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一位老年人臥床且失禁。在基本皮膚照護中，護理師發現薦骨處皮膚完整，但有局部無法變白的紅斑。完成個別化的皮膚完整性計畫。

Drop-down Rationale

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The nurse should first ::선택::massage the reddened area and reassess at the end of the weekwait to document the finding until the skin opensdocument and report a stage 1 pressure injury and reassess the full skin and risk profileclassify the finding as normal aging because the skin is intact. The nurse should then ::선택::use the same fixed turning interval for every client regardless of toleranceoffload the area using an individualized repositioning plan and an appropriate pressure-redistributing surfacekeep the client continuously supine so the sacrum can be observedplace a ring-shaped cushion directly under the reddened sacrum and ::선택::cleanse gently after incontinence, manage moisture, apply a barrier product as planned, and reassessscrub the skin vigorously after each incontinent episodeuse absorbent briefs alone without scheduled skin inspectionapply heat over the erythema to increase local sensation.

護理師應先 ::선택::按摩發紅區域，並於週末重新評估等到皮膚破損再記錄此發現記錄並通報第 1 期壓力性損傷，並重新評估全身皮膚與風險概況因皮膚完整而將此發現歸類為正常老化。接著護理師應 ::선택::對每位個案使用相同的固定翻身間隔，不論耐受度如何使用個別化的翻身計畫與適當的壓力重新分佈支撐面來解除該區域壓力讓個案持續平躺，以便觀察薦骨處將環形坐墊直接置於發紅的薦骨下方 並 ::선택::失禁後溫和清潔、處理濕氣、依計畫使用皮膚隔離產品，並重新評估每次失禁後用力擦洗皮膚僅使用吸收性尿布，不安排皮膚檢查在紅斑處熱敷以增加局部感覺。

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