McKenna's Pharmacology for Nursing, 2e

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P A R T 4  Drugs acting on the central and peripheral nervous systems

Focus the physical examination on the following: CV: blood pressure, pulse rate, peripheral perfusion, ECG CNS: orientation, affect, reflexes, grip strength Skin: colour, lesions, texture, temperature GI: abdominal examination, bowel sounds Respiratory: respiration, adventitious sounds Laboratory tests: renal and liver function tests Implementation Provide an opioid antagonist, facilities for assisted ventilation during IV administration. Provide comfort and safety measures: orientation, accurate timing of doses, monitoring for extravasation and additional measures for pain relief to increase effects. Provide support and reassurance to deal with drug effects and addiction potential. Provide teaching about the drug, dosage, drug effects and symptoms of serious reactions to report. Evaluation Evaluate drug effects: relief of pain, sedation. Monitor for adverse effects: CNS effects (multiple), respiratory depression, rash, skin changes, GI depression, constipation. Monitor drug–drug interactions: increased respiratory depression, sedation, coma with barbiturate anaesthetics, monoamine oxidase inhibitors, phenothiazines. Evaluate the effectiveness of the teaching program. Evaluate the effectiveness of comfort and safety measures. TEACHING FOR L.M. • An opioid is used to relieve pain. Do not hesitate to take this drug if you feel uncomfortable. Remember that it is important to use the drug before the pain becomes severe and thus more difficult to treat. • Common effects of these drugs include: • Constipation : Your healthcare provider will suggest appropriate measures to alleviate this common problem. • Dizziness, drowsiness and visual changes : If any of these occur, avoid driving, operating complex machinery or performing delicate tasks. If these effects occur in the hospital, the side rails on the bed may be raised for your protection. • Nausea and loss of appetite : Taking the drug with food may help. Lying quietly until these sensations pass may also help to alleviate this problem. • Report any of the following to your healthcare provider: severe nausea or vomiting, skin rash, or shortness of breath or difficulty breathing. • Avoid the use of alcohol, antihistamines and other over- the-counter drugs while taking this drug. Many of these drugs could interact with this opioid. • Tell any doctor, nurse, dentist or other healthcare provider involved in your care that you are taking this drug.

is in when L.M. begins demanding pain relief before the prescribed time limit. What implications will L.M.’s agitation have on the way that the staff respond to him and on other people in the area? What other measures could be used to help relieve pain and make the opioid more effective? What plans could the healthcare team make with L.M. to give him more control over his situation and increase the chances that the pain relief will be effective? DISCUSSION In assessing L.M.’s response to drug therapy, you suspect that the morphine was not providing the desired therapeutic effect. Numerous research studies have shown that, in general, the dose of opioids prescribed for acute pain relief provides inadequate analgesic coverage. It could be that the dose of morphine ordered for L.M. was just not sufficient to relieve his pain. This person has many causes of acute pain and will heal more quickly if the pain is managed better. He has requested more drugs because the dose is too small or the intervals between doses are too long to effectively relieve his pain. Other measures may be successful in helping the morphine relieve the pain. Back rubs, environmental controls to decrease excessive stimuli (e.g. noise, lighting, temperature, interruptions) and stress reduction may all be useful. Discussing the possibility of increasing the drug dose with the doctor would be appropriate. L.M. may be very anxious about his injuries, and the opportunity to vent his feelings and concerns may alleviate some of the tension associated with pain. He may fear that if he does not cover the pain before it gets too bad, it will be very hard to get any pain relief. The staff can work on this concern and figure out a way to reassure him. The healthcare team should try to discuss the concerns with L.M., including the concern about physical dependency. L.M. is a businessman and may respond positively to having some input into his care; he may even offer suggestions as to how he could cope better and adjust to his situation. Cortical impulses can close gates as effectively as descending inhibitory pathways, and stimulation of the cortical pathways through education and active involvement should be considered an important aspect of pain relief. Because L.M.’s injuries are extensive, a long-term approach should be taken to his care. The sooner that L.M. can be involved, the better the situation will be for everyone involved. CARE GUIDE FOR L.M.: OPIOIDS Assessment: History and examination Assess history of allergies to any opioid drug, respiratory

depression, GI or biliary surgery, hepatic or renal dysfunction, alcoholism or convulsive disorders.