— 降低風險 · MEDIUM · SATA —
護理師照護一位接受連續腸道灌食的病人，應採取哪些措施以降低吸入性肺炎的風險？（選所有適合的）
A nurse is caring for a client receiving continuous enteral tube feeding. Which interventions should the nurse perform to reduce the risk of 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 via X-ray before initial use✓ 正解在初次使用前透過X光確認管路位置
- CCheck gastric residual volume every 4 hours✓ 正解每4小時檢查胃殘留量
- DAdminister the feeding at a rapid bolus rate以快速推注的方式給予灌食
- EEnsure the feeding tube is secured properly to the nose✓ 正解確保餵食管路確實固定在鼻子上
— Explanation · 中文詳解 —
預防吸入性肺炎的關鍵在於防止胃內容物逆流。抬高床頭（30-45度）利用重力防止逆流；確認導管位置可確保灌食不進入氣管；監測殘餘量可評估胃排空功能；妥善固定管路可避免導管滑脫。快速灌食會誘發嘔吐，非預防措施。
To reduce aspiration risk, elevate the head of the bed to use gravity against reflux, verify tube placement radiographically, and monitor gastric residuals to assess emptying. Properly securing the tube prevents migration, whereas rapid bolus feeding increases the risk of gastric distension and vomiting.
✦ 台美臨床差異
美國多使用 pH 值結合氣泡試驗監測，但 X 光仍是黃金標準；台灣臨床對 pH 值檢測使用率較低。