— 生理適應 · EASY · SATA —
護理師照護一位薦骨處有早期壓瘡的病人，應採取哪些措施？（選所有適合的）
A nurse is caring for a client with early-stage pressure injury on the sacrum. Which actions should the nurse perform? (Select all that apply.)
- AReposition the client at least every two hours✓ 正解至少每兩小時重新安置病人姿勢
- BApply a hydrocolloid dressing to protect the area✓ 正解在水膠體敷料上保護該區域
- CMassage the reddened area to promote blood flow按摩發紅區域以促進血液循環
- DMaintain a dry and clean skin environment✓ 正解保持皮膚乾燥清潔的環境
- EIncrease protein intake in the diet✓ 正解增加飲食中的蛋白質攝取
— Explanation · 中文詳解 —
處理早期壓瘡（Pressure Injury）的臨床核心在於減壓（offloading）、保護皮膚屏障及提供組織修復所需的營養。一期壓瘡代表皮膚仍完整，但出現不可褪色之紅斑，此時重點在於預防惡化。透過定期翻身減輕持續性壓力，使用水膠體敷料（hydrocolloid dressing）提供封閉式癒合環境並減少摩擦，維持皮膚乾爽以防止潮濕引發浸潤（maceration），並補充蛋白質促進膠原蛋白合成與組織修復，是臨床照護的黃金準則。
Priority actions include repositioning the client regularly to relieve pressure, applying a hydrocolloid dressing to protect the skin, maintaining a dry and clean environment, and increasing protein intake to support tissue repair. Massaging the area should be avoided as it can cause further tissue damage.