— 基本照護與舒適 · EASY · MCQ —
護理師正在協助一位行動不便的病人翻身。護理師應採取哪項措施來預防皮膚剪力傷害？
A nurse is assisting a client with limited mobility to turn in bed. Which action should the nurse take to prevent skin shearing?
- ALift the client using a draw sheet.✓ 正解使用中單抬起病人
- BDrag the client across the linens slowly.在床單上緩慢拖行病人
- CPull the client up in bed using the axillae.透過腋下將病人拉起床
- DApply cornstarch to the back before moving.移動前在背部塗抹玉米澱粉
— Explanation · 中文詳解 —
預防剪力（Shearing）的關鍵是「抬起」而非「拖拉」。使用中單（Draw sheet）可以將病人的體重均勻分佈並將其身體抬離床面，避免皮膚與床單產生摩擦與剪力。剪力常見於病人從床上滑下或被拖動時，會損害深層組織。拉腋下會造成肩膀脫臼或神經損傷；拖行會直接造成摩擦傷；玉米粉已不再推薦使用，因為可能導致潮濕堆積或吸入風險。
To prevent shearing, the nurse must lift the client rather than drag them, as dragging creates friction and damages deep tissue. Using a draw sheet allows the nurse to evenly distribute weight and lift the body off the surface, effectively reducing shear forces.
✦ 台美臨床差異
美國醫院廣泛使用 Mechanical lifts (如 Hoyer lift) 進行轉移位以保護員工職業安全，台灣則較多依賴人力配合中單。