— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位薦骨處有第二期壓瘡的病人，下列哪些照護措施是適當的？（選所有適合的）
A nurse is caring for a client with a Stage 2 pressure ulcer on the sacrum. Which interventions are appropriate for wound management? (Select all that apply.)
- AClean the wound with sterile saline or a mild cleanser✓ 正解以無菌食鹽水或溫和清潔劑清潔傷口
- BMassage the reddened skin around the ulcer to increase perfusion按摩潰瘍周圍發紅的皮膚以增加血液灌注
- CApply a hydrocolloid dressing to provide a moist healing environment✓ 正解塗佈水膠體敷料以提供濕潤的癒合環境
- DReposition the client at least every two hours✓ 正解至少每兩小時為病人重新定位
- EMaintain a protein-rich diet to promote tissue repair✓ 正解維持高蛋白飲食以促進組織修復
— Explanation · 中文詳解 —
第二期壓瘡（Stage 2 pressure ulcer）涉及表皮與真皮層受損，護理目標是保護傷口床、維持濕潤環境、減壓與提供營養支持。清潔時需使用溫和清潔劑或生理食鹽水，並使用水膠體敷料（Hydrocolloid）覆蓋。定期翻身是預防與治療的核心，營養（蛋白質）則是組織修復的關鍵原料。絕對禁止對患處周圍進行按摩，因為這會損傷微血管，導致組織更嚴重壞死。
Appropriate interventions include cleaning the wound with sterile saline, applying a hydrocolloid dressing to maintain a moist healing environment, repositioning the client frequently to relieve pressure, and maintaining a protein-rich diet to support tissue repair. Massaging the area is contraindicated as it can cause further tissue damage. These measures protect the wound bed and promote epithelialization.