Documentation Guidelines

• Abdominal assessment: Description of wounds or surgical incisions, wound healing, presence of bowel sounds, location of bowel sounds, number and quality of bowel movements, patency of drainage tubes, color of urine, presence of bloody urine or clots, amount of urine, appearance of catheter insertion site, fluid balance (intake and output, patency of intravenous catheters, speed of fluid resuscitation)

• Comfort: Location, duration, precipitating factors of pain; response to medications; degree of pain control

• Presence of complications: Pulmonary infection, peritonitis, hemorrhage, wound infection, alcohol withdrawal

• Assessment of level of anxiety, degree of understanding, adjustment, family or partner's response, and coping skills

• Understanding of and interest in patient teaching

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