— 基本照護與舒適 · MEDIUM · SATA —
護理師照顧一位有壓瘡風險的老年病人，應將哪項介入措施納入照護計畫中？（選所有適合的）
A nurse is caring for an older adult client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care? (Select all that apply.)
- AApply a donut-shaped cushion to the sacrum在薦骨處使用甜甜圈形狀的軟墊
- BReposition the client at least every two hours✓ 正解至少每兩小時為病人重新擺放姿勢
- CKeep the skin clean and dry✓ 正解保持皮膚清潔與乾燥
- DUse a high-protein diet as prescribed✓ 正解依處方給予高蛋白飲食
- EMassage reddened bony prominences按摩發紅的骨突處
— Explanation · 中文詳解 —
預防壓瘡的核心原則為減壓、維持皮膚完整性及營養支持。每兩小時翻身可減少長時間受壓，保持皮膚清潔乾燥可防止浸潤，足夠的蛋白質攝取能促進組織修復。選項 A（甜甜圈軟墊）會阻礙血液循環；選項 E（按摩發紅處）會造成組織進一步損傷，皆屬錯誤行為。
Preventing pressure injuries involves repositioning the client at least every two hours to relieve prolonged pressure, keeping the skin clean and dry to prevent moisture-associated damage, and ensuring adequate protein intake to support tissue integrity. Donut cushions should be avoided as they impair circulation, and massaging reddened areas can cause further tissue damage.
✦ 台美臨床差異
美方教育非常強調禁止按摩骨突處；台灣臨床有時仍可見傳統護理手法建議按摩，需更新照護觀念。