Pain and Mobility

10.6 Non-Opioid Analgesics

Non-opioid analgesics include acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS).

Acetaminophen

Mechanism of Action

The mechanism of Acetaminophen is still somewhat unknown. However, it inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever primarily in the CNS.[1] Acetaminophen is not an anti-inflammatory agent.[2]

Indications for Use

Acetaminophen is used to treat mild pain and fever. It is indicated for pain related to arthritis and rheumatic disorders however, it does not have anti-inflammatory properties.

Nursing Considerations Across the Lifespan

Acetaminophen is safe for all ages and can be administered using various routes. There are special dosing considerations for pediatric and older adults due to the risk for hepatotoxicity.

Older adults are more susceptible to the negative effects of anti-inflammatories and should not exceed 4000 mg in 24 hours. Persons with alcohol use disorders should also have lower doses due to the risk for hepatotoxicity.

Adverse/Side Effects

Adverse effects include

  • Skin reddening
  • Hypersensitivity: Rash, fever
  • Hepatic failure (liver damage)
  • Renal damage

Example: Safety with Acetaminophen

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 2 tablets are truly administered every 4 hours over a 24-hour period, this would add up to 3900 mg of acetaminophen, which would exceed the recommended guidelines for a geriatric client and could cause liver damage.

If an overdose occurs, the antidote is acetylcysteine.

Client Teaching and Education

Medications should be taken as directed and the dosing schedule should be adhered to appropriately. Caution clients to not take multiple medications that have acetaminophen at the same time. Clients should not take the medication for more than 10 days. Additionally, clients should avoid using alcohol while taking these medications. Severe liver damage may occur if a client consumes 3 or more alcoholic drinks every day while using this product.[3] If a rash occurs, this should be reported to the healthcare 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 healthcare provider.[4]

Acetaminophen Medication Card

Now let’s take a closer look at the medication card for acetaminophen.[5] Medication cards like this 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.  Prototype or generic medication examples are also hyperlinked to a free resource at Daily Med. On the home page, enter the drug name in the search bar to read more about the medication.

Medication Card 10.6.1: Acetaminophen

Generic Name: acetaminophen

Prototypes/Brand Name: Tylenol, Panadol

Mechanism: Reduces fever by acting directly on hypothalamic heat-regulating center. Analgesic mechanism unclear. Not an anti-inflammatory agent

Therapeutic Effects

  • Antipyretic: Reduction in fever
  • Analgesic: Reduction in pain

Administration

  • Can be given orally or rectally
  • Assess pain prior to and after administration
  • Administer with a full glass of water
  • Maximum dose over 24-hour period:
    • 4000 mg adults,
    • 3200 mg geriatric
    • 2000 mg clients with chronic alcoholism

Indications

  • Arthritis and rheumatic disorders involving musculoskeletal pain
  • Common cold, flu, other viral and bacterial infections with pain and fever

Contraindications

  • Allergy to acetaminophen.
  • Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

Side Effects

  • Skin reddening
  • Hypersensitivity: Rash, fever
  • Hepatotoxicity (liver damage)
  • Renal damage
  • SAFETY: Do not exceed recommended dose. Report rash, bleeding, or yellowing of skin. If overdose, monitor serum levels. Antidote is acetylcysteine

Nursing Considerations

  • Assess history and physical condition related to liver and kidneys
  • Avoid using multiple preparations with acetaminophen

Clinical Reasoning and Decision-Making Activity 10.6.1

LightbulbYour client is admitted to the hospital with acute liver failure due to acetaminophen toxicity. Your client reveals that they have had a cold for several days and have been taking over-the-counter cold medications and acetaminophen for a headache. They also mention that every night after work they drink a “few” beers.

What client education about acetaminophen should be provided?

Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.

Non-steroidal Anti-inflammatories (NSAIDs)

Non-steroidal anti-inflammatories have analgesic, antipyretic and anti-inflammatory actions. Acytylsalicylic acid (ASA) also has an anti-platelet effect. ASA 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. You can watch this video about the mechanism of NSAIDs.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

 

This section will discuss ASA, ibuprofen, ketorolac, and celecoxib.[6]

Acetylsalicylic Acid

Mechanism of Action

Acetylsalicylic acid (aspirin) is a non-opioid NSAID analegesic, and anti-pyretic. It reduces inflammation and fever by inhibiting the production of prostaglandins. ASA also decreases platelet aggregation.

Indications for Use

Aspirin is used for the treatment of mild to moderate pain, fever, inflammatory conditions. Once-daily dosages are also used to reduce the risk of heart attack and stroke.

Nursing Considerations Across the Lifespan

ASA is safe for most adults and children older than 12 years of age. However, it is not the first choice of anti-inflammatory for children and should not be used with children at risk for Reye’s syndrome. ASA is not considered safe for pregnant or nursing women.

Older adults are more susceptible to negative GI and CNS effects of anti-inflammatories.

Adverse/Side Effects

ASA may cause toxicity, intolerance or hypersensitivity. If an overdose occurs, emergency gastric procedures may be needed such as gastric lavage. Adverse effects of ASA include GI upset, GI bleed, and tinnitus (ringing of the ears). ASA may cause a severe allergic reaction, which may include:

  • 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 client:

  • 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 3 or more alcoholic drinks every day while using this product

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

Client Teaching & Education

Clients should avoid concurrent use of alcohol while taking medication to avoid gastric irritation. This medication should be out of the reach of children. Additionally, clients should report tinnitus, unusual bleeding, or fever lasting greater than 3 days to the healthcare provider. Clients should also pause the use of ASA if going for surgery within one week. However, if on ASA for anti-platelet properties, clients should have alternative measures for preventing MI and stroke.

Safety Warning

Children or teenagers should not take aspirin to treat chickenpox 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.

ASA Medication Card

Now let’s take a closer look at the medication grid for ASA.[7]

Medication Card 10.6.2: ASA

Generic Name: acetylsalicylic acid

Prototype/Brand name: aspirin

Mechanism: Inhibits the synthesis of prostaglandins. Inhibition of platelet aggregation.

Therapeutic Effects

  • Treatment of mild pain and fever
  • Reduces the risk of heart attack and stroke

Administration

  • Given orally
  • Assess pain before and after
  • Not for children under 12
  • Take with a full glass of water and food. Sit upright for 15-30 min
  • Do not crush, chew, break, or open an EC pill. Swallow whole
  • chewable must be chewed
  • Stop 7 days prior to surgery

Indications

  • Mild to moderate pain
  • Fever
  • rheumatic fever, rheumatoid arthritis, osteoarthritis
  • Reduced risk of recurrent stroke in males.
  • MI prophylaxis

Contraindications

  • Allergy to salicylates, NSAIDs
  • Conditions that increase risk of bleeding, or clotting deficiencies.
  • Caution with impaired renal
  • Surgery scheduled within 1 wk
  • Pregnancy & breastfeeding
  • Do not use in children/ teens for chickenpox or flu symptoms without review for Reye’s syndrome.

Side Effects

  • Acute aspirin toxicity: hemorrhage, seizures, tetany, CV, renal and respiratory failure
  • Aspirin intolerance: bronchospasm, rhinitis
  • Nausea, hepatotoxicity
  • Blood loss
  • Hypersensitivity
  • Salicylism (Dizzy, tinnitus)
  • SAFETY: Emergency procedures if overdose (i.e., Gastric lavage, activated charcoal, etc.)

Nursing Considerations

  • Assess history, allergies, and physical condition related to liver, kidneys, hemostasis, viral infection, pregnancy, and lactation
  • Keep out of the reach of children
  • Report ringing in the ears; dizziness, confusion; abdominal pain; rapid or difficult breathing; nausea, vomiting, bloody stools.
Clinical Reasoning and Decision-Making Activity 10.6bImage of lightbulb in a circle

A client asks why aspirin is given to prevent a heart attack or stroke.

What is the nurse’s response?

Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.

Ibuprofen

Mechanism of Action

Ibuprofen is an NSAID that inhibits prostaglandin synthesis.

Indications for Use

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 Across the Lifespan

Ibuprofen is safe for infants 6 months or older. It is especially important not to use ibuprofen during the last 3 months of pregnancy unless directed to do so by a doctor because it may cause complications during delivery or in the unborn child.

Older adults are more susceptible to negative side-effects of anti-inflammatories.

Adverse/Side Effects

Adverse effects include headache, GI bleed, constipation, dyspepsia, nausea, vomiting, Stevens-Johnson syndrome, and renal failure.

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

  • hives
  • facial swelling
  • asthma (wheezing)
  • shock
  • skin reddening
  • rash
  • blisters

Stomach bleeding warning: This product contains a non-steroidal anti-inflammatory drug (NSAID), which may cause severe stomach bleeding. The chance for bleeding is higher if the client:

  • 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 3 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 client takes more than is directed or takes it for longer than directed.

Client Teaching & Education

Clients 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. Clients should be advised to not take the medication for longer than 10 days. If the client notices rash, visual changes, tinnitus, weight gain, or influenza-like symptoms, these should be reported to the healthcare provider immediately.[8]

Safety Warning

Ibuprofen is contraindicated for the treatment of peri-operative pain after coronary artery bypass graft.

Table 10.6c provides a medication card for various types of NSAIDs, including ibuprofen.

Clinical Reasoning and Decision-Making Activity 10.6cImage of lightbulb in a circle

A client who is a chronic alcoholic asks if it is okay to take ibuprofen for knee pain.

What is the nurse’s best response?

Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.

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 for Use

Ketorolac is indicated for the short-term (up to 5 days in adults) management of moderate to severe acute pain that requires analgesia at the opioid level. It usually is started through parenteral administration versus oral.

Nursing Considerations Across the Lifespan

Ketorolac is safe for most adults. It is not considered safe for pregnant or breastfeeding women. In general, ketorolac should be avoided by older adults due to high risk of toxicity. If necessary for use in older adults, the dosage should be reduced.

Adverse/Side Effects

Adverse effects include drowsiness, headache, GI bleed, abnormal taste, dyspepsia, nausea, Stevens-Johnson syndrome, edema, and renal failure.

Gastrointestinal Risk: Ketorolac (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 clients with active peptic ulcer disease, in clients with recent gastrointestinal bleeding or perforation, and in clients with a history of peptic ulcer disease or gastrointestinal bleeding. Elderly clients 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 the duration of use. Ketorolac is contraindicated for clients who have recently received coronary artery bypass graft (CABG) surgery.

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

Risk of Bleeding: Ketorolac inhibits platelet function and is, therefore, contraindicated in clients with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, and a high risk of bleeding. Ketorolac 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 is contraindicated in clients with previously demonstrated hypersensitivity to ketorolac or who have had allergic manifestations to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).

Client Teaching & Education

The use of ketorolac may cause dizziness or drowsiness. Clients should also avoid alcohol or other aspirin-containing products unless directed by their healthcare provider. If the client notices rash, visual changes, tinnitus, weight gain, or influenza-like symptoms, these should be reported to the healthcare provider immediately.[9]

Table 10.6c provides a medication card for various types of NSAIDs, including ketorolac.

Clinical Reasoning and Decision-Making Activity 10.dImage of lightbulb in a circle

Ketorolac IV was administered to a client for severe pain (rated as “8”) due to a back injury.

When should the effectiveness of the medication be evaluated?

Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.

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 for Use

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 Across the Lifespan

Celecoxib is considered safe for children 2 years or older. Dosage adjustment is required for clients with hepatic impairment (see Black Box Warning). It is not recommended for use during pregnancy.

Older adults are more susceptible to negative side-effects of anti-inflammatories.

Adverse/Side Effects

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

There are Black Box Warnings for increased risk of cardiovascular (CV) events and gastrointestinal bleeding, ulceration, and perforation. Health Canada has also issued a safety review of celecoxib.[10]

See more information about each condition below.

Cardiovascular Thrombotic Events: Non-steroidal 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 clients 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 clients and clients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious (GI) events.

Client Teaching & Education

Clients 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 healthcare provider.[11]

NSAID Medication Card

Now let’s take a closer look at the medication grid for the NSAIDS including ibuprofen, ketorolac, and celecoxib.[12]

Medication Card 10.6.3: NSAID

Generic Name (Prototype/Brand Name):

ibuprofen (Motrin, Advil)

ketorolac (Toradol)

celecoxib (Celebrex)

Mechanism: Anti-inflammatory and analgesic effects without the adverse effects associated with corticosteroids. Inhibition of prostaglandin synthesis. Blocks cyclooxygenase (COX) 1 and 2.

Therapeutic Effects

  • Treatment of mild pain and fever
  • Decreases pain and inflammation caused by arthritis or spondylitis

Administration

  • PO or IV/IM (ketorolac)
  • Assess pain before and after
  • Take with food or milk if upset stomach
  • Stay well hydrated
    • Absorption: GI
    • Metabolism: Liver
    • Excretion: Kidneys

Indications

  • Pain and inflammation related to arthritis
  • Mild to moderate pain
  • Pain from primary dysmenorrhea
  • Fever reduction

Contraindications

  • Allergy to NSAIDs or salicylate; or sulfonamides (celecoxib)
  • CV, renal, or liver dysfunction.
  • Peptic ulcer or known GI bleed
  • Thrombotic events
  • Pregnancy or lactation.
  • Drug-drug interactions:
    • Loop diuretics
    • Beta-blockers
    • Lithium toxicity (ibuprofen)
    • anticoagulants
    • ethanol ingestion

Side Effects

  • CNS: headache, dizziness, fatigue
  • CV: HTN, CVS events, heart failure, edema (Celecoxib)
  • GI: nausea, dyspepsia, GI pain, constipation, diarrhea,
  • Hema: bleeding (GI, gums), platelet inhibition,
  • Steven Johnson syndrome
  • Ketorolac: Abnormal taste
  • SAFETY: If overdose, implement gastric lavage.

Nursing Considerations

  • Assess for allergies, S&S of GI bleed, skin rash, renal function, Liver function.
  • Use drug only as suggested; avoid overdose.
  • Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision, black or tarry stools.
Clinical Reasoning and Decision-Making Activity 10.6eImage of lightbulb in a circle

A client has been prescribed celecoxib for their arthritic pain.

What client teaching does the nurse plan to provide?

Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.

  1. Frandsen, G. & Pennington S. (2018). Abrams’ clinical drug: Rationales for nursing practice (11th ed.). (pg.305, 310, 952-953, 959-960) Wolters Kluwer. ↵
  2. RNPedia. (2021). Acetaminophen nursing considerations and management. https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/acetaminophen-n-acetyl-p-aminophenol/ ↵
  3. Vallerand, A., & Sanoski, C. A. (2019). Davis’s Drug Guide for Nurses (16th ed.). F.A. Davis Company. ↵
  4. uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
  5. This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
  6. McCuiston, L., E., Vuljoin-DiMaggio, K., Winton, M., B., & Yeager, J. (2018) Pharmacology: A patient centered nursing process approach. (pp. 268-270, 324, 332) Elsevier. ↵
  7. This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
  8. uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
  9. uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
  10. Health Canada. (2016). Summary Safety Review - Celecoxib - Assessing the Risk of Serious Heart and Stroke Side Effects at High Doses Relative to Other Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/safety-reviews/summary-safety-review-celebrex-generics-assessing-risk-serious-heart-stroke-high-doses.html ↵
  11. uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
  12. This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵

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Fundamentals of Nursing Pharmacology - 1st Canadian Edition Copyright © 2023 by Chippewa Valley Technical College; Amanda Egert; Kimberly Lee; and Manu Gill is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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