Pharm (ATI 2)

Pain mediating chemicals (increase pain transmission and cause inflammatory response)
Bradykinins
Prostaglandins
Histamine
Substance P

Body’s natural pain killers (decrease pain transmission and produce analgesia)
– serotonin, enkephalins, endorphins
– bind to opioid receptors and inhibit the conduction of pain impulses

3 Types of opioid receptors
Mu
Kappa
Delta

Mu receptor
– stimulated by opioid drugs
– cause analgesia, euphoria, sedation, respiratory depression, physical dependence

Kappa receptor
– stimulated by opioid drugs (to a lesser effect)
– cause analgesia, sedation, psychic effects

Delta receptors
– no pharmacology effects

ACTH – adreno cortocotropin hormone
– hypothalamus stimulates pituitary gland to release ACTH
– ACTH stimulates adrenal glands to produce corticosteroids

Corticosteroids
– glucocorticoids: cortisol
– mineralocorticoids: aldosterone
– causes suppression of inflammation and immune response

Types of Analgesics
– NSAIDs: interfere with production of prostaglandins
– Opioids: stimulate opioid receptors

Types of Anti-inflammatories
– Glucocorticoids: produce strong anti inflammatory effect
– Uricosurics: decrease levels of uric acid

Nonopioid Analgesics
– NSAIDs that inhibit COX1 and COX2
– NSAIDs that inhibit COX2
– Acetaminophen
– Centrally acting nonopioids

NSAIDs that inhibit COX1 and COX2 (first generation)
– inflammation suppression
– analgesia for mild to moderate pain
– reduce fever
– dysmenorrhea
– inhibition of platelet aggregation (anti-coagulant)
– prototype drug: aspirin, ibuprofen (Advil, Motrin)

COX 1
– stimulates the release of protective prostaglandins
– gastric mucosal protectant
– enhances platelet aggregation
– promotes kidney function

COX 2
– stimulates the release of prostaglandins secondary to injury
– inflammation, pain, fever

Side Effects of NSAIDs that inhibit COX 1 and COX 2
– gastric upset, nausea, ulcers
– bleeding
– kidney dysfunction

Nursing Interventions for NSAIDs (first generation)
– monitor for signs of bleeding (black stools, abdominal pain, nausea)
– monitor I&O, BUN, creatinine
– recommend for short periods of time, and in low doses

NSAIDs that inhibit COX 2 (second generation)
– inflammation suppression
– analgesia for mild to moderate pain
– reduce fever
– dysmenorrhea
– prototype: celecoxib (Celebrex)

Side Effects of NSAIDs (second generation)
– less gastric effects (good)
– less renal effects (good)
– increased cardiovascular effects (bad)
– CV effects are a result of vasoconstriction and platelet aggregation

Nursing Interventions for second generation NSAIDs
– all same as first generation
– PLUS monitor for MI and CVA

Acetaminophen
– analgesia for mild to moderate pain
– reduce fever
prototype: acetaminophen (Tylenol)
– many of the same benefits as NSAIDs but with less side effects

Side effects of Acetaminophen
– liver damage (overdose)
– hypertension (with daily use, particularly women)

Nursing interventions for Acetaminophen
– monitor for liver damage
– antidote: acetylcysteine (Mucomyst)
– monitor blood pressure

Centrally acting Nonopioids
– moderate to severe pain
– prototype: tramadol (Ultram)
– binds to selected opioid receptors
– blocks reuptake of norepinephrine and serotonin in the CNS

Side effects of Centrally acting Nonopioids
– sedation, N/V, urinary retention
– respiratory distress and seizures are rare

Nursing Interventions for Centrally acting Nonopioids
– monitor for dizziness, esp. while ambulating
– recommend lowest possible dose, short term only
– give with food
– monitor respirations (below 12, stimulate breathing/give naloxone)

2 Types of opioid analgesics
– opioid agonists
– opioid agonist-antagonists

Opioid agonists
– bind primarily to Mu receptors to produce analgesic effects (mimics naturally occurring opioids)
– analgesia for moderate to severe pain
– analgesia, sedation, euphoria, respiratory depression
– prototype: morphine
– other drugs: fentanyl, methadone, codeine, oxycodone, hydrocodone

Opioid agonist-antagonists
– bind to Mu (as an antagonists) and Kappa receptors (as an agonist), simultaneously stimulating and blocking their analgesic effects (not as effective at reducing pain, but good for addicts and women in labor)
– milder analgesia effects for moderate to severe pain
– adjunct for anasthesia
– prototype: butorphanol, pentazocine (Talwin)

Nursing interventions for opioid agonists
– monitor respirations, administer naloxone if needed
– encourage patients to urinate every 4 hr
– monitor ambulation
– encourage stool softeners and fiber

Nursing Interventions for opioid agonist-antagonists
– do not administer to patients with cardiac problems (esp. MI)
– ask patients about opioid use before administration (can precipitate withdrawal in opioid users)

Opioid antagonist
– prototype: naloxone (Narcan)
– reverse effects of opioids

Uricosurics
– treat the hyperuricemia that causes gout
– prototype: allopurinol (Zyloprim)
– prevent formation and promote excretion of uric acid

Glucocorticoids
– suppress the inflammatory response and immune response
– mimic the naturally produced steroids of the adrenal glands

A HCP is caring for a patient who is opioid-dependent and is going to start taking butorphanol (Stadol). The patient is at risk for developing a syndrome that causes: (select all)

1. bronchospasm
2. vomiting
3. peripheral edema
4. abdominal cramps
5. hypertension

2. vomiting
4. abdominal cramps
5. hypertension

Abstinence syndrome, due to sudden drug withdrawal or use of an opioid agonist-antagonist such as butorphanol can cause fever, tremors, N/V, anxiety, restlessness, hypertension, and anorexia

A HCP should question the use of morphine for a patient who is taking which drug?

1. Phenobarbital (Luminal) for a seizure disorder
2. Warfarin (Coumadin) for anticoagulation
3. Glipizide (Glucotrol) for diabetes mellitus
4. Alendronate (Fosamax) for osteoporosis

1. Phenobarbital (Luminal) for a seizure disorder

Taking these medications together can cause increased CNS depression

Which drugs can increase the risk of Reye’s syndrome in children with viral infections?

1. Butorphanol
2. Acetaminophen
3. Tramadol
4. Aspirin

4. Aspirin

Manifestations of Reyes syndrome include lethargy and persistent vomiting

A HCP is caring for an older adult who is going to start taking prednisone for long-term treatment of rheumatoid arthritis. The HCP should monitor for which adverse effects?

1. Pulmonary embolism
2. Hepatitis
3. Bone loss
4. Breast cancer

3. Bone loss

Glucocorticoids can cause osteoporosis especially with long term use

A patient is about to begin taking prednisone to treat systemic lupus erythematosus. The HCP should give the patient which of the following instructions (select all)

1. Reduce the dose during periods of stress
2. Discontinue the drug gradually
3. Report illness or infection
4. Increase intake of calcium and vit D
5. Monitor for signs of gastric bleeding

2. Discontinue the drug gradually
3. Report illness or infection
4. Increase intake of calcium and vit D
5. Monitor for signs of gastric bleeding

Doses should be higher during times of stress

A patient is about to begin taking butuorphanol for pain control. The HCP should monitor the patient for which of the following adverse effects (select all)

1. infection
2. nausea
3. tachycardia
4. dizziness
5. headache

2. nausea
4. dizziness
5. headache

Unlikely to cause infection, more likely to cause bradycardia.

A HCP should question the use of morphine for a patient who is recovering from:

1. mastectomy
2. knee arthroplasty
3. cystoscopy
4. cholecystectomy

4. cholecystectomy

Morphine can cause biliary colic, it is inappropriate for patients who have just had biliary tract surgery such as cholecystectomy

A patient is about to begin taking tramadol (Ultram) to treat moderate acute pain. The HCP should include which of the following instructions?

1. increase fiber and fluid
2. take the drug with food
3. avoid driving after taking the drug
4. change positions gradually
5. reduce exercise level temporarily

1. increase fiber and fluid
2. take the drug with food
3. avoid driving after taking the drug
4. change positions gradually

Tramadol can cause constipation, N/V, sedation and drowsiness. Patients should increase exercise to minimize constipation

A patient has osteoarthritis and is about to begin taking aspirin. The HCP should tell the patient to report which of the following signs of salicylism? (select all)

1. fever
2. tinnitus
3. diaphoresis
4. thrombophlebitis
5. dizziness

2. tinnitus
3. diaphoresis
5. dizziness

Aspirin helps reduce fever and salicylism does not cause fever. Aspirin is unlikely to cause thrombophlebitis.

A patient is about to receive butorphanol (Stadol) to a patient for pain control. During administration, the HCP should take which of the following actions?

1. caution the patient about the drugs potential for abuse
2. withhold the drug for respiratory rates below 12/min
3. administer one nasal spray into each nostril
4. give the drug with an opioid agonist for maximal effects

2. withhold the drug for respiratory rates below 12/min

Low potential for abuse

An older adult is about to begin taking aspirin for an ankle sprain. The HCP should tell the patient to report which of the following adverse reactions?

1. polyuria
2. bone pain
3. weight gain
4. infection

3. weight gain

Aspirin can cause renal dysfunction. Weight gain is a sign of renal impairment (along with reduced urine output, edema)

BUN and creatinine levels should be monitored

A HCP should question the use of celecoxib (Celebrex) for a patient with:

1. rheumatoid arthritis
2. ankylosing spondylitis
3. an allergy to sulfonamides
4. adrenocortical insufficiency

3. an allergy to sulfonamides

Celecoxib treats rheumatoid arthritis and ankylosing spondylitis. Patients with allergies to sulfonamides or salicylates can react adversely to the drug

A patient is about to begin taking allopurinol (Zyloprim) to prevent hyperuricemia. The patient should report which of the following adverse effects? (select all)

1. palpitations
2. sore throat
3. vertigo
4. bruising
5. vision changes

2. sore throat
3. vertigo
4. bruising
5. vision changes

Allopurinol can decrease WBCs so fever and sore throat should be reported. Allopurinol can cause thrombocytopenia (platelet deficiency) which can increase bruising. Allopurinol can cause cataracts with long term use.

A patient is about to begin taking celecoxib (Celebrex) to treat rheumatoid arthritis. The patient should report which of the following adverse reactions?

1. chest pain
2. tinnitus
3. constipation
4. diaphoresis

1. chest pain

celecoxib can cause cariovascular and cerebrovascular events; report chest pain, shortness of breath, headache, weakness, numbness, confusion

A HCP should question the use of tramadol (Ultram) for patients with:

1. seizure disorder
2. hyperthyroidism
3. rheumatoid arthritis
4. urinary incontinence

1. seizure disorder

Tramadol, a nonopioid analgesic can cause seizure activity

A patient who takes furosemide (Lasix) is about to begin taking prednisone to treat inflammatory bowel disease. The HCP should monitor the patient for which of the following results of concurrent use of the two drugs?

1. hypercalcemia
2. hypoglycemia
3. hypothermia
4. hypokalemia

4. hypokalemia

Glucocorticoids (prednisone) can cause hypokalemia. Electrolyte imbalance increases with diuretics. Monitor potassium levels.

A patient should be advised to stop taking ibuprofen (Advil) for occasional headaches, if they have:

1. penicillin allergy
2. peptic ulcer disease
3. dysmenorrhea
4. hyperthyroidism

2. peptic ulcer disease

A patient is taking acetaminophen (Tylenol) for mild discomfort that does not require an opioid. The patient should report which of the following early signs of acetaminophen overdose? (select all)

1. diaphoresis
2. palpitations
3. shortness of breath
4. nausea
5. diarrhea

1. diaphoresis
4. nausea
5. diarrhea

Acetaminophen is unlikely to cause palpitations or shortness of breath. Palpiatations are likely with an opioid antagonist. Shortness of breath is likely with celecoxib.

Naloxone can reverse the effects of an excessive dosage of which of the following drugs?

1. aspirin
2. acetaminophen
3. morphine
4. prednisone

3. morphine

A patient is taking naloxene to treat morphine overdose. The HCP should monitor for which adverse effects? (select all)

1. tachypnea
2. increased pain
3. thrombophlebitis
4. tachycardia
5. hypertension

1. tachypnea
2. increased pain
4. tachycardia
5. hypertension

Naloxene is more likely to cause bleeding than a blood clot. Naloxene reverses analgesic effects of opioids.

A patient is about to begin taking allopurinol (Zyloprim) to treat gout. The HCP should monitor for hypersensitivity syndrome, which causes which of the following clinical manifestations?

1. fever
2. muscle pain
3. anxiety
4. tremors

1. fever

Hypersensitivity reactions (fever, rash, itching) can lead to renal or liver dysfunction

A HCP should question the use of acetaminophen for patients who have:

1. asthma
2. diabetes mellitus
3. heart failure
4. alcohol use disorder

4. alcohol use disorder

Acetaminophen cause cause liver toxicity

Patients should take acetaminophen (Tylenol) for which of the following? (select all)

1. to reduce fever
2. to decrease inflammation
3. to relieve mild pain
4. to promote sedation
5. to alleviate anxiety

1. to reduce fever
3. to relieve mild pain

Acetaminophen does not have anti-inflammatory effects. It does not cause sedation or reduce anxiety (morphine does)

A patient who takes low-dose aspirin to prevent cardiovascular events asks a HCP about taking ibuprofen (Advil) to treat rheumatoid arthritis. The HCP should respond by saying:

1. ibuprofen will increase the risk for salicylism
2. ibuprofen will reduce the antiplatelet effects of low dose aspirin
3. low dose aspirin will reduce the anti-inflammatory effects of ibuprofen
4. low dose aspirin will reduce the analgesic effects of ibuprofen

2. ibuprofen will reduce the antiplatelet effects of low dose aspirin

Low dose aspirin can ADD a slight anti-inflammatory and analgesic effect to that of ibuprofen. Taking the two together increases risk for bleeding.

A patient is receiving morphine for sever pain. The HCP should monitor for which adverse effects (select all)

1. diarrhea
2. urinary retention
3. respiratory depression
4. sedation
5. orthostatic hypotension

2. urinary retention
3. respiratory depression
4. sedation
5. orthostatic hypotension

Morphine is more likely to cause constipation than diarrhea

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