一位85歲長期臥床的男性正由護理之家的傷口護理師進行評估。在檢查其薦骨時，護理師看到了一個寬且深的火山口狀傷口。然而，整個傷口床的底部被一層厚重、暗黑且如皮革般堅硬的黑色焦痂（Eschar）及大量的黃色腐肉（Slough）完全遮蔽並覆蓋。因為如此，根本無法看見底下是否露出了骨頭或肌肉等結構。護理師必須對這個壓力性損傷做出何種適當的分級與記錄？
An 85-year-old bedridden male is being assessed by the wound care nurse in a nursing home. Upon inspecting his sacrum, the nurse visualizes a wide, deep crater-like wound. However, the entire base of the wound bed is completely obscured and covered by a thick, dark, leathery black layer of eschar and heavy yellow slough. The underlying structures such as bone or muscle are completely hidden from view. How must the nurse properly stage and document this pressure injury?
- AStage 4 Pressure Injury, because by definition any wound containing extensive black eschar has reached the bone.第 4 期壓力性損傷，因為根據定義，任何含有廣泛黑色焦痂的傷口都已到達骨骼。
- BStage 3 Pressure Injury, because the fat layer is visibly disintegrating beneath the eschar.第 3 期壓力性損傷，因為脂肪層在焦痂下可見正在分解。
- CUnstageable Pressure Injury, because the true deepest anatomical depth cannot be visualized due to the obscuring necrotic tissue.✓ 正解無法分級的壓力性損傷，因為由於壞死組織遮蔽，無法視覺化真正的最深解剖深度。
- DDeep Tissue Pressure Injury (DTPI), as the necrotic outer layer indicates massive internal trauma beneath the intact skin.深層組織壓力性損傷（DTPI），因為壞死的外層表明完整的皮膚下方有巨大的內部創傷。
本題測驗基礎照護領域中極度重要的技術：壓力性損傷/壓瘡（Pressure Injury）分級。根據國家壓瘡諮詢委員會 (NPIAP) 的嚴格指引，壓瘡的分級取決於受損穿透組織的「絕對物理深度（Anatomical depth）」，例如看到骨頭或肌腱就是 Stage 4，看到脂肪層是 Stage 3。然而，當傷口床底部的真實深度被大量的焦痂（Eschar，黑死組織）或腐肉（Slough，黃色壞死組織）完全覆蓋與遮蔽時，護理師或醫師是無法僅憑肉眼透過 X 光視力看穿死肉的。在無法確認最深處究竟是到了脂肪還是骨頭以前，這個傷口被歸類定義為「無法分級（Unstageable Pressure Injury）」（選項C為完美正解）。選項B與A皆是錯誤的主觀猜測。選項D「深層組織壓力性損傷 (DTPI)」通常指的是外表皮膚仍『完整未破裂』，但皮下出現如深紫色瘀青的組織壞死，而本題的傷口已經破裂形成巨大坑洞，故非 DTPI。
This question tests an extremely important fundamental nursing skill: staging of pressure injuries. According to the strict guidelines of the National Pressure Injury Advisory Panel (NPIAP), pressure injury staging depends on the absolute anatomical depth of tissue damage; for example, visible bone or tendon indicates Stage 4, while a visible fat layer indicates Stage 3. However, when the true depth of the wound bed is completely covered and obscured by extensive eschar (black necrotic tissue) or slough (yellow necrotic tissue), the nurse or provider cannot see through the necrotic tissue with the naked eye. Until the deepest level of tissue involvement can be confirmed (fat versus bone), the wound is classified as Unstageable Pressure Injury (option C is the correct answer). Options B and A are incorrect subjective guesses. Option D, Deep Tissue Pressure Injury (DTPI), typically refers to intact, unbroken skin with deep purple or maroon tissue necrosis underneath; the wound in this question has already broken down into a large crater, so it is not DTPI.
壓力性損傷分級指引 (NPIAP) 在台美幾乎是字對字翻譯且完全同步通用。「無法分級 (Unstageable)」就是用來稱呼那些被焦痂黑色蓋住的傷口，清創(Debridement)前無法鐵口直斷。