Documentation Guidelines

• Physical findings: Patency of airway, presence of clear breath sounds, vital signs, level of consciousness, urinary output, capillary blanch, skin temperature

• Response to pain: Location, description, duration, response to interventions

• Response to treatment: Chest tube insertion—Type and amount of drainage, presence of air leak, presence or absence of crepitus, amount of suction, presence of clots, response to fluid resuscitation; response to surgical management

• Complications: Hemorrhage (ongoing bleeding), infection (fever, wound drainage), inadequate gas exchange (restlessness, dropping SaO2)

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