護理師照護一位有壓瘡風險的病人，應包含哪些護理計畫？（選所有適合的）
A nurse is caring for a client who has a risk for pressure ulcers. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client at least every two hours✓ 正解至少每兩小時為個案翻身
- BKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- CMassage the reddened bony prominences按摩發紅的骨突部位
- DUse a foam mattress overlay or pressure-relieving device✓ 正解使用泡棉床墊覆蓋物或減壓裝置
- EElevate the head of the bed to 45 degrees constantly持續將床頭抬高至45度
核心概念：預防壓瘡（pressure ulcer）的關鍵護理措施。 為何正確答案對： A. 每至少兩小時翻身一次（Reposition the client at least every two hours）：長時間的局部壓力是壓瘡形成的主要原因。透過定時翻身（repositioning），可以分散身體各部位的壓力，促進血液循環，預防因持續受壓而導致的組織缺氧和損傷。每兩小時翻身是預防壓瘡的標準建議。 B. 保持皮膚清潔乾燥（Keep the skin clean and dry）：潮濕的皮膚（moisture）會軟化，增加皮膚的脆弱性，使其更容易受到摩擦和壓力的傷害。保持皮膚清潔（clean）和乾燥（dry）有助於維持皮膚的完整性，預防壓瘡。 D. 使用氣墊床或減壓裝置（Use a foam mattress overlay or pressure-relieving device）：對於有壓瘡風險的病人，使用特殊的壓力分散床墊（pressure-relieving mattress）或床墊覆蓋物（overlay）可以顯著減輕身體與床鋪之間的壓力，特別是骨突部位（bony prominences），是預防壓瘡的重要措施。 為何其他選項錯： C. 按摩紅腫的骨突部位（Massage the reddened bony prominences）：雖然按摩可以促進血液循環，但對於已經出現紅腫的骨突部位，進行按摩可能會對脆弱的皮下組織造成進一步的損傷（如剪力、摩擦），可能加劇組織破壞，甚至導致壓瘡的形成。早期發現的紅腫應記錄並減壓，而非按摩。 E. 將床頭抬高至 45 度角（Elevate the head of the bed to 45 degrees constantly）：將床頭抬高超過 30 度，尤其是在 45 度角，會增加病人身體與床鋪之間的滑動力（shear force），尤其是在骨盆區域。這種剪力會損害深層組織，是壓瘡形成的重要危險因子。因此，應盡量將床頭抬高角度維持在 30 度以內，除非有特定臨床需要（如呼吸窘迫）。 臨床思路：此題考量「基本照護與舒適」（Basic Care & Comfort）領域，重點在於預防壓瘡。壓瘡的預防是一個多面向的策略，包括減壓、保持皮膚完整、改善營養和促進循環。護理師應根據病人的風險評估結果，制定個人化的預防計畫，並確實執行。
Core concept: Key nursing interventions for the prevention of pressure ulcers. Why the correct answers are correct: A. Reposition the client at least every two hours: Prolonged localized pressure is the primary cause of pressure ulcer formation. Scheduled repositioning distributes pressure across different body areas, promotes blood circulation, and prevents tissue hypoxia and injury caused by sustained pressure. Repositioning every two hours is the standard recommendation for pressure ulcer prevention. B. Keep the skin clean and dry: Moisture softens the skin, increases its fragility, and makes it more susceptible to friction and pressure damage. Keeping the skin clean and dry helps maintain skin integrity and prevent pressure ulcers. D. Use a foam mattress overlay or pressure-relieving device: For patients at risk of pressure ulcers, the use of specialized pressure-relieving mattresses or overlays can significantly reduce pressure between the body and the bed, particularly over bony prominences, and is an important measure for pressure ulcer prevention. Why the other options are wrong: C. Massage the reddened bony prominences: Although massage may promote circulation, applying massage to bony prominences that already show redness can cause further damage to the fragile subcutaneous tissue (such as shear and friction), potentially aggravating tissue destruction and even contributing to pressure ulcer formation. Early redness should be documented and offloaded rather than massaged. E. Elevate the head of the bed to 45 degrees constantly: Elevating the head of the bed above 30 degrees, especially to 45 degrees, increases the shear force between the patient's body and the bed surface, particularly in the pelvic region. This shear force damages deep tissue and is an important risk factor for pressure ulcer formation. Therefore, the head of the bed should be maintained at 30 degrees or less whenever possible, unless there is a specific clinical indication (such as respiratory distress). Clinical reasoning: This question addresses the "Basic Care and Comfort" domain, focusing on pressure ulcer prevention. Prevention of pressure ulcers is a multifaceted strategy that includes offloading, maintaining skin integrity, optimizing nutrition, and promoting circulation. The nurse should develop an individualized prevention plan based on the patient's risk assessment and ensure it is carried out reliably.