— 基本照護與舒適 · MEDIUM · MCQ —
一位病人臥床時感到嚴重足跟疼痛。護理師應採取哪項措施以預防壓瘡形成？
A client reports severe heel pain while resting in bed. Which intervention should the nurse implement to prevent pressure ulcers?
- AMassage the reddened area on the heel按摩足跟上紅腫區域
- BApply a heating pad to increase circulation使用熱敷墊以增加血液循環
- CUse a pillow to elevate the calves to float the heels✓ 正解使用枕頭墊高小腿以懸空足跟
- DPlace a donut-shaped cushion under the heels在足跟下放置甜甜圈形坐墊
— Explanation · 中文詳解 —
減壓是預防足跟壓瘡的黃金標準。使用枕頭抬高小腿，使足跟懸空（Floating heels）能有效消除足跟的壓力點。甜甜圈形枕頭會造成周邊壓力集中，反而加速壞死。按摩患部可能導致組織受損，熱敷則會增加代謝需求且有燙傷風險。
To prevent pressure ulcers, the nurse should use a pillow to elevate the calves, effectively 'floating' the heels to eliminate pressure on the skin. Massaging reddened areas can cause tissue damage, while donut cushions restrict blood flow and heat increases metabolic demand in ischemic tissues.
✦ 台美臨床差異
美國醫院廣泛使用懸空足跟護具（Heel protectors），台灣臨床則多以枕頭運用為主。