# 護理師正照顧不動且營養不良之高齡病人(Braden 12)為高風險壓傷。護理師應執行哪些介入作為壓傷預防組合？請選擇所有適用項目。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=373515&lang=zh-tw  
> language: zh-TW  
> subject: Basic Care and Comfort  
> category: BCC

## 題目

護理師正照顧不動且營養不良之高齡病人(Braden 12)為高風險壓傷。護理師應執行哪些介入作為壓傷預防組合？請選擇所有適用項目。

1

使用適合病人風險等級之壓力重分配支撐面(低空氣流失或交替壓力床墊)。

2

於小腿下放枕將腳跟離床，或使用腳跟保護靴；不可將枕直接放於腳跟下方。

3

至少每2小時翻身，若紅斑持續則更頻繁；採30度側臥而非90度以降低股骨大轉子壓力。

4

轉介營養師以最適化營養；確保足夠蛋白質、熱量與水分支持皮膚完整。

5

至少每兩小時以輕柔的環狀動作按摩發紅部位，以促進局部血液循環並維持皮膚完整性。

## 解析

壓傷預防組合：每2小時以30度側臥翻身、以小腿下枕將腳跟離床(切勿直接置枕於腳跟下)、使用壓力重分配床墊、以蛋白/熱量/水分最適化營養。選項4錯誤 — 紅斑區按摩為禁忌；可能損傷已受損之組織並增加剪力。現行NPIAP/EPUAP指引明確指出「不可按摩」。

## 深入解析

兩個舊教科書陷阱仍出現於NCLEX：(1)「紅斑區按摩」 — 錯誤，可能造成深層組織傷害；(2)「甜甜圈/環形坐墊」 — 錯誤，將壓力分配至更小範圍反加重缺血。皆已由現代組合取代：翻身、減壓、分配、營養。

## 臨床情境

內外科病房之**不動且營養不良高齡者**。**Braden 12**(高風險)。白蛋白2.6 g/dL。皮膚目前完整但脆弱。

## 重要概念

- **Braden Scale** — 含6個次量表之壓傷風險評估工具；≤12=高風險、≤9=極高風險。
- **30度側臥位** — 側臥30度而非90度以避免直接壓迫大轉子。
- **腳跟減壓** — 以小腿下枕或腳跟保護靴使腳跟離床；不可將枕置於腳跟正下方。

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