— 照護管理 · HARD · MCQ —
護理師評估一位長期臥床病人的皮膚，何種發現需立即通知醫師？
A nurse is performing a skin assessment on an immobile client. Which finding requires immediate notification to the physician?
- APresence of a superficial blister on the elbow手肘處有淺層水泡
- BNon-blanchable erythema on the sacrum薦骨處有按壓不退色的紅斑
- CDry, scaly skin on the extremities四肢皮膚乾燥脫屑
- DDark, boggy, or mushy tissue on the heel✓ 正解腳跟處有深色、浮腫或軟爛的組織
— Explanation · 中文詳解 —
腳跟出現深色、軟爛或海綿樣組織，符合疑似深部組織損傷（Suspected Deep Tissue Injury, sDTI）的特徵。這顯示皮下組織已發生深度壞死，極易演變成嚴重的第三或第四級壓瘡。其他狀況雖需介入，但深部組織壞死具有極高感染與擴散風險，必須立即採取積極治療措施。
Dark, boggy, or mushy tissue on the heel is consistent with suspected deep tissue injury (sDTI). It indicates that deep subcutaneous tissue necrosis has occurred and is very likely to progress to severe Stage 3 or 4 pressure ulcers. The other findings require intervention, but deep tissue necrosis carries an extremely high risk of infection and extension, mandating immediate aggressive treatment.
✦ 台美臨床差異
美國護理師常依 Wound Care Nurse 的 protocol 啟動評估；台灣通常需醫師開立傷口護理會診。