The New Patch and the Dizzy Morning
Mrs. Chen is 81 and has dementia. She has a fentanyl patch for chronic back pain, changed every 72 hours by the nurse. Last night the aide noticed she was sleepy at dinner and skipped her evening walk. This morning she is hard to wake, her breathing is slow and shallow, and her fingertips look bluish. Her pupils are tiny. The aide is not permitted to change patches but can observe and report. The nurse is in a meeting. A second resident is calling for help with breakfast.
1. What is the aide's priority, and what should the aide do before the nurse arrives?
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The priority is to treat this as a possible opioid overdose and get emergency help, not to wait for the meeting to end. The aide should stay with Mrs. Chen, call for the nurse and activate the emergency call system, and start rescue breathing if she is not breathing adequately - the aide should not leave her alone. The aide should open the door, note the time, and check for a patch on her skin without removing it unless trained and directed to. The aide should report the small pupils, slow shallow breathing, bluish fingertips, and sleepiness since dinner. The aide should not give food or drink, should not try to walk her, and should not assume she is 'just tired.' Once help arrives, the aide should clear the second resident's call with another staff member or report it, so no one is abandoned.
2. The nurse finds the patch and notes it was changed yesterday. What should the nurse consider and document?
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The nurse should suspect opioid toxicity and follow the facility's emergency protocol, including calling for emergency services and preparing naloxone if available and within scope. The nurse should assess respirations, oxygen saturation, level of consciousness, and pupils, and should check whether the patch is intact, whether a second old patch was left on, and whether heat (a heating pad, fever, or hot bath) increased absorption. The nurse should document the time of the last patch change, site, dose, and all findings, and should report the event to the prescriber and the family. The nurse should also review whether the dose was appropriate for her age and kidney function. The aide's observations - sleepiness at dinner, skipped walk, bluish fingertips - belong in the record as early warning signs.