Documentation Guidelines

• Respiratory response: Rate and rhythm, presence of adventitious breath sounds; retractions or nasal flaring (pediatric); oxygen saturation; character and amount of expectoration; type, location, and patency of the artificial airway

• Cardiovascular response: Skin and oral mucosa color; heart rate and rhythm; peripheral pulses; location and degree of edema

• Presence of pain (chest or extremity), location, character, and intensity; swelling or warmth of the patient's extremities

• Complications: Hematuria, epistaxis, hemoptysis, bloody vomitus, bleeding

• Response to treatment: Anticoagulation, oxygen, sedation, surgery

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