While completing morning rounds, a nurse assesses a client who underwent a partial colectomy the previous day. The client is receiving continuous intravenous fluids and utilizing a morphine patient-controlled analgesia (PCA) device. The nurse observes that the client is profoundly somnolent, minimally responsive to tactile stimuli, and exhibits shallow respirations at a rate of 7 breaths per minute with an oxygen saturation of 85% on room air. Which immediate interventions are appropriate to mitigate further physiological risk? Select all that apply.
- Pause the continuous infusion and patient-initiated doses of the morphine PCA.Answer
- Prepare to administer intravenous naloxone as prescribed by the healthcare provider.Answer
- Apply supplemental oxygen and stimulate the client to take deep breaths.Answer
- DPosition the client flat on their back with the legs elevated to maintain blood pressure.
- EPerform a focused assessment of the surgical incision site to check for occult hemorrhage.
- FDelegate ongoing vital sign monitoring to the unlicensed assistive personnel (UAP) while retrieving the crash cart.
Answer
The correct interventions for suspected opioid-induced respiratory depression include pausing the PCA pump, preparing and administering naloxone, and applying supplemental oxygen while stimulating the client.
The client is exhibiting classic signs of acute opioid toxicity: profound sedation, significant bradypnea (7 breaths per minute), and hypoxia. The immediate priority is to stop the administration of the offending medication by pausing the PCA pump. Naloxone is an opioid antagonist that rapidly reverses respiratory depression and must be administered promptly. Concurrently, applying supplemental oxygen and physically stimulating the client helps manage the severe hypoxia and encourages spontaneous ventilation.
Step-by-Step Solution
Key Concept
Management of Opioid-Induced Respiratory Depression