SCHOOL OF HEALTH AND ALLIED HEALTH SCIENCES

Nursing Department
NUR 146 – Maternal and Child Nursing (RLE)

FDAR CHARTING
focus – data – action – response

SUBMITTED BY:
UMALI, TRISHA S.
(BSN 2-A1 Group 3)

SUBMITTED TO:
MS. KYRENE ROSALES
FDAR #1

DATE FOCUS TIME DAR

05/24/2021 Acute pain related to 08:00 AM
laceration (episiotomy)
of the delicate tissues as
evidenced by facial
grimace
D: The patient is awake, conscious, face
grimacing. Complained pain of laceration
with a scale of 9 out of 10; and presence
of diaphoresis
 Vital Signs: BP: 110/70; HR: 85;
RR: 19; Temp: 36.8; O2 Sat: 98%;
Weight: 109 lbs

A: Monitor pt’s vital signs. Assess the

episiotomy wound for abnormal
discharge and signs of infection. Place
the patient in a comfortable side-lying
position. Encourage the pt to do deep
breathing exercise and relaxation
techniques. Provide nonpharmacologic
pain management. Provide
pharmacologic pain management
(analgesics) as ordered.

R: Patient verbalized that pain was

minimized and relieved. Patient will
report decreased scale of pain.
FDAR #2

DATE FOCUS TIME DAR

05/24/2021 Anxiety related 01:30 PM D: The patient is awake, conscious,
to perceived threats to worried and confused. Patient was
scheduled for prenatal visit today in SWU
self and fetus MC and upon 12:40 RHU Center was
asked to perform IE there was iatrogenic
rupture of bag of water.

 Vital Signs: BP: 110/80; HR: 72; RR:

18; Temp: 36.2; O2 Sat: 98%;
Weight: 104 lbs

A: Encourage the pt to use relaxation

techniques. Encourage verbalization of
fears or concerns. Explain the
procedures, nursing interventions, and
treatment regimen. Keep communication
open; discuss with the client the possible
side effects and outcomes while
maintaining an optimistic attitude.

R: Patient is relaxed and verbalized that

she is not afraid of her situation and that
she understands her current condition.
FDAR #3

DATE FOCUS TIME DAR

05/24/2021 Decreased cardiac 09:40 PM
output related to
increased systemic
vascular resistance
secondary to mild
preeclampsia, as
evidenced by an
average blood
pressure level of
150/90 and
headache
D: Patient felt mild headache, dizzy and light
headed, she did not check her blood pressure. No
medication taken, patient was at work when she
suddenly felt light headed, dizzy, with headache,
now more intense, she took her blood pressure and
it was 150/90.
 awake, alert, pink palpebral conjunctiva, clear
breath sounds, equal chest expansion, dynamic
precordium, no murmur, gravida linea nigra, no
contractions, FH: 33 cm, FHT 128 BPM
 Vital Signs: BP: 150/90; HR: 94; RR: 24; Temp:
37.1; O2 Sat: 98%; Weight: 66.5 kg
A: Define and state the limits of desired BP. Explain
hypertension and its effect on the heart, blood
vessels, kidney, and brain. Assist the patient in
identifying modifiable risk factors like diet high in
sodium, saturated fats and cholesterol. Instruct the
patient to have bedrest and avoid environmental
stressors. Administer hypertensives as prescribed.

R: Patient had no elevation in blood pressure above

normal limits and will maintain blood pressure within
acceptable limits. Pt maintained adequate cardiac
output and cardiac index.
FDAR #4

DATE FOCUS TIME DAR

05/24/2021 Acute pain related to 05:30 AM D: The patient is awake, conscious, face
progress of labor as grimacing. Complained intermittent
hypogastric pain radiating at the
evidenced by back, every 5-10 minutes
intermittent
hypogastric and  Vital Signs: BP: 130/80; HR: 92; RR: 24;
back pain Temp: 37.1; O2 Sat: 98%;
Weight: 117 lbs

A: Encourage the pt to do deep breathing

exercise and relaxation techniques. Perform
a comprehensive assessment of pain.
Instruct client in relaxation techniques;
provide diversionary activities such as radio,
television, or reading. Provide
nonpharmacologic pain management.
Provide pharmacologic pain management
(analgesics) as ordered. Provide health
teachings based on the patient’s condition.
Assist pt with comfort measures.

R: Patient reported pain or discomfort

relieved and controlled. Pt demonstrated use
of relaxation skills.
FDAR #5

DATE FOCUS TIME DAR

D:  Infant – Frequently seeks to suckle at breast
05/24/2021 Insufficient 08:00 AM which results to prolonged breastfeed time, when
production of breastfeeding is in progress arching and crying,
maternal breastmilk fussiness is visible on the infant.

 Mother – “Kaunti lang ang gatas na nalabas at

nadedede ni baby kay nabubugnot at panay ang
iyak.” as stated by the patient; Few fluid intake 500
cc x 4 hours. “Noong makalawa pa unti yung gatas
na nalabas.” (2 days) claimed by the mother;
Fatigue and lack of rest due to the environment

A: Assess for presence/absence of related factors or

conditions that would preclude breastfeeding.
Assess breast and nipple structure. Evaluate and
record the mother's ability to position, give cues, and
help the infant latch on. Evaluate and record the
infant's suckling and swallowing pattern at the
breast. rovide support by actively helping the mother
to correctly position the baby to attain a good latch
on the nipple and encouraging her to continue trying.

R: Patient achieved effective breastfeeding. Pt

verbalized and demonstrated techniques to manage
breastfeeding problems.