一位高齡病人有皮膚完整性受損的風險，護理師在照護計畫中應納入哪些措施？（選所有適合的）
A nurse is caring for an older adult client who is at risk for skin breakdown. Which interventions should the nurse include in the care plan? (Select all that apply.)
- ATurn and reposition the client at least every two hours✓ 正解至少每兩小時為病人翻身並調整姿勢
- BMaintain the head of the bed at an angle of 45 degrees or higher將床頭維持在 45 度或更高的角度
- CApply a moisture barrier cream to the sacral area✓ 正解在薦骨區域塗抹濕氣屏障乳霜
- DEncourage adequate fluid and protein intake✓ 正解鼓勵攝取充足的液體和蛋白質
- EUse a specialized pressure-relieving mattress✓ 正解使用特殊的減壓床墊
預防壓力性損傷需兼顧減壓、皮膚屏障保護與營養攝取。每兩小時翻身是減壓標準作業，使用減壓床墊可分散支撐點壓力；水分與蛋白質則能增進組織修復力。床頭抬高超過 30 度容易產生剪力，因此不應長期維持在 45 度以上。保濕霜能防止皮膚因長期接觸排泄物而軟化受損。
Prevention of pressure injuries requires attention to pressure relief, skin barrier protection, and nutritional intake. Repositioning every two hours is the standard pressure-relief practice, and using a pressure-redistributing mattress disperses support-point pressure; fluid and protein intake support tissue repair. Elevating the head of the bed above 30 degrees readily produces shear forces, so it should not be maintained above 45 degrees for prolonged periods. Moisture barrier cream prevents skin maceration and damage caused by prolonged contact with excreta.
美台臨床皆重視褥瘡預防，但美國護理師常需記錄 Braden Scale 分數並據此自動啟動翻身 protocol，台灣則多以護理常規執行。