— 降低風險 · EASY · SATA —
護理師照護一位有壓瘡風險的病人，應將哪些措施納入護理計畫？（選所有適合的）
A nurse is caring for a client who is at risk for developing a pressure injury. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時為病人更換姿勢
- BMassage the reddened bony prominences按摩發紅的骨突處
- CKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- DElevate the head of the bed to 45 degrees將床頭抬高至 45 度
- EUse pillows to bridge bony prominences✓ 正解使用枕頭墊起骨突處
— Explanation · 中文詳解 —
預防壓瘡的核心在於減壓與皮膚護理。每 2 小時翻身是標準，保持皮膚清潔乾燥可減少浸潤風險，使用枕頭減壓可避開骨突處。按摩紅腫處反而可能傷害血管；床頭抬高 45 度會增加剪力風險，建議維持 30 度以下。
Preventing pressure injuries involves regular repositioning to relieve pressure, keeping the skin clean and dry to prevent moisture-associated damage, and using pillows to bridge bony prominences. Massage of reddened areas is contraindicated as it can cause tissue trauma, and elevating the head of the bed above 30 degrees increases shear forces.
✦ 台美臨床差異
台灣醫院目前推廣使用減壓氣墊床非常普及，美國則更強調護理計畫的執行準確度與護理師評估工具的使用。