— 照護管理 · EASY · SATA —
護理師應優先採取哪些行動以預防壓瘡？（選所有適合的）
Which of the following actions should the nurse prioritize to prevent pressure injuries? (Select all that apply.)
- AUsing pillows to offload heels✓ 正解使用枕頭墊高腳跟以減壓
- BMaintaining adequate protein and caloric intake✓ 正解維持充足的蛋白質與熱量攝取
- CApplying powder to moist skin areas在潮濕皮膚區域塗抹粉劑
- DKeeping the skin clean and dry✓ 正解保持皮膚清潔乾燥
- EUsing specialty mattresses for high-risk clients✓ 正解對高風險客戶使用特殊防壓瘡床墊
— Explanation · 中文詳解 —
預防壓瘡是多方面的照護，包含減壓（Pillows, Mattresses）、營養支持（Protein/Calories）、皮膚衛生（Clean/Dry）。使用痱子粉（Powder）已不建議，因其結塊後可能造成刺激或摩擦，對預防壓瘡無助，甚至有吸入風險。
Preventing pressure injuries requires a multifaceted approach including effective offloading of high-risk areas like heels with pillows, maintaining adequate nutrition for tissue integrity, and keeping skin clean and dry to prevent maceration. Specialty mattresses should be used for high-risk clients to distribute pressure, while powders are avoided as they can clump and irritate the skin.
✦ 台美臨床差異
美台對壓瘡預防指引（如 NPUAP 準則）皆高度一致。