Documentation Guidelines

• Respiratory response: Patency of airway; adequacy of ventilation (rate, quality, and presence of adventitious breath sounds); maintenance of chest tube system (suction, presence of air leaks, amount and quality of drainage)

• Incisional care: Description of dressing; appearance of wound

• Degree of pain; response to interventions to lessen pain

• Presence of complications related to the surgical procedure

• Amount of urinary output, color of urine, and patency of Foley catheter

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