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