Documentation Guidelines

• Physiological response: Adequacy of airway, breathing, circulation; vital signs; serial monitoring of neurological status; urine output; body weight

• History of injury, description, forces applied to the body during the trauma

• Response to treatment/medications: Pain, mobility, range of motion, muscle spasm, response to surgery, tolerance to nutrition

• Presence and response to traction and immobilization devices

• Complications: Infection, bleeding, anxiety, lack of mobility

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