護理師正在照護一位全層皮膚受損的壓力性損傷病人。傷口床佈滿了腐肉（slough）和焦痂（eschar），無法判定深度。護理師應如何記錄此傷口的分期？
The nurse is assisting a client with a full-thickness pressure injury. The wound bed is covered with slough and eschar, and the depth cannot be determined. How should the nurse document the stage of this injury?
- AUnstageable pressure injury✓ 正解無法分期的壓力性損傷
- BStage 4 pressure injury第 4 期壓力性損傷
- CDeep tissue pressure injury深層組織壓力性損傷
- DStage 3 pressure injury第 3 期壓力性損傷
核心概念：壓力性損傷的分期標準（NPUAP）。當傷口基底（wound bed）被腐肉或焦痂完全覆蓋，導致臨床人員無法肉眼評估傷口的實際深度（即無法看見真皮層以下的構造）時，該傷口被歸類為「無法分期」（Unstageable）。正確答案分析：根據定義，必須清除腐肉或焦痂露出傷口床後，才能精確判定是第 3 期（皮下脂肪暴露）或第 4 期（肌肉骨骼暴露）。錯誤選項：第 3 期（D）與第 4 期（B）都需要明確的深度視覺確認；深層組織損傷（C）通常表現為完整皮膚上的紫色或紅褐色變色，而非開放性壞死組織。臨床思路：對於無法分期的傷口，護理重點在於清創（Debridement），但在周邊循環不良的足跟部乾燥焦痂則不應隨意清除。
Core concept: NPUAP pressure injury staging criteria. When the wound bed is completely covered by slough or eschar so that clinical staff cannot visually evaluate the actual depth (i.e., cannot see the structures below the dermis), the wound is classified as Unstageable. Correct answer analysis: The slough or eschar must be debrided to expose the wound bed before it can be accurately determined whether the injury is Stage 3 (exposed subcutaneous fat) or Stage 4 (exposed muscle or bone). Incorrect options: Stage 3 (D) and Stage 4 (B) both require visual confirmation of depth. Deep tissue pressure injury (C) generally presents as intact skin with purple or maroon discoloration rather than open necrotic tissue. Clinical reasoning: For unstageable wounds, debridement is the focus of care, but in dry heel eschar with poor peripheral circulation it should not be removed indiscriminately.
美國護理師常需取得 WOCN（傷口造口專科護理師）認證才能進行進階清創，病歷紀錄需極其精確以符合健保給付（Insurance Reimbursement）；台灣則多由一般護理師進行換藥，嚴重傷口再請整型外科醫師處置，分期紀錄有時較為籠統。