護理師使用 Braden 量表評估病人的壓瘡風險。評估因子包含哪些?(選所有適合的)
A nurse is assessing a client for pressure injuries using the Braden Scale. Which factors are evaluated? (Select all that apply.)
- ASensory perception✓ 正解感覺知覺
- BMoisture✓ 正解濕度
- CActivity and mobility✓ 正解活動力與行動力
- DNutritional status✓ 正解營養狀況
- EBlood pressure and heart rate血壓與心率
Braden 量表(Braden Scale)是臨床上評估壓瘡(Pressure Injury)風險最廣泛使用的工具。它包含六個關鍵維度:感覺知覺(Sensory perception)、濕度(Moisture)、活動度(Activity)、移動度(Mobility)、營養狀態(Nutrition)以及摩擦力與剪力(Friction and Shear)。這六個因子從生理、環境與代謝層面全方位評估皮膚受損的可能性。血壓與心跳雖為重要生命徵象,但它們無法直接反映皮膚組織受壓或灌流不良的風險。
The Braden Scale evaluates six key dimensions: sensory perception, moisture, activity, mobility, nutritional status, and friction/shear. These factors comprehensively assess the risk of pressure injury from physiological, environmental, and metabolic perspectives. Vital signs like blood pressure and heart rate are not included as they do not directly reflect skin tissue vulnerability.