NR 325 Week 8 Opioid Sedation Deterioration Paper Example

The 2200 Row: Advancing Opioid Sedation on the First Night After Hernia Repair in a 63-Year-Old Man, Read Forwards

Student Name

College of Nursing, Chamberlain University

NR 325: Adult Health II

Instructor Name

Month Day, Year

The 2200 Row: Advancing Opioid Sedation on the First Night After Hernia Repair in a 63-Year-Old Man, Read Forwards

The Patient and the Chart

Mr. H. is 63, a retired machinist, with a body mass index of 38 and high blood pressure. His wife says he snores loudly and stops breathing in his sleep; no sleep study has ever been done. He had an open repair of a large ventral hernia and arrived on the surgical unit at 1600 with a hydromorphone patient-controlled analgesia pump, oxygen at 2 liters by nasal cannula, and gabapentin 300 mg ordered three times a day, first dose at 1800. The unit takes vital signs and a sedation score with the Pasero Opioid-induced Sedation Scale every two hours for the first 24 hours after surgery.

Table 1

Observations From Arrival to the Rapid Response Call

Note. Sedation scale scores: 1, awake and alert; 2, slightly drowsy, easily aroused; 3, frequently drowsy, drifts off to sleep during conversation; 4, somnolent, minimal or no response. The 0000 set was taken without waking the patient.

The observation chart for his first evening is reproduced in Table 1, because every claim in this paper is a claim about one of its rows. The case ends at 0140, when he was found barely rousable with a respiratory rate of 6, given naloxone, and moved to the step-down unit.

Reading the Chart Forwards

At 1800 nothing on the chart asks for action. His pain has come down from 7 to 5, he is alert with a sedation score of 1, and he is using the pump often, which fits pain rather than excess opioid. The one addition is the gabapentin, a sedating drug given to a man already receiving an opioid. Lee et al. (2015), reviewing 92 closed malpractice claims for postoperative respiratory depression, found that another sedating medication had been given alongside the opioid in 34% of them. At 1800 that is a risk, not a sign.

At 2000 three things have moved a little. His breathing has slowed from 16 to 14, his sedation score has risen from 1 to 2, and his pain has fallen to 3. Each is reasonable on its own: a patient whose pain is controlled breathes more slowly and dozes. A nurse reading this row with only what was on the chart at 2000 could fairly chart it and return at 2200, which is what happened. I do not nominate the 2000 row.

The Nominated Row, and Why

The 2200 row is the first that should have gone to somebody. Taken singly, none of its values is alarming: a rate of 12 is within most adult ranges, and 94% on oxygen passes most unit thresholds. The argument is about the row beside the two above it. The respiratory rate has now fallen at every set, from 18 to 16 to 14 to 12. The sedation score has risen to 3, and on the Pasero scale, 3 means the patient drifts off during conversation; Pasero (2009) sets out that at this level the opioid dose should be reduced and the patient watched more closely, because sedation usually comes before respiratory depression. Pain has reached 2 while the pump demands have dropped from 7 to 2, meaning he has stopped pressing the button because he is not awake enough to press it, not because he no longer needs to.

Two further facts make the row heavier than its numbers. The saturation of 94% is measured on oxygen, which can keep saturation acceptable while carbon dioxide rises from slow, shallow breathing; a falling saturation on oxygen is a late sign, not an early one. And the charted remark, sleeping comfortably, is a description of a sedation score of 3 in words that sound reassuring. The same row, written as frequently drowsy and drifting off mid-sentence, would have read as the scale intends it to be read.

The Gap Between Noticing and Telling

The information in the 2200 row reached a person who could act on it at 0140, when the rapid response team arrived: 3 hours and 40 minutes. In that interval there was one more contact, at 0000, when a saturation was taken but he was not woken, so no rate or sedation score was recorded. That set is the one most often defended with the words "let him sleep," and it is the exact circumstance the sedation scale is designed to prevent. A sleeping patient on an opioid is woken to be scored, because the score cannot be taken any other way.

Lee et al. (2015) found that somnolence had been noted before the event in 62% of the claims they reviewed, and the reviewers judged 97% of the events avoidable had monitoring and the response to it been better. They also found that the patient was discovered within two hours of the last nursing check in 42% of claims. Mr. H. fits that pattern closely: the drowsiness was charted, the check interval was two hours, and what was missing was the step between writing it down and telling someone.

The Ending Kept Out of the Argument

Mr. H. responded to naloxone within minutes and was moved to the step-down unit with continuous monitoring. By morning he was alert and his pain was managed with a lower pump dose and no gabapentin. The good outcome is not evidence that the night went well, and a worse outcome would not have made the 2200 row more important than it already was. The argument stands on what the chart showed at 2200.

What Carries to the Next Patient

Two things transfer from this chart to others. The first is that a sedation score of 3 is an action, not a description. At 2200 the nurse could have held further pump doses by telling the provider, woken Mr. H. fully, recounted his breathing over a full minute, and asked whether the gabapentin should continue and whether he could be monitored continuously. Jungquist et al. (2020), revising the American Society for Pain Management Nursing guideline on monitoring for opioid-induced sedation, sort risk into patient, treatment and care-environment factors and recommend closer and electronic monitoring as risk rises. Mr. H. had factors in all three: probable untreated sleep apnea and obesity, an opioid given with a second sedating drug, and checks two hours apart overnight.

The second is that a charted remark is part of the row. "Sleeping comfortably" at 2200 translated a warning into a reassurance, and the next nurse to read the chart read the reassurance. Writing the score in the words of the scale keeps its meaning intact for whoever reads the row next.

References

Jungquist, C. R., Quinlan-Colwell, A., Vallerand, A., Carlisle, H. L., Cooney, M., Dempsey, S. J., Dunwoody, D., Maly, A., Meloche, K., Meyers, A., Sawyer, J., Singh, N., Sullivan, D., Watson, C., & Polomano, R. C. (2020). American Society for Pain Management Nursing guidelines on monitoring for opioid-induced advancing sedation and respiratory depression: Revisions. Pain Management Nursing, 21(1), 7-25. https://doi.org/10.1016/j.pmn.2019.06.007

Lee, L. A., Caplan, R. A., Stephens, L. S., Posner, K. L., Terman, G. W., Voepel-Lewis, T., & Domino, K. B. (2015). Postoperative opioid-induced respiratory depression: A closed claims analysis. Anesthesiology, 122(3), 659-665. https://doi.org/10.1097/ALN.0000000000000564

Pasero, C. (2009). Assessment of sedation during opioid administration for pain management. Journal of PeriAnesthesia Nursing, 24(3), 186-190. https://doi.org/10.1016/j.jopan.2009.03.005