哪項措施對於接受管灌食的病人能有效降低吸入性肺炎風險？
Which of the following interventions is effective in reducing the risk of aspiration for a client receiving enteral tube feeding?
- AChecking gastric residual volume every 6 hours每 6 小時檢查胃殘留量
- BInfusing the formula as quickly as possible盡快輸注營養配方
- CMaintaining the head of the bed elevated at 30-45 degrees✓ 正解維持床頭抬高 30-45 度
- DPlacing the client in a supine position將病人置於仰臥位
對於接受管灌食（Enteral tube feeding）的病人，吸入性肺炎（Aspiration pneumonia）是重大風險。將床頭抬高 30-45 度是利用重力原理，防止胃內容物反流至咽喉並進入氣管。這是目前臨床預防吸入性肺炎最標準且具實證依據的護理措施，無論是否監測殘餘量，體位管理都是首要護理重點。
Aspiration pneumonia is a major risk for patients receiving enteral tube feedings. Elevating the head of the bed 30-45 degrees uses gravity to prevent reflux of gastric contents into the pharynx and trachea. This is currently the most standard and evidence-based nursing intervention for preventing aspiration pneumonia; regardless of whether gastric residual volume is monitored, positioning is the primary nursing focus.
美國部分醫療機構已不再強制要求每 4-6 小時測量殘餘量（GRV），因為過頻測量反而增加管路阻塞風險，護理重點已轉向監測吸入症狀（如咳嗽、呼吸音變化）與正確體位管理。