— 降低風險 · MEDIUM · SATA —
護理師評估一位壓力性損傷病人的傷口。下列哪些發現顯示傷口正在癒合？（選所有適合的）
A nurse is performing a wound assessment on a client with a pressure injury. Which findings indicate the wound is healing? (Select all that apply.)
- APresence of pink, granular tissue✓ 正解出現粉紅色、顆粒狀組織
- BPresence of eschar at the wound edges傷口邊緣出現焦痂
- CDecreased wound dimensions over time✓ 正解隨時間推移傷口尺寸縮小
- DAbsence of purulent drainage✓ 正解無膿性分泌物
- EPresence of yellow slough covering the wound bed傷口床覆蓋黃色腐肉
— Explanation · 中文詳解 —
傷口癒合評估的核心在於觀察肉芽組織的增生與感染徵象的消失。健康的肉芽組織（granular tissue）呈粉紅色至紅色，質地濕潤且顆粒狀，顯示血管新生良好。傷口尺寸縮小是癒合的客觀指標。缺乏膿性分泌物則代表傷口無明顯感染，適合進一步癒合。反之，焦痂（eschar）與腐肉（slough）皆屬壞死組織，會形成細菌滋生的溫床，必須先進行清創（debridement）才能進入正常的修復期。
Pink granulation tissue and decreasing wound size indicate healthy healing and new blood vessel formation. The absence of purulent drainage suggests that infection is controlled, whereas eschar and slough represent non-viable tissue that impedes healing.