— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位腳跟有第二期壓力損傷的病人，下列何項措施適當？
A nurse is caring for a client with a Stage 2 pressure injury on the heel. Which intervention is appropriate for this client?
- AApply a tight dressing to ensure protection from friction施加緊繃的敷料以確保摩擦保護
- BMassage the area around the injury to stimulate blood flow按摩受傷區域周圍以刺激血液循環
- CClean the wound with hydrogen peroxide twice daily每日兩次以雙氧水清潔傷口
- DElevate the heels off the bed using a pillow under the calves✓ 正解在小腿下方墊枕頭使腳跟懸空
— Explanation · 中文詳解 —
第二期壓傷表皮層受損，護理重點在於減壓（Offloading）。將腳跟懸空（懸空足）是最有效的減壓方式。按摩傷口周圍反而會導致微血管損傷；過氧化氫具有細胞毒性，會抑制肉芽組織生長；過緊的敷料會引發缺血，損害癒合過程。目標是提供濕潤癒合環境並維持血液循環。
Stage II pressure injury involves damage to the epidermis, and nursing care focuses on offloading. Suspending the heels (heel suspension) is the most effective offloading method. Massaging around the wound damages capillaries; hydrogen peroxide is cytotoxic and inhibits granulation tissue growth; overly tight dressings cause ischemia and impair healing. The goal is to provide a moist healing environment and maintain circulation.
✦ 台美臨床差異
美國對於壓傷分級與傷口管理有嚴謹的 WOCN 指引，台灣則多依據各醫院傷口照護小組的 Protocol。