— 基本照護與舒適 · EASY · MCQ —
護理師照護一位長期臥床且足跟有第二級壓瘡的病人。下列哪項護理措施最能促進傷口癒合？
A nurse is caring for an immobile client who has developed a Stage 2 pressure injury on the heel. Which intervention is most appropriate for promoting healing?
- AKeep the heel elevated off the bed surface using a pillow✓ 正解使用枕頭將足跟懸空於床面之上
- BApply a donut-shaped cushion under the heel在足跟下應用甜甜圈形墊
- CApply a heating pad to the area to increase circulation在患處應用熱敷墊以增加血流
- DMassage the skin surrounding the pressure injury daily每日按摩壓瘡周圍皮膚
— Explanation · 中文詳解 —
針對足跟壓瘡，最根本的護理原則是移除壓力。使用枕頭抬高腿部使足跟懸空（offloading）是臨床金標準。甜甜圈墊會造成周邊壓力集中反而惡化循環；按摩壓瘡部位可能損害脆弱的皮下組織；加熱墊易造成燙傷且對缺血性傷口無直接治療效果。
The most appropriate intervention is to keep the heel elevated off the bed surface using a pillow to completely offload pressure from the injured area. Offloading is the clinical gold standard for healing pressure injuries, whereas donut cushions, massage, and heat can further damage fragile tissues or impair circulation.
✦ 台美臨床差異
美國壓瘡護理指引高度強調床邊 offloading 裝置；台灣臨床常見受限於輔具，多使用捲起毛巾或枕頭來執行。