— 降低風險 · EASY · MCQ —
護理師照護一位接受連續管灌飲食的病人。為降低吸入性肺炎風險，下列哪項措施最重要？
A nurse is caring for a client with a continuous tube feeding. Which action is most important to reduce the risk of aspiration?
- AFlush the tube with water every shift每班次以水沖洗管路
- BCheck residual volume every 4 hours每 4 小時檢查殘餘量
- CVerify tube placement via pH testing透過 pH 值測試確認管路位置
- DElevate the head of the bed 30-45 degrees✓ 正解將床頭抬高 30-45 度
— Explanation · 中文詳解 —
維持床頭抬高 30-45 度是預防管灌病人吸入性肺炎最直接且有效的非侵入性物理措施。雖然檢查殘餘量與確認管路位置有其重要性，但重力導向的物理屏障在防止胃內容物逆流至食道與呼吸道方面具有決定性作用，是護理照護的基本防禦。
Maintaining the head of the bed elevated to 30–45 degrees is the most direct and effective noninvasive physical measure for preventing aspiration pneumonia in tube-fed patients. Although checking residual volume and confirming tube placement are also important, a gravity-based physical barrier plays a decisive role in preventing the reflux of gastric contents into the esophagus and airway and is a fundamental defense in nursing care.
✦ 台美臨床差異
美台臨床對於餵食姿勢的共識一致，但在評估殘餘量（GRV）的頻率上，美國較傾向根據 protocol 減少測量次數。