Name: Date: 09/09/2021

Student No.: BSN Level III

ACTIVITY No. 3

1. SBAR example for a patient with difficulty of breathing (Pneumonia).

Situation
“Mr. Lennon is having dyspnea, fever, and complaining
of his productive cough.”

Background
“The supporting background information is that he
started to have difficulties in breathing an hour ago and
has persistent productive cough of green phlegm. He is
also currently breathing through a device.”

Assessment
“My assessment of the situation is that he must be
breathing through a device with increased resistance.
Also, swelling and mucus in the airways can cause his
difficulty in breathing.”

Recommendation
“I recommend that his pulmonologist must see him
immediately to check his condition. And is there
anything I can do in the mean time?”

2. FDAR Charting for a patient with fever (Hyperthermia).

Date/ Time Focus Progress Notes
4/18/2021 Hyperthermia Data
 Temperature of
9:00AM 38.7°C via axilla
 Skin is red and hot
to touch
 Excessive
sweating
 Slurred Speech
 Confusion

Action
 Tepid Sponge
Bath (TSB)
 Elimination of any
excess clothing
and covers
8: 30AM
 Give prescribed
antipyretic
medications
 Encourage ample
amount of fluid
intake, orally
Response
11:00AM
 Temperature
decreased from
38.7°C to 37.3°C