Drug Therapy to Decrease Pain, Fever, And Inflammation Notes

Chapter 16 Objective: Drug Therapy to Decrease Pain, Fever, and Inflammation 1. Discuss the role of prostaglandins in the etiology of pain, fever, and inflammation. (pg. 723)  Pain is the sensation of discomfort, hurt, or distress  Prostaglandins sensitize pain receptors and increase the pain associated with other chemical mediators of inflammation and immunity  Fever is the elevation of body temperature above the normal range  Fever occurs when the set point of the hypothalamus is raised in response to the presence of pyrogens (fever-producing agents).  Inflammation is the normal body response to tissue damage from any source, and it may occur in any tissue or organ.  Prostaglandin E2 and others induce inflammation and also enhance the effects of other mediators of the inflammatory response. Local manifestations are redness, heat, edema, and pain. Redness and heat result from vasodilation and increased blood supply 2. Identify the major manifestations of fever and inflammation.  Systemic manifestations include leukocytosis, increased erythrocyte sedimentation rate, fever, headache, loss of appetite, lethargy or malaise, and weakness.  Both local and systemic manifestations vary according to the cause and extent of tissue damage. 3. Understand the pathophysiology of osteoarthritis. (pg.725)  Osteoarthritis produces inflammation and degeneration of joints.  The main function of cartilage is to absorb shock and decrease friction during movement and weight-bearing activities. The cartilage transmits the load down to the subchondral bone, dissipating the mechanical stress at the joint.  Along with the synovial fluid in the joint, the articular cartilage reduces friction when the joint moves.  Osteoarthritis is the degradation of the cartilage, bone, and synovium. Repetitive movement of a joint causes the articular cartilage to be worn down, leading to joint failure.  Chondrocytes develop in the joint with the release of enzymes, causing the joint to degenerate. 4. Understand the pathophysiology of gout. (pg.728)  Gout is an arthritic condition characterized by an overproduction of uric acid or an inability to excrete uric acid, resulting in hyperuricemia  There are three stages of gout.  Acute gouty arthritis or gouty attack, the first stage, is characterized by hyperuricemia, pain, and swelling of one joint. 1. The pain usually begins at night and persists for 10 days. The most commonly affected joint is the great toe.  Intercritical gout, the second stage, is characterized by a symptom-free period of several years followed by the recurrence of symptoms.  Chronic tophaceous gout, the third stage, is characterized by the presence of solid deposits of urate crystals, known as tophi, in the joints and elsewhere. 1. In the kidneys, urate deposits may form renal calculi or cause other damage. 2. After the first attack of acute gouty arthritis, up to 10 years may pass before permanent damage to the joints and kidneys occurs. 5. Identify the prototype and describe the action, use, adverse effects, contraindications, and nursing implications for the salicylates. (pg. 730)  Action- Aspirin (prototype)  The ability of aspirin to inhibit prostaglandins produces the inflammatory effects needed for analgesia and antirheumatic effects.  Authorities believe that the drug acts on the thermoregulatory center of the hypothalamus, thus blocking the effects of the endogenous pyrogens and inhibiting the synthesis of prostaglandins. Aspirin also has antiplatelet effects. At low doses, it blocks the synthesis of thromboxane A2 to inhibit platelet aggregation; this lasts for the life of the platelet.  Use:  As an analgesic agent, aspirin is used to relieve mild to moderate pain.  As an antipyretic agent, it is used only in adults.  As an anti-inflammatory agent, it is used to decrease inflammation in patients with osteoarthritis, juvenile rheumatoid arthritis, and spondyloarthropathies  Adverse Effects  GI adverse effects of aspirin include nausea, dyspepsia, heartburn, and epigastric discomfort. Decreased platelet aggregation results in GI blood loss and hemorrhage.  Contraindications  Aspirin is contraindicated in patients with a known sensitivity to aspirin; in those who are allergic to tartrazine, due to a cross-sensitivity; and in those with a known risk of bleeding.  Nursing Implications  Aspirin should be taken with a full glass of water or other fluid and with food or just following food. Administering the medication with food decreases gastric irritation.  If aspirin is given for pain, the nurse uses a pain scale to assess the intensity of the patient’s pain, which should decrease. 1. If the drug is given for fever, the nurse records the patient’s temperature every 2 to 4 hours and should see a reduction in temperature. 2. If the drug is given for inflammation, the nurse assesses for signs of inflammation, which should decrease.    Patients receiving aspirin as a preventive agent for myocardial infarction or transient ischemic attack should be without chest pain or confusion. The nurse assesses the patient for bleeding tendencies, GI irritation, nausea, vomiting, and diarrhea, which all may result from aspirin use. The nurse assesses the skin for signs of decreased coagulation. The nurse performs a thorough pulmonary and integumentary assessment, looking for signs of hypersensitivity to aspirin, including dyspnea, bronchospasm, and rash. 6. Identify the action, use, adverse effects, contraindications, and nursing implications for acetaminophen. (pg. 740-746)  Action  To reduce fever, acetaminophen acts directly on the hypothalamus to increase vasodilation and sweating. To diminish pain, it acts via an unknown mechanism of action.  Use  a nonprescription drug commonly used as an aspirin substitute because it does not cause nausea, vomiting, or GI bleeding and it does not interfere with blood clotting.  Acetaminophen is used to reduce fever and decrease minor pain. The drug is sometimes given to children and patients at risk for seizures who are receiving the diphtheria, pertussis, and tetanus immunization to reduce pain and fever; this is an unlabeled use.  Adverse Effects  Hepatotoxicity and renal failure are the most common adverse effects of acetaminophen. Hypersensitivity reactions marked by rash and fever may occur in patients who have developed an allergy to the drug.  Contraindications  known hypersensitivity to the drug. Caution is necessary with administration in impaired hepatic and renal function. The drug crosses the placenta and enters the breast milk; therefore, caution is also required in pregnancy and lactation.  Nursing Implications  Acetaminophen is administered orally or by rectal suppository. It is important that the recommended dosage not be exceeded. Acetaminophen should be given with food to reduce GI upset.  When administering acetaminophen as an antipyretic agent, the nurse assesses for reduced fever. The nurse records the patient’s temperature every 2 to 4 hours. When administering the drug as an analgesic, the nurse assesses for decreased pain.  The nurse assesses for jaundice. It is also important to assess urinary output, blood urea nitrogen, and creatinine because of the risk of renal toxicity. In addition, it is critical to assess for a rash or fever because these are the first signs of a hypersensitivity reaction. The nurse assesses a patient who has a history of myocardial damage and takes acetaminophen daily for chest pain and dyspnea. If the patient develops a rash, he or she should stop taking the drug. 7. Identify the prototype and describe the action, use, adverse effects, contraindications, and nursing implications for the propionic acid derivatives. (pg. 748- 756)  Action  Ibuprofen blocks prostaglandin synthesis and modulates T-cell production.  Use  Ibuprofen is used to relieve mild to moderate pain, including dysmenorrhea (painful menstruation).  Adverse Effects  Dry mouth, gingival hyperplasia, dyspepsia, heartburn, nausea, epigastric pain, constipation, and GI ulceration with occult blood loss.  Contraindications  Ibuprofen is contraindicated in patients with a known allergy to NSAIDs and salicylates. Allergic reactions are more common in patients with rhinitis, asthma, chronic urticaria, and nasal polyps  Nursing Implications  Medications and herbs interact with ibuprofen, increasing or decreasing its effects  When ibuprofen is administered for pain, the nurse assesses for pain. The patient should report diminished pain on a pain scale.  The nurse assesses the patient for dyspepsia or GI bleeding, including hemoptysis or melena.  In addition, the nurse assesses for signs and symptoms of hypersensitivity to ibuprofen, including rash and bronchospasm. 8. Identify the prototype and describe the action, use, adverse effects, contraindications, and nursing implications for the oxicam derivatives. (pg. 757-760)  Action- Meloxicam (Mobic)  Meloxicam is a COX-1 and COX-2 inhibitor, producing anti-inflammatory, analgesic, and antipyretic effects. It is more selective for COX-2 inhibition in the brain, kidney, ovary, uterus, cartilage, bone, and sites of inflammation.  Use  Meloxicam is administered for the treatment of osteoarthritis and rheumatoid arthritis.  Adverse Effects  Respiratory effects include dyspnea, hemoptysis, bronchospasm, pharyngitis, and rhinitis. Hematologic effects consist of bleeding, platelet inhibition, and decreased hemoglobin and hematocrit, along with bone marrow depression and edema. GI effects include nausea, dyspepsia, diarrhea, vomiting, and diarrhea.  Contraindications  Meloxicam should not be administered to patients with a known aspirin allergy. It is also contraindicated postoperatively in patients who have just undergone coronary artery bypass surgery.  Nursing Implications  When giving meloxicam for pain, the nurse assesses the pain level using a pain scale to determine that analgesic effects are attained. When giving it for fever, the nurse records the patient’s temperature every 2 to 4 hours to check for diminished body temperature. When giving it for inflammation, the nurse assesses for diminished redness and swelling. 9. Identify the prototype and describe the action, use, adverse effects, contraindications, and nursing implications of the acetic acid derivatives. (pg. 761- 768)  Action- Indomethacin (Indocin, Tivorbex)  Use  Indomethacin is administered to relieve pain associated with rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, bursitis, tendonitis, and gouty arthritis.  Adverse Effects  Abdominal pain, distention, vomiting, and transient ileus may occur. CNS adverse effects include headache, dizziness, somnolence, and insomnia. Patients are at risk for renal impairment and decreased clotting time. With IV preparations, the most severe respiratory adverse effect is pulmonary hemorrhage.  Contraindications  Indomethacin should not be administered to patients with a known history of salicylate hypersensitivity.  Nursing Implications  It is important to administer oral indomethacin after meals or with an antacid to decrease GI irritation. Patients with gouty arthritis should not take the sustainedrelease preparation.  Before administering indomethacin, it is important to assess patients for salicylate allergy, which can cause bronchospasm, dyspnea, and rash. 10. Identify the prototype and describe the action, use, adverse effects, contraindications, and nursing implications of the selective COX-2 inhibitors. (pg. 770-772)  Action- Prototype Celecoxib (Celebrex)  COX-2 is activated with inflammation. Celecoxib inhibits the COX-2 enzyme to decrease inflammation. It does not affect the COX-1 enzyme, thus protecting the lining of the GI tract and not inhibiting clotting factors.  Use  Administered for acute and long-term treatment of juvenile rheumatoid arthritis, rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis.  It is used to treat acute pain and primary dysmenorrhea.  Adverse Effects  CNS: adverse reactions of celecoxib include headache, dizziness, somnolence, and insomnia.  Derm: rash, pruritus, sweating, dry mucous membranes, and stomatitis.  Contraindications  Celecoxib is contraindicated in patients who have a known allergy to sulfonamides, NSAIDs, and aspirin. It is also contraindicated in patients with renal impairment.  Nursing Implications  When administering celecoxib, the nurse should be certain to administer it 2 hours before or after an antacid to ensure absorption.  The nurse assesses for diminished pain and swelling associated with inflammation.  The nurse assesses joints for redness, heat, and stiffness. Mobility should increase with the administration of celecoxib  The nurse assesses the patient for signs and symptoms of chest pain, shortness of breath, confusion, or numbness of the extremities. 11. Identify the prototype and describe the action, use, adverse effects, contraindications, and nursing implications for the mitotic agent. (pg. 774-777)  Action- Colchicine (Colcrys, Mitigare) Prototype  inhibits the migration of WBCs into the body tissues containing urate crystals. The phagocytic action of the drug decreases the inflammatory reaction to the urate crystals deposited in the tissues.  Use  treatment and prevention of gout  Colchicine is administered for the treatment and prophylaxis of acute gout in adults  Adverse Effects  GI: nausea, vomiting, and abdominal pain and dyspepsia.  Hemat: bone marrow depression and aplastic anemia  Peripheral neuropathy, alopecia, rash, purpura, dermatoses, myopathy, muscle pain, and weakness  Contraindications  Hypersensitivity  Should not be administered concurrently with cyclosporines or ranolazine or with a strong to moderate CYP3A4 inhibitor in the presence of hepatic or renal impairment.  Nursing Implications  Nurse assesses for decreased pain, swelling, and inflammation of affected joints  The nurse assesses for severe GI adverse effects such as vomiting and diarrhea,  The nurse also assesses for numbness, tingling, or muscle weakness. 12. Identify the prototype and describe the action, use, adverse effects, contraindications, and nursing implications for uricosuric medications. (pg.777)  Action- Allopurinol (Zyloprim) Prototype  Allopurinol inhibits the enzyme that is responsible for the conversion of purines to uric acid. This action reduces the purines to uric acid and thus reduces the uric acid production to decrease the serum and urinary uric acid levels. The result of this action is the reduction of the symptoms of gout.  Use  Allopurinol and uricosuric agents are administered for the management of the signs and symptoms of primary and secondary gout or stages of gout.  It is also given in acute and chronic tophaceous gout to reduce uric acid concentrations  Adverse Effects  CNS: drowsiness, headache, and vertigo.  Hemat: agranulocytosis, aplastic anemia, and bone marrow depression.  GI: nausea, vomiting, diarrhea, abdominal pain, and indigestion.  Contraindication  Patients with a known hypersensitivity to allopurinol should not take allopurinol. Also, patients with a family history or history of idiopathic hemochromatosis should not receive the drug.  Nursing Implication  Several medications, including azathioprine, mercaptopurine, cyclophosphamide, cyclosporine, and thiazide diuretics, increase the risk of uricosuric-associated toxicity. The administration of ampicillin and amoxicillin with allopurinol increases the risk of developing a rash. Anticoagulation effects are increased when combined with warfarin and aspirin. Alcohol combined with allopurinol decreases the excretion of uric acid.  The nurse assesses for diminished urine output or cloudy urine, which may be indicative of the development of uric acid kidney stones.  Assess for GI effects such as nausea, vomiting, diarrhea, and abdominal pain.  The nurse assesses for bruising, bleeding, and anemia. 13. Know how to implement the nursing process in the care of patients undergoing drug therapy for pain, fever, and inflammation.  Assessment  Assess for signs and symptoms  Assess for limitation in activity or mobility  Assess the use of OTC analgesic, antipyretic  Outcomes of Therapy  The patient will experience relief of discomfort with minimal adverse effects  The patient will experience increased mobility and activity tolerance  Avoid overuse of the drugs  Nursing interventions  Implement measures to prevent or minimize pain, fever or inflammation  Treat pain as soon as possible  Provide appropriate teaching for any drug therapy  Evaluation  Interview and observe regarding relief of symptoms  Interview and observe regarding mobility and activity levels  Select drugs appropriately