— 基本照護與舒適 · MEDIUM · MCQ —
護理師照顧一位足跟有第二期壓瘡的病人。下列哪項護理措施是合適的？
A nurse is providing care to a client with a stage 2 pressure injury on the heel. Which intervention is appropriate?
- AApply a heating pad to the wound site在傷口部位應用熱敷墊
- BKeep the heel elevated off the mattress✓ 正解將足跟抬高離開床墊
- CMassage the area firmly to improve circulation用力按摩該區域以促進血液循環
- DUse a donut-shaped cushion to relieve pressure使用甜甜圈形坐墊以減輕壓力
— Explanation · 中文詳解 —
足跟壓瘡的照護關鍵是「完全減壓」。利用軟枕將足跟懸空（offloading）可避免持續受壓導致二期傷口惡化。絕對禁止按摩紅腫部位以免加重微血管損傷。熱敷可能導致傷口燙傷或發炎，甜甜圈坐墊會阻礙局部血流並增加周邊受壓，均為錯誤處置。
The key intervention for a stage 2 pressure injury on the heel is complete offloading to prevent further tissue damage and allow healing. Elevating the heel off the mattress relieves pressure effectively, whereas massaging the area, applying heat, or using donut cushions can compromise circulation or worsen tissue necrosis.
✦ 台美臨床差異
美國護理機構高度依賴傷口造口專科護理師（WOCN）建議；台灣臨床多由一般護理師依據醫囑執行，減壓器材較受限。