評估病人的水分狀態,哪些方法是適當的?(選所有適合的)
Which of the following are appropriate methods for assessing a client's hydration status? (Select all that apply.)
- AMonitoring daily weights✓ 正解監測每日體重
- BMeasuring intake and output (I&O)✓ 正解測量攝入量和排出量(I&O)
- CAssessing skin turgor✓ 正解評估皮膚彈性
- DChecking mucous membranes✓ 正解檢查黏膜
- EPalpating the abdomen for tenderness觸診腹部是否有壓痛
水分狀態評估是護理基礎,旨在判斷病人是否存在脫水(Dehydration)或液體過多(Fluid volume overload)。護理師應綜合運用主觀與客觀數據,每日體重(Daily weights)是反映液體平衡最敏感的客觀指標,每日同一時間、同一磅秤量測最準確;出入量紀錄(I&O)能反映液體進出平衡,而皮膚彈性(Skin turgor)與黏膜濕潤度(Mucous membranes)則是臨床評估脫水程度的關鍵身體徵象。臨床思路應遵循先評估後執行,確保數據準確性。
Hydration status assessment determines whether the client is dehydrated or fluid-overloaded. The nurse uses both subjective and objective data. Daily weight, measured at the same time on the same scale, is the most sensitive objective indicator of fluid balance. I&O reflects net fluid balance; skin turgor and mucous membrane moisture are key physical findings of dehydration. Clinical reasoning follows the assess-before-act principle to ensure accurate data.