— 基本照護與舒適 · MEDIUM · MCQ —
一位臥床病人有壓瘡風險。下列哪項護理介入對預防皮膚破損最有效？
A client on bed rest is at risk for pressure ulcers. Which nursing intervention is most effective for preventing skin breakdown?
- AReposition the client every two hours✓ 正解每兩小時重新安置客戶姿勢
- BMaintain a high-Fowler's position at all times始終保持高福勒氏臥位
- CApply powder to keep the skin dry塗抹滑石粉以保持皮膚乾燥
- DMassage the bony prominences frequently經常按摩骨突處
— Explanation · 中文詳解 —
定期翻身（每兩小時）可減輕組織持續受壓導致的缺血。按摩骨突處（D）已被證實會損害組織，不可執行；塗抹粉末（C）可能會刺激皮膚或阻塞毛孔，不建議作為預防壓瘡措施；長期高坐位（B）會增加剪力與摩擦力，反而增加薦骨處壓瘡風險。
Repositioning the client every two hours is the most effective intervention to prevent pressure ulcers as it relieves sustained pressure on tissues and restores blood flow. Other actions such as massaging bony prominences or using powder can cause tissue damage or skin irritation, while maintaining a high-Fowler's position may increase shear forces and friction.
✦ 台美臨床差異
台美皆依循 Braden Scale 進行壓瘡風險評估，美國醫院多強制使用壓力減輕設備。