護理師照顧一位尾骨有第 2 級壓傷的病人。下列哪些護理措施是適當的？（選所有適合的）
A nurse is caring for a client with a Stage 2 pressure injury on the coccyx. Which nursing interventions are appropriate? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每2小時重新安置個案體位
- BMassage the reddened area to promote circulation按摩發紅區域以促進循環
- CUse a hydrocolloid dressing to keep the wound moist✓ 正解使用水膠體敷料以保持傷口濕潤
- DEncourage a diet high in protein and vitamin C✓ 正解鼓勵攝取高蛋白及維生素C飲食
- EApply a donut-shaped cushion to relieve pressure使用甜甜圈形軟墊以減輕壓力
第 2 級壓傷包含表皮與真皮層受損，護理重點在於減壓、營養補充與傷口濕潤癒合。按摩紅斑區域會對微血管造成機械性損害，已禁止使用；甜甜圈軟墊會導致區域性水腫並阻礙周邊血流，應避免。翻身、濕潤敷料與高蛋白飲食均為實證醫學支持的護理處置。
A Stage 2 pressure injury involves loss of the epidermis and partial dermis. Nursing focuses on pressure relief, nutritional support, and maintaining a moist wound environment for healing. Massaging reddened areas causes mechanical damage to fragile capillaries and is no longer recommended; donut-shaped cushions cause localized edema and impede peripheral blood flow and should be avoided. Repositioning, moist (hydrocolloid) dressings, and a high-protein diet are evidence-based nursing interventions.
美國醫院廣泛使用 Braden Scale 進行風險分級與預防計畫；台灣亦導入但記錄執行細節略有不同。