— 基本照護與舒適 · MEDIUM · SATA —
護理師指導預防皮膚破損的措施，應包含哪些內容？（選所有適合的）
A nurse is teaching a client about measures to prevent skin breakdown. Which instructions should be included? (Select all that apply.)
- AReposition the client at least every 2 hours✓ 正解至少每 2 小時協助病人翻身
- BUse a donut-shaped cushion to relieve pressure使用甜甜圈形坐墊以減輕壓力
- CKeep the skin clean and dry, especially in skin folds✓ 正解保持皮膚清潔乾燥，特別是皮膚摺皺處
- DApply a moisturizing lotion to bony prominences在骨突處塗抹保濕乳液
- EEnsure adequate protein and caloric intake✓ 正解確保充足的蛋白質與熱量攝取
— Explanation · 中文詳解 —
預防壓力性損傷的核心在於減壓、皮膚護理與營養支持。定時翻身能降低持續壓力，保持乾爽可避免浸漬，營養充足是組織修復的關鍵。甜甜圈形靠墊（B）會造成局部周圍壓力增加導致組織缺血；按摩骨突處（D）已被證實會破壞皮下微血管，應避免。
Preventing skin breakdown involves regular repositioning to relieve pressure, maintaining clean and dry skin to prevent maceration, and ensuring adequate nutrition for tissue integrity. Donut-shaped cushions should be avoided as they restrict blood flow to surrounding tissues, and massaging bony prominences is contraindicated because it can damage underlying capillaries.
✦ 台美臨床差異
美台護理教育對於『禁止按摩骨突』的教育內容已趨於一致，均強調壓力減輕與皮膚完整性保護。