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Module 4 Pharm

Terms in this set (69)

-morphine, hydromorphone, fentanyl, meperidine

-Common opioid analgesics: codeine, fentanyl, hydromorphone, meperidine, methadone, morphine, oxycodone

-MOA: binds to opioid receptors in CNS which blocks pain perceptions, this allows for analgesic repsonse

-Indications: used to treat moderate to severe pain and post-operative pain, also suppresses cough and in small doses can be used as a cough suppressant medication (ex. codeine)

-Contraindications: include known allergy or severe asthma

-Use caution: if patient has head injury, respiratory insufficiency, morbid obesity, sleep apnea, myasthenia gravis, paralytic ileus, or is pregnant

-Side effects: constipation, nausea, vomiting, sedation and mental clouding, respiratory depression, dry mouth, urinary retention, pruritis, dysphoria, euphoria, bradycardia, hypotension

-Toxicity and management of overdose: includes supporting the patient's airways as needed

-Antidote: nalaxone, expect patient to wake up in excruciating pain, vomiting can occur, best to prevent an overdose by doing good assessment of pt.

-Interactions: additive sedatice effect can result in loss of respiratory drive and can be fatal (alcohol, antihistamines, barbiturates, benzodiazepines, phenothiazine, centrally acting muscle relaxer (cyclobenzaprine) and other CNS depressants), paradoxical (monoamine oxidase inhibitors (MAOI'S))

-Opioids are contolled substances, schedule II (codeine, morphine, hydrocodone, meperidine, methadone), schedule III (codeine/hydrocodone mixed with other medications (hydrocodone and acetaminophen))
Assessments should include the following:
-Drug history
-Other prescribed medications (antihistamines, barbiturates, benzodiazepines, phenothiazine and other CNS depressants)
-Opioid use in past (is this an opioid tolerant patient or an opioid naïve patient? An opioid tolerant patient could take a larger dose whereas an opioid naïve patient would need a smaller dose)
-Vital Signs- especially blood pressure, heart rate and respiratory rate (think about the adverse effects of the opioids); do not give opioid if respiratory rate is less than 12.
-Urinary output (potential urinary retention)
-Pain (baseline assessment)
Assess for Contraindications and situations that require cautious use of opioids: Head injuries, increased intracranial pressure; Respiratory insufficiency; Shock or hypotension; Severe Renal disease (effects excretion and toxicity can occur, may need dose adjustment); and Severe Liver disease (effects metabolism and toxicity can occur, may need dose adjustment)

Diagnosis/problems:
-Acute pain
-Ineffective breathing patterns
-Risk for falls
-Constipation

Planning:
-Outcome identification:
-Surgical site pain will be decreased from 9 to 4 on a scale of 0-10 30 minutes after administration of intravenous morphine.

Implementation
-Administer before pain becomes severe
-Administer IV doses slowly- normally administering slowly over 5 minutes is recommended for morphine and hydromorphone.
-Monitor for pupil changes and reactions- pinpoint pupils can indicate morphine OD
-Monitor vs-RR <10(need to give naloxone), orthostatic hypotension
-If on PCA, continuous pulse oximetry recommended.
-Record I&O, especially noting patient's urinary output since morphine may cause urinary retention
-Check bowel sounds r/t side effect of constipation
-Have Naloxone available
-Use safety-side rails (x2; 4 raised side rails is considered a form of restraint and should be avoided), bed exit device (bed alarm)

Preventing side effects:
-Patient's may experience constipation with opioid analgesics. The nurse should encourage the patient to increase fluid, fiber and ambulation if possible. If these measures are ineffective, the nurse should notify the healthcare provider in order to obtain orders for stool softeners or stimulant laxatives.
-Patient's may experience nausea and vomiting. If ordered, the nurse should administer anti-emetic medications such as promethazine or ondansetron. If not ordered, the nurse should contact the healthcare provider in order to obtain a prescription for anti-emetic medications
-Respiratory suppression may occur. The nurse should count the respirations prior to administering any opioid analgesic and should not administer the medication if the breaths per minute rate is less than 12.
-Subacute overdose could occur over hours to days. The patient may experience respiratory depression, somnolence. Changing to a lower dose or holding a dose or two of the analgesic can help the patient during subacute overdose.
-Dry mouth can be helped by providing frequent oral care, sugar free hard candy for the patient to suck on, ice chips, and perhaps sugar free gum (however, I have known a patient who choked on her gum while under the influence of opioid analgesics).
-Since the patient may experience orthostatic hypotension, check the blood pressure prior to administering and withhold the dose if the blood pressure is less than 100 systolic (notify the health care provider when any medication is held). Teach the patient to rise in stages (sit on the side of the bed for a few seconds, then stand by the bed for a few seconds, then start taking a few steps).

Patient Teaching:
-Avoid alcohol and other CNS depressants
-Non-pharmacological measures of pain relief
-Opioids are addictive
-Teach family not to push the button in patient's using patient -controlled analgesia (PCA's)- You don't want to kill Grandma.

Evaluation:
-Pain level is decreased
-No signs of pain-facial grimacing, guarding, anxiety, tachycardia, hypertension.
-No adverse effects noted.
-Vital signs-look for respiratory rate, blood pressure and heart rate.
Assessment:
-Assess pain level if using for pain, assess patient temperature if using as antipyretic
-Assess past medical history
-Liver disease
-Assess lab work for liver (chronic acetaminophen abuse will result in elevated AST and ALT) and renal function (impaired renal function will impair clearance of the acetaminophen)
-Assess history of alcohol use (current and past use)

Diagnosis:
-Risk for injury
-Acute pain

Planning:
-Outcome Identification:
-Headache will decrease from 6 to 3 on scale of 0-10 after 1 hour of administration of acetaminophen.
-Temperature will be between 96-99 degrees Fahrenheit 1 hour after administration of acetaminophen.

Implementation:
-Monitor liver function
-Liver enzymes on lab
-Jaundice and dark urine (late sign of liver damage) The first place that you will see jaundice(that yellowing discoloration) is in the sclera of the eye.
-If over dose suspected, check acetaminophen level if within 4 hours of suspected over dose. If greater than 4 hours has passed, assume toxicity and start treatment
-Therapeutic acetaminophen level: 10-20 mcg/ mL
-Hepatotoxicity is > 200 mcg/mL (but if it has been greater than 4 hours since the ingestion of the acetaminophen, the levels are not accurate, due to liver changing acetaminophen to a metabolite; treatment with antidote will be advised)
-Treat overdose with antidote, acetylcysteine (IV is better tolerated)
-PO 140 mg/kg followed by 70 mg/kg Q4 hours x 17 doses (Health Care provider will order, this is not a nurse's role; knowing what to recommend is the nurse's role)
-IV-150 mg/kg over 60 minutes followed by 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours.

Patient teaching:
-Teach potential adverse effects of acetaminophen
-Teach recommended safe dose is 3000 mg/day (4000 mg is allowed but prolonged use can cause liver damage)
-Call poison control if overdose is suspected
-Teach to read labels for acetaminophen content
-Tylenol cold and sinus
-Tylenol PM
-Robitussin cold and flu
-Hydrocodone acetaminophen [Brand names: Vicodin (contains 300 mg acetaminophen); Lortab (contains 325 mg); Norco (contains 325 mg)] The opioid/acetaminophen combination analgesics used to allow up to 500 mg of acetaminophen but in 2014, the FDA banned any combination with more than 325 mg of acetaminophen due to risk of hepatotoxicity.

Evaluation:
-Pain level decreases
-Fever decreases
-No signs of adverse effects
-Evaluate for signs of liver damage (labs and jaundice)
Assessments should include:
-Assess medical history for past GI bleeding or GI ulcer, if recent, this will mean that aspirin should not be given to the client.
-Assess drug history for interactions-anticoagulants, other NSAIDs, or herbal products
-Assess the reason for administering the aspirin- pain, fever, heart health. Why the drug is given with provide your information for further assessments. For example, if it is given for pain, assess the client's pain level and location.
-Assess for history of asthma because this can predispose the patient to a hypersensitive reaction

Diagnosis:
-Risk for injury
-Chronic pain

Planning:
-Outcome Identification:
-Headache will decrease from 6 to 3 on scale of 0-10 after 1 hour of administration of aspirin.
-Temperature will be between 96-99 degrees Fahrenheit 1 hour after administration of aspirin.
-Patient will have no cardiovascular events during aspirin therapy (no heart attack or stroke).

Implementation:
-Monitor levels(Toxic if greater than 30 mg/dL)
-Monitor for signs and symptoms of toxicity (tinnitus and hearing loss)
-Monitor GI bleeding-dark tarry stools, coffee ground emesis
-Monitor for symptoms of an ulcer- epigastric pain, especially after eating
-Do not administer to patients with known GI ulcer or recent history of GI bleeding.
-Do not administer to children or teenagers with viral symptoms (Reye's Syndrome)
-Administer with food to help decrease the occurrence of GI ulceration

Patient Teaching
-Don't drink alcohol or take other highly protein bound drugs
-Don't take with other NSAIDS because it increases the chance of bleeding. Ibuprofen also may negate cardioprotective effects of aspirin.
-Watch for signs and symptoms of ulcer and/or GI bleeding (epigastric pain, dark tarry stools, coffee ground emesis)Let dentist know if taking aspirin prior to any dental work as this can increase bleeding
-Notify surgeon prior to surgery. Most likely will discontinue aspirin 3-7 days before surgery to reduce risk of bleeding (with the healthcare provider's approval)
-Talk to health care provider before starting new meds
-Do not take on an empty stomach, always take with food to help prevent the occurrence of GI ulceration.

Evaluation:
-Pain is decreased, fever is decreased, no signs of cardiovascular events (chest pain)
-Evaluate for side effects
Assessments should include the following:
-Assess History of allergy to NSAIDs
-Obtain drug and herbal history (other NSAID's, anticoagulants, garlic, ginkgo, ginseng, and ginger all increase chance of bleeding)
-Assess past medical history: contraindicated if severe renal disease; Gastric (peptic) ulcer; or bleeding disorder (hemophilia)

Nursing Diagnosis:
-Risk for injury and Activity intolerance

Planning:
-The patient's inflammatory process will subside in 1-3 weeks as evidenced by decreased swelling, pain, and loss of function.

Implementation:
-Observe for signs of GI bleeding (black tarry stools, coffee ground emesis)
-Report to healthcare provider if patient has GI discomfort, especially epigastric pain.
-Administer with food to help prevent gastric ulceration

Patient Teaching:
-Advise not to take aspirin with ibuprofen (increased chance of bleeding)
-Avoid alcohol
-Teach patient to inform dentist or surgeon of NSAIDs use as it should be discontinued 3-7 days prior to surgery (with approval of healthcare provider)
-Teach female patients do not take 1-2 days before menstruation to avoid heavy flow.
-Pregnant women should avoid NSAID's related to birth defects and increase bleeding with delivery
-Do not take on an empty stomach, always take with food.
-Teach patient to report s/s of GI bleeding, GI ulcers (epigastric pain, dark tarry stools, coffee ground emesis).
-Instruct patients not to take OTC ibuprofen preparations for more than 10 days for pain or more than 3 days for fever, and to consult health care professional if symptoms persist or worsen. Many OTC products contain ibuprofen; avoid duplication. I had a friend who took OTC ibuprofen every day for a couple of months because she was having neck pain and headaches. When she finally went to her doctor, it was discovered that she had chronic kidney disease as a result of the chronic use of ibuprofen.

Evaluate for effectiveness and for side effects