Documentation Guidelines

• Fluid volume parameters: Intake and output, urine character, urine specific gravity, urine protein, edema (location and degree of pitting), abdominal girth

• Condition of skin/mucous membranes: Turgor, membrane color and moisture, location of any skin breakdown (location, size, appearance, presence of drainage and character)

• Presence of GI complaints: Nausea, anorexia, diarrhea (if present, amount, frequency, color)

• Respiratory status: Rate and rhythm, lung expansion, presence of retractions or nasal flaring, adventitious breath sounds, type of expectorated secretions

• Comfort level: Type of discomfort, location, and intensity; if pain is present, describe the location, intensity (using a pain scale), and character

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