護理師照顧一位有壓瘡病史的病人，哪些照護計畫可促進皮膚完整性？（選所有適合的）
A nurse is caring for a client with a history of pressure ulcers. Which interventions should the nurse include in the care plan to promote skin integrity? (Select all that apply.)
- AApply moisture-barrier cream to bony prominences✓ 正解在骨骼突出處塗抹保濕屏障霜
- BReposition the client every 2 hours✓ 正解每2小時重新安置病人姿勢
- CMassage reddened bony prominences to increase circulation按摩發紅的骨骼突出處以增加血液循環
- DEnsure adequate protein intake✓ 正解確保充足的蛋白質攝取
- EMaintain the head of the bed at a 45-degree angle維持床頭抬高45度角
皮膚完整性的維護依賴減壓、濕度控制與營養。每兩小時翻身是減壓標準，水分保護膜可預防潮濕浸潤，足夠的蛋白質則是修復受損組織的基石。C 選項按摩紅腫部位已證實會傷害脆弱皮膚組織，造成深層受損；E 選項床頭過高會增加薦骨的剪力，應儘量平躺或維持 30 度以下。
Maintenance of skin integrity depends on pressure relief, moisture control, and nutrition. Repositioning every two hours is the standard for pressure relief, moisture barrier creams prevent maceration, and adequate protein intake is the cornerstone of tissue repair. Option C, massaging reddened areas, has been shown to injure already fragile skin tissue and cause deeper damage; option E, elevating the head of the bed to a high angle, increases shear over the sacrum, and the client should remain as flat as possible or with the head of the bed at no more than 30 degrees.
台美臨床對「壓瘡」照護指引高度一致，但美國護理師更常主動會診傷口護理師（WOCN）進行評估。