— 安全與感染控制 · EASY · MCQ —
護理師在教導病人預防壓瘡。哪句病人的話顯示他已經了解衛教內容？
A nurse is teaching a client about the prevention of pressure injuries. Which statement by the client indicates an understanding of the teaching?
- AI will shift my weight at least every hour while sitting in my chair✓ 正解坐在椅子上時，我至少每小時會轉換一次體重分佈
- BI will massage my bony prominences every time I turn每次翻身時，我會按摩骨突處
- CI will slide down in bed to maintain a comfortable position我會向下滑動以保持舒適的姿勢
- DI will keep my skin moist by applying a thick layer of lotion我會塗抹厚層乳液來保持皮膚濕潤
— Explanation · 中文詳解 —
預防壓瘡的核心是減壓（Offloading）。每小時更換姿勢（A）是預防壓瘡的黃金標準。按摩骨突處（B）會造成組織深層受損，應絕對避免。過度保濕（D）可能導致皮膚浸潤（Maceration）；滑動（C）會產生剪力（Shear），增加壓瘡風險。
The core of pressure ulcer prevention is offloading. Repositioning every two hours (A) is the gold standard for pressure ulcer prevention. Massaging bony prominences (B) can cause deep tissue damage and must be absolutely avoided. Excessive moisture (D) may lead to skin maceration; sliding (C) generates shear forces, increasing the risk of pressure ulcers.
✦ 台美臨床差異
美國護理重視壓瘡風險評估量表（Braden Scale）的即時介入，台灣則在長期照護機構中，對擺位枕的使用極為重視。