— 基本照護與舒適 · MEDIUM · MCQ —
病人右腳跟有第二期壓傷。下列何者為最適合的護理措施？
A client is diagnosed with a pressure injury on the heel stage 2. What nursing intervention is most appropriate for this stage?
- AMassage the area to stimulate blood flow按摩該區域以促進血液循環
- BKeep the heel in direct contact with the bed surface保持腳跟直接接觸床面
- 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用過氧化氫清潔傷口
— Explanation · 中文詳解 —
第二期壓傷表現為表皮與真皮層受損，呈淺潰瘍或水泡狀。水膠體敷料提供濕潤癒合環境並保護受損部位。A選項嚴禁按摩，以免加重局部缺血與組織受損；B選項會造成持續壓迫，必須使用枕頭抬高腳跟懸空；D選項過氧化氫會破壞肉芽組織。
For a stage 2 pressure injury on the heel, applying a hydrocolloid dressing is appropriate as it maintains a moist healing environment and protects the site from friction. Massaging the area is contraindicated as it can cause further tissue damage, and hydrogen peroxide is cytotoxic to healing tissue. The heel must also be offloaded to prevent continued pressure.
✦ 台美臨床差異
美國傷口護理常由 WOCN 專業護理師主導，台灣多由一般病房護理師負責，敷料選擇常受健保給付限制。