— 生理適應 · EASY · SATA —
護理師對於足跟出現早期壓瘡的病人應執行哪些護理措施？（選所有適合的）
Which of the following interventions should a nurse implement for a client with early stage pressure injury on the heel? (Select all that apply.)
- AMassage the reddened area to promote blood flow按摩發紅區域以促進血液循環
- BPlace a pillow under the calves to keep heels off the bed✓ 正解在小腿下墊枕頭以使足跟離開床面
- CApply a moisture-barrier cream to the skin在皮膚上塗抹防潮屏障乳霜
- DEncourage a diet high in protein and vitamin C✓ 正解鼓勵攝取高蛋白與維生素 C 的飲食
- EApply a hydrocolloid dressing to protect the site✓ 正解在水膠體敷料上保護患處
— Explanation · 中文詳解 —
足跟壓瘡的照護重點在於「減壓」與「營養」。絕對不可按摩紅腫區（Massage），因為這會加重皮下組織的缺血與受損。護理措施應包括：將足跟墊高使其懸空（Offloading），提供高蛋白與維生素 C 以促進傷口修復，並使用水膠體敷料（Hydrocolloid）保護傷口，減少摩擦。評估時應持續使用 Braden Scale 來追蹤風險變化。
Management of early-stage pressure injuries involves offloading pressure from the affected area, such as elevating the heels, and providing adequate nutrition with protein and vitamin C to support tissue repair. Hydrocolloid dressings protect the wound, but massaging reddened areas must be avoided as it causes further tissue damage.