背景：口腔護理是臨床護理人員常對於氣管內管留置病人執行的護理措施，透過口腔護理可減少病人口內細菌的孳生，阻斷呼吸器相關性肺炎的感染鏈，減少呼吸器相關性肺炎的發生。然而，卻有研究發現，護理人員在執行氣管內管留置病人口腔護理的執行方式缺乏一致性，搜尋相關文獻發現，目前國內仍較缺乏具信效度的氣管內管留置病人口腔護理照護指引。
目的：本研究將以實證為基礎，發展口腔護理照護指引，並了解指引之臨床適用性。
方法：本研究採指引發展之研究設計，以修正型德菲法共識決策程序達成專家共識，增加指引本土適用性，再經由外部審核對指引做整體的審核，另外亦實際推行至臨床單位，了解護理人員以照護指引進行護理過程的適用性。
結果：經修正型德菲法共識決策程序後，擬定照護指引共有54項建議，經方法學專家審視屬於非常建議及建議的等級，而僅有3項在護理人員評核的臨床適用性稍微偏低。
結論：本研究發展之「成人使用氣管內管口腔護理照護指引」具實證基礎與應用價值，然而指引仍須定時更新，才能確保其內容在臨床應用上的安全及適用性。

Background: Administering mouth care for the intubated patient is one of the routine practices in the intensive care unit. Studies revealed that regular mouth care for patients receiving mechanical ventilator could reduce the bacterial flora and decrease the incidence of ventilator-associated-pneumonia. However, there were different views on the methods of mouth care. Furthermore, there was no guideline about mouth care with intubated adults in Taiwan for the staff to follow.
Purpose: This study included two parts:（1）to develop an evidence-based clinical guideline of mouth care for intubated adults;（2）to evaluate the applicability of mouth care guideline used by clinical staff.
Method: This study followed the principle of the clinical guideline development. After the researcher applied the modified Delphi technique to investigate the applicability of each recommendation of the guideline, the external experts examined the guideline all over again. In addition, the guideline was applied to the clinical unit and the applicability of the guideline was reported.
Results: After the modified Delphi consensus decision-making process, the mouth care guideline included a total of 54 recommendations. The methodological experts examined the guideline and recommended that it is appropriate to be implemented. Only three of the recommendations were evaluated as lower applicability for nurses.
Conclusion: The guideline of the mouth care for the intubated patient was established in an evidence-based way and useful in clinical parctice. However, it is important to regularly update the guideline to ensure the safety and suitability in the clinical application.

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