— 降低風險 · EASY · SATA —
護理師應採取哪些措施以預防病人發生壓瘡？（選所有適合的）
Which of the following actions should the nurse take to prevent a client from developing pressure injuries? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每2小時協助病人翻身
- BMassage the reddened bony prominences按摩發紅的骨突處
- CKeep the client's skin clean and dry✓ 正解保持病人皮膚清潔乾燥
- DUse a foam wedge to keep the client off the sacrum✓ 正解使用海綿楔形墊使病人薦骨懸空
- EApply a tight abdominal binder to maintain posture使用緊身束腹帶以維持姿勢
— Explanation · 中文詳解 —
預防壓力性損傷（Pressure injuries）的核心在於減壓、減少摩擦力（Friction）與剪力（Shear），並維持皮膚完整性。每兩小時翻身是標準護理常規，能重建受壓部位的血流灌注。保持皮膚乾燥可防止浸漬（Maceration），而使用楔形墊（Foam wedge）將身體側傾至30度，可避開骨突處（如薦骨）的直接受壓。
The core of pressure-injury prevention is pressure reduction, minimizing friction and shear, and maintaining skin integrity. Repositioning every two hours is a standard nursing routine that restores perfusion to dependent areas. Keeping the skin dry prevents maceration, and using a foam wedge to tilt the body to 30 degrees offloads bony prominences such as the sacrum from direct pressure.