— 基本照護與舒適 · HARD · SATA —
護理師為長期臥床病人進行皮膚評估，發現薦骨有第一級壓瘡。下列哪些護理措施應納入照護計畫？（選所有適合的）
A nurse is performing a skin assessment on an immobile client and notes a Stage 1 pressure injury on the sacrum. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每兩小時為病人翻身
- BMassage the reddened area to improve circulation按摩發紅區域以改善循環
- CApply a hydrocolloid dressing to protect the skin✓ 正解敷用水膠體敷料以保護皮膚
- DKeep the sacral area clean and dry✓ 正解保持薦骨區域清潔乾燥
- EIncrease protein and calorie intake✓ 正解增加蛋白質和熱量攝取
— Explanation · 中文詳解 —
第一級壓瘡（Stage 1 pressure injury）的護理目標是防止組織進一步受損。護理重點在於減壓、保濕與營養支持。每兩小時翻身可持續減壓；水膠體敷料提供保護屏障；保持皮膚清潔乾燥可減少浸潤風險；充足的蛋白質與熱量則是組織修復的基礎。按摩紅腫處會破壞脆弱的皮下微血管，應絕對禁止，這是臨床護理中必須傳達的觀念。
Management of a Stage 1 pressure injury focuses on preventing further tissue damage through pressure redistribution, moisture control, and nutritional support. Repositioning every two hours, applying protective dressings, and maintaining clean, dry skin are essential interventions. Massage of the reddened area is contraindicated as it may cause additional deep tissue injury.