— 基本照護與舒適 · EASY · MCQ —
一位長期臥床的病人，護理師採取哪項措施最能有效預防壓瘡？
A nurse is caring for a client who is immobile. Which intervention is most effective in preventing pressure injuries?
- AApplying powder to the skin在皮膚上塗抹粉末
- BRepositioning the client every 2 hours✓ 正解每 2 小時重新定位客戶
- CKeeping the head of the bed elevated at 45 degrees保持床頭抬高 45 度
- DMassaging bony prominences按摩骨突處
— Explanation · 中文詳解 —
預防壓瘡的黃金準則是定時翻身，以減輕組織壓力與缺血。每兩小時翻身可確保皮膚灌流恢復。按摩骨突處（選項 D）會造成深層組織受損，目前已不建議；保持頭高 45 度容易造成剪力（Shearing），應限制在 30 度以內。
Repositioning the client every two hours is the most effective intervention to prevent pressure injuries by relieving prolonged tissue compression. Other measures such as massaging bony prominences are contraindicated as they can damage underlying tissues, and elevating the head of the bed too high increases shear forces. Maintaining proper skin hygiene without excessive moisture or friction is also essential for prevention.
✦ 台美臨床差異
台美兩地對壓瘡預防指引一致，皆遵循 NPUAP 建議，強調減壓姿勢與翻身頻率。