— 基本照護與舒適 · HARD · MCQ —
護理師照護一位第二期壓瘡病人。應使用什麼敷料？
A nurse is caring for a client with a stage 2 pressure injury. What should the nurse apply?
- ASurgical packing手術填塞
- BDry gauze乾紗布
- CHydrocolloid dressing✓ 正解水膠體敷料
- DNone, leave it open to air不適用，使其暴露於空氣中
— Explanation · 中文詳解 —
第二期壓瘡（Stage 2 pressure injury）涉及表皮與真皮層的部分厚度缺失，傷口呈現淺粉紅色潰瘍或水泡。照護目標是維持傷口濕潤環境（Moist wound healing），以促進上皮再生。水膠體敷料（Hydrocolloid）能提供封閉環境、吸收少量滲出液並減少疼痛，是標準護理處置。
A Stage 2 pressure injury is partial-thickness loss of skin involving the epidermis and dermis, presenting as a shallow open ulcer or fluid-filled blister. The goal is to maintain a moist wound healing environment to promote epithelialization. Hydrocolloid dressings provide an occlusive moist environment, absorb minimal exudate, and reduce pain. Dry gauze adheres to the wound, surgical packing is for deep tunneling wounds, and leaving the wound open slows healing.