NR-291 Pharmacology I Exam 4 Study Guide
NR-291 Pharmacology I Exam 4 Study Guide
Chapter 10: Analgesic Drugs
o Know and apply basic pharmacology
... [Show More] 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 [Show Less]