Documentation Guidelines

• Physical findings: Changes in vital signs, cardiopulmonary assessment, skin color, capillary blanch, level of activity, changes in level of consciousness

• Pain: Location, duration, precipitating factors, response to interventions

• Responses to interventions: Positioning, oxygen, hyperbaric oxygen, evacuation of air, car-diopulmonary resuscitation

• Development of complications: Seizures, cardiac arrest, severe anxiety, ineffective patient or family coping

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