— 降低風險 · MEDIUM · SATA —
護理師照護一位有吸入性肺炎風險的病人。下列哪些護理措施能有效降低此風險？（選所有適合的）
A nurse is providing care for a client who is at risk for aspiration. Which nursing intervention is effective in reducing this risk? (Select all that apply.)
- AMaintain the head of the bed at 30 to 45 degrees during feeding✓ 正解進食期間保持床頭抬高30至45度
- BEncourage the client to drink water between every bite鼓勵病人在每一口之間喝水
- CAssess the client's gag and swallow reflexes before feeding✓ 正解進食前評估病人的嘔吐和吞嚥反射
- DUse a straw to make it easier for the client to drink liquids使用吸管讓病人更容易飲用液體
- EInstruct the client to tuck their chin when swallowing✓ 正解指示病人在吞嚥時收下巴
— Explanation · 中文詳解 —
預防吸入性肺炎的核心是姿勢控制與吞嚥評估。坐姿 30-45 度以上可防逆流與誤吸。進食前務必確認吞嚥反射。下巴內收（Chin-tuck）可閉合會厭軟骨，保護氣管。B 選項錯誤，頻繁喝水增加誤吸風險；D 選項錯誤，吸管會使液體流速過快，對吞嚥功能受損者極度危險。
To reduce aspiration risk, the nurse should maintain the head of the bed at 30 to 45 degrees to use gravity and assess gag and swallow reflexes before feeding. Additionally, instructing the client to tuck their chin helps close the epiglottis, protecting the airway during swallowing.
✦ 台美臨床差異
在美國，語言治療師（SLP）介入非常頻繁且嚴謹，台灣則多由護理師與醫師共同評估吞嚥功能。