NUR5213 Module 6 pharmacology teaching plan example

Sleepy Is a Vital Sign: A Teaching Plan on Opioid Analgesics and Sedation Monitoring for Nurses in Their First Year, Built on the Pasero Scale

Student Name

American College of Education

NUR5213: Advanced Pharmacology for Health Educators

Module 6 Assignment

Instructor Name

April 11, 2028

Learners and the Problem

The learners are 18 nurses in the first year of practice in the residency program run by the author's professional development department at a composite community hospital. All have passed the licensing examination and completed orientation on medical-surgical or surgical units, where opioids are among the most common medications they give. During the past year, the hospital had seven events in which naloxone was given on a general unit for opioid-induced oversedation. In the review of those events, five patients had documented sedation scores at the level that should prompt holding the opioid and increasing monitoring, recorded one to three hours before naloxone was needed, and in three of those cases another opioid dose was given after the concerning score. Interviews with the nurses involved suggested that they saw the score but did not treat it as a warning; the patient was sleeping, and sleep was assumed to mean comfort.

The pattern matches national findings. Reviewing 92 closed malpractice claims in which opioids given after surgery depressed patients' breathing, investigators found that 88% of events took place in the first postoperative day, reviewers considered 97% preventable had monitoring and response been better, and in 62% of cases someone had already recorded that the patient was unusually drowsy (Lee et al., 2015). The problem this plan addresses is not that new nurses do not know opioids cause respiratory depression. It is that they do not yet treat sedation as the early sign of it.

The Pharmacology the Session Teaches

Opioid analgesics act mainly at mu opioid receptors. In the spinal cord and brain, receptor activation reduces the transmission and perception of pain. Mu receptors are also present in the brainstem centers that control breathing, where their activation blunts the brainstem's reaction to carbon dioxide building up in the blood. At therapeutic doses, the effect is small; as opioid levels rise, respiratory rate and depth fall, carbon dioxide accumulates and, eventually, oxygen falls. Opioids also act on arousal systems, producing sedation.

The sequence matters for monitoring. In most patients, increasing sedation precedes clinically significant respiratory depression, because the arousal systems are affected at lower opioid levels than the respiratory centers, and because a drowsy patient takes fewer deep breaths and sighs. For that reason, the monitoring guidelines of the American Society for Pain Management Nursing recommend regular assessment of sedation level with a valid scale, along with respiratory rate, depth and quality, rather than reliance on respiratory rate or pulse oximetry alone (Jarzyna et al., 2011). Pulse oximetry is a late indicator in patients receiving supplemental oxygen, because oxygen saturation can remain normal while carbon dioxide rises.

Risk rises with factors that nurses can identify: the first 24 hours after surgery or after an increase in dose, no recent opioid use, older age, obstructive sleep apnea, obesity, kidney impairment for opioids with active metabolites, and, most importantly, the concurrent use of other sedating drugs such as benzodiazepines, gabapentinoids and sedating antihistamines. In the claims analysis, concurrent nonopioid sedating medications were involved in about a third of events (Lee et al., 2015). A patient who is hard to keep awake is not resting comfortably; he is telling the nurse that the opioid dose has passed what his brainstem can tolerate.

Objectives

By the end of the session, nurses will be able to: explain, from the mechanism, why a patient on opioids usually becomes drowsy before breathing slows dangerously; identify at least five risk factors in a patient case, including concurrent sedating drugs; score sedation accurately on the Pasero Opioid-Induced Sedation Scale in video cases, with at least 80% agreement with expert scores; state the nursing action for each level of the scale, including when to hold the opioid, increase monitoring and notify the prescriber; and demonstrate the assessment in a simulated patient, including attempting to arouse the patient before scoring. The scale was chosen because, in a comparison of three sedation scales among medical-surgical nurses, it showed adequate reliability and validity and was rated highest for ease of use, nurses' confidence and usefulness for clinical decisions (Nisbet & Mooney-Cotter, 2009).

The Session

Part one, 25 minutes: the mechanism. A short interactive presentation covers mu receptors, the brainstem and the sequence from sedation to respiratory depression. Nurses are asked, before any content is given, what they would do for a post-operative patient who falls asleep in the middle of a sentence, and their answers are revisited at the end.

Part two, 35 minutes: scoring practice. Nurses watch eight brief recorded patient encounters, each showing a different depth of sedation, and score each independently on the scale, then compare scores with a partner and with an expert key. Disagreements are discussed, especially between the level at which a patient is frequently drowsy and drifts off during conversation, which calls for holding opioids and increased monitoring, and the level of acceptable drowsiness that is easy to arouse. The practice repeats until each nurse agrees with the key on at least seven of eight clips.

Part three, 40 minutes: simulation. In groups of three, nurses care for a manikin patient on the first night after knee replacement who has patient-controlled analgesia and has also received a benzodiazepine for anxiety. Over three stages, the patient becomes progressively harder to rouse while oxygen saturation remains normal on nasal oxygen. Nurses must score sedation, recognize the concurrent sedative, stop the opioid, stimulate the patient, assess respiratory rate and depth, call for help and prepare naloxone, and communicate the situation to the prescriber in SBAR form.

Part four, 20 minutes: debrief and commitments. The debrief asks each group when they first knew the patient was in danger and what almost led them to wait. Each nurse writes one change they will make on their next shift.

Assessment and Evaluation

Learning is assessed three ways. Scoring accuracy is measured with the video clips at the session and with a new set of six clips at 90 days. Knowledge of risk factors and actions is assessed with a short case-based quiz at the session and at 90 days. Performance is observed in the simulation with a checklist. The effect on practice will be evaluated on the residents' units by auditing, each month for six months, a random sample of 30 opioid administrations for a documented sedation score before the dose and the correct action when the score called for it, and by tracking naloxone administrations for oversedation on general units, with each event reviewed as before. If fewer than 90% of sampled doses have a sedation score documented beforehand by the third month, the audit results will be shared with unit managers and the residency preceptors will reinforce the practice at the bedside.

The plan also has limits that the evaluation must respect. Naloxone events are rare on any single unit, so a change in their number over six months may reflect chance rather than the session. The documentation audit is the more sensitive measure, and the event reviews will be read for whether a sedation score was recorded and acted on, which is the behavior the session targets. Nurses who complete the residency will teach the next cohort's simulation alongside the author, which both reinforces their own learning and builds a group of bedside nurses on each unit who can model the practice.

References

Jarzyna, D., Jungquist, C. R., Pasero, C., Willens, J. S., Nisbet, A., Oakes, L., Dempsey, S. J., Santangelo, D., & Polomano, R. C. (2011). American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing, 12(3), 118-145. https://doi.org/10.1016/j.pmn.2011.06.008

Lee, L. A., Caplan, R. A., Stephens, L. S., Posner, K. L., Terman, G. W., Voepel-Lewis, T., & Domino, K. B. (2015). Postoperative opioid-induced respiratory depression: A closed claims analysis. Anesthesiology, 122(3), 659-665. https://doi.org/10.1097/ALN.0000000000000564

Nisbet, A. T., & Mooney-Cotter, F. (2009). Comparison of selected sedation scales for reporting opioid-induced sedation assessment. Pain Management Nursing, 10(3), 154-164. https://doi.org/10.1016/j.pmn.2009.03.001