— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位足跟有第二級壓傷的病人，哪些護理措施是恰當的？（選所有適合的）
A nurse is caring for a client with a Stage 2 pressure injury on the heel. Which nursing interventions are appropriate? (Select all that apply.)
- AElevate the heels off the bed using a pillow under the calves✓ 正解在小腿下方墊枕頭使足跟懸空
- BMassage the reddened area to promote blood flow按摩發紅區域以促進血液循環
- CApply a hydrocolloid dressing to protect the wound✓ 正解敷貼親水性敷料以保護傷口
- DReposition the client every 2 hours✓ 正解每 2 小時重新定位個案
- EMassage the bony prominences to prevent further damage按摩骨突處以預防進一步損傷
— Explanation · 中文詳解 —
第二級壓傷涉及真皮層受損，應採取減壓策略。抬高足跟避免直接接觸床面（off-loading）是標準動作；敷料可促進癒合；定時翻身減壓。切記不可按摩發紅區域（B、E），按摩會損傷皮下組織，造成微血管破裂，加劇組織損傷。
A Stage 2 pressure injury involves damage to the dermis, and pressure-relief strategies should be used. Elevating the heels off the bed (off-loading) is a standard intervention; dressings promote healing; and scheduled repositioning relieves pressure. Reddened areas (Options B and E) must never be massaged, as massage damages subcutaneous tissue, rupturing capillaries and worsening tissue injury.
✦ 台美臨床差異
美國護理師依據 Braden Scale 決定翻身頻率，台灣常以兩小時為統一標準，缺乏彈性調整機制。