— 降低風險 · EASY · SATA —
下列哪些護理措施有助於預防臥床病人的壓瘡？（選所有適合的）
Which of the following nursing interventions help prevent pressure ulcers in a bedbound client? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時為病人翻身
- BMassage reddened bony prominences按摩發紅的骨突處
- CMaintain the head of the bed at 45 degrees將床頭維持在 45 度角
- DUse pillows to bridge bony prominences✓ 正解使用枕頭墊起骨突處
- EKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
— Explanation · 中文詳解 —
預防壓瘡的核心在於減壓、維持皮膚完整與控制濕度。每兩小時翻身可減少局部受壓；使用枕頭進行橋接（bridging）可避開骨突處受壓；保持皮膚清潔乾燥可防止浸潤。按摩發紅處會加重組織損傷，床頭抬高過高會增加剪力，皆不建議。
Pressure ulcer prevention centers on pressure relief, maintenance of skin integrity, and moisture control. Repositioning every two hours reduces localized pressure; using pillows to bridge bony prominences relieves pressure on them; and keeping the skin clean and dry prevents maceration. Massaging reddened areas worsens tissue damage, and elevating the head of the bed too high increases shear forces; neither is recommended.
✦ 台美臨床差異
台灣醫院多使用標準化壓瘡預防評估表（如 Braden Scale），美國則更重視針對高風險族群使用減壓氣墊床的適應症評估。