— 基本照護與舒適 · MEDIUM · SATA —
病人診斷為「皮膚完整性受損風險」與長期不動有關。護理師應執行哪些預防性措施？（選所有適合的）
A client has a nursing diagnosis of 'Risk for Impaired Skin Integrity' related to immobility. Which preventative interventions should the nurse perform? (Select all that apply.)
- AUse moisturizing soaps for skin cleansing✓ 正解使用滋潤型肥皂清潔皮膚
- BUse pillows to bridge bony prominences✓ 正解使用枕頭墊起骨突處
- CTurn the client at least every 4 hours至少每 4 小時為病人翻身一次
- DInspect bony prominences during every shift✓ 正解每班檢查骨突處
- EMaintain head of bed at 45 degrees at all times始終將床頭抬高 45 度
— Explanation · 中文詳解 —
預防皮膚受損：使用滋潤型清潔用品；以枕頭支撐空隙（橋式擺位）以分散壓力；每班檢查骨突處；翻身頻率應為每 2 小時，而非 4 小時。床頭抬高 45 度會增加骶尾部的剪力（Shearing force），應限制在 30 度以下。
Preventing skin breakdown involves using moisturizing cleansers to protect the skin barrier, bridging bony prominences with pillows to relieve pressure, and inspecting high-risk areas every shift. Repositioning should occur at least every two hours, and head-of-bed elevation should be limited to 30 degrees to minimize shearing forces.
✦ 台美臨床差異
美國使用 Braden Scale 決定翻身頻率，台灣臨床多為固定 2 小時，後者較為一體適用但較不彈性。