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  • Nurse'S Notes (Fdar Method) : Displayed No Expression of Pain

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    Mary Mathel Del Rosario
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    The nurse's notes document a patient's care for acute pain on 2/12/22 using three different documentation methods: FDAR, SOAP, and narrative. For the FDAR method, the data showed the patient's severe pain and vital signs. The nurse's actions were to monitor signs and provide pain management. For the SOAP method, the subjective data was the patient's pain complaint. The assessment was the pain was acute and related to increased heart rate and breathing. For the narrative method, the notes included details of care over time including monitoring, exams, treatments, and improved status.

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    Nurses notes NCM 103

    Original Title

    Act 2 Nurses Notes

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    The nurse's notes document a patient's care for acute pain on 2/12/22 using three different documentation methods: FDAR, SOAP, and narrative. For the FDAR method, the data showed the patient's severe pain and vital signs. The nurse's actions were to monitor signs and provide pain management. For the SOAP method, the subjective data was the patient's pain complaint. The assessment was the pain was acute and related to increased heart rate and breathing. For the narrative method, the notes included details of care over time including monitoring, exams, treatments, and improved status.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    14 views3 pages

    Nurse'S Notes (Fdar Method) : Displayed No Expression of Pain

    Uploaded by

    Mary Mathel Del Rosario
    The nurse's notes document a patient's care for acute pain on 2/12/22 using three different documentation methods: FDAR, SOAP, and narrative. For the FDAR method, the data showed the patient's severe pain and vital signs. The nurse's actions were to monitor signs and provide pain management. For the SOAP method, the subjective data was the patient's pain complaint. The assessment was the pain was acute and related to increased heart rate and breathing. For the narrative method, the notes included details of care over time including monitoring, exams, treatments, and improved status.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 3

    NURSE’S NOTES (FDAR METHOD)

    DATE TIME FOCUS NURSE’S NOTES (D.A.R. – Data, Action, Response)


    2/12/22 0900 Acute Pain D – Received patient with severe pain 10/10
    - Diaphoretic and pale
    - RR 28 breaths/m
    - HR 115 beats/m
    - Oxygen Sat 100% in a room temp
    - EKG result: Sinus tachycardia
    - BP: 120/80 mmHg
    A – Observe nonverbal cues and pain behaviors.
    - Monitor skin color and vital signs.
    - Provide nonpharmacologic pain management like distraction.
    - Provide pharmacologic pain management as ordered.
    R - Displayed no expression of pain.
    - Respiration rate and heart rate are normal.
    - Patients perspiration is normal; skin color is florid.
    1500 - Discharged MA. JESSICA D. ABES, RN
    LICENSE NUMBER 123456789

    NURSE’S NOTES (SOAP METHOD)


    DATE TIME FOCUS NURSE’S NOTES (D.A.R. – Data, Action, Response)
    2/12/22 0900 Acute Pain S – Complaints pain with severity of 10/10
    - Diaphoretic and pale
    O - RR 28 breaths/m
    - HR 115 beats/m
    - Oxygen Sat 100% in a room temp
    - EKG result: Sinus tachycardia
    - BP: 120/80 mmHg
    A – Acute pain related to tachypnea and increased heart rate.
    P - Monitor skin color and vital signs.
    - Provide nonpharmacologic pain management like distraction.
    - Observe nonverbal cues and pain behaviors.
    1500 - Administer pain medication management as ordered.
    MA. JESSICA D. ABES, RN
    LICENSE NUMBER 123456789

    NURSE’S NOTES (NARRATIVE METHOD)


    DATE TIME FOCUS NURSE’S NOTES (D.A.R. – Data, Action, Response)
    2/12/22 0900 Acute Pain – Received patient with severe pain 10/10
    - Diaphoretic and pale
    - RR 28 breaths/m
    - HR 115 beats/m
    - Oxygen Sat 100% in a room temp
    - EKG result: Sinus tachycardia
    - BP: 120/80 mmHg
    0920 - Encouraged the use of nonpharmacological pain relief management.
    - Monitored for any signs of cardiac conditions.
    0940 - Seen and examined by attending physician with orders noted.
    1000 - Administered pharmacological pain relief as ordered.
    - Adviced the patient to stay rested.
    1300 - Decreased RR to 22 breaths/m
    - Improved 02 sat to 97% room air temp
    - HR is 100 beats/m
    1400 - EKG result: normal
    1500 - Dischared MA. JESSICA D. ABES , RN
    LICENSE NUMBER 123456789

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