— 基本照護與舒適 · MEDIUM · MCQ —
護理師指導病人在家預防壓瘡。下列哪項建議最精確？
A nurse is teaching a client to prevent pressure injuries at home. Which recommendation is most accurate?
- AChange positions at least every 2 hours✓ 正解至少每 2 小時改變姿勢
- BUse donut-shaped cushions for comfort使用甜甜圈形坐墊以增加舒適度
- CMassage reddened skin areas按摩發紅的皮膚區域
- DKeep the head of the bed elevated at 45 degrees將床頭抬高至 45 度
— Explanation · 中文詳解 —
每兩小時翻身是減少受壓點最有效的物理方法（A）。按摩發紅部位（C）會導致組織進一步受損（禁止按摩受壓處）；甜甜圈坐墊（B）會導致局部血液淤積；床頭抬高 45 度（D）會增加薦骨剪力，若無必要不建議長時間維持。
Repositioning every two hours is the most effective physical method for relieving pressure points (A). Massaging reddened areas (C) causes further tissue damage and is contraindicated. Donut-shaped cushions (B) cause localized venous congestion. Elevating the head of the bed to 45 degrees (D) increases sacral shear force and is not recommended for prolonged periods unless necessary.
✦ 台美臨床差異
兩地皆遵循 NPUAP 壓瘡預防指引，實務上皆反對按摩發紅皮膚。