{"id":455,"date":"2019-12-01T20:17:10","date_gmt":"2019-12-01T20:17:10","guid":{"rendered":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/chapter\/10-6-non-opioid-analgesics\/"},"modified":"2021-12-07T11:31:03","modified_gmt":"2021-12-07T11:31:03","slug":"10-6-non-opioid-analgesics","status":"publish","type":"chapter","link":"https:\/\/pressbooks.publishdot.com\/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\">\n\nNon-opioid analgesics include acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDS).\n<h2>Acetaminophen<\/h2>\n<strong>Mechanism of Action<\/strong>\n\nAcetaminophen 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]<\/sup>\n\n<strong>Indications for Use<\/strong>\n\nAcetaminophen is used to treat mild pain and fever; however, it does not have anti-inflammatory properties.\n\n<strong>Nursing Considerations Across the Lifespan<\/strong>\n\nAcetaminophen is safe for all ages and can be administered using various routes.\n\nGeriatric populations should not exceed 3000 mg in 24 hours, and chronic alcoholics should not exceed 2000 mg in 24 hours due to the risk for hepatoxicity.\n\n<strong>Adverse\/Side Effects<\/strong>\n\nAdverse effects include skin reddening, blisters, rash, and hepatotoxicity.\n\nSevere liver damage may occur if a patient:\n<ul>\n \t<li>takes more than 4,000 mg of acetaminophen in 24 hours (3200 mg for geriatric adults, 2000 mg for chronic alcoholics)<\/li>\n \t<li>takes with other drugs containing acetaminophen<\/li>\n \t<li>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><\/li>\n<\/ul>\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. 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 patient and could cause liver damage.\n\nIf overdose occurs, the antidote is acetylcysteine.\n\n<strong>Patient Teaching &amp; Education<\/strong>\n\nMedications should be taken as directed and the dosing schedule should be adhered to appropriately.\u00a0 Patients should not take the medication for greater than 10 days.\u00a0 Additionally, patients should avoid taking alcohol while using these medications.\u00a0 If a rash occurs, this should be reported to the healthcare provider and the medication should be promptly stopped.\u00a0 Use of medications may interfere with blood glucose monitoring.\u00a0 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>\n\nNow let\u2019s take a closer look at the medication grid on acetaminophen in Table 10.6a.<sup>[footnote]Vallerand, A., &amp; Sanoski, C. A. (2019). <em>Davis\u2019s Drug Guide for Nurses<\/em> (16th ed.). F.A. Davis Company. [\/footnote],[footnote]Drugs.com [Internet]. <em>Aspirin<\/em>; \u00a9 2000-2019 [updated 1 December 28; cited 20 November 2019]. <a href=\"https:\/\/www.drugs.com\/aspirin.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.drugs.com\/aspirin.html<\/a>[\/footnote]',footnote]Centers for Disease Control and Prevention. (2019, August 28). <em>Opioid overdose, CDC guideline for prescribing opioids for chronic pain.<\/em> <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/prescribing\/guideline.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/drugoverdose\/prescribing\/guideline.html<\/a>[\/footnote]<\/sup> Medication grids are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below. Detailed information on a specific medication can be found for free at Daily Med at <a class=\"rId28\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/index.cfm\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/dailymed.nlm.nih.gov\/dailymed\/index.cfm<\/a>. On the home page, enter the drug name in the search bar to read more about the medication.\u00a0 Prototype\/generic medications listed in the grids below are also hyperlinked directly to a Daily Med page.\n\nTable 10.6a Acetaminophen Medication Grid\n<table class=\"grid\">\n<tbody>\n<tr class=\"a-R\">\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 80px\" scope=\"col\"><strong>Class\/<\/strong>\n\n<strong>Subclass<\/strong><\/th>\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 115.556px\" scope=\"col\"><strong>Prototype-<\/strong>\n\n<strong>generic<\/strong><\/th>\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 340.444px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 247.111px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 191.111px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr class=\"a-R\">\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 80px\" scope=\"row\"><strong>Nonopioid analgesic<\/strong>\n\n<strong>Antipyretic<\/strong><\/th>\n<td class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 115.556px\"><a class=\"rId34\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=9f7cca9d-4230-49d7-b805-a1fbc73e31c9\" target=\"_blank\" rel=\"noopener noreferrer\">acetaminophen<\/a><\/td>\n<td class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 340.444px\">Can be given orally, rectally, and IV\n\nAssess pain prior to and after administration\n\nAdminister with a full glass of water\n\nMaximum dose over 24-hour period:\n\n-4000 mg for adults,\n\n-3200 mg for geriatric patients\n\n-2000 mg for patients with chronic alcoholism<\/td>\n<td class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 247.111px\">Relief of mild pain and fever<\/td>\n<td class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 191.111px\">Skin reddening\n\nBlisters\n\nRash\n\nHepatic failure (liver damage)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n&nbsp;\n\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6a\n<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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\nYour patient is admitted to the hospital with acute liver failure due to acetaminophen toxicity. Your patient 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.\n\nWhat patient education about acetaminophen should be provided?\n\nNote: Answers to the Critical Thinking activities can be found in the \"Answer Key\" sections at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.6-non-opioid-analgesics\">\n<h2>Nonsteroidal Antiinflammatories (NSAIDs)<\/h2>\nNonsteroidal antiinflammatories have an analgesic effect, as well as antipyretic and antiinflammatory 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.<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>\n<h3>Aspirin<\/h3>\n<strong>Mechanism of Action<\/strong>\n\nAspirin produces analgesia and reduces inflammation and fever by inhibiting the production of prostaglandins. It also decreases platelet aggregation.\n\n<strong>Indications for Use<\/strong>\n\nAspirin 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.\n\n<strong>Nursing Considerations Across the Lifespan<\/strong>\n\nAspirin is safe for adults and children older than 12 years of age.\n\n<strong>Adverse\/Side Effects<\/strong>\n\nAdverse effects include GI upset, GI bleed, and tinnitus (ringing of the ears).\n\nAllergy alert: Aspirin may cause a severe allergic reaction, which may include:\n<ul>\n \t<li>hives<\/li>\n \t<li>facial swelling<\/li>\n \t<li>shock<\/li>\n \t<li>asthma (wheezing)<\/li>\n<\/ul>\nStomach bleeding warning: This product contains an NSAID, which may cause severe stomach bleeding. The chance for bleeding is higher if a patient:\n<ul>\n \t<li>takes a higher dose or takes it for a longer time than directed<\/li>\n \t<li>takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)<\/li>\n \t<li>has had stomach ulcers or bleeding problems<\/li>\n \t<li>takes a blood thinning (anticoagulant) or steroid drug<\/li>\n \t<li>is age 60 or older<\/li>\n \t<li>has 3 or more alcoholic drinks every day while using this product<\/li>\n<\/ul>\nAspirin is contraindicated if the patient has a bleeding disorder such as hemophilia or a recent history of bleeding in the stomach or intestine.\n\n<strong>Patient Teaching &amp; Education<\/strong>\n\nPatients should avoid concurrent use of alcohol while taking medication to avoid gastric irritation.\u00a0 Additionally, they should report tinnitus, unusual bleeding, or fever lasting greater than 3 days to the healthcare provider.\n\n<strong>Black Box Warning<\/strong>\n\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.\n\nNow let\u2019s take a closer look at the medication grid on aspirin in Table 10.6b.<sup>[footnote]Frandsen, G. &amp; Pennington S. (2018).\u00a0<em>Abrams\u2019 clinical drug: Rationales for nursing practice<\/em> (11th ed.). (pg.305, 310, 952-953, 959-960) Wolters Kluwer.[\/footnote],[footnote]Vallerand, A. &amp; Sanoski, C. A. (2019). <em>Davis\u2019s Drug Guide for Nurse (<\/em>16th ed.). F.A. Davis Company.[\/footnote],[footnote]Drugs.com [Internet]. <em>Aspirin<\/em>; \u00a9 2000-2019 [; updated 1 December 28; cited 20 November 2019].\u00a0<a href=\"https:\/\/www.drugs.com\/aspirin.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.drugs.com\/aspirin.html<\/a>[\/footnote],[footnote]Centers for Disease Control and Prevention. (2019, August 28). <em>Opioid overdose, CDC guideline for prescribing opioids for chronic pain<\/em>. https:\/\/www.cdc.gov\/drugoverdose\/prescribing\/guideline.html.[\/footnote]<\/sup>\n<h5>Table 10.6b Aspirin Medication Grid<\/h5>\n<table class=\"grid\">\n<tbody>\n<tr class=\"a0-R\">\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Class\/<\/strong>\n\n<strong>Subclass<\/strong><\/th>\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Prototype-<\/strong>\n\n<strong>generic<\/strong><\/th>\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 383.111px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 274.667px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 224.889px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr class=\"a0-R\">\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"row\"><strong>Nonopioid analgesic<\/strong>\n\n<strong>(NSAID)<\/strong>\n\n<strong>Antipyretic<\/strong><\/th>\n<td class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\"><a class=\"rId35\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=d4a4321f-17e6-49cd-b2a5-44b9cdf4869c\" target=\"_blank\" rel=\"noopener noreferrer\">aspirin<\/a><\/td>\n<td class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 383.111px\">\n<p style=\"background-color: #ffffff;margin-right: 19pt\">Give orally<\/p>\n<p style=\"background-color: #ffffff;margin-right: 19pt\">Assess pain prior to and after administration<\/p>\n<p style=\"background-color: #ffffff;margin-right: 19pt\">Children under 12 years: do not use unless directed by a provider<\/p>\n<p style=\"background-color: #ffffff;margin-right: 19pt\">Take with a full glass of water and sit upright for 15-30 minutes after administration<\/p>\nTake with food if the patient reports that aspirin upsets their stomach\n\nDo not crush, chew, break, or open an enteric-coated or delayed-release pill; it should be swallowed whole\n\nThe chewable tablet form must be chewed before swallowing\n\nShould be stopped 7 days prior to surgery due to the risk of postoperative bleeding<\/td>\n<td class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 274.667px\">Treatment of mild pain and fever\n\nReduces the risk of heart attack and stroke<\/td>\n<td class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 224.889px\">GI upset\n\nGI bleeding\n\nTinnitus<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 88.3889px\"><\/td>\n<td style=\"width: 89.2778px\"><\/td>\n<td style=\"width: 384.389px\"><\/td>\n<td style=\"width: 275.944px\"><\/td>\n<td style=\"width: 226.167px\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6b\n<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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\nA patient asks why aspirin is given to prevent a heart attack or stroke.\n\nWhat is the nurse\u2019s response?\n\nNote: Answers to the Critical Thinking activities can be found in the \"Answer Key\" sections at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>\n<span style=\"font-size: 1.424em\">Ibuprofen<\/span>\n<div class=\"1.6-non-opioid-analgesics\">\n\n<strong>Mechanism of Action<\/strong>\n\nIbuprofen inhibits prostaglandin synthesis.\n\n<strong>Indications for Use<\/strong>\n\nIbuprofen is used to treat mild to moderate pain and fever, inflammatory disorders including rheumatoid arthritis and osteoarthritis, and pain associated with dysmenorrhea.\n\n<strong>Nursing Considerations Across the Lifespan<\/strong>\n\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.\n\n<strong>Adverse\/Side Effects<\/strong>\n\nAdverse effects include headache, GI bleed, constipation, dyspepsia, nausea, vomiting, Steven-Johnson syndrome, and renal failure.\n\n<strong>Allergy alert:<\/strong> Ibuprofen may cause a severe allergic reaction, especially in people allergic to aspirin. Symptoms may include:\n<ul>\n \t<li>hives<\/li>\n \t<li>facial swelling<\/li>\n \t<li>asthma (wheezing)<\/li>\n \t<li>shock<\/li>\n \t<li>skin reddening<\/li>\n \t<li>rash<\/li>\n \t<li>blisters<\/li>\n<\/ul>\n<strong>Patient Teaching &amp; Education<\/strong>\n\nPatients should consume the medication with a full glass of water and remain upright for 30 minutes following medication administration.\u00a0 They should avoid the use of alcohol while taking this medication.\u00a0 Patients should be advised to not take the medication for longer than 10 days.\u00a0 If the patient 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>\n\n<strong>Stomach bleeding warning:<\/strong>\n\nThis product contains a nonsteroidal anti-inflammatory drug (NSAID), which may cause severe stomach bleeding. The chance for bleeding is higher if the patient:\n<ul>\n \t<li>is age 60 or older<\/li>\n \t<li>has had stomach ulcers or bleeding problems<\/li>\n \t<li>takes a blood thinning (anticoagulant) or steroid drug<\/li>\n \t<li>takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)<\/li>\n \t<li>has 3 or more alcoholic drinks every day while using this product<\/li>\n \t<li>takes more or for a longer time than directed<\/li>\n<\/ul>\n<strong>Heart attack and stroke warning:<\/strong>\n\nAll NSAIDs, except aspirin, increase the risk of heart attack, heart failure, and stroke. These can be fatal. The risk is higher if the patient takes more than is directed or takes it for longer than directed.\n\n<strong>Black Box Warning<\/strong>\n\nIbuprofen is contraindicated for the treatment of perioperative pain after coronary artery bypass graft.\n\nNow let\u2019s take a closer look at the medication grid on ibuprofen in Table 10.6c.<sup>[footnote]Frandsen, G. &amp; Pennington S. (2018).\u00a0<em>Abrams\u2019 clinical drug: Rationales for nursing practice<\/em> (11th ed.). (pg.305, 310, 952-953, 959-960) Wolters Kluwer.[\/footnote],[footnote]Vallerand, A. &amp; Sanoski, C. A. (2019). <em>Davis\u2019s Drug Guide for Nurse\u00a0<\/em>(16th ed.). F.A. Davis Company.[\/footnote]<\/sup>\n\nTable 10.6c Ibuprofen Medication Grid\n<table class=\"grid\">\n<tbody>\n<tr>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Class\/<\/strong>\n\n<strong>Subclass<\/strong><\/th>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Prototype-<\/strong>\n\n<strong>generic<\/strong><\/th>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 385.778px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 278.222px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 200.889px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"row\"><strong>Nonopioid analgesic<\/strong>\n\n<strong>NSAID<\/strong>\n\n<strong>Antipyretic<\/strong><\/th>\n<td style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\"><a class=\"rId36\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=0876ecb7-6b1f-45d8-8a40-6163776d81c3\" target=\"_blank\" rel=\"noopener noreferrer\">ibuprofen<\/a><\/td>\n<td style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 385.778px\">Given parenterally and orally\n\nAssess pain prior to and after administration\n\nMay take with food or milk if stomach upset occurs\n\nStay well hydrated to prevent renal failure\n\nAssess patient for signs of GI bleed\n\nAssess for skin rash\n\nMonitor BUN, serum creatinine, CBC, and liver function test\n\nDo not administer to patients who are allergic to aspirin or other NSAIDs<\/td>\n<td style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 278.222px\">To relieve mild pain and to reduce fever<\/td>\n<td style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 200.889px\">Headache\n\nGI bleed\n\nConstipation\n\nDyspepsia\n\nNausea\n\nVomiting\n\nSteven-Johnson syndrome\n\nRenal failure<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 88.3889px\"><\/td>\n<td style=\"width: 89.2778px\"><\/td>\n<td style=\"width: 387.056px\"><\/td>\n<td style=\"width: 279.5px\"><\/td>\n<td style=\"width: 202.167px\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6c\n<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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\nA patient who is a chronic alcoholic asks if it is okay to take ibuprofen for knee pain.\n\nWhat is the nurse\u2019s best response?\n\nNote: Answers to the Critical Thinking activities can be found in the \"Answer Key\" sections at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.6-non-opioid-analgesics\">\n<h3>Ketorolac<\/h3>\nKetorolac 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.\n\n<strong>Mechanism of Action<\/strong>\n\nKetorolac inhibits prostaglandin synthesis.\n\n<strong>Indications for Use<\/strong>\n\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.\n\n<strong>Nursing Considerations Across the Lifespan<\/strong>\n\nKetorolac is safe for adults. This dose should be reduced for patients ages 65 and over.\n\n<strong>Adverse\/Side Effects<\/strong>\n\nAdverse effects include drowsiness, headache, GI bleed, abnormal taste, dyspepsia, nausea, Steven-Johnson syndrome, edema, and renal failure.\n\n<strong>Patient Teaching &amp; Education<\/strong>\n\nThe use of ketorolac may cause dizziness of drowsiness.\u00a0 Patients should also avoid alcohol or other aspirin-containing products unless directed by their healthcare provider. If the patient 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>\n\n<strong>Gastrointestinal Risk<\/strong>\n\nKetorolac tromethamine (IV form) can cause peptic ulcers, gastrointestinal bleeding, and\/or perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Therefore, ketorolac tromethamine is contraindicated in patients with active peptic ulcer disease, in patients with recent gastrointestinal bleeding or perforation, and in patients with a history of peptic ulcer disease or gastrointestinal bleeding. Elderly patients are at greater risk for serious gastrointestinal events.\n\n<strong>Cardiovascular Thrombotic Events<\/strong>\n\nNonsteroidal 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.\n\nKetorolac tromethamine is contraindicated for patients who have recently received coronary artery bypass graft (CABG) surgery.\n\n<strong>Renal Risk<\/strong>\n\nKetorolac tromethamine is contraindicated in patients with advanced renal impairment and in patients at risk for renal failure due to volume depletion.\n\n<strong>Risk of Bleeding<\/strong>\n\nKetorolac tromethamine inhibits platelet function and is, therefore, contraindicated in patients with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, and a high risk of bleeding. Ketorolac tromethamine is contraindicated as a prophylactic analgesic before any major surgery.\n\n<strong>Hypersensitivity Reactions<\/strong>\n\nHypersensitivity reactions ranging from bronchospasm to anaphylactic shock have occurred and appropriate counteractive measures must be available when administering the first dose of ketorolac. Ketorolac tromethamine is contraindicated in patients with previously demonstrated hypersensitivity to ketorolac tromethamine or who have had allergic manifestations to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).\n\nNow let\u2019s take a closer look at the medication grid on ketorolac in Table 10.6d.<sup>[footnote]Vallerand, A. &amp; Sanoski, C. A. (2019).\u00a0<em>Davis\u2019s Drug Guide for Nurse (<\/em>16th ed.). F.A. Davis Company.[\/footnote],[footnote]This work is a derivative of by Daily Med and the U.S. National Library of Medicine in the public domain[\/footnote]<\/sup>\n\nTable 10.6d Ketorolac Medication Grid\n<table class=\"grid\">\n<tbody>\n<tr class=\"a2-R\">\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Class\/<\/strong>\n\n<strong>Subclass<\/strong><\/th>\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 89.7778px\" scope=\"col\"><strong>Prototype-<\/strong>\n\n<strong>generic<\/strong><\/th>\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 406.222px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 221.333px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 232px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr class=\"a2-R\">\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"row\"><strong>Nonopioid analgesic<\/strong>\n\n<strong>NSAID<\/strong><\/th>\n<td class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 89.7778px\"><a class=\"rId37\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=8accbb78-fc64-45d5-69b0-35c23a1d2a2e\" target=\"_blank\" rel=\"noopener noreferrer\">ketorolac<\/a><\/td>\n<td class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 406.222px\">Given orally, parenterally and as an ophthalmic solution\n\nAssess pain prior to and after administration\n\nTherapy should always be given initially by the IM or IV route; then use the oral route as a continuation of parenteral therapy\n\nStay well hydrated to prevent renal failure\n\nAssess patient for signs of GI bleed\n\nAssess for skin rash\n\nMonitor BUN, serum creatinine, CBC, and liver function tests\n\nDo not administer before any major surgery\n\nDo not administer to patients who are allergic to aspirin or other NSAIDs<\/td>\n<td class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 221.333px\">To relieve moderate pain short term (not to exceed 5 days)<\/td>\n<td class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 232px\">Drowsiness\n\nHeadache\n\nGI bleed\n\nAbnormal taste\n\nDyspepsia\n\nNausea\n\nSteven-Johnson syndrome\n\nEdema\n\nRenal failure<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 88.3889px\"><\/td>\n<td style=\"width: 91.0556px\"><\/td>\n<td style=\"width: 407.5px\"><\/td>\n<td style=\"width: 222.611px\"><\/td>\n<td style=\"width: 233.278px\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6d\n<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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\nKetorolac IV was administered to a patient for severe pain (rated as \u201c8\u201d) due to a back injury.\n\nWhen should the effectiveness of the medication be evaluated?\n\nNote: Answers to the Critical Thinking activities can be found in the \"Answer Key\" sections at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.6-non-opioid-analgesics\">\n<h3>Celecoxib<\/h3>\nCelecoxib is a COX-2 inhibitor.\n\n<strong>Mechanism of Action<\/strong>\n\nCelecoxib specifically inhibits the enzyme COX-2 that is required for the synthesis of prostaglandins.\n\n<strong>Indications for Use<\/strong>\n\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.\n\n<strong>Nursing Considerations Across the Lifespan<\/strong>\n\nCelecoxib is safe for children 2 years or older. Dosage adjustment is required for patients with hepatic impairment (see Black Box Warning).\n\n<strong>Adverse\/Side Effects<\/strong>\n\nAdverse effects include hypertension, peripheral edema, increased liver enzymes, abdominal pain, dyspepsia, gastroesophageal reflux disease, vomiting, and diarrhea.\n\nThere are Black Box Warnings for increased risk of cardiovascular (CV) events and gastrointestinal bleeding, ulceration, and perforation. See more information about each condition below.\n\n<strong>Patient Teaching &amp; Education<\/strong>\n\nPatients should take medication as directed and use the lowest effective dose for the shortest period of time.\u00a0 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>\n<p style=\"margin-left: 0pt\"><strong>Cardiovascular Thrombotic Events<\/strong><\/p>\nNonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in the treatment and may increase with duration of use. Celecoxib capsules are contraindicated in patients who have recently received coronary artery bypass graft (CABG) surgery.\n\n<strong>Gastrointestinal Bleeding, Ulceration, and Perforation<\/strong>\n<p style=\"margin-right: 18pt\">NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and\/or GI bleeding are at greater risk for serious (GI) events.<\/p>\nNow let\u2019s take a closer look at the medication grid on celecoxib in Table 10.6e.<sup>[footnote]Vallerand, A. &amp; Sanoski, C. A. (2019).\u00a0<em>Davis\u2019s Drug Guide for Nurse (<\/em>16th ed.). F.A. Davis Company.[\/footnote],[footnote]This work is a derivative of by Daily Med and the U.S. National Library of Medicine in the public domain[\/footnote]<\/sup>\n\nTable 10.6e Celecoxib Medication Grid\n<table class=\"grid\">\n<tbody>\n<tr class=\"a3-R\">\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 67.5556px\" scope=\"col\"><strong>Class\/<\/strong>\n\n<strong>Subclass<\/strong><\/th>\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 83.5556px\" scope=\"col\"><strong>Prototype-<\/strong>\n\n<strong>generic<\/strong><\/th>\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 420.444px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 254.222px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 233.778px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr class=\"a3-R\">\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 67.5556px\" scope=\"col\"><strong>NSAIDs<\/strong>\n\n<strong>COX-2 inhibitor<\/strong><\/th>\n<td class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 83.5556px\"><a class=\"rId38\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=27d813ea-7798-09cb-734b-b970d7248f1f\" target=\"_blank\" rel=\"noopener noreferrer\">celecoxib<\/a><\/td>\n<td class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 420.444px\">May be given with or without food\n\nMay sprinkle capsules on applesauce and ingest immediately with water\n\nMonitor patients for signs and symptoms of Steven-Johnson syndrome\n\nMonitor for signs and symptoms of GI bleed, hypertension, and heart failure\n\nMonitor liver enzymes<\/td>\n<td class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 254.222px\">To decrease pain and inflammation caused by arthritis or spondylitis<\/td>\n<td class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 233.778px\">Hypertension\n\nPeripheral edema\n\nIncreased liver enzymes\n\nAbdominal pain, dyspepsia, gastroesophageal reflux disease, vomiting, and diarrhea\n\nCardiovascular thrombotic events\n\nGI bleeding, ulceration and perforation\n\nHepatotoxicity\n\nHypertension\n\nHeart failure and edema\n\nRenal toxicity and hyperkalemia\n\nAnaphylactic reactions\n\nSerious skin reactions\n\nHematologic toxicity<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 67.9444px\"><\/td>\n<td style=\"width: 84.8333px\"><\/td>\n<td style=\"width: 421.722px\"><\/td>\n<td style=\"width: 255.5px\"><\/td>\n<td style=\"width: 235.056px\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6e\n<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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\nA patient has been prescribed celecoxib for their arthritic pain.\n\nWhat patient teaching does the nurse plan to provide?\n\nNote: Answers to the Critical Thinking activities can be found in the \"Answer Key\" sections at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>","rendered":"<div class=\"1.6-non-opioid-analgesics\">\n<p>Non-opioid analgesics include acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDS).<\/p>\n<h2>Acetaminophen<\/h2>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>Acetaminophen 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-455-1\" href=\"#footnote-455-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/sup><\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>Acetaminophen is used to treat mild pain and fever; 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.<\/p>\n<p>Geriatric populations should not exceed 3000 mg in 24 hours, and chronic alcoholics should not exceed 2000 mg in 24 hours due to the risk for hepatoxicity.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Adverse effects include skin reddening, blisters, rash, and hepatotoxicity.<\/p>\n<p>Severe liver damage may occur if a patient:<\/p>\n<ul>\n<li>takes more than 4,000 mg of acetaminophen in 24 hours (3200 mg for geriatric adults, 2000 mg for chronic alcoholics)<\/li>\n<li>takes with other drugs containing acetaminophen<\/li>\n<li>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-455-2\" href=\"#footnote-455-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/sup><\/li>\n<\/ul>\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. 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 patient and could cause liver damage.<\/p>\n<p>If overdose occurs, the antidote is acetylcysteine.<\/p>\n<p><strong>Patient Teaching &amp; Education<\/strong><\/p>\n<p>Medications should be taken as directed and the dosing schedule should be adhered to appropriately.\u00a0 Patients should not take the medication for greater than 10 days.\u00a0 Additionally, patients should avoid taking alcohol while using these medications.\u00a0 If a rash occurs, this should be reported to the healthcare provider and the medication should be promptly stopped.\u00a0 Use of medications may interfere with blood glucose monitoring.\u00a0 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-455-3\" href=\"#footnote-455-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/sup><\/p>\n<p>Now let\u2019s take a closer look at the medication grid on acetaminophen in Table 10.6a.<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-455-4\" href=\"#footnote-455-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a>,<a class=\"footnote\" title=\"Drugs.com [Internet]. Aspirin; \u00a9 2000-2019 [updated 1 December 28; cited 20 November 2019]. https:\/\/www.drugs.com\/aspirin.html\" id=\"return-footnote-455-5\" href=\"#footnote-455-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a>&#8216;,footnote]Centers for Disease Control and Prevention. (2019, August 28). <em>Opioid overdose, CDC guideline for prescribing opioids for chronic pain.<\/em> <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/prescribing\/guideline.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/drugoverdose\/prescribing\/guideline.html<\/a>[\/footnote]<\/sup> Medication grids are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below. Detailed information on a specific medication can be found for free at Daily Med at <a class=\"rId28\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/index.cfm\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/dailymed.nlm.nih.gov\/dailymed\/index.cfm<\/a>. On the home page, enter the drug name in the search bar to read more about the medication.\u00a0 Prototype\/generic medications listed in the grids below are also hyperlinked directly to a Daily Med page.<\/p>\n<p>Table 10.6a Acetaminophen Medication Grid<\/p>\n<table class=\"grid\">\n<tbody>\n<tr class=\"a-R\">\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 80px\" scope=\"col\"><strong>Class\/<\/strong><\/p>\n<p><strong>Subclass<\/strong><\/th>\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 115.556px\" scope=\"col\"><strong>Prototype-<\/strong><\/p>\n<p><strong>generic<\/strong><\/th>\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 340.444px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 247.111px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 191.111px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr class=\"a-R\">\n<th class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 80px\" scope=\"row\"><strong>Nonopioid analgesic<\/strong><\/p>\n<p><strong>Antipyretic<\/strong><\/th>\n<td class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 115.556px\"><a class=\"rId34\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=9f7cca9d-4230-49d7-b805-a1fbc73e31c9\" target=\"_blank\" rel=\"noopener noreferrer\">acetaminophen<\/a><\/td>\n<td class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 340.444px\">Can be given orally, rectally, and IV<\/p>\n<p>Assess pain prior to and after administration<\/p>\n<p>Administer with a full glass of water<\/p>\n<p>Maximum dose over 24-hour period:<\/p>\n<p>-4000 mg for adults,<\/p>\n<p>-3200 mg for geriatric patients<\/p>\n<p>-2000 mg for patients with chronic alcoholism<\/td>\n<td class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 247.111px\">Relief of mild pain and fever<\/td>\n<td class=\"a-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 191.111px\">Skin reddening<\/p>\n<p>Blisters<\/p>\n<p>Rash<\/p>\n<p>Hepatic failure (liver damage)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6a<br \/>\n<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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 patient is admitted to the hospital with acute liver failure due to acetaminophen toxicity. Your patient 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 patient education about acetaminophen should be provided?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;Answer Key&#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>Nonsteroidal Antiinflammatories (NSAIDs)<\/h2>\n<p>Nonsteroidal antiinflammatories have an analgesic effect, as well as antipyretic and antiinflammatory 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.<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-455-6\" href=\"#footnote-455-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/sup><\/p>\n<h3>Aspirin<\/h3>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>Aspirin produces analgesia and reduces inflammation and fever by inhibiting the production of prostaglandins. It also decreases platelet aggregation.<\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>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.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>Aspirin is safe for adults and children older than 12 years of age.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Adverse effects include GI upset, GI bleed, and tinnitus (ringing of the ears).<\/p>\n<p>Allergy alert: Aspirin 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 patient:<\/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>Aspirin is contraindicated if the patient has a bleeding disorder such as hemophilia or a recent history of bleeding in the stomach or intestine.<\/p>\n<p><strong>Patient Teaching &amp; Education<\/strong><\/p>\n<p>Patients should avoid concurrent use of alcohol while taking medication to avoid gastric irritation.\u00a0 Additionally, they should report tinnitus, unusual bleeding, or fever lasting greater than 3 days to the healthcare provider.<\/p>\n<p><strong>Black Box 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\u2019s take a closer look at the medication grid on aspirin in Table 10.6b.<sup><a class=\"footnote\" title=\"Frandsen, G. &amp; Pennington S. (2018).\u00a0Abrams\u2019 clinical drug: Rationales for nursing practice (11th ed.). (pg.305, 310, 952-953, 959-960) Wolters Kluwer.\" id=\"return-footnote-455-7\" href=\"#footnote-455-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a>,<a class=\"footnote\" title=\"Vallerand, A. &amp; Sanoski, C. A. (2019). Davis\u2019s Drug Guide for Nurse (16th ed.). F.A. Davis Company.\" id=\"return-footnote-455-8\" href=\"#footnote-455-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a>,<a class=\"footnote\" title=\"Drugs.com [Internet]. Aspirin; \u00a9 2000-2019 [; updated 1 December 28; cited 20 November 2019].\u00a0https:\/\/www.drugs.com\/aspirin.html\" id=\"return-footnote-455-9\" href=\"#footnote-455-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a>,<a class=\"footnote\" title=\"Centers for Disease Control and Prevention. (2019, August 28). Opioid overdose, CDC guideline for prescribing opioids for chronic pain. https:\/\/www.cdc.gov\/drugoverdose\/prescribing\/guideline.html.\" id=\"return-footnote-455-10\" href=\"#footnote-455-10\" aria-label=\"Footnote 10\"><sup class=\"footnote\">[10]<\/sup><\/a><\/sup><\/p>\n<h5>Table 10.6b Aspirin Medication Grid<\/h5>\n<table class=\"grid\">\n<tbody>\n<tr class=\"a0-R\">\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Class\/<\/strong><\/p>\n<p><strong>Subclass<\/strong><\/th>\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Prototype-<\/strong><\/p>\n<p><strong>generic<\/strong><\/th>\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 383.111px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 274.667px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 224.889px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr class=\"a0-R\">\n<th class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"row\"><strong>Nonopioid analgesic<\/strong><\/p>\n<p><strong>(NSAID)<\/strong><\/p>\n<p><strong>Antipyretic<\/strong><\/th>\n<td class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\"><a class=\"rId35\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=d4a4321f-17e6-49cd-b2a5-44b9cdf4869c\" target=\"_blank\" rel=\"noopener noreferrer\">aspirin<\/a><\/td>\n<td class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 383.111px\">\n<p style=\"background-color: #ffffff;margin-right: 19pt\">Give orally<\/p>\n<p style=\"background-color: #ffffff;margin-right: 19pt\">Assess pain prior to and after administration<\/p>\n<p style=\"background-color: #ffffff;margin-right: 19pt\">Children under 12 years: do not use unless directed by a provider<\/p>\n<p style=\"background-color: #ffffff;margin-right: 19pt\">Take with a full glass of water and sit upright for 15-30 minutes after administration<\/p>\n<p>Take with food if the patient reports that aspirin upsets their stomach<\/p>\n<p>Do not crush, chew, break, or open an enteric-coated or delayed-release pill; it should be swallowed whole<\/p>\n<p>The chewable tablet form must be chewed before swallowing<\/p>\n<p>Should be stopped 7 days prior to surgery due to the risk of postoperative bleeding<\/td>\n<td class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 274.667px\">Treatment of mild pain and fever<\/p>\n<p>Reduces the risk of heart attack and stroke<\/td>\n<td class=\"a0-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 224.889px\">GI upset<\/p>\n<p>GI bleeding<\/p>\n<p>Tinnitus<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 88.3889px\"><\/td>\n<td style=\"width: 89.2778px\"><\/td>\n<td style=\"width: 384.389px\"><\/td>\n<td style=\"width: 275.944px\"><\/td>\n<td style=\"width: 226.167px\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6b<br \/>\n<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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 patient 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;Answer Key&#8221; sections at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<p><span style=\"font-size: 1.424em\">Ibuprofen<\/span><\/p>\n<div class=\"1.6-non-opioid-analgesics\">\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>Ibuprofen 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><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Adverse effects include headache, GI bleed, constipation, dyspepsia, nausea, vomiting, Steven-Johnson syndrome, and renal failure.<\/p>\n<p><strong>Allergy alert:<\/strong> 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><strong>Patient Teaching &amp; Education<\/strong><\/p>\n<p>Patients should consume the medication with a full glass of water and remain upright for 30 minutes following medication administration.\u00a0 They should avoid the use of alcohol while taking this medication.\u00a0 Patients should be advised to not take the medication for longer than 10 days.\u00a0 If the patient 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-455-11\" href=\"#footnote-455-11\" aria-label=\"Footnote 11\"><sup class=\"footnote\">[11]<\/sup><\/a><\/sup><\/p>\n<p><strong>Stomach bleeding warning:<\/strong><\/p>\n<p>This product contains a nonsteroidal anti-inflammatory drug (NSAID), which may cause severe stomach bleeding. The chance for bleeding is higher if the patient:<\/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><strong>Heart attack and stroke warning:<\/strong><\/p>\n<p>All NSAIDs, except aspirin, increase the risk of heart attack, heart failure, and stroke. These can be fatal. The risk is higher if the patient takes more than is directed or takes it for longer than directed.<\/p>\n<p><strong>Black Box Warning<\/strong><\/p>\n<p>Ibuprofen is contraindicated for the treatment of perioperative pain after coronary artery bypass graft.<\/p>\n<p>Now let\u2019s take a closer look at the medication grid on ibuprofen in Table 10.6c.<sup><a class=\"footnote\" title=\"Frandsen, G. &amp; Pennington S. (2018).\u00a0Abrams\u2019 clinical drug: Rationales for nursing practice (11th ed.). (pg.305, 310, 952-953, 959-960) Wolters Kluwer.\" id=\"return-footnote-455-12\" href=\"#footnote-455-12\" aria-label=\"Footnote 12\"><sup class=\"footnote\">[12]<\/sup><\/a>,<a class=\"footnote\" title=\"Vallerand, A. &amp; Sanoski, C. A. (2019). Davis\u2019s Drug Guide for Nurse\u00a0(16th ed.). F.A. Davis Company.\" id=\"return-footnote-455-13\" href=\"#footnote-455-13\" aria-label=\"Footnote 13\"><sup class=\"footnote\">[13]<\/sup><\/a><\/sup><\/p>\n<p>Table 10.6c Ibuprofen Medication Grid<\/p>\n<table class=\"grid\">\n<tbody>\n<tr>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Class\/<\/strong><\/p>\n<p><strong>Subclass<\/strong><\/th>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Prototype-<\/strong><\/p>\n<p><strong>generic<\/strong><\/th>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 385.778px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 278.222px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 200.889px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr>\n<th style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"row\"><strong>Nonopioid analgesic<\/strong><\/p>\n<p><strong>NSAID<\/strong><\/p>\n<p><strong>Antipyretic<\/strong><\/th>\n<td style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\"><a class=\"rId36\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=0876ecb7-6b1f-45d8-8a40-6163776d81c3\" target=\"_blank\" rel=\"noopener noreferrer\">ibuprofen<\/a><\/td>\n<td style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 385.778px\">Given parenterally and orally<\/p>\n<p>Assess pain prior to and after administration<\/p>\n<p>May take with food or milk if stomach upset occurs<\/p>\n<p>Stay well hydrated to prevent renal failure<\/p>\n<p>Assess patient for signs of GI bleed<\/p>\n<p>Assess for skin rash<\/p>\n<p>Monitor BUN, serum creatinine, CBC, and liver function test<\/p>\n<p>Do not administer to patients who are allergic to aspirin or other NSAIDs<\/td>\n<td style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 278.222px\">To relieve mild pain and to reduce fever<\/td>\n<td style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 200.889px\">Headache<\/p>\n<p>GI bleed<\/p>\n<p>Constipation<\/p>\n<p>Dyspepsia<\/p>\n<p>Nausea<\/p>\n<p>Vomiting<\/p>\n<p>Steven-Johnson syndrome<\/p>\n<p>Renal failure<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 88.3889px\"><\/td>\n<td style=\"width: 89.2778px\"><\/td>\n<td style=\"width: 387.056px\"><\/td>\n<td style=\"width: 279.5px\"><\/td>\n<td style=\"width: 202.167px\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6c<br \/>\n<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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 patient 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;Answer Key&#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>Ketorolac 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.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>Ketorolac is safe for adults. This dose should be reduced for patients ages 65 and over.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Adverse effects include drowsiness, headache, GI bleed, abnormal taste, dyspepsia, nausea, Steven-Johnson syndrome, edema, and renal failure.<\/p>\n<p><strong>Patient Teaching &amp; Education<\/strong><\/p>\n<p>The use of ketorolac may cause dizziness of drowsiness.\u00a0 Patients should also avoid alcohol or other aspirin-containing products unless directed by their healthcare provider. If the patient 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-455-14\" href=\"#footnote-455-14\" aria-label=\"Footnote 14\"><sup class=\"footnote\">[14]<\/sup><\/a><\/sup><\/p>\n<p><strong>Gastrointestinal Risk<\/strong><\/p>\n<p>Ketorolac tromethamine (IV form) can cause peptic ulcers, gastrointestinal bleeding, and\/or perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Therefore, ketorolac tromethamine is contraindicated in patients with active peptic ulcer disease, in patients with recent gastrointestinal bleeding or perforation, and in patients with a history of peptic ulcer disease or gastrointestinal bleeding. Elderly patients are at greater risk for serious gastrointestinal events.<\/p>\n<p><strong>Cardiovascular Thrombotic Events<\/strong><\/p>\n<p>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.<\/p>\n<p>Ketorolac tromethamine is contraindicated for patients who have recently received coronary artery bypass graft (CABG) surgery.<\/p>\n<p><strong>Renal Risk<\/strong><\/p>\n<p>Ketorolac tromethamine is contraindicated in patients with advanced renal impairment and in patients at risk for renal failure due to volume depletion.<\/p>\n<p><strong>Risk of Bleeding<\/strong><\/p>\n<p>Ketorolac tromethamine inhibits platelet function and is, therefore, contraindicated in patients with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, and a high risk of bleeding. Ketorolac tromethamine is contraindicated as a prophylactic analgesic before any major surgery.<\/p>\n<p><strong>Hypersensitivity Reactions<\/strong><\/p>\n<p>Hypersensitivity reactions ranging from bronchospasm to anaphylactic shock have occurred and appropriate counteractive measures must be available when administering the first dose of ketorolac. Ketorolac tromethamine is contraindicated in patients with previously demonstrated hypersensitivity to ketorolac tromethamine or who have had allergic manifestations to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).<\/p>\n<p>Now let\u2019s take a closer look at the medication grid on ketorolac in Table 10.6d.<sup><a class=\"footnote\" title=\"Vallerand, A. &amp; Sanoski, C. A. (2019).\u00a0Davis\u2019s Drug Guide for Nurse (16th ed.). F.A. Davis Company.\" id=\"return-footnote-455-15\" href=\"#footnote-455-15\" aria-label=\"Footnote 15\"><sup class=\"footnote\">[15]<\/sup><\/a>,<a class=\"footnote\" title=\"This work is a derivative of by Daily Med and the U.S. National Library of Medicine in the public domain\" id=\"return-footnote-455-16\" href=\"#footnote-455-16\" aria-label=\"Footnote 16\"><sup class=\"footnote\">[16]<\/sup><\/a><\/sup><\/p>\n<p>Table 10.6d Ketorolac Medication Grid<\/p>\n<table class=\"grid\">\n<tbody>\n<tr class=\"a2-R\">\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"col\"><strong>Class\/<\/strong><\/p>\n<p><strong>Subclass<\/strong><\/th>\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 89.7778px\" scope=\"col\"><strong>Prototype-<\/strong><\/p>\n<p><strong>generic<\/strong><\/th>\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 406.222px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 221.333px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 232px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr class=\"a2-R\">\n<th class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 88px\" scope=\"row\"><strong>Nonopioid analgesic<\/strong><\/p>\n<p><strong>NSAID<\/strong><\/th>\n<td class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 89.7778px\"><a class=\"rId37\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=8accbb78-fc64-45d5-69b0-35c23a1d2a2e\" target=\"_blank\" rel=\"noopener noreferrer\">ketorolac<\/a><\/td>\n<td class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 406.222px\">Given orally, parenterally and as an ophthalmic solution<\/p>\n<p>Assess pain prior to and after administration<\/p>\n<p>Therapy should always be given initially by the IM or IV route; then use the oral route as a continuation of parenteral therapy<\/p>\n<p>Stay well hydrated to prevent renal failure<\/p>\n<p>Assess patient for signs of GI bleed<\/p>\n<p>Assess for skin rash<\/p>\n<p>Monitor BUN, serum creatinine, CBC, and liver function tests<\/p>\n<p>Do not administer before any major surgery<\/p>\n<p>Do not administer to patients who are allergic to aspirin or other NSAIDs<\/td>\n<td class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 221.333px\">To relieve moderate pain short term (not to exceed 5 days)<\/td>\n<td class=\"a2-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 232px\">Drowsiness<\/p>\n<p>Headache<\/p>\n<p>GI bleed<\/p>\n<p>Abnormal taste<\/p>\n<p>Dyspepsia<\/p>\n<p>Nausea<\/p>\n<p>Steven-Johnson syndrome<\/p>\n<p>Edema<\/p>\n<p>Renal failure<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 88.3889px\"><\/td>\n<td style=\"width: 91.0556px\"><\/td>\n<td style=\"width: 407.5px\"><\/td>\n<td style=\"width: 222.611px\"><\/td>\n<td style=\"width: 233.278px\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6d<br \/>\n<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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 patient 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;Answer Key&#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>Celecoxib 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 safe for children 2 years or older. Dosage adjustment is required for patients with hepatic impairment (see Black Box Warning).<\/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. See more information about each condition below.<\/p>\n<p><strong>Patient Teaching &amp; Education<\/strong><\/p>\n<p>Patients should take medication as directed and use the lowest effective dose for the shortest period of time.\u00a0 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-455-17\" href=\"#footnote-455-17\" aria-label=\"Footnote 17\"><sup class=\"footnote\">[17]<\/sup><\/a><\/sup><\/p>\n<p style=\"margin-left: 0pt\"><strong>Cardiovascular Thrombotic Events<\/strong><\/p>\n<p>Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in the treatment and may increase with duration of use. Celecoxib capsules are contraindicated in patients who have recently received coronary artery bypass graft (CABG) surgery.<\/p>\n<p><strong>Gastrointestinal Bleeding, Ulceration, and Perforation<\/strong><\/p>\n<p style=\"margin-right: 18pt\">NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and\/or GI bleeding are at greater risk for serious (GI) events.<\/p>\n<p>Now let\u2019s take a closer look at the medication grid on celecoxib in Table 10.6e.<sup><a class=\"footnote\" title=\"Vallerand, A. &amp; Sanoski, C. A. (2019).\u00a0Davis\u2019s Drug Guide for Nurse (16th ed.). F.A. Davis Company.\" id=\"return-footnote-455-18\" href=\"#footnote-455-18\" aria-label=\"Footnote 18\"><sup class=\"footnote\">[18]<\/sup><\/a>,<a class=\"footnote\" title=\"This work is a derivative of by Daily Med and the U.S. National Library of Medicine in the public domain\" id=\"return-footnote-455-19\" href=\"#footnote-455-19\" aria-label=\"Footnote 19\"><sup class=\"footnote\">[19]<\/sup><\/a><\/sup><\/p>\n<p>Table 10.6e Celecoxib Medication Grid<\/p>\n<table class=\"grid\">\n<tbody>\n<tr class=\"a3-R\">\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 67.5556px\" scope=\"col\"><strong>Class\/<\/strong><\/p>\n<p><strong>Subclass<\/strong><\/th>\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 83.5556px\" scope=\"col\"><strong>Prototype-<\/strong><\/p>\n<p><strong>generic<\/strong><\/th>\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 420.444px\" scope=\"col\"><strong>Administration <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 254.222px\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 233.778px\" scope=\"col\"><strong>Adverse\/Side Effects<\/strong><\/th>\n<\/tr>\n<tr class=\"a3-R\">\n<th class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 67.5556px\" scope=\"col\"><strong>NSAIDs<\/strong><\/p>\n<p><strong>COX-2 inhibitor<\/strong><\/th>\n<td class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 83.5556px\"><a class=\"rId38\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=27d813ea-7798-09cb-734b-b970d7248f1f\" target=\"_blank\" rel=\"noopener noreferrer\">celecoxib<\/a><\/td>\n<td class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 420.444px\">May be given with or without food<\/p>\n<p>May sprinkle capsules on applesauce and ingest immediately with water<\/p>\n<p>Monitor patients for signs and symptoms of Steven-Johnson syndrome<\/p>\n<p>Monitor for signs and symptoms of GI bleed, hypertension, and heart failure<\/p>\n<p>Monitor liver enzymes<\/td>\n<td class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 254.222px\">To decrease pain and inflammation caused by arthritis or spondylitis<\/td>\n<td class=\"a3-C\" style=\"background-color: transparent;padding: 5pt;border: 1pt solid #000000;width: 233.778px\">Hypertension<\/p>\n<p>Peripheral edema<\/p>\n<p>Increased liver enzymes<\/p>\n<p>Abdominal pain, dyspepsia, gastroesophageal reflux disease, vomiting, and diarrhea<\/p>\n<p>Cardiovascular thrombotic events<\/p>\n<p>GI bleeding, ulceration and perforation<\/p>\n<p>Hepatotoxicity<\/p>\n<p>Hypertension<\/p>\n<p>Heart failure and edema<\/p>\n<p>Renal toxicity and hyperkalemia<\/p>\n<p>Anaphylactic reactions<\/p>\n<p>Serious skin reactions<\/p>\n<p>Hematologic toxicity<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 67.9444px\"><\/td>\n<td style=\"width: 84.8333px\"><\/td>\n<td style=\"width: 421.722px\"><\/td>\n<td style=\"width: 255.5px\"><\/td>\n<td style=\"width: 235.056px\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.6e<br \/>\n<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-content\/uploads\/sites\/5\/2019\/12\/ORN-Icons_lightbulb-300x300-2.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 patient has been prescribed celecoxib for their arthritic pain.<\/p>\n<p>What patient teaching does the nurse plan to provide?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;Answer Key&#8221; sections at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-455-1\">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-455-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-455-2\">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-455-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-455-3\">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-455-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-455-4\">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-455-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-455-5\">Drugs.com [Internet]. <em>Aspirin<\/em>; \u00a9 2000-2019 [updated 1 December 28; cited 20 November 2019]. <a href=\"https:\/\/www.drugs.com\/aspirin.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.drugs.com\/aspirin.html<\/a> <a href=\"#return-footnote-455-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-455-6\">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-455-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-455-7\">Frandsen, G. &amp; Pennington S. (2018).\u00a0<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-455-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-455-8\">Vallerand, A. &amp; Sanoski, C. A. (2019). <em>Davis\u2019s Drug Guide for Nurse (<\/em>16th ed.). F.A. Davis Company. <a href=\"#return-footnote-455-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-455-9\">Drugs.com [Internet]. <em>Aspirin<\/em>; \u00a9 2000-2019 [; updated 1 December 28; cited 20 November 2019].\u00a0<a href=\"https:\/\/www.drugs.com\/aspirin.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.drugs.com\/aspirin.html<\/a> <a href=\"#return-footnote-455-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><li id=\"footnote-455-10\">Centers for Disease Control and Prevention. (2019, August 28). <em>Opioid overdose, CDC guideline for prescribing opioids for chronic pain<\/em>. https:\/\/www.cdc.gov\/drugoverdose\/prescribing\/guideline.html. <a href=\"#return-footnote-455-10\" class=\"return-footnote\" aria-label=\"Return to footnote 10\">&crarr;<\/a><\/li><li id=\"footnote-455-11\">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-455-11\" class=\"return-footnote\" aria-label=\"Return to footnote 11\">&crarr;<\/a><\/li><li id=\"footnote-455-12\">Frandsen, G. &amp; Pennington S. (2018).\u00a0<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-455-12\" class=\"return-footnote\" aria-label=\"Return to footnote 12\">&crarr;<\/a><\/li><li id=\"footnote-455-13\">Vallerand, A. &amp; Sanoski, C. A. (2019). <em>Davis\u2019s Drug Guide for Nurse\u00a0<\/em>(16th ed.). F.A. Davis Company. <a href=\"#return-footnote-455-13\" class=\"return-footnote\" aria-label=\"Return to footnote 13\">&crarr;<\/a><\/li><li id=\"footnote-455-14\">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-455-14\" class=\"return-footnote\" aria-label=\"Return to footnote 14\">&crarr;<\/a><\/li><li id=\"footnote-455-15\">Vallerand, A. &amp; Sanoski, C. A. (2019).\u00a0<em>Davis\u2019s Drug Guide for Nurse (<\/em>16th ed.). F.A. Davis Company. <a href=\"#return-footnote-455-15\" class=\"return-footnote\" aria-label=\"Return to footnote 15\">&crarr;<\/a><\/li><li id=\"footnote-455-16\">This work is a derivative of by Daily Med and the U.S. National Library of Medicine in the public domain <a href=\"#return-footnote-455-16\" class=\"return-footnote\" aria-label=\"Return to footnote 16\">&crarr;<\/a><\/li><li id=\"footnote-455-17\">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-455-17\" class=\"return-footnote\" aria-label=\"Return to footnote 17\">&crarr;<\/a><\/li><li id=\"footnote-455-18\">Vallerand, A. &amp; Sanoski, C. A. (2019).\u00a0<em>Davis\u2019s Drug Guide for Nurse (<\/em>16th ed.). F.A. Davis Company. <a href=\"#return-footnote-455-18\" class=\"return-footnote\" aria-label=\"Return to footnote 18\">&crarr;<\/a><\/li><li id=\"footnote-455-19\">This work is a derivative of by Daily Med and the U.S. National Library of Medicine in the public domain <a href=\"#return-footnote-455-19\" class=\"return-footnote\" aria-label=\"Return to footnote 19\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":2,"menu_order":6,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by"},"chapter-type":[49],"contributor":[],"license":[53],"class_list":["post-455","chapter","type-chapter","status-publish","hentry","chapter-type-numberless","license-cc-by"],"part":436,"_links":{"self":[{"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/455","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/wp\/v2\/users\/2"}],"version-history":[{"count":1,"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/455\/revisions"}],"predecessor-version":[{"id":456,"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/455\/revisions\/456"}],"part":[{"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/pressbooks\/v2\/parts\/436"}],"metadata":[{"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/455\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/wp\/v2\/media?parent=455"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapter-type?post=455"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/wp\/v2\/contributor?post=455"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/wp-json\/wp\/v2\/license?post=455"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}