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FDAR Charting for Patient Care

The document is a focus-charting note from a nurse documenting the care of a patient over the first day of admission. It notes the patient's initial vital signs and symptoms of fever, loss of appetite, and sleeplessness. Throughout the day the nurse monitored the patient's vital signs, administered IV fluids and medications as ordered, and provided comfort measures like sponge baths. The patient's temperature decreased but they continued to feel unwell and only ate a small portion of their lunch.

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357 views2 pages

FDAR Charting for Patient Care

The document is a focus-charting note from a nurse documenting the care of a patient over the first day of admission. It notes the patient's initial vital signs and symptoms of fever, loss of appetite, and sleeplessness. Throughout the day the nurse monitored the patient's vital signs, administered IV fluids and medications as ordered, and provided comfort measures like sponge baths. The patient's temperature decreased but they continued to feel unwell and only ate a small portion of their lunch.

Uploaded by

cleahis cruz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd

Irish Queenie L.

Malimban

April 27, 2016

1NUR3 | RLE 3

Ms. Kathleen V. Chan

Focus-charting (FDAR)

Date/Hour

Day 1

Focus

Progress Notes
D:>
Temperature of 39C
Pulse Rate of 108
beats/minute
Respiration Rate of 20
breaths per minute
Blood Pressure of 120/80
A:>
Gave him routine admission
care
R:>

D:>

A:>

Experiencing sleepless
nights for the last 3 days.
Has a loss of appetite
Teary eyes
Flushed face
Skin warm to touch
(+) rales
(-) wheezes
Monitored VS for every 4
hours and record
Administered IVF D5 NSS
(Normal Saline Solution)
for every 8 hours.
Administered Paracetamol
500 mg as per doctors
order.
Advised to increase the


R:>

intake of fluids and have


small frequent feedings.
Administered tepid sponge
bath.
Temperature decre
Fluid intake increased to
300cc
The patient ate 20-30% of
lunch served.
The patient expressed
malaise and the desire to
sleep.

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