— 基本照護與舒適 · MEDIUM · MCQ —
護理師在進行身體評估，哪一項關於皮膚完整性的觀察需立即回報？
A nurse is performing a physical assessment on a client. Which observation regarding skin integrity should be reported immediately?
- ANon-blanchable erythema over the sacrum✓ 正解薦骨部位有按壓不退色的紅斑
- BSmall ecchymosis from a recent venipuncture近期靜脈穿刺處的小塊瘀青
- CDry, flaky skin on the lower legs小腿乾燥脫屑
- DSuperficial skin tear on the forearm前臂淺層皮膚撕裂傷
— Explanation · 中文詳解 —
不褪色紅斑（Non-blanchable erythema）是第一級壓力性損傷的關鍵徵兆，表示微血管已受損，若不立即介入處理，將迅速惡化為深層損傷。A 為常見的老人乾燥問題；D、B 雖需處理，但危險性較 B 低，優先級排序應以預防壓瘡惡化為先。
Non-blanchable erythema over the sacrum indicates a Stage 1 pressure injury and underlying tissue ischemia, which requires immediate intervention to prevent progression to deeper tissue damage. Other findings such as ecchymosis, dry skin, or superficial tears are less urgent and can be managed with routine care.
✦ 台美臨床差異
美國護理品質指標（NDNQI）將壓瘡發生率列為重點，對每一級壓瘡的紀錄要求極高。