— 基本照護與舒適 · HARD · SATA —
護理師準備為昏迷病人進行口腔護理，應包含哪些步驟？（選所有適合的）
A nurse is preparing to provide oral hygiene for a client who is unconscious. Which action should the nurse include? (Select all that apply.)
- APosition the client in a side-lying position✓ 正解將病人置於側臥位
- BUse a lemon-glycerin swab to clean the teeth使用檸檬甘油棉棒清潔牙齒
- CSuction secretions as needed✓ 正解按需抽吸分泌物
- DAssess the mouth for lesions or dryness✓ 正解評估口腔是否有病變或乾燥
- EInsert a padded tongue blade to keep the mouth open✓ 正解插入帶襯墊的壓舌板以保持嘴巴張開
— Explanation · 中文詳解 —
昏迷病人護理重點在於預防吸入性肺炎與維護黏膜完整。採側臥可讓液體流出，使用抽吸設備維持呼吸道清潔。定期檢查黏膜狀況。使用壓舌板可防咬傷，但在協助下維持張口亦可。檸檬甘油棒具酸性且會導致黏膜乾燥，現已不建議使用。
Positioning the client side-lying facilitates drainage of secretions to prevent aspiration, while suctioning as needed maintains a clear airway. The nurse should assess the mouth for lesions or dryness to detect early signs of infection and use a padded tongue blade to protect both the client and nurse from injury. Lemon-glycerin swabs are avoided because they dry the oral mucosa.
✦ 台美臨床差異
台灣醫院常使用海綿刷（Toothettes）進行口腔護理，美國則更傾向於使用軟毛牙刷以達到機械性清除牙菌斑之效果。