Documentation Guidelines

• Laboratory findings: Serum electrolytes, osmolarity; daily flowsheet for easy day-to-day comparisons

• Physical responses: Respiratory status (rate, quality, depth, ease, breath sounds); vital signs; GI symptoms (nausea, vomiting, diarrhea); muscle strength, signs of muscle twitching, steadiness of gait, ability to perform activities of daily living; fluid balance, intake and output

• Condition of IV site, complications of IV therapy (infection, infiltration phlebitis)

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