# 一名護理師監測一名全膝關節置換術後病人,使用嗎啡之病人自控鎮痛(PCA)。下列何者為安全PCA管理之介入?(複選) > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=364913&lang=zh-tw > language: zh-TW > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## 題目 一名護理師監測一名全膝關節置換術後病人,使用嗎啡之病人自控鎮痛(PCA)。下列何者為安全PCA管理之介入?(複選) 1 只允許病人本人按按鈕,並衛教家屬不可代按 2 若疼痛控制不佳,未通知醫師即增加基礎注射速率 3 依排定時間監測鎮靜程度(Pasero)、呼吸、SpO2、疼痛 4 每次交班皆由兩位RN獨立核對pump設定與醫囑 5 床邊備有naloxone與球囊面罩可立即使用 ## 解析 PCA為高警示藥物給予系統。標準安全包含: 兩位RN獨立核對、防PCA-by-proxy(僅病人按)、結構化鎮靜與呼吸監測(Pasero、RR、SpO2)、即時可用之naloxone與氣道設備。未經醫囑增加基礎速率超出護理範圍且為重大安全違規。 ## 深入解析 臨床判斷 PCA安全要素: 獨立雙重核對、防PCA-by-proxy、結構化監測、naloxone隨時可用。基礎速率為最高風險參數 — 僅醫師可調整。家屬代按之PCA-by-proxy曾致命呼吸抑制,除非以AACA(經訓練之授權代理鎮痛)處方,否則嚴禁。 記憶口訣 PCA=只能病人按。Naloxone+RR+Pasero備齊。 韓 vs 美 ISMP與臺灣病人安全管理法皆將PCA類鴉片列為高警示。兩地皆要求交班時獨立雙重核對且禁止未授權之家屬或工作人員代按。Pasero量表於臺灣醫學中心亦廣泛使用。 ## 臨床情境 臨床指引 ISMP + ASPMN PCA安全: - 兩位RN獨立核對: 啟用、交班、換藥、調整劑量時 - 防PCA-by-proxy: 僅病人按;對家屬衛教並紀錄 - 鎮靜量表(Pasero) q1h x 4 後 q4h: S=熟睡、1=清醒、2=略嗜睡、3=頻繁嗜睡(暫停)、4=昏睡(暫停+naloxone) - RR與SpO2同步監測 - 床邊naloxone、球囊面罩、氧氣備妥 - 對opioid新手或高風險者搭配ETCO2監測 - 比較需求次數與實際給予 — 多次需求但少給藥=止痛不足 注意 過度鎮靜之naloxone: 0.04 mg IV q2min — 至RR >10且可被喚醒。大劑量會誘發劇烈反彈疼痛與肺水腫。重新評估前停止PCA注射。 ## 重要概念 - **PCA(病人自控鎮痛)** — 可程式化IV pump,病人經安全鎖定自行給予預設需求劑量。可選基礎輸注。常用類鴉片: morphine、hydromorphone、fentanyl。較PRN降低類鴉片總量並改善疼痛控制。 - **PCA by proxy** — 由家屬或工作人員為意識不清或鎮靜中之病人按按鈕。曾造成致命呼吸抑制。除非經明確授權之AACA(授權代理鎮痛)並有衛教與能力紀錄,否則嚴禁。 - **Pasero類鴉片誘導鎮靜量表** — 床邊鎮靜評估量表: S=易喚醒之睡眠、1=清醒、2=略嗜睡、3=頻繁嗜睡但可喚醒卻易再睡、4=昏睡僅最小反應。3-4級需暫停並立即通報醫師。 ## 相同主題題目 - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw) - [A nurse is monitoring a client receiving a continuous IV heparin infusion for pulmonary em…](https://mymerci.kr/pages/nclex_q.php?qn_id=363988&lang=zh-tw) - [A nurse is preparing to initiate a weight-based continuous IV unfractionated heparin infus…](https://mymerci.kr/pages/nclex_q.php?qn_id=364107&lang=zh-tw) - [A nurse is providing discharge teaching to a 65-year-old client newly prescribed warfarin …](https://mymerci.kr/pages/nclex_q.php?qn_id=364872&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=364913&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=364913&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=364913&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=364913&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=364913&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_