you are informed by your nurse manger about a large clinical issue involving a patient that has occurred on another unit. in your role as the cnl, hospital leadership has asked for you to temporarily work on a new unit to investigate the issue and offer solutions to improve practice. the clinical incident involved a postoperative patient on patient-controlled analgesia (pca) with a low-dose continuous infusion who became extremely over-sedated during the night. when the nurse discovered the patient,he had a respiratory rate of 5, oxygen saturations in the 60s, and appeared grossly cyanotic.
