Morphine Sulfate Nursing Implications |Patient Teachings |Nursing diagnosis |Interventions

Introduction

In this article, you’ll learn about Morphine sulfate nursing implications and patient teachings. Also, its dosage, mechanism of action, indication, side effects.

Morphine is a prototype opioid. Which is derived from the sap of the seed pods of the opium poppy plant. Codeine is a similar but less potent opium-derived medication.

Opioid analgesics work primarily on the central nervous system. It mostly activates μ-opioid receptors (MORs) and only slightly activates kappa (κ).

Mu receptor activation causes analgesia, respiratory depression, euphoria, and sedation. While kappa opioid receptors (KORs) only produces analgesic and sedative effect without respiratory depression and euphoria.

Morphine also has an antitussive effect which decreases coughing by acting on cough centers in the medulla of the brainstem.

Morphine sulfate is an opium alkaloid primarily used to treat moderate to severe acute or chronic pain. It is classified as a schedule-II controlled substance.

The opioid antagonist naloxone (Narcan) is an antidote for morphine overdose.

Generic Name: Morphine Sulfate

Brand Name(s): Arymo ER, Astramorph PF, Doloral (CAN), Duramorph PF, Infumorph, M-Eslon (CAN), Mitigo, MorphaBond ER, Morphine LP Epidural (CAN), MS Contin, Kadian, Oramorph SR, MS IR, Ratio-Morphine (CAN), Simplist, Statex (CAN)

Morphine Sulfate Class and Category

Pharmacologic class: Opioid agonist  

Therapeutic class: Opioid analgesic

Pregnancy category: C

Controlled substance schedule: II

Morphine Sulfate Dosage

Adults

  • PO: tabs: 10 – 30 mg, q4h, PRN.
  • PO: sol: 10 – 20 mg, q4h, PRN.
  • PO: SR tabs: 15 – 30 mg, q12h, PRN.
  • IV injection: 0.1 – 0.2 mg/kg, slow IV, q4h, PRN.
  • IV Infusion: 0.1 – 0.15 mg/kg/hr.
  • IM/SubQ: 10 mg, q4h, PRN.
  • Epidural: Initially, 5 mg as a single dose. 1 – 2 mg PRN. Maximum: 10 mg/24 hr.
  • Intrathecal: 0.2 – 1 mg, STAT.
  • PR: 10 – 20 mg, q4h, PRN.

Children

  • PO: 0.1 – 0.5 mg/kg, q4-6h, PRN.
  • IM/SubQ: 0.05 – 0.2 mg/kg q2-8h PRN; maximum dose: <15 mg/dose.
  • IV infusion: 0.01 – 0.04 mg/kg/hr postop, 0.04 – 0.07 mg/kg/hr for severe chronic cancer pain or sickle cell crisis.
  • PR: individualized dose.

Morphine Sulfate Pharmacokinetics and Pharmacodynamics

RouteOnsetPeakDuration
PO (tabs, sol)30 min1 – 2 hrs4 – 5 hrs
PO (ext. rel)Unknown3 – 4 hrs8 – 12 hrs
IVRapid20 min4 – 5 hrs
IM5 – 30 min0.5 – 1 hrs4 – 5 hrs
Subcutaneous10 – 30 min50 – 90 min4 – 5 hrs
PR20 – 60 min0.5 – 1 hrs3 – 7 hrs
Intrathecal15 – 60 minUnknownUp to 24 hrs
Epidural15 – 60 minUnknownUp to 24 hrs
Morphine sulfate pharmacokinetics & pharmacodynamics

Absorption: Morphine absorption in the GI tract varies when taken orally. Rapid absorption after IV, IM, and SQ administration.

Distribution: Protein binding is 20 – 35 percent.

Metabolism: Hepatic.

Half-life: 2 – 4 hours; Kadian (ext. rel) 11-13 hours.

Excretion: Mainly excreted via urine. Can be removed by hemodialysis.

Morphine Mechanism of Action

Morphine sulfate, an opioid agonist, is largely selective for the mu receptor (MOR). Morphine acts by binding those receptors in the brain and spinal cord to produce its analgesic effect.

Morphine sulfate produces drowsiness, mood changes, respiratory depression, decreased gastrointestinal motility, nausea, vomiting, and abnormalities in the endocrine and autonomic nervous systems in addition to analgesia.

Morphine’s primary therapeutic effect is analgesia. Additional therapeutic effects include anxiolysis, euphoria, and relaxation.

What are the indications of morphine sulfate?

Morphine sulfate indications include:

Off-label uses include:

  • To alleviate dyspnea in end-stage cancer or pulmonary disease
  • To induce sedation
  • Rapid-sequence intubation

What are the contraindications of morphine sulfate?

The contraindications of morphine sulfate are:

  • Hypersensitivity to morphine and its components
  • Bronchial asthma
  • Severe respiratory depression
  • Bowel obstruction
  • Hypovolemia
  • Shock
  • Known or suspected paralytic ileus
  • Concomitant use of monoamine oxidase inhibitors (MAOIs) or MAOI use within 14 days

Extreme Caution:

  • Cor pulmonale
  • Hypoxia
  • Hypercapnia
  • COPD
  • Preexisting respiratory depression
  • Head injury
  • Increased intracranial pressure (ICP)
  • Severe hypotension.

Caution:

  • Biliary tract disease
  • Pancreatitis
  • Renal or hepatic impairment
  • Addison’s disease
  • Cardiovascular disease
  • Morbid obesity
  • Adrenal insufficiency
  • Elderly
  • Hypothyroidism
  • Urethral stricture
  • Prostatic hyperplasia
  • Debilitated patients
  • Patients with CNS depression
  • Toxic psychosis
  • Seizures
  • Alcoholism

Morphine Sulfate Interactions

  • Concomitant use of alcohol, CNS depressants, antipsychotics, anxiolytics, benzodiazepines, cimetidine, general anesthetics can increase the risk of coma, hypotension, profound sedation, respiratory depression, and death.
  • Monoamine oxidase inhibitors (MAOIs) such as phenelzine, selegiline can produce serotonin syndrome.
  • Use of anticholinergics with morphine may cause severe constipation leading to ileus and urine retention.
  • Morphine sulfate reduces the effectiveness of diuretics.

Lab interactions

  • Morphine may increase serum amylase and lipase.

Herbal/food interactions

Herbs with sedative properties can enhance morphine’s CNS depression effect. Examples of such herbs include:

  • Kava kava
  • Chamomile
  • Valerian
  • St. John’s wort

What are morphine sulfate side effects?

Vancomycin side effects / adverse reactions include:

  • Constipation
  • Nausea/ vomiting
  • Somnolence
  • Lightheadedness
  • Dizziness
  • Drowsiness
  • Restlessness
  • Sedation
  • Lethargy
  • Malaise
  • Sweating
  • Orthostatic hypotension
  • Facial flushing
  • Skin allergies (e.g.; rash, pruritus)
  • Dyspnea
  • Confusion
  • Palpitations
  • Tremors
  • Urinary retention
  • Abdominal cramps
  • Vision changes
  • Dry mouth,
  • Headache
  • Decreased appetite
  • Pain and/or burning at the injection site
  • Decreased libido
  • Impotence
  • Infertility
  • Menstrual irregularities
  • Psychological dependence
  • Withdrawal symptoms

Life-threatening adverse effects:

  • Respiratory depression
  • Cardiac arrest
  •  Increased intracranial pressure (ICP)
  • Seizures
  • Stupor 
  • Coma
Black Box Warning!
Risk of addiction, misuse, and abuse.
Accidental ingestion result in overdose and death.
Life-threatening and fatal respiratory depression.
Neonatal opioid withdrawal syndrome.
Use of benzodiazepines and other CNS depressants with morphine can cause profound sedation, respiratory depression, coma, and death.
Epidural route can cause severe adverse effects.
Morphine’s Black Box Warning!

Morphine Sulfate Nursing Implications [Nursing Considerations]

Morphine sulfate’s nursing implications are divided into nursing assessment, nursing interventions, and evaluation. 

Morphine sulfate nursing assessment

  • Obtain medical and drug history. Morphine is contraindicated in certain medical conditions and drug-to-drug interactions can induce profound respiratory depression.
  • Obtain baseline vital signs. Note the rate and depth of respiration for reference. Morphine causes bradypnea and lowers systolic blood pressure.
  • Assess pain (such as onset, intensity, location, duration, characteristics) before each dose. 

Morphine sulfate nursing diagnosis

  • Acute pain (indication)
  • Chronic pain (indication)
  • Risk for injury (adverse effect)
  • Risk for constipation (adverse effect)
  • Acute substance withdrawal syndrome (adverse effect)

Morphine sulfate nursing interventions/ actions

  • Monitor vital signs frequently. Respiratory rate less than 10 breaths per minute may indicate respiratory distress.
  • Examine patient’s pupil changes and reaction. Morphine overdose might be indicated by pinpoint pupils.
  • Administer morphine before pain becomes intense to maximize its effectiveness.
  • Reassess pain.
  • Monitor and document patient’s urine output. Morphine may lead to urinary retention. The daily urine output should be at least 600mL.
  • Examine bowel sounds for slowed peristalsis. Morphine slows peristalsis and causes constipation. Patient may require dietary changes or laxatives.
  • Monitor CNS changes (such as dizziness, drowsiness, euphoria, confusion, LOC, pupil reaction).
  • If possible, check patient’s alertness and orientation before administering morphine.
  • Have emergency equipment and naloxone (Narcan) ready to reverse respiratory depression in case of morphine overdose.
  • Carefully validate the appropriate dose and timing before administering morphine.
  • Employ safety precautions as necessary (such as placing the patient in a recumbent position before administering the medication or using side rails).
  • For long-term use, a Risk Evaluation and Mitigation Strategy (REMS) is required before initiating morphine therapy.

Injectables administration considerations for morphine sulfate

  • Visually inspect for discoloration and presence of any precipitates before use. Discard if discolored or precipitate is present after shaking.
  • For direct IV, Morphine may be administered undiluted or diluted with water for injection or 0.9% Sodium chloride, a final concentration of 1–2 mg/mL. Administer slowly over 4 – 5 minutes.
  • For IV infusion, dilute with D5W and administer with a controlled infusion-control device.
  • IM and subcutaneous administration: Rotate sites and administer slowly.
  • Because of injection-site discomfort, the I.M. route should be avoided for long-term therapy.

Storage and handling

  • Store morphine between 15°-30°C (59°-86°F).
  • Protect from light.
  • Do not freeze.
  • Do not heat-sterilize.
  • Discard any unused portion.

Evaluation

Evaluate the effectiveness of morphine sulfate:

  • For decreased pain.
  • Vital signs remained within normal limits.

Pregnancy/breastfeeding considerations for morphine sulfate

  • No controlled studies have been conducted to evaluate morphine’s teratogenicity.
  • However, chronic use of morphine during pregnancy is associated with
    • neonatal opioid withdrawal syndrome,
    • reversible reduction in brain volume and size,
    • decreased ventilatory response to CO2, and
    • increased risk of sudden infant death syndrome.
  • DO NOT use morphine for a prolonged period of time during pregnancy. ONLY use with physician’s direction after risk assessment.
  • Morphine sulfate excretes through breastmilk. DO NOT breastfeed during morphine therapy.
  • Morphine may alter length labor stages. It is not recommended to use just before and/or during childbirth.
  • Opioid crosses the placental barrier, which can induce respiratory depression as well as psycho-physiologic effects in the newborn. Closely monitor the newborn for respiratory depression and excessive sedation.

Reproduction

  • Chronic use of morphine may lead to infertility.

What is the patient teaching for morphine sulfate?

The nursing patient teaching for morphine sulfate should include the following points.

  • Instruct the patient/family to take morphine dose exactly as prescribed. Also, not to crush,

break, chew, or dissolve extended-release capsules or tablets.

  • Tell patient to take morphine with food to avoid GI upset.
  • Tell the patient that extended-release forms of morphine can’t be interchanged.
  • Caution patient/family to keep morphine out of reach of children and pets. Because an unintentional morphine overdose can be fatal.
  • Educate regarding the harmful effects on fetuses to the patients of childbearing age. Also, to notify the prescriber if pregnancy is planned or suspected.
  • Educate the patient regarding withdrawal symptoms and warn against abrupt discontinuation of long-term morphine therapy.
  • Advise the patient to avoid driving and hazardous activities until the drug’s response is established.
  • Teach the adverse effects of morphine sulfate and when to notify the prescriber.
  • Inform regarding physical dependency with prolonged use.
  • Advise patient not to use alcohol, CNS depressants, and herbs with sedative properties.
  • Instruct the patient to change position slowly to avoid orthostatic hypotension.
  • Teach and encourage the use of non-pharmacological measures to alleviate pain. For example, deep breathing exercises, yoga, art therapy, nature therapy.  

Morphine Overdose Treatment

  • Naloxone (Narcan) is the antidote for morphine sulfate overdose. Administer 0.2 – 0.8 mg, IV.
  • Oxygen therapy.
  • IV fluids.
  • Vasopressors.
  • Close cardiac, respiratory, and fluid status monitoring.

Conclusion

You learned about morphine sulfate nursing implications and patient teaching in this article. In addition, you’ve learned about morphine’s mechanism of action, pharmacokinetics, dosage, indications, contraindications, and side effects.

Recommended Readings & Reference

FDA Morphine Sulfate injection information

FDA Morphine Sulfate tablets information

FDA MS CONTIN (morphine sulfate extended-release tablets) information

Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.

Kee, J., Hayes, E., & McCuistion, L. (2015). PHARMACOLOGY A Patient-Centered Nursing Process Approach (8th ed.). Elsevier Inc/Saunders.

Kizior, R., & Hodgson, K. (2021). SAUNDERS NURSING DRUG HANDBOOK 2021. Elsevier Inc.

Jones & Bartlett Learning. (2021). Nurse’s Drug Handbook (20th ed.). Jones & Bartlett Learning, LLC.

Skidmore-Roth, L. (2021). MOSBY’S 2021 NURSING DRUG REFERENCE (34th ed.). Elsevier Inc.

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