• Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Dose may need to be decreased by 25–50%. Initial drowsiness will diminish with continued use.Geri: Pedi: Assess geriatric and pediatric patients frequently; more sensitive to the effects of opioid analgesics and may experience side effects and respiratory complications more frequently.

» Assess bowel function routinely. Institute prevention of constipation with increased intake of fluids and bulk, and laxatives to minimize constipating effects. Administer stimulant laxatives routinely if opioid use exceeds 2–3 days, unless contraindicated.

• Assess type, location, and intensity of pain prior to and 1 hr following IM or PO and 5 min (peak) following IV administration. When titrating opioid doses, increases of 25–50% should be administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analogue scale or the patient reports satisfactory pain relief. When titrating doses of short-acting hydromorphone, a repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.

» Patients on a continuous infusion should have additional bolus doses provided every 15–30 min, as needed, for breakthrough pain. The bolus dose is usually set to the amount of drug infused each hour by continuous infusion.

» Patients taking sustained-release hydromorphone may require additional short-acting opioid doses for breakthrough pain. Doses should be equivalent to 10–20% of 24 hr total and given every 2 hr as needed.

» An equianalgesic chart (see Equianalgesic Dosing Guidelines) should be used when changing routes or when changing from one opioid to another.

» Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive hydromorphone for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term therapy.

• Assess cough and lung sounds during antitussive use.

• May ↑ plasma amylase and lipase concentrations.

• If an opioid antagonist is required to reverse respiratory depression or coma, naloxone (Narcan) is the antidote. Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by direct IV push every 2 min. For children and patients weighing <40 kg, dilute 0.1 mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL and administer 0.5 mcg every 2 min. Titrate dose to avoid withdrawal, seizures, and severe pain.