FDAR

Patient Initials: A.M.B

Room number: 1

Date/Time Focus Data:

09/05/2020 Knowledge deficit: -shortness of breath

8:00 am the prevention and -weakness

treatment of symptoms -productive cough

related to the condition -chest pain and epigastric discomfort

of inadequate information. -v/s taken as follows:

 Temp.- 38⁰C
 PR- 105 bpm
 RR- 30bpm
 BP- 100/60
 SpO2- 88%

Action:

-received pt. lying on bed c ongoing IVF of

PNSS 1L, infusing well; regulated at 20
gtts/min.

-On NPO temporarily

-monitor v/s and O2 saturation

-place pt. on comfortable position

-provide calm and well-ventilated

environment.

-assist pt. on laboratory test as ordered

-administered meds as per doctors order.

Response:

-V/S monitored and recorded as follows:

 Temp.- 37.6
 PR- 100bpm
 RR-27bpm
 BP-110/70
 SpO2- 93%
D. Abraham, RN
 FDAR

Patient Initials: A.M.B

Room number: 1

Date/Time Focus Data:

09/06/2020 Acute pain related to -weakness

6:00 am irritation of the mucosa -productive cough

and muscle apasm. -reduced lung excursion

-V/S taken as follows:

 Temp. 37.2⁰C
 PR- 98bpm
 RR- 25bpm
 BP- 110/80
 SpO2- 88%

Action:

-Ongoing IVF of D5LR 1L, well infused;

regulated at 30 gtts/min,

-monitor v/s and oxygen saturation

-place pt. on comfortable position

-provide calm and well-ventilated

environment

-on soft diet

-regulatedO2 at 3L/min

-watch for sign of bleeding

-continue meds as per doctor’s order

Response:

-V/S monitored and recorded as follows:

 Temp.- 37⁰C
 PR- 97bpm
 RR- 23bpm
 BP- 110/80
 SpO2- 93%

D. Abraham, RN
 FDAR

Patient Initials: A.M.B

Room number: 1

Date/Time: Focus: Data:

09/07/2020 Anxiety related to -Irritable

7:00 am threat to/or exchange -Restlessness

In health status. -Fear

-V/S monitored and taken as follows:

 Temp.- 37⁰C
 PR- 100bpm
 RR- 21bpm
 BP- 120/80
 SpO2- 95%

Action:

-Ongoing IVF of D5LR 1L, well infused,

regulated at 30 gtts/min.

-monitor pt. v/s

-on bland diet

-listen to the pt. concern

- continue medications

Response:

-V/S monitored and taken as follows:

 Temp.- 36.7⁰C
 PR- 95bpm
 RR- 20bpm
 BP- 120/80
 SpO2- 95%

-the feel relaxed and comfortable.

D.Abraham, RN
 FDAR

Patient Initials: A.M.B

Room number: 1

Date/Time: Focus: Data:

09/08/2020 Readiness for enhance -Relaxed

7:00 am health condition. -Comfortable

-V/S taken and monitored as follows:

 Temp.- 37⁰C
 PR- 90bpm
 RR- 21bpm
 BP- 110/80
 SpO2- 95%

Action:

-Ongoing IVF D5LR 100cc, well infused;

regulated at 30gtts/min.

-give pt. health teaching regarding on her

diet and lifestyle.

-home meds given with proper instruction

-remind pt. for follow up check up

Response:

-V/S taken and monitored as follows:

 Temp,- 36.5⁰C
 PR- 85bpm
 RR- 21bpm
 BP- 120/80
 SpO2- 95%

-IVF of D5LR removed.

D. Abraham, RN