Documentation Guidelines

• Physical response: Abdominal assessment (return of bowel sounds, relief of distension, and elimination patterns), vital signs, intake and output, pertinent laboratory findings

• Comfort: Location, type, and degree of pain; response to analgesia and other interventions

• Nutrition: Presence of nausea and vomiting, food tolerance, daily weights

• Postoperative recovery: Status of incisions and dressings, presence of complications (infection, lung collapse, hemorrhage), intractable pain

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