Subdural haematoma

Adam has been in hospital for five days following his accident. He has had
surgery to remove a subdural haematoma and to repair his right fractured tibia and
fibula. This requires a daily dressing to his leg and head, and it is causing him
considerable pain. He is on demand only PCA with fentanyl at 40mcg/ml, oxygen
2L/min. During a set of observation being taken, the nurse notices that Adam is a bit
drowsy when being spoken to, and difficult to rouse at some point. The nurse check the
medication chart and sees that there is a doctor’s order for Adam to be administered
Naloxone if he gets too difficult to rouse. The reaction is instantaneous and Adam is
wide awake and orientated.
For this assignment we are to link pathophysiology and pharmacology and
explain the reason why Adam might have become drowsy and difficult to rouse ( i.e
maybe because of too much pain relief/fentanyl dose) and also about Naloxone effect on
Adam, and what the nurse should recommend be done for Adam not to be drowsy and
difficult to rouse again (e.g lower the fentanyl dose etc).

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Medical conditions contribute primarily to the body state of rest. The treatments and
drugs administered to the patients may cause drowsiness. The drug Fentanyl may have been
the primary cause of drowsiness. Fentanyl is an opioid analgesic drug that is metabolized in
humans via the cytochrome p450 3A4 enzyme. The drug predominantly interacts with the
mu-receptors in the human system which is found in the brain and spinal cord. Its absorbance
in the body system has various alterations with drowsiness the most common. In achieving
this function, Fentanyl depresses the body respiratory centers and the constriction of pupils.
The drug effects may have led to the drowsiness symptoms observed on the patient (RxList,
2016) .
Sleepiness may also arise due to the patient’s mental states and lifestyle choices. In
this case, the patient’s mental state may have contributed to the drowsiness. Depression due to
the disease state’s high level of anxiety and stress could have increased the drowsiness in the
patient (, 2010) .
The patient could be suffering from sleeping disorders. The condition is primarily
brought about by less sleeping time. Due to the pain felt by the patient, he could be having
sleepless nights resulting to drowsiness during the day. Delayed sleep phase disorder could be
triggered by the medications given to the patient.
Naloxone is a known opioid antagonist. Its use on the patient is used as a reversal of
suspected opioid overdose. However an opioid withdrawal symptoms including drowsiness
occur to the patient upon administration of Naloxone. This could have also contributed to the
drowsiness of the patient.

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To prevent drowsiness, the caregivers should ensure the patient gets enough rest. To
treat drowsiness associated with the drug Fentanyl, drugs metabolized by the human
cytochrome p450 3A4, e.g. acetaminophen and midazolam, should be given to the patient, to
compete for the active sites of metabolism. This will reduce the rate of metabolism, reducing
the active compounds of the drug in the blood system (Micromedex, 2016) .

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References, 2010. Medications that can affect sleep. [Online]

RxList, 2016. Treatment of kidney failure. [Online]