— 基本照護與舒適 · HARD · MCQ —
護理師照護一位有傷口深及骨頭的壓瘡病人。這屬於第幾期？
A nurse is caring for a client with a pressure injury that has exposed bone. What stage is this?
- AStage 2第二期
- BStage 4✓ 正解第四期
- CUnstageable無法分期
- DStage 3第三期
— Explanation · 中文詳解 —
壓瘡分期：Stage 1 為紅斑（不退色）；Stage 2 為真皮層受損；Stage 3 為皮下脂肪可見；Stage 4 為深及肌肉、筋膜或骨頭。Unstageable 指的是有腐肉（Slough）或焦痂（Eschar）覆蓋無法辨識深度者。
Pressure ulcer staging: Stage 1 is non-blanchable erythema; Stage 2 involves partial-thickness loss of the dermis; Stage 3 exposes subcutaneous fat; Stage 4 extends into muscle, fascia, or bone. Unstageable refers to wounds covered by slough or eschar that prevent determination of depth.
✦ 台美臨床差異
美國 NPUAP 分期標準是全球指標，台灣臨床照護依循同樣定義。