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  • 1. Chapter 24Drugs Treating Mild to ModeratePain, Fever, Inflammation, andMigraine HeadacheCopyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

2. Fever Temperature regulation is a function of thehypothalamus. Normally, a homeostatic balance exists between bodyheat generated and body heat lost. Fever is the result of fever-inducing substances calledpyrogens. Fever causes activation of monocytes/macrophages,which in turn secrete cytokines. Cytokines increase the synthesis and secretion ofprostaglandin in the hypothalamus. This causes the hypothalamus to reset the bodytemperature.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 3. Inflammation Numerous types of stimuli cause the inflammatoryresponse. The classic signs of local inflammation are swelling, heat,redness, pain, and loss of function. Acute inflammation is divided into vascular and cellularresponses. The vascular response occurs almost immediately afterthe injury.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 4. Inflammation (cont.) The cellular response is divided into four phases: Margination of white blood cells (WBCs) to theperiphery of the blood vessels Emigration of WBCsthe WBCs migrate into thetissue spaces. Chemotaxiscellular debris become moreattractive to the WBCs. Phagocytosisneutrophils and monocytes engulfcellular debris.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 5. Prostaglandin Synthesis Prostaglandins modulate some components ofinflammation, body temperature, pain transmission, plateletaggregation, and many other body actions. They are derived from arachidonic acid, which is liberatedfrom the cell membrane in response to physical, chemical,hormonal, bacterial, or other stimuli. They are converted from arachidonic acid to prostaglandinsby the enzyme cyclooxygenase (COX). There are two forms of the COX enzyme: COX-1 and COX-2. COX-1 synthesizes prostaglandins that are involved in theregulation of normal cell activity. COX-2 appears to produce prostaglandins mainly at thesites of inflammation.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 6. Prostaglandin Synthesis (cont.)Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 7. Copyright 2012 Wolters Kluwer Health | Lippincott Williams & WilkinsPain The physiologic mechanisms involved in the painresponse are complex. The sensation of peripheral pain begins in afferentneurons called nociceptors. These receptors are activated by chemical mediators,such as prostaglandins, histamine, bradykinin, andserotonin. 8. Platelet Aggregation Simply speaking, platelet aggregation is the clumpingtogether of platelets in the blood. Platelet aggregation can be a beneficial process. Platelet aggregation can also be harmful. It is the firststep in a sequence of events that leads to the formationof a thrombus. The risk of platelet aggregation is increased in patientswho smoke and have hypercholesterolemia.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 9. Migraine Headache The two major types of migraine headache: Migraine with aura Migraine without aura It is postulated that migraine begins when intracranialblood vessels dilate. This dilation stimulates the trigeminovascular system,resulting in abnormally excitable neurons that send painimpulses to the brains pain receptors.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 10. Drugs to Treat Inflammation and Fever Salicylates, NSAIDs, and para-aminophenol derivativedrugs are used to treat inflammation and fever in avariety of conditions. Salicylates are used in managing conditions ranging froma simple headache to acute myocardial infarction (MI). NSAIDs are used primarily as anti-inflammatory drugsbut are also used extensively as analgesics. Prototype drug: acetylsalicylic acid (aspirin)Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 11. Aspirin: Core Drug Knowledge Pharmacotherapeutics Treat mild-to-moderate pain, prevent plateletaggregation Pharmacokinetics Absorbed in the stomach and small intestines; highlyprotein bound Pharmacodynamics Fever: inhibited PGE2 synthesis in the hypothalamus Inflammation: peripheral inhibition of prostaglandin Antiplatelet: irreversible inhibition of thromboxaneCopyright 2012 Wolters Kluwer Health | Lippincott Williams & WilkinsA2 12. Aspirin: Core Drug Knowledge (cont.) Contraindications and precautions Hypersensitivity, peptic ulcer disease, or bleedingdisorders, and children with illness Adverse effects Renal failure, abnormal bleeding, GI upset,drowsiness, and confusion Drug interactions Other drugs that are highly protein boundCopyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 13. Aspirin: Core Patient Variables Health status Assess for contraindications to therapy. Life span and gender Contraindicated in the last trimester of pregnancy Lifestyle, diet, and habits Assess use of OTC medications. Environment Assess understanding of drug therapy.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 14. Aspirin: Nursing Diagnoses and Outcomes Acute or chronic pain related to ineffectiveness of aspirin Desired outcome: The patient will contact theprescriber if pain persists. Risk for Injury: GI bleeding, hepatic or renal toxicityrelated to aspirin therapy Desired outcome: The patient will avoid injury bycontacting the prescriber if any signs of toxicityoccur.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 15. Aspirin: Nursing Diagnoses and Outcomes(cont.) Disturbed Sensory Perception (visual and auditory)related to blurred vision or tinnitus Desired outcome: The patient will contact theprescriber if blurred vision or tinnitus occurs. Ineffective Protection related to blood dyscrasias or rash Desired outcome: The patient will contact theprescriber if any signs of blood dyscrasias or rashoccur.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 16. Aspirin: Nursing Diagnoses and Outcomes(cont.) Deficient Fluid Volume related to nausea and vomiting Desired outcome: The patient will avoiddehydration by contacting the prescriber if persistentnausea or vomiting occurs. Risk for Injury related to self-medication Desired outcome: The patient will avoid injury bytaking aspirin as prescribed.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 17. Aspirin: Planning and Interventions Maximizing therapeutic effects Give with milk or food to decrease GI upset. When giving aspirin for its cardiovascular properties,use uncoated aspirin. Minimizing adverse effects Do not administer aspirin to a patient with a medicalcondition that contraindicates its use. It is important to monitor closely patients with pre-existingmedical conditions or those on drug therapythat may interact with aspirin.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 18. Aspirin: Teaching, Assessment, andEvaluations Patient and family education Teach proper administration of medication. Discuss side effects of therapy. Ongoing assessment and evaluation Monitor the patient who is taking aspirin for signsand symptoms of GI distress or bleeding, anemia,hepatotoxicity, and renal failure.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 19. Copyright 2012 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestion Why is aspirin contraindicated in children with varicella? A. Can cause bleeding from skin lesions B. Will decrease effectiveness of antibiotic therapy C. Can cause increased fever D. Can cause Reye syndrome 20. Copyright 2012 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswer D. Can cause Reye syndrome Rationale: Aspirin is contraindicated in children withvaricella or flu-like illness because it is associated withthe occurrence of Reye syndrome. 21. Nonsteroidal Anti-Inflammatory Drugs The NSAIDs are grouped by chemical classes. NSAIDs all inhibit COX and prostaglandin synthesis. The therapeutic efficacy of an NSAID in a particularpatient is based on clinical response and usually cannotbe predicted before its use. All NSAIDs carry a Black Box warning stating that theyincrease the risk of MI and stroke. Prototype drug: ibuprofenCopyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 22. Ibuprofen: Core Drug Knowledge Pharmacotherapeutics Arthritis, mild-to-moderate pain, primarydysmenorrhea, migraine headache, and fever Pharmacokinetics Absorbed from the GI system. Peak: 1 to 2 hours.Highly protein bound and is metabolized in the liver Pharmacodynamics Inhibited synthesis or release of prostaglandinsCopyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 23. Ibuprofen: Core Drug Knowledge (cont.) Contraindications and precautions GI disease Adverse effects GI upset and bleeding, hepatotoxicity, and acuterenal failure. Increases risk of CVA or MI withprolonged use. Drug interactions Similar to those of salicylatesCopyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 24. Ibuprofen: Core Patient Variables Health status Assess for contraindications to therapy. Life span and gender Assess age before administration of drug. Lifestyle, diet, and habits Assess other OTC use. Environment Assess environment where drug will be given.Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 25. Ibuprofen: Nursing Diagnoses andOutcomes Acute or Chronic Pain related to ineffectiveness ofibuprofen Desired outcome: The patient will contact theprescriber if pain persists. Increased Risk for Injury related to incorrect self-administrationor to drug-induced GI bleeding or hepaticand renal toxicity Desired outcome: The patient will remain free ofinjury by taking the drug only as directed. Inaddition, the patien