— 基本照護與舒適 · MEDIUM · SATA —
護理師照顧一位皮膚完整性受損的老年病人，應採取哪些措施以預防壓瘡？（選所有適合的）
A nurse is caring for an older adult with skin integrity issues. Which nursing interventions should be implemented to prevent pressure injuries? (Select all that apply.)
- AReposition the client at least every two hours✓ 正解至少每兩小時為病人翻身一次
- BMassage bony prominences to increase circulation按摩骨突處以增加循環
- CUse pillows to bridge bony prominences✓ 正解使用枕頭墊高骨突處
- DKeep the head of the bed elevated at 45 degrees將床頭抬高至45度
- EApply a moisture barrier cream for incontinent clients✓ 正解對失禁病人塗抹濕氣屏障乳霜
— Explanation · 中文詳解 —
預防壓瘡關鍵在於減壓、保持清潔與避免剪切力。每兩小時翻身、使用枕頭跨過骨突處（懸空法）、使用皮膚隔離霜（避免尿液浸漬）是標準護理。按摩骨突處會損傷皮下組織，禁止進行。床頭抬高超過 30 度會產生剪切力，增加薦骨壓瘡風險。
Preventing pressure injuries requires regular repositioning every two hours, using pillows to bridge bony prominences, and applying moisture barrier creams for incontinent clients. Massaging bony prominences is contraindicated as it damages tissue, and elevating the head of the bed above 30 degrees increases shear force.
✦ 台美臨床差異
台灣醫院多使用氣墊床與照護計畫，但翻身時的力學姿勢教育與美國相比，美國更強調使用輔助設備減少護理人員腰背負擔。