— 基本照護與舒適 · MEDIUM · SATA —
護理師準備餵食有吞嚥困難的病人。應包含哪些預防吸入性肺炎的措施？（選所有適合的）
A nurse is preparing to feed a client who has dysphagia. Which actions should the nurse include to prevent aspiration? (Select all that apply.)
- AEnsure the head of the bed is elevated at least 45-90 degrees✓ 正解確保床頭抬高至少 45-90 度
- BProvide thin liquids to facilitate swallowing提供稀薄液體以利吞嚥
- CCheck for pocketing of food in the cheeks✓ 正解檢查頰部是否有食物殘留
- DEncourage the client to tuck the chin when swallowing✓ 正解鼓勵個案在吞嚥時收下巴
- EFeed the client small amounts slowly✓ 正解少量多次緩慢餵食
— Explanation · 中文詳解 —
吞嚥困難（Dysphagia）病人發生吸入性肺炎（Aspiration pneumonia）的風險極高，護理重點在於利用重力輔助與保護氣道。應確保病人維持至少 45-90 度的坐姿，並進行下巴內收（Chin-tuck）以關閉會厭，防止食物進入氣管。此外，檢查口腔殘留（Pocketing）與少量餵食能有效減少誤吸風險。
To prevent aspiration, elevate the head of the bed to at least 45 degrees and encourage the client to tuck their chin when swallowing to protect the airway. The nurse should also feed small amounts slowly and check for food pocketing in the cheeks, avoiding thin liquids which pose a higher aspiration risk.
✦ 台美臨床差異
美國臨床多由語言治療師（Speech-Language Pathologist, SLP）進行吞嚥評估並給予明確的飲食質地（如 IDDSI 標準）建議，護理師須嚴格遵循其指引。