— 健康促進與維護 · EASY · SATA —
護理師應指導病人採取哪些措施以預防皮膚損傷？（選所有適合的）
Which of the following actions should the nurse teach a client to take to prevent skin breakdown? (Select all that apply.)
- AReposition every 2 hours✓ 正解每 2 小時重新擺位
- BKeep skin clean and dry✓ 正解保持皮膚清潔乾燥
- CUse a donut-shaped cushion for comfort使用甜甜圈形軟墊以增加舒適感
- DMaintain adequate hydration and nutrition✓ 正解維持充足的水分和營養攝取
- EMassage the reddened bony prominences按摩發紅的骨突處
— Explanation · 中文詳解 —
預防壓力性損傷（Pressure injury）的核心在於減壓與皮膚完整性維護。根據 NCLEX 臨床實證，必須透過規律翻身（每 2 小時）來分散骨突處壓力，並維持皮膚清潔乾燥以減少浸潤（Maceration）。營養支持（特別是蛋白質）對組織修復至關重要。臨床重點在於嚴禁按摩紅斑區，以免造成深層組織受損。
Preventing skin breakdown requires frequent repositioning to relieve pressure on bony prominences and maintaining clean, dry skin to prevent maceration. Adequate hydration and nutrition are essential for tissue integrity and repair, whereas massaging reddened areas can cause further tissue damage and donut cushions may restrict blood flow.