— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位長期臥床的老年病人。下列哪項措施最能有效預防壓瘡？
A nurse is caring for an older adult client who is immobile. Which intervention is best to prevent pressure injuries?
- AMassaging bony prominences daily每天按摩骨突處
- BApplying a donut cushion for comfort使用甜甜圈形坐墊以增加舒適感
- CUsing plastic pads to protect linens使用塑膠墊保護床單
- DRepositioning the client at least every two hours✓ 正解至少每兩小時為病人重新擺放體位
— Explanation · 中文詳解 —
預防壓瘡（Pressure injuries）的核心在於分散壓力與維持皮膚完整性。對於長期臥床或不動的病人，定時翻身（每兩小時）是最有效的介入措施，能減輕骨突處的持續壓力。按摩骨突處已證實會導致深層組織損傷，故禁忌；DONUT 坐墊會阻礙局部血液循環，加劇壓瘡；塑料墊則不透氣，容易造成潮濕與熱累積，這些皆是錯誤的護理觀念。護理師應結合翻身、使用減壓床墊與皮膚護理，全方位預防壓瘡。
Repositioning the client at least every two hours is the most effective intervention to redistribute pressure and prevent tissue ischemia over bony prominences. Massaging bony areas can cause further tissue damage, while donut cushions and plastic pads impair circulation and trap moisture, respectively.