Nonopioid analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS).

Acetaminophen

Mechanism of Action: Acetaminophen inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever primarily in the CNS.^[1]

Indications: Acetaminophen is used to treat mild pain and fever; however, it does not have anti-inflammatory properties.

Nursing Considerations: Acetaminophen is safe for all ages and can be administered using various routes.

Geriatric populations should not exceed 3,000 mg in 24 hours, and chronic alcoholics should not exceed 2,000 mg in 24 hours due to the risk for hepatoxicity.

Side Effects/Adverse Effects: Adverse effects include skin reddening, blisters, rash, and hepatotoxicity.

Severe liver damage may occur if a patient does the following:

• Takes more than 4,000 mg of acetaminophen in 24 hours (3,200 mg for geriatric adults, 2,000 mg for chronic alcoholics)
• Takes with other drugs containing acetaminophen
• Consumes three or more alcoholic drinks every day while using this product^[2]

Some medications are combined with acetaminophen and are prescribed “as needed,” so the nurse must calculate the cumulative dose of acetaminophen over the previous 24-hour period. For example, Percocet 5/325 contains a combination of oxycodone 5 mg and acetaminophen 325 mg and could be ordered 1-2 tablets every 4-6 hours as needed for pain. If two tablets are truly administered every 4 hours over a 24-hour period, this would add up to 3,900 mg of acetaminophen, which would exceed the recommended guidelines for a geriatric patient and could cause liver damage.

If overdose occurs, the antidote is acetylcysteine.

Patient Teaching & Education: Medications should be taken as directed and the dosing schedule should be adhered to appropriately. Patients should not take the medication for greater than ten days. Additionally, patients should avoid taking alcohol while using these medications. If a rash occurs, this should be reported to the health care provider, and the medication should be promptly stopped. Use of medications may interfere with blood glucose monitoring. If a fever lasts longer than three days or exceeds 39.5 C, this should be reported to the health care provider.^[3]

Now let’s take a closer look at the medication grid on acetaminophen in Table 10.6a.^[4]

Medication grids are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below. Detailed information on a specific medication can be found for free at DailyMed. On the home page, enter the drug name in the search bar to read more about the medication. Prototype/generic medications listed in the grids below are also linked to a DailyMed page.

Table 10.6a Acetaminophen Medication Grid

Nonsteroidal Anti-Inflammatories (NSAIDs)

Nonsteroidal anti-inflammatories have an analgesic effect, as well as antipyretic and anti-inflammatory actions. Some, such as aspirin, also have an antiplatelet effect. Aspirin and other NSAIDs relieve pain by inhibiting the biosynthesis of prostaglandin by different forms of the COX enzyme. COX2 inhibitors are selective and only inhibit the COX-2 enzyme. As a result of the inhibition of COX1 by an NSAID, there is decreased protection of the stomach lining and gastric irritation, and bleeding may occur. This section will discuss the following NSAIDs: aspirin, ibuprofen, ketorolac, and celecoxib.^[5]

Aspirin

Mechanism of Action: Aspirin produces analgesia and reduces inflammation and fever by inhibiting the production of prostaglandins. It also decreases platelet aggregation.

Indications: Aspirin is used for the treatment of mild pain and fever. Once daily dosages are also used to reduce the risk of heart attack and stroke.

Nursing Considerations: Aspirin is safe for adults and children older than 12 years of age.

Side Effects/Adverse Effects: Adverse effects include GI upset, GI bleed, and tinnitus (ringing of the ears).

Boxed Warning: Children or teenagers should not take aspirin to treat chicken pox or flu-like symptoms because of the risk of Reye’s syndrome. Reye’s syndrome primarily occurs in children in conjunction with a viral illness; it can cause symptoms such as persistent vomiting, confusion, or loss of consciousness and requires immediate medical attention.

Allergy Alert: Aspirin may cause a severe allergic reaction, which may include the following:

• Hives
• Facial swelling
• Shock
• Asthma (wheezing)

Stomach Bleeding Warning: This product contains an NSAID, which may cause severe stomach bleeding. The chance for bleeding is higher if a patient:

• Takes a higher dose or takes it for a longer time than directed
• Takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)
• Has had stomach ulcers or bleeding problems
• Takes a blood-thinning (anticoagulant) or steroid drug
• Is age 60 or older
• Has three or more alcoholic drinks every day while using this product

Aspirin is contraindicated if the patient has a bleeding disorder such as hemophilia or a recent history of bleeding in the stomach or intestine.

Patient Teaching & Education: Patients should avoid concurrent use of alcohol while taking medication to avoid gastric irritation. Additionally, they should report tinnitus, unusual bleeding, or fever lasting greater than three days to the health care provider.

Now let’s take a closer look at the medication grid on aspirin in Table 10.6b.^[6]

Table 10.6b Aspirin Medication Grid

Mechanism of Action: Ibuprofen inhibits prostaglandin synthesis.

Indications: Ibuprofen is used to treat mild to moderate pain and fever; inflammatory disorders, including rheumatoid arthritis and osteoarthritis; and pain associated with dysmenorrhea.

Nursing Considerations: Ibuprofen is safe for infants six months or older. It is especially important not to use ibuprofen during the last three months of pregnancy unless directed to do so by a doctor because it may cause complications during delivery or in the unborn child.

Side Effects/Adverse Effects: Adverse effects include headache, GI bleed, constipation, dyspepsia, nausea, vomiting, Steven-Johnson syndrome, and renal failure.

Allergy Alert: Ibuprofen may cause a severe allergic reaction, especially in people allergic to aspirin. Symptoms may include the following:

• Hives
• Facial swelling
• Asthma (wheezing)
• Shock
• Skin reddening
• Rash
• Blisters

Stomach Bleeding Warning: This product contains a nonsteroidal anti-inflammatory drug (NSAID), which may cause severe stomach bleeding. The chance for bleeding is higher if the patient:

• Is age 60 or older
• Has had stomach ulcers or bleeding problems
• Takes a blood-thinning (anticoagulant) or steroid drug
• Takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)
• Has three or more alcoholic drinks every day while using this product
• Takes more or for a longer time than directed

Heart Attack and Stroke Warning: All NSAIDs, except aspirin, increase the risk of heart attack, heart failure, and stroke. These can be fatal. The risk is higher if the patient takes more than is directed or takes it for longer than directed.

Boxed Warning: Ibuprofen is contraindicated for the treatment of perioperative pain after coronary artery bypass graft.

Patient Teaching & Education: Patients should consume the medication with a full glass of water and remain upright for 30 minutes following medication administration. They should avoid the use of alcohol while taking this medication. Patients should be advised to not take the medication for longer than ten days. If the patient notices rash, visual changes, tinnitus, weight gain, or influenza-like symptoms, these should be reported to the health care provider immediately.^[7]

Now let’s take a closer look at the medication grid on ibuprofen in Table 10.6c.^[8]

Table 10.6c Ibuprofen Medication Grid

Ketorolac

Ketorolac is an NSAID that is commonly used to treat “breakthrough” pain that occurs during the treatment of severe acute pain being treated with opioids.

Mechanism of Action: Ketorolac inhibits prostaglandin synthesis.

Indications: Ketorolac is indicated for the short-term (up to five days in adults) management of moderate to severe acute pain that requires analgesia at the opioid level.

Nursing Considerations: Ketorolac is safe for adults. This dose should be reduced for patients ages 65 and over.

Side Effects/Adverse Effects: Adverse effects include drowsiness, headache, GI bleed, abnormal taste, dyspepsia, nausea, Steven-Johnson syndrome, edema, and renal failure.

Gastrointestinal Risk: Ketorolac tromethamine (IV form) can cause peptic ulcers, gastrointestinal bleeding, and/or perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Therefore, ketorolac tromethamine is contraindicated in patients with active peptic ulcer disease, in patients with recent gastrointestinal bleeding or perforation, and in patients with a history of peptic ulcer disease or gastrointestinal bleeding. Elderly patients are at greater risk for serious gastrointestinal events.

Cardiovascular Thrombotic Events: Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in treatment and may increase with duration of use.

Ketorolac tromethamine is contraindicated for patients who have recently received coronary artery bypass graft (CABG) surgery.

Renal Risk: Ketorolac tromethamine is contraindicated in patients with advanced renal impairment and in patients at risk for renal failure due to volume depletion.

Risk of Bleeding: Ketorolac tromethamine inhibits platelet function and is, therefore, contraindicated in patients with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, and a high risk of bleeding. Ketorolac tromethamine is contraindicated as a prophylactic analgesic before any major surgery.

Hypersensitivity Reactions: Hypersensitivity reactions ranging from bronchospasm to anaphylactic shock have occurred, and appropriate counteractive measures must be available when administering the first dose of ketorolac. Ketorolac tromethamine is contraindicated in patients with previously demonstrated hypersensitivity to ketorolac tromethamine or who have had allergic manifestations to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).

Patient Teaching & Education: The use of ketorolac may cause dizziness of drowsiness. Patients should also avoid alcohol or other aspirin-containing products unless directed by their health care provider. If the patient notices rash, visual changes, tinnitus, weight gain, or influenza-like symptoms, these should be reported to the health care provider immediately.^[9]

Now let’s take a closer look at the medication grid on ketorolac in Table 10.6d.^[10]

Table 10.6d Ketorolac Medication Grid

Celecoxib

Celecoxib is a COX-2 inhibitor.

Mechanism of Action: Celecoxib specifically inhibits the enzyme COX-2 that is required for the synthesis of prostaglandins.

Indications: Celecoxib is used to treat the pain associated with osteoarthritis, rheumatoid arthritis (including juvenile), and ankylosing spondylitis. It also relieves the pain associated with dysmenorrhea.

Nursing Considerations: Celecoxib is safe for children two years or older. There is a Boxed Warning for required dosage adjustment for patients with hepatic impairment.

Side Effects/Adverse Effects: Adverse effects include hypertension, peripheral edema, increased liver enzymes, abdominal pain, dyspepsia, gastroesophageal reflux disease, vomiting, and diarrhea.

Boxed Warnings: There are Boxed Warnings for increased risk of cardiovascular (CV) events and gastrointestinal bleeding, ulceration, and perforation. See more information about each condition below.

Cardiovascular Thrombotic Events: Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in the treatment and may increase with duration of use. Celecoxib capsules are contraindicated in patients who have recently received coronary artery bypass graft (CABG) surgery.

Gastrointestinal Bleeding, Ulceration, and Perforation: NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious (GI) events.

Patient Teaching & Education: Patients should take medication as directed and use the lowest effective dose for the shortest period of time. If signs of GI toxicity occur, these should be reported immediately to the health care provider.^[11]

Now let’s take a closer look at the medication grid on celecoxib in Table 10.6e.^[12]

Table 10.6e Celecoxib Medication Grid