護理師照護一位有壓瘡病史的病人，應包含哪些護理計畫以預防皮膚進一步破損？（選所有適合的）
A nurse is caring for a client with a history of pressure ulcers. Which interventions should the nurse include in the care plan to prevent further skin breakdown? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時為病人翻身
- BMassage the reddened bony prominences daily每天按摩發紅的骨突處
- CUse pillows to bridge bony prominences✓ 正解使用枕頭墊高骨突處
- DKeep the head of the bed elevated at 45 degrees at all times始終將床頭抬高至 45 度
- EMaintain adequate protein intake in the diet✓ 正解飲食中維持充足的蛋白質攝取
預防壓瘡（Pressure Ulcers）的核心在於解除壓力、促進血液循環、維持皮膚完整性及充足的營養。壓瘡的發生與持續的壓力、剪力（Shear Force）和摩擦力有關，尤其在骨突處（Bony Prominences）。護理措施需著重於減輕這些因素對皮膚的影響。 正確答案 A, C, E 都是預防壓瘡的標準措施。選項 A（每 2 小時翻身）是為了分散壓力點，避免長時間受壓；選項 C（使用枕頭支撐骨突處）能減少骨突處與床面或支架的直接壓力與摩擦；選項 E（確保足夠蛋白質攝取）是維持皮膚修復能力與彈性的關鍵營養素。 錯誤選項 B（每日按摩發紅的骨突處）是錯誤的。發紅代表皮膚已受損，按摩可能加劇皮下組織的損傷，甚至導致血管破裂。正確做法應是減壓，而非按摩。選項 D（床頭抬高 45 度）會增加臀部與薦骨的剪力，加劇壓瘡風險，應維持在 30 度以下，除非有特定醫療需求。
Preventing skin breakdown involves relieving pressure by repositioning the client every 2 hours and using pillows to bridge bony prominences. Adequate protein intake is essential for maintaining skin integrity and promoting tissue repair. Nurses should avoid massaging reddened areas, as this can damage capillaries, and limit head-of-bed elevation to less than 30 degrees to reduce shear forces.