A nurse is caring for a patient receiving continuous morphine infusion for severe cancer pain. Which assessment finding requires the most immediate nursing intervention?
1Respiratory rate of 6 breaths per minute with shallow breathing✓ 정답
2Blood pressure of 90/60 mmHg (baseline 130/80 mmHg)
3Patient reports pain level of 8/10 on numeric scale
4Drowsiness with patient easily arousable to verbal stimuli
해설
Respiratory rate of 8 breaths/min with shallow breathing is the most critical finding, indicating life-threatening opioid-induced respiratory depression. Other options (mild hypotension, pain, drowsiness) are less urgent.
Clinical Judgment
This question tests Prioritization and Risk Recognition. You need to identify the Notify HCP! sign requiring the most immediate nursing intervention in a patient receiving continuous morphine infusion. The key is to identify Respiratory Depression, the most life-threatening side effect of opioids. In option 1, Respiratory rate of 8 breaths/min is significantly below the normal range (12-20 breaths/min) and is accompanied by shallow breathing. This is a Critical Cue that can rapidly progress to respiratory arrest, giving it the highest priority. The other options require monitoring but are not immediate life threats.
Memory Tip: The mnemonic to remember opioid side effect priorities is Respiratory Depression First. Assess in this order: Respiration > Circulation (hypotension) > Sedation.
KR vs US: Both Korea and the US evaluate respiratory depression as the highest priority risk. However, in the US NCLEX, the phrase "most immediate intervention" is a typical way to guide you toward identifying a breathing problem based on the ABCs (Airway, Breathing, Circulation) principle. The frequency and clarity of prioritization questions may be higher than on the Korean exam.
임상 시나리오
Clinical Practice Guide
Nurse's Safety Monitoring Protocol for Continuous Opioid Infusion:
1. Initial and Regular Assessment: Regularly monitor vital signs, especially respiratory rate and depth, and oxygen saturation (SpO2). Follow hospital policy, but assessment every 1-2 hours is common initially.
2. Notify HCP! Criteria: Report immediately if the adult respiratory rate is less than 12 breaths per minute, if there is a significant decrease from baseline respiratory rate, or if the patient is not arousable.
3. Naloxone Preparation: The opioid reversal agent naloxone should be kept in the unit or readily available.
4. Use of Over Sedation Scale: Objectively assess the level of sedation using a standardized tool such as the PAS (Passive Alertness Scale).
Caution: In SATA (Select All That Apply) questions asking "what a nurse should monitor for in opioid overdose," you may need to select all signs related to respiratory depression (decreased respiratory rate, decreased SpO2, abnormal breath sounds, decreased level of consciousness) and circulatory signs (hypotension, bradycardia). However, in single-choice questions asking for the "most immediate" action, always select respiratory status first.
핵심 개념
Opioid-induced Respiratory Depression — A life-threatening condition caused by opioid drugs suppressing the respiratory center in the brainstem. Respiratory rate, depth of breathing, and tidal volume decrease, which can progress to hypoxia and respiratory arrest.
Naloxone — It is an opioid receptor antagonist, an emergency medication that reverses respiratory depression in opioid overdose. The effect is rapid, but the half-life is short, so repeated administration may be necessary.
Continuous Infusion — A method of continuously administering medication intravenously. For opioids like morphine, it can provide continuous pain control, but the drug may accumulate in the body, increasing the risk of respiratory depression.
Sedation Scale — A tool for objectively assessing a patient's level of sedation (e.g., Pasero Opioid-induced Sedation Scale). It is used to detect oversedation early by categorizing levels such as "awake, responds to voice, responds to physical stimulation, no response."
Mu-opioid Receptor — Receptors in the brain and spinal cord where opioid drugs primarily bind. Binding to these receptors produces pain relief, sedation, and euphoria, along with side effects such as respiratory depression, constipation, and dependence.