— 基本照護與舒適 · MEDIUM · SATA —
在急性照護環境中，哪些病人跌倒風險最高？（選所有適合的）
Which clients are at the highest risk for falls in an acute care setting? (Select all that apply.)
- AA 45-year-old post-op patient receiving IV morphine✓ 正解接受靜脈注射嗎啡的45歲術後病人
- BAn 80-year-old patient with history of orthostatic hypotension✓ 正解有姿勢性低血壓病史的80歲病人
- CA 30-year-old patient with a fractured arm手臂骨折的30歲病人
- DA 75-year-old patient with recent onset of confusion✓ 正解近期出現意識混亂的75歲病人
- EA 20-year-old patient who is fully oriented完全定向力正常的20歲病人
— Explanation · 中文詳解 —
跌倒風險評估（fall risk assessment）的核心概念是識別生理機能與環境因素。嗎啡（morphine）會導致鎮靜與暈眩；姿勢性低血壓（orthostatic hypotension）會造成腦部灌流不足導致昏厥；急性混亂（confusion）則喪失判斷危險的能力。護理師應利用標準化量表（如 Morse Fall Scale）進行評估。
Clients receiving opioids like morphine are at high risk due to sedation and gait instability, while those with orthostatic hypotension may faint upon standing. Recent onset of confusion also significantly increases fall risk by impairing judgment and safety awareness.
✦ 台美臨床差異
美國醫院非常重視「跌倒防護計畫」（Fall Prevention Program），通常會針對高風險病人設置床邊警報器（bed alarm）及使用黃色防跌標示（fall risk wristband），此類流程在美國各州醫院極為一致。