— 基本照護與舒適 · MEDIUM · SATA —
護理師正在照護一位薦骨有壓瘡的病人。護理計畫應包含哪些措施？（選所有適合的）
A nurse is caring for a client with pressure ulcers on the sacrum. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client at least every 2 hours✓ 正解至少每2小時重新安置病人姿勢
- BMassage the reddened areas over the sacrum按摩薦骨區域發紅處
- CMaintain the head of the bed at or below 30 degrees✓ 正解保持床頭角度等於或小於30度
- DKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- EUse a donut-shaped cushion when sitting in a chair坐椅子時使用甜甜圈形坐墊
— Explanation · 中文詳解 —
壓瘡護理的核心在於減壓、維持皮膚完整性及控制濕氣。每兩小時翻身、床頭角度限制在 30 度以下（減少剪力）以及保持乾爽是標準照護。按摩紅斑區域會導致深層組織損傷，而甜甜圈型軟墊會阻斷血液循環，現已建議避免使用。
Preventing pressure ulcers involves frequent repositioning to relieve pressure, maintaining the head of the bed at 30 degrees or less to reduce shear forces, and keeping the skin clean and dry to prevent moisture-associated damage. Massaging reddened areas can worsen tissue injury, and donut cushions should be avoided as they restrict blood flow to the area.
✦ 台美臨床差異
台灣醫院目前多採用 Braden Scale 評估風險，對於壓瘡照護標準已與國際指引同步。