— 基本照護與舒適 · HARD · SATA —
護理師為一位活動受限的病人規劃護理，哪些措施能降低壓瘡風險？（選所有適合的）
A nurse is planning care for a client with restricted mobility. Which actions will reduce the risk of pressure ulcers? (Select all that apply.)
- AReposition the client at least every 2 hours✓ 正解至少每2小時為病人重新擺位
- BMassage reddened bony prominences to increase blood flow按摩發紅的骨突處以增加血液循環
- CKeep the head of the bed elevated at 45 degrees constantly持續將床頭抬高45度
- DUse pillows to bridge bony prominences✓ 正解使用枕頭墊高骨突處
- EMaintain a clean, dry, and wrinkle-free bed linen✓ 正解保持床單清潔、乾燥且無皺褶
— Explanation · 中文詳解 —
預防壓瘡的核心是減壓與維持皮膚乾燥。每兩小時翻身、使用軟枕進行減壓（bridge）以及保持床單乾燥平整，能有效避免組織缺血。按摩紅斑區會導致組織損傷，頭高 45 度會增加剪力（Shearing），應儘量避免或採取短時間抬高。
To reduce the risk of pressure ulcers, nurses should reposition clients at least every two hours to redistribute pressure and use pillows to bridge bony prominences. It is also essential to maintain clean, dry, and wrinkle-free bed linens to minimize moisture and friction. Massage should be avoided on reddened areas as it can cause further tissue damage.
✦ 台美臨床差異
美國醫院多使用高階壓力緩解氣墊床；台灣若預算受限，翻身與軟墊使用是主要手段。