— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位薦骨處有第二期壓瘡的病人。這類損傷預期會有哪些特徵？（選所有適合的）
The nurse is caring for a client with a stage 2 pressure injury on the sacrum. Which characteristics are expected for this type of injury? (Select all that apply.)
- APartial-thickness loss of dermis✓ 正解真皮層部分缺損
- BVisible subcutaneous fat皮下脂肪可見
- CA shallow, open ulcer with a red-pink wound bed✓ 正解淺層開放性潰瘍，具紅粉色傷口床
- DIntact or ruptured serum-filled blister✓ 正解完整或破裂之含血清水泡
- EPresence of slough or eschar存在腐肉或焦痂
— Explanation · 中文詳解 —
第二期壓瘡定義為真皮層部分受損（Partial-thickness），表現為淺層開放性潰瘍，基底呈粉紅色或紅色，無腐肉（Slough）。此外，完整或破裂的水泡（含血清）也屬於第二期。B（可見脂肪）屬於第三期；E（有腐肉或焦痂）通常見於第三、四期或無法分期（Unstageable）的壓瘡。正確識別分期有助於選擇合適的敷料，如親水性敷料（Hydrocolloid）。
Stage 2 pressure injuries involve partial-thickness loss of the dermis, presenting as shallow open ulcers with a pink-red wound bed or intact/ruptured serum-filled blisters. Subcutaneous fat visibility indicates Stage 3, while slough or eschar suggests Stage 3, Stage 4, or unstageable injuries.
✦ 台美臨床差異
分期標準全球通用 (NPUAP/EPUAP)，但美國 NCLEX 強調對壓力性損傷的預防性護理（如 Braden Scale 評估）與保險不給付院內產生壓瘡的政策。