NR 291 STUDY GUIDE EXAM 4 WITH ANSWERS

NR 291 STUDY GUIDE EXAM 4 WITH ANSWERS Chapter 10: Analgesic Drugs o Know and apply basic pharmacology principles for pain management o Know WHO Analgesic Ladder and apply to acute pain and chronic pain management o Opioid Drugs: 1, 5, 6, 11, 12, 13 (addicts and non-addicts)  Nice to know: • Nursing Considerations: o Medicate pts before the pain becomes severe (Around the Clock, ATC) o Pharmacologic and nonpharmacologic approaches to pain o Oral forms should be taken with food to minimize gastric upset o Ensure safety measures such as keeping side rails up, to prevent injury • Drug Interactions: o Alcohol, antihistamines, barbiturates, benzodiazepines, monoamine oxidase inhibitors • 4 categories of opioids: o Endogenous – produced by the body o Opium alkaloids – morphine o Semi-synthetic opioids – oxycodone, hydrocodone, hydromorphone, heroin o Fully synthetic opioids – propoxyphene, tramadol, pentazocine • Heroin, oxycontin, and hydrocodone/acetaminophen (Vicodin) have similar effects • Opioid ceiling effect – codeine, nalbuphine, pentazocine • Clonidine o Alpha-2 adrenergic agonist o Central inhibition of the hyper-nonadrenergic state that occurs in opioid withdrawal o Decrease BP and stress in the first few days of withdrawal  Good to know: • Rapid-onset opioids (fentanyl) o Do not have to swallowed (injection, buccal lozenge, or stick/sucker) o Approved for treatment of cancer-related breakthrough pain o Patches change every 72 hours  Dispose by flushing down toilet or sharps container, avoid heat over patch because can increase absorption • Use with extreme caution in pts with: o Respiratory insufficiency, elevated intracranial pressure, morbid obesity and/or sleep apnea, paralytic ileus, pregnancy • Adv Eff: o CNS depression  Leads to respiratory depression, most serious adv eff  Decreased BP and HR  Sleepiness o GI  Nausea and vomiting  Paralytic ileus  Constipation (Opioid Induced Constipation/ OIC) – adequate fluid and fiber intake to prevent • Methlnaltrexone bromide (Relistor) • Lubiprostone (Amitiza) o GU  Urinary retention o Skin  Diaphoresis, flushing, and itching o Eyes  Pupil constriction (miosis) • Hydromorphone o 8 times more potent than morphine o Epidural route can lead to increased ICP  Got to know: • Opioid antagonist drug: naloxone o Given IV push o Reverse adv eff of opioid drugs  Withhold dose and contact physician if there is a decline in the pt’s condition or if vital signs are abnormal, especially if respiratory rate is less than 10-12 breaths/min  Regardless of symptoms, when a pt experiences severe respiratory depression (dyspnea, diminished breath sounds, or shallow/irregular breathing) give opioid antagonist o Reversal agent for opioid addicts: naltrexone • Opioid withdrawal/opioid abstinence syndrome o Peak 1-3 days; duration 5-7 days o Manifested as: increased BP and HR, anxiety, irritability, confusion, insomnia, chills, hot flashes, diaphoresis, joint pain (arthralgia), lacrimation, rhinorrhea, nausea, vomiting, abd cramps, diarrhea, mydriasis, piloerection • Medication treatment for withdrawal o Clonidine (Alpha 2 Agonist) o Methadone  Long half-life, may lead to overdose/death  Opioid so fills the same receptors of abused opioid, but block the effects of street drugs and decreases cravings • Meperidine HCl o Toxic CNS, may lead to seizures; not long-term therapy  adjuvant drugs: know classifications; amitriptyline: 2; gabapentin: 2 o Nonopioids: 1, 2, 3, 5  Nice to know: • Acetaminophen content of all medications taken by the pt, both OTC (more than 600 drugs) and prescription o Inadvertent excessive doses may occur when different combination drug products are taken together  Good to know: • Contraindications/interactions (Acetaminophen) o Drug allergy o Liver dysfunction, possible liver failure o G6PD deficiency (hemolytic anemia) o Dangerous interactions may occur if taken with alcohol or other drugs that are hepatotoxic  Got to know – Acetaminophen • Maximum daily dose for healthy adults is being lowered to 3000mg/day o 2000mg/day for elderly or those with liver disease • Acetaminophen Toxicity o Lethal when overdosed: hepatic necrosis or hepatotoxicity o May remain symptom-free for up to 24 hours; after this initial period, the following symptoms are common:  Nausea, vomiting, abdominal pain, malaise, anorexia, confusion o Recommended antidote: acetylcysteine regimen  10 hours within overdose, 17 doses every 4 hours  Oral (bad tasting, odor or rotten eggs) or IV Chapter 11: General and Local Anesthetics o Nice to know:  General Nursing Considerations • During recovery, monitor for cardiovascular depression, respiratory depression, and complications of anesthesia • Implement safety measures during recovery, especially if motor or sensory loss occurs because of local anesthesia • Reorient pt to his or her surroundings  Balanced anesthesia • Administration of minimum doses of multiple anesthetic medications o Good to know:  General anesthesia • Sites primarily affected: o Heart, peripheral circulation, liver, kidneys, respiratory tract o Most common: myocardial and respiratory depression • Nystagmus can occur; other findings include skeletal muscle relaxation, hypotension, and increased ICP  Spinal headache may occur (40%) in spinal anesthesia • Dull, throbbing pain, varies in intensity from mild to incapacitating • Pain typically gets worse when pt sits up or stands and decreases or goes away when pt lies down • May also have dizziness, ringing in the ears (tinnitus), light sensitivity (photophobia), nausea  Local anesthetics with vasoconstrictors (epinephrine) • Why? o To prevent systemic absorption of anesthetic o To help confine local anesthetic to injected area o To reduce local blood loss during procedure • Caution into highly vascular tissue o Caution: face; tips of nose, ears, and fingers  NMBDs adv eff • Hypo/hypertension; tachy/bradycardia • Bronchospasm, excessive secretions o Got to know:  Moderate sedation reversal agents • Opioid antagonist drug: naloxone • Benzodiazepine antagonist drug: flumazenil  NMBDs • Artificial mechanical ventilation is required • Paralyze respiratory and skeletal muscles • Does not cause sedation, pain relief, or anxiety relief o Propofol for sedation in mechanically ventilated pts • Pt may be paralyzed yet conscious o Cannot move or communicate  Malignant Hyperthermia • Occurs during or after general anesthesia or use of some NMBDs • Sudden elevation in body temp (>104) • Tachypnea, tachycardia, muscle rigidity • Life-threatening emergency • Treatment – cardiorespiratory supportive care, dantrolene (skeletal muscle relaxant) o General Anesthesia: 1, 2, 5, 8, 12  Used during surgical procedures to produce – unconsciousness, skeletal muscular relaxation, and visceral smooth muscle relaxation  Pharmacology principles of balanced anesthesia  Inhaled: nitrous oxide: 1  Parenteral-adjunctive: 1 • Sedative-hypnotics: barbiturates (-bital), benzodiazepines (-zepam) (-zolam) • Opioid analgesics: fentanyl, morphine • NMBDs (-ium) • Anticholinergics: atropine, scopolamine o Moderate Sedation: 1, 2, 3, 11, 12  Called conscious sedation and procedural sedation  Opioid: fentanyl: 13  Benzodiazepine (-pam): midazolam: 13 o Local Anesthetics (-caine): 1, 2, 5, 8, 11, 12  Also called regional anesthetics  Types  Order of paralysis and recovery • Autonomic activity is lost • Pain and other sensory functions are lost • Motor activity is lost • Recovery occurs in reverse order as above  Common uses with different types • Spinal anesthesia o Control pain during surgical procedures and child birth • Infiltration anesthesia o Minor surgical and dental procedures • Nerve block anesthesia o Surgical, dental, and diagnostic procedures o Also used for therapeutic management of pain o Neuromuscular Blocking Drugs (NMDs) (-ium): 1, 2, 5, 11, 12  Main use: facilitating controlled ventilation during surgical procedures or in ICU setting  Order of paralysis and level of consciousness • First sensation is muscle weakness, followed by total flaccid paralysis • Small, rapidly moving muscles affected first (fingers, eyes), then limbs, neck, trunk • Finally, intercostal muscles and diaphragm affected, resulting in cessation of respirations Chapter 12: CNS Depressants & Muscle Relaxants o CNS Depressants  Nice to know: • Midazolam causes amnesia without loss of consciousness: o Endoscopy and colonoscopy procedures • Short-acting benzodiazepines generally used for pts with sleep-onset insomnia without daytime anxiety • Pt teaching o Check before taking any other meds, including OTC o Avoid alcohol and other CNS depressants o Take hypnotics 30-60 mins before bedtime for max effectiveness in inducing sleep (depends on drug’s onset) o Rebound insomnia may occur for a few nights after a 3-4 week regimen has been discontinued • Herbal products: kava-kava, lemon verbena, valerian o Used to relieve anxiety, stress, and restlessness and to promote sleep o Kava may cause temporary yellow skin discoloration (with extended, continued intake) and visual disturbances o Many drug interactions  Good to know: • Flunitrazepam o “rophies”, “roofies”, “date rape” drug o Not manufactured or legally marketed in the US • Benzodiazepines – Interactions o CNS depressants (alcohol, opioids) o Antibiotics, rifampin o Grapefruit juice • Ramelteon (sedative – hypnotic) o Does not cause CNS depression, mimic hormone melatonin o Use is to treat people who have difficulty falling asleep o No potential for abuse, only hypnotic not a controlled substance • Monitor for therapeutic effects o Increased ability to sleep at night o Fewer awakenings o Shorter sleep-induction time o Few adverse effects, such as “hangover” effects o Improved sense of well-being because of improved sleep  Got to know: • Benzodiazepines o Antidote – flumazenil o Long-acting benzos should not be used in the elderly since they are more sensitive to their effects and metabolize the drugs less efficiently o Fall hazard and cognitive impairment for elderly persons  Ataxia, excessive sedation o Most benzos cause REM rebound and a tired feeling (“hangover” effect) the next day; use with caution in the elderly • Warning! Slight overdose of older barbiturates can: o Frequently leads to respiratory depression or arrest o Overdose may produce CNS depression (sleep to coma and death)  Supportive care, activated charcoal to prevent absorption • Overdose of benzos or newer non-benzo sedative-hypnotics typically produce: o Anesthesia without risk (unless combined with alcohol)  Benzodiazepines (-zepam) (-zolam): 1, 2, 3, 5, 6, 7, 8, 11, 12, 13 • Habit forming; low therapeutic index  Sedatives-hypnotics: 1, 2, 3, 5, 7, 8 • ramelteon: 2, 5 • herbal products: kava-kava, lemon verbena, valerian: 1, 6  Barbiturates (-bital): 1, 5, 8, 12, 13 o Muscle relaxants: 1, 2, 3, 5  Nice to know: • Monitor for therapeutic effects o Decreased spasticity, decreased rigidity • Baclofen can be administered in an implantable pump device (epidural) • Methocarbamol may cause urine to turn green-black in color. This effect is harmless and will go away once the med is stopped  Good to know: • Adv Eff on CNS and skeletal muscles o Euphoria, lightheadedness, dizziness, drowsiness, fatigue, muscle weakness, others  Got to know: • Dantrolene o Treat and prevent malignant hyperthermia  Since it is an inherited disorder, ask pt if any family members died suddenly during surgery • Carisoprodol o Listed as one of the most abused mood-altering substances in the US and some states classify it as a Schedule IV drug o It is used to prolong the duration and increase the effects of alcohol or narcotics and to “take the edge off” the jittery feeling associated with cocaine abuse  cyclobenzaprine, dantrolene: 1  baclofen: 5, 11, 12  methocarbamol: 5, 11, 12  carisoprodol: 1, 2 Chapter 44: Antiinflammatory & Antigout Drugs o NSAIDs: 1, 2, 5, 6, 7, 8, 11, 12, 13  Nice to know: • Pt teaching o Therapeutic effects may not be seen for 3-4 weeks o Limit alcohol intake due to interaction with NSAIDs and risk of GI bleeding o Notify prescriber if adv eff become severe or if bleeding or GI pain occurs o Inform to watch closely for the occurrence of any unusual bleeding, such as in the stool o Enteric-coated tablets should not be crushed or chewed • Ketorolac o Powerful analgesic, like an opioid, not addictive o Short-term (5 days) • Celecoxib o First and only remaining COX-2 inhibitor  Others taken off the market due to increased risk of: MI, stroke, and death  Diclofenac (combo COX-1 and 2 inhibitor) o Contraindication in pts with known sulfa allergy • Herbals: Glucosamine and Chondroitin o Treat osteoarthritis pain; oral and injectable o Drug interactions  Enhance anticoagulant effects of warfarin  Glucosamine may cause increase in insulin resistance  Good to know: • Take withy a full (6-8 oz.) glass of water o If stomach upset occurs, take with food, milk, or an antacid • Conditions that may be contraindications to therapy: o GI lesions or PUD o Bleeding disorders o MI or stroke • Salicylate (aspirin) Toxicity o Cardiovascular – increased HR o CNS – tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, drowsiness o GI – n/v/d o Metabolic – sweating, thirst, hyperventilation, hypo/hyperglycemia  Got to know: Adv Eff • GI o Dyspepsia, heartburn, epigastric distress, nausea o GI bleeding, mucosal lesions (erosions or ulcerations)  Misoprostol can be used to reduce these dangerous effects • Renal o Reductions in creatinine clearance o Acute tubular necrosis with renal failure • CV o Noncardiogenic pulmonary edema • Integumentary o Steven-Johnson Syndrome  Got to know: • Reye’s Syndrome o Do not give salicylates (aspirin) to children and teenagers because of the risk of this syndrome o Contraindicated in children with flulike symptoms o Neurological defricits, lead to coma and liver damage • Pt Teaching o Check labels on all meds since many meds contain aspirin or other aspirin-like NSAIDs • Serious interactions can occur when given with: o Anticoagulants, aspirin, corticosteroids and other ulcerogenic drugs, diuretics, and ACE-I  4 properties (-profen) (-fenac)  acetylsalicylic acid (ASA): 1, 2, 5. 8, 11, 12  celecoxib: 8  indomethacin  ketorolac: 1, 2, 11, 12  naproxen  Combination forms o Herbal products: glucosamine, chondroitin: 1, 6, 8 o Antihyperuricemics or Antigout Drugs (-case): 1, 2, 3, 5, 8, 11, 12  Work either to correct overproduction or under excretion of uric acid  Nice to know: • May have an increase in gout flares when first start using these drugs  Good to know: • Clients with metabolic condition called glucose-6-phosphate dehydrogenase (G6PD) deficiency should not take these drugs o Risk severe damage to RBCs which could lead to anemia o Hereditary abnormality in the activity of an erythrocyte (RBC) enzyme  Got to know: • Pegloticase o Anaphylaxis and infusion rxns have been reported during and after administration  Premediate pts with antihistamines and corticosteroids • Allopurinol o Development of potentially life-threatening skin adv eff of exfoliative dermatitis, Stevens-Johnson Syndrome, and toxic epidermal necrolysis  allopurinol: 5  pegloticase: 5, 12; rasburincase