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基本照護與舒適 · MEDIUM · SATA

針對嚴重腹瀉的病人,哪些護理措施適合用於維持皮膚完整性?(選所有適合的)

Which interventions are appropriate to maintain skin integrity in a client with severe diarrhea? (Select all that apply.)

  • AFrequent cleansing after each stool✓ 正解
    每次排便後頻繁清潔
  • BApplying a moisture barrier cream✓ 正解
    塗抹保濕隔離霜
  • CUsing a rectal tube continuously
    持續使用直腸導管
  • DKeeping the skin air-dried when possible✓ 正解
    盡量讓皮膚自然風乾
  • EUsing strong antiseptic soap for cleansing
    使用強效抗菌肥皂清潔
Explanation · 中文詳解

嚴重腹瀉(severe diarrhea)會導致頻繁排便,糞便(尤其是含有消化酶和膽汁的內容物)會持續刺激肛周及會陰部皮膚,造成皮膚浸潤(maceration)、紅腫、破皮甚至潰瘍,增加感染風險。維持皮膚完整性(skin integrity)是照護的重點。 正確選項分析: A. 每次排便後立即清潔(Frequent cleansing after each stool):溫和、及時地清潔肛周皮膚,移除糞便殘留物,可減少皮膚持續受到刺激的時間。 B. 使用保濕隔絕霜(Applying a moisture barrier cream):這類乳霜(如凡士林、氧化鋅基底的產品)能在皮膚表面形成一層保護膜,隔絕糞便和濕氣對皮膚的直接接觸,預防皮膚損傷。 D. 盡可能讓皮膚風乾(Keeping the skin air-dried when possible):清潔後,讓皮膚在通風的環境下自然乾燥,有助於恢復皮膚的正常狀態,避免潮濕環境滋生細菌。 錯誤選項分析: C. 持續使用直腸導管(Using a rectal tube continuously):直腸導管(rectal tube)僅用於特定情況(如嚴重腹瀉導致的嚴重皮膚損傷,需暫時引流),且有增加直腸黏膜損傷、感染、電解質失衡等風險,不建議常規或持續使用。 E. 使用強效殺菌皂清潔(Using strong antiseptic soap for cleansing):強效殺菌皂(antiseptic soap)會過度去除皮膚的天然油脂和保護性酸膜(acid mantle),破壞皮膚的屏障功能,使皮膚變得更脆弱、乾燥,反而容易受損。 臨床思路:ABC 原則中的 A(Airway)對應到預防感染(吸入性肺炎或皮膚感染),B(Breathing)對應到維持體液平衡(腹瀉易導致脫水),C(Circulation)對應到維持皮膚灌流與完整性。皮膚照護是此情境下的優先考量之一,以預防併發症。

Maintaining skin integrity in clients with severe diarrhea involves frequent gentle cleansing after each bowel movement to remove irritating enzymes and applying moisture barrier creams to protect against maceration. Allowing the skin to air-dry when possible helps prevent fungal growth and maintains healthy skin conditions. Continuous use of rectal tubes is generally avoided due to risks of tissue damage, and harsh antiseptics should be used cautiously to prevent further irritation.

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