— 基本照護與舒適 · MEDIUM · MCQ —
護理師為一位長期臥床的病人制定護理計畫。下列哪項措施對於預防腳跟皮膚受損最有效？
A nurse is planning care for a client who is bedridden. Which intervention is most effective for preventing skin breakdown on the heels?
- APlacing a pillow under the calves to keep heels off the mattress✓ 正解在脛骨下放置枕頭以使腳跟離開床墊
- BEncouraging the client to perform foot exercises鼓勵病人進行足部運動
- CApplying moisturizing lotion to the heels twice daily每天兩次在腳跟上塗抹保濕乳液
- DWrapping the heels with gauze dressings用紗布敷料包裹腳跟
— Explanation · 中文詳解 —
預防腳跟壓瘡的核心原則是「徹底減壓」（Offloading）。使用枕頭墊在小腿下方，使腳跟懸空（Floating heels），能徹底消除腳跟承受的壓力。乳液（C）只能改善乾燥，無法減壓；運動（B）受限於臥床狀況；紗布（D）增加摩擦力且無法減壓。
The core principle for preventing heel pressure ulcers is complete offloading. Placing pillows under the calves so that the heels float ("floating heels") completely eliminates pressure on the heels. Lotion (C) only addresses dryness and provides no pressure relief; exercise (B) is limited by bed rest; gauze (D) increases friction and offers no offloading.
✦ 台美臨床差異
美台臨床皆推廣「懸空足」護理，台灣護理師常使用矽膠腳跟保護墊，效果與枕頭相似。