護理師為無意識病人進行口腔護理，哪些行動是適當的？（選所有適合的）

為無意識（unconscious）病人進行口腔護理（oral care）需特別謹慎，因為他們缺乏吞嚥、咳嗽和保護性反射，極易發生嗆咳（aspiration）及吸入性肺炎（aspiration pneumonia）。因此，護理措施的重點在於維持呼吸道安全與清潔。 正確選項分析： A. 採取側臥姿勢（Place the client in a side-lying position）：此姿勢能利用重力，使口腔分泌物或沖洗液自然流出口腔，避免流入氣管，是保護呼吸道安全的關鍵。 B. 使用牙刷清潔（Use a toothbrush to clean teeth and gums）：定期的口腔清潔對預防口腔感染（如鵝口瘡）和維持口腔黏膜健康很重要。使用軟毛牙刷輕柔清潔牙齒、牙齦和舌頭是適當的。 E. 準備抽吸設備（Keep suction equipment nearby）：由於病人可能無法有效清除分泌物，或在清潔過程中引發嘔吐，隨時準備好抽吸設備，以便及時清除口腔和喉嚨中的液體或嘔吐物，預防窒息和吸入。 錯誤選項分析： C. 直接將水灌入（Pour water into the mouth to rinse）：無意識病人無法控制吞嚥，直接灌水極易導致嗆入，引發吸入性肺炎。即使是沖洗，也應使用少量生理食鹽水，並配合抽吸。 D. 使用壓舌板維持開口（Use a padded tongue blade to keep the mouth open）：雖然需要維持口腔張開以利清潔，但不應使用硬的壓舌板，因其可能造成牙齒損傷或黏膜撕裂。可考慮使用口腔開口器（oral airway）或軟性輔具，並需評估病人情況。 臨床思路：ABC 原則中的 A（Airway）是首要考量。為無意識病人進行任何侵入性操作，都必須預期並預防潛在併發症，特別是呼吸道併發症。安全措施（Safety measures）的準備（如抽吸）是優先順序。 台美差異：在台灣，過去可能較少強調為無意識病人準備抽吸設備，或對壓舌板的使用較不嚴謹。但在美國，這兩點是標準照護要求，強調預防吸入性肺炎的風險。

Oral care for an unconscious patient requires special caution because the patient lacks swallowing, coughing, and protective reflexes, making aspiration and aspiration pneumonia highly likely. Therefore, the focus of nursing interventions is on maintaining airway safety and cleanliness. Analysis of correct options: A. Placing the client in a side-lying position: This position uses gravity to allow oral secretions or rinsing fluid to flow naturally out of the mouth, preventing them from entering the trachea, and is key to protecting airway safety. B. Using a toothbrush to clean teeth and gums: Regular oral hygiene is important to prevent oral infections (e.g., thrush) and to maintain mucosal health. Using a soft-bristled toothbrush to gently clean the teeth, gums, and tongue is appropriate. E. Keeping suction equipment nearby: Because the patient may be unable to effectively clear secretions or may gag during cleaning, suction equipment must be readily available to promptly remove fluids or vomitus from the oral cavity and pharynx and to prevent choking and aspiration. Analysis of incorrect options: C. Pouring water directly into the mouth: An unconscious patient cannot control swallowing, and pouring water directly carries a high risk of aspiration and aspiration pneumonia. Even when rinsing, a small amount of saline should be used in combination with suction. D. Using a padded tongue blade to keep the mouth open: Although the mouth must be kept open to facilitate cleaning, a hard tongue blade should not be used as it may injure the teeth or tear the mucosa. An oral airway or a soft assistive device should be considered, and the patient's condition must be assessed. Clinical reasoning: 'A' (Airway) in the ABC principles is the foremost consideration. Any invasive procedure performed on an unconscious patient must anticipate and prevent potential complications, particularly airway complications. Preparation of safety measures (such as suction) takes precedence. Taiwan-U.S. differences: In Taiwan, less emphasis may have been placed on preparing suction equipment for unconscious patients or on the stricter use of tongue blades. In the U.S., however, these two points are standards of care, emphasizing prevention of the risk of aspiration pneumonia.

台灣過去對於無意識病人進行口腔護理時，可能較少強調標準化的側臥姿勢與抽吸設備的隨時備用。雖然基本清潔概念相同，但在預防吸入性肺炎的嚴謹度上，美國的照護標準要求更高，更強調這些安全措施的落實。