— 基本照護與舒適 · MEDIUM · SATA —
護理師照顧一位足跟壓瘡的病人。下列哪些護理措施應包含在照護計畫中？（選所有適合的）
A nurse is caring for a client with a pressure injury on the heel. Which intervention should the nurse include in the plan of care? (Select all that apply.)
- AUse pillows to elevate the heel off the bed✓ 正解使用枕頭將足跟懸空於床面之上
- BMassage the reddened area around the wound按摩傷口周圍發紅區域
- CImplement a turning schedule every 2 hours✓ 正解實施每兩小時翻身計畫
- DApply a donut-shaped cushion to the heel在足跟處應用甜甜圈形坐墊
- EMaintain adequate protein intake✓ 正解維持充足的蛋白質攝取
— Explanation · 中文詳解 —
足跟減壓的核心是懸空（Offloading）。使用枕頭抬高足跟是最常見做法；定時翻身可減少全身性壓力。按摩紅腫處會傷害皮下組織，圓形墊子（donut cushion）會造成血管壓迫，應禁用。營養（蛋白質）是傷口癒合的關鍵。
Interventions should include elevating the heel off the bed to eliminate pressure, implementing a turning schedule every two hours to reduce sustained tissue stress, and maintaining adequate protein intake to support tissue repair. Massaging reddened areas can cause further tissue damage, and donut-shaped cushions should be avoided as they restrict blood flow.
✦ 台美臨床差異
美國醫院常見使用減壓敷料（如 Mepilex），台灣臨床亦普及，但對營養評估的重視程度在健保給付規範下有時受限。