FDAR CHARTING

(Focus-Data-Action-Response)

Age: __1d/o __ Sex: ___M____ CC: _Not indicated_____________________________________________________

Medical Diagnosis: __N/A____________________________________________________________________

Date, Time, and FOCUS PROGRESS NOTES

Shift

D- Received the baby with Height: 54cm, HC: 34 cm, CC: 32

cm, AC: 30cm, MAC:13 cm. The patient has poor sucking with his
September 7, 2019, Hypothermia mom's breast, cries immediately, and looked uncomfortable with
7:30 am, Prevention the position.

7-3 shift
For the 1st minute of life: infant’s body looks pink but the
extremities appear bluish, HR:120bpm, RR 60cpm: has slow
and irregular weak cry, has some facial grimace when
stimulated and full flexion of arms and legs.

5 minutes after: the skin appears pinkish all over the body, still
the same facial grimace when stimulated, well-flexed arms and
legs, and good strong cry. Po or sucking/swallowing noted,
weight: 3.5 kgs; Latest vital signs as follows: T:36.3C, PR: 153
bpm, SPO2 95% with 02, RR: 60 cpm

Skin is cracking pale with rare veins, cool skin, and appears
shivering when AC is on.

A- Monitored body temperature every 1 to 3 hours by axillary or

inguinal route. Recorded temperature and route. Monitored and
recorded neurologic status every 1 to 4 hours. Discussed
precipitating factors with family members. Instructed family
members in preventive measures, such as dressing the neonate
appropriately and providing adequate nutrition for the neonate’s
growth needs. Provided supportive measures:

➢ dress the neonate with an undershirt, diaper, and knitted

or stockinette cap and cover him with double blankets.

➢ avoid overheating the neonate

➢ keep the diaper area dry

➢ cover all metal of plastic surfaces that could come in

contact with the neonate

➢ maintain the room temperature between 23.9 °C and

25.6 °C

➢ postpone bathing the neonate

R- The goals were met, provided that the neonate’s temperature

returned to normal range, and does not shiver. The patient did not
develop complications of hypothermia. The family members were
able to verbalize understanding of the causes of hypothermia and

preventive measures. The family members were able to

demonstrate proper axillary of inguinal temperature measurement
technique.

Patient’s Name / Room No. | 1