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傷口護理護理師稽核一位無法自行移動、壓力性損傷高風險個案的照護。哪些處置需要追蹤？請標示會增加組織損傷風險的處置。

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Care area照護領域	Observed action觀察到的處置
Surface床墊表面	Uses a pressure-redistributing mattress matched to client risk使用符合個案風險的壓力重新分配床墊
Skin皮膚	Massages persistent nonblanching redness over the sacrum按摩薦骨處持續性不變白的發紅
Position姿勢	Repositions the client using an individualized schedule依據個別化計畫為個案翻身
Support支撐	Places a ring-shaped cushion directly under the sacrum在薦骨正下方放置甜甜圈式坐墊
Moisture潮濕	Applies a moisture barrier after prompt incontinence care在及時處理失禁後塗抹皮膚保護霜
Transfer轉位	Drags the client upward in bed without a lift sheet在沒有使用移位單的情況下將個案向上拖行
Heels足跟	Floats both heels so they remain free of the mattress讓雙足跟懸空，不接觸床墊
Assessment評估	Inspects skin and pressure points during each care interval在每次照護間隔期間檢查皮膚及受壓點
Hygiene衛生	Leaves a wet brief in place until the next scheduled round將濕尿布留置到下一次預定巡視時間

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