— 降低風險 · MEDIUM · SATA —
為了預防呼吸器相關肺炎（VAP），護理師應包含哪些護理計畫？（選所有適合的）
Which of the following interventions should a nurse include in the plan of care to prevent ventilator-associated pneumonia (VAP)? (Select all that apply.)
- AKeep the head of the bed elevated at 30 to 45 degrees✓ 正解將床頭抬高 30 至 45 度
- BPerform daily sedation vacations✓ 正解執行每日鎮靜暫停
- CSuction the endotracheal tube every 2 hours routinely每 2 小時常規進行氣管內管抽吸
- DImplement daily oral care with chlorhexidine✓ 正解實施使用 Chlorhexidine 的每日口腔護理
- EMaintain the cuff pressure between 20-30 cm H2O✓ 正解維持氣囊壓力在 20-30 cm H2O 之間
— Explanation · 中文詳解 —
VAP 預防的核心 bundle 包括：抬高床頭 30-45 度減少吸入、每日評估鎮靜狀況（sedation vacation）以利脫離呼吸器、使用 Chlorhexidine 進行口腔護理、以及維持氣囊壓力在適當範圍。常規抽痰（C選項）非預防 VAP 的證據支持手段，應採取「按需抽痰」。
The core VAP prevention bundle includes: elevating the head of the bed 30-45 degrees to reduce aspiration, daily sedation vacations to facilitate ventilator weaning, oral care with chlorhexidine, and maintaining cuff pressure within an appropriate range. Routine suctioning (option C) is not an evidence-supported measure for VAP prevention; suctioning should be performed as needed.
✦ 台美臨床差異
美國重症單位對於 VAP bundle 的執行與稽核極為嚴格；台灣醫療單位亦廣泛導入，但執行落實度與護病比相關。