— 基本照護與舒適 · MEDIUM · MCQ —
一位病人骶骨處有第二級壓瘡，下列哪項護理措施對於壓瘡預防最有效？
A client diagnosed with pressure ulcer stage II on the sacrum. Which nursing action is most effective for pressure ulcer prevention?
- AReposition the client every two hours✓ 正解每兩小時重新安置病人體位
- BKeep the skin hydrated with heavy powder使用大量粉末保持皮膚濕潤
- CMassage the reddened skin areas firmly用力按摩泛紅的皮膚區域
- DApply a donut-type cushion to the area在該部位應用甜甜圈型坐墊
— Explanation · 中文詳解 —
定時更換姿勢（Q2H）是減輕組織缺血壓力的黃金標準。長期受壓部位若未及時減壓，血液灌流將受阻導致損傷。按摩紅腫處會破壞脆弱組織，甜甜圈墊則會阻斷局部血液循環，應避免使用。保持皮膚清潔乾燥即可，過度使用粉末可能導致結塊摩擦。
Repositioning the client every two hours is the gold standard for relieving pressure and promoting tissue perfusion. This action prevents ischemia and subsequent skin breakdown in vulnerable areas. Other methods like massage or donut cushions can impair circulation or damage fragile tissue, while powders may cause friction.
✦ 台美臨床差異
兩地皆遵循 NPUAP/EPUAP 指引；台灣臨床因人力比限制，翻身執行率往往是品質指標審查重點。