QLexNursing

Client is difficult to arouse

💠 This indicates central nervous system depression, which is a known adverse effect of opioid analgesics such as morphine.

💠 A postoperative client who received morphine only 1 hour earlier should not have a declining level of consciousness this rapidly.

💠 Difficulty arousing the client suggests the early stages of opioid toxicity, even before other vital sign abnormalities appear.

💠 This change from the baseline (alert and oriented at 0900) is an acute neurological deterioration, which is a priority.

💠 The nurse must assess airway, stimulate the client, hold further opioids, and prepare to administer naloxone if indicated.

Respiratory rate 10/min

💠 A respiratory rate of 10/min is below the safe threshold for patients receiving opioids, who should be monitored for respiratory depression.

💠 Morphine decreases the brain’s respiratory drive, making hypoventilation a life-threatening complication.

💠 A rapid drop from 22/min (one hour earlier) to 10/min represents significant respiratory decline.

💠 When paired with decreased arousability, this confirms opioid-induced respiratory depression, which can progress to apnea if untreated.

💠 The nurse must intervene immediately to support ventilation and notify the provider.

Pulse oximetry 88% on room air

💠 An O₂ saturation of 88% indicates hypoxemia, a critical finding requiring immediate intervention.

💠 This is below the normal range of 95%–100%, and occurred after the administration of morphine, confirming inadequate oxygenation.

💠 Low oxygen saturation combined with low respiratory rate strongly suggests opioid overdose with impending respiratory failure.

💠 The client requires supplemental oxygen, close monitoring, and evaluation for naloxone administration to reverse opioid effects.

💠 Without prompt treatment, hypoxemia can lead to cardiac dysrhythmias, brain injury, or respiratory arrest.

Documentation That Does NOT Require Immediate Action

Temperature 37.5°C (99.5°F)

🟢This temperature is normal and not clinically concerning.

🟢It does not indicate infection, sepsis, or opioid sequelae.

🟢Postoperative clients often have minor temperature fluctuations.

🟢There is no rapid increase or associated concerning symptoms.

🟢No immediate intervention is required.

Pupils 3 mm, equal, reactive to light

🟢Pupils equal and reactive to light indicate normal neurological function in terms of cranial nerve III assessment.

🟢Although opioids commonly cause pinpoint pupils, 3 mm is not severely constricted.

🟢Pupil reactivity is preserved, which is a positive sign.

🟢This finding alone does not indicate impending respiratory arrest.

🟢No urgent action is needed based solely on this documentation.

Blood pressure 99/46 mmHg + heart rate 61/min

🟢Slight drops in blood pressure and heart rate can occur after morphine administration due to vasodilation and relaxation.

🟢These values are lower than baseline but not yet at a critical level requiring emergency intervention.

🟢The priority concerns with opioids are respiratory rate and level of consciousness, both of which are already addressed above.

🟢Monitor closely, but do not prioritize this over hypoventilation and hypoxia.

🟢These hemodynamic changes are secondary and not the first immediate threat to life.