{"id":422,"date":"2019-12-01T20:17:10","date_gmt":"2019-12-02T01:17:10","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/10-6-non-opioid-analgesics\/"},"modified":"2022-03-31T18:35:51","modified_gmt":"2022-03-31T22:35:51","slug":"10-6-non-opioid-analgesics","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/10-6-non-opioid-analgesics\/","title":{"raw":"10.6 Non-Opioid Analgesics","rendered":"10.6 Non-Opioid Analgesics"},"content":{"raw":"<div class=\"1.6-non-opioid-analgesics\">\r\n\r\nNon-opioid analgesics include acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS).\r\n<h3>Acetaminophen<\/h3>\r\n<strong>Mechanism of Action<\/strong>\r\n\r\nThe mechanism of <a href=\"http:\/\/openmd.com\">Acetaminophen<\/a> is still somewhat unknown. However, it inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever primarily in the CNS.<sup>[footnote]Frandsen, G. &amp; Pennington S. (2018). <em>Abrams\u2019 clinical drug: Rationales for nursing practice<\/em> (11th ed.). (pg.305, 310, 952-953, 959-960) Wolters Kluwer.[\/footnote].\u00a0<\/sup>Acetaminophen is not an anti-inflammatory agent.<sup>[footnote]RNPedia. (2021). Acetaminophen nursing considerations and management.\u00a0<a href=\"https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/acetaminophen-n-acetyl-p-aminophenol\/\">https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/acetaminophen-n-acetyl-p-aminophenol\/<\/a>[\/footnote]<\/sup>\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nAcetaminophen 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.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nAcetaminophen is safe for all ages and can be administered using various routes. There are <a href=\"https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/acetaminophen-n-acetyl-p-aminophenol\/\">special dosing considerations for pediatric and older adults <\/a>due to the risk for hepatotoxicity.\r\n\r\nOlder 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.\r\n\r\n<strong>Adverse\/Side Effects<\/strong>\r\n\r\nAdverse effects include\r\n<ul>\r\n \t<li>Skin reddening<\/li>\r\n \t<li>Hypersensitivity: Rash, fever<\/li>\r\n \t<li>Hepatic failure (liver damage)<\/li>\r\n \t<li>Renal damage<\/li>\r\n<\/ul>\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title\"><span style=\"color: #ffffff;\">Example: Safety with Acetaminophen\u00a0<\/span><\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nSome medications are combined with acetaminophen and are prescribed \u201cas needed,\u201d so the nurse must calculate the cumulative dose of acetaminophen over the previous 24-hour period.\r\n\r\nFor 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.\r\n\r\n<\/div>\r\n<\/div>\r\nIf an overdose occurs, the antidote is acetylcysteine.\r\n\r\n<strong>Client Teaching and Education<\/strong>\r\n\r\nMedications 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.<sup>[footnote]Vallerand, A., &amp; Sanoski, C. A. (2019). <em>Davis\u2019s Drug Guide for Nurses<\/em> (16th ed.). F.A. Davis Company.[\/footnote]<\/sup>\u00a0If 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.<sup>[footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\r\n<div class=\"1.5-cns-depressants-\">\r\n\r\nNow let's take a closer look at the medication grid for acetaminophen in Table 10.6a.<sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. [\/footnote]<\/sup>\r\n\r\n<\/div>\r\nMedication 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.\u00a0 Prototype or generic medication examples are also hyperlinked to a free resource at <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/index.cfm\">Daily Med<\/a>. On the home page, enter the drug name in the search bar to read more about the medication.\r\n\r\n<span style=\"text-align: initial; font-size: 14pt;\">Table 10.6a <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=c26f1872-ebff-4164-bf64-4272df43a2db\">Acetaminophen<\/a>\u00a0medication card.<sup>[footnote]RNPedia. (2021). <a href=\"https:\/\/www.rnpedia.com\">https:\/\/www.rnpedia.com<\/a>[\/footnote][footnote]DailyMed from US National Library of Medicine. www.dailymed.com[\/footnote][footnote]OpenMD.Com (2021). www.openmd.com[\/footnote][footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote][\/footnote]\u00a0<\/sup><\/span>\r\n\r\n<img class=\"alignnone size-full wp-image-2360\" src=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen.png\" alt=\"\" width=\"2484\" height=\"828\" \/>\r\n\r\n<\/div>\r\n<div class=\"__UNKNOWN__\">\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2>Clinical Reasoning and Decision-Making Activity 10.6a<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\" style=\"text-align: left;\">\r\n\r\nYour 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 \u201cfew\u201d beers.\r\n\r\nWhat client education about acetaminophen should be provided?\r\n\r\nNote: Answers to the Critical Thinking activities can be found in the \"<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>\" sections at the end of the book.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<div class=\"1.6-non-opioid-analgesics\">\r\n<h2>Non-steroidal Anti-inflammatories (NSAIDs)<\/h2>\r\nNon-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.\r\n\r\nhttps:\/\/www.youtube.com\/watch?v=qhiMmNZjHRg\r\n\r\n&nbsp;\r\n\r\nThis section will discuss ASA, ibuprofen, ketorolac, and celecoxib.<sup>[footnote]McCuiston, L., E., Vuljoin-DiMaggio, K., Winton, M., B., &amp; Yeager, J. (2018) <em>Pharmacology: A patient centered nursing process approach<\/em>. (pp. 268-270, 324, 332) Elsevier.[\/footnote]<\/sup>\r\n<h3>Acetylsalicylic Acid<\/h3>\r\n<strong>Mechanism of Action<\/strong>\r\n\r\n<a href=\"http:\/\/openmd.com\">Acetylsalicylic acid<\/a> (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.\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nAspirin 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.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nASA 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.\r\n\r\n<\/div>\r\n<div class=\"1.6-non-opioid-analgesics\">\r\n\r\nOlder adults are more susceptible to negative GI and CNS effects of anti-inflammatories.\r\n\r\n<strong>Adverse\/Side Effects<\/strong>\r\n\r\nASA 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:\r\n<ul>\r\n \t<li>hives<\/li>\r\n \t<li>facial swelling<\/li>\r\n \t<li>shock<\/li>\r\n \t<li>asthma (wheezing)<\/li>\r\n<\/ul>\r\nStomach bleeding warning: this product contains an NSAID, which may cause severe stomach bleeding. The chance for bleeding is higher if a client:\r\n<ul>\r\n \t<li>takes a higher dose or takes it for a longer time than directed<\/li>\r\n \t<li>takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)<\/li>\r\n \t<li>has had stomach ulcers or bleeding problems<\/li>\r\n \t<li>takes a blood-thinning (anticoagulant) or steroid drug<\/li>\r\n \t<li>is age 60 or older<\/li>\r\n \t<li>has 3 or more alcoholic drinks every day while using this product<\/li>\r\n<\/ul>\r\nASA is contraindicated if the client has a bleeding disorder such as hemophilia or a recent history of bleeding in the stomach or intestine.\r\n\r\n<strong>Client Teaching &amp; Education<\/strong>\r\n\r\nClients 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.\r\n\r\n<strong>Safety Warning<\/strong>\r\n\r\nChildren or teenagers should not take aspirin to treat chickenpox or flu-like symptoms because of the risk of Reye\u2019s 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.\r\n\r\nNow let's take a closer look at the medication grid for ASA in Table 10.6b.<sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. [\/footnote]<\/sup>\r\n\r\n<span style=\"text-align: initial; font-size: 14pt;\">Table 10.6a <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=baf5a1ba-14a7-4e0d-ba0c-a34c4befd8ae\">ASA<\/a>\u00a0medication card.<sup>[footnote]RNPedia. (2021). <a href=\"https:\/\/www.rnpedia.com\">https:\/\/www.rnpedia.com<\/a>[\/footnote][footnote]DailyMed from US National Library of Medicine. www.dailymed.com[\/footnote][footnote]OpenMD.Com (2021). www.openmd.com[\/footnote][footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote][\/footnote]\u00a0<\/sup><\/span>\r\n\r\n<img class=\"alignnone size-full wp-image-2361\" src=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid.png\" alt=\"\" width=\"2484\" height=\"1004\" \/>\r\n\r\n<\/div>\r\n<div class=\"__UNKNOWN__\">\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2>Clinical Reasoning and Decision-Making Activity 10.6b<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\" style=\"text-align: left;\">\r\n\r\nA client asks why aspirin is given to prevent a heart attack or stroke.\r\n\r\nWhat is the nurse\u2019s response?\r\n\r\nNote: Answers to the Critical Thinking activities can be found in the \"<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>\" sections at the end of the book.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<div class=\"1.6-non-opioid-analgesics\">\r\n<h3>Ibuprofen<\/h3>\r\n<strong>Mechanism of Action<\/strong>\r\n\r\n<a href=\"http:\/\/openmd.com\">Ibuprofen<\/a> is an NSAID that inhibits prostaglandin synthesis.\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nIbuprofen is used to treat mild to moderate pain and fever, inflammatory disorders including rheumatoid arthritis and osteoarthritis, and pain associated with dysmenorrhea.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nIbuprofen 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.\r\n\r\nOlder adults are more susceptible to negative side-effects of anti-inflammatories.\r\n\r\n<strong>Adverse\/Side Effects<\/strong>\r\n\r\nAdverse effects include headache, GI bleed, constipation, dyspepsia, nausea, vomiting, Stevens-Johnson syndrome, and renal failure.\r\n\r\nAllergy alert: Ibuprofen may cause a severe allergic reaction, especially in people allergic to aspirin. Symptoms may include:\r\n<ul>\r\n \t<li>hives<\/li>\r\n \t<li>facial swelling<\/li>\r\n \t<li>asthma (wheezing)<\/li>\r\n \t<li>shock<\/li>\r\n \t<li>skin reddening<\/li>\r\n \t<li>rash<\/li>\r\n \t<li>blisters<\/li>\r\n<\/ul>\r\nStomach 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:\r\n<ul>\r\n \t<li>is age 60 or older<\/li>\r\n \t<li>has had stomach ulcers or bleeding problems<\/li>\r\n \t<li>takes a blood-thinning (anticoagulant) or steroid drug<\/li>\r\n \t<li>takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)<\/li>\r\n \t<li>has 3 or more alcoholic drinks every day while using this product<\/li>\r\n \t<li>takes more or for a longer time than directed<\/li>\r\n<\/ul>\r\nHeart 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.\r\n\r\n<strong>Client Teaching &amp; Education<\/strong>\r\n\r\nClients 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.<sup>[footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\r\n\r\n<strong>Safety Warning<\/strong>\r\n\r\nIbuprofen is contraindicated for the treatment of peri-operative pain after coronary artery bypass graft.\r\n\r\nTable 10.6c provides a medication card for various types of NSAIDs, including ibuprofen.\r\n\r\n<\/div>\r\n<div class=\"__UNKNOWN__\">\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2>Clinical Reasoning and Decision-Making Activity 10.6c<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\" style=\"text-align: left;\">\r\n\r\nA client who is a chronic alcoholic asks if it is okay to take ibuprofen for knee pain.\r\n\r\nWhat is the nurse\u2019s best response?\r\n\r\nNote: Answers to the Critical Thinking activities can be found in the \"<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>\" sections at the end of the book.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<div class=\"1.6-non-opioid-analgesics\">\r\n<h3>Ketorolac<\/h3>\r\n<a href=\"http:\/\/openmd.com\">Ketorolac<\/a> is an NSAID that is commonly used to treat \u201cbreakthrough\u201d pain that occurs during the treatment of severe acute pain being treated with opioids.\r\n\r\n<strong>Mechanism of Action<\/strong>\r\n\r\nKetorolac inhibits prostaglandin synthesis.\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nKetorolac 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.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nKetorolac 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.\r\n\r\n<strong>Adverse\/Side Effects<\/strong>\r\n\r\nAdverse effects include drowsiness, headache, GI bleed, abnormal taste, dyspepsia, nausea, Stevens-Johnson syndrome, edema, and renal failure.\r\n\r\n<\/div>\r\nGastrointestinal 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.\r\n\r\nCardiovascular 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.\r\n\r\nRenal Risk: Ketorolac is contraindicated in clients with advanced renal impairment and in clients at risk for renal failure due to volume depletion.\r\n\r\nRisk 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.\r\n\r\nHypersensitivity 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).\r\n<div class=\"1.6-non-opioid-analgesics\">\r\n\r\n<strong>Client Teaching &amp; Education<\/strong>\r\n\r\nThe 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.<sup>[footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\r\n\r\nTable 10.6c provides a medication card for various types of NSAIDs, including ketorolac.\r\n\r\n<\/div>\r\n<div class=\"__UNKNOWN__\">\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2>Clinical Reasoning and Decision-Making Activity 10.d<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\" style=\"text-align: left;\">\r\n\r\nKetorolac IV was administered to a client for severe pain (rated as \u201c8\u201d) due to a back injury.\r\n\r\nWhen should the effectiveness of the medication be evaluated?\r\n\r\nNote: Answers to the Critical Thinking activities can be found in the \"<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>\" sections at the end of the book.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<div class=\"1.6-non-opioid-analgesics\">\r\n<h3>Celecoxib<\/h3>\r\n<a href=\"http:\/\/openmd.com\">Celecoxib<\/a> is a COX-2 inhibitor.\r\n\r\n<strong>Mechanism of Action<\/strong>\r\n\r\nCelecoxib specifically inhibits the enzyme COX-2 that is required for the synthesis of prostaglandins.\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nCelecoxib is used to treat the pain associated with osteoarthritis, rheumatoid arthritis (including juvenile), and ankylosing spondylitis. It also relieves the pain associated with dysmenorrhea.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nCelecoxib 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.\r\n\r\nOlder adults are more susceptible to negative side-effects of anti-inflammatories.\r\n\r\n<strong>Adverse\/Side Effects<\/strong>\r\n\r\nAdverse effects include hypertension, peripheral edema, increased liver enzymes, abdominal pain, dyspepsia, gastroesophageal reflux disease, vomiting, and diarrhea.\r\n\r\nThere 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.[footnote]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 [\/footnote]\r\n\r\nSee more information about each condition below.\r\n\r\n<\/div>\r\n<p style=\"margin-left: 0pt;\">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\u00a0who have recently received coronary artery bypass graft (CABG) surgery.<\/p>\r\nGastrointestinal 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.\r\n<div class=\"1.6-non-opioid-analgesics\">\r\n\r\n<strong>Client Teaching &amp; Education<\/strong>\r\n\r\nClients 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.<sup>[footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\r\n\r\n<\/div>\r\nNow let's take a closer look at the medication grid for the NSAIDS including ibuprofen, ketorolac, and celecoxib in Table 10.6c.<sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. [\/footnote]<\/sup>\r\n\r\n<span style=\"text-align: initial; font-size: 14pt;\">Table 10.6c NSAID medication card.<sup>[footnote]RNPedia. (2021). <a href=\"https:\/\/www.rnpedia.com\">https:\/\/www.rnpedia.com<\/a>[\/footnote][footnote]DailyMed from US National Library of Medicine. www.dailymed.com[\/footnote][footnote]OpenMD.Com (2021). www.openmd.com[\/footnote][footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote][\/footnote]<\/sup><\/span><a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=e914472b-c785-4c73-b37c-4d459166cf41\">ibuprofen<\/a>,\u00a0<a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=0c2c75c9-ed7b-46a8-9543-429bf2d8f090\">ketorolac<\/a>,\u00a0<a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=457eb10a-1188-4c43-a147-d258517342e8\">celecoxib<\/a>\r\n<div class=\"1.6-non-opioid-analgesics\">\r\n\r\n<img class=\"alignnone size-full wp-image-2366\" src=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs.png\" alt=\"\" width=\"2484\" height=\"1050\" \/>\r\n\r\n<\/div>\r\n<div class=\"__UNKNOWN__\">\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2>Clinical Reasoning and Decision-Making Activity 10.6e<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\" style=\"text-align: left;\">\r\n\r\nA client has been prescribed celecoxib for their arthritic pain.\r\n\r\nWhat client teaching does the nurse plan to provide?\r\n\r\nNote: Answers to the Critical Thinking activities can be found in the \"<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>\" sections at the end of the book.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>","rendered":"<div class=\"1.6-non-opioid-analgesics\">\n<p>Non-opioid analgesics include acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS).<\/p>\n<h3>Acetaminophen<\/h3>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>The mechanism of <a href=\"http:\/\/openmd.com\">Acetaminophen<\/a> is still somewhat unknown. However, it inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever primarily in the CNS.<sup><a class=\"footnote\" title=\"Frandsen, G. &amp; Pennington S. (2018). Abrams\u2019 clinical drug: Rationales for nursing practice (11th ed.). (pg.305, 310, 952-953, 959-960) Wolters Kluwer.\" id=\"return-footnote-422-1\" href=\"#footnote-422-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a>.\u00a0<\/sup>Acetaminophen is not an anti-inflammatory agent.<sup><a class=\"footnote\" title=\"RNPedia. (2021). Acetaminophen nursing considerations and management.\u00a0https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/acetaminophen-n-acetyl-p-aminophenol\/\" id=\"return-footnote-422-2\" href=\"#footnote-422-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/sup><\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>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.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>Acetaminophen is safe for all ages and can be administered using various routes. There are <a href=\"https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/acetaminophen-n-acetyl-p-aminophenol\/\">special dosing considerations for pediatric and older adults <\/a>due to the risk for hepatotoxicity.<\/p>\n<p>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.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Adverse effects include<\/p>\n<ul>\n<li>Skin reddening<\/li>\n<li>Hypersensitivity: Rash, fever<\/li>\n<li>Hepatic failure (liver damage)<\/li>\n<li>Renal damage<\/li>\n<\/ul>\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title\"><span style=\"color: #ffffff;\">Example: Safety with Acetaminophen\u00a0<\/span><\/p>\n<\/header>\n<div class=\"textbox__content\">\n<p>Some medications are combined with acetaminophen and are prescribed \u201cas needed,\u201d so the nurse must calculate the cumulative dose of acetaminophen over the previous 24-hour period.<\/p>\n<p>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.<\/p>\n<\/div>\n<\/div>\n<p>If an overdose occurs, the antidote is acetylcysteine.<\/p>\n<p><strong>Client Teaching and Education<\/strong><\/p>\n<p>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.<sup><a class=\"footnote\" title=\"Vallerand, A., &amp; Sanoski, C. A. (2019). Davis\u2019s Drug Guide for Nurses (16th ed.). F.A. Davis Company.\" id=\"return-footnote-422-3\" href=\"#footnote-422-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/sup>\u00a0If 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.<sup><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-422-4\" href=\"#footnote-422-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/sup><\/p>\n<div class=\"1.5-cns-depressants-\">\n<p>Now let&#8217;s take a closer look at the medication grid for acetaminophen in Table 10.6a.<sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain.\" id=\"return-footnote-422-5\" href=\"#footnote-422-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a><\/sup><\/p>\n<\/div>\n<p>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.\u00a0 Prototype or generic medication examples are also hyperlinked to a free resource at <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/index.cfm\">Daily Med<\/a>. On the home page, enter the drug name in the search bar to read more about the medication.<\/p>\n<p><span style=\"text-align: initial; font-size: 14pt;\">Table 10.6a <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=c26f1872-ebff-4164-bf64-4272df43a2db\">Acetaminophen<\/a>\u00a0medication card.<sup><a class=\"footnote\" title=\"RNPedia. (2021). https:\/\/www.rnpedia.com\" id=\"return-footnote-422-6\" href=\"#footnote-422-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><a class=\"footnote\" title=\"DailyMed from US National Library of Medicine. www.dailymed.com\" id=\"return-footnote-422-7\" href=\"#footnote-422-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a><a class=\"footnote\" title=\"OpenMD.Com (2021). www.openmd.com\" id=\"return-footnote-422-8\" href=\"#footnote-422-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-422-9\" href=\"#footnote-422-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a>[\/footnote]\u00a0<\/sup><\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-2360\" src=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen.png\" alt=\"\" width=\"2484\" height=\"828\" srcset=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen.png 2484w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen-300x100.png 300w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen-1024x341.png 1024w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen-768x256.png 768w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen-1536x512.png 1536w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen-2048x683.png 2048w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen-65x22.png 65w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen-225x75.png 225w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetaminophen-350x117.png 350w\" sizes=\"auto, (max-width: 2484px) 100vw, 2484px\" \/><\/p>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Clinical Reasoning and Decision-Making Activity 10.6a<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left;\">\n<p>Your 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 \u201cfew\u201d beers.<\/p>\n<p>What client education about acetaminophen should be provided?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>&#8221; sections at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.6-non-opioid-analgesics\">\n<h2>Non-steroidal Anti-inflammatories (NSAIDs)<\/h2>\n<p>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.<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"Pharmacology - Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/qhiMmNZjHRg?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>&nbsp;<\/p>\n<p>This section will discuss ASA, ibuprofen, ketorolac, and celecoxib.<sup><a class=\"footnote\" title=\"McCuiston, L., E., Vuljoin-DiMaggio, K., Winton, M., B., &amp; Yeager, J. (2018) Pharmacology: A patient centered nursing process approach. (pp. 268-270, 324, 332) Elsevier.\" id=\"return-footnote-422-10\" href=\"#footnote-422-10\" aria-label=\"Footnote 10\"><sup class=\"footnote\">[10]<\/sup><\/a><\/sup><\/p>\n<h3>Acetylsalicylic Acid<\/h3>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p><a href=\"http:\/\/openmd.com\">Acetylsalicylic acid<\/a> (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.<\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>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.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>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&#8217;s syndrome. ASA is not considered safe for pregnant or nursing women.<\/p>\n<\/div>\n<div class=\"1.6-non-opioid-analgesics\">\n<p>Older adults are more susceptible to negative GI and CNS effects of anti-inflammatories.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>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:<\/p>\n<ul>\n<li>hives<\/li>\n<li>facial swelling<\/li>\n<li>shock<\/li>\n<li>asthma (wheezing)<\/li>\n<\/ul>\n<p>Stomach bleeding warning: this product contains an NSAID, which may cause severe stomach bleeding. The chance for bleeding is higher if a client:<\/p>\n<ul>\n<li>takes a higher dose or takes it for a longer time than directed<\/li>\n<li>takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)<\/li>\n<li>has had stomach ulcers or bleeding problems<\/li>\n<li>takes a blood-thinning (anticoagulant) or steroid drug<\/li>\n<li>is age 60 or older<\/li>\n<li>has 3 or more alcoholic drinks every day while using this product<\/li>\n<\/ul>\n<p>ASA is contraindicated if the client has a bleeding disorder such as hemophilia or a recent history of bleeding in the stomach or intestine.<\/p>\n<p><strong>Client Teaching &amp; Education<\/strong><\/p>\n<p>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.<\/p>\n<p><strong>Safety Warning<\/strong><\/p>\n<p>Children or teenagers should not take aspirin to treat chickenpox or flu-like symptoms because of the risk of Reye\u2019s Syndrome. Reye&#8217;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.<\/p>\n<p>Now let&#8217;s take a closer look at the medication grid for ASA in Table 10.6b.<sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain.\" id=\"return-footnote-422-11\" href=\"#footnote-422-11\" aria-label=\"Footnote 11\"><sup class=\"footnote\">[11]<\/sup><\/a><\/sup><\/p>\n<p><span style=\"text-align: initial; font-size: 14pt;\">Table 10.6a <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=baf5a1ba-14a7-4e0d-ba0c-a34c4befd8ae\">ASA<\/a>\u00a0medication card.<sup><a class=\"footnote\" title=\"RNPedia. (2021). https:\/\/www.rnpedia.com\" id=\"return-footnote-422-12\" href=\"#footnote-422-12\" aria-label=\"Footnote 12\"><sup class=\"footnote\">[12]<\/sup><\/a><a class=\"footnote\" title=\"DailyMed from US National Library of Medicine. www.dailymed.com\" id=\"return-footnote-422-13\" href=\"#footnote-422-13\" aria-label=\"Footnote 13\"><sup class=\"footnote\">[13]<\/sup><\/a><a class=\"footnote\" title=\"OpenMD.Com (2021). www.openmd.com\" id=\"return-footnote-422-14\" href=\"#footnote-422-14\" aria-label=\"Footnote 14\"><sup class=\"footnote\">[14]<\/sup><\/a><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-422-15\" href=\"#footnote-422-15\" aria-label=\"Footnote 15\"><sup class=\"footnote\">[15]<\/sup><\/a>[\/footnote]\u00a0<\/sup><\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-2361\" src=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid.png\" alt=\"\" width=\"2484\" height=\"1004\" srcset=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid.png 2484w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid-300x121.png 300w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid-1024x414.png 1024w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid-768x310.png 768w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid-1536x621.png 1536w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid-2048x828.png 2048w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid-65x26.png 65w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid-225x91.png 225w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/acetylsalicylic-acid-350x141.png 350w\" sizes=\"auto, (max-width: 2484px) 100vw, 2484px\" \/><\/p>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Clinical Reasoning and Decision-Making Activity 10.6b<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left;\">\n<p>A client asks why aspirin is given to prevent a heart attack or stroke.<\/p>\n<p>What is the nurse\u2019s response?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>&#8221; sections at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.6-non-opioid-analgesics\">\n<h3>Ibuprofen<\/h3>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p><a href=\"http:\/\/openmd.com\">Ibuprofen<\/a> is an NSAID that inhibits prostaglandin synthesis.<\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>Ibuprofen is used to treat mild to moderate pain and fever, inflammatory disorders including rheumatoid arthritis and osteoarthritis, and pain associated with dysmenorrhea.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>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.<\/p>\n<p>Older adults are more susceptible to negative side-effects of anti-inflammatories.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Adverse effects include headache, GI bleed, constipation, dyspepsia, nausea, vomiting, Stevens-Johnson syndrome, and renal failure.<\/p>\n<p>Allergy alert: Ibuprofen may cause a severe allergic reaction, especially in people allergic to aspirin. Symptoms may include:<\/p>\n<ul>\n<li>hives<\/li>\n<li>facial swelling<\/li>\n<li>asthma (wheezing)<\/li>\n<li>shock<\/li>\n<li>skin reddening<\/li>\n<li>rash<\/li>\n<li>blisters<\/li>\n<\/ul>\n<p>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:<\/p>\n<ul>\n<li>is age 60 or older<\/li>\n<li>has had stomach ulcers or bleeding problems<\/li>\n<li>takes a blood-thinning (anticoagulant) or steroid drug<\/li>\n<li>takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)<\/li>\n<li>has 3 or more alcoholic drinks every day while using this product<\/li>\n<li>takes more or for a longer time than directed<\/li>\n<\/ul>\n<p>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.<\/p>\n<p><strong>Client Teaching &amp; Education<\/strong><\/p>\n<p>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.<sup><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-422-16\" href=\"#footnote-422-16\" aria-label=\"Footnote 16\"><sup class=\"footnote\">[16]<\/sup><\/a><\/sup><\/p>\n<p><strong>Safety Warning<\/strong><\/p>\n<p>Ibuprofen is contraindicated for the treatment of peri-operative pain after coronary artery bypass graft.<\/p>\n<p>Table 10.6c provides a medication card for various types of NSAIDs, including ibuprofen.<\/p>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Clinical Reasoning and Decision-Making Activity 10.6c<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left;\">\n<p>A client who is a chronic alcoholic asks if it is okay to take ibuprofen for knee pain.<\/p>\n<p>What is the nurse\u2019s best response?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>&#8221; sections at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.6-non-opioid-analgesics\">\n<h3>Ketorolac<\/h3>\n<p><a href=\"http:\/\/openmd.com\">Ketorolac<\/a> is an NSAID that is commonly used to treat \u201cbreakthrough\u201d pain that occurs during the treatment of severe acute pain being treated with opioids.<\/p>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>Ketorolac inhibits prostaglandin synthesis.<\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>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.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>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.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Adverse effects include drowsiness, headache, GI bleed, abnormal taste, dyspepsia, nausea, Stevens-Johnson syndrome, edema, and renal failure.<\/p>\n<\/div>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>Renal Risk: Ketorolac is contraindicated in clients with advanced renal impairment and in clients at risk for renal failure due to volume depletion.<\/p>\n<p>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.<\/p>\n<p>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).<\/p>\n<div class=\"1.6-non-opioid-analgesics\">\n<p><strong>Client Teaching &amp; Education<\/strong><\/p>\n<p>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.<sup><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-422-17\" href=\"#footnote-422-17\" aria-label=\"Footnote 17\"><sup class=\"footnote\">[17]<\/sup><\/a><\/sup><\/p>\n<p>Table 10.6c provides a medication card for various types of NSAIDs, including ketorolac.<\/p>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Clinical Reasoning and Decision-Making Activity 10.d<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left;\">\n<p>Ketorolac IV was administered to a client for severe pain (rated as \u201c8\u201d) due to a back injury.<\/p>\n<p>When should the effectiveness of the medication be evaluated?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>&#8221; sections at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.6-non-opioid-analgesics\">\n<h3>Celecoxib<\/h3>\n<p><a href=\"http:\/\/openmd.com\">Celecoxib<\/a> is a COX-2 inhibitor.<\/p>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>Celecoxib specifically inhibits the enzyme COX-2 that is required for the synthesis of prostaglandins.<\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>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.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>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.<\/p>\n<p>Older adults are more susceptible to negative side-effects of anti-inflammatories.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Adverse effects include hypertension, peripheral edema, increased liver enzymes, abdominal pain, dyspepsia, gastroesophageal reflux disease, vomiting, and diarrhea.<\/p>\n<p>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.<a class=\"footnote\" title=\"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\" id=\"return-footnote-422-18\" href=\"#footnote-422-18\" aria-label=\"Footnote 18\"><sup class=\"footnote\">[18]<\/sup><\/a><\/p>\n<p>See more information about each condition below.<\/p>\n<\/div>\n<p style=\"margin-left: 0pt;\">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\u00a0who have recently received coronary artery bypass graft (CABG) surgery.<\/p>\n<p>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.<\/p>\n<div class=\"1.6-non-opioid-analgesics\">\n<p><strong>Client Teaching &amp; Education<\/strong><\/p>\n<p>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.<sup><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-422-19\" href=\"#footnote-422-19\" aria-label=\"Footnote 19\"><sup class=\"footnote\">[19]<\/sup><\/a><\/sup><\/p>\n<\/div>\n<p>Now let&#8217;s take a closer look at the medication grid for the NSAIDS including ibuprofen, ketorolac, and celecoxib in Table 10.6c.<sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain.\" id=\"return-footnote-422-20\" href=\"#footnote-422-20\" aria-label=\"Footnote 20\"><sup class=\"footnote\">[20]<\/sup><\/a><\/sup><\/p>\n<p><span style=\"text-align: initial; font-size: 14pt;\">Table 10.6c NSAID medication card.<sup><a class=\"footnote\" title=\"RNPedia. (2021). https:\/\/www.rnpedia.com\" id=\"return-footnote-422-21\" href=\"#footnote-422-21\" aria-label=\"Footnote 21\"><sup class=\"footnote\">[21]<\/sup><\/a><a class=\"footnote\" title=\"DailyMed from US National Library of Medicine. www.dailymed.com\" id=\"return-footnote-422-22\" href=\"#footnote-422-22\" aria-label=\"Footnote 22\"><sup class=\"footnote\">[22]<\/sup><\/a><a class=\"footnote\" title=\"OpenMD.Com (2021). www.openmd.com\" id=\"return-footnote-422-23\" href=\"#footnote-422-23\" aria-label=\"Footnote 23\"><sup class=\"footnote\">[23]<\/sup><\/a><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-422-24\" href=\"#footnote-422-24\" aria-label=\"Footnote 24\"><sup class=\"footnote\">[24]<\/sup><\/a>[\/footnote]<\/sup><\/span><a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=e914472b-c785-4c73-b37c-4d459166cf41\">ibuprofen<\/a>,\u00a0<a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=0c2c75c9-ed7b-46a8-9543-429bf2d8f090\">ketorolac<\/a>,\u00a0<a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=457eb10a-1188-4c43-a147-d258517342e8\">celecoxib<\/a><\/p>\n<div class=\"1.6-non-opioid-analgesics\">\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-2366\" src=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs.png\" alt=\"\" width=\"2484\" height=\"1050\" srcset=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs.png 2484w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs-300x127.png 300w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs-1024x433.png 1024w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs-768x325.png 768w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs-1536x649.png 1536w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs-2048x866.png 2048w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs-65x27.png 65w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs-225x95.png 225w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/12\/NSAIDs-350x148.png 350w\" sizes=\"auto, (max-width: 2484px) 100vw, 2484px\" \/><\/p>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Clinical Reasoning and Decision-Making Activity 10.6e<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left;\">\n<p>A client has been prescribed celecoxib for their arthritic pain.<\/p>\n<p>What client teaching does the nurse plan to provide?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-10\/\">Answer Key<\/a>&#8221; sections at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"media-attributions clear\" prefix:cc=\"http:\/\/creativecommons.org\/ns#\" prefix:dc=\"http:\/\/purl.org\/dc\/terms\/\"><h2>Media Attributions<\/h2><ul><li >acetaminophen       <\/li><li >acetylsalicylic acid       <\/li><li >NSAIDs       <\/li><\/ul><\/div><hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-422-1\">Frandsen, G. &amp; Pennington S. (2018). <em>Abrams\u2019 clinical drug: Rationales for nursing practice<\/em> (11th ed.). (pg.305, 310, 952-953, 959-960) Wolters Kluwer. <a href=\"#return-footnote-422-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-422-2\">RNPedia. (2021). Acetaminophen nursing considerations and management.\u00a0<a href=\"https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/acetaminophen-n-acetyl-p-aminophenol\/\">https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/acetaminophen-n-acetyl-p-aminophenol\/<\/a> <a href=\"#return-footnote-422-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-422-3\">Vallerand, A., &amp; Sanoski, C. A. (2019). <em>Davis\u2019s Drug Guide for Nurses<\/em> (16th ed.). F.A. Davis Company. <a href=\"#return-footnote-422-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-422-4\">uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.unboundmedicine.com\/ucentral<\/a> <a href=\"#return-footnote-422-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-422-5\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>.  <a href=\"#return-footnote-422-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-422-6\">RNPedia. (2021). <a href=\"https:\/\/www.rnpedia.com\">https:\/\/www.rnpedia.com<\/a> <a href=\"#return-footnote-422-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-422-7\">DailyMed from US National Library of Medicine. www.dailymed.com <a href=\"#return-footnote-422-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-422-8\">OpenMD.Com (2021). www.openmd.com <a href=\"#return-footnote-422-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-422-9\">uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a> <a href=\"#return-footnote-422-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><li id=\"footnote-422-10\">McCuiston, L., E., Vuljoin-DiMaggio, K., Winton, M., B., &amp; Yeager, J. (2018) <em>Pharmacology: A patient centered nursing process approach<\/em>. (pp. 268-270, 324, 332) Elsevier. <a href=\"#return-footnote-422-10\" class=\"return-footnote\" aria-label=\"Return to footnote 10\">&crarr;<\/a><\/li><li id=\"footnote-422-11\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>.  <a href=\"#return-footnote-422-11\" class=\"return-footnote\" aria-label=\"Return to footnote 11\">&crarr;<\/a><\/li><li id=\"footnote-422-12\">RNPedia. 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(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  <a href=\"#return-footnote-422-18\" class=\"return-footnote\" aria-label=\"Return to footnote 18\">&crarr;<\/a><\/li><li id=\"footnote-422-19\">uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.unboundmedicine.com\/ucentral<\/a> <a href=\"#return-footnote-422-19\" class=\"return-footnote\" aria-label=\"Return to footnote 19\">&crarr;<\/a><\/li><li id=\"footnote-422-20\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>.  <a href=\"#return-footnote-422-20\" class=\"return-footnote\" aria-label=\"Return to footnote 20\">&crarr;<\/a><\/li><li id=\"footnote-422-21\">RNPedia. (2021). <a href=\"https:\/\/www.rnpedia.com\">https:\/\/www.rnpedia.com<\/a> <a href=\"#return-footnote-422-21\" class=\"return-footnote\" aria-label=\"Return to footnote 21\">&crarr;<\/a><\/li><li id=\"footnote-422-22\">DailyMed from US National Library of Medicine. www.dailymed.com <a href=\"#return-footnote-422-22\" class=\"return-footnote\" aria-label=\"Return to footnote 22\">&crarr;<\/a><\/li><li id=\"footnote-422-23\">OpenMD.Com (2021). www.openmd.com <a href=\"#return-footnote-422-23\" class=\"return-footnote\" aria-label=\"Return to footnote 23\">&crarr;<\/a><\/li><li id=\"footnote-422-24\">uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a> <a href=\"#return-footnote-422-24\" class=\"return-footnote\" aria-label=\"Return to footnote 24\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":103,"menu_order":6,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":["open-resources-for-nursing-open-rn"],"pb_section_license":""},"chapter-type":[48],"contributor":[68],"license":[],"class_list":["post-422","chapter","type-chapter","status-publish","hentry","chapter-type-numberless","contributor-open-resources-for-nursing-open-rn"],"part":405,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/422","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/users\/103"}],"version-history":[{"count":26,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/422\/revisions"}],"predecessor-version":[{"id":2697,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/422\/revisions\/2697"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/parts\/405"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/422\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/media?parent=422"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapter-type?post=422"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/contributor?post=422"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/license?post=422"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}