— 基本照護與舒適 · EASY · MCQ —
護理師照護一位長期臥床的病人，下列哪項措施對於預防壓力性損傷最有效？
A nurse is caring for a client who is immobile. Which action is the most effective way to prevent pressure injuries?
- AMassaging bony prominences按摩骨突處
- BRepositioning the client every 2 hours✓ 正解每 2 小時重新安置病人姿勢
- CApplying powder to keep the skin dry塗抹粉末以保持皮膚乾燥
- DUsing a donut-shaped cushion使用甜甜圈形坐墊
— Explanation · 中文詳解 —
預防褥瘡的核心是解除組織持續受壓。每兩小時翻身可確保受壓區域獲得血流灌注，防止組織缺血壞死。不建議按摩骨突處，以免造成深層組織損傷；甜甜圈軟墊會影響周圍循環，現代護理已不推薦；爽身粉可能在潮濕皮膚結塊造成摩擦。
The core of pressure ulcer prevention is relieving sustained tissue pressure. Repositioning every 2 hours ensures that pressure areas receive blood flow perfusion, preventing tissue ischemia and necrosis. Massaging bony prominences is not recommended, as it can cause deep tissue injury; donut cushions impair surrounding circulation and are no longer recommended in modern nursing practice; powder may clump on damp skin and cause friction.
✦ 台美臨床差異
台灣醫院對翻身時程記錄極為嚴格，常作為評鑑指標；美國則強調以風險評估工具（如 Braden Scale）輔助進行個別化照護計畫。