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2700 - Pain
Analgesics, anesthetics, and depressants
| Question | Answer |
|---|---|
| What is pain? | Subjective unpleasant sensory and emotional experience associated with actual or potential tissue damage. |
| Explain what nociceptive pain is. | Stimulation of nociceptors - signals travel though the spinal cord and reach the brain. 2 types: - Somatic - skin, mm, bones, joints - Visceral - Internal organs and smooth m |
| What are the 4 processes of nociception? | 1. Transduction - tissue injury and pain signal created 2. Transmission - signal travels to spinal cord and brain 3. Perception - brain recognizes pain 4. Modulation - brain can increase or decrease pain signals |
| Overview of analgesics | Medications used to relieve pain - don't cause loss of consciousness - used across all care settings |
| What are the 3 main classes of analgesics? | Opioid analgesics Non-opioid analgesics Adjuvant analgesics |
| Overview of adjuvant drugs | Drugs from chemical categories other than opioids that assist primary drugs in relieving pain. |
| What are some categories of adjuvant drugs? | NSAIDs Antidepressants Anticonvulsants Corticosteroids |
| Amitriptyline | Adjuvant drugs for neuropathic pain - Antidepressant |
| Gabapentin or pregabalin | Adjuvant drugs for neuropathic pain - Anticonvulsant |
| Overview of opioid drugs (uses, how they work, what they do/don't do) | Used for moderate to severe pain Bind to opioid receptors in the brain and spinal cord and change the perception of pain by reducing the transmission of pain signals to the brain. NOT anti-inflammatory or antipyretic |
| Codeine | Mild agonist opioid drugs |
| Hydocodone | Mild agonist opioid drugs |
| Morphine | Strong agonist opioid drugs |
| Hydromorphone | Strong agonist opioid drugs |
| Fentanyl | Strong agonist opioid drugs |
| Describe agonist opioids | Bind to opioid pian receptor and cause an analgesic response. |
| Describe agonist-antagonist opioids | Bind to opioid pian receptor and cause a weaker pain response. |
| What is the ceiling effect? | A drug reaches a maximum analgesic effect, so that analgesia does not improve even with higher dosages |
| Which classification of opioid analgesics have a ceiling effect? | Agonist-antagonist opioids |
| Describe antagonist opioids | Reverse the effects of opioid analgesics - bind to receptor and cause no response |
| What are the main opioid receptors in the brain and spinal cord? | μ (mu) – most important for pain relief κ (kappa) δ (delta) |
| What effect would be caused when an opioid binds to the μ (mu) receptor? | Analgesia, respiratory depression, sedation, euphoria |
| What effect would be caused when an opioid binds to the κ (kappa) receptor? | Spinal analgesia, sedation, miosis |
| What effect would be caused when an opioid binds to the δ (delta) receptor? | Analgesia |
| What is Equianalgesia? | |
| How much more potent is hydromorphone than morphine? | 5-8 times |
| What are the "random" uses for opioids? | Cough centre suppression Treatment of diarrhea |
| What are the contraindications for opioids? | Severe asthma Use with caution for the following: - Respiratory insufficiency - Elevated intracranial pressure - Morbid obesity - Sleep apnea - Paralytic ileus - Pregnancy |
| What are the key Opioid Analgesics Adverse Effects? | Sedation Respiratory depression Hypotension Itching Constipation |
| What are the key signs of opioid overdose? | Increasing sedation Respiratory depression Pinpoint pupils |
| In opioid toxicity/overdose, what are some actions if a pt. has respiratory depression? | Initial - Stimulate pt., assess airway, breathing, and RR Next steps - Ventilatory support & opioid antagonist |
| Morphine sulfate | Severe pain opioid analgesic PO, IV, IM, PR, Extended release |
| Oxycodone | Moderate to severe pain semi-synthetic opioid PO only - usually combined with acetaminophen - synergistic effect (Percocet) Extended release |
| Prior to administration of oxycodone, what does the nurse need to remember? - It should always be given on an empty stomach to improve absorption. - The medication must be diluted in 50 mL of saline - Do not crush the medication. - | Do not crush oxycodone - Extended release |
| What are methods of centrally stimulation methods? | Auditory Gentle touch Sternal rub Trap squeeze |
| What is a significant contraindication of morphine sulphate? | Do not use for kidney dysfunction and use with caution in renal impairment - it is broken down to active metabolites |
| Acetaminophen | 4000mg max Not to use with liver failure |
| What is dose dumping | A med released all at once - opioids = resp. depression. |
| What nursing interventions can be done for a pt. experiencing the following adverse effects? 1. Constipation 2. Nausea 3. Sedation 4. Respiratory depression | 1. Increase fluids, Fiber, movement, laxatives 2. Antiemetics, avoid strong odors, monitor for dehydration 3. LOC assessments, safety measures, avoid other CNS depressants 4. RR and quality, O2 saturation, encourage deep breathing, airway patency |
| Within what time frame can an opioid over dose occur? | Subacute or gradual - Hours to days |
| How long do the effects of naloxone occur? | 1 hr |
| What are the side effects to monitor for with the administration of naloxone? | Acute pain Withdrawal symptoms BP changes |
| MS Contin | Long-acting form of morphine provides 8-12hrs of pain relief |
| Hydromorphone | Potent opioid analgesic - IV, IM, SubQ, PO Used for severe pain |
| What is the equainalgesia for hydromorphone and morphine | Hydromorphone is 5-8x more potent that morphine |
| Codeine sulphate | Mild opioid analgesic - for moderate pain and cough |
| What is codeine sulphate commonly combined with? | Acetaminophen |
| What is the most common adverse effect of Codeine sulphate? | GI upset |
| Fentanyl | Very potent synthetic opioid for moderate to severe pain. IV, IM, transdermal, transmucosal Rapid onset |
| What property of fentanyl makes it get to the brain quickly? | It is extremely lipophilic |
| What kind of pt would a fentanyl patch be administered? How long does the patch last for? | An opioid tolerant patient. 72 hours of pain control |
| What is methadone hydrochloride used for? | - opioid dependance treatment - chronic and cancer pain |
| What are the serious risks for methadone hydrochloride? | - Unintentional overdose - QT prolongation/dysrhythmias Need to observe pt - controlled substance |
| What is Meperidine and what are it's safety concerns? | Short acting opioid - ROC- Don't use in older adults or renal impairment or chronic pain |
| What should opioid agonists- antagonists not be administered with? | Full opioid agonists |
| What is the purpose of combining naloxone with buprenorphine for the drug Suboxone? | Naloxone is added to limit misuse; it counteracts opioid effects of Buprenorphine which provides a weaker agonist effect than full opioid Ultimately helping manage withdrawal while reducing abuse potential. |
| Tramadol hydrochloride | Centrally acting analgesic for moderate to moderately severe pain |
| What are the key risks of Tramadol hydrochloride | Seizures Serotonin syndrome |
| What is the difference between general and local anesthesia? | General - loss of consciousness and protective reflexes - need mechanical ventilation Local - Loss of sensation in targeted tissues - no respiratory paralysis |
| What are the four primary effects general anesthetics have on the central nervous system? | Pain relief Depression of consciousness Skeletal muscle relaxation Reflex reduction |
| What does the Overton-Meyer theory suggest about the potency of general anesthetics? | Potency varies directly with lipid solubility—fat-soluble drugs are more potent. |
| Why can lipid-soluble anesthetic drugs easily cross the blood–brain barrier? | Because both nerve cell membranes and the blood–brain barrier have high lipid content. |
| What are the overall CNS effects of general anesthetics? | - Reduction of sensory and motor functions - Progressive depression of cerebral and spinal cord functions |
| What is malignant hyperthermia and what triggers it? What are the specific signs of it? | A rare, genetic life threatening reaction to certain anesthetic drugs. - massive release of Calcium Trigger - Volatile inhaled anesthetics - succinylcholine Signs - Sudden, extreme elevation in body temperature - Tachycardia - Muscle rigidity |
| What is the treatment for malignant hyperthermia? | - Cardiorespiratory supportive care - Dantrolene sodium, which reduces excess calcium in skeletal muscle |
| What are the drug interactions to keep in mind for general anesthetics? | Antihypertensives → increased hypotension β-blockers → increased myocardial depression |
| Ketamine hydrochloride (Ketalar) | General anesthesia for moderate sedation |
| What are the adverse effects of Ketamine hydrochloride (Ketalar)? | Hallucinations Vivid dreams Delirium |
| What drug is commonly known as "laughing gas"? What is the primary adverse effect of it? An what is it used for? | Nitrous oxide - used for dental procedures and/or adjunct to stronger agents AE - instant nausea |
| What are the primary clinical uses of propofol (Diprivan)? | - Induction and maintenance of general anesthesia - ICU sedation during mechanical ventilation - Sedation at lower doses |
| What are the onset and duration of propofol? | - Rapid onset: ~60 seconds - Short duration: 3–5 minutes |
| When do propofol vials need to be discarded? Why do they need to be discarded in that timeframe? | 6–12 hours Because propofol is lipid-based, it supports bacterial growth. |
| What are the adverse effects and precautions associated with propofol? | - Profound respiratory depression - Can cause hypotension (especially in hemodynamically unstable patients) - Risk of bacterial infections due to its formulation - Not given alone—often combined with other agents for balanced anesthesia |
| How is procedural sedation different than general anesthesia? | - Produces sedation without complete loss of consciousness - Typically does not cause respiratory arrest - Preserves airway reflexes—patient can maintain own airway and respond to verbal commands |
| What medications are commonly used for procedural sedation? | - IV benzodiazepine (e.g., midazolam) or propofol - Plus an opioid analgesic (e.g., fentanyl or morphine) |
| What safety measures are taken during procedural sedation? | - Airway reflexes are preserved, but respiratory therapist is on standby for intubation in case of complications - Used for diagnostic and minor surgical procedures |
| What is the primary function of local anesthetics? | - Used to make a specific body part insensitive to pain - Do not cause loss of consciousness |
| How do local anesthetics work at the cellular level? | - Block nerve impulse transmission in targeted areas by blocking sodium channels, preventing impulse conduction along axons |
| What are the main administration routes for local anesthetics? | - Topical: creams, gels, drops, powders, suppositories - Parenteral: Peripheral: infiltration or nerve blocks or Central: spinal or epidural techniques |
| Benzocaine | Local anesthesia agent |
| Lidocaine | Local anesthesia agent |
| What isthe key difference in injection sites for spinal vs. epidural anesthesia? | - Spinal (Intrathecal): Injected into the subarachnoid space (within CSF) - Epidural: Injected into the epidural space (outside the dura) |
| How do spinal and epidural anesthesia differ in onset and duration? | - Spinal: Rapid onset (1–5 min), fixed duration unless pump used - Epidural: Slower onset (10–20 min), adjustable duration via catheter |
| What are common uses and block types for spinal vs. epidural anesthesia? | - Spinal: Dense sensory & motor block; used for lower abdominal, pelvic, perineal, or lower limb surgeries - Epidural: Sensory ± motor block (dose dependent); used for labour, Caesarean, ortho surgery, and post-op pain |
| What is a major disadvantage of spinal anesthesia and how is it managed? | - Post-dural puncture headache (PDPH) - Managed with caffeine and blood patch transfusion to seal the leak |
| What is infiltration anesthesia and how is it administered? | - Small amounts of anesthetic are injected directly into tissues surrounding the operative site - Targets a small, localized area |
| Why is epinephrine often added to infiltration anesthesia? | Acts as a vasoconstrictor to: - Limit spread - Prolong effect - Reduce systemic absorption |
| What are common uses of infiltration anesthesia? | - Wound suturing - Dental procedures |
| What precaution should be taken when using infiltration anesthesia with vasoconstrictors? | - Avoid use in poorly circulated tissues (e.g., fingers, toes, ears, nose) - Vasoconstriction may worsen perfusion - be cautious to prevent tissue damage |
| What is the mechanism of nerve block anesthesia? | - Anesthetic solution is injected near major peripheral nerves or ganglia - Produces anesthesia at a distance from the injection site - Involves relatively deep injections (e.g., lidocaine) into locations adjacent to major nerve trunks |
| Lidocaine hydrochloride | Parenteral anesthetic - moderate potency Immediate onset 60-90 min duration |
| Tetracaine hydrochloride | Parenteral anesthetic - highest potency 5-10 min onset 90-120 min duration |
| Mepivacaine hydrochloride | Parenteral anesthetic - moderate potency Immediate onset 120-150 min duration |
| What is EMLA® cream (Lidocaine + prilocaine) used for? | Topical anesthetic to reduce pain from needle punctures (commonly in pediatrics). |
| What is the order of effects caused by local anesthetic drugs, and what is the order for recovery from these effects? | Loss: 1. Autonomic activity 2. Pain and sensory functions 3. Motor activity Recovery happens in reverse: 1. Motor function returns 2. Sensory function returns 3. Autonomic activity returns |
| What are the AE's of absorption of a vasoconstrictor itself? | Absorption of the vasoconstrictor itself can result in systemic toxicity, including: - Palpitations - Tachycardia - Nervousness - Hypertension |
| What do neuromuscular blocking drugs do? | They prevent nerve transmission in skeletal and smooth muscles, resulting in muscle paralysis. DO NOT cause sedation of analgesia |
| What is the safety precaution that needs to be in place for neuromuscular blocking drugs? | Mechanical ventilation |
| Succinylcholine | Short-acting depolarizing NMBD It mimics acetylcholine |
| Why should Succinylcholine be avoided in certain patients? | It causes potassium release from skeletal muscle cells, risking hyperkalemia. Avoid in burn/crush injuries, spinal cord injury, neuromuscular disorders, severe sepsis, or CKD. |
| Pancuronium bromide | Long-acting nondepolarizing NMBD used to facilitate intubation and muscle relaxation during long surgeries or mechanical ventilation. |
| Vecuronium | Intermediate-acting nondepolarzing NMBD - Used as an adjunct to general anesthesia - Facilitates tracheal intubation - Provides skeletal muscle relaxation during surgery - Maintains muscle paralysis during mechanical ventilation in critical care |
| What can prolonged use of Vecuronium cause? | - Prolonged use in the CCU can lead to extended paralysis and difficulty weaning from the ventilator |
| A patient in the ICU will be receiving a neuromuscular blocking drug (NMBD). Which piece of equipment is essential to have nearby when the nurse initiates this therapy? A. Defibrillator B. Sphygmomanometer C. Mechanical ventilator D. Oxygen source | C - Mechanical ventilator |
| What is the general effect of CNS depressant sedatives? | Inhibitory effect on CNS that reduce: Nervousness, excitability, irritability, physical dependency for alcohol withdrawal |
| What is the general effect of CNS depressant hypnotics? | Cause sleep More potent than sedatives |
| What are the 2 classifications of benzodiazepines? | - sedative-hypnotics - anxiolytic |
| Clonazeopam | Long acting benzodiazepine |
| Midazolam | Short acting benzodiazepine |
| Diazepam | Long acting benzodiazepine |
| Alprazolam | Intermediate acting benzodiazepine |
| Lorazepam | Intermediate acting benzodiazepine |
| What are the 5 factors of the CNS that benzodiazepines effect? | 1. Sedation 2. Antianxiety 3. Muscle relaxation 4. Anticonvulsant 5. Amnesia |
| What are the signs of benzodiazepine toxicity and overdose? | - Somnolence - Confusion - Coma - Diminished reflexes - Rarely hypotension and resp. depression unless given with other CNS depressants |
| What is the antidote for benzodiazepine toxicity? | Flumazenil |
| What are important nursing considerations when administering diazepam to older adults? | Increased risk of delirium, falls, and fractures in adults over 65; monitor for physical dependency and withdrawal symptoms after long-term use. |
| What are the key clinical uses of diazepam (Valium)? | - Anxiety - Acute alcohol withdrawal & delirium tremens - Sedation - Seizures & status epilepticus - Skeletal muscle relaxation (e.g., cerebral palsy, athetosis, stiff man syndrome) |
| What are the primary clinical uses of Midazolam? | Preoperative sedation Procedural sedation Induction of anesthesia Anxiolysis Amnesia during short procedures |
| What safety measures must nurses take when administering Midazolam? | Ensure resuscitation equipment and oxygen are immediately available; avoid rapid IV bolus; monitor for respiratory depression. |
| What is the onset and duration of Midazolam when given IV? | Onset: 1.5–5 minutes; anesthesia onset: 1.5–2.5 minutes; duration: ~2 hours. |
| What is the depressant that is less commonly used today due to safety concerns? | Barbiturates |
| Phenobarbital | Barbiturate used for tonic-colonic seizures and fever induced convulsions |
Created by:
ahgecas25