一位患有中風後嚴重吞嚥困難的65歲男性，正透過鼻胃管（NG Tube）以每小時 60 mL 的速度接受連續性腸道管灌食。在巡房期間，護理師觀察到個案幾乎平躺，床頭（HOB）僅抬高 10 度。他發出輕微的咕嚕聲，且血氧 SpO2 為 93%。護理師暫停了灌食並抽吸出高達 450 mL 的胃殘餘量 (GRV)。護理師的首要介入措施為何？（多選題）
A 65-year-old male with severe post-stroke dysphagia is receiving continuous enteral feeding via a nasogastric (NG) tube at 60 mL/hr. During patient rounds, the nurse observes the client lying almost flat with the head of the bed (HOB) elevated to only 10 degrees. He is gurgling slightly, and his SpO2 is 93%. The nurse pauses the feeding and aspirates 450 mL of gastric residual volume (GRV). What are the priority nursing interventions? (Select all that apply.)
- AImmediately elevate the head of the bed to a minimum of 30 to 45 degrees.✓ 正解立即將床頭抬高至少 30 至 45 度。
- BDiscard the 450 mL of aspirated gastric residual to urgently decompress the over-distended stomach.丟棄抽吸出的 450 mL 胃殘餘物，以緊急減壓過度擴張的胃部。
- CPerform a comprehensive respiratory assessment, including auscultating lung sounds, to check for aspiration.✓ 正解進行全面的呼吸道評估，包括聽診肺部聲音，以檢查是否有吸入性肺炎。
- DHold the continuous enteral feeding promptly and notify the healthcare provider regarding the high residual volume.✓ 正解立即暫停連續性腸道灌食，並通知醫療提供者關於高殘餘量的情況。
- EFlush the NG tube rapidly with 100 mL of sterile water to force the residual volume through the pyloric sphincter.快速以 100 mL 無菌水沖洗鼻胃管，以迫使殘餘物通過幽門括約肌。
本題測驗基礎生理照護：避免管灌食吸入性肺炎（Aspiration Pneumonia）。病患接收連續灌食卻幾乎平躺（10度），胃酸反流進入氣管的風險極高，且現已出現血氧下降與水泡聲，強烈暗示已經發生微量吸入（Micro-aspiration）。首要（最緊急）的物理介入是：立刻將床頭（HOB）抬高至少 30至45度以利用重力防止進一步的胃液逆流（選項A正確）。由於抽出高達 450 mL 的巨大胃殘餘量（通常大於 250 mL 就需高度警戒，多數機構大於 500 mL 為絕對停灌標準），代表胃排空遲緩，繼續灌食會直接引發嘔吐窒息，因此必須暫停灌食並通知醫師（選項D正確）。護理師必須立刻進行完整的呼吸道評估與聽診肺音，以確認是否已發生吸入性肺炎（選項C正確）。選項B錯誤且非常危險，胃酸中含有大量維持酸鹼平衡與電解質的物質，隨意丟棄大劑量的抽出物會導致難以挽回的代謝性鹼中毒或電解質失衡，應遵醫囑將部分或全部緩緩推回體內。選項E錯誤，胃部已經過度脹滿，再強行沖入 100 mL 的水只會立刻觸發強烈嘔吐。
This question tests fundamental physiologic care: preventing tube feeding aspiration pneumonia. The client receives continuous tube feeding but is lying nearly flat (10 degrees), placing him at extremely high risk for reflux of gastric contents into the airway. Additionally, he now exhibits decreased oxygen saturation and gurgling sounds, strongly suggesting that micro-aspiration has already occurred. The most urgent physical intervention is to immediately elevate the head of the bed (HOB) to at least 30–45 degrees to use gravity to prevent further gastric reflux (Option A is correct). Because a massive gastric residual volume of 450 mL was aspirated (typically >250 mL warrants high alert, and many institutions consider >500 mL an absolute hold criterion), this represents delayed gastric emptying, and continuing the feeding will directly cause vomiting and aspiration. Therefore, the feeding must be held and the provider notified (Option D is correct). The nurse must immediately perform a thorough respiratory assessment and auscultate lung sounds to determine whether aspiration pneumonia has occurred (Option C is correct). Option B is incorrect and dangerous: the aspirated gastric content contains large amounts of substances that maintain acid-base balance and electrolyte levels; discarding large volumes can cause irreversible metabolic alkalosis or electrolyte imbalance, and per orders, part or all of the aspirate should be slowly reinstilled. Option E is incorrect: the stomach is already over-distended, and forcing in another 100 mL of water would immediately trigger violent vomiting.
台美針對管灌照護的界線標準近乎一致：「灌食前後及期間床頭必須抬高 30 度以上」是鐵律。至於「抽出的殘留物是否丟棄」，全球護理標準皆倡導若非醫師要求減壓，否則盡可能不可隨意丟棄大體積殘留物以保護電解質。