一位腳跟有第二級壓瘡的病人需更換敷料。下列哪項護理措施最能促進癒合？
A client with stage II pressure injury on the heel requires dressing changes. Which intervention is most appropriate for promoting healing?
- AMassage the reddened skin around the injury to stimulate blood flow按摩受傷周圍發紅的皮膚以促進血液循環
- BElevate the heels off the mattress using a pillow✓ 正解使用枕頭將腳跟墊高使其懸空
- CClean the wound with hydrogen peroxide以雙氧水清潔傷口
- DApply a dry sterile gauze directly to the wound直接在傷口上覆蓋乾燥無菌紗布
第二級壓瘡（stage II pressure injury）的護理核心在於減輕壓力並提供促進癒合的傷口環境。第二級壓瘡涉及部分真皮層損失，傷口床呈紅粉色，可能伴隨完整或破裂的血清水泡。為了促進癒合，首要任務是移除造成壓力的根本原因，並避免任何可能損害新生組織的介入措施。 正確的護理措施應著重於保護受損區域、促進組織再生。將腳跟墊高使其懸空，能有效消除持續性壓力，這是壓瘡癒合的關鍵步驟。同時，避免使用具有細胞毒性的清潔劑或乾燥敷料，以維持傷口濕潤環境，支持肉芽組織形成和上皮化。
The core of nursing care for stage II pressure injury is to relieve pressure and provide a wound environment that promotes healing. A stage II pressure injury involves partial-thickness loss of the dermis, presenting as a red-pink wound bed, possibly with an intact or ruptured serum-filled blister. To promote healing, the primary task is to remove the underlying cause of pressure and avoid any interventions that may damage newly forming tissue. Appropriate nursing measures should focus on protecting the affected area and promoting tissue regeneration. Elevating the heels off the mattress effectively eliminates sustained pressure, which is the key step in pressure injury healing. At the same time, cytotoxic cleansers and dry dressings should be avoided to maintain a moist wound environment that supports granulation tissue formation and epithelialization.
台美在壓瘡護理原則上高度一致，皆強調減壓、維持濕潤傷口環境、避免細胞毒性物質。雖然敷料選擇或品牌可能因地區供應而異，但核心的護理策略和安全指引是全球通用的標準。例如，按摩發紅皮膚在兩地臨床實踐中均被嚴格禁止。