— 安全與感染控制 · HARD · SATA —
護理師對一位有壓傷病史的病人進行皮膚評估，哪些發現需要立即介入？（選所有適合的）
A nurse is conducting a skin assessment on a client with a history of pressure injuries. Which findings require immediate intervention? (Select all that apply.)
- ANon-blanchable redness on the sacrum✓ 正解薦骨處壓之不褪色紅斑
- BIntact skin that feels warm to the touch觸感溫暖且完整的皮膚
- CBoggy, mushy sensation at the injury site✓ 正解傷處有泥濘、鬆軟之感
- DClear, yellow drainage from a stage 2 wound第二級傷口有清澈黃色滲出液
- EBlistering on the heel✓ 正解腳跟處出現水泡
— Explanation · 中文詳解 —
非壓褪性紅斑（Stage 1）及深層組織損傷（Boggy 質感）代表組織深度受損。腳跟水泡在壓傷領域視為嚴重警訊，可能進展為壞死。溫暖皮膚可能僅為發炎反應，非立即危險，漿液性分泌物屬於正常傷口癒合過程。
Non-blanchable redness indicates Stage 1 pressure injury, while a boggy, mushy sensation suggests deep tissue injury, both requiring immediate intervention to prevent progression. Blistering on the heel is also a serious sign of severe pressure damage, whereas warmth may indicate localized inflammation and serous drainage is a normal part of the healing process.
✦ 台美臨床差異
美國壓傷評估採用 NPIAP 標準；台灣醫療院所多採用同樣標準，但在長期照護機構中照護強度有落差。