Documentation Guidelines

• Physical findings: Signs of blocked bile ducts (pain, nausea and vomiting, jaundice, brown urine, and gray or white stools); skin color and integrity; vital signs; signs of infection (fever, abdominal guarding, increasing white blood cell count)

• Pain control: Response to analgesics, response to nonpharmacologic strategies, location of pain, duration of pain, precipitating factors

• Postoperative assessment of incision, GI functioning, drainage devices (amount and color of drainage)

356 Gastric Cancer

• Nutrition: Daily weights, appetite, food intake, tolerance to food, presence of nausea and vomiting

• Psychosocial: Response to poor prognosis, support systems

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