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84 Cards in this Set
- Front
- Back
Fibromyalgia
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Pain all over body, every gate open and more, clusters of pain.
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PQRST
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Palliative/Provoking, Quality, Radiation, Severity, Timing
and LOCATION |
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Analgesics: Types, Fundamental use
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Narcotic (Opioid)
Non-narcotic (non-opioid) Anti-inflammatory Anti-migraine Used for pathophysiological pain NOT emotional or neuropathic pain |
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Pain: Types
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Acute
Cancer Chronic Somatic Superficial Vascular Visceral Neuropathic |
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Hydrocodone
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Percocet
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Hydromorphone
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Dilaudid: 5x power of morphine.
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Nursing Interventions: Controlled Substances
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Account for ALL controlled drugs
Use special records for controlled subs. COUNTERSIGN all discarded/waste meds Ensure records & drugs on hand MATCH (counts) Keep all controlled drugs LOCKED UP Only AUTHORIZED access |
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Narcotic Analgesics
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Schedule II drugs: potential for abuse
Suppress CNS Relieve pain, promote sleep Opiates: juice of opium poppy Opioids: synthetic subs w/opium properties |
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Narcotic Analgesics: S/Es
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Respiratory Depression: ↓ sensitivity to CO2 in brain stem (cf. COPD)
Inhibit cough reflex: ↓ sens of neurons in medulla that respond to cough Postural hypotension: d/t vasodilation Constipation: ↓ peristalsis Constricted (pinpoint) pupils: oculomotor nucleus - ennervation by mu & kappa receptors |
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Narcotic Analgesics: receptors
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Mu, Kappa, Alpha receptors (pain) in brain, ↓ sensitivity:
↓ peristalsis Can l/t impacted fecal matter - relieved w/ cathartics |
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Narcotic Analgesic Usage: May lead to
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Drug tolerance: start low, over time body more tolerant w/ S/Es
Drug dependence: result of above, means cannot D/C immediately, will l/t withdrawal. Need to be weaned off. Drug addiction: "lie, cheat, steal" to get drug. Addicted to euphoric feelings, NOT taking drug for pain relief. |
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Narcotic W/D: S/S
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A/N/V
Intestinal cramps Fever Syncope Lightheadedness [Remember Pace's story re. PT on honeymoon] |
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Prototype opioid: Morphine Sulphate: Class, Trade Names
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Narcotic opiate analgesic
Duramorph, MSIR (Immediate release), MS Contin (extended/continuous release) |
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Morphine Sulphate: Uses
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Relief of severe pain
Tx pain and anxiety in MI Smaller doses relieve dyspnea Drug of choice for pulmonary edema (↓ preload) |
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Morphine Sulphate: Action
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CNS depression, depression of pain impulses d/t binding w/ opiate CNS receptors
(Mu, Kappa, Alpha) |
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MS (Duramorph)
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IV, intrathecal (Spine), preservative free, heavy duty (childbirth)
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MSIR/MSSR
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MS immediate release
MS sustained release Enteric coating - w/ stoma, crush and halve dose Sustained/extended release 12 hr/24 hr |
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Morphine Sulfate: PO Dose/Administration
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Adult 10-30 mg q 2-4 hrs PRN w/ limit on no. w/in 24hrs
HOWEVER: Pace - best to write order for every 2 hours, aiming to relieve pain w/in 3 to 4 doses. Don't want to be chasing the pain. Peak is w/in 2 hrs. |
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Morphine Sulfate: Dosing naive PT
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Dosage based on two-week pain diary. PT notes how many tabs/day. Average/day starting dose.
No max dose; based on tolerance and reported pain. |
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Morphine Sulfate: Dosing SC/IM
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Adult: 5 - 15 mg q4hr PRN
Onset 15 - 30 min Peak SC: 50 - 90 min Peak IM: 0.5 - 1 hr Duration: 3 - 5 hr |
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Morphine Sulfate: Dosing IV
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Adult: 4-10mg q4hr PRN (can be diluted; inject over 5 min)
Onset: RAPID Peak: 20 min Duration: 3 - 5 hr |
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Morphine Sulfate: ICU notes
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"Brain dead" PT
Wean from ventilator Test response as controls are turned down. Fentanyl (analgesic) and Ativan (anxiolytic) q 5 mins: relieves dyspnea and pain Give as ordered, do not wait to see distress (as per Pace's colleague with 25 weanings) |
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Morphine Sulfate: Pharmacodynamics
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Absorption: PO varies d/t first hep. pass
IV rapid Distribution: PB 30%, crosses placenta, breast milk Metabolism: T 1/2 2.5 - 3 hr Excretion: 90% urine (need functional L and Ks) |
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Morphine Sulfate: Contraindications
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Asthma w/ respiratory depression
↑ ICP (receptors acting differently) Shock (sporadic vasc system) (also last two effect breathing drive) |
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Morphine Sulfate: Caution
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Repiratory, renal, hepatic Dx
MI Elderly Infants/children |
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Morphine Sulfate: Drug/Drug
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↑ effects alcohol, sedatives-hypnotics, antipsychotics, muscle relaxants
↑ sedation w/ kava kava, valerian, St John's Wort |
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Morphine Sulfate: Drug/Lab
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↑ AST, ALT
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Morphine Sulfate: S/Es
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A/N/V
Constipation, U retention (↑ sphincter tone) Drowsiness, sedation, confusion Dizziness, blurred vision (receptors in eye) Rash Bradycardia, flushing Euphoria Pruritus |
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Morphine Sulfate: A/Rx
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Hypotension
Urticaria Seizures Life-threatening: Resp. Depression, ↑ ICP |
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Morphine Sulfate: Antidote
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Naloxone (Narcan)
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PCA: Summary
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PT self-admins analgesics
Vial locked in pump, basal rate/hr Loading (rescue) or continual (basal) dose Predet. no./hr to prevent O/D Morphine w/ dilution 1mg/mL (200 mL bag can ↑ to 10 mg/mL) |
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PCA: Drugs
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Morphine Sulfate
Fantanyl (Sublimaze) - 5x power morphine Hydromorphone (Dilaudid) - 3x power morphine Check no. times PT hits PCA: e.g., 24x basal rate is too low. |
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PCA: Nursing Interventions
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Doc. Tx & effectiveness q2-4 hr
Assess pain & S/Es Record amount of drug infused PT to push button on pump before pain severe Remember non-pharm pain relief NO PCA by PROXY |
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Brompton's Cocktail
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Mixture:
Morphine Cocaine Dextroamphetamine Alcohol For SEVERE pain at EOL |
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Dr Flexner
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5 mL/q15 mins at bedside
Locked away from away from families Still occasionally used. But usually control w/ opioids and intrathecal instead. |
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Analgesics and children, elderly
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All these drugs can be administered to children/elderly just titrated down and in smaller doses
Insurance regulates what can be Rx MS cheap, Oxycodone 5 - 10x $$$ |
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Meperidine HCl (Demerol)
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Synth narcotic
Moderate - severe pain NOT LT (buildup of metabolites: normaperidine) - causes ↑ stim. and seizures |
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Meperidine HCl vs MS
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Dose: 80-100mg Demerol = 10mg MS (MS 8 - 10x stronger)
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Meperidine HCl (Demerol): Routes
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PO 1/2 effect of IM/SC/IV
Approx 50% metab'd in L and never reaches systemic circ. (used for post-surg anesthesia) |
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Meperidine HCl cf. w/ MS
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Demerol shorter duration than MS
No ↓ uterine contractions in labor < smooth muscle spasm < respiratory depression in newborn for OB analgesia |
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Meperidine HCl: S/Es; Drug/Drug
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Constipation, U retention
Possibly S/E: CNS tox. May l/t: tremors, hallucinations, seizures MAOIs Antipsychotics |
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Older Adults & Opioids: Problems
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↓ dose, not always effective
Drug/Drug risks and S/Es ↓ R and L Fx PT may not report pain Difficult to assess pain Usual doses may l/t ↑ sedation and ↑ duration Comorbs assessment |
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Analgesics: Those More Toxic in Older Adults
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W/ ↓ renal Fx:
Meperidine (Demerol) Pentazocine (Talwin) Propoxyphene (Darvon): this no longer available d/t cardiac tox. |
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Codeine Sulfate: Summary
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Mild - moderate pain
Combo'd w/ aspirin, acetaminophen In cough meds. ↓ cough reflex |
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Oxycodone: Summary, Class, Schedule
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Semisynthetic > potent than codeine
Opioid agonist, analgesic opioid Schedule II |
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Percocet
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Oxycodone + acetaminophen
[Builds up and damages liver, then switch to pure opioid] |
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Percodan
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Oxycodone + aspirin
[Risk of GI bleed] |
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Lortab, Vicodin
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Hydrocodone + acetaminaphen
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Fentanyl (Sublimaze): Class, Route
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Opioid analgesic (esp. w/ general anesthesia)
IM, IV, Transdermal patch (continuous) |
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Fentanyl (Sublimaze): Uses
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Adjunct to general anesthesia
Continuous chronic pain control (patch) In Open Heart Surg to limit O2 demands of myocardium |
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Fentanyl (Sublimaze): Dosing Note
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In mcg (micrograms NOT milligrams)
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Narcotic Agonists-Antagonists
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Opiates stim some opiate receptors while antagonizing others.
↓ CNS - changes pain perception |
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Narcotic Agonists-Antagonists: Cf w/ opiates
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Antagonists - ↓ risk of abuse
< GI S/Es Safe in labour but not clear if safe early in PG |
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Narcotic-Agoists-Antagonists: Uses, S/Es, A/Rx, W/D
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Moderate - severe pain
S/Es and A/Rx sim to opiate agonists W/D S/S Precautions w/ LF, RF Freq Narcotic use/dependence: NOT for chronic pain [stop gap for PT not able to have opioid] |
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Nalbuphine (Nubain): Narcotic opiate agonist-antagonist: Uses
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Moderate - severe pain
Labor pain |
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Nalbuphine (Nubain): S/Es, A/Rx
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S/Es sim to narcotic agonists
A/Rx [Rx depends on sens of PT]: Bradycardia Tachycardia Hypotension Hypertension |
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Narcotic opiate agonist-antagonists: examples
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Nalbuphine (Nubain)
Butorphanol (Stadol) |
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Narcotic/Opioid Analgesics: Nursing Interventions: Respiratory, BP, Safety
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Monitor RR W/H if:
RR <10/min Breathing shallow/labored HAVE ANTIDOTE ON HAND [Naloxone (Narcan)] Monitor BP W/H if systolic < 90mmHg Client Safety: Bed low, side rails up |
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Narcotic/Opioid Analgesics: Nursing Interventions: Pain rating
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0-10 scale adults, older children
0-5 smiley face scale younger children |
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Nursing Diagnoses: Narcotic Analgesics
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Acute pain r/t surgical tissue injury
Ineffective breathing pattern r/t excess morphine dosage |
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Narcotic analgesics: Nursing interventions
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Assess bowel Fx
↑ fluids & bulk diet Stool softeners, laxatives PRN Antiemetics PRN Check for drug tolerance: switch drug PRN |
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IMPORTANT Narcotic Analgesics: Nursing interventions
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Medicate B4 pain severe (never chase it)
Change PT position slowly Avoid driving/operating machinery, etc., at start of Tx No alcohol or other CNS depressants ORAL hygiene to ↓ dry mouth Best if routinely sched. NOT PRN: e.g., MS, Oxycod. Dilaudid q4hrs - give PT chance to say they don't need it. |
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Non-narcotic Analgesics: Uses, Examples, Action/Effect
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Mild-moderate pain
Non-addictive, less potent than narcotics OTC Aspirin, Acetaminophen, Ibuprofen, Naproxen Most antipyretic, antiplatelet (aspirin, ibuprofen, naproxen) |
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Anti-inflammatory drugs
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Prostaglandin inhibitors (↓ biosynth of prostaglandin, affect inflamm.)
Other properties: analgesic, antipyretic, anticoagulant |
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Prostaglandins
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Released in inflamm process
Chem mediators affecting: vasodilation smooth muscle relaxation >capillary permeability sensitize nerve cells to pain |
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Cyclooxygenase (COX-1 and COX-2)
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Enzyme ↑ synth of prostaglandins
Prostaglandins cause pain and inflamm at tissue injury site |
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Cyclooxygenase (COX-1, COX-2)
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COX-1 protects stomach lining, regs. clotting
COX-2 triggers inflamm & pain at site of injury |
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NSAIDS
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Inhibit/block both COX-1 and COX-2 unless selective for COX-2 only
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NSAIDS: 1st Generation
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Salicylates: Aspirin
Propionic acids: Ibuprofen (Motrin, Advil) |
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NSAIDS: 2nd Generation
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COX-2 Inhibitors: Celecoxib (Celebrex)
[Rofecoxib (Vioxx) off-market 2004 d/t deaths MI, stroke, etc. - Pace's seminar friend's wife] PTs taking ASA to ↓ MI, stroke NO benefit from COX-2 inhibs (d/t ASA ↓ serum levels of NSAIDS) |
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Ibuprofen (Motrin, Advil)
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1st generation NSAID
Proprionic acid Action: Inhibs prostaglandin synth Uses: anti-inflamm analgesic antipyretic |
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Ibuprofen: Dosage
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Adult: 200-800mg PO 2x/day
MAX: < 3.2g/day CHILD DOSE based on WT, AGE Accumulates in liver |
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Acetaminophen (Tylenol): Max dose
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Up to 4g/day
Accumulates in liver |
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Ibuprofen: Absorption, Distribution, Metabolism, Excretion
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Absorp: PO well absorb
Distr: PB: 98% Metab: T 1/2 2 - 4 hr Excr: U and some bile |
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Acetaminophen, Ibuprofen: Toxicity notes
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Accumulates in liver, not excreted.
LFTs |
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Ibuprofen: Contraindications
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Severe R or H Dx
Asthma PUD Caution: Bleeding D/Os Early PG, BFing SLE |
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Ibuprofen: Drug/Drug
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>bleeding time w/ PO anticoags
> effects phenytoin, sulfonamides, warfarin < effect w/ aspirin May ↑ severe S/Es LITHIUM |
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Ibuprofen: S/Es
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A/N/V/D
Edema Rash, purpura Tinnitus Fatigue, dizziness, lightheadedness Anxiety, confusion |
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Ibuprofen: A/Rx
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GI bleed
Lf-Thrntng: Blood dyscrasias Cardiac dysrrhythmias Nephrotoxicity Anaphylaxis |
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NSAIDS: Nursing Interventions
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Assess: pain PQRST; Temp
Give w/ glass water/food/antacids if GI irritation Monitor: CBC (inc. Hgb, Hct, pltlts) [check gums, petechiae, eccyhmosis, tarry stools] NOT B4 surg (24-48hrs prior) unless ordered Monitor for O/D and Tx PRN NEVER crush enteric coated Avoid alcohol |
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Aspirin
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1st Gen. NSAID, prostaglandin synth inhibitor
Analgesic anti-inflamm (less eff. here than other NSAIDS) Antipyretic (works at hypothal.) Antiplatelet ACTION: Inhibs prostaglandin synth & hypothalamic heat reg. center |
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Aspirin: Dosage
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Antiplatelet, Analgesic:
ADULT: 81 mg/day; 325-650mg PO q4hr PRN (MAX 4g/day) Arthritis: ADULT higher, selectively Rx divided doses based on PT; up to 3 - 5 g (3000 - 5000mg)/24hrs |
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Aspirin: Pharmacodynamics
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Abs: PO 80-100%
Distr: PB 59-90% (crosses placenta) Metab: T 1/2 2 -3h (low dose0 T 1/2 2 - 20h (hi dose) Excr: 50% U |
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Aspirin: Contraindications, Caution
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Hypersens to salicylates/NSAIDS
Flu/virus S/S in children (Reyes S - non-inflamm enceph) 3rd trim. PG (bleeding) Caution: R or H D/Os |