Documentation Guidelines

• Respiratory assessment: Rate and rhythm, lung expansion, breath sounds, color of skin and mucous membranes, oxygen saturation, patency and placement of artificial airways, response to mechanical ventilation

• Neurological assessment: Level of consciousness, strength and movement, status of cough and gag reflexes, cranial nerve function, ability to swallow

• Cardiovascular assessment: Heart rate and rhythm, blood pressure, peripheral pulses, color of complexion, skin temperature

• Response to medications, intubation, oxygen therapy, mechanical ventilation

• Condition of skin and mucous membranes

• GI assessment: Bowel sounds, presence of abdominal distension, volume and character of NG tube output, stool character, and bowel elimination patterns

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