— 基本照護與舒適 · MEDIUM · SATA —
護理師評估一位放置鼻胃管的病人，哪些發現顯示有吸入性肺炎風險？（選所有適合的）
Which assessment findings indicate that a client with a nasogastric tube is at risk for aspiration? (Select all that apply.)
- ADiminished gag reflex✓ 正解喉頭反射減弱
- BHead of bed elevated to 15 degrees✓ 正解床頭抬高 15 度
- CContinuous tube feeding infusion持續管灌輸注
- DHistory of gastroesophageal reflux✓ 正解胃食道逆流病史
- EPresence of a large amount of gastric residual volume✓ 正解存在大量胃殘餘量
— Explanation · 中文詳解 —
鼻胃管病人預防吸入需維持床頭抬高（至少 30-45 度），15 度過低。吞嚥反射差、胃食道逆流及大量殘餘胃容物均大幅增加逆流風險。連續灌食本身是處置方式，只要監測得當並非風險因子，但若伴隨胃排空延遲則需調整。
To prevent aspiration in clients with a nasogastric tube, the head of the bed must be elevated (at least 30-45 degrees); 15 degrees is too low. A diminished gag reflex, gastroesophageal reflux, and a large gastric residual volume all substantially increase the risk of reflux. Continuous feeding is itself a feeding method and, with appropriate monitoring, is not inherently a risk factor, though adjustments are needed if delayed gastric emptying coexists.
✦ 台美臨床差異
美國醫院多由護理師主導管灌安全檢查，台灣因護理人力比吃緊，有時依賴家屬執行，衛教品質更顯重要。