FDAR Charting

A patient has a fever of 39 degrees Celsius and complained of nose bleeding, nausea, a 7/10 throbbing headache that was eased by painkillers,
and an 8/10 cramping stomachache. The patient also stated that she had been irritable for the past two days.

Date and Time Focus Data, Action, & Response

D: Temperature of 39oC via axilla, skin is flushed
and warm to touch
4/25/22 Hyperthermia A: - Tepid sponge bath (tsb) done
8:00 pm - 7:30 pm> administered 250mg IV paracetamol
as per doctor’s order
- encouraged adequate oral fluid intake
- encourage adequate rest
R: 10:00pm> temperature decreased from 39 to
37.1oC
D: - Reports of sharp pain on the abdominal area
with a pain scale of 8 out of 10
4/25/22 - restless and irritable
6:25 am Pain - Facial grimacing
A: - administered celecoxib 200mg IV
- keep patient comfortable and safe
- encouraged deep breathing exercises and
relaxation techniques
R: patient reports pain was relieved
 D: unable to keep anything down for 24 hours
and is just throwing up “yellow stuff”. Color pale,
4/26/22 Nausea skin is warm and dry,
12:45 pm A: administered antiemetic
metoclopramide 10mg
R: patient states feels less nauseated, no
vomiting
D: suffering from nose bleeding
A: - Applied gentle suction to the nasal cavity to
remove excess blood & clots that block the
4/26/22 airway
6pm Nose bleeding - administered topical vasoconstrictive agents
- instructed the patient to use nasal saline spray
and antibiotic ointment and avoid strenuous
activities
R: pain was relieved and maintained a clear
airway as evidenced by arrest in nasal bleeding
Name: Kristine N. Olitin
Year & Block: 1-B