— 基本照護與舒適 · MEDIUM · SATA —
護理師在評估二級壓瘡時，應記錄哪些發現？（選所有適合的）
Which assessment findings should a nurse document for a client with stage 2 pressure injury? (Select all that apply.)
- AIntact skin with non-blanchable redness皮膚完整且壓之不褪色的紅斑
- BPartial-thickness loss of dermis✓ 正解部分真皮層缺失
- CShallow, open ulcer with a red-pink wound bed✓ 正解淺表開放性潰瘍，呈現紅粉色傷口床
- DFull-thickness tissue loss全層組織缺失
- EIntact or ruptured serum-filled blister✓ 正解完整或破裂的含血清水泡
— Explanation · 中文詳解 —
二級壓瘡的臨床表現為部分皮層缺失（Partial-thickness），傷口床呈現紅色或粉紅色。水泡（無論完整或已破裂）亦屬於二級壓瘡的特徵，因為水泡內含有漿液，反映了真皮層受損。一級壓瘡則是皮膚完整但有不可褪色的紅斑。三級以上則涉及全層皮膚缺失，甚至深至肌肉或骨骼。準確辨識壓瘡分級有助於後續傷口護理計畫的執行。
Stage 2 pressure injuries are characterized by partial-thickness loss of the dermis, presenting as a shallow open ulcer with a red-pink wound bed. Intact or ruptured serum-filled blisters are also hallmark findings of stage 2, distinguishing them from stage 1 (intact skin) and stage 3/4 (full-thickness tissue loss).