— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位容易產生壓瘡的病人。應採取哪些措施？（選所有適合的）
A nurse is caring for a client who is prone to pressure ulcers. Which interventions should be implemented? (Select all that apply.)
- AKeep the head of the bed at 45 degrees將床頭保持在45度角
- BUse pillows to bridge bony prominences✓ 正解使用枕頭墊高骨突處
- CApply moisture barrier cream to intact skin✓ 正解在完整的皮膚上塗抹防濕屏障乳霜
- DReposition the client every 2 hours✓ 正解每2小時重新安置病人姿勢
- ERub the skin vigorously to promote circulation用力擦拭皮膚以促進循環
— Explanation · 中文詳解 —
預防壓瘡重點是減壓、保持皮膚乾燥屏障。床頭抬高超過 30 度會增加薦骨剪力，45 度是不適當的。橋接（bridging）可讓骨突處懸空，保護皮膚。保護霜能保護皮膚不受尿液刺激。禁止摩擦皮膚，會導致表皮受損。
The focus of pressure injury prevention is to relieve pressure and maintain a dry skin barrier. Elevating the head of the bed above 30 degrees increases shearing forces over the sacrum, so 45 degrees is inappropriate. Bridging allows bony prominences to be suspended, protecting the skin. Barrier creams protect the skin from urinary irritation. Vigorously rubbing the skin is prohibited because it damages the epidermis.
✦ 台美臨床差異
美國護理師常使用 Braden Scale 進行結構化風險評估，台灣亦廣泛使用此量表。