Documentation Guidelines

• Physical findings: Signs of infection, cardiac monitoring results, breath sounds, heart sounds, intake and output, vital signs

• Laboratory results: Hemodynamic results; changes in chest x-ray

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

• Response to treatment: Change in pain, temperature reduction, increased activity tolerance

• Presence of complications: Myofibril degeneration, right- and left-sided heart failure

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