— 基本照護與舒適 · MEDIUM · MCQ —
護理師教導長期臥床病人預防壓力性損傷，哪項指導最有效？
A nurse is teaching a client about the prevention of pressure injuries. Which instruction is most effective for a client who is bedbound?
- AKeep the head of the bed elevated at 45 degrees將床頭抬高至 45 度
- BMassage bony prominences every 4 hours每 4 小時按摩骨突處
- CApply a donut-shaped cushion to the sacrum在薦骨處使用甜甜圈形坐墊
- DReposition the client at least every 2 hours✓ 正解至少每 2 小時協助病人翻身
— Explanation · 中文詳解 —
預防壓力性損傷（Pressure Injury）的關鍵在於定時減壓，以避免組織缺血壞死。對於長期臥床的病患，每兩小時變換姿勢是臨床實證的標準照護措施。護理師需確保變換姿勢時採取正確的姿勢（如側臥 30 度），並避免在受壓部位進行按摩，因為這會損傷脆弱的皮膚組織。此外，保持皮膚清潔乾燥與使用減壓輔具亦是重要策略。
Repositioning the client at least every two hours is the most effective evidence-based intervention to relieve pressure on vulnerable tissues and prevent ischemia. Other measures such as massaging bony prominences or using donut cushions can cause further tissue damage or restrict blood flow, while high Fowler's position increases shear forces on the sacrum.