— 降低風險 · MEDIUM · SATA —
護理師照護一位有壓瘡風險的病人，下列哪些照護計畫是必要的？（選所有適合的）
A nurse is caring for a client who is at risk for developing a pressure injury. Which actions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client at least every two hours✓ 正解至少每兩小時為病人翻身
- BMassage reddened bony prominences按摩發紅的骨突處
- CMaintain the head of the bed at an angle of 45 degrees or higher將床頭維持在 45 度或更高的角度
- DApply a moisture barrier cream to the skin✓ 正解在皮膚上塗抹濕氣屏障乳霜
- EUse 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
— Explanation · 中文詳解 —
壓瘡預防的核心在於減少壓力、剪切力與摩擦力。兩小時翻身、保護骨突處（如使用枕頭架高）、使用保濕屏障霜預防浸潤皆正確。選項 B 錯誤：按摩骨突處會損傷皮下組織；選項 C 錯誤：床頭抬高超過 30 度會增加剪切力，應儘量保持平躺或低於 30 度。
Pressure injury prevention focuses on reducing pressure, shear, and friction. Repositioning every two hours, using barrier creams to protect against moisture, and bridging bony prominences with pillows are appropriate. Massaging reddened areas damages underlying tissue and is contraindicated. Elevating the head of the bed above 30 degrees increases sacral shear force.
✦ 台美臨床差異
美國護理廣泛使用 Braden Scale 進行量化評估與文檔記載；台灣臨床亦全面導入 Braden Scale，但對於床頭抬高角度與翻身紀錄的查核在兩地標準相似。