Narcotic Analgesic Medications Narcotic Analgesics

Opioids Actions Analgesia Euphoria Sedation

Opioids Primary Use Moderate Pain Severe Pain Acute Pain Chronic Pain Breakthrough Pain

Opioids Other Uses Pre-Op Sedation Adjunct Anesthesia Anti Anxiety Diarrhea Opiate Dependence

Opioids Common Opioids Morphine sulfate Codeine meperidine HCl (Demerol) hydromorphone (Dilaudid) fentanyl (Duragesic) oxycodone (OxyContin)

Opioids Common Routes IV IM Subcutaneous Oral Transdermal Epidural

Opioids Adverse Reactions Euphoria, dysphoria, confusion, sedation Respiratory depression, cough depression Nausea, vomiting, constipation Hypotension, bradycardia or tachycardia Urinary hesitancy, dysuria Allergic reactions, pruritis Pain, irritation at injection site

Opioids Contraindications Opiate allergies Pulmonary diseases (asthma, COPD) Head injuries, increased intracranial pressure Convulsions Ulcerative colitis Renal or hepatic dysfunction

Opioids Precautions Not recommended during labor Not recommended during lactation Use caution with elderly Not recommended for biliary surgery

Opioids Precautions Opioid Naive Tolerance Addiction

Opioids Precautions Opioids and Acetaminophen Daily acetaminophen intake should NOT EXCEED 4 grams

Use caution whenever two or more CNS depressants given Opioids Interactions CNS Depressants Use caution whenever two or more CNS depressants given

Special Circumstances Opioids Special Circumstances Opiates of Choice Morphine Myocardial Infarct Meperidine Biliary Surgery Codeine Persistent Cough

Opioids Opiate Poisoning miosis hypoxia Respirations < 10 / min

Opioids Opiate Antagonist

Patient Controlled Analgesia (PCA) Opioids Patient Controlled Analgesia (PCA)

Opioids Epidural

Opioids Transdermal

Narcotic Analgesics Nursing Process Assessment Pain assessment Precipitating factors Nonpharmacological medications Time last medicated Response to last pain medication Allergies Bowel history

Narcotic Analgesics Nursing Process Planning Adverse reactions Expected pain relief Route of administration

Narcotic Analgesics Nursing Process Suggested Nursing Diagnoses Pain, acute Pain, chronic Constipation r/t adverse drug effects

Narcotic Analgesics Nursing Process Implementation Identify patient Observe 6 Rights

Narcotic Analgesics Nursing Process Evaluation Response to medication Evidence of adverse reactions Evidence of tolerance, addiction

Narcotic Analgesics Key Points Side Effects Lethargy, Confusion Constipation Adverse Reactions Respiratory Depression (Opiate Naïve) Opiate Poisoning Combination Drugs Be mindful of acetaminophen toxicity

Narcotic Analgesics Key Points Addiction Not likely to happen when purpose of drug is to relieve pain Tolerance Likely to occur, especially with morphine PCA’s PCA’s are PATIENT controlled, not nurse controlled

Narcotic Analgesics Key Points Opioids are drugs of choice for SOME pains Not ALL pain should be managed with Opioids Review: Thumbs Up? Thumbs Down?

Narcotic Analgesics Key Points Pain associated with Myocardial Infarction Morphine is the drug of choice

Narcotic Analgesics Key Points Pain associated with Ulcerative Colitis Opioids should be avoided

Narcotic Analgesics Key Points Pain associated with Gall Bladder surgery Avoid morphine Meperidine is drug of choice

Narcotic Analgesics Key Points Pain associated with Labor May prolong labor May cause respiratory depression in the newborn

Narcotic Analgesics Key Points Pain associated head injury Opioids may increase intracranial pressure (ICP)

Narcotic Analgesics Key Points Pain in patients with COPD Opioids cause respiratory depression

Narcotic Analgesics Key Points Pain in patients with seizure disorders Opioids may precipitate seizures

Anesthestic Medications

Anesthetic Medications Topical Application to body surface Cream, lotion, spray, gel, etc. May be given prior to an injection

Anesthetic Medications Local Infiltration Injection of anesthetic into tissue Example: Novacaine

Anesthetic Medications Regional Anesthesia Spinal Subarachnoid space Conduction Near a nerve

Anesthetic Medications Regional Anesthesia - Spinal Injected into subarachnoid space of spinal cord Most commonly 2nd lumbar vertebra Loss of feeling and movement Lower abdomen Perineum Lower extremities

Anesthetic Medications Regional Anesthesia – Conduction Blocks Epidural block Caudal block Brachial plexus block

Anesthetic Medications Preparing the patient for local or regional anesthetics Positioning Teaching Emotional Support

Anesthetic Medications Providing care after local or regional anesthesia Safety r/t lack of sensation Loss of body functions Hemorrhage Infection

Anesthetic Medications Preanesthesia Medications Opioids to decrease anxiety / apprehension Fentanyl (Sublimaze) Meperidine (Demerol) Morphine

Anesthetic Medications Preanesthesia Medications Barbiturates to decrease anxiety / apprehension Pentobarbital (Nembutal) Secobarbital (Seconal)

Anesthetic Medications Preanesthesia Medications Benzodiazepines to decrease anxiety / apprehension Chlordiazepoxide (Librium) Diazepam (Valium) Midazolam (Versed) Lorazepam (Ativan)

Anesthetic Medications Antiemetic Medications Decrease nausea / vomiting and side effect of drowsiness / antianxiety Hydroxizine (Vistaril) Promethazine (Phenergan)

Anesthetic Medications Antiemetic Medications Cholinergic blocking agents to decrease respiratory secretions and mucous production Atropine sulfate Robinul Scopolamine

Anesthetic Medications General Anesthesia Cause loss of consciousness Except for very short procedures, patient must be intubated Profound analgesia

Anesthetic Medications Types of General Anesthesia Barbiturates Methotrexital (Brevital) Propofol (Diprivan)

Anesthetic Medications Types of General Anesthesia Benzodiazepines Midazolam (Versed)

Anesthetic Medications Types of General Anesthesia Ketamine (Ketalar) Street Drug Special K

Anesthetic Medications Types of General Anesthesia Gases and Volatile Liquids Nitrous oxide

Anesthetic Medications Types of General Anesthesia Opioids Fentanyl (Sublimaze) Given as adjunct to other medications to produce reduced motor activity and profound analgesia Fentanyl + Inapsine = Innovar (neuroleptanalgesia but not complete loss of consciousness) Use of Inapsine has decreased due to risk of fatal cardiac arrhythmias

Anesthetic Medications Types of General Anesthesia Skeletal Muscle Relaxants Deep abdominal or chest surgery Facilitate endotracheal insertion Succinylcholine (Anectine)

Anesthetic Medications 4 Stages of Anesthesia Stage 1 – Analgesia Medication given to induce anesthesia Lasts 5 – 10 seconds

Anesthetic Medications 4 Stages of Anesthesia Stage 2 – Delerium Delerium Keep room quiet

Anesthetic Medications 4 Stages of Anesthesia Stage 3 – Surgical Analgesia Deep coma Surgery takes place

Anesthetic Medications 4 Stages of Anesthesia Stage 4 – Respiratory Paralysis ABNORMAL – Severe Complication Respiratory and Cardiac Arrest

Anesthetic Medications Nursing Responsibilities Preanesthesia Check Allergies Administer Pre-op medications observing 5 rights Provide safety after medications given

Anesthetic Medications Nursing Responsibilities Post Anesthesia: PACU Check airway for patency Observe for hypoxia, especially if nitrous oxide administered Position patient to prevent aspiration Check patient every 5 – 10 minutes, suctioning as needed

Anesthetic Medications Nursing Responsibilities Post Anesthesia: PACU (cont.) Exercise caution in administering opioids Record all medications given

Anesthetic Medications Nursing Responsibilities Post Anesthesia: Post-op Continue to exercise caution with opioid medications Refrain from barbiturates and benzodiazepines during first 24 hours Administer supplemental oxygen as needed

Anesthesia Medications Key Points Anesthesia can be Local Regional General

Anesthesia Medications Key Points Many different kinds of medications can induce anesthesia Barbiturates (Nembutal, Seconal) Benzodiazepines (Versed) Ketamine Nitrous oxide Opioids (Inapsine) Skeletal muscle relaxants (Anectine)

Anesthesia Medications Key Points Many different kinds of medications can induce anesthesia Barbiturates (Nembutal, Seconal) Benzodiazepines (Versed) Ketamine Nitrous oxide Opioids (Inapsine) Skeletal muscle relaxants (Anectine)

Anesthesia Medications Key Points Nursing Responsibilities are dependent upon type of anesthesia given, but always focus on Airway (respiratory depression, aspiration) Safety (confusion, lethargy) Comfort (without reentering anesthesia state)