護理師準備對一位重度疼痛病人給予嗎啡(Morphine Sulfate)。給藥前,下列哪項評估結果最重要需優先回報?
A nurse is preparing to administer morphine sulfate to a patient with severe pain. Which assessment finding is most important to report before administration?
- AHeart rate of 80 beats/min心率 80 次/分
- BPain scale score of 9/10疼痛量表評分 9/10
- CRespiratory rate of 10 breaths/min✓ 正解呼吸頻率 10 次/分
- DBlood pressure of 110/70 mmHg血壓 110/70 mmHg
嗎啡(Morphine Sulfate)屬於類鴉片止痛藥,其最致命的副作用為中樞神經系統與呼吸中樞抑制,導致呼吸頻率變慢、潮氣容積減少。臨床上,給藥前的生命徵象評估中,呼吸頻率(Respiratory rate)是關鍵指標。若呼吸頻率過低(通常 < 12 次/分),給藥將導致呼吸衰竭,故必須暫停給藥並立刻通知醫師。
Morphine sulfate is an opioid analgesic whose most lethal adverse effect is depression of the central nervous system and the respiratory center, leading to a decreased respiratory rate and reduced tidal volume. Clinically, respiratory rate is a key parameter in the pre-administration vital sign assessment. If the respiratory rate is too low (generally <12 breaths/min), administration will cause respiratory failure; the nurse must hold the dose and notify the physician immediately.