— 基本照護與舒適 · EASY · MCQ —
護理師照護一位因髖關節骨折而臥床的病人，下列哪項措施預防壓瘡最有效？
A nurse is caring for a client who is immobile due to a hip fracture. Which intervention is most effective in preventing pressure injuries?
- AMassaging reddened bony prominences按摩紅腫的骨突處
- BMaintaining a high-protein diet維持高蛋白飲食
- CRepositioning the client every 2 hours✓ 正解每 2 小時重新安置病人姿勢
- DApplying a donut-shaped cushion應用甜甜圈形坐墊
— Explanation · 中文詳解 —
針對長期臥床者，每兩小時翻身是減輕組織壓力最核心的預防策略。DONUT 坐墊會阻礙末梢循環加重缺血；按摩紅斑處會造成深層組織損傷，現行指引嚴禁對壓瘡前期皮膚按摩；營養雖重要，但翻身是更直接的物理性壓力緩解措施。
Repositioning the client every two hours is the most effective intervention for preventing pressure injuries in immobile patients because it redistributes pressure and prevents sustained tissue ischemia. Other methods like massaging reddened areas can cause further tissue damage, and donut cushions may impede blood flow, making frequent position changes the standard of care.
✦ 台美臨床差異
美國醫院廣泛使用自動翻身氣墊床，台灣在急性病房則高度依賴看護與家屬協助執行人工翻身。