— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位腳跟有第二期壓傷的病人，下列哪項護理措施合適？
A nurse is caring for a client with a stage 2 pressure injury on the heel. Which intervention is appropriate?
- AApplying a heat lamp to promote circulation使用熱燈以促進血液循環
- BElevating the heels off the mattress using a pillow✓ 正解使用枕頭將腳跟懸空於床墊之上
- CMassaging the skin around the pressure ulcer按摩壓瘡周圍的皮膚
- DCleaning the wound with hydrogen peroxide使用雙氧水清潔傷口
— Explanation · 中文詳解 —
第二期壓傷需減壓以促進組織癒合。懸空腳跟（Offloading）是防止持續性壓迫的黃金標準。按摩壓傷周圍區域可能導致深層組織損傷，熱燈會造成燙傷或過度乾燥，雙氧水則會殺死肉芽組織，均屬不建議的護理行為。
A stage 2 pressure injury requires pressure relief to promote tissue healing. Elevating (offloading) the heels is the gold standard for preventing ongoing pressure. Massaging the area around a pressure injury can cause deep tissue damage; a heat lamp may cause burns or excessive drying; and hydrogen peroxide destroys granulation tissue. None of these is recommended.
✦ 台美臨床差異
美國護理師常依循 Wound Care Nurse 的專家建議選用敷料；台灣則多由基層護理師依醫師處方使用常見敷料。