Beltran, Cyril Jan S.

BSN 2 A-6
FDAR
Date Shift Focus Time D=Data/ A=Action/ R= Response
1/19/21 06:00 - Receiving 07:00 D>Patient is awake, alert and is
2:00 PM Assessment standing near the bed; Patient
appears to be happy but there is
visible signs of discomfort; Patient’s
gown appear to be wet at the
breast area.
Breast 07:30 D>Patient reports breast
Engorgement
engorgement; “sakit kaayu ako
totoy, puno sha’g gatas ” as
verbalized by the patient; Patient
pain score of 9 out of 10 (with 10 is
the highest and 1 is the lowest).
08:30 A>Instruct client to fully empty her
breast at each feeding; Advise the
client to allow the infant to nurse
every 2 hours; Encourage client to
massage her breast from the top
and down over the nipple during
feeding; Instruct client to allow the
infant to feed 15 to 25 minutes per
breast, or until the breast softens;
Introduce client on breast pumps
and provide teaching on how to use
it; Encourage client to apply cool
compresses between feedings;
Encourage client to take warm
shower prior to breastfeeding;
Encourage patient to put cabbage
leaves at the breast to help
relieving pain; Instruct client to
alternating breasts at feedings so
the baby empties the supply;
Instruct the patient to properly
latch the infant to the breast by
aiming baby’s lower lip at the base
of the nipple; Instruct patient that if
pain persist call the NOD and
endorse to the attending physician.
R> Patient appears to be happy
displays no signs of discomfort; “Di
Endorsing 01:00
Assesment
 na sakit ako totoy, di pareha
ganeha” as verbalized by the
patient; Patient’s shirt doesn’t have
any evidence of milk leakage.
D> Patient is in low fowler’s
End of Shift 01:30 position and is sleeping.