— 安全與感染控制 · MEDIUM · SATA —
下列哪些發現顯示病人有發生壓力性損傷的風險？（選所有適合的）
Which of the following findings indicates that a nurse should be concerned about a client's risk for pressure injuries? (Select all that apply.)
- ASerum albumin level of 2.8 g/dL✓ 正解血清白蛋白濃度 2.8 g/dL
- BIncontinence of urine and stool✓ 正解大小便失禁
- CBraden Scale score of 12✓ 正解Braden 量表得分 12 分
- DAbility to reposition independently具備獨立翻身能力
- EPeripheral edema周邊水腫
— Explanation · 中文詳解 —
壓力性損傷風險評估包含營養狀況（Albumin）、水分暴露（失禁造成皮膚浸潤）以及 Braden Scale 評分。低於 18 分即屬風險族群，12 分為高風險。自主翻身能力反而能降低風險，水腫雖與組織循環有關，但非直接壓力損傷風險因子。
Pressure injury risk assessment includes nutritional status (albumin), moisture exposure (skin maceration from incontinence), and the Braden Scale score. A score below 18 indicates a population at risk; a score of 12 represents high risk. The ability to reposition independently actually lowers risk; edema relates to tissue perfusion but is not a direct pressure injury risk factor.
✦ 台美臨床差異
台美臨床對於 Braden Scale 的運用頻率相當，是強制執行的護理記錄。