Documentation Guidelines

• Physical response: Vital signs, neurological assessment, cardiopulmonary assessment, wound healing, signs of infection (fever, wound drainage, productive cough), important laboratory deviations (serious electrolyte imbalances, alterations in glucose levels)

• Nutrition: Daily weights, appetite, food tolerance, food preference, response to diet teaching, calorie count if indicated

• Emotional response: Concerns over body image, self-concept, mood, affect

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