— 降低風險 · MEDIUM · SATA —
護理師為一位長期臥床的病人進行皮膚評估，下列哪些發現應記錄為壓力性損傷形成的風險因子？（選所有適合的）
A nurse is performing a skin assessment on a bedbound client. Which findings should the nurse document as risk factors for pressure ulcer development? (Select all that apply.)
- AIncontinence✓ 正解大小便失禁
- BPeripheral edema✓ 正解周邊水腫
- CLow albumin level✓ 正解低白蛋白血症
- DDecreased sensory perception✓ 正解感覺知覺減退
- EHigh calorie diet高熱量飲食
— Explanation · 中文詳解 —
長期臥床病人極易發生壓力性損傷（Pressure ulcer）。風險因子包含：潮濕（失禁導致皮膚浸潤）、循環不良（水腫導致組織灌流下降）、營養不良（白蛋白低代表修復能力不足）、以及感知下降（無法感受壓力而未變換姿勢）。護理師應使用 Braden Scale 評估風險，並採取減壓措施，如定時翻身、使用氣墊床等。
Risk factors for pressure ulcers include incontinence causing skin maceration, peripheral edema impairing tissue perfusion, low albumin compromising skin integrity, and decreased sensory perception preventing weight shifts. These factors collectively increase the likelihood of tissue breakdown in bedbound clients.