Scenario Title
Patient Name
Medical Record #
Level (year 2, 2nd
term)
Author , w/email
Keywords - Theory
Keywords - Skills
Patient Controlled Analgesic - Narcotic Overdose
Tina Goss
DOB:
NUR 211
Course:
Age:
Marilyn McGuire Sessions, RN, MSN & Maureen Harter, RN, BSN
Respiratory, orthopedic
Narcan, respiratory support of patient with respiratory depression
Patient
Case
History:
72 y/o female patient admitted to the orthopedic floor. She fell at her daughters
home where she lives and sustained an intracapsular fx of the r-hip at the femoral
neck. She also has rheumatoid arthritis. Was diagnosed with early signs of
alzhemiers last month. Her daughter said she has periods of confusion. Patient is
being admitted to med surg unit from PACU after Total Hip Replacement.
Medical
history:
Allergies:
Meds:
history of Rheumatoid arthritis
VS:
BP
Labs:
HR
116/68
76
Pre-op labs WNL
NKA
Prednisone 5 mg po q day
Methotrexate 2.5 mg q week
RR
5’7”
Height:
18
T
37.2
Weight:
SpO2
120
97
Physician Orders: from Dr. Maurice Wood for Tina Goss DOB- 04/17/33 (age 72) Allergies –
NKA
1. Admit to orthopedic floor
2. DX – S/P Total R-hip replacement
3. IVF NS 125cc/hr
4. NPO
5. CDB, IS 10xq1 hr WA
6. VS q 15 x4, q 30 x2, q 1 x2, then q 4 hrs
7. Morphine sulfate via PCA - see PCA order form
8. Phenergan 12.5 – 25 mg IV q 4-6 hours PRN nausea
9. Zosyn 3.375 q 6hr
10. Toradol 15 mg IV q 6 hrs
11. Maintain SpO2 > 95% may titrate up with 2 L 02 per NC
12. Notify Physician: SPB>140<80, DBP >90<50; HR >120<50; RR >22<8; T>38.5;UOP
<30cc/hr x 8 hours
Initial Computer Set Up
VS:
BP
Lungs:
Heart:
Ectopy:
Other:
Report to
start
scenario:
110/60
HR
Lt:normal
72
RR
16
Rt:normal
T
37.2
Bowel
sounds
SpO2
96
hypoactive
Rhythm:
Waiting:
“ Tina is S/P total hip replacement.She was held over in PACU for observation for
nausea. She knows how to use the PCA pump as it was explained to her preoperatively. Vital signs are stable, right hip dressing in place, hemovac just
emptied, 70 cc serous sanguinous fluid measured. PACU put on abductor pillow
and that is in place. Patient sometimes seems a bit confused. Daughter has been
at the patients bedside and is very protective but just decided to go get something
to eat“
Priorities (in order)
VS, dressing, drain, I&O, IV
fluid, pain, comfort, sedation
Locate
and
Phenergan
draw
up
SN Interventions
Assess vitals etc.
Assess for severity of nausea
and need for Phenergan
Administer Phenergan
12.5mg IV following correct
procedure for IV push
Medication
Patient Responses
Patient is drowsy and
complaining of nausea
I really am feeling sick to my
stomach, starts to vomit
What are you doing? What is
that for?
Tina Goss Scenario cont’d
Patient’s vital signs will change
after Phenergan given.
Resp 12, BP 106/68, SPO2 94
Resp 8, BP 102/66, SPO2 89
Down to Resp 6,
Locate Narcan and prepare
to give
STOP PCA PUMP!
Continue to assess vitals
signs, put on O2
Draw up .4mg (1cc) naloxone
in a 10cc syringe, in same
syringe draw up 9 cc .9%
sterile normal saline, five 1cc
IV push naloxone into vein,
repeat every minute until
respiratory rate satisfactory. (
see document)
Take respirations down to 8,
BP to 90/56, HR, SPO2 to 85
.
Physician will order O2, EKG,
and blood gases and transport
of patient to ICU.
Know signs of adverse
Look for signs of
effects of Narcan
hypertension, tachycardia,
dysrhythmias, Nausea and
vomiting – have suction
available.
Faculty Notes (theory, medications, etc.)
1) Naloxone administration, PCA – Narcan document
Debrief Priorities (facts, feelings, behaviors, priorities, noticing, interpreting, responding,
evaluating and reflecting-what went well, what would you do differently)
1) 1.Phenergan 12-25mg which dose to choose and why, ( when giving IV, give in free
flowing IV line, do not give above a concentration of 25mg/ml, do not give at a rate above
25mg/minute, onset of action 3-5 minutes)
2) 2.Discussion Respiratory distress due to narcotic overdose, Stop narcotic, Maintain an
open airway, administer O2, administration of narcan, using correct dose etc, have suction
available to prevent aspiration if N& V occur.
3) 3.Narcan –adverse effects - Look for signs of hypertension, tachycardia, dysrhythmias,
Nausea and vomiting – have suction available –
Possible Increased Complexities for this scenario:
1.
References:
1.
Suggestions for Future Advanced Scenarios:
1.