— 生理適應 · MEDIUM · SATA —
對於留置鼻胃管的病人，下列哪些護理措施是適當的？（選所有適合的）
Which of the following are appropriate nursing interventions for a client with a nasogastric tube? (Select all that apply.)
- ACheck for placement via X-ray before initial feed✓ 正解初次灌食前透過X光確認管路位置
- BElevate the head of the bed to 30-45 degrees✓ 正解將床頭抬高30-45度
- CFlush the tube before and after medication✓ 正解給藥前後沖洗管路
- DMonitor for abdominal distention✓ 正解監測腹部脹氣情形
- EPush the tube if it is not draining若管路未引流則推動管路
— Explanation · 中文詳解 —
鼻胃管護理首重安全。首次放置後務必透過 X 光確認位置。餵食或給藥時頭部抬高 30-45 度可預防誤吸。給藥前後沖洗管路防止堵塞。監測腹脹以防灌食不耐受。絕對禁止自行推動未引流的管路，以免造成胃腸穿孔。
Nasogastric tube care prioritizes safety. After initial placement, position must be verified by X-ray. During feeding or medication administration, elevating the head of the bed 30–45 degrees prevents aspiration. Flushing the tube before and after medication prevents occlusion. Abdominal distention is monitored to detect feeding intolerance. The tube must never be advanced when it is not draining, as this can cause gastrointestinal perforation.
✦ 台美臨床差異
美國護理師對於鼻胃管位置確認更傾向於使用 X 光，台灣臨床常結合測酸鹼值與 X 光檢驗。