Which nursing actions would be appropriate when a nurse is initiating an infusion of morphine sulfate for a post-operative patient who is experiencing pain?
1. Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the start of the infusion.
2. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.
3. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each time.
4. Begin the infusion at the lowest ordered dose and increase the rate every 30 minutes if the patient continues to have pain.
2
Rationale 1: The desired effects should become apparent 5 minutes after intravenous administration.
Rationale 2: A critically ill patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the pain medication with intermittent boluses and increases in infusion until the drug attains steady state and the patient experiences pain relief.
Rationale 3: Assessing the patient 5 minutes after increasing the infusion rate each time might be too soon to assess for pain control.
Rationale 4: When IV infusion rates are repeatedly increased versus the administration of intermittent boluses as a means of responding to acute pain, the risk for excessive analgesia dosing exists.
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