病歷中的下列哪些發現應引起護理師對跌倒高風險的警覺？（選所有適合的）
Which of the following findings in a client's chart should alert the nurse to a significant risk for falls? (Select all that apply.)
- AAge of 75 years✓ 正解75歲
- BCurrent prescription of antihypertensive medication✓ 正解目前處方降血壓藥物
- CHistory of two falls within the past six months✓ 正解過去六個月內有兩次跌倒史
- DDiagnosis of orthostatic hypotension✓ 正解姿勢性低血壓診斷
- EBeing able to transfer independently with a walker能獨立使用助行器轉移
評估跌倒風險需結合生理因素、藥物影響及病史。年齡大於 65 歲為跌倒的自然危險因子，視力與平衡功能會隨年齡退化。降血壓藥物常導致姿勢性低血壓，是住院病人跌倒的主因之一。過去有跌倒史（特別是六個月內多次）是預測未來跌倒最強力的指標。姿勢性低血壓代表病人變換姿勢時灌流不足，容易產生眩暈並喪失意識。相比之下，能使用助行器獨立轉位代表病人的活動力與認知功能尚可，能正確使用輔具的病人跌倒風險反而較低。護理師應針對上述危險因子，實施如『床邊警示、頻繁巡視、起身緩慢指導』等安全預防措施，確保護理計畫的有效性。
Fall risk assessment must integrate physiologic factors, medication effects, and past history. Age greater than 65 is an inherent risk factor for falls because vision and balance decline with age. Antihypertensive medications frequently cause orthostatic hypotension and are a leading cause of falls in hospitalized patients. A history of prior falls, especially multiple falls within the past six months, is the strongest predictor of future falls. Orthostatic hypotension indicates inadequate perfusion during positional changes and can produce dizziness and loss of consciousness. By contrast, the ability to transfer independently with a walker indicates preserved mobility and cognitive function; patients who can correctly use assistive devices actually have a lower fall risk. Based on these risk factors, the nurse should implement safety precautions such as bed alarms, frequent rounding, and instruction on rising slowly to ensure the care plan is effective.
美國醫療系統高度依賴 Morse Fall Scale 或 Hendrich II Fall Risk Model 進行結構化評估並電子化追蹤；台灣臨床多使用 Morse Fall Scale，但常因病歷繁瑣而流於形式，護理師在交班時常以口頭提醒為主，較少使用電子化動態風險警示系統。