護理師正在檢視有壓力性損傷風險病人的照護計畫。哪項措施應優先執行以降低風險？
A nurse is reviewing the plan of care for a client at risk for pressure injuries. Which intervention should be prioritized to reduce this risk?
- APlace a donut-shaped pillow under the sacrum在薦骨下放置甜甜圈形枕頭
- BKeep the head of the bed elevated at 45 degrees將床頭抬高至 45 度
- CMassage bony prominences with lotion以乳液按摩骨突處
- DReposition the client every 2 hours✓ 正解每 2 小時重新安置病人姿勢
壓力性損傷（pressure injury），俗稱壓瘡，是長期臥床或活動受限病人常見且嚴重的併發症。其主要病因是皮膚和皮下組織因持續受壓、剪力（shear）或摩擦力（friction）而導致局部血液循環受損，進而缺血壞死。護理師在照護高風險病人時，預防是重中之重。 「每 2 小時翻身」是預防壓力性損傷最核心、最有效的護理措施之一。透過規律改變體位，可以重新分配身體壓力，減輕局部組織的持續受壓，恢復血液灌流，從而避免組織缺血和壞死。這是基於生理學原理的直接介入，對所有高風險病人均適用，且其臨床證據最為堅實。其他措施雖然也有助益，但翻身能直接解決壓力源，因此應優先執行。
Pressure injuries (commonly known as bedsores) are a frequent and serious complication in clients with prolonged bed rest or limited mobility. The main cause is impaired local blood circulation due to sustained pressure, shear, or friction on the skin and subcutaneous tissue, leading to ischemia and necrosis. Prevention is paramount for high-risk clients. Repositioning every 2 hours is one of the most fundamental and effective measures. Regular position changes redistribute body pressure, relieve sustained tissue compression, and restore perfusion, preventing ischemia. This is a direct physiologic intervention applicable to all high-risk clients with the strongest evidence base. Other measures help, but repositioning addresses the pressure source directly and should be the priority.
美國臨床指引強調 30 度側臥與減壓床墊使用；台灣臨床常強調 2 小時定時翻身紀錄。