護理師照顧一位薦骨壓瘡的病人，應包含哪些護理計畫？（選所有適合的）
A nurse is caring for a client with a pressure ulcer on the sacrum. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時為病人翻身
- BMassage the reddened areas to improve circulation按摩發紅區域以改善血液循環
- CUse pillows to keep heels off the bed✓ 正解使用枕頭使腳跟懸空離開床面
- DMaintain adequate protein and fluid intake✓ 正解維持充足的蛋白質與水分攝取
- EApply dry gauze directly to the wound bed將乾紗布直接覆蓋於傷口床
壓瘡（Pressure Ulcer）照護應遵循實證醫學指引。核心策略為：減壓（每兩小時翻身、使用減壓裝置）、改善組織灌流（維持皮膚完整）、以及提供足夠的營養與水分（蛋白質與熱量）。禁止按摩紅斑區，因為按摩會壓迫微血管，加重組織缺血與發炎。傷口處理應維持濕潤環境（moist wound healing），乾紗布會導致傷口沾黏與組織脫水。
Pressure ulcer care should follow evidence-based guidelines. Core strategies include: pressure relief (repositioning every 2 hours, using pressure-relief devices), improving tissue perfusion (maintaining skin integrity), and providing adequate nutrition and hydration (protein and calories). Massaging erythematous areas is prohibited because massage compresses capillaries, worsening tissue ischemia and inflammation. Wound care should maintain a moist environment (moist wound healing); dry gauze causes the wound to adhere and dries out the tissue.