一位高齡個案表示自己毫無價值且感到絕望。護理師應使用哪種評估工具來評估其自傷風險？
A nurse is caring for an elderly client who expresses feelings of worthlessness and hopelessness. Which assessment tool is most appropriate to evaluate the client's risk of self-harm?
- AMini-Mental State Examination (MMSE)迷你心智狀態檢查 (MMSE)
- BGeriatric Depression Scale (GDS)老年憂鬱量表 (GDS)
- CBraden Scale for Pressure Ulcer RiskBraden 壓瘡風險量表
- DColumbia-Suicide Severity Rating Scale (C-SSRS)✓ 正解哥倫比亞自殺嚴重程度評定量表 (C-SSRS)
針對自傷或自殺風險的評估，臨床公認的黃金標準是 C-SSRS。該量表能系統化詢問自殺意念、動機與計畫。MMSE 是評估認知功能，GDS 用於篩選憂鬱症狀但非專門評估自殺風險，Braden 量表則是評估壓瘡風險。護理師需具備評估自殺風險的專業敏感度，並能及時啟動安全照護流程。
The Columbia-Suicide Severity Rating Scale (C-SSRS) is the clinical gold standard for systematically assessing suicide risk, including ideation, intent, and planning. While tools like the Mini-Mental State Examination assess cognition and the Geriatric Depression Scale screens for depressive symptoms, they do not specifically evaluate self-harm risk. The Braden Scale is used for pressure ulcer prevention and is unrelated to mental health assessments.
美台皆廣泛採用 C-SSRS 作為病人入院及評估自殺風險的標準工具，護理紀錄需完整登載。