病人有壓力性損傷（褥瘡）風險，哪項護理措施最有效？
A client is at risk for pressure injuries. Which nursing intervention is most effective?
- ARepositioning the client every 2 hours✓ 正解每兩小時為病人翻身
- BUsing a donut-shaped pillow使用甜甜圈形枕頭
- CMassaging bony prominences按摩骨突處
- DKeeping the skin moist保持皮膚潮濕
壓力性損傷（Pressure injury）的主因是組織受壓導致局部缺血。翻身（Repositioning）是預防壓瘡最有效的物理性措施，透過每兩小時變換姿勢，能將壓力重新分配，讓受壓組織獲得血液灌流。過度按摩骨突處會損壞皮下微血管，而過度濕潤則易導致浸潤（Maceration）， donut 枕會造成局部缺血，故均應避免。
The primary cause of a pressure injury is local tissue ischemia from sustained pressure. Repositioning is the most effective physical measure for preventing pressure ulcers; turning the client every two hours redistributes pressure and restores blood perfusion to the affected tissues. Excessive massage of bony prominences damages subcutaneous capillaries, excessive moisture promotes maceration, and donut-shaped pillows cause localized ischemia, so all of these practices should be avoided.
美國臨床更強調使用 Braden Scale 進行風險評估，並依評估結果決定翻身頻率，而非一律兩小時。近年來更強調使用減壓氣墊床（Air mattress）與預防性敷料（Prophylactic dressings）。