— 基本照護與舒適 · MEDIUM · MCQ —
一位腳跟有壓瘡的病人被要求維持側臥姿勢，哪項護理措施對壓力分散最有效？
A client with a pressure ulcer on the heel is prescribed to be placed in a side-lying position. Which nursing intervention is most effective for pressure redistribution?
- APlacing a pillow between the ankles在兩腳踝之間放置枕頭
- BApplying a thick layer of lotion to the heel在腳跟上塗抹厚層乳液
- CUsing a donut-shaped cushion under the heel在腳跟下使用甜甜圈形坐墊
- DSuspending the heels off the bed using a pillow under the calves✓ 正解在小腿下放置枕頭使腳跟懸空
— Explanation · 中文詳解 —
預防腳跟壓瘡的金標準是徹底懸空（offloading）。將小腿下墊枕頭使腳跟懸空，可完全消除局部壓力。環形墊（donut）會阻礙血液循環，反而加重局部缺血；僅在腳踝間放置枕頭無法處理腳跟壓力；塗乳液對減少壓力無實質功效。
To effectively redistribute pressure and promote healing of a heel pressure ulcer, the nurse should suspend the heels off the bed by placing a pillow under the calves. This offloading technique eliminates direct pressure on the affected area, whereas donut cushions restrict blood flow and lotions do not reduce mechanical pressure.
✦ 台美臨床差異
美國臨床極度重視壓力源清除（Offloading），常有標準化減壓裝置（如 Heelbo）；台灣臨床有時仍可見 donut 型氣墊使用，需加強衛教。