Documentation Guidelines

• Response to surgical interventions: Condition of dressing and wound, stability of vital signs, recovery from anesthesia

• Presence of complications: Pain, edema, infection, seroma, limited ROM

• Knowledge of and intent to comply with adjuvant therapies

• Reaction to cancer and body changes

• Knowledge of and intent to comply with incision care, postoperative exercises, arm precautions, follow-up care, and early detection methods for recurrence

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