居家鼻胃管留置個案肺炎與照顧者口腔照護能力相關性之探討

研究背景：居家照護個案因疾病多伴有吞嚥障礙或營養問題，常以鼻胃管留置維持營養並預防吸入性肺炎，且因日常生活需依賴照顧者照顧，其口腔健康狀況皆不佳，而臨床上發現有些鼻胃管留置的個案除管灌外，是可以由口進食食物，然而這些個案因缺乏適當吞嚥評估及安全有效吞嚥訓練，更容易造成吸入性肺炎之風險。照顧者及家屬是居家個案飲食起居的第一線人員，但因缺乏口腔保健知識及吞嚥障礙的訓練指導而使口腔健康狀況及吞嚥障礙更加惡化，增加發生肺炎的風險，影響生活品質，並增加社會醫療之成本。研究目的：瞭解居家鼻胃管留置個案口腔衛生與咀嚼吞嚥狀況，並探討其照顧者口腔照護能力與個案肺炎相關性。研究方法：採橫斷性研究並以結構式問卷收集資料，研究對象為南部某居家護理所個案與其照顧者，總樣本數128人。研究結果：個案口腔衛生影響肺炎相關因子中，有口臭、硬口蓋有黏著物、口乾症及牙關緊閉有顯著相關，且經個案調整年齡、意識狀況、疾病項目及失能程度後，肺炎發生風險較無調整前高。管灌合併口進食個案飲食方式影響其肺炎，於進食時使用大湯匙餵食、進食時間少於30分、進食時看電視、一口飯菜量超過5ml、一口食物吞嚥2次及每天嗆咳至少1次有顯著相關，並於調整個案年齡、意識狀況、疾病項目及失能程度後，肺炎發生之風險較無調整前高。照顧者照護行為影響個案肺炎，起床後協助清潔口腔及使用海棉棒清潔與個案肺炎有顯著相關，且於調整照顧者性別、年齡、教育程度後，肺炎發生風險較無調整前高。結論：鼻胃管留置個案口腔健康、飲食狀況及照顧者口腔照護行為與其肺炎有顯著相關。因照顧者清潔時機及使用的工具不適當，其口腔衛生狀況仍是不佳狀態，且合併口進食個案，因照顧者缺乏接受吞嚥訓練相關指導，更加提升肺炎發生之風險。

關鍵字

居家照護；鼻胃管留置；口腔清潔；照顧者；照顧照護能力

並列摘要

Background: Home care cases often suffer from the accompanying dyspHagia or nutrition problems owing to disease factors, so the indwelling nasogastric tube is used to maintain nutrition and prevent aspiration pneumonia. Those subjects that rely on caregivers to take care of their daily life often have poor oral health. It is found clinically that besides feeding through the indwelling nasogastric tube, some cases can take food from the mouth. However, these patients are more susceptible to aspiration pneumonia owing to lack of appropriate swallowing evaluation and safe and effective swallowing training. Caregivers and the family members are directly responsible for the cases’ diet and daily life, but their lack of oral health knowledge and swallowing impairment training worsens the oral health condition and swallowing disorder, which will increase the risk of pneumonia, influence life quality and augment social medical cost. Objective: The study was to understand the oral health and chewing and swallowing condition of the casess with indwelling nasogastric tubes and investigate the correlation between caregivers’ oral care capability and cases’ pneumonia. Material and methods: The cross-sectional study was adopted and structured questionnaire was used to collect data. The study subjects were cases and caregivers in a home care organization in southern Taiwan. There were 128 samples in total. Results: In the terms of cases' oral health-related factors, bad breath, adhesive matter on hard palate, xerostomia and trismus were significantly correlated with pneumonia. After the adjustment of cases’ age, consciousness, disease items and disability degree, the relative risk of pneumonia was higher than that before adjustment. In the terms of cases with combined tube feeding and oral feeding, they had to be fed, were fed with a tablespoon, had feeding time shorter than 30 minutes, watched TV while being fed, had a mouthful larger than 5ml, had to swallow food twice and coughed at least once a day were significantly correlated with pneumonia. After the adjustment of cases’ age, consciousness, disease items and disability degree, the relative risk of pneumonia was higher than that before adjustment. In terms of the caregivers’ caring behavior and cases’ pneumonia, the caregivers whoes had cases’ mouths cleaned in the morning and use sponge stick were significantly correlated with cases’ pneumonia. After the adjustment of caregivers’ sex,age,education,the relative risk of cases’ pneumonia was higher than that before adjustment Conclusion: The oral health and dietary condition of cases with indwelling nasogastric tube and the caregivers’ oral care capability were significantly correlated with the occurrence of pneumonia. Though oral cleaning is routine care behavior for these cases, inappropriate cleaning timing and tools will lead to poor oral health conditions. Meanwhile, for cases with combined tube feeding and oral feeding, if the caregivers lack relevant swallowing training, the risk of pneumonia will be greatly increased.