護理師照護一位長期臥床病人,為了預防皮膚損傷,應採取下列哪項措施?
A nurse is caring for a client who is immobile. To prevent skin breakdown, which intervention should the nurse implement?
- AUse a donut-shaped cushion for support使用甜甜圈形狀的坐墊作為支撐
- BReposition the client every 2 hours✓ 正解每 2 小時重新定位病人
- CKeep the head of the bed elevated at 45 degrees將床頭抬高至 45 度
- DMassage the bony prominences frequently經常按摩骨突處
長期臥床病人極易發生壓傷(Pressure injury)。每 2 小時翻身是預防皮膚損傷最有效的方法,藉由定期改變受壓點,促進組織血液循環。按摩骨突處反而會破壞微血管,墊圈則會造成局部缺血,均應避免。床頭角度過高(超過 30 度)則會增加剪力(Shearing force),亦是護理時須注意的細節。
Clients on prolonged bed rest are highly prone to pressure injuries. Repositioning every 2 hours is the most effective measure for preventing skin breakdown by periodically changing the points of pressure and promoting tissue perfusion. Massaging bony prominences can damage capillaries, and donut-shaped cushions cause localized ischemia—both should be avoided. An excessive head-of-bed angle (greater than 30 degrees) increases shearing force, which is another important consideration during care.