— 照護管理 · MEDIUM · SATA —
對於壓力性損傷（褥瘡）的病人，下列哪些護理措施是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client diagnosed with a pressure injury? (Select all that apply.)
- ARepositioning the client every 2 hours✓ 正解每 2 小時重新安置個案姿勢
- BMassaging the reddened bony prominences按摩發紅的骨突處
- CKeeping the skin clean and dry✓ 正解保持皮膚清潔乾燥
- DUsing a donut-shaped cushion to relieve pressure使用甜甜圈形坐墊以減輕壓力
- EImplementing a high-protein, vitamin C-rich diet✓ 正解實施高蛋白、富含維生素 C 的飲食
— Explanation · 中文詳解 —
壓力性損傷護理重點為減壓、皮膚護理與營養支持。定時翻身、保持皮膚乾爽清潔及攝取高蛋白與維生素 C（促進組織修復）為標準護理措施。禁止按摩紅腫處，以免造成深層組織損傷；甜甜圈墊會妨礙血液循環，目前已不建議使用。
Appropriate interventions for pressure injuries include repositioning the client regularly to relieve pressure, keeping the skin clean and dry to prevent maceration, and providing high-protein nutrition with vitamin C to support tissue repair. Massaging reddened areas can cause further tissue damage, and donut-shaped cushions should be avoided as they restrict blood flow to the affected area.
✦ 台美臨床差異
台灣病房常使用氣墊床，且重視營養會診，標準流程與美國醫院的褥瘡照護指引高度一致。