護理師正在評估一位患有第三期壓力性損傷（壓瘡）的病人。護理師應預期見到哪種臨床表現？
A nurse is performing an assessment on a client with a Stage 3 pressure injury. Which clinical finding should the nurse expect?
- APartial-thickness loss of dermis presenting as a shallow open ulcer.部分真皮層缺失，呈現為淺表開放性潰瘍。
- BIntact skin with non-blanchable redness.皮膚完整但出現不可壓迫性紅斑。
- CFull-thickness tissue loss with visible subcutaneous fat.✓ 正解全層組織缺失，可見皮下脂肪。
- DFull-thickness tissue loss with exposed bone, tendon, or muscle.全層組織缺失，可見暴露的骨骼、肌腱或肌肉。
壓瘡分期是 NCLEX 必考重點。第三期壓瘡的定義是『全皮層缺失』（Full-thickness skin loss），可見皮下脂肪（Subcutaneous fat），但尚未深達骨頭、肌腱或肌肉。可能存在潛行（Tunneling）或口袋化（Undermining）。B 選項是第一期（皮膚完整但壓之不變白）；A 選項是第二期（真皮層部分受損，呈淺潰瘍或水泡）；D 選項是第四期（深達骨骼或肌肉）。區分三期與四期的關鍵在於『暴露的組織種類』。此外，若傷口被腐肉（Slough）或焦痂（Eschar）覆蓋導致無法判斷深度，則歸類為『無法分期』（Unstageable）。
NPUAP pressure-injury staging: Stage 1 is intact skin with non-blanchable erythema; Stage 2 is partial-thickness loss of dermis with a shallow open ulcer or blister; Stage 3 is full-thickness skin loss exposing subcutaneous fat (slough or tunneling may be present) but bone, tendon, and muscle are not exposed; Stage 4 involves full-thickness loss with exposed bone, tendon, or muscle. Wounds covered by slough or eschar that obscure depth are 'Unstageable.'
美國對於壓瘡分期嚴格遵循 NPIAP 標準，且若入院時未詳實記錄壓瘡，後續治療費用保險（Medicare/Medicaid）可能不予支付；台灣則由健保規範，但在臨床紀錄精確度上正逐步向國際標準看齊。