— 基本照護與舒適 · MEDIUM · MCQ —
護理師為意識不清的病人進行口腔護理，下列何項措施正確？
Which action should the nurse take when providing oral care to an unconscious client?
- APosition the client on their side with the head tilted forward✓ 正解將病人置於側臥位並頭部前傾
- BKeep the client in a supine position to prevent neck strain保持病人仰臥位以防止頸部勞損
- CUse a stiff-bristled toothbrush for thorough cleaning使用硬毛牙刷進行徹底清潔
- DUse a lemon-glycerin swab to clean the teeth使用檸檬甘油棉棒清潔牙齒
— Explanation · 中文詳解 —
意識不清者缺乏吞嚥反射，口腔護理時若平躺（Supine）極易導致吸入性肺炎。應將病人側臥（Lateral position）並讓頭部前傾，利用重力讓液體流出。檸檬甘油棉棒會使黏膜乾燥且刺激；硬毛牙刷會損傷脆弱的牙齦組織，應使用軟毛牙刷或海綿刷。
When providing oral care to an unconscious client, the nurse should position the client on their side with the head tilted forward to use gravity and prevent aspiration. Supine positioning is contraindicated due to high aspiration risk, and hard-bristled brushes or lemon-glycerin swabs should be avoided as they can cause tissue trauma or dryness.
✦ 台美臨床差異
台灣醫院對意識不清者的口腔護理多有標準化程序，重視避免誤吸；美國則強調使用 chlorhexidine 等特殊潔牙劑的頻率。