護理師照顧一位使用病人自控式止痛(PCA)幫浦注射嗎啡的病人,哪項評估為優先?
A nurse is caring for a client who is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump. Which assessment is the priority?
- ARespiratory rate✓ 正解呼吸頻率
- BLevel of sedation鎮靜程度
- CPain scale rating疼痛量表評分
- DBlood pressure血壓
嗎啡(Morphine)屬於鴉片類止痛藥,其核心副作用為中樞神經抑制,最嚴重的風險為呼吸抑制(respiratory depression)。在 ABC(Airway, Breathing, Circulation)原則下,呼吸狀態是評估此類藥物病人安全的最優先指標。雖然 PCA 泵有安全鎖定機制,但護理師仍需確保病人的呼吸頻率與深度在正常範圍內。
Morphine is an opioid analgesic, and its principal adverse effect is central nervous system depression, with respiratory depression being the most serious risk. Under the ABC (Airway, Breathing, Circulation) framework, respiratory status is the highest priority safety indicator for clients receiving this medication. Although the PCA pump has safety lockouts, the nurse must still ensure that respiratory rate and depth are within normal limits.