護理師針對有壓瘡風險的病人制定護理計畫，應包含哪些措施？（選所有適合的）
A nurse is planning care for a client who is at risk for developing pressure injuries. Which actions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client every 4 hours每4小時為病人重新擺放姿勢
- BKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- CApply cornstarch to skin folds在皮膚摺皺處塗抹玉米澱粉
- DUse a foam mattress overlay✓ 正解使用泡棉床墊覆蓋物
- EMaintain adequate protein and caloric intake✓ 正解維持充足的蛋白質與熱量攝取
預防壓瘡的核心在於減少壓力、保持皮膚清潔乾爽及營養支持。翻身頻率通常為每 2 小時一次（A錯誤）；玉米粉可能阻塞毛孔或堆積（C錯誤）。保持皮膚乾爽、使用減壓墊及攝取蛋白質以促進組織修復是標準護理手段。
The core of pressure injury prevention is reducing pressure, keeping skin clean and dry, and providing nutritional support. The repositioning frequency should generally be every 2 hours (A is incorrect); cornstarch may clog pores or cake on skin (C is incorrect). Keeping the skin dry, using pressure-redistribution surfaces, and ensuring adequate protein intake to promote tissue repair are standard nursing interventions.
美國護理強調 Braden Scale 的每日評估；台灣臨床亦採用 Braden Scale，但在執行翻身頻率上可能因人力比限制而產生落差。