Documentation Guidelines

• Physical response: Vital signs; signs of pain, guarding, abdominal rigidity; bowel sounds

• Response to medications, including antibiotics and analgesics, blood values (white blood cell count, electrolytes)

• Presence of complications: Respiratory distress, shock, inadequate renal output, unrelieved discomfort

• Appearance of dressing or wound: Bleeding, drainage, appearance of incision

• Level of activity: Activity tolerance, ability to ambulate

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