— 基本照護與舒適 · MEDIUM · MCQ —
一位患有尿失禁的病人，護理師採取下列哪項措施最能維護其皮膚完整性？
A nurse is caring for a client with urinary incontinence. Which intervention is the most appropriate for managing skin integrity?
- AChange the absorbent pad only when soaked仅在吸收墊浸透時才更換
- BUse a catheter to prevent wetness使用導尿管以防止潮濕
- CApply moisture barrier cream to the perineal area✓ 正解在會陰部位塗抹濕氣隔離霜
- DClean the area with hot water and soap用熱水和肥皂清潔該區域
— Explanation · 中文詳解 —
預防尿失禁皮膚炎（IAD）的標準護理為保持皮膚乾燥及建立屏障。A 使用隔離霜可形成保護層，防止尿液刺激皮膚。B 導尿管非預防皮膚完整性的首選手段（感染風險高）；C 熱水與皂鹼會破壞皮脂膜，加重乾燥與刺激；D 敷料應隨濕隨換，不可等到濕透才更換。
To maintain skin integrity in clients with urinary incontinence, apply a moisture barrier cream to protect the skin from urine irritation. Absorbent pads should be changed promptly when wet rather than waiting until soaked, and hot water with soap should be avoided as it dries and irritates the skin. Catheters are not appropriate for preventing skin breakdown due to infection risks.
✦ 台美臨床差異
美國護理機構對 IAD 的皮膚評估非常重視；台灣臨床較常依賴家屬自行處理更換，護理監測強度不一。