一位病人的腳跟處有第二期壓傷，護理師應包含下列哪項護理介入？
A client has a stage 2 pressure injury on the heel. Which intervention should the nurse include in the plan of care?
- AMassage the reddened area to promote circulation按摩發紅區域以促進血液循環
- BApply a heating pad to the area to increase blood flow在患部敷熱墊以增加血液流動
- 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 mattress using a pillow✓ 正解使用枕頭將腳跟懸空於床墊之上
第二期壓傷（Stage 2 pressure injury）涉及表皮與真皮層的損傷，照護原則是「減壓（Offloading）」。將腳跟懸空（Elevating heels）是預防壓迫加重最直接且有效的方法。按摩紅腫處會造成皮下微血管損傷，絕對禁止；加熱墊會導致燙傷與組織受損；雙氧水對肉芽組織具細胞毒性，會抑制癒合，臨床已不再用於傷口清潔。
A Stage 2 pressure injury involves loss of the epidermis and dermis, and the care principle is offloading. Elevating the heels off the bed is the most direct and effective way to prevent worsening pressure. Massaging reddened areas is absolutely contraindicated because it damages subcutaneous capillaries; heating pads cause burns and tissue injury; and hydrogen peroxide is cytotoxic to granulation tissue and inhibits healing, so it is no longer used clinically for wound cleansing.