護理師為一位有壓傷的病人制定照護計畫，哪項措施對預防傷口惡化至關重要？
A nurse is developing a plan of care for a client with a pressure injury. Which intervention is essential for preventing further breakdown?
- AApplying a hydrocolloid dressing.使用水膠體敷料
- BIncreasing protein intake in the diet.增加飲食中的蛋白質攝取
- CMassaging the bony prominences.按摩骨骼突出部位
- DRepositioning the client at least every 2 hours.✓ 正解至少每 2 小時為病人重新擺位
壓傷（pressure injury），又稱壓瘡，是因局部壓力長時間作用於皮膚及皮下組織，導致血液循環受阻而產生的組織損傷。預防壓傷及其惡化，最根本的原則是減輕或消除壓力點。正確答案 D 指出「至少每 2 小時重新定位病人（repositioning the client）」，這是最核心且最重要的預防措施。規律地改變病人的臥姿或坐姿，可以分散體重對骨骼突出部位（bony prominences）的壓力，促進血液循環，防止組織缺氧壞死。選項 A（使用水膠體敷料）和 B（增加蛋白質攝取）是輔助措施，有助於傷口癒合或預防，但無法取代移除壓力源。選項 C（按摩骨骼突出部位）在有壓傷風險或已有壓傷的部位，反而可能造成進一步的組織損傷，是應避免的。
A pressure injury (pressure ulcer) is tissue damage caused by sustained pressure on the skin and underlying tissues, which impairs circulation. The fundamental principle of prevention is to relieve or eliminate the pressure source. Option D—repositioning the client at least every two hours—is the most critical preventive measure. Regular position changes distribute weight away from bony prominences, restore circulation, and prevent ischemic necrosis. Option A (hydrocolloid dressing) and B (increased protein) are adjuncts that support healing or prevention but do not remove the pressure source. Option C (massaging bony prominences) can cause further damage to vulnerable tissue and should be avoided.
無顯著差異。壓傷的預防與照護原則（如定時翻身、減壓）在台灣與美國的臨床實務中是相同的。兩地都會採用壓力評估工具（如 Braden Scale），並強調移除壓力源作為預防壓傷惡化的核心策略。