— 降低風險 · EASY · SATA —
護理師評估病人的壓瘡風險，哪些因素會增加風險？（選所有適合的）
A nurse is assessing a client for potential risk of pressure ulcers. Which factors should the nurse identify as increasing this risk? (Select all that apply.)
- AImpaired sensory perception✓ 正解感覺受損
- BSerum albumin level of 2.2 g/dL✓ 正解血清白蛋白濃度為 2.2 g/dL
- CFrequent repositioning every 2 hours每兩小時頻繁翻身
- DUrinary incontinence✓ 正解尿失禁
- EDaily intake of protein-rich snacks每日攝取富含蛋白質的零食
— Explanation · 中文詳解 —
壓瘡風險評估（如 Braden Scale）核心在於感知能力、水分與營養狀態。感覺受損導致病人無法察覺壓力疼痛、低白蛋白暗示嚴重營養不良與組織修復力下降、失禁則增加皮膚潮濕浸潤風險。頻繁翻身與高蛋白飲食是預防而非風險因子，故不選。
Impaired sensory perception increases pressure ulcer risk because the client cannot feel pain or discomfort, leading to a failure to shift weight. Low serum albumin indicates protein malnutrition, which compromises skin integrity and tissue repair. Urinary incontinence exposes the skin to moisture, promoting breakdown and maceration.
✦ 台美臨床差異
美國機構多依賴 Braden Scale 電子化監控風險分級；台灣則常見於護理記錄單人工填寫評估，且對營養介入的重視程度常隨病房屬性而異。