— 基本照護與舒適 · HARD · MCQ —
病人被診斷為二級壓瘡，下列哪項護理措施最合適？
A client is diagnosed with a stage 2 pressure ulcer. What is the most appropriate nursing intervention for this wound?
- AApply a heating pad to increase blood flow放置熱敷墊以增加血液循環
- BClean the wound with sterile normal saline✓ 正解以無菌生理食鹽水清潔傷口
- CMassage the skin surrounding the ulcer按摩潰瘍周圍的皮膚
- DKeep the wound open to the air to dry讓傷口開放通風以保持乾燥
— Explanation · 中文詳解 —
二級壓瘡涉及表皮與真皮層受損。生理食鹽水清潔是標準護理，減少感染風險。按摩周邊會導致深層組織損傷（剪力），應避免；加熱墊容易造成燙傷；保持傷口濕潤癒合（moist wound healing）優於乾燥結痂，故不建議開放傷口乾燥。
A stage 2 pressure ulcer involves damage to the epidermis and dermis. Cleansing with normal saline is the standard of care and reduces infection risk. Massaging the surrounding skin can cause deep tissue injury (shear) and should be avoided; heating pads can cause burns; moist wound healing is preferred over dry eschar formation, so leaving the wound open to air to dry is not recommended.
✦ 台美臨床差異
美國護理師常受傷口造口護理師（WOCN）指導，台灣則多由臨床護理師依醫師醫囑換藥，但評估技巧需進一步精進。