護理師為壓力性損傷病人進行護理，應包含哪些措施？（選所有適合的）
A nurse is providing care to a client with pressure ulcers. 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 bony prominence areas按摩發紅的骨突處
- CMaintain adequate protein and calorie intake✓ 正解維持充足的蛋白質和熱量攝取
- DUse a donut-shaped cushion to relieve pressure使用甜甜圈形坐墊以減輕壓力
- EKeep the skin clean, dry, and hydrated✓ 正解保持皮膚清潔、乾燥和滋潤
壓力性損傷（Pressure Injury）的護理核心在於減壓、維持皮膚完整性及營養支持。翻身能改變受壓點，預防組織缺血；營養能促進傷口癒合；保持皮膚乾燥能減少浸潤（Maceration）。按摩骨突處與使用甜甜圈坐墊是臨床禁忌，因為會阻斷局部微血管灌流，反而加重組織受損。護理師應優先評估風險並執行減壓計畫。
The core of pressure injury care lies in pressure relief, maintaining skin integrity, and nutritional support. Repositioning shifts pressure points and prevents tissue ischemia; nutrition promotes wound healing; and keeping the skin dry reduces maceration. Massaging bony prominences and using donut-shaped cushions are clinically contraindicated because they impair local capillary perfusion and worsen tissue damage. The nurse should prioritize risk assessment and implement a pressure-relief plan.
在美國臨床環境中，對於高風險病人，除了翻身外，通常會嚴格依照 Braden Scale 評分結果，主動使用氣墊床（Pressure-reducing mattress）或凝膠墊，這些設備在美國醫院屬常規配置。