— 基本照護與舒適 · EASY · MCQ —
一位 75 歲行動受限的病人有壓瘡風險。哪項護理措施對預防皮膚破損最有效？
A 75-year-old client with limited mobility is at risk for pressure injuries. Which nursing intervention is most effective for preventing skin breakdown?
- AApply moisturizing powder to the skin在皮膚上塗抹潤膚粉
- BMassage the bony prominences daily每日按摩骨突處
- CReposition the client at least every 2 hours✓ 正解至少每2小時重新安置病人體位
- DKeep the head of the bed elevated at 45 degrees保持床頭抬高45度
— Explanation · 中文詳解 —
預防壓瘡的核心在於減輕局部壓力與剪力。每兩小時翻身可重新分配體重負擔，促進末梢血流。B選項按摩骨突處已證實會損傷皮下組織，現行指引禁止；A選項粉末可能結塊刺激皮膚；D選項若超過30度會增加薦骨剪力，導致更容易受傷。
The core of pressure injury prevention is relieving local pressure and shear forces. Repositioning the client at least every two hours redistributes weight-bearing stress and promotes tissue perfusion. Massaging bony prominences is contraindicated as it damages deep tissue, powders can accumulate and cause irritation, and elevating the head of the bed above 30 degrees increases shear forces on the sacrum.
✦ 台美臨床差異
台美皆遵循 NPUAP 壓瘡預防指引，臨床上對於床頭抬高角度的監控是降低院內感染與併發症的重要指標。