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基本照護與舒適 · MEDIUM · SATA

下列哪些類型的病人屬於發生壓力性損傷的高風險群?(選所有適合的)

Which of the following clients are at the highest risk for developing pressure ulcers? (Select all that apply.)

  • AAn older adult with a fractured hip who is immobile✓ 正解
    患有髖骨骨折且行動不便的老年人
  • BA client with chronic kidney disease on hemodialysis
    接受血液透析的慢性腎臟病病人
  • CA client with localized edema in the lower extremities✓ 正解
    下肢局部水腫的病人
  • DA client with urinary incontinence and moisture exposure✓ 正解
    有尿失禁且皮膚暴露於潮濕環境中的病人
  • EA postoperative client who is ambulating with assistance
    在協助下行走的術後病人
Explanation · 中文詳解

壓力性損傷(Pressure Injury)的形成核心在於組織受壓導致局部缺血與灌流不足。高風險群通常具備不動(Immobility)、感覺喪失、營養不良、皮膚潮濕(Moisture)或血液循環受損等因子。護理評估時,應優先考量這些會長期壓迫骨突處(Bony Prominences)或破壞皮膚屏障的因素。選項A、C、D分別涵蓋了物理性壓迫與皮膚浸潤,屬於標準Braden量表中的高風險指標。

The formation of pressure injuries centers on tissue compression leading to localized ischemia and inadequate perfusion. High-risk groups typically have factors such as immobility, sensory loss, malnutrition, moist skin, or impaired circulation. When the nurse performs an assessment, the highest priority should be given to factors that exert prolonged pressure on bony prominences or disrupt the skin barrier. Options A, C, and D, which cover physical pressure and skin maceration, are standard high-risk indicators on the Braden Scale.

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