DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

FDAR

Name of Patient: Regina Date of Admission: March 13, 2023

Age: 32 Years old Sex: female
Allergies: N/A Attending Physician: Dr. Vanguardia
Chief Complaint: Bronchial asthma and difficulty in breathing for 5 days with fever for 2
days

Date and Focus Progress notes

Time
 DATA:
March 13, Fever  difficulty in breathing suspect on Covid-19
2023  2 days fever
@7am  Lower segment cesarean section

ACTION:
1. Provide tepid sponge bath (TSB)
2. Monitor VS every hour as indicated especially
temperature
3. Identify factors that triggers hyperthermia and
review client health history
4. Monitor Intake and Output
5. Apply ice packs to the patient
6. Monitor the skin during the cooling process
7. Infuse intravenous cooled saline as ordered.
8. Adjust and monitor environmental factors like
room temperature and bed linens as indicated .
9. Provide medication as prescribed such as
paracetamol
10. Encourage adequate fluid intake.
RESPONSE:
 Goal was met
 The client became afebrile at the end of
the shift with the temperature of 37.4
degrees Celsius

Smart Gabrielle L. Cardos St.N

Name of Student