Documentation Guidelines

• Patient's description of pain and response to medications and alternative comfort measures

• Physical findings: Respiratory rate and rhythm, use of accessory muscles, character of breath sounds, mentation, pertinent laboratory findings, presence of fever

• Intake and output, fluid balance, weight changes, vital signs, results of renal profile laboratory studies

• Presence of nausea and vomiting, nasogastric tube, weight loss to 20% under ideal

• Presence of complications: Hemorrhage, sepsis, shock, respiratory distress syndrome, tetany, hyperglycemia

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