護理師照護一位骶骨有第二期壓瘡的病人，護理計畫中應包含哪些措施？（選所有適合的）
A nurse is caring for a client with a Stage 2 pressure ulcer on the sacrum. Which interventions should the nurse include in the care plan? (Select all that apply.)
- ATurn and reposition the client every 2 hours✓ 正解每兩小時為病人翻身並調整姿勢
- BMassage the reddened skin areas around the ulcer按摩潰瘍周圍發紅的皮膚區域
- CEnsure adequate protein and caloric intake✓ 正解確保攝取足夠的蛋白質和熱量
- DApply a hydrocolloid dressing to the wound✓ 正解在傷口上應用水膠體敷料
- EClean the wound with hydrogen peroxide用雙氧水清潔傷口
第二期壓瘡表現為表皮與部分真皮受損。護理重點在於減壓、營養補充與濕性癒合環境。翻身可減壓，營養是組織修復核心，水膠體敷料能維持濕潤癒合環境。按摩紅腫處會造成深層組織損傷（禁止），雙氧水會破壞新生的肉芽組織（禁止）。
A stage 2 pressure injury involves damage to the epidermis and part of the dermis. Nursing care focuses on pressure relief, nutritional support, and a moist wound-healing environment. Repositioning relieves pressure, nutrition is the core of tissue repair, and a hydrocolloid dressing maintains a moist healing environment. Massaging reddened areas can cause deeper tissue damage (prohibited), and hydrogen peroxide destroys newly formed granulation tissue (prohibited).
美國護理師常與造口傷口治療師 (WOCN) 合作照護，台灣則常見由醫師開立特定敷料給予。