護理師照護一位有褥瘡風險的病人。護理計畫應包含哪些措施？（選所有適合的）
A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時為病人翻身
- BKeep the skin clean and dry at all times✓ 正解隨時保持皮膚清潔乾燥
- CMassage reddened bony prominences按摩發紅之骨突處
- DElevate the head of the bed to 45 degrees constantly持續將床頭抬高 45 度
- EApply a moisture barrier cream to the skin✓ 正解在皮膚上塗抹濕氣隔離霜
壓力性損傷（Pressure ulcers）預防的核心為減壓（Pressure relief）與維持皮膚屏障。每 2 小時翻身可減少骨突處受壓時間；保持清潔乾燥能避免浸潤（Maceration）導致皮膚破損；保濕或使用隔離霜（Moisture barrier）則可保護表皮免受排泄物刺激。按摩骨突處會導致組織缺血加重，抬高床頭超過 30 度會增加剪力（Shear），均應避免。
The cornerstones of pressure ulcer prevention are pressure relief and maintenance of the skin barrier. Repositioning every 2 hours reduces the duration of pressure over bony prominences; keeping the skin clean and dry prevents maceration and breakdown; and applying a moisture barrier cream protects the skin from irritation by bodily excretions. Massaging bony prominences worsens tissue ischemia, and elevating the head of the bed above 30 degrees increases shearing forces, so both should be avoided.