Analgesics and Antipyretics

Pain

When nerve signals are sent to the brain (CNS) after feeling a hurtful sensation inside or outside the body, the brain perceives these signals as pain.

When the client complains of pain, it is important for the nurse to treat it. Pain: the fifth vital sign

Pain Transmission

Tissue injury causes the release of:

Bradykinin Histamine Prostaglandins Serotonin

These substances stimulate nerve endings, starting the pain process.

Pain Transmission Gate Theory

Most common and well-described theory of pain Uses the analogy of a gate to describe how impulses from injured tissues are sensed in the brain

Pain Transmission in the Spinal Cord

A fibers

C fibers

Myelin sheath Large fiber size Conduct quickly Sharp and welllocalized

No myelin sheath Small fiber size Conduct slowly Dull and nonlocalized

Neurotransmitters

Body has endogenous neurotransmitters

Endorphins Enkephalins Marathon runners and cyclists

Produced by body to fight pain

Bind to opioid receptors Inhibit transmission of pain by closing the gate

Management of Pain

Treat the cause. Select a safe analgesic. Select the analgesic that provides effective relief. Provide psychological support. Nursing actions: position change and back rub

Analgesics

Analgesic drugs relieve pain without causing loss of consciousness.

Opioid Analgesics

Opium has been used for thousands of years to alleviate pain. Opium is derived from the poppy plant. Opium produces pain relief by attaching to pain receptors. Narcotics are derivatives of opium. Narcotics are strong pain relievers.

Classifications of Opioid Analgesics

Classifications based on their actions:

Agonist Agonist-antagonist Partial agonist

Uses for Opioid Analgesics

Main use: to alleviate moderate to severe pain Opioids are also used for:

Cough suppression Diarrhea treatment

Effects of Opioid Analgesics

Euphoria Nausea and vomiting Respiratory depression Urinary retention Diaphoresis and flushing Pupil constriction (miosis) Constipation

Complications of Opioid Analgesics

Respiratory implications Constipation concerns

Opioid Analgesics: Nursing Assessments

Perform a thorough history. Obtain baseline vital signs and assessments. Assess for potential contraindications and drug interactions.

Opioid Analgesics: Nursing Implications

Oral formstake with food Ensure safety measures

Opiates: Opioid Tolerance

A common response to chronic opioid treatment Larger dose of opioids is required

Opiates: Physical Dependence

Physiologic adaptation to the presence of an opioid If in need of pain relief, give the medication

Opiates: Psychological Dependence (Addiction)

A pattern of compulsive drug use when the medication is not needed for physical pain relief

Opioid Analgesics: Nursing Implications

Law: narcotics must be kept under a double lock

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Opioid Analgesics: Nursing Implications

Pain management approaches Medical/nursing

Medicate clients before a procedure or an activity and/or When they are complaining of pain Back rub, musical therapy, and relaxation therapy

Nursing

Opioid Analgesics: Therapeutic Effects

Monitor for therapeutic effects

Increased comfort Activities of daily living improved

Opiate Antagonists

Naloxone (Narcan) and naltrexone (ReVia)

Opiate antagonists Bind to opiate receptors and prevent a response Used for reversal of opioid-induced respiratory depression

Opioid Analgesics: Nursing Implications

Rotate site for IM injections. Follow proper guidelines for IV administration, such as dilution and rate of administration. Check dosages carefully.

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Opioid Analgesics: Nursing Implications

Provide fluid and fiber.

Prevent constipation.

Prevent respiratory depression. Provide instruction for clients.

Drug administration Position changes

Analgesic Agents

Analgesic agents

Salicylates (ASA) Acetaminophen (Tylenol) Combination narcotic and non-narcotic analgesics Nonsteroidal anti-inflammatory drugs (NSAIDs)

Anti-inflammatory analgesic agents

ASA (Acetylsalicylic Acid)

Used for more than 100 years Action: peripherally interferes with synthesis of prostaglandins and chemical substances released from injured tissue Treats mild to moderate pain Antipyretic effect

ASA: Side Effects

Gastrointestinal irritation and bleeding Increases bleeding time Tinnitus Children: Reyes syndrome

Analgesic Agents: Acetaminophen

Mechanism of action

Blocks pain impulses peripherally

Relieves pain Reduces a feverantipyretic Weak anti-inflammatory Minimal effect on the central nervous system

Acetaminophen: Side Effects

Acute overdose causes hepatic necrosis.

Doses of 150 mg/kg

Long-term ingestion of large doses can result in nephropathy

Acetaminophen: Acute Overdose

Treatment: acetylcysteine

Oral form IV form now approved Prevents the formation of hepatotoxic metabolites

Anti-inflammatory Agents

Nonsteroidal Anti-inflammatory Drugs

Group of frequently prescribed drugs Treat pain Common drug

Acetylsalicylic acid (ASA) Hermann Kolbe

Uses for NSAIDs

Analgesic (mild to moderate) Antigout Anti-inflammatory Antipyretic Relief of vascular headaches Platelet inhibition

How NSAIDs Work

Stop the activation of the arachidonic acid pathway Reduce:

Pain Headache Fever Inflammation

Analgesics

Reduce pain by blocking prostaglandins

Antipyretics

Inhibit prostaglandin E2 in the brain

Inflammation Relief

Inhibit either the:

Leukotriene pathway Prostaglandin pathway Or both pathways

Pain Relief

Relief of mild to moderate pain

Bone, joint, and muscle pain Osteoarthritis Rheumatoid arthritis Juvenile rheumatoid arthritis Dysmenorrhea

Common NSAIDs

Common drugs that are used:

Ibuprofen (Motrin, Advil) Ketoprofen (Orudis) Ketorolac (Toradol) Naproxen (Naprosyn)

Gastrointestinal Side Effects

First-generation NSAIDs

Dyspepsia, heartburn, epigastric distress, nausea Gastrointestinal bleeding Mucosal lesions (erosions or ulcerations)

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Gastrointestinal Side Effects

Second-generation NSAIDs

Called COX-2 inhibitors

More specific in their action Reduce gastrointestinal distress

Cardiovascular Side Effects

Second-generation NSAIDs

Serious side effects:

Cardiac arrhythmias Heart attack Stroke

Celecoxib (Celebrex) may be removed Rofecoxib (Vioxx) removed from market by the FDA

Precautions

First and second generation

Do not take if you:

Have or had stomach ulcers and bleeding Have had asthma Have had an allergic response to aspirin or sulfa Have severe kidney problems Have severe liver problems Are pregnant

Renal Side Effects

Creatinine clearance reduced Renal failure

Acute tubular necrosis

Nursing Assessment

Before beginning therapy, perform thorough assessment for:

Gastrointestinal lesions or peptic ulcer disease Bleeding disorders Heart disorders Perform lab studies

CBC, platelet count, cardiac, renal, and liver

Medical History

Medication history Serious drug interactions

Alcohol Heparin and warfarin (Coumadin) Phenytoin Steroids Sulfonamides

Salicylates

Do not give Salicylates to children under age 12.

Reyes syndrome - Ralph Douglas Reye - rare childhood disease: a rare and serious childhood disease, usually following a respiratory infection, causing vomiting, fatty deposits in the liver, disorientation, and swelling of the kidneys and brain

Give with food and milk.

Client Education

Educate clients about precautions. Watch for:

Unusual bleeding, abdominal pain, and cardiac problems

Enteric-coated tablets should not be crushed or chewed.

Therapeutic Effects

Monitor for:

Decrease in swelling Decrease in pain Decrease in joint tenderness