Please help me answer this case study

Question

An 80 year old woman is living in LTC. Hx of hypertension, had a recent fall and had a total hip replacement. Postoperative pain is high, therefore she was discharged with a prescription for Morphine, 5 mg PO, q4h PRN. This is affecting her pain control, so a subcutaneous injection port was implanted yesterday to start injections. The dosage has been changed to 5 mg SC Q4h PRN. She's had three shots in the last 24 hours and is incredibly drowsy. You arrive to the floor and find her unable to waken. VS were reported to be 36.3, R-12, O2 Sats 94% on RA, 60, 98/68.

What's her Dx? Explain.

What assessments should you do?

Answer 1

I'm not a nursing student, so I can't speak to the appropriate assessments, but a couple things stand out in this case. First, the route of administration for the morphine has changed, and morphine will have higher bioavailability when given subcutaneously rather than orally. This could have led to her altered mental status. You always want to consider bioavailability when changing the route of administration for a medication.

Secondly, it is not unusual for a patient or staff to forget to discontinue a medication when another has been prescribed. The patient may be taking the oral morphine in combination with the much more potent subcutaneous morphine. This could definitely lead to her unresponsive state.

This is likely a morphine overdose. If you did a neurological assessment, you'd most likely see bilateral miosis of the pupils. Naloxone administration would be appropriate.