— 基本照護與舒適 · MEDIUM · SATA —
下列哪些評估發現顯示住院病人有較高的壓瘡風險？（選所有適合的）
Which of the following assessments would indicate an increased risk for pressure ulcers in a hospitalized client? (Select all that apply.)
- AAlbumin level of 2.5 g/dL✓ 正解白蛋白濃度為 2.5 g/dL
- BFrequent episodes of urinary incontinence✓ 正解頻繁發生尿液失禁
- CSpontaneous movement in bed在床上有自發性動作
- DBraden Scale score of 12✓ 正解Braden 量表得分為 12
- EPeripheral edema周邊水腫
— Explanation · 中文詳解 —
壓瘡風險評估涵蓋營養（白蛋白低代表營養不良）、濕度（失禁造成皮膚浸潤）、感覺與活動度。Braden 量表分數越低風險越高（12 分屬於高風險範圍）。自動在床上活動是保護因子，水腫雖然會影響循環，但非壓瘡直接風險因子，除非有皮膚受損疑慮。
Low albumin levels indicate poor nutrition, which impairs tissue repair and increases ulcer risk. Frequent urinary incontinence causes moisture-associated skin damage, softening the skin and promoting breakdown. A Braden Scale score of 12 signifies high risk for pressure ulcer development. Conversely, spontaneous movement helps redistribute pressure, and peripheral edema is not a direct primary risk factor in this context.
✦ 台美臨床差異
美國醫院廣泛使用 Braden 量表並強制紀錄；台灣臨床亦全面導入 Braden 量表評估。