病人正在使用靜脈嗎啡,起身時感到頭暈。護理師的最佳處置為何?
A client receiving IV morphine reports feeling dizzy and lightheaded upon standing. What is the nurse's best action?
- ADocument the symptom and leave the room記錄症狀並離開房間
- BAdminister an antiemetic immediately立即給予止吐藥
- CAssist the client to sit back down and monitor vital signs✓ 正解協助病人坐回原位並監測生命徵象
- DIncrease the IV infusion rate加快靜脈輸注速度
嗎啡(Morphine)屬於鴉片類止痛藥,其主要藥理機制包括周邊血管擴張,這會導致靜脈血液淤積,當病人姿勢改變(如從臥位改為站立位)時,引發姿勢性低血壓(Orthostatic hypotension)。護理師在此情境下的首要任務是防止病人跌倒,這是護理安全(Safety)的核心原則。立即協助病人坐下或躺下可減輕頭暈感並避免跌倒造成的二次傷害,隨後監測生命徵象(特別是血壓變化)有助於判斷藥物反應與生理穩定性。
Morphine can cause peripheral vasodilation, leading to orthostatic hypotension and dizziness upon standing, which poses a significant fall risk. The nurse’s priority is to ensure client safety by assisting the client to sit or lie down immediately to prevent injury, followed by monitoring vital signs to assess hemodynamic stability.
在美國臨床環境中,針對鴉片類藥物引起的副作用,護理師需嚴格執行 Fall Precautions(跌倒預防措施),且通常會將姿勢性低血壓教育列入 Discharge Planning(出院準備)中,提醒病人下床時採取「分段式起身」(Sit-dangle-stand)。