Republic of the Philippines

POLYTECHNIC STATE UNIVERSITY OF BICOL

Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
Bachelor of Science in Nursing

Fundamentals of Nursing (FDAR Charting)

Case Scenario:
Mr. Pedro Dimaano, a 56-year-old male retired policeman came to the emergency room of Our
Lady Mediatrix Hospital with shortness of breath. Three days ago, symptoms manifested and gradually
worsened. 2 years ago, he was hospitalized and was diagnosed with COPD. He has a portable oxygen
tank at home, which he uses every time he experiences SOB, which makes it difficult for him to sleep at
night. Upon assessment, his initial vital signs were BP: 170/110, PR: 86bpm RR: 28cpm Temp: 37.5 C
Weight: 75 kg, Height: 5’6 Ft. He denies fever, chills, cough, wheezing, sputum production, chest pain,
palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea. His
laboratory result shows paCO2 of 55mmHg, oxygen saturation of 89% and chest x-ray result shows
enlarged lungs with residual lung volume of 7 Liters.
On the second day of admission, he reported difficulty breathing at rest, forgetfulness, mild
fatigue, feeling chilled requiring blankets, increased urinary frequency, incontinence, and swelling in her
bilateral lower extremities that is new-onset and worsening. Subsequently, he has not ambulated from
bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath. There
are no known ill contacts at home. His family history includes significant heart disease and breast cancer
on her mother’s side. Social history is positive for smoking tobacco use at 30 packs for 15 years. He quit
smoking 2 years ago due to increasing shortness of breath. He does not drink alcohol and uses illegal
drugs. There are no known foods, drugs, or environmental allergies.
Past medical history is significant for COPD, hypertension, hyperlipidemia, diabetes mellitus,
tobacco usage, and obesity. Past surgical history is significant for an appendectomy.
His current medications include Breo Ellipta 100-25 mcg inhaled daily, hydralazine 50 mg by
mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, Duo-Neb inhaled q4 hr PRN,
levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day, nebivolol 5 mg by
mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by
mouth daily, isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily.

Lab/ Radiological test:

Chest Xray result reveals pneumonia
WBC at 14,000
RBC & Platelets normal
Stool and urine analyses are also normal
 Republic of the Philippines
POLYTECHNIC STATE UNIVERSITY OF BICOL
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
Bachelor of Science in Nursing

Document the care given by making a nurse documentation following the FDAR format.
FDAR for Second day of Admission:
Date/Hour Focus Progress Notes

04/16/22 Shortness of breath D: Patient cannot ambulate from bed for several
0900 days except to use the restroom due to feeling weak,
fatigued, and short of breath.
“I experience difficulty breathing at rest, and mild
fatigue.”
A: Monitor client’s vital signs especially respiration
rate.

Administered Breo Ellipta 100-25 mcg as per

doctor’s order.

Medical management was administered such as

oxygen supplementation, repositioning the patient
by elevating head of bed using upright Fowler’s
position, and removal of thick secretions.

Demonstrated and taught patient the importance of

each prescribed medication and how to properly
take them; demonstrated and encouraged patient to
perform deep breathing techniques.

Encourage patient to increase oral fluid intake.

1100 R: Return demonstration of properly taking

prescribed medication and perform the deep
breathing techniques.
“I feel a little better in terms of my breathing.”