia) (see page


PO: 10–20 mg tid (max: 180 mg/day) Dizziness, light-headedness, facial flushing,

heat sensitivity, diarrhea, peripheral edema,

headache, hypotension, constipation

nimodipine (Nimotop) PO: 60 mg q4h for 21 days; start

therapy within 96 hours of subarachnoid

haemorrhage

Myocardial infarction (MI), atrioventricular (AV)

block, hepatotoxicity

verapamil (Isoptin SR) (see page

456 for the Prototype Drug Box)

PO: 40–80 mg tid (max: 360 mg/day)

TRICYCLIC ANTIDEPRESSANTS

amitriptyline (Elavil) PO: 75–100 mg/day Sedation, drowsiness, orthostatic hypotension,

blurred vision, slight mydriasis, dry mouth, urinary

retention, constipation

imipramine (Tofranil) (see page 208


PO: 75–100 mg/day (max: 300 mg/day)

protriptyline (Vivactil) PO: 15–40 mg/day in three to four

divided doses (max: 60 mg/day)

MI, dysrhythmias, heart block, agranulocytosis,

angioedema, bone marrow depression




Drug



MISCELLANEOUS DRUGS

methysergide

(Sansert)

PO: 4–8 mg/day in divided doses Nausea, vomiting, sedation,

drowsiness, weakness, discoloration of

urine (for vitamin B2), painful Urination

onabotulinumtoxin A

(Botox)

IM: 155 units administered intramuscularly (IM) to

muscles of the head and neck area

riboflavin (vitamin B2) As a supplement: PO: 5–10 mg/day

For deficiency: PO: 5–30 mg/day in divided doses

Shortness of breath



Role of the Nurse: Antimigraine Therapy

• Obtaining medical history

• Obtaining list of allergies

• Assessing patient's pain level

• Obtaining history of medications and alcohol and CNS-depressant use

• Assessing frequency and intensity of the migraine headaches


Role of the Nurse: Antimigraine Therapy

• Providing a quiet, calm environment

• Applying cold packs to help lessen pain

• Assessing pain level before medication administration

• Monitoring for side effects

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