護理師照顧一位長期臥床病人,哪項護理行為對維持皮膚完整性至關重要?
A nurse is caring for an immobile client. Which nursing action is essential for skin integrity?
- AMassaging reddened areas to stimulate blood flow按摩紅腫部位以促進血液循環
- BChanging the client's position at least every 2 hours✓ 正解至少每2小時為病人更換姿勢
- CApplying talcum powder on the skin daily每日在皮膚上撒滑石粉
- DKeeping the client's head elevated at 60 degrees將病人頭部抬高60度
長期臥床病人極易因局部持續壓力導致組織缺血而產生壓瘡。每兩小時的翻身(Positioning)是臨床預防壓瘡最標準且有效的措施,能重新分配壓力,確保受壓部位的血液灌流。爽身粉會刺激呼吸道且可能造成毛孔阻塞,按摩紅腫處會傷害組織,過高的頭位(60度)會增加剪力(Shearing force),這些行為均會增加壓瘡風險。
Immobile clients are highly susceptible to pressure injuries from sustained localized pressure that causes tissue ischemia. Repositioning every two hours is the standard, most effective intervention to prevent pressure ulcers because it redistributes pressure and restores perfusion to compressed areas. Talcum powder can irritate the airway and clog pores, massaging reddened areas damages tissue, and head-of-bed elevation as high as 60 degrees increases shear force; all of these increase the risk of pressure injuries.