The nurse assesses the client who is 2 days postoperative to determine the need for continuing PCA. Which does the nurse use to decide that the client is ready for oral administration of anal-gesia?
1. Client is hypoventilating.
2. Pain level ranges from 2–4.
3. Sedation level is consistent.
4. BP 168/96, HR 110, RR 26
2
2. The nurse uses the client's pain level ranging from 2–4 to help determine that oral analgesia is suitable for the client because the client's pain level is consistently below the mid-range on the pain scale. PCA is more suitable for moderate to severe pain and oral analgesia is more suitable for low to moderate pain.
1. Hypoventilation is an adverse effect of opioid analgesia, regardless of the adminis-tration method. Hypoventilation indicates that the client potentially receives an ex-cessive dose of opioid or that the dose remains inadequate and the client is hypoven-tilating to prevent pain. Regardless of the cause, hypoventilation warrants further in-vestigation by the nurse to clarify the pain level and to improve ventilation.
3. A consistent sedation level is vague and provides little information about client status. A consistent sedation level can indicate a serious neurological impairment or excessive dosing and warrants further investigation. To rule out opioid toxicity as the cause of the client's neurological status, the provider can continue using the PCA to manipulate opioid administration quickly and to avoid oral administration to a client with a risk for aspiration.
4. An elevated blood pressure, heart rate, and respiratory rate are nonverbal indicators of pain and indicate inadequate pain relief.
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