護理師評估病人的壓瘡風險。下列哪些因素會增加皮膚受損的風險？（選所有適合的）
A nurse is assessing a client for pressure ulcers. Which factors increase the risk of skin breakdown? (Select all that apply.)
- AAdvanced age✓ 正解高齡
- BIncontinence✓ 正解失禁
- CFrequent repositioning頻繁翻身
- DMalnutrition✓ 正解營養不良
- EPeripheral edema✓ 正解周邊水腫
壓瘡（Pressure ulcer）的成因主要為局部組織缺血，受壓力、剪力（Shear）及摩擦力影響。評估高風險個案時，需考量生理結構（如高齡皮膚薄）、代謝狀況（營養不良）、環境刺激（失禁導致皮膚浸潤）及循環問題（水腫導致組織灌流下降）。護理師應透過 Braden Scale 等工具進行系統性評估。
The causes of pressure ulcers are primarily local tissue ischemia, influenced by pressure, shear, and friction. When assessing high-risk clients, the nurse should consider physiological structure (such as thin skin in older adults), metabolic status (malnutrition), environmental factors (incontinence causing skin maceration), and circulatory problems (edema decreasing tissue perfusion). The nurse should perform a systematic assessment using tools such as the Braden Scale.