A patient is at risk for developing pressure injuries due to prolonged immobility. Which intervention should the nurse prioritize?

A. A patient presents with sudden onset facial drooping and slurred speech: Charting by Exception focuses on documenting deviations from normal findings. Sudden facial drooping and slurred speech are abnormal and potentially indicative of a stroke or other urgent condition, requiring detailed documentation and prompt provider notification.

B. A patient reports no pain and demonstrates normal gait: Normal findings are considered expected and typically do not require additional documentation in a CBE system unless they change from baseline.

C. A patient has a blood pressure of 120/80 mmHg with no other changes: This is within normal limits and would not require additional notes, as CBE emphasizes abnormal or significant deviations.

D. A patient exhibits stable vital signs and no new symptoms: Stability and absence of symptoms reflect expected outcomes and are usually captured by the standard flow sheet in CBE, requiring no extra documentation.

A. Client's respiratory rate is 28 breaths per minute: This is objective data because it can be measured and verified by the nurse. Vital signs provide quantifiable information about the client’s physiological status.

B. Client states, "My chest feels tight and hurts when I breathe deeply": This is subjective data because it reflects the client’s personal experience and perception of symptoms. Subjective data cannot be measured directly and must be reported by the client.

C. Client's ECG results show abnormal activity: ECG findings are objective data because they are measurable, recorded, and interpreted using standardized criteria. They provide concrete evidence of cardiac activity.

D. Client is holding their chest and appears anxious: This is also objective data because it is observable and measurable behavior. The nurse can see and document these actions without relying on the client’s personal report.