— 基本照護與舒適 · EASY · MCQ —
為預防臥床病人產生壓力損傷,護理師應優先採取何項措施?
Which action should the nurse prioritize to prevent pressure injuries in a bedridden client?
- AReposition the client at least every two hours✓ 正解至少每兩小時為病人翻身
- BUse a donut-shaped cushion for comfort使用甜甜圈形坐墊以增加舒適度
- CKeep the linens tightly tucked to avoid wrinkles保持床單緊密鋪設以避免皺褶
- DMassage bony prominences regularly定期按摩骨突處
— Explanation · 中文詳解 —
定時翻身(每兩小時)是預防壓傷的金標準,能解除局部持續性壓力,讓血液恢復灌流。皺摺雖需整理,但翻身才是關鍵;按摩骨突處反而會造成深部組織損傷;甜甜圈軟墊(Donut cushions)會阻礙局部靜脈回流,已被臨床證實為壓傷的風險因子,絕對應避免使用。
Repositioning the client at least every two hours is the gold standard for preventing pressure injuries as it relieves sustained pressure on bony prominences and restores blood flow.
✦ 台美臨床差異
美國對於翻身紀錄有嚴謹的 EMR 審查機制;台灣護理師亦落實翻身,常運用翻身枕等輔具協助。