護理師照護使用 PCA 幫浦的病人。哪項評估最優先？
A nurse is caring for a client with a PCA (Patient-Controlled Analgesia) pump. Which assessment is the priority?
- AThe number of times the client pushed the button客戶按壓按鈕的次數
- BPain level on a scale of 1-101-10分的疼痛程度
- CAmount of medication remaining in the pump幫浦中剩餘的藥物量
- DRespiratory rate and depth✓ 正解呼吸頻率與深度
病人自控式止痛（PCA）通常使用強效鴉片類藥物（如 Morphine, Hydromorphone）。這類藥物最危險的副作用是中樞神經抑制導致的呼吸抑制。根據 ABC（氣道、呼吸、循環）優先原則，監測呼吸頻率與深度是護理照護的重中之重。若呼吸頻率低於每分鐘 12 次，或出現呼吸過淺、血氧下降，護理師必須立即介入。雖然評估疼痛分數與檢查藥量也很重要，但它們不直接涉及生命威脅。安全管理 PCA 的核心在於確保病人能在止痛的同時維持足夠的通氣功能。
Patient-controlled analgesia (PCA) typically uses potent opioids (such as morphine or hydromorphone). The most dangerous adverse effect of these drugs is central nervous system depression leading to respiratory depression. Based on the ABC (Airway, Breathing, Circulation) priority principle, monitoring respiratory rate and depth is the highest nursing priority. If the respiratory rate falls below 12 breaths per minute, or if shallow breathing or decreased oxygen saturation occurs, the nurse must intervene immediately. Although pain scoring and checking the amount of medication remaining are also important, they do not directly involve life-threatening risks. The core of safe PCA management is to ensure that the client maintains adequate ventilation while receiving analgesia.
美國醫院對 PCA 的管理極其嚴格，通常要求雙人核對（Double check）藥物濃度與設定。台灣醫院也有類似機制。NCLEX 考點強調「只有病人本人可以按壓按鈕（PCA by proxy is forbidden）」，這是台美共同強調的安全衛教。