對於皮膚破損高風險的病人，護理師應優先採取哪項措施？
Which intervention should the nurse prioritize for a client at high risk for skin breakdown?
- AApply powder to skin folds在皮膚皺褶處塗抹粉劑
- BReposition every 2 hours✓ 正解每2小時重新定位姿勢
- CMassage bony prominences按摩骨突處
- DKeep the head of the bed at 45 degrees將床頭抬高45度
皮膚破損，尤其是壓瘡（pressure injury/ulcer），是長期臥床、活動受限或營養不良病人常見的併發症。對於高風險病人，預防措施遠比治療重要。壓瘡的形成主要源於皮膚和皮下組織長時間承受壓力和剪力，導致局部血液循環受損和組織缺氧。因此，護理的核心策略是定期解除壓力，促進血液循環。 每兩小時翻身一次（reposition every 2 hours）是預防壓瘡最基本且最重要的護理介入措施。這項措施能夠有效分散身體骨突處的壓力，讓局部組織有足夠的時間恢復血液供應，從而預防組織缺血壞死。護理師應嚴格遵守翻身計畫，並搭配其他輔助措施，如使用減壓床墊、保持皮膚清潔乾燥等，以最大程度地降低皮膚破損的風險，確保病人的皮膚完整性。
Skin breakdown, especially pressure injury (pressure ulcer), is a common complication in patients who are bedridden, immobile, or malnourished. For high-risk patients, prevention is far more important than treatment. Pressure injuries form mainly because the skin and subcutaneous tissues are subjected to prolonged pressure and shear forces, resulting in impaired local circulation and tissue hypoxia. Therefore, the core nursing strategy is to relieve pressure regularly and promote circulation. Repositioning every 2 hours is the most fundamental and important nursing intervention for preventing pressure injuries. It effectively distributes pressure over bony prominences and allows local tissues sufficient time to restore blood supply, thereby preventing ischemic necrosis. Nurses should strictly follow the turning schedule and use adjunctive measures such as pressure-relieving mattresses and keeping the skin clean and dry to minimize the risk of skin breakdown and maintain skin integrity.
在美國，預防壓瘡的指引（如NPUAP/EPUAP）強調使用Branden量表或Norton量表進行風險評估，並根據評估結果制定個別化的翻身計畫和減壓措施。台灣的臨床實踐也遵循類似的國際指引，但對於預防性醫療耗材（如特殊減壓床墊、敷料）的普及率和給付標準，可能因健保制度和醫院政策而與美國有所差異。然而，每兩小時翻身的核心原則在兩地都是一致的黃金標準。