— 基本照護與舒適 · MEDIUM · SATA —
護理師準備餵食一位有吞嚥障礙且有吸入性肺炎風險的病人，應採取哪些措施？（選所有適合的）
A nurse is preparing to feed a client who has dysphagia and is at risk for aspiration. Which actions should the nurse include? (Select all that apply.)
- APosition the client upright at a 90-degree angle✓ 正解將客戶置於 90 度直立姿勢
- BEncourage the client to tuck the chin when swallowing✓ 正解鼓勵客戶吞咽時收下巴
- COffer thin liquids to keep the throat moist提供稀薄液體以保持喉嚨濕潤
- DKeep the suction equipment readily available✓ 正解隨時備妥抽吸設備
- ECheck the mouth for food pocketing after each swallow✓ 正解每次吞咽後檢查口腔是否有食物殘留
— Explanation · 中文詳解 —
防範吸入性肺炎的核心是姿勢正確與吞嚥技巧。90度直立可利用重力輔助下嚥；下巴內收可縮窄氣道入口。薄液體最易引發吸入，通常需增稠。隨時備妥抽吸器材（Suction）以備緊急噎食。口腔殘留物（Pocketing）常發生在患側，需定期檢查以防殘留物誤吸。
To prevent aspiration, position the client upright at 90 degrees and encourage chin tucking during swallowing to protect the airway. Keep suction equipment ready for emergencies and check for food pocketing after each swallow, as residual food increases aspiration risk. Thin liquids should be avoided as they pose a high aspiration risk; thickened liquids are typically safer.
✦ 台美臨床差異
台灣臨床常見營養師與語言治療師共同評估，護理師需落實團隊訂定的吞嚥計畫。