— 降低風險 · EASY · SATA —
護理師在預防長期臥床病人發生壓瘡時，應採取哪些措施？（選所有適合的）
Which actions are appropriate for a nurse to take when preventing pressure injuries in a bedridden client? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每2小時為個案翻身
- BMassage the bony prominences frequently經常按摩骨突處
- CKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- DApply a moisture barrier cream to the sacral area✓ 正解在薦骨區域塗抹保濕隔離霜
- EPlace a donut-shaped cushion under the hips在臀部下方放置甜甜圈形坐墊
— Explanation · 中文詳解 —
預防壓瘡的核心是減壓與皮膚護理。每 2 小時翻身是標準做法。按摩骨突處會損傷皮下組織，應絕對避免。保持皮膚乾爽並使用保濕隔離霜可減少失禁導致的浸潤。救生圈型墊子（Donut cushion）會阻礙局部血液循環，增加壞死風險。
Preventing pressure injuries requires repositioning the client every two hours to relieve tissue pressure and keeping the skin clean and dry to prevent maceration. Applying moisture barrier creams protects against irritation from incontinence, while massaging bony prominences and using donut cushions should be avoided as they can worsen tissue damage.
✦ 台美臨床差異
美國護理機構高度依賴 Braden Scale 評估，台灣則依各院評估表而異，但翻身頻率規定基本一致。