FDAR

Patient’s Name: Patient X Age: 79 years old

Date: Sept. 3, 2023 , 8:00 AM Chief Complaint: Two- week progression of episodic
shortness of breath

DATE & TIME FOCUS PROGRESS NOTES

Sept. 3, 2023 Activity DATA:

8:00 AM Intolerance
Subjective Data:
There was no verbalization acquired from the
patient.

Objective Data:

- Episodic shortness of breath.

- History of worsening dyspnea prompted by less
than normal activity.
- Tachpnea present
- Crackles at the base of lungs notes.
- (+) S4 sounds noted.

Vital Signs:

- Temp: 36.2 ℃
- RR: 28 cpm
- BP: 104/54 mmHg
- SpO2: 90%

ACTION:

- Monitored the patient’s oxygen saturation during

activity using a portable pulse oximeter.

- Monitored the cardiopulmonary status of the

patient by checking the vital signs q 2 hrs or before
and after the activity.

- Observed the patient’s response to activity and

documented in an activity chart.

- Elevated the head of the bed. Assist the patient to

the semi-fowler’s position.

- Assessed the need for ambulation aids.

- Encouraged light physical movement or routine

position changes.

- Taught the patent to gradually do more active

range of motion exercise while in bed.
 * Sitting from bed to chair
* Walking for a minute and sitting again

- Slow the pace of care and provide adequate rest

before and after periods of exertion (e.g.; bathing,
eating, exercise)

- Educated the patient and caregivers to recognize

signs of physical over-activity.

- Taught energy conservation techniques.

* Sliding rather than lifting
* Pushing rather than pulling
* Using wheeled carts
* Working at an even pace

RESPONSE:

Within after 8 hours, the client was able to manifest

the following:

A. An improvement in terms of:

I. Breathing Pattern
II. Vital Signs

B. Demonstrated of increased tolerance activities.

C. Verbalization of health teachings in terms of:

I. Active ROM
II. Deep Breathing Exercises

Vital Signs

- Temp: 36.7 ℃
- RR: 20 cpm
- BP: 105/75
- SpO2: 96%

EVALUATION:

- Fully Met
- Partially Met
- Unmet

Name: Kayesha E. Nuevo, SN Clinical Instructor:Mr. Paul Andre Lumigid