FDAR (GROUP 2)

Members:
Robert Ivan Agujar
Patricia Anahaw
Harneth Arcega
Reysie Velle Valino
Andrea Zantua
Gloriel Oliveros

Scene: A mother 65 years old Erica Gutierrez was admitted in the hospital due to high
blood pressure. She is manifesting nausea and vomiting and shortness of breath,
headache, and nape pain. She lives in Biñan, Laguna. Family history shows
hypertension and asthma.

Documentation:

Patient’s Profile

Name: Erica Gutierrez

Age: 65 years old

Sex: Female

Address: Biñan, Laguna

FDAR CHARTING

DATE/TIME FOCUS DATA, ACTION AND RESPONSE

11/12/21 High Blood Pressure D: Received in supine position with IV fluid of

9:00 AM D5LR at 1 Liter at 500 cc level. "Masakit batok ko
at nahihilo ako. Sobrang sakit ng ulo ko at
nasusuka ako. Nahihirapan din akong huminga."
as verbalized by patient. Cold and clammy skin,
VS: T: 37.3°C PR= 96 bpm RR= 15 cpm BP =
160/90 mmHg.----------------------------------------------
A: Position the patient in Semi-Fowler's Position.
Monitored and recorded vital signs. Administer
Losartan as ordered by physician. Provide the
following health education: Increase physical
activity or exercise regularly. Avoid foods high in
cholesterol and sodium. Instruct to eat fruits and
vegetables. Reduce and manage stress by
 learning and practicing relaxation
techniques---------------------------------------------------
3:00 PM R: Vital signs are stable (body temperature:
36.5°C, pulse rate: 70 bpm, respiration rate: 18
cpm, and blood pressure: 120/80 mmHg). Patient
is relieved from head and neck pain and nausea
as evidenced by the patient sleeping during
rounds--------------------------------------------------------