— 基本照護與舒適 · EASY · SATA —
護理師應將哪些評估發現記錄為「客觀」資料?(選所有適合的)
Which assessment findings should the nurse document as 'objective' data? (Select all that apply.)
- APatient states 'I feel nauseous'病人表示「我感到噁心」
- BSkin is cool and pale✓ 正解皮膚涼且蒼白
- CBlood pressure is 130/85 mmHg✓ 正解血壓為 130/85 mmHg
- DPatient reports pain level of 8/10病人報告疼痛程度為 8/10
- EPatient has 2+ edema in the lower extremities✓ 正解病人雙下肢有 2+ 水腫
— Explanation · 中文詳解 —
客觀資料(Objective data)是護理師可觀察、測量或檢驗所得。B(皮膚顏色觸感)、C(血壓數值)、E(水腫程度)皆可量化或明確觀察。A 與 D 屬於主觀資料(Subjective data),是病人自身的感受與描述。
Objective data are observable, measurable, or verifiable findings obtained by the nurse. B (skin color and texture), C (blood pressure value), and E (edema grade) can all be quantified or directly observed. A and D are subjective data, reflecting the client's own perceptions and reports.
✦ 台美臨床差異
台美護理紀錄皆極度強調主觀與客觀資料的嚴格分界,這對法律責任至關重要。