Which finding is an adverse effect associated with morphine and would be the priority if present?
1. The patient is very restless and cannot lie still.
2. The patient has not had a bowel movement in 3 days.
3. The patient's respiratory effort is slow and shallow.
4. The patient says, "I can't live without my morphine patches."
3
Rationale 1: Restlessness may occur but is not of highest priority.
Rationale 2: Constipation may occur but is not of highest priority.
Rationale 3: Respiratory depression may result in death and is the highest priority assessment finding.
Rationale 4: Psychological dependence may occur but is not of highest priority.
Global Rationale: Respiratory depression may result in death and is the highest priority assessment finding. Restlessness, constipation, and psychological dependence may occur but are not of highest priority.
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A.N. does not exhibit any signs of smoke inhalation injury and is admitted to the medical unit for further
treatment. As her nurse, you are concerned about meeting her needs for infection prevention, skin integ rity, nutrition, fluids, and psychologic support. Because of her significant burn injury, A.N. is at high risk for infection. What measures will you institute to prevent this?