Nursing care
PCA client breathing 8 times a minute: the order of nursing actions
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated October 2026
Short answer
When a client on an opioid PCA has a respiratory rate of 8 and is hard to rouse, the nurse stops the PCA, stimulates the client, calls for help and supports the airway and breathing, then gives naloxone according to protocol or order. Close monitoring continues afterwards, because naloxone can wear off before the opioid and breathing may slow again.
Stop the source and wake the client
Opioids depress the brain's drive to breathe, and the Merck Manual identifies respiratory depression, which can progress to apnoea, as the main danger of opioid toxicity. A slow rate with heavy sedation means the client is accumulating more drug than they can safely handle, so the first step is to stop further delivery by pausing or stopping the PCA pump.
Next, try to rouse the client with firm voice and touch, ask them to take deep breaths and check how easily they wake. Assess oxygen saturation, chest movement, pupil size and skin colour. Sedation and respiratory rate are monitored together when parenteral opioids are given, because an increasingly drowsy client often signals rising risk before breathing fails.
Support breathing and give naloxone as ordered
Call for help, using the rapid response team if the client does not rouse or breathing is inadequate. Open the airway, apply oxygen and be ready to ventilate with a bag and mask. Merck states that maintaining the airway and ensuring adequate ventilation is the first priority, and ventilation may need to start before or alongside naloxone in a client who is not breathing.
Give naloxone according to the protocol or order. It acts within minutes when given intravenously, and other routes are available if there is no line. Its effect can wear off before the opioid has cleared, so respiratory depression can return. Keep monitoring closely and expect the provider to review the pain plan.
Find the cause before restarting
Once breathing is safe, look for why the client became oversedated. Check the PCA settings against the order, the history of bolus demands and any continuous infusion. Ask whether anyone other than the client pressed the button, since PCA relies on the client self-titrating. Review other sedating medicines such as benzodiazepines, and risk factors such as sleep apnoea, lung disease or kidney impairment.
Document the event, the actions and the response, and report the device settings to the provider. The PCA is not restarted until the prescriber has reviewed the plan. Teach family members not to press the button for the client, and reinforce with the client that drowsiness is a reason to call the nurse rather than to press for more medicine.
Monitoring after the event
Once the client is breathing adequately, keep checking respiratory rate, sedation level and oxygen saturation at short intervals, following the unit's post-naloxone monitoring protocol. Watch especially if long-acting opioids are involved, because recurrence is more likely when the opioid outlasts naloxone. Continuous pulse oximetry may be ordered for the rest of the shift.
Expect pain to return when the opioid is reversed, and report it so the prescriber can adjust the plan, perhaps with non-opioid options. Reassure the client honestly about what happened. Document the event, the PCA settings and history, the naloxone given and the client's response, and complete an incident report according to local policy.
Worked example: why assess pain and call the family are wrong
In a hypothetical case, a post-operative client on a morphine PCA is found snoring, difficult to rouse, breathing 8 times a minute with oxygen saturation in the high eighties. Options include assessing the pain score, calling the family to stop pressing the button, documenting and rechecking in fifteen minutes, or stopping the PCA, stimulating and supporting breathing. The last is the priority.
Assessing pain makes no sense in a client who cannot be roused and does not address hypoventilation. Calling the family investigates a possible cause but leaves the danger in place. Rechecking later allows further deterioration. An assistant can bring the emergency cart and oxygen, but assessment, naloxone and airway management remain with the registered nurse and responding team.
Sources and further reading
Merck Manual Professional: Opioid toxicity and withdrawal. Respiratory depression progressing to apnoea, airway and ventilation as the first priority, naloxone routes and recurrence after naloxone wears off.
MSD Manual Professional: Treatment of pain. PCA self-titration, monitoring sedation and respiratory rate with parenteral opioids, risk factors for respiratory depression and naloxone onset and duration.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our pharmacology practice questions are the closest set to what this page covers.
One question from the pharmacology set
A client with heart failure is started on furosemide 40 mg PO daily. Which findings should the nurse report to the provider before administering the next dose? Select all that apply.
Rationale
Furosemide is a loop diuretic, so the two things you are watching are potassium and kidney function. A potassium of 2.9 mEq/L is below the 3.5–5.0 reference range and puts the client at risk for dysrhythmia — hold and report. Muscle cramps with palpitations are the clinical face of that same hypokalemia, so they are reported together, not separately. A creatinine that doubles signals the diuresis has outrun renal perfusion. A blood pressure of 132/78 and a 1 kg loss are the expected response to the drug working, not reasons to hold it.
Answer: A, D, E
Common questions
Why stop the PCA before giving naloxone?
Stopping the pump prevents more opioid from being delivered while the client is rescued. Naloxone without stopping the source can be overwhelmed as further doses arrive.
Can breathing slow down again after naloxone?
Yes. Naloxone's effect can wear off before the opioid's does, so close monitoring continues and repeat doses may be needed as ordered.
Who should press the PCA button?
Only the client. PCA is designed so a drowsy client stops pressing, which limits the dose. When someone else presses it, that safety feature is bypassed.
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