A 3-year-old is hospitalized following surgery for a ruptured appendix. Opioids were administered postoperatively to relieve pain. During assessment of the child, the nurse notes that the child is sleeping
Vital signs are as follows: temperature 97.8?F axillary, pulse 90, respirations 12, and blood pressure 100/60. Based on this assessment, the nurse concludes that the child is: 1. Comfortable, and the pain is controlled.
2. In shock secondary to blood loss during surgery.
3. Experiencing respiratory depression secondary to opioid administration for postoperative pain.
4. Sleeping to avoid pain associated with surgery.
3
Rationale:
1. Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a 3-year-old. The other vital signs are within normal limits for a sleeping 3-year-old.
2. Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a 3-year-old. The other vital signs are within normal limits for a sleeping 3-year-old.
3. Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a 3-year-old. The other vital signs are within normal limits for a sleeping 3-year-old.
4. Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a 3-year-old. The other vital signs are within normal limits for a sleeping 3-year-old.
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