護理師照顧一位有皮膚受損風險的高齡病人。為預防壓力性損傷，護理師應優先採取哪項干預措施？
A nurse is caring for an older adult client who is at risk for skin breakdown. Which intervention should the nurse prioritize to prevent pressure injuries?
- AReposition the client at least every 2 hours✓ 正解至少每 2 小時重新安置病人體位
- BApply a donut-shaped cushion to relieve pressure on the coccyx在尾骨處使用甜甜圈形坐墊以減輕壓力
- CKeep the head of the bed elevated at 45 degrees at all times始終將床頭抬高維持在 45 度
- DMassage reddened bony prominences twice daily每天兩次按摩發紅的骨骼突出處
預防壓力性損傷（壓瘡）的核心概念是『定時卸壓』。高齡病人皮膚變薄、皮下脂肪減少，骨突處承受的垂直壓力是微循環受阻的主因。每 2 小時更換一次體位是臨床公認能有效讓局部受壓組織恢復灌流的最有效方法。選項 B 的甜甜圈坐墊會導致周邊組織壓力更高，反而加重缺血；選項 D 針對發紅處按摩會加劇深層組織損傷，是過時且危險的做法；選項 C 長時間將床頭抬高 45 度會增加薦骨處的剪力（Shear Force），反而增加皮膚受損風險，一般建議維持在 30 度或以下。安全性原則要求護理師必須主動監測並排除壓力源。
The core concept of pressure injury prevention is 'scheduled pressure relief.' Older adults have thinner skin and reduced subcutaneous fat, so the perpendicular pressure on bony prominences is the main cause of impaired microcirculation. Repositioning every 2 hours is clinically recognized as the most effective method to allow local compressed tissues to regain perfusion. Option B's donut cushion creates higher pressure on surrounding tissues and worsens ischemia; option D, massaging reddened areas, exacerbates deep tissue injury and is an outdated and dangerous practice; option C, keeping the head of bed elevated to 45 degrees for prolonged periods, increases shear force at the sacrum and rather increases skin breakdown risk—generally, head-of-bed elevation should be maintained at 30 degrees or below. The safety principle requires the nurse to actively monitor and eliminate pressure sources.
美國 NCLEX 考試極度強調 Braden Scale 的評估與不按摩發紅處；台灣臨床上雖也遵循相同準則，但部分老一輩看護仍存有『按摩可活絡血路』的迷思，護理師需加強對照顧者的衛教與監督。