護理師準備對嚴重疼痛病人給予嗎啡(Morphine Sulfate)。給藥後最關鍵的監測項目為何?
A nurse is preparing to administer morphine sulfate to a patient with severe pain. Which assessment parameter is the most critical to monitor after administration?
- ALevel of consciousness意識水準
- BRespiratory rate✓ 正解呼吸頻率
- CBlood pressure血壓
- DHeart rate心率
嗎啡為類鴉片止痛藥,其最嚴重的副作用為抑制呼吸中樞。即使病人疼痛緩解,若呼吸速率過慢(<12 次/分),即可能有呼吸抑制風險。雖然血壓與意識也受影響,但呼吸頻率的改變是導致死亡的主要原因,監測順序應列於首位。
Morphine is an opioid analgesic, and its most serious adverse effect is suppression of the respiratory center. Even if the patient's pain is relieved, a respiratory rate that is too slow (<12 breaths/min) signals a risk of respiratory depression. Although blood pressure and level of consciousness are also affected, changes in respiratory rate are the leading cause of death, so respiratory-rate monitoring takes the highest priority.
美國廣泛使用 POSS(Pasero Opioid-Induced Sedation Scale)監測呼吸與鎮靜程度;台灣臨床多依賴常規生命徵象監測。