— 降低風險 · EASY · MCQ —
護理師照護一位足跟有第二期壓傷的病人。下列哪項護理計畫應包含？
A nurse is caring for a client with a stage 2 pressure injury on the heel. Which intervention should the nurse include in the plan of care?
- AMassage the reddened area to promote blood flow按摩發紅區域以促進血液循環
- BOffload the heel to eliminate pressure✓ 正解減壓足跟以消除壓力
- CApply a heating pad to increase local circulation應用熱敷墊以增加局部循環
- DKeep the wound open to air for faster drying讓傷口開放通風以加速乾燥
— Explanation · 中文詳解 —
壓力性損傷的核心處理原則是減壓（Offloading）。足跟處特別容易受到壓迫，使用保護墊或懸空足跟（Heel suspension）是標準處置。熱敷與按摩會造成組織進一步傷害，而傷口處應保持適度濕潤癒合而非風乾，風乾會導致痂皮形成並阻礙上皮癒合。
Pressure relief is the primary goal for pressure injury healing, so offloading the heel is essential. Massage, heat application, and allowing the wound to dry out can cause further tissue damage or impede proper moist wound healing.
✦ 台美臨床差異
美國護理師常有傷口造口護理師 (WOCN) 協助，台灣多由一般護理師依醫師或專科護理師指示處理。