— 基本照護與舒適 · MEDIUM · SATA —
一位診斷為身體活動受限的個案有壓力性損傷風險，護理師應包含哪些介入措施？（選所有適合的）
A client with a nursing diagnosis of Impaired Physical Mobility is at risk for developing pressure ulcers. Which interventions should the nurse include in the care plan? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每兩小時為個案翻身
- BMassage reddened bony prominences按摩發紅的骨突出處
- CKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- DUse a donut-shaped cushion for comfort使用甜甜圈形坐墊以增加舒適感
- EApply a moisture barrier cream to the sacral area✓ 正解在骶骨區域塗抹濕氣屏障乳霜
— Explanation · 中文詳解 —
預防壓力性損傷（Pressure ulcers）的重點在於減壓（Pressure relief）與保持皮膚完整性。翻身可改變受壓點，保持乾爽則可防止皮膚浸潤（Maceration）。對於已經紅腫的骨突處，按摩會導致組織進一步受損（深層組織損傷），應絕對避免。此外，甜甜圈墊（Donut cushion）會造成周邊循環阻礙，應改用減壓氣墊或凝膠墊。
To prevent pressure ulcers, nurses should reposition clients regularly to relieve capillary pressure and keep the skin clean and dry to prevent maceration. Massaging reddened areas should be avoided as it can cause deep tissue injury, and donut cushions should not be used because they impede circulation in surrounding tissues.