Question

A client is receiving opioid analgesia for pain control. The nurse is assessing the client for possible respiratory depression. Which method would be most reliable for the nurse to use to identify impending respiratory depression?

Answer 1

The most reliable method for a nurse to identify impending respiratory depression in a client receiving opioid analgesia is through close monitoring of vital signs, particularly the respiratory rate. Other methods include assessing the client's level of sedation using a standardized sedation scale and assessing the client's pain level using a pain assessment scale.

Step-by-step explanation:

The most reliable method for a nurse to identify impending respiratory depression in a client receiving opioid analgesia is through close monitoring of vital signs, particularly the respiratory rate. A decrease in the respiratory rate or shallow breathing can be an early sign of respiratory depression. Other signs may include confusion, drowsiness, and cyanosis (bluish discoloration of the skin and mucous membranes).

In addition to monitoring vital signs, the nurse can also assess the client's level of sedation using a standardized sedation scale such as the Richmond Agitation-Sedation Scale (RASS) or the Ramsay Sedation Scale. These scales provide a numerical rating based on the client's level of sedation, with higher scores indicating deeper sedation.

Furthermore, the nurse should assess the client's pain level and consider using a pain assessment scale, such as the Numeric Rating Scale (NRS), to determine if the opioid analgesia is effectively controlling the client's pain without causing excessive sedation or respiratory depression.