— 基本照護與舒適 · HARD · MCQ —
護理師使用 Braden Scale 評估病人的壓瘡風險。此量表包含下列哪些項目？
A nurse is assessing a client's risk for pressure injuries using the Braden Scale. Which subscales are included in this tool?
- APain, level of consciousness, vital signs, age, skin color疼痛、意識層次、生命徵象、年齡、膚色
- BSensory perception, moisture, activity, mobility, nutrition, friction/shear✓ 正解感覺知覺、濕度、活動力、行動能力、營養、摩擦力/剪切力
- CLaboratory values, respiratory rate, oxygen saturation, temperature實驗室數值、呼吸頻率、血氧飽和度、體溫
- DHeight, weight, intake/output, medical history, allergies身高、體重、出入量、病史、過敏史
— Explanation · 中文詳解 —
Braden Scale 是臨床最廣泛使用的壓瘡風險評估工具，由六個關鍵維度構成：感覺感知（Sensory perception）、潮濕程度（Moisture）、活動度（Activity）、移動能力（Mobility）、營養狀況（Nutrition）、摩擦與剪力（Friction/shear）。透過這些指標的量化評估，護理師能準確識別高風險病人，並針對其缺失項目擬定具體的預防計畫，如增加翻身頻率、使用減壓墊或改善營養攝取。
The Braden Scale assesses pressure injury risk using six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. These domains help identify clients at risk by evaluating factors that contribute to skin breakdown, allowing nurses to implement targeted preventive interventions.