— 降低風險 · MEDIUM · SATA —
下列哪些病人發生壓瘡的風險最高？（選所有適合的）
Which of the following clients are at high risk for developing pressure ulcers? (Select all that apply.)
- AAn older adult with limited mobility✓ 正解行動受限的老年人
- BA client with fecal or urinary incontinence✓ 正解有大便或尿液失禁的客戶
- CA client with a serum albumin level of 2.2 g/dL✓ 正解血清白蛋白濃度為 2.2 g/dL 的客戶
- DA client who is ambulatory with assistance需協助下行走的客戶
- EA client with diabetic neuropathy✓ 正解患有糖尿病神經病變的客戶
— Explanation · 中文詳解 —
壓瘡危險因子包括：活動受限、皮膚潮濕（失禁）、營養不良（白蛋白低於3.5 g/dL 為指標）、感覺喪失（神經病變）。行走需協助雖然屬於活動受限的一種，但相比之下，完全不能走或神經病變無法感知疼痛的病人風險更高。D選項通常風險較低。
Risk factors for pressure ulcers include limited mobility, skin moisture (incontinence), malnutrition (with albumin below 3.5 g/dL as an indicator), and sensory loss (neuropathy). Although a client who ambulates with assistance is still a form of limited mobility, the risk is comparatively lower than for clients who cannot walk at all or who cannot perceive pain due to neuropathy; option D is therefore generally lower-risk.
✦ 台美臨床差異
美國醫院廣泛使用 Braden Scale 評估，台灣則依各醫院評鑑指標要求，普遍也導入相關量表。