護理師照顧一位有皮膚受損風險的高齡病人。下列哪項措施對預防壓力性損傷最有效？
A nurse is caring for an older adult client who is at risk for skin breakdown. Which intervention is most effective for preventing pressure injuries?
- AApplying a thick layer of cornstarch to skin folds.在皮膚摺皺處塗抹厚層玉米粉
- BMassaging reddened bony prominences every 2 hours.每兩小時按摩發紅的骨突處
- CRepositioning the client at least every 2 hours.✓ 正解至少每兩小時為病人重新擺位
- DMaintaining the head of the bed at a 45-degree angle.維持床頭角度在45度
核心概念：壓力性損傷的預防機轉。預防損傷的核心在於「定時解除壓力」。每 2 小時翻身一次是臨床公認的標準，旨在避免局部組織長時間缺血、缺氧。為何正確答案對：規律變換體位能恢復受壓部位的血流，是預防壓瘡最經濟且有效的手法。為何其他選項錯：按摩發紅的骨突處（B）會加重深層組織的微血管損傷，目前實證醫學已禁止此行為；玉米粉（A）遇濕會結塊，增加磨擦力且易滋生細菌；床頭抬高 45 度（D）會增加薦骨部位的剪力（shearing force），應維持在 30 度以下。臨床思路：評估病人的 Braden Scale 分數，並根據其風險制定個別化的翻身班表。
The most effective intervention for preventing pressure injuries is repositioning the client at least every two hours to relieve pressure on bony prominences and restore tissue perfusion. Massaging reddened areas can damage fragile capillaries, while cornstarch may promote bacterial growth and increase friction. Additionally, elevating the head of the bed beyond 30 degrees increases shearing forces on the sacrum.
美國護理常態化使用高規格減壓床墊（Air-fluidized beds）比例較高，且強調護理師獨立評估 Braden Scale；台灣則較依賴家屬或照服員進行人工翻身，護理師需負擔較多督導與家屬衛教的角色。