# 一名臥床個案薦骨處有不可褪色紅斑且口服攝取不佳。哪項護理措施最適合納入照護計畫？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393671&lang=zh-tw  
> language: zh-TW  
> subject: Mobility/Immobility  
> category: BCC

## 題目

一名臥床個案薦骨處有不可褪色紅斑且口服攝取不佳。哪項護理措施最適合納入照護計畫？

## 選項

1. 每班按摩發紅的薦骨區。
2. 依排程翻身並解除薦骨壓力。 **✔ 正確答案**
3. 將床頭維持 60 度以改善營養。
4. 清潔護理前對薦骨熱敷。

**正確答案: 2**

## 解析

不可褪色紅斑表示壓力性損傷風險或早期壓力性損傷。定時翻身、解除壓力、保護皮膚與營養支持可減少惡化。按摩發紅組織、高床頭或熱敷可能加重組織傷害或剪力。

## 深入解析

臨床判斷
預防壓力性損傷時，先移除壓力與剪力，再考慮舒適措施。

記憶重點
薦骨發紅：不揉，翻身、減壓、保護、營養。

## 臨床情境

實務指引
AHRQ 壓力性損傷預防資料強調頻繁翻身與處理營養風險等最佳實務。

注意
不可褪色紅斑應視為警訊，而非一般皮膚刺激。

## 重要概念

- **壓力性損傷** — 與壓力、剪力或醫療器材壓迫相關的皮膚或下層組織局部損傷。
- **減壓** — 移除或重新分散脆弱組織上的壓力，以預防損傷。
- **剪力** — 皮膚停留原位而深層組織滑動所產生的力，高床頭時常增加。

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_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_