NSAIDS

Question 1

Properties of NSAIDS

Answer 1

• Analgesic (relieves pain)
• Antipyretic (prevent or reduce fever)
• Anti-inflammatory

Question 2

Acetylsalicylic acid (Aspirin)

Answer 2

Aspirin is the prototype salicylate and NSAID and is the most widely used drug in the world. A daily aspirin tablet (81 mg or 325 mg) is now routinely recommended as prophylactic therapy for adults who have strong risk factors for developing coronary artery disease or stroke. Also effective after a MI. The 81 mg strength & the 325 mg appear to be equally beneficial for the prevention of thrombotic events

• lower strength often chosen for patients who have elevated risk for bleeding, such as those with previous stroke history or history of peptic ulcer disease and those taking the anticoagulant warfarin (Coumadin)
• often used to treat the pain associated w/headache, neuralgia, myalgia, and arthralgia, as well as other pain syndromes resulting from inflammation which include arthritis, pleurisy, and pericarditis
• those w/ systemic lupus erythematosus may also benefit from aspirin therapy because of its antiheumatic effects
• also used for antipyretic action
• aspirin and other salicylates all have one very specific contraindication in children with flulike symptoms because the use of these drugs has been associated with Reye’s syndrome (acute potentially life threatening condition involving progressive neurologic deficits that can lead to coma and may also involve liver damage as well as by salicylate therapy itself, in the presence of a viral illness)
• survivors may or may not suffer permanent neurologic damage

Question 3

Why is acetylsalicylic acid (aspirin) used?

Answer 3

For its effect in inhibiting platelet aggregation, which has been shown to have protective qualities against certain cardiovascular events such as myocardial infarction (MI) and stroke.
-has been shown to reduce cardiac death after MI and should be administered at the first sign of MI. If not given prior to arriving to the ER, it is one of the first drugs given if there are no contraindications

Question 4

In 1899, acetylsalicylic acid (Aspirin) was marketed and rapidly became the most widely used drug in the world. The success of aspirin established the importance of drugs with antipyretic, analgesic, and antiinflammatory properties-properties that all NSAIDS share. The widespread used of Aspirin also yielded what?

Answer 4

Evidence of its potential for causing major adverse effects. Gastrointestinal intolerance, bleeding, and renal impairment became major limiting factors to its long-term administration
-As a result, efforts were mounted to develop drugs that did not have the adverse effects of aspirin. This led to the discovery of other NSAIDs, which are associated w/a lower incidence of and less serious adverse effects & often better tolerated than aspirin in patients with chronic diseases

Question 5

NSAIDs mechanism of action

Answer 5

• Inhibition of leukotriene pathway, the prostaglandin pathway, or both
• relieve pain, headache, & inflammation by blocking the chemical activity of the enzyme called cyclooxygenase (COX); which has 2 types
• COX-1 promotes synthesis of prostaglandins
• COX-2 promotes synthesis of prostaglandins involved in inflammatory processes
• leukotriene pathway inhibited by some anti-inflammatory drugs, but not salicylates
• all can be ulcerogenic and induce GI bleeding

Question 6

Platelet inhibition

Answer 6

Aspirin

Question 7

One notable effect of aspirin is

Answer 7

Its inhibition of platelet aggregation, also known as antiplatelet activity

• Has the unique property among NSAIDs of being an irreversible inhibitor of COX-1 receptors w/in the platelets themselves. This in turn results in reduced formation of thromboxane A2, a substance that normally promotes platelet aggregation.
• This antiplatelet action has made aspirin a primary drug in the Tx of acute MI & many other thromboembolic disorders.
• Other NSAIDs lack these antiplatelet effects

Question 8

Indications of NSAIDS

Answer 8

• Primarily used for their analgesic, antiinflammatory, and antipyretic effects, and for platelet inhibition
• also widely used for the Tx of rheumatoid arthritis & osteoarthritis, as well as other inflammatory conditions, rheumatic fever, mild-moderate pain, and acute gout
• beneficial as adjunctive pain relief in pt’s w/chronic pain syndromes
• sometimes combined w/opioid
• have opioid sharing effect when given together because the drugs attack pain using 2 diff. mechanisms
• show ceiling effect that limits their effectiveness

Question 9

Contraindications for NSAIDs

Answer 9

• known drug allergy & conditions that place patient at risk for bleeding (Vit k def, peptic ulcer disease)
• pt’s w/documented aspirin allergy cannot take them
• pregnancy C drugs for use during first two trimesters
• pregnancy D not recommended for use during the third trimester because it has association w/both excessive maternal bleeding and neonatal toxicity during perinatal period
• not recommended for nursing mothers, excreted in milk
• pt’s undergoing surgery need to stop taking them 1 week prior

Question 10

Adverse effects of NSAIDs

Answer 10

• Effect on GI tract (mild-severe, heart burn, GI bleeding)
• acute renal failure, especially if dehydrated
• many adverse effects are secondary to their inactivation of protective prostaglandins that help maintain normal integrity of stomach lining
• misoprostol (cytotec) can be giving with them to prevent gastric ulcers and GI bleeding
• all NSAIDs (except aspirin) share a black box warning regarding an increased risk for adverse cardiovascular thrombotic events, including fatal MI and stroke
• NSAIDs may counteract the cardioprotective effects of aspirin

Question 11

Toxicity and management of overdose for NSAIDs

Answer 11

• tinnitus and hearing loss
• in children it includes hyperventilation and CNS effects such as dizziness, drowsiness, and behavioral changes
• metabolic acidosis and respiratory alkalosis
• hypoglycemia
• acute overdose of nonsalicylate NSAIDs cause similar effects but not as extensive or dangerous. Include CNS toxicities (drowsiness, lethargy, mental confusion, paresthesias, numbness, aggresive behavior, disorientation, and seizures, and GI toxicities such as N/V & GI bleeding
• Tx: administration of activated charcoal, w/supportive and symptomatic tx initiated thereafter

Question 12

NSAIDs are a large and chemically diverse group of drugs with the following properties:

Answer 12

Analgesic
Antiinflammatory
Antipyretic
Aspirin-platelet inhibition

Question 13

NSAIDs are also used for the relief of:

Answer 13

• Mild to moderate headaches
• Myalgia
• Neuralgia
• Arthralgia
• Alleviation of postoperative pain
• Relief of the pain associated with arthritic disorders, such as rheumatoid arthritis, juvenile arthritis, ankylosing spondylitis, and osteoarthritis
• Treatment of gout and hyperuricemia

Question 14

NSAIDs mechanism of action (main points)

Answer 14

• Inhibition of the leukotriene pathway, the prostaglandin pathway, or both
• Blocking the chemical activity of the enzyme called cyclooxygenase (COX)
• Cyclooxygenase-1 (COX-1)
• Has a role in maintaining the GI mucosa
• Cyclooxygenase-2 (COX-2)

Question 15

NSAIDs: Mechanism of action for aspirin main points

Answer 15

• Irreversible inhibitor of COX-1 receptors within the platelets themselves
• Reduced formation of thromboxane A2, a substance that normally promotes platelet aggregation
• Other NSAIDs lack these antiplatelet effects

Question 16

The nurse is administering medications. One patient has an order for aspirin 325 mg by mouth daily and another patient has an order for aspirin 650 mg 4 to 6 times daily (maximum 4 g/day). The nurse understands that the indication for the 325 mg of aspirin once daily is 
	pain management.
	fever reduction.
	treatment of osteoarthritis.
	thromboprevention.

Answer 16

thromboprevention.
- “Low-dose” aspirin, such as 81 or 325 mg once daily, is given for thromboprevention. Dosages for pain, fever, or arthritis are much higher usually.

Question 17

Chemical categories of NSAIDs

Answer 17

• Salicylates
• Acetic acid derivatives
• Cyclooxygenase-2 (COX-2) inhibitors
• Enolic acid derivatives
• Propionic acid derivatives

Question 18

Salicylates

Answer 18

• Salicylic acid (aspirin)
• Inhibits platelet aggregation
• Antithrombotic effect: used in the treatment of MI and other thromboembolic disorders
• Examples: aspirin, diflunisal (Dolobid), choline magnesium trisalicylate (Trilisate), and salsalate (Salsitab)
• Reye’s syndrome

Question 19

Acetic Acid Derivatives

Answer 19

• indomethacin (Indocin)
• ketorolac (Toradol)
• diclofenac sodium (Voltaren)
• sulindac (Clinoril)
• tolmetin (Tolectin)
• etodolac (Lodine)
• meclofenamate (generic only)
• mefenamic acid (Ponstel)

Question 20

Acetic Acid Derivatives

Answer 20

Used to treat rheumatoid arthritis, osteoarthritis, acute bursitis or tendonitis, ankylosing spondylitis, and acute gouty arthritis
Promote closure of patent ductus arteriosus, a heart defect that sometimes occurs in premature infants
Ketorolac (Toradol) has powerful analgesic effects

Question 21

A hospitalized patient has an order for ketorolac (Toradol). The nurse notes that the order is only for 5 days. What is the reason for this?

The patient’s pain should subside by that time.
There are concerns about addiction to the drug.
The drug can cause severe renal and gastrointestinal effects.
The drug loses its effectiveness over time.

Answer 21

The drug can cause severe renal and gastrointestinal effects.
Rationale: The main adverse effects of ketorolac include renal impairment, edema, gastrointestinal pain, dyspepsia, and nausea. It is important to note that the drug can only be used for 5 days because of its potential adverse effects on the kidney and gastrointestinal tract.

Question 22

COX-2 Inhibitor

Answer 22

• celecoxib (Celebrex)
• First and only remaining COX-2 inhibitor
• Indicated for osteoarthritis, rheumatoid arthritis, acute pain symptoms, ankylosing spondylitis, and primary dysmenorrhea
• Adverse effects include headache, sinus irritation, diarrhea, fatigue, dizziness, lower extremity edema, and hypertension
• Little effect on platelet function
• Celecoxib is not to be used in patients with known sulfa allergy

Question 23

Propionic Acid Derivatives (names)

Answer 23

fenoprofen (Nalfon)
flurbiprofen (Ansaid)
ibuprofen (Motrin, Advil)
ketoprofen (Orudis KT)
naproxen (Naprosyn, Aleve)
oxaprozin (Daypro)

Question 24

Propionic Acid Derivatives are used for?

Answer 24

• Used for their analgesic effects in treating rheumatoid arthritis, osteoarthritis, primary dysmenorrhea, gout, dental pain, and musculoskeletal disorders
• Also used for antipyretic effects
• Naproxen has fewer drug interactions with angiotensin-converting enzyme inhibitors given for hypertension

Question 25

NSAIDs: Adverse Effects

Answer 25

- Gastrointestinal - Dyspepsia, heartburn, epigastric distress, nausea - GI bleeding* (gastric)* - Mucosal lesions* (erosions or ulcerations) * Misoprostol (Cytotec) can be used to reduce these dangerous effects.

Question 26

NSAIDs: Adverse Effects for renal and cardiovascular

Answer 26

1) Renal - Reductions in creatinine clearance - Acute tubular necrosis with renal failure 2) Cardiovascular - Non-cardiogenic pulmonary edema - ASA toxicity - Leaky capillaries - ↑ Pressure / ↓ Proteins

Question 27

NSAIDs: Salicylate Toxicity

Answer 27

1) Cardiovascular: Increased heart rate 2) Central nervous: Tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, lassitude, drowsiness 3) Gastrointestinal: Nausea, vomiting, diarrhea 4) Metabolic: Sweating, thirst, hyperventilation, hypoglycemia, or hyperglycemia

Question 28

NSAIDs: Interactions

Answer 28

-Serious interactions can occur when given with: ``` Anticoagulants Aspirin Corticosteroids and other ulcerogenic drugs Protein bound drugs Diuretics and ACE inhibitors ```

Question 29

NSAID interactions

Answer 29

- Alcohol - Anticoagulants - Aspirin and other salicylates w/other NSAIDs - Bisphosphonates - Corticosteroids adn other ulcerogenic drugs - cyclosporine - Diuretics and ACE inhibitors - lithium - protein-bound drugs - uricosurics - Herbals:feverfew, garlic, ginger, gingko

Question 30

Salicylates

Answer 30

- Aspirin most commonly used - many require prescription - commonly solid oral forms

Question 31

Contraindications for aspirin

Answer 31

In children with flulike symptoms, because it is associated w/Reye's syndrome

Question 32

Nursing process: Assessment for NSAIDs

Answer 32

-Drug allergies, contraindications, cautions, drug interactions -assess and document the duration, onset, location, & type of inflammatory and/or pain pt is experiencing as well as precipitating/exacerbating, or relieving factors -inspect joints -Age (children can't have because Reyes syndrome) -assess odor (vinegry associated w/breakdown) -w/aspirin check pt for history of respiratory problems, as well as those diagnosed w/triad -assess patient if they are taking ketorolac -assess underlying signs of infection -

Question 33

NSAIDs: Nursing Implications main points

Answer 33

Before beginning therapy, assess for conditions that may be contraindications to therapy, especially: GI lesions or peptic ulcer disease Bleeding disorders Assess for conditions that require cautious use Perform laboratory studies as indicated (cardiac, renal, and liver function studies; CBC; platelet count) Perform a medication history to assess for potential drug interactions Several serious drug interactions exist - Do not give salicylates to children and teenagers because of the risk of Reye’s syndrome Because these drugs generally cause GI distress, they are often better tolerated if taken with food, milk, or an antacid to avoid irritation Explain to patients that therapeutic effects may not be seen for 3 to 4 weeks

Question 34

Nursing Implications education

Answer 34

Educate patients about the various adverse effects of NSAIDs, and inform them to notify their prescriber if these effects become severe or if bleeding or GI pain occurs Inform patients to watch closely for the occurrence of any unusual bleeding, such as in the stool Advise patients that enteric-coated tablets should not be crushed or chewed Monitor for therapeutic effects, which vary according to the condition being treated Decrease in swelling, pain, stiffness, and tenderness of a joint or muscle area -Advise pt to avoid other ulcerogenic substances (alcohol, prednisone, aspirin-containing products, other NSAIDs) to help minimize risk for GI mucosal breakdown .

Question 35

Nursing diagnosis for NSAIDs

Answer 35

1) Acute pain related to the disease process or injury to joints and other disease-affected areas 2) Deficient knowledge related to first-time drug therapy for Tx of a disease process 3) Risk for injury related to the effects of the disease and tx on mobility and the performance of ADLs

Question 36

If aspirin is used as an antigout drug, the?

Answer 36

oral dosage forms are given w/food, milk, or meals

Question 37

Monitor serum levels of aspirin if aspirin therapy is used for?

Answer 37

antiarthritic effects

Question 38

Before administering antiinflammatory drugs what should the nurse do?

Answer 38

- head-toe assessment - measure vital signs - nursing assessment - obtain medication history - analyze lab tests reflecting hematologic, renal, and hepatic functioning before initiation of therapy is ordered (RBC, hemoglobin level, hematocrit, WBC, platelet, BUN, liver enzymes ALP, AST, LDH

Question 39

Salicylic acid or aspirin and other NSAIDs have antiinflammatory, antipyretic, analgesic, and antiplately activity but they also care a risk for?

Answer 39

Ulcerogenic and GI bleeding adverse effects. | -NSAIDs carry risk for acute reversible hepatotoxicity, renal failure, hearing loss, and noncardiogenic pulmonary edema

Question 40

Why is aspirin mainly used in smaller doses?

Answer 40

Because of the high risk for adverse effects that may be severe, if used in higher doses monitor for clinical presentation as well as serum aspirin levels to help distinguish among mild, moderate, and severe toxicity

Question 41

If aspirin is used as antipyretic the pt's temp. generally begins to decrease w/in

Answer 41

1 hour

Question 42

During therapy w/NSAIDs the nurse should monitor for?

Answer 42

bowel patterns, stool consistency, and any occurrence of GI symptoms and/or dizziness, and document findings - Monitor lab tests during high-dose or long-term Tx including; CBC, BUN levels, platelet count, serum bilirubin, AST, ALT levels - emphasize safe ambulation w/NSAID use as well as with the use of other antiinflammatory drugs or analgesics

Question 43

Evaluation for NSAIDs and aspirin

Answer 43

Therapeutic responses to NSAIDs include - decrease in acute pain, swelling, pain, stiffness, and tenderness of a joint or muscle area - improved ability to perform ADLs - improved muscle grip & strength - reduction in fever - return to normal lab values Monitor for occurrence of adverse effects and toxicity

Question 44

NSAIDs patient teaching

Answer 44

- sustained-release or enteric-coated dosage forms are not to be crushed or chewed - report ringing in ears, persistent GI or abdominal pain or easy bruising or bleeding - tell them full antiinflammatory effect may not be apparent immidately - tell them to share list of all medications - NSAIDs and aspirin generally discontinued 1 week before any type of surgery (oral or dental) - keep out of reach of children, if they ingest call poison control - educate pt adverse effects (dyspepsia, heartburn, gi bleeding) - instruct report immediate; black tarry stools, bleeding around gums, petechiae, ecchymosis, purpura - report s/s of toxicity (tinnitus, hearing loss, increased HR, dizziness, mental confusion, diarrhea - take NSAIDs w/ food, milk, or antacids to help minimize gi distress - alert pt to look alike sound alike drugs - alert them of black box warning

Question 45

NSAIDs often used in tx of?

Answer 45

- gout - osteoarthritis - juvenile arthritis - rheumatoid arthritis - dysmenorrhea - musculoskeletal injuries

Question 46

3 main adverse effects of NSAIDs

Answer 46

1) GI intolerance 2) bleeding (often gi bleeding) 3) renal impairment - Misoprostol (Cytotec) may be given to prevent GI intolerance and ulcers resulting from NSAIDs. It is known as a prostaglandin analogue.

Question 47

Contraindications to use of NSAIDs

Answer 47

GI tract lesions peptic ulcers bleeding disorders

Question 48

When a patient is receiving long-term NSAID therapy, which drug may be given to prevent the serious GI adverse effects of NSAIDs?

Answer 48

Misoprostol (Cytotec)

Question 49

The nurse recognizes that manifestations of NSAID toxicity include?

Answer 49

N/V

Question 50

During a teaching session about antigout drugs, the nurse tells the pt that antigout drugs work by which mechanism?

Answer 50

Decreasing serum uric acid levels

Question 51

When the nurse is teaching about antigout drugs, which statement by the nurse is accurate?

Answer 51

Colchicine is best taken on an empty stomach

Question 52

possible chronic salicylate intoxication s/s include

Answer 52

Tinnitus, headache, nausea

Question 53

What is the mechanism of action of nonsteroidal antiinflammatory drugs (NSAIDs)? Enhancing pain perception Inhibiting prostaglandin production Increasing blood flow to painful areas Increasing the supply of natural endorphins

Answer 53

Inhibiting prostaglandin production Prostaglandins are produced in response to activation of the arachidonic pathway. NSAIDs work by blocking cyclooxygenase (COX-1 and COX-2), the enzyme responsible for conversion of arachidonic acid into prostaglandins. Decreasing the synthesis of prostaglandins results in decreased pain and inflammation.

Question 54

``` When teaching a client about potential adverse effects of NSAID therapy, the nurse will teach the client to immediately notify the health care provider of which effect? Diarrhea Mild indigestion Black tarry stools Nonproductive cough ```

Answer 54

Black tarry stools A major adverse effect of NSAID therapy is gastrointestinal (GI) distress with potential GI bleeding. Black or tarry stools are indicative of a GI bleed.

Question 55

The nurse is administering probenecid (Benemid) to a client with recurrent strep throat. The nurse teaches the client that the MOST likely reason for taking this medication is for what drug effect? Increase uric acid excretion Prevent the occurrence of gout Inhibit bacterial growth and replication Prolong the effectiveness of penicillin therapy

Answer 55

Prolong the effectiveness of penicillin therapy Besides its use for the treatment of the hyperuricemia associated with gout and gouty arthritis, probenecid also has the ability to delay the renal excretion of penicillin, thus increasing serum levels of penicillin and prolonging its effect.

Question 56

What is advantage of COX-2 inhibitors over other NSAIDs? Maintain GI mucosa Have a longer duration of action Have a more rapid onset of action Are less likely to cause hepatic toxicity

Answer 56

Maintain GI mucosa By not inhibiting the COX-1 enzyme to maintain an intact gastric mucosal barrier by increasing secretion of mucus, the risks of GI adverse effects are decreased.

Question 57

The client asks the nurse about the use of herbal and dietary supplements to treat arthritis pain. What is the nurse’s best response? “High doses of vitamins and minerals have been used for many years to help maintain joint health.” “There really are no safe herbal treatments for pain. Your best action would be to take your prescription medications.” “Ginkgo biloba has shown tremendous benefit as an antiinflammatory drug and is used to treat the symptoms of pain.” “There is evidence that glucosamine sulfate with chondroitin does decrease joint stiffness and pain. Discuss this with your health care provider.” r.

Answer 57

“There is evidence that glucosamine sulfate with chondroitin does decrease joint stiffness and pain. Discuss this with your health care provider.” There is evidence that clients would benefit from glucosamine and chondroitin supplements to decrease the pain of osteoarthritis. However, they should always be used in consultation with a health care provider.

Question 58

``` The nurse knows colchicine (Colcrys) exerts its therapeutic effect by what action? Increases uric acid metabolism Decreases mobility of leukocytes Increases process of phagocytosis Increases production of lactic acid ```

Answer 58

Decreases mobility of leukocytes Colchicine works by inhibiting the metabolism and migration of leukocytes into joints affected by gout, thus resulting in decreased inflammation.

Question 59

Which nursing diagnosis is appropriate for a client prescribed colchicine (Colcrys)? Constipation related to adverse effect of the medication Risk for infection related to medication-induced leukocytosis Risk for injury related to adverse effect of life threatening seizures Risk for fluid volume deficient related to nausea, vomiting, and diarrhea

Answer 59

Risk for fluid volume deficient related to nausea, vomiting, and diarrhea Colchicine is administered on an hourly basis until pain is relieved, the client develops severe nausea and diarrhea, or the maximum dose (6 mg) has been administered. Bleeding into the GI or urinary tracts is a potential serious adverse effect of colchicine.