— 基本照護與舒適 · MEDIUM · SATA —
護理師評估一位有皮膚破損風險的病人。下列哪些措施是適當的護理介入？（選所有適合的）
A nurse is assessing a client who has a risk for skin breakdown. Which actions are appropriate interventions? (Select all that apply.)
- AKeep the heels elevated using a pillow✓ 正解使用枕頭墊高腳跟
- BApply a moisture barrier cream to the sacral area✓ 正解在薦骨部位塗抹濕氣屏障乳霜
- CEncourage a diet high in protein and vitamin C✓ 正解鼓勵攝取高蛋白及維生素 C 的飲食
- DMassaging areas of skin redness to improve blood flow按摩皮膚發紅區域以改善血液循環
- ELimit the use of incontinence briefs to only when necessary✓ 正解僅在必要時使用失禁墊
— Explanation · 中文詳解 —
預防壓力性損傷（Pressure injury）需要綜合性的護理策略。解除壓力（抬高腳跟）、皮膚屏障保護（骶骨處使用乳霜）、營養支持（蛋白質與維生素 C 是組織修復的關鍵）以及減少潮濕（減少尿布使用）皆是實證醫學支持的預防措施。特別注意，按摩發紅部位是錯誤的，因為這會對已經受損的微血管造成進一步破壞。
Pressure-injury prevention combines pressure offloading (heel elevation off the bed), moisture barrier protection at the sacrum, nutritional support (protein, vitamin C for collagen synthesis), and reducing moisture/incontinence exposure. Massaging reddened (erythematous) areas is contraindicated because it further damages already-fragile microvasculature and tissue.