— 基本照護與舒適 · EASY · MCQ —
一位有壓瘡風險的病人，下列哪項護理措施對預防皮膚破損最有效？
A nurse is caring for a client who has a risk for pressure injury development. Which nursing intervention is most effective for preventing skin breakdown?
- AApply moisturizing powder to the sacral area在薦骨部位塗抹潤膚粉
- BReposition the client every 2 hours✓ 正解每兩小時為病人翻身
- CKeep the head of the bed elevated at 45 degrees將床頭抬高45度
- DMassage the bony prominences daily每日按摩骨突出處
— Explanation · 中文詳解 —
預防壓瘡的核心原則在於減壓與減低剪力。每兩小時執行翻身計畫能促進血液循環並消除受壓部位的缺血壓力。按摩骨突出處會造成組織損傷，不可施行；粉末易造成毛孔阻塞或皮膚摩擦；床頭抬高過高會增加薦骨剪力，應避免。
Repositioning the client every 2 hours is the most effective intervention to relieve pressure and promote tissue reperfusion, thereby preventing pressure injuries. Other measures like massaging bony prominences can cause tissue damage, while excessive head-of-bed elevation increases shear forces. Consistent turning is fundamental to reducing ischemia and maintaining skin integrity.
✦ 台美臨床差異
美台臨床皆強調定時翻身，但台灣護理人力負荷較重，有時需仰賴家屬或照服員共同落實。