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護理師觀察一位腦中風後吞嚥困難個案的照護。哪些處置需要追蹤？請標示會增加吸入風險的處置。

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Current care plan現行照護計畫	Observed action觀察到的處置
The client was admitted after a stroke and remains nothing by mouth.個案因腦中風入院，目前仍禁食。	Water is offered before the initial swallowing screen is completed.在完成初步吞嚥篩檢前，即給予飲水。
The head and trunk are supported in a midline position.頭部與軀幹維持在中線位置並給予支撐。	The client sits upright at 90 degrees before the meal begins.進食前，個案採直立90度坐姿。
Right facial weakness and reduced right-sided sensation are documented.病歷記載有右側顏面無力及右側感覺減退。	Food is placed on the weaker side of the client's mouth.將食物放在個案口腔的患側。
The client remains alert and follows one-step directions.個案意識清醒，能遵從單一步驟指令。	Small spoonfuls are offered slowly with time between swallows.以小湯匙緩慢餵食，每口之間有停頓。
The caregiver says reclining will reduce the client's fatigue.照護者表示躺臥可減少個案疲勞。	The head of the bed is lowered to 30 degrees during feeding.餵食時將床頭搖低至30度。
The speech-language pathologist's current plan is visible at bedside.床邊備有語言治療師的現行計畫。	The prescribed texture and liquid consistency are verified first.先確認醫囑指定的質地與液體稠度。
Oral care is planned after the meal and again before sleep.計畫於餐後及睡前進行口腔護理。	The mouth is checked for pocketed food before another bite.在餵下一口前，先檢查口腔有無殘留食物。
The caregiver waits for the coughing to stop before the next spoonful.照護者等待咳嗽停止後再餵下一口。	Feeding continues after coughing begins and the voice sounds wet.咳嗽開始且聲音變得濕潤後，仍繼續餵食。
The nurse reassesses swallowing safety before intake resumes.護理師在恢復進食前，重新評估吞嚥安全。	The meal is paused when the client becomes tired or less attentive.當個案顯得疲倦或注意力下降時，暫停進食。

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