— 基本照護與舒適 · MEDIUM · SATA —
護理師照顧一位薦骨處有第二期壓傷的病人。預期會出現哪些特徵？（選所有適合的）
A nurse is caring for a client with a Stage 2 pressure injury on the sacrum. Which characteristics are expected? (Select all that apply.)
- APartial-thickness loss of dermis✓ 正解部分真皮層缺失
- BA shallow open ulcer with a red-pink wound bed✓ 正解淺表開放性潰瘍，傷口床呈紅粉色
- CFull-thickness tissue loss with visible fat全層組織缺失，可見脂肪
- DIntact or ruptured serum-filled blister✓ 正解完整或破裂的血清填充性水泡
- EPresence of slough or eschar存在腐肉或焦痂
— Explanation · 中文詳解 —
第二期壓傷特徵為：真皮層部分受損（A）、傷口床呈現粉紅色或紅色淺層潰瘍（B）、無腐肉。亦可表現為完整或破裂的血清性水泡（D）。C 為第三期（可見脂肪）；E 通常見於第三期、第四期或無法分期，第二期不應有腐肉或焦痂。
A Stage 2 pressure injury is characterized by partial-thickness loss of the dermis presenting as a shallow open ulcer with a red-pink wound bed without slough; it may also present as an intact or ruptured serum-filled blister. Visible subcutaneous fat denotes Stage 3, and the presence of slough or eschar indicates Stage 3, 4, or unstageable injury.
✦ 台美臨床差異
美國使用 NPUAP 分期系統，護理師需精確描述 wound bed；台灣教學系統相同，但傷口專科護理師在美國較為普及並主導治療方案。