# 一位活動受限的個案，其薦骨處有按壓不變白的紅斑。哪項介入措施最為適當？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394100&lang=zh-tw  
> language: zh-TW  
> subject: Mobility/Immobility  
> category: BCC

## 題目

一位活動受限的個案，其薦骨處有按壓不變白的紅斑。哪項介入措施最為適當？

## 選項

1. 每班用力按摩發紅區域。
2. 將個案直接置於薦骨上以減少髖部壓力。
3. 定時為個案翻身並使用減壓支撐面。 **✔ 正確答案**
4. 在該區域緊緊貼上膠布以保護它。

**正確答案: 3**

## 解析

按壓不變白的紅斑暗示早期壓力性損傷。應透過翻身、支撐面、濕氣控制、營養支持及皮膚檢查來解除壓力。按摩發紅組織或貼上緊繃膠布可能使損傷惡化。

## 深入解析

臨床判斷
壓力性損傷的預防始於解除壓力，而非搓揉受損組織。

記憶提示
按壓不變白的紅斑：解除壓力。

## 臨床情境

臨床實務指引
皮膚完整性照護包括翻身時間表、壓力重新分佈、濕氣管理、營養及每日檢查。

注意事項
勿按摩有按壓不變白紅斑的骨突處。

## 重要概念

- **壓力性損傷** — 由壓力或剪力造成的局部皮膚或組織損傷。
- **按壓不變白的紅斑** — 按壓時不會變白的紅斑，暗示組織損傷。
- **解除壓力** — 移除高風險區域的壓力。

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