— 基本照護與舒適 · MEDIUM · MCQ —
在評估病人壓力性損傷（壓瘡）風險時，下列哪項發現最具臨床指標意義？
Which assessment finding is most significant when evaluating a client's risk for pressure ulcer development?
- APresence of stage 1 redness over the sacrum薦骨部位出現第一期紅斑
- BSerum albumin level of 3.2 g/dL血清白蛋白濃度為 3.2 g/dL
- CHistory of recent weight loss近期體重減輕病史
- DDecreased sensory perception in the lower extremities✓ 正解下肢知覺減退
— Explanation · 中文詳解 —
根據 Braden Scale 原則，感覺知覺（Sensory Perception）障礙是壓瘡發展的首要關鍵，因為病人無法感覺到受壓導致的疼痛或不適，進而不會主動轉換姿勢。白蛋白偏低與體重減輕雖然是營養風險因子，但不如感覺喪失直接導致壓瘡發生來得危險。
Decreased sensory perception is the most significant risk factor because the client cannot feel pain or discomfort from prolonged pressure, preventing proactive repositioning. According to the Braden Scale, impaired sensation directly increases the likelihood of tissue ischemia and ulcer formation. While nutritional deficits like low albumin contribute to risk, the inability to sense pressure is the primary immediate danger.
✦ 台美臨床差異
美國護理常規使用 Braden Scale 結構化評估；台灣臨床亦導入此量表，但評估頻率與標準化程度因機構而異。