The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up?

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11ecbb05_cc5c_89d2_b433_85544f2eca9f_MD0009_00 Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory depression. Falling asleep during a conversation scores "3" on the Pasero Opioid-Induced Sedation Scale (POSS); no additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti-inflammatory medications) can be given if the client is still in pain. The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily aroused). (Option A) Nausea or vomiting is a typical side-effect of narcotic administration, especially when it is given in a larger dose or to the opioid-naïve client. It usually lessens with time and repeat administration. Nausea or vomiting would not be a concern unless it is excessive or severe. The nurse should ensure that the client receives adequate hydration (eg, intravenous fluids, clear liquids, antiemetics). (Option B) Constipation is a known side effect of opioid administration and does not lessen with long-term administration. Proactive measures are needed as long as the client is on narcotics. However, large intestine peristalsis does not usually start until 2-3 days after surgery. (Option D) Pruritus (itching) is a known side effect of narcotic administration. It is usually treated with diphenhydramine (Benadryl) or some other antihistamine. Educational objective: Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client.

The Nurse Administers the Prescribed Dose of Hydromorphone 2 Mg