Documentation Guidelines

• Cardiovascular responses: Blood pressure, pulse, presence of abnormal heart sounds; presence, location, and severity of edema; daily weights

• Renal responses: Character, amount, odor of urine

• Respiratory responses: Respiratory rate and effort, breath sounds

• Presence of complications: Fever, food intolerance, pulmonary congestion, shortness of breath, increasing peripheral edema, weight gain, skin breakdown, anuria

• Comfort: Type of discomfort, location and intensity, character, response to attempts to provide relief

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