The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
A.
delayed respiratory depression.
B.
inability to move lower extremities.
C.
pruritus.
D.
nausea and vomiting.
The Correct Answer and Explanation is:
The correct answer is B. inability to move lower extremities.
Explanation:
When a woman receives epidural or intrathecal opioids for pain relief during labor or a cesarean section, specific nursing observations are essential to monitor for adverse effects and ensure maternal safety. The primary concerns are delayed respiratory depression, pruritus, and nausea and vomiting.
- Delayed Respiratory Depression (A): One of the most serious potential complications of epidural or intrathecal opioid administration is respiratory depression. This effect may not be immediate and can occur hours after the initial administration, particularly with certain opioids like morphine, which have a longer duration of action. Nurses must continuously monitor the patient’s respiratory rate, oxygen saturation, and level of consciousness to detect early signs of respiratory compromise.
- Inability to Move Lower Extremities (B): While loss of sensation or motor function in the lower extremities can occur after epidural anesthesia due to the local anesthetics used, it is not a common side effect of opioids themselves. Opioids administered through the epidural or intrathecal route primarily act on pain receptors in the spinal cord without significantly affecting motor function. Thus, inability to move the lower extremities would more likely be associated with the anesthetic block rather than the opioid. This makes it an incorrect option as a key nursing observation for opioid-related side effects.
- Pruritus (C): Pruritus, or itching, is a common side effect of opioids administered through epidural or intrathecal routes. It can occur due to the opioid’s interaction with receptors in the central nervous system. Nurses should monitor and manage itching to improve the patient’s comfort, sometimes using antihistamines or opioid antagonists.
- Nausea and Vomiting (D): Another common side effect of opioid use is nausea and vomiting. This is due to the opioids’ stimulation of the chemoreceptor trigger zone in the brain. Antiemetic medications are often used to manage these symptoms. Close observation is necessary to prevent dehydration or discomfort.
In summary, while delayed respiratory depression, pruritus, and nausea and vomiting are key nursing observations for patients receiving epidural or intrathecal opioids, inability to move the lower extremities is not primarily caused by opioids and is more related to local anesthetics.