護理師正在為一位 Braden 量表評分為 12 分的病人制定照護計畫。哪項介入措施具有最高優先權？
A nurse is planning care for a client with a Braden Scale score of 12. Which intervention is the highest priority?
- AIncreasing the client's protein intake to 1.5 g/kg/day.將病人的蛋白質攝取量增加至每天每公斤 1.5 克
- BApplying a transparent dressing to the sacrum to prevent shear.在薦骨處貼上透明敷料以預防剪切力
- CImplementing a turning schedule of at least every 2 hours.✓ 正解實施至少每 2 小時翻身一次的計畫
- DMassaging reddened areas over bony prominences to improve circulation.按摩骨突處的發紅區域以改善循環
Braden 量表分數越低，發生壓力性損傷（壓瘡）的風險越高。12 分屬於『高風險』（High Risk，通常 10-12 分）。在所有預防措施中，解除壓力（Pressure relief）是核心原則。每 2 小時翻身一次是預防組織缺血最有效且最基礎的護理介入。雖然營養（蛋白質）對皮膚完整性很重要，但在高風險期，直接的物理減壓比生理補給更能立即阻斷壓瘡的形成。使用透明敷料僅能預防摩擦，不能減少垂直壓力。特別注意，按摩發紅部位是絕對禁忌（Contraindicated），因為那可能已經是深層組織受損，按摩會加劇毛細血管破裂。優先順序應始終遵循『先移除病因（壓力）』的邏輯。
A lower Braden Scale score indicates a higher risk of pressure injury. A score of 12 falls within the high-risk range (commonly 10-12). Among preventive measures, pressure relief is the central principle. Repositioning every 2 hours is the most effective and fundamental nursing intervention for preventing tissue ischemia. Although adequate nutrition (especially protein) is important for skin integrity, in high-risk periods direct physical pressure relief halts pressure ulcer formation more immediately than nutritional supplementation. Transparent dressings only prevent friction and cannot relieve perpendicular pressure. Notably, massaging reddened areas is absolutely contraindicated, because the underlying tissue may already be damaged and massage can worsen capillary disruption. Prioritization should always follow the logic of first removing the cause (pressure).
在美國 NCLEX 考試中，Braden Scale 12 分被視為明確的高風險指標，護理師需具備自主啟動減壓設備（如氣墊床）的權限；台灣臨床則常依據各院 protocol，有時需經由傷口護理師或醫師評估後才能申請特殊床墊，且 Braden 分數的申報與健保給付亦有連動。