Documentation Guidelines

• Physical findings related to the patient's respiratory status, including respiratory rate, depth, rhythm, breathing pattern, respiratory excursion, breath sounds, and cough effort

• Responses to the nursing interventions taken to support the patient's respiratory function, such as coughing, deep breathing, frequent position changes, and incentive spirometry

• Nutritional status: Patient's weight, measure to maintain nutrition (feeding patient, soft or pureed food, tube feeding)

• Patient's ability to perform activities of daily living

• Responses to all ROM exercises or active exercises

• Responses to equipment or assistive devices such as splints necessary in patient care

0 0

Post a comment