— 基本照護與舒適 · EASY · MCQ —
護理師照護一位高齡且有皮膚受損風險的病人。哪項措施是預防壓瘡最有效的方法？
A nurse is caring for an older adult client who is at risk for skin breakdown. Which intervention is the most effective way to prevent pressure injuries?
- AMassaging the bony prominences daily每日按摩骨突處
- BApplying a moisturizing lotion every four hours每四小時塗抹保濕乳液
- CMaintaining a head-of-bed elevation at 45 degrees保持床頭抬高45度
- DRepositioning the client at least every two hours✓ 正解至少每兩小時為病人翻身
— Explanation · 中文詳解 —
預防壓瘡（Pressure injury）最有效的手段是減壓（Pressure relief）。定期翻身（每兩小時）可恢復受壓部位的血液循環，防止組織缺血壞死。雖然保濕很重要，但無法取代減壓。骨突處按摩是錯誤做法，因為會破壞組織微血管，加速壞死。床頭抬高應限制在 30 度以內，以避免薦骨承受過大的剪力（Shear force）。
The most effective intervention to prevent pressure injuries is regular repositioning, typically every two hours, to redistribute pressure and restore blood flow to tissues. Massaging bony prominences is contraindicated as it can damage microvasculature, while elevating the head of the bed beyond 30 degrees increases shear forces. Although moisturizing helps, it cannot replace the need for mechanical pressure relief.