A nurse is assessing a client who is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump following orthopedic surgery. Upon entering the room, the nurse observes that the client is somnolent, has a respiratory rate of 8 breaths/min, and an oxygen saturation of 87% on room air. Which of the following immediate actions should the nurse take? Select all that apply.
- Stop the morphine infusion on the PCA pump.Cevap
- Administer the prescribed dose of intravenous naloxone.Cevap
- CDecrease the basal rate of the PCA pump by half.
- Apply supplemental oxygen using an appropriate delivery device.Cevap
- EInstruct the unlicensed assistive personnel (UAP) to continuously monitor the client's vital signs.
- Attempt to physically arouse the client and instruct them to take deep breaths.Cevap
Cevap
The correct actions are to stop the PCA pump, administer naloxone, apply supplemental oxygen, and physically arouse the client.
The client is experiencing acute opioid toxicity characterized by central nervous system and respiratory depression. According to the ABCs (Airway, Breathing, Circulation) of prioritization, immediate interventions must focus on restoring adequate ventilation and oxygenation. Stopping the continuous opioid infusion prevents further toxicity. Administering naloxone, an opioid antagonist, rapidly reverses the respiratory depression. Applying supplemental oxygen treats the severe hypoxia. Physically arousing the client and encouraging deep breathing provides immediate, temporary support of respiratory effort while the naloxone takes effect.
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Anahtar Kavram
Management of opioid-induced respiratory depression and patient-controlled analgesia (PCA) safety.