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-          Drug class: narcotic analgesic
-          Indication: Acute or chronic mild, moderate to severe pain

-          MoA: act on opioid receptors in CNS and GIT, producing analgesia

o   Effect varies depending on affinity for opioid receptors

-          Risks: respiratory depression and cardiovascular compromise i.e. hypotension and bradycardia

-          Practice points: assessment of sedation and associated side effects. Do not crush

-          Side effects: can cause constipation, requires laxatives

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1. Does this change your assessment and/or management of his pain? Why? Why not?
2. As part of the multi-disciplinary team, discuss evidence based strategies to manage James' pain.

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Class – opioid.

Mode of action – acts on receptors in CNS and GIT to produce analgesia, respiratory depression, sedation and constipation.

Adverse effects  - severe pain, nausea and vomiting, drowsiness, dizziness, headache, itchiness, dry mouth, constipation.

Nursing points – variety of routes used for administration (IV, SC, IM etc), always consider a laxative (can cause constipation), monitor bowel movements, encourage fluids, GCS assessment, Falls risk assessment, vital signs

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You will have already:
Identified if the NIMC is safe to administer his medications.
Identified what drug class this medication belongs to
Identified if the dose was okay to administer for this patient considering their age, route of administration and context.
Discuss your answers with your group members and place the group answer on the padlet. Only one group member to type in the box at one time.

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- Consult with the NIC/doctor for further advice
- Patient education about alcohol interaction with medications
- Alcohol can/may decrease the effects of certain medications
- How much alcohol? how many times?
- Thorough pain assessment

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Oxycodone/naloxone - opioid/opioid antagonist
Mode of acton: slow release - do not crush
Oxycodone acts on receptors in the CNS and GIT producing analgesia...
Naloxone blocks opioid receptor effects such as constipation...
Adverse effects:
- can cause respiratory depression
- causes sedation and drowsiness
- causes constipation
- abdominal pain

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keeps medication at a consent level above minimum effect of concentration

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Class – benzodiazepines.

Mode of action – inhibitory effects of GABA throughout the CNS, resulting in a sedative, relaxant effect on the muscles.

Adverse effects – drowsiness, oversedation, light-headedness, slurred speech, dependence.

Nursing points – risk of misuse, should be used for short-term relief (not used in long-term), vital signs, encourage fluids, GCS assessment, falls risk assessment

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Morphine
MODE OF ACTION:

Acts on the mu opioid receptors in the CNS by disrupting the communication of the pain impulse between the brain and the body.

INDICATIONS:

Severe pain

Opioid adjunct during general anaesthesia

Refractory chronic dyspnoea

Adjunct to acute pulmonary oedema

CONTRAINDICATIONS:

Renal impairment: Morphine’s active metabolites accumulate in renal impairment ; may cause delirium and respiratory depression - use with caution or use an alternative opioid analgesic

Avoid use in severe hepatic impairment as it may cause excessive sedation or coma

Gastrointestinal: caution with patients with an ileus: consider parenteral route of administration as oral route may have minimal effect

Respiratory: severe obstructive disease, sleep apnoea, asthma, respiratory reserve due to likelihood of respiratory depression

Elderly: at increased risk of falls, cognitive impairment, sedation and respiratory depression

Nursing Interventions:

Assess the patients pain scores at least 4 hourly.

Assess level of conciousness, BP, HR and respiration. If respiration is <10/min assess level of sedation.

Look into patient history for any signs of addiction.

Ensure that the patient is of physical wellness to be able to digest and breakdown the drug by checking their kidney and liver function.

Regular laxative use is important as soon as starting opioid treatment to avoid constipation

Monitor for symptoms of physical dependence (nausea, vomiting, sweating, diarrhoea, anxiety) and psychological anxiety

ADVERSE EFFECTS:

Orthostatic hypotension, respiratory depression, miosis, urinary retention, constipation, nausea and vomiting, dependence

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Significant risks / Interactions and Nursing practice points

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Significant risks / Interactions and Nursing practice points

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For each medication identify the significant risks or interactions with the other prescribed medications.
- Write the interaction or risk in the Title, then the medication/s involved and finally explain how the risk/interaction might develop (MOA).
- Following this write a few dot points on how the nurse can either prevent, identify or manage the risk.

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psychosocial assessment
how much alcohol, type of alcohol and frequency

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Points to consider here-
- What are your beliefs, views, biases etc?
- Barriers / facilitators to appropriate pain mgt
- Further questions to ask in assessing pain
- Effect of alcohol on analgesia requirement?

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Regular doses means pt reaches a steady state in relation to their pain levels and maintain within a therapeutic range

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class: anticoagulant
used to prevent and treat DVTs, and treat heart conditions

nursing intervention: check heart rate and blood pressure before administering medication

MOA - inactivates clotting factors.

Indications - preventing VTE in surgical patients, treating venous thrombosis.

Practice points - consider IV heparin if an invasive procedure is anticipated as anticoagulant effect is diminished more quickly after stopping.

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side effects: swelling, dark urine, rapid weight gain, jaundice, shortness of breathe, nausea, itching, tiredness, paleness, cold hands and feet

Celecoxib is responsible for prostaglandin synthesis, an integral part of the pain and anti - inflammatory effects

Class: NSAIDs

Indications - pain, osteoarthritis, rheumatoid arthritis.

Nursing practice points:
-Do not use >1 NSAID at a time
-For extra pain relief NSAIDs may be used with paracetamol and, if pain is severe, an opioid
-Do not stop low-dose aspirin treatment when using an NSAID
-Before starting chronic treatment, measure complete blood count, haemoglobin, BP, weight, creatinine and liver function, and repeat at least once a year during continued treatment

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-          Drug class: Non narcotic analgesic
-          Indication: Mild to moderate pain

-          MoA: Provide an analgesic effect by inhibiting prostaglandin synthesis in the CNS and activating descending pathways

o   Also has an antipyretic effect (reduces temperature)

-          Risks: significant risk of hepatoxicity or liver toxicity with elevated doses

-          Practice point: Closely monitor liver function. Do not crush.

o   Be aware of different strengths available in many brands

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Diazepam
Mode of action:

Acts as a sedative, muscle relaxant, anti-anxiety and ati-epileptic

INDICATIONS:

Short-term management of anxiety, agitation

Acute alcohol withdrawal

Muscle spasm or spasticity

Premedication

Procedural sedation

Status epilepticus

CONTRAINDICATIONS:

Respiratory depression

Myasthenia Gravis as it may worsen muscle weakness

Caution with elderly: risk of oversedation, risk of falls, and ataxia

Nursing Interventions:

Assess blood pressure, pulse and respiration (if IV)

Provide sips of water for dry mouth.

Provide fluids and fibre for constipation.

Evaluate therapeutic response, mental state and physical dependency after long-term use.

SIDE EFFECTS:

Drowsiness

oversedation

slurred speech

ADVERSE EFFECTS:

Dependence

Decreased libido

Hypotension

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Regular analgesia:

Keeps analgesia concentrations in the therapeutic range
Smaller initial doses vs PRN- this means bodily concentrations are less likely to enter the max range/toxic range, which is when side effects are greater. (less side effects)

Slow initial effect, not recommended when immediate relief is needed.

PRN:
Fast immediate effect, the mediation can have a somewhat lasting effect depending on the half life of the analgesia. Usually greater side effects as the dose is more likely to exceed therapeutic range. Will not maintain concentrations in MAC for a long period of time so effect is not long lasting

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Combining alcohol with opioids can cause: nausea and vomiting, headaches, drowsiness, fainting, or loss of coordination. It also can put you at risk for internal bleeding, heart problems, and difficulties in breathing/respiratory depression.

Patient education- James shoud be educated not to take alcohol to remove pain, particuarly when taken with medications as it is dangerous. The multidisciplinary team should discuss alternative pain relief options with James

Thorough pain assessment

Assessing whether James' current pain management for his chronic back pain/other pain is adequate, and investigate his pharmacological and non pharmacological pain management strategies he uses at home
evidence based strategies to manage James' pain
Heat packs, positioning, temporarily reducing activity

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1. yes
2. Analgesic (Opioid, non-opioid and NSAID), anti-coagulant
3. Yes, they are appropriate to the pt’s age, context and medication route

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Effects of alcohol on other medications?

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Effects of alcohol on other medications?

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Regular analgesia maintains steady state concentration

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James is on narcotics, specifically opoids, combining alcohol which is a depressant will cause drowsiness, altered consciousness, reduced balance/coordination, increased risk of falls.

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Question 1:
Yes it is legal

Question 2:
Morphine - opioid
Diazepam - bendodiazepam
Panamax Co - opioid
Enoxaparin - anticoagulant
Warfarin - anticoagulant
Celecoxib - NSAIDs
Paracetamol - non-narcotic analgesia
Targin - opioid

Question 3:
Yes, all medications have appropriate doses according to his age
PRN morphine – yes

PRN diazepam – yes

PRN panamax co – non, nil oral

Enoxaparin – yes

Celecoxib – no, pt is drowsy, chronic pain meaning taken before theatre (at home)

Paracetamol – yes

Targin – nil oral

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altered consciousness, drowsiness, fainting etc. Do NOT drive or operate heavy machinery as this can cause injury or death to person or others.

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Q1) All medications appear legal as they meet standards of the 5 rights of medication administration.

Warfarin does stand out however due to it’s “prescriber to enter individual doses” instruction.

Q2) Morphine: narcotic analgesic.

Diazepam: benzodiazepines

Panamax Co (paracetamol with codeine): paracetamol = non-narcotic analgesic, codeine = narcotic analgesic

Enoxaparin: anticoagulant

Warfarin: anticoagulant

Celecoxib: NSAIDs

Paracetamol: non-narcotic analgesic

Targin: narcotic analgesic

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Steady state concentration and avoid unnecessary pain for patient

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Patient education on non-pharmacological pain relief options, such as positioning etc.

Patient education on risks of utilising alcohol for pain relief.

Refer pt to alcohol withdraw team/physio.

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1. Yes
2. Diazepam - Benzodiazepines
Panamax Co - opioid analgesics
Wafarin - anticoagulant
Celecoxib - NSAIDs
Targin - Opioid analgesics
Enoxaparin - anticoagulant
Morphine - Opioid analgesics
Paracetamol - Non-opioid analgesics
3. yes

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Regular medication maintains a steady state concentration, so that it is having a consistent therapeutic effect.

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Class: anticoagulant

PRACTISE POINTS:
Monitor for bleeding and bruising in open wounds, surgical wounds

Anticoagulants can decrease BP. Monitor BP when possible

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Mode of action:
inhibition of COX -1 and COX-2

Adverse Effects:

Common (>1%)

nausea, dyspepsia, GI ulceration or bleeding, raised liver enzymes (especially diclofenac), diarrhoea, headache, dizziness, salt and fluid retention, hypertension

Dosage :

Risk of cardiovascular adverse events is dose-related; do not use >200 mg daily long term.

Nursing practise points:
Not recommended to give post operative, as the patient is likely to be dehydrated. Taking this medication when dehydrated will increase side effects and possibly increase renal failure risk

This medication should be eaten with food, as it can cause GI ulceration. If the patient can't eat yet, consider other analgesia.

Taking Celecoxib immediately post op may also increase risk of cardiovascular events.

Monitor for oedema and swelling, possibly because Celecoxib increases bp

Monitor for blood in stools, blood in vomit
To monitor renal function, look at proteins and ketones in urinalysis, fluid balance chart
blood test

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Paracetamol (non opioid analgesic) and Codeine (opioid) work together as analgesic to relieve moderate pain intended for short term pain relief (prostaglandins).
Stops pain messages being sent to brain.
Side effects: codeine causes constipation (in most cases coloxyl with senna is also given to counteract negative effects)
monitor liver function (blood tests) as paracetamol is metabolised here, beware of different strengths for pts.
Additionally, paracetamol will lower temperature.
Monitor obs:
temperature
blood pressure
pulse
sedation levels
pain levels