— 基本照護與舒適 · HARD · MCQ —
護理師評估病人的皮膚完整性，一期壓瘡的早期指標為何？
A nurse is assessing a client for skin integrity. What is a key sign of early pressure injury stage 1?
- AFull-thickness skin loss全層皮膚缺失
- BBlistering水泡形成
- CNon-blanchable erythema✓ 正解不可褪色的紅斑
- DSlough covering the wound傷口覆蓋腐肉
— Explanation · 中文詳解 —
壓瘡（Pressure injury）分級的核心在於皮膚組織損傷的深度。第一期壓瘡的定義為皮膚完整，但出現持續性的「不可褪色之紅斑」（non-blanchable erythema），這是微血管受壓導致局部血液循環障礙的早期警訊。若出現水泡、皮膚破損或壞死組織，則代表損傷已進展至更深層。臨床上，護理師應評估皮膚顏色、溫度與觸感，並優先對受壓部位進行減壓，防止損傷惡化。
Stage 1 pressure injury is characterized by non-blanchable erythema on intact skin, indicating localized tissue damage without breakage. This sign reflects impaired blood flow due to sustained pressure. Other findings like blistering, full-thickness loss, or slough indicate deeper tissue involvement consistent with higher-stage injuries.