護理師評估一位病人的跌倒風險。下列哪些因子會增加跌倒風險評分?(選所有適合的)
A nurse is assessing a client for risk of falls. Which factors contribute to a high-fall risk score? (Select all that apply.)
- AHistory of a recent fall✓ 正解近期跌倒史
- BUse of antihypertensive medications✓ 正解使用抗高血壓藥物
- CVisual impairment✓ 正解視覺障礙
- DAge under 50 years年齡低於50歲
- EAbility to ambulate independently能夠獨立行走
跌倒風險評估(如 Morse Fall Scale)是臨床護理的常規項目。風險因子包括:過往跌倒史(最具預測力)、服用抗高血壓藥物(可能導致姿態性低血壓)、視力受損(影響平衡感)以及其他影響認知或行動能力的因素。護理師需根據這些因子進行評估,並對高風險病人採取相應的預防措施,如增加監測頻率、協助起身等。
Fall risk assessment (e.g., the Morse Fall Scale) is a routine component of clinical nursing care. Risk factors include a previous history of falls (the strongest predictor), use of antihypertensive medications (which can cause orthostatic hypotension), visual impairment (which affects balance), and other factors that affect cognition or mobility. The nurse must assess based on these factors and implement appropriate preventive measures for high-risk clients, such as increased monitoring frequency and assistance with transfers.