Transcript Drugs Affecting the Central Nervous System

Drugs Affecting the Central
Nervous System
Chapter 10
Pain
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Defined as an unpleasant sensory and
emotional experience associated with either
actual or potential tissue damage.
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Pain is what a client says it is.
Pain exists whenever the patient says it does.
Acute Pain
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Pain that is sudden in onset, usually subsides
when treated, and typically occurs over less
than 6-week period of time.
Chronic Pain
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Persistent or recurring pain that is often
difficult to treat. Typically lasts longer than 3
months.
Pain Threshold
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Level of stimulus needed to produce a painful
sensation.
Pain Tolerance
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The amount of pain a client can endure
without it interfering with normal function.
Pain Source
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Somatic pain: originates from skeletal
muscles, ligaments and joints.
Visceral pain: originates from organs and
smooth muscle.
Superficial pain: originates from skin and
mucous membranes.
Cultural Implications
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Each culture has its own beliefs, thoughts,
and ways of approaching, defining, and
managing pain.
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Prayer
Laying on of hands
Healers
Implications for Transcultural Nursing
Practice
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Assessment of the type of intervention the
person desires.
Does the person wish traditional
interventions, expressions of nurturance and
compassion, psychological support, physical
interventions (soothing, having a brow wiped,
relaxation)? cultural support? medication? Or
a combination of these?
Cultural Groups and Pain
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Stereotypes:
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Mexican Americans have a low pain tolerance.
Italian Americans are very dramatic about their
pain
Jewish Americans complain a lot about pain.
African Americans report higher levels of chronic
pain and have a greater sensitivity to acute pain.
Asian Americans do not express their pain.
Alternative Methods
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Acupuncture
Massage
Herbs
Heat or ice application
Relaxation techniques
Psychological counseling
Acupuncture
Nerve Pain Tincture
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Recipe
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1 tsp Saint Johns Wort (flowering top), skull cap
leaves, fresh oats & licorice root.
½ gtt each tincture
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Ginger rhizome
Vervain leaves
Nursing Responsibilities
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Do a thorough assessment that includes
questions about the patients cultural
background and practices is important in the
effective and individualized delivery of
nursing care.
JCAHO Pain Standards
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The Joint Commission's 2001 pain
management standards state that every
patient has a right to have his or her pain
assessed and treated.
JCAHO standards dictate that a nurse will
evaluate the patients response to the pain
medication within 30 minutes to one hour
after administration of the pain medication.
Pain Tools
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Universal Pain Assessment Tool
Opioid Drugs
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Originate from the opium poppy.
20 different alkaloids are obtained from the
unripe seed of the plant.
Opioid Analgesics
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Powerful pain relievers.
Classified according to their chemical
structure and action.
Simple chemical modifications of the opium
alkaloids produce three different drugs.
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morphine-like drugs
meperidine-like drugs
methadone-like drugs
Anesthetic Drugs
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Strong opioid analgesics used in combination
with anesthetics during surgery.
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fentanyl
sufentanil
alfentanil
Goal: not only to relieve pain but also to maintain
a balanced state of anesthesia.
General Anesthesia
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Loss of sensation and usually of
consciousness without loss of vital functions
artificially produced by the administration of
one or more agents that block the passage of
pain impulses along nerve pathways to the
brain
Local Anesthesia
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Loss of sensation in a limited and usually
superficial area especially from the effect of a
local anesthetic.
Fentanyl
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Fentanyl injection has a rapid onset and short
duration.
Transdermal fentanyl patch is used for longterm pain management.
Opioids
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Opioids used to control moderate to severe
pain.
Schedule II Drugs
Classification – Opioid analgesics
 Morphine
 Codeine – often used in combination with
acetaminophen – Tylenol with codeine
 Hydrocodone – Vicodin - used in combination with
acetaminophen / aspirin / ibuprofen
 Hydromorphine – Dilaudid - More potent than
morphine
 Meperidine – Demerol
 Oxycodone – Percocet (with acetaminophen) or
Percodan (with aspirin)
Opioid Adverse Effects
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Cardiovascular: hypotension, palpitations, flushing
Central nervous system: sedation, disorientation,
euphoria, light-headedness, tremors.
Gastrointestinal: nausea, vomiting, constipation
Genitourinary: urinary retention
Respiratory: Respiratory depression and
aggravation of asthma.
Contraindications
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Known drug allergy
Severe asthma
Used with caution in:
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Patients with severe head injuries (mask level of
consciousness or LOC)
Morbid obesity with sleep apnea (depress
respirations while asleep)
Paralytic ileus (bowel paralysis) – opioids tend to
slow bowel
Psychologic Dependence
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Addiction: characterized by behaviors that
include one or more of the following:
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Impaired control over drug use
Compulsive use
Continued use despite harm
Craving
Physical Dependency
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Physiological adaption
Results in withdrawal symptoms when the
drug is discontinued.
Withdrawal symptoms include:
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Mental agitation
Tachycardia
Elevated blood pressure
Seizures
Opioid Tolerance
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State of adaption which results in reduced
effects of drug resulting on use of higher
dosing to get desired effect.
Toxicity
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Opioid antagonist bind to occupy all the
receptor sites blocking the action of the opiod
drug.
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nalaxone
naltrexone
Naloxone
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Brand name: Narcan
Classification Pharmacologic: opioid antagonist
Classification Therapeutic: antidote for opioid
Action: Competitively blocks the effects of opioids,
including CNS and respiratory depression, without
producing any agonist (opioid-like) effects.
Therapeutic Effects: reversal of signs of opioid
excess.
Narcan
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Route IV
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onset in 2-3 minutes
peak unknown
duration 45 minutes
IM, Subq
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onset 2-5 minutes
peak unknown
duration > 45 minutes
Drug Calculation
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The IV dose for naloxone (Narcan) is 0.02 to
0.2 mg q 2-3 minutes until response is
obtained.
Physician orders 0.1 mg
The drug is provided as 0.4 mg / mL
How much would you draw up to give the
appropriate dose? ____________
Morphine Sulfate
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Classification Pharmacologic: Opioid agonist
Classification Therapeutic: opioid analgesic
Indications: severe pain (postoperative,
fractures, burns), pulmonary edema, and pain
associated with myocardial infarct (MI).
Morphine
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Action: Binds to opiate receptors in the CNS.
Alters the perception of and response to
painful stimuli while producing generalized
CNS depression Therapeutic Effects:
decrease in severity of pain
Adverse Reactions: severe respiratory
depression, constipation
Morphine Effects
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IV maximal analgesia and respiratory
depression would occur within 10 to 20
minutes
IM: within 30 minutes
Sub Q: 60 to 90 minutes
PO: peak activity occurs in about 60 minutes
* higher dosage needed due to metabolism of
drug in the liver
Morphine Dosing
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Tablets come in 15 mg or 30 mg
Solution for IM, IV or sub Q: 10 mg/ml most
common
Medication Calculation
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Physician order 6 mg of morphine sulfate q 34 hours prn for severe pain.
The drug is provided as 10 mg / 1 mL.
How much of the drug would you need to
draw up the give the appropriate dose?
Nursing Responsibilities
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Pain assessment
Base-line vitals
Re-assess vitals after pain med administered
Assess bowel function
Overdose: Narcan used to reverse
respiratory depression
Constipation: ambulate! dietary fiber, fluids,
stool softener
Meperidine
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Therapeutic classification: opioid analgesic
Pharmacologic classification: opioid agonist
Schedule II drug
Action: Binds to opiate receptors in the CNS.
Alters the perception of and response to
painful stimuli, while producing generalized
CNS depression
Therapeutic effects: Decrease in severity of
pain.
Meperidine
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Demerol is a synthetic drug with the same
uses and adverse effects as morphine.
Less nausea and vomiting.
Use with caution due to neurotoxic
metabolism with chronic use
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CNS agitation (often exhibited as confusion)
Hallucinations
Tremors
seizures
Meperidine Dosing
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IV or IM
Provided as 10 mg/mL, 50 mg /mL, 75
mg/mL or 100 mg/mL
Dosage for adults: 50 to 150 mg every 3-4
hours
Dosage for pediatrics: 1 to 1.8 mg / kg q 3-4
hours (not to exceed 100 mg dose)
Medication calculation
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The physician order meperidine 75 mg prn q
3-4 hours for pain.
The vial provided is 50 mg / 1 mL.
How much of the mediation would you need
to draw up to give the appropriate dose?
Codeine
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Classification Pharmacologic: opioid agonist
Classification Therapeutic: allergy, cold and
cough remedies, antitussives, opioid
analgesics
Schedule II drug
Codeine
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Action: Binds to opiate receptors in the CNS.
Alters the perception of and response to
painful stimuli while producing generalized
CNS depression – decreases cough reflex –
decreases GI motility
Codeine
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Side Effects: confusion, sedation,
hypotension, constipation
Nursing responsibilities - same as morphine
Evaluation of effectiveness:
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Decrease in severity of pain without significant
alteration in level of consciousness
Suppression of cough
Control of diarrhea
Codeine Dosing
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Usually supplied in combination with other
analgesics
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Tylenol with codeine
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Tylenol # 2 = 15 mg codeine + 300 mg Tylenol
Tylenol # 3 = 30 mg codeine + 300 mg Tylenol
Tylenol # 4 = 60 mg codeine + 300 mg Tylenol
Most often given po with food
Most common side-effect: constipation
Methadone
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The drug of choice for detoxification
treatment for opioid addiction.
Nonopioid Analgesics
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Acetaminophen: Tylenol
Salicylates: aspirin
Acetaminophen
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Action: blocks peripheral pain impulses by
inhibition of prostaglandin synthesis.
Indication: treatment of mild to moderate
pain.
Contraindications:
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Drug allergy
Severe liver disease
G6PD disease
Toxicity
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Ingestion of large amounts of
acetaminophen, as in acute overdose, or
even chronic unintentional misuse can cause
hepatic necrosis.
Acute ingestion of acetaminophen doses of
150 mg / kg or more may result in hepatic
toxicity.
Treatment
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Acetylcysteine or Mucomyst
Action: Works by preventing the hepatotoxic
metabolites of acetaminophen from forming.
Initial loading dose of 140 mg / kg orally.
Followed by 70 mg / kg every 4 hours for 17
additional doses.
Note: if patient vomits within 1 hour the dose
should be given immediately.
All 17 doses must be given.
Drug Calculation
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A teenage girl is admitted for Tylenol
overdose weight is 120 pounds.
Mucomyst is ordered at 140 mg / kg for the
lst dose.
Weight in kg ______
What dose would you give __________ in
mg?
What dose would you give ________ in
grams?
Anti-inflammatories
Chapter 44
Inflammation
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Localized protective response stimulated by
injury to tissues that serves to destroy, dilute,
or wall off both the injurious agent and the
injured tissue.
Inflammatory response
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Mediated by two pathways:
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Prostaglandin (PG)
Leukotriene (TL)
Nonsteroidal anti-inflammatories
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Most commonly prescribed drugs.
70 million prescriptions per year
23 different NSAIDS
How do they work?
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Anti-inflammatories worth by inhibiting the
leukotriene (LT) and prostaglandin (PG)
pathways.
Most NSAIDS act on one or both of the
pathways.
Two important enzymes: Cox 1 and Cox 2
(they have a role in maintaining
gastrointestinal mucosa.
Side Effects of NSAIDs
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One of the more common complaints is
gastrointestinal distress
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Heart burn
Gastrointestinal bleeding
NSAIDs
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Used to treat rheumatoid arthritis and
osteoarthritis.
Rheumatoid Arthritis
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Systemic inflammatory disease often
effecting multiple joints. Involves
inflammation of the tissue surrounding the
joints that can lead to destruction of the joint.
Symptoms include pain, stiffness and
reduced range of motion.
Goal of drug therapy is to reduce the
symptoms – no cure
Rheumatoid Arthritis
Drugs used in arthritis
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Drugs:
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Aspirin (has been placed by newer drugs due to
gastrointestinal bleeding)
NSAIDs
DMARDs (Disease-modifying antirheumatic
drugs)
Acetic Acid Drugs
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Most widely knows: Aspirin
Aspirin (acetylsalicylic acid) was the first of
this drug classification (1899).
Other acetic drugs:
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indomethacin (Indocin)
diclofenac (Voltaren, Cataflam)
Reyes Syndrome
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The acetic classification of drugs (Aspirin) is
contraindicated in children.
Reyes syndrome is a neurological disease
process thought to be trigger by the use of
aspirin in children (flu and chickenpox).
Fever in children should always be managed
with acetaminophen (Tylenol).
naproxen
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Trade name: Naprosyn, Aleve
Therapeutic classification: nonopioid
analgesic, NSAIDs
Action: inhibits prostaglandin synthesis.
Indications: dysmenorrhea, inflammatory
disorders including rheumatoid arthritis
Therapeutic effects: decrease pain,
suppression of inflammation.
Antirheumatic Drugs
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Disease-modifying antirheumatic drugs
Drugs have a slow onset of action often
taking up to several weeks to see results.
A whole new group of IV meds have been
developed to control symptoms in patients
with multiple joint involvement.
Gout
When the body has to much uric acid, deposits
of uric acid crystals collect in tissue and joints
allopurinol
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Trade name: Lopurin, Aloprim
Action: inhibits the production of uric acid.
Client teaching:
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Advise patient to take with large glass of water.
Alcohol may decrease effectiveness of the drug