— 安全與感染控制 · MEDIUM · SATA —
下列哪些措施適合預防臥床病人的壓瘡發生？（選所有適合的）
Which of the following interventions are appropriate for preventing pressure injuries in a bedridden client? (Select all that apply.)
- ARepositioning the client every 2 hours✓ 正解每2小時為病人翻身
- BMassaging reddened bony prominences按摩充血的骨突處
- CApplying a moisture barrier cream to skin✓ 正解在皮膚上塗抹濕氣屏障乳霜
- DEnsuring adequate nutritional and protein intake✓ 正解確保充足的營養和蛋白質攝取
- EKeeping the head of the bed elevated at 45 degrees將床頭抬高至45度
— Explanation · 中文詳解 —
預防壓瘡關鍵在於減壓、皮膚護理與營養支持。定時翻身（A）、使用保護膜避免濕氣浸漬（C）、維持蛋白質營養（D）均為實證有效的護理。B 選項錯誤，按摩紅腫處會傷害組織；E 選項錯誤，超過 30 度易產生剪力。
The keys to pressure ulcer prevention are pressure relief, skin care, and nutritional support. Regular turning (A), use of a moisture barrier to prevent maceration (C), and maintenance of adequate protein intake (D) are all evidence-based nursing interventions. Option B is incorrect because massaging reddened areas damages tissue, and option E is incorrect because elevating the head of the bed above 30 degrees produces shear forces.
✦ 台美臨床差異
台灣醫院多使用 Braden Scale 評估，美國醫院則可能結合電子醫療系統的自動警示與翻身紀錄。