Documentation Guidelines

• Adequacy of airway: Patency of airway, ease of respiration, chest expansion, respiratory rate, presence of stridor or wheezes

• Cardiovascular assessment: Capillary blanch, quality of peripheral pulses, presence of goose-flesh, changes in vital signs (blood pressure and heart rate), skin color, cardiac rhythm, signs of uncorrected bleeding

• Body temperature

• Fluid balance: Intake and output, patency of IV lines, speed of fluid resuscitation

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