護理師正在識別有壓瘡風險的病人。哪些因素會增加此風險？（選所有適合的）
The nurse is identifying clients at risk for pressure ulcers. Which factors increase this risk? (Select all that apply.)
- AImmobility✓ 正解活動受限
- BIncontinence✓ 正解大小便失禁
- CAdequate nutrition營養充足
- DDiabetes mellitus✓ 正解糖尿病
- EDecreased sensory perception✓ 正解感覺知覺減退
壓瘡（Pressure Ulcers）的預防是護理品質的核心指標。風險因素主要圍繞在皮膚完整性的破壞與組織灌流受阻。活動受限（Immobility）導致局部組織長期受壓，血流中斷；失禁（Incontinence）使皮膚長期處於潮濕環境，易發生浸潤與破損；糖尿病（DM）引起微血管病變，影響傷口癒合；感覺遲鈍（Decreased sensory perception）使病人無法察覺受壓疼痛而主動變換體位。臨床思路上，護理師應使用 Braden Scale 進行系統化評估。營養充足是預防壓瘡的保護因素，而非風險因素，因為蛋白質與維生素 C 對組織修復至關重要。
Prevention of pressure ulcers is a core indicator of nursing quality. Risk factors focus on disruption of skin integrity and impaired tissue perfusion. Immobility produces prolonged pressure on local tissue and interrupts blood flow; incontinence leaves the skin in a persistently moist environment, where maceration and breakdown readily occur; diabetes mellitus causes microvascular disease that impairs wound healing; and decreased sensory perception prevents the patient from noticing pressure-related pain and changing position on their own. Clinically, the nurse should use the Braden Scale for a systematic assessment. Adequate nutrition is a protective factor against pressure ulcers, not a risk factor, because protein and vitamin C are essential for tissue repair.
台美在壓瘡預防上皆廣泛使用 Braden Scale。美國 NCLEX 非常強調「翻身時機（每 2 小時）」與「不可按摩骨突處」的衛教。此外，美國臨床對於「壓力性損傷（Pressure Injury）」的命名已取代舊稱「壓瘡（Pressure Ulcer）」。