— 降低風險 · MEDIUM · SATA —
為預防臥床病人產生壓瘡，下列哪些護理措施是必要的？（選所有適合的）
Which of the following interventions are essential to prevent pressure ulcers in a bedridden client? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每兩小時為病人翻身
- BKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- CMassage bony prominences regularly定期按摩骨突處
- DUse pillows to offload heels✓ 正解使用枕頭墊高腳跟以減輕壓力
- EMaintain head of bed at 45 degrees at all times始終將床頭抬高45度
— Explanation · 中文詳解 —
預防壓瘡重點在減壓、維持皮膚完整性與促進循環。兩小時翻身與使用枕頭墊高腳跟可有效減輕骨突處壓力。保持清潔乾燥可避免濕氣造成的浸潤。按摩骨突處現已證實會損傷皮下微血管，應避免。床頭抬高應避免超過 30 度以防剪力（Shearing）。
Preventing pressure ulcers requires redistributing pressure through frequent repositioning and offloading bony prominences like the heels with pillows. Keeping the skin clean and dry maintains integrity, while massaging bony areas is contraindicated as it can damage underlying tissue. Head-of-bed elevation should generally be limited to 30 degrees to reduce shear forces.
✦ 台美臨床差異
台灣與美國臨床指引皆已廢除「按摩骨突處」此舊有護理習慣，並加強剪力預防之衛教。