— 基本照護與舒適 · HARD · MCQ —
一位病人的壓瘡露出骨骼與肌腱。這是第幾期？
A client is diagnosed with a pressure injury that has exposed bone and tendon. Which stage is this?
- AStage 1第一期
- BStage 3第三期
- CStage 2第二期
- DStage 4✓ 正解第四期
— Explanation · 中文詳解 —
根據 NPUAP 分期：Stage 1 為皮膚完整但有發紅；Stage 2 為表皮層缺失；Stage 3 為全層皮膚缺失，可見皮下脂肪但無骨骼；Stage 4 為全層組織缺失，直接暴露肌肉、骨骼或肌腱。
A pressure injury exposing bone, tendon, or muscle is classified as Stage 4, representing full-thickness tissue loss with extensive destruction. Stage 1 involves non-blanchable erythema, Stage 2 involves partial-thickness loss, and Stage 3 involves full-thickness loss with visible fat but no exposed bone or tendon.
✦ 台美臨床差異
台美均採用 NPUAP 標準分期，但美國護理師常需配合創傷中心進行複雜的傷口照護評估。