— 降低風險 · MEDIUM · MCQ —
護理師照顧一位使用鼻胃管灌食的病人。下列哪項措施對預防吸入性肺炎至關重要？
A nurse is caring for a client with a nasogastric tube (NGT) for enteral feeding. Which action is essential to prevent aspiration?
- AElevate the head of the bed to 30 to 45 degrees✓ 正解將床頭抬高30至45度
- BFlush the tube with water after each feeding每次灌食後以水沖洗管路
- CCheck for gastric residual volume every 4 hours每4小時檢查胃殘留量
- DVerify tube placement by testing pH of aspirate透過檢測抽吸物的pH值來確認管路位置
— Explanation · 中文詳解 —
預防灌食吸入性肺炎最有效的物理性措施是維持床頭抬高 30-45 度，利用重力防止胃內容物反流至食道。雖然確認 pH 值、沖洗管路與評估殘餘量也是灌食流程的一部分，但對於「吸入」風險的預防，體位才是最直接的核心安全措施。
The most effective physical measure to prevent aspiration during tube feeding is to maintain the head of the bed elevated to 30-45 degrees, using gravity to prevent gastric contents from refluxing into the esophagus. Although checking the pH, flushing the tube, and assessing gastric residual volume are also part of the feeding protocol, positioning is the most direct and core safety measure for preventing aspiration.
✦ 台美臨床差異
美國護理常規中，連續性灌食病人亦需維持床頭抬高；台灣亦同，但針對部分危急重症病人，如需平躺檢查時，護理流程中需特別注意停止灌食。