A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA) pump. Which assessment finding requires the nurse's immediate intervention?
1Patient reports pain level of 6/10 on numeric rating scale
2Patient's blood pressure is 110/70 mmHg (baseline 120/80 mmHg)
3Patient's respiratory rate is 8 breaths per minute with shallow breathing✓ 정답
4Patient appears drowsy but arouses easily to verbal stimuli
해설
Respiratory rate of 8 breaths/min with shallow breathing indicates opioid-induced respiratory depression requiring immediate intervention. Other findings (pain 6/10, mild BP drop, drowsiness) are expected or less critical.
Clinical Judgment
This question evaluates patient safety prioritization and identification of clinical deterioration signs. When administering morphine via a PCA pump, the nurse's most important role is to balance effective pain control with the potentially life-threatening side effect of respiratory depression. Option 3's "respiratory rate of 8 breaths/min and shallow breathing" is a clinical crisis signal requiring immediate nursing intervention. The other options require monitoring but do not represent an immediate life threat.
Memory Tip:
Respiratory rate Under 12 is a Red flag! When monitoring opioids, always check RR (respiratory rate), SpO2 (oxygen saturation), and LOC (level of consciousness).
KR vs US
In Korea, PCA pump settings and monitoring are primarily a shared responsibility between doctors and nurses, whereas in the US NGN/CJMM, the emphasis is on the nurse's ability to proactively identify signs of respiratory depression through independent clinical judgment and initiate immediate interventions, such as stopping the PCA pump, before reporting. A shift in thinking is required, from "report to the doctor and receive orders" to "the nurse intervenes first."
Clinical Practice GuideThe core role of the nurse in PCA pump management is "Assess, Intervene, Reassess."1. Initial assessment: Before starting administration, record baseline respiratory rate, SpO2, level of consciousness, and pain score.2. Periodic monitoring: Follow hospital policy, but generally assess respiratory rate, depth, SpO2, and alertness within 1 hour after starting administration and regularly (e.g., every 4 hours).3. Intervention thresholds: Initiate immediate intervention if respiratory rate is less than 12 breaths/min, SpO2 is less than 95% (or a significant drop from baseline), or there is no response to deep stimulation.4. Immediate intervention: Temporarily stop the PCA pump, speak to the patient and gently shake to wake them, position in Fowler's position, administer oxygen if needed, prepare naloxone, and notify the medical team.
CautionA common pitfall in SATA (Select All That Apply) questions is mistaking common opioid side effects such as "pain score 6/10" or "mild drowsiness" for conditions requiring "immediate intervention." "Immediate Intervention" applies only to signs that directly threaten vital functions. Also, a blood pressure of 110/70 mmHg is only a slight drop from baseline (120/80) and remains within normal range, representing mild hypotension, a common side effect of opioids. This requires monitoring but is not an immediate crisis.
Patient-Controlled Analgesia — Patient-controlled analgesia. A device that allows the patient to press a button to self-administer a preset dose of analgesic (mainly opioids). It increases the efficiency of pain control but carries risks such as respiratory depression.
Opioid-Induced Respiratory Depression — Opioid-induced respiratory depression. This is a potentially life-threatening complication that occurs when opioid analgesics suppress the respiratory center in the brainstem. It is characterized by a decreased respiratory rate, reduced depth of breathing (shallow breathing), and resulting carbon dioxide retention and hypoxia.
Naloxone — Opioid antagonist. Competitively binds to opioid receptors to rapidly reverse the effects of opioids (pain relief, respiratory depression, sedation). Used as an emergency treatment for severe opioid-induced respiratory depression.
Hypoventilation — Hypoventilation. A condition where inadequate lung ventilation leads to an abnormally elevated level of carbon dioxide (PaCO2) in the blood. It is a key symptom of opioid overdose, characterized by slow and shallow breathing.
Sedation Scale — Sedation scale. A tool for objectively assessing the level of consciousness in patients receiving opioids (e.g., Pasero Opioid-Induced Sedation Scale). It divides stages from "easily awakened" to "no response to stimuli," helping to detect early signs of respiratory depression.