— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位第二級壓瘡的病人。下列哪些傷口護理措施是適當的？（選所有適合的）
A nurse is caring for a client with a pressure injury (stage 2). Which actions are appropriate for wound care management? (Select all that apply.)
- AClean the wound with hydrogen peroxide用雙氧水清潔傷口
- BCover the wound with a transparent film dressing✓ 正解用透明薄膜敷料覆蓋傷口
- CMaintain a moist wound healing environment✓ 正解維持濕潤的傷口癒合環境
- DReposition the client every 2 hours✓ 正解每兩小時重新安置病人體位
- EMassage the skin surrounding the wound按摩傷口周圍的皮膚
— Explanation · 中文詳解 —
第二級壓瘡為真皮層損傷。適當護理包括使用透明敷料（B）保護，並維持濕潤環境（C）促進上皮化。翻身（D）是預防壓瘡惡化之必要行動。過氧化氫（A）會傷害肉芽組織，不建議使用；按摩（E）會造成局部血管受損，嚴禁應用於患部周圍。
Appropriate management for a stage 2 pressure injury includes covering the wound with a transparent film dressing to protect the area and maintain a moist healing environment, which promotes epithelialization. Repositioning the client every 2 hours is essential to relieve pressure and prevent further tissue damage. Hydrogen peroxide and massage are contraindicated as they can damage healthy tissue and cause deeper injury.
✦ 台美臨床差異
美台對於壓瘡分級評估與敷料選用趨於一致，台灣目前積極導入國際傷口護理標準（如 NPIAP 指引）。