Managing Postoperative Pain with Signs of Respiratory Depression

Scenario

You are caring for a post-operative patient who has been receiving IV morphine for pain rated 9/10.
On reassessment, their respiratory rate (RR) is 8 breaths per minute, SpO₂ is 89%, and they are difficult to arouse.

Question: What immediate nursing actions should you take to ensure safety and effective pain management?

Best Practice Answer

1. Recognize This as an Emergency:
   The patient is exhibiting opioid-induced respiratory depression, a potentially life-threatening event.
   Pain control must be temporarily secondary to airway and breathing management.
   Remember: if RR < 10 or SpO₂ < 92%, act immediately.

2. Immediate Actions (First 1–2 Minutes):

   • Stop the opioid infusion or hold additional doses.
   • Stimulate the patient — call their name, shake gently, and use a sternal rub if needed.
   • Elevate the head of the bed to improve ventilation and airway patency.
   • Administer supplemental oxygen via nasal cannula or non-rebreather mask, as appropriate.
   • Assess airway patency, pulse, and level of consciousness; attach to continuous pulse oximetry and cardiac monitoring.

3. Pharmacologic Intervention:

   • If the patient remains unresponsive or RR < 8 and SpO₂ < 90% despite stimulation and oxygen:
     • Prepare and administer naloxone (Narcan) per standing protocol or provider order.
     • Standard dose: 0.4 mg IV push, repeated every 2–3 minutes as needed (up to 2 mg total).
     • Maintain IV access and closely observe for re-sedation after naloxone’s effect wears off (usually 30–90 minutes).

4. Escalate Care Promptly:

   • Activate a Rapid Response if breathing remains inadequate or patient remains obtunded.
   • Provide manual ventilation with a bag-valve mask if indicated while awaiting the team.
   • Ensure emergency airway equipment is at bedside.

5. After Stabilization:

   • Reassess respiratory effort, pain, level of consciousness, and vital signs frequently (every 5–15 minutes initially).
   • Once stable, collaborate with the provider to revise the pain management plan, considering alternatives such as:
     • Non-opioid analgesics (acetaminophen, NSAIDs)
     • Regional anesthesia (nerve blocks)
     • Lower-dose or extended-interval opioids with close monitoring
   • Educate the patient (once awake) about safe pain reporting and risks of over-sedation.

6. Documentation:

   • Record all vital signs, assessments, and interventions chronologically.
   • Include naloxone dose, timing, and patient response.
   • Note provider notification, new orders, and follow-up observations.
   • Accurate documentation demonstrates clinical vigilance and supports quality audits in opioid safety programs.

Real-World Application

This is one of the most frequently simulated clinical scenarios in hospital interviews and competency testing.
It evaluates your ability to prioritize airway, breathing, and circulation (ABC) over comfort — a key indicator of safe nursing judgment.

Strong candidates demonstrate:

• Early recognition of respiratory compromise (RR < 10, SpO₂ < 92%)
• Rapid, independent intervention without waiting for orders
• Clear, assertive SBAR communication with providers and rapid response teams

This scenario applies to PACU, med-surg, telemetry, step-down, and pain management units, where opioid safety remains a core nursing quality metric.

Tip: In interviews, say —
“I’d pause the opioid, support airway, give oxygen, and prepare naloxone — safety before comfort.”
This concise phrasing signals critical thinking, clinical safety awareness, and leadership under pressure.