N212-Morphine Sulfate

When should you re-assess the patient's pain after giving them morphine sulfate?

1 hr following PO, subcut, IM, and 20 min (peak) following IV administration

What is the half-life of morphine sulfate?

2-4 hr

When does IV morphine peak?

20 minutes

What is the duration of oral and IV morphine sulfate?

4-5 hours

When does oral morphine sulfate peak?

60 minutes

A nurse is preparing to administer morphine sulfate intravenously for a 6-year-old child in severe pain. The child has an intravenous (IV) infusion of D5W at 50 mL/hr through a peripherally inserted central catheter (PICC). Which action is best for the nurse to take to administer the medication? 1. Dilute the morphine sulfate with 5 mL of sterile water and administer over 5 minutes into the existing IV tubing's medication port closest to the client. 2. Administer the morphine sulfate undiluted into the existing IV tubing's medication port closest to the client. 3. Question the prescribed medication because morphine sulfate cannot be administered through a central line. 4. Disconnect the infusion, inject 3 mL of normal saline, and administer the morphine sulfate undiluted.

ANSWER: 1 The nurse should dilute the morphine sulfate before administration to prevent too-rapid administration and adverse effects. A single dose should be given over 4 to 5 minutes. To avoid too-rapid administration, a syringe pump should be used. Administering undiluted morphine sulfate to a child increases the risk of adverse effects. Morphine sulfate can be administered into a PICC access device. Unnecessary IV disconnections increase the risk for infection. Morphine sulfate is compatible with D5W. ➧ Test-taking Tip: Select an option that is the most complete and the safest for the child.

Nurse A is documenting administration of morphine sulfate in a client's electronic medical record (EMR). The nurse is called away to talk with a physician and quickly leaves the computer. Seeing a free computer, Nurse B selects a different client for documentation. Nurse B is also called away. Nurse A returns to the computer and completes documentation on Nurse B's client's record. Which nursing actions should have prevented this incorrect medical record entry? SELECT ALL THAT APPLY. 1. Log out of the system before leaving the computer 2. Check that the correct client is selected before beginning documentation 3. Tell Nurse B to make sure to select the right client before documenting 4. Ask another nurse to complete the documentation 5. Always log in when accessing a record 6. Always use the assigned user ID and created password when documenting in an EMR

ANSWER: 1, 2, 5, 6 Nurses should always log in with their personal user ID and password before documenting on a medical record and always log out before leaving the computer. Never use another person's computer access. Always make sure the correct client is selected. Nurse B did select the correct client, however, did not log out. A nurse should never have another nurse complete incomplete documentation. ➧ Test-taking Tip: Read each option carefully and think about actions that would prevent inappropriate documentation in an EMR. Apply knowledge of using information technology for accurate documentation.

Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to remove the chest tubes. Which intervention should the nurse plan to implement first? 1. Auscultate the client's lung sounds 2. Administer 4 mg morphine sulfate intravenously 3. Turn off the suction to the chest drainage system 4. Prepare the dressing supplies at the client's bedside

ANSWER: 2 Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first. Auscultating the client's lungs before and after the procedure, turning off the suction, and assembling the dressing supplies are all necessary, but administering the analgesic should be first. ➧ Test-taking Tip: Recall that focusing on the client should be the priority.

A client admitted with a diagnosis of acute coronary syndrome calls for a nurse after experiencing sharp chest pains that radiate to the left shoulder. The nurse notes, prior to entering the client's room, that the client's rhythm is sinus tachycardia with a 10-beat run of premature ventricular contractions (PVCs). Admitting orders included all of the following interventions for treating chest pain. Which should the nurse implement first? 1. Obtain a stat 12-lead electrocardiogram (ECG). 2. Administer oxygen by nasal cannula. 3. Administer sublingual nitroglycerin. 4. Administer morphine sulfate intravenously.

ANSWER: 2 Oxygen should be available in the room and should be initiated first to enhance oxygen flow to the myocardium. Though a stat 12-lead ECG is needed to identify ischemia or infarct location, the first action is to treat the client. Sublingual nitroglycerin dilates coronary arteries and will enhance blood flow to the myocardium. Once oxygen is in place and the vital signs known, nitroglycerin should be administered. Morphine sulfate is a narcotic analgesic used for pain control and anxiety reduction. Because it is a controlled substance, extra steps are needed to retrieve the medication from a secure source, so this is not the first action. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to establish the priority action. Improving oxygen flow to the myocardium is priority.

A nurse is caring for a 5-year-old child from Italy. The child is crying and the interpreter is stating that the child has extreme pain. The nurse's first priority should be to: 1. have the child's mother who knows limited English ask the child what hurts. 2. assess the level of the child's pain using an appropriate FACES pain rating scale. 3. administer morphine sulfate 1 mg IV as prescribed. 4. call the health-care provider to request a change in pain medication dosage as it is not adequately controlling the child's pain.

ANSWER: 2 The FACES pain-rating scale has been translated to a variety of languages. The nurse's judgment regarding the choice of pain medication and dose should be based on the reported level of pain. If possible, the nurse should do an independent assessment because sometimes information can be misinterpreted if there is limited knowledge of the language. Assessment should be completed prior to a pain intervention. There is no information indicating the need for the pain medication to be changed. ➧ Test-taking Tip: Note the key word "priority." Use the nursing process. Assessment is the first step.

A health-care provider (HCP) writes the following orders for a client admitted in sickle cell crisis: "oxygen 2L/NC, one unit MS 4 mg IV now, one unit packed red blood cells, and hydroxyurea (Hydrea®) 250 mg oral daily." In response to these orders, what action should a nurse take? 1. Initiate all orders as prescribed 2. Call the HCP to clarify the MS order 3. Prepare 4 mg MS for administration after initiating the oxygen 4. Verify with another nurse that MS should be morphine sulfate based on this client's condition

ANSWER: 2 The abbreviation MS is on the "do not use" list of abbreviations by The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]). It could be interpreted as morphine sulfate or magnesium sulfate. Initiating all orders, preparing and administering MS, or verifying the abbreviations MS with another nurse are unsafe actions. ➧ Test-taking Tip: Carefully read each prescribed order, noting that all would be appropriate for a client in sickle cell crisis except MS. MS could be either morphine sulfate (which is appropriate) or magnesium sulfate (which would be inappropriate).

A nurse in the Post-Anesthesia Care Unit (PACU) is caring for a client who received general anesthesia. Which interventions should the nurse implement when caring for this client? SELECT ALL THAT APPLY. 1. Teach the client how to use an incentive spirometer 2. Move the client into a lateral position to protect the airway 3. Administer morphine sulfate intravenously (IV) for pain control 4. Protect IV lines to prevent dislodgement during emergence delirium 5. Repeat orientation explanations until the amnesiac anesthesia wears of

ANSWER: 2, 3, 4, 5 Unless contraindicated, the side-lying position will prevent aspiration of secretions. Turning also will mobilize secretions. Analgesics are administered IV in the PACU for a rapid onset in controlling pain. Some clients emerge from anesthesia in an agitated state for a short period of time. This is termed emergence delirium. Amnesiac anesthesia causes a loss of memory. Repeat explanations such as "Mr. Brown, surgery is over; you are in the recovery room." The client would not be alert enough to be able to comprehend using the incentive spirometer and would not be ready to sit up to use it. ➧ Test-taking Tip: Visualize a client recovering from anesthesia and use the ABCs (airway, breathing, circulation) and Maslow's Hierarchy of Needs theory to assist in identifying appropriate interventions.

A charge nurse is reviewing documentation completed by a registered nurse (RN) and evaluating delegation abilities to a licensed practical nurse (LPN) and nursing assistant (NA). Which medical record documentation should the charge nurse determine may have occurred because of inappropriate delegation? Client Narrative Notes 1 0800 BP elevated at 150/90 mm Hg (obtained per J. Brown, NA). Client rates right shoulder incisional pain at 10/10. Morphine sulfate given intravenously for pain control. __________________________ M. Drew, RN. 2 1000 Assisted up to the bathroom per J. Brown, NA. Voided cloudy, foul-smelling urine. Urine output 20 mL/hr for past 4 hr. Dr. Peters notified. __________________________ M. Drew, RN. 3 1200 Fingerstick blood glucose 55 mg/dL (taken per J. Brown, NA). Given 4 units lispro (Humalog®) insulin subcut as ordered before lunch. __________________________ A. Smith, LPN 4 1400 Ambulated 100 feet in hallway. Assisted with hygiene while sitting in chair per RN direction. Hygienic care refused earlier due to fatigue. __________________________ J. Brown, NA

ANSWER: 3 Appropriate delegation includes assessing the knowledge and skill of the delegate. A glucose level of 55 mg/dL is low (normal = 70-110 mg/dL) and rapid-acting lispro insulin should not have been administered. There is no indication that the LPN notified the RN of the abnormal findings. Taking a blood pressure and reporting the findings to the RN is evident in option 1. Administering intravenous medications is within the RN scope of practice. Assisting a client to the bathroom is an appropriate task for the NA, reporting to the RN the findings is evident, and the RN's role in calling the physician is appropriate. Assisting a client with activity and hygienic care is appropriate NA tasks and reporting of refused hygienic care is evident. Documenting completion of tasks is appropriate for the NA. The location of documentation of task completion may vary by facility and may include only a flowsheet or narrative documentation. ➧ Test-taking Tip: Carefully read each option. Consider the RN's responsibility in assessing the knowledge and skills of the delegate.

A registered nurse (RN) assesses that a client is pale, diaphoretic, dyspneic, and experiencing chest pain. Which actions are best for the nurse to take? 1. Stay with the client, call the charge nurse for help, and call the patient care assistant (PCA) to bring an automatic vital signs machine to the room immediately. 2. Call the PCA to take the client's vital signs while the RN leaves to obtain a narcotic analgesic for administration and notify the charge nurse. 3. Apply oxygen, call the PCA to bring an automatic vital signs machine, and call the charge nurse for help and ask to bring the chart and morphine sulfate noted on the medication record. 4. Activate the emergency system for a code to get immediate help, apply oxygen, and send responders for needed equipment and medication.

ANSWER: 3 Because the client is in distress, the RN should stay with the client, apply oxygen, and obtain help from other members of the health-care team. Asking the charge nurse to bring the chart and morphine sulfate, or other medications noted in the chart, will save time in responding to the situation. The charge nurse should delegate locating the chart and obtaining the medication to another nurse. In option 1 the charge nurse is responding, but then either the nurse or the charge nurse would need to leave the room to obtain needed medication, causing a loss of time in treating the client's pain. In option 2 the RN leaves the room but should have stayed, as the client is in distress. In option 4, the code system should only be activated if the client's pulse or respirations are absent because activation will bring members from multiple departments. Some facilities have an acute response team (ART), which has a different composition of personnel who can respond in emergency situations. ➧ Test-taking Tip: Read each option carefully and systematically. Eliminate any options that allow the nurse to leave the room. Use the ABCs (airway, breathing, circulation) to establish the priority intervention for the RN.

A terminally ill, 46-year-old client has an order for morphine sulfate 2 mg to 6 mg intravenously (IV) every 2 hours prn for pain. A nurse administers 2 mg for the first dose, but after 20 minutes the client has no relief and experiences no side effects. What is the nurse's best action? 1.Wait until the 2 hours has elapsed from the time the 2 mg morphine sulfate was administered before giving additional medication, but implement complementary measures for pain control. 2. Call the physician to determine if additional medication can be administered now, since the client had inadequate pain relief. 3. Administer 4 mg of morphine sulfate at the peak effect of the first dose, which would be 20 minutes after the first dose. 4. Repeat the 2 mg of morphine sulfate now and, if not effective, administer the additional 2 mg in 15 minutes.

ANSWER: 3 The client has a range order for morphine sulfate. The total dose is 6 mg in a 2-hour period. Since the client had no relief after 15 minutes and no side effects, 4 mg should be administered to maximize pain control. The peak time for morphine sulfate administered IV is 20 minutes. Complementary measures can be used to distract the client from pain but should not replace analgesic medications for pain control. It is unnecessary to call the physician because the ordered dose is up to 6 mg in 2 hours. The initial dose of 2 mg did not relieve the client's pain; giving an additional 2 mg now and then waiting will only delay when the client can receive the next maximum dose of the medication for adequate pain control. ➧ Test-taking Tip: Recognize that the morphine sulfate has been ordered as a range order. Carefully consider the data in the situation.

A nurse assesses a client 6 hours postoperatively following a lumbar spinal fusion. The client is experiencing a headache rated at 8 out of 10 but denies nausea. The neurovascular status of the lower extremities is intact, and the vital signs are within the normal range. The client log rolls with assistance. The lungs have fine crackles in the left base. The back dressing has a dime-sized bloody spot surrounded by a moderate amount of clear yellowish drainage. Which nursing action demonstrates the nurse's best clinical judgment? 1. Administering morphine sulfate intravenously 2. Encouraging coughing and deep breathing 3. Reinforcing the incisional dressing 4. Notifying the client's physician

ANSWER: 4 A bloody area surrounded by clear yellowish fluid on the dressing and the client's headache suggest a cerebral spinal fluid leak, a complication following spinal fusion. The client may need to be kept on bedrest for a few days while the dural tear heals or may need a blood patch to seal the leak because the client is at risk for a central nervous system infection. All other actions are correct and should also be implemented. ➧ Test-taking Tip: Focus on the data and what the question is asking: "the best clinical judgment."

A client is being admitted to a postsurgical unit following anorectal surgery. A nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question? 1. Administer morphine sulfate per intravenous bolus before the first defecation 2. Administer sitz bath after each defecation 3. Begin high-fiber diet as soon as client can tolerate oral intake 4. Position client in supine position with the head of the bed elevated to 30 degrees.

ANSWER: 4 After anorectal surgery, the client should be positioned in a side-lying position to decrease rectal edema and client discomfort. Pain medication is recommended before the first defecation, and a sitz bath is encouraged for rectal cleansing after defecation. Prevention of constipation with a high-fiber diet is also recommended.

A nurse is reviewing orders received for a newly admitted child with second- and third-degree burns over 10% of the total body surface area (TBSA). The child weighs 20 kg. The nurse should seek further clarification from a physician when the physician's order is: 1. Ringer's lactate (RL) at 50 mL per hour for the next 8 hours. 2. insert a urinary catheter. 3. elevate the extremities above the level of the heart. 4. morphine sulfate IV prn for pain control.

ANSWER: 4 Because the order for morphine sulfate does not state a dose, the order should be clarified with the physician. If the physician intended the dose to be based on the weight of the child, then this should be included in the order. In the first 24 hours, fluid resuscitation is 4 mL/kg body weight per percentage of burn TBSA, with half over the first 8 hours and the remaining over the next 16 hours (4 mL X 20 kg = 80 mL; 80 mL X 10 = 800 mL for 24 hours; half of this is 400 mL over 8 hours; 400 ÷ 8 = 50 mL). A Foley urinary catheter is inserted so that urine output can be closely monitored as a guide for volume status. During the resuscitation phase, edema formation can decrease perfusion. Elevating the limbs above the heart level promotes gravity-dependent drainage. ➧ Test-taking Tip: Carefully read each option. Avoid reading into any option choice.

An elderly client with Alzheimer's dementia is being admitted from a postanesthesia unit following a hip hemiarthroplasty to treat a hip fracture. Which intervention should a nurse initially plan for the client's pain control? 1. Apply a fentanyl (Duragesic®) transdermal patch. 2. Initiate morphine sulfate per patient-controlled analgesia (PCA) with a basal rate. 3. Administer intravenous morphine sulfate based on the client's report of pain. 4. Administer scheduled doses of morphine sulfate intravenously around the clock.

ANSWER: 4 In addition to scheduling pain medication around the clock, supplemental NSAIDs can be administered to reduce inflammation and enhance the effects of the analgesic. A transdermal analgesic patch is used to treat chronic, not acute, pain. Usually a PCA affords the client better control over the pain and avoids the peaks and valleys associated with intermittent analgesics. However, the client with dementia would be unable to adequately use PCA. The client with dementia typically cannot report the level of pain accurately. ➧ Test-taking Tip: Note the client has Alzheimer's dementia. This influences the treatment choices.

Why should patients be advised to change positions slowly when on morphine sulfate?

Advise patient to change positions slowly to minimize orthostatic hypotension.

How can constipation be prevented in patients taking opioids?

Assess bowel function routinely. Institute prevention of constipation with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Administer stimulant laxatives routinely if opioid use exceeds 2-3 days, unless contraindicated.

What is the action of morphine sulfate?

Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Therapeutic Effects: Decrease in severity of pain.

What are side-effects of morphine sulfate?

CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: RESPIRATORY DEPRESSION. CV: hypotension, bradycardia. GI: constipation, nausea, vomiting. GU: urinary retention. Derm: flushing, itching, sweating. Misc: physical dependence, psychological dependence, tolerance.

Can patients drink alcohol on morphine sulfate?

Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication.

What are drug-natural product interactions of morphine sulfate?

Concomitant use of kava-kava, valerian, or chamomile can increase CNS depression.

When is morphine contraindicated?

Contraindicated in: Hypersensitivity; Some products contain tartrazine, bisulfites, or alcohol and should be avoided in patients with known hypersensitivity.; Acute, mild, intermittent, or postoperative pain (extended/sustained-release); Significant respiratory depression (extended/sustained-release); Acute or severe bronchial asthma (extended/sustained-release); Paralytic ileus (extended/sustained release)

For continuous infusion, what diluent should morphine sulfate be added to? What should the concentration be?

Diluent: May be added to D5W, D10W, 0.9% NaCl, 0.45% NaCl, Ringer's or LR, dextrose/saline solution, or dextrose/Ringer's or LR. Concentration: 0.1-1 mg/mL or greater for continuous infusion.

How should direct IV morphine sulfate be diluted? What should the concentration be per mL? How long should it be administered?

Dilute with at least 5 mL of sterile water or 0.9% NaCl for injection. Concentration: 0.5-5 mg/mL. Rate: High Alert: Administer 2.5-15 mg over 5 min.

Should PO morphine sulfate be administered with food or on an empty stomach? Why?

Doses may be administered with food or milk to minimize GI irritation.

Should morphine be diluted when given as an epidural? What are other considerations when morphine is given as an epidural?

Epidural: Administer undiluted. If a lidocaine test dose is administered, flush catheter with 0.9% NaCl and wait 15 min before administration of DepoDur. Do not use an in-line filter. Do not admix or administer other medications in epidural space for 48 hr after administration. Administer within 4 hr after removing from vial. Store in refrigerator; do not freeze.

When should morphine be used cautiously?

Head trauma; increased intracranial pressure; Severe renal, hepatic, or pulmonary disease; Hypothyroidism; Seizure disorder; Adrenal insufficiency; History of substance abuse; Undiagnosed abdominal pain; Prostatic hyperplasia; Patients undergoing procedures that rapidly decreased pain (cordotomy, radiation); long-acting agents should be discontinued 24 hr before and replaced with short-acting agents Geri: Geriatric or debilitated patients (dose decrease suggested) OB, Lactation: Avoid chronic use; has been used during labor but may cause respiratory depression in the newborn; Pedi: Neonates and infants 3 mo (more susceptible to respiratory depression) Pedi: Neonates (oral solution contains sodium benzoate which can cause potentially fatal gasping syndrome).

What should you assess patients for before and during administration of morphine sulfate?

High Alert: Assess level of consciousness, BP, pulse, and respirations before and periodically during administration.

What is the dosage for IM, IV, Subcut of morphine sulfate?

IM, IV, Subcut (Adults > 50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients—4-10 mg q 3-4 hr. MI—8-15 mg, for very severe pain additional smaller doses may be given every 3-4 hr.

What is the antidote for opioid toxicity? How is it administered?

If an opioid antagonist is required to reverse respiratory depression or coma, naloxone is the antidote. Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by direct IV push every 2 min.

What should you do if the respiratory rate of a patient on morphine sulfate is less than 10/min?

If respiratory rate is 10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Subsequent doses may need to be decreased by 25- 50%. Initial drowsiness will diminish with continued use.

Is morphine sulfate safe for pregnant women to take?

It is Pregnancy Category C. This means: Risk not ruled out: Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women, or no animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women.

Why shouldn't morphine be stopped suddenly after long-term use?

Morphine should be discontinued gradually to prevent withdrawal symptoms after long-term use.

Where is morphine sulfate metabolized and excreted?

Mostly metabolized by the liver. Active metabolites excreted renally.

Why should geriatric patients be assessed more frequently when on morphine sulfate?

Older adults are more sensitive to the effects of opioid analgesics and may experience side effects and respiratory complications more frequently.

What is the dosage for po/rectal of morphine sulfate?

PO, Rect (Adults > 50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients— 30 mg q 3-4 hr initially.

Since prolonged use may lead to physical and psychological dependence, should patients be prevented from receiving higher doses of morphine sulfate?

Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive morphine for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term therapy.

Why shouldn't direct IV morphine be rapidly administered?

Rapid administration may lead to increased respiratory depression, hypotension, and circulatory collapse.

What is more effective? PRN administration or regularly administering morphine sulfate?

Regularly administered doses may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.

What drug schedule is morphine sulfate?

Schedule II

What is the indication for morphine sulfate?

Severe pain. Management of moderate to severe chronic pain in patients requiring use of a continuous around-the-clock opioid analgesic for an extended period of time (extended/ sustained-release). Pulmonary edema. Pain associated with MI.

What is the therapeutic classification of morphine sulfate? What is the pharmacologic classification?

Therapeutic: opioid analgesics Pharmacologic: opioid agonists

What are drug-drug interactions of morphine sulfate?

Use with extreme caution in patients receiving MAO inhibitors within 14 days prior (may result in unpredictable, severe reactions—decrease initial dose of morphine to 25% of usual dose). Decreased CNS depression with alcohol, sedative/hypnotics, clomipramine, barbiturates, tricyclic antidepressants, and antihistamines. Administration of partial-antagonist opioid analgesics may precipitate opioid withdrawal in physically dependent patients. Buprenorphine, nalbuphine, butorphanol, or pentazocine may decrease analgesia. May increase the anticoagulant effect of warfarin. Cimetidine decrease metabolism and may increase effects.

How should morphine sulfate be titrated?

When titrating opioid doses, increases of 25-50% should be administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analogue scale or the patient reports satisfactory pain relief. When titrating doses of short-acting morphine, a repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.

Is morphine sulfate a high-alert medication?

Yes

Should morphine sulfate be diluted?

Yes