Documentation Guidelines

• Respiratory response: Rate and rhythm; lung expansion, respiratory effort, presence of retractions or nasal flaring (infants); presence of adventitious breath sounds; oxygen saturation; placement and patency of an artificial airway; character and amount of respiratory secretions; color of mucous membranes

• Presence, location, duration, and description of muscle spasms or seizures

• Physical responses: Condition of skin; bowel and urinary elimination patterns; description of stool and urine; pain and comfort level; condition of wound and dressings; weight; response to feedings; response to intravenous infusions, analgesics, muscle relaxants, and antipyretics

• Growth and development level, growth and development activities, response

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