護理師照護一位全髖關節置換術後第一天的病人。為預防皮膚破損，下列哪項護理措施最重要？
A nurse is caring for a client who is post-operative day 1 following a total hip replacement. Which intervention is most important for the nurse to implement to prevent skin breakdown?
- AMassage reddened bony prominences to improve circulation.按摩發紅的骨突處以改善循環
- BTurn the client every 4 hours while they are in bed.卧床期間每4小時翻身一次
- CKeep the client's skin clean and dry, especially in skin folds.✓ 正解保持病人皮膚清潔乾燥，特別是在皮膚摺皺處
- DPosition an abductor pillow between the legs when turning.翻身時在雙腿之間放置外展枕
預防皮膚破損（壓力性損傷）的核心在於控制微環境與定時減壓。對於髖關節置換術後的病人，由於活動受限，皮膚更容易受到汗液或失禁浸漬而破損。保持清潔乾燥（C）是維持皮膚完整性的基礎。按摩紅腫部位（A）目前已被實證證明會造成深層組織更嚴重的損傷，是絕對禁止的。翻身頻率（B）應至少每 2 小時一次，4 小時太久。雖然使用外展枕（D）是手術後維持關節穩定的必要措施，但其主要目的是預防脫臼而非直接預防皮膚破損。
Prevention of skin breakdown (pressure injury) centers on controlling the microenvironment and providing scheduled pressure relief. After hip arthroplasty, mobility limitations make skin more vulnerable to breakdown from moisture or incontinence. Keeping the skin clean and dry (C) is the foundation of skin integrity. Massaging reddened areas (A) is now evidence-based to cause deeper tissue damage and is absolutely contraindicated. Repositioning frequency (B) should be at least every 2 hours; 4 hours is too long. Although using an abduction pillow (D) is necessary postoperatively to maintain joint stability, its primary purpose is to prevent dislocation rather than directly to prevent skin breakdown.
美國護理實務中使用 Braden Scale 進行每日風險評估是法律與健保規範，且對「不可按摩發紅部位」的執行非常嚴格。台灣臨床實務中亦然，但護理記錄中對皮膚微環境的描述深度有時略有不同。