— 基本照護與舒適 · EASY · MCQ —
護理師為一位長期臥床病人規劃照護計畫。哪項措施對預防壓瘡最有效？
A nurse is planning care for a client who is immobile. Which intervention is most effective in preventing pressure injuries?
- AApplying powder to the skin to reduce friction在皮膚上塗抹爽身粉以減少摩擦
- BKeeping the head of the bed elevated at 45 degrees將床頭抬高至45度
- CMassaging reddened bony prominences按摩發紅的骨突處
- DTurning and repositioning the client every 2 hours✓ 正解每2小時為病人翻身並調整姿勢
— Explanation · 中文詳解 —
預防壓瘡（Pressure injury）的核心在於減輕持續性壓力（Pressure）。長期臥床病人若不動，骨突處（Bony prominences）會因受壓導致微血管血流阻斷，進而引發組織缺血壞死。每兩小時更換姿勢是臨床預防的核心標準，能確保局部組織獲得間歇性血液灌流，是目前公認最有效的物理性預防措施。
The cornerstone of pressure injury prevention is the relief of sustained pressure. In an immobile client, prolonged pressure over bony prominences interrupts capillary blood flow, leading to tissue ischemia and necrosis. Repositioning every 2 hours is the clinical standard for prevention, ensuring intermittent reperfusion of vulnerable tissue, and is currently recognized as the most effective physical preventive measure.