— 基本照護與舒適 · MEDIUM · MCQ —
護理師評估一位腳跟有第二級壓瘡的病患，護理計畫中應包含下列哪項措施？
A nurse is assessing a client who has a stage 2 pressure injury on the heel. Which intervention should the nurse include in the plan of care?
- APlace a donut-shaped cushion under the heel在腳跟下方放置甜甜圈形坐墊
- BMassage the reddened area to improve circulation按摩發紅區域以改善血液循環
- CApply a heating pad to promote healing使用熱敷墊以促進癒合
- DKeep the heel elevated off the bed surface✓ 正解使腳跟懸空，不接觸床面
— Explanation · 中文詳解 —
第二級壓瘡（Stage 2 pressure injury）特徵為表皮破損、真皮層外露。腳跟壓瘡的主要成因是長期受壓導致組織缺血。治療重點在於解除壓力（Offloading），透過懸空腳跟（Heel elevation）使患部完全不接觸支撐面，是促進癒合最有效的介入措施。過度的摩擦或錯誤的減壓輔具反而會加重病情。
The priority intervention for a stage 2 pressure injury on the heel is to relieve pressure by keeping the heel elevated off the bed surface. Donut cushions restrict blood flow, massage can damage fragile tissue, and heat may cause burns, making elevation the safest and most effective method to promote healing.