— 基本照護與舒適 · MEDIUM · SATA —
護理師照顧一位鼻胃管灌食病人，應採取哪些措施預防吸入性肺炎？（選所有適合的）
A nurse is caring for a client receiving enteral feedings. Which actions should the nurse take to prevent aspiration? (Select all that apply.)
- AVerify tube placement before each feeding✓ 正解每次灌食前確認管路位置
- BElevate the head of the bed to 30-45 degrees✓ 正解將床頭抬高 30-45 度
- CFlush the tube with 100 mL of water before feeding灌食前以 100 mL 水沖洗管路
- DAssess residual volume as per facility policy✓ 正解依機構政策評估殘留量
- ECheck the ph of the gastric aspirate✓ 正解檢測胃抽吸液的 pH 值
— Explanation · 中文詳解 —
預防鼻胃管吸入性肺炎，需確保管路位置正確（pH檢測、回抽物顏色確認）、灌食時維持半坐臥姿（30-45度）。過量沖洗（100 mL）並非標準，通常只需 30 mL 左右，過多沖洗會增加胃內負擔，增加逆流風險。
To prevent aspiration pneumonia in NG-tube-fed clients, tube placement must be verified (by pH testing and inspection of aspirated contents), and the client must be maintained in semi-Fowler's position (30–45 degrees) during feeding. Excessive flushing (100 mL) is not standard; usually about 30 mL is sufficient. Excessive flushing increases gastric volume and the risk of reflux.
✦ 台美臨床差異
美國多使用 pH 檢測帶；台灣早期仰賴抽氣檢測或打氣聽診，目前也逐步引進 pH 檢測。