— 降低風險 · EASY · SATA —
為了預防醫源性壓瘡，護理師應採取哪些措施？（選所有適合的）
Which actions should the nurse take to prevent hospital-acquired pressure injuries? (Select all that apply.)
- AReposition the bedbound client at least every 2 hours✓ 正解至少每兩小時為卧床病人翻身
- BMassage reddened bony prominences按摩發紅的骨突處
- CKeep the client’s skin clean and dry✓ 正解保持病人皮膚清潔乾燥
- DUse a donut-shaped cushion for pressure relief使用甜甜圈形軟墊以減輕壓力
- EApply barrier creams to moisture-exposed areas✓ 正解在暴露於濕氣的區域塗抹屏障霜
— Explanation · 中文詳解 —
壓瘡預防的三大支柱：減壓、保持皮膚清潔乾燥、保護受潮皮膚。按摩紅腫骨突處會損傷皮下組織，應禁止；甜甜圈軟墊會影響局部血液循環並造成周圍組織壓迫，現在臨床建議避免使用。正確選項包含定期更換姿勢、保持皮膚乾爽及使用隔離霜保護受損區域。
To prevent hospital-acquired pressure injuries, the nurse should reposition bedbound clients at least every 2 hours, keep the skin clean and dry, and apply barrier creams to moisture-exposed areas. Massaging reddened skin and using donut-shaped cushions are contraindicated as they can cause tissue trauma or restrict blood flow, increasing the risk of ischemia.
✦ 台美臨床差異
美國醫院廣泛使用 Braden Scale 進行結構化評估，台灣則依醫院指引，部分醫院使用自編評估表。