護理師照顧一位有壓瘡風險的長者。應將哪些措施納入護理計畫？（選所有適合的）
A nurse is caring for an older adult client who is at risk for pressure ulcers. Which 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
- BMassage reddened bony prominences按摩發紅的骨突處
- CKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- DMaintain the head of the bed at 45 degrees constantly持續將床頭抬高 45 度
- EApply a moisture barrier cream to the sacral area✓ 正解在薦骨部位塗抹保濕隔離霜
預防壓瘡的核心是減壓、保持皮膚完整性及維持乾燥。每 2 小時翻身可減少長時間組織壓迫。保持皮膚清潔乾燥可預防浸潤。使用保護膏能隔離尿液與糞便對皮膚的損害。按摩紅腫處（B）會造成組織損害，抬高床頭超過 30 度（D）會增加剪力風險，應避免。
The core of pressure ulcer prevention is offloading pressure, maintaining skin integrity, and keeping the skin dry. Repositioning every 2 hours reduces prolonged tissue pressure. Keeping the skin clean and dry prevents maceration. A barrier cream isolates the skin from urine and stool, preventing damage. Massaging reddened areas (option B) causes tissue damage, and elevating the head of the bed above 30 degrees (option D) increases shearing force; both should be avoided.
無顯著差異，皆遵循 Braden Scale 進行壓瘡風險評估與預防。