— 降低風險 · MEDIUM · SATA —
護理師照護一位留置鼻胃管的病人。下列哪些措施有助於預防吸入性肺炎？（選所有適合的）
A nurse is caring for a client with a nasogastric tube (NG tube). Which actions should the nurse take to prevent aspiration? (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
- BVerify tube placement by checking the pH of the aspirate✓ 正解通過檢查抽吸物的酸鹼值來確認管路位置
- CCheck gastric residual volume before each bolus feeding✓ 正解在每次推注餵食前檢查胃殘餘量
- DIrrigate the tube with 50 mL of sterile water every 4 hours每 4 小時用 50 mL 無菌水沖洗管路
- EFlush the tube before and after medication administration✓ 正解在給藥前後沖洗管路
— Explanation · 中文詳解 —
預防吸入性肺炎核心在於維持氣道通暢與防止胃內容物逆流。抬高床頭（30-45度）、餵食前確認置管位置（pH值）、監控胃殘餘量皆是降低吸入風險的實證護理措施。沖洗管路能維持通暢，避免藥物卡住導致後續需要重新放置管路，減少刺激。
Preventing aspiration pneumonia involves maintaining airway patency and preventing gastroesophageal reflux. Key evidence-based interventions include elevating the head of the bed, verifying tube placement via pH testing, and monitoring gastric residuals before feeding. Additionally, flushing the tube before and after medication administration helps prevent occlusion and ensures proper delivery.
✦ 台美臨床差異
美台對管路護理規範差異不大，主要在於 pH 值檢測的設備普及程度，台灣部分單位仍常用聽診法（雖不建議）。