10.6 Nonopioid Analgesics
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 client 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 client and could cause liver damage.
If overdose occurs, the antidote is acetylcysteine.
Health Teaching & Health Promotion: Medications should be taken as directed and the dosing schedule should be adhered to appropriately. Clients should not take the medication for greater than ten days. Additionally, clients 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 39.5º 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 medications. 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
| Class/Subclass | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| Nonopioid Analgesic Antipyretic |
acetaminophen | Can be given orally, rectally, and IV
Assess pain prior to and after administration Administer with a full glass of water Maximum dose over 24-hour period: -4,000 mg for adults -3,200 mg for geriatric clients -2,000 mg for clients with chronic alcoholism |
Relief of mild pain and fever | Skin reddening
Blisters Rash Hepatic failure (liver damage) |
Critical Thinking Activity 10.6a
A client is admitted to the hospital with acute liver failure due to acetaminophen toxicity. The client reveals 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 health teaching about acetaminophen should be provided?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
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 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 three or more alcoholic drinks every day while using this product
Aspirin is contraindicated if the client has a bleeding disorder such as hemophilia or a recent history of bleeding in the stomach or intestine.
Health Teaching & Health Promotion: Clients 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
| Class/Subclass</th | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| Nonopioid Analgesic (NSAID) Antipyretic | aspirin |
Give orally Assess pain prior to and after administration Children under 12 years: Do not use unless directed by a provider Take with a full glass of water and sit upright for 15-30 minutes after administration Take with food if the client reports that aspirin upsets their stomach Do not crush, chew, break, or open an enteric-coated or delayed-release pill; it should be swallowed whole The chewable tablet form must be chewed before swallowing Should be stopped seven days prior to surgery due to the risk of postoperative bleeding |
Treatment of mild pain and fever
Reduces the risk of heart attack and stroke |
GI upset
GI bleeding Tinnitus |
Critical Thinking Activity 10.6b
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” section at the end of the book.
Ibuprofen
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 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 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 client 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.
Health Teaching & Health Promotion: 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 ten days. If the client 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
| Class/Subclass | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| Nonopioid Analgesic NSAID Antipyretic | ibuprofen | Given parenterally and orally
Assess pain prior to and after administration May take with food or milk if stomach upset occurs Stay well-hydrated to prevent renal failure Assess client for signs of GI bleed Assess for skin rash Monitor BUN, serum creatinine, CBC, and liver function test Do not administer to clients who are allergic to aspirin or other NSAIDs |
To relieve mild pain and to reduce fever | Headache
GI bleed Constipation Dyspepsia Nausea Vomiting Steven-Johnson syndrome Renal failure |
Critical Thinking Activity 10.6c
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” section 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: 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 clients 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 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 duration of use.
Ketorolac tromethamine is contraindicated for clients who have recently received coronary artery bypass graft (CABG) surgery.
Renal Risk: Ketorolac tromethamine is contraindicated in clients with advanced renal impairment and in clients at risk for renal failure due to volume depletion.
Risk of Bleeding: Ketorolac tromethamine 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 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 clients with previously demonstrated hypersensitivity to ketorolac tromethamine or who have had allergic manifestations to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).
Health Teaching & Health Promotion: The use of ketorolac may cause dizziness of drowsiness. Clients should also avoid alcohol or other aspirin-containing products unless directed by their health care provider. If the client 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
| Class/Subclass | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| Nonopioid Analgesic NSAID | ketorolac | Given orally, parenterally, and as an ophthalmic solution
Assess pain prior to and after administration Therapy should always be given initially by the IM or IV route; then use the oral route as a continuation of parenteral therapy Stay well-hydrated to prevent renal failure Assess for signs of GI bleeding Assess for skin rash Monitor BUN, serum creatinine, CBC, and liver function tests Do not administer before any major surgery Do not administer to clients who are allergic to aspirin or other NSAIDs |
To relieve moderate pain short-term (not to exceed five days) | Drowsiness
Headache GI bleed Abnormal taste Dyspepsia Nausea Steven-Johnson syndrome Edema Renal failure |
Critical Thinking Activity 10.6d
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” section 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: 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 clients 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 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.
Health Teaching & Health Promotion: 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 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
| Class/Subclass | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| NSAIDs COX-2 Inhibitor | celecoxib | May be given with or without food
May sprinkle capsules on applesauce and ingest immediately with water Monitor clients for signs and symptoms of Steven-Johnson syndrome Monitor for signs and symptoms of GI bleed, hypertension, and heart failure Monitor liver enzymes. Boxed Warning for dosage adjustment for hepatic impairment Boxed Warnings for increased risk of cardiovascular (CV) events and gastrointestinal bleeding, ulceration, and perforation |
To decrease pain and inflammation caused by arthritis or spondylitis | Hypertension
Peripheral edema Increased liver enzymes Abdominal pain, dyspepsia, gastroesophageal reflux disease, vomiting, and diarrhea Cardiovascular thrombotic events GI bleeding, ulceration and perforation Hepatotoxicity Hypertension Heart failure and edema Renal toxicity and hyperkalemia Anaphylactic reactions Serious skin reactions Hematologic toxicity |
Critical Thinking Activity 10.6e
A client has been prescribed celecoxib for their arthritic pain.
What patient teaching does the nurse plan to provide?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
Test your knowledge with this NCLEX Next Generation style bowtie question: Acetaminophen.
- Frandsen, G., & Pennington S. (2018). Abrams’ clinical drug: Rationales for nursing practice (11th ed.). pp. 305, 310, 952-953, 959-960. Wolters Kluwer. ↵
- Vallerand, A., & Sanoski, C. A. (2019). Davis’s drug guide for nurses (16th ed.). F. A. Davis Company. ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- 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. ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
