護理師照顧長期臥床病人。下列哪些措施有助於預防壓瘡？（選所有適合的）
A nurse is caring for a client who is bedbound. Which actions should the nurse perform to prevent pressure injuries? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時為病人翻身
- BMassage reddened bony prominences按摩發紅的骨突處
- CKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- DUse a foam pillow to bridge the heels✓ 正解使用泡沫枕墊高腳跟
- EElevate the head of the bed to 45 degrees for long periods長時間將床頭抬高 45 度
預防壓瘡的核心是減壓與保持皮膚完整性。每兩小時翻身、保持皮膚乾爽清潔、以及使用軟墊抬高足跟防止腳跟壓瘡皆為標準程序。選項 B 為錯誤觀念，按摩紅腫部位會造成皮下組織損傷；選項 E 錯誤，超過 30 度的床頭角度會增加骶骨的剪力與摩擦力，加速皮膚破損。
The core of pressure injury prevention is pressure relief and maintenance of skin integrity. Repositioning every two hours, keeping the skin clean and dry, and using cushions to elevate the heels to prevent heel pressure ulcers are all standard practices. Option B reflects a misconception, since massaging reddened areas can damage the underlying subcutaneous tissue; option E is incorrect because a head-of-bed angle greater than 30 degrees increases shear and friction at the sacrum, accelerating skin breakdown.
美台皆採用 Braden Scale 進行壓瘡風險評估，但在台灣，床邊翻身紀錄表與減壓輔具的使用率提升中，護理師需更主動引導家屬協助。