醫療外科病房中，哪些病人屬於跌倒高風險群？（選所有適合的）
Which clients are at high risk for falls in the medical-surgical unit? (Select all that apply.)
- AA 75-year-old client with a history of orthostatic hypotension✓ 正解有姿勢性低血壓病史之 75 歲病人。
- BA 45-year-old client receiving scheduled morphine sulfate✓ 正解定期接受硫酸嗎啡治療之 45 歲病人。
- CA 60-year-old client who is independent with a walker能獨立使用助行器之 60 歲病人。
- DA 30-year-old client post-op day 1 from an appendectomy闌尾切除術後第一天之 30 歲病人。
- EAn 80-year-old client with visual impairment and confusion✓ 正解有視覺障礙及意識混亂之 80 歲病人。
跌倒風險評估（如 Morse Fall Scale）考量生理、藥物及環境因子。姿勢性低血壓會導致腦部灌流暫時不足而暈厥；鎮靜或止痛藥物（如 Morphine）會影響平衡感與警覺性；視覺障礙與混亂（Confusion）則大幅降低病人對環境風險的認知。護理師需針對這些高風險群，啟動防跌措施（如床欄、警報器、防滑襪）。
Fall risk assessment (e.g., the Morse Fall Scale) considers physiological, pharmacological, and environmental factors. Orthostatic hypotension can cause transient cerebral hypoperfusion leading to syncope; sedatives or analgesics (such as morphine) impair balance and alertness; visual impairment and confusion markedly reduce the patient's awareness of environmental hazards. Nurses must initiate fall-prevention measures (such as bed rails, alarms, and non-slip socks) for these high-risk groups.
美國醫院廣泛使用跌倒風險量表（如 Morse Fall Scale 或 Johns Hopkins Fall Risk Assessment Tool）進行量化評估，並有強制性的紅色識別手環與床邊警示系統。