— 降低風險 · MEDIUM · MCQ —
為了預防插管病人的呼吸器相關肺炎（VAP），護理師應採取哪項措施？
Which action should the nurse take to prevent ventilator-associated pneumonia (VAP) in an intubated client?
- AAdminister prophylactic antibiotics給予預防性抗生素
- BElevate the head of the bed 30-45 degrees✓ 正解將床頭抬高 30-45 度
- CChange the ventilator circuit daily每天更換呼吸器管路
- DSuction the airway every hour on the hour每小時定時抽吸呼吸道
— Explanation · 中文詳解 —
預防 VAP 的核心 Bundle 措施包括床頭抬高 30-45 度以降低吸入性肺炎風險、每日執行口腔護理（使用氯己定）、每日評估拔管可行性。定時抽痰或頻繁更換管路並非預防 VAP 的實證指引，反而可能增加感染或氣管黏膜損傷機會。
Core bundle measures to prevent VAP include elevating the head of the bed 30-45 degrees to reduce the risk of aspiration pneumonia, daily oral care (using chlorhexidine), and daily assessment of extubation readiness. Scheduled suctioning or frequent tubing changes are not evidence-based recommendations for VAP prevention; on the contrary, they may increase the risk of infection or tracheal mucosal injury.
✦ 台美臨床差異
美台在加護病房中皆嚴格執行 VAP Bundle，美國護理師在口腔護理方面的標準流程常結合專屬刷牙設備。