Postoperative Opioid and Anticoagulant Conflict
Mr. Okafor, 68, is 18 hours post open reduction of a hip fracture. He weighs 82 kg. Orders: enoxaparin 40 mg subcutaneously every 24 hours, morphine 4 mg IV every 4 hours as needed for pain, and ketorolac 15 mg IV every 6 hours scheduled. He has chronic kidney disease with an eGFR of 32 mL/min/1.73 m2 and takes warfarin at home for atrial fibrillation; the surgeon wrote enoxaparin without discontinuing warfarin. His last morphine dose was 90 minutes ago. He is drowsy, respiratory rate 9/min, SpO2 91% on room air, pupils 2 mm and sluggish. Pain score 2/10 at rest. The family asks why he is so sleepy.
1. Prioritize Mr. Okafor's medication-related problems and state the immediate nursing actions.
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Immediate threat: opioid-induced respiratory depression. RR 9/min with SpO2 91% and sluggish pupils 90 minutes after IV morphine is the most time-critical finding. Actions: stop further opioids, stimulate and reposition him, apply continuous pulse oximetry and capnography if available, prepare naloxone per protocol, and notify the prescriber and rapid response team if he does not improve. Reassess RR, sedation scale, and SpO2 every 15 minutes until stable.
Second problem: overlapping anticoagulation. Enoxaparin was ordered while home warfarin was never stopped, creating additive bleeding risk. Verify the last warfarin dose and INR, hold enoxaparin pending prescriber review, and monitor for bleeding (incision, urine, gums, neuro status).
Third problem: ketorolac with CKD. NSAIDs reduce renal perfusion; with eGFR 32 the scheduled ketorolac is unsafe and also raises bleeding risk on anticoagulation. Clarify with the prescriber and suggest an alternative analgesic.
Fourth: opioid dose in context. Age, CKD (reduced clearance of morphine metabolites), and concurrent sedatives increase sensitivity. Advocate for lower doses and a multimodal plan.
Explain to the family that the sleepiness is likely from pain medication and that monitoring is in place; avoid blame and document.
2. Write the SBAR communication to the prescriber and identify the monitoring parameters you will track for the next 24 hours.
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SBAR:
- Situation: Mr. Okafor, 68, 18 hours post hip ORIF, is drowsy with RR 9/min, SpO2 91% on room air, and sluggish pupils 90 minutes after IV morphine. Pain 2/10 at rest.
- Background: CKD eGFR 32, home warfarin for atrial fibrillation not discontinued, new enoxaparin 40 mg daily, scheduled ketorolac, morphine PRN.
- Assessment: Suspected opioid-induced respiratory depression plus additive bleeding risk from warfarin plus enoxaparin; NSAID risk with CKD.
- Recommendation: Hold further morphine and ketorolac, verify INR and last warfarin dose, hold enoxaparin pending review, order naloxone parameters, consider renal-safe analgesia, and specify monitoring frequency. Request clarification of anticoagulation plan.
Monitoring for 24 hours: respiratory rate and sedation scale every 1–2 hours while on opioids, continuous SpO2, pain scores before and after analgesia, bleeding signs (drain output, incision, urine, stool, neuro checks), hemoglobin and platelets, renal function, INR if warfarin continues, and fluid balance. Document each assessment and any escalation.