Salicylates Nursing Considerations & Management

Anti-inflammatory agents are drugs that block the effects of the inflammatory response. A popular and one of the oldest groups of anti-inflammatory agents is the salicylates.

Salicylates are salicylic acid compounds with anti-inflammatory, antipyretic (fever-blocking), and analgesic (pain-blocking) properties. These drugs are widely available as nonprescription drugs and are relatively nontoxic when used as directed. However, an individual’s response to different salicylates may vary.

Since salicylates are widely available over the counter (OTC), there is potential for abuseand overdosing. These drugs may also block the signs and symptoms of a present illness, contributing to the possibility of misdiagnosis.

Table of Common Drugs and Generic Names

Here is a table of commonly encountered anti-inflammatory agents, their generic names, and brand names:

Disease Spotlight: Diseases with Chronic Inflammatory Response

• The inflammatory response is a nonspecific reaction to any cellular injury and involves the activation of various chemicals and neutrophil activity. It destroys disease-causing microorganisms and promotes healing through a variety of potent chemical mediators. Clinical presentation includes heat (calor), redness (rubor), swelling (tumor), and pain (dolor).
• However, in conditions like neoplasms, viral invasions, autoimmune diseases, and transplanted organ rejections, inflammatory process becomes a chronic condition. In these conditions, damage is increased and inflammatory reactions are more severe.

Therapeutic Action

The desired and beneficial actions of salicylates are as follows:

• It inhibits synthesis of prostaglandin, an inflammatory reaction mediator.
• Antipyretic effect is through blocking of prostaglandin mediator of pyrogens (chemicals released by active white blood cells that cause increase in body temperature) at the thermoregulatory center of the hypothalamus.
• Aspirin at low levels can affect reduce platelet aggregation by inhibiting synthesis of thromboxane A₂, a potent vasoconstrictor that normally increases platelet aggregation and blood clot formation. On the other hand, at higher levels, it inhibits the synthesis of prostacyclin, a vasodilator that inhibits platelet aggregation.

Indications

Salicylates are indicated for the following medical conditions:

• Treatment of mild to moderate pain, fever, numerous inflammatory conditions (e.g., rheumatoid arthritis and osteoarthritis).
• Mesalamine and balsalazide are indicated for ulcerative colitis and other inflammatory bowel conditions in adults.
• Sodium thiosalicylate is used in treatment of arthritis and muscular pain.

Here are some important aspects to remember for indication of anti-inflammatory agents, anti-arthritis, and NSAIDs in different age groups:

Children

• Ensure correct dose because this population is more susceptible to GI and CNS side effects of drugs. Most of these drugs are available over the counter so primary caregivers should be instructed to read the label to find out the dose that they are supposed to give.
• Aspirin and choline magnesium trisalicylate are the salicylates recommended for children. However, they are contraindicated when risks for Reye Syndrome is present.
• Acetaminophen is the most used anti-inflammatory drug for children. Overdose can cause severe hepatotoxicity.
• In general, several NSAIDs are approved for use in children, i.e. ibuprofen, naproxen, tolmetin, meloxicam, and indomethacin for some cases.

Adults

• Caution about the presence of these drugs in many OTC products.
•  Instruct adults to report OTC drug use to their health care provider when they are receiving any other prescription drug to avoid possible drug-drug interactions and the masking of signs and symptoms of disease.

Cultural consideration: African Americans have a documented decreased sensitivity to the analgesic property of anti-inflammatory agents. They also have increased risk of developing GI adverse effects to these drugs. Educate these patients about signs and symptoms of GI bleeding and monitor them closely.

Pregnant women

• As for pregnant and nursing women, use is only justified when benefits clearly outweigh the risks.

Older adults

• Dose adjustment is needed as this age group is also more susceptible to GI and CNS drug side effects.
• Naproxen, ketorolac, and ketoprofen come with geriatric warnings because of reports of increased toxicity so these drugs should be avoided if possible.
• Gold salts, a treatment for arthritis is particularly toxic for geriatric patients. It can cause renal, GI, and liver problems.

Pharmacokinetics

Here are the characteristic interactions of salicylates and the body in terms of absorption, distribution, metabolism, and excretion:

Contraindications and Cautions

The following are contraindications and cautions for the use of salicylates:

• Allergy to salicylates, NSAIDS, tartrazine (dye with cross-sensitivity with aspirin). Prevent risk of allergic reaction.
• Bleeding abnormalities. Changes in platelet aggregation.
• Impaired renal function. Drug is excreted through urine.
• Chickenpox or influenza. Risk of Reye Syndrome in children and teenagers.
• Surgery or other invasive procedures within one week. Risk of increased bleeding.
• Pregnancy and lactation. Potential adverse effects on the neonate or mother.

Adverse Effects

Improper use of salicylates may result to these adverse effects:

• GI: nausea, dyspepsia, heartburn, epigastric discomfort
• Hema: blood loss, bleeding abnormalities
•  WARNING  Salicylism can occur with high levels of aspirin characterized by dizziness, ringing in the ears, difficulty hearing, nausea, vomiting, diarrhea, mental confusion, and lassitude.
•  WARNING  Acute salicylate toxicity occurs at doses of 20-25 g in adults or 4 g in children. Signs include hyperpnea, tachypnea, hemorrhage, excitement, confusion, pulmonary edema, convulsions, tetany, metabolic acidosis, fever, coma, and cardiovascular (CV), renal, and respiratory collapse.

Interactions

The following are drug-drug interactions involved in the use of salicylates:

• Anticoagulants: increased risk of bleeding
• NSAIDs: increased serum levels of NSAID
• Activated charcoal: decreased absorption of salicylates
• Antacids: decreased effects of the salicylates
• Carbonic anhydrase inhibitor: increased risk for salicylism

Nursing Considerations

Here are important nursing considerations when administering anti-inflammatory agents:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

• Assess for contraindications or cautions (e.g., history of allergy to salicylate and tartrazine, renal disease, bleeding disorders, pregnancy and lactation, etc.) to avoid adverse effects.
• Establish baseline physical assessment to monitor for any potential adverse effects.
• Assess for presence of skin lesions to monitor for dermatological effects.
• Monitor temperature to evaluate drug’s effectiveness in lowering temperature.
• Evaluate CNS status to assess CNS effects of the drug.
• Monitor pulse, blood pressure, and perfusion to assess for bleeding effects or cardiovascular effects of the drug.
• Evaluate respirations and adventitious sounds to detect hypersensitivity reactions.
• Perform a liver evaluation and monitor bowel sounds to detect hypersensitivity reactions, bleeding, and GI effects of the drug.
• Monitor laboratory tests for CBC, liver and renal functions tests, urinalysis, stool guaiac, and clotting times to detect bleeding or other adverse effects of the drug and changes in function that could interfere with drug metabolism and excretion.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

• Acute pain related to CNS and GI effects
• Risk for ineffective breathing pattern related to toxic effects
• Risk for disturbed sensory perception: auditory, kinesthetic related to toxic effects

Implementation with Rationale

These are vital nursing interventions done in patients who are taking anti-inflammatory agents:

• Administer drug with food to alleviate GI effects.
• Check all drugs being taken for possible salicylate ingredients to avoid toxic levels.
• Monitor for severe reactions to avoid problems and provide emergency procedure (e.g., gastric lavage, induction of vomiting, etc.)
• Arrange for supportive care and comfort measures (e.g., rest, environmental control) to decrease body temperature or to alleviate inflammation.
• Ensure patient is well hydrated during therapy to decrease risk of toxicity.
• Provide patient education about drug effects and warning signs to increase knowledge about drug therapy and to increase compliance with drug.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

• Monitor patient response to therapy (improvement in condition being treated, relief of signs and symptoms of inflammation).
• Monitor for adverse effects (e.g., GI upset, CNS changes, bleeding).
• Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.

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