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Hydromorphone (Dilaudid)

Opioid analgesic (high-alert; full mu-receptor agonist)

Mechanism of action

Semi-synthetic mu-opioid agonist roughly 5–7× more potent than morphine on a milligram basis (IV 1.5 mg ≈ morphine IV 10 mg). Less histamine release than morphine, so often preferred when pruritus or hypotension limit morphine. Used for moderate-to-severe acute pain, cancer pain, and palliative care.

Adverse effects

Life-threatening / NCLEX-tested

  • Respiratory depression — life-threatening, dose-dependent; the high potency makes dosing errors especially dangerous
  • Severe sedation, coma
  • Hypotension, bradycardia
  • Severe constipation, ileus
  • Urinary retention
  • Tolerance, physical dependence, opioid use disorder

Side effects

Common — what to teach

  • Drowsiness, sedation
  • Constipation
  • Nausea, vomiting (often improves)
  • Pruritus (less than morphine)
  • Miosis
  • Mild euphoria, dysphoria

Food & drug interactions

Same as other opioids. Other CNS depressants (benzodiazepines, alcohol, gabapentinoids, sedating antihistamines) compound respiratory depression — most opioid deaths involve a co-ingestant. MAOIs cause severe hypotension or hypertension. Naloxone reverses.

Nursing implications

Assessment, monitoring, patient teaching

  • DOSE-CONFUSION ALERT: hydromorphone 1 mg ≠ morphine 1 mg — hydromorphone is ~5–7× more potent. Famous error type: ordering "morphine 4 mg" but reading and giving "hydromorphone 4 mg." Always read the drug name AND dose; perform independent two-nurse verification on IV doses
  • Assess pain, RR, SpO2, and sedation level before and 15–30 min after IV doses; before and ~1 hour after PO
  • Have naloxone (Narcan) immediately available; teach household members to keep nasal naloxone at home for high-risk outpatients
  • Hold for RR < 12 or excessive sedation; stimulate, support airway, give naloxone if needed
  • Start a scheduled bowel regimen (stimulant laxative ± stool softener) when starting any chronic opioid
  • Counsel patients NOT to combine with benzodiazepines, alcohol, or other sedatives

When to hold / contraindications

  • RR < 12 (or institutional threshold)
  • Excessive sedation
  • SBP < 90 mmHg or symptomatic hypotension
  • Severe asthma exacerbation or active bronchospasm
  • Paralytic ileus
  • Acute head injury without trauma surgery direction

Memory anchor

"Hydromorphone 1 mg ≈ morphine 7 mg." The most common dose-confusion opioid error. Two-nurse check, read both name and dose before pushing.

Reminder: Drug cards are study aids, not clinical guidance. Always cross-check doses, holds, and contraindications with your facility's formulary and your clinical instructors before patient care.

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