一位 72 歲行動不便的個案有壓瘡風險。下列哪項護理措施對預防皮膚破損最有效？
A 72-year-old client with mobility impairment is at risk for pressure ulcers. Which nursing intervention is most effective for preventing skin breakdown?
- AApply powder to keep skin dry塗抹粉末以保持皮膚乾燥
- BReposition the client every 2 hours✓ 正解每 2 小時為病人翻身
- CElevate the head of the bed to 60 degrees將床頭抬高至 60 度
- DMassage reddened bony prominences按摩發紅的骨突處
預防壓瘡的核心在於減壓。每兩小時更換姿勢能重新分配壓力，確保組織血液灌流。按摩發紅處（選項D）會造成深層組織損傷，故禁忌使用。爽身粉（選項A）會結塊摩擦皮膚，反而增加破損風險。床頭過高（選項C）會增加剪力導致滑動，建議維持在 30 度以下。
The core of pressure ulcer prevention is pressure relief. Repositioning every two hours redistributes pressure and ensures tissue perfusion. Massaging reddened areas (option D) causes deep-tissue damage and is contraindicated. Body powder (option A) can clump, cause friction against the skin, and increase the risk of breakdown. Elevating the head of the bed too high (option C) increases shearing forces from sliding; the head of the bed should be maintained below 30 degrees.
美國護理師常依賴 Braden Scale 評估後由護理人員執行翻身計畫；台灣臨床則常由照服員協助，需加強溝通落實度。