護理師為一位尿失禁病人制定護理計畫，哪些措施有助於維護皮膚完整性？（選所有適合的）
Which interventions should the nurse include in the plan of care for a client with urinary incontinence to promote skin integrity? (Select all that apply.)
- AApply a moisture barrier ointment after each cleansing✓ 正解每次清潔後塗抹保濕屏障藥膏
- BCleanse the skin with hot water and strong soap用溫水和強效肥皂清潔皮膚
- CProvide scheduled toileting every 2 hours✓ 正解每 2 小時安排定時如廁
- DUse absorbent incontinence briefs as the primary intervention以吸收性失禁尿布作為主要介入措施
- ECheck the client for wetness at least every 2 hours✓ 正解至少每 2 小時檢查病人是否濕潤
尿失禁病人的皮膚護理重點在於『控濕』與『屏障』。尿液中的氨會改變皮膚 pH 值並破壞保護層，導致失禁性皮炎。塗抹隔離霜（A）能物理性阻隔濕氣與刺激物。定時如廁（C）是主動管理，旨在減少尿液與皮膚接觸的機會。定時檢查（E）確保潮濕能被及時發現並處理。熱水與強效皂（B）會帶走油脂並刺激受損皮膚，應使用溫水與溫和潔膚劑。尿布（D）雖能吸水，但會造成悶熱（微環境惡化），應作為輔助而非首選。護理師的思維應從『發生後清理』轉向『預防發生』，結合行為治療與局部保護，才能有效預防壓力性損傷。
Skin care for the incontinent patient focuses on moisture control and barrier protection. Ammonia in urine alters the skin pH and disrupts the protective layer, leading to incontinence-associated dermatitis. Applying a barrier cream (A) physically blocks moisture and irritants. Scheduled toileting (C) is a proactive management strategy aimed at reducing the contact time between urine and skin. Periodic skin inspections (E) ensure that moisture is detected and managed promptly. Hot water and strong soaps (B) strip skin oils and irritate already damaged skin; warm water and a mild cleanser should be used instead. Although diapers (D) absorb urine, they create a warm, humid environment (worsening the microclimate) and should be used as an adjunct rather than as the first-line measure. The nurse's mindset should shift from "cleaning up after the event" to "preventing it from happening," combining behavioral therapy with local skin protection in order to effectively prevent pressure injuries.
美國臨床高度重視「Incontinence-Associated Dermatitis (IAD)」的專門評估與專用清潔泡沫；台灣則較多使用傳統肥皂水清洗，且對於穿著尿布的依賴度在人力不足時往往較高。