Tramadol Nursing Implications
Tramadol Nursing Pharmacology
Tramadol is a synthetic opioid used as a pain medication for moderate to severe pain. It is commonly administered to adults experiencing severe pain.
There are a number of different pain modulators, neural inflammation markers, and immune mediators that can be influenced by this medication, which makes it useful for a wide range of pain conditions.
Tramadol is classified into two forms: intermediate-release and extended-release. The extended-release Tramadol is a biphasic formulation used to treat pain continuously since it is twice as effective as the regular form. However, this pain relief can’t be used on an as-needed basis.
Indications for Tramadol
Tramadol is an approved drug medication to relieve acute, moderate, and severe pain in adults. Moreover, it is used as an off-label treatment for premature ejaculation.
The following are conditions indicated by extended-release tablet:
- Treatment of choice for 24-hour or extended hour pain management
- Pain reliever of severe pain that requires daily or around the clock treatment
The following are conditions indicated by off-label tablets:
- Treatment of premature ejaculation
- Treatment for restless leg syndrome
Tramadol is commonly administered orally as a tablet, a solution (diluted), an extended-release, and an intermediate release tablet or capsule form.
As suggested, the regular tablet and solution are typically taken every 4 to 6 hours, with or without meals. Individualization of the dose is recommended based on the patient’s medical condition and reaction to treatment.
Typically, a low initial dose is used as a starting point, subsequently increasing the dose. A daily dose past 400 mg/day for adults is not recommended; however, the maximum dose is 300 mg/day for geriatric patients.
The following are essential aspects to remember for indication of Tramadol in different age groups:
- The use and safety of Tramadol in children have not been established. Hence, children younger than 18 should avoid this drug as a postoperative pain treatment.
- Safety has not been established for pregnant women and lactating mothers.
- The patient should be educated to take pain medication before it becomes acute.
- Older Adults
- Long-term safety has not been thoroughly documented.
Available forms of tramadol include the following:
- Immediate-release tablet: 50 mg, 100 mg
- Extended-release tablet: 100 mg, 200 mg, 300 mg
- Tablet as hydrochloride: 50 mg, 100 mg
Indications and recommended dosage for tramadol are as follows:
- Extended-Release: For 18 years or older, initially 100 mg/day per orem. The physician may increase or decrease the dose as needed. However, the recommended daily dose is no more than 300 mg.
- Immediate release: For those above the age of 75, recommended daily dose is no more than 300 mg/day.
- Children above the age of 12 should have their dosage and method of administration evaluated by a medical professional.
- Children under the age of 12 should not be treated with this medication.
Moderate to severe pain
- 50 to 100 mg per orem every 4 to 6 hours, as needed, for adults and children 16 years of age and older. The physician may increase or decrease the dose as needed. However, the recommended daily dose is no more than 400 mg.
- Oral solution: For adults, initially 25 mg/day.
- Oral tablets: For adults and older adults over 75 years of age, initially 25 mg taken in the morning.
- Children under the age of 12 should not be treated with this medication.
Patients currently taking tramadol Immediate-Release (IR)
- Calculate the required IR for 24 hours. ER doses should be started and adjusted to the next lowest 100-mg dose.
Renal Dose Adjustments
- Immediate-release: 50 mg, 100 mg per orem every 12 hours for CrCl is below 30 mL/min
- Hepatic Dose Adjustments
- Immediate-release: 50 mg per orem every 12 hours for severe hepatic impairment
Actions of Tramadol
Tramadol is an opioid analgesic that selectively binds and acts on varying opiate receptors on the central nervous system. Moreover, it acts as a serotonin-norepinephrine reuptake inhibitor (SNRI) that can interact with other serotonergic drugs (e.g., SNRI, serotonin reuptake inhibitors, cough medications, antidepressants, etc.).
Using these drugs in combination or in excess may result in serotonin syndrome (symptoms include changes in mentation, agitation, delirium, coma, and hallucinations) or reduce the efficacy of serotonergic antagonist antiemetic drugs.
It has a low affinity to the μ-opioid receptor, δ- and κ-opioid receptors. Meanwhile, the O-desmethyl (M1) metabolite binds more strongly to the μ-opioid receptor than the parent compound. For this reason, tramadol’s opioid effects are attributed to the latter.
While both the parent drug and metabolite exhibit a strong affinity for the mu receptor (MOR) over the delta receptor (DOR) and kappa receptor (KOR), tramadol alone is ineffective in modulating MOR.
Tramadol also impacts monoamines by modifying the actions of neurotransmitters involved in pain modulation, which results in activation of the descending inhibitory pathways.
This centrally acting opioid is a racemic mixture (having two enantiomers). Its multimodal mechanism contributes to tramadol’s analgesic property through two different mechanisms:
- Partial agonist activity to the μ opioid receptor due to tramadol and its primary metabolite (+)-O-desmethyl-tramadol (M1)
- The positive enantiomer inhibits serotonin reuptake, while the negative enantiomer inhibits noradrenaline reuptake.
These components are mutually exclusive and synergistic, enhancing tramadol’s capacity to modify pain perception and response. Additionally, it resembles the actions of other SNRI antidepressants.
Other than that, tramadol has the following actions:
- It has been suggested that it may be useful in treating neuropathic pain because of its N-Methyl-D-aspartate (NMDA) antagonistic properties. It acts by inhibiting or antagonizing the 5-HT 2C receptor.
- It has been suggested that it inhibits the alpha-7 nicotinic acetylcholine receptor, which is a crucial component of the brain’s cholinergic nerve system.
- Inhibits transient receptor potential vanilloid-1 (TRPA1) that stimulates pain sensation
- Acts as a muscarinic (M1 and M3) receptor antagonist
- This drug acts on alpha2-adrenoreceptors, adenosine A1 receptors, nicotinic acetylcholine receptors, and neurokinin receptors. As well as Nav1.2 (also known as voltage-gated sodium channel type II, alpha subunit) and transient receptor potential cation channel subfamily GV member 1 (TrpV1).
Side Effects of Tramadol
Despite tramadol’s standing as a reasonably safe and effective pain reliever, the drug can nonetheless have side effects. Geriatric patients or older adults (age 65 above) and those with a history of addiction are more susceptible to its adverse outcomes. The most common side effects are fatigue, somnolence, congestion, constipation, nausea, and weakness. Other general side effects include:
- Sore throat
- Itching or skin rash
They are more likely to occur during the first few weeks of treatment than regular dosages. This opioid painkiller can also cause unsettling or harmful alterations in the CNS, such as muscle spasms, hallucinations, physical tremors, and emotional changes. Combined use with other antidepressants and other medicines that influence serotonin is a common cause of this problem. Besides the CNS, the endocrine, cardiovascular, genitourinary, and cutaneous systems are also affected by this analgesic.
Adverse Reactions of Tramadol
Tramadol also has high addiction potential, especially when taken with other opioid medications. The risk of toxicity is much lower when a medicine is taken alone than when combined with other drugs. When this happens, it can cause fatal and life-threatening side effects such as:
- Respiratory depression
- Serotonin syndrome
An interprofessional team effort may be necessary if an overdose occurs. It can be fatal if not handled correctly. Overdosing on tramadol and abusing the drug can occur even before the drug is administered to the patient. Seek immediate medical attention if the following symptoms manifest while taking tramadol:
- Diminished consciousness or responsiveness
- Breathing difficulties
- Lack of muscle tone
- Excessive sleepiness
- Loss of consciousness (LOC)
- Change in consciousness
- Unusual tiredness
- Significant reduction in visual acuity coupled with dilated pupils
Tramadol may cause some adverse effects that do not necessitate medical treatment. These adverse effects may subside as the body responds to the medication.
The most common self-limiting symptoms are heartburn, irritability, joint pain, lethargy, fatigue, unusual drowsiness, uncontrollable euphoria, indifference, loss of strength, sore throat, and runny nose.
The less common side effects include: decreased appetite, back pain, altered skin integrity (e.g., blistering, irritation, crusting, and reddening), bloody urine, attentional disarray, cough with mucus, bloating, numbness, reduced desire for sexual contact, and painful urination.
Incidence not known side effects include:
- Skin coloration changes
- Difficulty swallowing
- Mental depression
- Poor coordination
- Slurred speech
- Inability to control speech or actions when excited
Cautions and Contraindications of Tramadol
When taken excessively or by patients with a history of dependence, addiction, and tolerance, tramadol can manifest side effects. It should be used with caution during pregnancy, and abstain near term since it can cause neonatal respiratory depression.
Long-term usage is related to neonatal abstinence syndrome. There is some indication that it may induce miscarriages in women who use it during the early stages of pregnancy, but this has not been confirmed with certainty.
- Central Nervous System: Tramadol, unlike some opioid agonists, does not trigger histamine release. Tramadol does not affect the left ventricular function and cardiac index when administered at therapeutic levels. Tramadol’s direct influence on the brain stem’s respiratory centers results in respiratory depression. As a result, the brain stem centers are less responsive to carbon dioxide tension and electrical nerve stimulation changes.
Tramadol helps diminish a person’s coughing response since it operates directly on the medulla’s cough center. Reduced analgesia may be required to provide antitussive effects.
If the pupil stays constricted even in dim light, it potentiates eye miosis. In this case, the analgesic also induces miosis. While pinpoint pupils are indicative of opioid overdose, it is not pathognomonic or strictly diagnostic for this disease. Moreover, taking doses over the prescribed range has been linked to an increased risk of seizures.
Patients with epilepsy, medical history, those with conditions associated with an increased risk of seizures, and those taking other medications known to lower the seizure threshold, may be more susceptible to convulsions.
- Endocrine System: Opioid drugs have been shown to affect the hypothalamic-pituitary-adrenal (HPA) axis. A decrease in plasma cortisol, testosterone, and a rise in serum prolactin are some of the alterations that can be observed. These hormonal shifts could show clinical symptoms. Tramadol-induced hyponatremia has only been seen in people with certain risk factors. For this reason, monitoring for signs and symptoms of hyponatremia is indicated for predisposed patients.
Meanwhile, hyponatremia caused by the inappropriate antidiuretic hormone syndrome appeared to be relieved by discontinuing the analgesics.
- Cardiovascular System: Tramadol may cause severe hypotension in patients who are concurrently taking medications such as sedatives, tranquilizers., general anesthetics, and tricyclic antidepressants. It can also affect individuals with compromised blood pressure regulation. In order to avoid hypotension, these individuals should be closely monitored after starting or adjusting the dosage of tramadol.
- Gastrointestinal System: tramadol as an analgesic also reduces gut motility associated with increasing smooth muscle tone in the lower part of the stomach and duodenum. Propulsive contractions or peristalsis are reduced, and digestion is retarded in the small intestine (SI). Moreover, constipation may occur due to diminished peristaltic waves in the colon.
Drug Interactions with Tramadol
Adverse drug interactions can result in serious side effects or problems, or even death in the worst-case scenario.
Some drugs can alter how tramadol is metabolized and cause its blood levels to rise or fall. Additionally, low tramadol levels may not sufficiently relieve pain, whereas increased tramadol levels may exacerbate the side effects. CYP2D6 enzymes are involved in the metabolism of tramadol; hence it may interact with any medication that has the ability to inhibit or stimulate these enzymes.
The following are drug interactions with tramadol:
- When combined with other opioid analgesics, there is an increased risk of adverse side effects, including liver failure
- Intramuscular (IM) injection during anesthesia can lead to a decrease in gastric secretion.
- Serotonin syndrome. When other serotonergic drugs (such as antidepressants, SNRI, SSRI, antitussives, anti-cough and cold) are taken in combination with tramadol, it can lead to serotonin syndrome (high serotonin levels). Insomnia, disorientation, hypertension, and a rapid heartbeat are indicators of this adverse drug reaction. While it has been demonstrated that it enhances the effects of antidepressants by increasing the amount of this chemical messenger released, it may also accumulate in the brain.
- Risk of seizure. When co-prescribed or taken in combination with other medications that lower the seizure threshold (such as amphetamines and antipsychotic drugs), this medication will enhance the risk of seizures or convulsions.
- Co-administration with coumarin derivatives raises the risk of an elevated International Normalized Ratio (INR) and ecchymoses.
- Long-term usage with CYP3A4 inhibitors can cause increased metabolism of CYP2D6 isoenzyme, resulting in less analgesia.
- Risk of CNS depression. The usage of tramadol with antipsychotic drugs, sedatives, and antiemetic medications can affect the CNS leading to risk or development of depression symptoms such as anxiety, insomnia, pale face, and uncontrolled emotion.
- Decreased treatment response. When taken with a cholinesterase inhibitor.
- Increased neurological toxicity. Taking this medication alongside other CNS depressants can cause a pharmacodynamic effect that increases the risk of coma, sedation, and respiratory depression.
- Taking tramadol in conjunction with alcohol can lead to serious sedation and difficulty breathing.
Nursing Considerations for Tramadol
- Assess the patient for loss of consciousness (LOC), somnolence and arousal difficulties. Notify the physician immediately if the patient is in a state of prolonged sedation.
- Take note of the age groups and the doses required to alleviate pain. Geriatric patients may require monitoring during dose titration, whereas others may need supplementary doses.
- Assess the source, location, and characteristics of pain. Collect subjective data and believe what the patient says.
- Assess the patient’s pain intensity and level of consciousness (LOC), especially when tramadol is given as a sedative for postoperative pain
- Evaluate the patient’s history of analgesic use and substance abuse. tramadol is not suggested for opioid-dependent people or who have received opioids in the past for more than one week.
- Seizures should be observed closely. When necessary, employ seizure precautions. It may occur within the approved dose range, but the risk may potentially be enhanced in larger doses or for people taking antidepressants, seizure threshold lowering drugs, and opioid analgesics.
- Overdose will lead to seizures and respiratory depression.
There are safety concerns about tramadol use, and it is essential to inform the patient the following:
- Take this medication exactly as directed by the handling physician. Adhere according to the directions and read the medication label.
- Never go beyond the prescribed dosage or immediately inform the doctor if there is a sense to take more.
- Tramadol tablets should never be broken or crushed to be inhaled or dissolved in a liquid to be injected into a vein. The likely outcome of this practice is death.
- For the oral form, never approximate the dose; instead, use a dose-measuring cup or the accompanying syringe.
- After starting tramadol, discontinue all other opioid drugs/medications.
- Tramadol can be taken with or without meals, but take it consistently within a specified time or period.
- It is possible to experience withdrawal symptoms if one abruptly discontinued tramadol use. Consult the handling physician before discontinuing any medication.
- Misuse or overdosing can lead to death.
- Tramadol should not be shared with anyone, especially someone who has a history of drug abuse. Addiction, overdosage, or death can result from misuse.
Tramadol Nursing Care Plan
Tramadol Nursing Diagnoses
- Anxiety related to the side effect of tramadol
- Nausea/Vomiting related to the side effect of tramadol
- Diarrhea/ Constipation related to the side effect of tramadol
- Disturbed Sleep Pattern related to the side effect of tramadol
- Risk for Confusion related to the side effect of tramadol
- Deficient Knowledge related to tramadol
Tramadol Nursing Assessment
|Nursing Interventions for Tramadol||Rationale|
|Assess the patient for signs and symptoms of pain and discomfort.||To confirm the indication for administering tramadol.|
|Assess if the patient has recently consumed alcohol. Check the patient’s medical history of: asthmarespiratory depressionparalytic ileus||Tramadol is generally contraindicated in patients who recently consumed alcohol because mixing both can further suppress the central nervous system. It must not be prescribed to patients with a history of respiratory depression due to the same reason.|
|Check the patient’s allergy status.||Previous allergic reactions to tramadol or any other opioid drug may render the patient unable to take them. Alternatives to tramadol should therefore be considered in case of allergy.|
|Assess if the patient is pregnant or lactating.||Tramadol should be ideally avoided in patients who are pregnant as this drug is under pregnancy category C and may have possible effects on the fetus such as birth defects.|
|Perform a pain assessment of the patient using a pain scale and ask the patient to describe the pain.||To confirm the indication for administering tramadol.|
|Assess the patient’s mucous membranes and his/her ability to swallow.||To check for any potential problems with administration, hydration, and absorption.|
To ensure that the right form of tramadol is given.
Tramadol Nursing Planning and Intervention
|Nursing Interventions for Tramadol||Rationale|
|Administer regular tramadol with or without food at the same time everyday. Give as-needed tramadol only after pain assessment.||To ensure optimal absorption and therapeutic action by tramadol, as well as reduce possible side effects.|
|Ask the patient to swallow the tramadol tablet whole, as prescribed. Do not crush the extended-release tablet. Avoid chewing, breaking, opening, and dissolving the tramadol extended-release tablet/capsule to avoid a fatal dose. Instead, swallow the long-acting formulation as a whole.||This will ensure adequate absorption of the drug being administered.|
|Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking tramadol. Instruct the patient on how to self-administer tramadol prior to discharge.||To inform the patient on the basics of tramadol, as well as to empower him/her to safely self-administer the medication.|
|Discourage alcohol intake or cannabis consumption when on tramadol.||Alcohol and cannabis can increase the nervous system side effects of tramadol, such as irritability, dizziness, and drowsiness.|
|Help the patient with activities of daily living as needed.||Tramadol may cause fatigue, dizziness, and drowsiness which may put the patient at risk for injury. Therefore, patients on tramadol require close supervision when doing ADLs.|
|Inform the patient that tramadol may cause mood swings and this should be reported to any healthcare professional once noticed.||To inform the patient of the possible side effect of the drug on his or her behavior and emotional state.|
Tramadol Nursing Evaluation
|Nursing Interventions for Tramadol||Rationale|
|Ask the patient to repeat the information about tramadol.||To evaluate the effectiveness of health teaching on tramadol.|
|Monitor the patient’s sleep pattern, behavior and mood changes.||Tramadol may cause insomnia, excessive sedation, mood or behavioral changes, which are side effects of the drug that must be dealt with. These should be monitored closely to ensure the patient’s safety and to check if the dose needs to be reduced or the drug must be discontinued.|
|Commence a pain chart.||To check for the effectiveness of tramadol on the patient’s pain levels.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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