— 生理適應 · EASY · MCQ —
一位四級壓瘡病患進行換藥，下列哪項護理措施是正確的？
A client with stage IV pressure ulcer is receiving a dressing change. Which nursing action is correct?
- AClean from the center of the wound outward✓ 正解從傷口中心向外清潔
- BClean the wound with hydrogen peroxide使用過氧化氫清潔傷口
- CPack the wound tightly with dry gauze用乾紗布緊密填塞傷口
- DIrrigate the wound with a 30 mL syringe and 19-gauge needle使用30 mL注射器和19-gauge針頭沖洗傷口
— Explanation · 中文詳解 —
四級壓瘡（Stage IV pressure ulcer）涉及深層組織受損，傷口照護須遵循「清潔、填充、覆蓋」原則。清潔時必須由乾淨處向污染處（由中心向外）進行，以避免將傷口邊緣的細菌帶入傷口中心。灌洗壓力必須適中，過大壓力會損傷肉芽組織，過小則無法移除壞死組織。填充須保持濕潤且鬆散，過緊填充會造成組織缺血壞死。
A Stage IV pressure ulcer involves deep tissue damage, and wound care follows the principle of cleanse, pack, and cover. Cleansing should proceed from clean to dirty (center outward) to avoid carrying bacteria from the wound edges into the center. Irrigation pressure must be moderate: too high damages granulation tissue, and too low fails to remove necrotic tissue. Packing must be moist and loose; packing too tightly causes ischemic tissue necrosis.