— 照護管理 · EASY · MCQ —
下列哪位病人發生壓瘡的風險最高？
Which of the following patients is at highest risk for developing pressure ulcers?
- AA patient who walks regularly定期行走的病人
- BA patient with good nutritional status營養狀況良好的病人
- CA patient with a high Braden scale scoreBraden 量表分數高的病人
- DA patient with immobility and incontinence✓ 正解行動不便且大小便失禁的病人
— Explanation · 中文詳解 —
壓瘡風險評估是預防工作的基礎。Braden Scale 是臨床最廣泛使用的工具，包含六個維度：感覺感知（Sensory perception）、潮濕程度（Moisture）、活動度（Activity）、移動能力（Mobility）、營養狀況（Nutrition）、摩擦與剪力（Friction/shear）。每個分項得分越低，代表風險越高。護理師應定期評估病人分數，並針對低分項目採取對應的預防策略（如翻身、減壓床墊、營養介入）。
Patients with immobility and incontinence are at the highest risk for pressure ulcers due to prolonged pressure on bony prominences and moisture-induced skin breakdown. In contrast, regular walking, good nutrition, and a high Braden scale score are protective factors that reduce the likelihood of developing pressure injuries.