A nurse is caring for a 65-year-old patient with chronic pain using a patient-controlled analgesia (PCA) pump with hydromorphone. Which assessment finding would require immediate nursing intervention?
The nurse observes that the patient's respiratory rate has decreased to 8 breaths per minute, and the patient appears drowsy but arousable.
1Patient reports pain level of 6 out of 10 on the pain scale
2PCA pump shows 15 doses delivered in the past 4 hours
3Patient's blood pressure is 110/70 mmHg
4Patient's respiratory rate is 8 breaths per minute with drowsiness✓ 정답
해설
Respiratory rate of 8 breaths per minute with drowsiness indicates opioid-induced respiratory depression, a critical finding requiring immediate intervention such as naloxone administration and respiratory support. Other findings (pain, PCA doses, stable BP) are less urgent.
Clinical Judgment
This question requires a core judgment combining Recognize Cues and Prioritize Hypotheses. The most dangerous complication during PCA pump use is Notify HCP!Respiratory Depression due to opioid overdose. Option 4 presents a dangerously low respiratory rate of 8 breaths per minute along with drowsiness, which is a critical cue requiring immediate intervention (e.g., stopping the PCA, stimulating breathing, preparing to administer Naloxone, notifying the physician). The other options describe pain management, medication administration patterns, and stable vital signs, which are important but not emergencies.
Memory Tip:
Respiratory Rate Less than 12 = Red Flag! (RRL12=RF) In patients using opioids, a respiratory rate below 12 is always a warning sign.
KR vs US:
While monitoring respiratory rate during PCA use is important in Korea, the US NGN evaluates the ability to identify this as a 'Threatening Cue' within the framework of the Clinical Judgment Measurement Model (CJMM) and compare and prioritize it against other less urgent information. The point is not just knowing that 'respiratory depression is dangerous,' but being able to pick out the cue that actually triggers emergency action from among multiple data points.
Clinical Practice Guide
The nurse's core role in PCA pump management is balancing effective pain control with safety monitoring. Close observation is especially necessary during the first 24 hours and after dose changes.
Caution:
For SATA (Select All That Apply) questions like "What nursing interventions are needed for a patient using a PCA pump?", you must select all correct interventions, such as monitoring respiratory rate/consciousness level, assessing pain intensity, checking PCA pump function and remaining volume, and providing patient/family education. However, for questions like this one that ask you to identify what requires "Immediate Intervention," there is a trap where you must focus on the single most critical, life-threatening clue.
Patient-Controlled Analgesia — Patient-controlled analgesia. A system that allows the patient to self-administer analgesics (mainly opioids) as needed within preset safety parameters (dose, lockout interval).
Respiratory Depression — Respiratory depression. A condition in which the respiratory rate decreases abnormally (less than 12 breaths per minute in adults) and breathing depth becomes shallow. It is the most serious side effect of opioid analgesics and can lead to respiratory arrest if left untreated.
Opioid — Opioids. A class of drugs such as morphine, fentanyl, and oxycodone that act on the central nervous system to produce powerful pain relief, but have side effects including respiratory depression, nausea, constipation, and dependence.
Naloxone — Naloxone (brand name Narcan). An antagonist that competitively binds to opioid receptors, rapidly reversing opioid effects (especially respiratory depression). Used as an emergency treatment for opioid overdose.
Sedation — Sedation, drowsiness. One of the side effects of opioids, which can be a precursor symptom of respiratory depression. Nurses should objectively monitor the level of sedation using assessment tools (e.g., Pasero Opioid-Induced Sedation Scale).