— 基本照護與舒適 · MEDIUM · MCQ —
護理師在評估一位腳後跟有二級壓瘡的病人。下列哪項措施應被執行？
A nurse is assessing a client with a Stage 2 pressure injury on the heel. Which intervention should the nurse implement?
- AKeep the heel in direct contact with the mattress保持腳跟直接接觸床墊
- BMassage the area to increase circulation按摩該區域以增加血液循環
- CApply a hydrocolloid dressing to protect the site✓ 正解塗佈水膠體敷料以保護患處
- DClean the wound with hydrogen peroxide以雙氧水清潔傷口
— Explanation · 中文詳解 —
二級壓瘡涉及表皮與真皮層部分損失。水膠體敷料（Hydrocolloid）能提供濕潤環境並保護傷口免受摩擦及污染。按摩會造成深層組織損傷，雙氧水具細胞毒性會延遲癒合，腳跟必須懸空（offloading）以防壓迫加重。
A stage 2 pressure injury involves partial-thickness loss of skin, so a hydrocolloid dressing is appropriate to maintain a moist healing environment and protect the wound from friction and contamination. Heels must be offloaded to relieve pressure, and massaging reddened areas or using hydrogen peroxide should be avoided as these actions can cause deeper tissue trauma or delay healing.
✦ 台美臨床差異
美國護理師對壓瘡的分級與敷料選擇有高度專業權限；台灣多依賴醫師開立之敷料處方，但護理師在傷口評估與照護建議上仍扮演關鍵角色。