— 基本照護與舒適 · MEDIUM · SATA —
護理師應採取哪些措施以預防長期臥床病人的壓瘡？（選所有適合的）
Which actions should the nurse take to prevent pressure ulcers in a bedridden client? (Select all that apply.)
- AReposition the client at least every 2 hours✓ 正解至少每兩小時為病人翻身
- BMassage reddened bony prominences daily每日按摩發紅的骨突處
- CKeep the linens dry and wrinkle-free✓ 正解保持床單乾燥且無皺褶
- DEncourage adequate fluid and protein intake✓ 正解鼓勵攝取充足的水分和蛋白質
- EPlace a donut-shaped cushion under the hips在臀部下方放置甜甜圈形坐墊
— Explanation · 中文詳解 —
預防壓瘡的核心原則為減壓、保持皮膚清潔乾燥與維持營養平衡。翻身可減輕局部受壓，保持床單平整乾燥減少磨擦與濕氣刺激。充足蛋白質與水分則是維持皮膚組織修復能力的必要條件。按摩紅腫處和使用甜甜圈枕頭已被證實會造成局部缺血。
Preventing pressure ulcers requires relieving pressure through regular repositioning, maintaining skin integrity by keeping linens dry and wrinkle-free, and supporting tissue health with adequate nutrition. Massaging reddened areas and using donut cushions are contraindicated as they can cause further tissue damage or restrict blood flow.
✦ 台美臨床差異
台灣醫院多使用氣墊床減壓，但在翻身時程上與國際標準（每2小時）一致。