哪些病人發生壓力性損傷(壓瘡)的風險最高?(選所有適合的)
Which clients are at the highest risk for developing pressure injuries? (Select all that apply.)
- AAn older adult who is bedbound✓ 正解長期臥床的年長成人
- BA client with stage 4 chronic kidney disease患有第四期慢性腎臟病的病人
- CA client with sensory impairment due to diabetes✓ 正解因糖尿病而有感覺障礙的病人
- DA healthy 30-year-old with a broken ankle腳踝骨折的健康 30 歲人士
- EA client with fecal incontinence✓ 正解有大便失禁的病人
壓瘡風險評估(如使用 Braden Scale)的核心因子包括活動力、感覺感知力與皮膚暴露程度。長期臥床(A)導致受壓部位無法緩解;感覺喪失(C)使得病人無法感知疼痛而主動移位;失禁(E)則導致皮膚長期浸潤,削弱皮膚屏障。這三者是壓瘡發生的高危險因子。健康年輕人(D)雖有骨折,但其組織耐受性佳,且多半能進行部分移位,風險相對較低。
The core factors in pressure-injury risk assessment (such as using the Braden Scale) include mobility, sensory perception, and skin exposure. Long-term bed rest (A) prevents relief of pressure on dependent areas; sensory loss (C) prevents the patient from feeling pain and actively shifting position; and incontinence (E) keeps the skin chronically moist and weakens the skin barrier. These three are high-risk factors for pressure injury. A healthy young person (D), although having a fracture, has good tissue tolerance and is mostly able to perform partial repositioning, so the risk is relatively lower.