— 基本照護與舒適 · MEDIUM · MCQ —
護理師評估一位病人薦骨處的壓傷，傷口呈現全層皮膚缺失且可見皮下脂肪。護理師應如何分級紀錄？
A nurse is assessing a client’s pressure injury on the sacrum. The wound shows full-thickness skin loss with visible adipose tissue. How should the nurse document this stage?
- AStage 3✓ 正解第三階段
- BStage 4第四階段
- CStage 1第一階段
- DStage 2第二階段
— Explanation · 中文詳解 —
壓傷（Pressure injury）分級是依據組織受損深度來判斷。第三期壓傷的定義是全層皮膚缺失，傷口床可見皮下脂肪（Adipose tissue），但筋膜、肌肉或骨骼尚未暴露。第一期僅為表皮紅腫且壓之不褪色；第二期為表皮與部分真皮受損，呈潰瘍或水泡；第四期則深及骨、肌腱或肌肉。正確的分級對於制定治療計畫與評估癒合進度至關重要。
Stage 3 pressure injuries are characterized by full-thickness skin loss with visible subcutaneous fat but without exposed bone, tendon, or muscle. This distinguishes it from Stage 4, which involves deeper tissue exposure, and Stage 2, which presents as partial-thickness loss.