護理師正在照顧一位接受持續性鼻胃管灌食的病人。下列哪項護理措施對預防併發症最重要？
A nurse is managing the care of a client with a continuous NG tube feeding. Which nursing action is most important to prevent complications?
- AFlush the tube with 100 mL of water after medications.給藥後以 100 mL 水沖洗管路
- BWarm the feeding formula to body temperature in a microwave.用微波爐將灌食配方加熱至體溫
- CCheck gastric residual volume every 24 hours.每 24 小時檢查胃殘留量
- DKeep the head of the bed elevated 30 to 45 degrees.保持床頭抬高 30 至 45 度正確答案
- D保持床頭抬高 30 至 45 度
持續性鼻胃管灌食最大的風險是逆流造成吸入性肺炎，維持床頭抬高 30–45 度（D）是最關鍵的預防措施。C 的觀念要更新：依 SCCM/ASPEN 現行指引，不建議把常規測量胃殘餘量（GRV）當作腸道灌食的監測手段；若機構仍在測，GRV 低於 500 mL 且無其他不耐受徵象時不應停灌，200–500 mL 時提高警覺並加強防吸入措施。灌食期間每 4 小時應核對的是鼻胃管外露記號位置有無改變。A 藥物後沖洗一般 15–30 mL 即可，100 mL 過量；B 絕對禁止微波加熱——受熱不均可能燙傷，配方維持室溫即可。
- A給藥後以 100 mL 水沖洗管路
藥後沖洗 100 mL 的水會給病人增加不必要的液體負擔，特別是心腎功能不全者。標準沖洗量應為 30 mL 左右。
- B用微波爐將灌食配方加熱至體溫
微波爐會造成「熱點」，極易燙傷消化道黏膜。灌食液只需放置室溫即可，過冷會刺激腸胃蠕動過快，但絕不微波。
- C每 24 小時檢查胃殘留量
持續灌食應每 4-6 小時檢查一次殘餘量，間隔 24 小時太長，無法及時發現胃排空延遲，會增加嘔吐與吸入風險。
- D · 正確答案保持床頭抬高 30 至 45 度
這是預防吸入性肺炎的黃金準則。抬高床頭能確保灌食液留在胃內，避免因平躺導致的逆流。這是最基本的安全要求。
美國 NCLEX 與最近趨勢（ASPEN 指引）對於是否例行檢查殘餘量（GRV）有爭議，但床頭抬高永遠是正確答案。台灣臨床仍嚴格要求每班檢查殘餘量（通常 >50-100cc 需暫緩），護理師應靈活運用。
English explanation
The greatest risk of continuous feeding is reflux leading to aspiration pneumonia. Maintaining the head of the bed elevated 30-45 degrees (D) is the most critical measure for preventing this serious complication, as it uses gravity to reduce gastric content reflux into the esophagus. Option C (checking residuals every 24 hours) is too infrequent; checks should generally be performed every 4-6 hours. Option A (flushing with 100 mL) is excessive; 15-30 mL after medications is generally sufficient, as excess water can cause fluid overload. Option B (microwave heating) is strictly forbidden, as uneven heating can cause burns; feeding formula should generally be kept at room temperature. The nursing priority is 'safety and airway protection,' and head-of-bed elevation is the first line of defense.
最近修訂：2026-10-05