The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client’s plan of care?
A.
Encourage the client to resume normal activities after medication administration.
B.
Observe the client for involuntary movements of the lips and tongue every day.
C.
Perform a daily whisper test of the client’s hearing to detect symptoms of ototoxicity.
D.
Implement ongoing assessments for signs of shallow or slow breathing.
The correct answer and Explanation is :
Correct Answer: D. Implement ongoing assessments for signs of shallow or slow breathing.
Explanation:
Torticollis, also known as wry neck, is a condition characterized by involuntary contraction of neck muscles, resulting in an abnormal head position. When caused by trauma, it may be painful and limit neck movement, which is why pain management is critical.
The client in this scenario has been prescribed tramadol, an opioid-like pain medication commonly used to manage moderate to severe pain. While tramadol is effective in treating pain, it comes with potential side effects, particularly those that affect the central nervous system and respiratory function.
Respiratory depression is a significant risk with opioid-like medications, including tramadol. This condition can result in shallow or slow breathing, which may lead to inadequate oxygenation, reduced carbon dioxide elimination, and potentially life-threatening respiratory complications if not closely monitored. Therefore, it is essential for the Practical Nurse (PN) to regularly assess the client’s respiratory status and look for signs such as:
- Slow, shallow, or irregular breathing
- Reduced oxygen saturation levels
- Cyanosis (bluish discoloration of the skin)
This close monitoring ensures timely intervention if respiratory depression occurs, such as adjusting the medication dose or administering a reversal agent like naloxone.
Why other options are incorrect:
- A. Encourage the client to resume normal activities after medication administration.
This is inappropriate, as tramadol can cause drowsiness, dizziness, and impaired judgment. Normal activities should not be resumed immediately without assessing the client’s tolerance to the medication. - B. Observe the client for involuntary movements of the lips and tongue every day.
This intervention is more appropriate for medications like antipsychotics, which can cause tardive dyskinesia, not tramadol. - C. Perform a daily whisper test of the client’s hearing to detect symptoms of ototoxicity.
Ototoxicity is not a known side effect of tramadol. Therefore, this assessment is irrelevant to this case.