A nurse is conducting hourly rounds on an inpatient dual-diagnosis unit and discovers a client unresponsive with cyanotic lips, pinpoint pupils, and a respiratory rate of 6 breaths per minute. The client has a documented history of severe opioid use disorder. Arrange the following nursing actions in the correct order of priority.
- 1Determine unresponsiveness and call for immediate help.
- 2Simultaneously check the carotid pulse and observe for breathing.
- 3Open the airway and initiate bag-valve-mask ventilations.
- 4Administer the prescribed dose of intravenous naloxone.
- 5Reassess the client continuously for recurrent respiratory depression.
Answer
The correct sequence is to first determine unresponsiveness and call for help, then check the pulse and breathing, initiate ventilations to correct hypoxia, administer naloxone to reverse the overdose, and finally monitor for recurrent respiratory depression.
According to basic life support and emergency guidelines for a suspected opioid overdose, the absolute first priority is to assess responsiveness and call for help to activate the emergency response system. Next, the nurse must simultaneously check for a pulse and breathing. Upon identifying severe respiratory depression (6 breaths per minute) with a likely pulse, the immediate physiological need is oxygenation; therefore, the nurse must open the airway and provide ventilations. Once breathing is mechanically supported, the nurse administers naloxone to reverse the opioid effects. Finally, continuous reassessment is critical because the half-life of naloxone is often shorter than the opioid ingested, putting the client at high risk for a recurrence of respiratory depression.
Step-by-Step Solution
Key Concept
Priority Management of Acute Opioid Overdose
Estimated Time:1m 30s