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FDAR Charting for Discharge Patient Care

The nurse's progress notes document a 65-year-old female patient admitted to the surgery ward with nausea, vomiting, abdominal pain, and headaches for several weeks who also presented with fever. The nurse promoted rest, administered pain medication and IV fluids as prescribed, monitored intake and output, and provided comfort measures, which eased the patient's pain and reduced her fever.

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Mark Zedrix Mediario
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2K views1 page

FDAR Charting for Discharge Patient Care

The nurse's progress notes document a 65-year-old female patient admitted to the surgery ward with nausea, vomiting, abdominal pain, and headaches for several weeks who also presented with fever. The nurse promoted rest, administered pain medication and IV fluids as prescribed, monitored intake and output, and provided comfort measures, which eased the patient's pain and reduced her fever.

Uploaded by

Mark Zedrix Mediario
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Nurse's Progress Notes

NURSE’S PROGRESS NOTES

SURNAME N/A AGE 65 HOSPITAL NO.


GIVEN NAME N/A SEX Female WARD Surgery
MIDDLE NAME N/A CS N/A BED NO.

DATE D – DATA DATE D – DATA


SHIFT FOCUS A – ACTION SHIFT FOCUS A – ACTION
TIME R – RESPONSE TIME R – RESPONSE
03-06-22 Nausea and D
7-3 vomiting for - Admitted patient on the ward,
several 65 years old female, conscious,
weeks; Pain with history of hypertensive
in upper disorder, arthritis, high
abdomen and cholesterol, diabetes mellitus
headache; type 2, hypothyroidism, obesity
Fever - Presented with intractable
nausea and vomiting for several
weeks
- Chief complaint of upper
abdominal pain and diffuse
headaches
- Febrile
A
- Promoted rest, positioned
comfortably in bed- semi-fowler’s
- Consent secured
- Vital signs taken and recorded
- Pain rating scale: 7/10
- Administered paracetamol IV as
prescribed
- Initiated IV rehydration as
prescribed
- Monitored intake and output
- Safety measures secured
- Comfort measures rendered
R
- Eased pain
- Temp went down to 37 C
- No further complaints

mzm
Mark Zedrix A. Mediario

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