一位長期臥床病人骶骨處產生第一級壓瘡，護理師應包含哪些護理計畫？（選所有適合的）
A nurse is caring for an immobile client who has developed stage 1 pressure ulcers on the sacrum. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- ATurn and reposition the client every 2 hours✓ 正解每 2 小時為病人翻身並重新定位
- BMassage the reddened area to promote blood circulation按摩發紅區域以促進血液循環
- CKeep the sacral area clean and dry✓ 正解保持薦骨區域清潔乾燥
- DUse a pressure-relieving mattress overlay✓ 正解使用減壓床墊覆蓋
- EApply a transparent film dressing to the area✓ 正解在該區域貼上透明薄膜敷料
針對第一級壓瘡（Pressure Ulcer Stage 1），護理核心在於消除導致組織缺血的壓力因子，並維持皮膚屏障完整性。第一級壓瘡表現為皮膚發紅但表皮未破損，此時若施加機械性壓力或摩擦，極易進展為深層組織損傷。正確介入包含定時翻身以重新分佈壓力、使用輔助器具減壓、維持薦骨部位乾燥清潔，以及使用透氣敷料（如透明薄膜）保護皮膚對抗剪力。臨床思路應優先考慮預防惡化，並確保營養評估與護理計畫的連貫性。
Interventions for stage 1 pressure ulcers focus on relieving pressure and protecting the skin barrier without causing further damage. The nurse should reposition the client every two hours, keep the area clean and dry, use pressure-relieving devices, and apply transparent film dressings to reduce friction. Massaging reddened areas is contraindicated as it can cause deep tissue injury.
台美臨床對於壓瘡分級與命名已統一遵循 NPIAP 指引，不再稱為「壓瘡」而是「壓力性損傷（Pressure Injury）」。台灣臨床偶有護理人員習慣按摩紅斑處，但在美國 NCLEX 考試中，按摩紅斑處為絕對錯誤選項。