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INTRODUCTION

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HIGH ALERT

nalbuphine (nal-byoo-feen)

Nubain

Classification

Therapeutic: opioid analgesics

Pharmacologic: opioid agonists/analgesics

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Indications
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Moderate-to-severe pain. Also provides Analgesia during labor, Sedation before surgery, Supplement to balanced anesthesia.

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Action
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Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. In addition, has partial antagonist properties, which may result in opioid withdrawal in physically dependent patients. Therapeutic Effects: Decreased pain.

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Adverse Reactions/Side Effects
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CNS: dizziness, headache, sedation, confusion, dysphoria, euphoria, floating feeling, hallucinations, unusual dreams. EENT: blurred vision, diplopia, miosis (high doses). Resp: respiratory depression. CV: hypertension, orthostatic hypotension, palpitations. GI: dry mouth, nausea, vomiting, constipation, ileus. GU: urinary urgency. Derm: clammy feeling, sweating. Misc: physical dependence, psychologic dependence, tolerance.

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PHYSICAL THERAPY IMPLICATIONS

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Examination and Evaluation
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  • Assess symptoms of respiratory depression, including decreased respiratory rate, confusion, bluish color of the skin and mucous membranes (cyanosis), and difficult, labored breathing (dyspnea). Monitor pulse oximetry and perform pulmonary function tests (See Appendix I) to quantify suspected changes in ventilation and respiratory function. Excessive respiratory depression requires emergency care.

  • Be alert for excessive sedation or changes in mood and behavior (euphoria, dysphoria, confusion, hallucinations). Notify physician or nurse immediately if patient is unconscious or extremely difficult to arouse.

  • Use appropriate pain scales (visual analogue scales, others) to document whether this drug is successful in helping manage the patient's pain.

  • Assess blood pressure (BP) and compare to normal values (See Appendix F). Report a sustained increase in BP (hypertension) or a fall in BP when patient assumes a more upright position (lying to standing, sitting to standing, lying to sitting). Document orthostatic hypotension and contact physician when systolic BP falls >20 mm Hg, or diastolic BP falls >10 mm Hg.

  • Assess dizziness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

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Interventions
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  • Implement appropriate manual therapy techniques, physical agents, and therapeutic exercises to reduce pain and help wean patient off opioid analgesics as soon as possible.

  • Because of the risk of abnormal BP responses, use caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (BP, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

  • Help patient explore other nonpharmacologic methods to reduce chronic pain, such as relaxation techniques, exercise, counseling, and so forth.

  • Guard against falls and trauma (hip fractures, head injury). Implement fall-prevention strategies (See Appendix E), especially if patient exhibits sedation, dizziness, or blurred vision.

  • To minimize orthostatic hypotension, patient should ...

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