A 62-year-old client with chronic low-back pain has taken sustained-release morphine 30 mg every 12 hours and scheduled acetaminophen for 3 months. Pain has decreased from 7/10 to 3/10, and walking has improved. Which actions should the nurse include in follow-up care? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Ongoing opioid therapy is judged by meaningful improvement in pain and function while risks remain acceptable, not by a goal of zero pain. Reassess function, adverse effects, goals, adherence, and the benefit-risk balance at follow-up (Choice 6). Sedation and respiratory risk require assessment and client education, particularly after treatment begins or the dose rises (Choice 1). Opioid-related constipation often persists; assess bowel function and use an individualized bowel regimen that commonly includes a stimulant or osmotic laxative plus nonpharmacologic measures (Choice 5). Do not continue 4 g/day of acetaminophen automatically without reviewing all sources and hepatic and alcohol-related risks (Choice 2). Do not escalate morphine solely from a numeric score without reassessment (Choice 3). Codeine still causes opioid toxicity and has clinically important metabolic variability; it is not automatically a safer breakthrough medication (Choice 4).
Clinical Judgment The clinical aim of long-term opioid therapy for chronic pain is functional improvement, not the elimination of pain. The nurse uses a multidimensional assessment — numeric pain score, function, side effects, and patient-defined goals — to guide every titration decision.
Memory Tip Opioid safety bundle = A-B-C: Assess multidimensional + Bowel regimen scheduled + Check sedation (POSS) and respiratory rate.
KR vs US In Korea, opioid-induced constipation is often under-treated because routine scheduled laxatives are less common in chronic pain clinics. NCLEX-RN expects the nurse to start a stool softener plus a stimulant laxative on the same day the opioid is started, not after constipation appears.
Clinical Practice GuideThe CDC 2022 Clinical Practice Guideline for Prescribing Opioids for Pain emphasizes individualized goal-setting, non-opioid first-line options, and the lowest effective opioid dose. The American Society for Pain Management Nursing recommends POSS-based sedation monitoring before each opioid dose, with respiratory rate as the late, most sensitive marker of opioid-induced respiratory depression.
CautionThe NCLEX trap is choosing the option that maximizes opioid dose to chase a zero-pain goal — chronic-pain therapy targets function, not numeric pain alone. Tolerance does not develop to opioid-induced constipation, so a scheduled bowel regimen is started early, not as needed.
Multimodal Analgesia — Combined use of two or more analgesic agents or techniques (acetaminophen, NSAIDs, opioids, regional anesthesia, non-pharmacological methods) targeting different pain pathways. Reduces opioid dose and side effects, and is the standard for chronic-pain care. NCLEX exam tip: when the prescription combines scheduled non-opioid plus opioid, do not discontinue the non-opioid.
POSS (Pasero Opioid-induced Sedation Scale) — A 5-point scale (S, 1, 2, 3, 4) used to detect sedation before opioid-induced respiratory depression. Score 3 (frequent drowsiness, falls asleep mid-conversation) or 4 (no response) requires holding the opioid and notifying the provider. NCLEX exam tip: sedation precedes respiratory depression; check POSS and respiratory rate before each opioid dose, especially after a dose increase.
Opioid-induced Constipation (OIC) — A near-universal side effect of opioid therapy with no tolerance development. Prevention requires a scheduled bowel regimen with both a stool softener (docusate) and a stimulant laxative (senna or bisacodyl) started on the same day the opioid is started. NCLEX exam tip: PRN laxatives alone are insufficient; the regimen must be scheduled and start early.