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The client arrived at the ER following a car crash. Client is a 37-year-old man presenting to the emergency room exhibiting symptoms consistent with opioid withdrawal.

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Potiential complication 2 : Fluid and electrolyte imbalance

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Potiential complication 2 : Fluid and electrolyte imbalance

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The patient is experiencing nausea and diarrhea. If not quickly resolved it could lead to severe dehydration. The constant loss of fluids could additionally cause the patient to experience electrolyte imbalances (ex; hypokalemia, hyponatremia, hypomagnesemia, etc.)

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Potiential complication 3 : Anxiety, agitation, suicide risk

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Potiential complication 3 : Anxiety, agitation, suicide risk

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The patient is becoming increasingly anxious and irritable, which raises the risk of violence toward others or self-harm. Opioid withdrawal can also lead to depression, especially in patients with a history of mental illness. Given that the patient is currently experiencing peak withdrawal symptoms, the risk of agitation and potential violence is heightened.

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With the patient being in the peak of opioid withdrawal, one of the biggest concerns is relapse. Withdrawal will cause the patient to have intense cravings. Additionally with worsening symptoms they will feel to urge to resolve these feelings by any means.

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PAUSE: Which one is the highest priority complication??

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PAUSE: Which one is the highest priority complication??

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Potential Complication #3 would be our HIGHEST PRIORITY!!

Since the patient is at a major a risk of suicidal ideation, we would expect the HCP to order a drug like methadone. Methadone is used for detoxification and maintenance treatment of opioid use disorder by reducing cravings and withdrawal symptoms. Given that his suicidal ideation is linked to withdrawal this would be a helpful treatment.

We would expect a Benzodiazepine for acute treatment of the anxiety and possibly an antidepressant if the provider sees it appropriate regarding the progress of the patient.

We would also expect to see an order for suicide precautions such as Q15 minute checks on the patient for supervision and monitoring for signs of self-harm. Assessment of suicide risk would also be done, utilizing tools like the Columbia-Suicide Severity Rating Scale and by directly asking the client if they are having suicidal thoughts and or have a plan.

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The patient reports a history of opioid use disorder for several years and a previous heroin overdose.

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The patient is experiencing opioid withdrawal symptoms including sweating, nausea/diarrhea, restlessness, rhinitis, yawning, piloerection, and describes feeling like he has "the flu". He appears anxious and irritable.

Vital Signs:

❤️ Heart rate: 110 bpm ❤️

🩸 Blood pressure: 150/90 mmHg 🩸

🫁 Respiratory rate: 22 breaths/minute 🫁

🌡️ Temperature: 37.5°C (99.5°F) 🌡️

💨 Oxygen saturation: 95% on room air 💨

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Address immediate needs by managing opioid withdrawal symptoms using a Measurement-Based Protocol, such as the Clinical Opiate Withdrawal Scale (COWS).

Provide symptomatic relief for nausea, diarrhea, and anxiety.

Monitor vital signs closely.

Facilitate a smooth transition to a higher level of care for ongoing management of his opioid use disorder.

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3 priority nursing interventions for each complication

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3 priority nursing interventions for each complication

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3 priority nursing interventions for each complication

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3 priority nursing interventions for each complication

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1. Monitor for signs of Overdose/Toxicity 🚨

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1. Monitor for signs of Overdose/Toxicity 🚨

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A relapse could to lead another opioid overdose. Continuous assessing and monitoring should be done to prevent the life-threatening concerns of opioid overdose/toxicity.

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3 priority nursing interventions for each complication 

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3 priority nursing interventions for each complication 

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1. Assess the level of anxiety or agitation every hour 😳

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1. Assess the level of anxiety or agitation every hour 😳

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A regular assessment of the patient's anxiety/agitation level allows us to monitor the severity and progression of the withdrawal symptoms. Continous monitoring allows preventative measures to be taken if escalation of severe symptoms occur.

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A patient that is actively going through opioid withdrawal may have enhanced irritability, impulsivity, or suicidal ideation. If agitation escalates, the patient could be at risk of hurting others or themselves.

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3. Provide a low-stimulation environment 🤫

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3. Provide a low-stimulation environment 🤫

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Such enviromnent can aid the patient by decreasing their anxiety, agitation, and other related opioid withdrawal symptoms. The lights, sounds, and hospital interruptions can make the patient more anxious, which increases the risk of agitation.

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1. Administer isotonic IV fluids to restore the patient’s fluid loss 🥤

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1. Administer isotonic IV fluids to restore the patient’s fluid loss 🥤

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Excessive fluid loss can occur with the patient’s nausea and diarrhea symptoms. These could lead to dehydration and later cause fluid and electrolyte imbalances. It could even potentially cause acid-base disturbances. Isotonic IV fluids like normal saline would help restore the intravascular volume and improve perfusion.

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2. Assess vitals signs every 2 hours (especially BP and HR) for indications of fluid and electrolyte imbalances 🫀

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2. Assess vitals signs every 2 hours (especially BP and HR) for indications of fluid and electrolyte imbalances 🫀

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Vital signs can be an early indicator of fluid volume status and physiological changes. Monitoring the patient’s vital signs frequently could allow timely interventions to prevent further fluid and electrolyte imbalance complications (such as arrhythmias).

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The patient’s diarrhea could lead to fluid volume loss. It is important to measure intake and output properly to detect early signs of dehydration. Knowing such factors would guide the fluid replacement therapy and prevent further complications.

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After stabilizing, the police came into the patient's room to discuss the crash. The patient was told that his soon-to-be ex-wife and best friend— who had been in the other vehicle—both died from their injuries. This conversation fully revealed to him that his wife and best friend had been secretly having an affair.

Struggling to process this, the patient disclosed that he himself had been secretly in love with his best friend for years. He further explained that his marriage had been an arrangement forced by the mafia, as his wife was the daughter of a mafia boss. He had agreed to the marriage only to stay close to the man he loved.

Now overwhelmed by grief, guilt, and fear of mafia retaliation, the patient’s mental health deteriorated quickly. He was later found attempting to break his hospital window in a suicide attempt.

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2. Provide the prescribed medication to manage the withdrawal symptoms 💊

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2. Provide the prescribed medication to manage the withdrawal symptoms 💊

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Overdose is the main complication of relapsing for a patient actively going through opioid withdrawal. Administering medication such as Naloxone (Narcan) would make the patient feel at ease, lower their cravings, and help the patient become stable both psychically and emotionally.

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This is a life threatening emergency where the patient is at a serious risk of injury or death, and may pose as a danger to others. Call the hospital security and code team to safely escort the patient away from the window and glass.

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3. Provide nonjudgemental emotional support and re-engage the patient into treatment 👩‍⚕️

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3. Provide nonjudgemental emotional support and re-engage the patient into treatment 👩‍⚕️

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When a patient relapses during opioid withdrawal, they may feel extreme emotions such as guilt, shame, embarrassment, etc. Providing nonjudgmental support is critical to reduce the stigma, build rapport, and promote treatment adherence for long term care.

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Obtain vitals and neurological status after the incident. The patient could have sustained an injury from his attempt on breaking the window, such as a fracture or head trauma. Establishing a baseline data is essential in detecting any deterioration.

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3. Initiate a 1 on 1 monitoring for suicide precaution 🧑‍⚕️ 🙍‍♂️

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3. Initiate a 1 on 1 monitoring for suicide precaution 🧑‍⚕️ 🙍‍♂️

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The patient is experiencing active suicidal ideation, therefore supervision is needed to ensure patient safety. This allows a close observation in the changes of mental status and a rapid intervention in the instance of the patient showing intent to harm themselves.