— 照護管理 · EASY · MCQ —
一位長期照護機構的高齡病患產生了壓力性損傷。護理師應優先採取哪項措施？
An elderly client in the long-term care facility has developed a pressure injury. Which action should the nurse take first?
- AAssess the wound's size, depth, and staging✓ 正解評估傷口的大小、深度和分期
- BNotify the family of the new finding通知家屬有新發現
- CDelegate wound care to the nursing assistant將傷口護理委派給護理助理
- DApply a dressing to cover the wound敷上紗布覆蓋傷口
— Explanation · 中文詳解 —
護理流程的第一步永遠是「評估（Assessment）」。在進行治療、通知家屬或授權之前，必須先明確定義傷口的性質（分級、大小、深度），以便建立基線數據並制定正確的護理計畫。未完成初步評估就進行包紮可能會掩蓋病情，而通知家屬則需依據評估結果說明才具意義。
The first step of the nursing process is always assessment. Before performing treatment, notifying the family, or delegating, the nurse must first clearly define the nature of the wound (stage, size, depth) to establish baseline data and create a correct care plan. Dressing the wound before completing the initial assessment may mask the condition, and notifying the family is meaningful only after the assessment is complete.
✦ 台美臨床差異
美台對壓瘡（Pressure Injury）的照護準則皆一致，強調及時發現、詳細分級記錄與 multidisciplinary team 的介入。