Davao Doctors College General Malvar Street, Davao City Nursing Program
Davao Doctors College General Malvar Street, Davao City Nursing Program
FDAR CHART
Name of Patient: Patient Miranda Date of Admission: August 5, 2021 Room: OPD
Age: 16 years old Sex: Female Civil Status: Single Chief of Complaint: Trauma due to sexual abuse
Religion: N/A Attending Physician: Dr. Casteel
FOCUS / NURSING
DATA ACTION RESPONSE
DIAGNOSIS
Risk for ineffective
childbearing Subjective: 1. Establish rapport 1. The patient and nurse
process related to “Kabata and trust are able to build rapport and
insufficient pa kaayo nako nahimong trusting relationship.
behavioral inahan, nganong nahitabo 2. Provide strict
readiness for man pud ni,dili pa ko ready confidentiality with the 2. Strict confidentiality of
parenting as ug dili pa ko kabalo” as patient. the patient is able to maintain at
evidenced by having stated by the patient. all time and only disclosed to
history of sexual 3. Be sensitive around the health care professionals
abuse. “Wa naman koy mabuhat. the client and approach involved.
Nahitabo nato. Basin with non judgemental
makasala pa ko kung manner 3. A sensitive and non
ipalaglag nako ang bata. judgemental environment is
Wala man siya’y sala.” as 4. Encourage maintained.
verbalized by the patient verbalization
4. The patient is ready to
Objective: 5. Emphasize that share in details about the
- The patient grew up at an saving their life is important abuse.
orphanage and never
disclosed herself that much. 6. Discuss to the client 5. The patient is able to
- The patient was a victim of the signs and symptoms express resolution of anger,
sexual abuse and does not that a person exposed to guilt, fear, depression, and low
talk about it. sexual abuse may self-esteem.
- The patient is hesitant experience as time passes
when being asked about her by, such as: 6. The patient is able to
family. - Anxiety discuss and share with us her
- The patient could not - Depression understanding the importance
believe and accept her fate - Insomnia of being aware that these signs
and could not look herself at - Nightmares and symptoms is a process that
the mirror during her first - Phobias many people the same with
trimester yet somehow felt their situation experiences.
excited about having a baby 7. Arrange support
unexpectedly. follow up: 7. The patient is ready to
- Vital signs: - Group therapy speak with a community-based
support group for rape victims in
- Individual therapy the center.
Vital Signs:
- Rape counselor
BP: 110/70 mmHg
- Support group 8. The patient is able to
Temp: 36.9°C
share with us the short-term
PR: 82-90 bpm
8. Educate the patient plan about her positive
RR: 18- 23 cpm
about parental strategies, parenting styles in terms of
Weight: 150 lbs
newborn care, childbearing, maternal responsivity, child
Height: 5’4 inches
and childrearing. punishments, and maternal
Blood type: A+
authoritarianism.
Fundic height: 32cms
9. Have someone stay
FHT: 125 BPM via Doppler
with the patient while 9. A companion is always
in Left upper quadrant
waiting for treatment, with her at all times. Sometimes
and/or after treatment. the patient asks for some alone
time.
EVALUATION:
FULLY MET
PARTIALLY MET
UNMET