— 基本照護與舒適 · EASY · MCQ —
一位高齡病人有壓力性損傷風險，下列哪項護理措施對維持皮膚完整性最有效？
A nurse is caring for an older adult client who is at risk for pressure ulcers. Which nursing intervention is most effective in maintaining skin integrity?
- AApplying powder to keep the skin dry塗抹粉末以保持皮膚乾燥
- BMassaging the bony prominences daily每日按摩骨突處
- CKeeping the head of the bed elevated at 45 degrees將床頭抬高至 45 度
- DRepositioning the client every 2 hours✓ 正解每 2 小時為病人翻身
— Explanation · 中文詳解 —
間歇性減壓是預防壓力性損傷的金標準。每兩小時更換姿勢能恢復受壓部位的血流灌流，防止組織缺氧壞死。按摩骨突處已證實會傷害真皮層結構；爽身粉易造成結塊摩擦；床頭抬高超過 30 度會增加剪力（Shearing），這對於臥床病人都是禁忌。
Repositioning the client every two hours is the most effective intervention for maintaining skin integrity as it relieves sustained pressure and restores blood flow to tissues. Massaging bony prominences can cause tissue trauma, and powders may increase friction. Elevating the head of the bed beyond 30 degrees increases shear forces, which can worsen pressure injuries.
✦ 台美臨床差異
美國醫院廣泛使用自動減壓氣墊床，台灣在長照或一般病房中，人力翻身紀錄仍是評鑑重點。