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Zorluk: OrtaReduction of Risk Potential

A nurse is evaluating a client who is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump following an abdominal laparotomy. The client is profoundly lethargic with a respiratory rate of 7 breaths per minute. A stat arterial blood gas (ABG) is drawn and yields the following results: pH 7.25, PaCO2 62 mm Hg, and HCO3 24 mEq/L. To immediately reduce the client's risk for cardiopulmonary arrest, which of the following actions should the nurse take first?

  1. Stop the continuous morphine infusion and prepare to administer the prescribed opioid antagonist.Cevap
  2. B
    Administer a prescribed intravenous bolus of sodium bicarbonate to rapidly correct the acid-base imbalance.
  3. C
    Lower the head of the bed to a completely flat, supine position to prepare for emergency intubation.
  4. D
    Auscultate all lung fields and obtain a complete set of vital signs before intervening.

Cevap

The correct action is to stop the continuous morphine infusion and prepare to administer the prescribed opioid antagonist.
The client is experiencing opioid-induced respiratory depression, evidenced by profound lethargy, a respiratory rate of 7 breaths per minute, and ABG results demonstrating uncompensated respiratory acidosis (low pH and significantly elevated PaCO2). The priority action to reduce the risk of cardiopulmonary arrest is to immediately stop the offending agent (morphine) and prepare to administer an opioid antagonist, such as naloxone, to restore an adequate respiratory drive.

Adım Adım Çözüm

1
Interpret the client's clinical presentation and ABG results.
The client has severe hypoventilation (7 breaths/min) resulting in uncompensated respiratory acidosis (pH 7.25, elevated PaCO2 62 mm Hg, normal HCO3 24 mEq/L).
Opioid analgesics like morphine cause central nervous system depression, which slows the respiratory drive and leads to carbon dioxide retention.
2
Determine the highest priority intervention based on the ABCs (Airway, Breathing, Circulation).
The immediate life-threatening issue is compromised breathing due to opioid toxicity.
Stopping the source of the toxicity (morphine) and reversing it with an antagonist (such as naloxone) is critical to restore adequate spontaneous ventilation and prevent arrest.

Anahtar Kavram

Anticipating and managing severe physiological complications of pharmacological therapies (opioid-induced respiratory acidosis).
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Konular

Reduction of Risk Potential

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