Dilaudid Nursing Considerations

Dilaudid is the brand name of the drug hydromorphone, a pure opioid. It is one of the treatment options for moderate to severe acute pain, as well as severe chronic pain.

Because of its extreme strength, the potential for addiction, and the risk of overdose, it is only administered when other first-line therapies have failed.

Furthermore, one of its off-label uses is for refractory cough suppression. Available in oral liquids, tablets, and IV solution forms, this medication is taken by mouth as directed by the physician, and prolonged use of this drug may be habit-forming.

 Indication of Dilaudid

• Pain relief. Dilaudid is a pure opioid that treats moderate to severe acute and chronic pain. However, it is only prescribed when other first-line treatments have not worked.
• Cough suppressant. Dilaudid inhibits the cough reflex by acting directly on the cough center in the medulla. By having a direct impact on the brain stem respiratory regions, Dilaudid suppresses the respiratory reflex.

Mechanism of Action of Dilaudid

Diaudid is an opioid agonist that binds to several opioid receptors. The suggested analgesic effect is related to the impact on the mu-opioid receptors.

It alters the perception and reaction to pain by binding to opiate receptors in the CNS and suppresses the cough reflex.

The extended-release form of hydromorphone takes six hours to start working and lasts for around thirteen hours, but the immediate-release form starts working in 15-20 minutes and lasts for three to four hours.

Pharmacokinetics of Dilaudid

• Absorption. Oral formulations for immediate release take effect in 15 to 30 minutes, peak in 30 to 60 minutes, and last 3 to 4 hours. The half-life is 2 to 3 hours. Extended-release formulations’ activity begins at 6 hours, peaks at 9 hours, and lasts for 13 hours. The half-life is between 8 and 15 hours. However, it is approximately 11 hours.
• Distribution. 8% to 19% of the medication is protein bound, and the volume of distribution is 4 L/kg.
• Metabolism. Most of it is converted to hydromorphone-3-glucuronide in the liver during the metabolism process known as glucuronidation.
• Elimination. The principal method of excretion is through the glucuronidated component of urine. The elimination of unaltered remnant form is in urine (7%) and feces (1%).

Side Effects of Dilaudid

A medication may have side effects in addition to the intended ones. Even though not all of these side effects are likely to occur, it requires medical treatment if they do. If the patient has any of the following side effects, closely monitor for any worsening:

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• Bloating or swelling of the face, arms, hands, lower legs, or feet
• Bloody, black, or tarry stools
• Decreased urination
• Dry mouth
• GI upset
• Wrinkled skin

Adverse Effects of Diladuid

• Agitation
• Blurred vision
• Changes in behavior
• Chest pain or discomfort
• Fast, pounding, slow, or irregular heartbeat
• Lightheadedness, dizziness, or fainting
• Mood or mental changes
• Rapid breathing
• Severe stomach pain, cramping, or burning
• Stiff neck
• Sunken eyes
• Trouble breathing
• Unusual tiredness or weakness
• Vomiting of material that looks like coffee grounds, severe and continuing
• Hypotension
• Coma
• Raised intracranial pressure
• Seizure
• Suicidal thoughts
• Apnea
• Respiratory depression or respiratory arrest
•  Drug dependence or drug withdrawal
• Drug withdrawal syndrome in newborns

Diladuid Overdose

The primary focus in overdose treatment should be reestablishing adequate respiratory exchange by creating a patent airway and implementing assisted or regulated breathing. The following are symptoms of Dilaudid toxicity:

• Slow or shallow breathing
• Difficulty breathing
• Sleepiness
• Unable to respond or wake up
• Muscle weakness
• Cold, clammy skin
• Narrowing or widening of the pupils (dark circles in the middle of the eyes)
• Slowed or stopped heartbeat
• Dizziness
• Fainting

Adverse Reactions of Dilaudid

• Cardiovascular. Angina pectoris, bradycardia, cardiac arrest, palpitations, circulatory depression, myocardial infarction, prolonged QT interval, severe cardiac arrhythmias, shock, ST-segment elevation, syncope, and ventricular tachycardia are all examples of cardiovascular problems.
• CNS. Agitation, coma, dizziness, dysphoria, mental clouding or depression, euphoria, faintness, nervousness, restlessness, sedation, seizures, visual disturbances, and weakness are all symptoms of the central nervous system (CNS).
• EENT. Blurred vision, diplopia, and miosis.
• Gastrointestinal. Constipation, dry mouth, nausea, vomiting, anorexia, abdominal distention, biliary tract spasm, decreased appetite, decreased intestinal motility, gastroesophageal reflux disease, and paralytic ileus are all symptoms of gastrointestinal (GI) problems.
•  Respiratory. Respiratory depression, respiratory arrest, hypoxia, bronchospasm, dyspnea, rhinorrhea, and flu-like symptoms (Exalgo).
• Renal. Urinary retention
• Others. Symptoms include flushing in the face, neck, and upper thorax, pruritus, sweating, urticaria, skin rash, hyperhidrosis, physical dependence, psychologic dependence, and tolerance.

Drug Interactions with Dilaudid

Dilaudid should not be combined with the following medication:

•  CNS Depressants. Concurrent use of another central nervous system (CNS) depressant, such as sedatives or hypnotics, general anesthetics, phenothiazines, tranquilizers, and alcohol, may induce additive depressant effects. It’s possible to experience respiratory depression, hypotension, and extreme drowsiness or coma. Reducing the dose of one or both agents is recommended when considering such combined therapy.
•  Agonist/Antagonist Opioid Analgesics. When a patient has previously received or is currently undergoing a course of therapy with a pure opioid agonist analgesic like Dilaudid, agonist/antagonist analgesics like pentazocine, nalbuphine, butorphanol, and buprenorphine, should be used with caution. In this case, combined agonist/antagonist analgesics may reduce Dilaudid analgesic effect and cause withdrawal symptoms in these patients.
• Monoamine Oxidase Inhibitor. Opioid toxicity or serotonin syndrome are two possible outcomes of MAOI and opioid interactions. Dilaudid should not be used by patients who are receiving MAOIs or within 14 days after stopping such treatment.
• Selective Serotonin Reuptake Inhibitors (SSRIs). The use of opioids in conjunction with other medicines that influence the serotonergic neurotransmitter system has resulted in serotonin syndrome. Carefully monitor the patient if combination use is necessary, especially when starting the treatment and adjusting the dosage. If serotonin syndrome is suspected, stop taking Dilaudid.
• Antidiuretics. Opioids can impair diuretic effectiveness by causing the release of the anti-diuretic hormone.   Evaluate patients for evidence of decreased diuresis and/or blood pressure changes, and adjust the diuretic dosage as needed.
• Anticholinergic. Combined use of anticholinergic medications may raise the risk of urine retention and chronic constipation, leading to paralytic ileus. When using Dilaudid along with other drugs, keep an eye out for any signs of urinary retention or decreased gastrointestinal motility in the patients.

The doctor may decide not to prescribe this drug or adjust some medicines the patient takes. The interactions listed above are not all-inclusive but have been selected for their potential importance.

Cautions Against Dilaudid

• It is essential to consult a doctor about the patient’s medical status before taking this medication. 
• Inactive ingredients (such as sulfites) in this product may cause allergic reactions or other problems. In some cases, Dilaudid may cause an allergic reaction if the patient is allergic to any sulfite-containing food or medication. For more information, the patient must consult the doctor or pharmacist.
• If severe allergic reactions occur, including anaphylaxis, it necessitates immediate medical attention. If the patient develops a rash, itching, hoarseness, difficulty breathing, difficulty swallowing, or swelling of the hands, face, or mouth while taking this medication, contact the doctor immediately.
• Dilaudid may cause dizziness or drowsiness. Driving, operating machinery, or doing anything else that requires alertness must be temporarily prohibited until it is safe to do it.
• Diualudid may interact with alcohol, prohibited drugs, and other central nervous system depressants (sleep aids, tranquilizers) unless directed by their doctor.  Since dangerous combined effects may develop, leading to severe damage or death, to avoid these adverse effects, talk to a doctor first.
• Liquid items may contain sugar. Exercise caution if the patient has diabetes or another condition that calls for reducing or eliminating sugar in the diet. Inquire with the doctor or pharmacist about the safety of this product.
• Older adults may experience more severe side effects from this medicine, particularly disorientation, drowsiness, dizziness, and shallow or slower breathing. Raise bed rails, and provide assistive devices to ensure safety, especially among the elderly. 
• Dosing mistakes may cause unintentional overdose and death. Make sure the dose is appropriately explained and administered. Healthcare professionals should advise patients to use extra caution while measuring the dosage and recommend calibrated equipment to precisely measure and administer the proper dose. Measuring using a teaspoon or tablespoon from the kitchen is not appropriate.
• During pregnancy, give this drug only when necessary. It could be harmful to a developing child. To a pregnant patient or planning to get pregnant, talk first with the doctor before starting the treatment to discuss the advantages and disadvantages with the doctor.
• When a pregnant woman takes Dilaudid, her newborn may suffer from neonatal withdrawal syndrome. This is why extended Dilaudid use during pregnancy is not advised. There should be adequate treatment provided when neonatal withdrawal syndrome poses a risk.
• For breastfeeding patients, consult with a doctor first. This medication is excreted in breast milk and may harm a nursing infant. Inform the doctor immediately if the baby develops unusual sleepiness, difficulty feeding, or breathing difficulties.
• This medicine may be habit-forming. Only use the prescribed dose if the medication is not working or doesn’t meet the desired effect. Call the doctor for instructions.
•  Long-term narcotic use can result in severe constipation. The doctor may advise taking laxatives, drinking plenty of fluids, or increasing the amount of fiber in the diet to avoid this. Follow the instructions strictly, as continued constipation can lead to more severe issues.
•  Overusing this medication may result in decreased infertility (inability to have children). Discuss this medication with the doctor before using it for those who intend to have children.
• Take it with or without food, but it may help to prevent nausea from taking it with food. Consult the doctor or pharmacist for advice on decreasing nausea ( such as lying down for 1 to 2 hours with as little head movement as possible). 
• Do not give Dilaudid to patients with bronchial asthma or any other type of respiratory disease that causes clinical respiratory insufficiency; it can cause respiratory arrest.
• In cases of gastrointestinal blockage or hypomotility, including ileus, avoid Dilaudid. Cautious dosing of this drug is necessary to avoid prolonged ileus.
• Dilaudid may increase the likelihood of seizures in individuals with seizure disorders and the risk of attacks occurring in other therapeutic situations. During treatment, keep an eye out for patients with a history of seizure disorders who have worsening seizure control.
• Dilaudid may cause spasms of the sphincter. Serum amylase levels may rise as a result of opioid use. Monitoring of symptoms in patients with biliary tract illness and acute pancreatitis is important to avoid worsening conditions.
• Dilaudid should be stored securely, out of the reach of children.  The unused Dilaudid tablets should be flushed into the toilet after they are no longer needed.
• Dilaudid and other opioid analgesics can induce severe hypotension in people whose capability to control blood pressure is already impaired due to low blood volume or by the concomitant use of medications like phenothiazines or general anesthetics.

Nursing Considerations for Patients taking Dilaudid

•  Assess vital signs before and during administration as Diladuid may put the patient at risk for general CNS depression. Watch for signs of severe sedation or alterations in mood or behavior (euphoria, dysphoria, confusion, hallucinations). Notify a doctor immediately if the patient is unresponsive, has low blood pressure, or is difficult to awaken.
• Evaluate indications of respiratory depression, such as slowed breathing, disorientation, bluish skin and mucous membranes (cyanosis), and complex, strained breathing (dyspnea). To measure suspected respiration and pulmonary function changes, monitor pulse oximetry and conduct pulmonary function testing. Severe respiratory depression needs emergency treatment.
• To determine whether this medication is effective in reducing the patient’s pain, use the relevant pain scales like visual analog scales and others.
• Because of the risk of respiratory depression, bradycardia, and hypotension during aerobic and other exercise programs, the patient should work out with caution. Evaluate the heart rate, ECG, and heart sounds, particularly during exercise. Report any symptoms of a slow heart rate (bradycardia) or other arrhythmias, such as palpitations, chest tightness, breathlessness, dizziness, and fatigue/weakness.
• Use the proper manual treatment methods, physical therapies, and therapeutic activities to lessen the patient’s discomfort and assist in weaning them off opiate analgesics as soon as possible.

• If taken as a cough suppressant, listen for breath and lung sounds and keep an eye on sputum output. Assess whether this medication works as a cough suppressant.
• For pregnant women, taking this medication runs the risk of giving birth to babies who develop neonatal withdrawal syndrome. If the infant exhibits any of the following symptoms: diarrhea, a loud cry, irritability, shakiness or tremors, weight loss, vomiting, or a failure to gain weight, call the doctor right away.

Nursing Care Plan for Patients on Diladuid

Possible Dilaudid Nursing Diagnoses

• Risk for Disturbed Thought Process
• Risk for Injury related to possible adverse effects (hypotension, lightheadedness, or disorientation)
• Ineffective Breathing Pattern related to possible respiratory distress secondary to an adverse reaction to the drug

Nursing Assessment

Nursing Planning and Intervention

Nursing Evaluation

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

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