— 基本照護與舒適 · MEDIUM · SATA —
護理師使用 Braden 量表評估病人的壓瘡風險,此量表包含哪些項目?(選所有適合的)
A nurse is assessing a client for pressure ulcer risk using the Braden Scale. Which factors are included in this assessment? (Select all that apply.)
- ASensory perception✓ 正解感覺知覺
- BMoisture✓ 正解濕度
- CActivity✓ 正解活動力
- DMobility✓ 正解行動能力
- ENutritional status✓ 正解營養狀況
— Explanation · 中文詳解 —
Braden 量表包含六大指標:感覺知覺、濕度、活動度、移動力、營養攝取、摩擦與剪力(Friction and Shear)。本題選項中 A 至 E 皆為正確指標,能有效預測皮膚受損風險,並依分數高低擬定護理策略。
The Braden Scale comprises six indicators: sensory perception, moisture, activity, mobility, nutritional status, and friction/shear. Options A through E in this question are all correct indicators that can effectively predict the risk of skin breakdown and guide nursing strategies according to the score.
✦ 台美臨床差異
美台醫療系統均廣泛應用 Braden Scale,但在台灣,除了量表外,護理師還需額外評估病人皮膚護理相關的洗澡頻率。