Documentation Guidelines

• Physical findings: Breath sounds, vital signs, level of consciousness, urinary output, skin temperature, amount and color of chest tube drainage, dyspnea, cyanosis, nasal flaring, altered chest expansion, tracheal deviation, absence of breath sounds

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

• Response to treatment: Chest tube insertion—type and amount of drainage, presence of air leak, presence or absence of crepitus, amount of suction, presence of clots, response to fluid resuscitation; response to surgical management

• Complications: Infection (fever, wound drainage); inadequate gas exchange (restlessness, dropping SaO2); tension pneumothorax

0 0

Post a comment