— 安全與感染控制 · MEDIUM · SATA —
下列哪些病人發生壓力性損傷的風險最高？（選所有適合的）
Which of the following clients are at the highest risk for developing pressure injuries? (Select all that apply.)
- AAn older adult with limited mobility✓ 正解行動受限的年長成人
- BA client with stage 3 heart failure第三階段心衰竭病人
- CA client with fecal incontinence✓ 正解糞便失禁病人
- DA client with diabetes mellitus✓ 正解糖尿病患者
- EA client with adequate sensory perception感官知覺正常的病人
— Explanation · 中文詳解 —
壓力性損傷（Pressure injury）風險評估主要依據 Braden Scale，涵蓋感官知覺、潮濕、活動度、移動力、營養及摩擦力/剪力。高風險群通常具有多重因子加成，如年長者皮膚脆弱且活動力受限、失禁導致皮膚長期潮濕浸潤（Maceration），以及糖尿病引起的神經病變導致對壓力痛覺不敏感。
Clients at highest risk for pressure injuries include those with limited mobility, as immobility causes prolonged pressure on bony prominences. Fecal incontinence increases risk because moisture promotes skin breakdown and maceration. Diabetes mellitus elevates risk due to neuropathy, which reduces sensation, and impaired healing capabilities.