護理師照顧一位長期臥床的病人，下列哪些措施有助於預防壓力性損傷？（選所有適合的）
A nurse is caring for a client who is immobile. Which of the following nursing interventions should the nurse include in the plan of care to prevent pressure ulcers? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每2小時重新安置病人姿勢
- 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
- DElevate the head of the bed to 45 degrees將床頭抬高至45度
- EUse pillows to bridge bony prominences✓ 正解使用枕頭墊起骨突處
預防褥瘡的三大支柱：壓力減輕、保持皮膚乾爽、維持正確體位。每兩小時翻身是黃金準則，利用枕頭墊高骨突處（如足踝、膝蓋）可減少受壓。按摩紅腫處已證實會傷害皮下組織，應避免；床頭抬高 30 度以上會增加剪力，應儘量避免長期過高。
Preventing pressure ulcers requires reducing pressure, maintaining skin integrity, and ensuring proper body alignment. Repositioning the client every 2 hours relieves pressure on bony prominences, while using pillows to bridge these areas further distributes weight. Keeping the skin clean and dry prevents maceration, which weakens the skin barrier. Conversely, massaging reddened areas causes tissue trauma, and elevating the head of the bed beyond 30 degrees increases the risk of shear forces.
台灣醫院評估褥瘡風險多使用 Braden Scale，執行翻身與減壓墊的使用與美國一致。