— 降低風險 · MEDIUM · SATA —
護理師照護一位腿部裝有外部固定器的病人，關於骨釘部位（pin site）的護理，哪些是適當的？（選所有適合的）
A nurse is caring for a client with an external fixation device on the leg. Which nursing interventions are appropriate for pin site care? (Select all that apply.)
- AUse aseptic technique for pin site cleaning✓ 正解使用無菌技術清潔骨釘部位
- BMonitor for signs of infection such as purulent drainage✓ 正解監測感染跡象，如膿性分泌物
- CRemove crusts around the pin site using hydrogen peroxide使用雙氧水清除骨釘周圍的痂皮
- DPerform pin site care using separate sterile swabs for each pin✓ 正解為每個骨釘使用單獨的無菌棉棒進行護理
- EInstruct the client that slight clear serous drainage is normal✓ 正解告知病患少量清澈血清狀分泌物屬正常現象
— Explanation · 中文詳解 —
骨釘護理須遵循無菌原則，降低感染風險。每個骨釘應使用獨立棉花棒清潔避免交叉感染。少量透明漿液性分泌物為術後正常現象。過氧化氫（雙氧水）會損傷皮膚組織，現今多建議使用生理食鹽水或醫師指定的清潔液，故不建議使用過氧化氫。
Pin site care requires strict aseptic technique to prevent bacterial introduction and the use of separate sterile swabs for each pin to avoid cross-contamination. While slight clear serous drainage is normal initially, hydrogen peroxide should be avoided as it damages tissue and delays healing. Monitoring for purulent drainage is essential for early detection of infection.
✦ 台美臨床差異
美國骨科護理衛教常會請病人或家屬參與骨釘護理；台灣多數由住院護理師執行，直到出院前才開始衛教。