— 安全與感染控制 · MEDIUM · SATA —
下列哪些病人發生壓瘡的風險最高？（選所有適合的）
Which clients are at highest risk for developing pressure injuries? (Select all that apply.)
- AA client with localized edema局部水腫的病人
- BA client who is wheelchair-bound✓ 正解輪椅使用者
- CA client with sensory impairment✓ 正解感覺障礙的病人
- DA client with fecal incontinence✓ 正解大便失禁的病人
- EA client with a low serum albumin level✓ 正解血清白蛋白水平低的病人
— Explanation · 中文詳解 —
壓瘡風險評估（如 Braden Scale）的核心因素包括：活動力受限、感覺缺失、皮膚潮濕（失禁）以及營養不良（低白蛋白）。長期坐輪椅易造成壓力集中，失禁則會使皮膚浸軟，營養不足則導致皮膚修復能力下降。
Clients at highest risk for pressure injuries include those with immobility, such as wheelchair users, and those with sensory impairments who cannot feel pain to shift weight. Fecal incontinence increases risk by causing skin maceration, while low serum albumin indicates poor nutrition that compromises skin integrity and healing. Localized edema alone is not considered a primary risk factor compared to these other conditions.
✦ 台美臨床差異
美台臨床皆高度重視 Braden Scale 評估，並將其納入護理紀錄規範。