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🛏️ 基础护理与舒适 · 第5课，共6课 · 6 min

压力性损伤：分期、翻身、喂养

Pressure Injuries: Stage It, Turn Them, Feed Them

🩹 骶骨上方一处发红区域，如果按压时不变白，就已经是1期压力性损伤。等到有人看到骨头时，考试中的分期问题反而是简单的部分了。

🩹 A reddened area over the sacrum that does not blanch when you press it is already a stage 1 pressure injury. By the time anyone sees bone, the staging question on the exam is the easy part.

💡 核心要点

1期为指压不变白的发红，2期为部分皮层缺损，3期可见脂肪，4期可见骨或肌腱，被覆盖时为不可分期。Braden分数越低风险越高；每2小时翻身并保护足跟。

Stage 1 non-blanchable redness, 2 partial thickness, 3 fat visible, 4 bone or tendon visible, unstageable when covered. Lower Braden means higher risk; turn every 2 hours and protect heels.

🧠 为什么重要

1期：皮肤完整，伴有指压不变白的发红；在较深的皮肤上，要观察颜色变化、发热、变硬或疼痛。2期：部分皮层缺损，伴有浅表开放性伤口或完整或破裂的水疱，呈粉红色且湿润，无腐肉。3期：全层缺损，可见脂肪，可能有潜行；看不到骨或肌腱。4期：全层缺损，骨、肌腱或肌肉外露。不可分期：基底部被腐肉或焦痂覆盖，因此看不到深度。深部组织损伤：皮肤完整或不完整，局部区域持续存在指压不变白的深红色、栗色或紫色变色，或表皮分离露出深色创面或充满血液的水疱（充满浆液的水疱属于2期）。要用BRADEN量表评估风险（感觉感知、潮湿、活动、移动、营养、摩擦力和剪切力）；分数越低风险越高，18分或以下视为有风险。预防措施包括至少每2小时变换体位、使用压力再分布支撑面、30度侧倾、让足跟悬空离开床面、床头抬高不超过所需高度以限制剪切力、潮湿管理，以及充足的蛋白质和热量。不要按摩发红区域，也不要使用环形垫。

STAGE 1: intact skin with NON-BLANCHABLE redness; in darker skin, look for color change, warmth, firmness or pain. STAGE 2: partial-thickness loss with a shallow open wound or an intact or ruptured blister, pink and moist, no slough. STAGE 3: full-thickness loss with visible fat, possibly undermining; no bone or tendon visible. STAGE 4: full-thickness loss with exposed bone, tendon or muscle. UNSTAGEABLE: the base is covered by slough or eschar so depth cannot be seen. DEEP TISSUE injury: intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon or purple discoloration, or epidermal separation revealing a dark wound bed or a blood-filled blister (a serum-filled blister is stage 2). Assess risk with the BRADEN scale (sensory perception, moisture, activity, mobility, nutrition, friction and shear); lower scores mean higher risk, with 18 or below considered at risk. Prevent with repositioning at least every 2 hours, pressure-redistribution surfaces, a 30-degree lateral tilt, heels floated off the bed, the head of the bed no higher than needed to limit shear, moisture management, and adequate protein and calories. Do not massage reddened areas and do not use donut-shaped cushions.

🏥 真实场景

🦶 一名不能活动的患者足跟有一处2 cm的紫色、完整且质地松软的皮肤区域。一名新护士记录为“1期”。经验丰富的护士将其更正为深部组织压力性损伤，把足跟垫在枕头上悬空，并为患者摄入不足和体重减轻安排营养师会诊。持续的深红色、栗色或紫色变色提示深部组织损伤，而分期决定伤口处理计划。

🦶 An immobile client has a 2 cm area of purple, intact, boggy skin on the heel. A new nurse charts 'stage 1'. The experienced nurse corrects it to deep tissue pressure injury, floats the heels on a pillow, and arranges a dietitian consult for the client's poor intake and weight loss. Persistent deep red, maroon or purple discoloration points to deep tissue injury, and staging decides the wound plan.

📌 要点总结

  • 指压不变白的发红已经是1期Non-blanchable redness is already stage 1
  • 不可分期是指被腐肉或焦痂覆盖；深部组织损伤呈深红色、栗色或紫色Unstageable means covered by slough or eschar; deep tissue injury is deep red, maroon or purple
  • Braden 18分或以下：有风险；按q2h翻身，让足跟悬空，防止潮湿和剪切力Braden 18 or below: at risk; turn q2h, float heels, protect from moisture and shear

✅ 自我测试

尾骨处一处压力性损伤显示全层组织缺损，可见皮下脂肪，但无骨或肌腱外露。这是哪一期？A pressure injury on the coccyx shows full-thickness tissue loss with visible subcutaneous fat but no exposed bone or tendon. Which stage is this?
  1. 2期Stage 2
  2. 4期Stage 4
  3. 3期Stage 3
  4. 1期Stage 1

答案: C · 3期

可见脂肪但无骨、肌腱或肌肉是3期的定义。4期有骨或肌腱外露。

Visible fat without bone, tendon or muscle defines stage 3. Stage 4 exposes bone or tendon.

一名患者的Braden量表评分为12。护士应如何解读？A client's Braden scale score is 12. How should the nurse interpret this?
  1. 风险低；常规护理就足够了Low risk; routine care is sufficient
  2. 风险高；开始预防计划High risk; start a prevention plan
  3. 评分无效，必须重新评分The score is invalid and must be repeated
  4. 只有营养需要关注Only nutrition needs attention

答案: B · 风险高；开始预防计划

Braden分数越低，风险越高；12分或以下视为高风险。

Lower Braden scores mean higher risk; 12 or below is considered high risk.

对于有压力性损伤风险的患者，哪项干预是合适的？Which intervention is appropriate for a client at risk of pressure injuries?
  1. 按摩发红的骨突部位以改善血液循环Massage reddened bony areas to improve circulation
  2. 每2小时变换体位并让足跟悬空Reposition every 2 hours and float the heels
  3. 坐着时使用环形垫减轻压力Use a donut cushion to relieve pressure when sitting
  4. 始终将床头保持在60度Keep the head of the bed at 60 degrees at all times

答案: B · 每2小时变换体位并让足跟悬空

变换体位和抬高足跟可减轻压力。按摩会损伤脆弱组织，环形垫会形成压力环，床头过高会增加剪切力。

Repositioning and heel elevation relieve pressure. Massage damages fragile tissue, donuts create pressure rings, and a high head of bed increases shear.

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