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照護管理 · HARD · SATA

病人使用 PCA(病人自控止痛幫浦)時,出現何種徵兆需要立即介入?(選所有適合的)

Which signs indicate a need for immediate intervention in a patient with a PCA pump? (Select all that apply.)

  • ARespiratory rate of 8 breaths/min✓ 正解
    呼吸頻率為每分鐘 8 次
  • BOxygen saturation of 89%✓ 正解
    血氧飽和度 89%
  • CPatient reports pain as 2/10
    病人報告疼痛指數為 2/10
  • DSedation score of 4 on a 0-4 scale✓ 正解
    鎮靜評分為 4(滿分 4 分)
  • EHeart rate of 80 bpm
    心率為每分鐘 80 次
Explanation · 中文詳解

PCA 幫浦使用時,護理師必須嚴密監控病人的呼吸狀態。阿片類藥物(Opioids)的主要致死性副作用是呼吸抑制。當呼吸速率過慢、氧飽和度下降及出現過度鎮靜(Sedation level 4 代表病人難以喚醒)時,代表病人已出現藥物中毒徵兆,必須立即採取停止給藥、維持呼吸道通暢、給予氧氣並考慮使用 Naloxone 拮抗。

While a PCA pump is in use, the nurse must closely monitor the client's respiratory status. The main life-threatening adverse effect of opioids is respiratory depression. When the respiratory rate decreases, oxygen saturation drops, and excessive sedation is present (sedation level 4 indicates that the client is difficult to arouse), these findings signal opioid toxicity, and the nurse must immediately stop the medication, maintain a patent airway, administer oxygen, and consider naloxone as an antagonist.

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