護理師照顧一位足跟皮膚破損的高齡病人，應採取哪些措施？（選所有適合的）
A nurse is caring for an older adult client with skin breakdown on the heels. Which interventions should the nurse implement? (Select all that apply.)
- AElevate the heels off the mattress using a pillow✓ 正解使用枕頭將足跟懸空於床墊之上
- BApply a donut-shaped cushion under the heels在足跟下放置甜甜圈形坐墊
- CMassage the reddened area to improve blood circulation按摩發紅區域以改善血液循環
- DPerform passive range-of-motion exercises as tolerated✓ 正解在病人耐受範圍內執行被動關節活動範圍運動
- EAssess nutritional status and protein intake✓ 正解評估營養狀況和蛋白質攝取量
皮膚破損或壓瘡照護重點在於「減壓」（Pressure relief）。足跟是壓瘡高風險區，應使用軟墊將足跟完全懸空（Offloading），避免與床墊直接接觸。Donut 型軟墊反而會因為阻礙周圍血流而加重缺血，應避免使用。被動關節活動（ROM）能改善全身血液循環與組織健康，適當的蛋白質與營養攝取則是組織修復的基礎。
Skin breakdown and pressure injury care center on pressure relief. The heel is a high-risk site for pressure injury, so a soft support should be used to completely offload the heel from the mattress and avoid direct contact. A donut-shaped cushion is contraindicated because it impedes circulation in the surrounding tissue and worsens ischemia. Passive range-of-motion exercises improve systemic circulation and tissue health, and adequate protein and nutritional intake is the foundation for tissue repair.