— 基本照護與舒適 · EASY · MCQ —
護理師照護一位無法行走的病人。哪項措施對於預防足跟壓力性損傷最有效？
A nurse is caring for a client who is non-ambulatory. Which action is most effective in preventing pressure injuries on the heels?
- AUse pillows to elevate the lower legs✓ 正解使用枕頭墊高小腿
- BKeep the bed in a Trendelenburg position保持床單於 Trendelenburg 姿勢
- CApply moisturizing lotion frequently經常塗抹潤膚乳液
- DMassage the heels daily每天按摩足跟
— Explanation · 中文詳解 —
對於長期臥床者，足跟是壓力性損傷的高發區。使用枕頭抬高小腿，目的是讓足跟完全懸空（off-loading），這是降低壓力的最有效方式。按摩皮膚易損傷軟組織，乳液無法取代壓力的移除，Trendelenburg 姿勢會增加頭部與上半身負荷，不適合預防壓力。
Elevating the lower legs with pillows is the most effective action because it completely off-loads pressure from the heels, which are highly susceptible to pressure injuries in non-ambulatory clients. Massaging reddened areas can cause further tissue damage, while lotions do not relieve pressure. Trendelenburg positioning increases bodily stress and is not indicated for pressure injury prevention.
✦ 台美臨床差異
台灣病房常使用氣墊床，但護理師仍需指導家屬進行正確的懸空擺位。