— 基本照護與舒適 · HARD · MCQ —
護理師照顧一位足跟有第二期壓傷的病人，哪項介入措施最能促進傷口癒合？
A nurse is caring for a client with a stage 2 pressure injury on the heel. Which intervention is most appropriate for promoting healing?
- AMassage the reddened area to improve blood flow按摩發紅區域以改善血液循環
- BInstruct the client to walk more to stimulate tissue growth指示病人多走路以刺激組織生長
- CKeep the heel elevated off the bed surface using a pillow under the calf✓ 正解使用枕頭墊在小腿下方，使腳跟懸空於床面之上
- DApply a heating pad to the area to increase circulation在該區域應用熱敷墊以增加循環
— Explanation · 中文詳解 —
足跟是壓傷高風險區，最有效的減壓方式是讓足跟懸空（off-loading），將枕頭墊在小腿下方，確保足跟不接觸床面。A選項按摩會損傷脆弱組織；C熱敷可能造成皮膚灼傷，且會增加局部代謝需求；D過度行走會增加局部壓力不利癒合。
Off-loading the heel is the gold standard for managing pressure injuries, achieved by placing a pillow under the calf to keep the heel suspended and free from contact with the bed surface. Massaging the area can damage fragile tissues, walking increases harmful friction and pressure, and heating pads pose a burn risk on insensate skin.
✦ 台美臨床差異
美國臨床多使用專用減壓鞋（Off-loading boots），台灣常見仍使用枕頭輔助。