— 基本照護與舒適 · MEDIUM · SATA —
護理師為足跟褥瘡病人規劃護理計畫，哪些措施適當？（選所有適合的）
A nurse is planning care for a client with pressure ulcers on the heels. Which interventions are appropriate? (Select all that apply.)
- AFloat the heels using pillows✓ 正解使用枕頭使足跟懸空
- BMassage the reddened area按摩發紅區域
- CApply a hydrocolloid dressing✓ 正解貼敷水膠體敷料
- DReposition the client every 2 hours✓ 正解每兩小時重新擺放病人姿勢
- EApply dry heat to the area對該區域施加乾熱
— Explanation · 中文詳解 —
足跟減壓重點為懸空（Floating），避免任何壓迫。按摩紅腫處已證實會傷害脆弱的組織，應禁止。水膠體敷料有助於維持濕潤癒合環境，定期翻身可減少長時間受壓。乾熱則可能造成局部血管擴張或燒燙傷風險，不建議使用。
The focus of heel pressure relief is floating, avoiding any compression. Massaging reddened areas has been shown to damage fragile tissues and is prohibited. Hydrocolloid dressings help maintain a moist healing environment, and regular repositioning reduces prolonged pressure. Dry heat may cause local vasodilation or burns and is not recommended.
✦ 台美臨床差異
美台護理對褥瘡照護指引一致，特別是禁止按摩患部這一觀念在台灣臨床已全面推廣。