Morphine: Nursing Considerations, Interventions, and Health Education

Introduction

Morphine is a potent opioid analgesic widely used in clinical settings for the management of moderate to severe pain. Its effectiveness in controlling pain, particularly post-operative, cancer-related, and chronic pain, makes it an essential drug in the nurse’s arsenal. However, due to its powerful pharmacological effects and risk of dependency, morphine administration requires careful consideration, vigilant monitoring, and patient education.

Overview of Morphine

Morphine is a naturally occurring alkaloid derived from the opium poppy. It acts primarily on the central nervous system (CNS) by binding to opioid receptors (mainly mu receptors), resulting in analgesia, sedation, and a sense of euphoria. While morphine is invaluable in pain management, its use is associated with significant side effects, including respiratory depression, constipation, nausea, and the potential for addiction.

Nursing Considerations

Assessment of Pain:

1. Conduct a thorough pain assessment using validated tools such as the Numerical Rating Scale (NRS) or Visual Analogue Scale (VAS).
2. Assess the characteristics of pain: location, intensity, duration, frequency, and relieving/aggravating factors.

Patient History:

1. Obtain a detailed medical history, focusing on previous opioid use, allergies, history of substance abuse, and any contraindications (e.g., severe respiratory depression, head injury, acute asthma).
2. Review concurrent medications to avoid harmful interactions (e.g., with sedatives, MAO inhibitors).

Baseline Observations:

1. Record baseline vital signs, especially respiratory rate, oxygen saturation, blood pressure, and heart rate.
2. Assess level of consciousness and orientation.

Route of Administration:

1. Select the appropriate route (oral, intravenous, intramuscular, subcutaneous, or epidural) as per physician’s prescription and patient needs.

Informed Consent:

1. Ensure the patient (or guardian) is informed about the purpose, risks, and benefits of morphine therapy.

Nursing Interventions

Preparation and Dosage:

1. Follow the “Five Rights” of medication administration: right patient, right drug, right dose, right route, and right time.
2. Double-check calculations and seek co-signature for high-alert medications like morphine.
3. Use aseptic technique, especially for parenteral administration.

Monitoring for Adverse Effects:

1. Monitor respiratory rate closely; withhold morphine and notify the physician if respiratory rate falls below 12 breaths per minute.
2. Observe for signs of sedation, hypotension, bradycardia, and allergic reactions.
3. Monitor for gastrointestinal side effects such as nausea, vomiting, and constipation.

Pain Reassessment:

1. Reassess pain 30-60 minutes after administration (depending on route) to evaluate efficacy and need for further intervention.

Prevention of Complications:

1. Encourage the patient to cough and breathe deeply to prevent atelectasis and pneumonia, especially in post-operative patients.
2. Institute fall precautions for sedated patients.
3. Administer antiemetics as prescribed to manage nausea.
4. Initiate bowel protocols (e.g., laxatives, increased fluid intake) to prevent constipation.

Documentation:

1. Record the time, dose, route, and site of administration.
2. Document pain scores before and after administration, side effects, and interventions provided.

Emergency Preparedness:

1. Keep naloxone (an opioid antagonist) readily available for the management of opioid-induced respiratory depression.
2. Be prepared to provide oxygen support and initiate emergency protocols if necessary.

Ongoing Monitoring and Interventions

Vital Signs:

1. Continue periodic monitoring of respiratory rate, pulse, blood pressure, and oxygen saturation throughout therapy.
2. Watch for signs of opioid toxicity: pinpoint pupils, shallow breathing, unresponsiveness.

Level of Consciousness:

1. Monitor for excessive sedation, confusion, or delirium, especially in elderly patients or those with renal/hepatic impairment.

Gastrointestinal Function:

1. Assess bowel movements daily; encourage fibre-rich diet and hydration.
2. Monitor for signs of paralytic ileus, a rare but serious complication.

Urinary Function:

1. Assess for urinary retention, particularly in older adults and those with prostatic hypertrophy.

Psychological Support:

1. Provide reassurance and emotional support, as chronic pain and opioid use can impact mental health.
2. Refer to counsellors or support groups as appropriate.

Health Education for Patients and Families

Purpose and Expected Outcomes:

1. Explain the reason for morphine therapy and the expected benefits in pain relief.
2. Set realistic expectations regarding pain control—complete absence of pain may not be possible, but the goal is to make pain manageable.

Administration Instructions:

1. Teach patients how to take morphine if prescribed for home use: dosage, timing, and what to do if a dose is missed.
2. Emphasise not to increase the dose without consulting a healthcare provider.

Recognition of Side Effects:

1. Educate about common side effects: drowsiness, constipation, nausea, and how to manage them.
2. Instruct to report alarming symptoms immediately, such as difficulty in breathing, severe drowsiness, chest pain, or allergic reactions (rash, swelling, itching).

Prevention of Constipation:

1. Advise on dietary modifications: increase fibre intake, drink plenty of water, and be physically active as tolerated.
2. Discuss the use of prescribed laxatives or stool softeners.

Fall and Injury Prevention:

1. Warn about the risk of drowsiness, dizziness, and slowed reactions—encourage the use of support while walking and getting up slowly from bed.
2. Advise to avoid operating machinery or driving while under the influence of morphine.

Addiction and Dependence:

1. Discuss the potential for dependence and addiction, especially with prolonged use.
2. Reassure that, when used for legitimate medical reasons and under supervision, the risk is minimised.
3. Encourage open communication about any concerns related to addiction.

Safe Storage and Disposal:

1. Emphasise the importance of keeping morphine out of reach of children and unauthorised persons.
2. Instruct on the proper disposal of unused or expired medication as per local guidelines to prevent misuse.

Drug Interactions and Alcohol:

1. Advise to inform all healthcare providers about morphine use, especially before starting new medications.
2. Warn against consuming alcohol or other CNS depressants while on morphine, as they can increase the risk of respiratory depression.

Follow-Up and When to Seek Help:

1. Encourage regular follow-up visits for pain assessment and dose adjustment.
2. Instruct to seek immediate medical attention for symptoms of overdose (slow or shallow breathing, extreme drowsiness, loss of consciousness).

Conclusion

Morphine remains a cornerstone in the management of moderate to severe pain, but its use demands a high level of vigilance and responsibility from nursing professionals. Safe and effective morphine administration hinges on comprehensive patient assessment, meticulous monitoring, prompt intervention for adverse effects, and robust patient and family education.

REFERENCES

1. Kizior, R. J., & Hodgson, K. J. (2020). Saunders Nursing Drug Handbook 2019. Elsevier Health Sciences.
2. Ernstmeyer K, Christman E, editors. Nursing Pharmacology [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK595000/
3. Skidmore-Roth, L. (2015). Mosby’s drug guide for nursing students (11th ed.). Elsevier Health Sciences.

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