— 基本照護與舒適 · MEDIUM · SATA —
一位長期臥床的病人，護理師應採取哪些措施以預防壓瘡？（選所有適合的）
A nurse is caring for an immobile client. Which nursing interventions are appropriate to prevent pressure ulcers? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時為病人更換姿勢
- BMassage 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
- DUse a foam mattress overlay✓ 正解使用泡沫減壓墊
- EElevate the head of the bed to 45 degrees constantly持續將床頭抬高 45 度
— Explanation · 中文詳解 —
預防壓瘡的核心在於減少壓力、摩擦力與潮濕。每兩小時翻身是標準程序；保持皮膚清潔乾燥可防浸潤；使用減壓墊有效分散壓力。按摩紅腫處已證實會損傷皮下組織故禁止；床頭抬高過高會導致剪力過大，應限制在 30 度以下。
Preventing pressure ulcers requires frequent repositioning every two hours, keeping the skin clean and dry to maintain integrity, and using pressure-redistributing surfaces like foam overlays. Massaging reddened areas is contraindicated as it causes tissue trauma, and excessive head-of-bed elevation increases shear forces.
✦ 台美臨床差異
台灣醫院多強調照護標準化，美國則更依賴 Braden Scale 分數進行風險評估並啟動預防性照護。