— 基本照護與舒適 · HARD · SATA —
護理師為一位腳跟二級壓傷的病人設計護理計畫，應包含哪些措施？（選所有適合的）
A nurse is developing a plan of care for a client with stage 2 pressure injury on the heel. Which interventions should the nurse include? (Select all that apply.)
- AElevate the heels off the bed using a pillow✓ 正解使用枕頭將腳跟懸空於床面之上
- BMassage the reddened area to improve circulation按摩發紅區域以改善循環
- CApply a hydrocolloid dressing to the site✓ 正解在患處塗佈水膠體敷料
- DIncrease protein intake in the diet✓ 正解增加飲食中的蛋白質攝取
- EReposition the client every 4 hours每4小時為病人翻身一次
— Explanation · 中文詳解 —
二級壓傷（Stage 2 pressure injury）涉及表皮與真皮層的損傷。護理計畫的核心在於減壓（Offloading）、營養支持與適當的傷口護理。腳跟為骨突處，最易發生壓傷，必須懸空處理。營養方面，高蛋白飲食能促進膠原蛋白合成與組織修復。敷料選擇上，水膠體（Hydrocolloid）能提供濕潤癒合環境。禁止按摩是為了防止對已受損的毛細血管造成進一步破壞。
Management of a stage 2 pressure injury involves offloading pressure, providing moist wound healing, and ensuring adequate nutrition. Heels should be elevated to prevent contact with the bed, and hydrocolloid dressings help maintain a moist environment. High protein intake supports tissue repair, while massage is contraindicated to avoid further tissue damage.