Documentation Guidelines

• Laboratory: Maintain a flowsheet on serum electrolytes for easy day-to-day comparisons

• Physical responses: Adequacy of airway, breathing, and circulation; vital signs, noting any respiratory difficulties such as rapid, shallow breathing patterns; cardiac rhythm; intake and output; presence of any neuromuscular twitching, tetany, or seizure activity; ability to swallow; presence or absence of gag reflex

• Any signs of alcohol withdrawal; management of the symptoms; response to treatment

• Duration, intensity, location, and frequency of pain; effectiveness of analgesics

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