— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位有壓瘡病史的病人。下列哪些因素會增加皮膚破損的風險？（選所有適合的）
A nurse is caring for a client with a history of pressure injuries. Which factors increase the risk of skin breakdown? (Select all that apply.)
- AImmobility and inability to reposition✓ 正解活動受限且無法自行翻身
- BLow serum albumin levels✓ 正解血清白蛋白水平偏低
- CFriction and shear forces✓ 正解摩擦力和剪力
- DFrequent incontinence causing moisture✓ 正解頻繁失禁導致皮膚潮濕
- EHigh protein intake高蛋白飲食
— Explanation · 中文詳解 —
壓瘡的形成主要由壓力、摩擦力、剪切力與濕度導致。低白蛋白血症（B）顯示營養不良，影響組織修復；失禁（D）造成的濕度會導致皮膚浸漬（Maceration）。高蛋白攝取（E）反而有助於皮膚完整性修復，因此並非風險因素。
Risk factors for pressure injuries include immobility, which causes prolonged tissue pressure; low serum albumin, indicating poor nutrition for tissue repair; friction and shear forces that damage deep tissues; and moisture from incontinence that breaks down the skin barrier. High protein intake is protective and supports skin integrity, so it is not a risk factor.
✦ 台美臨床差異
美國臨床護理師常使用 Braden Scale 進行結構化風險評估；台灣雖也有相關評估工具，但臨床常依賴護理師經驗與視覺評估。