一位患有晚期失智症的 75 歲病人，壓瘡風險極高。下列哪項護理措施對預防皮膚破損最有效？
A 75-year-old client with advanced dementia is at high risk for pressure ulcers. Which nursing intervention is most effective for preventing skin breakdown?
- AApplying a hydrocolloid dressing to all bony prominences在所有骨突處貼敷水膠體敷料
- BRepositioning the client at least every 2 hours✓ 正解至少每 2 小時為病人翻身
- CMassaging the bony prominences to promote circulation按摩骨突處以促進血液循環
- DMaintaining a strictly dry environment with high-heat lamps維持嚴格乾燥的環境並使用高溫燈
壓瘡預防的核心在於減壓與組織灌流。對於長期臥床或移動受限的失智病人，每兩小時執行一次翻身（轉位）是標準護理指引的基石，能有效中斷持續壓迫造成的局部缺血。按摩骨突處（選項C）在現代護理實證中已被強烈反對，因為按摩會導致皮下組織受到剪力傷害並造成血液流動阻滯。熱燈（選項D）會導致皮膚乾燥、燙傷風險提高，且會增加局部代謝需求。預防性敷料（選項A）雖有輔助作用，但不能取代翻身機制。此題強調的是最根本、最具實證支持的物理性預防手段，護理師應評估病人的耐受力並建立翻身鐘制度。
Pressure injury prevention centers on offloading pressure and maintaining tissue perfusion. For bedbound or mobility-limited clients with dementia, repositioning at least every 2 hours is the cornerstone of nursing guidelines, effectively interrupting localized ischemia from sustained pressure. Massaging bony prominences (C) is now strongly discouraged because it causes shear injury to subcutaneous tissue and impedes blood flow. Heat lamps (D) cause dryness and burns and increase metabolic demand. Prophylactic dressings (A) are adjunctive but cannot replace turning. The most evidence-supported intervention is physical pressure relief; the nurse should assess tolerance and establish a turning schedule.
美國護理常規中，翻身表（Turn clock）執行非常嚴格，護理師需精確記錄位置，並由護理佐理員（CNA）共同執行。台灣醫院常使用氣墊床減壓，但對於翻身的頻率紀錄有時較為鬆散，需加強落實人工翻身記錄。