— 安全與感染控制 · MEDIUM · SATA —
下列哪些護理措施有助於預防壓力性損傷？（選所有適合的）
Which nursing actions are appropriate to prevent pressure injuries? (Select all that apply.)
- ARepositioning the client every 2 hours✓ 正解每2小時協助病人翻身
- BMassaging reddened bony prominences按摩發紅的骨突處
- CKeeping the skin clean and dry✓ 正解保持皮膚清潔乾燥
- DUsing a trapeze bar to facilitate movement✓ 正解使用吊桿以促進活動
- EMaintaining the head of the bed at 45 degrees constantly持續將床頭抬高45度
— Explanation · 中文詳解 —
預防壓瘡的核心在於減壓與皮膚護理。每 2 小時翻身是標準程序；保持乾燥防止浸潤；利用拉手桿增加病人活動度。按摩發紅處會造成深層組織損傷，床頭抬高 45 度以上會產生剪力（Shearing），應盡量避免。
The core of pressure injury prevention is pressure relief and skin care. Repositioning every 2 hours is the standard procedure; keeping skin dry prevents maceration; using a trapeze bar increases patient mobility. Massaging reddened areas can cause deep tissue damage, and elevating the head of the bed above 45 degrees generates shearing force, both of which should be avoided.
✦ 台美臨床差異
美台臨床皆強調 Braden Scale 評估，但台灣對於高風險病人翻身護理的執行落實度常受限於人力比。