— 基本照護與舒適 · HARD · SATA —
護理師照護一位有壓瘡風險的病人，下列哪些是適當的護理措施？（選所有適合的）
A nurse is caring for a client who has a risk of pressure injury. Which actions are appropriate interventions? (Select all that apply.)
- AReposition the client at least every 2 hours✓ 正解至少每2小時為病人重新擺位
- BKeep the head of the bed elevated at 45 degrees or higher將床頭抬高45度或更高
- CMassage the bony prominences daily每日按摩骨突處
- DUse pillows to bridge bony prominences off the mattress✓ 正解使用枕頭墊高骨突處使其離開床墊
- EMaintain adequate protein and caloric intake✓ 正解維持充足的蛋白質與熱量攝取
— Explanation · 中文詳解 —
預防壓瘡的核心為減壓與改善組織灌流。每 2 小時翻身（A）、支撐骨突處（D）以及營養支持（E）均是實證建議。床頭抬高大於 30 度（B）會增加剪力，應避免；按摩骨突處（C）會破壞脆弱組織，現行指引已禁止。
The core of pressure injury prevention is to relieve pressure and improve tissue perfusion. Repositioning at least every 2 hours (A), supporting bony prominences (D), and providing nutritional support (E) are all evidence-based recommendations. Elevating the head of the bed above 30 degrees (B) increases shear and should be avoided; massaging bony prominences (C) damages fragile tissue and is prohibited by current guidelines.
✦ 台美臨床差異
美國護理品質指標（NDNQI）高度重視壓瘡發生率，台灣醫院評鑑亦將此列為重要護理指標，做法一致。