護理師協助行動受限的病人維持皮膚完整性，應包含哪些策略？（選所有適合的）
A nurse is assisting a client with limited mobility to maintain skin integrity. Which strategies should the nurse include? (Select all that apply.)
- AReposition the client at least every 2 hours✓ 正解至少每 2 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 moisture barrier creams for incontinence✓ 正解對於失禁病人使用防潮屏障乳液
- EElevate the head of the bed to 45 degrees constantly持續將床頭抬高至 45 度
維持皮膚完整性是預防壓力性損傷（Pressure Injury）的核心護理目標。策略重點在於減壓、保持環境乾燥及保護皮膚屏障。正確選項 A、B、D 分別對應了壓力管理、環境控制與化學屏障的保護；選項 C 的按摩骨突處與選項 E 的床頭搖高超過 30 度均已被實證為有害行為。在臨床照護中，必須將病人視為整體，優先評估皮膚受壓風險並採取預防措施。
Maintaining skin integrity is the core nursing goal for preventing pressure injuries. Strategies focus on pressure relief, keeping the environment dry, and protecting the skin barrier. Correct options A, B, and D correspond to pressure management, environmental control, and chemical barrier protection; option C (massaging bony prominences) and option E (constantly elevating the head of the bed beyond 30 degrees) are both proven to be harmful practices. In clinical care, patients must be considered holistically, prioritizing assessment of skin pressure risk and implementing preventive measures.
在美國臨床實務中，Pressure Injury 預防極度強調實證（Evidence-based practice），對於按摩骨突與高床頭角度的禁忌非常嚴格，護理師需精確遵循 Braden Scale 的評估結果執行 Intervention。