— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師準備經由 PCA 幫浦給予嗎啡,需進行哪些評估?(選所有適合的)
A nurse is preparing to administer morphine sulfate via PCA pump. Which assessments are required? (Select all that apply.)
- ARespiratory rate and depth✓ 正解呼吸頻率與深度
- BLevel of consciousness✓ 正解意識程度
- CPain intensity using a numeric scale✓ 正解使用數字量表評估疼痛強度
- DBowel sounds腸鳴音
- EOxygen saturation levels✓ 正解血氧飽和度
— Explanation · 中文詳解 —
PCA 給藥需嚴密監控 opioid 相關併發症。呼吸頻率及深度(A)與血氧監測(E)可偵測呼吸抑制;意識狀態(B)評估鎮靜程度;疼痛程度(C)用於評估藥效。腸鳴音(D)雖與嗎啡副作用有關,但非給藥當下的必要評估項目。
Required assessments for PCA morphine administration include monitoring respiratory rate, level of consciousness, pain intensity, and oxygen saturation to detect opioid-induced respiratory depression. While bowel sounds are relevant for long-term constipation management, they are not a priority assessment during immediate administration.
✦ 台美臨床差異
美國醫院對 PCA 有嚴格的單一病房監測規範,台灣 PCA 使用多需專科醫師照會且監測頻率視病房等級而定。