一位有壓瘡病史的病人，護理師應執行下列哪項措施以維護皮膚完整性？（選所有適合的）
A nurse is caring for a client with a history of pressure injuries. Which of the following interventions should be implemented to maintain skin integrity? (Select all that apply.)
- AReposition the client at least every 2 hours✓ 正解至少每2小時為病人更換體位
- BMassage the reddened bony prominences按摩發紅的骨突處
- CKeep the head of the bed elevated at 45 degrees將床頭抬高至45度
- DUse moisture barrier cream for incontinent clients✓ 正解為失禁病人使用皮膚屏障霜
- EEnsure the heels are floated off the bed surface✓ 正解確保腳跟懸空於床面之上
預防壓瘡的黃金準則包括定時翻身減壓、維持皮膚乾燥與完整。按摩發紅處會導致真皮層受損，應絕對禁止。抬高床頭 30 度以上會增加剪力風險，除非必要，否則應維持平躺或低角度。浮起腳跟能有效避免壓瘡好發部位受壓。
The cornerstones of pressure injury prevention include scheduled repositioning to relieve pressure and maintaining the skin clean and intact. Massaging reddened areas damages the dermis and is absolutely contraindicated. Elevating the head of the bed above 30 degrees increases shear force; unless necessary, the client should remain flat or at a low angle. Floating the heels effectively relieves pressure on a common site of pressure injury.
美國護理師常使用專業減壓墊（Air mattress），台灣常需依靠家屬協力翻身。