— 基本照護與舒適 · MEDIUM · SATA —
長期臥床病人有壓瘡風險，護理師應將哪些措施納入照護計畫？（選所有適合的）
A client on bed rest is at risk for pressure ulcers. Which interventions should the nurse include in the care plan? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時協助病人翻身
- BUse foam pillows to offload heels✓ 正解使用海綿枕頭墊高腳跟以減壓
- CMassage reddened bony prominences vigorously用力按摩骨突處發紅區域
- DKeep the head of the bed elevated above 45 degrees將床頭抬高超過 45 度
- EEnsure the skin is kept clean and dry✓ 正解確保皮膚保持清潔與乾燥
— Explanation · 中文詳解 —
預防壓瘡的核心在於減壓、保持皮膚乾爽及保護骨隆突處。每兩小時翻身是標準作業，墊枕頭可減少壓迫，保持乾燥可防浸潤。按摩發紅區域會破壞組織，導致壓瘡惡化；床頭抬高超過 30 度會增加剪力，不應常態維持高於 45 度。
Preventing pressure ulcers involves regular repositioning every two hours to restore tissue perfusion and using foam pillows to offload pressure from bony prominences like the heels. Keeping the skin clean and dry prevents moisture-associated skin breakdown, whereas massaging reddened areas can cause further tissue damage.
✦ 台美臨床差異
美國醫院廣泛使用自動氣墊床，台灣仍多仰賴傳統人工翻身記錄與護理紀錄核對。