背景：口腔癌病人初次接受治療時常因合併症發生而影響進食，因而加重營養不良的程度，影響治療的成效。護理人員是接觸病人時間最長的醫療人員，若能適時反應病患的營養狀態，提供合宜的營養照護措施，將可降低合併症的發生，提高治療的成效。目的：探討口腔癌病人接受初次治療期間，護理人員提供營養照護情形。方法：採用病歷回溯法，收集東部某醫學中心之癌症資料中心於2002年8月1日到2005年12月31日所登錄之口腔癌病患205人資料進行營養照護執行項目及內容分析，以相關護理記錄內容分析為依據。結果：共收錄205人，男性佔89.8%，平均年齡51.5（±10.7）歲，腫瘤分期以第四期41.5%佔最多。治療期間93.7%病患有口腔疼痛，56.5%出現口腔黏膜破損。只有61.9%病患有營養照護記錄包括：營養攝取情形、進食途徑、灌食管路照護、評估個案消化、由口進食情形、評估攝入熱量等。因治療所引發之合併症對飲食攝取的影響及體重改變情形未在記錄內容中呈現。結論：護理紀錄是呈現病患營養狀態與營養照護過程最直接的記錄，可以作為醫療團隊溝通的最佳平台，促進治療成效，同時亦可以提高護理照護品質

Background: The initial treatment complications affect eating often occurs in oral cancer patients. Malnutrition impacts the treatment effectiveness. Nurses are the longest-patient contact medical personnel. If nurses could response patients' nutritional status timely and provide appropriate nutritional care, might decrease the complications and promote the effectiveness of treatment. Purposes: The objective of this study was to explore of oral cancer patients receiving nutritional care during the initial treatment. Methods: The retrospective chart review study collected 205 patients with diagnosed as oral cancer from August 1, 2002 to December 31, 2005 in the cancer center of eastern Taiwan. The nursing records related to nutritional care were analyzed. Results: 205 of patients were recruited. Most of the patients were men with 89.8%, the average age was 51.5 (±10.7) years. TNM stage with stage IV accounted for up to 41.5%. Patients had the complication of oral pain were 93.7%, 56.5% with oral mucosal damage. Only 61.9% of patients had nutritional care records included: nutritional intake, intake method, feeding lumen care, digestion assessment, oral intake, and calorie intake. The complications related to nutritional intake and body weight change did not state in nursing records. Conclusions: Nursing records was the direct documentation to present patients' nutritional status and care process, as well as was the best platform for medical team communication to enhance the treatment effectiveness and promote the quality of nursing care.