Documentation Guidelines

• Cardiovascular response: Heart rate and rhythm; presence and character of peripheral pulses; capillary refill time; pulmonary artery pressure, central venous pressure, left atrial pressure, and right atrial pressure; cardiac output and index; oxygen delivery and oxygen consumption

• Respiratory response: Rate and rhythm; lung expansion; breath sounds; oxygen saturation; color of oral mucosa and skin; type, location, and patency of an artificial airway

• Neurological response: Level of consciousness, orientation, strength and movement of extremities, activity level, response to the parents or significant others

• Signs of infection: Response to antibiotics

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