護理師照護一位術後使用持續硬膜外止痛的病人，哪一項評估結果需要立即介入？
A nurse is caring for a postoperative client who is receiving continuous epidural analgesia. Which assessment finding requires immediate intervention?
- ABlood pressure 110/70 mmHg血壓 110/70 mmHg
- BLevel of sedation score 4 on a 0-4 scale✓ 正解鎮靜程度分數在 0-4 分量表中為 4 分
- CRespiratory rate of 10 breaths/min呼吸頻率為每分鐘 10 次
- DClient reports pruritus at the injection site病人主訴注射部位搔癢
硬膜外止痛常見副作用包括搔癢、低血壓、呼吸抑制。給藥後的鎮靜評分若過高，暗示藥物可能經由血管或腦脊髓液擴散，導致中樞神經嚴重抑制，需先停止輸注並給予呼吸監測與緊急處置。呼吸速率 10 次/分雖需監測但非立即危急，搔癢屬常見副作用。
Common side effects of epidural analgesia include pruritus, hypotension, and respiratory depression. If the sedation score after administration is excessively high, this suggests that the medication may have spread via the bloodstream or cerebrospinal fluid, causing severe central nervous system depression; the infusion must be stopped immediately, with respiratory monitoring and emergency intervention initiated. A respiratory rate of 10 breaths/min requires monitoring but is not immediately critical, and pruritus is a common side effect.
台灣醫院對硬膜外監測非常嚴謹，通常由麻醉科醫師每日巡視，護理師需依流程監測鎮靜分數。