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FDAR

The document summarizes a patient's post-operative care following excision of a sebaceous cyst on their upper back. On the morning of August 5th, the nurse monitored the patient's vital signs, assessed the surgical site for signs of infection, and encouraged hand washing and a protein-rich diet. No issues were observed. Later that morning, the patient reported mild pain and restlessness, so the nurse provided comfort measures and repositioning. By noon, the patient reported not sleeping well, so the nurse encouraged comfort measures like warm baths and positioning assistance, which helped the patient sleep well.

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Roxanne Ganayo Claver
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1K views2 pages

FDAR

The document summarizes a patient's post-operative care following excision of a sebaceous cyst on their upper back. On the morning of August 5th, the nurse monitored the patient's vital signs, assessed the surgical site for signs of infection, and encouraged hand washing and a protein-rich diet. No issues were observed. Later that morning, the patient reported mild pain and restlessness, so the nurse provided comfort measures and repositioning. By noon, the patient reported not sleeping well, so the nurse encouraged comfort measures like warm baths and positioning assistance, which helped the patient sleep well.

Uploaded by

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

FDAR

DATE/TIME FOCUS DATA, ACTION, RESPONSE


8/5/13
8am

Risk for infection r/t surgical site
excision

D > post op excision of
sebaceous cyst
Post op dressing @ left
upper back
VS:
T: 36.4 PR: 81
BP: 110/80 RR: 20

A > monitored VS
Assessed for the surgical
site for any foul odors,
swelling and puss
Encouraged pt. as well as
watcher to do hand
washing every now and
then
Encouraged to eat foods
rich in protein when able

R > absence of foul odors,
swelling and puss
Dressing was dry and
intact
10:00 am Mild Pain D > post op excision of
sebaceous cyst
Restlessness
Irritability

A > monitored VS
Provided comfort
measures
Placed pt. on a side-lying
position

R > dili na kayo sakit ang akong
likod as verbalized by pt.
Left on bed asleep

12NN Promotion of comfort and Sleep D > wala ko nakatulog ug
tarong mam as verbalized
by pt.
Lethargic
Irritability

A > provided comfortable
beddings such as a pillow
Encouraged comfort
regimens like warm bath
Encouraged position of
comfort with assistance

R > nakatulog na ko ug tarong
tarong as verbalized by the
pt.

FDAR DATE/TIME FOCUS DATA, ACTION, RESPONSE 8/5/13 8am Risk for infection r/t surgical site excision D > post
A > provided comfortable beddings such as a pillow  Encouraged comfort regimens like warm bath  Encouraged positi

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