Drugs Affecting the Central Nervous System

1. Drugs Affecting the Central Nervous System Chapter 10

2. Pain • Defined as an unpleasant sensory and emotional experience associated with either actual or potential tissue damage. • Pain is what a client says it is. • Pain exists whenever the patient says it does.

3. Acute Pain • Pain that is sudden in onset, usually subsides when treated, and typically occurs over less than 6-week period of time.

4. Chronic Pain • Persistent or recurring pain that is often difficult to treat. Typically lasts longer than 3 months.

5. Pain Threshold • Level of stimulus needed to produce a painful sensation.

6. Pain Tolerance • The amount of pain a client can endure without it interfering with normal function.

7. Pain Source • Somatic pain: originates from skeletal muscles, ligaments and joints. • Visceral pain: originates from organs and smooth muscle. • Superficial pain: originates from skin and mucous membranes.

8. Cultural Implications • Each culture has its own beliefs, thoughts, and ways of approaching, defining, and managing pain. • Prayer • Laying on of hands • Healers

9. Implications for Transcultural Nursing Practice • Assessment of the type of intervention the person desires. • Does the person wish traditional interventions, expressions of nurturance and compassion, psychological support, physical interventions (soothing, having a brow wiped, relaxation)? cultural support? medication? Or a combination of these?

10. Cultural Groups and Pain • Stereotypes: • Mexican Americans have a low pain tolerance. • Italian Americans are very dramatic about their pain • Jewish Americans complain a lot about pain. • African Americans report higher levels of chronic pain and have a greater sensitivity to acute pain. • Asian Americans do not express their pain.

11. Alternative Methods • Acupuncture • Massage • Herbs • Heat or ice application • Relaxation techniques • Psychological counseling

12. Acupuncture

13. Nerve Pain Tincture • Recipe • 1 tsp Saint Johns Wort (flowering top), skull cap leaves, fresh oats & licorice root. • ½ gtt each tincture • Ginger rhizome • Vervain leaves

14. Nursing Responsibilities • Do a thorough assessment that includes questions about the patients cultural background and practices is important in the effective and individualized delivery of nursing care.

15. JCAHO Pain Standards • The Joint Commission's 2001 pain management standards state that every patient has a right to have his or her pain assessed and treated. • JCAHO standards dictate that a nurse will evaluate the patients response to the pain medication within 30 minutes to one hour after administration of the pain medication.

16. Pain Tools • Universal Pain Assessment Tool

19. Opioid Drugs • Originate from the opium poppy. • 20 different alkaloids are obtained from the unripe seed of the plant.

20. Opioid Analgesics • Powerful pain relievers. • Classified according to their chemical structure and action. • Simple chemical modifications of the opium alkaloids produce three different drugs. • morphine-like drugs • meperidine-like drugs • methadone-like drugs

21. Anesthetic Drugs • Strong opioid analgesics used in combination with anesthetics during surgery. • fentanyl • sufentanil • alfentanil • Goal: not only to relieve pain but also to maintain a balanced state of anesthesia.

22. General Anesthesia • Loss of sensation and usually of consciousness without loss of vital functions artificially produced by the administration of one or more agents that block the passage of pain impulses along nerve pathways to the brain

23. Local Anesthesia • Loss of sensation in a limited and usually superficial area especially from the effect of a local anesthetic.

24. Fentanyl • Fentanyl injection has a rapid onset and short duration. • Transdermal fentanyl patch is used for long-term pain management.

25. Opioids • Opioids used to control moderate to severe pain.

26. Schedule II Drugs Classification – Opioid analgesics • Morphine • Codeine – often used in combination with acetaminophen – Tylenol with codeine • Hydrocodone – Vicodin - used in combination with acetaminophen / aspirin / ibuprofen • Hydromorphine – Dilaudid - More potent than morphine • Meperidine – Demerol • Oxycodone – Percocet (with acetaminophen) or Percodan (with aspirin)

27. Opioid Adverse Effects • Cardiovascular: hypotension, palpitations, flushing • Central nervous system: sedation, disorientation, euphoria, light-headedness, tremors. • Gastrointestinal: nausea, vomiting, constipation • Genitourinary: urinary retention • Respiratory: Respiratory depression and aggravation of asthma.

28. Contraindications • Known drug allergy • Severe asthma • Used with caution in: • Patients with severe head injuries (mask level of consciousness or LOC) • Morbid obesity with sleep apnea (depress respirations while asleep) • Paralytic ileus (bowel paralysis) – opioids tend to slow bowel

29. Psychologic Dependence • Addiction: characterized by behaviors that include one or more of the following: • Impaired control over drug use • Compulsive use • Continued use despite harm • Craving

30. Physical Dependency • Physiological adaption • Results in withdrawal symptoms when the drug is discontinued. • Withdrawal symptoms include: • Mental agitation • Tachycardia • Elevated blood pressure • Seizures

31. Opioid Tolerance • State of adaption which results in reduced effects of drug resulting on use of higher dosing to get desired effect.

32. Toxicity • Opioid antagonist bind to occupy all the receptor sites blocking the action of the opiod drug. • nalaxone • naltrexone

33. Naloxone • Brand name: Narcan • Classification Pharmacologic: opioid antagonist • Classification Therapeutic: antidote for opioid • Action: Competitively blocks the effects of opioids, including CNS and respiratory depression, without producing any agonist (opioid-like) effects. • Therapeutic Effects: reversal of signs of opioid excess.

34. Narcan • Route IV • onset in 2-3 minutes • peak unknown • duration 45 minutes • IM, Subq • onset 2-5 minutes • peak unknown • duration > 45 minutes

35. Drug Calculation • The IV dose for naloxone (Narcan) is 0.02 to 0.2 mg q 2-3 minutes until response is obtained. • Physician orders 0.1 mg • The drug is provided as 0.4 mg / mL • How much would you draw up to give the appropriate dose? ____________

36. Morphine Sulfate • Classification Pharmacologic: Opioid agonist • Classification Therapeutic: opioid analgesic • Indications: severe pain (postoperative, fractures, burns), pulmonary edema, and pain associated with myocardial infarct (MI).

37. Morphine • Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression Therapeutic Effects: decrease in severity of pain • Adverse Reactions: severe respiratory depression, constipation

38. Morphine Effects • IV maximal analgesia and respiratory depression would occur within 10 to 20 minutes • IM: within 30 minutes • Sub Q: 60 to 90 minutes • PO: peak activity occurs in about 60 minutes * higher dosage needed due to metabolism of drug in the liver

39. Morphine Dosing • Tablets come in 15 mg or 30 mg • Solution for IM, IV or sub Q: 10 mg/ml most common

40. Medication Calculation • Physician order 6 mg of morphine sulfate q 3-4 hours prn for severe pain. • The drug is provided as 10 mg / 1 mL. • How much of the drug would you need to draw up the give the appropriate dose?

41. Nursing Responsibilities • Pain assessment • Base-line vitals • Re-assess vitals after pain med administered • Assess bowel function • Overdose: Narcan used to reverse respiratory depression • Constipation: ambulate! dietary fiber, fluids, stool softener

42. Meperidine • Therapeutic classification: opioid analgesic • Pharmacologic classification: opioid agonist • Schedule II drug • Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized CNS depression • Therapeutic effects: Decrease in severity of pain.

43. Meperidine • Demerol is a synthetic drug with the same uses and adverse effects as morphine. • Less nausea and vomiting. • Use with caution due to neurotoxic metabolism with chronic use • CNS agitation (often exhibited as confusion) • Hallucinations • Tremors • seizures

44. Meperidine Dosing • IV or IM • Provided as 10 mg/mL, 50 mg /mL, 75 mg/mL or 100 mg/mL • Dosage for adults: 50 to 150 mg every 3-4 hours • Dosage for pediatrics: 1 to 1.8 mg / kg q 3-4 hours (not to exceed 100 mg dose)

45. Medication calculation • The physician order meperidine 75 mg prn q 3-4 hours for pain. • The vial provided is 50 mg / 1 mL. • How much of the mediation would you need to draw up to give the appropriate dose?

46. Codeine • Classification Pharmacologic: opioid agonist • Classification Therapeutic: allergy, cold and cough remedies, antitussives, opioid analgesics • Schedule II drug

47. Codeine • Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression – decreases cough reflex – decreases GI motility

48. Codeine • Side Effects: confusion, sedation, hypotension, constipation • Nursing responsibilities - same as morphine • Evaluation of effectiveness: • Decrease in severity of pain without significant alteration in level of consciousness • Suppression of cough • Control of diarrhea

49. Codeine Dosing • Usually supplied in combination with other analgesics • Tylenol with codeine • Tylenol # 2 = 15 mg codeine + 300 mg Tylenol • Tylenol # 3 = 30 mg codeine + 300 mg Tylenol • Tylenol # 4 = 60 mg codeine + 300 mg Tylenol • Most often given po with food • Most common side-effect: constipation

50. Methadone • The drug of choice for detoxification treatment for opioid addiction.