DATE/SHIFT TIME FOCUS D=DATA

A=ACTION
R=RESPONSE

4/30/21 9 AM DYSPNEA D - RR= 16

Use of accessory
muscle to breath
Patient is lethargic

6-2 9:30 AM A – Instructed the

patient to do pursed lip
breathing exercises
Using of fan for
ventilation
Encourage small
frequent feedings

10:15 am R – RR = 18
Patient was able to
partially breath
normally.

DATE/SHIFT TIME FOCUS D=DATA

A=ACTION
R=RESPONSE

4/30/21 8 AM ABDOMINAL PAIN D – Touch the patient’s

abdomen gently to
locate the pain
Ask the patient to
locate the pain
Use of Wong baker
pain scale to assess the
pain through the
patient’s face. (Wong
baker scale of 4)
6-2 8:30 AM A – Administer analgesic
as prescribed by the
 physician
Application of cold
packs to the abdomen.
Instruct the
guardians of the patient
to talk or interact with
the patient to distract
the patient from the
pain.
8:45 AM R – Patient was able to
be calm from the pain
and rested well
Wong baker scale of
2