護理師照護有壓瘡病史的病人,哪項護理措施可預防皮膚進一步潰瘍?
A nurse is caring for a client with a history of pressure injuries. Which nursing intervention should be implemented to prevent further skin breakdown?
- AUse a doughnut-shaped cushion for comfort使用甜甜圈形狀的坐墊以增加舒適感
- BReposition the client every 2 hours✓ 正解每 2 小時協助病人翻身
- CKeep the head of the bed elevated at 45 degrees將床頭抬高至 45 度
- DMassage the bony prominences frequently經常按摩骨突處
壓瘡(Pressure Injury)的形成主因是局部組織受壓導致缺血。定時變換體位(Repositioning)是減輕壓力的最有效手段。美國護理準則建議臥床病人每 2 小時變換一次體位,以恢復血液循環。其他選項如按摩會損傷已脆弱的皮下組織,抬頭過高會增加剪力,環形墊則會阻礙局部血液回流,皆應避免。
Pressure injuries result from prolonged tissue compression causing ischemia, making regular repositioning every two hours the most effective preventive measure. This practice redistributes pressure and restores blood flow to vulnerable areas. Interventions such as massaging bony prominences, using doughnut cushions, or elevating the head of the bed excessively can cause tissue trauma, impair circulation, or increase shear forces, thereby increasing the risk of skin breakdown.