— 降低風險 · MEDIUM · SATA —
下列哪些護理介入適用於預防活動受限病人的壓傷？（選所有適合的）
Which of the following nursing interventions is appropriate to prevent pressure injury in a client with limited mobility? (Select all that apply.)
- AUse a lift sheet to transfer the client✓ 正解使用抬布轉移病人
- BMaintain a 30-degree lateral position✓ 正解維持30度側臥姿勢
- CKeep the head of the bed below 30 degrees if possible✓ 正解盡量將床頭抬高保持在30度以下
- DApply barrier cream to high-risk areas✓ 正解在高風險區域塗抹保護性乳霜
- EMassage the bony prominences after every shift每班結束後按摩骨突處
— Explanation · 中文詳解 —
預防壓傷需減少摩擦力與剪力，使用移動滑布（Lift sheet）及維持 30 度側臥可減少骨突處壓力。限制床頭高度（< 30 度）可減少剪力滑動。E 選項錯誤，按摩骨突處會損傷微血管。 barrier cream 可保護皮膚免受失禁影響。
Use a lift sheet to reduce friction and shear during transfers, and maintain a 30-degree lateral position to avoid direct pressure on the greater trochanter. Keep the head of the bed below 30 degrees to minimize shear forces and apply barrier cream to protect skin from moisture.
✦ 台美臨床差異
兩國在預防壓傷的護理標準已高度同步，皆強調「不要按摩」的概念。