A breast cancer patient admitted in ICU and is getting opioid analgesic Inj. morphine to manage pain. What would be the priority nursing assessment?

1. A

   Respiratory rate

2. B

   Urine output

3. C

   Blood pressure

4. D

   Oxygen saturation

Appeared in: JIPMER Pondicherry NO - 2022

Explanation

• Morphine, a potent opioid, directly suppresses the respiratory center in the brainstem, making respiratory depression its most life-threatening adverse effect.
• A decreased respiratory rate is the earliest and most reliable clinical sign of impending opioid-induced respiratory failure.
• Nursing practice guidelines mandate assessing the respiratory rate before administering an opioid and withholding the dose if the rate is below a safe threshold (e.g., 10-12 breaths/min) to prevent respiratory arrest.
• Prioritizing respiratory rate allows for the earliest possible intervention before the patient's condition deteriorates to the point of hypoxia (low oxygen saturation).

Why Other Options Were Wrong

• Option B: While morphine can cause urinary retention, this condition is not as immediately life-threatening as respiratory depression.
• Option C: Morphine can cause hypotension, but this is a circulatory issue that is secondary in priority to the immediate life-threatening risk of respiratory arrest.
• Option D: Oxygen saturation is a crucial vital sign, but it is a lagging or late indicator of respiratory depression. The respiratory rate declines first, making it the primary warning sign.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Priority nursing assessment for opioid administration in acute care settings.
• Vigilant monitoring of respiratory rate is a fundamental nursing responsibility to ensure patient safety during opioid therapy.
• Nurses must be prepared to act quickly by withholding the opioid, stimulating the patient, and administering the reversal agent, naloxone, if respiratory depression is detected.
• The principle of 'start low and go slow' with opioid dosing is especially critical in opioid-naïve patients, the elderly, or those with comorbid conditions.

How to Approach the Question

• First, identify the key intervention in the clinical scenario: the administration of morphine, a potent opioid analgesic.
• Next, recall the most critical, life-threatening adverse effect associated with this class of medication. For opioids, this is respiratory depression.
• The question asks for the 'priority' nursing assessment. This requires you to select the action that addresses the most immediate danger to the patient's life.
• Evaluate each option to determine which one provides the earliest indication of this life-threatening complication.
• A decreased respiratory rate is the first sign of respiratory depression. Changes in urine output and blood pressure are less acute risks. A drop in oxygen saturation occurs after the respiratory rate has already fallen.
• Therefore, conclude that monitoring the respiratory rate is the highest priority.

Concept Tested & Keywords

• Concept Tested: Priority nursing assessment for opioid administration
• Stem keywords: breast cancer, ICU, opioid analgesic, Inj. morphine, pain, priority nursing assessment
• Lead-in keywords: priority
• Clinical cues: ICU setting implies a higher acuity patient requiring close monitoring.
• Clinical cues: Opioid analgesic (morphine) signals a high risk for specific adverse effects, primarily respiratory depression.

Question ID

QVmhU-gL-vL9SNbLz6ReFg

Copy ID

Reference Book

E6 Pharmacology Nursing Lilley 11e Part 1 pp. 177-179, 175-177