— 基本照護與舒適 · MEDIUM · SATA —
護理師為一位長期臥床的病人進行身體評估。哪些跡象顯示可能已發生壓力性損傷？（選所有適合的）
A nurse is performing a physical assessment on an immobilized client. Which findings indicate the development of pressure injuries? (Select all that apply.)
- ANon-blanchable redness on the sacrum✓ 正解薦骨處有無法壓退的紅斑
- BSkin temperature change compared to surrounding tissue✓ 正解與周圍組織相比皮膚溫度改變
- CPresence of localized edema✓ 正解存在局部水腫
- DReports of persistent pain in the area✓ 正解報告該區域持續疼痛
- EBlanchable erythema on the heel足跟處有可壓退的紅斑
— Explanation · 中文詳解 —
壓力性損傷評估重點在於組織缺血的徵兆。非蒼白性紅斑（不可壓退）為第一期損傷的關鍵特徵。此外，局部溫度變化、水腫及持續疼痛皆暗示皮下組織已有受損風險。可壓退紅斑（E選項）則屬於正常生理性充血，尚未達到損傷定義。
Pressure injury assessment focuses on signs of tissue ischemia. Non-blanchable erythema is the key feature of stage I injury. Local temperature changes, edema, and persistent pain also suggest that subcutaneous tissue is at risk. Blanchable erythema (option E) represents normal physiologic hyperemia and does not yet meet the definition of injury.
✦ 台美臨床差異
美國使用 NPUAP 分級系統非常嚴謹；台灣臨床護理師亦採此標準，但 documentation 的落實度因人力比偶有落差。