— 基本照護與舒適 · MEDIUM · MCQ —
護理師照顧一位有壓瘡風險的老年病人。下列哪項護理措施對預防皮膚破損最有效？
A nurse is caring for an older adult client who is at risk for pressure ulcers. Which nursing intervention is most effective for preventing skin breakdown?
- ARepositioning the client every 2 hours✓ 正解每2小時重新安置病人
- BApplying powder to the skin folds在皮膚摺皺處塗抹粉劑
- CMassaging the bony prominences every shift每班次按摩骨突處
- DMaintaining a strictly dry environment at all times始終保持嚴格乾燥的環境
— Explanation · 中文詳解 —
減輕壓力是預防壓瘡的核心。每兩小時翻身可重新分配體表受壓位置，避免局部組織因缺血而壞死。按摩骨突處現已證實有害，因為會進一步損傷脆弱的深層組織。保持適度滋潤與清潔同樣重要，但翻身是緩解壓力的最直接手段。
Repositioning the client every 2 hours is the most effective intervention because it relieves pressure on bony prominences and restores blood flow to ischemic tissues. Massaging bony areas is contraindicated as it can cause further tissue damage, while maintaining dryness alone does not address pressure relief.
✦ 台美臨床差異
台灣醫院多會使用氣墊床，翻身紀錄仍為護理紀錄重點，美方則高度仰賴壓瘡評估量表（如 Braden Scale）。